420 Ms management (2019): 1-15lec//1-15 lab// 1-15 instructions// 1-22.1// 1-22.2 start...... 1-29-31//1.29 lec//ch 16// 2.5a// 2.5b// 2.7// 2.12 Elb// 2.12 lab
"Remember To Drink Cold Beer"
Roots (ventral rami of C4,5,6,7,8,T1) Trunks (superior, middle, inferior) Divisions (3 anterior, 3 posterior ) Cords (lateral, posterior, medial) Branches (musculocutaneous n., axillary n., radial n., median n., ulnar n., medial antebrachial cutaneous n., medial brachial cutaneous n., medial pectoral n., intercostobrachial n.)
toe walking tests what nerve
S1, plantarflexion
What are the different accessory motion tests of the shoulder
SCJ (super/inf/anterior) ACJ (sup/inf/ant/post) GHJ (inf/ant/post) Grades: hypo-early tissue resistance normal hyper-late tissue resistance
capular pattern
a series of limitations of joint movement when the joint capsule is a limiting structure. ex. GH jnt patter: ER> abd > IR
plyometric contraction
a sudden eccentric loading and stretching of muscles followed by a strong concentric contraction
principles of msk management
acuity SINS (severity, irritability, nature, stage, and stability) promote healing/remove barriers to healing pt goals/expectations
possible disorders and causes of the anterior elbow (cubital fossa)
anterior capsular strain distal biceps tendon rupture or tendinitis dislocation of the elbow pronator syndrome (in throwers)
most common causes/associations of cubital fossa pain (elbow)
brachialis mm tear ex. rock climbing biceps lesion compress of PIN capsular injury
shoulder patho history
brief outline of pt: age, occupation, hand dominance, recreation pursuits, work requirements, and ADL mechanism of injury (help w/ preliminary dx) chief complaint quality of pain symptoms not assoc w/ movement (ex. pain at night, periarticular problem-> inflammation) location of pain (radiopathy, referred pain,...) what positions relieve pain general health (medications, allergies) previous PT/interventions (interventions, injections, surgery)
3+ grading of DTR
brisk (upper half of normal range)
extensor digiti minimi A OIN
extends 5th finger @ DIP O: lateral epicondyle I: extensor expansion of 5th DIP N: Radial n.
extensor carpi radialis brevis A OIN
extends and ABducts hand O: lateral epicondyle I: 3rd MC N: radial n.
extensor carpi ulnaris A OIN
extends and ADducts hand O: lateral epicondyle I; 5th MC N: RADIAL n.
extensor digitorum (UE) A OIN
extends fingers (MCP, PIP, mostly DIP) and extends hand O: lateral epicondyle I: entensor expansion- DIP N: radial n.
radio carpal (wrist) closed packed position
extension w/ radial deviation
what are some factors that affect tissue healing
extent of injury (macro or micor) tissue type (cartilage, ms, nerves) blood supply nutrition age (elderly and youth) comorbidities (ex. hypertension, diabetes, smoking)
what is the capsular pattern of the GH jnt
external rotation, abduction, and internal rotation
what falls within functional exam of an elbow exam
joint ROM mm performance mm length neuro status sensorimotor control special tests * impairment *standardized function **compared to unaffected side
LQ/UQ screen function
joint ROM, mm performance, mm length, neuro status sensorimotor control, and special tests (impairment, standardized, functional)
osteochondritis dissecans (OCD)
joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow
what is the clinical importance of the stages of healing
knowing stages allows you to match tissue loading capacity to appropriate tx (optimal loading zone) Rule of thumb: Do no harm Overload too exacerbates injury underloading tissue is not strengthened and recurrence of injury increases (most common PT mistake)
tennis elbow
lateral epicondy
dermatomes L4
medial calf
golfer's elbow
medial epicondylitis
reflexes of LQ screening
patella (L4), and achilles (S1)
late phase of shoulder tx and healing
restore kinematics (still caution w/ high 5 position) restore proprioception restore nm control Goals: don't allow dislocation increase strength, emphasis on control multiplanar sport/activity specific (thinking about what level they are returning to)
cardinal s/sx of inflammation
redness, heat, swelling, pain, and loss of fnx this will drive CDM
Severe progressive pain not affected by movement, persistent throughout the day and night, and associated with systemic signs, may indicate
referred pain from a malignancy. The exception to this may be adhesive capsulitis (frozen shoulder), which is often characterized by boring, unrelenting, aching pain, even at rest
scapular tests (2)
reposition assistance
special tests for scapula
repostion assistance
what does RI stand for
resistive isometric
post- operative pt MSK examination
respect protocol precautions/contraindications. Key to record: pain level, incision status, vascular, sensory and motor status above/below surgery, ROM (A or P), tolerance of exercise, functional ability, meds status
infective arthritis (at the elbow)
staph aureus, streptococcus and gonorrhea at the elbow, s/sx linked with drug abuse and need injection marks
first 150 degrees of arm elevation through flexion ms and actions
the UPPER and LOWER fibers of the trapezius contract concentrically, the fibers of the LOWER serratus anterior contract concentrically, the levator scapulae contracts eccentrically, (lengthening) the rhomboids contract eccentrically. (lengthening) x
most common association w/ medial elbow pain
tendinopathy (superficial wrist flexors, pronator teres) MCL sprain ulnar n compression
what causes chronic rotator cuff disease
tendinopathy-> partial tear -> full thickness tear
Step 1: garner trust post-shoulder surgery
teps for working with shoulder stiffness post-injury/surgery pt after injury/surgery have very difficult time relaxing (don't want to give their limb to you) commonly afraid, need to gain their trust get them to relax (if they are guarding during your manual tech, you will irritate their shoulder) pt buy in is IMPERATIVE
specificity
test is negative in those without target disorder (high specificity but low sensitivity may provide false negatives)
sensitivity
test is positive w/ target disorder (high sensitivity, low specificity, false positives)
sets and reps for tx
the goal of the exercise dictates how you prescribe sets and reps (power 1-5, strength 1-6, hypertrophy 6-15, and endurance 15+) and other principles: periodization % 1RM, 8RM, 20 RM ex velocity and type of contraction (isometric, eccentric, concentric)
what is the best type of tx?
the one that gets the pt better
TUBS
traumatic unilateral bankart surgery traumatic dislocation of the shoulder/freak injury as long as injury heals the outcome is good
ORIF
Open Reduction and Internal Fixation (orthopedic surgery)
what next, how to decide intervention?
tx must be focused on eliminating or decreasing cause(s) or identified problems Relies on ability to hypothesize a relationship between problem and pain ex. what's bothering them? they can't lift their shoulder, may start w/ ROM
soreness during warm-up that goes away but redevelops during session
2 days off, drop 1 level
burden of lateral epicondylitis
1-3% of the population affects 15% of workers who perform repetitive hand movements
labrum special tests
anterior (load and shift) SLAP (O'Brien's, speeds, Bicpes Load II) Posterior (Kim test)
what are instability tests of the shoulder?
anterior apprehension, posterior apprehension, and relocation tests
myotomes
muscle or groups of muscles innervated by a specific motor nerve (motor units/ ms innervations)
elbow extension ROM
0 hard end feel
tips for objective
1. assess don't assume 2. horses before zebras
soreness during warm-up that continues
2 days off, drop 1 level
shoulder flexion/bduction ROM
165-180 100-120 w/out scapula, 120-180 (last 60) w/ scapula firm
posterior interosseous nerve syndrome palpation (PINS)
2-4 cm below lateral epicondyle nerve is located near the shaft of the humerus and elbow, it is the deep motor branch of the radial n. proximal to the supinator arch
"shunt" ms
muscles that produce a compression at the joint surfaces of the joints they cross
burden of elbow injuries
2013- 12% Canadian workers claims were arm, wrist, and hand msk disorders and injuries located in supporting and related ms, ligaments, and capsules = lost time and lost income
is scapular dyskinesis associated w/ shoulder pain?
2018 study showed no difference in presence of dyskinesis in those w/ or w/out shoulder pain athletes with scapular dyskinesis did not have higher injury risk/rates compared to controls there is a differnce in degrees of scapular motion between dominant and non dominant in health pt
what are the "functional" ROM of the elbow?
30-130 deg. flexion 50 deg. pronation 50 deg. supination ROM of typical activity
proximal radioulnar open packed position
70 deg flexion 35 deg. supination
open packed position of the elbow (ulnahumeral jnt)
70 degrees flexion, 10 degrees supination
shoulder IR ROM
70-90 firm
beighton score
A Test for hypermobility. A score of 5 or more out of a possible 9 indicates hypermobility
what is the ultimate purpose of screening
A. delineate affected area and area to be examined further B. Rute out/clear body/structures that are not contributing to problem C. determine gross nature and site/symptoms of current problem, ad pt response D. determine grossly what changes pain (posture, movement...) E. all info used to guide a more detailed examination F. should only take 5-10 minutes
UQ screen elbow/forearm
AROM flexion (C5,6), extension (C7), pronation/supination at 90 flexion if no problems/pain provide overpressure (only to C5-7?)
what special shoulder test indicated subscapular involvement?
Belly press (upper subscap) lift off (lower subscap)
medications that commonly affect shoulder treatment
Corticosteroid use can cause osteoporosis and tendon atrophy and affects wound healing; therefore a history of its use may alter the differential diagnosis. not anticoagulant meds renal dialysis are at increased risk for tendon tears, as are patients who are 80 years of age or older
where are Heberden's nodes of the hand located?
DIP join osteoarthritis
types of referrals to PT for examination and evaluation
Direct Access, non-specific (protocol), consultative, prevention and health promotion. REGARDless of referal all will involve some version of MSK Exam
FT rotator cuff tear tests (5)
Drop arm ERRT ER lag Belly Press Lift Off
what special shoulder tests are may indicate infraspinatus?
ERRT (may indicated tear or involvement) ER Lag (cuff tear, and infraspinatus)
common mechanisms of elbow injury
FOOSH (sometimes coupled with neck injuries) fall on top of the elbow-> olecranon bursitis, ulnar n. lesion, olecranon fracture
tx strategy of repair/proliferation/regeneration stage of healing
GOAL: balance forces this is the point of best opportunity to influence tissue outcomes
What are the subacromial pain tests? (5)
Hawkins-Kennedy Neer's Painful Arc Full Can Speed's (must reproduce pt's symptoms)
APTA pt/client management model
Health screening examination evaluation dx prognosis > intervention outcomes
what are the components of a basic MSK exmaination?
History, review of systems, systems review, tests and measures.
ICF
International Classification of Functioning, Disability, and Health
dermatomal testing on LQ screening
L2-S1 : L1/2: anterior middle thigh L3: medial knee L4: medial calf L5: dorsal foot 1st and 2nd MT interspace S1: lateral border of the foot and posterior calf
LQ screening heel toe walking tests what nerves
L4, S1
heel walking tests what nerve
L4, dorsiflexion
shoulder pathological conditions associated with the LHB tendon including
LHB tendon degeneration, SLAP lesions, LHB tendon anchor abnormalities, and LHB tendon instability.
LHB
Long head of biceps
hypoxia
Low oxygen saturation of the body, not enough oxygen in the blood
peripheral nerve
Nerves functioning outside your brain and spinal cord.
where are Bouchard nodes of the hand located?
