All Ortho Labs Final

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muscle injury is called a

strain

Subscapularis self-stretch

stretch armpit

Yoga child's pose subscapularis stretch

stretch armpit

Subscapularis Stretches

stretch armpits

Realize that if you progress to testing each muscle with RROM, a person with epicondylitis will most likely have a

strong and painful contraction

RROM of extensor carpi ulnaris

ulnar side

Wrist and finger flexors - note that you can teach the patient how to perform manual therapy on themselves

(MFR along fascial lines, direct TP release, bowstringing, WardGreenman)

PROM: UE Muscle Length /Flexibility Assessment Pectoralis Minor

(acromion to table)

PROM: UE Muscle Length /Flexibility Assessment Latissimis Dorsi, Teres Major, and Rhomboids

(lateral epicondyle to table)

make sure to explain the pain rating

0-10 0 means no pain at all 10 is the worst imaginable pain

the next step after pendulum exercises (helps with impingement) Elevate the arms using the healthy arm to guide the injured arm. Increase the use of the injured arm as directed by comfort. Begin these exercises laying on your back, then progress to sitting and standing. As the person performs this exercise, watch for these common substitutions: Use of upper trapezius/shoulder shrugging (avoid by having the patient perform in front of a mirror). Use of trunk (side-bending and/or extension) to assist with the movement.

Active Assisted / Cane Exercises

enhance posture and also begin to flex the shoulder past 90 degrees, extended child's pose

From the quadruped-rocking-back position, the person could easily move into extended child's pose position, which is a great stretch of the axillary muscles and joint capsule. If the patient experiences a painful arc or any signs of compression/impingement, hold off performing this exercise until ample downward humeral glide is established.

Deviation from Typical: Tipped/tilted scapula: Short muscle(s) Long (potentially weak) muscle(s)

Inferior angle of scapula is lifted off thorax -Scapula does not rest flat against thorax; - coracoid process is closer to thorax/ribs short: pec minor and or biceps brachii long: lower trapezius

The five grades of joint mobilization as described by Maitland: Grade III

Large amplitude sustained or oscillatory movement performed into resistance or up to the limit of the range of joint motion. Used to maintain ROM. -

The course of the median nerve

Lateral and medial roots merge to form median nerve lateral to axillary artery; descends through arm adjacent to brachial artery, with nerve gradually crossing anterior to artery to lie medial to artery in cubital fossa

tests for non-specific impingement of the subacromial bursa, biceps tendon, or supraspinatus tendon.

Neer Impingement Test: Hawkins / Kennedy test for Shoulder Impingement:

Glenohumeral Hypomobility (Adhesive Capsulitis) what is happening with PROM and AROM

PROM = AROM and they are both poor

Deviation from Typical: Thoracic kyphosis: Short muscle(s) Long (potentially weak) muscle(s)

Greater than typical anterior curve of the thoracic spine. short: rectus abdominus long: thoracic extensors

Special Tests for Neural Compression Compression of the ulnar nerve

In the cubital tunnel Froment's sign

Wrist Accessory Motion Testing Side Tilt of the Triquetrum from the Ulna /(aka Stress Test of Ulnar Collateral Ligament of the Wrist) what does it assist with?

Direction of force: Curved Action: Distracting the triquetrum from the ulna, stressing the ulnar collateral ligament Positioning: The proximal hand stabilizes the ulna on the plinth. The distal hand grips the proximal row of carpals. Movement: Apply separation to/gap the ulno-carpal joint. * Assists with restoring (primarily) radial and (some) ulnar deviation.

Deviation from Typical: Adducted scapula: Short muscle(s) Long (potentially weak) muscle(s)

Scapula is closer than 3" to spine-Vertebral border of scapula is less than three inches from midline of thorax/spine short: rhomboids, middle trapezius long: serratus anterior

no pathology to the musculotendinous unit

Strong and painless:

major injury/ full thickness tear of the muscle-tendon (Grade III strain) unit OR the person has a neural deficit (injury to the motor nerve supplying the muscle > correlate with neural testing).

Weak and painless:

strictly pathologic Boggy end-feel:

a soft, "mushy" or "squishy" end-feel that typically accompanies joint effusion

Deep tendon reflexes,

also called muscle stretch reflexes, can triangulate specific spinal nerve involvement. In its simplest form, the quick stretch of the muscle-tendon unit caused by a strike by a reflex hammer stimulates the muscle spindle receptors which stimulates a reflex arc that travels to the spinal cord and back to the muscle, causing it to contract.

avascular necrosis

an area of bone tissue death caused by insufficient blood flow bone has died, when it gets injured the blood supply is weakened/gone, will become soft, less dense, need an x ray, doesnt have good blood supply bones that can do this - colles fracture (distal radius), femoral head, scaphoid

Identify, locate, and palpate the structures commonly involved with medial epicondylitis

flexor carpi radialis palmeris longus flexor carpi ulnaris

95% of all humeral dislocations are ______ and the position of injury is:

anterior falling back on hand abduction, external rotation (FOOSH)

Wrist Extensor Stretch

flex hand and fingers

capsular pattern Elbow/humeroulnar joint:

flexion is most limited, followed by extension

impingement posture

forward head rounded shoulders

sleep position If the legs are not stacked (ie, instead of one leg being atop the other, one leg is forward of the other), this will likely cause a

forward rotation (torsion) of the pelvis, and shortening of muscles such as the TFL

a biomechanical analysis of elevation is an important element of the physical examination for someone with suspected _______________

impingement

my right shoulder hurt

impingement labral tear rotator cuff frozen shoulder hypermobility

Pain and/or weakness with the Empty can test implicates

impingement of the supraspinatus and/or the subacromial bursa:

Strength Assessment. Weakness in key muscle synergies necessary for normal elevation of the upper extremity can contribute to __________

impingement.

Typically both fractures and Grade II and Grade III sprains require

immobilization whether by splinting or casting, typically for the length of time that it takes for them to heal. Physical therapy during this time is likely related to minimizing swelling and maintaining ROM at the other joints.

Wrist and long finger flexors

extend hand and fingers

Triceps stretch

extension and medial rotation

Clinicians grade the degree of pitting edema using the 1+ through 4+ scale below, based on the approximate number of seconds it takes for the pit to refill:

1+ barely detectable 2+ <15 seconds to refill 3+ 15-30 seconds to refill 4+ > 30 sec to refill

Take a few minutes to practice exercises/activities to improve posture, which helps to address the TOS:

Achieve axial extension, thoracic extension, and scapular adduction via the verbal and physical cueing Practice teaching exercises that "un-round" the shoulders:

Special Tests for Neural Compression Compression of the median nerve

By the Pronator Teres At the carpal tunnel Abductor pollicis brevis weakness Square-shaped wrist

ligament

Connects bone to bone

Contraindications for joint mobilization:

Hypermobility Malignancy Fracture - recent or unhealed Joint ankyloses (fusion) Active joint inflammation

Additional UE motions that you will assess: 1. 2. 3.

Make a fist with pronation and supination (forearm and hand motions) Flex/extend wrist, ulnar/radial deviation (wrist motions) Pinches: -tip pinch -key pinch -tripod/chuck pinch

The course of the ulnar nerve

Penetrates the medial intermuscular septum in the arm before passing in close relation to the medial epicondyle of the humerus (funny bone)

Ligamentous Stress Testing for wrist

Wrist radial collateral ligament stress test Wrist ulnar collateral ligament stress test

End-feels that may be normal or pathologic:

bony capsular/ligamentous ssoft-tissue approximation elastic/muscular

manual therapy of Pronator teres

bowstring or along fascial lines

A dermatome is the area of

cutaneous sensation associated with a specific spinal nerve root.

labral tear

damage to the glenoid labrum -painful clicks the labrum holds the ball of the ball and socket

bow-stringing: This technique can be incorporated into general massage, and if used with greater force and highly focused, becomes a ______________________

friction massage.

inferior humeral glide is associated with restoring

glenohumeral abduction,

how are sprains graded?

laxity and pain

Keep in mind that many people with impingement have weak _______ and _________ muscles and an over-active upper trapezius. This will be very apparent if they shrug their shoulders while performing an elevation activity/exercise.

middle and lower trapezius

median, ulnar, and radial nerves

nerves in the brachial plexus that supply the forearm, hand, and fingers

Example of bowstringing the extensor muscles at the lateral epicondyle using your thumbs.

photo - going perpendicular to muscle fibers

lateral epicondylitis: notes

pain in lateral epicondyle repetitive - gripping, extension of wrist, keyboard wrist extension extensor carpi radialis brevis extensor digitorum extensor carpi ulnaris palpate it will hurt tennis elbow

pain in forearm and hand

pronator teres neural entrapment

treating carpel tunnel syndrome notes

remove MOI - desk pad, wear wrist brace during sleep, antivibration gloves, good erogonomics 90-90-90 -aggravated with flexion or extension

RROM:

resistive range of motion Assessing the musculotendinous unit for injury Manual Muscle Testing (MMT): Assessing Muscle Strength

Infraspinatus and teres minor muscles:

rotate arm laterally external rot and abduction ex rot side lying ex rot side lying with weight ex rot prone with weight throw ball at trampoline

Boutonniere Deformity

split of the extensor mechanism that slips over the PIP joint producing a tell-tale finger deformity: tear in central slip PIP flexion DIP hyperextension

The end-feel that the therapists palpates helps to identify the _________

structure(s) that are producing the limitation at a joint.

three structures that can be impinged

subacromial bursa long head of biceps tendon supraspinatus tendon

strictly pathologic Empty end-feel:

the examiner feels no restriction to movement, the patient stops the movement due to severe pain.

