Clinical Skills (No Hand/Wrist)

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ankle mortise

The proximal concave articulating surface of the ankle joint, commonly referred to as the ________ _________, is formed by the medial aspect of the lateral malleolus, the distal tibia, and the lateral aspect of the medial malleolus.

Central stenosis

narrowing of the spinal canal

The patient lies on the nontest side with the hip and knee maintained in ﬂexion. The patient abducts the hip through full ROM. Palpation of glute med (distal to iliac crest). Resistance applied to lateral aspect of thigh, proximal to knee.

Hip ABduction MMT

Patient is supine and abducts the hip through full ROM. Therapist stabilizes the pelvis, palpates the glute med.

Hip ABduction MMT (Gravity eliminated)

Patient is supine. Stabilize the ipsilateral pelvis. Grasp the medial aspect of the distal femur. Move the femur to the limit of hip abduction motion (firm end feel).

Hip ABduction PROM

Same as ADduction PROM

Hip ABduction length tension test

Firm

Hip ABduction End Feel

Patient is supine with knees flexed to 90 degrees and hips flexed. Compare the prominence of the tibial tuberosities. Positive sign is tibial dropping back or sagging on the femur indicating a PCL tear

Posterior Sag Sign

Stenosis

Narrowing of central or lateral spinal canal Caused by enlarged Z-joints, osteophytes, listhesis, or disc bulge/herniation

interphalangeal (IP) joint flexion- extension

What joint and movement occurs at (2)?

Subtalar joint inversion-eversion

What joint and movement occurs at (5)?

Disc Sequestration

complete separation of disc material with rupture through PLL into the epidural space; free fragment herniation

Cauda Equina Syndrome

compression of lower spinal cord (risk of paralysis in legs)

Thompson test

compression of the calf muscle while observing for plantar flexion to assess the stability of the Achilles tendon

AROM

The patient contracts muscle to voluntarily move the body part through the ROM without assistance.

FAAM

A self-report outcome instrument developed to assess physical function for individuals with foot and ankle related impairments. 29-item questionnaire divided into two subscales: the Foot and Ankle Ability Measure, 21-item Activities of Daily Living Subscale and the Foot and Ankle Ability Measure,

The patient is supine. A roll is placed under the knee to maintain about 20° to 30° knee ﬂexion. The therapist grasps the dorsum of the foot with the radial border of the index ﬁnger over the anterior aspects of the talus and calcaneus. Firm end feel.

Ankle Plantar Flexion PROM

0-50º

Ankle Plantarflexion ROM

Disc Extrusion

Annular rupture Expelled nuclear material is attached to rest of disc

Spondylolisthesis

Anterior displacement of one vertebral body over another. Often associated with bilateral pars defects.

Firm

Hip Internal Rotation End Feel

0-45º

Hip Internal Rotation ROM

Soft/firm

Hip flexion end feel

Can be assessed using Hook Palpation. Place index finger on coracoid process, thumb on spine of the scapula, and middle finger on anterior aspect of the humerus to distinguish the relative position of the scapula and humeral head.

Assessment of the degree of tipping of the scapula.

Cognitive Factors

Attention Attitudes & Beliefs Expectations Self-Efficacy Catastrophising Coping

Hip Flexion

L2 Myotome

At the medial femoral condyle above the knee.

L3 Dermatome Key Point

anterior chest wall (starting just caudal to C5 dermatome anteriorly), posterior spine (sweeping across T1 vertebrae) to axilla, anteromedial medial arm to base of wrist

T1 Dermatome

PROM

The therapist or another external force part through the ROM.

Non-specific spinal conditions

These type of spinal conditions generally make up 80-85% of patients that PTs will see.

Cervical artery dissection

This is described as the following: •Dissection of internal carotid or vertebral artery •May be spontaneous or related to trauma •Usually in younger (avg. age is 40 y/o)

• Upper limb tension test A is positive • Reduced cervical rotation ROM <60º to involved side • Distraction test reduces symptoms • Spurling's test reproduces symptoms

Wainner's Cluster for Cervical Radiculopathy

metatarsophalangeal (MTP) joint abduction-adduction

What joint and movement occurs at (1)?

talocrural joint dorsiflexion-plantarflexion

What joint and movement occurs at (4)?

The patient is sitting. The shoulder is ﬂexe to 90° with slight horizontal adduction, and the elbow is extended. The patient is instructed to avoid trunk rotation, & protracts the scapula through full ROM.

Serratus Anterior MMT (Gravity Eliminated)

Yellow Flags

Psychosocial Considerations

Thoraco-lumbar flexion/extension

1. inclinometer T1-S2 - norm: F is 60 dg 2. Tape measure C7-S2 - norm: 10 cm (difference between start and end range is normal) - stabilize pelvis to prevent ant. pelvic tilt

Full Squat

Functional test for lower extremity

Thoracolumbar lateral flexion: tape measure - method 2

2. finger tip to floor - norm: 16-17 cm - problem--this measure effected by pt's body size, only should be used to compared repeated measures to a single subject

Inferior angle, superior angle, posterior tip, and anterior tip of acromion.

4 Point Scapular Palpation

Dizziness (vertigo) Diploplia (double vision) Dysarthria (speech) Dysphagia (swallowing) Drop attacks Nystagmus Numbness (peri-oral) Nausea/ vomiting

5 D's and 3 N's

Elbow flexion with forearm supinated (Biceps Brachii) or Wrist extension with radial deviation Extensor carpi radialis longus

C6 Myotome

0-20º

Ankle Dorsiflexion ROM

0-5º

Ankle Eversion ROM

0-5º

Ankle Inversion ROM

Stage of Disorder

Acute, sub-acute, chronic, or recurrent

Depression Anxiety Stress Fear Worry Frustration/Anger Increased pain attention/focus.

Affective Factors

Patient is supine with a roll placed under the knee to maintain about 20° to 30° knee ﬂexion. Axis is placed inferior to the lateral malleolus. Stationary Arm. Parallel to the longitudinal axis of the ﬁbula. Movable Arm. Parallel to the sole of the heel. 20º Dorsiflexion, 50º plantarflexion.

Ankle DF/PF Goniometry

Formed by 4 walls. Anterior: Pec Mj. Posterior: subscapularis and lat. dorsi. Medial: Ribcage and serratus anterior. Lateral: Biceps and coracobrachialis. Contents: brachial artery and brachial plexus.

Axilla Palpation

Lies at the level of the first cricoid cartilage.

C6 vertebral body palpation

Elbow Extension (Triceps Brachii) or MTP finger extension (extensor digitorum)

C7 Myotome(s)

Lies between the mastoid and the posterior border of the mandible.

C1 Transverse process palpation

top of head and down upper half of posterior head (can lightly pull hair)

C1/2 Dermatome

Cervical Flexion Rectus capitis anterior, longus capitis

C1/2 Myotome

Lies at the angle of the mandible.

C2 Vertebral Body Palpation

base of occiput and lateral neck

C3 Dermatome

Lies at the level of the thyroid isthmus, cranial to the sternal notch.

C7 vertebral body palpation

extension, internal rotation, abduction

Closed packed position for hip

Originates on the tip of the coracoid process, and inserts on to the middle third of the medial surface of the humerus. Palpate the medial humerus as you resist flexion, and ADduction of the arm to palpate the muscle contracting.

Coracobrachialis Palpation

Reticulopathy

Disease of a spinal nerve root.

Attaches to the spine of the scapula, the acromion, and the lateral 1/3 of the clavicle. The muscle fibres travel distally and merge at the deltoid tuberosity at the lateral aspect of the humerus. Anterior fibres flex and IR the humerus (resist this movement to feel the muscles contract). The middle fibres ABduct the arm. The posterior fibres extend and ER the humerus.

Deltoid palpation

Patient's elbow is flexed to 90 degrees with the forearm pronated and hand is in a fist. Stabilize the elbow and resists the patient's wrist extension Positive for pain in the lateral elbow indicating lateral epicondylitis

Cozen's Test

Screening test used to detect distal irritation or area of re-innervation of a nerve, performed by tapping directly over the path of the nerve to elicit a paresthesia in the affected nerve distribution.

Cubital Tunnel TInel's SIgn

It is difficult to feel through the musculature. Located on the lateral aspect of the humerus about halfway between the shoulder and the elbow. Slide your thumb down the arm until you feel a small mound on the lateral side of the arm. This is the insertion site of the deltoid muscle.

Deltoid tuberosity palpation

S2 Dermatome

Dermatome of the buttock, thigh, and leg posterior

L5 Dermatome

Dermatome of the dorsal foot, lateral lower leg

S1 Dermatome

Dermatome of the lateral and plantar aspect of foot, posterior lower leg

Sensitization

Ease of triggering response to stimuli such as • Movement • Posture • Load • Palpation • Sensory (light touch/ pressure/ thermal) • Stress/distress

Place hands on posterior aspect of patients head at midline. Move distally, in the midline, proximal to the base of the occiput. You will feel a small, prominent piece of bone placed centrally above the hairline

External Occipital Protuberance palpation

the shoulder is put in 90° elevation in the scapular plane in external rotation (thumb up) and manual resistance is given against further elevation.

Full Can Test

Combing or brushing hair

Functional External Rotation Movements

The patient is standing erect with the lower extremity in the anatomical position. The patient is positioned facing a stable plinth or wall.patient places the non-test leg ahead of the test leg and leans forward to place the hands on the plinth or wall. The patient is instructed to maintain the foot on the test side ﬂat on the ﬂoor, with the toes pointing forward, and to keep the knee in full extension as the leg moves over the foot. Alternatively, just perform ankle DF PROM.

Gastrocnemius Length Tension Test

Calf raises with knee extended. 5 = Maintaining the heel fully off the ﬂoor through more than six repetitions; 4 = Maintaining the heel fully off the ﬂoor through three to ﬁve repetitions with subsequent attempts resulting in decreased range; and 3 = Maintaining the heel off the ﬂoor through one to two repetitions only with subsequent attempts resulting in decreased range.

Gastrocnemius strength test

45º

Hip ABduction AROM

Patient is sitting in 90º hip and knee flexion. Patient internally rotates the hip (wings foot out), or externally rotates the hip (wings foot in). Resistance applied to lateral or medial aspect of lower limb proximal to ankle joint. Palpation of glute med for internal rotation (cannot palpate external rotators)

Hip internal/external rotation MMT

Patient is in supine with leg in 90º hip flexion/knee flexion), therapist supports the leg. Patient internally (wings foot out) or externally (wings foot in) rotates the hip through full ROM.

Hip internal/external rotation MMT (gravity eliminated)

Diagnosis

Identification of an injury or disease

Slide hand from the superior angle, along the medial border to the inferior end of the scapula, the inferior angle, which aligns with the T7 spinous process.

Inferior angle of Scapula palpation

L1 Dermatome

Inguinal/groin Dermatome

0-(-10)º

Knee Extension ROM

Spans from the crest of the ilium, sacral, lumbar, and 6 lower thoracic spinous processes, as well as the lower 3-4 ribs, rising anteriolaterally, sending a slip to the inferior angle of the scapula, as it passess it on its way to insert on the bicipital groove of the humerus. Find the lateral border of the scapula, and move laterally, to where you can grasp the thick bulk of the latissimus dorsi muscle, and possibly some of the teres major. Position the arm into extension and internal rotation, and resist extension and ADduction to feel the muscle contraction.

Latissimus Dorsi Palpation

The largest of the scalenes, it attaches to the C2 transverse process, and anterior tubercles of the transverse processes of C3 to C7, and then travels distally to the superior surface of the first rib. Resist ipsilateral side flexion to palpate the muscle contraction (will be deep in the post. triangle). Acting from above, the scalenes elevate the first rib to aid in respiration.

