Professional Documents
Culture Documents
Cce5 LTR PPT
Cce5 LTR PPT
Some Background
2 year degree/training as PTA Graduated 1980 from LACC 18 years practice Ithaca, NY 3 years practice Boston, MA
Private Practice Ergonomic Consultant
Structure of Content
Theory and Background Functional Anatomy Testing, Analysis & Diagnosis Hands-on practical experience
Overview of Weekend
Introduction & Testing
Basic Concepts & Foot Evaluation Manual Muscle Testing & Flexibility
Core Stability
Neck Flexors and Neck Stability Swiss Ball
Upper Body
Shoulder Rehabilitation Upper Extremity Rehabilitation
Assumptions
Detailed History including:
Nature of Chief Complaint Past Personal History & Review of Systems Past Family History
Role of Manipulation
Direct experience that.
Spinal manipulation is potent Chiropractic adjustment is central
Active management compliments Exercise programs do not replace the importance of manipulation
Low-Tech Rehab
What Low cost tools for rehabilitation Why Pain management, myofascial pain & long term fitness Who - Nearly all your patients How Selective techniques geared to individual need, dependent upon place in the treatment cycle
Philosophical Perspective
Passive vs. active management Part of problem or part of the solution Not dependent but empowered patients Differentiate & build your practice Give patients something to look forward to Its fun to teach!
Managed Care
Carriers are expecting active treatment protocols Continued reimbursement based upon outcomes Appreciable improvement when active management has been instituted
Getting Paid
97110 Rehab/Exercise 97112 Neuromuscular Re-Education One unit = 8 to 25 minutes One unit = $45
Pain
Immobility
Afferents
Neurological Basis
Large scale motor activity given preference Low grade pain perceived in absence of large scale motor activity Chronic pain associated with aberrant changes in dorsal horn organization Prompt action necessary to avoid these changes!
Interlocking Systems
Cognitive Perceptual
Limbic Emotional
Motor
Muscle strength deficiency Muscle tension, hypertonicity or shortening Foot dysfunction Recurrent patterns of segmental dysfunction Ergonomic factors
Rehabilitation
When most acute phase has passed Pain present so keeps patient interested Before auto discharge occurs
Goals of Rehabilitation
Decreasing pain Take away the fear of movement Decreasing mechanical stress on spinal structures Strengthening weak muscles Stabilizing hypermobile segments Improved mobility Improved posture Improved fitness levels to prevent injury
Increasing Compliance
Partnership with patient Have you engaged the patient?
Why am I doing this exercise? How does it relate to my diagnosis?
Post-instructional Check
Check patients technique within 1-3 day Are they doing the exercise(s) correctly? Are they doing them at the recommended frequency? Document compliance in SOAP
Documentation
Note the time rehabilitation started and ended in date area. Briefly describe type of exercise, program, tool and why. Describe patients immediate understanding Note frequency, duration, weight used and how many times per day List any handouts given to the patient
Patient Handouts
Ease of Creation Individualized Covers various rehab tools Covers documentation Reasonably priced
Swiss Ball
Trunk Strengthening Targeting of select muscle groups Enhanced Proprioception Mimics Real Activities & Demands FUN!