The Biomechanics of Upper Extremity Elevation "Elevation" refers to any motion where

the upper extremity positions the hand above shoulder level. This could be out to the side (abduction), forward (flexion), in the plane of the scapula (scaption), or some variation of these.

End-feels that are strictly pathologic:

Muscle-spasm end-feel: Boggy end-feel: Springy end-feel: Empty end-feel:

_______________ refers to any motion where the upper extremity positions the hand above shoulder level. This could be out to the side (abduction), forward (flexion), in the plane of the scapula (scaption), or some variation of these. It consists of an elegant interplay of muscle action coupled with accessory joint motions to position the hand in space. Recall that typical elevation for each of these motions is ___________ degrees

"Elevation" 0 - 180

Postural cue:

"Sternum to ceiling, level your head, gently squeeze your shoulder blades together."

Remember a key question to determine the mechanism of injury is ____________________________ Likely these activities could be contributing to the neural compression or entrapment.

"What are you doing when you have your pain?"

consider that optimal postural alignment of the scapula and humerus rely on a ___________ of muscles that have both length and strength:

"balance"

Many of these special tests are __________________ ie, they are designed to reproduce the symptoms of the problem they test. Students should be sure to ask the patient, "Is this the pain that brought you here / caused you to seek PT/OT?"

"provocative,"

Joint Motion with Typical Ranges Scapulothoracic - Glenohumeral Elevation - Flexion () - Abduction () - Scaption/plane of scapula ()

- Flexion (0 - 180) - Abduction (0 - 180) - Scaption/plane of scapula (0 - 180)

Scapula: optimal alignment

- The vertebral border is parallel to the spine and is about 3 inches from the midline of the thorax/spine - It is situated between the second and seventh thoracic vertebrae - It is flat against the thorax and is rotated 30 degrees anterior to the frontal plane.

Practice radial nerve gliding exercise

- nerves are like wet noodles, they glide but they dont stretch position 1: standing with body in relaxed posture position 2: shoulder depression position 3: arm internally rotated and wrist flexed position 4: lateral cervical flexion position 5: wrist flexed and shoulder extended

typical scapular posture >

- the vertebral border is parallel to the spine and is about 3 inches from it - is situated between T2 and T7 - is flat on the thorax and rotated 30° anterior to the frontal plane.

A sampling of exercises or therapeutic activities to lengthen the treated muscle(s) or strengthen its antagonist: Pectoralis Minor Stretches

--these lengthen pec minor -updog -hands behind back -hold for 30 sec -have them take a deep breath at the end

Cubital tunnel compression test:

-of ulnar nerve locate the medial epicondyle of the humerus and slide your finger about a half-inch distal and medial to it. This should put you near the origin of the flexor carpi ulnaris (confirm this by having the person flex and ulnarly deviate the wrist). If needed, move your palpating finger just a bit laterally to the origin of the FCU... you'll be in a slight depression, which is the superficial portion of the cubital tunnel (noted on the image at left with an X). Deeper pressure might cause slight ulnar nerve discomfort.

Bowstringing Technique:

-perpendicular to direction of muscle fibers -nice way to enter -one hand stabilize or stretch -assess, treat, reassess This technique is great for lengthening muscles that have mild to moderate tension, or that have become shortened due to muscle imbalances related to improper posture/movement. Place the patient in a maximally comfortable position, with the muscle relaxed as much as possible. Using the thenar eminence of your hand, or perhaps your thumbs, gently and slowly apply pressure that is perpendicular to the direction of the muscle fibers.

Hoffman - Tinel Sign for the Median Nerve:

-tapping the nerve The therapist evaluates for entrapment/irritation of the median nerve in the carpal tunnel. The therapist holds the patient's relaxed hand, palmar side up. The therapist then taps over the carpal ligament, moving distal to proximal. A positive test is tingling or electric sensations at the tunnel, or in the median nerve distribution of the hand.

The amount of laxity (sulcus sign)is graded on a zero to three scale:

0 = little/no movement 1 = humerus shifts to the edge of the glenoid 2 = humerus shifts over the edge of the glenoid and spontaneously relocates 3 = humerus shifts over the edge of the glenoid, doesn't spontaneously relocate

grading for sulcus sign/feagan test and load and shift test for shoulder instability

Recall the basic rules of thumb for musculoskeletal rehab progression:

1) Perform a comprehensive yet efficient history and physical examination and determine the physical therapy diagnosis/performance problem 2) Begin treatment by addressing pain/inflammation and restoring any lost joint mobility (accessory motions). At the shoulder, this includes stretching the inferior and posterior joint capsule, which often becomes tight due to the "folding" of this part of the joint capsule when the arm is inflamed and held in the dependent position. 3) Improve posture and movement by addressing any scapular and/or humeral impairments a. Gain muscle length b. Gain muscle strength and endurance c. Emphasize strengthening scapular stabilizers first, then glenohumeral muscles 4) Restore reaching synergies / movement re-education a. Ensure glenohumeral disassociation from scapula b. Restore 2:1 glenohumeral to scapulothoracic rhythm c. Exercise progression from AAROM to AROM to RROM 5) Progress to performing activities important to the patient ** Remember that patient education is an important part of each of the above elements

Thoracic Outlet Test for Costoclavicular Syndrome:

1st rib and clavicle The patient is sitting or standing. The therapist continuously palpates the radial pulse on the side being tested. While still palpating the radial pulse, the therapist abducts the arm to 45 degrees and extends the shoulder to 45 degrees, while applying a downward distraction to the upper extremity as the patient actively retracts and depresses the scapula. The patient holds his/her head in neutral (looks straight ahead) then takes a deep breath and holds it for 15 to 30 seconds. A positive test implicates compression by the clavicle or first rib.

UE deep tendon reflexes grading scale what is a normal reflex graded as?

2/4 0/4 no reflex (could indicate a lower motor neuron lesion) 1/4 diminished/sluggish 2/4 brisk/average/normal 3/4 exaggerated/hyper-reflexive 4/4 pathological/clonus (could indicate an upper motor lesion)

*Note that another key element of normal elevation is that from 90 degrees of elevation to 180 degrees, scapular and humeral disassociation must occur (ie, they move independent of each other, yet with a 'scapulo-humeral rhythm'). This should happen at a _______ ratio of glenohumeral to scapulothoracic motion. The remaining glenohumeral accessory motions (GH distraction, posterior glide of the humerus, anterior glide of the humerus, and to a lesser extent medial rotation) contribute to this disassociation.

