Download OMM 18: Hip and Pelvis Differentials – everything in red OMM 20

OMM 18: Hip and Pelvis Differentials – everything in red
OMM 20: Palpation/ROM of Pelvis and Hip
a. Identify landmarks and anatomical structures of the hip.
b. Identify the functional anatomy of the hip.
c. Name the musculoskeletal relationships involving the spine, pelvis and hip.
d. Recognize and palpitate for common somatic dysfunctions of the hip and how to
diagnose and include in a differential diagnosis.
e. Identify important landmarks which are utilized when osteopathically evaluating a
patient with a hip complaint.
f. Identify and demonstrate findings for somatic dysfunction of the hip involving:
i. Flexors/extensors
ii. Abductors/adductors
iii. Internal rotators/external rotators
iv. Iliotibial band
g. Recognize how a muscle may have a different motion/function when utilizing a
different joint (Ex: Hamstrings: hip extensor and knee flexor).
OMM 21: Ankle and Foot (everything he focused on)
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a. Recognize the surface anatomy of foot and ankle. AND f. Identify the various arches of the
foot and explain their function with respect to body mechanics.
I.
II.
III.
IV.
V.
True ankle = talotibial (dorsi and plantar flexor)
Transverse tarsal joint
Tarsal-metatarsal joint
Functional Arches
a. Lateral Arch focus: in walking, the distribution of weight shifts
i. from the heel to the lateral border of the foot,
(2) then to the metatarsal heads
(3) finally to the hallux for push off
b. Other arches of foot
i. Transverse Arch = cuneiforms, navicular, cuboid
1. Muscular attachments: peroneus longus m. induces eversion
(pronation) of cuboid
2. Tibialis anterior m. induces inversion (supination) of navicular
(dorsiflex)
3. These 2 actions combined allow the cuneiforms to depress
ii. “Metatarsal Arch” (not a TRUE arch) – articulations of metatarsal heads w/
phalanges
Functional ankle: motions
a. Tibiotalar joint (true ankle mortise)
i. Axis of Motion
ii. Major & Minor Motions
1. Dorsiflexion with posterior glide
2. Plantar flexion with anterior glide
b. Talocalcaneal joint, subtalar joint (shock-absorber)
i. Distributes forces for foot
ii. Axis of Motion
iii. Motions
VI.
VII.
VIII.
IX.
X.
1. Posterolateral glide with foot inversion
2. Anteromedial glide with foot eversion
c. PRONATION-SUPINATION at subtalar (talocalcaneal), on oblique axis
i. Supination: PIA (Dr Wms. memory hooks)
1. Plantar flexion
2. Inversion
3. aDduction
ii. Pronation: DEA (Dr Wms. memory hooks)
1. Dorsiflexion
2. Eversion
3. aBduction
iii. Lateral ankle ligaments: ATF, CF, PTF
1. ATF is MOST COMMON for ANKLE SPRAIN
iv. Medial ankle: Deltoid ligament
Plantar Fascia – really thick.
a. Function = provide static support for longitudinal arch of foot and assist w/ shock
absorption during foot strike
b. During the heel-off phase of gait, tension increases on the plantar fascia, which acts
as a storage of potential energy. During toe-off, the plantar fascia passively
contracts, converting the potential energy into kinetic energy and imparting greater
foot acceleration.
c. Is contiguous w/ gastroc and soleus fascia (called “gastrosoleus complex”)
d. PLANTAR FASCIITIS = pain by inflammation of the insertion of the plantar fascia on
the medial process of the calcaneal tuberosity
i. classic complaint is of pain, localized to the inner aspect of the heel, worse
in the morning on getting out of bed
ii. It usually subsides after several steps, but then recurs with increasing
frequency and severity with progressively less provocation. Often the pain
extends forward to involve the arch.
Ankle and foot ROM
a. Dorsiflex = 20 deg
b. Plantar flex = 50
c. Inversion = 5
d. Eversion = 5
e. aBduction = 10
f. aDduction = 20
Talus has Tripod action, distributes weight to : hindfoot (calcaneus), medial long arch,
lateral long arch.
a. Talus is a body weight distributor. Covered by ligamentous attachments and
articulation surces
The Mortise Joint
a. Ankle stability is increased in dorsiflexion, where the wide anterior talus fits into the
tib/fib mortise.
Why can you supinate more than dorsiflex the ankle?
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b. Identify and outline a systematic approach to evaluating a patient with foot/ankle
complaint(s). Document this in SOAP format. AND g. Identify and demonstrate the findings for
foot and ankle somatic dysfunction.
I.
II.
III.
IV.
V.
Tarsal Somatic Dysfunction
a. Cuboid – medial plantar edge rotates laterally
b. Navicular – lateral plantar edge rotates medially
c. Cuneiforms – 2nd cuneiform glides directly inferior
Somatic Dysfunction of Transverse Arch (Dx by palpating plantar surface for depressed
bones
a. Cuboid (lateral) tends to move laterally around an AP axis (eversion)
i. Edge is prominent midline on the plantar surface
b. Navicular (Medial) tends to move medially around an AP axis (inversion)
i. Edge is prominent midline on the plantar surface
SOAP – Taking a Hx, take into account
a. OLDCARTS
b. Previous injury or surgery
c. Meds and allergies
d. Social Hx work status, Fam Hx
e. ROS
SOAP - Physical Exam – Inspection
a. Note swelling, ecchymosis, deformity, scar, infection
b. Pes Planus
i. Longitudinal & transverse arches fall
ii. Talocalcaneal joint axis more horizontal
iii. Tarsal somatic dysfunction
iv. Navicular prominence on medial side of foot
c. Pes Cavus
i. Arches rise
ii. Axis more vertical
iii. Navicular less prominent
d. Checking Gait
i. Heel strike on outer 1/3 of heel
1. Heel wear pattern
ii. Bear weight on lateral longitudinal arch
iii. Transfer weight to 1st, 2nd, and 3rd metatarsals
1. 1st MTP joint dorsiflexion important for gait push-off (usually at
least 60 degrees)
iv. Push-off with great toe
e. ROM of ankle
i. Sit, have them dorsi, plantarflex, invert and evert. Active and passive.