Middle scalenes palpation

Fibroelastic membrane attaching to the external occipital protuberance, the posterior tubercle of the arch of C1, and successive spinous processes from C2 to C7. It provides attachment for muscles on either side of the neck and is tensed in flexion.

Nuchal Ligament palpation

Test of ITB tightness. Patient is in the side-lying position on the nontest side and holds the nontest leg in hip and knee ﬂexion to ﬂatten the lumbar spine. Stabilize the pelvis, bring the test leg into ABduction, hip extension and 90º knee flexion. Allow test leg to drop, if leg remains ABducted, TFL is short.

Ober's test

IO runs from the C2 spine lamina, upward and laterally to attach to the transverse process of C1. Contraction produces ipsilateral rotation of C1. SO passes from the TP of C1 superiorly to the occiput. Ask the pt. to look upwards, without moving the head, to activate this muscle.

Oblique Inferior and Superior Palpation

Talar Tilt

Patient in prone, knee at 90º and ankle at 0. Stabilize tib/fib, tilt foot medially to stress CFL, place foot in some plantar flexion and tilt again to stress ATFL. Positive if there is pain or increased laxity compared to contralateral side.

A towel is placed under the patients shoulder at the angle that parallels the pec minor to act as a fulcrum. Using a cross handed technique, stabilise the pec minor on the ribs and gently push along the coracoid to assess length.

Pectoralis Minor LTT

internal rotation of the ankle combined with medial force to assess the stability of the ACL. idea is to sublux the lateral tibia, then using the IT band to pull it back. Hold leg up by calcaneus. Some valgus pressure from outside hand, slight internal rotation, then adding flexion through to 90º. If it's positive around 20 or 30º the ITB will "clunk" the tibia back into position. Applying a slight valgus force the whole time through range.

Pivot Shift Test

Stenosis

Possible degenerative pathology of the C-spine. Abnormal narrowing of the spinal canal (can be central or lateral, usually due to osteophytes encroaching on the canal)

posterior tibiotalar ligament

Posterior third of deltoid ligament, prevents excessive dorsiflexion and eversion.

Lateral malleolus

Prominent distal end of the fibula on the lateral aspect of the ankle.

Medial malleolus

Prominent distal end of the tibia on the medial aspect of the ankle.

Achilles tendon

Prominent ridge on the posterior aspect of the ankle; tendon edges are palpable proximal to the posterior aspect of the calcaneus.

Eversion, dorsiflexion, ABduction

Pronation is a combination of what movements?

Hoffmans Reflex

Purpose: Upper motor neuron lesion Method: PT flicks the distal phalanx of the index, middle, or ring finger. Positive Test: Reflex flexion of the distal phalanx of the thumb or finger that was not flicked.

Cervical myelopathy

Red Flag. Compression of the spinal cord in the neck. Signs include -clumsiness (loss of hand dexterity) -Loss of balance/ wide stance gait -Paresthesia -Hyper-reflexia of Hoffman's or Babinski reflex

Sink through the soft tissue of the upper fibres of Trapezius, and follow the first rib posteriorly to its articulation with the first thoracic vertebrae. Once you've located the first rib, move inferiorly to locate the intercostal space, and further distal to locate the second rib.

Ribs 1 and 2 in Prone

plantarflexion

S1 Myotome

Find the mastoid process of the temporal bone behind the ear. The medial clavicle, where it attaches to the manubrium. Then follow a line between these two landmarks to outline a path along the SCM. Notice how both SCM's merge to form a V at the front of the neck. You can emphasize the muscle by having the patient rotate their head to the opposite side and slightly flex their neck.

SCM Palpation

Bony ridge that can be felt running along the top third of the scapula, with its root lining up approximately with the T3 spinous process.

Scapular Spine Palpation

Following the setting phase, there is a predictable scapulohumeral rhythm throughout the remaining arc of movement to 170° (Fig. 3-171). For every 15° of move- ment between 30° abduction or 60° ﬂexion and 170° of abduction/ﬂexion, 10° occurs at the glenohumeral joint and 5° occurs at the scapulothoracic joint.

Scapulohumeral Rhythm

The patient is sitting and assumes a relaxed, anatomical posture. Scapular Elevation Movement. The patient moves the shoulders toward the ears in an upward or cranial direction. Scapular Depression Movement. The patient moves the shoulders toward the waist in a downward or caudal direction

Scapulothoracic Joint AROM Elevation/Depression

Instruct the patient to place the left hand behind the neck, and reach down the spine as far as possible (abduction and lateral (upward) rotation, shoulder elevation and external rotation, elbow ﬂexion, forearm supination, wrist radial deviation, and ﬁnger extension). Instruct the patient to place the right hand on the low back, and reach up the spine as far as possible (adduction and medial (downward) rotation, shoulder extension and internal rotation, elbow ﬂexion, forearm pronation, wrist radial deviation, and ﬁnger extension) Switch.

Shoulder AROM Scan

1. Patient places hands behind back to achieve neutral spine. 2. Patient slumps forward at the thoracic and lumbar spine. 3. Patient flexes the neck by placing the chin on the chest. 4. Patient extends one knee as much as possible 5. Patient actively dorsiflexes the ankle

Slump Test Technique

Place the pt.s arm above their head in ABduction and ER. The subscapularis originates at the subscapular fossa on the anterior side of the scapula and inserts into the lesser tuberosity of the humerus. Palpate the lateral border of the scapula, moving lat. dorsi fibres out of the way to gain a purchase on the scapula. Resist shoulder IR and ADduction to feel the contraction.

Subscapularis Palpation

Slide your hand superiorly from the spine of the scapula to find the superior angle, as it aligns with the spinous process of T2.

Superior angle of Scapula palpation

From the external occipital protuberance, you will feel a ridge of bone running laterally to the right and left.

Superior nuchal line palpation

The patient is sitting. The arm is at the side, the elbow is ﬂexed to 90°, and the forearm is pronated. The patient supinates the forearm through full ROM. Palpation. Biceps brachii: anterior aspect of the antecubital fossa. Supinator: posterior aspect of the forearm, distal to the head of the radius. Resistance Location. Applied on the posterior surface of the distal end of the radius with counter pressure on the anterior aspect of the ulna (have them press into your thenar eminence so its more comfortable)

Supinator MMT

From the spine of the scapula, slide your fingers superiorly into the supraspinatus fossa. Palpate the supraspinatus laterally until it goes deep to the acromion. The supraspinatus tendon can be best felt at the front of the shoulder by having the patient put their hand behind their back, allowing the humeral head to medially rotate and better expose the tendon. Feel the rope like tendon anterior and inferior to the AC joint. Palpate the supraspinatus fossa while you resist ABduction to feel the shoulder contract.

Supraspinatus Palpation

Acute

Stage: The 'typical', or predicted and time-limited response to trauma or other noxious event. E.g.; ankle sprain in the last 24 hours. May develop in the absence of clear local tissue injury (insidious onset). E.g.; flares of osteoarthritis; rheumatoid arthritis.

Sub-Acute

Stage: This phase represents the transition following a traumatic injury to normal expected tissue healing (1-2 months or longer for some tissues e.g.; tendon). In the absence of a traumatic injury, it represents the phase of a disorder where symptoms usually subside as part of the natural history of the disorder.

Specificity

Specificity = TN / (TN + FP)

Originates from SP of T3-T6, and inserts on the posterior tubercle of the TP of C1-C3. Resist side flexion to palpate contraction.

Splenius Cervicis palpation

Move inferiorly to the bottom of the manubrium to appreciate how the manubrium and the body of the sternum lie in slightly different planes, forming the sternal angle, which sits at the level of the second costal cartilage.

Sternal angle palpation

Spondylolysis

Stress fracture of the pars interarticularis, commonly involved the adjoining pedicle and lamina. Lesions in the posterior vertebral arch. May be active bone stress and unconfirmed through radiologic imaging.

Plantar Flexion, inversion, ADduction

SuPINAtion is a combination of what movements?

Also known as the subdeltoid bursa. Most of the bursa sits deep to the acromion when the arm is at the side. Extending the arm posteriorly brings the bursa forward. From the front of the acromion with the patients arm extended, palpate gently between the deltoid and the rotator cuff tendons on the anterior shoulder to appreciate the bursa.

Subacromial Bursa Palpation

(20-35°) No OP, can still stabilize and guide movement

Thoracolumbar Extension AROM

(15-20°) Stabilize hips and OP through shoulders

Thoracolumbar Side Flexion AROM

(40-60°) Stabilize hips and OP above L1

Thoracolumbar flexion AROM

The patient is sitting. The ankle is in plantarﬂexion and the foot is in slight eversion.. The lower leg is supported against the therapist's thigh. The patient dorsiﬂexes the ankle and inverts the foot through full ROM. Palpation - tib anterior. Resistance - dorsomedial forefoot.

Tib Anterior strength test

1. Education to return to normal, non provocative pre-accident activities as soon as possible 2. Postural and mobility exercises to decrease pain and increase ROM 3. Reassurance to the patient that recovery is expected to occur within the first 2 to 3 months.

Treatment for acute neck pain with movement coordination impairments.

Posterior aspect of the shoulder. Formed by... Superiorly: Teres Mj. Medially: Long head of triceps Laterally: Lateral head of triceps and humeral shaft. Contents: Profunda brachia artery and radial n.

Triangular Interval Palpation

General Health Co-Morbidities Family History Personal History Medications Genetics

Whole Person Considerations

Black Flags

Workplace Factors Nature of work Job demands Workplace processes Compensation claim Claim acceptance Legal issue

Paresthesia

abnormal tactile sensation often described as creeping, burning, tingling, or numbness

Analgesia

absence of pain in response to stimulation which would normally be painful

Hypoesthesia

decreased touch sensation

Degenerative disc disease

dehydration and loss of disc structure

Dysesthesia

difficult or painful sensation

Babinski

fanning and curling toes when foot is stroked

· Slump test

identifies dysfunction of neurological structures supplying the lower limb

Anterior talofibular ligament

intrinsic ligament located on the lateral side of the ankle joint, between talus bone and lateral malleolus of fibula; supports talus at the talocrural joint and resists excess PF and INV

Borders: Anterior: Posterior border of SCM Posteriorly: Anterior margin of traps. Superiorly: Occipital bone Inferior: Omohyoid muscle. Floor: Lev scap., Splenius capitis, and scalenes.

posterior triangle palpation

Hypoalgesia

the same pinprick stimulus is less painful when delivered to the affected area compare to the normal skin area

Hyperalgesia

the same pinprick stimulus is more painful when delivered to the affected area compare to the normal skin area

Abnormal babinski

upgoing toes

Indications of neural compromise

· Descriptors of neural pain · Presence of any sensation changes · Patient reports weakness, clumsiness or changes in dexterity of the limbs

Tuberosity of the navicular bone

Bony prominence about 2.5 cm inferior and anterior to the medial malleolus.

Lies lateral to the cricoid cartilage, deep to the soft tissue

C6 anterior tubercle palpation

Triceps Tendon Reflex

C7 Reflex

Flexion of middle finger (DIP only) Flexor digitorum profundus Also Thumb extension

C8 Myotome

Cauda equina syndrome symptoms

Low back pain, weakness, saddle anesthesia, overflow urinary incontinence, loss of reflexes below cauda equina

On the anterior-medial thigh, at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament and the medial femoral condyle.

L2 Dermatome key point

Patellar tendon reflex

L3-L4 reflex

ACL test. Small knee flexion. Inside hand wraps from the tibial tuberosity around, outside hand stabilizes the femur. Try to move the tibia anteriorly (not the same as up). Done after posterior sag test to rule out PCL involvement which could give a false positive.

