!"#$%&'()*+,-%.)'&-&+%)*+89:;5<8/=<8:;+ Objectives !"#$%&'()*+,-%.)'&-&+%)*+/(-*0*+ /(-*0*+1$'20*($0&+1$'20*($0&+ Participants will: 3'$+456+1%-)3'$+456+1%-) 1. Understand how learning ultrasonography can advance your comprehension of MSK +-)+71 anatomy . AACPDM 2015 2. Be able to explain the advantages of Austin, TX ultrasonography in the diagnosis of MSK pain complaints in patients with CP. 3. Understand the use of ultrasonography for BRADLEY D. FULLERTON, MD, FAAPMR needle guidance in pain procedures . President, American Association of Orthopaedic Medicine www.aaomed.org
What is Prolotherapy? “A treatment to permanently strengthen the ‘weld ’ of disabled ligaments and tendons to bone by stimulating the production of new AUSTIN bone and fibrous tissue cells ”
Courtesy of Jeff Patterson, DO, Hackett-Hemwall Foundation 4 During his medical training, What is Hackett was influenced by Sir Henry Head who originated Prolotherapy? the phrase “Referred pain”
Clin Sci, 4,35 . 1939.
Courtesy of Jeff Patterson, DO, Hackett-Hemwall Foundation 5 6
Interspinous Ligaments ! What do you see here? not facets or discs
Kellgren, J.H. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin Sci,4,35 . 1939.
7 8 An Optic nerve “data dump”
10
Knee A Case of Knee pain effusion • 11 yo Cherokee female with spastic diplegia • Diffuse knee pain, increasing recently • Responds initially to phenol neurolysis of nerve to the rectus femoris • Patella Alta • Weak gluts • Crouched gait
11 12 Be a clinician and What be an empirical scientist stabilizes these “Science and art have in common intense structures? seeing , the wide-eyed observing that generates empirical information. - Edward Tufte
From Beautiful Evidence by Edward Tufte 2006, Pg 9, Graphics Press 14
What stabilizes Traditional Anatomy & this structure? Biomechanics • Muscles are defined by what they do to Q: If the skeleton the bones. is the frame, • Memorize origins and insertions how do we • Memorize actions of muscles understand soft • Picture lines of force and then we tissues? understand joint movement !right?
A: The soft tissues are secondary The current equation : Gluteus maximus Origin + Insertion = Action
1. Where does Gluteus Maximus originate ?
2. Where does Gluteus Maximus insert ?
What are the “textbook” actions “in real bodies, of gluteus maximus? muscles hardly ever 1. Hip extensor transmit their full force directly via tendons into the skeleton, as is usually 2. Hip external rotator suggested by our textbook drawings. They rather distribute a large portion of 3. Hip abductor (slight) their contractile or tensional forces onto fascial sheets.” - Schleip, Findley, Chaitow, 4. Posterior pelvis rotator (with fixed LE) Huijing
Introduction to Fascia, The Tensional Network of the Human Body , Churchill Livingstone, 2012 What stabilizes Kenneth Snelson’s “Floating compression” this structure?
Installation of Needle Tower II for Kenneth Snelson Exhibition, 1969, Kröller-Müller Museum, Otterlo, Netherlands
Installing Easy Landing, 1977, Baltimore, MD Photo by Katherine Snelson
Snelson making adjustments, Needle Tower II, 1971, Kröller-Müller Museum, Otterlo, Netherlands
Assembling Free Ride Home at Waterside Plaza, 1974, New York, NY 21 From: Kenneth Snelson, Art and Ideas 22
TENSEGRITY Steven Levin, “tensional integrity” MD • The compression www.biotensegrity.com elements are imbedded in the tension elements. • Continuous tension ! discontinuous compression.
“THE TENSION IS THE FRAME”
24 Normal Glut Max Gluteus maximus (with fascial continuity)
Proximal Attachment
“It arises from the iliac wing behind the posposterior gluteal line, including the iliac crest, from the posterior layer of thoracolumbar fasfascia, the posterior surfaces of the sacrum, coccoccyx, and sacrotuberous ligament and from X the fascia covering gluteus medius (the X gluteal aponeurosis).”
