NPTE - Musculoskeletal System

lumbricals

Flexion of digits 2-5 at MCP joints Extension of digits 2-5 at PIP joints Extension of digits 2-5 at DIP joints

Good minus MMT

(4-/5) The subject completes range of motion against gravity with minimal-moderate resistance.

transtibia suspension

- supracondylar cuff - thigh corset - supracondylar brim - "Rubber/Neoprene" sleve suspension - Waist belt with fork strap - suction with knee sleeve - shuttle lock - vacuum

Transtibial Amputation due to Arteriosclerosis Obliterans

Arteriosclerosis obliterans, also know as peripheral arterial disease (PAD) is a form of peripheral vascular disease that produces thickening, hardening, and eventual narrowing and occlusion of arteries. Results in ischemia and subsequent ulceration of affected tissues. Affected area may become necrotic, gangenous, and require amputation. Injury will occur to all structures that receive BF from vessels that have become occluded. Prolonged ischemia results in tissue death and infection. arteriosclerosis obliterans is most common arterial occlusive disease and account for approx 95% of cases of vascular disease. Risk factors associated with this include age, diabetes, sex, hypertension, high serum cholesterol LDL levels, smoking, impaired glucose, tolerance, obesity and sedentary lifestyle. Unsuccessful management of PAD may lead to uncontrolled infection, gangrene, necrosis, and amputation. Males have an overall higher incidence of arteriosclerosis than females. - Pt that requires transtibial ampuatation secondary to arteriosclerosis obliterans is typically over 45 and smoke (75-90%) and will present with intermittent claudication that produces cramps and pain in affected areas. Intermittent claudication will typically present in gastrocsoleus complex, secondary to its high O2 demand. Other characteristics include resting pain, decreased pulses, ischemia, pallor skin, and decreased skin temp. Dx using doppler ultrasonography, MRI or arteriography. these examine BF thru extremities. Physician examines limb for temp, skin condition, the presence of hair, sensation and palpable pulses when determining need for amputation. Claudication test, ankle bracial index, segmental limb pressures or pulse volume recordings may be used to assist w/ dx. - Pt status post transtibial amputation may have a decrease in cardiovascular status depending on frequency of intermittent claudication pt experienced prior to amputation. Pt may initially experience diminished balance secondary to loss of limb. may present with fatigue, loss of balance, phantom limb pain or sensation, hypersensitivity of residual limb, and psychological issues regarding loss of limb, and poor skin integrity. - PT and OT begin immediately after amputation. Preprosthetic intervention focuses on ROM, positioning, strengthening, desensitization, residual limb wrapping, functional mobility, gait training using AD, and pt ed for residual limb. Proper positioning should focus on proper positioning in order to avoid risk of knee flexion contracture. Pt may be able to return home with support and receive short term PT for prothetic training. Home care include limb desentization, stretching, proper positioning. Pt should be encouraged to perform cardiovascular activities on a frequent basis. In order to be successful, pt will need to consistently monitor residual limb and wrap to ensure proper shaping until prosthesis is tolerated. Arteriorsclerosis obliterans is a chronic disease that pt should continue to manage. Approx 20% of all individuals with arteriosclerosis obliterans have myocardial infarction or CVA at some pt after dx. - Regardless of what level amputation occurs, PT intervention will include desentization, phantom pain ed, proper compression and shaping, strengthing, self care, and mobility. Pts status post ampuation share common goal of functional prosthetic use.

Thumb Opposition

Tip of thumb to base of 5th digit

abductor digiti minimi

abducts 5th digit

gluteus medius

abducts, extends and medially rotates thigh

tibialis anterior

dorsiflexes and inverts foot

flexor pollicis longus

flexes thumb

Ataxic gait

gait characterized by staggering and unsteadiness, usually wide BOS and movements are exaggerated.

Steppage gait

gait in which the feet and toes are lifted through hip and knee flexion excessive heights; usually secondary to dorsiflexor weakness. The foot will slap at initial contact with the ground secondary to the decreased control

Principles of stretching - Stress-Strain Curve

graphical representation that depicts the relationship between the amount of force (stress) applied to connective tissue and the amount of deformation (strain) it experiences Toe region - initial stress that results in the wavy collagen fibers becoming straight and aligned with one another Elastic region - added stress to the tissue results in greater deformation, though the tissue returns to its resting length if the stretch force was not maintained. Tissues with greater stiffness will have a steeper slope in this portion of the curve. Plastic region - the addition of more stress results in permanent deformation even after the stretch force is no longer applied due to the failure of bonds between the collagen fibers

iliopsoas

hip flexion

osteomyelitits

infection that occurs in bone secondary to staphylococcus aureus microbe. exposure may occur thru direct contamination or secondary to infection elsewhere in body such as the bloodstream, a wound or nearby soft tissue. Damage to bone (sx, compound fx, or puncture wound that penetrates bone) may directly expose bone to infectious microbes in air or contaminating debris. Prolonged or sever cases of osteomyelitis may result in structural damage to the infected bone which could lead to amputation. - Signs and symptoms are similar to other types of infection - fever and chills common systemic complaints. Localized complaints include pain, edema and erythema. Conclusive dx may be delayed since symptoms tend to be generalized or vague. Pts w/ weakened immune system, diabetes, sickle cell disease, elderly, or undergoing hemodialysis are at greater risk. Pts who develop osteomyelitis secondary to wound infection may show significant changes in observable wound characteristics (color, amount of exudate, type of exudate, delayed healing) as well as slow or stagnant wound healing. Bone biopsy most conclusive procedure for dx.

spastic gait

stiff movement, toes catch and drag, legs held together, and hip and knee joints slightly flexed.. Commonly seen in spastic paraplegia

Person with limb loss

term describes an individual who has lost a limb due to amputation

Pylon prosthesis

term used to describe a pipe like structure used to connect the socket of the prosthesis to the foot/ankle components. The pylon assists w/ weight bearing and shock absorption.

Transfemoral Amputation due to Osteosarcoma

- osteosarcoma (osteogenic sarcoma) is second most common primary bone tumor and accounts for 15-20% of bone tumors. Osteosarcoma is highly malignant cancer that begins in the medullary cavity of a bone and leads to formation of a mass. It usually affect bones with an active growth phase such as the femur or tibia and is often located in the metaphysis. Amputation may be necessary to remove the tumor and surrounding tissues to avoid metastatic disease. Cancer cells are found in osteoblasts within the primitive mesenchymal cells of the medullary cavity of bone. Cancer rapidly proliferates, replaces normal bone, and causes tissue destruction. Osteosarcoma will also metastasize to the lungs very early in the disease process. Etiology remains unknown. This form of cancer primarilly affects males under 30 during growth spurts as an adolescent mainly. Risk factors associated with secondary osteosarcoma include Paget's disease, osteoblastoma, giant cell tumor or chronic osteomyelitis. Environmental and genetic factors have been associated with the disease and in many cases, amputation required to cease disease process. Osteosarcoma can be found most often in long bones especially at site of most active epiphyseal growth plate, distal femur, proximal tibia, proximal humerus and pelvis. Knee region accounts for approx 50% of osteosarcomas. Pt that require amputation secondary to osteosarcoma present with a mass often found in tibia or femur. - Symptoms iinclude pain and swelling within the extremity, pain worsens at night or with exercise, and a lump may develop in the extremity sometime after onset of pain. Osteosarcoma may weaken the involved extremity leading to fx. Fx may be first sign of osteosarcoma. Metastases appear in lung early in 90% of cases. Xray, MRI and scintigraphy are used to determine location, presence and size of tumor. The "Codman's triangle" can bee seen on xray indicating reactive bone at site where the periosteum has been elevated by neoplasm. Dx for osteosarcoma made solely thru tissue biopsy of tumor. - Pt with transfemoral amputation secondary to osteosarcoma may present with fatigue, loss of balance, phantom limb pain or sensation, hypersensitivity of residual limb, and psychological issues regarding loss of limb. Pt may have associated symptoms from chemotherapy that can include anemia, abnormal bleeding, infection and kidney impairment. Presence of these can have negative influence on pts ability to utilize a prothesis. - Tx includes pharm for pain meds and other meds to deter effects from cancer tx. PT and OT begin immediately after transfemoral amputation. Preprosthetic intervention focuses on ROM, positioning, strengthening, desensitization, residual limb wrapping, functional mobility, gait training, and pt ed for residual limb. Pt with transfemoral amputation should lie prone for period of time each day to prevent hip flexion contracture. Modalities may be used for increasing ROM and decreasing pain. Serial casting may be indicated if contracture develops. Pt may be able to return home with support and receive short term PT for prothetic training. Home care include limb desentization, stretching, proper positioning and prone lying. Pt must be independent with residual limb care, skin inspection, and proper wrapping. Endurance activities, strengthening and mobility with AD are necessary as a precursor for prosthetic training. Pt should be able to achieve goals and function w/ a prosthesis for all mobility including ambulation, balance and transfers, and stairs. post osteosarcoma 5 year cure rate is 70-80% with tx that may include amputation, radiation and chemotherapy. - Ewings Sarcoma is a malignant nonsteogenic primary bone tumore that infiltrates bone marrow and usually affect ppl under 20 years old. Pt presents w/ pain of increasing severity, swelling and fever. Tumor not found consistently in specific location in bone and is extremely malignant with a high frequency of metastases. 5 year survival rate approx 70%.

interossei

- palmar interossei: adducts digits II, IV, and V - dorsal interossei: abducts digits II, III, and IV

transtibial socket

- patella tendon bearing socket "PTB" - supracondylar patella tendon socket "PTS" - supracondylar - suprapatellar socket "SC - SP"

Laminectomy

- performed in presence of a disk protrusion or spinal stenosis. - complete laminectomy: removal of entire lamia, spinous process and associated ligamentum flavum. Vertebral segment much less stable. - Partial: removal of only one lamina. - Cervical and lumbar laminectomies are generally performed using a posterior approach. - Post op restrictions on weight that can be lifted, active motions especially extension. Body mechanics and posture emphasis of PT.

Liner prosthesis

- plays important role in comfort and health. Gel liners commonly made of silicone, used for cushioning residual limb and hosting a suspension mechanism such as a pin or lanyard. Seal in liners maintain suspension thru negative pressure. Liners are non-breathable: perspiration can buildup throughout day and result in friction issues that can cause irritation on skin of the residuum. Frequently doffing of liner may be required to dry it off along with the residual limb, liners must be carefully washed and dried to maintain hygienic environment and gel sheaths can be applied under the liner directly on the skin of the residual limb to serve to relieve irritation when using prosthesis.

Pinch Grip Test

- pt pinch the tips of the index finger and thumb together Positive Test: if pt cannot pinch tip to tip and instead presses the pads of the fingers together. indicative of pathology of the anterior interosseous nerve

Transhumeral Wrist Unit

- quick change unit - wrist flexion unit - ball and socket - constant friction

Transradial Wrist Unit

- quick change unit - wrist flexion unit - ball and socket - constant friction

Rotator cuff Tendonitis

- repetitive overhead activities can produce impingement of the supraspinatus tendon proximal to greater tubercle. Impingement caused by weak supraspinatus unable to depress head of humerus in glenoid fossa during elevation of arm. - as a result, humerus translates superiorly due to disproportionate action of the deltoid muscle. - Primary impingement - intrinsic and extrinsic factors within subacromial space - secondary impingement - symptoms occurs from poor mechanics or instability at shoulder joint - Supraspinatus most involved - originates on supraspinatus fossa of scapula and inserts on the greater tubercle of humerus - bicipital and infraspinatus tendonitis as well as bursitis may coexist as other contributing factors. - excessive overhead activities or excessive use of UE after prolonged period of inactivity have increased risk - 25-40 year olds most likely to happen - Pt reports difficulty with overhead activity, dull ache following periods of activity, feeling of fullness and painful arc in 60-120 deg active abduction - pain with palpation of musculotendinous junction of involved muscle and/or with stretching or resisted contraction of muscle. Pain increases at night while sleeping on that side - difficulty with dressing and repitive shoulder motions such as lifting, reaching, throwing, swinging or pushing and pulling of UE. - Special tests include empty can test, Jobe test, Neer impingement test, and Hawkins Kennedy impingement test - to confirm rotator cuff tendonitis or impingement. - often involves association with impingement involving supraspinatus tendon, glenoid labrum, long head of biceps and subacromial bursa..difficult to determine which one involved tho. - Acute rotator cuff tendonitis - Pharm pain relief w/ NSAIDs and analgesics. PT cryotherapy, activity modification, ROM (pulley or cane) and rest. After acute, strengthening starts (initiated w/ arm at side to prevent possiblity of impingement - elastic tubing or handheld weights are preferred equipment). since rotator cuff muscles are dependent on adequate O2 and BF, essential ROM and strengthing exercises are pain free. Important for all rotator cuff are strong prior to initiating overhead activities. Shoulder shrugs and push ups with arms abducted to 90 deg can be used to strength the upper trap and serratus anterior - promotes elevation of the acromion without direct contact with the rotator cuff. Return to previous level of functioning within four to six weeks. Stage 1 - localized inflammation, edema and minimal bleeding around rotator cuff, usually found in pop less than 25 years old Stage 2 - progressive deterioration of tissues surrounding rotator cuff..25-40 years old Stage 3 - end stage found in pts over 40. usualy disruption and/or rupture of numberous soft tissue structures - Prolonged inflammation of the rotator cuff tendon may facilitate eventually tearing of rotator cuff.

Piriformis Syndrome

- result of compression or irritation to proximal sciatic nerve due to piriformis muscle inflammation, spasm or contracture. Common etiology of LBP, sometimes referred to as "pseudosciatica" because of the similarity of symptoms. Piriformis muscle functions to abduct and ER hip. After exiting the greater sciatic foramen, sciatic nerve passes inferior to the piriformis before continuing distally along midline of posterior thigh. Trauma, mechanical dysfunction, scarring or entrapment due to soft tissue pathology cause this condition. As many as 50% of pts dx w/ piriformis syndrome have history of local trauma (contusion, THA). Abnormal gait mechanics, an exaggerated lumbar lordosis, periods of prolonged sitting and participation in vigorous physcial activity have also been IDed as potential contributing factors - pain presents first in area of mid buttock then progresses to radicular complaints in sciatic nerve distribution. Hip, coccyx, or groin pain may also be reported. Symptoms exacerbated by prolonged sitting and activities that combine medial rotation and adduction. Pain typically reproducible on palpation w/ positioning into flexion, adduction and medial rotation. Pain and weakness are likely w/ resistance testing during lateral rotation and abduction. Radicular symptoms typically exacerbated w/ SLR and alleviated w/ LE traction. piriformis syndrome is often misdiagnosed as it has near identical symptom presentation as L5-S1 radiculopathy which is due to either a herniated disk or stenosis. Piriformis syndrome considered a clinical diagnosis of exclusion. Exam should rule out similar dx such as trochanteric bursitis or myofascial pain. - conservative tx emphasizing pain management. PT begins w/ thermal modalities to improve quality of soft tissue mobs and stretching. Soft tissue massage, hip joint mobs, muscle energy and strain counterstrain techniques may further enhance relaxation of the piriformis and surrounding muscles. Existing sacroiliac dysfunction, leg length discrepancy, or other biomechanical factors should also be addressed. As symptoms decrease, gradual strengthening of the piriformis and surrounding muscles may be recommended to supplement stretching. Sx (piriformis tendon release, sciatic neurolysis) last resort when conservative fails. Conservative usually successful. Undiagnosed piriformis syndrome contributes to poor outcomes for pts undergoing sx for lumbar disk herniation.

Zero MMT

0/5 - subject demonstrates no palpable muscle contraction

Thoracolumbosacral Orthotic Brace (TLSO)

custom molded TLSO prevents all trunk motions. is commonly utilized as mean of post sx stabilization.

suprahyoid muscle group

digastric, stylohyoid, mylohyoid, geniohyoid Function: Depress the mandible

anconeus

extends forearm

triceps brachii

extends forearm; long head contributes to extension and adduction at shoulder joint

strain

injury involving the musculotendinous unit that involves a muscle, tendon, or their attachments to bone Grade 1: localized pain, minimal swelling and tenderness Grade 2: localized pain, mod swelling, tenderness and impaired motor function Grade 3: a palpable defect of muscle, severe pain, and poor motor function

tensor fasciae latae

Abducts, flexes, and rotates the thigh medially

scissor gait pattern

legs cross midline upon advancement

atlantoaxial joint

plane synovial joints that permit flexion and extension, lateral flexion and rotation of cervical spine...majority of rotation of skull on spinal column occurs here

Gastrocnemius

plantar flexes foot

Osseointegration (endoprosthesis)

the process of implanting a prosthetic device directly into the residual limb of a person with limb loss. This process negates the need for a socket component

Shoulder

the shoulder complex is formed by a series of unique articulations including the glenohumeral joint, sternoclavicular joint, acromioclavicular joint, and the scapulothoracic articulation

plantar fascia

thick layer of fascial tissue on the plantar aspect of the foot that originates on the calcaneal tuberosity and inserts into the plantar forefoot. The plantar fascia plays a role in supporting the weight of the body and also helps to support the arch of the foot for improved propulsion during gait.

extensor carpi ulnaris

wrist extension, ulnar deviation

External oblique

The external oblique functions to pull the chest downwards and compress the abdominal cavity, which increases the intra-abdominal pressure as in a valsalva maneuver. It also performs ipsilateral side-bending and contralateral rotation.

Hip

The iliofemoral joint is a synovial joint formed by the head of the femur and the acetabulum. The hip is classified as a ball and socket joint with three deg of freedom.

sacroiliac joint, symphysis pubis, and sacrococcygeal

Capsular Pattern: pain when joints are stressed

Cartilaginous Joints (Amphiarthroses)

Cartilaginous joints have hyaline cartilage or fibrocartilage that connects one bone to another..slightly moveable joints Synchondrosis: Hyaline cartilage that adjoins two ossifying centers of bone; provides stability during growth; may ossify to a synostosis once growth is completed; slight motion ex.) sternum and true rib articulation Symphysis: Generally located at the midline of the body; two bones covered with hyaline cartilage and connected by fibrocartilage; slight motion ex.) pubic symphysis

Ankle Foot Orthosis (AFO)

Cast mold of pts LE. Pt casted in a subtalar neutral position. Solid foot ankle orthoses control DF/PF and also inversion/eversion w/ a trim line anterior to malleoli. A posterior leaf spring is a plastic AFO w/ a trim line posterior to malleoli. Primary purpose is to assist w/ DF and prevent foot drop. It requires adequate medial/lateral control by the pt. AFO requires adequate medial/lateral control by pt. A floor reaction AFO assists w/ knee extension during stance thru positioning of a calf band and/or positioning at the ankle. AFOs commonly prescribed for pts w/ peripheral neuropathy, nerve lesions or hemiplegia.

Resistive Testing - Upper Quarter Screen

Cervical Rotation - C1 Shoulder elevation - C2-C4 Shoulder abduction - C5 Elbow Flexion - C5-C6 Wrist Extension - C6 Elbow Extension - C7 Wrist Flexion - C7 Thumb Extension - C8 Finger adduction - T1

longus colli muscle (longus cervicis)

Cervical flexion, ipsilateral laterally flexion and some cervical rotation

piriformis

abducts and laterally rotates hip

gemelli

abducts and laterally rotates thigh

gluteus minimus

abducts and medially rotates thigh

supraspinatus

abducts arm....one of the 4 rotator cuff muscles of the shoulder

abductor hallucis

abducts great toe

abductor digiti minimi

abducts little toe

abductor pollicis longus

abducts thumb extends thumb

abductor pollicis brevis

abducts thumb; opposition of thumb

Dorsal Interossei

abducts toes

Resistance training terminology - endurance

ability of a muscle to contract repeatedly against a light external load and resist fatigue over a prolonged period of time

Torque

ability of an external load to produce rotation around an axis, calculated by multiplying the magnitude of load by the moment arm

Principles of stretching - Elasticity

ability of soft tissue to return to its previous length after a stretch is no longer applied

prosthetic

an artificial body part, used as an adjective not a noun Ex) The prosthetic limb is broken

ligamentum nuchae

an elastic ligament that connects the vertebrae of the neck to the skull. restricts flexion in the cervical spine.

Deltoids

anterior deltoid: flexion, horizontal adduction, and medial rotation of the shoulder Middle deltoid: Abduction of the shoulder Posterior deltoid: Extension, horizontal abduction, and lateral rotation of the shoulder

Abnormal end feel

any end feel that is felt at an abnormal or inconsistent point in the ROM or in a joint that normally presents with a diff end feel Empty (cant reach end feel usually due to pain) ex.) joint inflammation, fracture, bursitis Firm ex.) increased tone, tightening of capsule, ligament shortening Hard ex.) fracture, osteoarthritis, osteophyte formation Soft ex.) edema, synovitis, ligament instability/tear

temporomandibular joint (TMJ)

Loose Packed Position: mouth slightly open (freeway space) Closed Packed Position: Clenched Teeth Capsular Pattern: limitation of mouth opening

palmar radiocarpal ligament

Maintains the alignment of the associated joint structures and limits hyperextension of the wrist

Retinacula of the ankle

Major retinaculum is the extensor retinaculum which lies on the anterior side of the joint. This structure contains the tendons on the extensor musculature and prevents them from "bowstringing" as the ankle dorsiflexes. There's also a flexor retinaculum and a peroneal retinaculum.

coracoacromial ligament

Makes a connection between the coracoid process and the acromion. Forms a roof over the humeral head and limits superior translation of the humeral head and prevents separation of the AC joint

Conducting Goniometric measurement

Recommended Procedure 1. Place pt in recommended testing position 2. stabilize proximal joint segment 3. move distal segment thru available ROM..make sure PROM is performed slowly, end of the range is attained and end feel is determined 4. make clinical estimate of the range of motion 5. return distal joint segment to the starting position 6. palpate bony anatomical landmarks 7. align goniometer 8. read and record starting position. remove goniometer 9. stabilize proximal joint segment 10. move distal segment thru full ROM 11. replace and realign goniometer. Palpate anatomical landmarks again if necessary 12. read and record ROM

isometric contraction

Muscle contracts but there is no movement, muscle stays the same length

temporalis muscle

Muscle of the side of the head that elevates and retracts the mandible, along with side to side movement of the mandible

extensor hallucis longus

Muscle that extends the big toe and dorsiflexes the foot.

flexor digitorum brevis

Muscle that flexes the toes and helps maintain balance while walking and standing.

Pain Transmission

Nociceptors are the terminal portions of two diff afferent neurons, A-delta fibers and C fibers. A-Delta fibers transmit detailed info rapidly from peripheral cutaneous structures while C fibers transmit info from deeper tissues (joints, viscera) and do so more slowly. Because of these diff, A delta fibers are more likely to transmit pain signals that are sharp and localized while C fibers transmit pain signals that are dull, aching and diffuse. These nerve fibers send their impulses to the dorsal horn of the spinal cord, where the impulses are then carried to the thalamus via the spinothalamic tracts. Then the signal is projected to the sensory cortex to be interpreted and become a conscious pain sensation.

Proprioceptive Neuromuscular Facilitation (PNF) stretching

PNF incorporates active muscle contractions into stretching techniques. muscular contraction thought to lead to muscle relaxation thru principles of autogenic or reciprocal inhibition and results in greater gains in muscle flexibility. these techniques exert their effects on muscle fibers and are more effective at treating ROM limitations due to muscle spasm as opposed to connective tissue tightness. Other theories include increased pt tolerance to the stretch and length changes secondary to the viscoelastic properties of muscle. Because PNF requires active muscular control from the pt, it is not an effective technique for pts with paralysis or spasticity. Common PNF techniques include contract-relax, agonist contraction, and contract-relax with agonist contraction

Carpal compression test (median nerve compression test)

PT holds pts wrist with both hands and applies pressure over the median nerve in the carpal tunnel for 30 sec. Test may be performed by placing the pts wrist in 60 deg flexion before applying pressure Positive Test: if pt experiences pain or paresthesia in the median nerve distribution

Reflex Testing - Lower Quarter Screen

Patella - L4 Achilles - S1

Ribs

Ribs 1-10 articulate with the thoracic vertebrae through the costovertebral joints and the costotransverse joints. Ribs 1-7 are attached to the sternum through the costal cartilage and ribs 8-10 join with the costal cartilage of ribs 1-7. Ribs 11-12 articulate only with the vertebral bodies of T11-12 but not the transverse process of the vertebrae..they are classified as floating ribs because they do not attach to the sternum or the costal cartilage at their distal end.

Standard Terminology gait

Stance Phase (60%) - Heel Strike - instant heel touches ground begins stance phase - Foot Flat - point which entire foot makes contact with ground, occurs directly after heel strike - Midstance - point during stance where entire body weight is directly over stance limb - Heel Off - point where heel of stance limb leaves ground - Toe Off - point in which only the toe of stance limb remains on the ground Swing Phase - Acceleration - begins when toe off is complete and reference limb swings until positioned directly under body - Midswing - point when swing limb is directly under body - Deceleration - begins directly after midswing, as the swing limb begins to extend, and ends just prior to heel strike

Rancho Los Amigos Gait

Stance Phase (60%) - Initial Contact - beginning of stance phase that occurs when foot touches ground - Loading Response - amount of time between initial contact and beginning of swing phase of other leg - Midstance - point in stance phase when other foot is off the floor until the body is directly over stance limb - terminal stance - when heel of stance limb rises and ends with other foot touching ground - pre-swing - begins when other foot touches ground and ends when stance foot reaches toe off Swing phase (40%) - initial swing - begins when stance foot lifts from floor and ends with max knee flexion during swing - midswing - begins with max knee flexion during swing and ends when tibia is perpendicular to the ground - Terminal swing - begins when tibia is perpendicular to ground and ends when foot touches ground

Gait

Stance Phase = 60% of gait cycle Swing phase = 40% gait cycle Standard terminology vs Rancho Los Amigos Terminology

amputation and prosthetics

Surgical removal of a body part, partial or full extremity, due to disease, trauma or injury. LE amputations significantly more common than UE amputations w/ peripheral disease serving as primary etiology. More prevalent in elderly. Many have comorbid dx of diabetes. Non-vascular causes of amputation includes traumatic, cancer related, and congenital conditions. - Amputation last course of action. Approx 50% of all older adults w/ limb loss due to vascular disease will die within 5 years. Of remaining, 50% of them will experience another amputation, either on same limb or contralaterally. - Prosthetics attempt to replace the missing body part to allow a pt improved function and cosmesis. PT and OT indicated for functional retraining w/ prosthesis. Prosthetist, OT and PT all involved in rehab.

Knee disarticulation

Surgical removal of the lower extremity through the knee joint - loss of all knee, ankle and foot function - residual limb can weight bear thru its end - susceptible to hip flexion contracture - knee axis of prosthesis is below the natural axis of the knee - gait deviations can occur secondary to malignment of the knee axis

tarsometatarsal (Lisfranc) amputation

Surgical removal of the metatarsals. Amputation preserves the dorsiflexors and plantarflexors. - loss of forefoot leverage - loss of balance - loss of weight bearing surface - loss of proprioception - tendency to develop equinus deformity

Forequarter (scapulothoracic) amputation

Surgical removal of the upper extremity including the shoulder girdle - Loss of all shoulder, elbow and hand function - most common cause is malignancy - function prosthetic use is common - a lightweight cosmetic prosthetic is typically well tolerated

Synovial joints (Diarthroses)

Synovial joints provide free movement between the bones they join and have 5 distinguishing characteristics: joint cavity, articular (hyaline) cartilage, synovial membrane, synovial fluid, and fibrous capsule. These joints are complex and most vulnerable to injury. Classified by type of movement and shape of articulating bones: Uniaxial Joint: 1 motion around 1 axis in 1 plane of body ex.) hinge (ginglymus) - elbow joint ex.) Pivot (trochoid) - atlantoaxial joint ex.) plane (gliding) - carpal joints Biaxial joint: movement occurs in 2 planes around 2 axes through convex/concave surfaces ex.) condyloid - metacarpophalangeal joint of finger ex.) saddle - carpometacarpal joint of the thumb Multi-axial joint: movement occurs in 3 planes and around 3 axes ex.) ball and socket - hip joint, shoulder joint

iliopsoas MMT supine

Technique 1 (emphasis on psoas major) Position: supine Fixation: stabilize opposite iliac crest Test: hip flexion in a position of slight abduction and slight lateral rotation Pressure: anteromedial aspect of the leg in the direction of extension and slight abduction GEP: No GEP

Muscle Performance

capacity of a muscle to do work. components of muscle performance include power, strength and endurance

Osteochondritis Dissecans

condition where subchondral bone and its associated cartilage crack and seperate from the end of bone. In severe cases, bone may actually detach and float freely in joint space. No etiology, thought that occurs secondary to a loss of BF (subchondral bone dies and seperates) to affected area possibly due to repetitive microtrauma. Primarily affects knee joint, ankle and elbow. - Symptoms include pain w/ functional activities, joint popping or locking, weakness, swelling and decreased ROM. xray, MRI and CT scan used to confirm dx. R/o arthritis. Wilson's Test can be performed to detect osteochondritis dissecans of knee.

thoracolumbar fascia

connected to the spinous processes of the lumbar vertebrae, the PSISs, and the iliac crests. The fascia consists of three layers that separate the lumbar muscles into three different compartments. This structure functions to provide stability to the spine, transmit forces, resist lumbar flexion and provide a site for muscular attachments.

coracohumeral ligament

connects coracoid process to the greater and lesser tuberosities of humerus. Ligament is found between the supraspinatus and subscapularis tendons. Limits inferior translation of the humeral head

Legg-Calve-Perthes Disease

degeneration of femoral head due to avascular necrosis (disturbance in blood supply). disease is self limiting and has 4 phases: condensation, fragmentation, re-ossification and remodeling. Etiology: trauma, genetic predisposition, synovitis, vascular abnormalities, infection Signs and symptoms: presents with pain, decreased ROM, antalgic gait, positive Trendelenburg sign. Tx: primary treatment focus is to relieve pain and maintain femoral head in proper position and improve ROM. PT intermittently for stretching, splinting, crutch training, aquatic therapy, traction and exercise. Orthotics and sx may be indicated based on classification and severity.

Q angle

degree of angle when measureing from midpatella to ASIS and to the tibial tubercle. normal q angle is 13 degrees for man and 18 degrees for a woman. An excessive Q angle can lead to pathology and abnormal tracking.

interosseous membrane

dense band of fibrous connective tissue connecting radius and ulna running obliquely. spans from the proximal radioulnar joint to the distal radioulnar joint and serves as a stabilizer against axial forces applied to the wrist.

Scalenus muscles

elevates first rib and second ribs, flex and ipsilaterally laterally flex neck...accessory muscle to inspiration

medial pterygoid muscle

elevates, protrudes and moves the mandible side to side

levator scapulae

elevation and downward rotation of scapula..ipsilaterally laterally flexes head

Make Test

evaluation procedure where pt is asked to apply a force against the dynamometer

Tight Retinacular Ligament Test

examiner places PIP joint in neutral and passively flexes the DIP (+) inability to flex the DIP indicates the retinacular ligaments or capsule may be tight. If PT is able to flex the DIP joint with the PIP joint in flexion, the retinacular ligaments may be tight and the capsule may be normal

lordosis

excessive curvature of the spine in an anterior direction usually seen in cervical or lumbar spine. common causes include weak ab muscles, pregnancy, excessive weight in abdominal area, and hip flexion contractures.

kyphosis

excessive outward curvature of the spine in a posterior direction, usually seen in thoracic spine. Common causes include osteoporosis, compression fxs, and poor posture secondary to paralysis

open chain exercise

exercise in which a distal segment of the body moves freely in space ex.) kicking a ball with lower leg

extensor digiti minimi

extends 5th digit

Quadratus Lumborum

extends and ipsilaterally laterally flexes vertebral column; fixes 12th rib during inspiration

gluteus maximus

extends and laterally rotates hip

extensor carpi radialis brevis

extends and radially deviates wrist

extensor hallucis brevis

extends big toe

Radial collateral ligament (lateral collateral ligament)

extends from the lateral epicondyle of the humerus to the lateral border and olecranon process of the ulna and to the annular ligament. It's a fan shaped ligament that prevents adduction of the elbow joint and provides reinforcement for the radiohumeral articulation. - can become stretched, frayed or torn through the stress of repetitive throwing motion over months or years. Fall on outstretched arm can lead to rupture, often with associated elbow dislocation

vastus intermedius

extends knee

vastus lateralis

extends knee

vastus medialis

extends knee

rectus femoris

extends leg and flexes thigh

biceps femoris

extends thigh and flexes leg; belongs to the hamstring group

extensor pollicis longus

extends thumb, radial deviation of wrist

extensor pollicis brevis

extends thumb, radially deviates wrist

extensor digitorum brevis

extends toes 2-4

extensor digitorum longus

extends toes and dorsiflexes foot

teres major

extends, adducts, and medially rotates arm

latissimus dorsi

extends, adducts, and medially rotates humerus...depressed the scapula

extensor digitorum communis

extension of digits

Plicae knee

extensions of the synovial membrane that are sometimes found in the anterior knee, most commonly medial to the patella. No specific function, though they can be a source of anterior knee pain.

glenoid labrum

fibrocartilage ring that deepens glenoid cavity and increase the size of the articular surface. consists of dense fibrous connective tissue that is often damaged with recurrent shoulder instability

interphalangeal joints

fingers and toes LPP: slight flexion CPP: full extension Capsular Pattern: flexion, extension

Metatarsal bar/pad

flat piece of padding placed just posterior to metatarsal heads either on the outer sole (bar) or inner sole (pad) of shoe. Helps relieve pressure from metatarsal heads by transferring to the metatarsal shafts, thus helping relive pain for pts w/ metatarsalgia.

coracobrachialis

flexes and adducts arm

Flexor Hallucis Brevis

flexes big toe

flexor digitorum superficialis

flexes digits 2-5

Lumbricals

flexes digits 2-5 extends digits 2-5

flexor digitorum profundus

flexes distal phalanges

biceps brachii

flexes elbow and supinates forearm (prime mover); flexes shoulder

brachialis

flexes forearm

brachioradialis

flexes forearm

flexor hallucis longus

flexes great toe; plantar flexes and inverts foot

Flexor digiti minimi brevis

flexes little toe

psoas major

flexes thigh at hip joint...On the lumbar spine, unilateral contraction ipsilaterally bends the trunk laterally, while bilateral contraction raises the trunk from its supine position.

flexor pollicis brevis

flexes thumb; opposition of thumb

flexor digitorum longus

flexes toes, plantar flexes and inverts foot

rectus abdominis

flexes trunk

palmaris longus

flexes wrist

sartorius

flexes, abducts, and laterally rotates thigh; flexes knee

flexor digiti minimi

flexion of digit 5 at MCP joint

Quadratus Plantae

flexion of toes 2-5

Ankle plantar flexors MMT

gastrocnemius and Plantaris Position: standing (patients may steady themselves with a hand on the table as long as they are not taking any weight on the hand) Test: rising on toes, pushing the body weight directly upward Pressure: body weight is resistance Grade 5 = 20 reps of heel raises 4 = 10-19 3 = 1-9 reps

Heel lift during midstance

insufficient dorsiflexion range, plantar flexor spasticity

Insufficient hip extension at stance

insufficient hip extension ROM, hip flexion contracture, lower extremity flexor synergy

Socket prosthesis

interface between the residual limb and prosthesis. Proper fitting socket disperses the pressure experienced in weight bearing throughout the limb, providing total contact with the surface. Certain areas of the residual limb are more pressure tolerant and can handle greater pressure than others. More tolerant: muscular areas than bony areas. Most common design for transfemoral prosthesis is an ischial containment socket. Transtibial prosthesis is a total surface bearing or patellar tendon-bearing socket.

halo vest orthosis

invasive cervical thoracic orthosis that provides full restriction of all cervical motion. secured by inserting 4 pins thru the ring into skull. commonly used with cervical spinal cord injuries to prevent further damage or dislocation during recovery period. Pt will wear halo vest until spine becomes stable.

Dynamic stretching

involves pt actively moving a body segment to the end of range (but not beyond this limit) while the antagonist muscle relaxes and stretches. Unlike static stretching, the end range movement is held only briefly and is performed repeatedly. most commonly used as a warm up to prepare the body for athletic activities. more effective at preparing the body for explosive movements when compared to static stretching. Dynamic stretching emphasizes a movement based approach while ballistic stretching emphasizes a bouncing movement

Amputee mobility predictor (AMPPRO)

measures ambulatory potential of lower limb prosthesis users. Balance, gait and transfers evaluated, then scored, correlated to K-level and utilized to help make decision about proper prosthesis prescription. Can be used on pts without prosthetic limb (AMPnoPRO)

extension assist

mechanism that assists the knee joint into extension during the swing phase of gait

muscle insufficiency

muscle contraction that is less than optimal due to an extremely lengthened, or extremely shortened position of the muscle.

isokinetic exercise

muscle contracts at a constant speed and variable load. the reaction force is identical to the force applied to the equipment. Cybex, Biodex and Lido are a few companies making isokinetic exercise equipment.

isotonic contraction

muscle shortens because muscle tension exceeds load

isometric exercise

muscular force is generated without a change in muscle length. often performed against an immovable object. Submax isometric exercises are traditionally used in rehab programs

Cadence

number of step an individual will walk over period of time. Avg for adult is 110-120 steps per min.

dorsal radiocarpal ligament

only major ligament on dorsal surface of the wrist serves to limit wrist flexion

opponens digiti minimi

opposition of 5th digit

opponens pollicis

opposition of thumb, flexion of thumb

hip external rotators MMT

piriformis, Quadratus femoris, obturator internus, obturator externus, gemellus superior, gemellus inferior Position: sitting with knees bent over table holding onto table Fixation: stabilizes later side of thigh/knee (counter pressure) Test: lateral rotation of thigh with leg in a position of an inward motion Pressure: applies pressure on medial side of the leg, above the ankle, pushing the leg outward in an effort to rotate the thigh medially GEP: No GEP

avulsion fracture

portion of bone becomes fragmented at site of tendon attachment from a traumatic and sudden stretch of tendon

serratus anterior

protracts and upwardly rotates scapula

Wound infections

residual limb can get infected following sx. Antibiotics are administered at time of sx to reduce risk of infection.

