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Textbook
Introduction
1. Cardiopulmonary system
2. Pulmonary system
3. Neuromuscular system
4. Pediatrics
5. Musculoskeletal system
5.1 Anatomy of musculoskeletal system
5.2 Foundation content of musculoskeletal system
5.3 Upper extremity anatomy
5.4 Special tests of upper extremity
5.5 Clinical presentation and interventions for upper extremity
5.6 Lower extremity anatomy
5.7 Special tests of lower extremity
5.8 Comparing clinical presentation and interventions of lower extremity
5.9 Spine, pelvis, and tempromandicular joint anatomy
5.10 Special tests of the spine, pelvis, and tempromandipular joint
5.11 Comparing clinical presentation and interventions for the spine, pelvis, and tempromandipular joint
5.12 Other MSK conditions
5.13 Gait
5.14 Prosthetics and orthotics
5.15 Medications, imaging, and fractures
5.16 Surgical protocols
6. Other system
7. Non-systems
Wrapping up
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5.11 Comparing clinical presentation and interventions for the spine, pelvis, and tempromandipular joint
Achievable NPTE-PTA
5. Musculoskeletal system
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Comparing clinical presentation and interventions for the spine, pelvis, and tempromandipular joint

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Spine and pelvis differential diagnosis

  • Spinal or intervertebral stenosis
    • Narrowing of spinal canal or intervertebral foremen
      • Can cause neurological or vascular dysfunction
  • Symptoms
    • Bilateral back, buttocks, and leg pain
    • Pain increases with extension
    • Pain increases with walking
    • Pain decreases with flexion and/or rest
  • Diagnosis
    • Clinical presentation
      • Special tests- bicycle test
    • MRI
    • CT imaging
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Flexion based exercises that centralize pain
    • Dynamic stability for trunk and pelvis
    • Manual therapy
    • Avoidance of extension, ipsilateral side-bending, and ipsilateral rotation

Facet joint dysfunction (two types: degenerative joint disease, facet entrapment)

  • Degenerative joint disease
    • Causes bone hypertrophy, capsular fibrosis, hypermobility or hypomobility at joint caused by natural process of aging
    • Occurs due to repetitive weight bearing of facets and intervertebral joints over life-span
  • Symptoms
    • Localized pain in the neck, back, or buttocks
    • Pain that worsens with certain movements, such as bending, twisting, or standing for long periods of times
    • Pain that radiates into the arms, legs, or shoulders
    • Difficulty moving the neck or back
    • Morning stiffness that improves with activity
  • Diagnosis
    • Clinical presentation
      • Special test- quadrant test
    • X-ray
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Spinal mobilization as appropriate
    • Exercise promoting dynamic stability of trunk and pelvis
  • Facet entrapment (acute locked back)
    • A condition where the small joints (facet joints) connecting vertebrae in the spine become inflamed or damaged, causing pain and potentially restricting movement
  • Symptoms
    • Dull, aching pain in the back or neck, which can worsen with certain movements or activities
    • Difficulty moving the spine - flexion is most comfortable for patient
    • Spasms in the back or neck muscles as a protective response to the pain.
    • Can cause nerve irritation can cause numbness or tingling in the arms, legs, or buttocks.
  • Diagnosis
    • Clinical presentation
      • Special test- quadrant test
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Facet manipulation to improve mobility

Disc Conditions

  • Internal disc disruption
    • Internal annulus is disrupted while outside structures remain intact
  • Symptoms
    • Chronic, central low back pain
    • Pain worsens with activity and loading the spine
    • Muscle spasms.
    • Pain may be constant or episodic
    • No neurological findings
  • Diagnosis
    • Clinical presentation
    • CT scan
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Joint mobilization
    • Patient education on biomechanics and positions to avoid
  • Posterolateral bulge/herniation
    • Overstretching or tearing of annular rings, vertebral endplate, and or ligamentous structures due to high compressive forces or repetitive trauma
  • Symptoms
    • Radicular pain
    • Lower extremity weakness
    • Lower extremity paresis
  • Diagnosis
    • Clinical presentation
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Improve dynamic stability of trunk and pelvis
    • Spinal manipulation
    • Manual traction
    • Positional gapping
    • Patient education on biomechanics
  • Central posterior bulge herniation
    • Overstretching or tearing of annular rings, vertebral endplate, and or ligamentous structures due to high compressive forces or long term postural misalignment
      • Move common in cervical spine
  • Symptoms
    • Radicular pain
    • Lower extremity weakness
    • Lower extremity paresthesia
    • Possible compression of spinal cord causing upper motor neuron lesion
  • Diagnosis
    • Clinical presentation
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Improve dynamic stability of trunk and pelvis
    • Spinal manipulation
    • Manual traction
    • Positional gapping

