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338 Cards in this Set
- Front
- Back
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Typical mechanism of injury of AC joint.
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Fall on adducted shoulder
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Classification of AC joint injuries
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* Rockwood classification
- Type I: tenderness without anatomic deformity - Type II: AC lig tear, CC lig sprain with preserved CC space. - Type III and IV: AC lig tear, CC lig tear and displaced CC space. |
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General treatment of AC joint injuries
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- Rockwood type I and II: rest, ice, sling, progressive ROM, return to play when non-tender and deltoid normal
- Unstable type 2 may require sling for 2-4 weeks - Type III and IV: can attempt conservative management but often need ORIF |
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2 basic risk factors for shoulder impingement
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- repeated overhead activity
- acromion shape |
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What time of day is shoulder impingement pain often the worst?
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At night; often bad with pressure on that shoulder
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What is the typical degrees for painful arch in shoulder impingement?
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70-110 degrees of shoulder abduction
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Which direction does the shoulder most common dislocate in?
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Anterior
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List 3 more common complications of shoulder dislocation
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- axillary nerve injury
- recurrent dislocations - rotator cuff tears. |
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What is a Bankart lesion?
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avulsion of the anterioinferior glenoid labrum and capsule from the glenoid rim
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What is thought to be the major factor in recurrent shoulder dislocations?
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Bankart lesions
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What is a Hill-Sachs lesion?
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A compression fracture of the humeral head (when posterolateral aspect of the humeral head compresses against the anterior glenoid rim).
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Rates of recurrent shoulder dislocation based on age:
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Younger: up to 90%
> 40yo: 10-15% |
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What is the Stimson technique?
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Method for reducing a shoulder dislocation where you lie prone and use a 5-10 wrist weight for distraction and reduce over 15-20 minutes.
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General approach to rehab after shoulder dislocation
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Sling for 1-3 weeks for capsular healing; maintain other UE ROM, isometric exercises (initially avoid greater than 45 degrees of abduction and any external rotation).
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Define adhesive capsulitis
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A syndrome characterized by a progressive painful loss of passive and active glenohumeral ROM.
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What is motions are most and least effected in adhesive capsulitis?
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- most: external rotation, abduction
- least: internal rotation |
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Typical recovery time for adhesive capsulitis.
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Months to years
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General risk factors for bicipital tendinitis
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- overhead activities
- sports - shoulder impingement |
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Named-test for biceps tendinitis
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Speed's test: resisted arm elevation against resistance; + is pain in bicepital groove
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Medial scapular winging indicates weakness in the ____ mm., innervated by the _____ nerve.
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- Serratus anterior
- Long thoracic nerve |
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Lateral scapular winging is typically causes by weakness in the ____ mm., innervated by the ____ nerve.
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- trapzeius
- CN XI |
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Lateral scapular winging can be elicited by
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shoulder abduction
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Golfer's elbow =
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Medial epicondylitis
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Tennis elbow =
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Lateral epidondylitis
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What structures are usually involved in Golfer's elbow?
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- tendinous origin of flexor-pronator mass
- MCL of the elbow |
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General approach to rehab in medial epicondylitis
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- stretch elbow during painful period
- when pain free start strengthening of all elbow/forearm muscles - consider elbow strap |
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Structures typically involved in tennis elbow
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Wrist extensor tendons, especially the ECRB.
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Where do you wear an elbow strap?
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Should be circumferential just distal to the elbow joint
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Modificatons to a tennis racket that can help with tennis elbow
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- larger racquet grip
- larger racquet head - less string tension |
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Typical surgical interventions for tennis elbow that has failed conservative therapy.
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- fasciotomy
- conjoined tendon fixation |
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What is DeQuervain's disease?
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Tenosynovitis of the 1st dorsal compartment of the hand
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Major tendons involved in DeQuervain's disease?
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- Abductor pollicus longus
- Extensor pollicus brevis |
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What named test is perormed for DeQuervain's disease?
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Finkelstein's test
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What type of splint is helpful in DeQuervain's?
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A thumb spica with the 1st MCP immobilized and the IP joint free.
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Which carpal bone is most commonly fractured?
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Scaphoid
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Where do you have pain with a scaphoid fracture?
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The snuffbox
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Treatment of scaphoid fracture with negative films and reasonable clinical suspicion
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Immobilization in short arm cast or thumb spica and repeat films in 2 weeks; if repeat films negative can consider CT/MRI.
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Where does the blood supply enter the scaphoid bone?
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The distal pole
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What type of scaphoid fractures put you at high risk for non-union/AVN?
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at the waist and proximal pole
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Treatment of displaced scaphoid fractures
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surgical
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Trigger finger aka
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digital stenosing tenosynovitis
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2 major disease that are risk factors for trigger finger
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- RA
- DM |
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Treatment of trigger finger
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- NSAIDs/ steroid injection
- Volar static hand splint with MCP immobilization for allows IP flexion (rests flexor tendons) - possible surgery if locked in flexion |
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What should you certainly stretch with trochanteric bursitis?
