NYCC Ebbets Lower Extremity exam I Fa10
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| quadriceps "Q" angle | angle made by 2 lines: ASIS to midline of patella & tibial tubercle to midline of patella
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| Terrible Triad (O'Donaghue's) |
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| Macro trauma | one crushing blow or incident
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| Micro trauma | repetitive, cumulative insults, repeated time upon time.
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| A closed kinetic chain |
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| How pronation affects the knee |
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| Lateral tracking | g
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| apprehension sign | occurs with a lateral tracking issue
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| Genu valgus | collapsed arch with great toe abducted
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| Genu varus | l
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| Genu Recurvatum | l
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| Screw home mechanism | how the tibia rotates from medial to slightly lateral as the leg is brought from flexed knee to fully extended knee
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| how does the body attempt to correct chronic chondromalacia patella? | by tightening the medial and lateral hamstrings
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| What simple method can decrease knee symptoms | 10-15lb. weight loss by patient
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| Which muscle, when strengthened, will lead to a 90% success rate in treating patello-femoral problems? | Vastus medialis
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| A strong quad is a | stable knee
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| How many girls in NCAA division I basketball will experience ACL injuries? | 1 out of 10
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| ABC'S of the knee | Alignment, Bone structure, Cartilage, Soft tissue
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| primary alignment of knee | flex/extend in sagittal plane
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| secondary alignment of knee | internal/external rotation {windshield wiper rotation} and aBduction/aDDuction
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| 3 translations at the knee: | compression-distraction, medial-lateral translation, anterior-posterior translation
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| Q Angle (looks like a lambda symbol or compass) | angle made by 2 lines: ASIS to midline of patella & tibial tubercle to midline of patella
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| looks like a compass or lambda symbol | Q angle
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| Avg Q angle Men: | 10-15%
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| Avg Q angle Women: | 15-20%
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| What could cause excessive Q angle measurement at the HIP? | larger angle in females due to wide pelvic brim for birth
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| What could cause excessive Q angle measurement at the KNEE? | knock-kneed and obese (the classic "tripod" of overweight people)
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| What could cause excessive Q angle measurement at the FOOT? | pathological pronation
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| Name the 6 bony landmarks/structures of the knee: | F. PLATH (Sylvia's brother): Femur, Patella, Lateral tibial plateau, Adductor tubercle, Tibial tubercle, Head of fibula
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| F. PLATH (Sylvia's brother): | Femur, Patella, Lateral tibial plateau, Adductor tubercle, Tibial tubercle, Head of fibula [parts of the knee]
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| 4 bones of the knee | femur, tibia, fibula, patella
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| form the largest lever in the body | Tibia and Femur! Femur and Tibia!
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| largest sesamoid bone in the body | patella
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| many injuries to the knee involve the | menisci (cartilage) and supporting ligaments
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| 2 types of knee trauma to cartilage/menisci & supporting ligaments | Micro- + Macro- trauma
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| Macrotrauma to knee | one crushing blow or incident
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| Microtrauma to knee | repetitive, cumulative insults, repeated time upon time.
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| Causes of microtrauma to knee | obesity, running, repetitive motion injuries, assembly line work
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| functions of menisci of knee | knee stabilization, shock absorption, lubrication, mobile buffering, load bearing
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| how many different ways are there to tear a meniscus | 4 and all but one require surgery
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| structure of the knee bearing 80% of ground contact? | medial meniscus
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| The medial meniscus bears ____% of weight of ground contact in the knee | 80%
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| what is the pivot point for internal and external rotation of the knee? | medial meniscus
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| which type of alignment does the medial meniscus bear? | secondary (internal/external rotation-the windshield wiper thing)
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| the Medial meniscus is the ________point for internal and external rotation | pivot! pivot! PIV-OOOOT!!!! (thank you, Ross, from Friends)
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| why is the medial meniscus predisposed to tearing upon external/internal rotational pivot? | because it's anchored to the internal capsule
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| LCL cause of injury | medial blow
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| MCL cause of injury | lateral blow
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| ACL cause of injury | decelerate and turn
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| PCL cause of injury | PCL is the strongest ligament in the knee, injured when crashing into dashboards. PCL's often injured in soccer goalie's due to landing while knee flexed.
