420 Ms management (2019): 1-15lec//1-15 lab// 1-15 instructions// 1-22.1// 1-22.2 start...... 1-29-31//1.29 lec//ch 16// 2.5a// 2.5b// 2.7// 2.12 Elb// 2.12 lab

"Remember To Drink Cold Beer"

Roots (ventral rami of C4,5,6,7,8,T1) Trunks (superior, middle, inferior) Divisions (3 anterior, 3 posterior ) Cords (lateral, posterior, medial) Branches (musculocutaneous n., axillary n., radial n., median n., ulnar n., medial antebrachial cutaneous n., medial brachial cutaneous n., medial pectoral n., intercostobrachial n.)

toe walking tests what nerve

S1, plantarflexion

What are the different accessory motion tests of the shoulder

SCJ (super/inf/anterior) ACJ (sup/inf/ant/post) GHJ (inf/ant/post) Grades: hypo-early tissue resistance normal hyper-late tissue resistance

capular pattern

a series of limitations of joint movement when the joint capsule is a limiting structure. ex. GH jnt patter: ER> abd > IR

plyometric contraction

a sudden eccentric loading and stretching of muscles followed by a strong concentric contraction

principles of msk management

acuity SINS (severity, irritability, nature, stage, and stability) promote healing/remove barriers to healing pt goals/expectations

possible disorders and causes of the anterior elbow (cubital fossa)

anterior capsular strain distal biceps tendon rupture or tendinitis dislocation of the elbow pronator syndrome (in throwers)

most common causes/associations of cubital fossa pain (elbow)

brachialis mm tear ex. rock climbing biceps lesion compress of PIN capsular injury

shoulder patho history

brief outline of pt: age, occupation, hand dominance, recreation pursuits, work requirements, and ADL mechanism of injury (help w/ preliminary dx) chief complaint quality of pain symptoms not assoc w/ movement (ex. pain at night, periarticular problem-> inflammation) location of pain (radiopathy, referred pain,...) what positions relieve pain general health (medications, allergies) previous PT/interventions (interventions, injections, surgery)

3+ grading of DTR

brisk (upper half of normal range)

extensor digiti minimi A OIN

extends 5th finger @ DIP O: lateral epicondyle I: extensor expansion of 5th DIP N: Radial n.

extensor carpi radialis brevis A OIN

extends and ABducts hand O: lateral epicondyle I: 3rd MC N: radial n.

extensor carpi ulnaris A OIN

extends and ADducts hand O: lateral epicondyle I; 5th MC N: RADIAL n.

extensor digitorum (UE) A OIN

extends fingers (MCP, PIP, mostly DIP) and extends hand O: lateral epicondyle I: entensor expansion- DIP N: radial n.

radio carpal (wrist) closed packed position

extension w/ radial deviation

what are some factors that affect tissue healing

extent of injury (macro or micor) tissue type (cartilage, ms, nerves) blood supply nutrition age (elderly and youth) comorbidities (ex. hypertension, diabetes, smoking)

what is the capsular pattern of the GH jnt

external rotation, abduction, and internal rotation

what falls within functional exam of an elbow exam

joint ROM mm performance mm length neuro status sensorimotor control special tests * impairment *standardized function **compared to unaffected side

LQ/UQ screen function

joint ROM, mm performance, mm length, neuro status sensorimotor control, and special tests (impairment, standardized, functional)

osteochondritis dissecans (OCD)

joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow

what is the clinical importance of the stages of healing

knowing stages allows you to match tissue loading capacity to appropriate tx (optimal loading zone) Rule of thumb: Do no harm Overload too exacerbates injury underloading tissue is not strengthened and recurrence of injury increases (most common PT mistake)

tennis elbow

lateral epicondy

dermatomes L4

medial calf

golfer's elbow

medial epicondylitis

reflexes of LQ screening

patella (L4), and achilles (S1)

late phase of shoulder tx and healing

restore kinematics (still caution w/ high 5 position) restore proprioception restore nm control Goals: don't allow dislocation increase strength, emphasis on control multiplanar sport/activity specific (thinking about what level they are returning to)

cardinal s/sx of inflammation

redness, heat, swelling, pain, and loss of fnx this will drive CDM

Severe progressive pain not affected by movement, persistent throughout the day and night, and associated with systemic signs, may indicate

referred pain from a malignancy. The exception to this may be adhesive capsulitis (frozen shoulder), which is often characterized by boring, unrelenting, aching pain, even at rest

scapular tests (2)

reposition assistance

special tests for scapula

repostion assistance

what does RI stand for

resistive isometric

post- operative pt MSK examination

respect protocol precautions/contraindications. Key to record: pain level, incision status, vascular, sensory and motor status above/below surgery, ROM (A or P), tolerance of exercise, functional ability, meds status

infective arthritis (at the elbow)

staph aureus, streptococcus and gonorrhea at the elbow, s/sx linked with drug abuse and need injection marks

first 150 degrees of arm elevation through flexion ms and actions

the UPPER and LOWER fibers of the trapezius contract concentrically, the fibers of the LOWER serratus anterior contract concentrically, the levator scapulae contracts eccentrically, (lengthening) the rhomboids contract eccentrically. (lengthening) x

most common association w/ medial elbow pain

tendinopathy (superficial wrist flexors, pronator teres) MCL sprain ulnar n compression

what causes chronic rotator cuff disease

tendinopathy-> partial tear -> full thickness tear

Step 1: garner trust post-shoulder surgery

teps for working with shoulder stiffness post-injury/surgery pt after injury/surgery have very difficult time relaxing (don't want to give their limb to you) commonly afraid, need to gain their trust get them to relax (if they are guarding during your manual tech, you will irritate their shoulder) pt buy in is IMPERATIVE

specificity

test is negative in those without target disorder (high specificity but low sensitivity may provide false negatives)

sensitivity

test is positive w/ target disorder (high sensitivity, low specificity, false positives)

sets and reps for tx

the goal of the exercise dictates how you prescribe sets and reps (power 1-5, strength 1-6, hypertrophy 6-15, and endurance 15+) and other principles: periodization % 1RM, 8RM, 20 RM ex velocity and type of contraction (isometric, eccentric, concentric)

what is the best type of tx?

the one that gets the pt better

TUBS

traumatic unilateral bankart surgery traumatic dislocation of the shoulder/freak injury as long as injury heals the outcome is good

ORIF

Open Reduction and Internal Fixation (orthopedic surgery)

what next, how to decide intervention?

tx must be focused on eliminating or decreasing cause(s) or identified problems Relies on ability to hypothesize a relationship between problem and pain ex. what's bothering them? they can't lift their shoulder, may start w/ ROM

soreness during warm-up that goes away but redevelops during session

2 days off, drop 1 level

burden of lateral epicondylitis

1-3% of the population affects 15% of workers who perform repetitive hand movements

labrum special tests

anterior (load and shift) SLAP (O'Brien's, speeds, Bicpes Load II) Posterior (Kim test)

what are instability tests of the shoulder?

anterior apprehension, posterior apprehension, and relocation tests

myotomes

muscle or groups of muscles innervated by a specific motor nerve (motor units/ ms innervations)

elbow extension ROM

0 hard end feel

tips for objective

1. assess don't assume 2. horses before zebras

soreness during warm-up that continues

2 days off, drop 1 level

shoulder flexion/bduction ROM

165-180 100-120 w/out scapula, 120-180 (last 60) w/ scapula firm

posterior interosseous nerve syndrome palpation (PINS)

2-4 cm below lateral epicondyle nerve is located near the shaft of the humerus and elbow, it is the deep motor branch of the radial n. proximal to the supinator arch

"shunt" ms

muscles that produce a compression at the joint surfaces of the joints they cross

burden of elbow injuries

2013- 12% Canadian workers claims were arm, wrist, and hand msk disorders and injuries located in supporting and related ms, ligaments, and capsules = lost time and lost income

is scapular dyskinesis associated w/ shoulder pain?

2018 study showed no difference in presence of dyskinesis in those w/ or w/out shoulder pain athletes with scapular dyskinesis did not have higher injury risk/rates compared to controls there is a differnce in degrees of scapular motion between dominant and non dominant in health pt

what are the "functional" ROM of the elbow?

30-130 deg. flexion 50 deg. pronation 50 deg. supination ROM of typical activity

proximal radioulnar open packed position

70 deg flexion 35 deg. supination

open packed position of the elbow (ulnahumeral jnt)

70 degrees flexion, 10 degrees supination

shoulder IR ROM

70-90 firm

beighton score

A Test for hypermobility. A score of 5 or more out of a possible 9 indicates hypermobility

what is the ultimate purpose of screening

A. delineate affected area and area to be examined further B. Rute out/clear body/structures that are not contributing to problem C. determine gross nature and site/symptoms of current problem, ad pt response D. determine grossly what changes pain (posture, movement...) E. all info used to guide a more detailed examination F. should only take 5-10 minutes

UQ screen elbow/forearm

AROM flexion (C5,6), extension (C7), pronation/supination at 90 flexion if no problems/pain provide overpressure (only to C5-7?)

what special shoulder test indicated subscapular involvement?

Belly press (upper subscap) lift off (lower subscap)

medications that commonly affect shoulder treatment

Corticosteroid use can cause osteoporosis and tendon atrophy and affects wound healing; therefore a history of its use may alter the differential diagnosis. not anticoagulant meds renal dialysis are at increased risk for tendon tears, as are patients who are 80 years of age or older

where are Heberden's nodes of the hand located?

DIP join osteoarthritis

types of referrals to PT for examination and evaluation

Direct Access, non-specific (protocol), consultative, prevention and health promotion. REGARDless of referal all will involve some version of MSK Exam

FT rotator cuff tear tests (5)

Drop arm ERRT ER lag Belly Press Lift Off

what special shoulder tests are may indicate infraspinatus?

ERRT (may indicated tear or involvement) ER Lag (cuff tear, and infraspinatus)

common mechanisms of elbow injury

FOOSH (sometimes coupled with neck injuries) fall on top of the elbow-> olecranon bursitis, ulnar n. lesion, olecranon fracture

tx strategy of repair/proliferation/regeneration stage of healing

GOAL: balance forces this is the point of best opportunity to influence tissue outcomes

What are the subacromial pain tests? (5)

Hawkins-Kennedy Neer's Painful Arc Full Can Speed's (must reproduce pt's symptoms)

APTA pt/client management model

Health screening examination evaluation dx prognosis > intervention outcomes

what are the components of a basic MSK exmaination?

History, review of systems, systems review, tests and measures.

ICF

International Classification of Functioning, Disability, and Health

dermatomal testing on LQ screening

L2-S1 : L1/2: anterior middle thigh L3: medial knee L4: medial calf L5: dorsal foot 1st and 2nd MT interspace S1: lateral border of the foot and posterior calf

LQ screening heel toe walking tests what nerves

L4, S1

heel walking tests what nerve

L4, dorsiflexion

shoulder pathological conditions associated with the LHB tendon including

LHB tendon degeneration, SLAP lesions, LHB tendon anchor abnormalities, and LHB tendon instability.

LHB

Long head of biceps

hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

peripheral nerve

Nerves functioning outside your brain and spinal cord.

where are Bouchard nodes of the hand located?

