MSK Notes Weeks 1-6 PDF

2.1 Lumbar Spine Anatomy Overview & Function - Supports the upper body - Transmits force (weight) of upper body to pelvis & LE - Posture - Protects spinal cord - Could be source of injury - Should be included as part of the examination Review - Consists of 5 vertebrae - Normal lordosis Joints - 5 pa...

2.1 Lumbar Spine Anatomy Overview & Function - Supports the upper body - Transmits force (weight) of upper body to pelvis & LE - Posture - Protects spinal cord - Could be source of injury - Should be included as part of the examination Review - Consists of 5 vertebrae - Normal lordosis Joints - 5 pairs of facet joints - Facet Joint - Apophyseal or Zygoapophyseal joints - Diarthrodial joints consist of superior & inferior facets & a capsule - Facets carry 20% of load - Most of load goes through vertebral body Facet Joints - Overview - Superior articulating process - Inferior articulating process - Transverse processes are typically at same level as spinous process - Function - Orientation gradually changes from sagittal to frontal plane - Frontal plane orientation provides restriction from anterior shear - Rotation limited & facets control FLEX, EXT, LAT FLEX - Orientation - Superior articulating process face med/post - Inferior articulating process face lat/ant - Capsule is limitation when FLEX forward Open & Close Packed Position - Open Pack - Midway b/w FLEX & EXT - Close Pack - EXT Ligaments - Spine - Anterior Longitudinal Ligament (ALL) - Posterior Longitudinal Ligament (PLL) works w/ facet capsule to restrict flexion - Ligamentum Flavum - Supraspinous Ligaments - Interspinous Ligaments - Inter transverse Ligaments - Pelvis - Iliolumbar Ligament - Helps stabilize L5 w/ ilium - Prevents ANT displacement of L5 sagittal plane for flex ext L5 turns into frontal plane 2.2 Lumbar Disc Overview & Function - Shock absorber - Distributes load applied to spine - Allow movement b/w vertebra - Degeneration occurs over lifetime Anatomy - Annulus Fibrosis - Fibrocartilage - Sharpey’s fibers in outer ring - Attaches to vertebral bodies - Nucleus Pulposus - Hydrophilic Mucoid Tissue - Water-binding capacity decreases w/ age - Lose it around age 20 - Eventually replaced w/ collagen Endplate - Disc attaches to vertebra via cartilaginous endplate - Allows fluid to move b/w disc & vertebral body - Receives nutrition by diffusion through endplate - Pressure lowers w/ normal lordotic curve - Pressure can push fluid into vertebral body if defects are present resulting In Schmorl’s nodules Loading - Different posture increase loading on discs - Standing considered normal - ‘Lifting Wrong’ has greatest pressure on L3 disc in example - Nerve Roots - Exit via intervertebral foramina - Named for the vertebra above - Ex. L4 root exits b/w L4-L5 - L5-S1 most common site for problems as it bears more weight than other vertebral levels - Angle of L5-S1 greater than others, has greater risk of stress applied to it connected by sharpey’s fibers 2.2 pelvic anatomy pelvic ring: fxn SIJ form ‘key’ of arch bw the 2 pelvic bones force is transferred from spine to LEs (thru pelvic ring) any imbalance (ROM, muscle strength) can put greater stress on jnts above & interferes w transmission of kinetic energy acts as a buffer to decrease forces to spine and upper body caused by contact of lower limbs to ground——from bottom, up going to help transfer forces coming up thru pelvic ring SIJ: anatomy and fxn 1. part synovial (diarthrodial) and part syndesmosis: slightly movable ~4-7 degrees 2. act as a shock absorber 3. open pack position: neutral 4. closed pack position: nutation 5. jnts become less mobile w aging 6. symphysis pubis is joined by fibrocartilaginous disc ligaments of pelvis long post sacroiliac: limits ant pelvic rot short post sacroiliac: limits ALL motions (v fxnal) sacrotuberous and sacrospinous: limit nutation and post innominate rot iliolumbar: stablilizes L5 on ilium stabilization mechanism form closure: shape of the anatomy and integrity of ligaments maintain stability firm closure of keystone force closure: compression generated by muscles and ligament tension reacting to applied load provides compression to make forces w/in SIJ to maintain sacrum sitting in pelvis outer group: deep longitudinal muscle system 1. crossing pattern to stabilize pelvis a. erector spinae b. deep laminate of thoracolumbar fascia c. sacrotuberous ligament d. biceps femoris *all of the following are for stability* posterior oblique muscle system posterior: anterior: crossing of glut max, lats crossing of IO and EO and and thoracolumbar fascia to abdominal fascia crossing over give stability to ADDuctors inner muscle system lateral system 1. 