Foam Rolls
Compliments Swiss ball type activities Trunk stability Balance and coordination
Soft Kickball
Resistance exercises neck flexors Post-MVA rehabilitation Headaches Extensor & SCM myofascial pain Loss of cervical lordosis
Elastic Bands
Strengthening for all extremities Graded resistance activities Easy to target selective groups Functional activities can be mimicked
Kinesiotaping
Provides touch to area of chief complaint Lifts skin to open lymphatic channels Increased mechanoreceptor stimulation
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Summary of Process
Examination/Analysis Diagnosis
Understand contributing factors Patient seen in wholestic manner
Small change inferior = large change superior Bed of proprioceptors is rich given role of feet in standing and locomotion
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Foot Dysfunction
Foot dysfunction < > foot pain Recurrent dysfunction in:
Ankle, knees, hip Sacral-iliac joints, lumbar spine Neck, headaches Shoulder diagnosis
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Observe
Hip Height Difference Achilles Tendon Deviation Medial Malleolus Hallux Valgus Deviation
Palpate
Inform the patient of your intentions Hold the ankle with one hand Firmly palpate the longitudinal arch
Taut Loss of height Pes Planus Tender
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Heel strike moment facilitation of quadriceps group Loss of strength at this moment = inhibition at moment weight shifts to limb in stance
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Proprioceptors
Heel Strike through Toe-Off
Golgi tendon organs (GTO) activated Spindle cell receptors in longitudinal arch Between each bone capsular receptors Mechanoreceptors in longitudinal ligament
Neurological Basis
GTO signals to anterior horn of spinal cord Type 1B afferents signal inhibition Possible nocioception below threshold for perception Upon taping, possible unloading of mechanoreceptors in the plantar fascia
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Recommendation
Do not need to have positive heel strike to recommend orthotics Pronation alone adequate indicator Common bilateral equal pronation off the shelf device may suffice Marked deviation with chronic foot pain podiatrist referral may be indicated
Supinated Feet
High arch = rigid arch Inflexible Poor shock absorption Tendency towards heel pain
Types of Orthotics
Casting weight bearing Casting non-weight bearing Hard vs. soft
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Documentation
S: The patient states that her symptoms of headaches/shoulder pain/low back pain is/are worse after long period of standing at work, although she does not complain of foot pain. O: While weight bearing there is a deviation of the Achilles tendon bilaterally with the right greater then the left. This deviation on the right appears to be approximately 15 degrees with the medial malleolus also more prominent on the right towards the midline. Palpation with light/moderate/deep pressure of the mid longitudinal arch while weight bearing elicited marked/moderate/mild tenderness and there was mild/moderate/marked tonicity of the plantar musculature. The strength of the quadriceps muscle was bilaterally +5. When heel strike was mimiced the strength of the quadriceps bilaterally/right/left was inhibited to +4. Taping of the ankle into neutral position and elevation of the arch with two closely set bands was performed. After this procedure the heel strike response was retested with the quadriceps strength returning to +5. A: Bilateral pronation, right > left with proprioception loss during gait contributing to biomechanical problems of the ankle/knee/hip sacral iliac joint(s)/lumbar spine/shoulder/cervical spine. It is my opinion that P: Cast the patient for ___________ orthotics, dispense and monitor for improvement in the biomechanical dysfunction of ___________ (named regions). It may also be valuable to provide manipulation for the intrinsic foot bones to aid the patient's adaptation to the orthotics.
Stages of Assessment
Do we have stability across the region? Is there flexibility in all muscles that cross the joint or that effect the region? Is there adequate range of motion
Segmental (vertebral) Global
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Applied Kinesiology
Prior to Goodheart muscle testing existed! Muscle testing will lead to various conclusions Emphasis Relation to vertebral subluxation Weakness secondary to biomechanical factors
Role of Manipulation
Profound effects that are:
Direct Corresponding to neurological level Indirect complex proprioception mechanisms
If weakness persists
Are you adjusting all involved segments? Is the muscle weak for another reason?
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Leads to:
Muscle imbalance Overstress on structures of musculoskeletal system
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Myofascial Pain
Prime Mover - weak
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Muscle Palpation-Described
Area being palpated?
Example: Right pectoralis minor
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Iliopsoas
L2, 3
Rectus Femoris
L2, 3, 4
Sartorius
L2-L3
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Hip Adductors
L2, 3
Quadratus Lumborium
T12, L1-4
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Gluteus Medius
L4, 5, S1
Gluteus Maximus
L4, 5, S1
Piriformis
L5, S1 & S2
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Hamstrings
L5, S1, 2
Rectus Abdominus
Caution: Not to be done with an acute or grossly unstable patient! Use the Swiss ball as a functional test.
Caution: Not to be done with an acute or grossly unstable patient! Use the Swiss ball as a functional test.
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Gastrocnemius/Soleus
S1-S2
Latissimus Dorsi
Thoracodorsal, C6, 7 & 8
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Pectoralis Major
Clavicular
C5-C6
Sternal
C6-C7
Deltoids
Axillary, C5, 6
Supraspinatus
Suprascapular, C5
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Infraspinatus
C4, C5 & C6
C5-T1
Subscapularis
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Rhomboids
C5
Palpate the inferior aspect of the scapula to feel if it remains fixed towards the spine.