2:1

Up to 90 degrees of elevation (both abduction and flexion) Disassociation of humeral and scapular motion is apparent and Ratio of glenohumeral to scapulothoracic motion is ________

2:1

After the patient has gotten proficient with cat-cow, you can add the following three exercises, which will help to further enhance posture and also begin to flex the shoulder past _____ degrees, however because the movement occurs in a closed chain, typically the patient will not experience any impingement, but always be alert to this possibility Quadruped-rocking-back exercise: extended child's pose upward facing dog

Part II: Treating Glenohumeral Hypermobility

A key aspect of addressing GH hypermobility is to promote healing/scarring of the injured structures and to try to preserve as much of their joint stabilizing qualities as possible. As such, most patients who have experienced a dislocation will be immobilized for some degree of time- time frames will vary depending if surgery was performed or not At some point, however, you will begin work to start moving the shoulder, while optimizing stability in the process.

glenohumeral dislocations and labral injuries notes

AROM is more than PROM (with hypermobility) -be careful with external rotation load and shift test, PROM, AROM, looking for increased accessory motion, clear joints above and below, MMT, general strength screen special tests - load and shift test, sulcus sign, apprehension tests, jobes

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Medial Tilt (aka Elbow Varus / Lateral Collateral Ligament Stress Test):

Action: Gap the lateral aspect of the elbow. Positioning: Flex the elbow to 20 - 30 degrees and, stabilizing with one hand at the humeral epicondyle and the other above the wrist, apply a varus stress to the elbow. The humerus will tends to internally rotate with this maneuver and requires the therapist to apply and external rotation force with the stabilizing hand. Movement: Varus maneuver.

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Lateral Tilt (aka Elbow Valgus /Medial Collateral Ligament Stress Test):

Action: Gap the medial aspect of the elbow. Positioning: Flex the elbow to 20 - 30 degrees and, stabilizing with one hand at the humeral epicondyle and the other above the wrist, apply a valgus stress to the elbow. The humerus will tend to externally rotate with this maneuver and requires the therapist to apply and internal rotation force with the stabilizing hand. Movement: Valgus maneuver.

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Proximal Shift of Radius on Ulna Direction of force:

Along the shaft of the radius. Action: proximal shift of the radius on the ulna. Positioning: Flex the elbow to 90 degrees and apply pressure through the thenar eminences. The client's wrist should be in approximately 10-15 degrees of wrist extension. Be careful about the forces you impart through their wrist! Movement: Apply a downward force through the shaft of the radius. *Assists in restoring elbow flexion.

y strip for lat/medial epicondylitis

Anchor the base of the "Y" with no tension Pull the ends of the "Y" laterally with about 75 per cent tension Anchor the last ½ inch of the "Y" with no tension Avoid placing wrinkles in the underlying skin as you lay down the tape Trigger points located in center of the Y

0 - 30 degrees of abduction/ 0 -60 degrees of flexion _____________ is the primary flexor

Anterior deltoid

Autonomous zones of the hand:

As indicated earlier in this lab, you can quickly assess the status of the median, ulnar, and radial nerves by examining those regions (autonomous zones) of the hand that are solely innervated by one nerve (ie: there is no sensory overlap). Test light, sharp, and dull sensation of these autonomous zones: Median nerve - volar/palmar tip of index Ulnar nerve- volar/palmar tip of little/fifth finger Radial nerve - dorsal web space of thumb

Ward- Greenman Direct and Indirect Techniques for Myofascial Release intrsuctions

Begin by palpating for areas of fascial restriction (ie: greater tissue tension, resistance to gliding of the tissue, etc.) Typically the therapist's hands are placed symmetrically over the area. The therapist initially applies a slight downward compression force with his/her hands, then, while holding this downward compression, moves the hands away from each other (distraction), stretching the tissue between the hands. Add a slight twisting force and assess which directions cause the tissues to subtly tighten (the combination of these motions is called "engaging the barrier" which is a direct technique). The therapist holds the tension while the patient breathes in and out, slowly and deeply. After a few seconds, the therapist should palpate a relaxation or "release" of the tissue. It may feel as though her/his hands have moved slightly farther apart. The tissue may "reorganize," and become tight in new directions. The therapist simply reintroduces tension (compression, distraction, and twisting) in these new directions and repeats the process. To make this an indirect technique, the therapist may move both hands toward each other, thus moving away from the barrier.

Exercise Progression

Begin thinking about exercise progression, where you move from a less-difficult exercise to a higher-level/morechallenging one that strengthens the same target muscle(s).

Tunnel of Guyon

Between pisiform and hook of hamate distal Ulnar nerve passes through

Lacertus fibrosis

Bicipital aponeurosis. A broad aponeurosis of the biceps brachii which is located in the cubital fossa of the elbow and separates superficial from deep structures in much of the fossa

types of manual therapy techniques we learned -geared toward muscle-facial unit

Bowstringing Myofascial release (MFR) o Direct MFR "trigger point" release o Direct MFR along fascial lines o Ward-Greenman technique Manually stretching muscles as an adjunct to manual therapy Indirect MFR of the shoulder girdle "Courtesy stretch" Exercise prescription as an adjunct to manual therapy

UE Motor Innervation Assessment (Myotomes)

C4 spinal nerve root: shoulder shrug/upper trap C5 spinal nerve root: elbow flexors/ biceps C6 spinal nerve root: wrist extensors/ extensor carpi radialis C7 spinal nerve root: elbow extensors/ triceps C8 spinal nerve root: finger flexors / flexor digitorum T1 spinal nerve root: ad-abduction of fingers/ interosseous muscles

Locate/palpate areas of potential ulnar nerve compression/entrapment:

Cubital tunnel at posterior elbow (usually due to compression such as leaning on a desk - "students elbow"-- via triceps) Triceps hypertrophy Flexor carpi ulnaris (at arcade of froshe) Arcade of Frohse Guyon's canal (between hamate and pisiform; typically related to compression from bicycling/leaning on handlebars)

Glenohumeral Accessory Motion Testing Lateral Rotation of Humerus

Direction of force: Outward/lateral rotation Action: Stretch the anterior-medial portion of the capsule. Positioning: The proximal hand is on the head of humerus or as close as possible (minor adjustments or position of the hand are often necessary for the client's comfort). The distal hand stabilizes the distal humerus. Movement: Rotate the humerus outward; the motion occurs along the long axis of the humerus. *It is typically useful to perform both medial and lateral rotation glides to restore humeral rotation.

Wrist Accessory Motion Testing Ulnar Glide of the Scaphoid what does it assist with?

Direction of force: Toward the ulna / downward Action: Glide the scaphoid in an ulnar direction. Positioning: The proximal hand stabilizes the radius and ulna. The distal hand grips the proximal row of carpals. Movement: Distract the joints, then perform an ulnar/downward glide. *Assists with restoring radial and (mostly) ulnar deviation.

Ligamentous Stress Testing for elbow

Elbow medial collateral ligament/valgus stress test Elbow lateral collateral ligament/varus stress test Annular ligament stress test (nursemaid's elbow test)

capsular pattern Elbow/humeroulnar joint: Elbow/humeroradial joint:

Elbow/humeroulnar joint: flexion is most limited, followed by extension Elbow/humeroradial joint: equal loss of pronation and supination

treating TOS

Finally, assess any activities that may be re-enforcing poor posture and work with the patient to recognize and self-correct those postures (beginning with taping for postural correction can help provide those cues when the patient is alone.

Njoo (1994) showed that therapists can, while being mindful of not causing too much discomfort, reliably locate trigger points by:

Finding a palpable tender spot in the muscle Reproducing the person's pain with pressure Observing a jump sign characterized by vocalization by the patient or withdrawal (p.317)

Joint Motion with Typical Ranges Elbow Flexion () Extension ()

Flexion (0 - 150) Extension (0)

Joint Motion with Typical Ranges Wrist Flexion () Extension () Radial deviation () Ulnar Deviation ()

Flexion (0 - 80) Extension (0 - 70) Radial deviation (0 - 20) Ulnar Deviation (0 - 30)

Strength Assessment with Dynamometer and Pinch Gauge what is it used for? what is a dynomometer?

For wrist and hand assessments, clinicians might use dynamometers to assess grip and pinch strength. A dynamometer is a hand-held device that measures force, typically reflected in kilograms and/or pounds of force.

Test for Gamekeeper's Thumb / Test of the Ulnar Collateral Ligament of the Thumb:

Grasp the patient's thumb so that your index finger is just distal to the metacarpalphalangeal (MP) joint of the thumb, and your thumb is over the lateral aspect of the MP joint. Slowly yet firmly create a force couple that stresses the ulnar collateral ligament. A positive test is indicated by pain and/or laxity/sprain of the ulnar collateral ligament. This maneuver can also be performed to assess the radial collateral ligament of the thumb (reverse Gamekeeper's thumb).

ligament grade sprain Grade : I (mild) Description : Signs and Symptoms : Implications :

ligament grade sprain Grade : III (severe) Description : Signs and Symptoms : Implications :

III (severe) Total rupture of the ligament Severe pain initially, followed by little or no pain (total disruption of nerve fibers), profuse swelling and bruising, loss of structural integrity with marked abnormal motion. PROM findings > severe joint instability, possible pain in the surrounding tissues. Needs prolonged protection, surgery may be considered, often permanent functional instability

Neural Examination: Peripheral Nerves

If you have ruled out involvement of the spinal nerves but neural symptoms are present, it is important to examine the peripheral nerves.