PIP joint osteoarthritis
tx tactics during inflammatory phase of healing
PRICE, pain free ROM, pt education on re-positions and activities, maybe gentle isometrics, gentile mobilities, and maintain aerobic fitness
post-op orthopedic surgions and PTs
PTs are the rehabilitation experts Ortho surgoesn have very little exposure to PT during their schooling protocols are a guideline (understand principles behind the protocols) we are a team
what are some of the most responsive pt-reported outcome measures of the elbow
Patient-rated elbow evaluation (PREE) american shoulder and elbow surgeon form Disabilities of the arm, shoulder, and hand
humeral propeller ms
Pectoralis major and latissimus dorsi ms, only ms in UE to have positive correlation between PEAK Torque and pitching velocity, and during propulsive phase of swim stroke also includes teres major and pec minor
diagnosis: underlying cause of problem
Problem... may be related to impairments maybe related to pathology, or a function limitations, societal limitations, or disabilities
pronator teres OIAN
Pronation and forearm flexion O: medial epicondyle I: radius N: medina n.
strengthen ms or increase joint motion (major intervention principle)
ROM exercise hierarchy (PROM> AAROM> AROM> ARROM) Strengthening exercise heirarchy (ex. starting and progressing)
Systemic causes of insidious shoulder pain include
RA (morning stiffness that goes away in 1 hr) and inflammation lupus, gallbaldder ds, liver ds typically ahve additional s/sx chronic resp or Cv conditions
treating injury due to hypoxia
RICE could limit further injury tx of secondary injury can also reduce the inflammatory cycle time and improve outcomes
SAID principle
Specific Adaptations to Imposed Demands
what comprises the biopsychosocial model?
person, biology, psychology, and social environment
A number of investigations have aimed to determine if adaptations in scapular movement occur in individuals with impingement or rotator cuff disease
Specifically noted are a decreased scapular movement toward: upward rotation, posterior tilt, and external rotation during humeral elevation
what part of the exam is most important?
Subjective, contains 80% used for diagnosis
Examination: specific testing may include
Tests neurological conditions, vascular integrity, specific syndromes, self-reported outcome measures
special tests for the AC joint
active compression cross arm
UQ screen TMJ
active open mouth, can they fit two knuckes in, notes symmetrical, clicks, pops, pain,
physiological resistance/fitness of healthy tissue
able to resist stress
paresthesia
abnormal sensation
0 grading of DTR
absent (areflexia)
bankart lesion
abulsion of labrum from glenoid
stages of healing
acute phase, repair/proliferation phase remodeling/maturation phase
stiff shoulder condition
adhesive capsulitis/ osteoarthritis/ sometimes RC tears and post-operative <80% contralateral side is considered overly stiff (20% discrepancy normal) don't torture pt (MUA: old method had you stretch them out, this only aggrivates it, and is extremely painful) new method (LOA) catching it late says to wait, it will loosen up/ surgery
no soreness
advance 1 level per wk or as instructed
2+ grading of DTR
average (lower half of normal range)
special tests for subscapularis
belly press (upper) lift-off (lower) bear hug
in the shoulder where is there more frequency occurrences of macro and micro-traumas
capsule, RTC, and labrum
acute phase of healing
coagulation and inflammaiont
research on shoulder "impingement" mechanism
conterindicated information: impingement occurs in first 30 degrees of abduction, but this is when there is the most space within the GH joint those that were asymptomatic had less space in their joint than the symptomatic pt supraspinatous is not in the shoulder space of impingement (floroscopy study) shaved acromion to make more space- 20% still have full RC tears
trochlear chondromalacia (elbow)
damage to the cartilage, is the formation of early arthritis. ... Thus, any grinding with translation of the patella in the trochlea groove, or evidence of pain or swelling with activities
1+ grading of DTR
decreased (hyporeflexia)
principles of msk evaluation: prognosis
determine predicted optimal level of functional improvement, time to reach, and specified intervals may include why (ex. diabetes medication may lengthen episode of care...)
cellulitis
diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling feels hot and tender can spread to other parts of the body not typically spread from person to person
AC joint injury: other shoulder condition
fairly common, " separation" MOI: fall or contact on pt of shoulder (clavicle slips off acromion) usually tx w/ brace and PT distal clavicle excision if necessary painful or degenerative AC joint can restrict/alter ROM usually localized over AC joint worse at end range elevation and horizontal add (limited to approximately 110 degrees of elevation if clavicle doesn't move) step deformity- AC not aligned, one sticking up
FOOSH injury
fall on outstretched hand sprain or strain to wrist, elbow, shoulder, serious: fractures wrist, elbow or shoulder, AC separation, clavicle fracture, GH fracture/dislocation
flexor carpi ulnaris A OIN
flexes and aDducts hand O: medial epicondyle and olecranon I: 5th metacarpal, pisiform, hook of hamate N: ulnar n.
flexor digitorum superficialis A OIN
flexes fingers @ PIP and MCP and flexes hand O: medial epicondyle and radius I: middle phalanges (2-5) N: median n.
palmaris longus A OIN
flexes hand O: medial epicondyle I: palmar aponeurosis N: median n.
what special shoulder test is biased towards suprasinatus but doesn't isolate it completely?
full can
The clavicle must be able to fully rotate for
full elevation to occur; otherwise elevation would be limited to approximately 110 degrees.
IP closed packed position
full ext
shoulders instability tests (3)
hand supinated, arm 90 abd, elbow 90 flexion, slowly ER while watching pt's face Positive: apprehension/guarding Interpretation: anterior shoulder instability
what is cubitus valgus
having a carrying angle >15 degrees common in women to have 15 or more degrees
Subjective screening questions
health history (red flags) pain at night recent trauma (MVA) cardiac (MI, chest pain, nausea, sweating, jaw pain) pulmonary (shoulder pain w/ cough or deep breath) GI (GI symptoms associated w/ shoulder pain)
outcome of shoulder instability
high recurrent rate of dislocation without surgery (60-90% in high risk populations, less in general population) repeated dislocations-> anterior glenoid bone loss-> lartarjet 40% OA in 10-15 years post (degenerative symptoms due to repeated dislocations) ex. TUBS
who is at risk of trigger finger
high risk factor in those whose work or hobbies requires repetitive gripping actions more common in women or diabetics
resisted ms testing of LQ screening
hip flex L1-2, knee ext L3, ankle DF L4, hallux ext L5, resisted knee flexion/hamstring S2
4+ grading of DTR
hyperactive w/ clonus (hyperreflexia)
tx tactics for remodeling/consolidation stage of tissue healing
increase exercise load; Open K chain and Closed-K Chain exercises; SAID principle
IFC
interferential current
another word for tactics
intervention
maintaining and improving overall fitness
look beyond the joint general fitness important (to optimal healing, pt confidence, and maintenance/improvement of associated body areas) use creative solutions that preserve safety and promote healing (empower them to stay active)
normal physical stress/demand on tissues leads to
maintenance
controlling pain and inflammation
major intervention, PRICE (protect, rest, ice, compress, elevate) conduct early , controlled, gentle motions (as long as it's not contraindicated) Knowledge of meds being used (NSAIDs and coritsone) respect all precautions/contraindications (ex. some tissue needs mobilization other doesn't) Advice on re-positioning/activities to avoid worsening and promote motion
UQ screen fingers
make a fist (AROM flexion), open hand 9AROM extenion ), no overpressure
MVC
maximal voluntary contraction
specificity of exercises shoulder example (isolation exercises)
most effective way to work to work the middle traps and lower traps is in the prone position >80% MVC (maximum voluntary contraction)
summary of intervention
must be SAFE (known indications/contraindications) scientifically sound targeted to pt problems, stage of healing and adequate dosage to reasonably achieve stated goals practice to implement creative (w/ specific goals in ind and never at expense of safety)
what is the triangle sign (elbow)
narrowness of the angle of the joint, used to track swelling assume 90 deg. flexion of the elbow mark the olecranon, lateral and medial epicondyles connect all to form a triangle should shrink with full extension (will not in cases of great swelling, because it prevents extension)
Protection phase of shoulder healing and tx
negative pressure lost during dislocation (takes a wk to restore) sling (no longer used in Europe, they educate pt on safe ROM goals: don't allow another dislocation reduce pain and inflammation restore cuff nms activity (sub-max isometrics)
dermatome T4
nipple
Burden of elbow neuropathy
often involve the median or radial nerve may involved peripheral entrapment of median, ulnar, or radial at elbow or wrist most common conditions affected this region are lateral epicondylitis, medial epicondylitis, and carpal tunnel syndrome
possible disorders and causes of posterior elbow pain
olecranon bursitis olecranon process stress fracture triceps tendinitis
most common causes of posterior elbow pain
olecranon bursitis triceps tendinosisi valgus extension overload
how do you know if you've achieved the goals and expected outcomes?
outcome measures use +/- impairment functional level measures use standardized or non-standardized measures SMART goals
shoulder patho preliminary dx based on mechanism of injury
overhead exertion w/ repetitiv motion: subacromial path, subacromial bursitis, SIS, RC tendinopathy, RC tear, bicipetal tendinopathy fall/FOOSH- sprain or strain to wrist, elbow, shoulder, serious: fractures wrist, elbow or shoulder, AC separation, clavicle fracture, GH fracture/dislocation fall on tip of shoulder: AC separation, compression periostitis (bone contusion), cervical spine injury (similar to s/sx of AC separation_ horizontal force extension AB/ER- anterior dislocation shoulder pain- orthopedic swimmer injury (40-91%), linked to decreased humeral head stabilization due to fatigue of upper back, RF ms, and pec ms.
common shoulder stiffness AAROM tx
pendulum wand pulley UBE Aquatic therapy
best exercise position for MVC for Serratus anterior (w/ least contribution of other ms)
plyometric pushup
best exercise position for MVC for middle and lower traps (w/ least contribution of other ms aka isolation exercise)
prone, >80% MCV
intermediate phase of shoulder tx and healing
restore normal kinematics (cautions w/ high 5 position) restore proprioception (proprio cell repair) restore nm control progress closed-chain to open-chain Goals: don't allow another dislocation regain scapula thoracic and scapulohumeral rhythm increase strength, emphasis on control uniplanar (avoid the high 5)
dermatome C8
ring and small finger, ulnar forearm
SINSS
severity: pain scale, level of impairment fnx irritability: provoking, skin (color), response nature stage (rapidly changing, bettering better or worse or stays the same) stability
size classification of RC tears
small <1 cm medium <3 cm large <5 cm massive >5cm (usually retracts)
soreness during warm-up that goes away
stay at level that led to soreness
LOA adhesive capsulitis
surgery to cut out fibrotic capsule usually bolus PT directly after surgery (come in every single day right after tx)
TOS
thoracic outlet syndrome
Rotator Cuff Tears
type: partial or full thickness location: bursal, articular, mid-substance with/without retraction Key findings: positive drop arm, ER weakness possible substantial loss of ROM and/or MMT negative instability (won't have instability) common impairments: significant weakness (otherwise same as SAP)
what are common hand deformities are present in Rheumatoid Arthritis (RA)?
ulnar drift and finger abnormalities
anterior translation forces (ER) and distraction force generated with pitching are equal
1/2 body weight during the late cocking phase, and equal to body weight during the deceleration phase.