Lower Trapezius
Because of attachment of lower trapezius to inferior scapula, palpate for maintenance of scapula in a diagonal towards lower thoracic spine.
Mid-Trapezius
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Teres Major
C6-C7
Upper Trapezius
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Reciprocal Inhibition
Hamstring to Quadriceps (likely) Quadriceps to Hamstrings (less likely) Adductors to Abductors (likely) Abductors to Adductors (less likely)
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Summary
Understand balance of function across joint Analysis of various factors effecting muscle Check if VSC is causing weakness Disuse atrophy of select groups is common Selective strengthening programs based upon findings
Neck Flexors
Anatomy Review Syndromes and Symptoms Myofascial Pain Patterns Observation & Testing Strengthening Expectations & Charting
Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.
Longus Colli
Anterior rami C2-C6
Scalaneus Anterior
Anterior rami C4-C6
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Spinal portion of Accessory Nerve (Cranial XI) & Anterior rami C2-C3
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Suboccipitals
Semispinalis Capitis
Splenius Capitis
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Upper Trapezius
Temporalis
Spindle Cells
Rich endowment of spindle cells in:
Neck flexors Sub-occipital triangle Longus colli
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Pre-Disposing Factors
History of a motor vehicle accident (or several) or other neck trauma, even if this event was many years ago Occupational flexor dominant Behavioral slumped body posture
Syndromes
Loss of the cervical lordotic curve visible on a lateral radiograph Anterior head carriage Hypertonicity of the sub-occipital muscles, levator scapula, upper trapezius, SCM's and TMJ related muscles Headaches, especially those of myofascial origin (see muscles noted above)
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Syndromes
TMJ dysfunction Inability to maintain cervical corrections Chronic tension between the shoulders
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Suboccipitals
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Postural Evaluation
Testing - Observation
Have table at horizontal neutral Arms overhead decrease role of synergists
Translation or chin jut Fasciculations Chest raised Arms brought forward Terminal flexion or none
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Testing Challenge
Chin tuck 15-20 degrees of flexion Two finger or hand edge resistance
Strengthening
Guide patient to neutral head position Have the patient walk into the ball slowly. Avoid translation Instructions: Keep ear over shoulder
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Strengthening
Hands on the wall to maintain the the chestwall inter-space Keep just enough pressure to maintain the ball on the forehead
Strengthening
With guidance have the patient perform a chin tuck Do they feel an increase in pressure on the forehead?
Strengthening
Guidance can be given both during the chin tuck & flexion Always ask permission to touch
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Strengthening
Have the patient complete flexion Repeat at least several times under observation to insure correct technique
Follow-up
Insure compliance by having the patient return in 2-3 days for an exercise check Watch for lack of neutral start, translation or excessive pressure
Additional Care
Regular manual manipulation Coaching in proper ergonomics and posture Performance of gentle and regular stretching of the cervical extensor groups Soft tissue release techniques
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Charting
Objective: What was observed? What was the results of testing? Assessment: Loss of deep neck flexor strength Plan: Strengthen with soft ball 10x twice per day Recheck patients compliance and technique within three days
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Muscle Flexibility
Testing of Key Groups
Vladimir Janda
Czech doctor of neurology & physical medicine Extensive contribution to understanding muscle function
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Overstress of:
Cervical cranial junction
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Adequately stabilization of one end Smooth motion during stretch, especially at end range Patients perception of tightness not a reliable guide Rely on maintaining positional stability & doctors assessment of end feel
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Hamstring Assessment
Opposite knee bent Support the heel in a bent elbow Apply pressure to anterior tibia
Hamstring Assessment
Palpate at ASIS for pelvis movement >70 degrees flexion = marked loss of length
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Hip Adductors
Move the non-testing leg approximately 15 degrees into abduction Cradle the leg as in assessment of the hamstrings Slowly abduct the leg, palpating for when pelvic movement sets in
Hip Adductors
Leg should be abduct to 45 degrees without pelvic movement Flexing the knee eliminates the hamstrings as a source of restriction
Assessment - Piriformis
Flex the leg to no more than 60 degrees Provide compression along the axis of the femur Adduct the thigh Internally rotate the femur Feel for smooth movement with no restriction
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Palpation - Piriformis
Mentally draw a line between the PSIS and the greater trochanter The second line is from the ischial tuberosity to the ASIS
