Differential Diagnosis Differential Diagnosis � Central Disc Derangement � Present with mid- line back pain. � Usually no neurological S & S’s. � May or may not present with signs of dysfunction. � Special testing/ imaging to confirm. � Usually do well. � Rowing.
Differential Diagnosis Differential Diagnosis � Osteitis Pubes � Pain in groin or hip flexor area. � May have symptoms uni- or bilaterally. � Usually have associated dysfunctions, which may be different day- to- day. � Referral and special testing/ imaging. � Good luck!!!
Differential Diagnosis Differential Diagnosis Harris and Murray, British Medical Journal, 1974, 4, 211- 216
Differential Diagnosis Differential Diagnosis ASIS Avulsion Fracture Pavlov, Clinics in Sports Medicine, Vol. 6, No. 4, October, 1987
Differential Diagnosis Differential Diagnosis � Tumor � Pubic Stress Fracture � Facet Joint Inflammation � Hip Joint (Acetabulum) Pathology � All of the Hernia’s (Gilmore’s Groin, Sportsman’s Hernia, Athletic Pubalgia )
Differential Diagnosis Differential Diagnosis � Transitional vertebrae (variation) � Sacralization of L 5 � Fusion of L5 with sacrum
Differential Diagnosis Differential Diagnosis � Transitional Vertebrae (variation) � Lumbarization of S 1 � Resulting in a sixth lumbar vertebrae, and only four sacral vertebrae.
Barrier Concept Barrier Concept � Point beyond which a joint will not move � Types: � Physiological - limit of active range � Anatomical - limit of passive range � Going beyond anatomical barrier results in joint disruption
Barrier Concept Barrier Concept � Types (cont.) � Restrictive - point in the range of motion where all of the slack is taken out. Muscle - spasm can be a cause or an � effect of biomechanical changes
Barrier Concept Barrier Concept MIDLINE TOTAL RANGE OF MOTION ANATOMICAL LIMITS
Barrier Concept Barrier Concept MIDLINE P P R R ACTIVE RANGE OF O O MOTION M M PHYSIOLOGICAL LIMITS ANATOMICAL LIMITS
Barrier Concept Barrier Concept NEW MIDLINE OLD MIDLINE MOTION ACTIVE RANGE OF PROM LOSS MOTION PHYSIOLOGICAL RESTRICTIVE BARRIER LIMITS ANATOMICAL LIMITS
Leg Length Discrepancies Leg Length Discrepancies � Do not underestimate the effect of small differences in leg length. � Use of good heel lifts can be very effective at correcting leg length discrepancies and eliminating muscle barriers. � Felt or cork lifts will only last a short time, especially in a heavier athletes.
Leg Length Discrepancies Leg Length Discrepancies
Leg Length Discrepancies Leg Length Discrepancies � Evaluate in supine with knees bent, feet aligned from side and front views. � Eliminates muscle barrier discrepancies .
Leg Length Discrepancies Leg Length Discrepancies � http://www.bmlbasic.com/ � Heel lifts; 3 mm, 5 mm, 7 mm, 9 mm, 12 mm � Select “D 60” (Red Brown)
Biomechanical Evaluation Biomechanical Evaluation � History- key component � Inspection- dominant eye � Palpation- subtle changes � Functional movement- normal biomechanics
History History � What are your motion limitations? � What are your activity limitations?
History History � How does this affect the rest of your activities? Sitting in class? Riding in a car? � Does the pain interrupt your sleep? Is sleep position affected or changed? � Any other related previous injury? Lower leg fracture?
Inspection Inspection � View from front, back, and each side � Begin with static standing � Looking for anatomical differences between each side � Begins at the feet and ends at the head
Inspection Inspection Static Standing Anterior View Lateral View Posterior View
Inspection Inspection Static Standing
Inspection Inspection � Observe for tibial bowing unilaterally or bilaterally. � Observe stance pattern.
Static Standing Static Standing � Observe height of popliteal lines.
Static Standing Static Standing � Observe height of gluteal folds.
Static Standing Static Standing � Observe height of both PSIS.
Static Standing Static Standing � Observe height of both ASIS.
Static Standing Static Standing � Observe height of both Iliac Crests.
Spinal Alignment Spinal Alignment � Spinal alignment in extension and flexion. � Shoulder height. � Discernable “C” curve or “S” curve.
Standing Motion Standing Motion � Repeated flexion x ten.
Standing Motion Standing Motion � Repeated Extension x ten.
Standing Motion Standing Motion � Does either motion : � increase pain? � decrease pain? � have no effect on pain? � Part of the McKenzie Approach Exam.
Standing Motion Standing Motion � Ask athlete to flex the trunk while you have your thumbs at each PSIS/ sulcus. � You should see & palpate symmetrical motion at your thumbs.
Standing Motion Standing Motion � Ask the athlete to perform a “stork stand”. � You should observe symmetrical motion at your thumbs.
Standing Motion Standing Motion � Repeat this test with hip extension. � You should observe symmetrical motion at your thumbs .
Seated Flexion and Extension Seated Flexion and Extension � Same procedure � Observe for as standing symmetrical motion. motion tests.
Supine Supine � Anatomical symmetry of pubic rami. � Allow the athlete to perform this test by themselves. � Do not perform in private office without observer (coach, another ATC, etc.).
Supine Supine � Place each thumb on the corresponding ASIS. � Looking for the involved side to be either more anterior and medial or posterior and lateral.
Supine Supine � Place each thumb on the corresponding ASIS. � Looking for the involved side to be either more anterior and medial or posterior and lateral.
Supine Supine � Place each thumb on the correspondin g ASIS. � Looking for the involved side to be either more superior or inferior.
Supine Supine � Perform other traditional hip and sacroiliac joint tests: � Patrick or Fabere Test. � Hip Scour. � R/O hip/ acetabular pathology.
Long Sit Test Long Sit Test � Perform long sit test � Initially observe for symmetry of medial malleoli. � Ask athlete to sit and touch their toes. � Observe for any changes in leg length. � Not consistent w/ rules that appear in textbooks.
Long Sit Test Long Sit Test
Long Sit Test Long Sit Test
Pelvic Rock Test Pelvic Rock Test � Pelvic rock and long leg traction to look for. restrictions in movement. � Used to confirm finding of dysfunction.
Long Leg Traction Long Leg Traction � Pelvic rock and long leg traction to look for restrictions in movement. � Used to confirm finding of dysfunction.
Prone- - Spring Test Spring Test Prone � Used to check the mobility of the spine. � Place one hand on top of the other and press down into the spine. � Work your way up the spine.
Prone Prone � Use your fingertips to check sulcus, which is just medial to the PSIS, depth in neutral (flexion) and in extension (sphinx position).
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