The long head of the biceps and the triceps muscles are major dynamic stabilizers of the G-H joint, predominately functioning
functioning as "shunt" muscles (muscles that produce a compression at the joint surfaces of the joints they cross) during high-velocity activities
movement screening for objective documentation
general: elevation in scapular plane specific: pick a fnx task based on pt's subjective report of their fnx limitations used movement screen to help guide objective examination???
local sources of shoulder pain
glenohumeral joint scapulothoracic joint acromioclavicular joint sternoclavicular joint
open packed position of the shoulder
glenohumeral position: 55 deg aBduction 30 deg horizontal adduction externally rotated
closed packed position of the shoulder
glenohumeral position: 90 deg aBduction full external rotation full aBduction
what is the triangle space? (elbow)
good measure of swelling (**compare to other side) flex the elbow to 90deg mark the oleranon, radial head, and lateral epicondyle
proximal humeral fractures: stiff shoulder condition
occurs w/ falls or pathologically usually occurs at surgical neck of the humerus +/- cuff tear tx. : protection and ORIF (open reduction and internal fixation)
possible disorders and causes of posteromedial elbow pain
olecranon tip stress fracture posterior impingement in throwers trochlear chondromalacia
pronator compression palpation test
on both arms place pressure on the pronator teres (4 cm below cubital crease) Positive: REPROduced paresthesia in lateral 3 1/2 digits within 30 seconds or less (unaffected arm remains asymptomatic)
UQ cervical myotome tests
one motion per myotome C4- scapular elevation C5- shoulder abd C5/C6 elbow flexion C7 elbow extension C6- wrist extension C8- wrist extension T1- fingers together/apart -protraction/retraction, internal/external rotation, supinate/pronate, fist, opposition
Disabilities of the Arm, Shoulder and Hand
one of the most responsive patient-reported outcome measures of the elbow 6 items on symptoms and pain 24 items for fnx shorter version: QuickDASH
Patient-Rated Elbow Evaluation (PREE)
one of the most responsive pt reported outcome ms of the elbow 5 items for pain 15 items for fnx (10 specific, 5 typical activities) scaled on a 11 pt (0-10) numerical rating scale
American Shoulder and Elbow Surgeons (ASES) Form
one of the most responsive pt-outcome measures of the elbow consists of a pt self-rated part and an examiner based part scale each item: pain (5 visual analog) fxn (12 likert scaled-4 levels) satisfaction (1 Visual analog)
MSK examination interview techniques
open-ended vs close-ended (avoid leading questions), funneling technique (general to specific), FUPS (follow up questions), paraphrasing, and establishing pt's goal and expectations
what joint position are Accessory assessments ALWAYS conducted in
open-packed position
what ms are involved in medial epiconylitis?
pronator teres (median n.) flexor Carpal Ulnar (ulnar n.) flexor Carpal Radialis (medina n.) palmaris longus (median n.) flexor digitorum superficialis (median n.)
sub-acromial pain synderon
proper name for shoulder impingement pain originating from structures in the subacromial space (cuff, bursa, LHB) purposely vague: allows for uncertainty, and multiple mechanisms (that may be causing the pain)
PNF
proprioceptive neuromuscular facilitation
What is PROM as it relates to selective soft tissue tension testing
pt is NOT activating contractile elements to move joint (examiner is providing force), non-contractile elements still stressed because joint is being moved. IF pain, it is more likely non-contractile elements since they are not being stressed, exception is if ms is bein stretched!!!)
tx for strength and control
straight planes-> multiplanar isometric-> isotonic-> plyometric (if you don't have control in isometric then isotonic is a disaster)
Specific testing: neurological conduction
strength/MMT, sensation (sensory testing), DTR (integrity of spinal reflex arc), pathological reflexes (ex. babinski), and tests of neural integrity
categories of special tests for the shoulder
sub-acromial pain tests rotator cuff tear test instability tests labral tests other scapular (Must reproduce pt's symptoms)
Full Can test
subacromial pain test 90 flexion and Abduction/scapular plane, thumbs up Break test (overpressure) Positive: anterolateral pain Interpretation: subacromial structures might be pain generating, weakness might be a cuff tear "biases" supraspinatus but impossible to isolate empty can= thumb down
Hawkins-Kennedy test
subacromial pain test 90 shoulder and elbow flexion, internally rotation, stabilize humerus while putting pressure on forearm to internally rotation. (can run arm under their elbow, to put pressure on their shoulder and other hand to internally rotate) positive: anterolateral pain Interpretation: subacromial structures might be pain generator Good at ruling out shoulder pain, Bad at ruling in specific structure
Painful Arc
subacromial pain test AROM bduction Positive: pain 60-120 subacromial, 170+ AC joint Interpretation: suacromial structure might be pain generating Good at ruling in shoulder pain bad at ruling out specific structures
Neer's test
subacromial pain test full internal rotation w/ elbow straight, then bring shoulder into flexion Positive: anterolateral pain Interpretation: subacromial structures might be pain generator Good at ruling out shoulder pain Bad at ruling in specific structure
Speed's Test
subacromial pain test fully externally rotation arm, resists through full flexion range Positive: anterolateral pain Interpretation: subacromial structures might be pain generating "biases" LHB, isolation impossible
what are laxity tests of the shoulder and other?
sulcus and beighton score tests
other special shoulder tests (3)
sulcus, cross-arm, and AC shear
SLAP tear
superior labrum anterior to posterior
Supinator ms A OIN
supinates forearm (chief supinator) O: lateral epicondyle and Ulna I: proximal radius N: Radial n.
James Cyriaz
the doctor who provoked tissue, selective soft tissue tension testing
From approximately 150-180 degrees of arm elevation through flexion ms and action
the lower fibers of the serratus anterior contract ISO metrically, the lower fibers of the trapezius contract concentrically, the pectoralis minor contracts eccentrically, the upper fibers of the serratus anterior contract eccentrically
RC full thickness tear
the ms will begin to shrink and pull away from it's insertion point it can retract up to 4-5 cm components of individual ms cells shorten surgery: stretch out the ms and reattach it but this makes the ms very weak, do not know if ms cell structures can rebuild
reverse scapulohumeral rhythm
the scapula moves more than the humerus, occurs in conditions such as adhesive capsulitis.
dynamic scapular assessment
the scapulae tend to move symmetrically (except throwers) watch scapular through flexion and abduction, using 1-2 lbs wt can make dyskinesis more obvious using inferior angles, medial border, and spine to track movement asymmetry does not indicate pathology use scapular test and clinical reasoning to help you determine if scapula is contributing to symptoms dyskinesis potential contributors: ms/ weakness/imbalance (correlate w/ MMT and symptoms), nerve injury (MMT/RI and symptoms), and dynamic control
assessing and addressing the kinetic chain of the shoulder
thoracic spine scapulothoracic glenohumeral (prime movers and dynamic stabilizers) elbow/wrist (don't just tx the symptoms, tx the source)
what are the main principles of msk examination?
thorough subjective interview (pt, patterns, clusters, and signs) formulate a hypothesis observe movement and posture determine which tests and ms to use collect data support or challenge hypothesis
microtrauma instability
throwers/overhead atheltes/swimmers stretch out capsule repetitive microtrauma causes capsule to be inflammed and instability sometimes surgery is done to shorten or tighten but in systemically lax people their tissues will just stretch out again
dermatome C6
thumb and radial forearm
what is a primary injury
tissue destruction is a direct result from trauma
scientific research for principles of shoulder tx
tissue healing constraints UE biomechanics nm pathology activity specific tasks
what is secondary injury
tissue injury or cell death is the reslt of ischemia (lack of blood) due to blockage of blood/oxygen supply to an injured area
tissue healing in youth
tissue is in developing
UQ screen of cervical region is done why?
to check if pain source is coming from cervical spine/nerves roots
Pain due to rotator cuff pathology and impingement,
usually felt over the anterior or lateral part of the shoulder, can be characterized by radiation down the upper arm, and is aggravated with overhead activities
Pain due to A-C joint pathology
usually located at the superior region of the shoulder or well localized at the A-C joint itself, and there is often a clear history of injury to this region. Severe pain on top of the shoulder with an associated deformity could indicate an A-C joint sprain. Posterior neck pain may be indicative of a cervical radiculopathy, as neither the A-C joint nor a subacromial irritation refers pain to this area
VAS item scaling
visual analog scale
Chronis pain MSK examination
w/ behavioral issues, may shift focus of exam away from pain and towards functional abilities. w/ low irritability, may need to increase force or have pt do increased reps to reproduce symptoms
normal or excessive ROM w/out symptoms chart (elbow)
w/ passive overpressue: normal end feel abnormal end feel
What information should be gathered during history portion of a subjective exam of the elbow?
what brings them in today? chief complaint movement impairment fnx problems age mechanism of injury
designing tx for shoulder stiffness post injury/surgery
where is stiffness coming from? joint, ms length, pain, ms strength (don't forget strength- gravity mitigated movements) ASSESS DON'T ASSUME commonly tx: manual (PROM/stabilize scap, accessory motion: GH, ST, AC, and straight plane/Corners/Combined motion
what kind of pt w/ musculoskeletal problems?
-healthy, any age with micro or microtrauma. -individuals w/ ds of any system that manifests itself into a msk problem -individuals w/ congential/acquired problems -individual w/ pre/post surgery conditions
what do tests and measures determine?
which structures are involved, reduce symptoms (tests of provocation), id faulty movment patterns possibly contributing to pain production, confirm/refute working hypothesis, and establish objective data baseline
Evidence Based Practice in guding testing choice
Ideally pick high sensitivity and high specificity. Reliable and valid.
exs of specific test: self-reported outcome measures
Oswestry diability index for LBP, UEFS, or DASH for shoulder pain, etc
malignancy
a dangerous cancerous growth that sheds cells into body fluids and spreads to new locations to start new cancer colonies
stereognosis
ability to recognize objects by feeling their form, size, and weight while the eyes are closed
thoracic outlet syndrome
absent radial pulse with positional change
mobilization terminology
begining, middle and end of available range, rate of force applied, location of range of available movement, direction of force, target of force, relative structural movement, pt position
80% of the time the dx can be mad from the _____
history: pain, impairments, fxn problems. Thus interview techniques are important
LQ screening
lumbar AROM if no pain overpressure (OP) gait observation heel and tow walking (L4, S1) seated: dermatomeal test, resisted ms tests, and reflexes Supine: PROM hip flex/ext/ abd, IR, ER, knee flex/ext, ankle DF/PF, no pain apply over pressure, SLR (single leg raise) Prone: passive knee flexion w/ hip ext (femoral nerve) and resisted knee flexion (S2)
interpreting RI testing (Dr. Cyriax): strong and painful
minor, local lesion of ms/tendon
LQ/UQ screen inspection
posture/orientation, gaitn, skin status, quality of mvt (ribs and spine)
what is the purpose of MSK examination?
primarily to collect relevant data (info) to be able to make decisions about appropriate managment of the pt problem(s), and data colection (info) for CDM
nerve root
the base of each of the 31 pairs of spinal nerves that branch off the spinal cord through spaces between vertebrae. merge to form peripheral nerves leading to dermatomes and myotomes
therapeutic use of joint acessory motions -> jnt mobilization/manipulation tx tenchniques
therapeutic grades of motion (per maitland system) non-thrust oscillatory techniques Grades I-IV: Grade I and II pain relief, begining of range, small oscillation Grade III-IV improve restricted motion, large oscillation Grade V: High velocity thrust/manipulations
why use UQ/LQ testing
to localize problem and rule in/out additional problems (source vs cause), followed up by regional examination w/ specifically chosen tests and measures based on working hypothesis (confirm/refute via positive/negative results) ex. decide what tests to use is source of pain local or cause neural
Acute pain MSK examination
w/high tissue irritability, may not be able to collect all data at first visit, may need to focus on Pain Relief Before reliable data collection possible
what happens with history, review of systems, and systems review?
whther to go on to a physical exam, how aggressive/gentle w/ physical exam (SINSS), specific physical exam test relevance (most info w/ least amount of testing), and begin to develop working hypothesis or dx (to support or refute w/ physical exam)
romberg test
-ask client to stand with feet at comfortable distance apart, arms at sides, and EYES CLOSED -expected finding: client should be able to stand with minimal swaying for at least 5 seconds DC-ML tract (conscious proprioception)
elbow flexion ROM
0-140-150 soft or firm end feel
soreness day after lifting (not ms soreness)
1 day off, no advancemet
how do PTs make diagnoses?
it doesn't have to be a specific structure Use Clinical practice guidelines (CPG) response of tissue loading
why is the elbow susceptible to mobility and stability problems in general?
