Soft Tissue Therapy
Class at the National Academy of Osteopathy
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| ____________is an increase in the normal thoracic kyphotic curve, with protracted scapular & forward head posture. | What does Hyperkyphosis look like? |
| - Pain from facet joint approximation (closeness), - Muscle Imbalances - Thoracic, cervical and rib ROM is reduced - Poor Postural Habits - TOS or TMJ | Functional symptoms of Hyperkyphosis? |
| Wedging or spinal fusion. Postural displacement of the nucleus pulposus. These are possible structural causes of __________________? | Structural symptoms of Hyperkyphosis? |
| ________________ is an increase in the normal lumbar lordotic curve with increased anterior pelvic tilt and hip flexion. | Hyperlordosis is what? |
| • Compensatory hyperkyphosis • Spondylothesis - a defect of the neural arch. • Head forward posture | Pathologies & compensatory postural dysfunctions (that may be present) with Hyperlordosis? |
| Contracture; Adhesion | The two types of scarring that cause a reduction in ROM: ___________ – shortening of connective tissue or structures over or around a joint ___________ -- Reduced motion at a joint allows cross links to form among collagen fibres |
| Scar tissue adhesions are? | ___ ____ ____ with an injury or acute inflammatory response. Collagen fibres form in a random pattern adhering structures together – skin, muscle, fascia, |
| ____________ occur when there is ongoing chronic inflammation. | Fibrotic Adhesions occur when.... |
| Irreversible contracture is what? | ______ ______ – fibrotic tissue or bone replaces muscle and connective tissue |
| What is "Proud Flesh" scarring? | ________ results from an abnormal healing process. A raised red structure, composed of disorganised collagen & capillaries is evident. |
| ________ is an overstretch injury to a musculotendinous unit | Define "strain". |
| Rest, Ice, Compression, and Elevation is used to treat, specifically, what grade of strain? | What does "RICE" mean? |
| The difference: Strains happen to musculotendinous units/muscles. Sprains happen to ligaments/connective tissue. | What's the difference between a strain and a sprain? |
| Trauma related sudden twist or wrench of a joint beyond its normal ROM is called what? | What causes sprains? |
| • Grade 1 sprain; 4-5 days • Grade 2 sprain; 7-14 days • Grade 3 sprain; immobilization usually removed at 6-8weeks. This could take several months to heal completely. | Return to activity for sprains?; ( a rough guideline) • Grade 1 sprain; ??? • Grade 2 sprain; ??? • Grade 3 sprain; ??? |
| Cruciate Ligaments. | Name this ligament. |
| This | Which is the ACL and which is the PCL? |
| The ACL is injured more often than the PCL because it is the strongest of the two __(what does C stand for)__ ligaments. | Which is more often injured? The Anterior Cruciate Ligament or the Posterior Cruciate Ligament? Which is stronger? |
| The ACL connects what two bones? | The _CL prevents the tibia from sliding too far forward from underneath the femur. It limits their rotation. |
| The _CL is mainly a stabilizer joint. | What is the main function of the PCL? |
| It prevents the sideways motion of your knee. | What does the medial collateral ligament do? |
| - Blow to lateral/outer knee - Forced hyperextension with internal rotation of the tibia - Blow to posterior/back tibia This causes _CL injury. | What are the main causes of ACL injury? |
| Lateral, Medial | Label the medial and lateral Menisci. |
| A twisting movement (outside of normal rotation) while the foot is weight bearing and anchored to the ground. | What kind of movement might cause injury to the menisci? |
| False. This cruciate ligament is needed for walking backwards, however, it is needed for steping downward, in a foreward motion. | True or False. The PCL is the main cruciate ligament used to help you walk foreward. |
| True, the _CL is the main cruciate ligament in helping you walk forewards. | True or False. The ACL is the main cruciate ligament used to help you walk foreward |
| Tenderness along joint line and possible swelling | In a menisci and/or cruciate ligament injury, what are the clinical manifestations you might find during palpation? |
| Grade 3 or total rupture of ACL: unable to continue activity, may report popping feeling at time of injury | What are some symptoms of a totally ruptured, grade 3 ACL injury? |