Lachman Test

The patient is in a prone-lying posi- tion at the edge of the plinth. The arm is at the side, with the shoulder in internal rotation. The palm faces the ceiling. The patient extends the shoulder through full ROM while maintaining slight shoulder adduction Palpation. Latissimus dorsi: lateral to the inferior angle of the scapula or at the posterior wall of the axilla Teres major: posterior wall of the axilla lateral to the axil- lary border of the scapula. Resistance Location. Applied proximal to the elbow joint

Latissimus Dorsi and Teres Major MMT

The patient is in a side-lying position on the nontest side, with the arm at the side and the shoul- der in internal rotation. The patient extends the shoulder while maintaining shoulder adduction. Palpation. Latissimus dorsi: lateral to the inferior angle of the scapula or at the posterior wall of the axilla Teres major: posterior wall of the axilla lateral to the axil- lary border of the scapula.

Latissimus Dorsi and Teres Major MMT (Gravity Eliminated)

Knee Flexion

S2 myotome

Sensitivity

Sensitivity = TP / (TP + FN)

The patient is supine or sitting. The therapist stabilizes the trunk, grasps the distal humerus, moves the humerus laterally and upward to the limit of motion for elevation through abduction.

Shoulder Elevation Through Abduction (Glenohumeral Joint, Scapular and Clavicular Motion) PROM

The patient is prone or sitting. The arm is at the side, with the palm facing medially. The therapist stabilizes the scapula, and moves the humerus posteriorly until the scapula begins to move

Shoulder Extension PROM

The patient is supine. The shoulder is in 90° of abduction, the elbow is ﬂexed to 90º. The therapist stabilizes the scapula, therapist grasps the distal radius and the ulna, and moves the dorsum of the hand toward the ﬂoor to the limit of external rotation.

Shoulder External Rotation PROM

Hand Behind Head (could also cue them to scratch the back of their head or opposite shoulder).

Shoulder External Rotation Scan

Hand behind back

Shoulder External Rotation Scan

Goniometer Axis. The axis is placed at the lateral aspect of the center of the humeral head about 2.5 cm inferior to the lateral aspect of the acromion process when in ana- tomical position Stationary Arm. Parallel to the lateral midline of the trunk. Movable Arm. Parallel to the longitudinal axis of the humerus, pointing toward the lateral epicondyle of the humerus.

Shoulder Flexion AROM + OP Assessment

Muscle Length Assessment

passively stretch (i.e., lengthen) the muscle across the joint(s) crossed by the muscle. When the muscle is on full stretch, the end feel will be ﬁrm, and the patient will report a pulling sensation or pain in the region of the muscle.

Locate the long head of biceps in the intertrabecular groove, between the greater and lesser tubercles deep to the deltoid. Passively IR and ER the arm to palpate the tendon in this groove. The short head arises from the coracoid process, and travels distally with the long head to insert on the medial elbow. Resist elbow flexion and supination to palpate the contraction.

Biceps Palpation

Work Considerations

Blue and Black Flags

Cervical side flexion Sternocleidomastoid

C3 Myotome

Lies at the level of the hyoid bone

C3 Vertebral Body Palpation

posterior neck, top of shoulder girdle over clavicle

C4 Dermatome

Shoulder Elevation Upper Trapezius

C4 Myotome

Lies at the level of the superior thyroid cartilage.

C4 Vertebral body palpation

posterior neck and just below clavicle anteriorly, down anterolateral shoulder, arm and forearm to base of wrist

C5 Dermatome

Shoulder ABduction (Middle deltoid)

C5 Myotome(s)

Lies at the level of the inferior thyroid cartilage.

C5 vertebral body palpation

Stabilize the humerus at the elbow and resist at the anterior forearm. Open packed position for the UH joint is 70 degrees of flexion, 10 degrees supination

Elbow flexion RIM

The patient lies prone in a relaxed state. The therapist is standing next to the patient, at the side of the leg that will be tested. One hand should be on the lower back, the other holding the leg at the heel. Passively flex the knee in a rapid fashion. The heel should touch the buttocks.

Ely's Test

the shoulder is pm in 90° elevation in the scapular plane in maximal internal rotation (empty can position) and manual resistance is given against further elevation

Empty Can Test

reach into a back pocket, perform toilet hygiene, tuck in a shirt, and hook a bra

Functional Internal Rotation Movements

Move your fingers inferiorly and laterally about 2cm from the acromion, under the deltoid, to feel the hard surface of the greater tuberosity. It is the most prominent part of the lateral aspect of the shoulder, and the insertion point for the rotator cuff muscles.

Greater tuberosity of humerus palpation

Patient is supine. Hip on full flexion and slowly extend the knee (distal end), or knee on full extension and slowly flex the hip (proximal end

Hamstring Length Tension Test

Passive internal rotation is performed with the shoulder in 90° of forward flexion. A painful test is an indication for subacromial impingement ; the test will be negative in case of internal impingement.

Hawkins Kennedy Test

Knee Extension

L3 Myotome

From the bicipital groove, passively externally rotate the arm and move medially onto the lesser tuberosity. It is anterior and inferior to the acromion, approximately 3cm, and can be better appreciated by rotating the humerus and feeling it move under your finger.

Lesser tuberosity palpation

Attaches to the superior angle of the scapula. It will feel ropy as it travels superiorly along the lateral side of the neck to the transverse processes of the upper four cervical vertebrae. Here, it lies deep to the traps. Use the soft pads of your fingers to avoid compressing the roots of the brachial plexus that exit along the same levels. Resist scapular elevation from the superior angle of the scapula to feel the muscle contract.

Levator Scapula Palpation

Degenerative disc disease

Possible degenerative pathology of the C-spine. Dehydration and loss of disc structure

Spondylosis

Possible degenerative pathology of the C-spine. a degenerative disorder that can cause the loss of normal spinal structure and function

PCL stability Patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner sits on the patient's feet and grasps the patient's tibia and pushes backwards. POSITIVE TEST: SLIDING

Posterior Drawer Test

1.Hx of neck pain 2. Whiplash 3. Headaches 4. Neural compromise/pain 5. Suspicion of CNS disease 6. Unclear of source of symptoms. 7. Differentiate between PNS source and CNS pathology (red flag)

Reasons for performing a UQ scan (7)

1. Pain Intensity (6 or greater useful cut score for prognosis) 2. Self-reported disability (Neck disability Index >30%) 3. Pain Catastrophizing (Impact of Events Scale >33 score) 4. Cold Hyperalgesia

Recommended tools for developing a prognosis in neck pain/ WAD

Originates from C7-T6 TP, and C4-C6 articular processes, and attaches to the medial area between the superior and inferior nuchal lines. Weak contralateral rotator when acting unilaterally. Resist bilateral extension to try and feel the contraction

Semispinalis capitis palpation

Originates from T1-T6 TP, and attaches to the sides of the SP of C2-C5. Resist bilateral extension, or contralateral side flexion to try and feel the muscle contract.

Semispinalis cervicis palpation

High Sensitisation- Helpful/ Protective

Sensitivity level: High pain, possibly including allodynia and hyperalgesia of affected structures. In the acute to sub-acute stages this increased sensitisation can be considered protective. SHould decrease as disorder settles.

Low Sensitization

Sensitivity level: Low responsiveness to stimuli such as posture, movement and palpation of local neck structures. Pain with postures and movements consistent with the clinical picture.

High Sensitisation- Unhelpful

Sensitivity level: Pain with allodynia/hyperalgesia and either localized or more widespread, beyond what might be expected for clinical history and stage.

The patient is prone or supine. In prone, the shoulder is in 90° of abduction, the elbow is ﬂexed to 90°. The therapist stabilizes the scapula and maintains the position of the humerus, grasps the distal radius and the ulna, and moves the palm of the hand toward the ceiling to the limit of internal rotation

Shoulder Internal Rotation PROM

Performed in an open packed position with a pillow on tha pts. lap, supporting their elbow. From the sitting position, flexion, extension, AB and ADduction can be performed by placing resistance on the humerus. For IR and ER, place the elbow in 90º flexion and resist at the wrist.

Shoulder RIMS

Anterior border of the tibia

Subcutaneous bony ridge along the anterior aspect of the leg.

The patient is prone. The shoulder is abducted to 90°, the elbow is ﬂexed to 90°, the arm proximal to the elbow is resting on the plinth. The patient internally rotates the shoulder by moving the palm of the hand toward the ceiling. Palpation. Subscapularis is too deep to palpate. Resistance Location. Applied proximal to the wrist joint

Subscapularis MMT

1. Determine your level of concern about potential red flags 2. Decide on your clinical action based on that level of concern 3. Consider the pathway for emergency or urgent referral.

The international framework for serious spinal pathology includes three steps...

Goniometry

The measurement of the range of motion of a joint of the body

Endfeel

The sensation transmitted to the therapist's hand at the extreme end of the PROM that indicates the structures that limit the joint movement.

Attaches to the superior nuchal line of the occipital bone, the external occipital protuberance, nuchal ligament, and C7 SP. The upper fibres travel vertically downwards to attached to the upper third of the clavicle. Ask your pt. to side flex the neck to the same side, and turn their head to the opposite side to your palpating hand, resisting the movement to feel contraction.

Upper fibres of trapezius palpation

MTP joint flexion-extension

What joint and movement occurs at (3)?

posterior

With the ankle in plantarﬂexion, the narrower ________(anterior/posterior) aspect of the body of the talus lies within the mortise and allows additional motion to occur at the joint.

The patient is sitting. The elbow is ﬂexed, the forearm is resting on a table in pronation, the wrist is in neutral position, the hand is over the end of the table, and the ﬁngers are relaxed. The therapist stabilizes the forearm and grasps the metacarpals. Firm or hard end feel.

Wrist Extension AROM + OP

The patient is sitting. The elbow is ﬂexed, the forearm is resting on a table in prona- Forms tion, the wrist is in neutral position, the hand is over the end of the table, and the ﬁngers are relaxed. The therapist stabilizes the forearm and grasps the metacarpals. Firm end feel.

Wrist Flexion AROM + OP

Thoracolumbar lateral flexion: tape measure - method 1

1. finger tip of 3rd finger to thigh - difference from relaxed stance position to laterally flexed position - mark start and end range points on lateral thigh - normal: 22 cm

Lumbar flexion/extension/lateral flexion: Inclinometer and tape measure - how do we measure? where do you put it? what are the norms?

1. inclinometer -S2 (between PSIS)- T12 (to last rib and go medial - line them up to zero, have pt slowly touch toes -need to subtract the differnece Norms: - flexion: 60, extension: 20-25, Lateral flexion: 25-30 dg (have inclinometer face you on S2 and T12)

Thoracolumbar rotation

1. inclinometers (T1-S2) - bend over, have one arm touch the other and rotate -norm: 33 dg in each direction -have pt look to the opposite direction 2. goniometer - seated, turn trunk to left --stationary arm: w/acromion --moving arm: parallel to acromions --axis center of top of subject's head norm: 45 dg *key is eyeball posture*,

Thoracolumbar lateral flexion

1. inclinometers (T1-S2). No norm stated but lumbar LF is 25-30 dg 2. Goniometers - standing: stationary arm perpendicular to floor, axis at S2, moving arm with C7 - norm: 35 dg

Pain Behaviors

A functional behavior category. Overt behavioural responses to pain experience or the anticipation of pain. May include facial grimacing, frowning, breath holding, groaning, demonstrative displays of pain, overt avoidance behaviors, use of unaffected body regions to support the affected area such as using the arms to move from sitting to standing.

Mixed Pain

A combination of various pain types, for example, nociceptive and neuropathic pain components in an individual with low back pain and painful lumbar radiculopathy; or neuropathic pain combined with functional pain (sciatic and irritable bowel or dysmenorrhea or fibromyalgia).

Slump Test

A neural tension test used to detect altered neurodynamics or neural tissue sensitivity.

Prone Knee Bend

A neural tension test used to stress the femoral nerve and the mid lumbar (L2-L4) nerve roots. Positive if unilateral pain is produced in the lumbar region, buttocks, posterior thigh, between the ranges of 80-100 degrees of knee flexion in a combination of these regions.