it is located between two of the most mobile joints of the body
Kim test
labral tear test seated, 90 abd, 90 elbow flexion compress the joint, moving it diagonally in horizontal add and flexion, while providing posterior force to the humerus (CAN position forearm on their back to keep them from going forward, and prevent dislocation, w/ same hand pulling humerus into labrum) Positive: pain/apprehension Interpretation: posterior labral tear
Biceps Load II
labral tear test supine, 120 abd, 90 elbow flexion, resist elbow flexion Positive: deep anterior pain Interpretation: SLAP tear w/ bicep involvement
O'Brien test
labral test seated, 90 flexion, horizontal adduction, full internal rotation, break test Positive: deep anterolateral pain Interpretation: SLAP tear must rule out subacromial and AC pain or just the position will hurt
scapular rehab algorithm
lack of soft-tissue flex or lack of ms performance
Other considerations biopsyhcosocial
lanuage barriers, cultural beliefs and values, and psychosocial factors
dermatomes S1
lateral border of the foot and posterior calf
most common elbow injury in >35 yoa
lateral epicondalgia
where does most swelling occur in the elbow?
lateral epicondyle prevents full extension triangle space and sign "tests"
what are the most common neuropathic injuries affecting the elbow, forearm, and wrist?
lateral epicondylitis medial epicondylitis carpal tunnel syndrome
shoulder: Weakness may be the chief complaint,
leading to some diagnostic confusion. It is important to distinguish true weakness from weakness secondary to pain, both in terms of history and examination findings. Painless weakness is usually due to neurological problems or myopathies, although peripheral nerve injuries can be painful Shoulder weakness may be caused by a rotator cuff tear or nerve injury (suprascapular, axillary, long thoracic, or thoracodorsal nerves, or cervical nerve root injury)
burden of medial epicondylitis
less common than lateral epicondylitis 10-29% of all epicondylitis diagnoses US cost 22 billion annually due to medical care and lost work
what might a snapping noise or feeling in the elbow indicate?
may indicate moving in or out of the ulnar nerve on the medial epicondyle or medial head of triceps or both
radial nerve compression/injury
may occur at any pt along the anatomic course of the nerve, w/ varied etiolgies compression can cause denervation or extensor or supinator ms and numbness or parethesis in distribution of sensation (RSN) resulting in pain, weakness and dysfunction most frequent site is in the proximal forearm near supinator and may involve the interosseous branch can occur w/ fractures of the humerus can also occur in the distal wrist
possible disorders and causes of the medial elbow pain
medial epicondylitis ulnar collateral ligament injury ulnar neuritis/ ulnar nerve subluxation valgus extension overload overuse syndrome flexor (pronator ms strain) fracture little league elbow
dermatome L3
medial knee
parameters of msk management
methods, mode, device intensity, load, or temp frequency, duration progression/regression all based on SINSS, acuity, age, pt preferences
dermatome C7
middle finger
carpometacarpal open packed position
middle of abduction and adduction middle of flexion and extension
shoulder strength test for objective documentation
minor vs major injury vs nerve (resisted isometrics) MMT (ms performance) consider using 90/90 positions for overhead athletes, poor reliability/validity for 4/5 and greater , use HHD if possible, and pain influences strength no matter how touch you are Selective tissue tensioning: poor validity/reliability in shoulder and cuff tendons form a sock, interface w/ jt capsule Ms length test
carpometacarpal closed packed position
none
interpreting RI testing (Dr. Cyriax): strong and painfree
normal, no lesion of ms/tendon
dx a degenerative tear
MRI- gold standard Ultrasound- just as good as MRI, much cheaper, no contraindications for metal implants or daustrophobia CORRELATION of imaging to physical exam
AMBRI
atraumatic, multidirectional, bilateral, rehab, inferior capsular shift surgery has poor outcome due to the multidirectional instability/laxity, surgery doesn't fix the actual problem
boney bankart
avulsion of labrum that pulls off a piece of glenoid
hills-sachs
posterior humeral head compression fx
UQ screen intrinsic ms
pt hold fingers together PT pulls apart (T1), hold fingers apart PT squeezes them together (T1) no over pressure
teach pt/family self-management (intervention)
shared decision-making pt/family education critical (some don't care) educate to help understand (using EBP to prove tx) (their problem(s), self-manage pain relief, long term resolution, tx interventions/progression)
dermatome C5
shoulder
why do a cancer screen with and elbow injury?
some bone cancers develop in the elbow and cause elbow pain that's why general health screenings are so important (for ruling in or out)
what special shoulder test may indicated/biased biceps but it impossible to isolated?
speed's test biceps load II (may indicate SLAP tear w/ biceps involvement)
special tests of biceps (LHB)
speeds
high physical stress/demand on tissues leads to
injury
% loss of extension as it relates to degree of flexion contracture
there is a greater loss of extension with greater degree of elbow flexion contracture
palpation of ruptured biceps tendon
this would show up as a palpable mass in the shoulder or elbow depending on which end ruptured
Degenerative cuff tears
thought to be a normal aging process 30% 40+ yoa 80% 60+ yoa con commonly be asymptomatic unclear how tear becomes sympotmatic
total mass of the shoulder ms (IR and ER)
total muscle mass of the shoulder's internal rotators (subscapularis, anterior deltoid, pectoralis major, latissimus dorsi, and teres major) is much greater than that of the external rotators (infraspinatus, teres minor, and posterior deltoid) IR 1.75 x greater torque than ER
non-standardized functional outcome measures
transfers/mobility/specific tasks as measured by -level of assistance (+1,+2,+3) -amount of assistance (independent, contact guard, min/mod/max assist) -distance/time ms (jump, time to pick up, etc) -observed specific qualitative change in performance -Gait (distance, cadence, velocity, observation, force platform, EMG)
moderate (positive overload) physical stress/demand on tissues leads to
increased tolerance (hypertrophy)
Phase II tissue healing: repair/proliferation phase
48-72 hours and up to 3-6 wks repair through 3 phases: 1. Resolution: little damage, and normal tissue approximation 2. Regeneration: replacement of tissue by same tissue 3. Repair: original tissue replaced w/ scar tissue -less viable that normal tissue, may compromise healing -6 mo or more to contract, 12 mo to fully mature
Radial tunnel syndrome (RTS) palpation
5 cm bellow lateral epicondyle insertion point will show lateral elbow and dorsal forearm pain, which may radiate to wrist and dorsum of the fingers intermitten compression of the radial n. from radial head to inferior border of the supinator ms w/out obvious extensor ms weakness more prevalent in men than women between ages 30-50
proximal radioulnar joint closed packed position
5 deg supination
functional tests of the elbow
5 reps/lbs functional 3-4 reps/lbs fxn fair 1-2/active: fnx poor 0: non-fxn elbow flexion w/ wt standing elbow ext: wall pushup standing facing door: turning door know into supination standing facing door: turning door knob into pronation
distal radioulnar closed packed position
5 supination
shoulder extension ROM
50-60 firm (some can get up to 90)
what ROM of the elbow is required for eating, dressing, and daily hygiene?
60-100 (combing hair 112) athletes need 10-20% greater ROM ex. overhead/throwing athletes
all screenings includ
A. AROM, B. PROM w/ over pressure C. Resisted iosmetrics (test myotomes/nerve roots, and contractile tissue) D. sensory testing (dermatomes and nerve roots) E. reflex test (specific nerve root) F: pathologic reflexes (babinski, hoffman's)
ERRT test
FT rotator cuff tear test Resisted ER at 0 positive: pain or weakness Interpretation: infraspinatus tear/involvement Good at ruling in but not at ruling out
multi-directional shoulder instability
AMBRI multiple directions of instability (ant, post, infer) young females, generalized laxity (beighton score), swimmers, gymnasts, softball pitchers usually atraumatic, sublux/dislocation occurring w/ low risk actvitiy (ADL's, sleep, etc) rehab is the gold stanard tx, avoid surgery due to poor outcome (lax -> surgery- > lax again) pain and instability: surrouding ms highly irritated from trying its best to provide dynamic stability paresthesia (abnormal dermal sensation: ex. tingling, numb, pricking, chills, burning, ...)
UQ cervical spine screen
AROM if no pain, may perform overpressue (done cautiously, provoking facets and compressing spinal nerves) systematically move from certical spine -> distally (then to TMJ, sho girld, shoulder, elbow, forearm, wrist, hand) resisted test for myotomes (conduct one motion per nerve C4-T1) dermatomal testing reflexes - watch face for expression
UQ screen shoulder
AROM: flexion, abduction (C5), ER/IR compares sides if no problems/pain provide overpressure (not for shrugs but yes for capsule)
UQ C-spine
AROM: flexion, ext, side bending, rotation if no problem or pain apply overpressure watch face
UQ screen shoulder girdle
AROm elevation (C4), depression, protraction, retraction, compare sides
UQ screen wrsit
AROm flexion and exteion (C6), overpressure if no problem
RCD/ subacromial impingement syndrome theories
Supraspinatus tendon tendon overlaod and degeneration OR mechanical compression in SA space
Lift off test
FT rotator cuff tear test hand behind back, pt lifts hand away from back (can add resistance) Positive: unable to lift Interpretation: lower subscap tear
belly press test
FT rotator cuff tear test pt hand on stomach,bring their elbow forward while maintaining pressure on stomach (resisted internal rotation) Positive: unable to bring elbow forward Interpretation: upper subscapula tear
UQ cervical screening dermatomal tests
C4: traps C5: shoulder C6: thumb & radius forearm C7: middle fingers C8: ring & small finger, ulnar forearm _______ not part of test usually T4: nipple T10: umbilicus
UQ cervical screening reflex tests
C5/6 biceps C7 triceps C5/6 brachioradialis Hoffmans's hand (UMN?)
dermatomes near the elbow
C6 radial forearm C7 middle finger C8 pinky T1 ulnar forearm back of fingers 1-3 -> radial (up to PIP joint) pinky and half of 4th-> ulnar palmar side fingers 1-3 Median
ER lag test
FT rotator cuff tear test ~20 degrees of scapular plane, 90 elbow flexion, externally rotate shoulder and ask pt to hold. Positive: pt unable to hold and arm falls into internal rotation Interpretation: cuff tear (infra) Good at ruling in but not at ruling out
dermatome L2
anterior middle thigh
what is a true shoulder impingment
bone spur in the GH joint
prognosis/ rehab potential
pt potential to improve
dermatome C4
traps
UQ screen thumb
AROm flexion, extension (C8), ABB, ABD
elderly and MSK
elderly may be limited by fatigue, may need accomodations with vision/hearing and positional problems.
picture of what scapular position
elevated R and depressed in L
order of scapular assessment
elevated/depressed, rotated, AB/ADducted, tilt, and winging
MSK assess: quality
end feel, soft, firm, hard, empyt, springy, spongy, boggy, and pain provocation?
most common association w/ lateral elbow pain?