PIP joint osteoarthritis

tx tactics during inflammatory phase of healing

PRICE, pain free ROM, pt education on re-positions and activities, maybe gentle isometrics, gentile mobilities, and maintain aerobic fitness

post-op orthopedic surgions and PTs

PTs are the rehabilitation experts Ortho surgoesn have very little exposure to PT during their schooling protocols are a guideline (understand principles behind the protocols) we are a team

what are some of the most responsive pt-reported outcome measures of the elbow

Patient-rated elbow evaluation (PREE) american shoulder and elbow surgeon form Disabilities of the arm, shoulder, and hand

humeral propeller ms

Pectoralis major and latissimus dorsi ms, only ms in UE to have positive correlation between PEAK Torque and pitching velocity, and during propulsive phase of swim stroke also includes teres major and pec minor

diagnosis: underlying cause of problem

Problem... may be related to impairments maybe related to pathology, or a function limitations, societal limitations, or disabilities

pronator teres OIAN

Pronation and forearm flexion O: medial epicondyle I: radius N: medina n.

strengthen ms or increase joint motion (major intervention principle)

ROM exercise hierarchy (PROM> AAROM> AROM> ARROM) Strengthening exercise heirarchy (ex. starting and progressing)

Systemic causes of insidious shoulder pain include

RA (morning stiffness that goes away in 1 hr) and inflammation lupus, gallbaldder ds, liver ds typically ahve additional s/sx chronic resp or Cv conditions

treating injury due to hypoxia

RICE could limit further injury tx of secondary injury can also reduce the inflammatory cycle time and improve outcomes

SAID principle

Specific Adaptations to Imposed Demands

what comprises the biopsychosocial model?

person, biology, psychology, and social environment

A number of investigations have aimed to determine if adaptations in scapular movement occur in individuals with impingement or rotator cuff disease

Specifically noted are a decreased scapular movement toward: upward rotation, posterior tilt, and external rotation during humeral elevation

what part of the exam is most important?

Subjective, contains 80% used for diagnosis

Examination: specific testing may include

Tests neurological conditions, vascular integrity, specific syndromes, self-reported outcome measures

special tests for the AC joint

active compression cross arm

UQ screen TMJ

active open mouth, can they fit two knuckes in, notes symmetrical, clicks, pops, pain,

physiological resistance/fitness of healthy tissue

able to resist stress

paresthesia

abnormal sensation

0 grading of DTR

absent (areflexia)

bankart lesion

abulsion of labrum from glenoid

stages of healing

acute phase, repair/proliferation phase remodeling/maturation phase

stiff shoulder condition

adhesive capsulitis/ osteoarthritis/ sometimes RC tears and post-operative <80% contralateral side is considered overly stiff (20% discrepancy normal) don't torture pt (MUA: old method had you stretch them out, this only aggrivates it, and is extremely painful) new method (LOA) catching it late says to wait, it will loosen up/ surgery

no soreness

advance 1 level per wk or as instructed

2+ grading of DTR

average (lower half of normal range)

special tests for subscapularis

belly press (upper) lift-off (lower) bear hug

in the shoulder where is there more frequency occurrences of macro and micro-traumas

capsule, RTC, and labrum

acute phase of healing

coagulation and inflammaiont

research on shoulder "impingement" mechanism

conterindicated information: impingement occurs in first 30 degrees of abduction, but this is when there is the most space within the GH joint those that were asymptomatic had less space in their joint than the symptomatic pt supraspinatous is not in the shoulder space of impingement (floroscopy study) shaved acromion to make more space- 20% still have full RC tears

trochlear chondromalacia (elbow)

damage to the cartilage, is the formation of early arthritis. ... Thus, any grinding with translation of the patella in the trochlea groove, or evidence of pain or swelling with activities

1+ grading of DTR

decreased (hyporeflexia)

principles of msk evaluation: prognosis

determine predicted optimal level of functional improvement, time to reach, and specified intervals may include why (ex. diabetes medication may lengthen episode of care...)

cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling feels hot and tender can spread to other parts of the body not typically spread from person to person

AC joint injury: other shoulder condition

fairly common, " separation" MOI: fall or contact on pt of shoulder (clavicle slips off acromion) usually tx w/ brace and PT distal clavicle excision if necessary painful or degenerative AC joint can restrict/alter ROM usually localized over AC joint worse at end range elevation and horizontal add (limited to approximately 110 degrees of elevation if clavicle doesn't move) step deformity- AC not aligned, one sticking up

FOOSH injury

fall on outstretched hand sprain or strain to wrist, elbow, shoulder, serious: fractures wrist, elbow or shoulder, AC separation, clavicle fracture, GH fracture/dislocation

flexor carpi ulnaris A OIN

flexes and aDducts hand O: medial epicondyle and olecranon I: 5th metacarpal, pisiform, hook of hamate N: ulnar n.

flexor digitorum superficialis A OIN

flexes fingers @ PIP and MCP and flexes hand O: medial epicondyle and radius I: middle phalanges (2-5) N: median n.

palmaris longus A OIN

flexes hand O: medial epicondyle I: palmar aponeurosis N: median n.

what special shoulder test is biased towards suprasinatus but doesn't isolate it completely?

full can

The clavicle must be able to fully rotate for

full elevation to occur; otherwise elevation would be limited to approximately 110 degrees.

IP closed packed position

full ext

shoulders instability tests (3)

hand supinated, arm 90 abd, elbow 90 flexion, slowly ER while watching pt's face Positive: apprehension/guarding Interpretation: anterior shoulder instability

what is cubitus valgus

having a carrying angle >15 degrees common in women to have 15 or more degrees

Subjective screening questions

health history (red flags) pain at night recent trauma (MVA) cardiac (MI, chest pain, nausea, sweating, jaw pain) pulmonary (shoulder pain w/ cough or deep breath) GI (GI symptoms associated w/ shoulder pain)

outcome of shoulder instability

high recurrent rate of dislocation without surgery (60-90% in high risk populations, less in general population) repeated dislocations-> anterior glenoid bone loss-> lartarjet 40% OA in 10-15 years post (degenerative symptoms due to repeated dislocations) ex. TUBS

who is at risk of trigger finger

high risk factor in those whose work or hobbies requires repetitive gripping actions more common in women or diabetics

resisted ms testing of LQ screening

hip flex L1-2, knee ext L3, ankle DF L4, hallux ext L5, resisted knee flexion/hamstring S2

4+ grading of DTR

hyperactive w/ clonus (hyperreflexia)

tx tactics for remodeling/consolidation stage of tissue healing

increase exercise load; Open K chain and Closed-K Chain exercises; SAID principle

IFC

interferential current

another word for tactics

intervention

maintaining and improving overall fitness

look beyond the joint general fitness important (to optimal healing, pt confidence, and maintenance/improvement of associated body areas) use creative solutions that preserve safety and promote healing (empower them to stay active)

normal physical stress/demand on tissues leads to

maintenance

controlling pain and inflammation

major intervention, PRICE (protect, rest, ice, compress, elevate) conduct early , controlled, gentle motions (as long as it's not contraindicated) Knowledge of meds being used (NSAIDs and coritsone) respect all precautions/contraindications (ex. some tissue needs mobilization other doesn't) Advice on re-positioning/activities to avoid worsening and promote motion

UQ screen fingers

make a fist (AROM flexion), open hand 9AROM extenion ), no overpressure

MVC

maximal voluntary contraction

specificity of exercises shoulder example (isolation exercises)

most effective way to work to work the middle traps and lower traps is in the prone position >80% MVC (maximum voluntary contraction)

summary of intervention

must be SAFE (known indications/contraindications) scientifically sound targeted to pt problems, stage of healing and adequate dosage to reasonably achieve stated goals practice to implement creative (w/ specific goals in ind and never at expense of safety)

what is the triangle sign (elbow)

narrowness of the angle of the joint, used to track swelling assume 90 deg. flexion of the elbow mark the olecranon, lateral and medial epicondyles connect all to form a triangle should shrink with full extension (will not in cases of great swelling, because it prevents extension)

Protection phase of shoulder healing and tx

negative pressure lost during dislocation (takes a wk to restore) sling (no longer used in Europe, they educate pt on safe ROM goals: don't allow another dislocation reduce pain and inflammation restore cuff nms activity (sub-max isometrics)

dermatome T4

nipple

Burden of elbow neuropathy

often involve the median or radial nerve may involved peripheral entrapment of median, ulnar, or radial at elbow or wrist most common conditions affected this region are lateral epicondylitis, medial epicondylitis, and carpal tunnel syndrome

possible disorders and causes of posterior elbow pain

olecranon bursitis olecranon process stress fracture triceps tendinitis

most common causes of posterior elbow pain

olecranon bursitis triceps tendinosisi valgus extension overload

how do you know if you've achieved the goals and expected outcomes?

outcome measures use +/- impairment functional level measures use standardized or non-standardized measures SMART goals

shoulder patho preliminary dx based on mechanism of injury

overhead exertion w/ repetitiv motion: subacromial path, subacromial bursitis, SIS, RC tendinopathy, RC tear, bicipetal tendinopathy fall/FOOSH- sprain or strain to wrist, elbow, shoulder, serious: fractures wrist, elbow or shoulder, AC separation, clavicle fracture, GH fracture/dislocation fall on tip of shoulder: AC separation, compression periostitis (bone contusion), cervical spine injury (similar to s/sx of AC separation_ horizontal force extension AB/ER- anterior dislocation shoulder pain- orthopedic swimmer injury (40-91%), linked to decreased humeral head stabilization due to fatigue of upper back, RF ms, and pec ms.

common shoulder stiffness AAROM tx

pendulum wand pulley UBE Aquatic therapy

best exercise position for MVC for Serratus anterior (w/ least contribution of other ms)

plyometric pushup

best exercise position for MVC for middle and lower traps (w/ least contribution of other ms aka isolation exercise)

prone, >80% MCV

intermediate phase of shoulder tx and healing

restore normal kinematics (cautions w/ high 5 position) restore proprioception (proprio cell repair) restore nm control progress closed-chain to open-chain Goals: don't allow another dislocation regain scapula thoracic and scapulohumeral rhythm increase strength, emphasis on control uniplanar (avoid the high 5)

dermatome C8

ring and small finger, ulnar forearm

SINSS

severity: pain scale, level of impairment fnx irritability: provoking, skin (color), response nature stage (rapidly changing, bettering better or worse or stays the same) stability

size classification of RC tears

small <1 cm medium <3 cm large <5 cm massive >5cm (usually retracts)

soreness during warm-up that goes away

stay at level that led to soreness

LOA adhesive capsulitis

surgery to cut out fibrotic capsule usually bolus PT directly after surgery (come in every single day right after tx)

TOS

thoracic outlet syndrome

Rotator Cuff Tears

type: partial or full thickness location: bursal, articular, mid-substance with/without retraction Key findings: positive drop arm, ER weakness possible substantial loss of ROM and/or MMT negative instability (won't have instability) common impairments: significant weakness (otherwise same as SAP)

what are common hand deformities are present in Rheumatoid Arthritis (RA)?

ulnar drift and finger abnormalities

anterior translation forces (ER) and distraction force generated with pitching are equal

1/2 body weight during the late cocking phase, and equal to body weight during the deceleration phase.

