lower extremity group 4. intake form 22 year old female treatment for pain box checked primary...
TRANSCRIPT
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Lower Extremity
Group 4
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Intake Form
• 22 year old female• Treatment for pain box checked• Primary Complaint: Pain in both legs while
exercising.• Boxes Checked: Sharp, Numb, Tingling and
Burning• Pt. doesn’t know what is causing complaint
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Intake Form
• Exercises 3x/wk-- 2x run 4 miles– 1x run 6 miles
• No hx trauma/illness• Mother had breast cancer (in remission)
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OPQRST• Onset: four months ago• Provocation: After 10 mins of activity burning and
sharp pain in both shins. Tightness, sometimes tingling. Sometimes her left foot feels numb.
• Palliative: Pain goes away once she stops the activity.
• Quality: Burning, Sharp – Pain is hard to point out direct area.
• Radiating: It stays in the shin, with symptoms in her feet if she tries to push through.
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OPQRST Cont.
• Severity: Pain gets to point where it is unbearable.• Timing: only after 10 minutes of moderate exercise.• Treatment: none• Activities of daily living: They are not directly
affected but exercise is big part of life.• Environmental: none• Medications: Tylenol / Aspirin
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Preliminary Diagnosis
• Shin splints • Deep Vein
Thrombosis• Tibialis posterior
tendinitis• Somatic Dysfunction
of Lower Extremity
• Tibialis anterior tendinitis
• Pes Anserinus bursitis
• Tibial Stress Fracture
• Lower Cross Syndrome
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Initial Exam Posture Findings-
• Hyperlordosis lumbar• Anterior head carriage • High right shoulder • Internal rotation of shoulders
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Chiropractic Listings
• C4 RP• L1 LP• L5 LP• Bilateral AS ilium fixation
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Measurement Normal % of normal
Flexion 50 60 83
Extension 35 25 140
Left Lat Flexion 20 25 80
Right Lat Flexion 20 25 80
Lumbar Range of Motion:
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Inspection
• Inspect legs bilaterally for 5 P’s:– Pain– Pallor– Paresthesias– Paralysis– Pulselessness
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Initial Exam Findings
• Neurological– Unremarkable
• Vascular– Unremarkable
• MMS– 4/5 bilateral extensor hallucis longus, extensor digitorum
longus, tibialis anterior, peroneus longus, brevis, tertius
• Orthopedic– Unremarkable
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Exam• Pts exam findings were not conclusive to
expected finding of fx.• Lumbar Series - Ferguson line measured 54 degrees.
• Further investigation warranted.• X-ray series taken of both legs rule out
pathology– Negative
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Exam cont…
• Stress fx suspected as finding. • Refer out for Triple Phase Bone Scan
(TPBS).• Research stats (TPBS) is gold standard
and “test of choice” for differential diagnosis and clinical management.
• Use MRI- where avoidance of radiation exposure is desirable
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Results of TPBS
• Healed stress fracture • No current bone abnormalities
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Follow up questions
• Running terrain?– Flat, uphill, downhill, track, grass, concrete
• Willing to change?– Running vs. cycling
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Exam
• What is causing Pain?
• Repeat exam after exertion of pain.• Have pt. run on treadmill until pain is
unbearable.• Exam before run, immediately after, 5
minutes, 10 minutes and when symptoms no longer present.
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Follow up Exam
• Prior to running (Reexamination)– Findings WNL
• Post exercise– 5 minutes, 10 minutes and when symptoms
no longer present
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Inspection
• Immediately after exertion-• Inspected legs bilaterally for 5 P’s:
– Pain– Pallor– Paresthesias– Paralysis– Pulselessness
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Neurological Testing
Initial• Neurological
– Unremarkable
• Vascular– Unremarkable
• MMS– 4/5 L Dorsiflexors
• Orthopedic– Unremarkable
Post• Tight sensation anterior
legs & dorsum of feet• decreased sensation on
dorsum L foot, altered sensation between 1st & 2nd toes
• decrease vibratory sensation of pure patch
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Vascular Testing
Initial• Neurological
– Unremarkable
• Vascular– Unremarkable
• MMS– 4/5 L Dorsiflexors
• Orthopedic– Unremarkable
Post• decreased dorsalis
pedis pulse
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MMS Testing
Initial• Neurological
– Unremarkable
• Vascular– Unremarkable
• MMS– 4/5 L Dorsiflexors
• Orthopedic– Unremarkable
Post• Dorsiflexion of ankle
– Tibialis anterios: 3/5
• Toe extension– Extensors hallicus
longus & digitorum longus: 3/5
• Passive stretch deep, achy pain
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Orthopedic Testing
Initial• Neurological
– Unremarkable
• Vascular– Unremarkable
• MMS– 4/5 L Dorsiflexors
• Orthopedic– Unremarkable
Post• Deep palpation elicited
pain
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After 5 minutes
• Findings same after immediate exercise.
• No worsening noted
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After 10 minutes
• Pt. describes decrease in tightness.
• Pt. sensation on dorsum of feet increased.
• Vibratory sensation still affected.• Deep palpation elicited pain• Noticeable increase of dorsalis pedis
pulse
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33 Minutes
• Pain symptoms no longer present
• Decrease vibratory sensation of the first 2 toes still noted
• Deep palpation elicited pain.