epicondylosis, if tender on bony proninance
Radiohumeral open packed position
full extension full supination
closed packed position of the elbow (ulnahumeral jnt)
full extension, and full supination
MCP closed packed position
full flexion
thumb MCP closed packed position
full opposition
Elbow subjective examination History: common questions to the pt
-what brings you to the clinic today? can be broad and vague BUT, it can elicit information that is relevant to the pt in the outcome, and what is meaningful to the pt (ex. movement impairment and fnx problems, pain, tenderness) asking about a mechanical injury (ex. FOOSH) -onset/weakness/pain? (neuropathological) -hand dominance -What elicits pain?/What reduces pain? -what is pt occupation? what equipment do they use regularly? -duration of symptoms? has it improve or worsened (especially since seeing MD) -location of symptoms? (local/referred) -joint noise/crepitus/snapping -neck and shoulder pain -systemic/infectious -symptoms at night/day -sensory changes/ms weakness (ex. tingling)
gradings of deep tendon refelxes (DTR)
0- absent (areflexia) 1+ decreased (hyporeflexia) 2+ average (lower half of normal range) 3+ brisk (upper half of normal range) 4+ hyperactive w/ clonus (hyperreflexia)
forearm supination ROM
0-80 firm end feel (no bony block for radius)
forearm pronation ROM
0-80 hard end feel (radius block)
shoulder ER ROM
0-90 (usually less in most ppl) firm
Objective Examination steps for the shoulder
1. inspection/observation, posture 2. palpation 3. ROM 4. MMT 5. Ms length testing 6. accessory motion testing 7. reflexes, dermatomes, myotomes 8. functional testing
MSK examination Precautions and contraindications
1. malignancy 2. unhealed fracture 3. excessive pain 4.total joint replacements-mechanims of the joint may be self-limiting, so some techniques may be inappropriate 5. newly formed connective tissue 6. RA/connective tissue ds. 7. hypermobility 8. joint effusion 9. inflammation 10. when pt s/sx contra-indicate its use
basic principles of accessory motion testing
1. pt is maximally relaxed 2. usually test from "resting poisition" (open or closed packed) of joint, must know resting position 3. palpate to find appropriate landmarks 4. good bone contract for good fixation 5. hands as close as possible to joint line 6. place yourself in good position and work with gravity whenever possiblen/needed 7. stabilize one segment while mobilizing other (move parallel to joint surface- adapt to angle),and which articular surface s convex/concave/planar 8. understand which osteokinematic motion associated with Glide You Deliver 9. assess: amount of motion (usually glide) present, endfeel, and any pain with motion
distal radioulnar open packed position
10 deg supination
normal vs excessive shoulder stiffness post-surgery
<80% contralateral shoulder motion (non-surgical) surgical technique (arthroscopic vs open, anatomical vs non-A.) previous level of fnx instability hs
Phase III: Remodeling tissue healing
3 mo to 2 yrs laying down of collagen and strengthening of fibers balance must be maintained between synthesis and lysis. Osteoblast/osteoclasts etc... must take into consideration forced applied and immobilization/mobilization relative to tissue type and healing time
isolation exercise
A motion that if done correctly only targets one specific muscle may not elicit max activation but elicits higher activation w/ least activation of other nearby ms ex. plyo-push-up does not activate SA to the maximum, but it does isolate ms activation to most SA, while minimizing other ms LT, MT, and UT
pain map
A. "impingement syndrome" pain sharp and burning shoulder, dull down arm, possible numbness or dorsal hand B. rotator cuff sharp pain in shoulder, dull down arm C. glenohumeral joint arthritis, mixed dull and sharp pain shoulder and down, w/ some localized burning pain D. instability mixed dull and sharp in proximal shoulder and arm E. AC joint pathology sharp/shooting/stabbing in shoulder at AC and some dull nearby F. calcific tendinitis sharp/stabbing pain in shoulder
Jendrassik maneuver
Facilitates the stretch (knee jerk) reflex Clasp left an right hands together in front of your chest Force and cutaneous mechanoreceptors activate class of spinal interneurons that transmit force signals to interneurons of the lumbar plexus that excite interneurons synapsing on quadricep motorneurons -> increase activation of muscle *Contractile force changed but latency period did not drastically
shoulder evaluation
Following the examination, and once the clinical findings have been recorded, the clinician must attempt to determine: a SPECIFIC DX or a WORKING HYPOTHESIS based on a summary of all of the findings. This diagnosis can be structure related (medical diagnosis) or a diagnosis based on the preferred practice patterns as described in the Guide to Physical Therapist Practice.
tx strategies for inflammatory stage of healing
GOAL: decrease pain while preventing progression to chronic inflammation. use gentle and controlled mobilities
tx strategy for remodeling/consolidation stage of tissue healing
GOAL: tissue able to response to ADL forces; anticipated laod (sports, activity, work task specifics)
what are some common movement exam and basic assessments for an elbow injury
How does the pt sit? are they leaning over unaffected hand? how do they reach for objects? how do they perform their ADLs like washing hair, brushing teeth, or eating or drinking? do they have difficulty tying their shoes/typing/writing? How do they put their shirt on or their pants? ... (other movement requiring elbow and UE fnx?
special tests for the shoulder tell us what?
Integrity of cuff integrity of capsulolabral complex presence of instability subacromial pain AC joint pathology help rule in/out need to use tests w/ good sensitivity and/or specificity (ideally >80%) Must reproduce pt's symptoms
why is knowledge of hand dominance relevant w/ elbow injuries
It's important for assessing if compensating with the other arm is a realistic option/expectation could be part of the mechanism of injury, such as repetitive actions (ex. carpenter or throwing athlete)
Examination testing: specific tests
Joint stability and ligamentous integrity, neurological conduction, vascular integrity, specific syndromes, and self-reported outcome measure
shoulder exam picture
Level 1: screening (history, exam, flags) -appropriate for PT, PT and referral, and NA for PT Level 2: pathoanatomic Dx specific physical exam: origin (subacromial pain/RTC ds, stiff, loose) and /non-origin of symptoms Level 3: rehab classification 1. tissue, irritablily 2. impairment (high, moderate, or low irritability and impairement)
Superior labral anterior to posterior (SLAP) labral tear
MOI: traction injury (catching a car), repetitive biceps contraction (overhead), and compressed loading in flex/abd Type 2 most common (40%) common in throwers (may need surgery, 80% pitchers and it's career ending) degenerative if 40+ yoa (no surgery, if bicep involved additional precautions) type 2 and 4 don't stress, cartilage slow heal, biceps can completely tear off
What is thoracic outlet syndrome? (TOS)
Mechanical compression of neural or vascular structures traversing the lower neck into the arm Associated with signs/symptoms of ischemia or neuropathy
Specific test: Join stability and ligamentous integrity
Mild (1st deg), Moderate (2nd deg), and severe (3rd deg)
Joint motion for shoulder objective documentation
PROM in supine (scapula is stabilized) AROM in supine or seated (scap is supported vs unsupported) GH vs shoulder relationship between A vs PROM vs end feel capsular pattern (intra-articular vs extra-articular) reverse capsular pattern "impingement" painful arc Accessory motion: (laxity ms/note, or instability symptoms)
shoulder positions that relieve pain that help identify patho
Pain relieved with the elbow supported is suggestive of A-C separation and rotator cuff tears. Pain relieved by circumduction of the shoulder with an accompanying click or clunk could indicate an internal derangement or subluxation. Pain relieved with arm distraction is suggestive of bursitis or rotator cuff tendinopathy. Pain relieved when the arms are held in a dependent position suggests TOS.
principles of MSK evaluation
Problem Identification (PIP, NPIP) Hypothesis development (HOACC-II): tests and ms challenge or support Underlying cause of problem (cause of s/sx) Rule in/out alternatives based on pt findings and factors determine likely category based on patters of s/sx (remember horse not zebra) CAUTION: settling on dx too early
treatment tactics during repair/proliferation/regeneration stage of healing
ROM exercises (A/AA), jt/soft tissue mob, submax isometrics, ms flexibility, postural education, avoid compensatory movements and don't over load
quality of shoulder pain
Radicular pain tends to be sharp, burning, and radiating. Bone pain is deep, boring, and localized. Muscle pain can be dull, aching, and hard to localize. Tendon pain tends to be hot and burning. Vascular pain can be diffused, aching, and poorly localized and may be referred to other areas of the body. The intensity of pain may wax and wane with particular motions associated with specific activities
what might be a systematic problem associated with the elbow
Rheumatoid arthritis (RA, autoimmune ds) check for hand deformities: ulnar drift, finger abnormalities Osteoarthritis- Heberden's nodes common w/ OA of the hand mostly on DIP and Bouchard's on the PIPs
specific order of LQ screening
STANDING: gross posture (spnal curve, position of PSIS and ASIS), observation of gain, toe walk (L4), heel walk (S1), AROM of lumbar (apply overpressure) SITTING: AROM lumbar rotation (overpressure), reflexes (achilles S1/2 and petellar L3/4) resisted movement :(hip L1-2, knee ext (L3), ankle dorsi (L4), big toe ext (L5). Dermatomes L2-S1, babinski reflex SUPINE: Passive hip flexion, rotation abd, IR, ER, (no problems apply over pressure) passivie knee: flexion/ext (if no pain, overpressure) passive foot: DF,PF, inversion and eversion (no pain overpressure) SLR test (compare sides) PRONE: passive knee flexion w/ hip ext (clear femoral nerve: hip ext and knee flex) resisted knee flexion (S2) compare sides
branching of the median nerve
The median nerve arises from the cubital fossa and passes between the two heads of pronator teres. It then travels between flexor digitorum superficialis and flexor digitorum profundus before emerging between flexor digitorum superficialis and flexor pollicis longus. The unbranched portion of the median nerve (which arises from the cubital fossa) innervates muscles of superficial and intermediate groups of the anterior(flexor) compartment except flexor carpi ulnaris. The median nerve does give off two branches as it courses through the forearm: The anterior interosseous branch courses with the anterior interosseous artery and innervates all the muscles of the deep group of the anterior compartment of the forearm except the medial (ulnar half,which is supplied by ulnar nerve) half of flexor digitorum profundus and flexor carpi ulnaris muscle. It ends with its innervation of pronator quadratus. The palmar cutaneous branch of the median nerve arises at the distal part of the forearm. It supplies sensory innervation to the lateral aspect of the skin of the palm (but not the digits). Hand The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there it sends off several branches: 1. Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called "the million dollar nerve").Here it provides motor innervation to opponens pollicis, abductor pollicis brevis and superficial part of flexor pollicis brevis. 2. Digital cutaneous branches to common palmar digital branch and proper palmar digital branch of the median nerve which supply the: a) lateral (radial) three and a half digits on the palmar side b) dorsum of the tips of index, middle and thumb 3. The median nerve supplies motor innervation to the first and second Lumbricals of the hand.
Other AC joint injuries Types
Type I lig stretched Type II partial rupture of AC lig Type III complete rupture of AC and CC lig Type IV clavicle displaces posterior/over acromion (surgery) Type V clavicle displaced but still under skin (surgery) Type VI clavicle underneath coracoid (very rare) (surgery) ORIF surgery (open reduction and internal fixation)
inflammation
a localized response to an injury or to the destruction of tissues complex and multi-staged process predictable, but phases overlap, acute is necessary but chronic is hazardous treatable, impressionable influenced by many intrinsic and extrinsic factors disagreement on intervention of inflammatory response
what is the carrying angle of the elbow
between 10-15 degrees men tend to be closer to 10 deg. women tend to be closer to 15+ deg. >15 deg. cubitus valgus <5-10 deg. cubitus varus ("Gunstock deformity")
posterior interosseous nerve syndrome (PINS)
a neuropathic compression of the posterior interosseous nerve where it passes through the radial tunnel. Innervates most of the wrist extensors: Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Supinator muscle Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis
promote and progress healing (intervention principle)
adjust all management to stage of healing criteria to advance plan of care (if pain is adequately under control, tissue is healed, ROM restored tolerance for strengthening (vs specific timeline)) can educate to help them progress on their own, and spread out visits
what is the job of the RC?