Straight Leg Raise Test

A neural tension test where the lower limb is passively flexed at the hip with knee in full extension. Can be used to rule in or out neural tissue involvement as a result of a space occupying lesion, often a lumbar disc herniation. It is one of the most common neurological tests of the lower limb.

Manual Muscle Test

A procedure for the evaluation of the function and strength of individual muscles and muscle groups based on effective performance of a movement in relation to the forces of gravity and manual resistance.

Lower Quadrant Scan

A quick test that we may choose to do at the beginning of our assessment to help guide us through our physical assessment. It encompasses AROM with OP of our lumbar movements, and some hip, knee and ankle movements.

1. In painful conditions. 2. In the presence of an inﬂammatory process 3. In patients taking medication for pain or muscle relaxants 4. In the presence of marked osteoporosis (or other bone structure compromising conditions) 5. In assessing a hypermobile joint. 6. In patients with hemophilia. 7. In the region of a hematoma, 8. In assessing joints if bony ankylosis is suspected. 9. After an injury where there has been a disruption of soft tissue 10. In the region of a recently healed fracture. 11. After prolonged immobilization of a part.

AROM Precautions

The patient is sitting with the ankle and foot in anatomical position. The therapist grasps the lateral aspect of the forefoot and inverts/supinates the foot/ankle. Firm end feel.

Ankle Supination PROM

Meniscal stability test. 58% statistical accuracy. Patient in prone, distract the knee at 90º flexion and perform lateral and medial rotation. Repeat with compression. Excessive rotation or discomfort +ve, more pain with compression vs distraction hints to a meniscal tear.

Apley's Test

Comes off the posterior cord of the brachial plexus, at the level of the axilla. It travels through the quadrangular space and winds around the surgical neck of the humerus. It is fairly superficial in the axilla and can become compressed by using crutches or fracture of the proximal head of the humerus.

Axillary Nerve Palpation

The patient is supine or sitting. The arm is at the side, the elbow is extended, and the forearm is supinated. The patient ﬂexes the elbow through full ROM. Palpation. Anterior aspect of the antecubital fossa. Resistance Location. Applied proximal to the wrist joint on the anterior aspect of the forearm.

Biceps Brachii MMT

The patient is sitting with the arm supported. The patient ﬂexes the elbow through full ROM.

Biceps Brachii MMT (Gravity eliminated)

Patient is supine with the shoulder in extension over the edge of the plinth, the elbow is ﬂexed, and the forearm is pronated. Take up length in the shoulder by extending the humerus until the scapula moves. The elbow is extended to the limit of motion so that the biceps brachii is put on full stretch.

Biceps LTT

Lies between the greater and lesser tuberosities of the humerus. Locate the greater tuberosity, and passively externally rotate the arm. As the greater tuberosity moves out from underneath your thumb, the dip that is felt is the bicipital groove. Tendon of long head of biceps lies on the floor of the bicipital groove.

Bicipital groove palpation

Biceps tendon reflex Brachioradialis Tendon Reflex

C5/6 Reflex

posterior neck, over top of shoulder, down posterolateral arm and forearm to thumb

C6 Dermatome

posterior neck, the posterior aspect of the arm and forearm to the anterior and posterior middle 2-3 fingers

C7 Dermatome

Sink into the soft tissue at the top of the shoulder, and feel for the first rib. Follow it to the midline posteriorly, to the spinous process. This should be T1. Place one finger on the spinous process of T1, and one finger on the spinous process above (C7). Ask patient to slowly flex and extend neck, C7 moving into the finger with flexion, and disappearing with extension.

C7 and T1 Spinous Processes Palpation

posterior spine and medial aspect of arm and forearm to 4 th and 5 th digits

C8 Dermatome

Prominent "S" shaped bone in the anterior thorax that connects the upper limb to the trunk. You may palpate its whole length from the lateral (acromial) to the medial (sternal) end.

Clavicle Palpation

Locate the sternal head of SCM on the manubrium. Palpate laterally and superiorly, you will feel a strong pulse of the carotid a. Gently move your fingers superiorly, adjacent to the anterior border of the SCM, and follow the pulse. At the level of the superior border of the thyroid cartilage, the Common carotid a. divides into external and internal carotid a's. The carotid sinus and body are at this junction. Do not palpate aggressively.

Common carotid artery, carotid sinus, and carotid body palpation

• Observation • AROM with OP (C-spine, TMJ, Shoulder, elbow wrist, fingers) • Myotomes • Dermatomes • Reflexes • Neurodynamic Tests

Components of an upper quadrant scan

Nociceptive Inflammatory

Considered under the term nociceptive pain, can be associated with acute tissue damage, infection, or active inflammatory conditions such as rheumatoid arthritis.

The patient is in a side-lying position on the non test side. The arm is at the side, with the shoulder in slight abduction and external rotation and the elbow fully ﬂexed with the forearm supinated. The patient ﬂexes and adducts the shoulder through full ROM. Palpation. Proximal one-third of the anteromedial aspect of the arm

Coracobrachialis MMT (Gravity Eliminated)

Approx. 2.5 cm inferiorly and to the outer 1/3 of the clavicle, within the deltopectoral triangle. Sink through the soft tissue of the anterior fibres of deltoid, and press upward and laterally. It will most likely be tender. It is the attachment for pectoralis minor and the short head of biceps.

Coracoid Process of Scapula Palpation

Over the medial malleolus.

L4 Dermatome Key Point

ankle dorsiflexion

L4 Myotome

Bringing the arm up through ABduction, and asking them to slowly lower the arm. If they can't control the descent it is positive. Is generally covered with AROM in ABduction.

Drop Arm Test

Loading the arm in internal/external rotation in any range, while palpating for muscle contraction and humeral head position. Can feel for muscle firing, or humeral head staying centered. Positive if there is pain or the humeral head does not center well. Usually tested with resistance at 0, 45 and 90º ABduction.

Dynamic Rotary Stability Test

The patient is sitting. The arm is at the side, and the elbow is ﬂexed to 90° with the forearm in mid position. Therapist stabilized the humerus and grasps the distal radius and ulna. Firm end feel

Elbow Supination AROM + OP

Force is applied to the lateral upper arm and medial forearm, applying a varus force across the elbow and feeling for any ligamentous instability.

Elbow Valgus Test

Force is applied to the medial upper arm and lateral forearm, applying a varus force across the elbow and feeling for any ligamentous instability.

Elbow Varus Test

Have the patient tightly grasp a pencil in the arm being tested. The axis is placed over the head of the third metacarpal. Stationary Arm. Perpendicular to the ﬂoor. Movable Arm. Parallel to the pencil. Forearm pronation (80° to 90° from midposition) Forearm supination (80° to 90° from midposition)

Elbow pronation/ supination goniometry

The patient is sitting. The arm is at the side, and the elbow is ﬂexed to 90° with the forearm in mid position. The therapist grasps the distal radius and the ulna. The forearm is rotated externally from midposition so that the palm faces upward and toward the ceiling to the limit of forearm supination, or rotated internally so that the palm faces downward and toward the ﬂoor to the limit of fore- arm pronation.

Elbow pronation/supination PROM

• Positive cervical flexion rotation test • Headache reproduced with provocation of the upper cervical segments • Limited cervical ROM and upper cervical segmental mobility • Strength, endurance and coordination deficits of the neck muscles

Expected exam findings for Neck pain with headaches/ cervicogenic headaches.

Frequency: More is better, as long as its tolerable/not causing flare ups. Intensity: i.e. how far you go and what symptoms are acceptable (i.e. go up to 5/10 pain, or only go to 90º) TIme: Sets and reps Type: The set up (PROM, AAROM, AROM, bands, position, straps, etc.)

FITT Prescription for ROM

female sex, older age, coexisting psychosocial pathology, and radicular symptoms

Factors that may be associated with poorer prognosis of neck pain resolution.

Objective measure of ankle swelling. Start in 90 degrees flexion. Start halfway between tib anterior tendon and lateral malleolus. Move tape medially across instep to just anterior of navicular tuberosity, around the arch, then around the ankle joint (just distal to medial malleolus), across achilles, and back to starting point.

Figure of 8

The first rib is just distal to the base of the posterior triangle, below the clavicle, making it difficult to palpate. Anteriorly, it attaches to the costal notch of the manubrium, immediately below the most superior notch for the clavicle/ SC joint. Posteriorly it attaches to the body and transverse processes of T1.

First Rib in Supine

• Washing Axilla or back • Closing a horizontal window

Functional Horizontal ADduction movements

The patient is supine or sitting. The arm is at the side with the elbow ﬂexe to 90°. The therapist stabilizes the scapula and clavicle, grasps the distal humerus, and moves the humerus laterally and upward to the limit of motion of glenohumeral joint

Glenohumeral Joint (Shoulder) Abduction PROM

Using a wide, pinch grip, follow the humerus superiorly, sinking through the soft tissue on the anterior and posterior aspects to appreciate the head of the humerus.

Head of humerus palpation

Canadian C-Spine Rules

High risk people 1. age > 65 2. dangerous mechanism 3. Paresthesias in the extremities If YES then get an X RAY IF NO to Above then: 1. absence of midline tenderness 2. simple rear end MVA 3. sitting position in ER 4. ambulatory at any time 5. delayed onset of neck pain If NO to these then XRAY IF YES to above proceed to ROM measurement 1. able to rotate neck 45 degrees both ways If NO to this then XRAY If YES to this that no films needed

Patient is supine. Axis is placed over the ASIS on the side being measured. Stationary Arm: Along a line that joins the two ASISs. Movable Arm: Parallel to the longitudinal axis of the femur, pointing toward the midline of the patella. 30º.

Hip ADduction Goniometry

Patient is supine. Test limb is brought out to 20-30º abduction, patient adducts hip through full ROM.

Hip ADduction MMT (gravity eliminated)

Same as ABduction PROM

Hip ADductor length tension test

The patient is in the prone-lying. Flexes the knee through full ROM. Resistance Location. Applied proximal to the ankle joint on the posterior aspect of the leg

Knee Flexion MMT

The patient is side-lying on the nontest side. Stabilization. The therapist stabilizes the thigh. End Position. The patient ﬂexes the knee through full ROM

Knee Flexion MMT gravity eliminated

On the dorsum of the foot at the third metatarsal phalangeal joint.

L5 Dermatome Key Point

Extensor Hallucis Longus (great toe extension)

L5 Myotome

Achilles tendon reflex

L5-S1 reflex

From the inferior angle, press through the musculature to follow the lateral border superiorly and laterally towards the axilla, where if forms the glenoid fossa.

Lateral Border of Scapula Palpation

These deep muscles are situated on the anterior cervical vertebral bodies and transverse processes. They are not directly palpable. Ask the pt. to slightly nod their head to activate these muscles. Palpate the neck to see if the global muscles are activating. The absence of a palpable contraction serves as an indication that these muscles are functioning.

Longus Capitis and Longus Colli palpation

L2 Dermatome

Mid anterior thigh dermatome

The patient is sitting. The test arm is at the side in neutral rotation, and the elbow is extended. The patient abducts the arm to 90°. Palpation. Middle ﬁbers of deltoid: inferior to the tip of the acromion process. Supraspinatus: too deep to palpate. Resistance Direction. Shoulder adduction.

Middle Fibers of Deltoid and Supraspinatus MMT

The patient is supine. The test arm is at the side in neutral rotation with the elbow extended. The patient abducts the shoulder to 90°. Palpation. Middle ﬁbers of deltoid: inferior to the tip of the acromion process. Supraspinatus: too deep to palpate.