| The areas are the sacroilliac joint, the patella and the ankle. | What 3 areas must be mobilized for an ACL injury? |
| Rest, ice, compression, and elevation. | What does RICE stand for? |
| Introducing cross fibre frictions (massage), and fascial release as appropriate (gentile, sustained pressure to the connecting fibres) Bonus: contrast hydrotherapy, if available. | A cruciate ligament injury demands working of the SI, patella and ankle. What else might one add to in-clinic treatment? |
| No. This is used mainly in chronic menisci and PCL/ACL injuries, as well as some LATE-SUB acute injuries. | Typically, should cross-fibre frictions (massage) be used BEFORE late-subacute status on a Menisci or Cruciate Ligament injury? When should it be used? |
| FALSE. If someone is using crutches, you should also treat their shoulder girdle, neck and arms, as well as their injured areas (and corresponding structures). This is to alleviate the stress it causes on these upper areas, and prevent injury, as they are now carrying weight they are not meant to. Insurance has nothing to do with it. | True or False: if someone is using crutches due to a lower-limb injury, and they are an insurance patient, you do not treat their shoulder girdle, neck and arms. |
| ____________; trauma related sudden twist or wrench of the joint beyond its normal range of motion | What causes dislocations? |
| The joint is the weak link in a closed kinetic chain; falling on an outstretched hand; is this a direct or indirect dislocation cause? | In indirect dislocation, why does the injury happen? |
| Pathological: rheumatoid artheritis, paralysis/neuromuscular issues. Previous Dislocations, deformity, ligamentous laxity (loose muscles/muscle weakness). | What are some factors in the patient's history that might suggest they have a higher likelihood for dislocation? |
| A fracture that is caused when a ligament, that attatches to a bone, breaks off a part of the bone, instead of separating from the bone, at the time of injury. | What is an avulsion fracture? |
| Extreme, sickening pain (nearly a solid "10"), heard a snapping/popping sound, joint appears deformed (due to rupture of joint capsule/ligaments), heat present, possible hematoma ( RED, black and blue bruising due to some bleeding under skin, sometimes in the joint capsule). | How might a patient describe a dislocation, when they experienced it? Both in feeling and appearance (Acute)? |
| True. You can do this a number of ways: light massage, movement, compression, protection (splints, etc). How hard you push your patient in these techniques, however, varies by severity. | True or False: Regardless of the stage of the dislocation, you should always try to prevent/lessen edema. |
| ___________; A break in the continuity of the bone. | Define "Fracture": |
| Define "Fracture". | "a break in the continuity of a bone" |
| Describe this type of fracture: closed/simple | Skin is intact in this fracture |
| Describe this type of fracture: Open/Compound | Bone has torn through the skin or a body cavity in this fracture |
| Describe this type of fracture: Complete | Broken into 2 or more pieces in this fracture |
| Describe this type of fracture: Incomplete | Periosteum intact, bone is bent or cracked in this fracture |
| Describe this type of Complete fracture: Transverse | Usually stay in place after reduction(surgery or tractioning to bring separated edges together) take longer to heal in this fracture |
| Describe this type of Complete fracture: Oblique/Spiral | Heal quicker, but harder to keep in place, even when splinted |
| Describe this type of Complete fracture: Comminuted | Often unstable. Consists of 2 or more fragments, making healing difficult |
| Describe this type of Complete fracture: Avulsion | Ligament/tendon pulls off portion of bone it is attached to |
| Describe this type of Complete fracture: Osteochondral | Fragments of articular cartilage shear away from joint surface, often during a dislocation or sprain |
| Describe this type of incomplete fracture: Compression | Bone is crushed. Occurs in cancellous bone – vertebral body |
| Describe this type of incomplete fracture: Greenstick | Bone is bent or partially broken. Found in children under 10 years old |
| Describe this type of incomplete fracture: Perforation | From a missile wound - gunshot wound |
| Describe this type of incomplete fracture: Stress | Cracks in bone due to over use or repetitive actions. Common sites are tibia, metatarsals, navicular, femur & pelvis. Often simply resembles a crack. |