dynamic stabilizer of the GH joint, reduces stress on ligaments compresses the humeral head into the glenoid 60% restraint is restive 40% restraint is static
MSK assess: Quantity
amount of motion present, hypermobility, hypomobility, normal/ideal
dyskinesis
an alteration in the normal position or motion of the scapula during coupled scapulohumeral movements ex. of dyanmic assessment https://www.youtube.com/watch?v=mm0MlTE4ziI
dermatomes
an area of the skin supplied by nerves from a single spinal root
labral tears w/ instability true for young not old
anterior/inferior: commonly occur w/ instability (88-100%) Posterior: commonly occurs w/ instability Superior (SLAP): under 40 commonly occurs w/ instability, over 40 more degenerative
passive articular motion tests of the radiohumeral joint
anterior/posterior glide distraction
Analyze and Integrate Entire Kinetic Chain (Major principle of intervention)
any one area is part of larger, interconnected chain regional interdependence to gain optimal control of one area you must have motor control of entire chain Use OKC -> CKC continuum
why sensory test
assesses the integrity and intactness of cortical sensory processing, performed throughout the dermatomal areas Tests: 1. light tough (Dc-ML tract) which is also vibration, conscious proprioception, and 2 pt discrimination 2. pinprick (pain- detected by the lateral spinothalamic tract) also temperature extremes, and crude touch
pathology of shoulder instability
bankart lesion- avulsion of labrum from glenoid bony bankart- avulsion of labrum that pulls of a piece of glenoid hill-sachs- posterior humeral head compression fx watch for neurovascular bundle injury suspect RC w/ dilocations over 40 (despite episode of instability, concern is stiffness) common to have numbness and tingling w/ dislocation impacted bone damage don't tend to heal, bone stays dented
shoulder pathology and imaging
bilateral MRI findings in individuals w/ unilateral shoulder pain: 100% subjects had pathoanatomical alterations in both shoulders 97% subjects had tendinopathy in both shoulders partial cuff tear in 37% of symptomatic shoulders, 31% asymptomatic shoulders 61% symptomatic had bursitis, 75% asymptomatic had bursitis 83% symptomatic had AC joint degenerative findings 86% asymptomatic had AC degenerative findings
random fnx shoulder tests
biomechanical fnx, basic fnx, one-arm hop test (athlete return to play), shoulder outcome scale, UCLA shoulder scale, simple shoulder test shoulder pain and dynamic index PENN shoulder score patient-specific fnx scale
ruptured biceps tendon
can occur at either attachment pt shows up as a palpable mass in the shoulder or elbow mechanism of injury varies: elderly- degenerative change athletic injury- wt lifting or throwing (especially in younger pt) trauma at any age usually associated w/ "pop" sound
tx of adhesive capsulitis
can take 1-2 years to resolve early stage <3 mo: mild diffuse pain, slight loss of motion, mimics SAP Freezing 3-9 mo: pain and loss of motion, PT ineffective Frozen 9-15 mo: pain reduced, loss of motion halts, PT can be effective Thawing: motion restores, PT very effective
possible disorders and causes of lateral elbow pain
capitellum fracture cervical radiculopathy (referred pain) lateral epicondylitis lateral collateral injury synovitis osteochondral degenerative changes osteochondritis disseicans (Panner's ds) Posterior interosseous nerve syndrome (PINS) radial head fracture radial tunnel syndrome
What is adhesive capsulitis?
capsular pattern, w/ unexplained significant pain and loss of motion (can't intervene early, pain will go away) difficult to dx early as it mimics SAP MRI can spot ds process unknown etiology unknown pathophysiology (inflammation and resultant fibrosis) 70% females, 40+ yoa, diabetics traumatic or atraumatic the synovium is red, inflamed and extremely painful -> loss of motion->stiffness
median nerve entrapment can lead to what common neuropatholgies (3)
carpal tunnel syndrome pronator syndrome (sensory) AIN syndrome (motor) - anterior interosseus syndrome nerve arises from the cubital fossa and passes between the two heads of the pronator teres then travels to flexors -branch is the anterior interosseous innervating deep ms (ex. digitorum profundus and pronator quadratus) -branch: plamar cutaneous
three likely causes of shoulder complex dysfunction (assuming systemic or serious causes ruled out)
compromised passive restraint component of shoulder girdle compromies nms system's production or control of sho girdle motion compromised 1+ neighboring jnts (AC, SC, scapulothoracic, lower cervical spine)
isotonic contraction
concentric muscle shortens because muscle tension exceeds load
none/low physical stress/demand on tissues leads to
cell death, cells need stimulation to stay alive
extreme physical stress/demand on tissues leads to
cell death, cells stressed to the point of no longer being able to repair themselves
shoulder pain due to referred pain source
cervical (radiculopathy) thoracic outlet vascular (angina, mi) pulmonary cancer (bone, lung, breast) GI (spleen, diaphragm, gallbladder)
most common causes of numbness in the shoulder and arm are due to
cervical or upper thoracic involvement, with either the segmental roots involved or the brachial plexus. The patient should be questioned about recent changes in work requirements or environment, and the presence of neck pain.
Impairment level outcome measures
change in joitn A/PROM: goni/inclinometer, ms force production: MMT, dynamometry, instrument pain: intensity: VAS, numerical, facial expression scale pain: location: change in area sensation: body diagram area affected, modality lost/present, semmes weinstein filaments coordination: activity specific assessment via #, speed, quality, etc
Anterior interosseus nerve syndrome (AINS) (elbow)
characterized by complete or partial loss of motor function of the ms innervated by the AIN (motor branch of the median nerve in the forearm)
shoulder palpation for objective documentation
check major joitns and soft tissue strcutures" pain/tenderness diffuse tenderness and tender/trigger pts abnormal texture/tone (ms bulk) abnormal structure/alignment can be use to assess tx response and guide tx (ex. pain present XX, 4 wk later, no pain at XX)
main subjective criteria to cover
chief complaint impairment/fnx/disability pain: (location, quality, duration, affect, intensity/irritability, paint hs, aggravating/alleviating factors, pt goals, P1-3)
shoulder patho and age significance
children/adolescents: epiphysitis of humerus or osteogenic sarcoma 20-40 yoa calcific depositions 30+ chondrosarcomas 40-50 yoa RC degeneration 45-60 yoa frozen shoulder, assoc w/ medical condition: DM, ischemic heart ds
what are the AROM of UQ cervical screening
chin tuck, extension lateral bend ear to shoulder rotation (overpresure, hand on temples open palm above ears)
shoulder instability dx
clinical (boxy), or radiograph
severe (3rd deg) jnt stability and ligamentous integrity
complete disruption of ligamention which can occur at its boney attachment or within the substance of the ligament
double crush syndrome
compression of a nerve at proximal site, that causes reduction of nerve conduction at distal compression site sometimes associated with TOS (thoracic outlet syndrome)
pronator (teres) syndrome PTS
compression of the median nerve in the forearm that results in predominantly sensory alteration in the median nerve distribution of the hand and palmar cutaneous distribution of the thenar eminence
scapular pivoter ms
comprise the trapezius, serratus anterior, levator scapulae, rhomboid major, and rhomboid minor scapulothoracic articulation
radiohumeral jnt closed packed position
elbow 90 flexion supinated 5 deg.
cubital tunnel syndrome
condition that involves pressure or stretching of the ulnar nerve (funny bone), which can cause numbness or tinging in the ring and small fingers, pain in the forearm, and/or weakness in the hand can be caused by direct pressure on the nerve, stretching of the nerve or frequency snapping of the nerve over the bone
full thickness cuff tear tests using special tests
confirm FT-RCT: painful arc, ERRT (pain/weak), ER lag (sup/infraspinatus), IR lag and lift off (subscap), drop arm, atrophy of infraspinatus, and belly off (subscap) rule out FT-RCT: ERRT (pain weakness), IR lag and lift off (subscap), empty can, and full can combine tests ???
diagnosing subacromial pain- systems reviews
confirm subacromial pain: single tests: painful arc, resisted ER (ERRT) pain or weakness, full can, and drop arm Rule out subacromial pain: single tests: painful arm, resisted ER (ERRT)- pain or weakness, hawkins, neer, full can, empty/jobe can Combo tests: 3/3 tests: hawkins, painful arc, resisted ER (pain/weakness) 3/5 tests: hawkins, neer, painful arc, empty can, resisted ER
DC-ML (dorsla column- medla lemniscal tract)
conscious proprioception sensory tract and somatosensory tract: light touch, vibration, postiion sense/proprioception, kinesthesis (movement sense) and stereognosis
what are MAJOR intervention principles?
control pain and inflammation correct posture and movement impairments increase flexibility and strength of ms analyze and integrate the entire kinetic chain incorporate nms re-education improve fnx outcome promote and progress healing maintain/improve overall fitness teach pt/family self-management (many of these go hand-in-hand, never treat in isolation, check other movements, Progress!)
what might be injured in the elbow if the chief complaint is the point of the elbow?
could be olecranon bursitis
what is gunstock deformity
cubitus varus <5-10 deg. of carrying angle of the elbow
tissue healing in the elderly
decreased tissue healing due to quality of the tissue, decreased proteoglycans, and elastin content
low physical stress/demand on tissues leads to
decreased tolerance to stress (atrophy, or deconditioning)
impact of ds/weakness/trauma on tissue physiological resistance/fitness
decreases tolerance to stress
humeral positioner ms
deltoid (C5-6), originates from the lateral third of the clavicle, the superior surface of the acromion, and the spine of the scapula (Fig. 16-13). It inserts into the deltoid tuberosity of the humerus. position the humerus in space
Evaluation/interpretation of exam findings
develop working hypothesis or dx (to direct PT management), use pattern recognition, interpret data (different conclusions), concept of differential dx, develop prognosis (duration), and plan of care (POC) (may document mutliple hypothesis with sufficient reasoning for either)
barriers to RC tear research
difficult to study the shoulder -black box -most mobile joint of the body (complex biomechanically, and difficult to model) Inconsistent inclusion/exclusion criteria -tendinopathy-> full thickness tear -prevalence of asymptomatic pathology
most common elbow injuries in children
dislocation of the radial head child complains of pain and can't supinate their forearm
unidirectional shoulder instability
dislocation or subluxation 90% anterior or ant/inf typically young males, collision sports (societal difference) FOOSH, high 5 position, and horizontal abduction dx: clinical or radiographs (boxy, looks like result of sulcus))
paralysis or weakness of the serratus anterior muscle results in
disruption of normal shoulder kinesiology. slight disability with partial paralysis profound disability with complete paralysis. As a rule, persons with complete or marked paralysis cannot elevate the arms above 110 degrees of abduction
repetitive hyperextension followed by pronation (high 5 position) of the elbow can affect what tissue
distal biceps lacertus fibrosus in the cubtial fossa
elbow joint capsule
does not respond well to injury forms thick scar tissue prone to flexion contractures % loss of extension as it relates to degree of flexion conracture
toe the line of tx
don't over challenge or under challenge the ms Soreness rules
common shoulder stiffness AROM tx
don't promote poor movement gravity assisted -> gravity minimized -> against gravity ex. shoulder flexion (prone> sidelying> standing flexion) -can also use adjustable table
dermatome L5
dorsal foot, 1st and 2nd metatarsal interspace
secondary "impingement" sub-acromial pain/cuff tendinopathy
due to: lack of laxity (caused by repeated microtrauma-> leads to loss of control) ms imbalances capsular/soft tissue imbalances poor scaplohumeral rhythms want to restore "normal" kinematics
Defensible documentation and MSK management?
every not includes pt education ...... ....\ ....
treat inorder to restore function
every treatment is selected to target specific impairments that have been objectively identified during the examination the impairment must be linked to functional/measurable goals (ex. physician gives prescription for specific documentation, so do we)
ex of a specific test: specific syndrome
ex. thoracic outlet syndrome
infants/children and MSK
exam through play activities and discussion with family (ex. how to test sensation or ROM in very young child)
extensor carpi radialis longus A OIN
extends and ABducts hand O: humerus/ lateral I: 2nd MC N: Radial n.
what ms are involved in lateral epicondylitis?
extensor carpi radialis longus (radial n.) extensor carpi radialis brevis (radial n.) extensor digitorum (radial n.) extensor digiti minimi (radial n.) extensor carpi ulnaris (radial n.) compression or damage to lower brachial plexus results in krumpke palsy
importance of the external rotation during humeral elevation can be demonstrated clinically
f the humerus is held in full IR, only about 60 degrees of G-H abduction is passively possible before the greater tuberosity impinges against the coracoacromial arch and blocks further abduction. This helps explain why individuals with marked IR contractures cannot abduct fully, but can elevate the arm in the sagittal plane.
flexor carpi radialis A OIN
flexs and abducts hand O: medial epicondyle I: 2nd metacarpal M: median n.