Middle Fibers of Deltoid and Supraspinatus MMT (GRavity Eliminated)

Tibiocalcaneal ligament

Middle third of deltoid ligament, prevents excessive dorsiflexion and eversion.

also called *Rectus Femoris Contracture Test* patient is positioned at the *end of table* w/only the butt on the table ___Patient flexes 1 knee to their chest while supine & the other knee should *remain at 90* of knee flexion ___If not at 90, examiner tries to passively bring the knee to 90 while palpating the muscle ___Bilaterally performed ___Positive findings: knee does not remain at 90 &/or hip flexes ___Indications: tight rectus femoris &/or iliopsoas (can be differentiated by extending the knee to rule out RF)

Modified Thomas Test

2, 50

Most cases of acute (<6 weeks' duration) neck pain will resolve to a large extent within ____ months, but close to _____% of patients will continue to have some pain or frequent recurrences 1 year after occurrence.

An ankle X-Ray series is only required if there is any pain in the malleolar zone and... Bone tenderness at the posterior edge or tip of the lateral malleolus (A) OR Bone tenderness at the posterior edge or tip of the medial malleolus (B) OR An inability to bear weight both immediately and in the emergency department for four steps A foot X-Ray series is only required if there is any pain the midfoot zone and... Bone tenderness at the base of the fifth metatarsal (C) OR Bone tenderness at the navicular (D) OR And inability to bear weight both immediately and in the emergency department for four steps

Ottawa ankle rules

Nociplastic

Pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors, or evidence for disease or lesion of the somatosensory system causing the pain. States include fibromyalgia, irritable bowel syndrome, interstitial cystitis and tension type headache.

Neuropathic

Pain caused by a lesion or disease of the peripheral somatosensory nervous system. This term is designed to contrast with nociceptive pain. Atypical verbal descriptors (e.g.; tingling, burning, stabbing, electric shocks); common in conditions such as shingles, cervical or lumbar radiculopathy, neuritis, neuroma, phantom limb pain, trigeminal neuralgia, or diabetic neuropathy; sensory abnormalities (loss or gain of sensitivity).

Trendelenburg's sign

Patient standing and asked to stand on one leg (flex opposite knee). Observe pelvis of stance leg (+) TEST: when ipsilateral pelvis drops when lower limb support is removed while standing.

The patient is supine. The shoulder is abducted to 90°, and the elbow is ﬂexed to 90°. The patient horizontally adducts the shoulder through full ROM. Palpation. Pectoralis major sternal head: anterior border of the axilla. Pectoralis major clavicular head: inferior to the middle of the anterior border of the clavicle. Resistance Location. Applied on the anterior aspect of the arm proximal to the elbow joint

Pectoralis Major (Sternal and Clavicular Heads) MMT

The patient is sitting. The shoulder is abducted to 90°, the elbow is ﬂexed to 90°, and the arm is supported by the therapist. The patient horizontally adducts the shoul- der through full ROM.

Pectoralis Major (Sternal and Clavicular Heads) MMT (Gravity Eliminated)

The patient is supine with the shoulder in external rotation and 90° elevation through a plane mid- way between forward ﬂexion and abduction. The elbow is in 90° ﬂexion. The shoulder is moved into horizontal abduction to the limit of motion, to put the pectoralis major on full stretch.

Pectoralis Major LTT

Lies deep to pec mj., travelling from ribs three to five to attach on to the coracoid process. Slide under pec mj. and sink through to palpate over the ribs, moving towards the coracoid process. In the presence of pec mn. tightness, the scapula may be tipped anteriorly

Pectoralis Minor Palpation

The patient is in a side-lying position on the nontest side with the foot over the edge. . The patient everts the foot through full ROM while keeping the toes relaxed. Resistance Location: Applied on the lateral border of the foot and on the plantar surface of the ﬁrst metatarsal. Palpation : Superior to the lateral malleolus (longus) or proximal to the base to the fifth MT (brevis).

Peroneus Strength test

Lifestyle Factors

Physical Activity Sedentary Lifestyle Sleep Smoking Alcohol Obesity/Low BMI Nutrition/Diet

Functional Behaviors

Physical Manifestations of a person's pain experience. Include Movement Impairments, Impairment of Control, Pain Behaviors, and Deconditioning. Can be classified as either Helpful or Unhelpful.

The patient is sitting. The shoulder is abducted to about 75°. The patient horizontally abducts and slightly externally rotates the shoulder. Palpation. Inferior to the lateral aspect of the spine of the scapula.

Posterior Fibers of Deltoid MMT (Gravity Eliminated)

The patient is prone. The shoulder is abducted to about 75°, the elbow is ﬂexed to 90°, and the forearm is hanging vertically over the edge of the plinth. The patient horizontally abducts and slightly externally rotates the shoulder Palpation. Inferior to the lateral aspect of the spine of the scapula. Resistance Location. Applied on the posterolateral aspect of the arm proximal to the elbow joint (

Posterior Fibers of Deltoid MMT

Calcaneus

Posterior aspect of the heel.

Posterior talofibular ligament

Posterior lateral ankle ligament, prevents excessive DF and INV.

The patient is sitting. The arm is at the side, the elbow is ﬂexed to 90°, and the forearm is supinated. The patient pronates the forearm through full ROM. Palpation. Pronator teres: proximal one-third of the anterior surface of the forearm on a diagonal line from the medial epicondyle of the humerus to the middle of the lateral bor- der of the radius. Resistance Location. Applied on the anterior surface of the distal end of the radius with counter pressure on the posterior aspect. (have them press into your thenar eminence so its more comfortable)

Pronator MMT

The patient lies prone, and the therapist stands on the affected side and stabilizes the pelvis to prevent anterior rotation with one hand. With the other hand, the therapist then maximally flexes the knee to end range. If no positive signs are noted in this position, the therapist proceeds to extend the hip while maintaining knee flexion.

Prone Knee Bend Test Technique

At the posterior aspect of the shoulder, formed by, superiorly: teres minor Inferiorly: Teres major Medially: Long head of triceps Laterally: Humeral shaft It contains the axillary nerve (travelling to innervate the teres mn. and deltoid, and sensation to the lateral arm), the posterior circumflex humeral artery.

Quadrangular Space Palpation

Specific Musculoskeletal Disorder

Refers to a disorder where pain and symptoms can be directly attributes to a biological process associated with the MSK system.

0 Absent (areflexia); always abnormal 1 Diminished (hyporeflexia) - spinal nerve root or peripheral nerve 2 Normal 3 Exaggerated, brisk 4 Clonus, very brisk (hyperreflexia) - upper motor neuron lesion (SC or cerebral); always abnormal

Reflex Grading

From the TMJ, move your fingers inferiorly to follow the posterior border of the ramus of the mandible. You will feel the angle of the mandible at the most distal portion fo the ramus, which is the junction of the posterior border of the ramus, and inferior border of the mandible.

Ramus of the mandible

RC Mj. attaches to the spine of C3, running superiorly and laterally to the inferior nuchal line of the occiput. RC Mn. runs from the medial part of C1 to the superior nuchal line. These muscles extend the head at the CO-1 and C1-2 joints, and Mj can also ipsilaterally rotate the head at these joints.

Rectus Capitis Mj. and Mn. palpation

Resisted Isometric Movements

Resisted muscle test (isometric resistance) testing in the resting position of the joint (to limit ligamentous assistance). Mainly looking for muscle activation.

R Mn. starts at the spinous processes of C7 & T1, and R Mj. starts at the spinous processes of T2 to T5. Palpate through the thin Trapezius muscle to feel the Phombiods as the fibres travel superiorly towards the medial border of the scapula. Both muscles insert into the superior medial border of the scapula. Resist scapular retraction and depression to palpate the muscle contracting.

Rhomboid Major and Minor Palpation

The patient is prone. The dorsum of the hand is placed over the buttock of the non test side, and the shoulders remain relaxed. The patient raises the arm away from the back. The weight of the raised upper extremity provides resistance to the scapular test motion. Palpation. On a point of an oblique line between the vertebral border of the scapula and C7 to T5. Resistance Location. Applied over the scapula

Rhomboid Major and Rhomboid Minor MMT

The patient is sitting. The dorsum of the hand is placed over the non test side buttock. The patient adducts and medially rotates the scapula by moving the arm away from the back while maintaining the hand over the buttock. $

Rhomboid Major and Rhomboid Minor MMT (Gravity Eliminated)

Head of the first metatarsal

Round bony prominence at the medial aspect of the ball of the foot, at the base of the great toe.

Head of the fibula

Round bony prominence on the lateral aspect of the leg level with the tibial tuberosity

On the lateral aspect of the calcaneus.

S1 Dermatome Key Point

At the midpoint of the popliteal fossa.

S2 Dermatome Key Point

Lumbar flexion/extension: Schober method (tape measure)

S2 between PSIS and T12- 15 cm up 1. NORM: flexion 6-7cm (difference between start & end range) 2. extension: 1.5 cm difference

Made up of the medial head of the clavicle, the sternum, the edge of the first rib, and has an articular disc between the first two bones, completely dividing the joint. Slide fingers medially along the clavicle, until it goes into a small groove off the sternal end. Ask the patient to actively elevate and depress his or her scapula to palpate movement that occurs at this joint.

SC Joint Palpation

Palpate the mastoid process behind the ear, and just below this you will feel the proximal part of the SCM. It also attaches to the lateral half of the superior nuchal line of the occiput. The muscle travels inferiorly/anteriorly to attach to the medial clavicle, and manubrium of the sternum Ask the pt. to sideflex towards your hand and rotate away to feel the the muscle contract.

SCM palpation

The patient is in a side-lying position with the hips and knees ﬂexed, the head relaxed and supported on a pillow. The therapist cups the inferior angle of the scapula with one hand and elevates the scapula, while controlling the direction of movement with the other hand

Scapulothoracic Joint PROM Elevation/Depression

The therapist grasps the vertebral border and inferior angle of the scapula using the thumb and index ﬁnger of one hand and rotates the scapula. The therapist's other hand is placed on top of the shoulder girdle to assist.

Scapulothoracic Joint PROM Medial/Lateral Rotation

The therapist grasps the vertebral border and inferior angle of the scapula using the thumb and index ﬁnger of one hand and abducts the scapula. The thera- pist's other hand is placed on top of the shoulder girdle to assist in abduction.

Scapulothoracic Joint PROM Protraction/Retraction

The patient is standing and facing a wall. The hands are placed on the wall at shoulder level, the shoulders are in slight horizontal abduction, and the elbows are extended. The patient pushes the thorax away from the wall so that the scapulae abduct. Weakness is demonstrated by "winging" of the scapula.

Serratus Anterior Clinical Test

The patient is supine. The shoulder is ﬂexed to 90° with slight horizontal adduction. The patient protracts the scapula through full ROM. Resistance Location. Applied on the distal end of the humerus. Palpation. Midaxillary line over the thorax.

Serratus Anterior MMT

Originates from the anterior surfaces of the first 8 to 9 ribs, and inserts onto the anterior surface of the medial border of the scapula. Resist protraction, ABduction, and upward rotation to palpate the muscle contracting.

Serratus Anterior Palpation

Goniometer Axis. The axis is placed on top of the acro- mion process Stationary Arm. Perpendicular to the trunk. Movable Arm. Parallel to the longitudinal axis of the humerus.

Shoulder ABduction AROM + OP Assessment

Goniometer Axis. The axis is placed on top of the acro- mion process Stationary Arm. Perpendicular to the trunk. Movable Arm. Parallel to the longitudinal axis of the humerus.

Shoulder ADduction AROM + OP Assessment

The patient is in a crook-lying. The therapist grasps the distal humerus. The therapist moves the humerus anteriorly and upward to the limit of motion for shoulder elevation through ﬂexion. The axis of the goniometer is placed at the lateral aspect of the center of the humeral head. Stationary Arm. Parallel to the lateral midline of the trunk. Movable Arm. Parallel to the longitudinal axis of the humerus.