X Distal Attachment
“Th“The fibers descend downwards and laterally. The deeper fibers of the lower part of the musmuscle are inserted into the gluteal tuberosity. The superficial fibers and the upper deep part of the muscle end in a tendinous sheet, which paspasses lateral to the greater trochanter and is attached to the iliotibial tract of the fascia lata.”
25
Gluteus Maximus Gluteus Maximus
Stecco A, et al., The anatomical and functional relation between gluteus maximus and fascia lata, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt. Vleeming, 2007 Stecco A, 2013. 2013.04.004 Superior Gluteus Maximus – Inferior Gluteus Maximus “inserts” into “inserts” into the iliotibial band the Lateral Intermuscular Septum
Stecco A, et al., The anatomical and functional Stecco A, et al., The anatomical and functional relation between gluteus maximus and fascia The upper 80% of the fibers relation between gluteus maximus and fascia The lower 20% of the fibers lata, Journal of Bodywork & Movement Therapies lata, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt. (2013), http://dx.doi.org/10.1016/j.jbmt. 2013.04.004 2013.04.004
What are the “real body” actions Biotensegrity based anatomy/ of gluteus maximus? biomechanics • Muscles are not structures that “pull” on 1. Tensions the fascia lata (i.e. the bones to cause movement. appendicular fascia of the thigh) • Bones float in a variable tension network – Tensions the iliotibial band consisting of muscle and fascial elements – Tensions the lateral intermuscular septum of • Fascial continuity provides passive tension the thigh • Muscles fibers within the fascia provide 2. Tensions the thoracolumbar fascia dynamic tension 3. Tensions the gluteal aponeurosis over • Thus, bones move (or, in the setting of outside gluteus medius forces, remain stable) when the tension around 4. Tensions the sacrotuberous ligament them changes. 32 33 34
What do you see here?
CP
Fit Athlete
35 36 Sonographic Palpation
37 38
PRONE SLR PRONE SLR
39 40 PRONE SLR S/P numbing A Case of Foot Pain
• 9 yo Cherokee female with spastic diplegia • Diminishing returns from botulinum toxin injections 2009 • Opted for tendon lengthening March 2010 – Bilateral medial and lateral hamstring – Bilateral gastrocnemius lengthening • Presented October 2010 with 6 month h/o of left foot pain described as “electric, burning” sensation on plantar surface 41 42
History PE
• Pain in left leg immediately • MEDICATIONS • Able to stand and walk steps with SMO’s after surgery • Amitriptyline 10mg and rolling walker – None on right leg qhs • Left long leg cast split at 7 • Gabapentin 2400mg/ • Ashworth 0-1 in achilles/hamstrings days due to progressing symptoms, day (900-600-900) significant edema • Dysesthesias over plantar foot • Baclofen 5 mg tid • Cast sock had rolled up to popliteal • Normal sensation elsewhere space creating a pressure ulcer • Omeprazole qd and scar • Polyethylene glycol qd • (+/-) Tinel’s over medial calf at distal scar • Spasticity and ROM had • Mag Sulfate prn • Tender diffusely over medial calf, especially improved after surgery; however, at distal scar she avoided walking due to left foot pain
43 44 Ultrasonography Longitudinal View
45 46
Ultrasonography
47 48 Fibular (i.e. peroneal) nerve Fibular (i.e. peroneal) nerve Hydrodissectiony Hydrodissection
49 50
US in Clinical TREATMENT US in Clinical TREATMENT Middle aged Soccer/Futbol player Dx: Fibular nerve impingement - mild Lateral calf pain, hip pain US in Clinical TREATMENT Treatment : Nerve hydrodissection for compressive neuropathies • Lidocaine 1% for skin and subcutaneous
• 27g, 1.25 inch needle Peter A. • 5% Dextrose in water (D5W) for Huijing hydrodissection
Fascia, The Tensional Network of • 25g, 2” needle the Human Body , Churchill Livingstone, 2012 54