Palpation - Piriformis
Palpation where these two lines cross Palpation is conducted with one hand reinforcing the other and is very deep
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Pectoralis Major
Patient supine close to the edge of the examination table Stabilization of the trunk is essential Place the arm in slight external rotation at 120 degrees of abduction Palpate the muscle for tenderness while detecting the length
Upper Trapezius
Patient supine, stand at the head of the table Use your right hand on top of the right shoulder to assess elevation Use the left hand to flex the head fully, followed by lateral flexion Head rotation is to the ipsilateral side. Traction the shoulder girdle inferior
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Levator Scapulae
With the patient supine, stand at the head of the table Flex the head while maintaining downward pressure on the shoulder Head is rotated contralateral to the side being held Depress the shoulder girdle and assess the quality of the end feel, comparing left and right sides Also palpate the insertion of the levator scapulae at the superior angle of the scapula
Move into stretch position slowly Setting the intensity (just right 4-6)
Fine tune the position
Basic Instructions
10-12 Breaths per position (audible) Notice softening or increased ease Release the pose carefully Repeat the position of challenge
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Stretch - Iliopsoas
Stretch - Iliopsoas
Stretch - Iliopsoas
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Stretch - Piriformis
Stretch - Piriformis
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Resource
Stretching by Bob Anderson
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Global Evaluation
Relative function of muscle groups Weakness or hypertonicity Compensatory mechanisms Neurological deficit Synergetic movement Lack of balance
General Indications
Decreased range of motion Decreased strength Decreased balance reactions Decreased coordination Decreased endurance Decreased proprioception
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Contra-Indications
Profound balance problems Acute pain Distress with sitting Increase in pain during exercises Ringing in the ears Ball frightens patient
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Misconceptions
Definition < > Toned Abdominal Muscles Raw Strength vs. True Functional Tone
Reminders to Patients
Exercises take concentration Safety zone if they fall Perform exercises slowly (generally) Any exercise can be backed down
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Reminder to Doctor
Doctor - No hard agenda on a given visit Observe Guide and encourage Advance program only when appropriate
Abdominal Sit-Back
Feet spread apart Roll hip forward Slowly lean straight back Lean back to point can still maintain mobility
Doctor Observes: How steady? Fasciculations Maintaining balance Anterior vs. posterior pelvic tilt
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Diagonal Sit-Back
Feet spread apart Roll hip forward Slowly lean back diagonal Lean back to point can still maintain mobility
Doctor Observes: How steady? Fasciculations Maintaining balance Anterior vs. posterior pelvic tilt
Contralateral Puppet
Do not advance if the one leg lift is poor! Lift leg and arm at the same time Keep torso even and balanced
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Quadratus Lumborium
Hip pointed at ceiling Bring hip to shoulder, shoulder to hip Not a lateral leg lift alone
Bridged Supine
Lay over the ball Feet spread apart at first Arms out for stability Start with ball under mid back Slowly roll out to ball across upper shoulders Maintain flat abdominal platform
Full-Spine Roll-Out
Start seated & slowly roll out Feet wide apart Slowly stretch torso over ball Place arms at 45 degrees overhead Lay back and let neck relax Coming up start with neck curl
Contraindications: Neck pain Poor stability on less advanced exercises
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Full-Spine Roll-Out - 1
Full-Spine Roll-Out - 2
Full-Spine Roll-Out - 3
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Full-Spine Roll-Out - 4
Gluteus Medius
Lay on side over the ball Bend bottom leg underneath Keep hip pointed at the ceiling Lift high leg towards ceiling
Gluteus Maximus
Lay prone over the ball on knees With knee bent, lift one leg Keep torso flat with no torque Do not want lumbar extensor activation
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Progressive Push-Ups
Lay prone over the ball Have ball hit across hips Keeping back stable perform push-up Slowly walk out to knees Eventually walk out to ankle Always maintain flat back platform with no dipping
Progressive Push-Ups - 1
Progressive Push-Ups - 2
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Progressive Push-Ups - 3
Rhomboids
Face down kneeling Arm out at 45 degree to head/neck Thumb up Attempt to lift arm Doctor observe/palpate for scapular control
Rhomboids 2
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Balancing Bear
Kneel on all fours on ball Maintain position Dont fall off
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Kneeling on Ball
From Balancing Bear advance Kneeling on ball From arms outstretched to resting on hips Great for knee stability from trunk
Foam Rolls
Beginners Position
Sit back on the foam roll placed vertically under the full length of your back Have your head and neck supported on the foam roll Bend your knees with your feet on the floor
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Have Fun!
