The Importance of a Good Physical Exam

Another link for people to check out this week as we steadily progress through exams... I can see the light!
This clip may deal with the relationship between Radiology and the Emergency Room, but that is just one situation where a good clinical exam is so important. Having the skills to properly inspect a patient is something every physician requires or you might end up in a frustrating conversation like this... Let's just hope that one of you aren't the one with the IQ of french fries. Enjoy!

http://www.youtube.com/watch?v=Es1TtaVXO2I&feature=youtube_gdata_player

Fibrodysplasia Ossificans Progressiva

Hello there! Finals are upon us at Boucher and as such, everyone is in a bit of a time crunch. This week I'm linking you to an interesting article I read on The Atlantic which consistently has well-written articles on health, wellness and medicine. I found this one to be particularly fascinating as we were covering bone and bone development at the time in our Biomed class.

It's a little bit of a read, but well worth it. Click here to read about FOP and the girl who turned to bone. 

Osgood-Schlatter Disease

Having sore knees is both painful and frustrating whether you're a 75 year old out for a walk or a 12 year old sidelined at football practice. I was the latter- for a few summers, I was the husky youngster that over-exerted myself and wound up with Osgood-Schlatter disease. Luckily, mine was a very minor case and after football practice I recovered with adequate rest and ice. Others, however, may take weeks to months for recovery and could possibly deal with this issue well into adulthood.

What is it?

Osgood-Schlatter disease is characterized by:

• An enlargement of the tibial tuberosity, just below the patella, that is painful and tender
• Knee pain that worsens with activity- running, jumping, climbing etc- and improves with rest
• Tightness of the surrounding muscles, especially the thigh muscles

A typical image of someone suffering from Osgood-Schlatter disease
Source: http://louisvilleorthopedics.com/

How does it happen?

A nice side angle showing where the patellar
ligament pulls away from the tibial tubercle.
Source: http://www.laserhealthsolutions.com

Osgood-Schlatter disease happens by repeated stress on the tibia by the patellar ligament (also known as the patellar tendon), which is pulled by the quadriceps every time they are engaged. As the quads are used and pull on that tendon, it may pull away from the tibial tuberosity (or tubercle), resulting in the pain and swelling that is common with the disease. If the issue is not treated, it may progress far enough to be a full avulsion fracture. Overtime, the adolescent's bone may try to heal itself and close that gap with new bone growth- this is going to result in a bony lump at that spot. 

Contraction of the powerful quadricep muscles
will cause irritation of the patellar tendon and
tibial tuberosity.
Source: http://activerelease.ca/wordpress/

How to treat it

For most kids, R.I.C.E. (see our previous post to refresh your memory on dealing with inflammation) will do the trick. The period of rest will differ for each young athlete- in my case, I would usually need a few days between practices or games to feel ready to run again, others may take as long as 4 weeks. In mature patients, surgery does become an option if the skeleton is fully grown but the knees are still bothered by Osgood-Schlatters.

For more information on Osgood-Schlatter disease and many others, check out the Professional Health Conditions Manual.

Also, if you're looking to take your studying with you on the go,  download the new ProHealth App from the iTunes store FOR FREE until the end of the month! It's an easy to use and informative app that lets you take much of the Professional Health Muscle Manual with you on your iPhone or iPad. All you have to do is search "ProHealth" on iTunes to find it and you will be on your way with an excellent new tool to excel in your studies.

ProHealth App

Good evening everyone! Exciting news from Professional Health Systems. Our new app is up and running on iTunes for you to download, and make sure you do it soon as it is FREE until the end of the month. The app includes flash cards that will help you study or brush up on your anatomy wherever you are. If you're the type of person who suddenly has the urge to know which muscles help you chew or what the anconeus muscle does, then this app is for you.
If you download it and have any feedback at all, we would love to hear it! Get back at us on the blog with any comments you may have.

The Limb Numbing Lumbar Disc Herniation

Can you do this without feeling any numbness below your knee or pain in your hip? If no...well you just MIGHT have a disc herniation.

What exactly is a Disc Herniation?

Source: http://www.backpainhelptoday.com/herniated-disc/

Source: http://www.columbianeurosurgery.org/wp-content/2009/11/sc.gif

The "disc" in disc herniation is referring to the intervertebral disc (seen on the right, but also in blue below) that can be likened to a jelly doughnut. The "jelly" on the inside is called the nucleus pulposus (in white) and the "doughnut" is a ligamentous structure called the anulus fibrosus (in pink).





Simply put, a disc herniation is a tear in the anulus fibrosus which leads to the protrusion/bulging of the nucleus pulposus. This bulge can compress a nerve root which may cause symptoms seen in a disc herniation.

These bulges can be either posterior or lateral (depending on where the ligament tears), but they occur most commonly at the L4-L5 or  L5-S1 spinal level.




What is the cause of disc herniation and what are the symptoms?

Disc herniations can be caused by repetitive lifting and twisting events (as demonstrated by Deanna Savant in the above video). Improper lifting techniques can lead to a disc herniation, but remember it is due to REPETITIVE TRAUMA and NOT a single event; so following in Sally O'Malley's steps one or two times might not a disc herniation.