1. glute med and min multifidus 2. transverse abdominis 2. CL ADD 3. pelvic floor muscles examination of pelvic floor dysfxn: referral to pelvis floor specialist is recommended make up our “anatomical weight belt* gives us stability on all 4 sides ant post groups a. m’s and ligaments involved in post tilt b. m’s and ligaments involved in ant tilt motion of pelvis on a fixed femur pic A hamstrings: pull down bc of attachment at the ischial tub rectus abdominis working in the front to cause a posterior tilt pic b rectus abdominis- pulling down erector spinae- pulling up summary 1. pelvic ring consists of a stable sacrum fixed between 2 pelvic bones 2. ligamentous structures act as passive restraints to assist with stability for the sacrum and pelvis 3. form and force closure are two mechanisms that enable to pelvic to maintain stability 4. muscle groups/systems help to actively stabilize the pelvic joints and assist in load transfer during gait and activities nadia- always follow 2.4 lumbar spine and pelvis biomechanics vertebral body for when we talk about lumbar we always have to consider throacic dir *for this lecture we will only look at lumar* if move to right then vertebral body lumbar flex go to right?? flex inf articulate process (facets) moves ant/sup sup tilt and glide to vert body -compression on ant aspect and nucleus pupolsis migrate post restriction facet capsule lumbar ext ext inf facets moves post/inf inf tilt and glide of vert body -stretch on ALL -disc migrates ant and is compressed post restriction SPs SP can limit bc they “kiss” lumbar lat flex lat flex (side bend) ipsi inf facets moves inf and post, med CL inf facets moves sup and ant, lat why? there is a coupled motion of ipsi rot towards the side of lat flex lumbar rot not a primary motion for lumbar rotation ipsi inf facet moved medial CL inf facet moves lat -v small mvmnt in lumbar spine mostly to assist w lat flex as coupled motions follow body of vertebrae when rot sacrum relative motion nutation: relative ant rot of base of sacrum relative to ilium ilium would be post rot counternutation: relative post rot of base of sacrum relative to ilium ilium would be more of ant rot sacrum nutation and counternutation occurs in sag plane nutation: base moves inf and ant while coccyx moves post counternutation: base moves upward and post while coccyx moves ant arthrokinematics: nutation nutation a. ant sacrum on ilium or lumbar flexion induces anterior nutation of pelvis? b. post ilium on sacrum both occurring simultaneously post rot of spine = arthrokinematics: counternutation counternutation a. post rot of sacrum on ilium or b. ant rot of ilium on sacrum both are occurring simultaneously summary 1. the facet orientation in the lumbar spine dictates the motion allowed 2. there is a coupling motion that occurs with lumbar lateral flexion and rotation 3. motion of the sacrum is relative to the ilium flexion 2.5 Lumbar Disc Pathology LUMBAR DISC Objectives: Extent of disc injuries and the deformations How the disc can generate pains in the low back Identify patterns of pain associated with a disc injury 4 DIFFERENT TYPES OF DISC INJURY , Nucleus pulposus bulges but does not rupture annulus Outermost annulus contains some of the nucleus bulging out Annulus is perforated. Nucleus comes out beyond the annulus nucleus Disc fragments outside of the annulus Severity: Other symptoms can include myelopathy, cauda equina syndrome, nerve root compression Myelopathy: Fragments that exit can go into the canal and cause this. Which can lead to cervical pain, numbness, difficulty walking Cauda Equina Syndrome: concerns with bowel and bladder symptoms Nerve root compression: Radicular symptoms, radiating pain other than local area of injury (MOST COMMON) Changes to the disc- Increasing load and Aging Causes degeneration hydration starts going away starting at 20 Only the outer layer of the annulus has vascular and neurological input/ innervation. The inner 2/3 of the annulus and the nucleus propulsus has none. Structures that can be influenced by disc injuries include ALL (Anterior Longitudinal Ligament) Facets Nerve Roots Disc Injury Presentation 30-50 years old Across the back, can be unilateral and can migrate to leg Difficulty moving in the morning when body is not warmed up Sitting or flexion can aggravate it Painful when coughing sneezing or straining Favorable Conditions absence of pain when doing a straight legged raise on the contralateral side No pain with lumbar extension Greater than 50% relief or improvement in the first 6 weeks since onset Unfavorable Conditions Positive for pain on contralateral straight legged raise Pain with lumbar extension Lack of 50% or greater pain relief in the first 6 weeks since onset Notice the L4 intervertebral disc injury affecting the L5 Nerve root compression norms w/ loading vertebral body - 80% facets - 20% Notice a larger herniation compressing against 2 nerve roots A massive herniation can involve all nerve roots in the cauda equina that can result in bowel and bladder paralysis 2.6 Sacroiliac Joint Pathology S1] Objectives: Understand the SIJ and mechanism of injuries there The patterns of pain at the SIJ Recognize symptoms of pelvic pathology TYPES OF INJURY Inflammation/Trauma or overuse Hypomobiity Hypermobility/Instability How do injuries happen at the SIJ Sudden jarring by stepping off a curb or in a hole cause you’re blind and can’t see Overzealous Kick/ Missing of kicking an object cause you suck Falling on your big or flat butt whichever one you have Lift and Twist involving the lumbar spine di who LOL Pain Pattern of SIJ Injury Local, or can