Spondylosis

  • Spondylosis is a degenerative condition of the spine that involves changes in the intervertebral discs and facet joints, commonly referred to as spinal osteoarthritis.
  • Can be caused by degeneration of the intervertebral disc (disc desiccation), formation of osteophytes (bone spurs), or possible narrowing of the intervertebral
  • Symptoms
    • Gradual onset of chronic back pain and stiffness, especially in the cervical and lumbar spine
    • Limited range of motion, especially extension and rotation
    • May be asymptomatic or cause radicular symptoms if nerve compression occurs
  • Diagnosis
    • X-ray: Reduced disc space, osteophyte formation, facet joint changes
    • MRI: Assesses neural compression and disc degeneration
  • Medical management
    • NSAIDs pain and inflammation
    • Muscle relaxants if muscle spasms are present
    • Corticosteroid injections (epidural or facet joint) for nerve root involvement
    • Surgical intervention (e.g., decompression or fusion) in cases of severe stenosis or myelopathy
  • Physical therapy management
    • Postural education and ergonomic training
    • Stretching of tight musculature (e.g., hamstrings, hip flexors)
    • Strengthening of spinal stabilizers, especially deep core muscles
    • Manual therapy to improve mobility
    • Aerobic conditioning (walking, cycling)
    • Education on activity pacing and joint protection

Spondylolysis

  • Stress fracture or defect in the pars interarticularis, the segment of bone between the superior and inferior articular processes of a vertebra.
  • Often occurs due to repetitive hyperextension, particularly in young athletes
  • Most commonly affects the L5 vertebra
  • Symptoms
    • Localized low back pain, worsened with lumbar extension
    • Possible tight hamstrings
    • Usually no neurological symptoms
  • Diagnosis
    • Oblique lumbar X-ray: Shows “Scotty dog with a collar” appearance
    • CT or MRI may confirm the presence of the defect
  • Medical management
    • Activity modification (rest from extension-heavy sports)
    • NSAIDs for pain relief
    • Bracing (e.g., lumbosacral orthosis) to allow healing
    • In rare non-healing cases, surgical fixation
  • Physical therapy management
    • Education: Avoid extension-based movements initially
    • Core stabilization exercises (neutral spine control)
    • Hamstring stretching and hip mobility work
    • Gradual return to sport with movement re-education
    • Emphasis on lumbar-pelvic control during dynamic a

Spondylolisthesis

  • Anterior slippage of one vertebra over the vertebra below it. It may be the result of spondylolysis (isthmic) or degenerative changes.
  • Types
    • Isthmic: Due to bilateral pars defects (common in younger individuals)
    • Degenerative: Due to facet joint and disc degeneration (common in older adults)
  • Symptoms
    • Low back pain with or without radicular symptoms
    • Tight hamstrings and altered posture
    • Palpable step-off deformity
    • In severe cases, may present with neurological deficits
  • Diagnosis
    • Lateral X-ray: Shows degree of vertebral slippage (graded I–V based on percent displacement)
    • MRI: Identifies soft tissue or neural involvement
  • Medical management
    • NSAIDs, acetaminophen, or muscle relaxants for pain
    • Epidural steroid injections if radiculopathy is present
    • Bracing for pain control and stability
    • Surgical intervention (e.g., spinal fusion) in cases of high-grade slippage or neurological compromise
  • Physical therapy management
    • Core strengthening to stabilize the lumbar spine
    • Postural retraining
    • Avoid lumbar hyperextension and heavy axial loading
    • Stretching tight muscles (especially hamstrings)
    • Manual therapy for adjacent segment mobility
    • Progressive return to activity under supervision
    • Education on body mechanics and functional movement patterns