Shoulder Elevation Through Flexion (Glenohumeral Joint, Scapular and Clavicular Motion) PROM

Shoulder Extension AROM + OP Assessment

The patient is sitting. The shoulder is in 90° of abduction and neutral rotation. . The therapist supports the arm in abduction and grasps the distal humerus, and moves the humerus posteriorly to the limit of motion for horizontal abduction and anteriorly to the limit of motion for horizontal adduction.

Shoulder Horizontal Abduction and Adduction PROM

Base of the fifth metatarsal bone

Small bony prominence at the midpoint of the lateral border of the foot.

Social Factors

Socioeconomics Education Relationships Health Literacy Culture Health Care

Calf raises with knee flexed. 5 = Maintaining the heel fully off the ﬂoor through more than six repetitions; 4 = Maintaining the heel fully off the ﬂoor through three to ﬁve repetitions with subsequent attempts resulting in decreased range; and 3 = Maintaining the heel off the ﬂoor through one to two repetitions only with subsequent attempts resulting in decreased range.

Soleus strength test

Abduction of little finger (MTP Joint) ABductor digiti minimi Can be done as general ADduction or ABduction of the fingers.

T1 Myotome

The patient is in a side-lying position on the test side with the knee slightly ﬂexed. The patient inverts the foot through full ROM with slight plantarﬂexion. Palpation. Between the tip of the medial malleolus and the navicular bone. Resistance Location. Applied on the medial border of the forefoot.

TIb Posterior Strength test

• Therapist places index or little fingers on inside / outside of patient's ears to evaluate for equality of movement of the condyles & feel for clicking / grinding • Look for deviation of mandible through movement - usually a "C" or and "S" deviation

TMJ assessment

Meniscal tear test. test uninjured leg first. Have patient stand on leg flexed at 20º. Therapist stands in front of them and offers arms for support. Have patient rotate back and forth over tibia. +ve if painful in joint line during rotations.

Thessaly Test

At the posterior aspect of the shoulder. Formed by Superiorly: Lower border of Teres Mn. Inferiorly: Teres Mj. laterally: Long head of triceps. Contents include scapular circumflex artery.

Triangular Space Palpation

1. Patient education and advice focusing on reassurance, encouragement, prognosis, and pain management 2. Mobilization combined with an individualized, progressive submaximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioral therapy 3. TENS

Treatment for chronic neck pain with movement coordination impairments.

Multimodal intervention approach including manual mobilization techniques plus exercise (eg, strengthening, endurance, flexibility, postural, coordination, aerobic, and functional exercises) for those patients expected to experience a moderate to slow recovery with persistent impairments.

Treatment for persistent or slow recovering neck pain with movement coordination impairments.

The patient is supine. The shoulder is internally rotated and ﬂexed to 90°, the elbow is ﬂexed, and the forearm is supinated. The patient extends the elbow through full ROM. Palpation. Just proximal to the olecranon process. Resistance Location. Applied proximal to the wrist joint on the posterior aspect of the forearm

Triceps Brachii MMT

The patient is sitting with the arm supported. The patient extends the elbow through full ROM, avoiding the close-packed position.

Triceps Brachii MMT (gravity eliminated)

The patient is sitting with the shoulder in full elevation through forward ﬂexion and external rotation. The elbow is in extension and the forearm is in supination. The elbow is ﬂexed to the limit of motion so that the triceps is put on full stretch.

Triceps LTT

Made up of three heads. The long head can be located along the proximal and medial aspect of the posterior arm, and see how it disappears under the posterior deltoid towards the infra-glenoid tubercle. The lateral head lies superficially towards the deltoid. The medial head lies deep to the long head, however the distal attachment can be palpated near the medial epicondyle. Follow the muscle inferiorly along its length until the tendon inserts into the olecranon at the elbow. Resist elbow extension to palpate contraction.

Triceps Palpation

Nerve Bias: Median nerve & AIN Sequence: -shoulder depression w/ 110º abduction - elbow flexion to 90º - Lateral shoulder rotation - forearm supination - wrist, finger & thumb extension - Slow elbow extension Sensitization: contralateral cervical side bend (bend head to opp side)

ULTT 1/A (serving tray)

Nerve Bias: Radial nerve Sequence: -shoulder depression w/ 10 deg abduction (use your hip) - elbow flexion to 90º - forearm pronation - wrist, finger &t thumb flexion & ulnar deviation - slow elbow extension until symptoms are provoked Sensitization: contralateral cervical side bend (bend head to opp side)

ULTT 3/C (waiters tip)

Divided into four areas. Most distal is the only palpable area. From subclavian a. to the C6 transverse foramen. Important to understand its pathway as we work with area's it transverses.

Vertebral artery palpation

The patient is sitting. The forearm is resting on a table in pronation, the wrist is in neutral position, the hand is over the end of the table, and the ﬁngers are relaxed. The therapist stabilizes the forearm and grasps the metacarpals. Firm/Hard end feel.

Wrist Radial Deviation AROM + OP

Wrist Ulnar deviation AROM + OP

Follow the sternum inferiorly until you fall into the soft tissues of the abdomen. Then move proximally, slightly, to the tip of the xiphoid process.

Xiphoid process palpation

Locate the TMJ, and move anteriorly to the zygomatic arch.

Zygomatic arch

Modified Thomas Test

L3 Dermatome

medial knee dermatome

Calcaneofibular ligament

intrinsic ligament located on the lateral side of the ankle joint, between the calcaneus bone and lateral malleolus of the fibula; supports the talus bone at the ankle joint and resists excess DF and INV

L4 Dermatome

medial lower leg dermatome

Anaesthesia

loss of sensation

The traps originate from the External Occipital Protuberance, ligamentum nuchae, and spinous process of C7 through to T12. It attaches to the spine of the scapula, lateral acromion, clavicle, and superior nuchal line. Resist scapular depression and upward rotation at 120º of shoulder ABduction.

lower fibres of trapezius

The traps originate from the External Occipital Protuberance, ligamentum nuchae, and spinous process of C7 through to T12. It attaches to the spine of the scapula, lateral acromion, clavicle, and superior nuchal line. Resist scapular retraction and upward rotation at 90º of abduction.

middle fibres of trapezius palpation

Myotome

muscle or group of muscles supplied by a specific spinal nerve

disc protrusion

nucleus bulges against an intact annulus

Disc Prolapse

only the outermost fibers of the annulus fibrosus contain the nucleus

Medial talocalcaneal ligament

passes from the medial tubercle of the posterior process of the talus to the posterior edge of the sustentaculum tali and the adjacent medial surface of the calcaneus; reinforces the anatomic subtalar joint, medially. Prevents excessive eversion.

·Straight leg Raise (SLR)

passive dorsiflexion of the foot in the supine patient with the knee and hip extended; back pain with this indicates nerve root compression or impingement

Neck pain with radiating pain

-upper extremity sx, usually radicular or referred pain, that are reproduced or aggravated by spurling's, ULTT, and reduced with neck distraction -CROM rotation <60 degrees ipsilateral -signs of nerve root compression -success with reducing UE sx with initial exam and interventions

Deconditioning

A Functional behavior category. A consequence of lifestyle changes, exercise avoidance or habitual postural and movement patters resulting in a deficit in muscle strength, endurance, or physical capacity.

Movement Impairments

A category of functional behavior. Restricted active and passive movement in the direction of pain provocation.

Spondylosis

A degenerative disorder that can cause the loss of normal spinal structure and function

Overpressure

A gentle pressure applied by the therapist at the end of AROM to determine end feel.

Red Flag

A sign or symptom that suggests the possibility of a particular problem that is very serious. Refer for appropriate investigation/management.

Slide hand superior-laterally along the spine to the posterior tip of the acromion. Feel anteriorly along the lateral border, to the anterior tip where it articulates with the clavicle.

Acromion Palpation

Locate the clavicle and move laterally towards the acromion. Notice a small step when you leave the surface of the clavicle. Palpate with one hand, the acromion, and the other, the clavicle. Induce joint play like movement to appreciate the joint line. The AC ligament runs from the acromion process to the lateral end of the clavicle and helps prevent the lateral clavicle from springing upwards. The Coracoacromial ligament attaches from the coracoid, and moves upwards, laterally, to the top of the acromion process. It is a classic site of subacromial impingement.

AC Joint Palpation

1. If motion to the part will cause further damage or interrupt the healing process immediately after injury or surgery. 2. If the therapist suspects a subluxation or dislocation or fracture. 3. If myositis ossiﬁcans or ectopic ossiﬁcation is suspected or present

AROM contraindications

Borders. Anteriorly: Neck midline Posteriorly: SCM anterior border Superiorly: Mandible Contents: Suprahyoid, infrahyoid, and hyoid muscles. Cranial nerves Vagus and Glossopharyngeal. Transverse cervical nerve and hypoglossal. Vessels: Common, int., and ext. carotid a.'s, int. jugular v., and carotid sinus.

Anterior triangle palpation

The patient is supine. A roll is placed Form under the knee to position the knee in about 20° to 30° ﬂexion and place the gastrocnemius on slack. The therapist applies traction to the calcaneus and using the forearm moves the dorsal aspect of the foot toward the anterior aspect of the lower leg. Firm end feel

Ankle Dorsiflexion PROM

The patient is sitting with the ankle and foot in anatomical position. The therapist grasps the medial aspect of the forefoot and inverts/supinates the foot/ankle. Firm end feel.

Ankle Pronation PROM

ACL stability test. Knee is in 90º flexion with patient in supine. Sit on patients foot to stabilize the lower limb. Palpate the hamstring tendons and line thumbs up with M & L patellar tendon lines. Pull anterior, will feel a "gap" with the thumbs and possibly hamstring spasm if +ve.

Anterior Drawer Test

The patient is sitting. The arm is at the side, with the shoulder in slight abduction and the palm facing medially . The patient ﬂexes the shoulder to 90°, simultaneously slightly adducting and internally rotating the shoulder joint. Palpation. Anterior aspect of the shoulder joint Resistance Location. Applied on the anteromedial aspect of the arm just proximal to the elbow joint

Anterior Fibers of Deltoid MMT

The patient is in a side-lying position on the nontest side. The patient ﬂexes the shoulder to 9 simultaneously slightly adducting and internally rotating the shoulder joint. Palpation. Anterior aspect of the shoulder joint

Anterior Fibers of Deltoid MMT (Gravity Eliminated)

Tibionavicular ligament

Anterior third of deltoid ligament, prevents excessive plantar flexion and eversion.

The axillary artery continues distally into the upper arm as the brachial artery, travelling between the biceps and triceps as it travels distally into the elbow. The brachial pulse can be felt between these muscles on the medial proximal aspect of the upper arm. Palpate biceps, and move medially, palpating under it to appreciate the pulse.

Brachial artery palpation

Lies in the posterior triangle of the neck. Formed by roots C5-T1, and nerve trunks pass inferiorly and laterally between the anterior and middle scalene muscles. It is not palpable, but you should know where it is.

Brachial plexus palpation

Disc Herniation

Bulging of an intervertebral disc out of its normal space

Return to the external occipital protuberance and locate C2. From the midline, moving approximately 1 thumbs width right and left, you will be able to palpate the posterior paraspinal muscles overlying the lamina. The Z-joints of C1 are deep to these tissues. Continue distally to locate the lamina/ Z-joints of remaining cervical vertebrae. Palpate again in supine, inducing small flex/extension joint play to appreciate movements.

Cervical Facet Palpation

Locate external occipital protuberance. Move fingers slowly caudally. As you move off the skull, you will feel a depression where the posterior arch of C1 lies. Continue distally to palpate SP of C2, and the SP of the remaining vertebrae (C7 most prominent)

Cervical Spinous processes palpation

Locate the mastoid processes at the base of the skull behind each earlobe. Move fingers inferiorly and anteriorly to locate the angle of the jaw. Midway between these two points is the C1 transverse process (typically tender) C2 TPs are just distal and slightly medial. Continue down to palpate remaining segments. SCM must be moved anteriorly for distal segments

Cervical Transverse Processes Palpation

Fracture Cord compression (cervical myelopathy) CAD (Cervical Artery Dysfunction) Malignancy Infection

Cervical red flags include...

