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Terms in this set (272)

A 44-year-old female with severe rheumatoid arthritis comes to your office with neck pain. She has
a history of chronic neck pain, however recently her pain has increased. She denies any trauma
and does not recall any specific event that would cause her neck pain to increase. On examination, she has severely diminished range of motion. Palpation of her cervical paraspinals reveals areas of fibrotic tissue with some tenderness noted in the sub-occipital region. The third
cervical segment is sidebent left. Neurologic examination is normal

Which of the following describes an appropriate osteopathic technique for C3?

A) C3 is sidebent to the left and rotated to the right against the restrictive barrier, the
patient then rotates to the left against the physician's counter force for 3-5 seconds, then
the physician passively rotates the cervical spine farther to the left.

B) C3 is sidebent and rotated to the right against the anatomic barrier, the patient then rotates to the left against the physician's counter force for 3-5 seconds, then the
physician passively rotates the cervical spine farther to the right.

C) C3 is sidebent and rotated to the right against the restrictive barrier, the patient then rotates to the left against the physician's counter force for 3-5 seconds, then the
physician passively rotates the cervical spine farther to the right.

D) The patient's neck is sidebent to the left and rotated to the left, a high velocity, low amplitude right rotational thrust is applied to the third cervical segment.

E) The patient's neck is sidebent and rotated to the right, a high velocity, low amplitude right sidebending thrust is applied to the third cervical segment.

Transient synovitis of the hip (also known as toxic synovitis) is a nonspecific, common,
unilateral (5% bilateral) inflammatory arthritis involving the hip joint, which occurs in children under 10
years of age (typically 3-6 years of age).

It is the most common cause of limp with hip pain in children.

The male to female ratio is 3-5: 1.

There may be a history of a preceding upper respiratory tract
infection. Pain may be present in the hip, antero-medial aspect of the thigh and the knee.

Occasionally, a low-grade fever of 100-101F may be present. X-ray of the hip is normal.

Septic arthritis is a serious pyogenic infection of the joint space. It occurs most often in children less
than 3 years old. The joint is swollen, and effusion, erythema, tenderness, pain and warmth are evident. The child may have a history of a recent bacterial infection. Septic arthritis is usually accompanied by a fever. The knee is the most commonly affected joint followed by the hip, elbow, and
ankle. Answer A

Legg-calve-Perthes disease is a juvenile idiopathic avascular necrosis of the femoral head. The onset is insidious taking weeks to months, which does not fit the case history. Answer B

Slipped capital femoral epiphysis represents a displacement of the femoral head from the femoral neck
due to a stress fracture through the femoral capital epiphyseal growth plate. It is classically seen in obese adolescent males. This would have been diagnosed by the X-ray of the hip. Answer C

Developmental dislocation of the hip encompasses the severity spectrum from mild acetabular dysplasia to frank dislocation. Hip X-ray would have demonstrated a shallow acetabulum with a completely or partially subluxed femoral head. Answer D

A patient with low back pain radiating into BOTH lower extremities may be of neurogenic or musculoskeletal origin. Of all the neurogenic or musculoskeletal possibilities the most important entity to rule out is Cauda Equina Syndrome (CES). CES is an entrapment of terminal nerve roots of the spinal cord. This can be due to a central disc herniation. If S2-S4 nerve roots are involved incontinence can result. If this occurs, immediate surgical decompression is indicated. If decompression is delayed, this may result in irreversible incontinence.

Unilateral loss of the superficial abdominal reflex indicates a lower motor neuron lesion from T7 - L2,
depending on where the absence is noted. If a lower motor neuron lesion was suspected, such as a
herniated disc, it may impact his diagnosis, but this treatment is still likely to be conservative management. Answer A

If the patient had an absent Achilles reflex, this would indicate a lower motor neuron lesion at S1 If this were present, the treatment would still likely be conservative. Answer C

A downgoing plantar response when trying to elicit a Babinski reflex is a normal adult response. In other words, there is no Babinski reflex therefore, there is no suspected upper motor neuron lesion. However, the patient may still have a LMN lesion present. Answer D

A unilateral loss of the cremasteric reflex suggests a lower motor neuron lesion between L1 and L2.
This finding may impact diagnosis and treatment, however it would not impact the diagnosis and
treatment as much as it would if it were cauda equina syndrome. Answer E

Treatment to improve lymphatic return should start with removal of all central restrictions (release the diaphragm and rib raising), followed by release of the periphery (lymphatic pumps). The basic lymphatic treatment program includes:

1) Releasing the diaphragms: Restrictions within the thoracic inlet will obstruct lymph drainage from anywhere in the body. Redoming the diaphragm will produce effective pressure gradients
and enhance lymph return. Restrictions within the pelvic diaphragm will decrease lower extremity lymphatic drainage.

2) Rib raising to reduce hypersympathetic activity (larger lymph channels receive sympathetic
innervation and mobilizing ribs will also enhance respiration).

3) Lymphatic pumps: A pedal pump will promote further lymph return.

There is a lot of debate about which diaphragm to release first; most say release the thoracic inlet first,
but this answer is not fully established. What you should remember for the boards is to release the diaphragm and perform rib raising before starting lymphatic pumps.

