9/12/12. Differen'al Diagnosis III: Neuromusculoskeletal DD 722. What does evidence- based. prac'ce mean to you? Will you be an evidence- based

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1 Differen'al Diagnosis III: Neuromusculoskeletal DD 722 Dr. James J. Lehman Associate Professor of Clinical Sciences University of Bridgeport College of Chiroprac'c What does evidence- based prac'ce mean to you? Will you be an evidence- based prac''oner? What is pa'ent- centered care? 1

My Message Pa'ent centered care requires medical doctors and chiropractors to work side- by-

enhances pa'ent safety and quality of care.

The language in the bill ensures that doctors of chiroprac7c can be included on these

2 My Message Pa'ent centered care requires medical doctors and chiropractors to work side- by- side. Integra'on of evidence- based chiroprac'c services into the health care system enhances pa'ent safety and quality of care. The Affordable Care Act permits chiropractors to func7on as members of the primary care team. The language in the bill ensures that doctors of chiroprac7c can be included on these pa7ent- centered and holis7c teams. The non- discrimina7on provision li=s some of the burden imposed by unfair limita7ons of certain insurance companies. 2

Pain Care in America Must Change Most people in pain, including those with chronic

But current systems of care do not adequately train or support internists, family

care in mee7ng the challenge of trea7ng pain as a chronic illness.

3 Pain Care in America Must Change Most people in pain, including those with chronic symptoms, go to primary care providers to get relief. But current systems of care do not adequately train or support internists, family physicians and pediatricians, the other health care providers who provide primary care in mee7ng the challenge of trea7ng pain as a chronic illness. Primary care providers o=en receive lidle training in the assessment and treatment of complex chronic pain condi7ons. Achilles Tendon Pa'ent centered care requires medical doctors and chiropractors to work side- by- side. Strongest tendon in the body Provides the power in the push off phase of the gait cycle Strain of Plantar Fascia Related to 'ght achilles tendon and gastrocnemius muscles Common in runners and dancers May lead to plantar fascii's 3

Achilles Rupture Osseous Pain 1. Pop or snap 2. Feels like a gunshot or kick 3.

may be a dull ache, crampy or spasm sensa'on Trigger points may be localized with pin point pain or diffuse with poor

pain without movement Stabbing or lightning- like Tingling and/or numbness Generalized Pain Descrip'on Myofascial Trigger

4 Achilles Rupture Osseous Pain 1. Pop or snap 2. Feels like a gunshot or kick 3. Inability to ambulate Generalized Pain Descrip'on Joint pain may be constant dull, deep ache but sharp upon mo'on Muscle pain may be a dull ache, crampy or spasm sensa'on Trigger points may be localized with pin point pain or diffuse with poor localiza'on and paresthesias (formica'on) Generalized Pain Descrip'on Nerve pain may be: Constant Burning and or hot Sharp pain without movement Stabbing or lightning- like Tingling and/or numbness Generalized Pain Descrip'on Myofascial Trigger Point Ligament pain may be a burning, dull or a deep ache but it may be referred to scleratomes Bone pain may be a deep burning or dull sensa'on Vascular pain is usually a throbbing sensa'on 4

Myofascial Pain & Dysfunc'on Referred Pain Plantar Fascii=s Pain

point refers to the dorsum of foot and large toe Travell and Simons

= no pain 1 = pain with palpa'on 2 = pain and wincing with palpa'on 3

5 Myofascial Pain & Dysfunc'on Referred Pain Plantar Fascii=s Pain Specific referenced muscle referral zones Anterior 'bialis trigger point refers to the dorsum of foot and large toe Travell and Simons Soleus Plantar and Achilles Examina'on Pain/Tenderness Grading Scale 0 = no pain 1 = pain with palpa'on 2 = pain and wincing with palpa'on 3 = pain, wincing and withdrawal from palpa'on 4 = will not permit palpa'on Cipriano 5

6 Observa'on of Ruptured Achilles Thompson s Test Flex knee Squeeze calf Mechanical contrac'on of gastrocnemius and soleus will not plantar- flex the foot 6

7 Treatment and Preven'on of Pedal Problems Stretching Rest and massage Sleeping posture Hydra'on Properly fidng shoes Shock absorp'on ortho'cs 7

8 8

Observa=on Ankle Sprain Lateral ankle sprain is

sprain Grade I II III Overstretch Par'al Rupture

and swelling Ecchymosis Minimal Moderate Severe

None Usual Most always Ankle Examina'on Palpa'on

9 Observa=on Ankle Sprain Lateral ankle sprain is the most common ankle sprain Grades of an ankle sprain Grade I II III Overstretch Par'al Rupture Loss of func'onal ability Minimal Some Great Pain and swelling Ecchymosis Minimal Moderate Severe Usually not Common Yes Difficulty weight bearing None Usual Most always Ankle Examina'on Palpa'on and Range of Mo'on Subtalar Examina'on Passive Range of Mo'on 9

Anterior drawer test To assess the integrity of the anterior talofibular

If the ligament is torn, the talus will subluxate anteriorly compared with

the opposite forces to challenge the posterior talofibular Inversion

integrity of the calcaneofibular ligament and/or anterior talofibular

indicated only if a pa'ent has pain in the malleolar zone and any of the

10 Anterior drawer test To assess the integrity of the anterior talofibular ligament. If the ligament is torn, the talus will subluxate anteriorly compared with the unaffected ankle Posterior Drawer Test Posterior drawer employs just the opposite forces to challenge the posterior talofibular ligament. Inversion stress test or talar =lt OEawa Ankle and Foot Rules To assess the integrity of the calcaneofibular ligament and/or anterior talofibular ligaments Should be used to determine necessity of radiographic examina'on of the trauma'zed ankle and foot. Ohawa Rules Zones Ohawa Ankle and Foot Rules Ankle radiography is indicated only if a pa'ent has pain in the malleolar zone and any of the following findings: bone tenderness at 'p of medial or lateral malleolus or the inability to bear weight (four steps) immediately ajer injury and in the emergency department or physician's office. 10

Ohawa Ankle and Foot Rules Foot radiography is indicated only if a pa'ent has pain in the midfoot zone and any of the

immediately ajer injury and in the emergency department or physician's office.