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ITB
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Typical triggers for IT band syndrome
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- overtraining
- running on uneven surfaces |
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Typical source of pain from IT band syndrome
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Pain at the knee when the ITB slides over the lateral femoral condyle; most at risk at 20-30 degrees of flexion.
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People with ITB syndrome are usually tender over
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Gerdy's tubercle
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Named test of IT band length
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Ober's
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General rehabilitation for ITB syndrome
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- stretch ITB, hip flexors and gluteus max
- strengthen hip abductors - correct foot pronation |
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Typical time course for ITB syndrome to improve
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2-6 months
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What muscles make up the pes anserine?
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- Sartorius
- Gracilis - Semitendinosis |
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What's the mneumonic for pes anserine?
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Say Grace before Tea
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Where does the pes anserine insert?
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MEDIAL proximal tibia
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General rehabilitation for pes anserine bursitis
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- stretching of medial hamstrings
- where knee pads (athletes) - steroid injections |
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Attachments of the ACL
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anterior medial tibial --> medial lateral femoral condyle
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ACL prevents/restricts which movements
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- anterior translation of the tibia
- ER of tibia on femur - knee hyperextension |
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Primary function of ACL in athlete
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maintain joint stability during deceleration
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Typical mechanisms of injury for the ACL
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- lateral trauma to the knee
- pivoting / cutting - hyperextension - hyperflexion |
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What is the Lachman test used for?
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Tests posterior fibers of ACL (knee flexed 20 degrees, better than anterior drawer test)
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Imaging test of choice for ACL injury
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MRI
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What secondary injury is common after ACL tears?
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Patellar pain with quad weakness
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2 major strengthening exercises to focus on after ACL tears.
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- hamstrings to hold tibia in place
- terminal range squats for quad strength to prevent knee pain |
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Bracing in ACL injuries should limit
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- terminal extension
- rotation |
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Post-op rehab for ACLs typically lasts
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6-9 months
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Typical precautions right after ACL surgery
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WBAT in an extension knee brace
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General course of conservative strengthening in ACL rehabilitation
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ROM with CPM, include patella up to 6 weeks, advance as tolerated 6-10 weeks, shift to focus on strengthening at 10 weeks
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Attachments of the PCL
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- posterior tibia
- medial femoral condyle |
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PCL prevents/limits which movements?
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- internal rotation
- posterior translation of the tibia - aid in knee flexion |
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3 classic mechanisms of injury for PCL
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- MVC when knee hits dashboard
- High valgus stress - Falling on flexed knee |
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Is swelling common with PCL injuries?
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no
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2 tests for PCL integrity
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- posterior drawer test
- sag test (posterior displaced tuberosity with the quad relaxed) |
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Treatment of mild PCL sprain
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Quad strengthening
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Treatment of sever PCL injury
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Arthoscopic repair
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Which meniscus in the knee is more often injured?
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medial
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Typical mechanism of injury for knee meniscus
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excess rotational stress, usually twisting on a flexed knee
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Gold standard for diagnosis of a tear of the meniscus?
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arthroscopy
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When should you refer meniscus tears to surgery?
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Mechanical symptoms
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Which portions of the meniscus have vascular supply and which do not?
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- Outer 1/3: vascular, can repair
- Inner 2/3: non-vascular |
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When can patients fully weight bear after meniscal repair?
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When pain free (often takes 6 weeks)
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What position/activity is discouraged after meniscal injury/repair?
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deep squatting
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General risk factors for patellofemoral syndrome
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- overuse
- muscle imbalance - biomechanical factors (pronation, increased q angle) |
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Classic history of patellofemoral syndrome
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anterior knee pain worse with activity, prolonged sitting and descending stairs
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Classic rehab approach for patellofemoral syndrome
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- avoid prolonged sitting
- quad strengthening (short arch closed kinetic chain in 0-45 deg to strengthen all quads); avoid full ROM and open chain - stretching quads, hamstrings, ITB and PF |
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What's the McConnell technique?
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Type of taping technique suing super-rigid, cotton mesh highly adhesive tape to change biomechanics and neuromuscular re-education. Especially used for patella and shoulder.
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2 major causes of exercise induced leg pain?
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- medial tibial stress syndrome
- chronic compartment syndrome |
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"Shin splints" is better defined as
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exercise induced tibial pain without evidence of fracture on x-ray
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Sports especially at risk for medial tibial stress syndrome
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- running
- gymnasts - dnacers |
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Risks factors for medial tibial stress syndrome
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- sport type
- increase in exercise intensity - poor footwear - hard training surface - poor biomechanics |
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Where is the pain location and typical pattern for medial tibial stress syndrome?
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- localized pain in distal 1/3 tibia
- quickly relieved by rest, not aggravated by passive stretch |
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Why do we care if tibial stress fractures are medial vs. anterior?
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Anterior often take several months of rest and/or bone graft to heal.
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What x-ray view is needed to see anterior tibial stress fractures?
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oblique x-ray
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Typical pain characteristics for chronic compartment syndrome of the leg
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- pain with a certain amount/duration of exercise
- parasthesia, numbness, weakness in the distribution associated with the compartment |
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Edx studies in chronic compartment syndrome usually show
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normal findings
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What pressure measurements are consistant with chronic compartment syndrome as a source of leg pain?
