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233 Cards in this Set
- Front
- Back
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weak foot dorsiflexors
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foot slap
L4/L5 |
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weakness of tibialis anterior
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foot drop gait
L4 |
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weakness of gastrocnemius and soleus
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flat foot gait
S1/S2 |
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weak ankle dorsiflexors cause the patient to excessively flex the hip in order to clear floor with the foot
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steppage gait
L4/L5 |
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foot is VARUS during swing phase
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Peroneal/fibularis muscle weakness
S1 |
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Weak quadriceps gait
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Back knee gait
L2,3,4 |
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patient thrusts trunk posteriorly in order to maintain HIP extension
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Gluteus maximus lurch
S1 |
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Hemiplegia or gluteus medius weakness
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circumduction gait
L5 |
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body weight is thrown over the INVOLVED hip, causing a big swing of LATERAL trunk
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gluteus MEDIUS lurch
L5 |
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Spastic Diplegia means?
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patient uses short steps and drags the ball of foot across the floor. Patient's legs are EXTENDED and thighs CROSS forward over each other with each step
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Spastic diplegia (short steps, dragging ball of foot with extended legs crossing each other)
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Scissors gait
CNS |
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MUSCULAR DYSTROPHY gait where patient's legs are spread wide apart and WADDLING develops due to weak gluteal muscles
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waddling gait
muscle problem |
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Parkinson's disease gait where initial steps are short so feet barely clear ground and soles of feet scrape the floor. Steps become successively more rapid.
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FESTINATION gait
RETROPULSION gait melanin-containing nerve cells of brain stem problem |
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'mechanism of injury"
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explains how a person got hurt
includes: overuse, obesity, mechanical defects, hard level floor injuries, cheap shoes |
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joint most commonly affected by OA
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great toe
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gives special sensation between toes 1 and 2
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DEEP peroneal nerve
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antagonist of posterior tibialis
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peroneus/fibularis brevis
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99% of feet are perfect at birth,
8% have trouble by one year, ___% at five years and ___% by age twenty. |
41% @ 5 years
80% @ 20 years (Podiatry Society of NY) |
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classification of ankle joint
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hinge/ginglymus joint
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The foot acts as a shock absorber & balances body. More importantly, it acts as a _______ lever during supination and a ________ adapter during pronation.
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rigid lever during supination
mobile adapter during pronation |
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the foot acts as a mobile adapter during
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pronation
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the foot acts as a rigid lever during
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supination
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4 foot arches
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1. Medial longitudinal
2. Lateral longitudinal 3. Transverse 4. Anterior transverse (debatable) |
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bones of medial transverse arch
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Calcaneus
Talus Navicular Cuneiforms 1 + 2 Metatarsals 1 + 2 |
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bones of transverse arch
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Cuneiforms 1.2.3
CUBOID (cornerstone!) |
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cornerstone of transverse arch
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cuboid
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bones of lateral longitudinal arch
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calcaneus, cuboid, 4th and 5th metatarsals
*Keystone = cuboid! |
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bones of the lateral longitudinal arch
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calcaneus, cuboid, 4th and 5th metatarsals
CUBOID is keystone |
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bones of anterior transverse arch
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metatarsals 1-5 proximal to metatarsal heads
**keystone is MIDDLE CUNEIFORM |
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how many bones in the foot - this is 1/4 of the bones in the body?
ligaments? muscles? |
26 bones
107 ligaments 19 muscles |
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SEAT of upright posture and has NO muscular attachments
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Talus
-part of talo-crural joint -talar dome between tibia and fibula |
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keystone and cornerstone of foot!
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Cuboid
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When is cuboid a cornerstone?
A keystone? |
cuboid cornerstone TRANSVERSE
cuboid keystone LATERAL longitudinal |
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always involved in foot problems, this bone is a common subluxation/fixation area and is related to FIBULAR HEAD subluxation
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Cuboid (the keystone & cornerstone)
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-common site of stress fracture
-Morton's neuroma -fibrous adhesions between it and its neighbor |
4th metatarsal
(marry me, Morton - I will stress you out and we'll stick together) |
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marry me, Morton
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4th metatarsal for Morton's neuroma
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avulsion fracture site
peroneus/fibularis brevis insertion |
5th metatarsal
(makes very painful to walk on forefoot) |
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bone that can be fractured or dislocated with hallux valgus
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sesamoid
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what foot pathology causes dislocation of sesamoid bone?