Postural Correction: Teaching Patients Proper Alignment and Taping as Re-enforcement

Improving a person's posture can influence their biomechanics and improve function. Clinicians can help a person improve their posture in many ways, including verbal cues and providing physical correction (including use of kinesiotape - both of which we will do today), and through exercise and activity prescription (more to come on this important approach in subsequent labs).

Enhance inferior joint capsule extensibility via manual therapy -helps with impingement

In addition to using the joint mobilization technique of inferior glide to stretch the inferior joint capsule, you can also lengthen it and nearby muscles via manual therapy. With your palpating fingers, feel the contours of the humeral head, and then assess for areas of capsular tightness. Release these areas using the "along fascial lines" technique, or any other one that works for you. Students who have an aversion to the axilla will need to work particularly hard to embrace the amazing utility of this technique. Recall that many myofascial restrictions occur where muscles cross/border each other. The axilla is perhaps the number one area in the body where more muscles neighbor/cross each other than any other part of the body.

Restoring Accessory Motion at Joints Using Joint Mobilization

In orthopedic practice we have a saying, "If you fail the test, it becomes your treatment." Once you've identified what is limiting joint motion, you can begin to treat it. If a tight muscle is limiting ROM, you'd work to lengthen it. If pain is limiting ROM, you'd use interventions to alleviate the discomfort. If joint capsule stiffness is the limiting factor, you'd address that by gaining joint capsule mobility by restoring the lost accessory motions.

Treating Impingement

Key to treating impingement, along with most other problems at the shoulder, is to think your way through what problems are contributing to the dysfunction. The below algorithm (discussed in class) should help you to organize your approach to treatment based on the problem(s) identified in your assessment.

The five grades of joint mobilization as described by Maitland: Grade II

Large-amplitude sustained or oscillatory movement performed within the range but not reaching the limit of the range of joint motion. It can occupy any part of the range that is free of any stiffness or muscle spasm. Also used to treat pain. -

Signs of inconsistent readings of dynomometer

Low force readings throughout the test Flat curve lines. Higher forces at positions 1 and 5 (beginning and ending positions). Facial grimaces and/or shaking of the upper extremity during test. Excessive variance between two to three trials at the same position.

UE Pattern 1: what are the directions? what movements does this hit?

Medial Rotation & Extension "Stand in a tall position with your feet together and toes pointing forward. Take your arm and reach behind your back and aim to touch the bottom of your opposite shoulder blade." Watch for scapular dyskinesis. Able to touch inferior angle of right/left scapula?

The Brachial Plexus: Diagnosing and Treating Compression/Entrapment (Thoracic Outlet Syndrome)

Note that irritation of the brachial plexus will cause numbness, tingling, and possibly motor deficits of the nerves associated with the compressed branch(es) of the plexus. Be very alert to postural deviations and/or repeated motions that might produce this posture as the potential mechanism of injury. Recall the differential diagnosis tests for thoracic outlet syndrome. 1. Thoracic Outlet Test for Tight Anterior Scalene / Adson Maneuver: 2. Thoracic Outlet Test for Costoclavicular Syndrome: 3. Thoracic Outlet Test for Pectoralis Minor Syndrome / Hyperabduction Test: 4.Thoracic Outlet Test for a Cervical Rib / Halstead Maneuver

"Flossing" of the Median Nerve:

Note that this particular series of images depicting median nerve "flossing" emphasizes gliding of the median at its proximal and distal ends. . Should the course of conservative management of CTS not be fruitful, then it is likely the patient will undergo carpal tunnel decompression surgery. Familiarize yourself with the post-operative management as described by Maxey and Magnusson (2013).

Rotator Cuff Rehab compared to impingement

One of the most readily apparent similarities of rotator cuff and impingement is the progression of exercises from PROM to AAROM to AROM to Function. Perhaps the greatest difference is that the timeframes for progression in Rotator Cuff rehabilitation is dependent on tissue healing times, whereas for shoulder impingement it is dictated more by gains in strength and changes in pain with elevation.

adhesive capsulitis PROM and AROM

PROM = AROM

impingement how does AROM compare to PROM

PROM goes further than AROM

Indications for joint mobilization:

Pain - oscillations at the joint to stimulate neural mechanoreceptors in the joint capsule to override signals sent to the brain by pain receptors (nociceptors) Joint hypomobility - typically associated with capsular fibrosis due to joint capsule inflammation and scarring (fibrosis) associated with immobilization.

Assessing for DeQuervain's Tenosynovitis

Palpation: tenderness to palpation will be apparent in the "snuffbox" where the tendons are located; it is also likely you will note significant tone/increased tension in the Abductor Pollicis Longus and Extensor Pollicis Brevis muscles. As you're palpating the tendons, can you discern one tendon from the other in the shared sheath (sometimes you can, sometimes you can't). The differential diagnosis test used to rule in this problem is: Finkelstein Test / Test for Stenosing Tenosynovitis of the Abductor Pollicis Longus and Extensor Pollicis Brevis: The patient flexes the thumb toward the palmar base of the fifth finger, then flexes the fingers over the thumb. The patient then actively ulnarly deviates the wrist. A sharp, significant pain is indicative of a positive test. A mild degree of discomfort is normal.

goal of these exercises is to regain/maintain normal biomechanics of elevation, which includes appropriate use and timing of scapular and glenohumeral muscles. Therapist-assisted reaching, a.k.a. "Wax on - Wax off"

Patient and therapist sit tall, facing each other. Their lower backs slightly arched and sternums toward the ceiling. The therapist places his/her palm against the patient's palm. The patient gently pushes into the therapist's hand, and the therapist provides a gentle counterforce (this produces a slight downward glide of the humerus). The patient raises the arm toward the ceiling, and the therapist follows. The patient is careful not to shrug the shoulders. If this occurs, the therapist may provide assistance until this substitution disappears. The therapist may have the patient stop at various points along the way to strength the muscles isometrically. If needed, the therapist and patient may externally rotate the humerus to decrease the possibility of impingement. Variations: "wax on / wax off"... the therapist and patient perform circular motions with the upper extremity, being careful to avoid any painful arcs. This exercise is a great way to monitor for substitution with the upper trapezius and to give the patient cues to relax it. It is a good one to perform in conjunction with the trapezius re-balancing exercises.

Carpal Tunnel Syndrome

Perhaps the most well-known of compression/entrapment syndromes, CTS is compression of the median nerve caused by inflammation/swelling in the carpal tunnel, typically related to a MOI of repetitive use of the finger flexors often in postures of wrist flexion or extension, direct compression to the wrist at the transverse carpal ligament, prolonged vibration, weight gain, or via wrist fracture.

With regard to exercise and activity instruction, better than average therapists:

Place the patient in optimal posture and alignment before each exercise Give verbal instruction and feedback Give physical cues and feedback, which taper as the patient becomes more independent Emphasize patient successes (catch the patient "doing things right")

Restore Joint Mobility Deficits Having just reviewed all the accessory motions of the shoulder girdle, identify the three that are particularly important with regard to the biomechanics of elevation and offsetting impingement. Question for the always-thinking evidence-based therapy

Posterior Rotation of the Clavicle Inferior Glide of the Humeral Head with Abduction/ Inferior Glide of the Humeral Head with Flexion Lateral Rotation of Humerus

PROM: Key Accessory Motions Associated with Elevation clavicle

Posterior glide of clavicle Rolling of clavicle (anterior & posterior) At 90 degrees of elevation, the coracoclavicular ligaments (the conoid and the trapezoid) become tight causing the crank-like clavicle to rotate backward, which causes the distal clavicle and AC joint to elevate.

treating TOS relating to tight muscles

Practice: Palpate and perform myofascial release (MFR) of: The Anterior scalene (use any technique that you believe is helpful, including MFR along fascial lines and Ward-Greenman) -Locate the anterior scalene on the lateral aspect of the cervical spine around the C4 region, just behind the sternocleidomastoid and just anterior to the upper trapezius. Palpate along its length (but be careful, this is a very tender muscle) to its insertion on the first rib. Pectoralis minor (bowstringing, along fascial lines, Ward-Greenman) Recall the manual therapy rule: You should always prescribe an exercise or functional activity to maintain the length that you've gained with your treatment. This is often a stretch of the target muscle or sometimes the muscle that is antagonistic to it. It can certainly be a functional activity that enhances posture as well.