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>30mmHg at rest
>60mmHg 15 sec post exercise >20mmHg 2 min post exercise |
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Initial treatment of chronic compartment syndrome of the leg
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- NSAIDs
- footwear - correct training errors - refer for possible surgery if no better in 1-2 months of retraining |
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Risk factors for achilles tendinitis
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- overuse
- overpronation - heel varus deformity - poor flexibility of PF and hamstrings |
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Classic sports for achilles tendinitis
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- Basketball (jumping)
- Runners who increase mileage or start hills |
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Severe cases of achilles tendinitis may take ___ months for recovery
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24 months
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Most common mechanism of injury for ankle sprain
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Lateral ankle sprain from a inversion injury on a PF foot
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Order of involvement of ligaments in ankles sprain
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ATFL --> CFL --> PTFL
ATFL = anterior talofibular lig. CFL = calcaneofibular lig. PTFL = posterior talofibular lig |
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When is an anterior draw test for the ankle considered positive?
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>5mm displacement
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What is the talar tilt test and what does it test?
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- Inversion stress to talus
- positive if 10+ degrees greater motion than unaffected side - checks integrity of the CFL |
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Medial ankles injuries involving the deltoid ligament often have an associated
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proximal fibula fracture (Maisonneuve fracture)
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What are the 3 phases of ankle sprain rehabilitation?
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- Phase I (days 1-3): RICE
- Phase II (weeks): restore ROM, strengthen ankle stabilizers, stretch PF - Phase III (weeks-mo): when motion is near normal, add proprioceptive and endurance exercises |
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What should you avoid in the first 24 hours after an ankle sprain?
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- hot showers
- EtOH - methylsalicylate compounds (BenGay) - anything else that increases swelling |
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Give one example of return to play guidelines after ankle sprain
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- Grade I (no laxity): 0-5 days
- Grade II (mild laxity): 7-14 days - Grade III (can't bear weight): 21-35 days - Syndesmosis injury: 21-57 days |
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Classic history for plantar fasciitis
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pain with first few steps in the morning or pain worse at beginning of activity
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Treatment of plantar fasciitis
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- relative rest
- daily stretching - fell cushioned shoes - soft medial arch supports - night splints |
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Typical symptom resolution for plantar fasciitis occurs within
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6-12 weeks
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Complication of corticosteroid injection for plantar fasciitis
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necrosis of the heel fat pad; cannot be easily treated/reversed
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What surgery is done for plantar fasciitis
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release of the fascia where it attaches at the calcaneus
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Most common cause of sudden cardiac death in young male athletes
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hypertrophic cardiomyopathy
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Exercise stress testing is recommended for which group of asymptomatic individuals prior to starting vigorous exercise?
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- men greater than 45
- women greater than 55 |
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What constitutes a "vigorous" exercise program
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reach greater than 60% of VO2 max
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What level of visual impairment is concerning for sports participation?
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Uncorrected greater than 20/40
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What are the classic PE findings for hypertrophic cardiomyopathy?
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- displaced point of maximal impulse
- systolic murmur that increases with upright posture/valsalva and decreased with squatting |
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Contraindications to sports participation
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- myo/pericarditis
- hypertrophic cardiomyopathy - uncontrolled severe HTN - suspected CAD - long QT - recent TBI (contact) - poorly controlled seizures - unexplained UE radic symptoms/stingers - mono with splenomegaly - sickle cell disease (relative) - untreated eating disorder |
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What are the general activity restrictions in sickle cell disease?
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no high exertion, contact or collision sports
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Normal q angle in men
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13 degrees
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Normal q angle in women
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18 degrees
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Lifetime risk of hip fracture in industrialized nations
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- women 18%
- men 6% |
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1 year mortality after hip fracture
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20%
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Percentage of people non-ambulatory after a hip fracture
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20%
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Advantages and disadvantages for non-cemented hip arthroplasty
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- more durable surface
- longer period of non-weight bearing/protected weight bearing |
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General hip precautions after hip arthroplasty
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Usually last 6-12 weeks
- Hip flexion to 90 - No adduction past midline - No ER - No IR when hip flexed (further restrictions based on if gluteus medius preserved or not) |
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Groups with poorer results after hip arthroplasty
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- younger
- male - obese - highly active |
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Presumed key factor in total knee arthroplasty prosthetic failure
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wear of the polyethylene liner (micro debris can trigger an inflammatory reaction which may lead to component loosening)
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Define pain
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an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP definition)
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Define dysesthesia
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An unpleasant abnormal sensation whether spontaneous or evoked
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Define paresthesia
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an abnormal sensation, whether spontaneous or provoked
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Define hyperalgesia
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an increased response to a stimulus which is normally painful
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Define allodynia
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pain due to a stimulus that does not normally provoke pain
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Define chronic pain
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Pain that exceeds the actual course of an injury or disease; often considered pain for more than 6 months
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Define chronic pain syndrome
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patients behave in a learned patterns in order to maintain secondary gains
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How have pain drawings been validated to help assess psychological components of pain?
