Week 9, Tuesday

Illness Script - Cervical

Sprain:

  • whiplash, hyper flexion/hyperextension

  • Tears in facet capsule or annulus

  • Repetitive overuse

  • ~1 million whiplash/year

  • Neck pain from ligaments, referred pain, achy

  • +PROM

  • -RROM

  • -Valsalva

  • -Max. Foram compression

  • +jackson

  • +foraminal compression

  • +distraction

  • +shoulder depression

  • -neuro (no arm pain)

Bulge:

  • annular injury

  • Degenerative

  • More common in females

  • C6/7 most common

  • 25% of cervical radiculopathy Ed’s

  • 2-4% prevalence

  • Neck pain only from annulus, achy

  • +/- Valsalva

  • +foraminal compression

  • +max foram. compression

  • +Jackson

  • -distraction

  • +ROM

  • Extremity symptoms:

    • Protrusion =neck and arm pain

    • Rupture= shoulder, arm, hand pain

    • +Bakody

    • Possible neuro

Strain:

  • Torn muscle fibers or fascia

  • Repetitive overuse

  • Neck pain from muscles

  • Stiff in AM, loosens with movement

  • -PROM

  • +RROM

  • -Valsalva

  • -compression Tests

  • +distraction Possible

  • +shoulder depression (Distracted side)

  • -neuro

If there is a positive Valsalva, think Disc lesion

Patho Systemic Spine ppt

What would tell you the pain could be systemic?

  • Etiology unknown

  • Lasted more than 2-3 months

  • Only relief when laying supine

  • Constitutional symptoms

  • No position increases or decreases the pain

Common Systemic symptoms:

  • Systemic tends to be bilateral

  • Posture doesn’t affect

  • Deep, boring, radiating pain

  • Segmental pain with radiation inside body

  • 4+ joints (polyarticular)

Organs can refer pain

Epidemiology:

  • sex

  • Age

  • Race

  • Risk factors

  • Prevalence

  • Incidence

DISH: Diffuse Idiopathic Skeletal Hyperostosis

  • ossification of anterior Long spinal ligaments, increases Ca salts, 4+ segments

  • 25% of males over 50 y/o

  • 15% of females over 50 y/o

  • Multifactorial heredity - 6-12%

  • 80% have pain/stiffenss in thoracic spine, difficulty swallowing

  • T7-T11

  • Not common in extremities or before age 50

  • Risk factors - Diabetes

  • Increased risks of spinal fracture

  • Facets and SI not involved

  • Not an inflammatory arthritide

  • 3+ syndesmophytes (takes 4 bones)

  • Inflammatory affect when the bone calcifies

  • These guys love Chiros

AS: Ankylosing Spondylitis

  • Enthesistis - inflammatory arthritides that fuses the spine overtime (causing “bamboo spine”)

  • 4:1 male DX by age 20

  • Pain> 5 months, insidious onset

  • SI and Hip pain most common

  • Spinal stiffness

  • Prevalence 0.1%-0.4%

  • Hyperkyphosis

  • Flares and remissions (can have weeks-months of severe pain followed by weeks-months of little to no pain)

  • Also affects eyes, ankle, shoulder joints, inflammatory bowel diseases, heart

  • Genetic= HLA-B27

  • Pain usually starts in the SI and Hips

  • Autoimmune disease

  • You can often see it on X-ray because of the new bone forming

  • Palpating is like palpating a concrete block because there is very little to no give in the spine

  • Low velocity adjustments are good for these patients

Inflammatory arthritides are widespread, not local, because they are always driven by an auto immune dysfunction

Psoriatic Arthritis:

  • chronic inflammatory skin condition

  • Severe itching, most commonly in patches on the elbows, knees and scalp

  • Up to 30% will develop psoriatic arthritis

  • Inflammatory arthritide (enthuses and synovial)

  • Joint six appear ~10 years after the skin condition

  • Starts ~40-60 y/o

  • Males=females

  • 7.5 million Americans have the skin condition

  • Psoriatic arthritis is between 0.25% and 1% of the population

  • Psoriatic arthritis can cause erosion of joints

  • Affects spine and extremities

  • Pitting nails

  • 78% have Sacroilitis

Sacroilitis:

  • mechanical or systemic

  • Inflammation of the SI joint(s) Due to arthritis, injury, pregnancy, or bacterial infection

  • Associated with AS and inflammatory arthritis (Reiter’s, psoriatic)

  • Buttock and LBP

  • Mostly males

  • Prolonged staying/stair climbing/running/seated

Peptic Ulcer Disease (PUD):

  • Visceral somatic referred pain (thoracic)

  • Erosion of the lining of the stomach or small intestine - H. Pylori bacteria

  • Adults

  • Gastric - pain after eating

  • Duodenal (4:1) - pain 2-3 hours after eating

  • 4-6 million per year, 6,000 deaths

  • Most are uncomplicated

  • Middle back pain, burning, stomach pain, dark stools

  • Alarm - weight loss, difficulty swallowing, bleeding, anemia, family history

  • Risk - overuse of aspirin, alcohol, smoking

Abdominal Aortic Aneurysm (AAA):

  • Weakening of the aortic wall

  • >3cm or 1.5X normal size

  • Asymptomatic until it tears open/ruptures

  • Sx. Tearing/ripping back pain where the teat occurs

    • Pulsation and pain in the abdomen

    • LBP when it bleeds

    • Increased pulse rate

    • SOB

    • Nausea

  • Acute onset, very sudden

  • 50% arrive at hospital alive

    • The other 50% don’t usually have symptoms, and these people die before they get to the ER