| What kind of fracture is this: | Colle`s fracture – transverse fracture of the radius just proximal to the wrist allows the fragment to rotate and displace dorsally, giving a ‘dinner fork’ deformity. Mechanism of injury fall onto outstretched hand |
| What kind of fracture is this, AND what kind of movement in a fall is reqired for this to happen? | Galeazzi fracture – break of the radial shaft & dislocation of the inferior radioulnar joint. Mechanism of injury fall on hand with a rotational component |
| What kind of fracture is this: | Pott`s fracture – distal fibula breaks close to lateral malleolus. Deltoid ligament may also rupture or avulse the medial malleali. Mechanism of injury is eversion with some external rotation. |
| What kind of fracture is this: | Dupuytren`s fracture – the fibula fractures higher up, the medial malleaoli avulses and the talus is pushed superiorly between the tibia & fibula. Mechanism of injury is eversion with some external rotation. Eversion of the heel (the heel bone pushes away from the body) |
| What 3 broad reasons can cause a fracture? | - Trauma or sudden force, which creates more stress than the bone can absorb; direct or indirect. - Overuse or repeated wear - Pathology |
| What are some common pathologies that might cause an increase in fractures? Name 2. | Osteoporosis, bone cysts, tumours, (any illness/abnormality that decreases bone density) |
| What are 3 possible EARLY COMPLICATIONS (first few weeks) for fractures? | - torn muscles, tendon & ligamentous damage - compartment syndrome - nerve injuries - vascular injuries - joint hemathrosis (bleeding) - bone & soft tissue infections - deep vein thrombosis - various problems caused by poorly fitting casts |
| What are 3 possible LATE COMPLICATIONS (X > a few weeks) for fractures? | - delayed union and non-union of the fracture, malunion, myositis ossificans, - nerve compression, - nerve entrapment, - bone necrosis, - volkmans ischemic contracture, - joint stiffness, - disuse atrophy. - There may also be complications relating to the external fixators or metal plates used. |
| Describe the symptom picture of someone during the immobilization stage of a fracture. Describe 3. | • pain near and at injury site, as well as swelling/bruising • Antalgic posture/gait • Tissue repair and callus formation occuring. Adhesions developing around injury • Reduced circulation, edema, disuse atrophy & connective tissue contracture in tissues under cast. Possible cartilage health decrease in joints – lack of succusive action & reduced circulation. • Hypertonicity & trigger points present |
| Describe the symptom picture of someone after the immobilization of a fracture has been removed. | • Fracture site healing and remodelling • Poor tissue health. Dry skin. Bruising may be brown, yellow & green/gone. •Pain/Stiffness at injury site • Muscle Weakness •Antalgic gait/posture •Hyper tonicity, trigger points in crossing/supporting structures and •Possibly pocket of edema still remaining |
| How do you treat a fracture DURING the immobilization period? Name 3 Dos/Don'ts | During immobilization; • Do not interfere with healing process. Refer if complications suspected • Reduce inflammation, pain & sympathetic nervous system firing. • Treat compensating structures - DO NOT TREAT INJURY SITE DIRECTY • Reduce edema – lymph drainage • Maintain local circulation proximal to injury site – effleurage/petrisage • Maintain ROM – proximal & distal joints |
| How do you treat a fracture AFTER the immobilization period? Name 3 Dos/Don'ts | • Reduce pain, decrease sympathetic nervous system firing. (i.e. massage) • Reduce edema/promote distal venous return (circulation) • Improve tissue health – remove dry flaky skin • Treat compensating structures • Reduce hypertonicity & trigger points • Treat compensative structures (including Mobilize hypomobile) •Maintain ROM -- Do not mobilize structures •Once consolidation of joint/break has occurred mobilize joints that were under cast -- not possible if pins/wires were added |
| What are contradictions in treating immobilized fractures (when should you not treat)? Name at least 2. | • Limb not tractioned before union has occurred • Hot hydrotherapy not applied distal or immediately proximal to cast • With open reduction, no on site work performed until skin heals • With stress fractures no on site massage while fracture point is tender |