Rocker bar

similar to metatarsal bar in placement, consists of convex strip instead of flat strip. assists pts who have difficulty w/ terminal stance phase of gait secondary to limited mobility withing foot especially at great toe. Helps relieve pressure from metatarsal heads for pts w/ pain in that region.

supinator

supinates forearm

Hemipelvectomy amputation

surgical removal of Half of pelvis and entire LE - all functions of hip, knee, ankle and foot are absent - most common cause is malignancy - doesnt allow for activation of the prosthesis thru a residual limb - prosthetic limb advancement initiated thru pelvic motion

hip disarticulation amputation

surgical removal of LE from the pelvis - all functions of hip, knee, ankle and foot are absent - most common cause is malignancy - doesnt allow for activation of the prosthesis thru a residual limb - prosthetic limb advancement initiated thru pelvic motion

Digit amputation

surgical removal of a digit at either the metacarpophalangeal, proximal interphalangeal or distal interphalangeal level - preserved function is highly variable depending on number of digits involved and level of amputation - prostheses are not typically utilized - a long transradial amputation may be more functional if multiple digits are involved at proximal levels

Acquired Amputation

surgical removal of a limb due to disease, trauma or infection. Further defined as traumatic or non-traumatic

Partial hand amputation

surgical removal of a portion of the hand and/or digits at either the transcarpal, transmetacarpal, or transphalangeal level - loss of a portion of digit/hand function - limb sparing technique utilized when functional pinch can be preserved - toe transfer to replace a thumb may be considered if prosthesis fails

Syme's amputation

surgical removal of the foot at the ankle joint with removal of the malleoli - loss of all foot functions - residual limb can weight bear thru its end - residual limb is bulbous w/ a non cosmetic appearance - dog ears must be reduced for proper prosthetic fit - adaptations required for the increased weight of the prosthetic - adaptations required due to diminished toe off during gait

Wrist disarticulation amputation

surgical removal of the hand through the wrist joint - loss of all hand function - relatively uncommon level of amputation - cosmetic and functional prosthetic disadvantages

Elbow disarticulation amputation

surgical removal of the lower arm and hand through the elbow joint - loss of all elbow and hand function - most commonly due to trauma - allows for self-suspending socket - an external prosthetic elbow joint is typically required.

anterior talofibular ligament

taut during PF, resists inversion of the talus and calcaneus also resists anterior translation of the talus on the tibia

Base of support

the distance measured between the left and right foot during progression of gait; the distance decreases as cadence increases; the average for an adult is 2 - 4 inches

moment arm

the linear distance from the axis of rotation to the site of the external load

stress-relaxation

the longer a stretching force is maintained, the more the tension within the tissue decreases, therefore less force is required to maintain the same tissue length

Ligaments of the ankle

the majority of ligaments in the ankle are areas of increased density within the joint capsule and as a result, damage to the ankle ligaments typically produces damage to the joint capsule and irritation of the synovial lining

Retinacula of the knee

the medial and lateral retinacula are ligamentous structures that attach the patella to the femur, tibia and menisci. The lateral retinaculum is the stronger of the two and players a larger role in patellar positioning.

midtarsal joint

the midtarsal (transverse tarsal) joint is formed by the talocalcaneonavicular joint and the calcaneocuboid joint. the joint is considered to have two axes, one longitudinal and one oblique. Motions around both axes are triplanar Osteokinematic motions: inversion, eversion Loose Packed Position: midway between extremes of range of movement Close Packed Position: supination Capsular Pattern: dorsiflexion, plantar flexion, adduction, medial rotation

Wrist

wrist complex is formed by the radiocarpal and midcarpal joints. radiocarpal joint attaches the hand to the forearm. The midcarpal joint is formed by the articulation of the proximal and distal row of carpals.

extensor carpi radialis longus

wrist extension, radial deviation

flexor carpi radialis

wrist flexion, radial deviation

flexor carpi ulnaris

wrist flexion, ulnar deviation

Soleus

plantar flexion

plantaris

plantar flexion

Peroneus Brevis

plantar flexion and eversion

adductor pollicis

adducts thumb

Plantar Interossei

adducts toes

Pectineus

adducts, flexes, and medially rotates thigh

adductor longus

adducts, flexes, and medially rotates thigh

adductor magnus

adducts thigh

Bicipital Tendonitis

inflammatory process of long head of biceps tendon; can be a component of impingement syndrome. Repeated full abduction and lateral rotation of humeral head (overuse) can lead to irritation that produces inflammation, edema, microscopic tears within the tendon and degeneration of tendon itself. sports (swim, throwing, swinging) or work activities that cause frequent and repeated overhead use of shoulder (damaged cells dont have time to heal). Takes a while (years?). Can also be caused secondary to other shoulder pathology including rotator cuff disease, impingement syndrome, or intra articular pathology such as labral tears. - pt reports deep ache directly in front and on top of shoulder. Ache may spread down into biceps muscle and is made worse with overhead activities or lifting heavy objects. Rest reduces pain. catching or slipping sensation of biceps muscle indicates tear of transverse humeral ligament. Positive indicators of bicipital tendonitis are bicipital tendonopathy, pain to palpate over anterior shoulder in area of bicipital groove, pain with biceps resistance test (speeds), and a positive yergason's test. May experience shoulder instability and subluxation with long term chronic tendonitis secondary to bicep degeneration. Bicipital tendonitis will also frequently accompany impingement syndrome, rotator cuff tendonitis, and forms of glenohumeral instability. - Goal is to relieve pain, reduce inflammation, and regain full ROM without pain. Rest and/or immobilization w/ splint or removable brace for brief period of time. Avoid all overhead movements, reaching and lifting. Pharm includes NSAIDs which will decrease pain and inflammation. Active PT not initially, pt ed, guidelines for restrictions, pendulum exercises and TENS, ice and heat to reduce pain are. Iontophoresis or phonophoresis can be used. After acute phase, PT focuses on stretching and strengthening of affected muscle groups to prevent future injury and improve healing. Sx only recommended for pts that havent progressed w/ conservative tx for 6 months - includes arthroscopic decompression and acromioplasty with anterior acromionectomy. Ongoing home PT important to prevent risk of recurrence. Slowly return to previous level of activity once pain or discomfort is gone with activity. On average 6-8 weeks for recovery. 10% of pts dont achieve positive outcome and have further deterioration or rupture of tendon. - similar condition is glenoid labral tear. - fibrocartilage rim that surrounds glenoid cavity, increases depth and protects edge of bone within joint capsule. anterior damage or subluxation increases risk of labral tear. Bankart lesion - avusion of labral ligamentous complex from anteroinferior aspect of glenoid. Most common lesion resulting in anterior joint instability. CT scan dx, sx successful for repair.

transradial Suspension

- Triceps cuff - Harness - Cable system

wear schedule

"break in" schedule normally prescribed for first few weeks of wear. allows for monitoring and accommodation to sensation of weight bearing thru residuum. Start w/ 1 hour a day of total wear time w/ half of time spent ambulating. Every 30 mins or immediately after walking, skin should be inspected for breakdown. If tolerating prosthesis well and no breakdown, an hour is added each day while still using 50% rest:use rule. if no breakdown still, amount of time between inspection is gradually expanded by 15-30 min. Eventually this schedule wont be needed.

talipes equinovarus

"clubfoot" is a deformity characterized by the heel pointing downward and the forefoot turning inward Etiology: unknown cause, theories postulate familial tendency, positioning in utero or a defect in the ovum. Condition accompanies other neuromuscular abnormalities including spina bifida and arthrogryposis and may result from lack of movement in utero Signs and symp: adduction of forefoot, varus positioning of hindfoot, and equinus at ankle Tx: medical management begins shortly after birth and includes splinting and serial casting. Goal is to restore proper positioning of foot and ankle. Failed management or sever involvement may require sx intervention and subsequent casting.

Poor Plus MMT

(2+/5) The subject is able to initiate movement against gravity.

Poor Minus MMT

(2-/5) The subject does not complete range of motion in a gravity eliminated position.

Good Plus MMT

(4+/5) The subject completes range of motion against gravity with moderate-maximal resistance.

SAID principle

(Specific Adaptations to Imposed Demands) - the body will adapt according to the specific type of training utilized. To bring an improvement in pts function, type of training should specifically mirror the desired goal. Ex.) pt needs greater muscle power, exercises chosen shoulder focus on improving power

acromioclavicular ligaments

(superior and inferior) span from the acromial process to the distal end of the clavicle and function to stabilize the joint. Surrounds the AC joint on all sides and helps to control horizontal movements of the clavicle

Congenital Torticollis

(wry neck) characterized by a unilateral contracture of the Sternocleidomastoid muscle. identified in first 2 months of life Etiology: Unknown cause but causative factors include malposition in utero, breech position and birth trauma. Signs and symptoms: lateral flexion to same side as contracture, rotation toward opposite side and fascial asymmatries. treatment: conservative for the first year with emphasis on stretching, active ROM, position and caregiver education. possible surgery if conservative tx has failed and child is over 1 years old. Surgical released followed by PT for ROM and proper alignment.

Upper Quarter Screen ROM

- AROM of cervical spine and upper extremities - Passive overpressure of the cervical spine and upper extremities if pt doesn't exhibit signs and symptoms of pathology.

Achilles Tendon Rupture

- Achilles tendon is the largest and strongest tendon in the human body and is formed from the tendinous portion of the gastrocnemius and soleus muscle coalescing above the insertion on the calcaneal tuberosity. Rupture usually occurs one to two inches above tendinous insertion on calcaneous. Theories suggest rupture occurs when tendon undergoes degenerative changes due to hypovascularity in tendon in combo with repetitive microtrauma creating degenerative changes in the tendon. - Achilles tendon rupture most frequently occurs when pushing off of a weight bearing extremity with extended knee, through unexpected DF while weight bearing or with a forceful eccentric contraction of PFs. participation in sports that require quick changing footwork like football, tennis, basketball, and softball are high risk activities. Other factors are improper shoe wear during high risk activities, and altered biomechanics at the foot during activities (flattened arch). greatest incidence betweenn 30-50 yrs of age without history of calf or heel pain due to decrease in BF to the area but still commonly participate in recreational activities. A person with corticosteroid injections to the tendon may also have a predisposition for rupture. More common in men or those that don't consistently exercise but are "weekend warriors" - pt will present with swelling over the distal tendon, a palpable defect in the tendon above the calcaneal tuberosity and pain and weakness with PF. Pt may limb and say there was a pop followed by severe pain. pt will typically be unable to stand on their toes and tend to exhibit a positive Thompson test. MRI will confirm, x-ray should also be used to rule out avulsion fracture. - rehab incorporates immobilization thru casting or sx for repair or reconstruction. NSAIDs, acetaminophen or narcotics to relieve pain depending on physician preference. Non-sx treatmentincludes serial casting for 10 weeks, followed by use of heel lift to decrease stress on tendon for 3-6 months. PT begins when cast is removed after 6-8 weeks (post op). PT includes ROM, stretching, icing, AD training, endurance program, gait training, strengthening, plyometrics, and skill specific training. Modalities, pool therapy, and other cardiovascular equipment may assist in recovery of function motion and endurance. Pt is to ice and elevate early in rehab while at home, also includes ROM, strength, gait, endurace, and high level skill and sport specific tasks. 6-7 months of rehab. If pt doesnt get sx and heals on own, 40% in rerupture risk of tendon compared to 5% for sx pt and higher rate of return to sport. - Similar condition is achilles tendonitis - acute or chronic condition due to repetitive microtrauma that builds scar tissue in area over time. Pt reports aching after activity and progresses to pain with walking. Localized tendernesss and swelling in that area. In acute stage, pt should utilize anti-inflammatory meds, rest 2-3 weeks and use heel lift. In chronic stage, symptoms and pain may last beyond 6 weeks, exam reveals a thickened and nodular achilles tendon and sx may be warranted.

Thoracic Outlet Syndrome Special Tests

- Adson maneuver - Allen Test - Costoclavicular Syndrome Test - Roos Test - Wright Test (hyperabduction test)

Vascular insufficiency of the wrist/hand special tests

- Allen Test - Capillary Refill Test

Ligamentous Instability of ankle Special Tests

- Anterior Drawer Test - Lateral rotation stress test (Kleiger test) - Talar tilt test

Ligamentous instability of the knee special tests

- Anterior Drawer test - Lachman test - lateral pivot shift test - Posterior drawer test - posterior sag sign - solcum test - valgus stress test - varus stress test

Meniscal pathology special tests

- Apley's compression test - bounce home test - McMurray test - thessaly test

Shoulder Dislocation Special Tests

- Apprehension test for anterior shoulder dislocation - apprehension test for posterior shoulder dislocation - sulcus sign

Pediatric special tests of the hip

- Barlows Test - Ortolani's Test

Fibrous Joints (Synarthroses)

- Bones that are united by fibrous tissue and are nonsynovial - Movement is minimal to none...movement dependent on length of fibers uniting bones Suture: Union of two bones by a ligament or membrane; immoveable joint; eventual fusion is termed synostosis ex.) sutures of the skull Syndesmosis: Bone to bone by a dense fibrous membrane or cord; very little motion ex.) tibia and fibula with interosseous membrane Gomphosis: two bony surfaces connect as peg in hole; only gomphosis joints in body are teeth and corresponding sockets in the maxilla/mandible; the periodontal membrane is the fibrous component of the joint ex.) tooth in its socket

Contracture/Tightness Of wrist/hand special tests

- Bunnel-Littler Test - Tight Retinacular Ligament Test

Neurological Dysfunction of wrist/hand Special Tests

- Carpal Compression Test (median nerve compression test) - Froment's Sign - Phalen's Test - Tinel's Sign

Epicondylitis Special Tests

- Cozen's Test - Lateral Epicondylitis Test - Medial Epicondylitis Test - Mill's Test

Rotator Cuff Pathology/Impingement Special Tests

- Drop arm test - Hawkins-Kennedy impingement test - Infraspinatus Test - Lateral Rotation lag sign - Lift off sign (medial rotation) - Neer impingement test - Supine impingement Test - Supraspinatus test

Neurological dysfunction of the elbow special tests

- Elbow flexion test - Pinch grip test - Tinel's sign

Transtibial Shank

- Exoskeleton- rigid exterior - Endoskeleton - Pylon covered with foam

intervertebral joints

- Formed by the superior and inferior surfaces of the vertebral bodies and the associated intervertebral disks

Transhumeral Suspension

- Harness - Cable system - Suction

spinal fusion

- Indicated in presence of axial pain w/ unstable spinal segments, advanced arthritis or uncontrolled peripheral pain. Bone harvested from pts body (often iliac crest) and used to fuse two vertebrae together. Screws (pedicle screws) usually used to immobilize the segments while bony callus forms between the segments. Cervical fusion: anterior approach. Lumbar fusion: posterior approach. Fusion creates immobility at one segment while leading to hypermobility at adjacent segments due to this which can hasten onset of degeneration. - Restrictions post op on lifting, active motions (bending and twisting). Early PT involves ed on bed mobility and transfers in hospital without compromising precautions. Bracing (cervical collar, thoracolumbar sacral orthosis) may be used to assist w/ compliance w/ movement precautions (especially if sx didnt use instrumentation (screws). 6 weeks post op starts outpatient therapy. If instrumentation used to stabilize segments, PT can begin sooner and be more aggressive. Emphasis placed on proper body mechanics, posture, and core stabilization.

PCL reconstruction

- Injuries to PCL much less common than ACL. If PCL injury occurs in isolation sx may not be needed. Sx is indicated if pain and/or instability do not improve w/ PT. Similar options for graft as w/ ACL. - Rehab protocol same w/ ACL however weight bearing and ex progression more gradual. Exercises should limit posterior shear forces within knee and repetitve knee flexion should be avoided.

Transhumeral Elbow Unit

- Internal or external locking elbow unit

disk herniation

- Intervertebral disk composed on inner like jelly (nucleus pulposus) and outer cartilaginous structure (annulus fibrosus) Disk herniation occurs when nucleus pulposus bulges thru exterior wall of annulus fibrosis. Most commonly at posteriolateral portion of disk where disk is weakest and most likely to fissure. Commonly caused by twisting and bending of spine often with some external load (bending to pick up heavy object). Can happen acutely or gradually over time with repeated twisting and bending motions. Can also often be result of gradual, age related changes that cause disk degeneration like losing water content over time causing disks to be less flexible and increases likelihood of tearing or rupturing the annulus fibrosis. Risk factors for herniation include being overweigh and having an occupation that requires repetitve lifting, bending or twisting. - When disk herniates, often compresses nearby roots and cause pain, numbness, and/or weakness into extremities. most herniation occur at L4-L5 or L5-S1 vertebral level. Presentation most commonly includes low back pain followed by unilateral radicular leg pain (though bilateral is possible). Pain most common symptom, pt may also experience numbness, tingling and weakness in distribution of affected nerve. Symptoms exaggerated by sitting, walking, standing and any increase in intra-abdominal pressure (coughing, sneezing). Less common but disk herniations can happen in cervical spine. MRI visualized disk herniation, EMG and nerve conduction velocity testing determines extent of peripheral nerve damage. PT exam includes neural provocation testing (slump test, SLR) as well as assessment of strength, sensation and DTRs. - Tx includes avoiding provocative positions, ed on activity modification and appropriate body mechanics, soft tissue manipulation, lumbar stabilization exercises, traction, and modalities for pain relief. Once tolerated, McKenzie extension exercises likely to be incorporated into exercise program. Pharm includes NSAIDs, narcotic meds, nerve pain meds, and muscle relaxants. Conservative tx highly successful but if not, cortisone injection may be needed and a small % will need sx (microdiscectomy). Months needed to resolve symptoms. Pts with a disk "bulge" in which the annulus fibrosus fibers are unaffected are less likely to need sx and more likely to experience a full recovery. Pts with larger herniations or rupture of disk in which annulus fibrosus fibers are compromised are more likely to experience reoccurance of symptoms.

Posterior cruciate ligament sprain

- Intracapsular ligament that attaches posterior tibial plateau and lateral side of medial femoral condyle..prevents posterior translation of tibia on the femur and provides rotational stability to the knee. PCL injuries generally occur secondary to traumatic events when posteriorly directed force is applied to the tibia in relation to the femur (when knee hits dashboard in MVA). Hyperflexion of knee without a traumatic blow can also lead to a PCL sprain. 3 point scale grading w/ grade 3 indicated complete rupture. Most tears occur where ligament attaches to tibia. Isolated PCL injuries far less common than ACL cuz PCL is stronger ligament. Injuries to PCL often occur with concurrent damage to ACL, collateral ligaments and/or menisci. participating in contact activities requiring high level of agility are susceptible to PCL injury. Muscle weakness resulting in poor dynamic stability may also increase incidence of this type of injury. - PCL injury results from acute trauma, audible pop may be heard with immediate onset of pain and swelling. Injury generally not as debillitating as ACL tear. may feel instability w/ walking and pain w/ descending stairs or squatting. MRI used to confirm, xray to r/o fx. Special tests: posterior drawer test, posterior sag sign, and the quads active drawer test to confirm PCL sprain. An arthrometer may be used to ID laxity in knee and determine extent of damage. Exam should consist of assessment of other ligaments and meniscus as well as PCL cuz they could occur in conjunction. - PCL sprain often tx conservatively w/ icing, rest, bracing, anti-inflammatory meds, and PT. PT focus on reduced swelling, regaining full ROM, and strengthing of knee. Strengthening exercises that place posterior shear force on knee (open chain hamstrings) should be avoided to allow ligament to heal. Home care is frequent icing and exercises (specifically quad strengthning). Pts do well w/ conservative tx especially if they can improve quads strength to help stabilize knee. Pts w/ isolated PCL injury that is grade 1 or 2 dont need sx and experience full recovery. Sx to reconstruct ligament with tissue graft needed if conservative fails. Functional bracing may be needed if pt plans to return to sports. pts w/ PCL injury are more prone to mensical damage in years following injury (just like all ligamentous injuries of knee).

Lateral Ankle Sprain

- Inversion causes majority of sprains. Lateral ligament complex (anterior talofibular (ATFL), calcaneofibular, and posterior talofibular ligaments) involved - they function to resist varus stress. This is cuz ankle strong medially due to deltoid ligaments which resists valgus forces - causes medial malleolus to fracture due to attachment there before deltoid ligament fails. ATFL most likely of three lateral ligaments to sustain damage (resists anterior translation of talus on tibia and inversion of talus and calcaneus - ligament becomes taut during PF. - ppl in sports with high levels of agility (soccer) or jumping (bball, vball) more susceptible. deconditioning, poor proprioception, and obesity contribute as well. Recurrent sprains common due to combo of residual ligament laxity and decreased proprioceptive responses. - Pain and tenderness along lateral aspect of ankle especially at ATFL. pain limits strength assessment but AROM should be assessed for achilles rupture. Antalgic gait pattern. Pain with passive inversion and PF due to maximally stretching ATFL. Laxity, ecchymosis and moderate to severe edema noticed and persists even after pain diminishes and function returns. Special test: anterior drawer test assess ATFL, talar tilt assesses CFL. Distal pulses and sensory integration should be assessed cuz neurovascular complications could accompany the ligamentous injury. PTFL strongest ankle ligament. check for neurovascular, osteochondral or chondral injuries to talar dome or achilles tendon rupture, along with proprioceptive changes with ankle sprain. - Tx includes proprioceptive deficits due to them being common after sprain to decrease recurrent injury. Initialy RICE, NSAIDs and/or acetiminophen for pain. Sx not indicated unless fracture or neurovascular disruption. Crutches can be used to limit weight bearing until full weight bearing tolerated. PT to increase ROM, proprioception, decrease edema, begin light resistive exercsises (open chain, closed chain, isometric). passive stretching, joint mobs if capsular restriction noted. Resistive ex should include peroneal muscles as they provide ankle with stability. Proprioceptive and balance retraining thru single legged stance on variable surface. Gait training, stairs, sport specific agility training. Modalities include ESTIM (for pain, edema, inflammation and soft tissue restrictions), transverse friction massage to healing ligament to prevent adherence of scar tissue to adjacent structures after inflammation has decreased. Complete functional progression prior to returning to full activity. Grade 2 ankle sprain heal 2-6 weeks fully in no other structures involved. period of supportive tape recommended for a period of time during sports after pt demonstrates full pain free ROM, minimal pain or tenderness with palpation, normal gait pattern, normal proprioception, and competence with agility testing pt can return to sport. Residual laxity increases pts risk of recurrence. - high ankle sprain or sprain of syndesmotic ligaments attaching tibia and fibula that function to stabilize ankle mortise can happen. Ligaments are deep, so lots of force required to injure them. Ankle fracture sometimes comes with this. If tear unrecognized, severe post traumatic arthiritis will likely result. sx required for significant tear of this.

transfermoral suspension

- Lanyard strap - shuttle lock - suction - seal in liner suction, skin fit suction - partial suction - silesian bandage, pelvic belt/band - vacuum

posterior longitudinal ligament

- Limits flexion of the spine - Reinforces posterior aspect of the intervertebral disks

Biceps Tendon Pathology Special Tests

- Ludington's Test - Speed's Test - Yergason's Test

meniscal tear

- Menisci are c shaped structures made of fibrocartilage that sit on each side of tibial plateua. Function to absorb shock and distribute loads in knee joint. Medial more commonly affected than lateral due to it being more firmly attached to tibia. Tears commonly occur as result of traumatic injury often involving twisting of knee in semiflexed position w/ foot planted on ground. Meniscal tears often occur secondary to a hyperflexion injury. Degeneration causes it in elderly (simple pivoting or squatting movement may be enough to cause it). Location of tear (inner vs outer meniscus) important in determining appropriate tx. can occur in isolation or in conjuction w/ ligamentous injuries (ACL tear). Pts in sports that involve quick cutting and pivoting movements more likely. Elderly cuz w/ increasing age, cartilage thins and weakens. Pts w/ instability of knee secondary to weakness or ligamentous deficiency more likely for tears. - Meniscal tears characterized by joint line pain and tenderness, swelling, loss of ROM (sometimes w/ mechanical block), complaint of catching or locking within joint and feelings of instability. Degenerative more gradual symptoms, traumatic more sudden. Xrays to r/o fx, MRI confirms presence of meniscus. PT exam includes palpation, ROM assessment and special tests: mcmurray test, apley's compression test and thessaly test. - age, activity level and location and extent of tear consideration for PT or sx. Conservative tx involves rest w/ limited weight bearing, ice, anti-inflammatory meds, and PT. PT goals are reduce sweling, normalize ROM, improve strength. some meniscal tears heal on own. A tear in outer 1/3 of meniscus more likely to heal spontaneously cuz its vascular and conservative tx successful. inner 2/3, sx may be necessary. If conservative tx fails, for young pts whose lesion is in vascular portion, full repair is usually performed. For older pts or those who have lesion in avascular portion of meniscus, partial meniscectomy in which torn tissue is excised likely to be performed. Pts who have sx are eventually able to return to Previous level of function.

Sx to fix articular cartilage defects - LE

- Microfracture procedure uses an awl to penetrate subchondral bone, causes an ingrowth of fibrocartilage. - Osteochondral autograft transplantation: sx where cartilage is harvested from several non-weightbearing surfaces to form plug that can fill chondral defect. - Autologous chondrocyte implantation: sx where healthy cartilage is harvested and cultured so it will grow then later implanted into cartilage defect. - weight bearing restrictions post op: allow healing to occur. Pt will often be in brace locked into extension. ROM progression dependent on location and size of lesion. Larger lesion, slower progression.

Glenohumeral dislocation - Anterior

- Occurs when head of humerus is traumatically seperated from the glenoid fossa. Mechanism typically involves external blow or loading force when shoulder is in abduction, lateral rotation and extension (throwing, spiking a vball). Stability maintained by GH joint capsule, ligaments, rotator cuff muscles and glenoid labrum. Loading applied to joint when its in vulnerable position could cause stretching or tearing of stabilizing structures allowing joint to dislocate. Fx may also occur. - shoulder most frequently dislocated joint with 90% of dislocations anteriorly. Most common between 18-25 years old and those engaging in sports. Elderly as well from falls. - Clinical presentation consists of visible deformity, severe pain and significant ROM limitations prior to relocation. affected limb will typically be in position in slight abduction and lateral rotation with pt unable to touch opposite shoulder with contour looking more square than unaffected shoulder. Humeral head will typically be palpable anteriorly in subcoracoid region. Once dislocation reduced, most severe pain symptoms resolve. Positive apprehension sign is likely. Check radial pulses to assess vascular injury (medial emergency is diminished or absent). Decreased sensation or motor function in the axillary, musculocutaneous, and radial nerve distributions may also be observed. X-ray performed. - Tx initially focused on pharm pain management and joint reduction. Acutely, analgesic meds used to improve comfort and relax muscles before relocation. After reduction, analgesics and NSAIDs. Sx may be necessary if joint cant be reduced or if adjacent structural damage is significant (Bankart lesion, detached labrum, rotator cuff tear, fx). PT to assist with pain management and prevent loss of function. Modalities to facilitate muscle retraining and for pain (ice). strengthening initially using isometrics and gradually progressing to resisted activities emphasizing shoulder stabilizers. PT includes ROM, joint mobs, stretching, postural ed, protective positioning, edema management and activity modification. Aggressive strengthening program will permit return to sports but risk of reinjury great in contact sports. In elderly, emphasize fall prevention and joint protection. Recurrent dislocations may require sx and may require avoidance of participation in high risk activities.

Osteokinematic and arthrokinematic Motions

- Osteokinematics typically consist of flexion/extension, abduction/adduction, and internal rotation/external rotation. - Arthrokinematics is the small movements happening at the joint surface. Arthrokinematic movements typically consist of rolls, glides/slides, and spins.

Acromioclavicular crossover test

- PT moves pts shoulder into 90 deg flexion, then fully horizontally adducts the shoulder. Positive Test: pain over the acromioclavicular joint indicative of AC joint injury - Test can be performed actively by pt.

Anterior Labral Tear Test

- PT places pts hip in full flexion, lateral rotation and abduction to begin the test. PT then moves the hip into extension, medial rotation and adduction Positive Test: presence of pain and/or a click. Used for diagnosing an anterior labral tear, though it may also be indicative of iliopsoas tendonitis or anterior-superior impingement

Documentation of recorded measures

- Patient medical records is one of the primary ways that health care providers keep each other informed of current patient status and other relevant info. Critical to provide effective and safe medical care. - Documenting 10-105 degrees for knee flexion means pt ROM starts at 10 deg knee flexion and ends at 105 degrees (95 degrees of total ROM) - Documenting 10-0-105 degrees means 10 degrees of knee hyperextension and 105 deg knee flexion (115 deg total ROM)

Mobilization technique

- Pt should have a general understanding for the purpose of mobilization, relax during treatment, and the PT should be in a comfortable position - PT position should allow for optimal control of movement, explain mob to pt, and complete a general exam of pt prior to treatment - use gravity to assist with mob, mob performed initially in LPP, and maintain contact with mobilizing hand as close to joint space as possible - allow one digit to palpate joint line when possible, mobilize one joint in one direction at a time, use a mob belt or wedge to assist with stabilization when needed and constantly modify mob techniques based on respond. - compared quality and quantity of joint play bilaterally and reassess each pt prior to every treatment session

Discharge guidelines following THA

- Pts need to following strict precautions and guidelines for up to three months following THA. Failure to do so jeopardizes the integrity of the sx procedure and creates an unnecessary safety risk. - Avoid crossing the legs in a sitting position - sit in firm chairs and avoid sitting in low or soft furniture. Limit forward bending when sitting or standing. - stand with feet in neutral position (avoid turning toes inward) - use a pillow or splint between the legs when in bed - avoid pulling blankets up in bed with forward bending - place a night stand on the same side of bed as uninvolved side - use a raised toilet seat or portable commode for toileting - Use a rubber, non skid bath mat in shower - use a long handled brush to avoid leaning forward when bathing - when walking, turn to the uninvolved side to avoid pivoting on involved - walk for short periods and gradually increase the time period to improve endurance - when ascending stairs, step up with the uninvolved leg - when descending stairs, step down with involved leg

Transfemoral Socket

- Quadrilateral socket - Ischial containment socket

Total Shoulder Arthroplasty (TSA)

- Severe pain and impaired shoulder motion due to deterioration of Glenohumeral joint indicated for TSA if conservative tx has failed to improve condition. Irreparable damage, deterioration and destruction to humeral head and glenoid fossa within shoulder complex by wear and tear, inflammation or previous injury. - Indications for sx include severe glenohumeral degenerative joint disease, pain and limited ROM secondary to osteoarthritis, rheumatoid arthritis, avascular necrosis, fx or rotator cuff arthropathy..severe cases include bone tumor, Paget's disease or recurrent dislocation. - Pt will have impaired ROM at shoulder, independence with functional mobility and ADLs and have severe pain. TSA performed secondary to arthritis seen in pts between 55-70 years. TSA secondary to damage from dislocation or avascular necrosis usually performed on pts 40-50 years. Xray, CT scan or MRI used to reveal level of degeneration within shoulder and allow physician to assess integrity of rotator cuff and deltoid muscles as well. - Sx complications include mechanical loosening of prosthesis, instability, rotator cuff tear, implant failure, heterotopic ossification and intraoperative fx. Pt post op for TSA on avg remains in hospital for 2-5 days. Success of TSA relys on style of implant, quality of soft tissue and bone and rehab program. Pharm intervention includes anticoagulation and pain meds. PT is initiated day after sx and follows rehab protocol designed by surgeon. Shoulder remains immobilized in slimg during initial rehab. Neer shoulder protocol advocates initiating isometric shoulder exercises 3 weeks post op and active shoulder exercises 6 weeks post op. PROM and AAROM are indicated but AROM at shoulder contraindicated during first phase of rehab. PT management included pain management, prevention of adhesions, functional activities, PROM/AAROM, and eventually AROM, therapeutic ex, edema management, pt ed in self ROM and wand/pendulum exercises and use of modalities. Pt cant perform any form of medial or lateral rotation beyond 35-40 deg during first two to three weeks post op. Goal of TSA is to relieve pain and regain functional motion. Longer life expectancy of shoulder prosthesis due to shoulder not being weight bearing joint. High success rate with TSA...pt should avoid activities such as heavy lifting, chopping wood, or contact sports since these can increase risk of fx, loosening of the joint, or rotator cuff repair. Precautions are usually to avoid ER and extension to help protect subscapularis (that was detached) and anterior portion of capsule (anterior approach most often used). Resisted internal rotation avoided and may also be restrictions of weight bearing thru arm on lifting or carrying. - shoulder hemiarthroplasty is similar sx.. involves replacement of head and neck of humerus leaving glenoid fossa of the scapula intact. Indicated when humeral head has fx or deteriorated. may also be done if pt doesnt have enough bone density to support the glenoid component or when there are significant rotator cuff deficiencies that exist. - Reverse TSA reverses concave-convex relationship of joint and is sx of choice if pt has a dysfunctional rotator cuff. All surgeries listed above usually involve an anterior approach in which the subscapularis is detached for easier access to joint.

Transradial Socket

- Standard socket covers two thirds of forearm - standard socket may be shortened to allow for increased pronation/supination ability - Supracondylar sockets are self-suspending and require no additional harness apparatus

Sx for meniscus injuries

- Sx performed arthroscopically. Partial meniscectomy where torn piece of meniscus is removed (for older individuals or when tear is in inner 2/3rds where healing is poor). Or repair of meniscus where tear sutured back together (younger pts or tear on outer 1/3rd.) - Tx depends on if meniscus was repaired. following repair, period of restricted weight bearing and bracing. Limitations on progression of ROM, specifically flexion. Following partial, pt is full weight bearing w/ no brace. No rehab constrictions and recovery time is significantly quicker.

temporomandibular joint dysfunction (TMD)

- TMJ is a complex joint classified as condylar, hinge and synovial joint that contains fibrocarilaginous surfaces and articular discs. - TMD occurs due to changes in joint structure that result from injury, derangement or incongruence of the TMJ, intra articular disks and/or supporting structures - inflammation and muscle spasm surrounding joint produce symptoms. - Over time the meniscus of the TMJ becomes compressed and torn allowing the bony portion of the joint (ball and socket) to deteriorate secondary to the grinding of bone on bone - TMD can occur secondary to multiple causative factors including trauma, congenital abnormalities, internal derangement of joint structure, arthritis, dislocation, disk degeneration, metabolic conditions and stress - Risk factors include chewing on one side, eating tough food, clenching, and grinding teeth..habits of gun chewing and biting nails increase incidence - Pts are typically between 20 to 40 years old with women more likely. - 90% of TMD pts are women in childbearing years..10.8 million Americans have TMD. - c/o pain (persistent or recurring), muscle spasm, abnormal or limited jaw motion, headache and tinnitus - all these can be unilateral or bilateral - pt will also c/o feeling and hearing a click or popping sound with motion of TMJ, locking, restriction of motion on unaffected side. - Common underlying causes include arthritis, fx, congenital abnormalities, dislocations, and tension relieving habits (chewing gum, bruxism, clenching or grinding teeth) - Tx includes pharm, splinting, PT, and possible sx - Pharm: analgesics, NSAIDs, muscle relaxants, and antianxiety meds - Splint: to assist with realignment of joint and a guard or bite plate to maintain proper positioning and avoid grinding thru night - PT: pt ed on habits (nail biting), posture retraining, use of modalities (moist heat, ice, biofeedback, ultrasound, ESTIM, TENS and massage). Soft tissue manipulation, joint mobs, ROM, stretching, occlusal appliance prescription and relaxation techniques - Sx: if conservative fails (5%) condylectomy, osteotomy, arthrotomy, arthroscopy, reduction of subluxation, or joint debridement - Myofascial pain dysfunction is a nonarticular disorder that affects area surrounding TMJ. Symptoms produced secondary to muscle spasm. MPD more in females and can be psychophysiologic origin. Habits such as grinding and jaw clenching increase muscle tension of mm of mastication and crease spasm. MPD can mimic TMD.

Torticollis (congenital)

- Tortilcollis (twisted neck) - neck involuntarily unilaterally contracts to one side secondary to contraction of SCM - head laterally flexes towards contracted muscle, chin faces opp direction and there may be facial asymmetries - Torticollis is a disease and a symptom of many conditions. - Congential torticollis could be caused by muscle injury due to birth trauma, breech position in utero or other forms of intrauterine positioning. Infants born with this appear healthy at delivery but over days or weeks develop swelling over injured SCM. - Typically children with congenital torticollis have had breech or difficult forceps delivery. - Intermittent painful spasms of SCM, traps and other neck muscles may occur. - first sign may be a firm nontender enlargement of SCM visible at birth or within the infants first few years of life. Mass usually localized near clavicular attachment on SCM enlarges during first few weeks and then gradually decreases and disappears by 6th month of life. ONly remaining finding is the torticollis posturing. - presence of mall over SCM along with classic posturing confirms presence of congenital torticollis - Up to 20% of children with congenital torticolis have congenital dysplasia of hips, and many also present with facial asymmetries and plagiocephaly or flattening on the skull. - treated with non operative intervention for 12-24 months before sx considered - Pharm includes NSAIDs, benzodiazepines and other muscle relaxants, anticholingerics, and local intramuscular injections of botulinum toxin or phenol - PT includes caregiver ed, passive stretching to SCM and upper traps, massage, local heat, analgesics, sensory biofeedback, TENS. - AROM w/ stretngthing to correct infants positon of head. - caregiver ed in feeding and sleeping position to promote stretch - if conservative fails, sx for SCM release or selective denervation - a cervical collar may be used for first 6-12 weeks post op - PT post op includes manual stretching of neck to maintain overcorrected position (3x daily for 3-6 months) - 85-90% of pts respond to stretch and treatment first year of life..if left untreated, congenital torticollis could have detrimental affects on natural growth and development - torticollis can be acquired at older age. Acute wryneck is term to describe common torticolis that develops overnight without provocation. self limiting and usually subsides in 1-2 weeks. Infectious torticolis may occur when surrounding tissues become infected with a retropharyngeal abscess, nasopharyngeal abscess, tonsilitis, and sinusitis.

Upper Limb Tension Tests

- Types of neural provocation maneuvers. Tests require an ordered sequence of movements occuring at the shoulder, arm, elbow, forearm, wrist and hand. Symptoms and relevant changes in symptoms shoulder identified after each step - A sensitization test is often employed if symptoms are minimal or absent after the identified sequence. Upper limb tension tests are recommended for pts with symptoms in the arm, head, neck and thoracic spine. Each test begins with the noninvolved side being tested first.

Elbow Ligamentous Instability

- Valgus Stress Test - Varus Stress Test

Transhumeral Terminal Device

- Voluntary opening or closing - Body-powered, externally powered, myoelectric or hybrid - Hook, mechanical hand, cosmetic glove

Transradial Terminal Device

- Voluntary opening or closing - Body-powered, externally powered, myoelectric or hybrid - Hook, mechanical hand, cosmetic glove

single axis foot

- allows for motion in singular plane - improved knee stability during weight acceptance - lacks energy return function if not paired with a dynamic response foot

Transradial Elbow Unit

- attaches to either triceps cuff or upper arm pad - flexible or rigid hinge connects socket to proximal component

Swelling of the knee special tests

- brush test - patellar tap test

dynamic response foot

- can be articulating or non-articulating - keel has the capability to store and return some energy - may have a split keel to allow for improved surface accomodation

Cervical spine special tests

- cervical flexion rotation test - distraction test - foraminal compression test' - vertebral artery test

myositis ossificans

- condition characterized by the calcification of muscle (bone growth in muscle belly). Caused by neglecting to properly treat a muscle strain. Failing to apply cold or heat after injury or having intense therapy or massage too soon after injury are precipitating factors that disrupt heating and lead to abnormal bone growth. Muscles in arms and legs (quads) more susceptible cuz they are more susceptible to traumatic injury. Bone will begin to grow 2-4 weeks after injury and will mature within 3-6 months. - initial stage, pt presents w/ typical symptoms of contusion (pain with activity, stiffness and pain after prolonged rest w/ swelling, tenderness and bruising). Within few weeks, development of further symptoms (noticeable hard lump in muscle belly, increased pain and decreased ROM that had previously been improving). X-ray confirms - performed 3 weeks after injury. R/o other conditions w/ similar characteristics (osteosarcoma)

Orthotics Prosthetics User Survey (OPUS)

- consists of functional status, quality of life, and satisfaction modules. Survey is simple to administer

Patient based outcome measures

- determine impact of amputation on pts quality of life, societal engagement and satisfaction. Administered at baseline and at d/c to account for multi dimensional changes that have or have not been experienced.