Shoulder Rehabilitation
Anatomy Review Muscle Testing Review Common Problems Treatment
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Evaluation
History Orthopedic, neurological & physical
Remember probing palpation of soft tissue structures to patient tolerance
Radiographic
Osteonecrosis, both humeral heads, due to steroids used to treat this patient's chronic leukemia
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Improper coupled motions across joint Excessive wear and tear of soft tissues
Myofascial Pain
Prime Mover - weak
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Trigger Points
Latissimus Dorsi
Mid-thoracic Posterior scapula Anterior shoulder Entire arm to hand
Subscapularis
Trigger Points
Teres major
Trigger Points
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Trigger Points
Deltoid
Local pain at shoulder
Trigger Points
Coracobrachialis
Similar to deltoid Arm, forearm & wrist
Trigger Points
Biceps brachii
Pain lateral shoulder Pain anterior elbow
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Trigger Points
Supraspinatus
Mimics subdeltoid bursitis Elbow, arm & forearm
Treatment Steps
Pain relief
Ice, modalities (electrical stimulation, ultrasound) Possible start trigger point release work
Passive motion Manipulation when applicable Gentle resistance within non-painful range Gradual increase in range and resistance
Passive Motion
Pendulums or Codmans arm swing
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Passive Motion
Wall walking
Resistance Exercises
Internal Rotation
Pectoralis major Subscapularis
Resistance Exercises
External Rotation
Teres minor
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Resistance Exercises
Abduction
Supraspinatus Deltoid
Resistance Exercises
Scapular Retraction
Rhomboids Trapezius
Scapular Fixing
Subscapularis
Knee Rehabilitation
Wobble Board Resistance Bands Stretching
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Overview
Anatomy Review Syndromes and Symptoms Myofascial Pain Patterns Observation & Testing Strengthening Expectations & Charting
What do we know?
Rule out primary pathologies Diagnosis do we treat, co-manage or refer?
Anatomy Review
Quadriceps
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Anatomy Review
Adductors
Anatomy Review
Tensa Fascia Lata
Anatomy Review
Gluteus Medius
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Anatomy Review
Hamstrings
Anatomy Review
Gastrocnemius
Soleus
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Feet Biomechanics
Pronation causes angular forces Supination causes contralateral stresses Poor proprioception causes abherrent muscle firing during the gait cycle
Rocker Board
Renewal of proprioception Progression
Two feet AP motion with control One foot - maintaining control
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Wobble Board
Two feet AP rocking with control Two feet lateral stability One foot four point motion One foot slow circles without touching floor
Muscular Tension
Hamstrings Quadriceps Group Calf Group (soleus & gastrocnemius) Adductors Abductors Gluteal group
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Stretching
Hamstrings
Stretching
Calf Group
Gastrocnemius
Soleus
Stretching
Quadriceps femoris
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Reciprocal Inhibition
Hamstring to Quadriceps (likely) Quadriceps to Hamstrings (less likely) Adductors to Abductors (likely) Abductors to Adductors (less likely)
Strengthening
Quadriceps
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Strengthening
Gluteus medius
Strengthening
Adductors
Strengthening
Abductors
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Syndromes- Indicators
Facet syndrome Excessive lumbar lordosis Poor abdominal control/positioning Chronic low back pain with weight bearing Poor standing posture Runners posture
Assessment
Lateral lumbar radiographs Standing postural analysis Muscle testing for facetal jamming
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Radiographic Analysis
Progression
Prone position & strengthening Standing wall tilts Standing, walking & running
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One-Third Curl