| What are contradictions in treating fractures AFTER immobilization has been REMOVED (Dos and Don'ts)? Name at least 3. | • No overpressure of involved joints until union has occurred • Hydrotherapy temperature extremes avoided on tissue that were under the cast. • No long deep longitudinal strokes on tissues that were under cast until muscle tone & tissue health has improved • Passive stretching should be pain free until tissue health & muscle tone improve • No local heat over pins, screws or wires |
| What is a whiplash injury? What is a common way to get such an injury? What body part is usually the most common place to recieve such an injury? | A __________ injury is an acceleration-decceleration injury. These injuries frequently happen in motor vehicle accidents, or in contact sports. Typically, this injury happens in the neck, and can effect any structure therein. Other common areas are the jaw, or anywhere on the spine or back muscles. |
| Describe the 5 grades of Whiplash injury, to the best of your ability. This is to check understanding. Answers in brackets are bonus. | Whiplash Classifications (very simplified; only DIFFERENCES will be listed): Grade 1: Nearly zero issues (categories: motion, ligamentous, neurological) Grade 2: Slight limitation only. Grade 3: Slight-moderate (hematomas might be present from this grade upward) Grade 4: Moderate-severe. Fracture or disc derangement is present (ligamenous rutpure from this grade onward is possible) Grade 5: Severe. Requires surgical management or stabilization |
| What are the 3 types of Whiplash collisions, and what kind of impact does each indicate? | Type 1 collision; rear impact Type 2 collision; side impact Type 3 collision; front impact |
| What are the 4 PHASES of Whiplash recovery, plus their time periods? | • Stage 1; acute injury, inflammation phase, upto 72 hrs post accident • Stage 2; subacute, repair phase, 72 hrs – 14 weeks • Stage 3; remodelling phase, 14 weeks – 12 months or more • Stage 4 chronic permanent |
| What is the name of the classification used in Canada (except Quebec) to classify Whiplash injuries? If you are in the Province of Quebec, what classification does Quebec use? | Canada: Foreman & Croft Classification (F/C) Quebec: Quebec task force classification (QTF) Q: What are these classifications for? |
| True or false: Deafness, TMJ Pain, Tinnitus, nausea are symptoms that can only develop *during* the "less subacute" stage of healing in a whipplash injury. | False. These symptoms can happen immediately with whiplash injury (usually developed within 72 hours of injury). This can be due to brain trauma, nerve damage and/or ligamentous damage, among other things. |
| True or false, nerve atrophy takes more than 72 hours to develop, after whiplash injury, if it's going to happen. | False. Nerve atrophy, if it will develop, will develop during acute stages of whiplash recovery (within 72 hours). |
| True or false: In the late remodelling phase (near completely healed) of a whiplash, the longus capitus is likely in chronic spasm. Over time this spasm will flatten the cervical spine lordosis, destabilising the vertebrae & exerting compression on the cervical discs. | FALSE (trick question). It is the Longus Coli that is more likely to flatten the lordotic curve, due to its insertion on more than twice as many spots on the cervical vertebra. |
| If the longus coli is in chronic spasm (tightness), and it is going to flatten the lordotic curve of the neck, what should you do about it? This is causing them cervical disc pain, and weakened their vertebra. Currently, the patient is in the remodelling phase of their healing, OR this is an old injury that is causing them chronic issues. | You should work on gently increasing their range of motion, and strengthening the other muscles in the neck, to help the neck right itself. If it is indeed an old injury, also increase bloodflow to the area. This will likely cause your patient to feel a little stiff or sore the next day. This is normal. If they have no edema during treatment, have them ice, then heat the sore area, if they feel discomfort the next day. CONTRADICTION: Do not advise this if the patient has screws or wires in their neck. |
| Joint injuries from whiplash can over time lead to what kinds of joint conditions? | Degenerative disc disease or osteoarthritis of the cervical spine. |