Whiplash associated disorders (WAD)

  • Occurs in cervical spine when excess shear and tension occur on the structures of the cervical spine
    • Structures damaged are facets/articular processes, facet joint capsule, ligaments disc, anterior/posterior muscles, fracture to odonotoid process, TMJ, spinal nerves, cranial nerves
  • Symptoms
    • Heachaches
    • Limited mobility
    • Vertigo
    • Hearing loss or ringing in the ears
    • Difficulty swallowing
    • TMJ dysfunction
    • Disequilibrium
    • Anxiety
  • Diagnosis
    • Clinical presentation
      • Canadian c-spine rues
    • MRI
    • CT scan
    • X-ray
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Spinal manipulation
    • Patient education on biomechanics and positions to avoid
    • Joint mobilization
    • Functional training

Sacroiliac joint conditions

  • Causes of dysfunction can be inflammation, degenerative changes, or abnormal movement patterns
    • Can be associated with lumbar spine so will need to examine both when pain reported
  • Symptoms
    • Lower back pain, often on one side
    • Pain that radiates to the buttocks, hips, or thighs
    • Pain that worsens with activities such as sitting, standing, or walking
    • Stiffness in the lower back or hips, especially after sitting for long periods
  • Diagnosis
    • Clinical presentation
    • Special test- SI gapping, SI compression, Gaenslens test
    • MRI
    • X-ray
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Spinal manipulation
    • Patient education on biomechanics and positions to avoid
    • Joint mobilization
    • Functional training

Sacral Spondylolisthesis

  • Forward slippage of the sacrum or L5 over the sacrum due to instability such as trauma, stress fractures, or degenerative changes
  • Symptoms:
    • Low back pain (worse with extension).
    • Sacral/hip pain.
    • Tight hamstrings.
    • Possible nerve compression leading to leg pain or weakness.
  • Diagnosis:
    • Clinical presentation
    • X-ray
    • MRI
    • CT scan
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Treatment
    • Core stabilization exercises.
    • Physical therapy for posture correction.
    • Bracing for mild cases

Upslip of the Ilium (Superior Ilium Displacement)

  • The ilium on one side moves superiorly relative to the sacrum.
  • Common causes:
    • Trauma (e.g., stepping off a curb forcefully, falling on one side), muscle imbalances.
  • Impaired (Weak/Lengthened) Muscles:
    • Gluteus medius & gluteus minimus (difficulty stabilizing the pelvis).
    • Quadratus lumborum (opposite side) (overstretched and weak).
    • Hip adductors (on the affected side, often lengthened).
  • Tight/Overactive Muscles:
    • Quadratus lumborum (same side) (shortened, pulling the ilium superiorly).
    • Iliopsoas (on the affected side, can contribute to pelvic asymmetry).
    • Hamstrings (may compensate for instability).

Downslip of the Ilium (Inferior Ilium Displacement)

  • The ilium on one side moves inferiorly relative to the sacrum.
  • Common causes:
    • High-impact trauma, instability in the sacroiliac (SI) joint.
  • Impaired (Weak/Lengthened) Muscles:
    • Quadratus lumborum (same side) (overstretched and weak).
    • **Gluteus medius & gluteus minimus **(lack of pelvic stability).
    • Hip abductors (due to altered pelvis positioning).
  • Tight/Overactive Muscles:
    • Hip adductors (same side) (contracting to stabilize the pelvis).
    • Quadratus lumborum (opposite side) (may tighten in compensation).

TMJ conditions

  • Can be due to
    • Osteoarthritis, rheumatoid arthritis
    • Myofascial pain- pain in muscles controlling TMJ
    • Dislocation of jaw
  • Symptoms
    • Joint noise when opening mouth
    • Joint locking
    • Loss of range of motion
    • Lateral deviation during depression or elevation of mandibile
    • Decreased strength of mandible
    • Headache
    • Ringing in ears
    • Forward head posture
    • Can have cervical spine pain
  • Diagnosis
    • Clinical presentation
    • X-ray
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Muscle relaxants
  • Physical therapy management
    • Patient education on biomechanics and positions to avoid
    • Joint mobilization
    • Biofeedback
    • Modalities for pain and inflammation
    • Night splinting

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