feel like pain in the buttocks, or posterior thigh Can be Unilateral Painful Movements Sit to Stand/Transitional Movements Turning in bed , getting out of bed Stepping up with a single limb Some Special Complications and other Factors Ankylosing Spondylitis Starts at SIJ, and migrates to spine. A sclerosis, which means it is a thickening and lack of joint space. This is accompanied by irregular joint surfaces. When it migrates to spine, spine becomes stiff. Present in men between 15-35 years old. Rheumatoid Arthritis Inflammatory response you can find out through blood work Reiter Syndrome Inflammatory polyarthritic disorder typically in young men. Joint pain and stiffness A baby growing inside a birthing person. Pregnancy Pelvic Pathology Avulsion fractures of the pelvis are possible typically with athletes in track. 2:1 male to female. Sprain of SIJ can be caused also by hormonal changes that cause laxity in the joints SPINE 2.7 Spinal Conditions Objectives: Recognize spinal dysfunctions at the lumbar spine Patterns of pain with spinal dysfunction Symptoms related to the function and anatomy Dysfunctions at the spine normally refer to the injuries or the trauma/degeneration at a segment A segment includes the vertebral body, disc, nerve root, and facets Spondylosis Degenerative disease Vertebral discs gets thinner and less hydrated. LOSS OF DISC HEIGHT Causes arthritic conditions as well as bone spur growth to the sides of the vertebral bodies Bone spurs (osteophytes) CAUSES: Aging, repetitive use, trauma PRESENTATION: Stiffness, limited sitting tolerance, and pain with movement and activity SpondyLOLysis Defect in the pars interarticularis or arch of the vertebra CAUSES: hyperextension and rotation, Pain radiates to buttocks and leg, WORSE with strenuous activity Unilateral tenderness, X-ray reveals Scottie dog fracture (From oblique view of the xray) Spondylolisthesis CAUSES: Anterior displacement of one vertebra on another from trauma, ligamentous disruption, disc disruption Graded by percentage of slippage PRESENTATION: Numbness or weakness in one or both legs Pain increases with extension exercises RETROLISTHESIS: posterior shift. Instability: Movement of the segments beyond normal constraints Erratic pain dues to many factors like hypermobility, laxity, congenital reasons Central Stenosis Narrowing of spinal canal Narrowing of the Foraminal Stenosis foramen, where nerve roots exit Caused by bone growth, or herniated disc. Can compress spinal cord, cauda equina, nerve roots They don’t like extension Walk up hill is flexion, easier for them 2.8 Patterns of Low Back Low Back Pain 80% of people will experience this lumbar strains/sprains idiopathic = nonspecific - ex: ligamentous or muscle involved Lumbargo = mechanical back pain mechanical causes (anatomical abnormalities spondylosis - wear and tear spains/strains - IVD Degeneration/herniation Non mechanical (visceral/referred pain) inflammatory jt condition radiculopathy (sciatica) spondylilisthesis stensosis infections skeletal irregularities tumors neurovascular kidney stones endometriosis fibromyalgia - non degenerative - scoliosis. kyphosis, lordosis congenital abnormalities mechanical low back pain refers to butt/thighs sometimes stiffness/pain in the AM start pain fwd flexion & returning normally hurts mechanical low back pain cont pain produced by - ext, side flexion, rot, standing, walking, sitting, exercise (basically anything) pain worse through day pain relived by change of pos (makes this unique in back pain realm) - feels better lying down, especially fetal position neurogenic pain pain from n. injury spinal n. inflamed, squeezed, pinched could be from herniated disc impeding n. root numbness/weakness in LE 7 normally not beyond knee back pain dominant patterns facet jt involvement disc involvement flexion stiff in the AM ext/rot cause pain - extra hydration w/ inflammation relief w/ ext days to months (sudden on slow) relief w/ flexion - creates gapping for pressure relief days to weeks (sudden) leg pain dominant patterns neurogenic intermittent claudication n. root involvement (cauda equina involvement) (inflammatory) flexion = pain relief w/ ext weeks to months walking (ext) =. pain relief w/ sitting/posture change no time influence known goal: for pain to be centralized again summary non specific low back pain can mean a lot but normally musculoligamentous etiology low back pain causes = mechanical, non mechanical, visceral mechanical low back pain = back dominant non mechanical low back pain = leg dominant centralization of pain is retreat of most distal aspect of pain toward midline of spine peripheralization of pain moves distally into leg 80% on vertebral body 20 % on facets form = how anatomy forms it force = contractile stabilization!!! central stenosis ext hurts like old person pushing grocery cart SI pain point directly at pain spot point sign “fortin” can go into glutes/lumbar/ lat thigh? pts will hold their lower back to help them stabilize or not move too much for pain Gower’s sign using thighs or something else to push back up with instability (for people >40) gowers sign: push up from thighs/surfaces