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 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 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 become such a pain in the back? Gait cycle

Left 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 ! Interosseous Membrane

Extends between the interosseus crests of the and

Helps to stabilize the Tib-Fib relationship

Separates the muscles of the front and the back of the leg Interosseous membrane

Ankle

Inversion Most common Anterior/Posterior Talofibular Fibulocalcaneal ligament

Eversion Deltoid ligament

High Ankle

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 (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 in extension Glut Maximus Glut Medius Fascia Lata deep fascia of the 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?

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