The long head of the biceps and the triceps muscles are major dynamic stabilizers of the G-H joint, predominately functioning

functioning as "shunt" muscles (muscles that produce a compression at the joint surfaces of the joints they cross) during high-velocity activities

movement screening for objective documentation

general: elevation in scapular plane specific: pick a fnx task based on pt's subjective report of their fnx limitations used movement screen to help guide objective examination???

local sources of shoulder pain

glenohumeral joint scapulothoracic joint acromioclavicular joint sternoclavicular joint

open packed position of the shoulder

glenohumeral position: 55 deg aBduction 30 deg horizontal adduction externally rotated

closed packed position of the shoulder

glenohumeral position: 90 deg aBduction full external rotation full aBduction

what is the triangle space? (elbow)

good measure of swelling (**compare to other side) flex the elbow to 90deg mark the oleranon, radial head, and lateral epicondyle

proximal humeral fractures: stiff shoulder condition

occurs w/ falls or pathologically usually occurs at surgical neck of the humerus +/- cuff tear tx. : protection and ORIF (open reduction and internal fixation)

possible disorders and causes of posteromedial elbow pain

olecranon tip stress fracture posterior impingement in throwers trochlear chondromalacia

pronator compression palpation test

on both arms place pressure on the pronator teres (4 cm below cubital crease) Positive: REPROduced paresthesia in lateral 3 1/2 digits within 30 seconds or less (unaffected arm remains asymptomatic)

UQ cervical myotome tests

one motion per myotome C4- scapular elevation C5- shoulder abd C5/C6 elbow flexion C7 elbow extension C6- wrist extension C8- wrist extension T1- fingers together/apart -protraction/retraction, internal/external rotation, supinate/pronate, fist, opposition

Disabilities of the Arm, Shoulder and Hand

one of the most responsive patient-reported outcome measures of the elbow 6 items on symptoms and pain 24 items for fnx shorter version: QuickDASH

Patient-Rated Elbow Evaluation (PREE)

one of the most responsive pt reported outcome ms of the elbow 5 items for pain 15 items for fnx (10 specific, 5 typical activities) scaled on a 11 pt (0-10) numerical rating scale

American Shoulder and Elbow Surgeons (ASES) Form

one of the most responsive pt-outcome measures of the elbow consists of a pt self-rated part and an examiner based part scale each item: pain (5 visual analog) fxn (12 likert scaled-4 levels) satisfaction (1 Visual analog)

MSK examination interview techniques

open-ended vs close-ended (avoid leading questions), funneling technique (general to specific), FUPS (follow up questions), paraphrasing, and establishing pt's goal and expectations

what joint position are Accessory assessments ALWAYS conducted in

open-packed position

what ms are involved in medial epiconylitis?

pronator teres (median n.) flexor Carpal Ulnar (ulnar n.) flexor Carpal Radialis (medina n.) palmaris longus (median n.) flexor digitorum superficialis (median n.)

sub-acromial pain synderon

proper name for shoulder impingement pain originating from structures in the subacromial space (cuff, bursa, LHB) purposely vague: allows for uncertainty, and multiple mechanisms (that may be causing the pain)

PNF

proprioceptive neuromuscular facilitation

What is PROM as it relates to selective soft tissue tension testing

pt is NOT activating contractile elements to move joint (examiner is providing force), non-contractile elements still stressed because joint is being moved. IF pain, it is more likely non-contractile elements since they are not being stressed, exception is if ms is bein stretched!!!)

tx for strength and control

straight planes-> multiplanar isometric-> isotonic-> plyometric (if you don't have control in isometric then isotonic is a disaster)

Specific testing: neurological conduction

strength/MMT, sensation (sensory testing), DTR (integrity of spinal reflex arc), pathological reflexes (ex. babinski), and tests of neural integrity

categories of special tests for the shoulder

sub-acromial pain tests rotator cuff tear test instability tests labral tests other scapular (Must reproduce pt's symptoms)

Full Can test

subacromial pain test 90 flexion and Abduction/scapular plane, thumbs up Break test (overpressure) Positive: anterolateral pain Interpretation: subacromial structures might be pain generating, weakness might be a cuff tear "biases" supraspinatus but impossible to isolate empty can= thumb down

Hawkins-Kennedy test

subacromial pain test 90 shoulder and elbow flexion, internally rotation, stabilize humerus while putting pressure on forearm to internally rotation. (can run arm under their elbow, to put pressure on their shoulder and other hand to internally rotate) positive: anterolateral pain Interpretation: subacromial structures might be pain generator Good at ruling out shoulder pain, Bad at ruling in specific structure

Painful Arc

subacromial pain test AROM bduction Positive: pain 60-120 subacromial, 170+ AC joint Interpretation: suacromial structure might be pain generating Good at ruling in shoulder pain bad at ruling out specific structures

Neer's test

subacromial pain test full internal rotation w/ elbow straight, then bring shoulder into flexion Positive: anterolateral pain Interpretation: subacromial structures might be pain generator Good at ruling out shoulder pain Bad at ruling in specific structure

Speed's Test

subacromial pain test fully externally rotation arm, resists through full flexion range Positive: anterolateral pain Interpretation: subacromial structures might be pain generating "biases" LHB, isolation impossible

what are laxity tests of the shoulder and other?

sulcus and beighton score tests

other special shoulder tests (3)

sulcus, cross-arm, and AC shear

SLAP tear

superior labrum anterior to posterior

Supinator ms A OIN

supinates forearm (chief supinator) O: lateral epicondyle and Ulna I: proximal radius N: Radial n.

James Cyriaz

the doctor who provoked tissue, selective soft tissue tension testing

From approximately 150-180 degrees of arm elevation through flexion ms and action

the lower fibers of the serratus anterior contract ISO metrically, the lower fibers of the trapezius contract concentrically, the pectoralis minor contracts eccentrically, the upper fibers of the serratus anterior contract eccentrically

RC full thickness tear

the ms will begin to shrink and pull away from it's insertion point it can retract up to 4-5 cm components of individual ms cells shorten surgery: stretch out the ms and reattach it but this makes the ms very weak, do not know if ms cell structures can rebuild

reverse scapulohumeral rhythm

the scapula moves more than the humerus, occurs in conditions such as adhesive capsulitis.

dynamic scapular assessment

the scapulae tend to move symmetrically (except throwers) watch scapular through flexion and abduction, using 1-2 lbs wt can make dyskinesis more obvious using inferior angles, medial border, and spine to track movement asymmetry does not indicate pathology use scapular test and clinical reasoning to help you determine if scapula is contributing to symptoms dyskinesis potential contributors: ms/ weakness/imbalance (correlate w/ MMT and symptoms), nerve injury (MMT/RI and symptoms), and dynamic control

assessing and addressing the kinetic chain of the shoulder

thoracic spine scapulothoracic glenohumeral (prime movers and dynamic stabilizers) elbow/wrist (don't just tx the symptoms, tx the source)

what are the main principles of msk examination?

thorough subjective interview (pt, patterns, clusters, and signs) formulate a hypothesis observe movement and posture determine which tests and ms to use collect data support or challenge hypothesis

microtrauma instability

throwers/overhead atheltes/swimmers stretch out capsule repetitive microtrauma causes capsule to be inflammed and instability sometimes surgery is done to shorten or tighten but in systemically lax people their tissues will just stretch out again

dermatome C6

thumb and radial forearm

what is a primary injury

tissue destruction is a direct result from trauma

scientific research for principles of shoulder tx

tissue healing constraints UE biomechanics nm pathology activity specific tasks

what is secondary injury

tissue injury or cell death is the reslt of ischemia (lack of blood) due to blockage of blood/oxygen supply to an injured area

tissue healing in youth

tissue is in developing

UQ screen of cervical region is done why?

to check if pain source is coming from cervical spine/nerves roots

Pain due to rotator cuff pathology and impingement,

usually felt over the anterior or lateral part of the shoulder, can be characterized by radiation down the upper arm, and is aggravated with overhead activities

Pain due to A-C joint pathology

usually located at the superior region of the shoulder or well localized at the A-C joint itself, and there is often a clear history of injury to this region. Severe pain on top of the shoulder with an associated deformity could indicate an A-C joint sprain. Posterior neck pain may be indicative of a cervical radiculopathy, as neither the A-C joint nor a subacromial irritation refers pain to this area

VAS item scaling

visual analog scale

Chronis pain MSK examination

w/ behavioral issues, may shift focus of exam away from pain and towards functional abilities. w/ low irritability, may need to increase force or have pt do increased reps to reproduce symptoms

normal or excessive ROM w/out symptoms chart (elbow)

w/ passive overpressue: normal end feel abnormal end feel

What information should be gathered during history portion of a subjective exam of the elbow?

what brings them in today? chief complaint movement impairment fnx problems age mechanism of injury

designing tx for shoulder stiffness post injury/surgery

where is stiffness coming from? joint, ms length, pain, ms strength (don't forget strength- gravity mitigated movements) ASSESS DON'T ASSUME commonly tx: manual (PROM/stabilize scap, accessory motion: GH, ST, AC, and straight plane/Corners/Combined motion

what kind of pt w/ musculoskeletal problems?

-healthy, any age with micro or microtrauma. -individuals w/ ds of any system that manifests itself into a msk problem -individuals w/ congential/acquired problems -individual w/ pre/post surgery conditions

what do tests and measures determine?

which structures are involved, reduce symptoms (tests of provocation), id faulty movment patterns possibly contributing to pain production, confirm/refute working hypothesis, and establish objective data baseline

Evidence Based Practice in guding testing choice

Ideally pick high sensitivity and high specificity. Reliable and valid.

exs of specific test: self-reported outcome measures

Oswestry diability index for LBP, UEFS, or DASH for shoulder pain, etc

malignancy

a dangerous cancerous growth that sheds cells into body fluids and spreads to new locations to start new cancer colonies

stereognosis

ability to recognize objects by feeling their form, size, and weight while the eyes are closed

thoracic outlet syndrome

absent radial pulse with positional change

mobilization terminology

begining, middle and end of available range, rate of force applied, location of range of available movement, direction of force, target of force, relative structural movement, pt position

80% of the time the dx can be mad from the _____

history: pain, impairments, fxn problems. Thus interview techniques are important

LQ screening

lumbar AROM if no pain overpressure (OP) gait observation heel and tow walking (L4, S1) seated: dermatomeal test, resisted ms tests, and reflexes Supine: PROM hip flex/ext/ abd, IR, ER, knee flex/ext, ankle DF/PF, no pain apply over pressure, SLR (single leg raise) Prone: passive knee flexion w/ hip ext (femoral nerve) and resisted knee flexion (S2)

interpreting RI testing (Dr. Cyriax): strong and painful

minor, local lesion of ms/tendon

LQ/UQ screen inspection

posture/orientation, gaitn, skin status, quality of mvt (ribs and spine)

what is the purpose of MSK examination?

primarily to collect relevant data (info) to be able to make decisions about appropriate managment of the pt problem(s), and data colection (info) for CDM

nerve root

the base of each of the 31 pairs of spinal nerves that branch off the spinal cord through spaces between vertebrae. merge to form peripheral nerves leading to dermatomes and myotomes

therapeutic use of joint acessory motions -> jnt mobilization/manipulation tx tenchniques

therapeutic grades of motion (per maitland system) non-thrust oscillatory techniques Grades I-IV: Grade I and II pain relief, begining of range, small oscillation Grade III-IV improve restricted motion, large oscillation Grade V: High velocity thrust/manipulations

why use UQ/LQ testing

to localize problem and rule in/out additional problems (source vs cause), followed up by regional examination w/ specifically chosen tests and measures based on working hypothesis (confirm/refute via positive/negative results) ex. decide what tests to use is source of pain local or cause neural

Acute pain MSK examination

w/high tissue irritability, may not be able to collect all data at first visit, may need to focus on Pain Relief Before reliable data collection possible

what happens with history, review of systems, and systems review?

whther to go on to a physical exam, how aggressive/gentle w/ physical exam (SINSS), specific physical exam test relevance (most info w/ least amount of testing), and begin to develop working hypothesis or dx (to support or refute w/ physical exam)

romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and EYES CLOSED -expected finding: client should be able to stand with minimal swaying for at least 5 seconds DC-ML tract (conscious proprioception)

elbow flexion ROM

0-140-150 soft or firm end feel

soreness day after lifting (not ms soreness)

1 day off, no advancemet

how do PTs make diagnoses?

it doesn't have to be a specific structure Use Clinical practice guidelines (CPG) response of tissue loading

why is the elbow susceptible to mobility and stability problems in general?

it is located between two of the most mobile joints of the body

Kim test

labral tear test seated, 90 abd, 90 elbow flexion compress the joint, moving it diagonally in horizontal add and flexion, while providing posterior force to the humerus (CAN position forearm on their back to keep them from going forward, and prevent dislocation, w/ same hand pulling humerus into labrum) Positive: pain/apprehension Interpretation: posterior labral tear

Biceps Load II

labral tear test supine, 120 abd, 90 elbow flexion, resist elbow flexion Positive: deep anterior pain Interpretation: SLAP tear w/ bicep involvement