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Diagrams with unusual distributions correlate with symptom magnification and psychological significance.
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High scores in the affective section of the McGill Pain Questionnaire correlate with...
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greater anxiety and sickness impact regardless of pain intensity
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2 primary factors that directly trigger pain in afferent neurons
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- leukotrienes
- prostaglandins |
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Where do A-delta fibers primarily synapse in the spinal cord?
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Rexed laminae I and V
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Where do C fibers primarily synapse in the spinal cord?
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Rexed laminae II
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What pain information travels in the neospinothalamic tract and where does it go?
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- rapid precise pain localization
- posterior ventral thalamus --> postcentral sensory cortex |
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What pain information travels in the paleospinothalamic and spinoretibular tracts and where does it go?
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- poorly localized, dull, aching, and burning sensations
- hypothalamus and intralaminar thalamic nuclei --> limbic system |
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Who and when proposed the gate control theory of pain?
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Melzack and Wall in 1965
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Describe the gate control theory of pain
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activation of large diameter sensory afferents can inhibit the transmission of pain signals from small-diameter pain fibers through interactions in the substantia gelatinosa of the dorsal horn
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Describe the 7 general steps in pain between activation of the peripheral nociceptor to overall reaction
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1. transduction in peripheral nociceptor
2. transmission in peripheral neuron 3. central facilitation 4. modulation 5. spinal reaction 6. Neocortical and paleocortical perception 7. Supraspinal reaction |
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What's the difference between Complex Regional Pain Syndrome for types I and II
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- CPRS type I: not associated with a known nerve injury
- CPRS type II: associated with a nerve injury |
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Typical presenting history of CPRS
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Traumatic or neurological event followed by immobility
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What are the general stages of CPRS?
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- Acute (hyperemic) stage
- Dystrophic (ischemic) stage - Atrophic stage |
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Describe the acute stage of CPRS
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- aka hyperemic stage
- constant burning pain, hyperpathia/allodynia, local edema/warmth, skin smooth and taut. - lasts several weeks to 6 months |
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Describe the dystrophic stage of CPRS
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- cold, atrophic extremity with increase edema, increased pain, muscular wasting, patchy osteoporosis and decreased function
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Describe the atrophic stage of CPRS
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- marked trophic changes with weakness and loss of ROM; pain may be reduced
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Generally favored most effective treatment for CPRS
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sympathetic blocks in the acute phase
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Define myofascial pain syndrome
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exquisitely painful trigger points with characteristic patterns of referred pain.
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What is the female to male ratio in myofascial pain syndrome?
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3:1
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What is the female to male ratio in fibromyalgia?
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10:1
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What is typically injected for trigger point injections when using local anesthetic?
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0.5cc of 1% lidocaine
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Common associated findings with whiplash
|
-headaches
- dizziness - visual disturbances - ulnar sensory changes |
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Whiplash generally improves within what time frame?
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2 weeks
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If neck or headache symptoms after whiplash injury continue at 4 weeks, consider
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- head CT for HA
- cervical spine MRI for neck pain |
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Point and lifetime prevalence of low back pain
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- point: 15-30%
- lifetime: 60-70% |
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Percentage of patients with low back pain at 4 weeks that have a definable lesion
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~15%
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Most helpful ROS/history questions for low back pain
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- general pain history
- age - cancer history - weight loss - response to previous therapy - IV drug use - UTI - Psych history |
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Decreased lumbar lordosis with back pain may indicate
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- disc problem
- vertebral collapse |
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Increased lumbar lordosis with back pain may indicate
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- obesity
- high grade spondylolisthesis |
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During what part of the straight leg raise is the sciatic nerve stretched the most?
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between 35 and 70 degrees
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+ SLR at more than 70 degrees tends to reflect what pathology
|
pain secondary to the joint
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How were Waddell's signs meant to be used
|
- in low back pain considering pain behaviors; if more than 3 or the 5 Waddell signs are positive then a non-organic basis for the physical complaints is likely and the physical exam is likely invalid
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What are the Waddell's signs?
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1. Regionalization
2. Overreaction (to non-painful stimuli) 3. Simulation (pain with axial loading) 4. Distraction (inconsistent results with distraction) 5. Tenderness (non-anatomic or superficial) |
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DISH stands for
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Diffuse idiopathic skeletal hyerostosis
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What is the evidence for use of NSAIDs in acute low back pain
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- Different NSAIDs without different benefits
- good for pain - do not change return to work, natural history or chronic pain |
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Why is bed rest not recommended for back pain
|
- it has not shown to work
- there are complications with immobilization including loss of bone mineralization and weakness |
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Risk factors for internal disc disruption?
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- repetitive twisting
- prolonged sitting |
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Typical history of internal disc disruption
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Insidious pain with exacerbation by lifting, coughing, sitting, standing or transitional movements.
