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L. Larson, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Associate Professor, Mercer University School of Medicine

The stance phase: this forms 60 percent of the gait and here the foot is on the ground (Figs 26. The swing phase: this forms 40 percent of the gait cycle and here the foot is not in contact with the ground (Figs 26. In normal gait, each leg alternatively goes through a stance phase and a swing phase. Backward lurch To clear the dropped foot from the ground Legs cross while walking When shortening > 2" No flexion at hip Limping gait with the hand on the knee Pelvis drops on opposite side of the hip Probable diagnosis Any painful lesion of foot, knee, hip, etc. It is a highly subjective complaint and can be classified as mild, moderate or severe. Deformity: Sudden onset of deformity is usually seen in fresh fractures and dislocations. Long-standing deformities are usually seen in old fractures and other nontraumatic disorders like congenital, developmental, and metabolic conditions. The patient may complain of cosmetic and functional impairment due to the deformity. Limitations of joint movements: In the initial stages, it may be due to muscle spasm; and in the later stages, it may be due to intra-articular adhesions. The patient may complain of difficulty or alteration in various day-to-day activities like walking, squatting, running, working, etc. Limb weakness: this may be due to disuse atrophy, motor problems like polio, motor neuron disease, etc. Gluteus medius gait Gluteus maximus gait High stepping gait Scissors gait Short leg gait Anterior polio Foot drop Cerebral palsy Limb shortening (congenital or acquired) Septic arthritis at hip Polio Stiff hip gait Quadriceps gait Trendelenburg gait Calcaneus gait Stiff knee gait Ataxic gait Hysterical gait No push off Pelvis raised during swing phase Child walks with legs apart Seen in conversion hysteria. Approach to Orthopedic Disorders 359 Signs General: Look for the signs of anemia, fever, weight loss, etc. Remember A fixed deformity is the angle between the neutral position of the normal joint and the position the deformed joint will reach. Also, examine the level of the swelling and identify whether it is epiphyseal, metaphyseal or diaphyseal (Figs 26. The plane of the swelling could be either bone (swelling decreases Movements of joint: ?Active movement the patient himself moves the joint in one direction and later in the other. To know the apparent length of the lower limbs measurement is taken from the xiphisternum to the medial malleolus (Fig. Irregular thickening of bone and persistent discharging sinus: If this is present along with scars fixed to bone, it indicates chronic osteomyelitis (see box for causes of persistent sinus) (Fig. Quick facts-sinus tracts Causes of persistent discharging sinus: ?Unobliterated cavities. Measurements: Accurate limb length measurements give vital clues regarding the diagnosis. To know the limb length: For this, measurement is taken between two fixed bony points and is always compared with the normal. Upper limbs ?Arm length: From the angle of acromion to the lateral epicondyle of humerus (Fig. Lower limbs ?Thigh length: From anterosuperior iliac spine to the medial knee joint line. Special investigations: ?Radiography: At least two views of the affected part should be taken, oblique views and some special views are required in some cases. Thus, a reasonably accurate diagnosis can be made by following the guidelines discussed above. Steps in the process of diagnosis At the end of investigation At the end of examination At the end of history Final Provisional Guess Fig. One has to 27 ?Deformities and their Management Acquired deformities are more commonly encountered than the congenital variety. They may be so severe that the child is still born or may be so minor that it is not noticeable (See section on Congenital Deformities). Tethering of Muscles and Tendons this can take place due to the growth of fibrous tissue following infections or due to callus following fractures. Tethering restricts the joint movements and if held for some time deformity results. Arthritis Any joint may give rise to muscle spasm in the initial stages and fibrous or bony ankylosis in later stages giving rise to deformities. Postural this is due to improper postural habits like hallux valgus in women due to tight and rigid shoes.