O'Brien test

labral test seated, 90 flexion, horizontal adduction, full internal rotation, break test Positive: deep anterolateral pain Interpretation: SLAP tear must rule out subacromial and AC pain or just the position will hurt

scapular rehab algorithm

lack of soft-tissue flex or lack of ms performance

Other considerations biopsyhcosocial

lanuage barriers, cultural beliefs and values, and psychosocial factors

dermatomes S1

lateral border of the foot and posterior calf

most common elbow injury in >35 yoa

lateral epicondalgia

where does most swelling occur in the elbow?

lateral epicondyle prevents full extension triangle space and sign "tests"

what are the most common neuropathic injuries affecting the elbow, forearm, and wrist?

lateral epicondylitis medial epicondylitis carpal tunnel syndrome

shoulder: Weakness may be the chief complaint,

leading to some diagnostic confusion. It is important to distinguish true weakness from weakness secondary to pain, both in terms of history and examination findings. Painless weakness is usually due to neurological problems or myopathies, although peripheral nerve injuries can be painful Shoulder weakness may be caused by a rotator cuff tear or nerve injury (suprascapular, axillary, long thoracic, or thoracodorsal nerves, or cervical nerve root injury)

burden of medial epicondylitis

less common than lateral epicondylitis 10-29% of all epicondylitis diagnoses US cost 22 billion annually due to medical care and lost work

what might a snapping noise or feeling in the elbow indicate?

may indicate moving in or out of the ulnar nerve on the medial epicondyle or medial head of triceps or both

radial nerve compression/injury

may occur at any pt along the anatomic course of the nerve, w/ varied etiolgies compression can cause denervation or extensor or supinator ms and numbness or parethesis in distribution of sensation (RSN) resulting in pain, weakness and dysfunction most frequent site is in the proximal forearm near supinator and may involve the interosseous branch can occur w/ fractures of the humerus can also occur in the distal wrist

possible disorders and causes of the medial elbow pain

medial epicondylitis ulnar collateral ligament injury ulnar neuritis/ ulnar nerve subluxation valgus extension overload overuse syndrome flexor (pronator ms strain) fracture little league elbow

dermatome L3

medial knee

parameters of msk management

methods, mode, device intensity, load, or temp frequency, duration progression/regression all based on SINSS, acuity, age, pt preferences

dermatome C7

middle finger

carpometacarpal open packed position

middle of abduction and adduction middle of flexion and extension

shoulder strength test for objective documentation

minor vs major injury vs nerve (resisted isometrics) MMT (ms performance) consider using 90/90 positions for overhead athletes, poor reliability/validity for 4/5 and greater , use HHD if possible, and pain influences strength no matter how touch you are Selective tissue tensioning: poor validity/reliability in shoulder and cuff tendons form a sock, interface w/ jt capsule Ms length test

carpometacarpal closed packed position

none

interpreting RI testing (Dr. Cyriax): strong and painfree

normal, no lesion of ms/tendon

dx a degenerative tear

MRI- gold standard Ultrasound- just as good as MRI, much cheaper, no contraindications for metal implants or daustrophobia CORRELATION of imaging to physical exam

AMBRI

atraumatic, multidirectional, bilateral, rehab, inferior capsular shift surgery has poor outcome due to the multidirectional instability/laxity, surgery doesn't fix the actual problem

boney bankart

avulsion of labrum that pulls off a piece of glenoid

hills-sachs

posterior humeral head compression fx

UQ screen intrinsic ms

pt hold fingers together PT pulls apart (T1), hold fingers apart PT squeezes them together (T1) no over pressure

teach pt/family self-management (intervention)

shared decision-making pt/family education critical (some don't care) educate to help understand (using EBP to prove tx) (their problem(s), self-manage pain relief, long term resolution, tx interventions/progression)

dermatome C5

shoulder

why do a cancer screen with and elbow injury?

some bone cancers develop in the elbow and cause elbow pain that's why general health screenings are so important (for ruling in or out)

what special shoulder test may indicated/biased biceps but it impossible to isolated?

speed's test biceps load II (may indicate SLAP tear w/ biceps involvement)

special tests of biceps (LHB)

speeds

high physical stress/demand on tissues leads to

injury

% loss of extension as it relates to degree of flexion contracture

there is a greater loss of extension with greater degree of elbow flexion contracture

palpation of ruptured biceps tendon

this would show up as a palpable mass in the shoulder or elbow depending on which end ruptured

Degenerative cuff tears

thought to be a normal aging process 30% 40+ yoa 80% 60+ yoa con commonly be asymptomatic unclear how tear becomes sympotmatic

total mass of the shoulder ms (IR and ER)

total muscle mass of the shoulder's internal rotators (subscapularis, anterior deltoid, pectoralis major, latissimus dorsi, and teres major) is much greater than that of the external rotators (infraspinatus, teres minor, and posterior deltoid) IR 1.75 x greater torque than ER

non-standardized functional outcome measures

transfers/mobility/specific tasks as measured by -level of assistance (+1,+2,+3) -amount of assistance (independent, contact guard, min/mod/max assist) -distance/time ms (jump, time to pick up, etc) -observed specific qualitative change in performance -Gait (distance, cadence, velocity, observation, force platform, EMG)

moderate (positive overload) physical stress/demand on tissues leads to

increased tolerance (hypertrophy)

Phase II tissue healing: repair/proliferation phase

48-72 hours and up to 3-6 wks repair through 3 phases: 1. Resolution: little damage, and normal tissue approximation 2. Regeneration: replacement of tissue by same tissue 3. Repair: original tissue replaced w/ scar tissue -less viable that normal tissue, may compromise healing -6 mo or more to contract, 12 mo to fully mature

Radial tunnel syndrome (RTS) palpation

5 cm bellow lateral epicondyle insertion point will show lateral elbow and dorsal forearm pain, which may radiate to wrist and dorsum of the fingers intermitten compression of the radial n. from radial head to inferior border of the supinator ms w/out obvious extensor ms weakness more prevalent in men than women between ages 30-50

proximal radioulnar joint closed packed position

5 deg supination

functional tests of the elbow

5 reps/lbs functional 3-4 reps/lbs fxn fair 1-2/active: fnx poor 0: non-fxn elbow flexion w/ wt standing elbow ext: wall pushup standing facing door: turning door know into supination standing facing door: turning door knob into pronation

distal radioulnar closed packed position

5 supination

shoulder extension ROM

50-60 firm (some can get up to 90)

what ROM of the elbow is required for eating, dressing, and daily hygiene?

60-100 (combing hair 112) athletes need 10-20% greater ROM ex. overhead/throwing athletes

all screenings includ

A. AROM, B. PROM w/ over pressure C. Resisted iosmetrics (test myotomes/nerve roots, and contractile tissue) D. sensory testing (dermatomes and nerve roots) E. reflex test (specific nerve root) F: pathologic reflexes (babinski, hoffman's)

ERRT test

FT rotator cuff tear test Resisted ER at 0 positive: pain or weakness Interpretation: infraspinatus tear/involvement Good at ruling in but not at ruling out

multi-directional shoulder instability

AMBRI multiple directions of instability (ant, post, infer) young females, generalized laxity (beighton score), swimmers, gymnasts, softball pitchers usually atraumatic, sublux/dislocation occurring w/ low risk actvitiy (ADL's, sleep, etc) rehab is the gold stanard tx, avoid surgery due to poor outcome (lax -> surgery- > lax again) pain and instability: surrouding ms highly irritated from trying its best to provide dynamic stability paresthesia (abnormal dermal sensation: ex. tingling, numb, pricking, chills, burning, ...)

UQ cervical spine screen

AROM if no pain, may perform overpressue (done cautiously, provoking facets and compressing spinal nerves) systematically move from certical spine -> distally (then to TMJ, sho girld, shoulder, elbow, forearm, wrist, hand) resisted test for myotomes (conduct one motion per nerve C4-T1) dermatomal testing reflexes - watch face for expression

UQ screen shoulder

AROM: flexion, abduction (C5), ER/IR compares sides if no problems/pain provide overpressure (not for shrugs but yes for capsule)

UQ C-spine

AROM: flexion, ext, side bending, rotation if no problem or pain apply overpressure watch face

UQ screen shoulder girdle

AROm elevation (C4), depression, protraction, retraction, compare sides

UQ screen wrsit

AROm flexion and exteion (C6), overpressure if no problem

RCD/ subacromial impingement syndrome theories

Supraspinatus tendon tendon overlaod and degeneration OR mechanical compression in SA space

Lift off test

FT rotator cuff tear test hand behind back, pt lifts hand away from back (can add resistance) Positive: unable to lift Interpretation: lower subscap tear

belly press test

FT rotator cuff tear test pt hand on stomach,bring their elbow forward while maintaining pressure on stomach (resisted internal rotation) Positive: unable to bring elbow forward Interpretation: upper subscapula tear

UQ cervical screening dermatomal tests

C4: traps C5: shoulder C6: thumb & radius forearm C7: middle fingers C8: ring & small finger, ulnar forearm _______ not part of test usually T4: nipple T10: umbilicus

UQ cervical screening reflex tests

C5/6 biceps C7 triceps C5/6 brachioradialis Hoffmans's hand (UMN?)

dermatomes near the elbow

C6 radial forearm C7 middle finger C8 pinky T1 ulnar forearm back of fingers 1-3 -> radial (up to PIP joint) pinky and half of 4th-> ulnar palmar side fingers 1-3 Median

ER lag test

FT rotator cuff tear test ~20 degrees of scapular plane, 90 elbow flexion, externally rotate shoulder and ask pt to hold. Positive: pt unable to hold and arm falls into internal rotation Interpretation: cuff tear (infra) Good at ruling in but not at ruling out

dermatome L2

anterior middle thigh

what is a true shoulder impingment

bone spur in the GH joint

prognosis/ rehab potential

pt potential to improve

dermatome C4

traps

UQ screen thumb

AROm flexion, extension (C8), ABB, ABD

elderly and MSK

elderly may be limited by fatigue, may need accomodations with vision/hearing and positional problems.

picture of what scapular position

elevated R and depressed in L

order of scapular assessment

elevated/depressed, rotated, AB/ADducted, tilt, and winging

MSK assess: quality

end feel, soft, firm, hard, empyt, springy, spongy, boggy, and pain provocation?

most common association w/ lateral elbow pain?

epicondylosis, if tender on bony proninance

Radiohumeral open packed position

full extension full supination

closed packed position of the elbow (ulnahumeral jnt)

full extension, and full supination

MCP closed packed position

full flexion

thumb MCP closed packed position

full opposition

Elbow subjective examination History: common questions to the pt

-what brings you to the clinic today? can be broad and vague BUT, it can elicit information that is relevant to the pt in the outcome, and what is meaningful to the pt (ex. movement impairment and fnx problems, pain, tenderness) asking about a mechanical injury (ex. FOOSH) -onset/weakness/pain? (neuropathological) -hand dominance -What elicits pain?/What reduces pain? -what is pt occupation? what equipment do they use regularly? -duration of symptoms? has it improve or worsened (especially since seeing MD) -location of symptoms? (local/referred) -joint noise/crepitus/snapping -neck and shoulder pain -systemic/infectious -symptoms at night/day -sensory changes/ms weakness (ex. tingling)

gradings of deep tendon refelxes (DTR)

0- absent (areflexia) 1+ decreased (hyporeflexia) 2+ average (lower half of normal range) 3+ brisk (upper half of normal range) 4+ hyperactive w/ clonus (hyperreflexia)

forearm supination ROM

0-80 firm end feel (no bony block for radius)

forearm pronation ROM

0-80 hard end feel (radius block)

shoulder ER ROM

0-90 (usually less in most ppl) firm

Objective Examination steps for the shoulder

1. inspection/observation, posture 2. palpation 3. ROM 4. MMT 5. Ms length testing 6. accessory motion testing 7. reflexes, dermatomes, myotomes 8. functional testing