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Best PE test for lumbar radiculopathy
|
+ crossed-straight leg raise
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Useful signs and symptoms in lumbar radiculopathy
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- pos crossed SLR
- pain at night - severe radicular pain - unilateral leg pain worse than back pain - loss of lordosis |
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2 most common levels of lumbar disc herniations causing radiculopathy
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- L4-5 (L5 radic)
- L5-S1 (S1 radic) |
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Typical definition of clinically significant lumbar spinal stenosis on MRI
|
AP diameter less than 7-10 mm
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Typical pain features for lumbar spinal stenosis
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- pain with standing or walking, insidious
- worse with walking downhill, with lumbar extension, relieved with lumbar flexion |
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Does lumbar z-joint pain radiate below the knee?
|
no
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2 most common levels involved in spondylolysis
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* L5
L4 |
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Where is spondylolisthesis most commonly seen
|
at lumbosacral junction
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Causes of spondylolisthesis
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- spondylolysis
- degeneragtive changes - Paget's disease - Bony dysplasia |
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General rehabilitation approach to less than grade 2 spondylolisthesis
|
- heat
- massage - stretching of hip flexors, hamstrings and PF - lumbar flexion/isometric exercises (avoid extension) |
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when should you send a spondylolisthesis for surgical evaluation
|
grade 3 or 4 or any neuro symptoms
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What are the 10 essential points of a modalities prescription?
|
1. Diagnosis
2. Impairments/disability 3. Precautions 4. Modality 5. Area to be treated 6. Intensity/settings/temp range 7. Frequency of treatment 8. Duration of treatment 9. Goals/objective of treatment 10. Date of re-evaluation |
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What is the therapeutic heat range?
|
40-45 C
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How long should therapeutic heat be maintained?
|
5-30 minutes
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Define superficial heat
|
1-2 cm
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Define deep heat
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3.5-8cm
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Give examples of modalities that use conduction
|
(direct transfer of heat by contact)
- paraffin, heat packs |
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What's the heat usually set at for paraffin and why can we tolerate it so hot?
|
52-54C; poor heat conductivity allows tolerance.
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Give examples of modalities that use convection
|
(flow of heat)
- fluidotherapy, whirlpool, moist air |
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Give examples of modalities that use conversion
|
(non-thermal energy into heat)
- infrared - ultrasound - shortwave diathermy - microwave diathermy |
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Depth of penetration of infrared
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2cm
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Depth of penetration of US
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3.5-8cm
|
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Where is the greatest heating for US located?
|
At the bone-tissue interface
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What are the frequency parameters for US?
|
0.8-1-1 MHz
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What are the intensity parameters for US?
|
0.5-4 W/cm2
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What are the treatment area parameters for US?
|
100cm2
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What are the duration parameters for US?
|
5-8 min
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In short wave diathermy, which is heat more fat or muscle?
|
fat
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What is the penetration of short wave diathermy
|
4-5cm
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What is the most commonly used frequency for short wave diathermy
|
27.12MHz
|
|
|
What are the general contraindications to heat therapy?
|
- acute hemorrhage
- bleeding dyscrasia - inflammation - malignancy - insensate skin - inability to respond to pain - atrophic skin - ischemia |
|
|
Specific contraindications for US?
|
- treatment over fluid filled cavities (eye, uterus)
- no treatment near pacemaker - not near laminectomy site or joint prosthesis |
|
|
Specific contraindications of short wave diathermy
|
- childrens (immature epiphyses)
- metallic implants - contact lenses - menstruating/pregnant |
|
|
Specific contraindications of micro wave diathermy
|
eyes (develop cataracts)
|
|
|
Which penetrates deeper for micro wave diathermy - 915 MHz or 2450 MHz
|
915
|
|
|
How can cold decreased spasticity?
|
Group Ia firing rates are decreased which reduces the muscle stretch reflex
|
|
|
Physiologic effects of superficial cold
|
- hemodynamic vasoconstriction
- slowing of nerve conduction velocity |
|
|
Contraindications for cold therapy
|
- ischemia
- insensate skin - severe HTN - cold sensitivity syndromes (Raynaud's, cryoglobinemia, cold allergey) |
|
|
General guidelines for cervical traction
|
25-30 pounds at 30 degrees of flexion
|
|
|
In what position is the cervical intervertebral space the greatest?
|
at 30 degrees of flexion
|
|
|
General weight guidelines for lumbar traction
|
26% of body weight needed for friction (supine with hips and knee flexes), another 25% of body weight needed for vertebral separation
|
|
|
General contraindications to spinal traction
|
- ligamentous instability
- osteomyelitis - discitis - bone malignancy - spinal core tumor - severe osteoporosis - untreated HTN |
|
|
Additional cervical spine traction contraindications
|
- vertebrobasilar artery insufficiency
- RA - midline herniated disk - acute torticollis |
|
|
Additional lumbar spine traction contraindications
|
- restrictive lung disease
- pregnancy - active peptic ulcers - aortic aneurysm - gross hemorrhoids - cauda equina syndrome |
|
|
Contraindications to TENS
|
- near pacemakers
- pregnant - not to be done over carotid sinus |
|
|
2 hypotheses about why TENS works
|
- gate theory of pain where the stimulation of A-beta and A-gamma fibers stimulate interneruons in substantia gelatinosa which inhibit lamina V where the pain neurons synapse
- may release B-endorphins |
|
|
What are the 2 general approaches to settings in TENS?