Single axis knee

- difficult to reciprocate during gait - may or may not have knee extension assist and/or weight activated stance phase control - constant friction mechanism

Wrapping

- elastic wrap should not have wrinkles - Diagonal and angular pattern should be used - dont wrap in circular patterns - provide pressure distally to enhance shaping - anchor wrap above knee for transtibial amputations - anchor wrap around pelvis for transfemoral amputations - promote full elbow extension for transradial amputations. - promote full knee extension for transtibial amputations - promote full hip extension for transfemoral amputations - secure the wrap with tape, do not use clips - use 2-4 inch wrap for UE amputations - use 3-4 inch wrap for transtibial amputations - use 6 inch wrap for transfemoral amputations - rewrap frequently to maintain adequate pressure

Contracture/tightness of the hip special tests

- elys test - obers test - piriformis test - Thomas Test - Tripod sign - 90-90 straight leg raise test

Prosthesis Evaluation Questionnaire (PEQ)

- evaluate prosthesis and life w/ it. composed of 9 validated scales..usual analogue scale used w/ most questions to assess satisfaction, well being, pain, frustration and residual limb health

break test

- evaluation procedure where a patient is asked to hold a contraction against pressure that is applied in the opposite direction to the contraction

transfermoral shank

- exoskeleton - rigid exterior - endoskeleton - pylon covered with foam

orthotics

- external device provides support or stabilization, improves function, corrects deformities and distributes pressure from one area to another. Made from plastic, metal, leather, fabric, elastic or hybrid materials. Can be custom made or over the counter. Available in various prefabricated size. lightweight, adjustable, easy to don and doff. Functions include preventing deformity, maintaining proper alignment, inhibiting tone, assisting weak limbs, protecting against injury and facilitating motion. Factors to consider when prescribing include static vs dynamic, temporary vs permanent, level of support required, energy efficiency, cosmesis and cost.

Hydraulic/microprocessor foot

- finer control over the stability/mobility of motions - improved shock absorption - not appropriate for all environmental conditions and demands

Insert prosthesis

- flexible or soft inset can be used to accommodate for space in the prosthetic socket. Soft inserts (made from foam material) offer improved cushioning on residual limb during weight bearing. Flexible inserts made of plastic and similar to a foam insert, can improve the comfort and fit of the prosthesis. Unlike a foam insert which can offer some shock absorption, the hard insert relieves pressure through a series of buildups and reliefs molded into the insert.

spondylolisthesis

- forward slippage of one vertebra on vertebra below - classifications include congenital, isthmic, degenerative, post-traumatic, and pathologic spondy. - degenerative (DS) caused by weakening of joints allowing forward slippage due to arthritis and degeneration (changes include segmental ligamentous instability and subluxation of the hypertrophic facet joints which can result in stenosis of the spinal canal) - Most common site of DS is L4-L5 - slippage causes cauda equina symptoms secondary to stenosis - L4 nerve root is compressed in L4-L5 spondy. Other structures that can be irritated include intervertebral disk, posterior and anterior longitudinal ligaments, and vertebral periosteum and bone - slippage usually limited due to the secondary bony restraints of the spine due to all structures of spine remaining intact. - DS usually affects ppl over 50 years and more common in African Americans and women . - primary symptom is back pain..increases w/ exercise, lifting overhead, prolonged standing, getting out of bed or car, walking up stairs or an incline and positioning in extension. - pain may be severe and radiate depending on area of stenosis secondary to vertebral slippage. - sensory and motor loss may be significant and follow a myotomal and/or dermatomal pattern. - Most pts dont have significant neurological deficits, some do - Plain radiographs confirm dx - If slippage of vertebra worsens, it does not necessarily correspond to an increase in symptoms. - If pt does experience ongoing neurological deficits, sx will be required regardless of amount of slippage. If conservative tx fails or pain becomes disabling, sx recommended. - Tx initially included ed, medication, activity mod, and PT intervention. - Pharm includes NSAIDs to decrease inflammation, Corticosteroids for severe symptoms..activity mod and rest for further decrease in inflmmation to subside and improve symptoms. (avoid long term bed rest) - Once acute phase done, PT includes Williams flexion exercises to strengthen abs and reduce lumbar lordosis, back school, modalities, postural ed, other exercises for core stabilization and increase flexibility. - External support such as bracing or wearing a corset may relieve intradiscal pressure - Majority of DS pts are successful with PT. - Congenital spondy slippage happens due to anamoly or defect in fusion of neural arch. usually in upper sacral arches or L5 and usually dx during growth spurts between 12 and 16 years old. Normally pain free to this pt and begin having back pain, sciatica pain and other symptoms. Strong genetic association found with congenital spondy.

Lumbar/sacroiliac region special tests

- gapping test - sacroiliac joint stress test - sitting flexion test - slump test - standing flexion test - straight leg raise test

Patellofemoral Syndrome

- general term describing pain or discomfort in the anterior knee - Caused by abnormal tracking of patella between femoral condyles and pulled too far laterally during knee extension. -often termed chondromalacia patella (which refers to softening of the articular cartilage of the patella) - damages the articular cartilage of patella Etiology: repetitve overuse disorder resulting from increased force at the patellofemoral joint. Factors involved with increased force at joint include decrease quad strength, decreased LE flexibility, patellar instability, increased tibial torsion or femoral anteversion. Pts at increased risk include females, individuals experiencing a growth spurt, runners who have recently increased milage and overweight individuals. More common in females, during adolescent years and correlated to activity level. Associated with OA in older ppl. Additional factors associated with patellofemoral syndrome include patella alta, insufficient lateral femoral condyle, weak vastus medialis obliquus, excessive pronation, excessive knee valgus, and tightness in LE (iliopsoas, hammys, gastroc and vastus lateralis). increased Qangle (measured using ASIS, the midpoint of patella and the tibial tubercle - 13 deg for males, 18 deg for females is normal) and alignment of feet can be causative factor as well. Signs and symp: anterior knee pain, pain with prolonged sitting, swelling, crepitus, pain when ascending and descending stairs. Gradual onset of anterior (retropatellar) knee pain following increased activity. Activities that increase patellofemoral compressive forces include stair climbing, jumping, prolonged static positioning (sitting with knee flexed at 90 in car, plane, etc). Visible quad atrophy (especially vastus medialis obliquus), point ternderness along lateral border of patella and crepitus when patella is manually pressed into trochlear groove. May c/o burning pain during stairs or sitting long periods. Special Test: Clarke's Sign. Diff Dx includes ruling out hip, osgood-schlatter syndrome, neuroma, patella tendonitis, plica syndrome, and infection of knee joint. Tx: Pharm includes acetominophen, NSAIDs, and steroid injections into joint. Tx is dependent on factors associated w/ abnormal patellar tracking. PT tx includes modalities to decrease pain and inflammation, controlling edema, stretching (emphasis on hammys, IT band, TFL, and rectus femoris), strengthening (quads, SLR, mini squats and incorporating hip adductors), LE flexibility to improve ROM, medial patella glides, biofeedback (to selectively train muscle), patella taping and activity modification. LE strengthening should emphasize the quads (particularly vastus medialis oblique) while minimizing patellofemoral compressive forces (avoid deep squats). Usually successful with conservative, sx is rare. Return to full function in 4-6 weeks usually. - Patellar tendonitits - overuse condition with inflammation of patella tendon. From repetitive jumping. C/o pain over anterior portion or superior tibia w/ jumping and stairs. prolonged sitting experiences pain and point tenderness at superior pole of patella tendon. Management is similar to patellofemoral syndrome.

Colles' Fracture

- happens frequently when someone reaches forward with hands attempting to break a fall (FOOSH - fall on outstretched hand). Signficant momentum and body weight wrist absorbs while in hyperextended positon - transverse fx of distal radius due to direct trauma. mechanism causes lunate to act as a wedge resulting in a shear force and distal displacement of the radius. Damage to ulnar aspect of wrist such as ulnar collateral ligament or styloid process are also common occurances of FOOSH injury. - Pt will presnet w/ pain and edema in close proximity to fx site, Dinner fork or bayonet deformity may be present with more sever colles' fxs as a result of dorsal displacement of distal radius, carpals, and hand in relation to forearm. Pts w/ osteoporosis are at risk for these fx when falling from standing position. X-ray for fx, MRI for soft tissues. Pts subjective report of mechanism of injury and current symptoms are important for dx.

Polycentric knee

- heavier than single axis - reciprocal gait is more fluid - may or may not have a knee extension assist and/or a weight activated stance phase control - constant friction mechanism

Adaptations to resistance training - endurance training

- increased capillary bed density - increased mitochondrial density - increased stores of ATP, creatine phosphate and other energy sources - increased tensile strength of tendons and ligaments - increased bone mineral density - decreased body fat %

Fit issues

- most common complaint is regarding comfort of socket on residual limb. fit issues can be managed thru manipulation of sock ply, alignment of liners in the socket, and training the pt on how to dynamically adjust the fit to accommodate fluctuations in size of residual limb thruout day. Too tight, determine if pt has been wearing shrinker thru day when not wearing prosthesis. Too loose, adjust sock ply. If theyve been wearing shrinker and still too tight, review of meds and diet may be warranted.

Thoracolumbar Spine Goniometry - Flexion and extension

- most commonly measured with a measuring tape instead of a goniometer. Align measuring tape between the spinous processes of T1 and S2 and record the distance. Have pt bend forward gradually while therapist allows tape measure to unwind and second distance is recorded. amount of thoracic and lumbar flexion is determined by calculating the difference between the first and second measurements. Extension of thoracic and lumbar spine is measured in a similar manner. Average Adult ROM: Flexion = 0-80 deg Extension = 0-25 deg

Trinity Amputation and Prosthesis Experience Scales-revised (TAPES-R)

- multidimensional instrument used to examine psychosocial process involved in adjusting to using an amputation and a prosthesis. 4 sections: activity restriction, psychosocial adjustment, satisfaction w/ prosthesis, and factors influencing health both related to and unrelated to the amputation. Test takes approx 15 mins to administer

Microprocessor knee

- multiple programs available to accommodate the activity level of the user - allows for fluid management of descending stairs - requires charging - variable friction for improved swing and stance phase control

Potential consequences of resistance training

- muscle fatigue - delayed onset muscle soreness - valsalva maneuver

Adaptations to resistance training - strength training

- muscle fiber hypertrophy - fiber type remodeling from 2B to 2A - increased neuromuscular activity (# of motor units, firing rate) - decreased or no change in capillary bed density - decreased mitochondrial density - increased stores of ATP, creatine phosphate, and other energy sources - increased tensile strength of tendons and ligaments - increased bone mineral density - increased lean body mass - decreased body fat %

SACH foot (solid ankle cushion heel)

- non articulating with a rigid keel - inexpensive - low maintenance - cushioned heel for shock absorption - lacks energy return - cannot accommodate to uneven surfaces

De Quervain's Tenosynovitis

- result of inflammatory process involving tendons and synovium of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) at base of the thumb. repetitive activities of thumb abductino and extension (racquet sports, heavy lifting) cause this. Pain located at base of thumb within snuff box. - APL and EPB covered by synovial sheath and pass thru the anatomical tunnel that is created by the extensor retinaculum and the radial styloid process. Inflammation of tendons and synovium results in inpingement of tendons as they move thru the tunnel. Direct trauma or structural anomalies in the area can also restrict tendon mobility and cause symptoms of de Quervain's tenosynovitis. - Pts report localized pain and tenderness in area of anatomical snuffbox which may occasionally radiate into the forearm. degree of reported pain tends to be activity dependent and typically improves w/ rest and worsens w/ activity or resisted testing. Edema may be at base of thumb, and severe edema can cause symptoms of nerve entrapment particularly in the superficial branch of the radial nerve. Dequervains more prevelant among women w/ higher risk among new mothers due to the repetitive lifting and carrying of the infant. Special test: Finkelstein's test. Activities of daily living and functional limitations should also be reviewed in order to ID exacerbating factors.

Convex surface moving on a concave surface

- roll and slide occur in the opposite direction - mobilizing force should be applied in the opposite direction of the bone movement

Concave surface moving on a convex surface

- roll and slide occur in the same direction - mobilizing force should be applied in the same direction as the bone movement

Transfemoral Knee

- single axis knee - polycentric knee - hydraulic knee - microprocessor knee

foot system transfemoral

- solid ankle cushion heel (SACH) - stationary attachment flexible endoskeleton (SAFE) - single axis - multi-axis - hydraulic - powered - dynamic response

transtibial foot system

- solid ankle cushion heel (SACH) - stationary attachment flexible endoskeleton (SAFE) - single axis - multi-axis - hydraulic - powered - dynamic response

Transhumeral Socket

- standard socket extends to acromion level - modified design allows for more stability with rotational movements - lightweight friction units may be used with passive prosthetic arms

Anterior cruciate ligament reconstruction

- sx on pts w/ ACL tear causing pain and/or instability. Sx often performed arthroscopically. Use of autograft over allograft. Bone-patellar tendon-bone graft is gold standard cuz it uses bone to bone healing, its considered a stronger graft w/ good fixation. Use of gracilis and/or semitendinosus also common but not as strong cuz of tendon to bone healing. - Some period of immobilization in a hinged brace (initially locked into extension) w/ some weight bearing restrictions. Brace unlocked when pt demonstrates good quads control. initial PT: ROM w/ emphasis on full knee extension early. Strengthening can occur soon after sx typically includes isometric quad, hamstring and close chain exercises. Open chain ex between 0-45 deg of flexion avoided since they place stress on graft. Pts w/ patellar tendon bone graft may have anterior knee pain and should be cautious w/ quad strengthening. Pts w/ hamstring graft should be cautious w/ flexion ex. Graft tissue most vulnerable at 6-8 weeks post op. As tendon transforms into ligamentous tissue, it becomes weaker before it gets stronger. Failure of graft site happens around 6-8 weeks secondary to poor complaince w/ protocol. Graft maturation 100% around 12-16 months (however most protocols allow return to sports around 6 months). In order to return to sports, pt must have no pain or effusion, full ROM, no instability, quad strength at 85-90% opposite leg, hamstring strength 90-100% opp leg and functional leg testing (single leg hop) thats 85-90% opp leg.

Lateral ankle reconstruction

- sx secondary to complete tear of ATFL or CFL or secondary to chronic ankle instability. 2 methods of reconstruction, both use open approach. Repair of torn ligaments sutured back together. Second is harvesting an autograft (usually peroneus brevis) to replace torn ligaments. (when original ligaments cant be repaired due to deterioration). Sx may include arthroscopy or subchondral drilling since high % of unstable ankles have chondral lesions within joint. - Protective cast worn (one week) then placed in walking cast or boot for several weeks followed by brace. Initially pt non-weight bearing while in cast, then progressed to partial and full weight bearing once in walking boot. PT doesn't begin right after sx. Early PT: increasing pts ROM while protecting repaired tissues. Caution when ROM into inversion since this will stress repaired tissues. Bracing long term if pt returns to sport.

Rotator cuff repair

- tears graded according to depth (partial vs full) and width (small <1cm, medium 1-3cm, massive >5cm). Small partial thickness tears: debridement; all others need repair (reapproximated and fixated using sutures, anchors, tacks or staples.) Just like decompression, generally arthroscopically, but could use open or mini open. - immobilized in sling for few weeks, sling may contact abduction pillow. PT PROM and AAROM initially. Strengthening later. Precautions: no AROM, lifting, weight bearing thru arm all for several weeks. Depending on muscle repaired, may be precautions for ROM for rotation. Extension avoided if deltoid repair took place.

Osgood-Schlatter disease

- traction apophysitis occurring at the tibial tuberosity. Symptoms result of local inflammation and exacerbated by running, jumping and squating. May be caused by repeated microtrauma. Repeated tension at insertion of patella tendon can cause small avulsion at tuberosity thereby producing pain and edema. Over time heterotopic bone formation may produce visible lump over tibial tuberosity. Most common in adolescents following period of rapid long bone growth during which soft tissue tension may be temporarily increased before accommodating to change in limb length. 20% of adolescents involved in sports that require running, jumping, swift changes in direction and repeated knee flexion (soccer, ballet) effected. More among boys but gap has lessened as girls become more active in sports. - Characterized by local pain and edema with point tenderness over patella tendon's insertion on tibial tuberosity. Pain exacerbated by activities that increase traction forces at tibial tubercle or put pressure directly on affected area. Symptoms typically reproduced w/ resisted knee extension and alleviated w/ rest. Generalized tightness in hip and knee common especially quads. FIrm mass palpable if heterotopic ossification occurs. - Conservative tx emphasis on pain management. modify or avoid pain producing activities that increase patella tendon tension, use ice, rest and NSAIDs or acetaminophen for pain. Knee immobilizer could be used during acute phase for rest and infrapatella strap may assist in distributing traction forces once acuity reduced and activities resumed. Sx rare. PT during acute exacerbation may include pallative modalities, activity modification, and gentle stretching. Progressive stretching, strengthening and cross training activities (swimming, cycling) should begin once acute symptoms have abated. At home, rest, ice, exercise and cross training and joint protection. acute exacerbations are common until long bones stop growing and discomfort may last for years until tibial growth plate closes but condition is self limiting. Conservative tx successful in 90% of cases. Bondy lump remains after symptoms resolve but rarely interferes w/ function. Complications are uncommon but include chronic pain, localized edema and ossicle formation..if symptoms continue after reaching skeletal maturity, sx may be needed.

Ligamentous Instability of the wrist/hand Special Tests

- ulnar collateral ligament instability test

isometric dynamometry

- used to measure static strength or without any movement. The extremity is restrained by straps to prevent movement benefits - attaining peak and avg force data, reaction time, rate of motor recruitment and max exertion data. Safe, simple, easy to interpret data and cheap disadvantages - cant convert data to functional activities, caution with acute orthopaedic injury, osteoporosis or hernia contraindications - fractures and significant hypertension

Hydraulic knee

- variable friction for improved swing and stance phase control

Subacromial Decompression

- when shoulder impingement doesnt respond to conservative tx. Approach can be open (deltoid is detached, mini open (deltoid is only split) or arthroscopic. Can also involve acromioplasty, bursectomy, removal of distal clavicle (in cases where it's degenerated) and release of coracoacromial ligament. - Sling used 1-2 weeks, early rehab: pain, gentle ROM. Later rehab: strengthening. Avoid passive extension if deltoid repair was performed to prevent stress on repair site. Tx focus: posture, strengthening scapular upward rotations - reduce recurrance of impingement. Rehab is rapid and full.

Anterior ligament elbow

-Capsular in nature and function -Stretches from the radial collateral ligament and attaches above the upper edge of the coronoid fossa, extending to just below the coronoid process

articular capsule hip

-Extends from the lateral and inferior surfaces of the pelvic girdle to the intertrochanteric line and intertrochanteric crest of femur -Reinforced by the iliofemoral, pubofemoral, and ischiofemoral ligaments

zygapophyseal joints (Facet Joints)

-FORMED BY THE RIGHT AND LEFT SUPERIOR ARTICULAR FACETS OF ONE VERTEBRA AND THE RIGHT AND LEFT INFERIOR ARTICULAR FACETS OF AN ADJACENT SUPERIOR VERTEBRA Loose Packed Position: Midway between flexion and extension Closed Packed Position: Extension

impingement syndrome

-One of most common injuries of the shoulder -often caused by repetitive microtrauma from UE activity performed above the horizontal plane -Individuals participating in throwing activities, swimming, and racquet sports are particularly susceptible to impingement syndrome Etiology: caused by humeral head and associated rotator cuff attachments migrating proximally and becoming impinged on the undersurface of the acromion and the coracoacromial ligament Signs and symptoms: discomfort or deep mild pain within shoulder, pain with overhead activities, painful arc of motion (70-120 deg abduction), + impingement sign, tenderness over the greater tuberosity and bicipital groove Treatment: RICE, NSAIDs and activity modification initially. Once tolerated, txt includes rotator cuff strengthening and scapular stability exercises. Longer term prevention includes continued strengthening of the rotator cuff and scapula stabilizers, along with improved biomechanics related to sport specific or relevant work activities.

rotator cuff tear

-can be torn due to an acute traumatic incident or as a result of a chronic degenerative pathology (supraspinatus tendonitis) -Patients 50 years of age and older are particularly susceptible to tears due to chronic degenerative pathology -rotator cuff tears are classified as partial thickness or full-thickness, acute, chronis or degenerative -Partial thickness: extends through only a portion of the tendon -Full thickness tear: complete tear of the tendon -size of tear can range from small (1cm or less) to large (more than 5cm) - most commonly involve the supraspinatus tendon..more severe or traumatic involve subscapularis and infraspinatus. - all four rotator cuff muscles originate on scapula and insert on humerus. Support and mobility demands are greatest for supraspinatus (GH abduction and depression of humerus head). Etiology: intrinsic factors: impaired blood supply to tendon resulting in degeneration, decreases in tissue elasticity (older population tears from this) Extrinsic factors: trauma, repetitive microtrauma and postural abnormalities (younger population tears from this) Signs and symp: arm positioned in IR and adduction, point tenderness at greater tubercle and acromion, marked limitation in shoulder flexion and abduction with upper trap recruitment evident, increased tone in anterior shoulder structures. Most common c/o pain and weakness. Pain exacerbated by movements reported in lateral aspect of shoulder with radiating symptoms into upper arm and deltoid region. Pain more specific and acute with trauma injury, not degenerative. More pain with partial tearing due to increased tension on remaining fibers and neural tissue but retain most functional abilities. Large partial thickness or full thickness significant functional deficits esp with tasks of GH lateral rotation and abduction. Other c/o shoulder instability and stiffness, sense of GH grinding with mobility, crepitus, night pain, and discomfort when lying on affected side. MRI to dx. Special tests: drop arm, empty can for supraspinatus pathology. Pain with resisted muscle testing is likely to be greatest with a partial-thickness tear. GH instability, impingement (supraspinatus tendon, long head of biceps tendon, subacromial bursa and suprascapular nerve) also associate with rotator cuff tears. Small avulsion fx of greater tuberosity could accompany it in young active individuals. Tx: RICE, NSAIDs and analgesics initially. Potentially local cortisone injections. Goal: to prevent adhesive capsulitis and strengthen UE musculature. Sx management to repair tendon can be arthroscopic, mini-open w/ arthroscopic assist or traditional open approach. Sx may include repair of tendon w/ subacromial decompresssion. Following sx, pt will be immobilized in sling..time will vary depnding on sx procedure, surgeon preference and size of tear. A large tear may require 4-6 weeks of immobilization. PT begins w/ cryotherapy, activity modification, rest, gentle isometrics and PROM and gradually moves to Active Assisted ROM. Focus then becomes restoring normal mobility with AROM, joint mobs and isometric exercises w/ modalities once approved by surgeon. Activities that promote scapular stability, postural re ed, and modification of functional, work and rec activities are emphasized. Pt will gradually become functional w/ activities of daily living and progress to more aggressive strengthening activies. Regain functional use of shoulder in 4-6 months. Return to functional activities requiring dynamic overhead motion occurs in 9-12 months. Sports beyond a year. Failure to adequately treat rotator cuff tear could develop into adhesive capsulitis or degenerative changes since tendon doesn't heal on own (turns to scar tissue). increased risk of rerupture in size greater than original tear. - Biceps tendon rupture includes long head of biceps tendon. Most among men 40-60 years, secondary to chronic inflammatory or degenerative changes. Sports, trauma or heavy lifting in younger pop. C/o severe pain that worsens at night and with overhead and repetitive activities. Palpable and visible mass noted in upper arm where muscle mass has been retracted.

lateral epicondylitis (tennis elbow)

-irritation or inflammation of the common extensor muscles at their origin on the lateral epicondyle of the humerus. Inflammation continues to injure the tissue. -Individuals who take part in racquet sports or activities requiring throwing are at the greatest risk for developing lateral epicondylitis. Also seen in painting, gardening and hand tools. Etiology: repetitive eccentric loading against resistance of wrist extensor muscles (repeated overuse - extension and supination usually), usually extensor carpi radialis brevis, resulting in microtrauma. Other muscles can be damaged including extensor digitorum, extensor carpi radialis longus and extensor carpi ulnaris. Poor mechanics, fault equipment (tennis racquet with handle too small or string w/ too much tension). Common between 30-50 years old due to loss of extensibility of CT w/ age. Men more than women Signs and symptoms: Primary symptom is pain. pain present immediately anterior or distal to lateral epicondyle of humerus. Worsens w/ repetition and resisted wrist extension. Also worsens with wrist flexion and elbow extension (stretch), and resisted radial deviation. Sometimes pain radiates into dorsum of hand. Pt may have difficulty holding or gripping objects and decreased forearm strength. Elbow ROM usually normal. Localized tenderness over lateral epicondyle and may present with localized swelling. Pain increases with activity and at night. Increase in pain at lateral epicondyle with resisted wrist extension implies extensor carpi radialis brevis involement. Tx: If involved in sport, remediation and modification in training, technique,and equipment. protection (resting splints to relieve tension), RICE, NSAIDs, activity modification initially. Phonophoresis with hydrocortisone or iontophoresis with dexamethosone may be used. PT increases strength (wrist, elbow, and hand), flexibility and endurance of wrist extensors wtih pain free exercises. Strap placed 2-3 in distal to elbow joint to reduce muscle tension on epicondyle...may diminish or eliminate symptoms. Modalities include ESTIM, cryotherapy. As pt progresses, resistive isokinetic, and sport specific exercises be introduced. Wean from brace prior to completing rehab. Pt should be able to return to all previous functional activities without restriction. - Lateral epicondylitis commonly recurs but with continued stretching and exercise it decreases risk. Sx may be indicated if it doesn't improve after 2-3 months.

Meniscus tear

-medial and lateral menisci are firmly attached to the proximal surface of the tibia -menisci are thick at the periphery and thinner at their internal unattached edges -medial meniscus is more commonly injured than the lateral meniscus because it is less mobile due to its attachment to the joint capsule -The incidence of medial meniscal tears increases significantly over time with ACL deficiency -meniscal injuries are definitively diagnosed by arthoscopy or magnetic resonance imaging Etiology: fixed foot rotation while weight bearing on flexed knee...this produces compression and rotational forces on meniscus Signs and symptoms: joint line pain, swelling, catching or locking sensation. Special Tests: Apleys compression test, bounce home test, McMurray Test Tx: RICE, NSAIDs, analgesics initially. modallities and strengthening. Sx ranging from partial meniscectomy to meniscal repair warranted for active individuals. Sx performed on tears located on outer edges of meniscus due to increased vascularity.

juvenile rheumatoid arthritis

-most common chronic rheumatic disease in children -presents with inflammation fo the joints and connective tissue -Classification of JRA includes: systemic, polyarticular, and oligoarticular Etiology: unknown..virus, infection or trauma triggers autoimmune response in child with genetic predisposition Signs and symptoms: based on classification of JRA. - systemic JRA: 10-20% cases - acute onset, high fevers, rash, enlargement of spleen and liver, inlfammation of heart and lungs - Polyarticular JRA - 30-40% - high female incidence, significant rheumatoid factor and arthritis in 4+ joints with symmetrical involvement - Oligoarticular (pauciarticular) JRA - 40-60% - less than 5 joint with asymmetrical involvement Treatment: Pharmacological management for inflammation and pain thru NSAIDs, corticosteroids, antirheumatics and immunosuppressive agents. PT includes PROM, AROM, positioning, splinting, strengthening, endurance training, weight bearing activities, postural training, functional mobility. Modalities (paraffin, ultrasound, warm water, cryotherapy) for pain. Sx may be indicated secondary to pain, contractures or irreversible joint destruction.

Medial collateral ligament sprain

-runs from slightly above the medial femoral epicondyle to the medial aspect of the shaft of the tibia - resists valgus force and lateral rotation of tibia (especially during knee flexion)..primary stabilizer of medial knee. -often involves injury to other knee structures such as the ACL or medial meniscus. Medial capsular ligament also involved. Etiology: contact or noncontact, fixed foot, tibial rotational injury w/ valgus force and external tibia rotation. football, skiing and soccer. Generally caused frmo a lateral blow to knee. Muscle weakness resulting in poor dynamic stabilization may also increase the incidence of this type of injury. Signs and symptoms: knee pain, swelling, antalgic gait, decreased ROM, feeling of instability. Valgus test to assess (discernable laxity 5-15 deg). Inability to fully extend and flex knee, pain and significant tenderness along medial aspect of knee w/ antalgic gait, and potential decrease in proprioception and strength. Instability of joint and slight to mod swelling around knee. More severe swelling indicates cruciate or meniscus involvement. Unless other involvement, MRI not generally used to dx. ACL and meniscus often accompany MCL so perform tests on those. Tx: RICE, NSAIDs, analgesics (acetiminophen) and brace (immobilizer or hinge brace) with crutches (until pt can adequately extend knee) to limit weight bearing initially. PT begins with ROM, and light strengthening exercises as tolerated (heel slides or stationary cycling without resistance). Strengthening gradually becomes more aggressive - directed towards quads with isometrics and closed chain activities - and functional activities (gait, stair climbing) are introduced. Modalities such as ESTIM for pain and inflammation. Transverse friction massage to healing ligament to prevent adherence to surrounding structures. (Cant massage proximal attachment due to potential bony periosteal disruption) Sx rarely required due to vascularity of MCL. functional progression prior to returning to unrestricted activity. 4-8 weeks for grade 2 assuming no other structures involved. Return to full activity once full ROM, no limp, no swelling and competence with agility testing. Any residual laxity increases risk of reinjury. - LCL attaches proximally on lateral femoral condyle and runs distally and posteriorly to insert on head of fibula...LCL injuries are less common than MCL. medical management is the same as MCL.

Stages of gripping

1. Hand opens fully by activation of wrist and finger extensors and hand intrinsics 2. fingers around object, grasp object requiring activation of finger flexors and hand intrinsics 3. force of grasp is modified by shape of weight, fragility, and surface characteristics of object 4. released by opening hand which is activation of extensors.

Trace MMT

1/5 - muscle contraction can be palpated but no joint movement

Festinating gait

A gait pattern where a patient walks on toes as though pushed. It starts slowly, increases, and may continue until the patient grasps an object in order to stop.

Vaulting Gait

A gait pattern where the swing leg advances by compensating through the combination of elevation of the pelvis and plantar flexion of the stance leg.

Poor MMT

2/5 - pt completes ROM in a gravity eliminated position

Fair MMT

3/5 - completes ROM against gravity without manual resistance

Fair Plus MMT

3+/5 - Part moves through complete ROM against gravity with minimal resistance

Fair Minus MMT

3-/5 mm strength does not complete ROM against gravity, but completes more than half of the range

Good MMT

4/5 - completes ROM against gravity with moderate resistance

Normal MMT

5/5 - completes ROM against gravity with max resistance

cervical spine

7 cervical vertebrae. First two, atlas and axis are unique where the atlas (C1) supports the weight of the head through two facet joints which form the atlanto-occipital joint. The axis (C2) has a superior projection called the dens. The articulation between the dens and the anterior arch of the atlas forms the atlantoaxial joint Osteokinematic motions: flexion, extension, lateral flexion, rotation Loose Packed Position: midway between flexion and extension Close Packed Position: extension Capsular Pattern: lateral flexion and rotation equally limited, extension

Circumduction gait

A gait pattern characterized by a circular motion to advance the leg during swing phase; this may be used to compensate for insufficient hip or knee flexion or dorsiflexion.

Equine gait

A gait pattern characterized by high steps; usually involves excessive activity of the gastrocnemius.

double step gait

A gait pattern in which alternate steps are of a different length or at a different rate.

Craig-Scott knee-ankle-foot Orthosis

A KFO designed specifically for persons with paraplegia. This design allows a person to stand w/ a posterior lean of the trunk.

hemiplegic gait

A gait pattern in which patients abduct the paralyzed limb, swing it around, and bring it forward so the foot comes to the ground in front of them.

Parkinsonian gait

A gait pattern marked by increased forward flexion of the trunk and knees; gait is shuffling with quick and small steps; festinating may occur.

Myoelectric prosthesis

A device using electromyography signals to control movements of the prosthesis w/ surface electrodes or implantable wires

Trendelenburg gait

A gait pattern that denotes gluteus medius weakness; excessive lateral trunk flexion and weight shifting over the stance leg.

Tabetic gait

A high stepping ataxic gait pattern in which the feet slap the ground.

Anterior Cruciate Ligament (ACL)

A ligament in the knee that attaches to the anterior aspect of the tibial plateau. restricting anterior movement of the tibia on the femur - may be injured through a noncontact twisting injury associated with hyperextension and varus or valgus stress to the knee. Also, tibia being driven anteriorly on femur, femur going posteriorly on tibia or severe knee hyperextension can injure it Special tests include anterior drawer test, lachman test, lateral pivot shift test and slocum test

Posterior Cruciate Ligament (PCL)

A ligament in the knee that runs from the intercondylar area of the tibia to the lateral aspect of the medial femoral condyle in the intercondylar notch. The PCL prevents posterior displacement of the tibia on the femur. may be injured when the superior portion of the tibia is struck with the knee flexed. common occurance is in a MVA when leg collides against dashboard. Other mechanisms is when tibia is being driven posteriorly on femur, femur anteriorly on tibia, or severe knee hyperflexion. Special tests: posterior sag sign and posterior drawer test

Bioelectrical Impedance Analysis (BIA)

A method of assessing body composition by running a low-level electrical current through the body and measures the resistance to the current flow. technique based on principal that resistance to electrical current is inversely related to the composition of water in the body. population specific equations are available but the general population formula is height^2/resistance. Standard error is +/- 3%. Limitations include subject needs to be properly hydrated and all guidelines of protocol need to be followed. Protocol: cant eat or drink within 4 hours or testing. No vigorous physical activity within 12 hours. urinate within 30 mins to testing. avoid alcohol for 48 hours prior to testing. avoid excessive water intake.

McGill Pain Questionnaire

A pain assessment tool that is divided into four parts with a total of 70 questions Part 1 = pt marks on drawing of body to indicate area and type of pain (internal or external) Part 2 = Pt chooses 1 word to best describe pain from each of the 20 categories Part 3 = Pt describes pattern of pain, factors that increase and relieve pain Part 4 = pt rates the intensity of pain on scale of 0-5 - valid, reliable, and most widely used pain assessment scale - can be used to establish a baseline, evaluate treatment, and monitor progress

Antalgic gait

A protective gait pattern where the involved step length and stance time is decreased in order to avoid weight bearing on the involved side usually secondary to pain. Typically associated with rapid and shorter swing phase of uninvolved limb. Causes includes disease (usually bone or joint), joint inflammation, or injuries to muscles, tendons, and/or ligaments

Muscle Anatomy

A single muscle is made up of several muscle fibers and the connective tissue layers that surround and lie within the muscle. Endomysium - innermost connective Tissue layers that covers individual muscle fibers perimysium - CT layer that groups bundles of muscle fiibers (a fasciculus) together epimysium - outermost CT layer that surrounds the entire muscle - each muscle fiber is its own cell and it made up of several subunits called myofibrils, which are in turn made up of sarcomeres (smallest unit of muscle that gives it the ability to contract) - Sarcomeres are composed of myofilaments actin and myosin. The actin and myosin attach to one another and slide together and apart to allow for muscle contraction and relaxation

cerebellar gait

A staggering gait pattern seen in cerebellar disease.

stretching

A therapeutic technique used to improve joint ROM and muscle flexibility by increasing the extensibility of the musculotendinous unit and connective tissues Indications: decreased joint ROM or decreased muscle flexibility Contraindications: acute inflammation, during soft tissue healing (ex. following a tendon repair), ROM limited by bone on bone contact, recent fracture, hypermobility, hypomobility that allows for improved function (ex. tenodesis grip), acute pain associated with stretching

Stance control (safety)

A weight-activated mechanism that maintains knee extension during weight bearing even if the knee joint is not fully extended. If the knee is flexed greater than what the control mechanism is designed for, the mechanism will not engage

ROM - Lower Quarter Screen

AROM of lumbosacral spine and LEs Passive overpressure of the lumbosacral spine and LEs if pt doesn't exhibit signs and symptoms of pathology

disease-modifying antirheumatic drugs (DMARDs)

Action: Slow/stop rheumatic disease progression used early in disease process before widespread damage to affected joints. Act to induce remission by modifying pathology and inhibiting immune response responsibel for rheumatic disease Side effects: nausea, headache, joint pain and swelling, GI distress, fever, sore throat, hair loss, potential sepsis, liver dysfunction, retinal damage, toxicitiy Implications for PT: Many of agents have high incidence for toxicity. Ex) Rheumatrex (methotrexate), Arava (leflunomide) Antimalarial: Aralen (chloroquine), Plaquenil (hydroxychloroquine) Gold compounds: Ridaura (auranofin), Solganal (aurothioglucose) Tumor necrosis factor inhibitors: Humira (abalimumab), Enbrel (entanercept)

Nonopiod Agents

Action: analgesia and pain relief, antiinflammatory effects, anti-pyretic (anti fever), promotes reduction of prostaglandins (decreases inflammatory process), decreases uterine contractions Indications: mild to moderal pain of various origins, fever, headache, muscle ache, inflmmation (except acetominophen), dysmenorrhea (mentstral cramps), reduction of risk of Myocardial Infarction (asprin only) Side effects: nausea, vomiting, vertigo, abdominal pain, gastrointestinal distress or bleeding, ulcer formation, potential for Reye syndrome in children (aspirin only) Pt implications: Pts at increased risk for masked pain that would allow for movement beyond limitation or false understanding of their level of mobility. complaints of stomach pain should be taken seriously w/ a subsequent referral to a physician ex: tylenol (acetaminophen), Non-steroidal anti inflammatories (NSAIDs), aspirin (acetylsalicylic acid), aleve (naproxen), advil (ibuprofen), Celebrex (celecoxib)

Opioid Agents (Narcotics)

Action: opioid agents provide analgesia for acute severe pain management. Med stimulates opioid receptors within the CNS to prevent pain impulses from reaching their destination. Certain drugs are also used to assist w/ dependency and withdrawal symptoms. Indications: moderate to severe pain of various origins, induction of conscious sedation prior to diagnostic procedure, management of opioid dependence, relief of severe and persistent cough (codeine) Side effects: mood swings, sedation, confusion, vertigo, dulled cognitive function, orthostatic hypotension, constipation, incoordination, physical dependence, tolerance Implications for PT: PT must monitor pt for potential side effects, especially signs of respiratory depression. Tx thats otherwise painful should be scheduled approx 2 hours after administration to maximize the analgesic benefit. A pt may not accurately report if a particular technique is painful Ex) Roxanol (morphine), Demerol (meperidine), OxyContin (ocycodone), Sublimaze (fentanyl), Paveral (codeine)

Reversibility Principle

Adaptations seen with resistance training are reversible if body is not regularly challenged with same level or resistance or greater. Reversibility effects can begin within 1-2 weeks of stopping an exercise program.