Locate/palpate areas of potential anterior interosseous nerve compression/entrapment:

Pronator teres Proximal arch of flexor digitorum superficialis

Proximally derived scapular dyskinesis involves structures ______ Distally derived structures include the _______

Proximally derived scapular dyskinesis involves structures proximal and posterior to the glenohumeral joint along with the pectoralis minor. Distally derived structures include the clavicle, the AC and SC joints, the subacromial space, and the glenohumeral joint.

Ligamentous Stress Testing for clavicle

Sternoclavicular Acromioclavicular (O'Brien sign or Paxino's test)

minor injury of the muscle-tendon unit - either exercise-induced pain, Grade I or mild Grade II strain. Use the patient history to determine if the problem is exercise-induced (related to recent increase in activity), or Grade I or mild Grade II (usually related to some type of trauma; mild Grade II strains might show very slight weakness as compared to the opposite side, or may be strong but with a patient report of greater pain).

Strong and painful:

Varus and Valgus Stress Tests of the MP, PIP, & DIP Joints of the Fingers and the MP & IP Joints of the Thumb:

Support the patient's relaxed hand with yours. Grasping the proximal and distal phalanxe of the joint you are testing, apply a varus force, then a valgus force (gapping the medial and lateral aspects of the joint). Assess for instability and/or patient discomfort and compare to the opposite side.

my arm hurts and goes numb

TOS neural entrapment cervical spine

long head of biceps specific impingement tests

Test of the Long Biceps Tendon / Yergason's Test: Alternate Test of the Long Biceps Tendon / Speed's Test:

Radial nerve tension test Weakness of the wrist extensors Numbness/tingling along radial nerve distribution if these tests are positive, what could the issue be?

The Radial Nerve: Diagnosing and Treating Compression/Entrapment Positive findings from the physical exam that could indicate radial nerve involvement include:

Verbal cueing of postural correction:

The first (and perhaps most important) step to improve a person's posture is to bring it to their attention. Simply demonstrating good alignment yourself will provide a great non-verbal cue. providing three simple verbal cues can be of great help: 1. Move your sternum/heart up toward the ceiling 2. Level your head/chin 3. Gently squeeze your shoulder blades together Frequently, people will over-correct their posture and assume a military stance. If this occurs, simply ask the person to decrease their posture or "back off" about 10%. Educating your patients about proper alignment and good posture should occur during the person's initial visit.

MFR uses activating forces that are both intrinsic and extrinsic. The intrinsic forces include ______________ Extrinsic forces are ___________

The intrinsic forces include respiration, muscled contraction, and eye movements, along with theorized forces such as inherent tissue motion and body rhythms. Extrinsic forces are applied by the therapist and include the application of appropriate amounts of tension via compression, traction, and/or twisting (Greenman, 1996).

Inhibitory Strap/Taping: for lateral/medial epicondylitis

The literature offers no firm conclusions on the effectiveness of counterforce straps or taping. Bisset et al (2005) demonstrated no difference between application of counterforce straps and placebo. This said, do not underestimate the power of the placebo effect: As many as 35% of people who are given a placebo believe that it relieves their symptoms. An important consideration for clinicians is if/when to use the placebo effect in the clinical setting. Practice inhibitory taping of the wrist extensors or flexors using Kinesiotape. Realize that the technique depicted in the photos below is similar to the manual therapy inhibitory technique of "bowstringing" in that the tape (and tension) are applied perpendicular to the direction of wrist extensor muscle fibers. You may use "Y-strips" of tape (as shown in the photo), strategically placing the tape so that trigger points lie in the area between the ends of the "Y." You may also use an "I-strip" (not shown), which is a single strip of Kinesiotape, applied similarly to how one would wear an over-the-counter counterforce strap.

Clinicians diagnose glenohumeral hypomobility/adhesive capsulitis via:

The patient history which includes pain, inflammation, and immobilization AROM (elevation): diminished scapular setting/early scapular motion and loss of 2:1 glenohumeral to scapulothoracic motion. When the person moves their arm, the scapula and the humerus move as one unit because of the stiffness of the joint capsule. PROM: in which the person presents with loss of ROM with capsular end-feels earlier in the range than expected Diminished accessory motions - typically associated with a capsular pattern (recall that the capsular pattern for the glenohumeral joint is external rotation > abduction > internal rotation once you gain joint ROM, your treatment for adhesive capsulitis will consist of exercise/activity prescription and progression that parallel those of impingement and rotator cuff repair.

Test of the Ulnar Nerve / Froment's Sign:

The patient is either seated or standing, and holding a sheet of paper between the pad of the thumb and lateral aspect of the index finger. The examiner then attempts to pull the paper out, while the patient tries to hold it in place. If the ulnar nerve is intact, the patient will use the adductor pollicis to adduct the thumb, while keeping the interphalangeal joint extended (a negative test), by using a lateral or key pinch. If the nerve is injured, the patient will compensate by using the flexor pollicis longus, indicated by flexion of the interphalangeal joint of the thumb (a positive test).

Jobe Relocation Test / Confirmatory test for Anterior Instability:

The patient is in the same position as the anterior apprehension test, at the point in external rotation where the patient felt apprehension. The therapist applies a posterior pressure to the anterior humeral head. The test is positive if the patient's symptoms of instability /apprehension decrease or if you are able to gain greater external rotation with the application of the posterior pressure. Compare to opposite side.

Stress Test of Radial Collateral Ligament of the Wrist (also known as the Side Tilt test of the Navicular/Scaphoid):

The patient is sitting with the wrist supported on the table. Gently grasp the distal radius and ulna with one hand, and the proximal row of carpals with the other. Apply a force that passively moves the wrist into ulnar deviation (gapping the radio-carpal joint). Assess for instability and/or patient discomfort and compare to the opposite side.

Feagan test

The sulcus test can also be applied with the patient's shoulder at 90 degrees abduction (Feagan test). Compare to opposite side. 0 = little/no movement 1 = humerus shifts to the edge of the glenoid 2 = humerus shifts over the edge of the glenoid and spontaneously relocates 3 = humerus shifts over the edge of the glenoid, doesn't spontaneously relocate

Hoffman-Tinel Sign : Ulnar Nerve.

The therapist taps over the area of the ulnar groove (between the olecranon process and the medial epicondyle). A positive sign is indicated by a tingling or electric shock sensation in the ulnar distribution of the forearm and the hand. funny bone

Special Tests for Neural Compression Brachial Plexus /Thoracic Outlet Tests:

These tests are performed to differentiate which structures are causing an impingement of the neurovascular bundle of the thoracic outlet. A test is positive when the radial pulse is significantly diminished or obliterated and is accompanied by pain or numbness of the upper extremity. A diminished pulse in and of itself is not a positive test. When based solely on a diminished radial pulse, these tests are unreliable, since pulse alterations may be found in a high percentage of asymptomatic individuals sensitivity and specificity of these tests are "low."

Cervical spine/spinal nerve screen: Neural Examination: Spinal Nerves

These tests help to rule in or rule out problems of the cervical spine, which can produce pain in the upper extremity. Perform active cervical movements with overpressures (assessing endfeel). If AROM and/or PROM with over-pressure produce pain, then the practitioner will want to investigate further Assess the mechanics of the motion (i.e.: look for restrictions) and for pain: -forward bend -backward bend -rotation left -rotation right -sidebend left -sidebend right

apprehension tests for dislocated shoulders

These tests rely on a person's sense that the joint is moving toward a position of dislocation, causing them to exhibit signs of apprehension (tensing up, stopping the motion, etc.) which is a positive finding, suggesting instability in one or more directions.

The Upper Extremity Orthopedic Evaluation Form

This form provides the structure for the initial assessment. The goal is that students will incorporate this into their approach to patients with upper extremity orthopedic conditions. Because this is a comprehensive form, students must make decisions (and provide their rationale) about what to perform as part of their assessment - and what parts to leave out- based on relevance to the patient's problem.

Cat - Cow: a.k.a. "cats and dogs."