|
- "Conventional" is high frequency (50-100Hz), low amplitude, short duration is barely perceptible and requires adjustment as people accommodate
- "Accupuncture-lie" uses larger amplitude, low frequency (1-4Hz) that may be uncomfortable. |
|
|
What are the 3 classic western techniques in massage?
|
- effleurage (stroking)
- petrissage (kneading) - tapotment (percussion) |
|
|
What does the swedish approach to massage combine?
|
tapotment + petrissage + deep tissue massage
|
|
|
What is deep friction massage used for?
|
Breaking up adhesions in chronic muscle injuries
|
|
|
What is the goal of myofascial release/how is it done?
|
release soft tissue entrapped in tight fascia through the prolonged application of light pressure in specific directions
|
|
|
What are the absolute contraindications to massage?
|
- malignancy
- DVT - atherosclerotic plaques - infection |
|
|
What are the relative contraindications to massage?
|
- incompletely healed scar tissue
- anticoagulation - calcified soft tissues - skin grafts |
|
|
Define phonophoresis
|
topical medicals are mixed with an acoustic coupling medium and are driving into the tissue by ultrasound
|
|
|
2 common medications involved in phonophoresis
|
- steroids
- analgesics |
|
|
List 8 common uses for phonophoresis
|
- OA
- bursitis - capsulitis - tendonitis - strains - contractures - scar tissues - neuromas |
|
|
Define iontophoresis
|
electrical currents are used to drive medications across biological membranes (try to avoid systemic effects)
|
|
|
Who put forth the 6 determinants of gait...and when?
|
Sanders, Inman and Eberhart in 1953
|
|
|
List the 6 determinants of gait
|
1. Pelvic rotation int he horizontal plane
2. Pelvic tilt in the frontal plane 3. Knee flexion 4. Knee motion 5. Ankle motion 6. Lateral pelvic displacement |
|
|
What are the determinants of gait (generally)
|
Describes 6 ways that normal gait is more efficient by minimizing vertical and lateral excursions of the body's center of mass.
|
|
|
Describe pelvic rotation in the horizontal plane as a determinant of gait
|
- pelvis rotates 4 deg each side
- maximal during double support - elevates the nadir of center of mass about 3/8" |
|
|
Describe pelvic tilt in the frontal plane as a determinant of gait
|
- pelvis drops 5 degrees on the side of swinging leg
- decreases the apex of center of mass about 3/16" |
|
|
Describe knee flexion as a determinant of gait
|
- knee flexion during midstance lower center of mass 7/16"
|
|
|
Describe knee and ankle motion as determinants of gait
|
smooths out the pathway to make the curve more sinusoidal
|
|
|
Describe lateral pelvic displacement as a determinant of gait
|
- normal valgus at the knee decreases lateral sway
- reduces total horizontal excursion from 6" to less than 2" |
|
|
During what phases of the gait cycle do the ankles dorsiflexors concentrically and eccentrically contract?
|
- concentric: swing phase
- eccentric: heel strike to foot flat |
|
|
During what phases of the gait cycle do the ankle plantarflexors concentrically and eccentrically contract?
|
- concentric: push off
- eccentric: midstance |
|
|
During what phases of the gait cycle do the hip abductors concentrically and eccentrically contract?
|
- concentric: none
- eccentric: stance (limit pelvic tile of swing phase leg) |
|
|
During what phases of the gait cycle do the hip flexors concentrically and eccentrically contract?
|
- concentric: swing phase to clear leg
- eccentric: after mid-stance to slow trunk |
|
|
During what phases of the gait cycle do the hip extensors concentrically and eccentrically contract?
|
- concentric: none
- eccentric: before heel strike to foot flat |
|
|
During what phases of the gait cycle do the knee extensors concentrically and eccentrically contract?
|
- concentric: toe off
- eccentric: stabilize in heel strike |
|
|
Classic location of center of mass at rest
|
2" anterior to S2
|
|
|
Where is the GFR vector in relation to the hip, knee and ankle at initial contact?
|
- hip: anterior
- knee: through - ankle: posterior |
|
|
Where is the GFR vector in relation to the hip, knee and ankle at loading response?
|
- hip: anterior
- knee: posterior - ankle: posterior |
|
|
Where is the GFR vector in relation to the hip, knee and ankle at midstance?
|
- hip: posterior
- knee: posterior - ankle: anterior |
|
|
Where is the GFR vector in relation to the hip, knee and ankle at terminal stance?
|
- hip: posterior
- knee:anterior - ankle: anterior |
|
|
Where is the GFR vector in relation to the hip, knee and ankle at pre-swing?
|
- hip: anterior
- knee: posterior - ankle: anterior |
|
|
The only muscle active in normal quiet standing?
|
Triceps surae, mostly just the soleus
|
|
|
Typical gait deviations noted in an antalgic gait?
|
- decreased stance phase
- reduced step length on unaffected side - increased time in double support |
|
|
Characteristic observation with weak plantarflexors
|
Shortened step-length on contralateral side
|
|
|
Treatment of gait problems from weak plantarflexors
|
AFO with long sole shank to simulate PF during terminal stance
|
|
|
Which side drops in a Trendelenburg gait?