Rhomboids

Adduct (Retract) and elevate the scapula. Downward rotation of scapula

Non-Weight bearing rigid removable limb protectors

Advantages: Removable - accommodates edema fluctuation - easily applied - prevents contracture - provides protection Disadvantages: Not for ambulatory purposes

Rigid (plaster of paris) - postoperative dressings

Advantages: allows early ambulation w/ pylon - promotes circulation and healing - stimulates proprioception - provides protection - provides soft tissue support - limits edema - ability to utilize an IPOP (immediate post-operative prosthesis) Disadvantages: immediate wound inspection not possible - doesnt allow for daily dressing change - requires professional application

Semi-rigid (unna paste, air splint)

Advantages: reduces post operative edema - provides soft tissue support - allows for earlier ambulation - provides protection - easily changeable Disadvantages: Doesn't protect as well as rigid dressing - Requires more changing than rigid dressing - may loosen and allow for development of edema

Soft (Ace wrap, shrinker)

Advantages: reduces post-operative edema - provides some protection - relatively inexpensive - easily removed for wound inspection - allows for active joint ROM Disadvantages: Tissue healing is interrupted by frequent dressing changes - joint ROM may delay the healing of the incision - less control of residual limb pain - cannot control the amount of tension in the bandage - risk of tourniquet effect - shrinker cannot be applied until sutures/staples are removed.

Transverse tarsal (chopart's)

Amputation through the talonavicular and calcaneocuboid joints. The amputation preserves the plantar flexors, but sacrifices the dorsiflexors often resulting in an equinus contracture - loss of forefoot leverage - loss of balance - loss of weight bearing surface - loss of proprioception - tendency to develop equinus deformity

non-traumatic amputation

An amputation that is not the result of direct injury. Vascular disease and infection are types of non-traumatic amputations

Shrinker

An elastic sleeve that is placed over the end of the residual limb to control edema and encourage limb shaping

Rotationplasty

An operation where a portion of the limb is removed while the remaining limb below is rotated and reattached. -Often performed as a treatment for distal femoral osteosarcoma

Anaerobic Glycolysis or Lactic Acid System

Anaerobic Metabolism - Energy system used for ATP in high intensity, short duration activities such as sprinting 400 to 800m. - Stored glycogen is split into glucose through glycolysis and then split again into pyruvic acid. Energy released during this process forms ATP and the process does not require O2 but the anaerobic glycolysis results in the formation of lactic acid which causes muscular fatigue. - 50% slower than the phosphocreatine system and provides 30-40 seconds of muscle contraction. - Doesn't use O2, only uses carbohydrates (glycogen and glucose). Releases enough energy for the resynthesis of only small amounts of ATP

ATP-PC or Phosphagen System

Anaerobic Metabolism - Energy system used for ATP production in high intensity, short duration exercise such as sprinting 100m. - Phosphocreatine decomposes and releases large amounts of energy used to construct ATP. 2-3x more phosphocreatine in cells of muscles than ATP and process occurs almost instantaneously allowing for ready to use energy. - This system provides energy for muscle contraction for up to 15 seconds. It doesn't depend on a long series of chemical reactions or O2, and ATP and PC are stored directly within the contractile mechanisms of the muscle making this function readily available.

Tunnel of Guyon

Anatomic region formed by the hook of the hamate bone and the pisiform bone, whereby the ulnar nerve and artery enters the hand. compression of the nerve in this location may result in ulnar tunnel syndrome

Gait and muscle activity - midswing

Ankle - DFs continue to contract concentrically to maintain DF. Knee - minimal since forward momentum allows for advancement of limb hip - minimal since forward momentum allows for advancement of limb

Gait and muscle activity - terminal swing

Ankle - DFs continue to contract concentrically to maintain DF. Ankle invertors also contract concentrically to prepare the foot for initial contact. Knee - Quads contract concentrically to place knee in extension for initial contact while hamstrings act eccentrically to control for rate of knee extension Hip - hip extensors contract eccentrically to slow rate of hip flexion and prepare limb for initial contact.

Gait and muscle activity - Initial swing

Ankle - DFs contract concentrically to clear foot from ground Knee - hamstrings assist with foot clearance by flexing knee Hip - hip flexors continue to produce hip flexion to advnace limb forward

Gait and muscle activity - loading response

Ankle - Dorsiflexors act eccentrically to control lowering of foot towards ground...in latter portion of phase, PF eccentrically control DF as tibia moves over foot while simultaneously the tib posterior eccentrically controls pronation of foot Knee - Quads contract eccentrically to control knee flexion as lim accepts the weight of the body. In latter portion of phase, quads contraction becomes concentric to draw the femur forward over tibia. Hip - throughout the phase, hip extensors contract concentrically to produce hip extension

Gait and muscle activity - Initial Contact

Ankle - Dorsiflexors place ankle in DF during heel strike and prepare to lower foot towards ground Knee - Quads contract to place knee in extension while hamstrings stabilize knee and prevent hyperextension Hip - hip extensors and abductors contract to stabilize trunk and pelvis over leg

Gait and muscle activity - pre-swing

Ankle - PFs are at peak activity as foot "toes-off" the ground knee - hamstrings begin to produce knee flexion to prepare for swing phase..momentum of body aids motion Hip - iliopsoas begins to work concentrically to produce hip flexion, along with other hip flexors (ex. rectus femoris, sartorius, adductor longus)

Gait and muscle activity - terminal stance

Ankle - PFs begin to work concentrically to aid foot in propulsion of body forward knee - remains limited Hip - abductors continue to stabilize pelvis and iliopsoas continues to slow rate of hip extension

Gait and muscle activity - midstance

Ankle - ankle PFs continue to act eccentrically to control DF as body moves over stance leg Knee - minimal in knee, however quads contract concentrically to continue producing closed chain knee extension Hip - hip abductors stabilize pelvis and prevent contralateral hip drop (trendelenburg). Illiopsoas also begins to contract eccentrically to control hip extension

Toe Down Instead of Heel Strike

Ankle And Foot - Cause by PF spasticity, PF contracture, weak DFs, DF paralysis, leg length discrepancy, hindfoot pain

Foot slap gait deviation

Ankle and foot - Caused by weak dorsiflexors or dorsiflexor paralysis

Clawing of toes

Ankle and foot - caused by toe flexor spasticity, positive support reflex

Residuum

Another commonly used term for residual limb

Dermatome Testing - Lower Quarter Screen

Anterior thigh - L2 Middle third of anterior thigh - L3 Patella and medial malleolus - L4 Fibular Head and dorsum of foot - L5 Lateral and plantar aspect of foot - S1 Medial aspect of posterior thigh - S2 perianal area - S3-S5

sternoclavicular joint

Articulation between the medial end of the clavicle and the manubrium of the sternum. saddle shaped synovial joint with 3 deg of freedom. A fibrocartilaginous disc between the manubrium and the clavicle enhances the stability of the joint, serves as the axis for clavicular rotation and acts as a shock absorber - Osteokinematic motions: elevation and depression, protraction and retraction, medial and lateral rotation - Loose packed position: arm resting by side - Close packed position: maximum shoulder elevation - Capsular pattern: pain at extreme ranges of movement

trapezius

Assists in rotating the scapula during abduction of humerus above horizontal; upper fibers elevate and upwardly rotate the scapula along with extending the neck, middle fibers adduct (retract) the scapula, and lower fibers depress and aid the upper traps in upward rotation of the scapula

alar ligaments

Attach the lateral aspect of the dens of the axis to the Occipital condyles. These ligaments function to resist flexion, contralateral side bending and contralateral rotation. Also help to limit sagittal plane translation between the atlas and the occiput

semispinalis cervicis

Bilaterally- Extend the vertebral column. Unilaterally- contralateral lateral flexion and rotation of neck

Reflex Testing - Upper Quarter Screen

Biceps - C5 Brachioradialis - C6 Triceps - C7

Multifidus

Bilateral backward extension, unilateral side-bending to the ipsilateral side, rotation to the *contralateral* side

longissimus cervicis

Bilateral- extensors straightening the neck Unilaterally- ipsillaterally rotate and laterally flex head

Iliocostalis cervicis

Bilateral- extensors straightening the neck Unilaterally- ipsilaterally laterally flex and rotate the head

Splenius Cervicis muscle

Bilaterally they extend the neck; unilaterally they ipsilaterally laterally flex and rotate the head and neck

Neuroma

Bundle of nerve endings that group together; can produce pain due to scar tissue, pressure from the prosthesis or tension on the residual limb

Classes of levers

Class 1 lever - fulcrum (axis of rotation) is between the effort (force) and resistance (load). very few of these in body. ex) seesaw or triceps brachii completing elbow extensions Class 2 lever - Load is between the fulcrum and the force. The length of the effort arm is always longer than the resistance arm and gravity is the effort and muscle activity is the resistance in most cases. ex) wheelbarrow or a pushup Class 3 lever - Force in between the fulcrum and load. The length of the effort arm is always shorter than the resistance arm. Class 3 levers permit large movements at rapid speeds and are most common type of lever in body. ex) shoulder abduction with weight at the wrist. (fulcrum is shoulder joint) or elbow flexion with weight at wrist and effort is forearm muscles.

metatarsophalangeal joint

Connects the metatarsals to the digits LPP: neutral CPP: full extension Capsular Pattern (1st digit): extension, flexion Capsular Pattern (2nd-5th): Variable

tarsometatarsal joint

Connects the tarsal bones to the metatarsal bones LPP: midway between the extremes of range of movements CPP: supination

forefoot

Consists of: - Tarsometatarsal joints - Metatarsophalangeal joints - Interphalangeal joints

Sternocleidomastoid

Contraction of one side: ipsilaterally laterally flexes neck, rotates head to opposite side; Contraction of both sides together: flexes neck...accessory muscle of inspiration

Rotatores

Contralaterally rotates trunk and neck, extends trunk and neck

K-level 0

Description: Prosthesis will not enhance quality of life or mobility Knee Unit: Not eligible for prosthesis Foot/ankle assembly: not eligible for prosthesis

K level 2

Description: Tranverse low level barriers: curbs, stairs, uneven surfaces; limited community ambulator Knee Unit: polycentric, constant friction mechanism Foot/ankle assembly: flexible-keel foot, multi-axial foot/ankle

K-level 4

Description: exceeds basic ambulation skills, exhibits high impact, stress or energy levels; typical of child, athlete or active individual Knee Unit: any system Foot/ankle assembly: any system

K-level 1

Description: transfers, ambulate on level surfaces, fixed cadence, limited or unlimited household ambulator Knee Unit: single axis, constant friction mechanism Foot/ankle assembly: SACH, single axis

K-level 3

Description: variable cadence ambulator, unlimited community ambulator, traverse most environment, prosthetic use beyond simple locomotion Knee Unit: hydraulic/pneumatic, microprocessor, variable friction mechanism Foot/ankle assembly: energy storing, dynamic response foot, multi-axial foot/ankle

Radiocarpal joint

Distal radius and proximal carpal row (scaphoid, lunate, and triquetrum) The joint has two deg of freedom and is encased in a strong capsule reinforced by numerous ligaments shared with the midcarpal joint. There is the a radioulnar articular disc as well which connects the medial aspect of the distal radius to the distal ulna. - Osteokinematic motions: Flexion, extension, radial and ulnar deviation - Loose packed position: neutral with slight ulnar deviation - Close packed position: extension with radial deviation - Capsular pattern: flexion and extension equally limited.

Muscle Spindle

Distributed throughout the belly of the muscle. They function to send information to the nervous system about muscle length and rate of change of its length. Important in the control of posture and involuntary movements (with the help of the gamma system)

Three Cardinal Planes of the Body

Each plane is referred to from anatomical position Frontal (coronal) plane - Anterior-posterior axis; motions include abduction and adduction. You see body from anterior and posterior sections. Sagittal plane - medial-lateral axis; motions include flexion and extension. You see body from left and right sections. Transverse plane - Vertical axis; Motions include medial and lateral rotation. You see body in upper and lower halves.

Masseter

Elevates, protracts and retracts the mandible; also side to side movement of mandible

Golgi Tendon Organ

Encapsulated sensory receptors, very sensitive to active muscle contraction tension. Transmits information about tension or rate of change of tension within the muscle. On average, 10-15 muscle fibers are connected in series with each GTO and provides the nervous system info about the tension of those fibers.

Endogenous Opiods

Endogenous opiods (opiopeptins - also known as endorphins) also control pain regulation. These substances bind to opioid receptors located throughout nervous system resulting in inhibition of pain signals. Opiopeptins have a direct effect on nerve signals by controlling the amount of calcium and potassium that move into and out of the cell during depolarization. They also have an indirect effect on nerve signals by inhibiting the release of GABA, a substance that normally inhibits the activity of structures that help control pain, such as A-beta fibers.

extensor indicis

Extension of digit 2 at MCP joint

calcaneofibular ligament

Extracapsular ligament that resists inversion of the talus within midrange of talocrural motion.

Semimembranosus

Flexes leg at the knee and extends thigh at the hip; belongs to the hamstring group

Semitendinosus

Flexes leg at the knee and extends thigh at the hip; belongs to the hamstring group

Functional Testing - Lower Quarter Screen

Heel walking - L4-L5 Toe Walking - S1 Straight Leg Raise - L4-S1

circumduction during gait

Hip - compensation for weak hip flexors, compensation for weak DFs, compensation for weak hamstrings

Resistive Testing - Lower Quarter Screen

Hip Flexion - L1-L2 Knee Extension - L3-L4 Ankle Dorsiflexion - L4-L5 Great Toe Extension - L5 Ankle Plantar Flexion - S1

Range of motion requirements for NORMAL gait

Hip flexion = 0 to 30 degrees needed Hip Extension = 0-10 deg needed Knee flexion = 0-60 deg needed knee extension = 0 deg needed ankle dorsiflexion = 0-10 deg needed ankle PF = 0-20 deg needed

Scanning exam to rule out referral of symptoms from other tissues

History --- Observation --- Scanning Examination (AROM, PROM, resistive isometric movements, peripheral joint scan, myotomes, sensory testing, reflexes - ALL OF CERVICAL OR LUMBAR SCREEN) ---Decision: Spinal Joints or Peripheral Joints? (Educated Guess) --- EITHER Spine (cervical or lumbar - special tests (sensory or reflex), joint play, palpation, imaging techniques --- OR --- Peripheral Joint (AROM, PROM, resisted isometric movements, special tests (sensory, reflex), joint play, palpation, imaging techniques

force-velocity relationship

In concentric contraction, As the speed of contraction increases, the force it is able to exert decreases. during eccentric contractions, as the speed of contraction increases, force of contraction increases

Contractures

Joint immediately proximal to amputation site is most susceptible. failure to initial full ROM early in post op phase and poor positioning of residual limb significantly increases risk. - transmetatarsal and Syme's - equinus deformity - transtibial - knee flexion contracture transfemoral - hip flexion and abduction contracture.

ULTT3

Joint positioning sequence: shoulder depression with 10 deg abduction, elbow extension, forearm pronation, wrist flexion and ulnar deviation, finger and thumb flexion, shoulder medial rotation Sensitization test: contralateral cervical lateral flexion Nerve Bias: radial nerve

ULTT2

Joint positioning sequence: shoulder depression with 10 deg abduction, elbow extension, forearm supination, wrist extension, finger and thumb extension, shoulder lateral rotation Sensitization test: contralateral cervical lateral flexion Nerve Bias: median nerve, musculocutaneous nerve, axillary nerve

ULTT4

Joint positioning sequence: shoulder depression with 10-90 deg abduction, elbow flexion, forearm supination, wrist extension and radial deviation, finger and thumb extension, shoulder lateral rotation Sensitization test: contralateral cervical lateral flexion Nerve Bias: ulnar nerve

ULTT 1 (median nerve)

Joint positioning sequence: shoulder depression with 110 deg abduction, elbow extension, forearm supination, wrist extension, finger and thumb extension Sensitization test: contralateral cervical lateral flexion Nerve Bias: median nerve, anterior interosseous nerve

hyperextension of knee in stance

Knee - compensation for weak quads, PF contracture

excessive knee flexion with swing

Knee - flexor withdrawal reflex, lower extremity flexor synergy

medial epicondylitis

Known as golfer's elbow: tendonitis that occurs at medial epicondyle of elbow from overuse where tendons are overworked and inflamed or a traumatic event. Commonly occurs w/ repetitive wrist or elbow motions or gripping seen in golfers, throwers or racket sports. Affects tendons of muscles in anterior forearm (pronators, wrist flexors and finger flexors - all share common tendinous sheath at origin on medial epicondyle). Tendons of flexor carpi radialis and pronator teres most often affected, ulnar nerve can also become irritated as it passes thru cubital tunnel in this region. Pts who have poor flexibility, strength and endurance of affected muscles are more prone to acquiring medial epicondylitis. Other risk factors: improper equipment (wrong size racket grip) or technique (excessive top spin in tennis) - can occur sudden (trauma) or gradual..pt will report pain and tenderness over medial epicondyle, have pain with resisted wrist flexion, pronation and w/ gripping. May be weakness w/ these movements. If ulnar nerve affected, pt could experience pain and paresthesias into forearm and 4th and 5th digits. Assessment includes clearing ulnar collateral ligament since damage can mimic symptoms of medial epicondylitis. - Majority of pts improve w/ conservative tx. Initial tx is rest, ice, anti-inflammatory meds, massage, stretching, and bracing to help control acute symptoms. Once pain subsides, strengthening exercises, especially eccentric for forearm musculature, can be initiated. Cortisone injection may be used for symptoms. Sx involves debridement of degenerated tissue if needed. PT mainly consists of stretching and strengthening of wrist flexors and forearm pronator muscles as well as icing and pt be compliant w/ bracing to help prevent irritation to tissues. To prevent recurrance, pts need to maintain good forearm strength and flexibility, and correct technique and equipment and limit volume of repetitive motions.

distal radioulnar joint

LPP: 10 deg supination CPP: 5 deg supination Capsular Pattern: full range of movement, pain at extremes of rotation

carpometacarpal joint

LPP: midway between abduction and adduction, midway between flexion and extension

midtarsal joint

LPP: midway between extremes of range of movement CPP: supination Capsular Pattern: dorsiflexion, PF, adduction, medial rotation

metacarpophalangeal joint

LPP: slight flexion CPP (fingers): full flexion CPP (thumb): full opposition Capsular Pattern: flexion, extension

acetabular labrum

Labrum consists of a fibrocartilaginous rim attached to the margin of the acetabulum. Enhances the depth of the acetabulum

anterior sacroiliac ligament

Ligament that connects the anterior surface of the ilium to the anterior aspect of the sacrum. It's a thickening of the joint capsule and is considered the weakest of the sacroiliac ligaments.

Tarsal Tunnel Syndrome

Located on medial aspect of the ankle and is formed by the flexor retinaculum, superior aspect of the calcaneus, the medial wall of the talus and the medial-distal aspect of the tibia. The tibial nerve, posterior tibial artery and tendons of the flexor hallucis longus, tibialis posterior and flexor digitorum longus muscles pass through the tarsal tunnel. Tarsal tunnel syndrome occurs as a result of compression of the tibial nerve as it passes through the tarsal tunnel, causing neuropathy in the distribution of the nerve. - The tibial nerve is injured by compression within the tarsal tunnel causing motor and sensory disturbances. Intrinsic (tumor, scar tissue) extrinsic (crush injury, severe ankle sprain), or tension factors (pes planus, deformity, hindfoot valgus deformity)/ - Symptoms include pain, numbness, paresthesias in foot that may be initially mistaken for plantar fasciatis. Antalgic gait pattern is common when symptoms are exacerbated. Rest alleviates but doesnt completely resolve. Muscle atrophy, neurological signs (+ Tinel's sign w/ tibial nerve assessment posterior to the medial malleolus, diminished light touch and temperature sensations) in distribution of tibial nerve and its branches. Confirmed thru electromyography (EMG) or nerve conduction velocity study (NCV). R/o other sources of peripheral neuropathy.

Joint Receptors - Pacinian Corpuscles

Location: Fibrous layer of joint capsule Sensitivity: High frequency vibration, acceleration and high velocity changes in joint position Primary Distribution: All joints

Joint Receptors - Ruffini Endings

Location: Fibrous layer of joint capsule Sensitivity: Stretching of joint capsule; amplitude and velocity of joint position Primary Distribution: Greater density in proximal joints, particularly in capsular regions

Joint Receptors - Golgi-Mazzoni Corpuscles

Location: Joint Capsule Sensitivity: Compression of joint capsule Primary Distribution: Knee joint, joint capsule

Joint Receptors - Free Nerve Endings

Location: Joint Capsule, ligaments, synovium, fat pads Sensitivity: Sensitive to non-noxious mechanical stress and noxious mechanical or biochemical stimuli Primary Distribution: All joints

Joint Receptors - Golgi Ligament Endings

Location: Ligaments, adjacent to ligaments' bony attachment Sensitivity: Tension or stretch on ligaments Primary Distribution: Majority of joints

isokinetic dynamometry

Measures the strength of a muscle group during a movement with constant predetermined speed. Device will alter resistance to accomodate for change in length tension ratio and lever arm throughout the entire arc of motion. muscle group will max contract thru the motion...common speeds are 60,120 and 180 deg per sec benefits: ability to test muscle strength at various speeds, measure power, and never have ore resistance than they can handle in an isokinetic test disadvantages: high cost, limitations in patterns of movement, higher level of understanding required by pt, this method doesnt correlate to function since ppl dont perform at constant velocities in daily activities

Medicare classification levels

Medicare functional classification levels (MFCL) commonly known as "K-level" - classifies pts on functional ability. Plays a primary role in what componentry will be used in a pt's prosthesis. K-level can be determined objectively with use of outcome measures such as Amputee Mobility Predictor (AMPPRO), or thru a thorough history and examination of the pt. Determination of the K-level would be made by the medical doctor, prosthetist, and PT.

Osteoarthritis

Most common type of joint disease - chronic disease of slow progression that causes degeneration of articular cartilage, primarily in weight bearing joints (synovial joints). Deformity and thickening of subchondral bone occurs resulting in impaired functional status. Any joint can be involved but most common includes hands, weight bearing joints (hip and knee). Primary (idiopathic and occurs in older ppl) and secondary (trauma or other predisposing condition) - occurs in young individuals) forms...excessive wear and tear and secondary inflammatory changes. Starts with degenerative alterations primarily in articular cartilage usually a result of excessive loading in normal joint or normal loading in abnormal joint. Cartilage is lost and results in loss of joint space. Etiology: unknown. appears during middle age and affects nearly everyone by age 70. occurs more commonly in men than women til age 55 then more commonly in women later in life. Risk factors include being overweight, age, obesity, trauma, genetic factors, inflammation, neuromuscular disorders, metabolic disorders infection, fractures or other joint injuries and occupation or athletic overuse. Hands (DIP, PIP), knees, hips and spine with bilateral symmetry seen with primary OA. Signs and symp: Pain is the initial and principal source of morbidity in OA. gradual onset of pain at affected joint, increased pain after exercise, increased pain with weather changes, enlarged joints, crepitus, stiffness, limited joint ROM, Heberdens nodes (palpable osteophytes in DIP often seen in women but not men), and Bouchard's nodes (also more common in women). Increased incidents in sprains and strains around affected joint. radiographs show diminished joint space or a bone spur. Pt often c/o deep and aching joint pain exacerbated by prolonged activity and use. Initially, pts have pain during activity and alleviated by rest, with progression comes morning stiffness and increased pain at rest that may not respond to analgesics. Erythema or warmth over joints is not usually present but effusion may exist. With severe progression, malalignment, limitation, deviated gait, atypical movement patterns and muscle atrophy may occur. X-Ray dx. Tx: reduce pain, promote joint function and protect the joint. Pharmacological management includes acetaminophen, NSAIDs, and corticosteroids. Glucocorticoid intra-articular injection may also be prescribed to improve pts symptoms, however must be used sparingly due to long term negative effects. PT includes PROM, AROM, heating and cooling agents, pt ed, strengthening, TENS (Transcutaenous, electrical nerve stimuation), energy conservation, weight loss, body mechanics, joint protection techniques, and bracing to preserve joint motion and flexibility. Nutrition ed and weight loss to decrease stress on joints. Sx intervention can range from arthroscopic sx to total joint arthroplasty if conservative tx fails. PT cannot change ultimate outcome of disease however can assist during periods of exacerbation and minimize effects - 80-90% over 65 years have evidence of primary OA. OA of knee is leading cause of disability in elderly - Psoriatic arthritis is rheumatic condition where inflammatory arthritis is seen with psoriatic skin lesions. Symptoms are silver or grey scaly spots on scalp, elbows, knees and spine, pitting of fingernails and toenails, pain and swelling in more than one joint, and swelling of fingers and toes. Usually between 20-50 but can occur at any age. Unknown cause, suggested relationship to genetic inheritance, psoriasis and environmental factors.

Sock prosthesis

Normal for pt w/ limb loss to experience decreased volume in residual limb, especially in first year. Prosthetic socks are used to maintain a congruent and comfortable fit to accomodate this space. Made from cotton, wool and synthetic materials, comes in 1, 3 and 5 ply. General rule of thumb: when # of ply exceeds 12-15, prosthetist should be notified as a recasting may be needed. Some socks are split ply and will have a greater/lesser ply distally than proximally. Socks must be carefuly applied as to eliminate any wrinkles otherwise wearer may experience discomfort or breakdown in the area of increased pressure.

Shoulder Goniometry- Extension

Patient Position: Prone Stabilization: thorax to prevent flexion of spine end feel: Firm Axis: Acromial Process Stationary Arm: Midaxillary Line of thorax Moveable Arm: Lateral midline of humerus using the lateral epicondyle of the humerus for reference Average Adult ROM: 0-60 deg

Wrist Goniometry: Extension

Patient Position: Sitting next to a supporting surface with the shoulder abducted to 90 deg and the elbow flexed to 90 deg Stabilization: radius and ulna to prevent supination or pronation End-Feel: firm Axis: lateral aspect of the wrist over triquetrum Stationary Arm: lateral midline of the ulna using the olecranon and ulnar styloid process for reference Moveable Arm: lateral midline of the fifth metacarpal Average Adult ROM: 0-70 deg

Wrist Goniometry: Flexion

Patient Position: Sitting next to a supporting surface with the shoulder abducted to 90 deg and the elbow flexed to 90 deg Stabilization: radius and ulna to prevent supination or pronation End-Feel: firm Axis: lateral aspect of the wrist over triquetrum Stationary Arm: lateral midline of the ulna using the olecranon and ulnar styloid process for reference Moveable Arm: lateral midline of the fifth metacarpal Average Adult ROM: 0-80 deg

Wrist Goniometry: Ulnar Deviation

Patient Position: Sitting next to a supporting surface with the shoulder abducted to 90 deg and the elbow flexed to 90 deg Stabilization: radius and ulna to prevent supination or pronation End-Feel: firm Axis: over the middle of the dorsal aspect of the wrist over the capitate Stationary Arm: dorsal midline of the forearm using the lateral epicondyle of the humerus for reference Moveable Arm: dorsal midline of the third metacarpal Average Adult ROM: 0-30 deg

Wrist Goniometry: Radial Deviation

Patient Position: Sitting next to a supporting surface with the shoulder abducted to 90 deg and the elbow flexed to 90 deg Stabilization: radius and ulna to prevent supination or pronation End-Feel: firm or hard Axis: over the middle of the dorsal aspect of the wrist over the capitate Stationary Arm: dorsal midline of the forearm using the lateral epicondyle of the humerus for reference Moveable Arm: dorsal midline of the third metacarpal Average Adult ROM: 0-20 deg

Forearm Goniometry - Supination

Patient Position: Sitting with elbow flexed to 90 deg Stabilization: distal end of the humerus to prevent lateral rotation and adduction of the humerus End-Feel: firm Axis: medial to the ulnar styloid process Stationary Arm: parallel to the anterior midline of the humerus Moveable Arm: ventral aspect of the forearm, just proximal to the styloid process of the radius and ulna Average Adult ROM: 0-80 deg

Forearm Goniometry - Pronation

Patient Position: Sitting with elbow flexed to 90 deg Stabilization: distal end of the humerus to prevent medial rotation and abduction of the humerus End-Feel: firm or hard Axis: lateral to the ulnar styloid process Stationary Arm: parallel to the anterior midline of the humerus Moveable Arm: dorsal aspect of the forearm, just proximal to the styloid process of the radius and ulna Average Adult ROM: 0-80 deg

Elbow Goniometry - Extension

Patient Position: Supine Stabilization: Humerus to prevent flexion of the shoulder End-Feel: Hard Axis: Lateral Epicondyle of the humerus Stationary Arm: lateral midline of the humerus using the center of the acromial process for reference Moveable Arm: lateral midline of the radius using the radial head and radial styloid process for reference Average Adult ROM: 0 deg

Elbow Goniometry - Flexion

Patient Position: Supine Stabilization: Humerus to prevent flexion of the shoulder End-Feel: Soft Axis: Lateral Epicondyle of the humerus Stationary Arm: lateral midline of the humerus using the center of the acromial process for reference Moveable Arm: lateral midline of the radius using the radial head and radial styloid process for reference Average Adult ROM: 0-150 deg

Shoulder Goniometry- Adduction

Patient Position: Supine Stabilization: thorax to lateral flexion of spine End feel: Firm Axis: Anterior Aspect of the acromial process Stationary Arm: Parallel to the midline of the anterior aspect of the sternum Moveable Arm: medial midline of the humerus

Shoulder Goniometry- Flexion

Patient Position: Supine Stabilization: thorax to prevent extension of spine end feel: Firm Axis: Acromial Process Stationary Arm: Midaxillary Line of thorax Moveable Arm: Lateral midline of humerus using the lateral epicondyle of the humerus for reference Average Adult ROM: 0-180 deg

Shoulder Goniometry - Abduction

Patient Position: Supine Stabilization: thorax to prevent lateral flexion of spine end feel: Firm Axis: anterior aspect of the acromial process Stationary Arm: Parallel to the midline of the anterior aspect of the sternum Moveable Arm: medial midline of the humerus Average Adult ROM: 0-180 deg

Shoulder Goniometry- Medial Rotation

Patient Position: Supine with shoulder abducted to 90 deg and elbow flexed to 90 deg Stabilization: distal end of the humerus to maintain the shoulder in 90 deg abduction End Feel: Firm Axis: Olecranon Process Stationary Arm: parallel or perpendicular to the floor Moveable Arm: ulna using the olecranon process and ulnar styloid process for reference Average Adult ROM: 0-70 deg

Shoulder Goniometry- Lateral Rotation

Patient Position: Supine with shoulder abducted to 90 deg and elbow flexed to 90 deg Stabilization: distal end of the humerus to maintain the shoulder in 90 deg abduction End Feel: Firm Axis: Olecranon Process Stationary Arm: parallel or perpendicular to the floor Moveable Arm: ulna using the olecranon process and ulnar styloid process for reference Average Adult ROM: 0-90 deg

Hip goniometry - extension

Patient Position: prone Stabilization: pelvis to prevent anterior tilting End-Feel: firm Axis: over the lateral aspect of the hip joint using the greater trochanter of the femur for reference Stationary Arm: lateral midline of the pelvis Moveable Arm: lateral midline of the femur using the lateral epicondyle for reference Average Adult ROM: 0-30 deg

Subtalar Goniometry - inversion

Patient Position: prone with the foot extended over a supporting surface Stabilization: tibia and fibula to prevent knee and hip motion End-Feel: firm Axis: posterior aspect of the ankle midway between the malleoli Stationary Arm: posterior midline of the lower leg Moveable Arm: posterior midline of the calcaneous Average Adult ROM: 0-5 deg

Subtalar Goniometry - eversion

Patient Position: prone with the foot extended over a supporting surface Stabilization: tibia and fibula to prevent knee and hip motion End-Feel: firm or hard Axis: posterior aspect of the ankle midway between the malleoli Stationary Arm: posterior midline of the lower leg Moveable Arm: posterior midline of the calcaneous Average Adult ROM: 0-5 deg

Hip goniometry - lateral rotation

Patient Position: sitting Stabilization: distal end of the femur End-Feel: firm Axis: anterior aspect of the patella Stationary Arm: perpendicular to the floor or parallel to the supporting surface Moveable Arm: anterior midline of the lower leg using the crest of the tibia and a point midway between the two malleoli for reference Average Adult ROM: 0-45 deg

Hip goniometry - medial rotation

Patient Position: sitting Stabilization: distal end of the femur End-Feel: firm Axis: anterior aspect of the patella Stationary Arm: perpendicular to the floor or parallel to the supporting surface Moveable Arm: anterior midline of the lower leg using the crest of the tibia and a point midway between the two malleoli for reference Average Adult ROM: 0-45 deg

Cervical spine goniometry - lateral flexion

Patient Position: sitting Stabilization: shoulder girdle and chest to prevent flexion of the thoracic and lumbar spines End-Feel: firm Axis: over the spinous process of the C7 vertebra Stationary Arm: with the spinous processes of the thoracic vertebrae so that the arm is perpendicular to the ground Moveable Arm: along the dorsal midline of the head using the occipital protuberance for reference Average Adult ROM: 0-45 deg

Thoracolumbar Spine Goniometry - Rotation

Patient Position: sitting on a chair without a back with the feet positioned on the floor for pelvic stabilization Stabilization: pelvis to prevent rotation End-Feel: firm Axis: over the center of the cranial aspect of the head Stationary Arm: parallel to an imaginary line between the two prominent tubercles on the iliac crests Moveable Arm: along an imaginary line between the two acromial processes Average Adult ROM: 0-45 deg

Ankle (talocrural) Goniometry - Dorsiflexion

Patient Position: sitting with knee flexed to 90 deg Stabilization: tibia and fibula to prevent knee and hip motion End-Feel: firm Axis: lateral aspect of the lateral malleolus Stationary Arm: lateral midline of the fibula using the head of the fibula for reference Moveable Arm: parallel to the lateral aspect of the 5th metatarsal Average Adult ROM: 0-20 deg

Midtarsal (transverse tarsal) Goniometry - Inversion

Patient Position: sitting with knee flexed to 90 deg Stabilization: tibia and fibula to prevent knee and hip motion End-Feel: firm Axis: anterior aspect of the ankle midway between the malleoli Stationary Arm: anterior midline of the lower leg using the tibial tuberosity for reference Moveable Arm: anterior midline of the second metatarsal Average Adult ROM: 0-35 deg

Midtarsal (transverse tarsal) Goniometry - Eversion

Patient Position: sitting with knee flexed to 90 deg Stabilization: tibia and fibula to prevent knee and hip motion End-Feel: firm or hard Axis: anterior aspect of the ankle midway between the malleoli Stationary Arm: anterior midline of the lower leg using the tibial tuberosity for reference Moveable Arm: anterior midline of the second metatarsal Average Adult ROM: 0-15 deg

Ankle (talocrural) Goniometry - Plantarflexion

Patient Position: sitting with knee flexed to 90 deg Stabilization: tibia and fibula to prevent knee and hip motion End-Feel: firm or hard Axis: lateral aspect of the lateral malleolus Stationary Arm: lateral midline of the fibula using the head of the fibula for reference Moveable Arm: parallel to the lateral aspect of the 5th metatarsal Average Adult ROM: 0-50 deg

Thumb Goniometry - Carpometacarpal Adduction

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: carpals and second metacarpal to prevent wrist motion End-Feel: firm Axis: over the lateral aspect of the radial styloid process Stationary Arm: lateral midline of the second metacarpal using the center of the second metacarpophalangeal joint for reference Moveable Arm: lateral midline of the first metacarpal using the center of the first MCP joint for reference

Thumb Goniometry - Carpometacarpal Abduction

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: carpals and second metacarpal to prevent wrist motion End-Feel: firm Axis: over the lateral aspect of the radial styloid process Stationary Arm: lateral midline of the second metacarpal using the center of the second metacarpophalangeal joint for reference Moveable Arm: lateral midline of the first metacarpal using the center of the first MCP joint for reference Average Adult ROM: 0-70 deg

Thumb Goniometry - Carpometacarpal Flexion

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: carpals, radius, and ulna to prevent wrist motion End-Feel: firm Axis: over the palmar aspect of the first carpometacarpal joint Stationary Arm: ventral midline of the radius using the ventral surface of the radial head and radial styloid process for reference Moveable Arm: ventral midline of the first metacarpal Average Adult ROM: 0-15 deg

Thumb Goniometry - Carpometacarpal Extension

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: carpals, radius, and ulna to prevent wrist motion End-Feel: firm Axis: over the palmar aspect of the first carpometacarpal joint Stationary Arm: ventral midline of the radius using the ventral surface of the radial head and radial styloid process for reference Moveable Arm: ventral midline of the first metacarpal Average Adult ROM: 0-20 deg

Finger Goniometetry - Metacarpophalangeal Abduction

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: metacarpal to prevent wrist motion End-Feel: firm Axis: over the dorsal aspect of the MCP joint Stationary Arm: over the dorsal midline of the metacarpal Moveable Arm: dorsal midline of the proximal phalanx

Finger Goniometry - Metacarpophalangeal Adduction

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: metacarpal to prevent wrist motion End-Feel: firm Axis: over the dorsal aspect of the MCP joint Stationary Arm: over the dorsal midline of the metacarpal Moveable Arm: dorsal midline of the proximal phalanx

Finger Goniometetry - Metacarpophalangeal Extension

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: metacarpal to prevent wrist motion End-Feel: firm Axis: over the dorsal aspect of the MCP joint Stationary Arm: over the dorsal midline of the metacarpal Moveable Arm: over the dorsal midline of the proximal phalanx Average Adult ROM: 0-45 deg (hyperextension)

Finger Goniometetry - Metacarpophalangeal Flexion

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: metacarpal to prevent wrist motion End-Feel: firm or hard Axis: over the dorsal aspect of the MCP joint Stationary Arm: over the dorsal midline of the metacarpal Moveable Arm: over the dorsal midline of the proximal phalanx Average Adult ROM: Digits 2nd to 5th: 0-90 deg Thumb: 0-50 deg

Finger Goniometry - Distal interphalangeal extension

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: middle and proximal phalanx to prevent motion at the PIP joint End-Feel: firm Axis: over the dorsal aspect of the DIP joint Stationary Arm: over the dorsal midline of the middle phalanx Moveable Arm: over the dorsal midline of the distal phalanx Average Adult ROM: Digits 2-5: 0-10 deg (hyperextension)

Finger Goniometry - Distal interphalangeal flexion

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: middle and proximal phalanx to prevent motion at the PIP joint End-Feel: firm Axis: over the dorsal aspect of the DIP joint Stationary Arm: over the dorsal midline of the middle phalanx Moveable Arm: over the dorsal midline of the distal phalanx Average Adult ROM: Digits 2-5: 0-90 deg

Finger Goniometry - proximal interphalangeal extension

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: proximal phalanx to prevent motion at the MCP joint End-Feel: firm Axis: over the dorsal aspect of the PIP joint Stationary Arm: over the dorsal midline of the proximal phalanx Moveable Arm: over the dorsal midline of the middle phalanx

Finger Goniometry - proximal interphalangeal flexion

Patient Position: sitting with the forearm and hand on a supporting surface Stabilization: proximal phalanx to prevent motion at the MCP joint End-Feel: firm, soft or hard Axis: over the dorsal aspect of the PIP joint Stationary Arm: over the dorsal midline of the proximal phalanx Moveable Arm: over the dorsal midline of the middle phalanx Average Adult ROM: Digits 2-5: 0-100 deg Thumb: 0-80 deg

Cervical spine goniometry - extension

Patient Position: sitting with the thoracic and lumbar spine supported Stabilization: shoulder girdle and chest to prevent extension of the thoracic and lumbar spine End-Feel: firm Axis: over the external auditory meatus Stationary Arm: perpendicular or parallel to the ground Moveable Arm: along the base of the nares or if using a tongue depressor, align the goniometer parallel with the tongue depressor Average Adult ROM: 0-45 deg