The protocol includes eleva'ng the ankle and protec'ng it with a compressive device.

11 Ohawa Ankle and Foot Rules Foot radiography is indicated only if a pa'ent has pain in the midfoot zone and any of the following findings: bone tenderness at base of 5 th metatarsal or navicular or the inability to bear weight (four steps) immediately ajer injury and in the emergency department or physician's office. Talar Tilt Test The assessment reveals a grade 3 lateral ankle sprain of the anterior talofibular and calcaneofibular ligaments? PRICE The immediate goals of trea'ng acute ankle sprain are to decrease pain and swelling and protect ankle ligaments from further injury. The PRICE (Protec'on, Rest, Ice, Compression, Eleva'on) treatment protocol for acute ankle injury is commonly used. The protocol includes eleva'ng the ankle and protec'ng it with a compressive device. Ice is applied to the injured ankle, and the pa'ent is advised to rest for up to 72 hours to allow the ligaments to heal. Aircast Ankle Brace A Cochrane review showed that lace- up or semirigid supports are more effec've for ankle injury than tape or elas'c bandages High Ankle or Syndesmo=c Sprain Test The crossing of the affected leg over the other leg will produce pain with a high ankle sprain of the interosseous membrane. 11

$fracture of the 'bia/fibula or syndesmo'c sprain.$ No'ce separa'on of the 'bia and fibula due to syndesmo'c

High Ankle Sprain Surgical Repair Syndesmo'c ligament sprain

screw corrects alignment and stabilizes without compressing

$Plantar fascii's 5. Avulsion fracture 6. Stress fracture 7.$

12 Poh s Compression Test Stress Radiographic Study Tests for fracture of the 'bia/fibula or syndesmo'c sprain. No'ce separa'on of the 'bia and fibula due to syndesmo'c sprain. High Ankle Sprain Surgical Repair Syndesmo'c ligament sprain Squeeze test Stress radiographs Syndesmo'c screw Syndesmo'c screw corrects alignment and stabilizes without compressing the syndesmo'c ligament. Condi=ons of the foot and ankle 1. Achilles tendoni's 2. Shin splints 3. Lateral ankle sprain 4. Plantar fascii's 5. Avulsion fracture 6. Stress fracture 7. Complete fracture 8. Blister 9. Subungual hematoma 10. Ganglionic cyst 12

Evalua'on of the Knee What type of injuries should we

Knee Injury Strain, Sprain, Internal Derangement Please

injury. Knee Pain Osgood Schlaher s Disease? Jumper s knee?

Patellofemoral Dysfunc'on Patella Apprehension Test Pain and

patellar disloca'on Patellofemoral Dysfunc'on Dreyer s Test

13 Evalua'on of the Knee What type of injuries should we consider with our differen'al diagnosis of the knee? Knee Injury Strain, Sprain, Internal Derangement Please differentiate an internal derangement from an external knee injury. Knee Pain Osgood Schlaher s Disease? Jumper s knee? PFA? Collateral ligament sprain? Meniscal tear? Patellofemoral Dysfunc'on Patella Apprehension Test Pain and apprehension are present Posi've test indicates lateral patellar disloca'on Patellofemoral Dysfunc'on Dreyer s Test Stabilize quadriceps tendon and pa'ent able to raise leg indicates trauma'c patellar fracture 13

Patellofemoral Dysfunc'on Clarke s Patellar Scrape Test Pain and

patellae Pes Anserinus From anterior to posterior, pes anserinus is

medial collateral ligament Osgood Schlaher s Lesion Anterior

Fracture may occur with an acute injury Thessaly Test for Meniscal

14 Patellofemoral Dysfunc'on Clarke s Patellar Scrape Test Pain and crepita'on may indicate patellofemoral arthralgia or chondromalcia patellae Pes Anserinus From anterior to posterior, pes anserinus is made up of the tendons of the sartorius, gracilis, and semitendinosus muscles. Conjoined tendon lies superficial to the 'bial inser'on of the medial collateral ligament Osgood Schlaher s Lesion Anterior tubercle of 'bia inflamma'on with young athletes who run and jump Fracture may occur with an acute injury Thessaly Test for Meniscal Tear Posi=ve findings Repeat process at 20 degrees Pain medial or lateral Clicking or locking Most accurate at 20 degrees of knee flexion 14

Grading Strain & Sprain Injuries Grade 1:

15 Grading Strain & Sprain Injuries Grade 1: Microscopic tears Grade 2: Par'al tears Grade 3: Complete tear with rupture Causes of Popliteal Cyst An accumula'on of synovial fluid Meniscal tears in children DJD in adults Remember It is an honor and a privilege to treat another human being. One Final Thought Diagnosis is the key to successful treatment! Ligament Injuries Medial collateral and anterior cruciate ligaments are the most commonly injured. 15

Ankle and Foot Orthopaedic Tests Orthopedics and Neurology DX 612

Ankle and Foot Orthopaedic Tests Orthopedics and Neurology DX 612 James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic Ankle & Foot Anatomy Stability of the ankle is dependent