|
The contralateral pelvis
|
|
|
How do you compensate for a Trrrendelenburg gait?
|
Ipsilateral trunk lean
|
|
|
What is classically observed in the gait of someone with hip extension weakness?
|
posterior trunk / extensor lurch
|
|
|
Treatment of bilateral extensor lurch gait?
|
2 crutches or canes for a 3 point gait
|
|
|
Why is gait speed slowed in the hemiplegic patient
|
to maintain optimal energy expenditure
|
|
|
The classic triad of Parkinson's disease...
|
tremor, bradykinesia, instability with at least 2 affecting gait
|
|
|
Festination gait is classically associated with
|
parkinsons
|
|
|
Turns in a Parkinson gait are made
|
en bloc
|
|
|
treatment of Parkinson gait
|
- heel lifts and assistive devices to decrease falls backwards
- weighted assistive devices - PT for postural issues |
|
|
When do patients typically use foot slap vs. steppage gait in TA weakness?
|
>3/5 = foot slap
<3/5 = steppage gait |
|
|
A standard AFO with plantar flexion stop may destabilize
|
the knee
|
|
|
What AFO option will assist dorsiflexion but still allow for plantarflexion and knee stability?
|
Posterior spring AFO
|
|
|
How should you ascend stairs with a cane?
|
Strong limb --> weak limb and cane
|
|
|
How do you measure appropriate can length?
|
from the bottom of the shoe's heel to the top of the greater trochanter
|
|
|
What position should the elbow be in when using a cane that is correctly sized?
|
20 degrees of flexion to allow for assistance during push-off
|
|
|
Maximum percentage of body weight that a cane can unload
|
20%
|
|
|
Why are crutches more stable than canes?
|
They have 2 points of contact with the body
|
|
|
What muscles are important in ambulating with crutches?
|
Should depressors (latissimus dorsi and pectoralis major), triceps, biceps, quads, hip ext, hip abd
|
|
|
How do you measure correct axillary crutch length?
|
Measure the distance from the anterior axillary fold to the ground 6 inches lateral to the bottom of the heel while standing and add 1-2"
|
|
|
What is the correct UE position when using a crutch?
|
elbow flexed 30 deg, wrist in extension, fingers forming a fist
|
|
|
Forearm crutches aka
|
Lofstrand crutches
|
|
|
What is the major indication for forearm crutches?
|
When pressure to the trunk is contraindicated
|
|
|
Should you pad the top of an axillary crutch?
|
No, this encourages weight on the brachial plexus
|
|
|
A single forearm crutch can unload what % on body weight?
|
40-50%
|
|
|
2 point crutch gait aka
|
"hop-to"
|
|
|
What is the general 3 point crutch gait?
|
Crutches advanced together, then LEs advanced individually
|
|
|
Walkers can unload what percentage of LE weight?
|
up to 100%
|
|
|
Why are walkers more stable that crutches/canes?
|
Wider base of support
|
|
|
How do you properly fit a walker?
|
With the walker 10-12" in front of the patient they should be standing straight with relaxed level shoulders and elbows flexed to 20 degrees
|
|
|
When are rolling walkers indicated
|
- after joint replacement (allow for smoother gait)
- when pts lack the UE strength/coordination to lift a regular walker |
|
|
Why can a hemiwalker be better than a quad cane?
|
More lateral support
|
|
|
Platform walkers bear weight through
|
the elbows (bypass the hand)
|
|
|
Examples of indications for platform walkers
|
- UE joint deformities, grip weakness, flexion contracture of the elbow, multiple fractures
|
|
|
Mneumonic for foot amputations
|
Chopart is shorter, Lisfranc is longer
|
|
|
Incidence of major amputations per year in US
|
70,000
|
|
|
% of amputation in US due to peripheral vascular disease
|
65%
|
|
|
% of amputation in US due to trauma
|
25%
|
|
|
% of amputation in US that are congenital
|
5%
|
|
|
% of LE amputees from diabetes who will have the other leg amputated within 5 years
|
about 50%
|
|
|
% of amputation in US due to malignancy
|
5%
|
|
|
Typical age range for amputation from malignancy
|
10-20 years
|
|
|
What is the preferred mature residual limb length and shape in transhumeral amputations
|
cylindrical appendage with retention of the deltoid tuberocity with goal up to 90% of length
|
|
|
What is the preferred mature residual limb length and shape in transradial amputations
|
shape of natural limb, longer is better for heavy labor, try to preserve brachioradialis to improve EF; medium length is better for externally powered prostheses
|
|
|
What is the preferred mature residual limb length and shape in transfemoral amputations
|
conical shape with longer length
|
|
|
What is the preferred mature residual limb character in a short transfemoral amputation?
|
preserving the greator trochanter and the hip abductors
|
|
|
What is the preferred mature residual limb length and shape in transtibial amputations
|
cylindrical 1/3 of original tibial length with retention of patellar tendon; fibula should be shorter than the tibia.