MSK examination Precautions and contraindications

1. malignancy 2. unhealed fracture 3. excessive pain 4.total joint replacements-mechanims of the joint may be self-limiting, so some techniques may be inappropriate 5. newly formed connective tissue 6. RA/connective tissue ds. 7. hypermobility 8. joint effusion 9. inflammation 10. when pt s/sx contra-indicate its use

basic principles of accessory motion testing

1. pt is maximally relaxed 2. usually test from "resting poisition" (open or closed packed) of joint, must know resting position 3. palpate to find appropriate landmarks 4. good bone contract for good fixation 5. hands as close as possible to joint line 6. place yourself in good position and work with gravity whenever possiblen/needed 7. stabilize one segment while mobilizing other (move parallel to joint surface- adapt to angle),and which articular surface s convex/concave/planar 8. understand which osteokinematic motion associated with Glide You Deliver 9. assess: amount of motion (usually glide) present, endfeel, and any pain with motion

distal radioulnar open packed position

10 deg supination

normal vs excessive shoulder stiffness post-surgery

<80% contralateral shoulder motion (non-surgical) surgical technique (arthroscopic vs open, anatomical vs non-A.) previous level of fnx instability hs

Phase III: Remodeling tissue healing

3 mo to 2 yrs laying down of collagen and strengthening of fibers balance must be maintained between synthesis and lysis. Osteoblast/osteoclasts etc... must take into consideration forced applied and immobilization/mobilization relative to tissue type and healing time

isolation exercise

A motion that if done correctly only targets one specific muscle may not elicit max activation but elicits higher activation w/ least activation of other nearby ms ex. plyo-push-up does not activate SA to the maximum, but it does isolate ms activation to most SA, while minimizing other ms LT, MT, and UT

pain map

A. "impingement syndrome" pain sharp and burning shoulder, dull down arm, possible numbness or dorsal hand B. rotator cuff sharp pain in shoulder, dull down arm C. glenohumeral joint arthritis, mixed dull and sharp pain shoulder and down, w/ some localized burning pain D. instability mixed dull and sharp in proximal shoulder and arm E. AC joint pathology sharp/shooting/stabbing in shoulder at AC and some dull nearby F. calcific tendinitis sharp/stabbing pain in shoulder

Jendrassik maneuver

Facilitates the stretch (knee jerk) reflex Clasp left an right hands together in front of your chest Force and cutaneous mechanoreceptors activate class of spinal interneurons that transmit force signals to interneurons of the lumbar plexus that excite interneurons synapsing on quadricep motorneurons -> increase activation of muscle *Contractile force changed but latency period did not drastically

shoulder evaluation

Following the examination, and once the clinical findings have been recorded, the clinician must attempt to determine: a SPECIFIC DX or a WORKING HYPOTHESIS based on a summary of all of the findings. This diagnosis can be structure related (medical diagnosis) or a diagnosis based on the preferred practice patterns as described in the Guide to Physical Therapist Practice.

tx strategies for inflammatory stage of healing

GOAL: decrease pain while preventing progression to chronic inflammation. use gentle and controlled mobilities

tx strategy for remodeling/consolidation stage of tissue healing

GOAL: tissue able to response to ADL forces; anticipated laod (sports, activity, work task specifics)

what are some common movement exam and basic assessments for an elbow injury

How does the pt sit? are they leaning over unaffected hand? how do they reach for objects? how do they perform their ADLs like washing hair, brushing teeth, or eating or drinking? do they have difficulty tying their shoes/typing/writing? How do they put their shirt on or their pants? ... (other movement requiring elbow and UE fnx?

special tests for the shoulder tell us what?

Integrity of cuff integrity of capsulolabral complex presence of instability subacromial pain AC joint pathology help rule in/out need to use tests w/ good sensitivity and/or specificity (ideally >80%) Must reproduce pt's symptoms

why is knowledge of hand dominance relevant w/ elbow injuries

It's important for assessing if compensating with the other arm is a realistic option/expectation could be part of the mechanism of injury, such as repetitive actions (ex. carpenter or throwing athlete)

Examination testing: specific tests

Joint stability and ligamentous integrity, neurological conduction, vascular integrity, specific syndromes, and self-reported outcome measure

shoulder exam picture

Level 1: screening (history, exam, flags) -appropriate for PT, PT and referral, and NA for PT Level 2: pathoanatomic Dx specific physical exam: origin (subacromial pain/RTC ds, stiff, loose) and /non-origin of symptoms Level 3: rehab classification 1. tissue, irritablily 2. impairment (high, moderate, or low irritability and impairement)

Superior labral anterior to posterior (SLAP) labral tear

MOI: traction injury (catching a car), repetitive biceps contraction (overhead), and compressed loading in flex/abd Type 2 most common (40%) common in throwers (may need surgery, 80% pitchers and it's career ending) degenerative if 40+ yoa (no surgery, if bicep involved additional precautions) type 2 and 4 don't stress, cartilage slow heal, biceps can completely tear off

What is thoracic outlet syndrome? (TOS)

Mechanical compression of neural or vascular structures traversing the lower neck into the arm Associated with signs/symptoms of ischemia or neuropathy

Specific test: Join stability and ligamentous integrity

Mild (1st deg), Moderate (2nd deg), and severe (3rd deg)

Joint motion for shoulder objective documentation

PROM in supine (scapula is stabilized) AROM in supine or seated (scap is supported vs unsupported) GH vs shoulder relationship between A vs PROM vs end feel capsular pattern (intra-articular vs extra-articular) reverse capsular pattern "impingement" painful arc Accessory motion: (laxity ms/note, or instability symptoms)

shoulder positions that relieve pain that help identify patho

Pain relieved with the elbow supported is suggestive of A-C separation and rotator cuff tears. Pain relieved by circumduction of the shoulder with an accompanying click or clunk could indicate an internal derangement or subluxation. Pain relieved with arm distraction is suggestive of bursitis or rotator cuff tendinopathy. Pain relieved when the arms are held in a dependent position suggests TOS.

principles of MSK evaluation

Problem Identification (PIP, NPIP) Hypothesis development (HOACC-II): tests and ms challenge or support Underlying cause of problem (cause of s/sx) Rule in/out alternatives based on pt findings and factors determine likely category based on patters of s/sx (remember horse not zebra) CAUTION: settling on dx too early

treatment tactics during repair/proliferation/regeneration stage of healing

ROM exercises (A/AA), jt/soft tissue mob, submax isometrics, ms flexibility, postural education, avoid compensatory movements and don't over load

quality of shoulder pain

Radicular pain tends to be sharp, burning, and radiating. Bone pain is deep, boring, and localized. Muscle pain can be dull, aching, and hard to localize. Tendon pain tends to be hot and burning. Vascular pain can be diffused, aching, and poorly localized and may be referred to other areas of the body. The intensity of pain may wax and wane with particular motions associated with specific activities

what might be a systematic problem associated with the elbow

Rheumatoid arthritis (RA, autoimmune ds) check for hand deformities: ulnar drift, finger abnormalities Osteoarthritis- Heberden's nodes common w/ OA of the hand mostly on DIP and Bouchard's on the PIPs

specific order of LQ screening

STANDING: gross posture (spnal curve, position of PSIS and ASIS), observation of gain, toe walk (L4), heel walk (S1), AROM of lumbar (apply overpressure) SITTING: AROM lumbar rotation (overpressure), reflexes (achilles S1/2 and petellar L3/4) resisted movement :(hip L1-2, knee ext (L3), ankle dorsi (L4), big toe ext (L5). Dermatomes L2-S1, babinski reflex SUPINE: Passive hip flexion, rotation abd, IR, ER, (no problems apply over pressure) passivie knee: flexion/ext (if no pain, overpressure) passive foot: DF,PF, inversion and eversion (no pain overpressure) SLR test (compare sides) PRONE: passive knee flexion w/ hip ext (clear femoral nerve: hip ext and knee flex) resisted knee flexion (S2) compare sides

branching of the median nerve

The median nerve arises from the cubital fossa and passes between the two heads of pronator teres. It then travels between flexor digitorum superficialis and flexor digitorum profundus before emerging between flexor digitorum superficialis and flexor pollicis longus. The unbranched portion of the median nerve (which arises from the cubital fossa) innervates muscles of superficial and intermediate groups of the anterior(flexor) compartment except flexor carpi ulnaris. The median nerve does give off two branches as it courses through the forearm: The anterior interosseous branch courses with the anterior interosseous artery and innervates all the muscles of the deep group of the anterior compartment of the forearm except the medial (ulnar half,which is supplied by ulnar nerve) half of flexor digitorum profundus and flexor carpi ulnaris muscle. It ends with its innervation of pronator quadratus. The palmar cutaneous branch of the median nerve arises at the distal part of the forearm. It supplies sensory innervation to the lateral aspect of the skin of the palm (but not the digits). Hand The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there it sends off several branches: 1. Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called "the million dollar nerve").Here it provides motor innervation to opponens pollicis, abductor pollicis brevis and superficial part of flexor pollicis brevis. 2. Digital cutaneous branches to common palmar digital branch and proper palmar digital branch of the median nerve which supply the: a) lateral (radial) three and a half digits on the palmar side b) dorsum of the tips of index, middle and thumb 3. The median nerve supplies motor innervation to the first and second Lumbricals of the hand.

Other AC joint injuries Types

Type I lig stretched Type II partial rupture of AC lig Type III complete rupture of AC and CC lig Type IV clavicle displaces posterior/over acromion (surgery) Type V clavicle displaced but still under skin (surgery) Type VI clavicle underneath coracoid (very rare) (surgery) ORIF surgery (open reduction and internal fixation)

inflammation

a localized response to an injury or to the destruction of tissues complex and multi-staged process predictable, but phases overlap, acute is necessary but chronic is hazardous treatable, impressionable influenced by many intrinsic and extrinsic factors disagreement on intervention of inflammatory response

what is the carrying angle of the elbow

between 10-15 degrees men tend to be closer to 10 deg. women tend to be closer to 15+ deg. >15 deg. cubitus valgus <5-10 deg. cubitus varus ("Gunstock deformity")

posterior interosseous nerve syndrome (PINS)

a neuropathic compression of the posterior interosseous nerve where it passes through the radial tunnel. Innervates most of the wrist extensors: Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Supinator muscle Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis

promote and progress healing (intervention principle)

adjust all management to stage of healing criteria to advance plan of care (if pain is adequately under control, tissue is healed, ROM restored tolerance for strengthening (vs specific timeline)) can educate to help them progress on their own, and spread out visits

what is the job of the RC?

dynamic stabilizer of the GH joint, reduces stress on ligaments compresses the humeral head into the glenoid 60% restraint is restive 40% restraint is static

