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Opso Summer 2014 The Lower Extremity OPSO Summer Primary Care CME Conference August 15, 2014 K. Turner Slicho, DO Case Presentation 53-year-old Caucasian female complains of left sided SI pain described as an ache w/o radiation Initial onset of pain was 25 years ago, when her back “seized up” bending over to put her toddler to bed. Infrequent issues over the next 10-15 years, then began to be more problematic Now, constant pain over the last 2 years Numbness in a small area of left shin. Denies weakness, tingling Case Presentation Unable to sit for long periods, bend over, cross legs comfortably Does not lift her grandson Does not brush teeth bending over without holding the sink No longer exercising due to pain 15 chiropractic session with two different providers over 2 years with “absolutely zero effect” on her pain 12 physical therapy sessions with marginal effect Case Presentation PMHx: Unremarkable** FHx: Cancer, DM, Food Allergies, Meniere’s Disease, Restless leg syndrome, Ulcerative colitis PSHx: C-section 1990, Appendectomy 2009, Hernia repair 2005 Meds: Diclofenac 100mg BID Case Presentation X-Ray: L4-L5 degenerative changes. Normal pelvis and SI joints bilaterally MRI: mild degenerative changes L3-S1 without significant neuroforaminal or spinal stenosis Neurosurgical evaluation : non-surgical back Case Presentation Gen: NAD, A&O x 3 Neuro: 2+/4 DTR’s, Strength 5/5, no motor deficits, mild sensory loss in left superio-lateral shin Extremities: no edema, ecchymosis, peripheral pulses normal Case Presentation: Somatic Dysfunction findings Cervical: Left posterior OA facet restriction Lumbar: L5 ERSl, left iliolumbar ligament hypertonicity, mild left psoas spasm and left erector spinae m. spasm Sacrum: L on LOA torsion Pelvis: Left innominate anteriorly, bilateral gluteus medius m. hypertonicity, right TFL hypertonicity LE: Left talus plantarflexed, left fibular head posterior, bil. interosseus membrane restriction Case presentation Patient treated with MFR, BLT, FPR, ME techniques Instructed to follow-up in 1 week, and continue diclofenac as prescribed Patient to avoid heavy lifting until F/U Patient returned 1 week later, reporting she was symptom free since her last treatment Case Presentation: Somatic Dysfunction findings Cervical: Left posterior OA facet restriction Lumbar: L5 ERSl, left iliolumbar ligament hypertonicity, mild left psoas spasm and left erector spinae m. spasm Sacrum: L on LOA torsion Pelvis: Left innominate anteriorly, bilateral gluteus medius m. hypertonicity, right TFL hypertonicity LE: Left talus plantarflexed, left fibular head posterior, bil. interosseus membrane restriftion The Lower leg Why did the ankle become such a pain in the back? Gait cycle Left foot steps forward Heel strike :Left innominate posteriorly rotated, right anterior right foot plantar flexed During this motion, the sacrum rotates right Toward mid-stance, the left leg is straight and the innominate is rotated anteriorly Sacrum rotates left, lumbar spine side-bends left, rotates right Left leg swings through, foot into plantar flexion Right leg then steps forward, repeating the cycle on the other side Gait cycle image Where did the numbness in the shin come from? ` Fibular Head Reciprocal motion Plantar flexion of the ankle causes posterio-medial Posterior S/D can cause common peroneal nerve injury Fibular head is most common site of injury Foot drop Dorsiflexion of the ankle causes anterio-lateral movement of fibular head Take Home: The ANKLE FUNCTIONALLY STOPS AT THE KNEE! Interosseous Membrane Extends between the interosseus crests of the tibia and fibula Helps to stabilize the Tib-Fib relationship Separates the muscles of the front and the back of the leg Interosseous membrane Ankle Sprains Inversion Most common Anterior/Posterior Talofibular ligaments Fibulocalcaneal ligament Eversion Deltoid ligament High Ankle Sprain Extensor digitorum longus Origin: Lateral condyle of the tibia Upper ¾ of the anterior surface of the body of the fibula Upper part of the interosseus membrane Deep surface of the fascia Intermuscular septa between it and the tibialis anterior Extends toes and dorsiflexes the foot Opposite motion of inversion ankle sprain High Ankle Sprain Sprain of the syndesmotic ligaments that connect the tibia and fibula on the lower leg Described as high because they are located above the ankle Sudden forceful outward