Symptoms include:

• Low back pain (at first) because you have sprained your back (torn those ligaments)
• Numbness and tingling into extremity in a dermatonal pattern, usually L5-S1 (refer to page 360 - 361 in the Muscle Manual for a map of the dermatones)

What confirmatory tests can be performed?

Straight Leg Raise Test

When you are at the apex (or at the maximum point where there is no reproduction of symptoms) and have dorsiflexed the foot, bend the knee and continue to flex the hip to rule out any hip problems. A positive test will show possible sciatic nerve impingement due to disc herniation.

Deep Tendon Reflex (DTR)

For disc herniations, the "ankle jerk" reflexes (testing L5-S1) is most applicable. An abnormal reflex (must perform test bilaterally to determine what's considered normal for the patient) may confirm lumbar disc herniation, but other tests must be performed.

Resisted dorisflexion test

The patient will dorsiflex as shown in the video, but instead of the elastic band, the practitioner will push the patient's foot into plantar flexion and the patient will be asked to resist their force. If the patient cannot (or weakly can) resist the practitioner's force, it may confirm a disc herniation impinging the sciatic nerve.

Treatment of a disc herniation

Acute Disc Herniation:

• Decrease inflammation (via PRICE) and decrease load bearing
• Avoid any twisting or aggravating activity (especially the activity that caused the injury in the first place)
• Lock the pelvis in a neutral position for any movements (to protect the back and decrease potential for further injury)

Chronic Disc Herniation:

• Spinal decompression
• There are several ways to decompress the spine:
• Inversion table
• Decompression machine
• Hanging from a stable door/bar
• Simply laying down (takes the pressure off the spine and allows for re-hydration of discs)

A disc herniation should resolve itself IF you deal with it EARLY/ACUTELY, don't wait until it becomes chronic and a major problem! If you want to be able to kick and stretch at 50 like Sally O'Malley, PROTECT THAT BACK and get it looked at early!

The Hip!

     No, not the Tragically Hip... which would possibly make for a more interesting article, who doesn’t love Gord Downie and the boys? Instead today we’re going to have an overview of the hip and some aspects of it that are important for everyone to understand. 

Great hip flexion Mr. Downie! But not the point of this post. Source: www.windsorstar.com

     Depending on who you ask, the hip can mean different things. It’s a large area and it is vital to differentiate between the hip joint, the hip bone, the sacroiliac joint or soft tissue surrounding the area. Often, patients will present with pain saying that their hip hurts and be pointing vaguely to somewhere near the iliac crest or perhaps their anterior superior iliac spine. While these are part of the hip bone, also known as your pelvic or coxal bone, it’s important to have a good understanding of the hip to help you discern exactly which structure the patient is talking about. 

Source: Gray's Anatomy

    The left hip bone with a good view of the acetabulum
where the femoral head sits. Source: Gray's Anatomy

     The hip bone is actually made up of three bones- the ilium, ischium and pubis, which do not finish fusing together until approximately age 25. The hip bones come together anteriorly at the pubic symphysis and posteriorly at the two sacroiliac joints. An important thing to remember is that three of the SI joint ligaments (sacrotuberous ligament, sacrospinus ligament and sacroiliac ligament) are three of the strongest you will find in the human body. The hip bone has a myriad of important muscular attachments, some of these include the quadratus lumborum, iliacus, gluteus max, med and min. Pictures help for a better understanding of all the bone structure and muscle attachments in this area and The Pro Health Muscle Manual is a great tool to help you learn. On the lateral side of the hip bone is where you will find your hip joint, also known as the acetabulofemoral joint (because of the hip structure acetabulum creating a ball and socket joint with the head of the femur). This is the area replaced when you hear about somebody getting a hip replacement (not for the squeamish). For more information on both the anatomy of this area and testing it, check out the Physical Assessment Manual.                                          

     Another area of the hip bone worth mentioning is the ischial tuberosity. I don’t know how many of you practice yoga, but if you have ever heard a teacher tell you to “root down into your sit bones” and not know what the heck they were talking about, this is it. Your ischial tuberosity is the bony segment you can feel if you pull a cheek away while sitting on your bottom, and it really helps you find stability on the floor for seated postures. It’s an important anatomical location in yoga (check out this article for a better understanding) and also in everyday anatomy. The ischial tuberosity wraps around towards the pubis bone, creating a space known as our obturator foramen which allows the passage of blood vessels and nerves. 

An excellent picture from Gray's showing all three bones of the hip bone and 

the Ischial Tuberosity (Tuberosity of Ischium). Source: Gray's Anatomy

     Hip injuries are a common issue today. Maybe it’s an athlete with a hip flexor problem, the development of osteoarthritis in the hip joint, or the unfortunate case of an elderly person falling and breaking their hip. All of these problems will require a thorough understanding of the hip’s anatomy and if you want solid resources to learn from or supplement your practice with, take a look at Pro Health’s full line of products.