This is a combination of two yoga postures that can be very helpful in gaining the last few degrees of elevation via thoracic extension. Emphasizes gaining extension/flexion through the entire spine. This is a good beginning exercise for patients with impingement because it doesn't place the humerus in more than 90 degrees of flexion. Watch for and avoid movement only at one segment (correcting this may require manual therapy to gain spinal motions). Tight hip muscles (especially hip flexors) may inhibit movement below L1 or L2.

Direct Method of Myofascial Release Along Fascial Lines

This technique works well when you are dealing with bands of myofascial restrictions in one or more muscles

Hoffman-Tinel sign for Nerve Regeneration in the Hand:

This test indicates the rate of regeneration of the sensory fibers of an injured nerve. The therapist begins gently tapping at the distal aspect of the sensory distribution of the nerve being tested, then begins to move proximally. The most distal point at which the sensation of tingling or "electricity" is felt represents the limit of nerve regeneration. Therapists can use this test to assess regeneration of any superficial nerve. This test, although commonly used in the clinic, is not valid for nerve entrapment syndromes, such as carpal tunnel syndrome

Ligamentous Stress Testing for hand

Thumb ulnar collateral ligament stress test (gamekeeper's thumb test) Thumb and digit MP, PIP, & DIP varus and valgus stress tests

If orthopedic practitioners strive for one common goal in treating the muscles of patients, it is this:

To gain muscle length with strength.

grade 3 severe sprain

Total rupture of the ligament Severe pain initially, followed by little or no pain (total disruption of nerve fibers), profuse swelling and bruising, loss of structural integrity with marked abnormal motion. PROM findings > severe joint instability, possible pain in the surrounding tissues. Needs prolonged protection, surgery may be considered, often permanent functional instability

Practice: Perform manual therapy on the following structures plus teach the person how to stretch each one: -- stretch muscles for radial nerve compression

Triceps (MFR along fascial lines, MFR direct trigger point release, Ward-Greenman) Bracialis and brachioradialis (MFR along fascial lines, MFR direct trigger point release, Ward-Greenman) Extensor carpi radialis brevis (bowstringing, MFR along fascial lines, MFR direct trigger point release, WardGreenman) Supinator (bowstringing, MFR along fascial lines, Ward-Greenman)

The Ulnar Nerve: Diagnosing and Treating Compression/Entrapment Positive findings on these differential diagnosis tests could indicate ulnar nerve involvement:

Ulnar nerve tension testing Froment's sign Wartenburg's sign Correlate with numbness/tingling along ulnar nerve distribution

Commit to memory the cardinal rule of manual therapy (of which joint mobilization is one form):

You never perform manual therapy without prescribing at least one exercise or activity to maintain the ROM you just gained.

A myotome is

a group of muscles that a single spinal nerve innervates. A person with injury to the spinal nerve segment supplying a muscle will present with neural weakness. This is quite different from muscle weakness that is caused by disuse (atrophy). Assess the motor innervation (myotome) of the upper extremity (spinal nerves C4 - T1) by performing a strength test of the muscle(s) indicated below. Determine if a patient's loss of strength is related to neural involvement/injury: Any deficits in a myotome should correlate with a dermatome, implicating the same spinal nerve segment.

ultrasound,

a modality used to warm the joint capsule which can greatly enhance joint mobilization by fostering lengthening of the collagen that comprises the capsular tissue and assist in restoring accessory motions that have become limited. -can use with joint mobs

strictly pathologic Springy end-feel:

a pronounced rebound sensation much like pushing off from a rubber pad or squeezing an eraser. Typically caused by a mechanical block produced by a loose body such as with osteochondritis dessicans or displaced meniscus.

PROM: UE Muscle Length /Flexibility Assessment Pectoralis Major (clavicular)

abduction (lateral epicondyle to table)

As you observe upper extremity movement, appreciate how each joint moves in conjunction with those __________ and ___________

above and below You should assess these motions as part of your initial screening process, noting limitations (that you observe or that the patient reports) at particular joints or those movements that cause pain, assessing these in greater depth with PROM and RROM.

after Active Assisted / Cane Exercises: progress to

active exercises

myotomes T1 spinal nerve root:

ad-abduction of fingers/ interosseous muscles

skill of manual therapy, which is a collection of techniques directed toward soft tissues that focus on _______________, _____________, _________________, and _______________

alleviating pain, increasing tissue length, inducing relaxation, and enhancing function

median nerve (or its branch, the _______________________)

anterior interosseous nerve

PROM: UE Muscle Length /Flexibility Assessment Pectoralis Major (sternal)

arm up in scaption (lateral epicondyle to table)

Pec minor and biceps stretch

arms behind back -do this if TOS, and hyperabduction test is positive, pec minor is tight could also do updog

Recall that accessory motions (also known as __________ or ____________) relate to the "roll and glide" (as well as spin, compression, and distraction) motions of one joint surface against another as a physiological motion (flexion, extension, etc.) is happening.

arthrokinematics or osteokinematics

Many biomechanical deviations and proximally derived scapular dyskineses are related to _____________ which link with deficits in muscle length and/or strength.

atypical posture

Part II: Treating Glenohumeral Hypermobility notes

avoid external rotation , extension, abduction for anterior dislocations avoid flexion, adduction, internal rotation for posterior dislocation

The _________ nerve may be one of structures injured, (with humeral dislocation) particularly with anterior inferior dislocations. It supplies motor input to the deltoid, teres minor, and the long head of the triceps, along with sensory input to the inferior region of the deltoid (the area in yellow at right).

axillary

MFR applies the principles of ______________________ and the _____________________ by stimulation of mechanoreceptors in the fascia. The resistant barrier may be engaged directly with tissue stretching, or loading can occur in the direction away from the barrier in an indirect fashion.

biomechanical loading of soft tissue neural reflex modifications

pain in the wrist

carpal tunnel de quervains ligament

hurts to move thumb and wrist

de quervains

Therapists can treat TP's through __________ and ___________ methods of myofascial release (MFR)

direct indirect

which is more intense ward-greenman or direct MFR?

direct MFR

PROM: UE Muscle Length /Flexibility Assessment Lateral humeral rotators

do medial rotation (measure medial rotation with goniometer)

Lower Trapezius strengthening

do the "Y"

myotomes C7 spinal nerve root:

elbow extensors/ triceps

proximal shift of the radius on the ulna helps to restore

elbow flexion

myotomes C5 spinal nerve root:

elbow flexors/ biceps

Pronator teres stretch

elbow fully extended while forearm fully supinated

Differential diagnosis or "special tests" come near the _______ of the physical examination

end

Identify, locate, and palpate the three structures typically involved with lateral epicondylitis:

extensor carpi radialis brevis extensor digitorum extensor carpi ulnaris

capsular pattern Glenohumeral joint:

external rotation is most limited, followed by abduction, then internal rotation

The joint capsule can be injured and become inflamed like any other tissue and is quite susceptible to ___________________, particularly if the injured joint is immobilized (whether intentionally or unintentionally), which can lead to hypomobility (limited passive movement). Conversely, if the joint was dislocated or subluxed or mobilized too early in the healing process, it can become hypermobile (have excessive passive movement).

fibrosis/contracture

median nerve gliding at the hand

fist to finger and wrist extension then gently stretch thumb

capsular pattern Distal interphalangeal joint (DIP):

flexion is most limited, followed by extension

0 - 30 degrees of abduction/ 0 -60 degrees of flexion "Scapular setting" occurs: Most motion is at the ______________ joint

glenohumeral

Deviation from Typical: Downwardly rotated scapula: Short muscle(s) Long (potentially weak) muscle(s)

glenoid fossa is lower than superior medial angle of scapula. -Spine of scapula and glenoid fossa are oriented down/inferiorly short: rhomboids, levator scapula long: upper trapezius

brachial plexus gliding exercises:

go from all the way slacked to all the way tensed turn on and off symptoms 3-4 times a day to start with position 1: head laterally flexed to the affected side and with the fingers, wrist, and elbow flexed position 2: the head comes to neutral position 3: hand has moved across the chest and down to hip level position 4: arm gradually abducts towards position 5 and 6 position 7: lateral cervical flexion to the opposite side is the final component of the glide

Pectoralis Major Stretch

goal posts on wall

^Manual stretch of the rhomboids, using modified joint mobilization position with patient prone.