Cervical spine goniometry - rotation

Patient Position: sitting with the thoracic and lumbar spine supported Stabilization: shoulder girdle and chest to prevent rotation of the thoracic and lumbar spines End-Feel: firm Axis: over the center of the cranial aspect of the head Stationary Arm: parallel to an imaginary line between the two acromial processes Moveable Arm: with the tip of the nose or if using a tongue depressor, align the goniometer parallel with the tongue depressor Average Adult ROM: 0-60 deg

Cervical spine goniometry - flexion

Patient Position: sitting with the thoracic and lumbar spine supported Stabilization: shoulder girdle and chest; the patient's hands should be placed on their knees End-Feel: firm Axis: over the external auditory meatus Stationary Arm: perpendicular or parallel to the ground Moveable Arm: along the base of the nares or if using a tongue depressor, align the goniometer parallel with the tongue depressor Average Adult ROM: 0-45 deg

Thoracolumbar Spine Goniometry - Lateral flexion

Patient Position: standing with feet shoulder width apart Stabilization: pelvis to prevent lateral tilting End-Feel: firm Axis: over the posterior aspect of the spinous process of S2 Stationary Arm: perpendicular to the ground Moveable Arm: along the posterior aspect of the spinous process of T1 Average Adult ROM: 0-35 deg

Knee goniometry - extension

Patient Position: supine Stabilization: femur to prevent rotation, abduction, and adduction of the hip End-Feel: firm Axis: lateral epicondyle of the femur Stationary Arm: lateral midline of the femur using the greater trochanter for reference Moveable Arm: lateral midline of the fibula using the lateral malleolus and fibular head for reference

Knee goniometry - flexion

Patient Position: supine Stabilization: femur to prevent rotation, abduction, and adduction of the hip End-Feel: soft or firm Axis: lateral epicondyle of the femur Stationary Arm: lateral midline of the femur using the greater trochanter for reference Moveable Arm: lateral midline of the fibula using the lateral malleolus and fibular head for reference Average Adult ROM: 0-135 deg

Hip goniometry - adduction

Patient Position: supine Stabilization: pelvis to prevent lateral tilting End-Feel: firm Axis: over the ASIS of the extremity being measured Stationary Arm: align with imaginary horizontal line extending from one ASIS to the other ASIS Moveable Arm: anterior midline of the femur using the midline of the patella for reference Average Adult ROM: 0-30 deg

Hip goniometry - abduction

Patient Position: supine Stabilization: pelvis to prevent lateral tilting and rotation; trunk to prevent lateral flexion End-Feel: firm Axis: over the ASIS of the extremity being measured Stationary Arm: align with imaginary horizontal line extending from one ASIS to the other ASIS Moveable Arm: anterior midline of the femur using the midline of the patella for reference Average Adult ROM: 0-45 deg

Hip goniometry - flexion

Patient Position: supine Stabilization: pelvis to prevent posterior tilting End-Feel: soft or firm Axis: over the lateral aspect of the hip joint using the greater trochanter of the femur for reference Stationary Arm: lateral midline of the pelvis Moveable Arm: lateral midline of the femur using the lateral epicondyle for reference Average Adult ROM: 0-120 deg

Peroneus Longus

Plantar flexion and eversion of foot; stabilizes the lateral ankle and arch of the foot

tibialis posterior

Plantar flexion and inversion of foot

Posture - Lower Quarter Screen

Plum line - indicates ideal positioning of body parts assuming a straight line shown. - Should be.. - through bodies of lumbar vertebrae - slightly posterior to the hip joint - slightly anterior to the axis of the knee joint - slightly anterior to the lateral malleolus - through the calcaneocuboid joint Abdomen - to about age 10, abdomen protrudes a little, in older children and adults it should be flat. Faulty posture includes entire abdomen protrudes or lower part protrudes while upper is pulled in spine and pelvis side view - front of pelvis and thighs are in straight line, buttocks not prominent in back but slope slightly downward. Spine has 4 curves..in neck and lower back curve is forward...in upper back and sacral region its backwards. sacral region is the only one that has a fixed curve while others are flexible. Faulty posture includes lordosis - low back arches forward too much, pelvis tilts forward too much (front of the thigh forms an angle when the tilt is too much). normal forward curve of low back straightens, pelvis tilts backwards as in swayback and flat back postures. increased backward curve in upper back (kyphosis or round upper back.) Increased forward curve of neck which is almost always accompanied by round upper back and seen as a forward head. Hips, pelvis and spine back view - body weight distributed evenly, spine doesn't curve left or right (A slight deviation to left in right handed individuals and to the right in left handed individuals isnt uncommon. also a tendency toward a slightly low right shoulder and a slightly high right hip is frequently found in right handed people and vise versa for left handed people). Faulty posture is one hip is higher (lateral pelvic tilt). sometimes it appears higher due to sideways sway of the body has made it more prominent (tailors and dressmakers often notice this). Hips are rotated so that one is farther forward than the other (clockwise or counter clockwise) knees and legs - legs are straight, kneecaps face straight ahead when feet are in good position. Knees are straight (not flexed or hyper extended). Faulty posture is knees touch when feet are apart (knock knees), knees are apart when feet touch (bowlegs), knees curve slightly backward (Hyperextended knee, back knee), knee bends slightly forward (flexed knee), kneecaps face slightly toward eachother (medially rotated femurs), kneecaps face slightly outward (laterally rotated femurs) Feet - in standing longitudinal arch has shape of a half dome. in barefoot or shoes, feet toe-out slightly, in heels feet are parallel. in walking feet are parallel and weight is transferred from heel along the outer border to the ball of the foot. in sprinting, feet are parallel or toe in slightly and weight is on balls of feet and toes because heels dont touch ground. Faulty posture is low longidtudinal arch or flat foot, low metatarsal arch (usually indicated by calluses under the ball of the foot). weight borne on the outer border of the foot (pronation or ankle rolls in), or on the outside of the foot ( supination or ankle rolls out). toeing out while walking or while standing with heels (slue-footed). toeing in while walking or standing (pigeon toed). Toes - straight (not curled or bent upward), not squeezed together, overlap but extend forward in line with foot. Faulty posture is toes bend up at the first joint and down at middle joints so weight rests on tips of toes (hammer toes - associated with wearing shoes that are too short). big toe slants inward toward midline of foot (hallux valgus or bunion - associated with wearing shoes that are too narrow or pointed at the toes.) - although desirable, rarely a pt will demonstrate ideal alignment with all landmarks above.

Lower abdominals MMT

Position: Supine Fixation: none Test: PT assists pt in raising legs to a vertical position with knees straight. pt needs to rotate pelvis so back is flat against table. Pt needs to keep back flat while lowering legs to table while keeping head and shoulders against table. test ends when pt low back rises from table and is no longer flat Pressure: lowering movement tilts pelvis anteriorly and acts as a strong resistance against the abs which are holding pelvis posteriorly..force is exerted by the hip flexors and the leg. Grading: 5 = w/ arms folded against chest pt able to keep low back flat and lower legs to table level (0 to 15 deg away from table) 4 = keep back flat and lower legs to 30 deg 3+ = keep low back flat and lower legs to 60 deg

Posture - Upper Quarter Screen

Plum line - indicates ideal positioning of body parts assuming a straight line shown. - Should be.. - slightly posterior to coronal suture - through axis of auditory meatus - through axis of the odontoid process - midway through tip of the shoulder Head - Good posture is head held erect with good balance. faulty posture is chin too high, head protruding forward, head tilted or rotated to one side. Arms and shoulders - arms relaxed at sides with palms facing towards body, elbows slightly bent, forearms hang forward. Shoulders level and even, shoulder blades lie flat against rib cage with them not too far or wide apart. Avg is 4 in of seperation in adult. Faulty posture includes arms stiffly in a position, arms rotated so palms face backwards, one shoulder not level with other or both shoulders hiked, forward or dropping, shoulders rotated. Shoulder blades too far apart, prominent, or pulled back to far. Shoulder blades standing out from the rib cage (winged scapulae). Chest - Good posture is slightly up and forward with back in good posture. halfway between full inspiration and expiration. Faulty posture is depressed or "hollow-chest" position. Lifted or help up too high by arching back, ribs more prominent on one side or lower ribs flaring out or protruding. - although desirable, rarely a pt will demonstrate ideal alignment with all landmarks above.

erector spinae MMT

Position: Prone Fixation: PT stabilizes legs because hip extensors need to give fixation of the pelvis to the thighs Test: trunk extension to subjects full ROM Pressure: gravity. Hands are placed behind the head, or hands behind the lower back Grading: 5 = complete movement and hold the position with hands behind head 4 = same but with hands flat on back 3 = ability to clear the sternum off table with arms extended near side of body

Apley's compression test

Position: Prone with knee flexed to 90 deg. - PT stabilizes the pts femur using one hand and places other hand on pts heel. PT medially and laterally rotates the tibia while applying a compressive force thru the tibia. Positive Test: pain or clicking and is indicative of a meniscal lesion

Yergason's Test

Position: Sitting with 90 deg of elbow flexion and the forearm pronated. The humerus is stabilized against the patients thorax. - Therapist places one hand on the pts forearm and the other hand over the bicipital groove. Pt is directed to actively supinate and laterally rotate against resistance. Positive Test: indicated by pain or tenderness in bicipital groove and may be indicative of bicipital tendonitis

Cyriax Sign of the Buttock

Position: Supine - PT performs a passive SLR on pt. If SLR is positive end feel is usually spasm or capsular. Then return pt to neutral and passively flex the hip with the ipsilateral knee flexed to end range Positive Test: If no change in range of motion, the pathology is within the hip or buttock, and not the hamstrings or sciatic nerve. The second part of the test usually has an empty end-feel and is more painful than the first part. To be positive, the Sign of the Buttock must have all present: restriction of SLR concurrently with limited hip flexion and a non-capsular pattern of restriction of hip joint ROM.

Upper Abdominal MMT

Position: Supine Fixation: None Test: Have pt do a trunk curl slowly completely flexing the spine Pressure: resistance is by head , upper trunk and arms depending on position Grading: 5 = completed with hands behind head 4 = hands across chest 3+ = arms extended forward 3 = arms extended forward but pt unable to hold the position

Brachioradialis MMT

Position: Supine Fixation: PT places one hand under elbow Test: elbow flexed at slightly less than 90 deg with forearm in neutral (between pronation and supination) thumb points towards ceiling Pressure: against lower forearm (proximal to wrist) in direction of extension GEP: Pt in short sitting with arm abducted to 90 deg and supported by examiner

Brachialis MMT

Position: Supine Fixation: PT places one hand under elbow Test: elbow flexed at slightly less than 90 deg with forearm pronated. thumb points in/towards body Pressure: against lower forearm (proximal to wrist) in direction of extension GEP: Pt in short sitting with arm abducted to 90 deg and supported by examiner

Biceps Brachii MMT

Position: Supine Fixation: PT places one hand under elbow Test: elbow flexed at slightly less than 90 deg with forearm supinated. thumb points out away from body Pressure: against lower forearm (proximal to wrist) in direction of extension GEP: Pt in short sitting with arm abducted to 90 deg and supported by examiner

External and internal abdominal obliques MMT

Position: Supine Fixation: stabilize legs Test: pt clasps hands behind head, PT places pt into testing position of trunk flexion and rotation and pt needs to hold position Pressure: weight of trunk Grading: 5 = ability to hold position with hands clasped behind head 4 = arms crossed over chest 3+ = arms extended 3 = ability to hold the trunk in enough flexion and rotation to raise both scapular regions from the table

abductor digiti minimi MMT

Position: Supine or sitting Fixation: hand Test: abduction of little finger Pressure: ulnar side of the little finger in direction of adduction towards midline of hand

Supraspinatus test

Position: arm in 90 deg abduction followed by 30 deg horizontal adduction with thumb pointing down. - Therapist resists pts attempt to abduct arm. Positive Test: indicated by weakness or pain and may be indicative of a tear of the supraspinatus tendon, impingement or suprascapular nerve involvement.

Elys Test

Position: prone - PT passively flexes pts knee Positive Test: spontaneous hip flexion occurring simultaneously with knee flexion. indicative of a rectus femoris contracture

Quadratus Lumborum MMT

Position: prone Fixation: by the muscles which hold the femur firmly in the acetabulum Test: elevation of the pelvis laterally. Extremity is placed in slight extension and in the degress of abduction that corresponds with the line of the fibers of the Quatratus Lumborum Pressure: traction on the extremity opposing the line of pull of the QL. if the hips are weak, pressure may be given against the posteriolateral iliac crest opposite the line of pull of the muscle Grading: 3 = Pt standing and hikes the hip against gravity 2 = pt lies prone and hikes hip on the table

Teres minor and infraspinatus MMT

Position: prone Fixation: examiner places one hand under the arm near the elbow and stabilizes the humerus to ensure rotation by preventing adduction or abduction. Towel can be placed under humerus for comfort. Test: lateral rotation of humerus with elbow at right angle Pressure: pressure applied in the direction of medially rotating humerus GEP: in prone, hang arm with elbow extended off table, perform lateral rotation by bringing the hand away from body

rhomboids, trapezius and levator scapulae MMT

Position: prone Fixation: none Test: adduction and elevation of the scapula with medial rotation of the inferior angle, elbow flexed; the humerus is adducted toward the side of the body in slight extension and slight lateral rotation (chicken wing position) Pressure: pressure applied with one hand against the patient's arm in the direction of abducting the scapula and rotating the inferior angle laterally and against the patients shoulder, with the other hand in the direction of depression GEP: No GEP

teres major MMT

Position: prone Fixation: none Test: extension and adduction of the humerus in the medially rotated position with the hand resting on the PSIS Pressure: against the arm, above the elbow, in the direction of abduction and flexion GEP: No GEP

Lower Trapezius MMT

Position: prone Fixation: one hand below the scapula on the other side Test: adduction and depression of scapula, with lateral rotation of the inferior angle. arm is placed diagonally overhead (45 deg shoulder abduction) in line with the lower fibers of trapezius Pressure: against forearm in a downward direction towards the table GEP: No GEP

Latissimus Dorsi MMT

Position: prone Fixation: one hand from the examiner may apply a counter pressure laterally on the pelvis Test: adduction of the arm, with extension, in a medially rotated position Pressure: against the forearm, in the direction of abduction and slight flexion of the arm GEP: No GEP

Alternate Rhomboid Test

Position: prone Fixation: one hand on opposite scapular area to prevent trunk rotation Test: adduction of the scapula with downward (medial rotation) and without elevation of the shoulder girdle. Place the shoulder in 90 deg abduction and medial rotation so that the thumb is pointing down Pressure: against the forearm in a downward direction toward the table GEP: No GEP

Middle trapezius MMT

Position: prone Fixation: one hand on the opposite scapular area to prevent trunk rotation Test: adduction of the scapula with upward (lateral) rotation and without elevation of the shoulder girdle. Place shoulder in 90 deg abduction and lateral rotation so thumb is pointing up Pressure: against forearm in a downward direction toward the table GEP: No GEP

triceps brachii MMT

Position: prone Fixation: shoulder at 90 deg abduction, neutral rotation, with arm supported between shoulder and elbow by the table. Examiner places one hand under the arm near the elbow to cushion the arm from table pressure Test: elbow begins in flexion then extend the elbow (slightly less than full elbow extension) Pressure: against forearm (proximal to wrist on ulnar side) in the direction of flexion GEP: short sitting with arm abducted to 90 deg and supported by examiner ALTERNATE POSITION: Position: supine Fixation: shoulder is in 90 deg of flexion with arm supported in a perpendicular position to table Test: extension of the elbow (slightly less than full elbow extension) Pressure: against the forearm (proximal to wrist on ulnar side), in the direction of flexion

subscapularis MMT

Position: prone Fixation: towel can be placed under humerus for pt comfort, if not, examiners hand near elbow cushions against table pressure and stabilized humerus to ensure rotation by preventing adduction or abduction Test: medial rotation of humerus with elbow held at right angle Pressure: pressure applied in direction of laterally rotating humerus GEP: from prone position, hang arm with elbow extended off table and perform medial rotation by bringing your hand towards the body

Thompson Test

Position: prone with feet extended over edge of table - Pt relaxes and PT squeezes muscle belly of gastrocnemius and soleus muscles Positive Test: absence of PF and may indicate ruptured achilles tendon

soleus MMT

Position: prone with knee flexed to 90 Fixation: support leg proximal to the ankle Test: plantar flexion of ankle joint, without inversion or eversion of foot Pressure: against calcaneus, pulling the heel in direction of DF

gluteus maximus MMT

Position: prone with knee flexed to 90 deg or more Fixation: posteriorly the back muscles, laterally the abdominals Test: hip extension with knee flexed Pressure: against lower part of the posterior thigh in direction of hip flexion GEP: side on side on the opposite of the leg your testing and extend hip with a slide board under the leg

Craig's Test

Position: prone with test knee flexed to 90 deg - PT palpated posterior aspect of the greater trochanter and medially and laterally rotates the hip until the greater trochanter is parallel with the table. - The degree of femoral anteversion corresponds with the angle formed by the lower leg with the perpendicular axis of table. Normal anteversion for an adult is 8-15 deg

Elbow Flexion Test

Position: pt fully flexes both elbows while extending their wrists and hold the position for 3-5 mins Positive Test: tingling or paresthesia is noted in the ulnar nerve distribution of the forearm and hand. Indicative for cubital tunnel syndrome

Adson Maneuver

Position: pt in sitting or standing - Therapist monitors radial pulse and asks pt to rotate their head to face test shoulder. Pt then extends head while PT laterally rotates and extends pts shoulder Positive Test: indicated by an absent or diminished radial pulse and may be indicative of thoracic outlet syndrome

Neer Impingement Test

Position: pt in sitting or standing - Therapist positions one hand on posterior aspect of pts scapula and the other hand stabilizing the elbow. Therapist elevates pts arm thru flexion Positive test: indicated by a facial grimace or pain and may be indicative of shoulder impingement involving the supraspinatus tendon

Hawkins-Kennedy Impingement Test

Position: pt in sitting or standing. - PT flexes the patient's shoulder to 90 degrees and medially rotates the shoulder - Positive Test: indicated by pain. Indicates shoulder impingement involving the supraspinatus tendon.

Ludington's Test

Position: pt in sitting with both hands clasped behind the head with the fingers interlocked - Pt alternately contracts and relaxes the biceps muscles. Positive Test: absence of movement in the biceps tendon. Indicates of a rupture of the long head of the biceps.

Supine impingement test

Position: pt lies supine while therapist passively moves shoulder into full flexion - Therapist laterally rotates and adducts the shoulder so that arm is near the pts head. From this position, therapist medially rotates shoulder. Positive Test: a significant increase in pain with medial rotation

Lift off sign (medial rotation lag sign)

Position: pt stands and places dorsum of hand on low back - Pt asked to move hand away from back. If unable, therapist moves hand away from their back for them. Pt asked to hold position Positive Test: inability to hold position. Indicates a subscapularis lesion is present

Infraspinatus Test

Position: pt stands with arms at side, elbow to 90 flexion, humerus medially rotated to 45 - PT applies medial rotation force to the forearm that pt resists Positive Test: pain or weakness (inability to resist medial rotation) indicates the presence of an infraspinatus strain or tear

lateral rotation stress test (Kleiger Test)

Position: seated at edge of table with knee in 90 deg flexion - PT stabilizes the pts lower leg with one hand and hold the pts foot in neutral with their other hand. PT then applies a lateral rotation force to the foot. Positive Test: If pt experiences pain over the anterior or posterior tibiofibular ligaments and the interosseous membrane, then the test is + for a high ankle sprain (syndesmosis injury). The test is + for a deltoid ligament tear if pt has pain medially and the therapist can feel the talus shift away from the medial malleolus

gluteus minimus MMT

Position: sidelying Fixation: stabilize pelvis to prevent pt from rotation away from sidelying (preventing substitution by hip flexors or extensors) Test: Abduction of the hip in a position of neutral between flexion and extension and no rotation (foot lies parallel to the mat table with toes pointing outward) Pressure: against leg in the direction of adduction and very slight extension GEP: lying supine and bringing the leg into an abduction position

gluteus medius MMT

Position: sidelying Fixation: stablize the pelvis to prevent the pt from rotating away from sidelying (preventing substitution by the hip flexors or extensors) Test: abduction or hip with slight extension and slight ER (toes point toward the ceiling) with knee extended Pressure: against leg near ankle, in direction of adduction and slight flexion GEP: lying supine and bringing the leg in an abduction position

Ober's Test

Position: sidelying w/ lower leg flexed at the hip and knee - PT moves test leg into hip extension and abduction and then attempts to slowly lower the test leg. Positive Test: an inability of the test leg to adduct and touch the table. Indicative of an Iliotibial band or a tensor fasciae latae contracture

Talar tilt test

Position: sidelying with knee flexed to 90 deg - PT stabilizes distal tibia with one hand while grasping the talus with the other hand. Foot is maintained in a neutral position. PT tilts the talus into abduction and adduction Positive Test: excessive adduction and may be indicative of a calcaneofibular ligament sprain

Lateral trunk flexors MMT

Position: sidelying with pillow between thighs and legs. body in a straight line. top arm extended down side with fingers closed to not hold onto thigh while bottom arm is across the chest with hand holding the upper shoulder to rule out assistance by pushing up the elbow Fixation: hold down legs to counterbalance the weight of the trunk Test: trunk raising sideways without rotation Pressure: body weight Grading: 5 = ability to raise trunk laterally from sidelying position to a point of max lateral flexion 4 = underneath shoulder 4 inches from table 3 = underneath shoulder 2 inches up from table

Piriformis test

Position: sidelying with test leg positioned toward the ceiling and the hip flexed to 60 deg - PT places one hand on the pts pelvis and other hand on pts knee. While stabilizing the pelvis, PT applies a downward (adduction) force on knee. Positive Test: pain or tightness. Indicative of piriformis tightness or compression on the sciatic nerve caused by the piriformis

slump test

Position: sits at end of table and is asked to "slump" (move into lumbar and thoracic flexion) and then brind their chin toward their chest. - PT uses one hand to maintain the position of full spinal flexion while using the other hand to place the pts ankle into DF. Pt then actively extends the knee (or this can be done passively). If pt cant fully extend the knee because of pain, the PT asks the pt to extend their neck and then try to extend the knee again Positive test: if symptoms decrease with knee extension or the pt can extend the knee farther, test is + for neural tension

Costoclavicular syndrome test (thoracic outlet syndrome)

Position: sitting - PT monitors radial pulse and assists pt to assume a military posture Positive Test: absent or diminished radial pulse. Indicates TOS caused by compression of subclavian artery between the first rib and clavicle

Mill's Test

Position: sitting - PT palpates lateral epicondyle, pronates the pts forearm, flexes the wrist and extends the elbow Positive test is indicated by pain in the lateral epicondyle region and may be indicative of lateral epicondylitis

Medial Epicondylitis Test

Position: sitting - PT palpates medial epincondyle and supinates the pts forearm, extends the wrist and extends the elbow. Positive test: pain in the medial epicondyle region and may be indicative of medial epicondylitis

Lateral Epicondylitis Test

Position: sitting - PT stabilizes the elbow with one hand and places the other hand on the dorsal aspect of the pts hand distal to the PIP joint. Pt asked to extend the third digit against resistance Positive test: indicated by pain in the lateral epicondyle region or muscle weakness. Indicative of lateral epicondylitis

Ulnar collateral ligament instability test

Position: sitting - Pt holds pts thumb in extension and provides a valgus force to the MCP joint of the thumb Positive Test: excessive valgus movement. Indicative of a tear of the ulnar collateral and accessory collateral ligaments. This type of injury is referred to as gamekeeper's or skier's thumb

Posterior Deltoid MMT

Position: sitting Fixation: if trunk is weak then stabilize scapula..if not then none Test: shoulder abduction (to 90 deg), slight shoulder extension with the humerus slightly IR. elbow flexed to 90 Pressure: against the posterolateral surface of the arm, at the proximal elbow in the direction of adduction and slight flexion GEP: No GEP, observe grades 3-5 ALTERNATE POSITION Position: prone Fixation: scapula must be stabilized Test: horizontal abduction of the shoulder with slight ER Pressure: against posterolateral surface of the arm, in a direction obliquely downward and midway between adduction and horizontal adduction GEP: No GEP

Middle deltoid MMT

Position: sitting Fixation: if trunk is weak then stabilize scapula..if not then none Test: shoulder abduction, elbow flexed to 90, no rotation..give max pressure at 90 deg shoulder abduction (after 90 deg the trap begins to become recruited) Pressure: against dorsal surface of the distal end of the humerus if the elbow is flexed and push downward direction towards floor GEP: same movement but in a supine position on table

Anterior deltoid MMT

Position: sitting Fixation: if trunk is weak then stabilize scapula..if not then none Test: shoulder abduction, slight flexion, humerus in ER, elbow flexed to 90..this position is held while pressure is applied Pressure: against the anteromedial surface of the arm (just above the elbow) in the direction of slight adduction and extension GEP: No GEP, only observe grades 3-5 ALTERNATE POSITION: Position: sitting Fixation: if trunk is weak then stabilize scapula..if not then none Test: shoulder flexion up to 90 with elbow flexed and forearm pronated Pressure: applied to proximal elbow towards shoulder extension GEP: lying in sideline performing shoulder flexion

distraction test

Position: sitting - PT places one hand under the pts chin and the other hand under the occiput. PT then applies an upward distraction force. Positive Test: positive for cervical nerve root compression if pain is decreased with the distract force - this test is used for pts who are currently experiencing radicular symptoms

Phalen's Sign

Position: sitting or standing - PT flexes the pts wrist maximally and asks pt to hold the position for 60 sec Positive test: tingling in the thumb, index finger, middle finger, and lateral half of the ring finger. Indicative of carpal tunnel syndrome due to median nerve compression

Grind Test

Position: sitting or standing - PT stabilizes pts hand and grasps the pts thumb on the metacarpal. PT applies compression and rotation thru the metacarpal Positive test: indicated by pain and may be indicative of degenerative joint disease in the carpometacarpal joint

Tinel's Sign

Position: sitting or standing - PT taps over the volar aspect of pts wrist Positive test: tingling in the thumb, index, middle and lateral half of the ring finger distal to the contact site at the wrist. Indicative of carpal tunnel syndrome due to median nerve compression

Allen Test (wrist)

Position: sitting or standing - Pt opens and closes hand several times in succession and then maintains the hand in a closed position. PT compresses the radial and ulnar arteries. Pt then asked to relax the hand and the therapist releases the pressure on one of the arteries while observing the color of the hand and fingers. Positive Test: delayed or absent flushing of the radial or ulnar half of the hand. Indicative of an occlusion in the radial or ulnar arteries

Supraspinatus MMT

Position: sitting or standing Fixation: none Test: pt elevates shoulder (in between abduction and flexion) to 110 deg with elbow slightly flexed and shoulder internally rotated (thumbs pointing down). Maintain that position with pressure Pressure: applied at proximal wrist downward towards the ground ALTERNATE 1: Position: sitting with neck extended and laterally flexed towards test side with face rotated away Fixation: none, sitting provides more stability than standing Test: with elbow bent to a right angle the arm is placed into 90 deg shoulder abduction. arm is slightly forward from the mid coronal plane and held in a few deg ER. Pt needs to hold this position Pressure: applied at proximal elbow and push downward towards ground ALTERNATE 2 Position: sidelying or standing Fixation: none Test: arm at pts side.. attempt to bring arm in abduction with the elbow extended against pressure (test performed from 0-15 deg abduction) Pressure: applied at the distal forearm (dorsal surface towards adduction

Finkelstein Test

Position: sitting or standing and pt makes a fist with thumb tucked inside fingers. - PT stabilizes pt forearm and ulnarly deviates wrist Positive test: pain over the abductor pollicis longus and extensor pollicis brevis tendons at the wrist and may be indicative of tenosynovitis in the thumb (de Quervain's disease)

Froment's sign

Position: sitting or standing while holding a piece of paper between the thumb and index finger - PT attempts to pull paper away from pt Positive Test: pt flexing the distal phalanx of thumb due to adduct pollicis muscle paralysis. If at the same time pt hyperextends the MCP joint of the thumb, it's termed Jeanne's sign. Both findings are indicative of ulnar nerve compromise or paralysis

Murphy Sign

Position: sitting or standing while making a fist Positive test: pts third metacarpal remaining level with the second and fourth metacarpals. indicative of a dislocated lunate

Roos Test

Position: sitting or standing with arm positioned in 90 deg abduction, lateral rotation and elbow flexion - Pt opens and closes theirs hands for 3 mins Positive Test: inability to maintain the test position, weakness of the arms, sensory loss or ischemic pain. Indicates TOS

Lateral rotation lag sign

Position: sitting or standing with elbow bent - Therapist passively moves their shoulder into 20 deg scaption and near end range lateral rotation and asks pt to hold that position Positive Test: pt cannot hold the position (ex. shoulder moves into more medial rotation. Indicative infraspinatus and/or supraspinatus pathology - can perform test at varying levels of elevation

Speed's Test

Position: sitting or standing with elbow extended and forearm supinated. - Therapist places one hand over the bicipital groove and other hand on the volar surface of the forearm. Therapist resists active shoulder flexion Positive Test: pain or tendernes in bicipital groove region and may be indicative of bicipital tendonitis

Allen test (thoracic outlet syndrome)

Position: sitting or standing with test arm in 90 deg abduction, lateral rotation and elbow flexion. - Pt asked to rotate head away from test shoulder while PT monitors radial pulse. Positive Test: absent or diminished pulse when head is rotated away from test shoulder. May be indicative of TOS

Drop Arm Test

Position: sitting or standing with the arm in 90 deg of abduction - Pt slowly lowers arm to their side Positive Test: indicated by pt failing to slowly lower arm to their side or presence of severe pain and may be indicative of a tear in the rotator cuff

Wright test (hyperabduction test)

Position: sitting or supine - PT moves pts arm overhead in frontal plane while monitoring the pts radial pulse Positive Test: absent or diminished radial pulse. Indicates compression in the costoclavicular space

Bunnel-Littler test

Position: sitting w/ MCP joint held in slight extension - PT attempts to move the PIP joint into flexion. If PIP joint doesn't flex with the MCP joint extended, may be a tight intrinsic muscle or capsular tightness. If the PIP joint fully flexes with the MCP joint in slight flexion, may be intrinsic muscle tightness without capsular tightness

extensor carpi radialis longus MMT

Position: sitting with elbow about 30 deg from 0 ext Fixation: forearm slightly less than full pronation and rests on table Test: extension of wrist towards radial side Pressure: against dorsum of hand along the second and third metacarpal bones in direction of flexion toward ulnar side

extensor carpi radialis brevis MMT

Position: sitting with elbow fully flexed (have pt lean forward to flex elbow) Fixation: the forearm is in slightly less than full pronation and rests on table for support Test: extension of wrist toward radial side. Elbow flexion makes extensor carpi radialis longus less effective by being in shortened position Pressure: against dorsum of hand along the second and third metacarpal bones in direction of flexion toward ulnar side

Valgus Stress Test (Elbow)

Position: sitting with elbow in 20-30 deg flexion - Therapist places one hand on elbow and other hand proximal to pts wrist. PT applies a valgus force to test the medial collateral ligament while palpating medial joint line. Positive Test: indicated by increased laxity in the MCL when compared to the contralateral limb, apprehension or pain. Indicative of medial collateral ligament sprain.

Varus Stress Test (Elbow)

Position: sitting with elbow in 20-30 deg flexion - Therapist places one hand on elbow and other hand proximal to pts wrist. PT applies a varus force to test the lateral collateral ligament while palpating the lateral joint line. Positive Test: indicated by increased laxity in the LCL when compared to the contralateral limb, apprehension or pain. Indicative of lateral collateral ligament sprain.

Cozen's Test

Position: sitting with elbow in slight flexion - PT places their thumb on pts lateral epicondyle while stabilizing the elbow joint. Pt is asked to make a fist, pronate the forearm, radially deviate, and extend the wrist against resistance. Positive test: pain in the lateral epicondyle region or muscle weakness. Indicative of lateral epicondylitis

Tinel's sign

Position: sitting with elbow in slight flexion - PT taps with the index finger between the olecranon process and the medial epicondyle Positive Test: tingling sensation in the ulnar nerve distribution of the forearm, hand and fingers. Indicative of ulnar nerve compression or compromise

foraminal compression test

Position: sitting with head laterally flexed. - PT places both hands on top of the pts head and exerts a downward force. Positive Test: pain radiating into the arm toward the flexed side and may be indicative of nerve root compression

sitting flexion test

Position: sitting with knees flexed to 90 deg and feet on floor. pts hips should be abducted to allow pt to bed forward - PT places thumbs on inferior margin of the posterior superior iliac spines and monitors the movement of the bony structures as the pt bend forward and reaches the floor Positive test: one PSIS moving farther in the cranial direction and may be indicative of an articular restriction

Tripod Sign

Position: sitting with knees flexed to 90 deg over edge of table - PT passively extends one knee Positive Test: tightness in hamstrings or extension of trunk in order to limit the effect of the tight hamstrings

Tibial Torsion Test

Position: sitting with knees over edge of table - PT places thumb and index finger of one hand over the medial and lateral malleolus. PT then measures the acute angle formed by the axes of the knee and ankle. Normal lateral torsion of the tibia is considered to be 12-18 deg in an adult

Jerk Test

Position: sitting with shoulder elevated to 90 deg and in medial rotation with elbow bent - Therapist provides an axial compression force through the pts elbow while horizontally adducting the shoulder Positive test: sudden clunk or jerk as the humeral head subluxes posteriorly indicates the presence of posterior instability. A second clunk or jerk may be heard when shoulder is returned to the starting position as the humeral head reduces. A complaint of pain with this test could indicate the presence of a posterior labral lesion

Trendelenburg Test

Position: standing and asked to stand on one leg for approx 10 seconds Positive Test: a drop of the pelvis on the unsupported side. indicative of weakness of the glut medius muscle on the supported side

standing flexion test

Position: standing with feet 12 inches apart. - PT places their thumbs on the inferior margin of the PSIS's and monitors movement of the bony structures as the pt bends forward with the knees extended Positive Test: one PSIS moving farther in a cranial direction and may be indicative of an articular restriction.

Sulcus Sign

Position: standing with pts arm in 20-50 deg abduction - Therapist grasps pts elbow and pulls arm inferiorly Positive Test: If a sulcus sign (depression seen between the acromion and humeral head is noted indicated inferior instability. - Graded by measuring the vertical length of depression 1+ for <1cm 2+ for 1-2cm 3+ for >3cm

thessaly test

Position: stands on one leg with approx 5 deg of knee flexion while PT provides their hands to assist the pt with their balance - Pt rotates the femur on the tibia laterally and medially three times. test is repeated with a 20 deg knee bend Positive Test: Joint line discomfort or catching or locking in the knee, test is positive for meniscal tear. Test should be performed on the unaffected extremity first and then the affected extremity

Active compression test (O'Brein's Test)

Position: stands with shoulder flexed to 90 deg, horizontally adducted 10-15 deg and medially rotated so the thumb points downward. - Pt resists as PT applies downward force on the arm. Shoulder then laterally rotated and same downward force is applied. Positive Test: pt experiences pain when the shoulder is in medial rotation but has decreased pain when shoulder is laterally rotated. Indicative of a superior labral tear. - Important to ensure pain is not located over the AC joint with this test

Quadrant scouring Test

Position: supine - PT passively flexes and adducts hip with knee in max flexion. PT applies a compressive force thru the shaft of the femur while continuing to passively move the pts hip Positive Test: grinding, catching or crepitation in the hip and may be indicative of pathologies such as arthritis, avascular necrosis or an osteochondral defect

Glenoid labrum tear test

Position: supine - PT places one hand on the posterior aspect of the pts humeral head while the other hand stabilizes the humerus proximal to the elbow. Pt passively abducts and laterally rotates the arm over the pts head and then proceeds to apply and anterior directed force to the humerus Positive Test: indicated by a clunk or grinding sound. Indicative of a glenoid labrum tear.

straight leg raise test

Position: supine - while pt in supine, PT flexes pts hip while maintaining knee extension and slight medial rotation of the hip. PT continues to flex the hip until pt complains of tightness or pain in low back or posterior leg. PT then lowers the leg until the pt feels no pain or tightness. At this point, the PT dorsiflexes the ankle (or has pt flex their neck) Positive Test: If symptoms return, test is + for neural tension or a lesion within the spinal cord (disk herniation)

Pectoralis Minor MMT

Position: supine Fixation: None Test: forward thrust of shoulder with arm at side Pressure: against anterior aspect of shoulder downward toward the table GEP: No GEP

Pronator teres and quadratus MMT

Position: supine Fixation: elbow held against pt side to avoid any shoulder abduction movement Test: pronation of the forearm with the elbow partially flexed (pronator teres) or elbow completely flexed (pronator quadratus - makes humeral head of pronator teres less effective by being in shortened position) Pressure: at the lower forearm above the wrist (to avoid twisting the wrist) in the direction of forearm supination

Pectoralis major: upper fibers MMT

Position: supine Fixation: examiner holds opposite shoulder to table Test: elbow extended and shoulder at 90 deg flexion and slight medial rotation, the humerus is horizontally adducted toward sternal end of the clavicle Pressure: against forearm, in direction of horizontal abduction GEP: no GEP

Pectoralis Major: Lower fibers MMT

Position: supine Fixation: examiner places one hand on opposite iliac crest to hold the pelvis firmly on the table Test: elbow extended with shoulder in flexion and medial rotation, adduction of the arm obliquely toward the opposite iliac crest Pressure: against the forearm obliquely, in a lateral and cranial direction GEP: No GEP

Supinator and Biceps MMT

Position: supine Fixation: hold shoulder in flexion with elbow completely fixed Test: supination of the forearm with elbow at right angle or slightly below Pressure: at distal end of forearm above the wrist in the direction of pronation ***Supinator is tested with biceps elongated or shortened - same test but elbow is fully flexed or extended

Serratus anterior MMT

Position: supine Fixation: none Test: abduction of the scapula, projecting the upper extremity anteriorly with the hand in a fist Pressure: against pt fist, transmitting the pressure downward through the extremity to the scapula in the direction of adducting the scapula GEP: No GEP

tensor fasciae latae MMT

Position: supine Fixation: pt hold onto table Test: abduction, flexion and medial rotation of hip with knee extended Pressure: against the leg, in direction of extension and adduction GEP: No GEP

sacroiliac joint stress test

Position: supine - PT crosses their arms, placing the palms of the hands on the pts ASIS's. PT applies a downward and lateral force to the pelvis Positive Test: unilateral pain in the SIJ or gluteal area and may be indicative of SIJ dysfunction

Hughston's plica test

Position: supine - PT flexes the knee and medially rotates the tibia with one hand while other hand attempts to move the patella medially and palpate the medial femoral condyle. Positive Test: a popping sound over the medial plica while the knee is passively flexed and extended...may be indicative of an abnormal or irritated plica.

cervical flexion rotation test

Position: supine - PT fully flexes the pts cervical spine. PT then rotates the cervical spine in each direction while maintaining flexion. pt should have approx 45 deg rotation in each direction. Positive Test: limited rotation in this position indicates dysfunction is likely occurring at the atlantoaxial joint. This test can also be used as a provocative test for cervicogenic headache

mcmurray test

Position: supine - PT grasps the distal leg with one hand and palpates the knee joint line with the other. W/ knee fully flexed, PT medially rotates tibia and extends knee. PT repeats same procedure while laterally rotating the tibia. Positive Test: click or pronounced crepitation felt over the joint line and may be indicative of a posterior meniscal lesion

Bounce home test

Position: supine - PT grasps the pts heel and maximally flexes the knee. Pts knee is extended passively Positive Test: incomplete extension or a rubbery end feel and may be indicative of a meniscal lesion

brush test (knee)

Position: supine - PT places one hand below the joint line on the medial surface of the patella and strokes proximally with the palm and fingers as far as the suprapatellar pouch. The other hand then strokes down the lateral surface of the patella Positive Test: a wave of fluid just below the medial distal border of the patella ...indicated of effusion in the knee

vertebral artery test

Position: supine - PT places pts head into extension, lateral flexion, and rotation to the ipsilateral side Positive Test: dizziness, nystagmus, slurred speech or loss of consciousness and may be indicative of compression of the vertebral artery.