(70°) • OP if appropriate, can still stabilize and guide movement

Cervical spine Extension ROM

(70-90° each direction) • Stabilize opposite shoulder and OP through upper C-sp/occiput on same side as shoulder stabilization

Cervical spine Rotation ROM

(20-45° each direction) • Stabilize opposite shoulder and OP through upper C-sp/occiput on same side as shoulder stabilization

Cervical spine Side Extension ROM

(80-90°) • Up to 2 finger breadths between chin and chest is considered normal (with the mouth closed) • Stabilize at T1 and OP through the occiput

Cervical spine flexion ROM

The patient is supine. The shoulder is in slight abduction and external rotation; the elbow is ﬂexed with the forearm in supination. The patient ﬂexes and adducts the shoulder while maintaining the shoulder in external rotation. Palpation. Proximal one-third of the anteromedial aspect of the arm Resistance Direction. Shoulder abduction and extension.

Coracobrachialis MMT

In supine, locate the outer 1/3 of the clavicle, move inferiorly, and sink through the soft tissue of the anterior fibres of deltoid. You will feel a firm, rounded bone, often tender to touch.

Coracoid Process of Scapula Palpation (Supine)

Red flags in LBP

Cord signs, progressive neurology, cauda equina signs, malignancies, systemic inflammatory disorders, infections.

The patient is supine or sitting. The arm is in the anatomical position with the elbow in extension. A towel is placed under the distal end of the humerus to accommodate the range of motion The therapist grasps the distal radius and the ulna, and moves the forearm in a posterior direction, to the limit of motion of elbow extension/hyperex- tension

Elbow Extension PROM

Stabilize the humerus at the elbow and resist at the posterior forearm. Open packed position for the UH joint is 70 degrees of flexion, 10 degrees supination

Elbow Extension RIM

The patient is supine or sitting. The arm is in the anatomical position with the elbow in extension. A towel is placed under the distal end of the humerus to accommodate ROM.

Elbow Flexion AROM + OP

The patient is supine or sitting. The arm is in the anatomical position with the elbow in extension. A towel is placed under the distal end of the humerus to accommodate the range of motion The therapist grasps the distal radius and the ulna, and moves the forearm in an anterior direction, to the limit of motion of elbow ﬂexion.

Elbow Flexion PROM

Elbow Pronation AROM + OP

The patient is supine or sitting. The arm is in the anatomical position with the elbow in extension. Muscular men may not achieve 0º due to biceps tension

Elbox Extension AROM + OP

The axis is placed over the lateral epicondyle of the humerus. Stationary Arm. Parallel to the longitudinal axis of the humerus. Movable Arm. Parallel to the longitudinal axis of the radius. Elbow ﬂexion (150°) Elbow Extension (0-15º)

Elbox Flexion/ Extension goniometry

Slide your palpating finger laterally, off the side of the upper part of the manubrium, to feel the first costal cartilage, which joins the first rib to the manubrium.

First costal cartilage palpation

Impairments of Control

Functional Behavior category, where pain is associated with aberrant movement and postural control or muscle activity. Typically this presentation is unhelpful and provocative.

• Writing on a vertical surface

Functional Horizontal ABduction movements

The range of 60° of shoulder extension is primarily obtained through the glenohumeral joint. Getting out of a chair or clasping a bra are functional movements.

Functional Shoulder Extension Movements

The patient is in a crook-lying or a sitting position. . The therapist places one hand on the axillary border of the scapula to stabilize the scapula. The therapist grasps the distal humerus, moving the humerus anteriorly and upward to the limit of motion

Glenohumeral Joint (Shoulder) Flexion PROM

The anterior humeral joint line can be traced starting from the anterior aspect of the axilla and moving superiorly towards the anterior aspect of the acromion. The rest of the GH joint is too deep to palpate.

Glenohumeral Joint line palpation

Making a fist, and spreading fingers

Global test for fingers and thumb AROM

What do you expect from this session/interaction? What are your goals or what are you hoping to achieve? - Addressing goals and expectation are important for individual compliance and 'buy-in' and to align with individual-centred care.

Goals/Expectations Questions (subjective interview)

The patient is supine. The hip is ﬂexed. The goniometer is placed the same as for knee ﬂexion. While maintaining the hip in 90° ﬂexion the knee is extended to the limit of motion so that the hamstring muscles are put on full stretch. Firm end feel.

Hamstring Length tension test

Patient is supine.The axis is placed over the ASIS on the side being measured. Stationary Arm: Along a line that joins the two ASISs. Movable Arm: Parallel to the longitudinal axis of the femur, pointing toward the midline of the patella. 45º.

Hip ABduction Goniometry

30º

Hip ADduction AROM

Soft/Firm

Hip ADduction End Feel

The patient lies on the test side. Therapists stands behind and against patients buttocks, and abducts non test leg to 25º. Test limb is adducted to meet non-test limb. Palpation of adductors on the medial distal aspect of the thigh. Resistance is applied on the medial aspect of the thigh, proximal to knee.

Hip ADduction MMT

Patient is supine. Stabilize the ipsilateral pelvis. Grasp the distal femur. Move the femur to the limit of hip adduction. Soft/Firm end feel.

Hip ADduction PROM

0-45º

Hip Abduction ROM

0-30º

Hip Adduction ROM

30º

Hip Extension AROM

Firm

Hip Extension End Feel

The axis is placed over the greater trochanter of the femur. Stationary Arm, Parallel to the midaxillary line of the trunk. Movable Arm, Parallel to the longitudinal axis of the femur, pointing toward the lateral epicondyle. Limit is 30º.

Hip Extension Goniometry

Patient leans over end of plinth (trunk is prone). Patient extends the hip with knee held in extension. Palpation of glute max, medial to its insertion on the gluteal tuberosity or adjacent to its origin from the posterior aspect of the ilium. Resistance applied to the posterior aspect of the thigh proximal to knee joint.

Hip Extension MMT

The patient is lying on the nontest side with the hip and the knee ﬂexed. The patient extends the hip through full ROM while the therapist supports the limb.

Hip Extension MMT (gravity eliminated)

The patient is prone. Stabilizes the pelvis, grasp the anterior aspect of the distal femur, move the femur posteriorly to the limit of hip extension (firm end feel).

Hip Extension PROM

0-30º

Hip Extension ROM

45º

Hip External Rotation AROM

Firm

Hip External Rotation End Feel

0-45º

Hip External Rotation ROM

120º

Hip Flexion AROM

Hip Flexion Goniometry

The patient is sitting or supine with the knee ﬂexed. Hip is flexed through full ROM. Resistance applied over the anterior aspect of the thigh proximal to the knee joint.

Hip Flexion MMT

Patient is lying on the nontest side and the patient holds the nontest leg in maximal hip and knee ﬂexion. Therapist supports the weight of the test leg, patient moves through full flexion ROM (knee to chest)

Hip Flexion MMT (gravity eliminated)

The therapist stabilizes the ipsilateral pelvis at the ASIS and iliac crest. Raise the lower extremity off the plinth and grasps the posterior aspect of the distal femur. Move the femur anteriorly to the limit of hip ﬂexion

Hip Flexion PROM

0-120º

Hip Flexion ROM

Thomas test. Thigh not touching plinth, passivley extend the knee. If thigh touched, shortness of Rec Fem can be to blame. If no change, hip flexion contracture (tight iliopsoas). Shortness of the tensor fascia latae may be suspected if the thigh is observed to abduct as the hip joint extends

Hip Flexor length tension test

45º

Hip Internal Rotation AROM

Patient is sitting or supine with the hip and knee ﬂexed to 90°. Grasp the distal tibia and ﬁbula. Move the tibia and ﬁbula in a lateral direction to the limit of hip internal rotation, and in a medial direction to the limit of hip external rotation. Firm end feels.

Hip Internal/External Rotation PROM

Patient is sitting. In sitting, the hip being measured is in 90° of ﬂexion and neutral rotation with the knee ﬂexed to 90°. The axis is placed over the midpoint of the patella. Stationary Arm: Perpendicular to the ﬂoor. Movable Arm. Parallel to the anterior midline of the tibia. 45º end position for both.

Hip internal/external rotation goniometry

Non-Specific Musculoskeletal disorder

If there is either non underlying pathology, or no robust correlation between the clinical presentation and the underlying pathology, the diagnosis is labeled in this way.

The patient is prone. The shoulder is abducted to 90°, the elbow is ﬂexed to 90°, and the arm proximal to the elbow is resting on the plinth. The patient externally rotates the shoulder by moving the dorsum of the hand toward the ceiling. Palpation. Infraspinatus: over the body of the scapula just inferior to the spine of the scapula. Teres minor: not pal- pable. Resistance Location. Applied proximal to the wrist joint on the posterior aspect of the forearm

Infraspinatus and Teres Minor MMT

The patient is sitting. The arm is at the side, with the shoulder adducted in neutral rotation, and the elbow is ﬂexed to 90° with the forearm in midposition. The patient externally rotates the shoulder by taking the hand away from the body.

Infraspinatus and Teres Minor MMT (Gravity Eliminated)

The infraspinatus sits within the infraspinatus fossa which can be outlines by the medial border, lateral border, and spine of the scapula. Its tendon inserts onto the medial facet of the greater tuberosity of the humerus. Teres minor is a small muscle that begins on the lateral scapula and inserts on the inferior facet of the greater tuberosity of the humerus. It fits between the infraspinatus and teres major. Palpate the infraspinatus fossa while you resists shoulder external rotation.

Infraspinatus and Teres Minor Palpation

Midway between the key sensory points for T12 and L2.

L1 Dermatome Key point

Individuals Perspective

Key Question What are your main problems or concerns? - Provides overall context for the clinical interaction . - May be related to pain, function or quality of life. - Acknowledgement and addressing individual's perspective required.

Functional Capacity

Key Questions How do these problems affect your daily activities/ quality of life? What can you do? - Could be difficult to delineate in a 'pain focused' individual. - Look for what can be done and build from there.

Test of joint effusion. PROCEDURE:-Supine, w/ knee in EXT (as much as poss)-light/mod sweeping motion w/ fingers/hands around Patella-sweep inf/lat, up around to inf/med POSITIVE: fluid moving or accumulating as a bulge in inf aspect of patella

Knee Brush/Stroke/Bulge Test

The axis is placed over the lateral epi- condyle of the femur. Stationary Arm. Parallel to the longitudinal axis of the femur, pointing toward the greater trochanter. Movable Arm. Parallel to the longitudinal axis of the ﬁbula, pointing toward the lateral malleolus. Limit ~10º.

Knee Extension Goniometry

Knee Flexion Goniometry

0-135º

Knee Flexion ROM

BIlateral Squat, Single Leg Squat, Gait Analysis, Single leg Balance

Knee Functional Tests

• Therapist's Distal Hand Placement. The therapist grasps the distal tibia and ﬁbula. • End Positions. The therapist moves the lower leg to ﬂex the hip and knee to the limit of knee ﬂexion • End Feels. Flexion—ﬁrm/soft; extension/hyperextension— ﬁrm.

Knee PROM

Integrity of the Medial Collateral Ligament. Internal hand stabilizes tibia just superior to ankle, external hand stabilized femur just proximal to knee. Leg is placed in extension and slight external rotation, and perform passive ABduction in the knee joint. Excessive gaping/pain is +ve. Repeat in 20-30º flexion.