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hallux valgus
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The 5th metatarsal and the _____ ________ are avulsion sites
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lateral malleolus
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Why is the lateral malleolus prone to avulsion or high ankle sprain?
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because the fibula and patella are the only NON-WEIGHT BEARING bones in lower extremity
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where is the avascular zone of the Achilles tendon?
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2-4 cm above calcaneus
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The Achilles tendon makes dorsiflexion difficult with age, leading to longer
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pronation at mid-stance
'too long' |
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What is prone to spontaneous rupture after 40yrs?
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Achilles tendon
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causes pin point pain due to decrease of WINDLASS effect
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plantar fascitis
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caused by fixation of the talo-navicular-cuneiform complex
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plantar fascitis
*treated with a night splint/boot |
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name the talo-fibular ligaments (3)
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a. Anterior
b. posterior c. Calcaneal |
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80% of ankle sprains
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plantar flexion-inversion sprain
*graded I, II, III |
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Most common LIGAMENT SPRAIN in ankle
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lateral ligament
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Talo-Fibular ligaments are also called the ___________ ligament and what is memorable about them?
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Lateral, sprained in 80% of ankle cases
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-plantar calcaneo-navicular ligament is parallel to it.
-plastically deformed during pes planus |
SPRING! ligament
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how might you correct pes planus and what ligament is responsible?
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restoration of medial longitudinal arch
spring! ligament |
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name 4 deltoid ligament components
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1. anterior tibotalar
2. tibionavicular 3. tibiocalcaneal 4. posterior tibiotalar |
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a random re-growth of nerve tissue on the metatarsal pad that chronically irritates the nerve or tendon sheath
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Neuroma
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The ankle can dorsiflex ____ deg.
The great toe can dorsiflex ___ deg. |
ankle dorsiflex = 20 deg.
great toe dorsiflex = 70 deg. |
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The ankle can plantarflex _____ deg. but the great toe can plantarflex a little further to 45 deg.
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ankle plantarflex = 40 deg.
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Inversion
Eversion Adduction Abduction of ankle |
30, 20, 20, 10 degrees
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how do ankles get hurt (mechanisms of injury)
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-Overuse as a training error (48% overtrain)
-Training surfaces -Mechanical defect |
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Name kinds of mechanical defects that lead to ankle injury
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pes planus
tarsal coalition pathological pronation toe deformities |
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hard level floor theory
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mechanisms of injury to foot and ankle due to unyielding stress on foot of a hard surface and causes lack of proprioreception in foot
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60% of people wear shoes that are too _______.
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small
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leads to muscular atrophy, injury and perpetuation of pain cycle in foot due to shoes too small and ?
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Soft cast nature of shoe
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what part of poor quality shoes causes injury?
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crappy mid-sole quality
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most ankles and feet do NOT receive proper ________ after injury and suffer what?
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rehab
atrophy, loss of proprioreception, functional instability, re-injury |
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Right now, ___% of Americans are obese. What percentage is predicted fat by 2050?
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60% now, 100% later
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Obesity causes excessive stress on the
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knees, increased force of ground contact, Q-angle increases
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sprained ankle, shin splints, fot drop, Achilles tendintits, stress fracture, MTP's, adhesions, Morton's neuroma, Reiter's syndrome, black toe
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signs and symptoms
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sprained ankle etiology
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plantar flexion - inversion sprain 80%
graded I, II, III |
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explain grades I, II, and III for ankle sprain
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I - Anterior Talo-Fibular ligament
II - Calcaneal-Fibular ligament III - Posterior Talo-Fibular ligament sore and ATF (I) torn, significant disability |
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muscle responsible for shin splint pain and remedy
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posterior tibialis muscle
foot drills - remedy |
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nerve and disc injury preceding
FOOT DROP |
common peroneal/fibular n.