As a general rule, diaphragms are first released before applying lymphatic techniques. This ensures the least amount of lymphatic resistance and maximizes the performance of the lymphatic technique (in this case pedal pump). Answers B and C

Although rib raising, pectoral lift and pedal pumps will enhance lymphatic drainage, this answer does not list any diaphragm releases and therefore it is not the best answer. Answer D

Answer E is not the best answer because it does not address the lower extremity edema. Answer E

The patient's aggravating factors and alleviating factors along with the physical findings should indicate to the test taker that this patient most likely has lumbar spinal stenosis. Lumbar stenosis is narrowing of the spinal canal and/or intervertebral foramina. As the patient extends his Lumbar spine (by standing or walking) the intervertebral foramen physiologically becomes more narrowed. If a patient has narrowing of this area neural impingement can occur. Patient's symptoms
will usually improve with flexion of the lumbar spine (sitting). Radiographically, degenerative changes are present in patients with spinal stenosis. Spondylosis is a radiographic term for general degenerative changes. It is virtually a universal finding in elderly patients (even patients without spinal stenosis). Therefore out of the choices given, this is the most likely finding.

A herniated disc is possible, however it is less likely because the pain is made better with lumbar flexion (sitting). The absent Achilles reflexes is likely due to diabetic peripheral neuropathy. Answer A

Although we do not know the extent of this patient's prostate cancer, the likelihood of him having
vertebral metastasis (usually seen as lytic lesions) is far less than the likelihood of spondylosis. Answer

Spondylolisthesis is a much less frequent a finding than spondylosis in the elderly population. Answer

Compression fractures of the lumbar spine are far less common than spondylosis. In addition,
spondyltic changes are usually seen with and often occur before compression fractures. Answer E

There are two main phases of gait. 1) The swing phase and 2) the stance phase.

The swing phase starts at toe off and terminates at heel strike. The stance phase starts at heel strike
and terminates at toe off. In the swing phase the innominate rotates posteriorly around the inferior
transverse axis of the sacrum. In the stance phase the innominate rotates anteriorly around the inferior
axis of the sacrum.

When a person is ambulating the innominates rotate about a transverse axis (as above) while the
sacrum rotates about two oblique axes. Weight bearing on the left leg will cause a left oblique axis to be
engaged, and the opposite is true for the right leg. Sacral rotation will then occur about these two axes.
Answer A

As a person inhales the diaphragm pushes downward, decreasing the lumbar lordosis causing the
sacral base to move posterior. This motion will decrease the lumbosacral angle. Answer C

Nutation and counternutation are terms used for motion at the sacral base associated with craniosacral
motion. Flexion of the cranial bones will cause the sacral base to extend (move posterior). This is called counternutation. Extension of the cranial bones will cause the sacral base to flex (move anterior).
This is called nutation. Answer D

Sacral dysfunction on a left oblique axis will yield a positive seated flexion test on the right, however
other sacral dysfunctions are also seen with a positive seated flexion test on the right (e.g. right
unilateral sacral flexion or extension). Therefore a positive seated flexion test on the right will not always indicate a sacral dysfunction on a left oblique axis. Answer E
An 81-year-old male comes to your clinic with a complaint of right shoulder pain. He injured his
shoulder while playing golf three months ago. He went to the emergency room, where the
doctor told him he most likely tore his rotator cuff. He was given a sling and discharged. He has been using the sling for three months. His pain is mostly resolved, however he still has some pain with shoulder movement. On examination, inspection of the shoulder is normal
without atrophy. There is tenderness at the tip of the acromion, however shoulder impingement signs are negative. Active and passive range of motion testing reveals: 60 glenohumeral abduction, 60° of forward flexion, 10° of external rotation, 20° of internal rotation of the left, extension is normal. Pain is present at the end of range of motion in all planes. Range of
motion testing of the left shoulder is normal. X-rays are normal and there is no evidence of a high riding humeral head.

Which of the following statements best explains this patient's decreased range of motion.

A) The patient suffered a partial tear in his rotator cuff resulting in pain and thus limiting his
range of motion.

B) The patient suffered a complete tear in his rotator cuff resulting in limited range of

C) Chronic impingement has resulted in inflammation of the rotator cuff tendons thus
causing limited range of motion.

D) Prolonged immobility of the shoulder has resulted in fibrosis of the joint capsule causing
decreased range of motion.

E) A tear in the anterior glenoid labrum resulted in decreased range of motion in the stated
planes and preserved range of motion with extension

Piriformis syndrome is a peripheral neuritis of the sciatic nerve. Symptoms are easily confused with those of a herniated lumbar disk or facet joint pathology. The patient often complains of hip and buttock pain radiating down the posterior thigh, possibly to the calf or foot. On physical exam there is an absence of neurologic deficits, and a characteristically exquisite tenderpoint anywhere along
the piriformis muscle.

Factors causing this syndrome are irritation or inflammation of the sciatic nerve, including piriformis muscle spasm, local trauma to the buttocks, repeated mechanical stressors (e.g. running) pelvic instability and excessive local pressure (e.g. sitting), especially in thin or cachectic patients.

Psoas syndrome presents with low back pain, especially in the lumbar region with radiation down the
posterior thigh only to the knee. The Jones tenderpoint associated with this syndrome is about one inch
medial to the anterior superior iliac spine. Answer A

Posterior facet syndrome presents with low back pain, which radiates to the buttocks and sometimes the
calf or ankle. Physical examination generally reveals motion restriction of one or more vertebral segments, limited spinal range of motion, local paravertebral spasm and tenderness. Pain is typically
exacerbated with lumbar extension. There would be no characteristic Jones tenderpoint at the piriformis
muscle, and no neurologic deficit. Answer B

Cauda equina syndrome is compression of the nerve roots of the cauda equina. Typical symptoms are saddle anesthesia, decreased deep tendon reflexes, decreased rectal tone, and loss of bowel and
bladder control. Answer C

Sacroiliac joint syndrome usually presents with pain at the sacroiliac joint area, restricted sacral motion,
and associated spasm of one or more of the muscles attaching to the sacrum. Pain is typically at the
SI joint itself, not in the middle of the buttock. Answer E