Anterior Drawer Test

Position: supine - PT stabilizes the distal tibia and fibula with one hand while the other hand holds the foot in 20 deg of plantar flexion and draws the talus forward in the ankle mortise Positive Test: excessive anterior translation of the talus away from the ankle mortise and may be indicative of an anterior talofibular ligament sprain

gapping test

Position: supine - PT crosses their pts arms and applied pressure in a downwar and lateral direction to each ASIS Positive Test: pain in the SIJ, gluteus or posterior leg, the test is positive for a sprain of the anterior sacroiliac ligaments

Homan's sign

Position: supine and pt actively extends knee - PT then raises straight leg to 10 deg, then passively and abruptly DF foot and squeezes the calf with the other hand Positive Test: deep calf pain and tenderness..may indicate presence of DVT

90-90 straight leg raise test

Position: supine and pt stabilizes the hips in 90 deg of flexion with the knees relaxed - PT instructs the pt to alternately extend each knee as much as possible while maintaining the hip in 90 deg flexion Positive Test: knee remaining in 20 deg or more of flexion and indicative of tight hamstrings

flexor digitorum superficialis MMT

Position: supine or sitting Fixation: examiner stabilizes the metacarpophalangeal joint, with wrist in neutral or slight extension Test: flexion of proximal interphalangeal joint with the distal interphalangeal joint extended...of the 2nd, 3rd, 4th and 5th digits Pressure: against palmar surface of the middle phalanx in the direction of extension

extensor carpi ulnaris MMT

Position: supine or sitting Fixation: forearm in full pronation and rests on table Test: extension of wrist towards ulnar side Pressure: against dorsum of hand along 5th metacarpal bone in direction of flexion toward the radial side

flexor carpi radialis MMT

Position: supine or sitting Fixation: forearm in slightly less than full supination rests on table or held by examiner Test: flexion of the wrist toward the radial side Pressure: against the thenar eminence in the direction of extension toward the ulnar side

palmaris longus and brevis MMT

Position: supine or sitting Fixation: forearm in supination rests on table Test: testing of palmar fascia by strongly cupping the palm of the hand and flexion of the wrist Pressure: against the thenar and hypothenar eminences in the direction of flattening the palm of the hand and against the hand in the direction of extending the wrist

abductor hallicus MMT

Position: supine or sitting Fixation: grip heel firmly Test: abduction of big toe from the axial line of foot. difficult to obtain for avg person so action may be demonstrated by having pt pull the forefoot in adduction against pressure of examiner Pressure: against medial side of the first metatarsal and proximal phalanx. muscle can be palpated and often seen along the medial border of the foot

Abductor pollicis brevis MMT

Position: supine or sitting Fixation: hand Test: abudction of the thumb ventralward from the palm Pressure: against the proximal phalanx in the direction of adduction toward the palm

adductor pollicis MMT

Position: supine or sitting Fixation: hand Test: adduction of the thumb towards the palm Pressure: against medial surface of the thumb in the direction of abduction away from the palm

flexor pollicis brevis MMT

Position: supine or sitting Fixation: hand Test: flexion of MCP joint of thumb without flexion of interphalangeal joint Pressure: against palmar surface of proximal phalanx in the direction of extension

flexor digiti minimi MMT

Position: supine or sitting Fixation: hand Test: flexion of the MCP joint with interphalangeal joints extended Pressure: palmar surface of the proximal phalanx in the direction of extension

Opponens pollicis MMT

Position: supine or sitting Fixation: hand Test: flexion, abduction, and slight medial rotation of the metacarpal bone so that the thumbnail shows in palmar view Pressure: against the metacarpal bone in the direction of extension and adduction with lateral rotation

opponens digiti minimi MMT

Position: supine or sitting Fixation: hand and first metacarpal Test: opposition of fifth metacarpal towards first Pressure: against palmar surface along the first metacarpal in direction of flattening the palm of the hand.

extensor pollicis longus MMT

Position: supine or sitting Fixation: hand and gives counter pressure against palmar surface of first metacarpal and proximal phalanx Test: extension of the interphalangeal joint of thumb Pressure: against dorsal surface of interphalangeal joint of thumb in the direction of flexion

flexor pollicis longus MMT

Position: supine or sitting Fixation: metacarpal bone and proximal phalanx of the thumb in extension Test: flexion of the interphalangeal joint of thumb Pressure: against palmar surface of distal phalanx in direction of extension

lateral pterygoid muscle

Protrudes, moves side to side and depresses the mandible

dorsal interossei MMT

Position: supine or sitting Fixation: stabilization of adjacent digits to give fixation of digit toward which finger is moved and to prevent assistance from digit on other side Test and pressure or traction (against middle phalanx) first: abduction of index finger toward thumb. Pressure against redial side of index in direction of middle finger second: abduction of middle finger toward index finger. hold middle finger and pull in direction of ring finger third: abduction of middle finger toward ring finger. Hold middle finger and pull in direction of ring finger fourth: abduction of ring finger toward little finger. Hold ring finger and pull in direction of middle finger

Palmar interosseous MMT

Position: supine or sitting Fixation: stabilization of adjacent digits to give fixation of digit toward which finger is moved and to prevent assistance from digit on other side Test and pressure or traction (against middle phalanx) first: adduction of thumb towards index finger (acting with adductor pollicis and first dorsal interosseous). hold thumb and pull in radial direction second: adduction of index finger toward middle finger. hold index finger and pull in direction of ring thumb third: adduction of ring finger toward middle finger. Hold ring finger and pull in direction of little finger fourth: adduction of little finger toward ring finger. Hold little finger and pull in ulnar direction

abductor pollicis longus MMT

Position: supine or sitting Fixation: stabilize wrist Test: abduction and slight extension of the first metacarpal bone Pressure: Against lateral surface of the distal end of the first metacarpal in the direction of adduction and flexion

extensor pollicis brevis MMT

Position: supine or sitting Fixation: stabilize wrist Test: extension of MCP joint of thumb Pressure: dorsal surface of the proximal phalanx in direction of flexion

extensor digitorum longus and brevis MMT

Position: supine or sitting Fixation: stabilizes foot in slight PF Test: extension of all joints of the second thru 5th digits Pressure: against dorsal surface of toes in direction of flexion

extensor hallicus longus and brevis MMT

Position: supine or sitting Fixation: stabilizes foot in slight PF Test: extension of metatarsophalangeal and interphalangeal joints of the great toes Pressure: against dorsal surface of the distal and proximal phalanges of the great toe in the direction of flexion **if weak, the ability to DF the ankle joint is decreased

flexor hallicus brevis MMT

Position: supine or sitting Fixation: stabilizes foot proximal to the metatarsophalangeal joint and maintains a neutral position of the foot and ankle Test: flexion of the metatarsophalangeal joint of the great toe Pressure: against the plantar surface of the proximal phalanx, in the direction of extension

flexor digitorum brevis MMT

Position: supine or sitting Fixation: stabilizes proximal phalanges and maintains a neutral position of the foot and ankle Test: flexion of PIP joints of 2nd thru 5th digits Pressure: against plantar surface of the middle phalanx of four toes in direction of extension

flexor hallicus longus MMT

Position: supine or sitting Fixation: stabilizes the metatarsophalangeal joint in a neutral position and maintain the ankle joint approximately midway between DF and PF. If flexor hallicus brevis is very strong and the flexor hallicus longus is weak, it is necessary to restrict the tendency for the metatarsophalangeal joint to flex by holding the proximal phalanx in slight extension Test: flexion of the interphalangeal joint of the great toe Pressure: against the plantar surface of the distal phalanx in the direction of extension

Extensor digitorum longus and brevis MMT

Position: supine or sitting Fixation: stabilizes the metatarsophalangeal joints and maintains the foot and ankle in approx 20 to 30 deg PF Test: extension of the interphalangeal joints of the four lateral toes Pressure: against dorsal surface of the distal phalanges, in direction of flexion

lumbricals and plantar interossei MMT

Position: supine or sitting Fixation: stabilizes the midtarsal region and maintains a neutral position of the foot and ankle Test: flexion of the metatarsophalangeal joints of the 2nd thru 5th digits with an effort to avoid flexion of the interphalangeal joints Pressure: against the plantar surface of the proximal phalanges of the four lateral toes

extensor digitorum, extensor indicis and extensor digiti minimi MMT

Position: supine or sitting Fixation: stabilizes wrist avoiding full extension Test: extension of MCP joints of 2nd thru 5th digits with IP joints relaxed Pressure: dorsal surfaces of proximal phalanges in direction of flexion

flexor digitorum profundus MMT

Position: supine or sitting Fixation: w/ wrist in slight extension, examiner stabilizes proximal and middle phalanges Test: flexion of the distal interphalangeal joint of 2nd third fourth and fifth digits. Each finger is tested Pressure: against palmar surface of the distal phalanx in the direction of extension

lumbricals MMT

Position: supine or sitting Fixation: wrist in slight extension if theres wrist weakness Test: extension of interphalangeal joints with simultaneous flexion of MCP joints (hold piece of paper)

flexor carpi ulnaris MMT

Position: supine or sitting Fixation: forearm in full supination and rests on table or supported by examiner Test: flexion of wrist towards ulnar side Pressure: against hypothenar eminence in direction of extension toward the radial side

tibialis anterior MMT

Position: supine or sitting (with knee flexed if any gastroc tightness is present) Fixation: supports leg above ankle joint Test: DF of ankle joint and inversion of the foot with extension of great toe Pressure: against medial side, dorsal surface of the foot, in direction of PF of the ankle joint and eversion of foot

flexor digitorum longus MMT

Position: supine or sitting. with gastroc tightness, knee should be flexed to permit a neutral position of foot Fixation: stabilizes metatarsals and maintains a neutral position of the foot and ankle Test: flexion of DIP joints of the 2nd thru 5th digits Pressure: against plantar surface of distal phalanges of the four toes in direction of extension

Apprehension test for Anterior shoulder dislocation

Position: supine with arm in 90 deg abduction and 90 deg elbow flexion - Therapist laterally rotates pts shoulder Positive Test: apprehension or facial grimace prior to reaching an end point

Apprehension test for posterior shoulder dislocation

Position: supine with arm in 90 deg flexion and medial rotation. - Therapist applies a posterior force through the long axis of humerus Positive Test: look of apprehension or facial grimace prior to reach an end point

tibialis posterior MMT

Position: supine with extremity in lateral rotation Fixation: supports leg above ankle joint Test: inversion of foot with PF of the ankle joint Pressure: against medial side and plantar surface of the foot, in the direction of dorsiflexion of the ankle joint and eversion of the foot

fibularis longus and brevis MMT

Position: supine with extremity medially rotated, or sidelying on the opposite side Fixation: support leg above ankle joint Test: eversion of the foot with PF of ankle joint Pressure: against lateral border and sole of the foot in the direction of inversion of the foot and DF of the ankle joint

lateral pivot shift test

Position: supine with hip flexed and abducted to 30 deg with slight medial rotation - PT grasps the leg with one hand and places the other hand over the lateral surface of the proximal tibia. PT medially rotates the tibia and applies a valgus force to the knee while the knee is slowly flexed Positive test: palpable shift or clunk occurring between 20 and 40 deg flexion and is indicative of anteriolateral rotatory instability. The shift or clunk results from the reduction of the tibia on the femur

noble compression test

Position: supine with hip slightly flexed and knee in 90 deg flexion - PT places thumb of one hand over the lateral epicondyle of the femur and other hand around pts ankle. PT maintains pressure over the lateral epicondyle while pt is asked to slowly extend the knee Positive Test: pain over the lateral femoral epicondyle at approx 30 deg knee flexion and may be indicative of iliotibial band friction syndrome

True leg length discrepancy test

Position: supine with hips and knees extended, the legs 15-20cm apart and the pelvis in balance with the legs. - Using a tape measure, PT measures from the distal point of the anterior superior iliac spines to the distal point of the medial malleoli. Positive Test: a bilateral variation of greater than 1 cm and may be indicative of a true leg length discrepancy

Barlow's Test

Position: supine with hips flexed to 90 deg and knees flexed - PT tests each hip individually by stabilizing the femur and pelvis with one hand while the other hand moves the test leg into adduction while applying forward pressure posterior to the greater trochanter. Positive Test: click or clunk indicative of a hip dislocation being reduced - This test is a variation of Ortolani's Test

Ortolani's Test

Position: supine with hips flexed to 90 deg with knees flexed - PT grasps the legs so that their thumbs are placed along the pts medial thighs and the fingers are placed on the lateral thighs towards the buttocks. PT abducts the pts hips and gentle pressure is applied to the greater trochanters until resistance is felt at approx 30 deg Positive Test: click or a clunk..indicative of a dislocation being reduced

patella tap test

Position: supine with knee flexed or extended to a point of discomfort - PT applies a slight tap over the patella Positive Test: if the patella appears to be floating and my be indicative of joint effusion

Lachman test

Position: supine with knee flexed to 20-30 deg - PT stabilizes the distal femur with one hand and places the other hand on the proximal tibia. PT applies an anterior directed force to the tibia on the femur. Positive test: excessive anterior translation of the tibia on the femur with a diminished or absent end point and may be indicative of an ACL injury

varus stress test

Position: supine with knee flexed to 20-30 deg. - PT positions one hand on the lateral surface of the pts ankle and the other hand on the medial surface of the knee. PT applies a varus force to the knee with the distal hand Positive test: excessive varus movement and may be indicative of a lateral collateral ligament sprain. Positive test with the knee in full extension may be indicative of damage to the LCL, posterior cruciate ligament, arcuate complex and posteriolateral capsule.

valgus stress test

Position: supine with knee flexed to 20-30 deg. - PT positions one hand on the medial surface of the pts ankle and the other hand on the lateral surface of the knee. PT applies a valgus force to the knee with the distal hand Positive test: excessive valgus movement and may be indicative of a medial collateral ligament sprain. Positive test with the knee in full extension may be indicative of damage to the MCL, posterior cruciate ligament, posterior oblique ligament and posteriomedial capsule.

slocum test

Position: supine with knee flexed to 90 and hip flexed to 45 deg. - PT rotates the pts foot 30 deg medially to test anteriolateral instability. PT stabilizes lower leg by sitting on the forefoot. PT grasps the pts proximal tibia with two hands, places their thumbs on the tibial plateau and administers an anterior directed force to the tibia on the femur. Positive test: movement of the tibia occurring primarily on the lateral side and may be indicative of anterolateral instability. The test can also be performed to assess anteriomedial instability by rotating the pts foot 15 deg laterall.

Anterior Drawer Test

Position: supine with knee flexed to 90 deg and hip flexed to 45 deg - PT stabilizes the lower leg by sitting on the forefoot. PT grasps the pts proximal tibia with two hands, places their thumbs on the tibial plateau and administers an anterior directed force to the tibia on the femur Positive test: excessive anterior translation of the tibia on the femur with a diminished or absent end point and may be indicative of an anterior cruciate ligament injury

posterior sag sign

Position: supine with knee flexed to 90 deg and hip flexed to 45 deg Positive test: tibia sagging back on the femur and may be indicative of a PCL injury

posterior drawer test

Position: supine with knee flexed to 90 deg and the hip flexed to 45 deg - PT stabilizes lower leg by sitting on forefoot. PT grasps the pts proximal tibia with two hands, places their thumbs on the tibial plateau and administers a posterior directed force to the tibia on the femur Positive test: excessive posterior translation of the tibia on the femur with a diminished or absent end point and may be indicative of a Posterior cruciate ligament injury.

Clarke's sign

Position: supine with knees extended - PT applies slight pressure distally with web space of their hand over the superior pole of the patella. pt contracts the quads muscle while PT maintains pressure on patella Positive Test: failure to complete the contraction without pain..indicative of patellofemoral dysfunction

patellar apprehension test

Position: supine with knees extended - PT places both thumbs on medial border of patella and applies a laterally directed force Positive Test: a look of apprehension or an attempt to contract the quads in an effort to avoid subluxation and may be indicative of patella subluxation or dislocation

Thomas Test

Position: supine with legs fully extended - pt brings one of their knees to chest in order to flatten the lumbar spine. PT observes the position of the contralateral hip while the pt holds the flexed hip Positive Test: the straight leg rising from the table and may be indicative of a hip flexion contracture

Patrick's Test (FABER)

Position: supine with test leg flexed, abducted, and laterally rotated at the hip onto the opposite leg - PT slowly lowers the test leg thru abduction towards the table Positive Test: failure of the test leg to abduct below the level of the opposite leg. Indicative of iliopsoas, sacroiliac or hip joint abnormalities

Dermatome Testing - Upper Quarter Screen

Posterior Head - C2 Posterior-lateral neck - C3 Acromioclavicular joint - C4 Lateral arm - C5 Lateral forearm and thumb - C6 Palmar distal phalanx - middle finger - C7 Little finger and ulnar border of hand - C8 Medial forearm - T1

medial or lateral whip

Posthetic causes: -excessive rotation of the knee -tight socket fit -valgus in the prosthetic knee -improper alignment of toe break Amputee Causes: improper training, weak hip rotators, knee instability

Timeline

Pre-prosthetic phase of rehab: immediately post amputation; generally last 6 weeks. PT: focuses on protecting limb, preventing contractures, developing single limb mobility skills and preparing the pt for the prosthetic phase of rehab. Some cases, pt fit w/ IPOP (immediate post operative prosthesis) which allows for immediate weight bearing using a prosthesis. More commonly, pt will be evaluated for first prosthesis once sutures and staples have healed and residual limb skin integrity is intact (4-6 weeks). Once sutures removed, pts can start wearing shrinker (sized by prothetist). After eval, pt will receive first prothestic limb (the temporary prosthesis). Allows pt to participate in prostehtic phase of rehab. In this phase, modifications made to improve comfort and function of prosthesis during weight bearing activities so prosthetist involved. After months of working w/ this, when fit is comfy and appropriate and residual limb volumes stabilized, the permanent prosthesis manufactured. Medicare supports new prosthesis every 5 years and based on activity level of pt, repairs/replacements may needed before this.

Bursae of the knee

Prepatellar, Anserine, Semimembranosus, others include popliteus, gastrocnemius, superficial infrapatellar, deep infrapatellar. Prepatellar: lies over the patella and allows for greater freedom of movement of the skin covering the anterior aspect of the patella Superficial infrapatellar bursa: lies between the patellar tendon and skin Deep infrapatellar bursa lies between the patella tendon and the tibia

Excessive knee flexion during stance

Prosthetic causes: -socket set forward in relation to foot -foot set in excessive dorsiflexion -stiff heel -prosthesis too long Amputee causes: knee flexion contracture, hip flexion contracture, pain anteriorly in residual limb, decrease is quad strength, poor balance

forward trunk flexion

Prosthetic causes: -socket too big -poor suspension -knee instability Amputee causes: hip flexion contracture, weak hip extensors, pain w/ ischial weight bearing, inability to initiate prosthetic knee flexion

rotation of forefoot at heel strike

Prosthetic causes: excessive toe out built in, loose fitting socket, inadequate suspension, rigid SACH heel cushion Amputee Causes: poor muscle control, improper training, weak medial rotators, short residual limb

Vaulting Gait

Prosthetic causes: posthesis too long, inadequate socket suspension, excessive alignment stability, excessive PF Amputee Causes: residual limb discomfort, improper training, fear of stubbing toe, short residual limb, painful hip/residual limb

Abducted gait deviation

Prosthetic causes: prosthesis too long, high medial wall, poorly shaped lateral wall, prosthesis positioned in abduction, inadequate suspension, excessive knee friction Amputee Causes: abduction contracture, improper training, adductor roll, weak hip flexors and adductors, pain over lateral residual limb

Circumducted gait

Prosthetic causes: prosthesis too long, socket too small, excessive knee friction, excessive PF Amputee Causes: abduction contracture, improper training, lacks confidence to flex knee, weak hip flexors, painful anterior distal residual limb, inability to initiate prosthetic knee flexion

lateral bending gait deviation

Prosthetic causes: prosthesis too short, improperly shaped lateral wall, high medial wall, prosthesis aligned in abduction Amputee Causes: poor balance, abduction contracture, improper training, short residual limb, weak hip abductors on prothetic side, hypersensitive and painful residual limb

Hip ORIF

Proximal hip fx commonly occur in femoral neck or in intertrochanteric region. Femoral neck fxs are intracapsular and may lead to disruption of blood supply to femoral head. Because of this, nonunion and osteonecrosis are more common w/ these fxs. Intertrochanteric fxs are extracapsular and dont affect blood supply. implant failure is more of a problem w/ these fxs and fixation needed is greater. Fxs can also occur in subtrochanteric region (distal to trochanters). Fixation usually occurs w/ use of plates, screws or an intrameduallary nail. For older pts w/ poor healing capacity, THA often considered. Always an open procedure for THA and depending on approach, TFL, glut med, and vastus lateralis may be affected. If fx sit is intracapsular, a capsulotomy will be performed. - early weight bearing, weight bearing restriction based on age, location of fx and bone quality. Initial PT: ambulation and ROM. Isotonic strengthening later when muscles heal a bit. Muscles effected depend on sx and site of fx (greater trochanteric fx: glut med...less tronchanter fx iliopsoas). Signs of fixation failure: persistent thigh or groin pain, leg length discrepancy that was not initially present, positioning of limb in ER or trendelenburg sign that doesn't improve w/ strengthening.

Iliofemoral joint

Proximal surface of the iliofemoral joint consists of the acetabulum which is oriented laterally, inferiorly and anteriorly. Distal joint surface consists of the convex head of the femur. Osteokinematic motions: flexion, extension, abduction, adduction, medial and lateral rotation - Loose packed position: 30 deg flexion, 30 deg abduction, slight lateral rotation - Close packed position: full extension, medial rotation - Capsular pattern: flexion, abduction, medial rotation (sometimes medial is most limited)

Bursae of the hip

Psoas (iliopectineal or iliopsoas), trochanteric, ischial (ischiogluteal) Bursae Iliopsoas bursae: located between the anterior joint capsule and iliopsoas tendon Trochanteric Bursae: multiple trochanteric bursae all of which lie between the greater trochanter and the different gluteal muscles ischiogluteal bursae: located between the ischium and the glut max

red flags

Pt must be educated on preventing, Identifying, and reporting issues associated with residual limb ASAP to prevent secondary complications. Includes skin breakdown w/ daily inspections and hygiene, identifying abrasions or wounds that have formed, and discontinuing wearing the prosthesis until the limb has been examined by a physician.

osteogenesis imperfecta

Rare congenital disorder of collagen synthesis. Affects all CT in body, reducing production of collagen by 20-50%. Genes COL1A1 and COL1A2 become mutated. OA can compromise growth, hearing, cardiopulm function and joint integrity. connective tissue disorder that affects formation of collagen during bone development. 4 classifications of osteogenesis imperfecta that vary in levels of severity. 30-50 thousand ppl in US with OI. Etiology: caused by genetic inheritance with type I (mildest form - normal appearance and growth with frequency of fractures ceasing after puberty - present with blue sclera, easy bruising and triangular face with possible hearing loss) and IV (mild - osteoporosis, mild to mod fragility - shorter stature, bowing of long bones, barrel shape chest, brittle teeth, possible hearing loss, normal sclera and normal life expectancy with fx getting better at puberty.) considered autosomal dominant traits. Types II (most severe - child dies in utero or by early childhood - multiple fractures, extreme deformities, soft skull) and III (severe - significant growth retardation, progressive deformities, ongoing fxs, severe osteoporosis, blue sclera, traingular face, and significant limits with functional mobility) considered autosomal recessive traits. Signs and symp: pathological fractures, brittle bones (osteoporosis), hypermobile joints, bowing of the long bones, weakness, scoliosis, impaired respiratory function. Skin biopsy to determine type. X-rays and bone scans for fx. Bone densitometry for bone mass and estimate risk of fx. - Children with OI have delayed developmental milestones due to ongoing fxs, immobilization and laxity of joints with poorly developed muscles. - Type 1 are community ambulators, 57% of type 4 are household ambulators with 26% community, type 3 26% household. Tx: Tx directed at controlling symptoms and goals include maximizing independence with mobility, improving bone mass and muscle strength, and prevention of fxs and deformity. treatment begins at birth with caregiver education on proper handling and facilitation of movement. PT will focus on AROM emphasizing symmetrical movements, positioning, functional mobility, fracture management, and use of orthotics. All strengthening needs to avoid rotational forces, placing weights/resistance near joints and using long lever arms. Swimming is a good alternative. In severe cases where ambulation is not realistic, wheelchair prescription and training and indicated. nutrition and dental care are important. Sx called "rodding" could be indicated if child has more than 2 fxs of same bone within 6 months. Predictor of future ambulation is childs ability to sit by 10 months age. - Arthrogryposis multiplex congenita (AMC) - non progressive neuromuscular disorder that results from multiple conditions that limit fetal movement in an intact skeleton and cause multiple congenital contractures at birth. Born with muscle atrophy and weakness, articular rigidity. Primary forms of AMC include contracture syndromes, amyoplasia and distal arthrogryposis. Ambulation is dependent on progression.

Type 1 Muscle Fibers

Red, Tonic, Slow Twitch, Slow Oxidative, Aerobic Low fatigability, high capillary density, high myoglobin content, smaller fibers, extensive blood supply, large amount of mitochondria Ex.) marathon, swimming

Type 2 Muscle Fibers

Red/White (Type 2a fibers appear red, type 2b appear white), Phasic, Fast Twitch, Fast-glycolytic, Anaerobic High fatigability, low capillary density, low myoglobin content, larger fibers, less blood supply, fewer mitochondria Ex.) sprinting, high jumping

Residual limb

Remaining part of limb following amputation. characterized based on its location and length

Arthrokinematic Motion - distal tibiofibular joint

Resting Position: 0 deg PF Convex: fibula Concave: tibia Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - proximal tibiofibular joint

Resting Position: 0 deg PF Convex: tibia Concave: fibula Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - Talocrural joint

Resting Position: 10 deg PF, midway between max inversion and eversion Convex: talus Concave: tibia and fibula Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - Distal radioulnar joint

Resting Position: 10 deg supination Convex: ulna Concave: radius Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - tibiofemoral joint

Resting Position: 25 deg flexion Convex: femur Concave: tibia Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - patellofemoral joint

Resting Position: 25 deg flexion Convex: patella Concave: femur Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - Hip joint

Resting Position: 30 deg flexion, 30 deg abduction, slight lateral rotation Convex: femur Concave: acetabulum Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - glenohumeral joint

Resting Position: 55 deg abduction, 30 deg horizontal adduction Convex: humerus Concave: glenoid Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - Ulnohumeral joint

Resting Position: 70 deg flexion, 10 deg supination Convex: humerus Concave: ulna Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - proximal radioulnar joint

Resting Position: 70 deg flexion, 35 deg supination Convex: radius Concave: ulna Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - sternoclavicular joint

Resting Position: Anatomical position ***Elevation/Depression*** Convex: Clavicle Concave: Sternum Osteokinematic/Arthrokinematic Motion: Opposite Direction ***Protraction/Retraction*** Convex: Sternum Concave: Clavicle Osteokinematic/Arthrokinematic Motion: Same Direction

Arthrokinematic Motion - radiohumeral joint

Resting Position: full extension, full supination Convex: humerus Concave: ulna Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - subtalar joint

Resting Position: midway between extreme of ROM Convex: anterior and middle talus Concave: anterior and middle calcaneus Osteokinematic/Arthrokinematic Motion: Same Direction Convex: posterior calcaneus Concave: posterior talus Osteokinematic/Arthrokinematic Motion: Opposite Direction

Arthrokinematic Motion - intermetatarsal joint

Resting Position: midway between extremes of Range of movement Convex: more medial metatarsals Concave: more lateral metatarsals Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - temporomandibular joint

Resting Position: mouth slightly open (freeway space) Convex: mandible Concave: temporal bone Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - metatarsophalangeal joint

Resting Position: neutral Convex: metatarsals Concave: phalangeals Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - radiocarpaljoint

Resting Position: neutral with slight ulnar deviation Convex: carpals Concave: radius Osteokinematic/Arthrokinematic Motion: opposite direction

Arthrokinematic Motion - Metacarpophalangeal joints of digits 2-5

Resting Position: slight flexion Convex: metacarpals Concave: phalangeals Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - interphalangeal joints of the toes

Resting Position: slight flexion Convex: proximal phalanges Concave: distal phalanges Osteokinematic/Arthrokinematic Motion: same direction

Arthrokinematic Motion - proximal and sital interphalangeal joints of digits 2-5

Resting Position: slight flexion Convex: proximal phalanges Concave: distal phalanges Osteokinematic/Arthrokinematic Motion: same direction

Support During Gait Cycle

Right Heel Initial Contact - Double support from 0-10% of gait cycle Right single support - single support from 10-50% gait cycle Left heel initial contact - double support from 50-60% gait cycle Left Single Limb support - single support from 60-100% gait cycle until right heel initial contact again Total: Each LE has 60% stance phase, 40% swing phase - Double support = 20% of gait cycle - Single Limb Support - 80% of gait cycle (40% a piece)

pelvic rotation

Rotation of the pelvis occurs opposite the thorax in order to maintain balance and regulate speed. Average for an Adult during gait: 8º (4º forward with swing leg, 4º backwards with stance leg).

intervertebral foramina

Spinal nerves and blood vessels exit the spinal column through the foramina. The size of the intervertebral foramen increases with flexion and contralateral sidebending and decreases with extension and ispilateral side bending. nerve root entrapment can result from closure or narrowing of the intervertebral foramen due to arthritic changes, spurring or narrowing of the intervertebral disks.

Corset

Spine - provides abdominal compression and support. Utilized to provide pressure and relieve pain associated w/ mid and low back pathologies.

Normal gait

Stance phase (60%) 1) Initial Contact/Heel Strike - Erect and Neutral trunk, forward rotation of pelvis, hip flex 30 deg with neutral position, full extension of knee, neutral ankle with heel first contact, neutral position of toes 2) Loading Response/Foot Flat - Erect and Neutral trunk, less forward rotation of pelvis, hip flex 30 deg with neutral position, flexion of knee 15 deg, PF of ankle 15 deg, neutral position of toes 3) Midstance - Erect and Neutral trunk, neutral rotation of pelvis, hip extending to neutral with neutral position (no rotation, adduction or abd), extending to neutral knee, ankle goes from PF to 10 deg DF, neutral position of toes 4) Terminal Stance/Heel Off - Erect and Neutral trunk, 4-5 deg backward rotation of pelvis, hip hyperextension 10 deg with neutral position, full extension of knee, neutral ankle with tibia stable and heel off prior to initial contact of opp foot, neutral position of IP, extending MP 5) Pre-swing/Toe Off - Erect and Neutral trunk, 4-5 deg backwards rotation of pelvis, hip neutral to extension with neutral position, flexion of knee 35 deg, PF of ankle 20 deg, neutral IP and extended MP of toes Swing Phase (40%) 6) Initial Swing/Acceleration - Erect and Neutral trunk, 4-5 deg backwards rotation of pelvis, hip flexion 20 deg with neutral position, flexion of knee 60 deg, PF of ankle 10 deg, neutral position of toes 7) Midswing - Erect and Neutral trunk, neutral rotation of pelvis, hip flexion 20-30 deg with neutral position, flexion of knee 30-60 deg, neutral ankle, neutral position of toes 8) Terminal Swing/Deceleration - Erect and Neutral trunk, forward rotation of pelvis 4-5 deg, hip flexion 30 deg with neutral position, extension of knee 0 deg, neutral ankle, neutral position of toes

Parapodium

Standing frame designed to allow a pt to sit when necessary. Its a prefabricated frame and ambulation is achieved by shifting weight and rocking the base across the floor. Its primarily used by the pediatric population

Iliopsoas MMT sitting

Technique 2 Position: sitting with knees bent over the side of the table. Hold onto table to prevent leaning backwards Fixation: stabilize shoulder on same side of the leg your testing Test: hip flexion with knee flexed, raising thigh a few inches off the table Pressure: against anterior thigh, in direction of extension GEP: sidelying on the opposite side of the leg you are testing and flex hip with knee flexed using a slide board underneath the leg.

Anterior Cruciate Ligament Sprain

The ACL runs from the anterior intercondylar area of the tibia to the medial aspect of the lateral femoral condyle in the intercondylar notch. Ligament prevents anterior displacement of tibia to the femur. Permits up to 500 pounds of pressure before rupture. Ligament has poor blood supply and can't heal with complete tear. Extent of sprain is classified according to extent of ligament damage. Grade 1 involves microscopic tears, Grade 3 is completely torn (in middle of ligament) with excessive laxity. Etiology: Noncontact twisting injury with hyperextension, hyperflexion, rapid deceleration, varus or valgus stress to the knee or landing in an unbalanced position. Often involves injury to medial capsule, medial collateral ligament and menisci. 2/3 of time theres an ACL tear, it comes with accompanying meniscal tear. collateral ligaments may be involved but not as common as meniscus. When ACL, MCL and medial meniscus are damaged, "unhappy triad". sports requiring high levels of agility (vball, bball, soccer) or high contact sports (football) increases risk. Women in sports have a much higher risk. Increased risk also includes body movement, positioning, muscle strength, joint laxity, Q ankle and a narrow intercondylar notch. Peak is 14-29 years - most active. Signs and symptoms: Pt may report a loud pop or feeling the knee "giving way" or "buckling" indicates complete tear followed by dizziness, sweating and swelling. Complete tear comes with significant pain, effusion, edema and significant limited ROM. May or may not be able to bear weight. Special tests for ACL tear are anterior drawer test, lachman test, and lateral pivot shift test. MRI used for dx, x-ray used to rule out fracture. Perform all tests bilaterally. Treatment: Management includes controlling edema, increasing ROM, strengthening and improving fluidity of gait. For those having sx, patellar tendon most utilized graft for intra articular reconstruction. Pts also initially present with knee immobilizer and crutches to protect the reconstructed ligament. RICE, NSAIDS, and analgesics initially. Initial PT involves protecting integrity of the graft, controlling edema and improving ROM. Pain modulation, patellar mobility, AROM, gait activities, and quad exercises are interventions. As pt progresses, closed chain strengthening exercises are focus with selected functional activites. Closed chain more desirable cuz they minimize anterior translation of the tibia. Pts need to complere a functional progression prior to return to sport. Aggressive strengthening program necessary once acute phase over for those not electing sx but they will be at risk for instability and subsequent deterioration of joint surfaces. Return to previous level of function in 4-6 months for sx pts. - LE strengthening exercises emphasizing quads and hamstrings. Surgery is warranted for complete (grade 3) ACL tear. Sx consists of intra-articular reconstruction using patellar tendon, IT band or hamstrings tendon. Derotation brace my be beneficial with ACL deficient knee however has limited benefits for pt following surgical reconstruction.

myodesis

The anchoring of muscle tissue or tendon to bone using sutures that are passed through small holes drilled in the bone. This procedure is performed as part of the amputation closure process.

Glenohumeral joint

The synovial ball-and-socket joint of the shoulder; 3 degrees of freedom; formed by the convex head of the humerus and the concave glenoid fossa. the relatively small articular surface of the glenoid fossa in relation to the size of the humerus head makes the glenohumeral joint inherently unstable. - Osteokinematic motions: flexion, extension, abduction, adduction, medial and lateral rotation - Loose packed position: 55 deg abduction, 30 deg horizontal adduction - Close packed position: abduction and lateral rotation - Capsular pattern: lateral rotation, abduction, medial rotation

Pistoning

The translation of the prosthetic limb from the residual limb. It is the result of inadequate suspension and can result in distal residual limb skin issues

cubital fossa

The triangular area anterior to the elbow, bounded by a line between the bony epicondyles of the humerus on each side, and framed below by pronator teres and brachioradialis muscles Contains several structures including the biceps brachii tendon, median nerve, radial nerve, brachial artery and median cubital vein

Uncovertebral joints (Joints of Luschka - or the uncinate processes)

The uncovertebral joints are formed between the lateral projections on the inferior surface of one vertebra and the lateral projections on the superior surface of the vertebra below it. These are found between C3 and T1. Function to guide motion in the sagittal plane and limit motion in the other 2 planes.

digastric muscle

This muscle depresses the mandible. When one opens their mouth they are depressing the mandible. Retracts mandible as well.

Exoskeletal shank

This type of shank consists of a rigid external frame covered with a thin layer of tinted plastic to match the skin color distally

Endoskeletal shank

This type of shank consists of a rigid pylon covered with a material designed to simulate the contour and color of the contralateral limb.

Principles of stretching - viscoelasticity

Time dependent property of soft tissue that initially resists deformation, such as change in length, of the tissue when a stretch force is first applied, but allows for tissue elongation as the stretch is held for longer duration. As with elasticity, the tissue will return to its previous length after the stretch is no longer applied

Capillary Refill Test

Time is takes for the capillary bed to refill after it is occluded by pressure is an indicator of impaired perfusion to the extemities. Procedure: apply firm pressure over nail bed or bony prominence until nail or skin blanches, release the pressure, observe time to regain full color Interpretation: Normal = full color returns in < 2 sec Abnormal = refill time > 2 sec; indicates BF is compromised (arterial occlusion, hypovolemic shock, hypothermia)

pectoralis major

Together: Adduction and medial rotation of humerus...depression of scapula Clavicular Head: flexion of the humerus Sternocostal Head: Extension of humerus from a flexed position

Trochanteric Bursitis

Trochanteric bursa located between femoral trochanteric process, glut med, and the iliotibial tract. can be acute (contusion w/ direct impact from falls or sports) or from cumulative trauma (running producing friction between bursa and IT band) to lateral hip causing irritation to tronchanteric bursa. Pathology doesnt involve actual hip joint. Factors that contribute to onset are true or functional leg length discrepancy, history of lateral hip sx, and participation in sports that involve significant amount of running or contact. Greater in women who are active, can also happen in sedentary ppl. - Classic symptom is pain at lateral hip which may radiate to lateral aspect of thigh. Point tenderness and reproduction of pain are typical w/ palpation. Symptoms exacerbated by weight bearing activity or direct pressure on affected area. Passive hip movement involving lateral rotation and abduction or resisted hip flexion and abduction are likely to reproduce symptoms. Pts may also c/o pain related weakness in affected LE. Exam should r/o similar dxs (sciatic pain, iliotibial band syndrome, femoral head avascular necrosis) - Tx includes Pharm - anti-inflammatory or anesthetic agent which may be used in comb w/ local injection into trochanteric bursa (many pts require multiple injections). Multiple injections in combo with other conservative interventions for full symptom resolution. PT emphasize stretching (especially IT band, TFL, lateral hip rotators, quads and hip flexors.) Soft tissue massage, iontophoresis, phonophoresis, and palliative interventions such as TENs. Education regarding activity mod and stretching techniques. Gait abnormalities such as leg length discrepancies or antalgic gait patterns should be addressed appropriately w/ ADs, orthotics, heel lifts or bracing. Athletes should be educated on all this along with appropriate protective padding for contact sports and avoidance of excessive unidirectional activities. Sx uncommon and for those who conservative fails and have delibitating disabilities. Home cares consists of rest, ice, NSAIDs and ther ex. Need to avoid exacerbating activities that may perpetuate inflammatory symptoms during recovery. Combo of local injections and PT has been very successful. In some pts, symptoms of pain, altered gait and sleep disturbances associated w/ rolling onto affected side may become chronic.