*L4/L5 disc injury peripheral neuropathy, diabetes |
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muscle weak in foot drop
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tibialis anterior
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what percentage of dorsiflexion comes from tibialis anterior and what condition results from weakness of this muscle?
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80%,
foot drop |
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Rubber band feel around tendon with pain upon PLANTAR flexion is an ____________ injury.
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Achilles tendon
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Achilles injury treatment
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eccentric lifts to strengthen gastroc/soleus
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How do MTP's occur
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as "constellation" patterns
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An adhesion of scar/connective tissue is only ___% as strong as healthy tissue.
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70%
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Well localized pain between the 3rd and 4th metatarsals.
A callus forms and there is random re-growth of nerve tissue. |
Morton's neuroma
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syndrome caused by STD - "cannot see, cannot pee, cannot dance with me"
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Reiter's syndrome
(STD, male predominance, polyarthritis, conjunctivitis, urethritis) |
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repeated microtrauma ruptures the capillaries of the toe
pawing action of toe |
Black toe
court sports, hiking, marathons cross file nail bed with emory board |
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most important muscle of balance and proprioreception
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Soleus
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phasic muscles have _____fibers
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white
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As a result of many repetitions of a skill or technical element, the fundamental nervous processes of _______________....resulting in fine motor skills.
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excitation and inhibition
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main goals of ankle rehab
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1. restore ROM
2. strengthen joint capsule 3. restore proprioreception 4. regain ligament strength 5. restore function |
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_________ is more important than strength when it comes to reflex muscular stimulation of a joint.
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SPEED!
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direct measure of proprioreception
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postural sway during a limb test
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what heightens postural control and benefits human movement?
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Proprioreceptive training
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Can you change the schematic homunculus representation allocations of sensory/proprio in the brain?
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yes
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the process of restoring someone to a useful life who has been ill, injured or otherwise handicapped
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rehabilitation
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name 4 goals of rehab
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immediately lower swelling
restore ROM, etc. test resume training for lifestyle |
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In rehab, we do not address ______.
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speed
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may not be a natural or healthy thing to do for your body, but is physical work on performance-based outcomes
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training
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rehab dichotomies:
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ADL's vs. Training
Green zone vs Red zone Pain free vs Pain Rhythmic vs Stabilization |
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examples of rhythmic vs stabilization
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rhythmic: cycling, swimming, jogging
stabilization: physioball, lower core stability |
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Most difficult clinical challenge
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Patient compliance
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name some exercise prescriptions:
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sets, reps, time, number, frequency, intensity, density
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a collection of reps
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sets
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one full motion
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rep
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According to Hammer, activation of muscles important for:
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good posture (static)
control of repeated moves control of gait (dynamic) |
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sports, ADL's
coordination body posture stabilization |
all things involving BALANCE
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Coordination involves _____ actions (sprinter) and muscle antagonist/agonist. Example:
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speed
Rachmaninoff played 80 notes per sec, used 400 muscles per sec |
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Used by actors, singers, voice projection, Alexander technique
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Body Posture (aspect of balance)
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soft tissue patterns repeatedly present
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constellation MFTP's
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sign of weak glutes
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Trendelenberg sign (medial and lateral pelvic stabilizers)
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what kind of muscles enhance/control core stability
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red fiber postural
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Is 1/100th of a second important?
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Yes, don't you watch horse racing?
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Why do people sprain ankles?
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poorly dev neural pathways - previous injuries - atrophy - loss of proprioreception - fcn instability - reinjury
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What percentage of foot injuries are actually ankle injuries?
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85%
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When sprained ankle, what to do chiro?
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long axis traction of toes
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What does Hammer say chronic ankle sprain causes?
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lack of adequate proprioreception input and then dysregulation via CNS (not weak ligaments, etc)
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How to improve proprioreception?
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Challenge the system!
Clarify the pathways! |
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How does a person "challenge the system" to improve proprio?
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one-leg drills
balance board balance shoes plyometrics |
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plyometrics
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"stretch-shortening cycle" that can reduce reaction time by 50%
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What's the catch with plyometrics?