  • This can be seen on X-ray

  • Blood Pressure drops when there is a tear

  • Can see sometimes when patient lays supine, you can see their abdomen pulsing

  • Not all rupture, fast expanding types at most risk

  • >5.5cm or expands ½ cm in 6 months

  • 4-6:1 maple

  • 0.5%-3.2% prevalence

  • Risk- Caucasians over 65 y/o, smoking, hypertension, coronary artery disease

  • 14th cause of death @ 6,000/year

Spinal Metastasis:

  • Cancer cells from one area (primary) level through the circulatory system to other body areas (metastasis)

  • 77% come with an established cancer DX

  • 23% metastasis is the first symptom

  • X-ray shows dark or white spots on the bones

  • Easy to spread to all bones of the spine because there are no Valves on those arteries

  • Bone will begin collapsing because the cancer eats away at it

  • A good way to CYA is to ask ROS questions that can help rule these things out

  • Bone is the third most common organ affected by metastases, after the lung and liver

  • Spinal Metastasis = 50% from the breast, prostate, lung

    • 2/3 occur in the thoracic spine

  • Stage 4 = 3-5% of all cancers

  • Breast is #1 malignancy, #2 COD in women, 2/3 spread to the spine, 69% of advanced disease goes to spine

  • Prostate - 50-70 y/o males, #2 malignancy death, 80% diagnosed at local stage, 80% of metastasis Les tot he spine

  • Lung is #3 cancer that spreads to the bone, 30-40% metastasize to the spine, 70% to thoracic spine, 20% to lumbar spine, 10% t cervical gradual onset

Malignancy: the absence of all the following criteria rules out this DX

  • Older than 50

  • Hx of cancer

  • Symptoms more than one month

  • Unexplained weight los

Osteoporotic Compression Fractures:

  • 800K per year

  • Most common fx

  • Silent until it fails

  • Risk factors= post menopausal, Caucasian, steroid/prednisone use, over the age of 70, previous DX, poor diet, lack of exercise

  • Pain is worse with movement/changing positions, coughing sneezing

  • Increased kyphosis Results

  • Sudden onset for no reason

  • Can be anywhere from Silent to very painful

  • Thoracic, thoracolumbar area most common T12-L2

  • 25% of all post menopausal

  • 40-50% of women over age of 80

  • Height shortens

  • Males risk is 50% less than females

The test will basically just be mechanical vs systemic

  • vindicate will be on the test

  • Disease questions will be black and white

  • Illness scripts are the best study guides for the neck and low back

  • Need to know what positions put more pressure on what parts of the spine

  • Multiple choice, true/false, and some short answer questions

  • Must-not-miss, most probable, vindicate, etc.

Lower Extremity pdf

Most mechanical issues are monoarticular

You need to do a good history and perform a good exam

Hip Joint:

  • 6 ranges of motion

  • Ball-and-socket joint

  • Strong fibrous capsule and powerful muscles

  • Synovial joint (can have synovitis)

  • Key feature is referred groin pain

  • Mechanical:

    • Trauma, acute

  • Pathological:

    • Systemic, chronic

Hip Osteoarthritis:

  • Decreased ROM-

    • abduction, internal and external rotation

  • Wear and tear of cartilage causing fragmentation, leads to altered biomechanics

  • Groin and buttock pain, grinding and crunching

  • Very common

  • Onset = 60 y/o

  • Risk -

    • previous trauma, obesity, heavy physical labor, genetics, endocrine

  • Any joint with degenerated fibrocartilage or hyaline cartilage will cause grinding and crunching feelings

Labral Tear of the Hip:

  • labrum

    • Deepens the hip socket

    • Decreases friction

    • Adds stability

  • Tearing or detachment of the fibrocartilaginous labrum can cause

    • click

    • pop

    • feeling like the hip will give way

  • Inner 2/3 - poor blood supply

  • 90% groin pain, gluteal pain

  • Trauma -

    • acute or overuse

  • Risk-

    • Congenital dysplasia, capsule laxity, older

  • 20% of athletes with groin pain, any age

  • Female 3:1 male

Cartilage fails with compression

Piriformis Syndrome:

  • Sciatic nerve chemically irritated from the myofascitis of the Piriformis muscle, can compress the sciatic nerve

    • Piriformis causes 6-10% of all sciatica

  • Women 6:1

    • Middle age, runners, bikers

  • external rotation of the leg

  • Deep buttock pain/tigh pain

    • “Migraine the butt”

    • Sciatica to the knee/thigh pain

      • Most common scenario, but can go to the plantar foot

  • Prolonged seated, climbing stairs provocative

    • Once provoked unable to find position of relief

  • Wakes up at night

  • Walking, massage, stretching, roller all palliative

Trochanteric Bursitis:

  • Inflammed Trochanteric Bursae

  • Female 4:1

    • Any age, more common 30-50 y/o

  • Acute trauma or overuse

  • Associated with running, biking, direct impact

  • Swelling may be visible, warm

  • Pain localized over trochanter/lateral pain

  • Painful to lay on involved side

  • Provoked by activity

  • Risk-

    • Overuse, leg length inequity, obesity, contracture of soft tissue, injury to hip or SI, OA of hip

IT Band Syndrome/ Tendinitis:

  • inflammation of ITB which rubs against lateral femoral condyle, bend knee at 30*

  • Associated with athletes

  • Male=female

  • Lateral buttock/hip and/or knee pain

    • May feel repetitive pop by knee

  • Overuse-

    • Runners, bikers, rowing, weight lifters

    • “Runner’s knee”

  • Most common cause of lateral knee pain

  • Risk-

    • Overuse, leg length inequality, poor shoes, over pronation, genu varum, muscle imbalance