SOAP – Palpation
a. Anterior: Tibialis anterior, Extensor hallucis longus and brevis, Extensor digitorum,
Dorsalis pedis (PULSE), midfoot
b. Medial: Tibialis posterior, Flexor digitorum, Flexor hallucis, Posterior tibial artery
(PULSE)
c. Lateral: Peroneus longis and brevis, ATF, CF ligaments, Cuboid, 5th MT base
d. Plantar: Plantar fascia, Sesamoids of 1st MTP, Cuboid
e. Posterior: Calcaneus & Achilles tendon
f. They HAVE to take off their shoes.
g. A complete exam means both sides examined, and looking at one joint above and
below the problem area.
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c. Recognize and demonstrate to your faculty screening tests for the ankle and foot and
understand what a positive finding means.
I.
II.
III.
IV.
Swing Test for talar dysfunction
a. Can detect subtle loss of motion
b. The foot is kept parallel to the floor with the knee flexed. If there is a plantar flexed
talus (anterior dysfunction) then the foot will appear plantar flexed toward the
ground at the barrier.
Stability Tests
a. Anterior drawer test – test anterior talofibular ligament (ATF). Hand on thir foot,
slide it toward ya, you should feel an endpoint
b. Talar Tilt test – test integrity of CalcanealFibular Ligament (CF). right hand fingers
are monitoring the space just below the lateral malleolus. The talus and calcaneus
are rotated toward the medial side.
c. Reverse Talar Tilt – test integrity of deltoid ligmment. Reverse of talr tilt (rotate
toward Lateral malleolus)
d. Talocalcaneal Dysfunctio test - Talar glide (talus on calcaneus)
i. Test glide (talus on calcaneus) in an anteromedial/ posterolateral direction
as limited by talocalcaneal ligament
ii. S/D is named for the direction it wants to go
iii. Eversion = anteromedial shift
iv. Inversion = posterolateral shift
Manual Muscle Testing
a. Subjective scale of 5
b. Compare to other side
c. 0 no motion
d. 1 a flicker
e. 2 motion with gravity
f. 3 motion against gravity
g. 4 some resistance
h. 5 full strength
i. Patient should be stronger than you!!!!
Special Tests
a. Thompson Test - Squeeze of the calf plantar flexes the foot if achilles tendon is
intact.Done against gravity to increase sensitivity.
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d. Identify common findings in an ankle sprain including its effect on other joints.
I.
General – Ankle Sprains
a. Common Mechanism
i. Inversion, plantar flexion
ii. ATF is usually injured
b. Exam Findings
i. Edema prominent
ii. Decreased ROM
iii. Pain at ATF
iv. Increased anterior drawer, ? Talar tilt
v. + swing test
vi. Late ecchymosis
c. Ankle Exam
i. Perform evaluation
ii. Dorsiflexion, plantar flexion, inversion and eversion.
1. Note excessive inversion. c/w history of inversion sprain, often
multi sprains.
iii. A tibiotalar dysfunction may cause a discrepancy in your Ankle Drawer Test.
d. Sprain Degrees of Severity
i. 1st Degree
1. Ligament integrity
2. Conservative care
nd
ii. 2 Degree
1. Partial tearing (slight laxity)
2. Usually no need for surgery
rd
iii. 3 Degree
1. Complete rupture
2. Immobilization
3. Surgery rarely indicated
e. Ankle Drawer Test
f.
Motion Issues secondary to trauma
i. Shape of talus
1. Inversion, plantar flexion puts narrow posterior talus in mortise
joint
2. Offers little stability; forces ligaments & muscle effort for stability
ii. Peroneal muscles
1. Rapidly eccentrically loaded
iii. Talus jammed into joint
1. Weight of body coming down ‘jams’ talus into crural (distal tib/fib)
articulation
g. Shin splints - complaint is usually of pain at the medial border of the tibia, the bone
on the inside of the lower leg. It involves degeneration and micro-tearing of the
tendons of the muscles that flex the toes and the forefoot- the flexor digitorum
longus, flexor hallucis longus and tibialis posterior. The usual biomechanical source
of the syndrome is either functional lowering of the longitudinal arch together
with hyperpronation which is normally compensated for by the tendons of those
muscles; or through weakness and overloading of the muscle in front of the shin,
the tibialis anterior.
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I.
II.
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e. Recognize and identify the neural, vascular and lymphatic structures/regions of the
ankle/foot and their importance.
Dorsal Foot innervation
a. “L4-L5-S1” – know that there’s no true L5 reflex but you can check extensor halluces
longus
b. Saphenous n, superficial and deep peroneal n, sural n.
Plantar Foot Innervation
h. Review OMM techniques for the foot and ankle. (I just copied these over from the class
PPT, you may want to check them against the lab PPT.)