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years of prep
exponential ground reaction forces (slamming joints) |
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Classical balance techniques
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Hatha yoga
Martial arts Alexander and Feldenkrais Somatics |
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Focus factors that negate proprioreception
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concentration
& Jendrassik's maneuver |
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Fatigue factors that negatively affect proprioreception
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muscular exhaustion
CNS exhaustion (7x longer) |
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Maximum force is applied 6x - why?
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creatine phosphate
axioplasmic factors (time down the axon for products) |
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disease negatively affects proprioreception. Example?
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Multiple sclerosis:
climatic, genetic, metabolic - gold deficiency |
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What diet factor crashes proprioreception?
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dehydration
*decreased electrolytes |
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What medical preventative treatment might negatively affect proprioreception?
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vaccination
*compromise brain, CNS |
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What histological factor negatively affects proprioreception?
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Acquired material
*scar tissue decreases nerve transmission and response |
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INFLAMMATION screws proprioreception. How?
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fluid accumulation - movement down, proprio down, fluid exchange down, macrophages UP, DJD!
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Acquired material
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scattered nervous transmission due to age due to unwanted scar tissue in the muscle (damage)
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affects 80-90% of males and females by age 65
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Osteoarthritis
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Gout can be a precursor to
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congestive heart disease
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the only disorder that will cause osteophytes without sclerosis or joint space narrowing
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diffuse idopathic skeletal hyperstosis
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Close to 50% of all hip fractures are in people 80+ with women representing %?
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75-80% the over 80+ set
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why do adolescent boys develop SCFE?
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longer growth spurts subjecting the hip joint to increased shearing forces
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How many radiographs needed to offer any diagnostic value?
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2
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What attaches to periosteum (sticky for CT)?
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Sharpey's fibers
*poor proprioception, tendonitis |
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In a mature skeleton, what envelopes both the metaphyses and diaphyses on long bones?
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Periosteum
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Most active layer of periosteum
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inner cambrium
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Densest and strongest of all bone
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cortex(ical)/compact/lamellar bone
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What type of bone has Haversian canals? and is called, properly, Lamellar (layered thin plates or scales) bone?
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Cortex/compact bone
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Strong indicator of bone tumors and cancer can be gleaned from
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cortex/compact
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membrane lining medullary cavity
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endosteum
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covers ALL trabeculae and inner cortical margins
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endosteum
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Lies within the inner cavity of bone, traversed by thin interconnecting trabeculae
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Medulla/spongy/trabecular bone
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divisions of growing bone (list from top to bottom on femur)
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epiphysis, physis (epiphyseal growth plate), apophysis (greater trochanter), metaphysis (neck), diaphysis (shaft)
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site of muscular attachments on a long bone and COMMON AVULSION AREA
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apophysis
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most famous apophysis?
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Milton Berle?
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end of growing bone that fuses with shaft at skeletal maturity. Composed of CARTILAGE
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Epiphysis
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Most METABOLICALLY ACTIVE site of bone so common site of tumors and infections
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Metaphysis
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Cartilage growth plate between metaphysis (metabolically active tumor site) and epiphysis (end)
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Physis (growth plate)
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Responsible for longitudinal (lengthening) of long bones
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physis
*radiolucent in skeletally immature |
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#1 rule of X-ray analysis
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2 views - see the WHOLE picture and don't get drawn into anomalies
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ABCD'S of X-ray analysis
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Alignment
Bones Cartilage Destruction (density) Soft tissue |
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Use a _______ to view an x-ray
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system
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views needed for x-ray
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two projections:
1. A-P 2. Lateral to medial |
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Certain injuries and pathologies might require more than A-P and Lateral views
> what are the other views? |
obliques
special shots |
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Concerning the A for Alignment:
are the lines smooth with natural breaks? How will you know? |
By knowing the NORMAL anatomy
("knowing what's normal will expose the pathology" - Balliet) |
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Use knowledge of posture when viewing x-rays to determine (3)
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listhesis
rotation malposition |
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Bones - count the ________ of bones
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number
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What to look for in cortex x-ray?
In medulla x-ray? |
cortex - pencil thin abnormal lucencies
medulla - trabecular pattern norms |
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Questions like:
Are there well-maintained heights? Is there vacuum phenomena? An evidence of erosions? |
Cartilage/Discs
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What are examples of destructive pathologies?
