From Childhood to Adulthood OMT for LOWER EXTREMITY Hip, Knee, Ankle, Foot. Objectives
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1 From Childhood to Adulthood OMT for LOWER EXTREMITY Hip, Knee, Ankle, Foot Jan Hendryx, DO, FAAO Peek n Peak CME March 1, 2019 Objectives 1. Demonstrate knowledge of the anatomy of the lower extremity- Hip, Knee, Ankle, Foot 2. Discuss and describe the clinical presentation and diagnosis of common injuries to the lower extremity 3. Describe and demonstrate a complete H&P examination of the lower extremity 1
2 Objectives 4. Describe and demonstrate OMT techniques to treat lower extremity injuries and conditions: Specifically 1. FPR for Musculature/plantar fascia 2. Iliopsoas Muscle Energy/Hip capsule bounce 3. 5 (6 or 7)-Step Knee Treatment 4. Ankle/foot HVLA and articulation Hip Problems A patient presents with hip pain 2
3 Common Hip DDx Strain (muscles) Sprain (ligaments) Arthritis (OA, RA) Bursitis Radiculopathy Fracture Tumor Infection Synovitis Traumatic Somatic Dysfunction Pelvic girdle has three joints: Anatomy Acetabulofemoral joint - (hip joint) Sacroiliac joint (sacrum is the base of the spine & the innominate is considered part of the leg) Pubic symphysis (anterior strut that provides stability during walking or sitting) - The main motions of the pubic symphysis are superior/inferior glide and separation/compression 3
4 Anatomy Acetabulofemoral joint: Ball & socket joint- mobility & weight bearing Intrinsic stability due to shape, ligamentous & cartilaginous attachments Consists of: Acetabulum - Ilium - Ischium - Pubis Femoral head Mechanics 4
5 Muscle Function Hip Flexors: Iliopsoas - (hypertonic, runners, soccer, skaters have increased lumbar lordosis) Rectus femoris (stiff knee gait, retro patellar pain) Sartorius Muscle Function Hip Extensors Gluteus maximus Hamstrings Medial hamstrings - Semimembranosus - Semitendinosus Lateral hamstrings - Biceps femoris 5
6 Muscle Function Adductors 5 muscles Adductor longus Adductor brevis Adductor magnus Pectineus Gracilis Muscle Function Abductors Gluteus medius Gluteus minimus 6
7 Knee Problems A patient presents with knee pain Common Knee DDx Strain (muscles) Sprain (ligaments) MCL, LCL Medial/lateral Meniscal tear ACL/PCL tear Arthritis (OA, RA) Bursitis Radiculopathy Fracture Tumor Infection Synovitis Baker Cyst Traumatic Somatic Dysfunction Fibular head Tibiofemoral Chondromalacia patella Osgood-Schlatter 7
8 Knee Anatomy Meniscus 8
9 Observation, Inspection Bursitis 9
10 Osteoarthritis Knee Osteoarthritis Knee 10
11 KNEE ROM Flexion Degrees Extension 0-5 Degrees Tib-fib ER/IR 10 Degrees Ankle/Foot Problems A patient presents with ankle/foot pain 11
12 Common Ankle/Foot DDx Strain (muscles) Sprain (ligaments) Arthritis (OA, RA) Fracture Radiculopathy Fracture Traumatic/Achilles Tendon Plantar fasciitis Somatic Dysfunction Lateral Ankle Complex 12
13 Medial Ankle Complex Triangular deltoid ligament attachments tuberosity of navicular sustentaculum tali calcaneus medial tubercle of talus Epidemiology Estimated that there is one inversion injury of the ankle per 10,000 persons per day (U.S. 23,000/day) Ankle sprain is the most common sports injury (can be treated acutely and chronically with OMT!*) In running and jumping sports accounts for 25% of injuries Large majority of pts. are <35y.o., most are 15-19y.o. 13
14 Clinical Evaluation Ankle/Foot lateral malleolus arches plantar fascia 5 th Metatarsal base ligaments - (next two slides) Valgus test Varus test Clinical Evaluation Ankle/Foot Varus Test - Lateral ligaments Valgus Test - Deltoid (medial) ligament 14
15 Physical Exam Tests for ankle stability Anterior drawer test if positive is indicative of ATFL tear perform at neutral and at 10 degrees of plantar flexion Mechanism of Injury Tears progress in predictable sequence ATFL, anterolateral capsule, distal tibiofibular ligament, CFL, PTFL if PTFL ruptures, ankle dislocation may occur, eversion injuries may fracture the fibula inversion is most common sprain.85% 15
16 Inversion 85% Eversion 15% Physical Exam Palpate point of maximal tenderness include palpation of proximal fibula 16
17 Bones of the Foot Calcaneus Talus Navicular Cuboid Cuneiforms (3) Metatarsals (5) Phalanx (14) Accessory bones (up to 24) Be Mindful of the 5th 17
18 Rearfoot Injuries Talar Stress Fractures Calcaneal Stress Fractures Retrocalcaneal bursitis. Plantar fasciitis Somatic dysfunctions Metatarsalgia Pain in the region of the metatarsal heads. Ground reactive forces are not properly distributed. 18
19 Plantar Fasciitis SSX- First step in AM worst & w/ activity Point tender over medial calcaneal tuberosity Gastroc/achilles tight, overpronation common Pain reproduced w/ jumping on involved toes Fat Pad Syndrome- No pain w/ toe jumping may see heel spur in 30% Plantar Fasciitis Plantar Fascia- maintains longitudinal arch Provides shock absorption Helps develop push-off powerrunning/jumping Weight gain, growth spurt, poor shoeware Can be treated quickly and effectively with OMT!* (FPR) 19
20 OMT for Lower Extremity 1. Hip 1. FPR Muscles 2. Spencer Technique for the Hip 3. Fulford (see below) 2. Knee 1. 5 (6, 7)-Step Knee Treatment 1. Popliteal fossa MFR 2. Fulford technique 3. Fibular Head FPR (jiggle technique) 4. BLT 5. Patellar MFR 3. Foot/Ankle (HVLA, MFR, FPR) Questions? 20
21 References An Osteopathic Approach to Diagnosis and Treatment. DiGiovanna Second Ed: Atlas of Human Anatomy. Netter Clinically Oriented Anatomy. Moore Essentials of Muscluloskeletal Care. Walter Greene, MD. Pages Foundations of Osteopathic Medicine, 3 rd edition. Chila Physical Examination of the Spine and Extremities. Hoppenfeld. 21
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