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| strongest ligament in knee | PCL (soccer goalie, dashboard)
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| muscle that counteracts lateral pull of the 3 other quads | Vastus Medialis Oblique (VMO)
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| all knee pathologies present with what soft tissue pathology? | MFTP myofascial trigger points
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| how do you strengthen the vastus medialis and thereby counteract the strong lateral pull of the other 3 quadriceps muscles on the knee? | terminal leg extensions (the last 15% of leg extension)
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| Causes of meniscal tears | twisting knee with foot planted and knee flexed
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| Signs/Symptoms of meniscal tear | knee "locks", knee unstable, (+) McMurray's sign
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| treatment of meniscal tear | Extent? arthroscopic surgery (read the Polkingham article)
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| a knee that "locks" is indicative of? | a meniscal tear
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| describe McMurray's test | for meniscal tear: valgus test, patient prone, flexed knee, medially rotate and bring down towards table. 'Pop!' noise indicates (+) McMurray's and possible meniscal tear
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| Osgood-Schlatter disease (Dr. Ebbets had this) | often caused by growth spurts in adolescent males 10-15 yrs old, traction injury, tibial apophysis - TEARING at tibial tuberosity
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| where does the patellar ligament injury occur with Osgood-Schlatter disease? | tibial tuberosity
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| treatment for Osgood-Schlatter disease | yoga, rest, flexibility, Epsom salt baths
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| Cause of IT band syndrome | downhill running, hyperpronation
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| Symptoms of IT band syndrome | pain at lateral femoral condyle = GERDY's tubercle
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| Treatment of IT band syndrome | orthotics, Kinesio-tape, stretch Iliotibial band, ART (assisted release technique)
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| Cause of Pes Anseri bursitis (goose's foot) | direct trauma, any hamstring injury
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| Pes Anserinus | Semitendinosis, Sartorius, Gracilis
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| Signs/Symptoms of Pes Anseri bursitis | general tenderness, medial to tibial tuberosity
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| Treatment of Pes Anseri bursitis | ice! Kineseo-tape, flexibilty
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| cause of OA (DJD) of knee | macrotrauma, microtrauma
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| sign/symptom of OA of knee | morning stiffness, mild joint effusion
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| treatment of OA of knee | water therapy, peanut oil, glucosamine, joint manipulation
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| can joint manipulation be used to treat OA of knee? | yes!
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| cause of ACL injury | quick deceleration with turn, landing off balance, exacerbated by large Q angle
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| what exacerbates an ACL injury | large Q angle
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| sign/symptom of ACL injury | pop or snap, knee gives out, (+) AP draw sign
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| (+) AP Draw sign indicates what? | ACL injury (sign of 4 then pop or snap)
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| treatment of ACL injury | surgery
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| cause of Chondromalacia Patella | degeneration of cartilage on underside of patella due to increased force or lateral tracking
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| what kind of tracking causes Chondromalacia Patella? | lateral
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| sign/symptom of chondromalacia patella | pain in the knee garbage can diagnosis
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| treatment of chondromalacia patella | knee sleeve, strengthen quads, flexibility, peanut oil
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| thickest cartilage in body is located | on patella
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| is the patellar cartilage on the femur or the patella? | underside of patella
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| cause of lateral tracking problems (like chondromalacia patella)? | weak VMO, increased Q-angle, pathologic pronation, genu valgus
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| sign/symptoms of lateral tracking problems | pain at lateral border of patella, frank dislocation, (+) Patella Scrape, apprehension
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| treatment of lateral tracking problems | terminal leg extensions (last 15 degrees), pelvic adjustment
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| a pelvic adjustment will help correct what kind of knee problem? | lateral patellar tracking issue
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| ecchymosis | j
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| stereognosis | l
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| graphesthesia | l
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| two-point discrimination | abcd
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| a painful arc | abcd
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| clincial judgement | abc
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| orthopedic test | abc
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| thermography | abc
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| smoking one pack of cigs per day is the heart-strain equivalent of carrying an extra __lbs. in weight | 80
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| medical diagnoses is said to be accurate ___% of the time | 65
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| strains become a chronic problem because they heal with ___________ scar tissue. | inelastic
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| HIPpRONEL (definition) | acronym for Chief Complaint
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| HIPpRONEL | History, Inspection, Palpation, Percussion, ROM, Orthopedic tests, Neurologic finding, Exams, Lab work
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| H | History
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| I | Inspection
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| P | Palpation
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| p | percussion
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| R | ROM
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| O | Orthopedic Tests
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| N | Neurologic finds
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| E | Exams- diagnostic tests (x-rays/radiographs/plain films, etc.)
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| L | Lab work
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| The patient will always give you the __________? | diagnosis
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| Chief complaints are stated how? | in the patient's own words
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| How should you begin a chief complaint interview? | with an open-ended question such as, "What problem brought you here today? How long has it been going on? When did you notice it began?"
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| Along with open-ended questions for chief complaint, also address (2) | frequency and duration
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| History is made up of lmnopqrst: | location, mechanism of injury, nature of pain, onset, palliate/provoacative, quality of pain, rate/region, severity, time
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| l | location
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| m | mechanism of injury
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| n | nature of pain
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| o | onset
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| p | palliative/provocative
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| q | quality
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| r | rate/region
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| s | severity
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| t | time
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| History (lmnopqrst) is made up of pertinent details regarding patient's problem. L is for location, which means? | point, trace or circle the location
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| M is for mechanism, which means? | What caused the problem?