relationships between pain, impairments, functional changes
focus of PT: ICF model (International Classificiation of Functioning, Disability, and Health- ICF) -sometimes tissue is not the issue, return to best function
shoulder examination
focused, systematic, and thorough observation: gait, posture, static scapula position Palpation: anterior/superior, lateral, posterior, inferior A/PROM: elevation, extension, rotation, horizontal add, examin dynamic scap position Resistive tests examin movement patterns: Serratus Anterior, shoulder Abd, Fnx tests (ROM) Ms length tests passive accessory motion tests and scapulothoracic, SC special tests (including stability and apprehension, subl/relocation)
clinical use of accessory motions determine:
hypomobility (restricted, abnormal end feel, pain) hypermobility (excessive, abnormal endfeel, pain) clinical instability (unstable disrupts osseous and ligamentous structure of joint- > loss of fnx. specific jnt stability tests are used to detect this.
causes of shoulder stiffness
immobilization lack of movement (pain or fear avoidance) poor pt compliance synovitis surgery CRPS (RSD)
occupation and elbow injuries
important to know the physical demands of the job what kinds of equipment is being used (ex. construction equipment requires high force high reps of the UE)
most common chief complaints of the shoulder
include pain, instability, stiffness, deformity, locking, and swelling.sometimes complain of catching, clunking, grinding, or popping of the shoulder with various movements. (maybe asymptomatic and nonpatho, BUT may indicate labral disorder, RC tear, snapping scapula, bursitis, biceps tendon disorder (sound/sensation painful))
sx of too much overload
increased pain that does not resolve in 12 hrs pain that is increased over previous session or comes on earlier in exercise session (maybe warm up longer) increased swelling, warmth, redness in injury area decreased ability to use body during movement involving injured region Red flags: red, swollen which is acute inflammation, back off
general health screening for specific types of inflammation specific to the elbow
infective arthritis (need injection marks at elbow) cellulitis CRPS
exercise selection for the shoulder
infinite number of ways to get a pt from point A to B correct tx is one that gets the pt better (tip: get really good at the basics) pre-req is strength in order to build up load tolerance based on the exam findings knowledge of anatomy/movement awareness of surgical procedure understanding of biomechanics understanding of pathophysiology use the best combo of evidence/clinical standards: CPGs and PTNow
what are the three stages of tissue healing?
inflammatory Repair/proliferation/regeneration remodeling/consolidation
Examination tests and measures: observations
informal (prior/during hx), more formal (inspect, palpate, test), general to specific overview, gait/fnx movement, posture/position, skin/nails/scars (color, wounds, sn of infection), Quality/ease/difficulty of movements; guarding, compensations, use of assistive devices,. Movement, posture, ROM (acitve, passive, end-feel), MMT (strength, pain provocation), and special tests
inflammation and pain cycle
injury/pain/spasm/atrophy/weakness lead to inflammation -> pressure -> pain
Physical exam of UQ/LQ screen includes
inpsection, palpation and function inspection: posture/orientation, gaitn, skin status, quality of mvt (ribs and spine) Palpation: skin/fascia, ms/tendon, ligament, capsule/bursae, bone Function: joint ROM, mm performance, mm length, neuro status sensorimotor control, and special tests (impairment, standardized, functional)
main categories does an objective exam address
inspection/observation, palpation, and function
shoulder posterior apprehension
instability test of the shoulder hand supinated, hand under posterior shoulder (prevent dislocation), 90 scaption provide gentle posterior load while moving into horizontal adduction Positive: if apprehensive Interpretation: posterior shoulder instability (previous dislocation/sublexation)
cubital fossa
is an area of transition between the anatomical arm and the forearm. It is located as a depression on the anterior surface of the elbow
Clinical Decision making (CDM)
is not a one-time event, it's on-going, circular process ex. PCMM: examination> eval> dx> prognosis> intervention> outcome>
load and shift test
labral test seated or supine grasp humeral head, compress and move anterior/posterior Positive: deep symptoms reproduced Interpretation: possible anterior or posterior labral involvement clicking means nothing unless it's symptomatic
clinical characteristics of repair/proliferation/regeneration stage of the healing process?
less warmth, edema, tender palpation, pain felt concurrently w/ tissue stretch
Accessory motion testing (translations)
limitations in biomechanical research: jt capsule is a balloon (can't just stretch one side) choose direction based on biomechanics first -determine if it contributes to loss of motion (whole PURPOSE) -jnt hypomobility w/out ROM impairment does not need to be tx -assess, tx, re-assess to make sure your accessory motion contributes to ROM only occurs passivley (can not be consciously done by ms movement)
how do elbow flexion contractures affect daily life?
limits extension limits ability of people to reach forward
labral tests of the shoulder (4)
load and shift o'brien biceps load II Kim
potential sources of shoulder pain
local: GHj, Scapulothoracic j, AC jt, sternoclavicular jnt Referred: cervical (radiculopathy), thoracic outlet, vascular (angina, MI), pulmonary, cancer (bone, lung, breast), and GI (splee, diaphragm, gallbadder)
mild (1st deg) jnt stability and ligamentous integrity
localized tenderness and swelling over site of injury; some fibers are torn but NO demonstrable loss clinically or functionally of the integrity of the ligament
chronic inflammation
long onset and duration sub-acute is ~1mo chronic is months-years repeated microtrauma, overuse, abuse, tissue degeneration if inflammation persists longer than the severity of the injury would dictatate
moderat (2nd deg) jnt stability and ligamentous integrity
many but not all of the fibers are torn; clinical evidence of joint instability but stress testing does not demonstrate complete functional loss of integrity of ligament
Adolescene and MSK
may be harder to engage (meh, shrugs)
shoulder impingement of the sub-acromial structures
mislabeled as pinching between the acromion and great tuberosity of the humerus limited evidence on compression mechanism (SA isn't even in the space during most compressed position) perpetuates flawed mechanism and therefore flawed tx decisions multiple trials have found acromioplasty (shaving acromion down) did not prevent tears or reduce pain
what do Clinical Practice guidelines (CPG) include for evaluation
mobility impairment movement impairment stiff, loose, painful
Complete paralysis of the trapezius usually causes
moderate to marked difficulty in elevating the arm over the head. The task, however, can usually be completed through full range as long as the serratus anterior remains totally innervated.
Pain with RI
more likely contractile element involved since non-contractile elements are not being stressed (joint is relatively still). Exception, if an inflamed tissue like a bursa lies underneath ms that's contracting, it can cause pain)
sub-acromial pain/cuff tendinopathy
most common reason for shoulder pain (acute or chronic) Key findings: painful arc palpate to differentiate bicep vs cuff no substantial shoulder weakness no instability signs positive SAP tests Common impairements (assess don't assume): minor loss of motion thoracic spine stiffness tight pec minor/posterior shoulder weak scapular ms typically from abrupt overuse
Anterior/Inferior labral tears
most common to occur during dislocation can tear labrum or avulse from glenoid same MOI as anterior dislocation deep anterolateral pain usually hurts more after use as opposed to during (due to inflammation) click doesn't count unless painful or locking (if dislocated, pt likely has a labral tear, no need to perform test, rick< reward, also high change of re-dislocation best to do apprehensive tests)
posterior labral tear
most commonly occur during dilocation reverse bankart same MOI as posterior dislocation (horizontal adducted, w/ posterior force) deep pain, posteriolateral usually hurts more after use than during (due to inflammation) ex. football lineman, baseball/golf swing many ppl are lax posteriorly (when checking be careful of sublex)
shoulder stiffness following surgery
most frequent complaint following surgery limits fnx, but may also lead to early degeneration
typical body tissue healing response and general characteristics
most injuries heal without complications in a predictable series of events Area is red, warm, swollen, and painful, pain is present w/out motion, lasts 48-72 hours and up to 7-10 days pain occurs w/ activity or motion usually lasts 10-6 wks pain occurs after activity, usually lasts 6-12 wks timelines are separate but may overlap they are not absolute
accessory motions
movement in the joitn and surrounding tissue necessary for normal ROM but that cannot be activley performed by the pt
what is the job of the scapula
moves with the humerus to maintain length tension relationships provides a stable base for GH mobility (proximal stability promotes distal mobility)
RC repair and ms tissue
ms tissue quality is a strong predictor of repair failure -degree of atrophy -fatty infiltration long-term outcomes and fxn scores are improved if ms degeneration is at least halted
interpreting RI testing (Dr. Cyriax): weak and painfree
ms/tendon rupture or loss of innervation or disuse
UQ shoulder screen review
neurological status central vs nerve root vs peripheral (cervical vs TOS vs carpal tunnel)
radio carpal (wrist) open packed position
neutral, w/ slight ulnar deviation
SLAP tear for over 40 outcome
no different outcome because it's due to degeneration
Analyzing entire kinetic chain: continuum of open to closed kinetic chain
no jnt translation in dynamic fnx activities (recruit primary and secondary stabilizers) restore activity- or sport specific pattern assess readiness to return to daily activity/fnx/sport
clinical characteristics of remodeling/consolidation stage of tissue healing
no wrmth, edema, slight tender to palpate, tolerates more stretch prior to feeling pain
objective examination of the elbow includes:
observation/inspection/normal fxn position/movement palpation posture: carrying angle/triangle space/triangle sign UQS (UQ screen) ROM MMT Reflexes, dermatomes, myotomes fnx testing accessory motion testing ms length testing
Progression of tx
occurs continuous through re-examination evaluate pt progress by comparing baseline findings to current status: - is fnx improving? -has fnx diminished? -is there no change in fnx? also check in w/ pt, are they tired of the program or bored, are they doing their HEP, is it working for them?
most common elbow injury in 15-20 yoa
osteochondritis dissecans
AC shear test
other special shoulder test in seated, arm at side, compress the clavicle and scapula (use end of clavicle and acromial notch, palm on scapula) Positive: pain over AC Interpretation: AC joint involvement
cross arm test
other special shoulder test in seated, horizontally add arm to opposite shoulder, can add resistance Positive: pain over AC Interpretation: AC join involvement (if acute AC just PROM will cause pain, power lifters and contact athlete may have chronic AC symptoms, place hand on opposite shoulder and resist inferior force on elbow, this increases compression forces and elicit pain in AC joint, pain should be superficial/palpable)
sulcus test
other special shoulder test in seated, inferiority (straight axial) distraction of the shoulder Positive: if 1 finger distraction from sulcus (considered lax), should tighten in ER (present indicated ER rotator involved injury) Interpretation: only measures laxity
what kinds of problems require MSK exam?