Patient can perform a good anterior pelvic tilt Cross arms over chest or behind the head Set a pelvic tilt Slowly curl 1/3 towards full sit-up Hold for a slow count of 3-5 Slowly roll back down while maintaining the pelvic tilt throughout
Wall-Tilt
If the patient shows good control during pelvic tilts and 1/3 curls Start in a low squat and perform tilt against the wall Slowly move up the wall, performing a tilt at each level If shoulders start to roll forward then patient to perform exercise at last correct level
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Standing Tilt
If the patient can work their way up the wall to nearly standing One hand low on the anterior pelvic area One hand in the lumbar lordosis Perform a pelvic tilt without shoulders rolling forward Imagine a sky hook lifting head towards the ceiling All postural changes occur from the pelvis up Goldielocks Principle for degree of tilt
McKenzie Method
Comprehensive assessment Positions that centralize pain Committed to either flexion or extension Performance independently at home Neutral spine and dynamic muscle support of their spine
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Observation/Assessment
Patient's response to repeated, near end-range spinal motions Patients are diagnosed with either postural, dysfunction or derangement Derangement = alteration in the structure and mechanics of the intervertebral disc
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Introduction
Biomechanics are considered Touch on carpel tunnel syndrome Complete work-up including:
Metabolic Cervical Disc Tumors especially apical lung Orthopedic & Neurological
Anatomy Review
Pronator Quadratus
Approximates ulna & radius Inhibited by injury
Extension of wrist
Anatomy Review
Flexor digitorium profundus
Hypertonicity leads to medial epicondylitis
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Anatomy Review
Extensor digitorium communus
Hypertonicity leads to lateral epicondylitis Frequent source of myofascial pain syndrome
Anatomy Review
Pronator teres
Consider involvement when pronation causes pain
Anatomy Review
Median nerve
Ulnar nerve
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Myofascial Pain
Latissimus dorsi Pain in the arm, forearm & hand
Myofascial Pain
Scalenes Pain along entire upper extremity to wrist & hand Associated chest pain Post MVA
Myofascial Pain
Extensors Wrist pain Pseudo-carpal tunnel Painful weak grip Frequently associated with lateral epicondylitis
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Myofascial Pain
Finger Flexors Stiff fingers Pseudo-carpal tunnel Frequently associated with medial epicondylitis Wrist & finger pain
Myofascial Pain
Palmaris longus Hand pain Associated with Dupuytrens Contracture
Myofascial Pain
Opponens Pollicis Thumb pain
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Treatments - Passive
Spinal manipulation Extremity manipulation Ischemic compression Kinesiotaping Gentle stretching
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Manipulation - Rationale
Spinal: Consider levels of innervations to injured area Primary problem = extremity Reflex arcs will spinal segmental dysfunction Marked reduction in healing time gained
Extremity Manipulation
Is there joint instability?
Yes: may be contraindicated No: proceed as indicated
Ischemic compression
In belly of muscle palpate for area of:
Taut Tenderness Nodularity Possible fasciculation or involuntary twitch
Steady pressure to patient tolerance Patient takes slow deep breaths Cannot breath through pain, too much
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Kinesiotaping
Provides touch to area of chief complaint Lifts skin to open lymphatic channels Increased mechanoreceptor stimulation
Held for ten slow deep breaths Patient to pace themselves Can be done with elbow bent Excellent injury prevention for patients who use their hands a lot
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Forearm - Flexors
Outstretched arm Reach across fingers Gently pull back Can be performed with elbow bent Hold for ten slow deep breaths
Forearm - Extensors
Outstretched arm Reach across back of knuckles Gently pull back Can be performed with elbow bent Hold for ten slow deep breaths
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Compare Extremities
Kinesthetic feedback How does the stretched side compare to the unstretched side?