Ulnar collateral ligament sprain - thumb

UCL sprain of thumb is most common ligament injury of hand. occurs secondary to traumatic even in which excessive valgus force is applied to the MCP joint of thumb. "gamekeepers thumb" or "skier's thumb". UCL is on medial side of thumbs MCP joint and acts as an important stabilizer of the thumb. Grade of the sprain indicates extent of injury to the ligament. Grades 1 and 2: majority of ligament intact. Grade 3 sprain involves complete tear. - Signs and symptoms: pain, tenderness, ecchymosis (discoloration of skin from bleeding underneath) and swelling near thumb's MCP joint, specifically on medial side. Other symptoms are instability of the joint and weakness w/ grasping objects. X-rays r/o fx. PT should assess integrity of UCL by performing ligament stability testing of thumb. When applying a valgus force to the MCP joint, a movement of greater than 30-35 deg indicates a complete tear of the UCL.

Aerobic Metabolism or Oxygen System

Used during low intensity, long duration exercise such as running a marathon. Yields by far the most ATP of the three systems but requires series of complex chemical reactions. - Provides energy through the oxidation of food and provides energy as long as there is nutrients to utilize. The combination of fatty acids, amino acids, and glucose with oxygen releases energy that forms ATP

Anterior Compartment Syndrome

When the pressure of the anterior compartment of the lower leg increases secondary to swelling. This increase in swelling results in occlusion of BF which may cause ischemia and necrosis of the surrounding nerves and musculature. Acute compartment syndrome is a medial emergency often caused by traumatic injury and can lead to irreversible muscle damage. Chronic compartment syndrome most often occurs secondary to athletic exertion and is typically not a medical emergency. - This condition affects anterior compartment of lower leg which consists of tib anterior, extensor hallucis longus, extensor digitorum longus and peroneus tertius muscles. Fascia doesnt stretch so increase in pressure causes increased compression on capillaries, nerves and muscles in anterior compartment and if not relieved, irreversible damage to nerves and muscles may result secondary to ischemia. - tightness and tenderness over muscle belly of tib anterior that doesnt decrease w/ elevation or pain meds. Pain increases w/ passive stretching or active use of muscle. Pt also likely to experience paresthesias and/or numbness in distribution of deep peroneal nerve. Physicians test compartment syndrome w/ needle or catheter. In case of chronic compartment syndrome, measurements can be compared before and after exercises. Exam needs to r/o DVT, fx and peripheral nerve injury.

spiral fracture

a break in a bone shaped like an "S" due to torsion and twisting

Atlanto-occipital joint

a condylar synovial joint that permits flexion and extension of the cranium. Noted when nodding Capsular Pattern: Extension, side flexion equally limited

Gracilis

adducts thigh

Lateral Collateral Ligament (LCL)

a ligament that attaches to the femur (lateral epicondyle) and the fibula (fibular head); maintains stability of the lateral aspect of the knee joint and prevents excessive varus displacement of the tibia relative to the femur - May be injured with a pure varus load at the knee without rotation. often happens with contact activities that has medial blow to the knee. Rarely torn without a concurrent injury to ACL or PCL. Special Tests: Varus Stress test

isokinetic contraction

a muscle contraction produced by a variable external resistance at a constant speed

rotator interval

a space in the anterosuperior shoulder that consists of and is bordered by the coracohumeral ligament, superior glenohumeral ligament, joint capsule and the supraspinatus and subscapularis tendons

knee

a synovial joint consisting of three bones (femur, tibia, patella) and two primary articulations (tibiofemoral, patellofemoral) enclosed within a single joint capsule. Hinge joint formed by the articulation of the tibia within the femur, with two degrees of freedom

Elbow

a synovial joint consisting of three bones (humerus, radius and ulna) and three primary articulations (radiohumeral, ulnohumeral, and proximal radioulnar joints) enclosed within a single joint capsule. Elbow is classified as a hinge joint formed by the articulation of the ulna with the humerus

rheumatoid arthritis

a systemic autoimmune disorder of unknown etiology. presents w/ chronic inflammatory reaction in synovial tissues of joint that results in erosion of cartilage and supporting structures within capsule. Onset may occur at any joint but its common in small joint of hand, foot, wrist and ankle. Disease has periods of exacerbation and remission. Dx based on clinical presnetation of involved joints, presence of blood rheumatoid factor and radiographic changes. Etiology: unknown. 1-2% of America is affected. Women 3x more likely than men..common age is 40-60 Signs and symptoms: may be gradual or immediate symptoms. symmetrical involvement, pain and tenderness of affected joints, morning stiffness, warm joints, decrease in appetite, malaise, increased fatigue, swan neck deformity (DIP flexion, PIP hyperextension), boutonniere deformity (DIP extension, PIP flexion) low grade fever. Tx: Goal: reduce inflammation and pain, promote joint function and prevent joint destruction and deformity. Pharmacological management includes NSAIDs to reduce inflammation and pain. Corticosteroids may be desireable during severe flare ups or when the pts condition is not responding to NSAIDs. Disease modifying antirheumatic meds are slow acting and take weeks to months to become affective however they have the ability to slow the progression of joint destruction and deformity. PT include PROM, AROM, heading and cooling agents, splinting, pt ed, energy conservation, body mechanics and joint protection techniques.

adductor brevis

adducts thigh

Anterolateral approach THA

access to hip occurs thru interval between tensor fasciae latae and glut med muscle. Some portion of hip abductors are released from greater trochanter and hip is dislocated anteriorly Hip precautions: avoid flexion of hip beyond 90 deg, extension of hip, lateral rotation and adduction

Sprain

acute injury to a ligament Grade 1: mild pain and swelling, little to no tear of the ligament Grade 2: moderate pain and swelling, minimal instability of joint, minimal to moderate tearing of ligament, decreased ROM Grade 3: severe pain and swelling, substantial joint instability, total tear of ligament, substantial decrease in ROM

Tendonitis

acute or chronic inflammation of a tendon. Symptoms: gradual onset, tenderness, swelling and pain.

Bursitis

acute or chronic inflammation of bursa. Symptoms: limitations in AROM secondary to pain and swelling.

Adductor Hallucis

adducts great toe

Manual Muscle Testing (MMT)

allows therapist to assign specific grade to a muscle, based on whether patient can hold the limb against gravity, how much manual resistance can be tolerated and whether joint has full ROM

Congenital Hip Dysplasia

also known as developmental dysplasia...characterized by malalignment of femoral head in acetabulum. develops during last trimester in utero Etiology: malposition in utero, environmental and genetic influences, cultural predisposition Signs and symptoms: asymmetrical hip abduction with tightness and femoral shortening on involved side. Ortolanis test, Barlow's Test, and diagnositic ultrasound to dx. Treatment: dependent on age, severity and initial attempts to reposition femoral head thru use of harness, bracing, splinting, traction. Open reduction with application of hip spica cast may be required if conservative tx fails. PT indicated after cast removal for stretching, strengthening and caregiver education.

flexor retinaculum

also known as transverse carpal ligament - a ligamentous structure that crosses the palmar aspect of wrist forming the most anterior aspect of the carpal tunnel. Retinaculum prevents the tendons from "bowstringing" as wrist is flexed. Also serves as attachment site for the thenar and hypothenar muscles.

Range of Motion (ROM)

amount of mobility available at a single joint - may be affected by structure of joint of soft tissue extensibility surrounding joint - ROM classified as passive, active-assisted or active

traumatic amputation

amputation performed secondary to a direct injury. A car accident or gunshot wound are potential examples of injuries resulting in traumatic amputation.

L-Test

amputee mobility..very similar to TUG but these are diff.. 1) 90 deg turn after initial 3m 2) total length ambulated is 20m, not 6m 3) 4 turns involved - mean times established based on amputation level, age, and use of AD - useful to supplement or use w/ other functional outcome measures cuz its easy to administer

Heel wedge

applied to medial heel to prevent excessive hindfoot eversion or to the lateral heel to prevent excessive hindfoot inversion. Used to treat symptoms associated w/ pes planus or pes cavus

joint capsule of the shoulder

arises from the glenoid fossa and the glenoid labrum to blend with the muscles of the rotator cuff. Volume of the joint capsule is twice as large as the size of the humeral head. Capsule is reinforced by the glenohumeral ligaments and the coracohumeral ligament.

brachial plexus

arises from the nerve roots of C5 through T1. These nerve roots combine to form trunks, then later divide to form divisions, cords, and finally the peripheral nerves. These nerves that arise provide innervation to the entire upper quarter.

Coccyx

articulates with the sacrum and consists of four small fused vertebral bodies. Does not have a specific purpose and is considered an embryological remnant.

distal tibiofibular joint

articulation between the distal fibula and the fibular notch of the tibia

prosthesis

artificial body part, used as a noun, not an adjective. For example, "My prosthesis is broken"

Functional outcome measures

assess locomotor or physiological abilities of pt thru physical tasks

transverse humeral ligament

attaches to greater and lesser tubercles of the humerus, bridging over the intertubercular sulcus (bicipital groove); crosses anterior to the tendon of the long head of the biceps brachii muscle and helps maintain this tendon in the bicipital groove

Close chain exercise

body moving over a fixed distal segment. ex.) squat lift

costoclavicular ligament

band of connective tissue that unites the medial clavicle with the first rib. primary supporting ligament for the sternoclavicular joint

transtibial amputation

below knee amputation - loss of active foot and ankle motions - weight bearing in the prosthesis should be distributed over the total residual limb - areas of primary weight bearing should be pressure tolerant - adaptations required for balance - susceptible to both knee and hip flexion contractures

lateral hamstrings MMT

biceps femoris flex and laterally rotate the knee joint Position: prone Fixation: hold thigh down firmly on table Test: flexion of knee between 50 and 70 deg with thigh in slight lateral rotation and leg in slight lateral rotation on thigh Pressure: against leg, proximal to the ankle, in the direction of knee extension. Dont apply pressure against the rotation component.

Deep vein thrombosis

blood clot forms in a large vein..potential to dislodge as embolism and travel until is blocks artery. Heparin is an anticoagulant commonly used to reduce risk of DVT following sx.

compound fracture

bone breaks through the skin

comminuted fracture

bone that breaks into fragments at the site of injury

genu varum

bowing of the legs w/added space between the knees while standing w/the feet together. Genu varum increases compression of medial tibial condyle and increases stress to the lateral structures. Genu varum is termed bowleg.

stress fracture

break in a bone due to repeated forces to a particular portion of the bone

nonunion fracture

break in a bone that has failed to unite and heal after 9-12 months

closed fracture

break in a bone where skin over the site remains intact

greenstick fracture

break on one side of a bone that does not damage periosteum on opposite side. often seen in children.

Sacrum

broad thick bone consisting of five fused vertebrae that fixate the spinal column to the pelvis. Main functions of the sacrum are to provide an attachment for the iliac bones and to protect the pelvic organs. The sacrum is attached to the pelvic by strong ligaments forming the sacroiliac joint.

shoulder stabilization surgeries

capsular shift sx: presence of chronic shoulder instability - tighten joint capsule by cutting capsule and overlapping ends to reduce capsular redundancy. Also electrothermally assisted sx where thermal energy shrinks and tightens capsular tissue. Portion of capsule tightened dependant on direction of instability. Anterior capsule mostly due to anterior stability most common. labral repairs: labral tears accompany dislocation injuries a lot. Bankart repair: repair anterior labrum. SLAP repair: superior labrum. both generally performed arthroscopically. Can be open (subscap m may need to be detached) - If anterior capsule affected: normal sling. Avoid ER, extension and horizontal abduction. resisted IR if subscap detached. - If posterior capsule: immobilized in hand shake position w/ shoulder in neutral rotation. Avoid IR, flexion and horizontal adduction. - Initial PT: AROM and eventually strengthening when some AROM comes back. If SLAP repair, pt should avoid contracting or stretching biceps since its attached to superior labrum.

Triangular Fibrocartilage Complex (TFCC)

cartilaginous disc that sits between the ulna, lunate and triquetrum. Disc provides stability to the wrist joint, connecting the radius and ulna together and allowing for better distribution of forces through the wrist.

Ballistic stretching

characterized by quick, jerky movements that result in a rapid change in muscle length. Muscle is placed near end ROM and then pt bounces back and forth to place repetitive stretch on the muscle (high intensity, short duration). because it occurs quickly, it activates the muscle spindles and results in greater resistance to stretch therefore is not as effective for improving extensibility but its effective for preparing muscles for athletic activity. More likely to lead to muscle soreness and injury due to high intensity of stretch force.

psychological impact

common for pts to have negative thoughts and emotions following amputation. Can include grief, denial, anxiety, depression and suicidal feeling. May be elevated in pts w/ emergency amputations since they havent had time to mentally prepare for loss.

Pes anserine

common insertion of the sartorius, gracilis, semitendinosus. Located medial and distal to the tibial tuberosity. Pain and/or swelling in this region may indicate the presence of pes anserine bursitis

Hip hiking during swing

compensation for weak dorsiflexors, compensation for weak knee flexors, compensation for extensor synergy pattern

coracoclavicular ligament

connects the clavicle to the coracoid process. Consists of the conoid and trapezoid ligaments. Acts as the primary support of the AC joint, limiting superior translation of the clavicle

sacrospinous ligament

connects the ischial spine to the lateral sacrum and coccyx and also has fibers that blend with the fibers of the sacrotuberous ligament. functions to limit anterior rotation of the sacrum on the pelvis.

ligamentum flavum

connects the lamina of one vertebra to lamina of the vertebra above it serves to limit flexion and rotation of the spine

iliolumbar ligament

connects the posterior portion of the ilium to the transverse process of the L5 vertebra and function to limit all motions between L5 and S1

interosseous sacroiliac ligament

connects the sacrum and the ilium and is located deep to the posterior sacroiliac ligament. Is strong and functions to resist anterior and inferior movements of the sacrum.

arcuate ligament complex

consist of the arcuate ligament, oblique popliteal ligament, LCL, popliteus tendon, lateral head of gastroc assists cruiciate ligaments in controlling posterolateral rotatotory instability of the knee and provides support to the posterolateral joint capsule

interosseuous membrane of leg

consists of a strong fibrous tissue that serves to fixate the fibula to the tibia. Distally, the structure blends into the anterior and posterior tibiofibular ligaments and provides additional support at the distal tibiofibular syndesmosis joint

iliofemoral ligament

consists of a thickened portion of the articular capsule that extends from the anterior inferior iliac spine of the pelvis to the intertrochanteric line of the femur. Considered the strongest ligament of the body, serves to prevent excessive hip extension and assists to maintain upright posture.

ischiofemoral ligament

consists of a thickened portion of the articular capsule that extends from the ischial wall of the acetabulum to the neck of the femur. Weakest of the three ligaments, serves to reinforce the articular capsule.

pubofemoral ligament

consists of a thickened portion of the articular capsule that extends from the pubic portion of the rim of the acetabulum to the neck of the femur. The structure serves to prevent excessive abduction of the femur and limits hip extension

annular ligament

consists of band of fibers that surrounds the head of the radius. Allows the head of the radius to rotate and retain contact with the radial notch of the ulna

Proximal radioulnar joint

convex rim of the head of radius articulates with concave radial notch of ulna - Osteokinematic motions: pronation, supination - Loose packed position: 70 deg elbow flexion, 35 deg supination - Close packed position: 5 deg supination - Capsular pattern: supination, pronation

Muscle Fatigue

decreased ability of a muscle to produce force against a load with increasing reps. Muscle fatigue is reversible (strength will improve after a period of rest). Fatigue will depend on fiber distribution in muscle. Type 1 (slow twitch) generate low force for long durations while type 2 (fast twitch) produce large amounts of force over short durations. - signs and symptoms of excessive fatigue include muscle pain and cramping, tremors, movement that becomes slow and jerky, inability to complete full movement pattern and use of substitution patterns..decrease load or take rest break if signs are noticed..if pt continues exercising in presence of excessive muscle fatigue, could lead to further injury. - pt with certain neuromuscular disorders (myasthenia gravis, multiple sclerosis) may fatigue more quickly...pushing these pts to point of fatigue may actually result in worsening their symptoms - pts with cardiovascular or pulmonary disease fatigue more quickly and may need longer recovery periods during exercise.

anatomical snuff box

depression found on the dorsal surface of the wrist near the distal radius. bordered by tendons of the abduction pollicis longus, extensor pollicis brevis, and extensor pollicis longus. Location often used for palpation of scaphoid when there is concern for a fracture.

Reciprocating Gait Orthosis (RGO)

derivative of HKAFO and incorporates a cable system to assist w/ advancement of the LEs during gait. When pt shifts weight onto a selected lower extremity, the cable system advances the opp LE. Used primarily for pts w/ paraplegia.

milwaukee orthosis

designed to promote realignment of spine due to scoliotic curvature. Custom made extends from pelvis to upper chest. Corrective padding applied to areas of severity of curve

Convex-Concave Rule

determines the direction of decreased joint gliding and the appropriate direction for the mobilizing force

Medial Collateral Ligament (MCL)

distal end of femur (slightly above medial femoral condyle) to proximal end of tibia (medial aspect of the shaft of the tibia)...deep fibers are attached to the medial meniscus; major purpose is to prevent excessive valgus displacement of the tibia relative to the femur - may be injured with a pure valgus load at the knee without rotation. sustained usually in contact activities with lateral blow to knee. injury to MCL often involves other structures like ACL or medial meniscus Special Tests: Valgus Stress Test

step length

distance between the heel strike of one foot and the heel strike of the other foot. Avg for adult is 28 inches

stride length

distance measured between right heel strike and the following right heel strike. Avg for an adult is 56 inches (double step length)

Peroneus Tertius

dorsiflexion, eversion

pectoralis minor

downwardly rotates and protracts scapula

Principles of stretching - Creep

due to the viscoelastic property, soft tissue that is stretched for a sustained duration will elongate and not return to its original length after the load has been removed. The principle of creep is the basis for stretching

No toe off

forefoot/toe pain, weak PF, weak toe flexors, insufficient PF ROM

subtalar joint (talocalcaneal)

formed by 3 articulation (anterior, middle, posterior) between the talus and calcaneus. 1 deg of freedom. The anterior and middle articulations are formed by two convex facets on the talus and two concave facets on the calcaneus. Posterior articulation is formed by a concave facet on the inferior surface of the talus and a convex facet on the body of the calcaneus. Osteokinematic motions: inversion, eversion Loose Packed Position: midway between extremes of range of motion Close Packed Position: supination Capsular Pattern: limitation of varus range of movement

intervertebral discs

formed by a dense layer of collagen fibers and fibrocartilage called the annulus fibrosus as well as a flexible inner layer called the nucleus pulposus. The annulus fibrosis is firmly attached to the adjacent vertebrae and provides tensile strength to the disk during spinal movement. The nucleus pulposus is a gelatinous mass located centrally in the disk. Flexion of a vertebral segment causes the anterior portion of the disk to be compressed and the posterior portion to be distracted.

Ankle and foot

formed by a series of unique articulations including the distal tibiofibular joint, talocrural joint, subtalar joint, midtarsal joint, and forefoot

scapulothoracic articulation

formed by body of the scapular and muscles covering the posterior chest wall. motion consists of sliding of scapula on thorax. Not a true anatomical joint because it lacks the necessary synovial joint characteristics

deltoid ligament

formed by the anterior tibiotalar ligament, tibiocalcaneal ligament, posterior tibiotalar ligament, and tibionavicular ligament. the ligament provides medial ligamentous support by resisting eversion of the talus

patellafemoral joint

formed by the convex patella and the concave trochlear groove of the femur. The patella slides superiorly in knee extension and inferiorly in knee flexion. Patella rotation and tilting also occur during knee extension and flexion

Ulnohumeral joint

formed by the hourglass-shaped trochlea of the humerus and the trochlear notch of the ulna - Osteokinematic motions: flexion, extension - Loose packed position: 70 deg elbow flexion, 10 deg supination - Close packed position: extension - Capsular pattern: flexion, extension

sacral plexus

formed by the lumbosacral trunk, the ventral rami of S1-S3 and the descending portion of S4. supplies the muscles of the buttocks and through the sciatic nerve, innervates the muscles of the posterior thigh and lower leg.

lumbar plexus

formed by the nerve roots of T12 and L1-L4. innervates the anterior and medial muscles of the thigh and the dermatomes of the medial leg and foot. The largest and most important branches of the plexus are the obturator and femoral nerves.

cubital tunnel

formed by the ulnar collateral ligament, the flexor carpi ulnaris, the medial head of the triceps, and the medial epicondyle. The ulnar nerve runs through the cubital tunnel. The cubital tunnel becomes smallest with the elbow held in full flexion

hip internal rotation MMT

gluteus minimus, gluteus medius, and tensor fascia latae Position: sitting with knees bent over table and holding onto table Fixation: stabilize medial side of the thigh/knee (counterpressure) Test: medial rotation of thigh with leg in a position of an outward motion Pressure: examiner applies pressure to the lateral side of the leg, above the ankle, pushing the leg inward in an effort to rotate the thigh laterally GEP: No GEP

strength

greatest amount of force that can be produced within a single contraction, which may be assessed clinically by determining pts 1 RM (max amount of weight that can be lifted once)

sacrotuberous ligament

has several attachment sites included the PSIS, lateral sacrum, coccyx, and ischial tuberosity. The ligament primarily functions to resist sacral anterior rotation and prevent superior translation of the sacrum

cruciform ligament

has vertical and horizontal portions. Vertical portion connects the dens of the axis to the foramen magnum. Horizontal connects the dens with the atlas. this ligament functions to limit upper cervical flexion as well as translation of the atlas on the axis.

talocrural joint

hinge, synovia joint formed by the distal tibia, talus, and the fibula. the talocrural joint offers significant stability in dorsiflexion however it becomes much more mobile with plantarflexion Osteokinematic motions: dorsiflexion, plantarflexion Loose Packed Position: 10 deg plantarflexion, midway between max inversion and eversion Close Packed Position: max dorsiflexion Capsular Pattern: plantarflexion, dorsiflexion

Infraspinatus

horizontal abduction and lateral rotation of arm; one of the 4 rotator cuff muscles

teres minor

horizontal abduction and laterally rotates arm; one of the 4 rotator cuff muscles

Densitometry

hydrostatic weighing - calculates density of the body by immersing a person in water and measuring amount of water displaced. % of body fat calculated by calculating the measured water displaced in an equation based on achimedes principle. Most widely used lab procedure to determine body density. Limitations are the need to account for residual lung volume during submersion and pt toleration of water submersion. Standard error = 2-2.5% plethysmography - calculates density of body by utilizing the amount of air displaced during testing within a specialized closed chamber. CHange in pressure within the chamber is measured and converted to % of body fat using a standardized equation

Hypersensitivity

hypersensitivity of residual limb can significantly impede or even prevent the appropriate fit and functional use of a prosthesis. Specific desensitization techniques and early fitting of a temporary prosthesis are key components in post ambulation rehab. Weight bearing, massage, tapping, and residual limb wrapping are all commonly used interventions to facilitate desensitization.

erector spinae muscles

iliocostalis, longissimus, spinalis bilaterally Extend the back, provide ipsilateral trunk rotation and lateral flexion

tibiofibular joint

immovable synarthrosis Capsular Patter: pain when joint stressed

Resistance Training Principle - overload principle

in order for a muscle to adapt and become stronger, the load that is placed on it must be greater than what it is normally accustomed to. In resistance training, volume (sets, reps) or intensity (resistance) of exercise can be altered to challenge muscle

edema

increased volume of fluid in soft tissue outside joint capsule

effusion

increased volume of fluid within a joint capsule

Hip-Knee-Ankle-Foot Orthosis (HKAFO)

indicated for pts w/ hip, foot, knee, and ankle weaknesses. Consists of bilateral knee-ankle-foot orthoses w/ an extension to hip joints and a pelvic band. Orthosis can control rotation at hip and abduction/adduction. Orthosis is heavy and restricts pt to a swing- to or swing thru gait pattern.

plantar fasciitis

inflammation of the plantar fascia at the proximal insertion on the medial tubercle of the calcaneus. Plantar fascia is a broad structure comprised of CT which spans from the calcaneus to the metatarsal heads. The structure is designed to provide support to arch of the foot. Excessive tension over time creates chronic inflammation and microtears at the proximal insertion of the plantar fascia. chronic overuse condition to repetitive stretching of plantar fascia thru excessive foot pronation during loading phase of gait. The abductor hallucis, flexor digitorum brevis and quadratus plantae muscles share same origin on medial tubercle of calcaneus and may also become inflamed and irritated. Etiology: associated with acute injury from excessive loading of foot or chronic irritation from an excessive amount of pronation during gait or prolonged duration of pronation. Tightness of foot and calf muscles, obesity, and possessing high arch as well can cause. Endurance sports, job of prolonged standing and walking increase risk. Most commonly in pts 40-60 years old Signs and symp: tenderness at the insertion of the plantar fascia, presence of heel spur (bony hypertrophy at origin of plantar fascia - plantar fasciatis is a relative of heel spur syndrome), pain that is worse in morning in the heel after first standing up in morning (fascia is contracted, stiff and cold) or after periods of prolonged activity, difficulty with prolonged standing, and pain when walking in bare feet. Most common symptoms that relates to dx is radiating pain up calf or into toes where 84% of cases have this. sometimes pain decreases during non weight bearing and starts again when weight bearing. Point tenderness on calcaneal insertion of plantar fascia. Tightness in achilles tendon found in majority of pts. Pt's sometimes describe pain as "moving around foot". Tx: RICE, NSAIDs, and analgesics initially. Local cortiocosteroid injections could be used as well. Heel cup, massage using a tennis ball or rolling pin, ice massage, deep friction massage, medial longitudinal arch taping, and joint mobs. Prevention includes heel cord stretching, use of appropriate soft soled footware, heel inserts, foot orthotic prescription and avoiding sudden changes in intensity of training programs. Modification of activities to include non-weightbearing endurance activities, plantar fascia stretching and achilles tendon stretching. After acute phase, intrinsic and extrinsic muscle strengthening. Orthotics may be used to minimize hyperpronation. Night splints and stretching of gastroc and plantar fascia at home. Initially treated by symptoms, if pain lasts 6-8 weeks, MRI confirms dx. Return to previous function in 8 weeks, total resolution up to 12 months. At risk for further plantar fasciitis. - Tarsal tunnel syndrome - tarsal tunnel is where tibial nerve passes between medial malleolus and calcaneus. Nerve splits into medial and lateral plantar nerves while in tunnel. TT syndrome characterized by pain with weight bearing but not with direct palpation to plantar fascia...c/o numbness, burning pain, tingling, and paresthesias at heel. Etiology - entrapment and compression of posterior tibial nerve or plantar nerves within tarsal tunnel due to inflammation or thickening of flexor retinaculum

acromioclavicular joint

irregular joint between the acromion process of the scapula and the lateral end of the clavicle. plane synovial joint with 3 deg of freedom - Osteokinematic motions: anterior and posterior tilting, upward and downward rotation, protraction and retraction - Loose packed position: arm resting by the side - Close packed position: arm abducted to 90 - Capsular pattern: pain at extremes of range of movement

Resistance Training Parameters - intensity of resistance training

is determined by amount of weight being used which will also determine # of reps able to perform. Amount of weight expressed as % of 1 rep max. Intensity chosen depends on goals of the training program. - to increase strength, lower reps of higher intensity loads - to increase endurance, higher reps (20+) or lower intensity load prescribed - Increase power, low reps (1-3) of very high intensity loads are used

pubic symphysis

joint between the two pubic bones. Ends of the bones are covered in hyaline cartilage with a fibrocartilage disk between them. Motion at this joint is very limited.

Insufficient knee flexion with swing

knee effusion, quad extension spasticity, PF spasticity, insufficient flexion ROM

Exaggerated knee flexion at terminal stance

knee flexion contracture, hip flexion contracture

genu valgum

knees touch while standing with feet separated. will increase compression of lateral tibial condyle and increase stress to medial structures. also called knock-knee.

Osgood-Schlatter disease

known as traction apophysitis, a self limiting condition that results from repetitive traction on the tibial tuberosity apophysis Etiology: repetitive tension to the patellar tendon over tibial tuberosity in young athletes. Can result in small avulsion of the tuberosity and subsequent swelling Signs and symp: point tenderness over patella tendon at insertion on tibial tubercle, antalgic gait, pain w/ increasing activity Tx: education, icing, flexibility, and eliminating activities that place strain on patella tendon (squatting, running, jumping)

grade 3 joint mobilization

large amplitude movement performed up to the limit of range

grade 2 joint mobilization

large amplitude movement performed within the range but not reaching the limit of the range and not returning to the beginning of range

Exercise sequence

large muscle groups should be exercised before small, mult joint before single joint, high intensity exercises should be performed before low intensity exercises. However, can disregard this if it conflicts with the rehab goals of a specific pt.

Menisci of the knee

lateral and medial meniscus are firmly attached to the proximal surface of the tibia. They are thick at the periphery and thinner at their internal unattached edges. they function to deepen the articular surfaces of the tibia where they articulate with the femoral condyles. function also as shock absorbers and contribute to lubrication and nutrition of the joint.

Scoliosis

lateral curvature of spine. Condition most often quantified using the Cobb method with a standing radiograph. Scoliosis is often classified as functional neuromuscular or degenerative. Functional scoliosis results from abnormalities in the body that indirectly impact the spine (leg length discrepancy, muscle imbalance, poor posture). Referred to as nonstructural scoliosis since the curves are flexible and can be corrected with lateral bending (can be caused by poor posture or leg length discrepancy). Neuromuscular scoliosis results from developmental pathology resulting in alteration within the structure of the spine. This type is often observed in pts with cerebral palsy or marfan syndrome. Degenerative scoliosis occurs due to the normal aging process and is facilitated by changes such as osteophyte formation, bone demineralization and disk herniation. Neuromuscular and degenerative scoliosis are considered to be forms of structural scoliosis since the curves are inflexible and do not reduce with lateral bending Etiology: 1/10 children affected by scoliosis (1/4 of those treated for it) idiopathic scoliosis (80% of cases) is most commonly diagnosed between 10 and 13 years old. Girls and boys have similar risk of developing mild curve (10 deg or less) however girls have a significantly greater risk of acquiring a curve greater than 30 deg. Curves under 20 deg dont cause a person to experience significant problems or impairment. COuld be infantile (0-3 years old), juveitle (4 to puberty - convex thoracic curve towards right w/ rib humb on convex side of curve), or adolescent (12 for girls, 14 for boys), or adult (skeletal maturation scoliosis). Signs and symp: shoulder level asymmetry with or without presence of rib humb. Pain not typically associated with the spinal curvature, rather it is a result of abnormal forces placed on other tissues of the body due to curvature. Common postural finding include increased spacing between elbow and trunk during standing, leg length discrepancy, uneven shoulder and hip heights, and prominence on one side of the pelvis or breast (due to rotation of curve). If a progressive scoliosis is untreated, derformity can increase to an angle in excess of 60 deg and cause pulmonary insufficeincy, sig pain, impairment in lung capacity, and degenerative changes including arthritis and disk pathology. Early screening, detection and treatment are necessary to control the curvature and avoid sx. X-rays should be taken in an anterior and lateral view with pt standing and bending over. A device (scoliometer) can be used to measure ankle of trunk rotation. Cobb method used to determine angle of curve. Tx: focus of tx determined based on magnitude of curve and degree of progression. If curve is not progressing, no formal action is taken. PT includes ESTIM (pain) and biofeedback for education with proper posture and positioning, muscle strengthening and flexibility exercises, shoe lifts and bracing, and respiratory function. Spinal orthosis is often warranted with a curve that ranges between 25 and 40 deg. Sx may be required with curves greater than 40 deg (spinal stabilization - Harrington rod and and posterior spinal fusion). Under 25 deg should be monitored every 3 months. Breathing exercises and a strengthening program for the trunk and pelvic muscles are indicated. PT after sx for breathing exercises, posture, flexibility, general strengthing, and respiratory muscle strengthening. - Prognosis - based on age and severity. Early intervention results in best outcome. ONce bone growth complete, curve doesnt progress if remains below 40 deg. If over 50 deg, progression of curve each year of life.

obturator internus

laterally rotate and abducts hip

obturator externus

laterally rotates thigh

Direct lateral approach THA

leaves the posterior portion of glut med attached to greater trochanter. Requires longitudinal division of tensor fasciae latae and vastus lateralis, along with a release of the anterior portion of glut med. Since posterior soft tissues and capsule are left intact, approach minimizes probability of dislocation and may be ideal for noncompliant pts to avoid posterior disloaction. Hip precautions: avoid flexion of hip beyond 90, extension of hip, lateral rotation and adduction

retrocalcaneal bursa

lies anterior to the achilles tendon where it attaches into the superior calcaneus and acts as a cushion between the tendon and the bone. Irritation of the bursa, due to trauma or overuse, can result in retrocalcaneal bursitis

subscapular bursa

lies beneath the subscapularis muscle and above the anterior joint capsula; bursa that prevents rubbing of the subscapularis muscle tendon against the scapula; anterior shoulder fullness may indicate articular effusion secondary to distention of the bursa.

olecranon bursa

lies posterior to the olecranon process and is considered the main bursa in the elbow. commonly becomes inflamed with direct trauma to the elbow due to its superficial position

ligamentum teres

ligament at the head of the femur; provides a physical attachment between the head of the femur and the inferior rim of the acetabulum. contains blood vessels and nerves contained in a sheath to the head of the femur; provides minimal stability to the hip

radial collateral ligament wrist

ligament running from the styloid process of the radius to the lateral surface of the scaphoid. serves to limit ulnar deviation and becomes taut when the wrist is in extremes of extension and flexion

extensor retinaculum

ligamentous structure that extends over the dorsal surface of the wrist, covering the tendons of the extensor musculature. Retinaculum prevents the tendons from "bowstringing" as wrist is extended.

anterior longitudinal ligament

limits extension of the spine and reinforces the anterior portion of the intervertebral disks and vertebrae

interspinous ligament

located between the spinous processes; serve to limit flexion and rotation of the spine

carpal tunnel

located close to the deep surface of the flexor retinaculum. Median nerve enters the palm through the carpal tunnel. Any condition that significantly reduces the size of the carpal tunnel (tenosynovitis, inflammation of the flexor retinaculum) may result in compression of the median nerve.

static stretching

low-intensity, long-duration muscle elongation that involves placing muscle at its max length and holding the position against an external force for a prolonged period of time. This form leads to less activation of muscle spindles and less resistance to stretch - considered the safest form of stretching and results in greatest gains in tissue extensibility...30 sec hold has been shown to result in significant ROM gain

work

magnitude of a load (weight) multiplied by the distance the load is moved (ROM used)

congenital limb deficiencies

malformation that occurs in utero secondary to impaired developmental course. classified longitudinal (reduction or absence within long axis of bone) or transverse (limb that has developed to a particular level beyond which no skeletal element exist). Etiology: idiopathic or genetic in origin. Poor blood supply, constricting amniotic bands, infection and maternal drug exposure could also cause it. Signs and symptoms: structural or acquired abnormality of a limb, phantom limb pain Treatment: treatment may focus on symmetrical movements, strengthening, ROM, weight bearing activities and prosthetic training when appropriate.

subscapularis

medially rotates arm; one of the 4 rotator cuff muscles

Transtibial Knee

not needed

midcarpal joint

motion of the wrist results in complex motion between the proximal and distal of carpals with the exception of the pisiform. The joint surfaces are reciprocally convex and concave.

Passive Range of motion (PROM)

movement produced by an external force without muscular activation from pt. PROM is only performed within the available ROM. Any movement beyond end range is considered stretching Indications: pt unable to move body segment (comatose, paralyzed), pt is cognitively impaired and unable to move body segment, active movement contraindicated (post surgery), active movement is painful, PT is preparing joint for stretching, PT teaching an active movement to pt. Benefits: improves mobility of connective tissues and muscles, prevent joint contracture formation, improves circulation and synovial fluid movement for cartilage health, decreases pain, and improves pts awareness of movement

active assisted range of motion (AAROM)

movement produced by pt thru active muscular contraction with some assistance from an external force Indications: pt unable to fully contract muscle (paresis, pain), full activation of muscle is contraindicated (post op), performed prior to initiating active movement Benefits: improves mobility of connective tissues and muscles, prevent joint contracture formation, improves circulation and synovial fluid movement for cartilage health, decreases pain, improves neuromuscular activity, and improves kinesthesia and proprioception

Active Range of Motion (AROM)

movement that is produced by pt thru active muscular contraction without any external assistance Indications: Pt is able to contract muscle but demonstrates weakness, performed prior to initiating resistance training to teach the desired movement Benefits: improves mobility of connective tissues and muscles, prevent joint contracture formation, improves circulation and synovial fluid movement for cartilage health, decreases pain, improves neuromuscular activity, improves kinesthesia and proprioception, and improves strength in very weak muscles (ex. 3/5 strength)

isotonic exercise

muscle contraction is generated with the muscle exerting a constant tension. Or Muscle movement with a constant load. Performed against resistance, often employing equipment such as handheld weights. There are two types of isotonic contractions: concentric (shortens) and eccentric (lengthens a muscle)

Spinal stenosis - Lumbar

narrowing of either the lumbar vertebral or intervertebral foramina. Symptoms produced as a result of mechanical compression on either the spinal cord or exiting nerve roots and may be exacerbated by bony degeneration or instability. Primary spinal stenosis accounts for small % of dxs and is result of congenital malformation of spinal structures while secondary spinal stenosis refers to narrowing due to acquired changes in foramina. Structural changes may include degeneration of vertebral segment, disk herniation, osteophyte formation, and hypertrophy of structures such as ligamentum flavum. Other etiologies include trauma, compression fx, systemic conditions (tumor, ankylosing spondylitis) and iatrogenic factors (laminectomy, discectomy). Primary risk factors of secondary spinal stendosis is age due to degenerative change that are part of normal aging process. - LSS symptoms include gradual onset and worsening of chronic pain at midline of lumbar region, may include unilateral nerve root radiculopathy, paresthesia, weakness and diminished reflexes. Rare cases it presents bilaterally w/ bilateral weakness, paresthetia, diminished coordination, ataxic gait, balance dysfunction, bowel/bladder dysfunction and hyperreflexia. Symptoms exacerbated by activities that increase lumbar extension (standing upright, lying prone) and are alleviated by rest and activities that increase lumbar flexion (leaning on grocery cart, sitting). Many adopt stooped posture to reduce lumbar lordosis and minimize symptoms. MRI dx LSS. - Conservative tx of LSS focused on pharm including NSAIDs (pain and anti-inflammation), muscle relaxants (for sleep comfort). PT focuses on improving function and pain management. Strength, flexibility and endurance ex aim to improve muscular support and spinal stability. TENs and other modalities help w/ tolerance for activities by decreasing pain. AD eases excessive strain on postural muscles caused by a forward flexed or kyphotic posture if pt unable to assume normal posture without exacerbation of symptoms. Sx (lumbar laminectomy) if conservative fails and symptoms become disabiling. Home program includes heat or cold, TENs, exercise and weight loss, with ed on activity modification. LSS is a progressive condition but pts who are symptomatic, PT can assist in minimizing effects of the condition and maximizing independence. Some with LSS are asymptomatic and others result in significant disability due to pain and muscle weakness.