• Dorsalis pedis pulse strong and symmetrical
• Dorsiflexion (Tibialis anterior) 4/5
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Compartment SyndromePressure Measurements
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Compartment SyndromePressure Measurements
• Simple Needle– 18 gauge– Least accurate– Usually gives falsely
higher reading
• Slit Catheter and Side ported needle– No significant difference– More accurate
Side port
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• Measurements must be made in all compartments
• Anterior and deep posterior are usually highest• Measurement made within 5 cm of fx• Marginal readings must be followed with repeat
physical exam and repeat compartment pressure measurement
Compartment SyndromePressure Measurements
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Diagnosis
• Chronic Anterior Compartment syndrome 729.72
• Muscle weakness 728.87
• Lower Cross Syndrome 781.92
• Somatic Dysfunction of Lower Extremity 739.6
• Pelvic Somatic Dysfunction 739.4
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Anterior Compartment Syndrome
Etiology
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Two main types
• Acute - associated with trauma in the affected compartment.
• Chronic - aka exertional compartment syndrome (CECS)
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• leg is divided into 4 compartments
• Surrounded by inelastic fascial
• ↑pressure damaged muscles
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• Predominantly a problem amongst athletes– Accounting for up to 60% of all lower leg injuries [2] but can
occur in the general population
• CECS– an activity-related – reversible increase in intracompartmental
pressure – results in decreased tissue perfusion and
abnormal neuromuscular function. [2]
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Symptoms
• Muscle pain, tenderness, fatigue, damage, inflammation, edema and increased compartment pressure have been known to result from eccentric exercise.
• Increased pressure Numbness paresthesia ischemia
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Just prior to heel contact the body weight is forward of the opposite forefoot while the contact leg is
falling toward the floor, resulting in an abrupt loading of the heel with an acceleration of the bodyweight [13]. Ground reaction forces are
approximately 110-125% of bodyweight during this period.
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“Anterior Compartment Pressures in Cyclists”
• Many of the literature suggests there are no cases of CECS in cyclists.
• Cycling – Non-weight bearing activity – Tibialis anterior only contracts
concentrically.
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Differentiating Among Types
• Type I– Pain associated with healing stress
fractures
• Type II– Pain at the same level of activity or
distance
• Type III– Pain that increases after activity
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Management
• Conservative treatment
• Open contact with Orthopedic Surgeon
• Surgical treatment final option
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Phase 1
• Stop all activities that cause symptoms
• Frequency: 3x’s/wk for 4 wks
• Graston along with PIR
• Adjustment: postural abnormalities, hyperlordosis
• Reduce inflammation with nutrition
• digital foot scan (Stabilizers)
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Phase 2
• Frequency: 2x/wk for 4wks
• Adjustment
• Therapeutic Exercises
• Stretches
• Continued Nutritional support
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• Standing shin Stretch
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• Anterior, Lower Leg Flexion:
• Tibialis Anterior, Dorsi Flexors
• Sit up straight with your legs in front of you (use a back support if necessary). Place the exercise handle across your toes.
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Phase 3
• Adjustments
• Therapeutic Exercises
• Continued Nutritional support
• Start Biomechanical reeducation
• Taping
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Goals
• Eliminate Chronic Anterior Compartment Syndrome
• Decrease/eliminate risk of acute compartment syndrome.
• Avoid Fasciotomy
• Postural correction
• Core strengthening
• Pt. able to return to normal exercise routine
• Proper biomechanics while running
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Progress and Measurements
• The First Phase of treatment should reduce pain and inflammation and improving muscle strength.
• Decrease dural adhesions, facial thickening, and break up scar tissue.
• Manual muscle strength of foot and toe dorsiflexors and foot everters.
• Improve cervical and lumbar ranges of motion and decrease fixations.
•
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Progress and Measurements:
• The Second Phase of treatment includes improving muscle strength, cervical and lumbar range of motion.
• Begin running again in small amounts (1 mile max). • Manual muscle strength of foot and toe dorsiflexors
and foot everters to 5/5.• Improve cervical and lumbar ranges of motion to
normal.
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Progress and Measurements:
• The Third Phase of treatment is to maintain the results in phase I and II.
• Patient should be able to run at the level she was prior to when pain started.
• Maintain manual muscle strength of foot and toe dorsiflexors and foot everters to 5/5.
• Maintain normal cervical and lumbar ranges of motion.
•
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references
• [1] “A Comparison of anterior compartment pressures in competitive runners and cyclists.– The American Journal of Sports Medicine. Vol. 21, No. 1, pg
36, 1993.
• [2] “Chronic Exertional compartment Syndrome’– The American Journal of Sports Medicine. Vol. 31, No. 5, pg
770, 2003.
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References
• Souza, Thomas A. Differential Diagnosis and Management For the Chiropractor.4th edition.Jones and Bartlett Publishers 2009. pgs 434-437
• Deirdre B. Birtles et. Al.Venous Obstruction in Healthy Limbs: A model for Chronic Compartment Syndrome.Medicine &Science in Sports & Exercise.1638-1644, 2003.
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references
• [1] “A Comparison of anterior compartment pressures in competitive runners and cyclists.– The American Journal of Sports Medicine. Vol. 21, No. 1, pg
36, 1993.
• [2] “Chronic Exertional compartment Syndrome’– The American Journal of Sports Medicine. Vol. 31, No. 5, pg
770, 2003.