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| Regarding M for mechanism, what are some possible causes of the problem? | Repetitive motion injury (RMI), unknown, macrotrauma (blow or break), obesity, microtrauma (repetitive)
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| Percentage of obese Americans | 60%
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| N is for the nature of the pain. What are some descriptors for Nature? | hot/cold, intermittent, throbbing, constant, burning, stiffness, dull ache
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| O is for onset. This is of medical and legal importance. What are the questions for Onset? (2) | WHEN did the problem start? Time and place?
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| P is for palliative/provocative. In other words, ? | What makes it better? What makes it worse?
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| What are some possible subcategories of P for Palliative/Provocative? | postural positions, treatments, times of day, movements, medications
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| Q is for Quality of pain. This is similar to nature (N) of pain, but more specific to nerve vs. muscle. What are some descriptors for Quality of pain? | numbness, tingling, sharp, dull, electric-like, burning
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| R is for Region/Radiation of pain. What should you ask the patient to do to demonstrate R for Region/Radiation? | trace the pattern
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| What will R for region/radiation distinguish? | radicular pain vs. radiculopathy
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| S is for Severity of pain. What can be used to assess S for Severity? | Oswestry scale (points totaled), Scale of 1-4 or 1-10, Visual analogue scale of 100mm., Pain map
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| ADL | Activities of Daily Living
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| Oswestry scale | S for Severity rating: cervical and lumbar questionnaires, ADL's
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| T is for Times of day. What are the potential T for Times of day you may ask a patient about? | Pain upon: wake up, bedtime, sleep, before-during-after activity
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| History goes through what letters of the alphabet? | L-T
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| HIPpRONEL | Chief Complain acronym: History (lmnopqrst), Inspection SAD ED:(, Palpation, Percussion, ROM, Orthopedic tests, Neurological finds, Ex-rays!, Labs
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| HIPpRONEL-H is History (lmnopqrst) then HIPPRONEL-I is Inspection of SAD ED:( | :(SAD ED - Scars, Abrasions, Discoloration, Edema, Deformities
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| HIPPRONEL-I...SAD ED :( | HIPPRONEL-I: Scars, Abrasions, Discoloration, Edema, Deformities
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| HIPPRONEL-P is Palpation. We Inspect SAD ED:( then we offer him a MALT while we Palpate: | Malpositions, Anomalies, Landmarks, Tenderness
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| fix a MALT for sad ed while we palpate: | Malpositions, Anomalies, Landmarks, Tenderness
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| HIPpRONEL-p is percussion. What are we trying to hear when we percuss a patient? | Sounds! -air, fluid, solid masses. Tympanic!-gastric air bubble. Resonance! -healthy lungs. Dull! -liver. Flat! -muscle
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| HIPPRONEL-R is Range of motion (ROM). What are the ROM's for HIPPONEL? | bilateral symmetry, Active (done first) to test muscle, Passive (done 2nd) to test tendon, Overpressure at endrange to test joint, painful arcs as impingement sites, end feels
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| ROM symmetry | bilaterally
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| active ROM | done first, before passive, to test muscle
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| passive ROM | done second, after active, to test tendon
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| overpressure at end range during ROM tests | joint
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| a painful arc during ROM tests for | areas of impingement
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| Why would we test for end feels during ROM assessment? | because we are Chiropractors!
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| HIPPRONEL-O is Orthopedic tests which are _________. They apply stress to bones, joints, ligaments, cartilage and tendons. | provocative
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| HIPPRONEL-Orthopedic tests underscore the importance of knowing the underlying _________ | anatomy
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| Fabare-Patrick test as an _________ test. | orthopedic
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| What does FABARE mean? | ?????
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| Name the HIPPONEL-Orthopedic tests | Fabare-Patrick, Straight Leg Raise (SLR)
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| What do differential tests establish? | ?????
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| HIPPRONEL-N is Neurological test (MRS). What does MRS mean? | Muscle, Reflex, Sensation
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| M.R.S. neurological testing: Muscle tests use the | Wexler scale 0-5
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| M.R.S. neurologica testing: Reflex testing is for testing the? and uses what scale? | Deep Tendon Reflexes: 0-no response, +1-sluggish, +2-normal, +3-hyperactive, +4-hyperactive, intermittent or transient clonus
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| M.R.S. neurological testing: Sensation tests rely on ? | Dermatome and myotome maps, VDPP (Vibration, Discrimination, Propriorecption, Pressure), Pain and Temperature, Cortical sensory, Stereognosis, 2-Pt.discrimination, Graphesthesia
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| graphesthesia | can a patient discern a number or letter drawn on back?