MSK assess: Quantity

amount of motion present, hypermobility, hypomobility, normal/ideal

dyskinesis

an alteration in the normal position or motion of the scapula during coupled scapulohumeral movements ex. of dyanmic assessment https://www.youtube.com/watch?v=mm0MlTE4ziI

dermatomes

an area of the skin supplied by nerves from a single spinal root

labral tears w/ instability true for young not old

anterior/inferior: commonly occur w/ instability (88-100%) Posterior: commonly occurs w/ instability Superior (SLAP): under 40 commonly occurs w/ instability, over 40 more degenerative

passive articular motion tests of the radiohumeral joint

anterior/posterior glide distraction

Analyze and Integrate Entire Kinetic Chain (Major principle of intervention)

any one area is part of larger, interconnected chain regional interdependence to gain optimal control of one area you must have motor control of entire chain Use OKC -> CKC continuum

why sensory test

assesses the integrity and intactness of cortical sensory processing, performed throughout the dermatomal areas Tests: 1. light tough (Dc-ML tract) which is also vibration, conscious proprioception, and 2 pt discrimination 2. pinprick (pain- detected by the lateral spinothalamic tract) also temperature extremes, and crude touch

pathology of shoulder instability

bankart lesion- avulsion of labrum from glenoid bony bankart- avulsion of labrum that pulls of a piece of glenoid hill-sachs- posterior humeral head compression fx watch for neurovascular bundle injury suspect RC w/ dilocations over 40 (despite episode of instability, concern is stiffness) common to have numbness and tingling w/ dislocation impacted bone damage don't tend to heal, bone stays dented

shoulder pathology and imaging

bilateral MRI findings in individuals w/ unilateral shoulder pain: 100% subjects had pathoanatomical alterations in both shoulders 97% subjects had tendinopathy in both shoulders partial cuff tear in 37% of symptomatic shoulders, 31% asymptomatic shoulders 61% symptomatic had bursitis, 75% asymptomatic had bursitis 83% symptomatic had AC joint degenerative findings 86% asymptomatic had AC degenerative findings

random fnx shoulder tests

biomechanical fnx, basic fnx, one-arm hop test (athlete return to play), shoulder outcome scale, UCLA shoulder scale, simple shoulder test shoulder pain and dynamic index PENN shoulder score patient-specific fnx scale

ruptured biceps tendon

can occur at either attachment pt shows up as a palpable mass in the shoulder or elbow mechanism of injury varies: elderly- degenerative change athletic injury- wt lifting or throwing (especially in younger pt) trauma at any age usually associated w/ "pop" sound

tx of adhesive capsulitis

can take 1-2 years to resolve early stage <3 mo: mild diffuse pain, slight loss of motion, mimics SAP Freezing 3-9 mo: pain and loss of motion, PT ineffective Frozen 9-15 mo: pain reduced, loss of motion halts, PT can be effective Thawing: motion restores, PT very effective

possible disorders and causes of lateral elbow pain

capitellum fracture cervical radiculopathy (referred pain) lateral epicondylitis lateral collateral injury synovitis osteochondral degenerative changes osteochondritis disseicans (Panner's ds) Posterior interosseous nerve syndrome (PINS) radial head fracture radial tunnel syndrome

What is adhesive capsulitis?

capsular pattern, w/ unexplained significant pain and loss of motion (can't intervene early, pain will go away) difficult to dx early as it mimics SAP MRI can spot ds process unknown etiology unknown pathophysiology (inflammation and resultant fibrosis) 70% females, 40+ yoa, diabetics traumatic or atraumatic the synovium is red, inflamed and extremely painful -> loss of motion->stiffness

median nerve entrapment can lead to what common neuropatholgies (3)

carpal tunnel syndrome pronator syndrome (sensory) AIN syndrome (motor) - anterior interosseus syndrome nerve arises from the cubital fossa and passes between the two heads of the pronator teres then travels to flexors -branch is the anterior interosseous innervating deep ms (ex. digitorum profundus and pronator quadratus) -branch: plamar cutaneous

three likely causes of shoulder complex dysfunction (assuming systemic or serious causes ruled out)

compromised passive restraint component of shoulder girdle compromies nms system's production or control of sho girdle motion compromised 1+ neighboring jnts (AC, SC, scapulothoracic, lower cervical spine)

isotonic contraction

concentric muscle shortens because muscle tension exceeds load

none/low physical stress/demand on tissues leads to

cell death, cells need stimulation to stay alive

extreme physical stress/demand on tissues leads to

cell death, cells stressed to the point of no longer being able to repair themselves

shoulder pain due to referred pain source

cervical (radiculopathy) thoracic outlet vascular (angina, mi) pulmonary cancer (bone, lung, breast) GI (spleen, diaphragm, gallbladder)

most common causes of numbness in the shoulder and arm are due to

cervical or upper thoracic involvement, with either the segmental roots involved or the brachial plexus. The patient should be questioned about recent changes in work requirements or environment, and the presence of neck pain.

Impairment level outcome measures

change in joitn A/PROM: goni/inclinometer, ms force production: MMT, dynamometry, instrument pain: intensity: VAS, numerical, facial expression scale pain: location: change in area sensation: body diagram area affected, modality lost/present, semmes weinstein filaments coordination: activity specific assessment via #, speed, quality, etc

Anterior interosseus nerve syndrome (AINS) (elbow)

characterized by complete or partial loss of motor function of the ms innervated by the AIN (motor branch of the median nerve in the forearm)

shoulder palpation for objective documentation

check major joitns and soft tissue strcutures" pain/tenderness diffuse tenderness and tender/trigger pts abnormal texture/tone (ms bulk) abnormal structure/alignment can be use to assess tx response and guide tx (ex. pain present XX, 4 wk later, no pain at XX)

main subjective criteria to cover

chief complaint impairment/fnx/disability pain: (location, quality, duration, affect, intensity/irritability, paint hs, aggravating/alleviating factors, pt goals, P1-3)

shoulder patho and age significance

children/adolescents: epiphysitis of humerus or osteogenic sarcoma 20-40 yoa calcific depositions 30+ chondrosarcomas 40-50 yoa RC degeneration 45-60 yoa frozen shoulder, assoc w/ medical condition: DM, ischemic heart ds

what are the AROM of UQ cervical screening

chin tuck, extension lateral bend ear to shoulder rotation (overpresure, hand on temples open palm above ears)

shoulder instability dx

clinical (boxy), or radiograph

severe (3rd deg) jnt stability and ligamentous integrity

complete disruption of ligamention which can occur at its boney attachment or within the substance of the ligament

double crush syndrome

compression of a nerve at proximal site, that causes reduction of nerve conduction at distal compression site sometimes associated with TOS (thoracic outlet syndrome)

pronator (teres) syndrome PTS

compression of the median nerve in the forearm that results in predominantly sensory alteration in the median nerve distribution of the hand and palmar cutaneous distribution of the thenar eminence

scapular pivoter ms

comprise the trapezius, serratus anterior, levator scapulae, rhomboid major, and rhomboid minor scapulothoracic articulation

radiohumeral jnt closed packed position

elbow 90 flexion supinated 5 deg.

cubital tunnel syndrome

condition that involves pressure or stretching of the ulnar nerve (funny bone), which can cause numbness or tinging in the ring and small fingers, pain in the forearm, and/or weakness in the hand can be caused by direct pressure on the nerve, stretching of the nerve or frequency snapping of the nerve over the bone

full thickness cuff tear tests using special tests

confirm FT-RCT: painful arc, ERRT (pain/weak), ER lag (sup/infraspinatus), IR lag and lift off (subscap), drop arm, atrophy of infraspinatus, and belly off (subscap) rule out FT-RCT: ERRT (pain weakness), IR lag and lift off (subscap), empty can, and full can combine tests ???

diagnosing subacromial pain- systems reviews

confirm subacromial pain: single tests: painful arc, resisted ER (ERRT) pain or weakness, full can, and drop arm Rule out subacromial pain: single tests: painful arm, resisted ER (ERRT)- pain or weakness, hawkins, neer, full can, empty/jobe can Combo tests: 3/3 tests: hawkins, painful arc, resisted ER (pain/weakness) 3/5 tests: hawkins, neer, painful arc, empty can, resisted ER

DC-ML (dorsla column- medla lemniscal tract)

conscious proprioception sensory tract and somatosensory tract: light touch, vibration, postiion sense/proprioception, kinesthesis (movement sense) and stereognosis

what are MAJOR intervention principles?

control pain and inflammation correct posture and movement impairments increase flexibility and strength of ms analyze and integrate the entire kinetic chain incorporate nms re-education improve fnx outcome promote and progress healing maintain/improve overall fitness teach pt/family self-management (many of these go hand-in-hand, never treat in isolation, check other movements, Progress!)

what might be injured in the elbow if the chief complaint is the point of the elbow?

could be olecranon bursitis

what is gunstock deformity

cubitus varus <5-10 deg. of carrying angle of the elbow

tissue healing in the elderly

decreased tissue healing due to quality of the tissue, decreased proteoglycans, and elastin content

low physical stress/demand on tissues leads to

decreased tolerance to stress (atrophy, or deconditioning)

impact of ds/weakness/trauma on tissue physiological resistance/fitness

decreases tolerance to stress

humeral positioner ms

deltoid (C5-6), originates from the lateral third of the clavicle, the superior surface of the acromion, and the spine of the scapula (Fig. 16-13). It inserts into the deltoid tuberosity of the humerus. position the humerus in space

Evaluation/interpretation of exam findings

develop working hypothesis or dx (to direct PT management), use pattern recognition, interpret data (different conclusions), concept of differential dx, develop prognosis (duration), and plan of care (POC) (may document mutliple hypothesis with sufficient reasoning for either)

barriers to RC tear research

difficult to study the shoulder -black box -most mobile joint of the body (complex biomechanically, and difficult to model) Inconsistent inclusion/exclusion criteria -tendinopathy-> full thickness tear -prevalence of asymptomatic pathology

most common elbow injuries in children

dislocation of the radial head child complains of pain and can't supinate their forearm

unidirectional shoulder instability

dislocation or subluxation 90% anterior or ant/inf typically young males, collision sports (societal difference) FOOSH, high 5 position, and horizontal abduction dx: clinical or radiographs (boxy, looks like result of sulcus))

paralysis or weakness of the serratus anterior muscle results in

disruption of normal shoulder kinesiology. slight disability with partial paralysis profound disability with complete paralysis. As a rule, persons with complete or marked paralysis cannot elevate the arms above 110 degrees of abduction

repetitive hyperextension followed by pronation (high 5 position) of the elbow can affect what tissue

distal biceps lacertus fibrosus in the cubtial fossa

elbow joint capsule

does not respond well to injury forms thick scar tissue prone to flexion contractures % loss of extension as it relates to degree of flexion conracture

toe the line of tx

don't over challenge or under challenge the ms Soreness rules

common shoulder stiffness AROM tx

don't promote poor movement gravity assisted -> gravity minimized -> against gravity ex. shoulder flexion (prone> sidelying> standing flexion) -can also use adjustable table

dermatome L5

dorsal foot, 1st and 2nd metatarsal interspace

secondary "impingement" sub-acromial pain/cuff tendinopathy

due to: lack of laxity (caused by repeated microtrauma-> leads to loss of control) ms imbalances capsular/soft tissue imbalances poor scaplohumeral rhythms want to restore "normal" kinematics

Defensible documentation and MSK management?

every not includes pt education ...... ....\ ....

treat inorder to restore function

every treatment is selected to target specific impairments that have been objectively identified during the examination the impairment must be linked to functional/measurable goals (ex. physician gives prescription for specific documentation, so do we)

ex of a specific test: specific syndrome

ex. thoracic outlet syndrome

infants/children and MSK

exam through play activities and discussion with family (ex. how to test sensation or ROM in very young child)

extensor carpi radialis longus A OIN

extends and ABducts hand O: humerus/ lateral I: 2nd MC N: Radial n.

what ms are involved in lateral epicondylitis?

extensor carpi radialis longus (radial n.) extensor carpi radialis brevis (radial n.) extensor digitorum (radial n.) extensor digiti minimi (radial n.) extensor carpi ulnaris (radial n.) compression or damage to lower brachial plexus results in krumpke palsy

importance of the external rotation during humeral elevation can be demonstrated clinically

f the humerus is held in full IR, only about 60 degrees of G-H abduction is passively possible before the greater tuberosity impinges against the coracoacromial arch and blocks further abduction. This helps explain why individuals with marked IR contractures cannot abduct fully, but can elevate the arm in the sagittal plane.

flexor carpi radialis A OIN

flexs and abducts hand O: medial epicondyle I: 2nd metacarpal M: median n.