Lighter Warmer More at ease
Dyna-Flex
Gyroscopic action provides resistance Full circle of strength training Enhanced stability across wrist
Handmaster Plus
Open
Closed
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Wristiciser
Go through all principle diagnosis
Summary
Multifactorial nature of hand, wrist and arm pain CTS may be present yet with other contributors LTR instituted only when: Through understanding of diagnosis has been reached Acute phase has passed
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Pain Presentation
Bilateral anterior-medial knee pain with left side more troubled then the right Aggravated by squatting, prolonged sitting and extending the leg into extension Feels like the knee is going to lock when the knee is in flexion 3 months prior had a couple of acute episodes during a long inventory inspection, which called for repeated squatting & kneeling, with pain so intense the patient could not arise. Within an hour of aggravation, the knees felt fine
Pain Drawing
Primary pain quality = achy
History - Activity
50 year old male Recreational bicyclist 34X/wk for 45 minutes per session on X-country ski simulator (Nordic-Trak)
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History - Occupational
Occupation warehouse inspection, calling for sitting at a computer, repeated kneeling and squatting and standing on hard concrete floors Medical history unremarkable No trauma to the area of involvement
History - Podiatrist
Pronation corrected many years ago by orthotics
Physical Examination
Visual inspection unremarkable with no edema Q angle normal Knee ROM full & without pain Motion palpation detects a definite eccentric glide of the patella bilaterally as patient extends the knee Pain upon palpation at lateral aspects of knee, left > right
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Q-Angle (Reference)
The Q-angle (or "quadriceps angle) is formed in the frontal plane by two line segments:
from tibial tubercle to the middle of the patella from the middle of the patella to the ASIS
The q-angle in adults is typically 15 degrees. Increases or decreases in the q-angles are associated in cadaver models with increased peak patellofemoral contact pressures (Huberti & Hayes, 1984). Insall, Falvo, & Wise (1976) implicated increased q-angle, along with patella alta, in a prospective study of patellofemoral pain. Increases in q-angle are associated with:
femoral anteversion external tibial torsion laterally displaced tibial tubercle genu valgus
References: Huberti, H.H., & Hayes, W.C. (1984). Patellofemoral contact pressures: The influence of Q-angle and tendofemoral contact. Journal of Bone and Joint Surgery, 66A, 715-724. Insall, J., Falvo, K.A., & Wise, D.W. (1976). Chondromalacia patellae: A prospective study. Journal of Bone and Joint Surgery, 58A, 1-8.
Orthopedic Evaluation
Thomas Test - indicative of a flexion contracture involving the iliopsoas musculature
Positive
Physical Examination
Marked tenderness of the entire iliotibial band, especially near the distal portion when mild to moderate pressure was applied No obvious muscle atrophy Circumference of thighs was symmetrical
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Physical Examination
Latent trigger point of vastus medialis
Orthopedic Evaluation
Abduction Stress Test (valgus) Indicative of a medial collateral ligament injury
Negative
Orthopedic Evaluation
Adduction Stress (varus)
Negative
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Orthopedic Evaluation
Apleys Compression Meniscus Injury Negative
Orthopedic Evaluation
Clarkes Sign
Mildly Positive Indicative of patellar chondromalacia
Orthopedic Evaluation
Trendelenburgs Test
Suggestive of insufficiency of the hip abductor system
Mildly positive
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Muscle Testing
+5 bilateral quadriceps
Muscle Testing
Hamstrings +5 bilaterally
Muscle Testing
+4 Hip Adductors bilaterally
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Muscle Testing
+4 gluteus medius bilaterally
Muscle Testing
Poor core stability
Poor Flexibility
Hamstrings Calf musculature
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Chiropractic Findings
Gillets Test Motion Palpation L/S spine Mild extension fixation right ilium Conclusion: not a significant contributor to patients symptoms Possibly compensatory to knee pain
IDK
I dont know!
Condromalacia Patella
Functional Muscle Imbalance Myofascial Pain of Vastus Medialis Iliotibial Band Syndrome
Treatment
Soft tissue release of ITB Deep pressure to tolerance for vastus medialis trigger point
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Treatment
Strengthening of:
Adductors Gluteus Medius
Treatment
Core stability strengthening Progressive Swiss Ball routines
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Treatment
Stretching :
Iliopsoas Calf group Hamstrings
Conclusions
Orthopedic testing is valuable yet has limits In the face of hard orthopedic findings, functional testing may lead to actual conservative therapy applied Multiple diagnosis may exist and all may need to be pursued Use your knowledge to understand
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