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bony pathology -arthritis
systemic disease - cancer metabolic disease - local infection |
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What to look for in x-ray view of soft tissue?
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edema
foreign bodies artifacts (staples, calcifications, stones, clips, etc) |
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Describe a Salter-Harris fracture
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*epiphyseal plate
*Type II most common (shearing) *Type V - compression |
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List some Hip radiographic studies
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OA
SCFE Acetabulum protrusio Smith-Peterson pins |
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List some Knee radiographic studies
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OA
fracture Osgood-Schlatter |
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List some Foot radiographic studies
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Pott's fracture
gout DJD/OA polydactyly |
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Causes of OA Hip
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macro trauma
micro trauma |
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Radiographic signs of Hip OA
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joint space narrowing
sclerosis osteophytes |
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Hip DJD has same symptoms as OA (jt space narrowing, sclerosis, osteophytes) but since this is an Ebbets test and therefore peculiar, what is clinical presentation of Hip DJD?
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Decreased ROM flexion
External rotation of thigh/foot |
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What type of fracture is an SCFE?
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Salter-Harris type I
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SCFE characteristics
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adolescent
black males 10-15 yrs old in rapid growth spurt |
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SCFE results in ________________ 1% and then heals with a short limb.
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avascular necrosis
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medial migration of femoral head (viewed via Kohler's line/Kohler's teardrop)
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Acetabulum Protrusio
femoral head moves medially due to thinning of acetabulum and appears as a "tear drop" in pelvic brim |
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Causes of Acetabulum Protrusio
(Kohler's Tear Drop) |
RA, DJD
Female Triad neoplasm |
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When are Smith-Peterson pins used?
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Hip fracture
*forms a callous, leads to more fracturing of the hip |
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Knee OA presentation
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non-uniform loss of joint space with intrarticular bodies (joint mice)
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On which side is knee OA prevalent
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Medial (larger condyle)
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Knee OA may present with subchondral ________ and osteophytes, as well as __________ deformity.
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subchondral sclerosis
articular deformity |
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What is the NB of a closed femoral fracture?
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fibula
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Most common in adolescent males due to jumping activities
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Osgood-Schlatter's Disease
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Pain, swelling, tenderness at tibial tubercle resulting in usual loss of knee flexion
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Osgood-Schlatter's Disease
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also called a Boot fracture
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Pott's fracture
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6-7 cm above lateral malleolus fracture due to leaping or jumping
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Pott's fracture (boot fracture)
*could be HIGH ANKLE SPRAIN instead |
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swelling of primarily great toe due to increase in serum uric acid
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Gout
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precursor to heart disease
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Gout
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cause of gout
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purine-rich diet
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MOST COMMON area of DJD
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Ist MTP
(great toe joint/same as gout area) |
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associated with hallux valgus
Problem site because? |
DJD at 1st MTP
Problem because of pronation and eversion during toe off screwed up |
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too many damn fingers and toes
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polydactyly
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Injuries are often ____-related.
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age
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What did Selye mean by "stress?"
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strain
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The deficiency that can cause both tight muscles and defective CT
|
Mg+
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may produce alteration of the PATELLAR REFLEX
|
L3 disc prolapse
(L1 ain't got none!, L2 & 3 have secondary patella, L4 patella, L5 medial hamstring, S1 Achilles) |
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What are we observing in LATERAL posture?
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foot up!
Lateral malleolus Knee Greater trochanter AC joint EAM (ear) Coronal suture |
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Draw the lateral line from the bottom up for me
|
foot up!
Lateral malleolus - knee - greater trochanter - AC joint - EAM - coronal suture |
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P-A Postural Analysis
|
foot posture
Knees - varus/valgus Hip height 12th rib alignment Inferior angle of scapula Shoulder height/even Ear lobe height/even Head tilt Chin visible? |
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Tight PIRIFORMIS
|
Left foot toes out
Sciatic problems Piriformis syndrome |
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Piriformis is toe out and Tight PSOAS is toe ___ with ________ of foot.
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in with pronation of foot
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Causes of tight PSOAS?