relationships between pain, impairments, functional changes

focus of PT: ICF model (International Classificiation of Functioning, Disability, and Health- ICF) -sometimes tissue is not the issue, return to best function

shoulder examination

focused, systematic, and thorough observation: gait, posture, static scapula position Palpation: anterior/superior, lateral, posterior, inferior A/PROM: elevation, extension, rotation, horizontal add, examin dynamic scap position Resistive tests examin movement patterns: Serratus Anterior, shoulder Abd, Fnx tests (ROM) Ms length tests passive accessory motion tests and scapulothoracic, SC special tests (including stability and apprehension, subl/relocation)

clinical use of accessory motions determine:

hypomobility (restricted, abnormal end feel, pain) hypermobility (excessive, abnormal endfeel, pain) clinical instability (unstable disrupts osseous and ligamentous structure of joint- > loss of fnx. specific jnt stability tests are used to detect this.

causes of shoulder stiffness

immobilization lack of movement (pain or fear avoidance) poor pt compliance synovitis surgery CRPS (RSD)

occupation and elbow injuries

important to know the physical demands of the job what kinds of equipment is being used (ex. construction equipment requires high force high reps of the UE)

most common chief complaints of the shoulder

include pain, instability, stiffness, deformity, locking, and swelling.sometimes complain of catching, clunking, grinding, or popping of the shoulder with various movements. (maybe asymptomatic and nonpatho, BUT may indicate labral disorder, RC tear, snapping scapula, bursitis, biceps tendon disorder (sound/sensation painful))

sx of too much overload

increased pain that does not resolve in 12 hrs pain that is increased over previous session or comes on earlier in exercise session (maybe warm up longer) increased swelling, warmth, redness in injury area decreased ability to use body during movement involving injured region Red flags: red, swollen which is acute inflammation, back off

general health screening for specific types of inflammation specific to the elbow

infective arthritis (need injection marks at elbow) cellulitis CRPS

exercise selection for the shoulder

infinite number of ways to get a pt from point A to B correct tx is one that gets the pt better (tip: get really good at the basics) pre-req is strength in order to build up load tolerance based on the exam findings knowledge of anatomy/movement awareness of surgical procedure understanding of biomechanics understanding of pathophysiology use the best combo of evidence/clinical standards: CPGs and PTNow

what are the three stages of tissue healing?

inflammatory Repair/proliferation/regeneration remodeling/consolidation

Examination tests and measures: observations

informal (prior/during hx), more formal (inspect, palpate, test), general to specific overview, gait/fnx movement, posture/position, skin/nails/scars (color, wounds, sn of infection), Quality/ease/difficulty of movements; guarding, compensations, use of assistive devices,. Movement, posture, ROM (acitve, passive, end-feel), MMT (strength, pain provocation), and special tests

inflammation and pain cycle

injury/pain/spasm/atrophy/weakness lead to inflammation -> pressure -> pain

Physical exam of UQ/LQ screen includes

inpsection, palpation and function inspection: posture/orientation, gaitn, skin status, quality of mvt (ribs and spine) Palpation: skin/fascia, ms/tendon, ligament, capsule/bursae, bone Function: joint ROM, mm performance, mm length, neuro status sensorimotor control, and special tests (impairment, standardized, functional)

main categories does an objective exam address

inspection/observation, palpation, and function

shoulder posterior apprehension

instability test of the shoulder hand supinated, hand under posterior shoulder (prevent dislocation), 90 scaption provide gentle posterior load while moving into horizontal adduction Positive: if apprehensive Interpretation: posterior shoulder instability (previous dislocation/sublexation)

cubital fossa

is an area of transition between the anatomical arm and the forearm. It is located as a depression on the anterior surface of the elbow

Clinical Decision making (CDM)

is not a one-time event, it's on-going, circular process ex. PCMM: examination> eval> dx> prognosis> intervention> outcome>

load and shift test

labral test seated or supine grasp humeral head, compress and move anterior/posterior Positive: deep symptoms reproduced Interpretation: possible anterior or posterior labral involvement clicking means nothing unless it's symptomatic

clinical characteristics of repair/proliferation/regeneration stage of the healing process?

less warmth, edema, tender palpation, pain felt concurrently w/ tissue stretch

Accessory motion testing (translations)

limitations in biomechanical research: jt capsule is a balloon (can't just stretch one side) choose direction based on biomechanics first -determine if it contributes to loss of motion (whole PURPOSE) -jnt hypomobility w/out ROM impairment does not need to be tx -assess, tx, re-assess to make sure your accessory motion contributes to ROM only occurs passivley (can not be consciously done by ms movement)

how do elbow flexion contractures affect daily life?

limits extension limits ability of people to reach forward

labral tests of the shoulder (4)

load and shift o'brien biceps load II Kim

potential sources of shoulder pain

local: GHj, Scapulothoracic j, AC jt, sternoclavicular jnt Referred: cervical (radiculopathy), thoracic outlet, vascular (angina, MI), pulmonary, cancer (bone, lung, breast), and GI (splee, diaphragm, gallbadder)

mild (1st deg) jnt stability and ligamentous integrity

localized tenderness and swelling over site of injury; some fibers are torn but NO demonstrable loss clinically or functionally of the integrity of the ligament

chronic inflammation

long onset and duration sub-acute is ~1mo chronic is months-years repeated microtrauma, overuse, abuse, tissue degeneration if inflammation persists longer than the severity of the injury would dictatate

moderat (2nd deg) jnt stability and ligamentous integrity

many but not all of the fibers are torn; clinical evidence of joint instability but stress testing does not demonstrate complete functional loss of integrity of ligament

Adolescene and MSK

may be harder to engage (meh, shrugs)

shoulder impingement of the sub-acromial structures

mislabeled as pinching between the acromion and great tuberosity of the humerus limited evidence on compression mechanism (SA isn't even in the space during most compressed position) perpetuates flawed mechanism and therefore flawed tx decisions multiple trials have found acromioplasty (shaving acromion down) did not prevent tears or reduce pain

what do Clinical Practice guidelines (CPG) include for evaluation

mobility impairment movement impairment stiff, loose, painful

Complete paralysis of the trapezius usually causes

moderate to marked difficulty in elevating the arm over the head. The task, however, can usually be completed through full range as long as the serratus anterior remains totally innervated.

Pain with RI

more likely contractile element involved since non-contractile elements are not being stressed (joint is relatively still). Exception, if an inflamed tissue like a bursa lies underneath ms that's contracting, it can cause pain)

sub-acromial pain/cuff tendinopathy

most common reason for shoulder pain (acute or chronic) Key findings: painful arc palpate to differentiate bicep vs cuff no substantial shoulder weakness no instability signs positive SAP tests Common impairements (assess don't assume): minor loss of motion thoracic spine stiffness tight pec minor/posterior shoulder weak scapular ms typically from abrupt overuse

Anterior/Inferior labral tears

most common to occur during dislocation can tear labrum or avulse from glenoid same MOI as anterior dislocation deep anterolateral pain usually hurts more after use as opposed to during (due to inflammation) click doesn't count unless painful or locking (if dislocated, pt likely has a labral tear, no need to perform test, rick< reward, also high change of re-dislocation best to do apprehensive tests)

posterior labral tear

most commonly occur during dilocation reverse bankart same MOI as posterior dislocation (horizontal adducted, w/ posterior force) deep pain, posteriolateral usually hurts more after use than during (due to inflammation) ex. football lineman, baseball/golf swing many ppl are lax posteriorly (when checking be careful of sublex)

shoulder stiffness following surgery

most frequent complaint following surgery limits fnx, but may also lead to early degeneration

typical body tissue healing response and general characteristics

most injuries heal without complications in a predictable series of events Area is red, warm, swollen, and painful, pain is present w/out motion, lasts 48-72 hours and up to 7-10 days pain occurs w/ activity or motion usually lasts 10-6 wks pain occurs after activity, usually lasts 6-12 wks timelines are separate but may overlap they are not absolute

accessory motions

movement in the joitn and surrounding tissue necessary for normal ROM but that cannot be activley performed by the pt

what is the job of the scapula

moves with the humerus to maintain length tension relationships provides a stable base for GH mobility (proximal stability promotes distal mobility)

RC repair and ms tissue

ms tissue quality is a strong predictor of repair failure -degree of atrophy -fatty infiltration long-term outcomes and fxn scores are improved if ms degeneration is at least halted

interpreting RI testing (Dr. Cyriax): weak and painfree

ms/tendon rupture or loss of innervation or disuse

UQ shoulder screen review

neurological status central vs nerve root vs peripheral (cervical vs TOS vs carpal tunnel)

radio carpal (wrist) open packed position

neutral, w/ slight ulnar deviation

SLAP tear for over 40 outcome

no different outcome because it's due to degeneration

Analyzing entire kinetic chain: continuum of open to closed kinetic chain

no jnt translation in dynamic fnx activities (recruit primary and secondary stabilizers) restore activity- or sport specific pattern assess readiness to return to daily activity/fnx/sport

clinical characteristics of remodeling/consolidation stage of tissue healing

no wrmth, edema, slight tender to palpate, tolerates more stretch prior to feeling pain

objective examination of the elbow includes:

observation/inspection/normal fxn position/movement palpation posture: carrying angle/triangle space/triangle sign UQS (UQ screen) ROM MMT Reflexes, dermatomes, myotomes fnx testing accessory motion testing ms length testing

Progression of tx

occurs continuous through re-examination evaluate pt progress by comparing baseline findings to current status: - is fnx improving? -has fnx diminished? -is there no change in fnx? also check in w/ pt, are they tired of the program or bored, are they doing their HEP, is it working for them?

most common elbow injury in 15-20 yoa

osteochondritis dissecans

AC shear test

other special shoulder test in seated, arm at side, compress the clavicle and scapula (use end of clavicle and acromial notch, palm on scapula) Positive: pain over AC Interpretation: AC joint involvement

cross arm test

other special shoulder test in seated, horizontally add arm to opposite shoulder, can add resistance Positive: pain over AC Interpretation: AC join involvement (if acute AC just PROM will cause pain, power lifters and contact athlete may have chronic AC symptoms, place hand on opposite shoulder and resist inferior force on elbow, this increases compression forces and elicit pain in AC joint, pain should be superficial/palpable)

sulcus test

other special shoulder test in seated, inferiority (straight axial) distraction of the shoulder Positive: if 1 finger distraction from sulcus (considered lax), should tighten in ER (present indicated ER rotator involved injury) Interpretation: only measures laxity

what kinds of problems require MSK exam?

pain, functional changes/losses (loss of ability), and impairments (stiff, weakness) (last two go hand in hand)

Chronic Regional Pain Syndrome (CRPS)

pain, swelling, stiffness, vascular changes w/ minor or severe trauma characterized by prolonged or excessive pain and changes in skin color, temp, swelling in affected area chronic (lasting greater than 6 mo) pain condition that most often affects one limb (arm/leg/hand/foot) usually after an injury believed to be caused by damage to, or malfunction of, the peripheral and central nervous system more common in women, it can occur in anyone at any age, peaking at 40 yoa, rare in elderly, very few in children 10 yoa and under, and almost none in children under 5 yoa

clinical characteristics of inflammatory

pain, warmth, tender palpation, swelling, limited ROM from pain/tissue damage, pain B4 end of ROM (empy end feel)

interpreting RI testing (Dr. Cyriax): weak and painful

partial rupture of ms/tendon or acute, inflammatory jnt process or pain induced inhibition due to serious joint/ms lesion

partial tear location classification of RC tears

partial-thickness tears are more common and include lesions a. bursal side b. midsubstance c. articular side d. full-thickness (lesion extending from articular surface through bursal surface)