pain, functional changes/losses (loss of ability), and impairments (stiff, weakness) (last two go hand in hand)
Chronic Regional Pain Syndrome (CRPS)
pain, swelling, stiffness, vascular changes w/ minor or severe trauma characterized by prolonged or excessive pain and changes in skin color, temp, swelling in affected area chronic (lasting greater than 6 mo) pain condition that most often affects one limb (arm/leg/hand/foot) usually after an injury believed to be caused by damage to, or malfunction of, the peripheral and central nervous system more common in women, it can occur in anyone at any age, peaking at 40 yoa, rare in elderly, very few in children 10 yoa and under, and almost none in children under 5 yoa
clinical characteristics of inflammatory
pain, warmth, tender palpation, swelling, limited ROM from pain/tissue damage, pain B4 end of ROM (empy end feel)
interpreting RI testing (Dr. Cyriax): weak and painful
partial rupture of ms/tendon or acute, inflammatory jnt process or pain induced inhibition due to serious joint/ms lesion
partial tear location classification of RC tears
partial-thickness tears are more common and include lesions a. bursal side b. midsubstance c. articular side d. full-thickness (lesion extending from articular surface through bursal surface)
Drop arm test
passively abduct arm above 90, ask pt to slowly lower their arm back down Positive: unable to eccentrically control lowering Interpretation: rotator cuff tear Good at ruling in and out
improving fnx outcome (intervention principle)
per individual pt needs, and what level of fnx returning to SAID principle consider endurance and power (and strength)
what could locking or catching in the elbow mean
possible a loos body in the elbow lack of full extension w/ pain- synovitis pitcher w/ medial pain- ligament sprain (pop w/ pain) tennis player- ask about change in equipment (grip size, string tension, etc...) duration- acute or chronic inflammation pain location: local or referred
increasing flexibility (major principle of intervention)
post-isometric relaxation techniques (ex. contract-relax) low load, prolonged duration stretching dynamic stretching adjunct modalities/sub max ex. to heat tissue (more compliant) or cool tissue (reduce pain) manual technique (tips use ms length positions, creep, dynamic, INCREASE CORE temp its better than applying heat)
common stiff shoulder dx that may use accessory motion
post-operative care post-immobilization care adhesive capsulitis GHJ OA (is it the same as other side, atypical motion may be their normal!!!) joint mobilization should increase ROM if that's the cause (follow convex-concave)
what falls within inspection/observation of an elbow examination
posture/orientation gait skin status quality of movement ** all compared to unaffected side visualized and expose both arms inspect for scars, deformities, and swelling (lateral epicondyle) note assymmetry, hypertrophy/atrophy, bruising/wasting/ms spasm note carrying angle
dx labral tear
primarily made on hs, as special tests are poor and clinical exam can mimic instability/SAP traditional MRIs are unreliable Need MR arthrogram: MRI + dye injection into joint -dye leaks out-> likely a labral tear Anterior: SN.75, SP.73 Posterior: SN .50, SP .92 SLAP: SN .66 SP.82
Injury Process
primary injury, secondary injury
what is AROM and seelctive soft tissue tension testing
pt is activating contractile elements to move joint, stressing non-contractile elements because joint is being moved. Pain indicates contractive or non-contractile elements involved (can't distinguish becuase both are being tested)
Resistive isometric (RI)
pt is stressing/activating contractile elements to produce the requested contraction. NOT stressing non-contractile elements particularly since joint stays relativley still.
correcting posture and movement impairments if related to pt problem (major intervention principle)
pt learns to prevent habitual tissue abuse posture education and problem-solving: establish optimal static and dynamic postural patterns to protect joint/soft tissue (ergonomic suggestions, static, and dynamic habit patterns) pt awareness of movement, help them understand why movement hurts (ex. joint swelling), what escalates/decreases pain, teaching about open packed positions
Standardized fnx outcome measures
pt reported outcome ms: ex. Oswestry Disability Index (ODI) Disability Index for Shoulder Hand (DASH) LE functional scale (LEFS) pt-performed outcome measures: ex. 30s sit to stand 2 in walk test single limb hop apta.org/outcomemeasures/ ptnow.org/tests-measures
shoulder systems review
pt suitable for PT intervention
Shoulder imaging
pt w/ imaging, request both the image and radiologist impression leave the imaging review until after the exam (UNLESS imaging directly impacts exam ex. S/P fracture or ORIF Refer when: suspicious of fracture or dislocation and/or red flags
principles of msk management: intervention
pt/family educations (part of every note) therapeutic exercise (impairment/fnx training, based on pt preferences <- may require creativity ex. car washing) nms re-education manual therapy gait training/therapeutic activities assistive devices/orthoses referral/consultation each has a billing code
Principles of msk management
purpose of utilizing PT, intervention is based on PT's assessment of current problem and timely response and progress toward achieving goals Parameters for intervention (based on SINSS), acuity, age, pt preferences optimizing functional independence (pt instruction, promoting pro-activity)
MUA adhesive capsulitis
put under anesthesia, then move arm to break up tissue extremely painful, especially the more irritated and inflamed the state of the shoulder before hand moving away from this
principles of shoulder post-op tx
race between fixation failure and biologic healing not all tissue is of good quality and not all fixation is rigid, adjustments in protocol are necessary limited by the slowest healing structure procedure- modified rehab (rehab is dependent on surgery) rehab-modified procedure (surgery altered for rehab)
osteoarthritis: stiff shoulder condition
rarely symptomatic if <45 yoa pain and progressive fnxal limitations capsular pattern promote movement without aggravating synovitis Joint replacement: Total shoulder arthroplasty (TSA) if healthy cuff Reverse TSA if cuff is not healthy (picture)
why are the s/sx of inflammation important to clinician?
read the response in order to guide therapeutic intervention timeline, redness, swelling, heat, pain, loss of fnx should note intervention based on initial inflamation prior to applying intervention
UE proprioceptive and NM control exercises
rhythmic stabilization (sense protibation and respond w/ co-contraction) PNF (proprioceptive nms facilitation) ball on wall (ex. ABCs on yoga ball) rebound ball toss closed-chain body blade
shoulder protector ms
rotator cuff ms (supraspinatus, infraspinatus, teres minor, and subscapularis) long head of the biceps brachii (weak shoulder flexor, humeral head depresion, anterior/post stabilizer, limits ER, lifts labrum, compressor of the GH jnt) fine tune humeral head position during arm elevation (no fixed axis in the shoulder)
objective portion of a shoulder exam should include
scapula/clavicle, humerus, skin (distal too), and posture movement screen (joint motion) palpation UQ screen strength evidence suggests erect thoracic kyphosis associated with improved shoulder flexion and abduction ROM, not enough specific methodology evidence to suggest thoracic kyphosis rehab is associated with shoulder pain
overall assessment of scapula
scapular dyskinesis is normal resting position doesn't matter movement symmetry (may vary in overhead athletes) evidence is limited by our lack of ability to define clinical scapular dyskinesis use of scapular assistance and re-position tests to help in CDM Assess static position and dynamic position
assessing the scapula, what should we do?
scapular dyskinesis is normal resting position probably doesn't matter movement symmetry (may not be symmetrical in overhead athletes) evidence is limited by ability to define scapular dyskinesis use scapular assistance and reposition test to help in CDM
repositions scapular test
scapular test pt standing, lifts arm into scaption (document pain), pull scap into posterior tilt and retraction, have pt repeat test Positive: if tilt decreases pain Interpretation: scapular dyskinesis may contribute to pain
Assistance scapular test
scapular tests pt standing lifts arm into scaption (document pain), cue scapula into upward rotation as pt repeats test Positive: if position decreases pain Interpretation: scapular dyskinesis may contribute to pain
spinal thalamic tract
sensory tract that detecs light touch and pressure
lateral spinal thalamic tract
sensory tract that detects pain and extreme temperatures
sub-acromial decompression
shave off undersurface of acromion/coracoacromial arch to increase sub-acromial space doesn't prevent RCD progression doesn't show improved outcomes over rehab alone or compared to placebo despite evidence, it's still a commonly performed surgery
acute inflammation
short onset and duration 0-14 days visible, palpable, but more obvious to pt change in hemodynamics and cellular fnx pro-inflammatory vs anti-inflammatory factors ex. ecamosis (internal bleeding), fusion w/in capsule, and edema escaping
shoulder relocation
shoulder instability test during anterior apprehension (hand supinated), provide posterior force (pushing shoulder posteriorly) Positive: if still apprehensive Interpretation: if anterior symptoms go away shoulder is instability
example exercise that has the least contribution of the upper traps (UT) compared to activation of other shoulder ms (MT, LT, and SA)
sidelying catching exercise
Clinical decision making paradigm
stiff vs loose vs painful vs combination. Limitation in motion (quantity: deg/ROM, and quality: end feel), where is the limitation capsular patter or noncapusular, what is the most painful test?
incorporate nms red-education (principle of intervention)
stimulate afferent to get dynamic jnt control and enhance motor responses start early in rehab stage (if safe) proprioceptive training sequence
what is the strengthening exercise hierarchy?
single-angle, submax isometric in neutral > multiple angle max iso> small arc submax isotonics> fnx ROM submax isotonics
what falls within palpation of an elbow exam
skin/fascia ms/tendon ligament capsule/bursae bone **compared to unaffected side
LQ/UQ screen palpation
skin/fascia, ms/tendon, ligament, capsule/bursae, bone
IP open packed position
slight flexion
MCP open packed position
slight flexion
Soreness rules
soreness during warm-up that continues - 2 days off, drop down 1 level soreness during warm-up that goes away- stay at level that led to soreness soreness during warm-up that goes away but redevelops during session - 2 days off drop down 1 level soreness the day after lifting (not ms soreness)- 1 day off, no advancement in program no soreness- advance 1 level per wk or as instructed
passive articular motion tests of the ulnarhumeral joint
stabilize the humerus distraction/ compression medial/lateral glide (can grab the olecranon for easier motion)
static scapular assessment position
static asymmetry is normal need to establish a starting position, what is there position? elevated/depressed, anterior/posterior tilt, protracted/retracted, upward/downward rotation ex. winging (medial border)
proprioceptive training sequence
static stabilization via wt shifts or alternating resistance (perturbation, balance board, swiss ball, etc) double limb to single limb progressively increase required functional range dynamic stabilization exercsies (intro of ballistic/impact ex. narrow BOS; change WB surface from hard>soft>uneven) can use distractions, asking about their day
trigger finger
stenosing tenosynovitis, condition in which one of your fingers gets stuck in flexed position may straighten with a snap occurs when inflammation narrows the space within the sheath that surrounds the tendon in the affected finger if severe may become locked in the flexed position more common in women or diabetics
Step 2: catch it early
steps for working with shoulder stiffness post-injury/surgery "oucne of prevention-= pound of cure" early recognition of pt prone to stiffness or becoming stiff -> more likely success of intervention post-op contact surgeon to develop a plan ms frequently for objective tracking!!!
step 3: motion is lotion
steps for working with shoulder stiffness post-injury/surgery early active and passive motion movement -> cycling of synovial fluid -> lubrication/joint nutrition Caution: Do within surgical precautions/restrictions
steps for tx a stiff shoulder post injury/operation (6)
steps for working with shoulder stiffness post-injury/surgery step 1: trust Step 2: catch it early step 3: motion is lotion step 4: length step 5: toe the line
Step 4: length
steps for working with shoulder stiffness post-injury/surgery use our knowlege of tissue biomechanics to determine hold/tx duration creep occurs in most tissues after 2 min (cumulatively exceed 2 min) low load long duration most effective
step 6: back of tricks
steps for working with shoulder stiffness post-injury/surgery use thermal modalities before/during tx (raising core temp better) IFC during tx (interferential current) PNF contract relax (proprioceptive neural facilitation set aside pride, whatever gets pt moving HEP imperative to keep motion gained know when to slow down, speed up, or call for help
shoulder exam palpation
sternoclavicular jnt, clavicle, acromioclavicular jnt, acromion, bicipital groove/LHB, coracoid, subscap tendon, supraspinatus tendon, and infraspinatus tendon
adhesive capsulitis CPG (guidelines) reccommendations
translational manipulation (under anesthesia- WEAK) corticosteroid injection (w/ shoulder mob and stretching, short-term pain relief -STRONG) pt education (encourage fnx, pain-free ROM, match stretch intensity- Moderate) modalities (tech to reduce pain and improve ROM-WEAK) jnt mobilization (reduce pain, increase motion-WEAK) stretching exercises (stretch as tolerated- Moderate)
loose shoulder conditions
traumatic instability (TUBS) multi-directional instability (AMBRI) labral tears (boxy appearance of the shoulder))
dermatome T10
umbilicus
principles of tx a loose shoulder
use scientific research tx impairments to restore fnx assess and address the kinetic chian don't just tx symptoms/tx source exercise selection sets and reps toes the line (no over or under challenge ms) strength and control shoulder instability macro or micro trauma Phase: protection, intermediate, late UE proprioceptive and NM control exercise scap exercises
greatest activation of the subscapularis
with the arm in the scapular plane at 90 degrees of elevation and neutral humeral rotation (thumb up) effective humeral head depressor
what are the main principles of msk evaluation
working dx (movement system dx) prognosis goals (outcomes) plan
is elbow hyperextension normal
yes, as long as it's asymptomatic
what does age have to do with types of elbow injuries?
young children- dislocation of the head of the radius, child complains of pain and can't supinate 15-20 yoa- osteochondritis dissecans >35 yoa- lateral epicondalgia