The collagen fibers creep into the folds that form between the fingers and attach to the basal membrane of the muscle. At the other end, the tendons attach to bone via fibrocartilage and mineralized fibrocartilage. Collagen fibers penetrate the mineralized fibrocartilage into the subchondral bone, contributing to better attachment. The relationship between stress and deformation of tendons is the same as for the ligaments (Figure 1. Initially, the collagen fibers are easily stretched from their normal wavy appearance, in the elastic zone the tendon behaves like an ideal spring, whereas ruptures occur in the deformation zones: first single fibers, then total ruptures. Adaptation to Training the tendons adjust to training in the same manner as the ligaments-by increasing the tendon strength through collagen synthesis, cross-link formation and training improved material properties of the tendinous tissue, and if trained sufficiently some increase in tendon cross-sectional area can be seen. Acute exercise results in an increase in collagen synthesis within and around the tendon tissue. Collagen synthesis remains increased for 2? days, indicating that training every second or third day is most likely a sufficient stimulus for tendon protein generation. In addition, the relative load intensity required is less than in muscle, which means that also moderate exercise, either concentric or eccentric, will result in elevated formation of new collagen in tendon. Changes in physical activity levels, either increased training or detraining/ immobilization, quickly (within 1? weeks) alter mechanical properties, most likely through increased or decreased cross-link formation, respectively. In contrast, changes in collagen-rich fibril structures require several months to years to occur. Tendon Injuries Tendons can be injured in several different ways, both as acute injuries and as overuse injuries. Because tendons are usually superficial, they can be severed by a penetrating stab or a cut, such as one caused by the edge of a skate. These types of tendon ruptures usually occur in connection with eccentric force generation, such as in the Achilles tendon when pushing off at the start of a sprint run. Tendon ruptures may be partial or total, and they usually occur in the midtendon substance but may also occur in the bone?endon junction or as avulsion fractures. Acute tendon injuries are most common in athletes and recreational exercisers between 30 and 50 years of age in explosive sports, often without previous symptoms or warning. Some studies reveal that structural and degenerative changes can be seen in the tendon prior to exercise. Several different terms are habitually used to describe these overuse injuries: tendinitis (tendon inflammation), tenosynovitis (tendon sheath inflammation), tenoperiostitis 9 (inflammation of tendon insertions and origins), periostitis (periosteal inflammation), and bursitis/hemobursitis (bursal inflammation, possibly with bleeding). All these terms describe the parts of the tendon or the surrounding tissue that is affected, and all have the ending "itis," indicating the pathophysiological condition of inflammation. Even though the concept of inflammation has been used traditionally, the pathogenesis for overuse injuries in tendons is uncertain. Although tendon loading does not normally cause more than a 4% change in length (i. Therefore, a potential explanation of what is called tendinitis is that repetitive microtrauma causes injuries that are greater than the fibroblasts are able to repair, resulting in inflammation. It is also possible that cumulative microtrauma can affect collagen cross-bridges, other matrix proteins, or microvascular elements in the tendon. Also, loading that extends the tendon less than 4% can lead to overuse symptoms, and it is likely caused by inadequate time to adapt to each training load. One problem with explaining tendon overuse as inflammation is that the histological findings do not match those seen with inflammation-surgical specimens are devoid of inflammatory cells. However, degenerative changes, changed fibril organization, reduced cell count, vascular ingrowth, and, occasionally, local necrosis with or without calcification are seen. The concept of tendinosis was introduced to describe these types of focal degenerative changes. Because the relationship between degenerative changes and symptoms is unclear, the terms "tendinosis" or "tendinopathy" are now commonly used to describe chronic tendon pain. The new terminology emphasizes the need for the terminology to correspond to the histological findings.

I considered this so important that in 1892 I went to Bonn, Germany, to confer with Dr. During the succeeding years I made numerous experiments with the same object, but the results were uniformly negaIn 1900, however, after I had evolved tive. For more than eighteen years I have been reading treatises, reports of scientific transactions, and articles on Hertz-wave telegraphy, to keep was asked whether such a system would be of practical value, he did not think so, and he was correct in his forecast. The best that might have been expected was a method of communication similar to the Lorn resistance morn* Alternator Friction Device ^<^S Lour resistance. At that machine before the American Intime I was in the midst of pressstitute of Electrical Engineers at ing work in connection with the this remarkable and complete story of his discovery of the Columbia College, which laid the commercial introduction of my "True Wireless" and the principles upon which transmission foundation to a new and far more system of power transmission, and reception, even in the present day systems, are based, Dr. Altho the but, nevertheless, caught the fire Nikola Tesla shoivs us that he is indeed the "Father of the Wirelaws of electrical resonance were of enthusiasm and fairly burned less. He convinces us that the real Hertz waves are blotted kinson, had even indicated their ly, as soon as I had freed myself out after they have traveled but a short distance from the sender. He shows it is probable that those experiapparatus with the object of exby examples with different forms of aerials that the signals picked ments of mine were the first pubploring the field opened up by up by the instruments must actually be induced by earth currents lic exhibition with resonant cirDr. Tesla also disproves the "Heaviside layer" cuits, more particularly of high itations of the devices he had theory from his personal observations and tests. It was a perall kinds of devices could be operated inspiration led me to the invention of the fectly well-established fact that a circuit, thru a single wire without return. This traversed by a periodic current, emitted of 1891 I was already so far advanced in some kind of space waves, but we were in the development of this new principle that ignorance as to their character. The His Experimental Demonstrations Before the American Institute of Electrical Engineers Hertz-wave theory, by its fascinating hold With the High Frequency Alternator Shown on the imagination, has stifled