|
|
|
When can elastic shrinker socks be worn after amputation
|
When the incision has healed they should be worn at all times when the person is not wearing a prosthesis
|
|
|
List mechanisms for residual limb shaping after amputation
|
- figure of 8 elastic bandage qid
- elastic shrinker - immediate post-operative fitting prosthesis (IOPO) - rigid removable dressing |
|
|
Common contractures after LE amputation
|
HF, H abd, KF
|
|
|
Classic strategies for prevention of contractures after LE amputation
|
- prone 15 min tid
- firm mattress - knee extension while resting |
|
|
Good test for CV demand for walking with a prosthesis
|
Ability to walk with a walker without prosthesis
|
|
|
When do most patients get their definitive prosthesis?
|
3-6 months
|
|
|
What is the purpose of the socket in a prosthetic limb?
|
Connect the residual limb with the rest of the prosthesis and (in LEs) helps transfer body weight to the ground.
|
|
|
The patellar tendon bearing socket is also known as the
|
Total contact socket
|
|
|
What are the "pressure tolerant" areas where the prosthesis generally bears weight in a transtibial amputation?
|
- patellar tendon
- pre-tibial muscles - lateral fibular surface - popliteal fossa - gastroc-soleus |
|
|
What are the classic "pressure sensitive" areas that should be avoided in designing a transtibial socket?
|
- fibular head
- tibial condyles - distal fibula - tibial tubercle, crest and distal tibia - hamstring tendons |
|
|
"Stump chocking" often shows up as what skin change
|
verrucous hyperplasia
|
|
|
Give 3 categories of types of suspension options for transtibial prosthesis.
|
differential pressure, anatomic, sleeve
|
|
|
SACH foot stands for...
|
Solid Ankle Cushioned Heel
|
|
|
Give 4 categories of feet for prosthetic limbs
|
- SACH
- Single axis foot - Multi axis foot - Dynamic elastic response foot |
|
|
What is the typical angle of fit for a transfemoral socket and why?
|
5 degrees of flexion and adduction to given the hip extensors and abductors a mechanical advantage
|
|
|
What are the 2 major types of sockets for transfemoral amputees?
|
Quadrilateral design
Ischial containment design |
|
|
Which transfemoral design is narrow AP?
|
quadrilateral
|
|
|
Which transfemoral design is narrow M-L?
|
Ischial containment
|
|
|
What are the general advantages and disadvantages of a quadrilateral design socket?
|
- easy to make
- less stable for shorter limbs - less comfortable |
|
|
What are the general advantages and disadvantages of a ischial containment socket?
|
- better stability especially for shorter limbs
- more efficient energy with narrow ML |
|
|
What is included in the "bony lock" of the ischial containment socket?
|
- ischial tuberosity
- pubic ramus - greater trochanter |
|
|
Give 4 examples of suspension options for transfemoral sockets
|
-suction
-silesian belt/bandage -total elastic suspension (belt; TES) - pelvic band and belt |
|
|
What are the main advantages and disadvantages of the single axis or constant friction knee?
|
Advantages: durable, inexpensive
Disadvantages: fixed cadence, poor stability, only indicated for level surfaces |
|
|
What are the main advantages and disadvantages of the stance control or safety knee?
|
Advantages: cannot be flexed during weight bearing so more stance phase stability, good in poor hip control, allows for more ambulation on uneven terrain
Disadvantages: delays swing phase because full unloading is needed to bend the knee |
|
|
What are the main advantages and disadvantages of the polycentric knee?
|
Advantages: knee remains behind the GFR for more stability, closer to anatomic knee location, good cosmesis especially with sitting
Disadvantages: heavy, expensive (especially used in knee disarticulations) |
|
|
What are the main advantages and disadvantages of the fluid controlled knee?
|
Advantages: automatic swing phase control at variable cadences, smooth natural gait
Disadvantages: heavy, costly |
|
|
What are the main advantages and disadvantages of the manual locking or fixed lock knee?
|
Ultimate in stability but awkward and energy consuming
|
|
|
When can phantom pain develop after amputation?
|
Any time
|
|
|
What percentage of patients experience phantom sensations and pain 6 months after amputation?
|
sensations 79%
pain 72% |
|
|
Risk factors for phantom pain?
|
Chronic pain, pain immediately prior to amputation
|
|
|
Why does choke syndrome develop in amputations?
|
Proximal limb pressure without full distal contact, often with an underlying vascular disorder.
|
|
|
What is the typical energy expenditure for able bodied adults at self selected walking speed?
|
4.3Kcal/min
|
|
|
What is the % energy expenditure increase at self selected walking speed for transtibial amputees?
|
23%
|
|
|
What is the % energy expenditure increase at self selected walking speed for tranfemoral amputees?
|
99%
|
|
|
What is the % energy expenditure increase at self selected walking speed for bilateral transtibial amputees?
|
41%
|
|
|
What is the % energy expenditure increase at self selected walking speed for bilateral transfemoral amputees?
|
186%
|
|
|
What is the % energy expenditure increase for amputees using a wheelchair?
|
9%
|
|
|
What is the % decrease in self selected walking speed pace for transtibial amputees?
|
20%
|
|
|
What is the % decrease in self selected walking speed pace for transfemoral amputees?
|
51%
|