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high pelvis/hip
reactive scoliosis |
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Weak GLUT MEDIUS
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*elevation of right hip, shoulder, ear
*RIGHT P.I. listing usually indicates RIGHT GLUTEUS is stronger |
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what are the 3 muscles that can, over time, lead to excessive wear and tear and ultimately injury?
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weak glute medius
tight piriformis tight psoas |
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Percentage of all athletic injuries involving foot and ankle
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15%
|
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percentage of running injuries from the KNEE DOWN
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79%
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FOOSH
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Falls Onto Out-Stretched Hand with a force 3-5x body weight
|
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Female basketball players are 8x more likely to have an _____ injury than males.
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ACL
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What is the only TYPE of injury we cannot prevent?
|
Accidents
*if you want to see the list of preventables, look in the notes. |
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Girls are inherently unstable (hahaha). What percentage of girls have instability injuries?
|
78%
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81% of Men have ______ injuries.
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Overuse
(I'll say!) |
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Women are injured by overuse and alignment issues such as
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Q-angle, pathologic pronation, genu valgus, female triad
|
|
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Boys are injured by growth plate issues such as
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knee, heel, elbow and Salter-Harris fractures
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What types of injuries do we, as chiropractors, see?
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Repetitive motion
Chronic overuse Imbalances due to activity and adaptive postures Accidents Physiologic Psychological |
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strains, sprains and tendonitis result from
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repetitive motion
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tendon, muscle-tendon and growth-plate junction injuries result from
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chronic overuse
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lifting, pushing or pulling activities
and sitting, standing or sleeping in adaptive postures result in |
Imbalance injuries
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unplanned outcomes result in what type of injury
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accidents
(the only non-preventable) |
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biochemical imbalances
and acidic pH injuries |
Physio-logic
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compulsive behaviors
anxiety depression injuries |
Psycho-logic
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having qualities or properties that differ according to the angle measured
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anisotropic
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not (an) having the same (iso) nutritional requirements or processes (trophic).
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anisotrophic
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Joints have an ________ quality and must be specifically targeted to strengthen dynamic stabilizers.
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anisotrophic
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specific muscle DYNAMIC STABILIZERS (3) that need re-training of movement (isolation of specific muscle groups)
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GLUTEUS MEDIUS
TIBIALIS POSTERIOR ADDUCTORS |
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What's most important on this list:
Plyometrics - Eccentric strength - Core stability - Torque - Arms/Hands - Heel cups - Medial/Lateral stability |
Eccentric strength
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"stretch-shortening cycle"
squat 1.5x body weight Years of prep/anatomical adap. Improve explosiveness |
PLYOmetrics
*ask if it is age appropriate |
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"Negatives"
STRONGEST action of body Requires longest recovery Good for 'sticking points' Used sparingly |
ECCENTRIC Strength
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Why should you NOT do sit-ups with a medicine ball?
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because you are using postural, red-fiber muscles to do explosive strength movements
*Slow oxidative (also called slow twitch or fatigue resistant fibers) are Type Red Fibers |
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Found in large numbers in postural muscles
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type I red fiber slow oxidative POSTURAL slow twitch
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Core stability is not _________
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strength.
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involves the proprioreceptive responsiveness of intrinsic muscles - ability of TRUNK muscles to stabilize torso so we can accelerate the limbs
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Core stability
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How is core stability trained?
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balance activities, rotational moves
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ROTARY stretch reflex
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Torque
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allows fro greater generation of power but extremes create injury.
Elasticity and Anatomical Adaptation VERY IMPORTANT |
Torque (rotary stretch reflex)
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Talking Arms
How to improve shoulder? Forearm? Wrist/fingers? |
Shoulder: rotator needs stabilization, serratus anterior needs stable scapula.
Forearm: stabilize the wrist. Wrist/fingers: grip strength |
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How to prevent calcaneus bruise?
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Heel cups
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all jumpers should use
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heel pads (less is more)
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What muscle groups must be retrained for medial/lateral stability?
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adductors and abductors
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dynamic stability of medial/lateral stabilizers is to eliminate unwanted ____ to within 1/100 sec.
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sway
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How do we make the majority of illnesses and injuries disappear?
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Prevention!
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