creative efin Fig. The idea presented itself once more, very carefully, with these imAs regards signaling without wires, the to me that it might be possible, under ob- history of science shows that theoWith every new truth that is revealed we get a better understanding of Nature and our conceptions and views are modified. I dilators had first to energy oi these bad to b< transformed transmitters and collected. Loosely linked with the latter was a high tension secondary which was tuned to the primary. The operation of devices thru a single wire without return was puzzling at first nit can be readily because of its novelty. I will briefly touch upon the salient advances as they were made in the gradual development of the system. It was an excellent machine for experimental purposes, furnishing sinufirst my scribed by Tesla In His Lecture Before the Institution of E lectrical Engi- neers, London, February, 1892. The output was comparatively large, due to the fact that as much as 30 amperes per square millimeter could be past thru the coils without injury. Corresponding to the terminal capacity of the electric begun Stmi/atiy funed but as a matter of fact I spent the two plying osci/tanans of orbi/rary frequency Transforming circuit f H> tuned k> fi^ue^cyor~arcuifli t or a harmonic of the same. Consider now the effect of such a conductor of vast dimensions on a circuit exThe upper diagram of Fig. As both parts of the system on either side of the node vibrate at the same rate, we have evitions dently, May, substance, is 1919 incandescent the system of today and I am single authenticated instance of successful transmission at considerable distance by different instrumenIt might, perhaps, not be clear to talities. Diagram Explaining the Relation Between the Effective and the pacity C becomes commensurate to that of approximates L, in other the earth, words, the node is close to the ground connection. The exact determination of its position is very important in the calculation of certain terrestrial electrical and geodetic data and I have devised special means with this purpose in view. My original plan of transmitting energy without wires is shown in the upper diagram of Fig. I such units in order to intensify the effects, an idea which may yet prove valuable. In the analog two tuning forks are provided, one at the sending and the other at the receiving station, each having attached to its lower prong a piston fitting in a cylinder. The two cylinders communicate with a large elastic reservoir filled with an incom- Measured those tion Current in the Antenna. I gave to the world a wireless system of potentialities far beyond anything before conceived. Evidently, as the periodic impulses pass thru the wire, differences of potential will be created along the same as well as at right angles to it in the surrounding medium and either of these may be usefully applied. Thus at a, a circuit comprising an inductance and capacity is resonantly excited in the transverse, and at b, in the longitudinal sense. At c, energy is collected in a circuit parallel to the conductor but not in contact with it, and again at d, in a circuit which is partly -:%.

Bring yourself only to the edge of the stretch, so that you can remain there, breathe, and allow the piriformis to release. Bring your right foot forward as well, until your heel is in line with your left hip and your shin is at about a 45-degree angle. To stretch the right piriformis, lean your upper body forward, tuck your left toes under, and slide or walk your left leg straight back, allowing your right thigh to rotate out passively as your hip descends toward the floor (Fig. If you find this pigeon pose stretch too intense or difficult, try a variation: Place your right leg up on a table and lean forward, using your hands on the table for balance, as you walk your left foot back (Fig. Our medical professionals have years of experience and expertise in all spinal conditions including traumatic injuries and deformities. Listed among the leading national physicians in spine health with State-of-the-Art facilities in Commack, West Islip, Garden City and Manorville. We are committed to delivering the highest quality of individualized comprehensive care to each patient with compassion and integrity. We identify the cause of the symptoms & develop an individual effective treatment plan by exploring a variety of medical options which may include nonsurgical treatment and when specifically indicated, operative intervention to return patients to active healthy lifestyles. The most common cause for sciatica is irritation of the spinal nerves in or near the lumbar spine. Piriformis syndrome can be painful, but it is seldom dangerous and rarely leads to the need for surgery. Most people with this condition can reduce the pain and manage the problem with simple methods, such as physical therapy. This guide will help you understand ?how the problem develops ?how doctors diagnose the condition ?what treatment options are available Anatomy What parts of the body are involved? The lower lumbar spinal nerves leave the spine and join to form the sciatic nerve. It connects to the sacrum, the triangular shaped bone that sits between the pelvic bones at the base of the spine. The other end of the piriformis muscle connects by a tendon to the greater trochanter, the bump of bone on the top side of your hip. This is because the sciatic nerve runs under (and sometimes through) the piriformis muscle on its way out of the pelvis. The piriformis muscle can squeeze and irritate the sciatic nerve in this area, leading to the symptoms of sciatica. Many doctors think that the condition begins when the piriformis muscle goes into spasm and tightens against the sciatic nerve, squeezing the nerve against the bone of the pelvis. The pain can radiate down the leg all the way to the foot and may be confused for a herniated disc in the lumbar spine. Eventually the muscle heals, but some of the muscle fibers inside the piriformis muscle are replaced by scar tissue. The piriformis muscle can tighten up and put constant pressure against the sciatic nerve. When they do sit down, they tend to sit with the sore side buttock tilted up rather than sitting flat in the chair. Your doctor will ask questions about your symptoms and how the pain is affecting your daily activities. Your doctor will also want to know what positions or activities make your symptoms worse or better. You will be asked about any injuries in the past and about any other medical problems you might have such as any arthritis that runs in the family. Next the doctor examines you by checking your posture, how you walk, and where your pain is located. Your skin sensation, muscle strength, and reflexes are also tested because it is difficult to distinguish pain coming from the sacroiliac joint from pain coming from other spine conditions. If there is any question whether you might have an infection or some type of arthritis affecting multiple joints, laboratory tests may be ordered. You may need to have blood drawn and give a urine sample to send to the laboratory for special tests.