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| stereognosis | can a patient distinguish an object by touch alone?
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| HIPPRONEL-E is Exams: give examples of anatomical exams | x-rays, CAT, MRI
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| HIPPRONEL-E is Exams: give examples of physiological exams | SSEP (sensory nerve), NCV/EMG (motor nerve), Thermography
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| SSEP | sensory nerve test - physiological exam for HIPPRONEL chief complaint
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| NCV/EMG | motor nerve test - physiological test for HIPPRONEL chief complaint
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| HIPPRONEL-L is Labs. Name the 4 lab tests: | CBC, blood chem, UA, PSA
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| CBC | complete blood count
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| UA | urine analysis
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| PSA | prostate-specific antigen
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| the 'gapping' of a joint | joint play
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| the springiness at the limits of joint play | end feel
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| palpation of a joint and joint space through well-defined movements - simply stated: palpation with movement | POMP (passive osteokinematic motion palpation)
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| joint play or gapping tested at the elastic barrier, take the slack out and spring, there are 6 end-feels you need to know | Accessory motions
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| a therapeutic action of continuous motion within the elastic barrier | mobilization
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| well-intentioned dynamic thrust PAST the elastic barrier into the paraphysiologic space | therapeutic adjustment/manipulation
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| bone to bone end-feel demonstrated by | elbow extension
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| elbow extension is which end-feel? | bone to bone
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| spasm end-feel demonstrated by | hypertonic muscle
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| hypertonic muscle is which end-feel | spasm
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| capsular end-feel demonstrated by | shoulder in external rotation
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| shoulder in external rotation is which end-feel? | capsular
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| springy block demonstrated by | internal joint derangement
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| internal joint derangement is which end-feel? | springy block
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| tissue approximation demonstrated by | arm flexion
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| arm flexion is which end-feel? | tissue approximation
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| empty feel demonstrated by | joint ligamentous laxity
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| joint ligamentous laxity is which end feel? | empty
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| painful arcs are areas of | impingement
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| an area of impingement will be demonstrated by a | painful arc
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| SLR (straight leg raise) could indicated one of two things: | tight hamstrings give pain in back of leg, disc herniations give pain in low back and toes
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| how many Wexler grades? | 6 (0-5 with 5 as normal)
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| How many DTR grades? | 5 (0-4 with 4 as hyperactive, intermittent, clonus)
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| normal DTR? | grade 2
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| what kind of test is Babinski's? | DTR (looking for UTS - upward toe sign)
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| the distal segment moves AWAY from the midline | valgus
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| the distal segment moves towards the midline | varus
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| another term for hyperextension | recurvatum
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| 3 areas at which valgus or varus can occur in the lower extremity: | coxa valgus/varus, genu valgus/varus, subtalar valgus/varus
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| musculotendon injury | strain
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| ligamentous injury | sprain
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| name 6 tendons and ligaments of the knee | PCL, ACL, Transverse ligament, Lateral Collateral Ligament, Medial Collateral Ligament, Patellar tendon, Patellar ligament
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| name the important cartilage of the knee | menisci
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| what 3 things can be done to get the patient's attention? | non-obtrusive bump (nob), tap (t), eye contact (ec) for 3 seconds at 3rd eye if necessary
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| DASED | Discolorations, Abrasions, Scars, Edema, Deformities
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| MALT | Malpositions, Anomalies, Landmarks, Tenderness
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| How do we motion palpate the knee? | put fingers in 'eyes of the knee' and flex/extend through ROM
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| what accessory motions are tested at the knee? | joint play (gapping), looking for 6 end feels
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| what is a good way to assess the knee? | POMP - doctor induced motion through well defined direction and amt of movement, palpating through joint space, NO springing, passive ROM from neutral to elastic barrier
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| order of knee exam: | Active ROM then POMP then Accessory motion (joint play)
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| knee POMP (4) | flexion, extension, internal and external rotation
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| knee accessory motions (5): | long axis distraction, valgus/varus tilt, AP/PA glide, internal rotation, external rotation
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| flexion/extension POMP of the knee is done by placing your fingers where? | in the eyes of the knee
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| internal/external rotation of knee procedure | their calf on your knee, externally and internally rotate the leg at the ANKLE
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| AP/PA knee POMP | bend their knee and place foot flat on table, gently kneel on their dorsum of foot to secure, grasp leg and place thumbs in eyes of the knee, pull tibia forward (anterior translation) and push in (posterior translation)
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| name some common knee conditions | Osgood-Schlatter's, hamstring strain, myofascial trigger points, ACL injury, Meniscus injury, Ligament injury, groin pull
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| what are we checking for during active range of motion of knee | creptius; synovial or bursal thickening; function
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