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Ebbets Extremity I

NYCC Ebbets Lower Extremity exam I Fa10

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