The psychic centres forced open by a diseased blood-stream perceive anything that comes within their range of vision. At the commencement of our diagnosis we must distinguish between three broad classes of psychic disturbance: those which are a by-product of physical disease, those which are due to malicious human action, and those which are due to non-human interference. There are two ways in which he can do this, and he ought to use them both, so that they countercheck each other. Let one person do the psychism and another the observation, and let proper precautions be taken to prevent the results of the clairvoyant investigation being vitiated by suggestion, or by the thought-reading of previously conceived opinions held in the mind of any of the persons concerned. It was of course so thoroughly impregnated with his own emanations as to be useless. A psychometrical specimen should be some object thoroughly impregnated with the vibrations of a person. If it is cut so that it will refract light it can be very good; if it is flat and purely transparent, like a window pane, it is almost useless. Some psychics can work from a photograph, but this method is not, strictly speaking, psychometry, for the mental image evoked by the photograph is used to pick up the corresponding image in the reflecting ether. Great care should be used in taking a psychometric specimen, for it is readily contaminated by the magnetism of anyone who handles it, who is in proximity to it, or who even thinks about it concentratedly. For instance, if while packing up such a specimen for sending off you are brooding over the problem it presents and working out your own theory, the psychometrist may pick up your thought-form instead of reading the conditions of the person to whom the object belongs. As a matter of fact, it belonged to neither, but had been packed in surgical cotton-wool. Take a piece of "virgin" black or white silk (not coloured), large enough to serve as a wrapper. In the occult sense, "virgin" means something that has never been used for any other purpose. An article which does not lend itself to handling by this method can be picked up with sugar-tongs or the points of a pair of scissors and laid on the square of silk in which it is to be wrapped. Pack the wrapped article in a wooden box, being sure that any padding which is used is also virgin. It is exceedingly undesirable to take notes in the presence of a patient, because it makes him nervous, for he feels that, in the words of the police-court, "everything he is saying will be taken down and used as evidence against him. Remember that you are dealing with a person who has something of either the psychic or the neurotic, or very likely both, in his disposition, and that your attitude towards him, and even your unspoken thoughts, will influence him profoundly. If he feels that you are doubting his veracity, he will lose his self-confidence and begin to think that his experiences may, after all, be the fruits of his own imagination. Consequently, he will suppress things which may be all-important from the diagnostic standpoint. It is in this outpouring of relevant and irrelevant detail that you are going to find your clues. There are certain landmarks which you want to look out for in taking this case-history, but you do not want to let your patient realise what you are looking for, because if you have won his confidence, he will be very apt to take on your view-point, and if he sees you have formed any opinion, he will unconsciously twist incidents so that they fit in with that opinion. If you suspect that sex plays a part in his trouble, and he guesses the trend of your questionings, he will immediately cover his tracks, and you will find it very difficult to get at the facts at all. By approaching thus indirectly you not only get at the real facts of the case, but spare his feelings. If you found that all the crises of the case occurred on Thursdays, or round about the Vernal Equinox, or at the full moon, you would have a piece of information which was of 77 of 103 considerable significance. You would be sure of one thing, at any rate, that you were dealing with a case in which the invisible psychic tides played a part. Information should also be sought concerning the place or places in which the different crises of the trouble took place, and especially the circumstances attending its first onset. Having obtained such geographical information as you can, study it carefully in connection with a large-scale Ordnance map. Note whether there are any prehistoric remains in the neighbourhood, and if so, how the house bears in relation to them. Observe not only whether it is near any of them, but whether it is in a direct line between any two of them. If the reply is in the affirmative, it may safely be presumed that local conditions are at the bottom of the trouble. It may also be that the trouble does not depend upon the place, but upon some person residing at the place.