twisting of the foot Common in contact and cutting sports OMT and Acute Ankle Sprain N = 55 (28 in treatment group, 27 control) Patients 18+ y.o. with unilateral ankle sprain Both groups received current standard of care for ankle sprains Treatment group had one session of OMT Both groups returned for F/U one week later OMT and Acute Ankle Sprain Results OMT group had statistically significant improvement in edema and pain and a trend towards increased ROM immediately following OMT At F/U, both groups were significantly improved Patients in OMT group had statistically significant improvement in ROM compared to the control JAOA, Vol 103, No. 9, Sept. 2003, Eisenhart et. al. “Osteopathic Manipulative Treatment in the Emergency Department for Patients with Acute Ankle Injuries” Acute Ankle Sprain OMT HVLA likely not tolerated Make sure to address lymphatic restrictions Popliteal fascia Pelvic/abdominal diaphragm Thoracic outlet on left Effleurage Counterstrain/MFR to gastrocnemius/soleus m. Ankle Injury Recurrence Epidemiologic study conducted among 3 categories of Hong Kong Chinese athletes National teams Competitive athletes Recreational athletes Questionnaire sent to athletes having a history of ankle sprain Ankle Injury Recurrence Only athletes involved in sports on a regular basis chosen All must have sprained ankle(s) at least once, with detectable swelling and pain around the injured ankle Athletes with acute ankle sprain within a 3-month period excluded 400 questionnaires distributed and collected, 20 incomplete 380 for data analysis Ankle Injury Recurrence 73% of all athletes had recurrent ankle sprain 59% of these athletes had significant disability and residual symptoms which led to impairment of their athletic performance Residual problems included: Pain, instability, crepitus, weakness, stiffness, swelling British Journal of Sports Medicine 1994; 28(2). MPhil et. al. An epidemiological survey on ankle sprain Fibular head posterior Seated modification Can be modified for anterior or posterior fibular head MFR of IOM can be done from this position as well Muscle Energy Technique 3 IT Band Functional Anatomy of Lower Extremity IT band doesn’t contract! Transfers contractile forces TFL Superior Gluteal Nerve L5/S1 Courses between glut med and min Stabilizes hip in extension Glut Maximus Glut Medius Fascia Lata deep fascia of the thigh Fascia Lata Fibrous sheath that encircles the thight like a subcutaneous stocking and tightly binds its muscle Lateral Surface: combines with tendons of glut max and TFL to form IT band IT band extends from iliac crest to lateral condyle of the tibia In the erect posture, acting from below, it will serve to steady the pelvis upon the had of the femur, and by means of the IT band, it steadies the condyles of the femur on the articular surfaces of the tibia, and assists glut max in supporting the knee in a position of extension TFL Basic functional movement is walking TFL is a hip abductor Works in synergy with glut med/min to abduct the thigh and internally rotate the thigh TFL Injury? Stand on one leg with other leg raised If pain at the hip and knee and difficulty maintaining balance, can indicate TFL injury The Glutes: Beyond the Piriformis School OMT courses tend to focus on piriformis m. Gluteus maximus muscle is the LARGEST muscle in the human body Antagonist to iliopsoas muscle LBP implications Dysfunction of all the gluteal muscles can easily be assessed and treated with minimal patient assistance Treatment of Glutes Patient in lateral recumbent position Doctor stands behind the patient Gluteal region TPs assessed as well as myofascial tension Can move from one TP to the next assessing, and stopping to treat if warranted Treatment of Glutes Myofascial release Vector of force generally aimed towards the pubic symphysis 3D vector aimed at epicenter of tension Goal is to match your force vector to the tension of the tissue NOT ischemic compression/inhibition Good visual: Melt a chocolate chip to the tip on a hot dash board Gluteus medius Gluteus minimus Piriformis Tensor Fascia Lata All TP images from triggerpoints.net Deeper muscles of the pelvis Questions? Please feel free to leave topics of interest for future talks in the course comments section of the evaluation Welcome to email me as well: [email protected] - personal [email protected] - practice http://theosteopathportland.com .
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