Drop arm test

passively abduct arm above 90, ask pt to slowly lower their arm back down Positive: unable to eccentrically control lowering Interpretation: rotator cuff tear Good at ruling in and out

improving fnx outcome (intervention principle)

per individual pt needs, and what level of fnx returning to SAID principle consider endurance and power (and strength)

what could locking or catching in the elbow mean

possible a loos body in the elbow lack of full extension w/ pain- synovitis pitcher w/ medial pain- ligament sprain (pop w/ pain) tennis player- ask about change in equipment (grip size, string tension, etc...) duration- acute or chronic inflammation pain location: local or referred

increasing flexibility (major principle of intervention)

post-isometric relaxation techniques (ex. contract-relax) low load, prolonged duration stretching dynamic stretching adjunct modalities/sub max ex. to heat tissue (more compliant) or cool tissue (reduce pain) manual technique (tips use ms length positions, creep, dynamic, INCREASE CORE temp its better than applying heat)

common stiff shoulder dx that may use accessory motion

post-operative care post-immobilization care adhesive capsulitis GHJ OA (is it the same as other side, atypical motion may be their normal!!!) joint mobilization should increase ROM if that's the cause (follow convex-concave)

what falls within inspection/observation of an elbow examination

posture/orientation gait skin status quality of movement ** all compared to unaffected side visualized and expose both arms inspect for scars, deformities, and swelling (lateral epicondyle) note assymmetry, hypertrophy/atrophy, bruising/wasting/ms spasm note carrying angle

dx labral tear

primarily made on hs, as special tests are poor and clinical exam can mimic instability/SAP traditional MRIs are unreliable Need MR arthrogram: MRI + dye injection into joint -dye leaks out-> likely a labral tear Anterior: SN.75, SP.73 Posterior: SN .50, SP .92 SLAP: SN .66 SP.82

Injury Process

primary injury, secondary injury

what is AROM and seelctive soft tissue tension testing

pt is activating contractile elements to move joint, stressing non-contractile elements because joint is being moved. Pain indicates contractive or non-contractile elements involved (can't distinguish becuase both are being tested)

Resistive isometric (RI)

pt is stressing/activating contractile elements to produce the requested contraction. NOT stressing non-contractile elements particularly since joint stays relativley still.

correcting posture and movement impairments if related to pt problem (major intervention principle)

pt learns to prevent habitual tissue abuse posture education and problem-solving: establish optimal static and dynamic postural patterns to protect joint/soft tissue (ergonomic suggestions, static, and dynamic habit patterns) pt awareness of movement, help them understand why movement hurts (ex. joint swelling), what escalates/decreases pain, teaching about open packed positions

Standardized fnx outcome measures

pt reported outcome ms: ex. Oswestry Disability Index (ODI) Disability Index for Shoulder Hand (DASH) LE functional scale (LEFS) pt-performed outcome measures: ex. 30s sit to stand 2 in walk test single limb hop apta.org/outcomemeasures/ ptnow.org/tests-measures

shoulder systems review

pt suitable for PT intervention

Shoulder imaging

pt w/ imaging, request both the image and radiologist impression leave the imaging review until after the exam (UNLESS imaging directly impacts exam ex. S/P fracture or ORIF Refer when: suspicious of fracture or dislocation and/or red flags

principles of msk management: intervention

pt/family educations (part of every note) therapeutic exercise (impairment/fnx training, based on pt preferences <- may require creativity ex. car washing) nms re-education manual therapy gait training/therapeutic activities assistive devices/orthoses referral/consultation each has a billing code

Principles of msk management

purpose of utilizing PT, intervention is based on PT's assessment of current problem and timely response and progress toward achieving goals Parameters for intervention (based on SINSS), acuity, age, pt preferences optimizing functional independence (pt instruction, promoting pro-activity)

MUA adhesive capsulitis

put under anesthesia, then move arm to break up tissue extremely painful, especially the more irritated and inflamed the state of the shoulder before hand moving away from this

principles of shoulder post-op tx

race between fixation failure and biologic healing not all tissue is of good quality and not all fixation is rigid, adjustments in protocol are necessary limited by the slowest healing structure procedure- modified rehab (rehab is dependent on surgery) rehab-modified procedure (surgery altered for rehab)

osteoarthritis: stiff shoulder condition

rarely symptomatic if <45 yoa pain and progressive fnxal limitations capsular pattern promote movement without aggravating synovitis Joint replacement: Total shoulder arthroplasty (TSA) if healthy cuff Reverse TSA if cuff is not healthy (picture)

why are the s/sx of inflammation important to clinician?

read the response in order to guide therapeutic intervention timeline, redness, swelling, heat, pain, loss of fnx should note intervention based on initial inflamation prior to applying intervention

UE proprioceptive and NM control exercises

rhythmic stabilization (sense protibation and respond w/ co-contraction) PNF (proprioceptive nms facilitation) ball on wall (ex. ABCs on yoga ball) rebound ball toss closed-chain body blade

shoulder protector ms

rotator cuff ms (supraspinatus, infraspinatus, teres minor, and subscapularis) long head of the biceps brachii (weak shoulder flexor, humeral head depresion, anterior/post stabilizer, limits ER, lifts labrum, compressor of the GH jnt) fine tune humeral head position during arm elevation (no fixed axis in the shoulder)

objective portion of a shoulder exam should include

scapula/clavicle, humerus, skin (distal too), and posture movement screen (joint motion) palpation UQ screen strength evidence suggests erect thoracic kyphosis associated with improved shoulder flexion and abduction ROM, not enough specific methodology evidence to suggest thoracic kyphosis rehab is associated with shoulder pain

overall assessment of scapula

scapular dyskinesis is normal resting position doesn't matter movement symmetry (may vary in overhead athletes) evidence is limited by our lack of ability to define clinical scapular dyskinesis use of scapular assistance and re-position tests to help in CDM Assess static position and dynamic position

assessing the scapula, what should we do?

scapular dyskinesis is normal resting position probably doesn't matter movement symmetry (may not be symmetrical in overhead athletes) evidence is limited by ability to define scapular dyskinesis use scapular assistance and reposition test to help in CDM

repositions scapular test

scapular test pt standing, lifts arm into scaption (document pain), pull scap into posterior tilt and retraction, have pt repeat test Positive: if tilt decreases pain Interpretation: scapular dyskinesis may contribute to pain

Assistance scapular test

scapular tests pt standing lifts arm into scaption (document pain), cue scapula into upward rotation as pt repeats test Positive: if position decreases pain Interpretation: scapular dyskinesis may contribute to pain

spinal thalamic tract

sensory tract that detecs light touch and pressure

lateral spinal thalamic tract

sensory tract that detects pain and extreme temperatures

sub-acromial decompression

shave off undersurface of acromion/coracoacromial arch to increase sub-acromial space doesn't prevent RCD progression doesn't show improved outcomes over rehab alone or compared to placebo despite evidence, it's still a commonly performed surgery

acute inflammation

short onset and duration 0-14 days visible, palpable, but more obvious to pt change in hemodynamics and cellular fnx pro-inflammatory vs anti-inflammatory factors ex. ecamosis (internal bleeding), fusion w/in capsule, and edema escaping

shoulder relocation

shoulder instability test during anterior apprehension (hand supinated), provide posterior force (pushing shoulder posteriorly) Positive: if still apprehensive Interpretation: if anterior symptoms go away shoulder is instability

example exercise that has the least contribution of the upper traps (UT) compared to activation of other shoulder ms (MT, LT, and SA)

sidelying catching exercise

Clinical decision making paradigm

stiff vs loose vs painful vs combination. Limitation in motion (quantity: deg/ROM, and quality: end feel), where is the limitation capsular patter or noncapusular, what is the most painful test?

incorporate nms red-education (principle of intervention)

stimulate afferent to get dynamic jnt control and enhance motor responses start early in rehab stage (if safe) proprioceptive training sequence

what is the strengthening exercise hierarchy?

single-angle, submax isometric in neutral > multiple angle max iso> small arc submax isotonics> fnx ROM submax isotonics

what falls within palpation of an elbow exam

skin/fascia ms/tendon ligament capsule/bursae bone **compared to unaffected side

LQ/UQ screen palpation

skin/fascia, ms/tendon, ligament, capsule/bursae, bone

IP open packed position

slight flexion

MCP open packed position

slight flexion

Soreness rules

soreness during warm-up that continues - 2 days off, drop down 1 level soreness during warm-up that goes away- stay at level that led to soreness soreness during warm-up that goes away but redevelops during session - 2 days off drop down 1 level soreness the day after lifting (not ms soreness)- 1 day off, no advancement in program no soreness- advance 1 level per wk or as instructed

passive articular motion tests of the ulnarhumeral joint

stabilize the humerus distraction/ compression medial/lateral glide (can grab the olecranon for easier motion)

static scapular assessment position

static asymmetry is normal need to establish a starting position, what is there position? elevated/depressed, anterior/posterior tilt, protracted/retracted, upward/downward rotation ex. winging (medial border)

proprioceptive training sequence

static stabilization via wt shifts or alternating resistance (perturbation, balance board, swiss ball, etc) double limb to single limb progressively increase required functional range dynamic stabilization exercsies (intro of ballistic/impact ex. narrow BOS; change WB surface from hard>soft>uneven) can use distractions, asking about their day

trigger finger

stenosing tenosynovitis, condition in which one of your fingers gets stuck in flexed position may straighten with a snap occurs when inflammation narrows the space within the sheath that surrounds the tendon in the affected finger if severe may become locked in the flexed position more common in women or diabetics

Step 2: catch it early

steps for working with shoulder stiffness post-injury/surgery "oucne of prevention-= pound of cure" early recognition of pt prone to stiffness or becoming stiff -> more likely success of intervention post-op contact surgeon to develop a plan ms frequently for objective tracking!!!

step 3: motion is lotion

steps for working with shoulder stiffness post-injury/surgery early active and passive motion movement -> cycling of synovial fluid -> lubrication/joint nutrition Caution: Do within surgical precautions/restrictions

steps for tx a stiff shoulder post injury/operation (6)

steps for working with shoulder stiffness post-injury/surgery step 1: trust Step 2: catch it early step 3: motion is lotion step 4: length step 5: toe the line

Step 4: length

steps for working with shoulder stiffness post-injury/surgery use our knowlege of tissue biomechanics to determine hold/tx duration creep occurs in most tissues after 2 min (cumulatively exceed 2 min) low load long duration most effective

step 6: back of tricks

steps for working with shoulder stiffness post-injury/surgery use thermal modalities before/during tx (raising core temp better) IFC during tx (interferential current) PNF contract relax (proprioceptive neural facilitation set aside pride, whatever gets pt moving HEP imperative to keep motion gained know when to slow down, speed up, or call for help

shoulder exam palpation

sternoclavicular jnt, clavicle, acromioclavicular jnt, acromion, bicipital groove/LHB, coracoid, subscap tendon, supraspinatus tendon, and infraspinatus tendon

adhesive capsulitis CPG (guidelines) reccommendations

translational manipulation (under anesthesia- WEAK) corticosteroid injection (w/ shoulder mob and stretching, short-term pain relief -STRONG) pt education (encourage fnx, pain-free ROM, match stretch intensity- Moderate) modalities (tech to reduce pain and improve ROM-WEAK) jnt mobilization (reduce pain, increase motion-WEAK) stretching exercises (stretch as tolerated- Moderate)

loose shoulder conditions

traumatic instability (TUBS) multi-directional instability (AMBRI) labral tears (boxy appearance of the shoulder))

dermatome T10

umbilicus

principles of tx a loose shoulder

use scientific research tx impairments to restore fnx assess and address the kinetic chian don't just tx symptoms/tx source exercise selection sets and reps toes the line (no over or under challenge ms) strength and control shoulder instability macro or micro trauma Phase: protection, intermediate, late UE proprioceptive and NM control exercise scap exercises

greatest activation of the subscapularis

with the arm in the scapular plane at 90 degrees of elevation and neutral humeral rotation (thumb up) effective humeral head depressor

what are the main principles of msk evaluation

working dx (movement system dx) prognosis goals (outcomes) plan

is elbow hyperextension normal

yes, as long as it's asymptomatic

what does age have to do with types of elbow injuries?

young children- dislocation of the head of the radius, child complains of pain and can't supinate 15-20 yoa- osteochondritis dissecans >35 yoa- lateral epicondalgia