Muscle Imbalances

occurs when one muscle is weak and its antagonist is strong Weakness permits a postural deformity, shortness creates it and prevents normal movement and posture

single support phase

occurs when only one foot is on the ground and occurs twice during a single gait cycle

Viscerogenic pain

pain that results from an internal organ that can refer to a distant site or mimic musculoskeletal pain. Theory is viscerosomatic convergence is the reason for this as afferent inputs for visceral and somatic structures converge as they approach the CNS and the brain interpret viscerogenic pain as originating from a musculoskeletal structure. This pain differs from musculoskeletal in many ways and is important one identifies this pain - Viscerogenic pain doesn't change based on movement or positioning of the body part but musculoskeletal does. Also, due to organs having innervation from multiple spinal cord levels and a low density of nerve receptors, the pain is often diffuse and poorly localized. Viscerogenic pain may also be accompanied by other systemic symptoms such as nausea, vomiting, weight loss, pallor, profuse sweating, fever and abnormal vital signs. Common referred sites are the shoulder, scapula, back, chest, pelvis, SIJ, groin and hip. Ex) myocardial infarction - heart innervated by C3-T4 and thus cardiac pathology can be referred to left side of body in chest, mid back, shoulder, arm, neck or jaw Kehr's sign - blood that accumulates in abdominal cavity as a result of rupture to the spleen, can cause irritation of diaphragm and refer pain to left shoulder due to innervation of phrenic nerve (C3-C5). Kehr's sign is + when pressure to the upper abdomen or supine positioning results in left shoulder pain Gallstones - or other gallbladder conditions can refer pain to the right upper abdomen and interscapular region due to the gallbladders innervation from mid thoracic spinal segments. If an inflammed gallbladder leads to irritation of the diaphragm, pain may also refer to the right shoulder.

phantom limb

painless sensation where pt feels limb is still present. Common immediately after amputation and will subside w/ desensitization and prosthetic use, however may continue for extended periods of time for some pts.

Joint Mobilization

passive movement technique designed to improve joint function Indications: restricted joint mobility, restricted accessory motion, desired neurophysiological effects Contraindications: active disease, infection, advanced osteoporosis, articular hypermobility, fracture, acute inflammation, muscle guarding, joint replacement

Hip adductors MMT

pectineus, adductor magnus, gracilis, adductor brevis, adductor longus Position: sidelying with body and LEs straight Fixation: hold upper leg in an abduction position and the patient should hold onto the table for stability Test: adduction of LE in an upper direction from table with no rotation, flexion or extension of hip Pressure: against medial aspect of distal end of the thigh (above the knee), in direction of abduction GEP: lying supine and bring the leg into an adduction position with a slide board underneath the leg

Dynamometry

process of measuring forces doing work dynamometer - a device that measures strength through use of a load cell or spring loaded guage which includes... - hand held dynamometer - measures grip strength..normally pts dominant hand grip strength is 5-10 pounds greater than non-dominant. Can also be used to assess strength of an extremity by having pt exert max force against dynamometer through isometric contraction..portable non electric units include a hydraulic or sping loaded system and display force on a gauge. Electrical units display force digitally and grip strength is recorded in pounds or kg. demonstrates intrarater reliability of >.94..same dynamometer and tester should consistently be used.

pronator quadratus

pronates forearm

pronator teres

pronates forearm

Principles of stretching - Plasticity

property of soft tissue that allows for tissue elongation even after a stretch is no longer applied

Glucocorticoid Agents (Corticosteroids)

provide hormonal, anti-inflammatory, and metabolic effects including suppression of articular and systemic diseases. reduce inflammation in chronic conditions that can damage healthy tissue thru series of reactions. Vasoconstriction results from stabilizing lysosomal membranes and enhancing the effects of catecholamines. Indications: replacement therapy for endocrine dysfunction, anti-inflammatory and immunosuppressive effects; tx of rheumatic, respiratory and various other disorders Side effects: muscle atrophy, GI distress, glaucoma, adrenocortical suppression, drug induced Cushing's syndrome, weakening w/ breakdown of supporting tissues (bone, ligament, tendon, skin), mood changes, hypertension Implications for PT: wear a mask when working w/ pt since immune system is weakened while on glucocorticoids. Must be aware of signs of toxicity including buffalo humb, moon face, and personality changes. Pts at risk for osteoporosis and muscle wasting. Tx of an injected joint will require special care due to ligament and tendon laxity or weakening. Ex) Dermacort (hydrocortisone or cortisol), Cordrol (prednisone), Pediapred (prednisolone), Medrol (methylprednisolone), Decadrol (dexamethasone), Nasonex (momestasone)

Knee-ankle-foot orthosis (KAFO)

provides support and stability to the knee and ankle. Allows for a lock mechanism at knee that provides stability. Ankle also held in proper alignment.

Radiohumeral joint

proximal joint surface of the radiohumeral joint is the ball-shaped capitulum of the distal humerus. the distal joint surface is the concave head of the radius - Osteokinematic motions: flexion, extension, pronation, supination - Loose packed position: full extension, full supination - Close packed position: 90 deg flexion, 5 deg supination - Capsular pattern: flexion, extension, supination, pronation

tibiofemoral joint

proximal joint surface of the tibiofemoral joint is formed by the convex medial and lateral condyles of the distal femur. the distal joint surface is formed by the concave medial and lateral condyles of the proximal tibia Osteokinematic motions: flexion, extension, medial and lateral rotation - Loose packed position: 25 deg flexion - Close packed position: full extension, lateral rotation of tibia - Capsular pattern: flexion, extension

Phantom pain

pts perception of painful stimuli as it relates to the residual limb. Pain can be continuous or intermittent, local or general, and short term or permanent. Pain can disable pt and interfere w/ rehab. Tx includes TENS, ultrasound, icing, mirror therapy, relaxation techniques, desensitization, and prosthetic use.

Upper Quarter Screen

rapid assessment of mobility and neurologic function of the cervical spine and upper extremities. Performed with pt sitting. Components of the screen.. 1) Posture, 2) ROM, 3) Resistive Testing, 4) Reflex Testing, 5) Dermatome Testing

Lower Quarter Screen

rapid assessment of mobility and neurologic function of the lumbosacral spine and lower extremities. Performed with pt sitting or standing. Components of the screen.. 1) Posture, 2) ROM, 3) Functional Testing, 4) Resistive Testing, 5) Reflex Testing, 6) Dermatome Testing

Rest Interval

recovery period between sets will vary depending on the intensity of the exercise. For high intensity exercise, a longer rest interval is needed (3 or more mins) for lower intensity exercise, a shorter rest interval is adequate (1 to 2 mins). Pt with a lower fitness level may need longer rest interval

Quadriceps MMT

rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius extend the knee joint Position: sitting with knees over side of the table holding onto the table Fixation: hold thigh down firmly onto table. May put hand under distal end of thigh to cushion that part against table pressure Test: full extension of knee joint without rotation of thigh Pressure: against leg, above the ankle, in direction of flexion **if theres weakness it may result in knee hyperextension. Walking with weak quads requires the patient to lock the knee joint by slight hyperextension

Polycentric knee

refers to a knee joint that has multiple axes of rotation that allows for a more natural gait cycle when compared to a single axis knee

posterior ligament elbow

resembles the anterior ligament . blends on each sides with the collateral ligaments and is attached to the upper portion of the olecranon fossa, and to just below the olecranon process

Glenohumeral Instability

refers to excessive translation of the humeral head on the glenoid during active rotation. Instability involves varying degrees of injuries to dynamic and static structures that function to contain the humeral head in the glenoid. Subluxation refers to joint laxity, allowing for more than 50% of the humeral head to passively translate over the glenoid rim without dislocation. Dislocation is the complete separation of the articular surfaces of the glenoid and the humeral head. Approx 85% of dislocations detach the glenoid labrum (ie, Bankart lesion) Etiology: combination of forces stress the anterior capsule, glenohumeral ligament, and rotator cuff causing the humerus to move anteriorly out of the glenoid fossa. Anterior dislocation is most common and is associated with shoulder abduction and lateral rotation Signs and symptoms: subluxation: feeling the shoulder "popping" out and back into place, pain, parasthesias, sensation of the arm feeling "dead". Positive apprehension test, capsular tenderness, swelling - Dislocation: severe pain, paresthesias, limited ROM, weakness, visible shoulder fullness, arm supported by contralateral limb Treatment: initial immobilization with sling for 3-6 weeks. RICE and NSAIDS initially. following immobilization, ROM, isometric strengthening should be initiated followed by progressive resistive exercises emphasizing internal and external rotators as well as large scapular muscles.

total knee arthroplasty (TKA)

refers to removal of proximal and distal joint surfaces of the knee and replacing them with an implant. Most commonly performed surgery for advanced arthritis of the knee. TKA can be classified several diff ways. first way is based on # of compartments replaced. Unicompartmental indicates that only the medial or lateral joint surface was replaced, bicompartmental procedure indicates entire surface of femur and tibia replaced. tricompartmental procedure includes replacement of the femur and tibia along with the patella. Implant can be classified by degree of constraint. An unconstrained design offers no inherent stability and relies on soft tissue integrity for stability (primarily used with unicompartmental arthroplasty). Semiconstrained design offers some degree of stability without compromising mobility. Most common classification of TKA. Fully constrained design offers most stability by restricting one or more planes of motion. Results in greater implant stress with a higher likelihood of implant problems (wear, failure, loosening). Avg lifespan is 15-20 years. Minimally invasive sx becoming more common with TKA. Only requires 3-5 inch incision compared to 8-12 inch incision. THerefore, less soft tissue trauma and minimal damage to quads (quads weakness correlates to greater risk of falling so decreased falls). This results in decreased hospital stays, improved ROM, and improved strength. Fixation methods include cemented, uncemented (bone ingrowth) and hybrid. Type of fixation selected is influenced by pt activity level, co-morbidities, life expectancy and tightness of fit of the femoral component achieved during sx. Cemented remains most common and allows for either partial weight bearing or weight bearing as tolerated post op. Noncemented requires toe touch weight bearing for up to six weeks to allow for bone to grow and affix to prosthesis. Potential complications are DVT, infection, pulmonary embolus, peroneal nerve palsy, restricted ROM, periprosthetic fractures and chronic joint effusion. Etiology: TKA is effective. osteoarthritis (most common) and osteomyelitis associated with need for it cuz associated with progressive and disabling pain within knee joint. Degenerative process that causes destruction of articular cartilage and resultant bone on bone contract within joint due to decreased joint space and osteophyte formation. Injury occurs to femoral condyles, tibial articulating surface and dorsal side of patella. Pt with history of high impact sports or trauma to knee at higher risk for arthritis. Obesity, varus/valgus deformity, previous mechanical derangement, infection, rheumatoid arthritis, hemophilia, crystal depostition diseases, avascular necrosis or bone dysplasia at knee are some contributing factors. Signs and symp: severe pain that worsens with weight bearing and motion, loss of mobility , gross instability or limitation in ROM, marked deformity of the knee, failure of non-operative management or previous surgical procedure. Night pain is common. Other symptoms are swelling, locking, giving way of knee. Xrays and MRI determine extent of deterioration. Arthritis impact measurement tool helps establish objective baseline. Contraindication to TKA include active infection of knee, severe obesity, significant genu recurvatum, arterial insufficiency, neuropathic joint and certain mental illnesses. Post surgical complications include vascular damage, infection, patellofemoral instability, fx surrounding prosthesis, pulmonary embolism, nerve damage, loosening of prosthesis, and arthrofibrosis. Tx: Post Op Pharm includes anticoagulant therapy and pain meds. Post op care includes knee immobilizer, elevation of limb, cryotherapy, intermittent ROM using CPM machine and initiation of knee protocol exercises. initially PT focuses on decreasing inflammation and allowing tissues to heal, emphasizing adherence to knee precaution, minimizing muscle atrophy and regaining full PROM. Early PT should focus on mobility training with proper weight bearing status using an appropriate AD. Early amb training encouraged to avoid deconditioning and decrease risk of DVT. A goal of 90 deg knee flexion and 0 deg knee extension established prior to d/c from hospital. knee flexion requires 90 deg for activities of daily living and 105 deg to rise comfortably from sitting. Therapeutic activities include ankle pumps, quads, and glut sets, hamstring sets, AROM and stretching. For couple months after sx, knee precautions need to be used to avoid excessive stress to knee: avoid squatting, quick pivoting, do not use pillows under knee while in bed, and avoid low seating. Outpatient PT recommended to progress pt from an AD. When physician progressed pt to weight bearing as tolerated, PT intervention should include strengthening with closed chain exercises and functional activities. As pt progresses, treatment moves toward regaining full strength, endurance, and independence in the home setting. Advanced therapeutic activities include wall slides, controlled lunges, stationary cycling, and step ups. Pt will experience relief of pain that will allow full return to previous level of function within 8-12 weeks post op. Life expectancy of prosthesis is 15-20 years. - Patellectomy (sx removal of patella) indicated for comminuted fx of patella that cant be repaired with internal fixation. can include entire patella or just inferior or superior pole of patella. Retinaculum and externsor mechanism also repaired w/ sx and pt immobilized for 6-8 weeks. Once PT starts, begins with ROM and closed chain ex.

Dysvascular

refers to the disease of the blood vessels, including peripheral vascular disease, peripheral arterial disease, and complications related to diabetes

frequency of resistance training

refers to the number of times per week resistance exercises are performed and is dependent on the intensity and volume of exercise and fitness level of pt. For more intense exercise, training should be performed less frequent (2-3x per week). same applies for pts with lower fitness level. For pts in rehab program, exercise can be performed several times a day if the intensity and volume is kept low. Exercise that is performed too frequently may lead to overtraining and a decline in the pts condition or performance

double support phase

refers to the two times during a gait cycle where both feet are on the ground. Double support time increases as speed of gait decreases. does not exist when running

gate-control theory

regulation of pain or ability for other stimuli to help decrease the sensation of pain. A-delta and C fibers synapse with a secondary neuron which sends the signal to the brain. However, they also synapse with an inhibitory interneuron at the same junction where A-alpha and A-beta fibers provide input to these inhibitory interneurons and therefore these fibers inhibit or "close the gate" on pain. Use of E-STIM and massage work on this theory by stimulating A-alpha and A-beta fibers.

body composition

relative % of body weight that is comprised of fat and fat free tissue. Hydrostatic weighing, skinfold measurements, plethysmography, BMI and bioelectrical impedance analysis are the methods for testing. Healthy range of body fat is 12-18% for males and 18-23% females.

total hip arthroplasty (THA)

removal of proximal and distal joint surfaces of hip with subsequent replacement by acetabular component and a femoral implant. Acetabular component press fit into place, but occassionally held in place by screws. Bone is removed from femur with subsequent shaping to accept the femoral stem with the attached prosthetic femoral head. Sx approach can be anterolateral, direct lateral, or posteriolateral approach. Selected approach determines necessary hip precautions post op Fixation can be cemented or cementless. Cemented fixation allows weight bearing as tolerated on involved LE often immediately since cement achieves max fixation in 15 mins. Cementless and hybrid fixation rely on bone growth and may dictate partial weight bearing or non weight bearing initially. Weight bearing determined by surgeon, typically based on the mechanical fixation of the prosthesis within the acetabulum and femur. primary indication for cementless fixation is a young active individual (less than 65 years old). Minimally invasive sx techniques require 1-2 incisions, usually less than 10 cm in length. Benefit of minimally invasive procedures is less soft tissue trauma and an accelerated post op recovery. Avg lifespan for THA is 15-20 years (younger individuals may need one or more revision procedures) Complications for THA include DVT, infection, pulmonary embolus, heterotopic ossification, femoral fractures, dislocation, and neurovascular injury Etiology: THA is an elective sx. Medical conditions include osteoarthritis, rheumatoid arthritis, osteomyelitis, developmental displasia, osteomylelitis, and avascular necrosis. Trauma, repetitve microtrauma, obesity, nutritional imbalances, falls or abnormal joint mechanics or a nonunion fx could result in intra articular disease. Arthritis causes hip joint to undergo degenerative process inclduing destruction of articular cartilage that results in bone to bone contact. Usually acetabulum and femoral head require THA but if acetabulum doesnt exhibit degenerative changes, then only femoral head is replaced in a hemiarthroplasty procedure. Signs and symp: prior to sx, severe pain w/ weight bearing, loss of mobility, gross instability, or limitation in ROM, failure of non-operative management or a previous sx procedure. Pt usually over 55 years and has experienced consistent pain with no relief thru conservative measures and it limits pts functional mobility consistently. X-ray, MRI used to view joint. A standardized pain assessment scale and the Arthritis impact measurement tool may be used to establish objective baseline. Contraindications for THA are active infection, severe obesity, arterial insufficiency, neuromuscular disease, and certain mental illness. Post sx complications include nerve injury, vascular damage, dislocation, pulmonary embolism, myocardial infarction, and CVA. Prothesis also at risk for loosening, infection, fx, heterotopic ossification Tx: PT focuses on decreasing inflammation and allowing tissues to heal, emphasizing adherence to hip precautions, minimizing muscle atrophy, and regaining full PROM. Pharm includes anticoagulant therapy and pain meds. Post op, hip precautions and use of abduction pillow (posteriolateral approach), and initiation of PT and hip protocol exercises. hip protocol exercises include ankle pumps, quads and glut sets, heel slides, and isometric abduction, assistive device training and progressive ambulation. Pt ed on hip precautions and weight bearing status, scar management and soft tissue mobilizations. At time of hospital d/c, pt should be able to flex hip 90 deg. Early ambulation encouraged to avoid deconditioning and the risk of DVT. Practice all mobility while maintaining hip precautions. As pt progresses, tx moves towards regaining full strength and endurance and attaining independence in home setting. Pt should have diminished to no pain, increased strength and endurance, and improved mobility within six to eight weeks post op. 85-95% of pts have pain relief and improved function post op..lasts 15-20 years. Validated scoring systems such as the Harris Hip Scoring system or the special surgery rating system are measures used to determine the quality of life after THA. - Hemiarthroplasty of the hip is a replacement of the femoral head due to a subcapital fx of the femur or degeneration of the femoral head. Sometimes used as alternate to THA for elderly pts that sustain hip fx or pts with shortened lifespan.

Pathology of the Musculoskeletal System - Achilles Tendonitis

repetitive overuse disorder (caused by faulty technique or changes in training intensity) resulting in microscoping tears of collagen fibers on the surface or in the substance of the achilles tendon. The tendon is often impacted in an avascular zone located two to 6 cm above the insertion of the tendon. - Pts with limited flexibility and strength in the gastrocnemius and soleus complex and pts with a pronated or cavus foot are at increased risk. Activities associated with this are basketball, gymnastics, and dancing. A hx of achilles tendonitis increases likelihood of tendon rupture later in life. - aching or burning in posterior heel, tenderness of achilles tendon, pain with increased activity, swelling and thickening of the tendon area, muscle weakness due to pain and morning stiffness are signs and symptoms - Treatment: RICE (rest, ice, compression, elevation), NSAIDs (Nonsteroidal anti-inflammatory meds, and analgesics as needed. heel lift and cross training to limit tensile loading thru tendon. Prevention includes heel cord exercises, use of soft soled footwear, eccentric strengthing of gascrocsoleus, and avoid sudden changes in intensity of training program.

Hygiene

residual limb should be carefully washed, inspected and maintained to prevent the formation of wounds or infections. Particular importance for pts with impaired vascular perfusion or history of wounds or infection. Once post surgical residual limb has fully closed and no evidence of exudate present, washing with warm water and a mild hypoallergenic soap. If lotion is advised, should not be petroleum-based and shouldnt be applied prior to donning the prosthesis since it may inhibit suspension. Residual limb and contralateral foot should be inspected daily for areas of breakdown. If area of breakdown, rash, or wound is identified, it may be necessary to have area inspected by prothetist or physician prior to donning prosthesis

posterior talofibular ligament

resists posterior displacement of talus on tibia

supraspinous ligament

restricts flexion in the thoracic and lumbar spine

Adhesive Capsulitis (Frozen Shoulder)

results in loss of ROM in active and passive shoulder motion due to soft tissue contracture and causes pain. Caused by adhesive fibrosis (fibrotic thickening) and scarring between the capsule, rotator cuff, subacromial bursa and deltoid (anterior joint capsule). The inflamed capsule becomes adherent to the humeral head and undergoes contracture. Classified as primary or secondary where primary occurs spontaneously and secondary results from an underlying condition. A decrease in space within capsule leads to a decrease of synovial fluid and further irritation to the glenohumeral joint Etiology: related to direct inury or occur insidiously. females more affected, 40-60 years old, Pts with diabetes, thyroid abnormalities, and cardiopulmonary conditions at increased risk (primary adhesive capsulitis). Secondary adhesive capsulitis can result from trauma, immobilization, complex regional pain syndrome, rheumatoid arthritis, abdominal disorders and psychogenic disorders. Orthopaedic intrinsic disorders that may initiate this process include supraspinatus tendinitis, partial tear of the rotator cuff, bicipital tendonitis. self-limiting condition typically resolves in 1-2 years and some have residual loss of motion. 2% of population in US has this, 11% of ppl with diabetes mellitus. (10-15% of those develop bilateral). Signs and symptoms: Acute phase has localized pain often extended down arm, subjective reports of stiffness, night pain, restricted ROM in capsular pattern (lateral rotation, abduction, medial rotation). PROM limited due to pain and guarding. During chronic phase, pain is usualy localized around brachial region, pt not awakened by pain, and PROM is limited due to capsular stiffness. Limitations include glenohumeral motion, elevation and lateral rotation. For Dx, all plane of motion limited but greatest restriction in abduction and lateral rotation with tightness within anteroinferior joint capsule, pain with stretching and restriction with PROM and AROM Treatment: Pharm management includes control of pain thru acetaminophen, longer acting analgesics, NSAIDs and narcotics. Physician may also inject shoulder with corticosteroids to assist with recovery of motion. Sx could be needed to break up adhesion or release muscles adhered to capsule if conservative management fails. PT during acute phase includes icing or heat, gentle joint mobs, progressive strengthening, pendulum exercises, and isometric strengthening. During chronic phase, PT includes ultrasound, grade 3 and 4 mobs, increasing the extensibility of the joint capsule, and techniques such as PNF to restore painless functional ROM. Avoid overstretching and elevating pain - can result in further loss of ROM. Surgical option include suprascapular nerve block and closed manipulation under anesthesia. Home program in acute phase should include self stretching but avoid abduction secondary to risk of damage to subacromial tissue. Chronic phase emphasive self stretch, progressive exercises, posture management, PNF and other exercises such as pendulum exercises and "wall-climbing" to improve ROM. After dx, outpatient PT for 3-5 months, spontaneous recovery in 12-24 months. Estimated 7-14% experience some permanent loss of ROM at shoulder joint..asymptomatic and doesnt affect pts functional ability. - Arthrogram can assist w/ diagnosis by detecting decreased volume of fluid within joint capsule. Glenohumeral joint normally hold 16-20 mL of fluid, but 5-10 mL with adhesive capsulitis. - Acute bursitis similar condition. intense pain over lateral brachial region secondary to calcific tendonitis. AROM and PROM in all directions limited by pain. severe pain when abduction >60 and flexion >90 deg. Acute bursitis last a few days, fully resolve in weeks.

Heel lift

rigid insert which adds extra height to heel of shoe. Takes pressure off of achilles tendon for pts w/ achilles tendonitis or a recent repair of the tendon. Heel lifts are also used to help limit effects of a leg length discrepancy

Sugar tong splint

rigid splint covering wrist and elbow joints. allows for greater immobilization than volar or dorsal forearm splint. Limits supination and pronation and any wrist motion. Starts at dorsum of hand, extends along dorsal forearm to wrap around elbow and continues along volar forearm to end at palmar aspect of hand. Elbow in 90 deg of flexion w/ wrist and forearm in neutral when splinting. Commonly used for tx of carpal fxs and distal radius or ulna fxs.

Long arm splint

rigid splint covers elbow joint (posterior side) spanning from wrist to distal humerus. Immobilize elbow joint for healing following injury or sx. Prevents elbow flexion and extension, and supination and pronation. Following elbow or proximal forearm fx or treating soft tissue injury (ex. tendonitis, tendon repair). Elbow placed in 90 deg flexion w/ forearm in neutral.

radial gutter splint

rigid splint covers radial side of forearm and hand as well as 2nd and 3rd digits. includes a thenar hold to allow free movement of thumb. immobilizes metacarpals and phalanges - used following fx of these. When splinting, MCP joints placed in 60-90 deg flexion w/ IP joints in full extension w/ wrist in slight extension.

Thumb Spica Splint

rigid splint covers radial side of forearm, hand and thumb. May cover entire thumb or stop at proximal phalanx of thumb and allow for IP motion. Used to immobilize wrist and MCP joint of thumb - treats gamekeepers thumb, scaphoid fxs, first metacarpal fxs, de Quervain's syndrome and other thumb injuries. When splinting wrist in 20 deg extension w/ MCP joint in slight flexion

Ulnar Gutter Splint

rigid splint covers the ulnar side of forearm and hand as well as 4th and 5th digits. immobilizes metacarpals and phalanges - commonly used for fx of these. When splinting, MCP joints placed in 60-90 deg flexion w/ IP joints in full extension w/ wrist in slight extension.

volar/dorsal forearm splint

rigid splint extends from proximal forearm to metacarpal heads, allowing for full elbow and MCP joint motion. Splint includes thenar hole for free movement. Used to immobilize wrist - used for treating fxs of carpals, fx of distal radius or ulna or soft tissue conditions (sprain, tendonitis). Position of wrist varies - wrist in 20 deg extension (finger flexors shortened and have improved mechanical advantage for grasping).

Distal interphalangeal splint

rigid splint that is placed on the volar or dorsal aspect of finger and spans from the tip of finger to proximal portion of middle phalanx. Immobilizes DIP to allow rest, healing of painful or inflamed joint. Mallet finger (DIP joint should be placed in neutral or slight hyperextension to allow for healing of damaged extensor tendon), distal phalanx fx, and DIP joint arthritis indicated.

Posterior cruciate ligament sprain

runs from posterior intercondylar area of tibia to lateral aspect of the medial femoral condyle in the intercondylar notch. Ligament prevent posterior displacement of tibia in relation to femur Etiology: landing on tibia w/ flexed knee or hitting dashboard in MVA w/ flexed knee. Isolated PCL tears are not common and often involve ACL, MCL, LCL or menisci Signs and symp: feeling as if femur is sliding off tibia. swelling and mild pain, but often pt asymptomatic. Special tests: posterior drawer test, posterior sag sign Tx: RICE, NSAIDs, analgesics initially. PT includes LE strengthening and functional progression. Sx treatment can occur, however, procedure is not as evolved as procedure for ACL. If sx performed, isolated hamstring exercises are avoided for min of 6 weeks

Ulnar collateral ligament (medial collateral ligament)

runs from the medial epicondyle of the humerus to the proximal portion of the ulna. Ligament prevents excessive abduction of the elbow joint - can become stretched, frayed or torn through the stress of repetitive throwing motion over months or years. Fall on outstretched arm can lead to rupture, often with associated elbow dislocation

trapeziometacarpal joint

saddle joint Capsular pattern: abduction, extension

Foot Orthosis (FO)

semirigid or rigid insert worn inside shoe - crrects foot alignment and improves function, relieves foot pain. Custom molded.

Limb Loss specific outcome measures

sensitive to needs, adjustment and functional demands of living w/ limb loss...other outcome measures that can be used are timed up and go and six minute walk test.

gait cycle

sequence of motions that occur from one initial contact of the heel to the next initial contact of the same heel.

Anthropometry

skinfold measurement - measures % of body fat thru measurement of 9 standardized sites. correlation relies on the theory that the amount of subcutaneous fat is proportional to the total fat in the body. limitations include experienced examiner and variance from standards based on gender, age and ethnicity. Standard error is 3%. Procedure: all measurements should be taken on right side of body - multiple measurements at each site..retest if diff is greater than 1-2mm - skinfold calipers positioned 1cm away from examiners fingers when pinching the side, positioned perpendicular to the skinfold and centered - wait 1-2 sec before reading caliper - maintain pinch while reading caliper There are 7-site and 3-site formulas to calculate % of body fat. Specific formulas also for gender, sport, ethnicity and age. common sites are abdominal, triceps, biceps, chest/pec, medial calf, midaxillary, subscapular, thigh, and suprailiac. Triceps and subscapular used the most

grade 1 joint mobilization

small amplitude movement performed at the beginning of range

grade 4 joint mobilization

small amplitude movement performed at the limit of range

grade 5 joint mobilization

small amplitude, high velocity thrust technique performed to snap adhesions at the limit of range

heel cushion

soft pad placed on heel of inner sole to cushion heel and decrease pain in that region. May be used for pts w/ calcaneal spur or plantar fasciitis.

sinus tarsi

space located between the inferior talus, superior calcaneus, and anterior portion of the lateral malleolus. This area contains ligaments that can also be injured during a common inversion ankle sprain.

femoral triangle

space located in the anterior hip. Bordered by the inguinal ligament, sartorius, and adductor longus. Within the space the femoral artery and lymph glands can be palpated. The femoral nerve and vein also pass through this space

THA precautions

specific sx approach determined based on pt activity level, co-morbidities, life expectancy, anticipated compliance, and surgeon familiarity. PTs must have awareness of each type of approach including the structures impacted and associated hip precaution.

Delayed Onset Muscle Soreness (DOMS)

specific type of post exercise soreness that is thought to result from microtrauma to the muscle and its connective tissues that occurs during resistance training. DOMS is most commonly noted in pts who have engaged in high intensity, eccentric strengthening exercises, especially if pt has recently begun a resistance training program. - characterized by tenderness to palpation in the muscle belly or at the muscle tendon junction, soreness with passive stretching or active contraction of the muscle, and decreased ROM and strength. Symptoms usually reach their peak two days after exercise and can last for several days. Soreness will diminish with each successive training session as the muscle adapts to higher levels of stress. - diminish level of DOMS by slowly increasing the intensity of a new exercise program. Performing only isometric and concentric exercises reduces likelihood of DOMS significantly

Posterolateral approach THA

splitting the glut max muscle in line with the muscle fibers. The short ERs are then released and the hip abductors are retracted anteriorly. this approach maintains the integrity of the glut med and vastus lateralis muscles. Femur is then dislocated posteriorly. most commonly used approac for THA, procedure also results in a high post op dislocation rate and joint instability due to interruption of posterior capsule. Hip precautions: avoid flexion of hip beyond 90 deg, adduction and medial rotation

length-tension relationship

states the ability of a muscle to produce force depends on the length of the muscle. A muscle can usually produce a max force near its normal resting length. If muscle is shortened or lengthened, it will produce less force.

Transfer of training principle

states there can be carryover effect from one exercise or task to another. Ex.) pt exercises to improve muscular strength can also see improvements in endurance. However, carryover effects are far less beneficial than the adaptations that result from more specific training.

infrahyoid muscles

sternohyoid, omohyoid, sternothyroid, thyrohyoid Function: depress the mandible

power grip

strong or forceful grip needed...stabilization of object against palm of hand - fingers are in flexion with wrist in ulnar deviation and slight extension - cylindrical grasp - entire hand wrapping around object with thumb on one side and four fingers on opp side of object ex.) soda can - Fist grasp - cylindrical grasp but grasping smaller object where thumb and fingers overlap ex.) hammer - Spherical grasp - entire hand wrapping around spherical object...great amount of thumb opposition and fingers are seperated from one another ex.) baseball Hook grasp - use of 2nd and 3rd IP joint to create a hook to hold object..controlled by forearm flexors and extensors ex.) a bucket

Contusion

sudden blow to body. results in mid to severe damage to superficial and deep structures. Tx: AROM, ice, compression

transfemoral amputation

surgical removal of the lower extremity above the knee joint - length of residual limb w/ regard to leverage and energy expenditure - knee componentry will determine ability to functionally reciprocate gait - stance control may not activate until weight bearing occurs thru the limb - donning can be more difficult than w/ a transtibial amputation - weight bearing thru the ischium in an ischial containment socket - susceptible to hip flexion contracture - adaptation required for balance, weight of prosthesis and energy expenditure

Hemicorporectomy amputation

surgical removal of the pelvis and both lower extremities

Transradial amputation

surgical removal of the upper extremity distal to the elbow joint - Loss of all hand function - must be minimum of 5 cm proximal to distal radius - typically result of trauma - trauma associated fx, dislocation, or peripheral nerve injury may delay prosthetic interventions - functionally preferred over wrist disarticulation or selected partial hand amputations - most common level of UE amputation

Transhumeral amputation

surgical removal of the upper extremity proximal to the elbow joint - loss of all elbow and hand function - most commonly due to trauma - typically 7-10cm proximal to the distal humeral condyles - trauma associated fx, dislocation, or peripheral nerve injury may delay prosthetic interventions - second most common level of UE amputation

Shoulder disarticulation

surgical removal of the upper extremity through the shoulder - Loss of all shoulder, elbow and hand function - most common cause is malignancy or severe electrical injuries - function prosthetic use is possible - an external prosthetic shoulder joint is typically required

myoplasty

suturing amputated muscle flaps together over the end of a bone following an amputation

Achilles tendon repair

sx performed on active pts w/ achilles tendon tear. sx performed within days of injury (arthroscopically - torn portion sutured back together). when repair is delayed after injury, sx is open procedure where augmentation w/ graft (flexor hallucis longus, peroneus brevis, plantaris) used for repair instead of suturing original tendon. - casted w/ ankle in slight PF initially. may be non-weight bearing for first few weeks. Pt transitioned to cast or boot that places ankle in neutral - partial weight bearing. PT take caution w/ exercises that stretch achilles tendon or require PF until tendon is well healed.

Valsalva maneuver

technique often used to increase intra-abdominal and intrathoracic pressures during anaerobic activities that require a large effort, such as lifting a heavy box from the floor. its performed by forcefully exhaling against a closed glottis, nose and mouth while simultaneously contracting the ab muscles. Increases in internal pressures helps to stabilize the spine during heavy exertion and is therefore employed during power lifting to help improve performace - can be useful, however it leads to undesireable effects on the cardiovascular system and shoulder be avoided in all pts, especially pts with cardiovascular disease (hypertension, coronary artery disease, stroke), with intervertebral disk pathology or who have recently undergone eye surgery. Pts need to be taught to breathe rhythmically and to exhale during the portion of exercise that requres more exertion

suspension prosthesis

terms used to describe how the prosthetic socket is attached to the residual limb. Common types of suspension include vacuum, shuttle lock, suction, waist belt and harness

Degree of toe-out

the angle formed by each foot's line of progression and a line intersecting the center of heel and second toe. The average degree of toe-out for an adult is 7 degrees.

subacromial bursa

the bursa extends over the supraspinatus tendon and the distal muscle bely, beneath the acromion and deltoid muscle. The bursa facilatates movement of the deltoid muscle over the fibrous capsule of the shoulder joint and supraspinatus tendon. The bursa is involved with impingement beneath the acromial arch.

power

the rate at which work is done (work divided by time)

Medial hamstring MMT

the semitendinosus and semimembranosus flex and medially rotate the knee joint Position: prone Fixation: hold the thigh down firmly on table Test: flexion of knee between 50 and 70 deg with thigh in medial rotation and leg medially rotated on thigh Pressure: against leg proximal to the ankle, in the direction of knee extension. Don't apply pressure against the rotation component

Thoracolumbar spine

thoracic spine = 12 vertebrae with long prominent spinous processes. First 10 thoracic vertebrae have articular facets on each transverse process where the ribs articulate. Lumbar Spine = 5 vertebrae that provide the primary stability for the low back Osteokinematic motions: flexion, extension, lateral flexion, rotation Loose Packed Position: midway between flexion and extension CPP: extension Capsular Pattern: lateral flexion and rotation equally limited, extension

taylor brace

thoracolumbosacral orthosis that limits trunk flexion and extension through a 3 point control design.

fat pads in knee

three fat pads in the knee: quadriceps, prefemoral, and infrapatellar. Infrapatellar is one of the most commonly affected and can be a source of anterior knee pain when it becomes impinged (Hoffa's syndrome)

glenohumeral ligaments

three ligamentous bands (superior, middle, inferior) that reinforce the joint capsule, anteriorly Superior: limits adduction of the shoulder along with lateral rotation of the shoulder within 0-45 deg abduction Middle: limits lateral rotation within 45-90 deg abduction Inferior: has an anterior and posterior band that limits lateral and medial rotation above 90 deg abduction. Between these two bands theres an axillary pouch that limits inferior translation when the shoulder is above 90 deg abduction.

Visual analogue scale

tool used to assess pain intenisty using a 10-15 cm line..reassessed frequently to record changes and progress and predict outcome. This scale is highly sensitive if small increments such as mm are used to measure pain. valid tool if measured accurately

Volume of resistance training

total amount of work performed and is calculated as the (total number of reps x intensity). Reps inversely related to intensity. 2-4 sets commonly prescribed

Normal End feel

type of resistance that is flex when passively moving a joint through the end range of motion. certain tissues and joints have a consistent end feel described as firm, hard or soft. Pathology can be ID through noting the type of abnormal end feel within a joint Firm (stretch) ex.) ankle dorsiflexion, finger extension, hip medial rotation, forearm supination hard (bone to bone) ex.) elbow extension soft (soft tissue approximation) ex.) elbow flexion, knee flexion

Internal oblique

unilateral action: ipsilateral rotation and lateral flexion of abdomen and spine; bilateral action: flexion of spine; forced exhalation

Numerical rating scale

used to assess pain of a scale of 0-10 or 0-100. 0 = no pain..10 or 100 = worst pain ever. used as baseline and should be reassessed at regular intervals to monitor progress.

Precision grip

used when accurate and precise movements of hand are needed...involved MCP and IP joints on radial side of hand - digital prehension grip - three finger pinch when pulp to pulp contact between thumb, index finger and middle finger ex.) holding a pencil - lateral prehension grip - contact between thumb and lateral side of index finger ex.) using a key - tip prehension grip - tip pinch characterized by thumb opposition so that tip of the thumb contacts tip of another finger ex.) holding a needle.

Insufficient hip flexion at initial contact

weak hip flexors, hip flexor paralysis, hip extensor spasticity, insufficient hip flexion ROM

Exaggerated knee flexion at contact

weak quads, quad paralysis, hamstring spasticity, insufficient extension ROM

Passive muscle insufficiency

when a 2 joint muscle cannot lengthen to the extent required to allow full ROM of all joints in crosses simultaneously

Active muscle insufficiency

when a 2-joint muscle is incapable of shortening to the extent required to produce full ROM at all joints crossed simultaneously

Oxford exercise technique

•allows for progressive fatigue, slightly better than delorme though no statistical significance • 3 sets of 10 reps from 100->75-> 50% of 10 rep max

Exaggerated hip flexion during swing

• Lower extremity flexor synergy • Compensation for insufficient ankle dorsiflexion.

Delorme exercise protocol

•Progressive resistive exercise for strength (isotonic) • 3 sets of 10 reps from 50->75->100% of 10 rep max