Knee Valgus Test

Integrity of Lateral Collateral Ligament. Patient in supine. Therapist is positioned on medial side of the leg. Outside hand stabilizes tibia above ankle joint, inside hand stabilizes femur proximal to knee. Apply slight lateral roation and passive ADduction in the knee joint. Repeat in 20-30º flexion

Knee Varus Test

The patient is sitting. The knee is ﬂexed and a pad is placed under the distal thigh. Resistance Location. Applied on the anterior surface of the distal end of the leg.

Knee extension MMT

The patient is side-lying on the nontest side.

Knee extension MMT (gravity eliminated)

Participants are asked to place their foot in such a way that a imaginary line drawn through the heel and big toe are aligned on the tape measure on the floor. Lunge forward until their knee touches the wall, keeping heel on the floor. About 1 hand width, or 5", is normal range. Measurement error of 1.9 cm (need >1.9cm to say there is improvement)

Knee to wall Dorsiflexion test

The patient is prone. The head is rotated to the opposite side, and the shoulder is abducted to about 130°. The patient raises the arm to produce depression and adduction of the scapula. Palpation. Medial to the inferior angle of the scapula. Resistance Location. Isometric grading is preferred, and the resistance is applied over the scapula

Lower Fibers of Trapezius MMT

The patient is prone with the arms by the sides. The patient depresses and adducts the scapula through full ROM.

Lower Fibers of Trapezius MMT (Gravity Eliminated)

Place a palpating finger anterior to the external auditory meatus of the ear. As your pt. to open and close their mouth, and feel the condyles of the TMJ move. Feel for symmetry of movement of the two sides.

Mandibular condyle palpation.

The most superior part of the sternum, articulating with the clavicle, first, and second ribs. Locate the jugular notch, which can be either flat, or bowl shaped at the superior aspect of the manubrium. Feel laterally to locate the attachments of the costal cartilage.

Manubrium palpation

Place your fingers on the side of the jaw, between the angle of the mandible and the zygomatic arch. Locate the muscle tissue. Ask the pt. to carefully clench the teeth, and feel the contraction.

Masseter Palpation

Test for meniscal tears. Knee must be fully flexed, need the compressive force. Adding external rotation, maintain the external rotation and extend knee. Want to control the end range, so keep femur nice and close to the body. Looking for pain, clunking. Repeat with internal rotation. Better test of posterior meniscus tears then anterior (not as much compression on anterior horns)

McMurray's Test

Patient is sitting, elbow flexed to 90° and supported/stabilized. Passively supinate forearm, extend elbow, and extend wrist (+) TEST: Reproduces pain at medial epicondyle

Medial Epicondylalgia Test

Both muscles lie deep to the zygomatic arch and the ramus of the mandible. The lateral pterygoid is difficult to palpate due to its location. The medial pterygoid may be palpated extra-orally by sliding the index finger medially to the inferior border of the ramus. Pressing superior until resistance is met, the laterally to further palpate the lateral pterygoid. As your pt. to close their jaw and protrude it to the side you are palpating to feel the muscle contract.

Medial and lateral pterygoid palpation

From the superior angle, move distally to palpate the medial border approximately 5-6 cm lateral to the thoracic spinous processes, covering ribs 2-7, and ending at the inferior angle.

Medial border of Scapula palpation

The patient is prone. The shoulder is abducted to 90° and laterally rotated so the thumb points toward the ceiling. The elbow is extended. The patient raises the arm toward the ceiling and adducts the scapula toward the midline. Palpation. Between the medial (vertebral) border of the scapula and the vertebrae, above the spine of the scapula. Resistance Location. Applied at the distal forearm

Middle Fibers of Trapezius MMT

The patient is sitting. The shoulder is abducted to 90° and laterally rotated. The patient adducts the scapula through full ROM.

Middle Fibers of Trapezius MMT (Gravity Eliminated)

• Neck pain with mobility deficits • Neck pain with movement coordination impairments (including whiplash-associated disorder [WAD]) • Neck pain with headaches (cervicogenic headache) • Neck pain with radiating pain (radicular)

Neck Pain Classifications

Noncontinuous, unilateral neck pain and associated (referred) headache (precipitated or aggravated by neck movements of sustained postures/positions)

Neck Pain with Headaches

Typically a muscular driven pain. Muscle imbalance often due to injury. Careful assessment of functional movements, ROM, and muscle strength/endurance will help determine which muscles to treat.

Neck pain with movement coordination impairments (including WAD)

Forced maximal forward flexion in internal rotation with the scapula fixed into depression. Pain at the from of the shoulder is an indication for subacromial impingement, whereas patients with internal impingement will exhibit pain at the posterior aspect of the shoulder (slightly change testing position imo neutral rotational position/external rotation and fixing the scapula to from).

Neer Impingement Test

Allodynia

Pain due to a stimulus that does not normally provoke pain

Nociceptive

Pain that arises from actual threatened damage to non-neural tissue and is due to the activation of nociceptors. The term is used to describe pain occurring with a normally functioning somatosensory nervous system. Typically short lasting, stimulus-response coupled (familiar behavioural protective responses that favour recovery).

Ankle Talar Tilt Deltoid

Patient in prone, knee at 90º and ankle at 0. Therapist stands on patient nontest side. Stabilize tib/fib, passively evert calcaneus (tilt laterally) to stress the deltoid. Some plantar or dorsiflexion can be used to isolate individual ligaments.

Spans the medial aspect of the clavicle, anterior aspect of the manubrium, and costal cartilage of the first six ribs. Follow the fibres as they travel laterally to insert on the lateral lip of the bicipital groove of the humerus. Position the arm at 90º flexion with slight internal rotation, and resist ADduction for the clavicular fibres. Move the arm to a slight oblique angle towards the opposite hip and resist ADduction again for the sternal fibres.

Pectoralis Major Palpation

Blue Flags

Perceptions of Work Job satisfaction Job culture Co-worker support Management support Suitable duties

0: no response 1+: diminished response 2+: normal physiologic response 3+: increased response (brisk) 4+: hyper-reactive, often associated with clonus

Reflex scale

This muscle lies deep at the side of the neck, behind the SCM, attaching to the C3 through C6 anterior tubercles of the transverse processes, and is aligned almost vertically to attach to the first rib. Place the head in slight flexion, and resist ipsilateral side flexion to palpate the muscle contraction (will be deep in the post. triangle). Acting from above, the scalenes elevate the first rib to aid in respiration.

Scalenes Anterior palpation

Attaches to the tips of the posterior tubercles of the transverse processes of C4 to C6, and inserts onto the second rib. Acting from above, the post scalenes elevate the second rib and aid in respiration. Resist ipsilateral side flexion to palpate the muscle contraction (will be deep in the post. triangle).

Scalenes posterior palpation

The SAT, in which scapular movement quality is examined, consists of manual assistance of correct scapular movement during elevation of the arm. Reduction of pain during this movement compared to non-assistance confirms scapular involvement in the shoulder complaints

Scapular Assistance Test

Purpose: Detect weak scapular stabilizers and instability (SICK scapula) Method: Pt. is standing and PT stabilizes the pt's clavicle & scapula while providing a tactile cue to inferior angle of scapula Pt. then performs shoulder flexion. Positive Test: Decreases pain, improved ROM, and improves RTC strength with PT support.

Scapular Retraction Test

Downward rotation: The patient extends and adducts the arm to place the hand across the small of the back and the inferior angle of the scapula moves in a medial direction Upward rotation: The patient elevates the arm through ﬂexion or abduction

Scapulothoracic Joint AROM Medial/Lateral Rotation

Movement. From the start position, the patient ﬂexes the arms to 90°, and protraction is observed as the patient reaches forward. The vertebral borders of the scapulae move away from the vertebral column. Retraction: The patient moves the scapulae horizontally toward the vertebral column.

Scapulothoracic Joint AROM Protraction/Retraction

Second rib provides attachment for the posterior scalene. It attaches to the second costal notch on the lateral aspect of the sternal angle between the manubrium and the body of the sternum.

Second RIb in Supine

Step 1: Scan (sharp/dull, testing scattered areas) Step 2: Compare (distal vs. proximal areas, right vs left) Step 3. Mapping and documentation (Carefully map the area of altered sensation found in steps 1 and 2. Orderly series of identical pinprick stimuli. Test sequentially in a ring around the limb and then map proximally and distally to determine the area of sensory change.) Step 4. Document

Somatosensory testing

Beneath upper traps is splenius capitis; a flat, quadrilateral muscle, originating from the lower half of the nuchal ligament, C4-C6, and the SP of C7-T4. It inserts onto the mastoid process and the occipital bone. Resist ipsilateral side flexion and rotation to feel the contraction.

Splenius capitis palpation

Recurrent

Stage: - Experiencing a new episode of previously experienced musculoskeletal symptoms following a period of being symptom-free. - In reality some patients may present with ongoing, mild persistent symptoms, but have recent episode of increased symptoms that are impacting on the usual activities .

Chronic/Persistent

Stage: - Most commonly defined by a time frame of greater than three to six months duration, or pain that extends beyond the expected period of disorder resolution. - Some disorders are chronic, though episodes of pain are recurrent/episodic

The patient is sitting. The shoulder is slightly abducted in neutral rotation and the elbow is ﬂexed to 90° with the forearm in midposition. The patient internally rotates the shoulder by bringing the palm of the hand toward the abdomen

Subscapularis MMT (Gravity Eliminated)

Modified hinge joint formed by condyles of the head of the mandible inferiorly, and the articular tubercle and mandibular fossa superiorly. Palpate anterior to the external auditory meatus and ask the pt. to open and close the jaw, and move in lateral deviation, to feel the movement.

TMJ joint palpation

The muscle attaches inferiorly on the coronoid process, and ramus of the mandible. Ask the pt. to close their mouth and gently clench their teeth to feel the muscle contract. Also retracts the mandible.

Temporalis palpation

Teres Mj. originates from the dorsal surface of the inferior angle of the scapula, and attaches to the medial lip of the bicipital groove of the humerus. Find the lateral border of the scapula, and follow these fibres laterally towards the axilla, where they blend with fibres of the lat. dorsi. Resist shoulder ADduction and IR to feel the muscle contracting.

Teres Major Palpation

Ankle Anterior drawer

Test of ATFL injury. Patient is long sitting on plinth with foot over edge. Stabilize distal tib/fib, glide calcaneus anteriorly over talus.

Functional Tests

Tests of basic functions of daily living or possibly sport movements (i.e. sit to stand). Provides quick information about quality of movement, pain during a movement, AROM, and muscle strength.

A thorough subjective history and taking blood pressure (Neuro exam (including cranial nerve exam) and auscultation can also provide important information)

The best screening tools for CAD include...

(3-18°) Done in sitting, OP through shoulders

Trunk Rotation AROM

Nerve Bias: Median nerve, musculocutaneous nerve, axillary nerve Sequence: -shoulder depression w/ 10 deg abduction - Elbow flexion to 90º - forearm supination - wrist, finger & thumb extension -Shoulder lateral rotation - Slow elbow extension until symptoms appear Sensitization: contralateral cervical side bend (bend head to opp side)

ULTT 2/B

Nerve Bias: Ulnar nerve (C8 and T1) Sequence: -shoulder depression w/ 90º deg abduction - forearm pronation - wrist, finger & thumb extension & radial deviation - shoulder lateral rotation -slowly flex the elbow by bringing fingers towards patients ear. Sensitization: contralateral cervical side bend (bend head to opp side)

ULTT 4/D (party mask)

The patient is sitting. The patient elevates the shoulder girdle(s) to bring the acromion process closer to the ear. Palpation. Upper ﬁbers of trapezius: on a point of a line midway between the inion and the acromion process. Resistance Direction. Scapular depression.

Upper Fibers of Trapezius and Levator Scapulae MMT

The patient is prone. The arm is at the side, and the shoulder is in neutral rotation. The patient elevates the scapula through full ROM.

Clinical Skills (No Hand/Wrist)

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