grab scapula

healing time of wrist sprains

grade 1: 10 days-2weeks grade 2: 2 weeks - 2 months grade 3: 7 weeks- 18 months

Once you've identified painful and/or hypomobile accessory motions at a joint or joints, you can then treat those using __________________, also known as ______________

graded oscillations or joint mobilizations

Thoracic Outlet Test for a Cervical Rib / Halstead Maneuver:

halstead- hell no - cervical rib The patient is sitting or standing. The therapist continuously palpates the radial pulse on the side being tested. While still palpating the radial pulse, the therapist abducts the arm to 45 degrees, extends the shoulder to 45 degrees, and externally rotates the upper extremity while applying a downward distraction to the arm. The patient is then asked to fully turn her head away from the side being tested and extend the cervical spine. A positive test implicates a probable cervical rib. cervical rib = halstead = hell no "look away"

A common site of compression of the ulnar nerve its distal segment in the Tunnel of Guyon (formed by the retinaculum that spans the _____________________ and ________________ bones).

hook of the hamate and the pisiform

If one or more joints lack full mobility (ie, they are ___________), make note of that on the preceding chart and also note the end-feel you palpate when applying overpressure at the end of the range of motion. If the end-feel is capsular and it appears earlier in the ROM than expected, consider whether this is a capsular pattern or not.

hypomobile

Pain and/or weakness with the Yergason's and/or Speed's tests implicates

impingement of the long head of the biceps:

MFR of subscapularis

in armpit

Selective Functional Movement Assessment:

incorporate "Eyes wide open" into their practices. The Selective Functional Movement Assessment (SFMA) approach is a helpful method for assessing and quantifying universal motions that comprise daily activities. cervical spine upper extreamity multi-segmental flexion multi-segmental extension multi-segmental rotation single leg stance arms down deep squat

Latissimis dorsi and teres major muscles:

intenral rot kneeling rows lat pull down with bands lat pull down machines, pull ups

Subscapularis muscle: exercises

internal rotation prone-internal rot hold 15 sec sitting with theraband last 20 degrees of internal rot

autonomous zone

is an area where there is no sensory overlap with other nerves. For the median nerve, this is the palmar tip of the index finger, for the ulnar nerve it is the palmar tip of the little/fifth finger, and for the radial nerve it is the dorsal web space of the thumb

End-feel

is the quality of the resistance to movement that the examiner feels when coming to the end point of a particular movement End-feel provides the therapist with critical information about what structure(s) is/are limiting motion. Some end-feels may be normal or pathologic, depending upon the movement they accompany at a particular joint, and the point in the range of movement at which they are felt, other end-feels are strictly pathologic

Scapular rehab algorithm

know this chart

hasnt been right since i dislocated my shoulder

labral tear apprehension testss dislocation

Recall that radial tunnel syndrome (entrapment of the radial nerve at the Arcade of Frohse) is often misdiagnosed as ________________________ Know the difference in location of symptoms including tenderness to palpation. (Also realize that you will not have a positive radial neural tension test with lateral epicondylitis.)

lateral epicondylitis (tennis elbow).

In orthopedic practice we have a saying, "If you fail the test, it becomes your treatment." Once you've identified what is limiting joint motion, you can begin to treat it. If a tight muscle is limiting ROM, you'd work to _________ it. If pain is limiting ROM, you'd use interventions to alleviate the discomfort. If joint capsule stiffness is the limiting factor, you'd address that by gaining _____________. More to come on these treatment strategies in upcoming labs!

lengthen joint capsule mobility

Not all differential diagnosis tests have information about reliability, validity, sensitivity, or specificity of the test: and a "positive" test doesn't necessarily mean a person has a specific pathology... it just suggests that the ___________ exists that this is the case. Students should cluster similar tests (especially if the clinometric properties are not strong) to triangulate findings.

likelihood Students should correlate the differential diagnosis tests with other findings from the history and physical examination to determine the PT diagnosis / occupational performance problem. Don't "bet the farm" on the findings of one test.

Teres Major Stretch

looks like triceps stretch and side bend

If hypomobility is noted, the therapist should measure how much motion is _________

lost using a goniometer and then needs to determine what is causing the limitations.

Weak and painless:

major injury/ full thickness tear of the muscle-tendon (Grade III strain) unit OR the person has a neural deficit (injury to the motor nerve supplying the muscle > correlate with neural testing).

Deviation from Typical: Winged scapula: Short muscle(s) Long (potentially weak) muscle(s)

medial border of scapula is lifted off thorax- Scapula does not rest flat against thorax; short: subscapularis long: serratus anterior

Note that the level where the anterior interosseous nerve branches from the ________________ varies from one person to another.

median nerve -pronaotr teres -ligament of struthers (present in only 1% of the population) -lacertus fibrosis

Test for a Square-shaped Wrist:

median nerve test (carpel tunnel) a square -shaped wrist is one whose wrist ratio (anteroposterior dimension divided by mediolateral dimension) is greater than or equal to .70. Square-shaped wrists have a high correlation with carpal tunnel syndrome. Measure the anteroposterior and mediolateral dimensions of the wrist at the distal flexor wrist crease, preferably with a sliding caliper. If a caliper is not available, use a ruler. A wrist ratio greater than or equal to .70 is positive.

< Recognize that with hypermobility, you have _______________ accessory motion than expected. End-feel usually will be either capsular/ligamentous, or muscular, depending on structures injured by the MOI.

Deviation from Typical: Humeral anterior glide: Short muscle(s) Long (potentially weak) muscle(s)

more than 1/3 of humerus protrudes beyond the AC joint short: Pectoralis major, infraspinatus, teres minor, posterior capsule is stiff long: Subscapularis

strictly pathologic Muscle-spasm end-feel:

movement stops fairly abruptly, perhaps with some "rebound" due to muscles contracting reflexively to prevent further movement. Magee (1997) describes an early muscle spasm end-feel occurring early in the range as being protective in nature following an injury, and a late muscle spasm end-feel occurring late in the range as a result of joint instability.

Clinicians use RROM to assess for injuries to the

musculotendinous unit (strains). Use isometric resisted test positions (these are the same as manual muscle testing/MMT test positions) to implicate specific muscles and/or their tendons.

Enhance posture

o Education in good posture/alignment o Taping for postural correction o Manual therapy and exercise prescription (lengthen short muscles via manual therapy and stretching exercises and strengthen long/weak muscles) to use the muscles to maintain optimal alignment Wall clock exercise Thoraco-scapular Strengthening with Pectoralis Minor Stretch

Strengthen humeral downward glide synergy/force couple

o Infraspinatus and teres minor (external rotation strengthening, bilateral external rotation exercise) o Subscapularis (medial rotation with arm held at side) o Wall slide

Strengthen scapular synergy muscles (co-contractions and force couples mentioned in the Ellenbecker and Cools algorithm):

o Upper trapezius (again, if overly strong, do not strengthen with additional exercises) o Lower trapezius o Serratus anterior > Include strengthening in the part of the ROM where 'stutters' or hits a 'hitch' during movement Ball-on-the-wall Dynamic hug

Strengthen scapular stabilizers

o Upper trapezius (note: often times the upper trapezius is overly strong and individuals may substitute its use for weaker muscles; if this is the case, you do not want to strengthen it more) o Middle trapezius (prone horizontal abduction with external rotation; middle trapezius) o Lower trapezius (prone row) o Cools et al (2007) have demonstrated that the following exercises are optimal for restoration of trapezius muscle imbalances: Forward flexion in side-lying Side-lying external rotation Prone extension

To clear the joints above and below the joint(s) that is/are limited, use AROM and PROM of those joint motions, along with over-pressure (and note the end-feel): -take to end range then overpressure If the glenohumeral joint is limited:

o the joint above is the cervical spine - assess with AROM and overpressure of cervical flexion, extension, rotation, and side-bending plus compression/distraction o the joint below is the elbow - assess with AROM and overpressure of elbow flexion and extension and pronation -supination If the joint above or below is also restricted, move on to clear the next joint above or below

o the joint above is the elbow - assess with AROM and overpressure of elbow flexion and extension and pronation -supination o the joints below are those of the hand/fingers and thumb - assess these by having the person open and close the hand/make a fist If the joint above or below is also restricted, move on to clear the next joint above or below

o the joint above is the glenohumeral joint - assess with AROM and overpressure of GH flexion, extension, abadduction, and medial-lateral rotation o the joint below is the wrist joint - assess with AROM and overpressure of wrist flexion, extension, radial and ulnar deviation If the joint above or below is also restricted, move on to clear the next joint above or below

an empty end-feel indicates that _____________

pain is limiting the motion,

Perform RROM only in muscles that appear to be injured based on reports of ______________ or based on the ______________. Note response to resistance as strong or weak, painful or painless. Identify grade of strain based on these findings. Correlate the positive RROM findings with palpation of the involved muscles, which should be tender/painful to palpation in the area of injury.

pain with movement mechanism of injury

Recall the "circle stability" concept that identifies the structures that provide ___________ stability (ligament, joint capsule, and the glenoid labrum) and the muscles that offer ___________ stability to the glenohumeral joint (Wilk & Arrigo, 1993).

passive active The humeral head may not only tear the structures that it moves through in the direction of the dislocation, but it may also tear the structures that it pulls along with it, thus tearing tissues on both sides of the "circle."

potential median nerve compression/entrapment

pectoralis minor subscapularis ligament of struthers (The ligament of Struthers exists in only 1% of the population) lacertus fibrosis/bicipital aponeurosis (located around the biceps tendon... this is what helps to hold the tendon in place... typically moves medially from the tendon) pronator teres wrist flexors and extrinsic finger flexors carpal tunnel/transverse carpal ligament

Excellent first exercise for gaining/maintaining glenohumeral joint mobility and to help with scapular-humeral disassociation. Very helpful to maintain ROM gained following joint mobilization. -helps with impingement

pendulum exercise Key for this exercise is allowing gravity to pull the humerus away from the glenoid, then to use momentum of the arm's weight (not glenohumeral muscles) to produce the movement. Often times, patients have a very hard time not using glenohumeral muscles, or simply relaxing enough to allow the motion. Cue the patient to stabilize/adduct their scapula, then begin the pendulum motion. -using gravity and momentum

(Bowstringing brachioradialis

perpendicular to fibers

MFR Extensor carpi radialis brevis (or digitorum or ulnaris)

photo

Bowstringing the pectoralis minor:

photo - going perpendicular to muscle fibers

Indirect Method of MFR for the Shoulder Girdle: Indirectly loading the fascia via ____________

positioning. (Primarily for the muscles of the shoulder girdle: Levator scapula, upper trapezius, middle trapezius, rhomboids.) This is a more gross, but less invasive technique. Place your palpating hand with your thumb over the upper trapezius and levator scapula and your fingers fanned out along the rhomboids and middle trapezius. ^ The patient is rolled onto her side to illustrate hand placement for the indirect method of MFR for shoulder girdle. Treatment should occur with the patient supine. ^ Hand placement to provide counter-resistance with therapist's right upper extremity for MFR of shoulder girdle With the other hand at the patient's elbow, fully internally rotate the upper extremity, then bring the arm from an adducted position toward abduction. As you move the extremity toward abduction, palpate for increases in tension of the tissues at the shoulder. When you note increased tension, have the patient gently contract the muscle by "making the arm an inch shorter." The therapist applies counter-resistance. "Take up the slack" into more internal rotation. Continue this through the range of abduction. Next, fully externally rotate the upper extremity and move from the adducted position toward abduction. Palpate for tissue tension increases and follow the same method performed with internal rotation

The less-common humeral dislocations are _______________, and the position of injury is:

posterior fall forward

radial nerve comes off the

posterior cord of the brachial plexus and remains posterior in the upper half of the arm before looping around the humerus (in the spiral groove) and then traverses anteriorly just above the lateral epicondyle, at which point it exits through the radial tunnel at the level of the Arcade of Frohse (which is simply the proximal portion of the supinator muscle) and then travels down the radial and dorsal aspect of the forearm to the hand.

Once you've improved ROM via stretching & mobilization, begin exercises to improve ________ and ________ (note that you don't have to achieve full ROM or perfect posture before you do so, but you should have made substantial gains). Refer to the Exercises for the Upper Extremity handout for specifics related to the exercises listed below (and realize that the exercises listed are the tip of the proverbial iceberg).

posture and muscle performance

Position sense/proprioception assessment: -UE Posiiton Sense Assessment (proprioception) -when is proprioceptive assessment needed?

proprioceptive assessment is warranted if the joint capsule and/or ligaments have been injured (such as with a dislocation or sprain) or are otherwise involved

Proximally derived scapular dyskinesis involves structures Proximally derived scapular dyskinesis can involve (items in blue font reflects those addressed in this course):

proximal and posterior to the glenohumeral joint along with the pectoralis minor. Neural pathology (long thoracic, spinal accessory, or dorsal scapular) Postural dysfunction including head forward, thoracic kyphosis, and/or scoliosis Lumbopelvic (core) weakness Weakness in scapular synergy muscles (upper trapezius, lower trapezius, serratus anterior) Pectoralis minor shortness/contracture

Many biomechanists categorize the causes of scapular dyskinesia as being either __________ or _____________

proximally derived or distally derived

supinator stretch

pull arm in pronation

Wrist extensor stretch

put them in full flexion

RROM of flexor carpi radialis

radial side

Symptoms suggesting that a patient's problem may involve one or more nerves include:

radiating (shooting) pain, numbness, tingling, or weakness (potentially dropping things). Occupational and physical therapists can use specific examination procedures to determine if the neural involvement is related to: spinal nerve(s) the brachial plexus in the thoracic outlet the peripheral nerves

Injuries to nerves can manifest as

radiating pain, numbness, tingling, and/or muscular weakness. pins and needles

The joint capsule - like ligament and sometimes bone - controls the amount of __________________ present at a joint. It produces a _________________ end-feel that is essentially the same as the end-feel produced by ligaments. Clinical experience with passive motion testing will lead to an appreciation of what normal joint capsule accessory motions feel like (evident in most rehab sciences students) and what is restricted (hypomobile) or excessive (hypermobile).

range of motion firm, leathery

Levator scapula stretch

rotate head down

MFR of supinator

rub on supinator

Triceps MFR (can be performed in supine as well)

rub on triceps

Deviation from Typical: Depressed scapula: Short muscle(s) Long (potentially weak) muscle(s)

scapula sits lower than T2-T7 short: pectoralis major, latissimus dorsi long: upper trapeius

myotomes C4 spinal nerve root:

shoulder shrug/upper trap

Upper Trapezius stretch

side bend head down

An injury to a ligament is a ___________ and clinicians quantify the degree of injury as

sprain, Grade I, Grade II, and Grade III (see below). The greater the degree of sprain, the greater the instability of the joint. Further, ligaments contribute to the roll and/or glide that influence joint arthrokinematics.

A capsular pattern is a ___________

stereotypical limitation of motions at a joint that presents as gradations of loss of motion in distinct directions at the joint, which is caused by shortening of the joint capsule thus producing a capsular end-feel for each motion (Cyriax, 1982) that occurs earlier in the range of motion than expected.

and a firm-leathery end-feel would suggest that a _________

stiff joint capsule is limiting motion.

With both sprains and fractures, if the person is seen clinically after healing has occurred, likely it is for

stiffness of the joint capsule.

^ MFR of subscapularis in lengthened positon. Not illustrated: MFR in shortened position. ^ MFR of subscapularis with active motion. (Patient medially rotates humerus through last 30.)

subscap in armpit

factors limiting inferior translation

superior joint capsule and superior GH lig - main structures limiting inferior subluxation in the dependent position inferior glenohumeral ligament - most effective stabilizer above 45 degrees of abduction

Pronator Teres Stretch

supinate and stretch

biceps

supination and flexion eccentric curl with theraband - supine positon gravity assisted biceps curl with dumbbell

Deviation from Typical: Shoulder medial rotation: Short muscle(s) Long (potentially weak) muscle(s)

the antecubital fossa faces medially and the olecranon faces laterally short: Pectoralis major, latissimis dorsi; lateral humeral rotators may be stiff if the scapula is abducted or depressed long: infraspinatous and teres minor may be long (if scapular position is correct)

Remember that therapists base the grade of sprain on

the degree of pain noted during stress testing as well as the degree of stability or instability as compared to the uninvolved side

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Pectoralis Major (sternal/lower portion):

the patient lies supine with knees bent and lower back flat on the table. Place the patient's arm in about 135° of abduction, with the elbow extended. The shoulder will be in lateral rotation. If there is normal length in this portion of the muscle, the patient's arm drops to table level and the lower back remains flat. This portion of the muscle is short if the extended arm does not drop to the level of the table. If short, measure the distance from the lateral epicondyle to the table surface.

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Pectoralis Minor:

the patient lies supine, arms at sides, elbows extended, palms upward, knees bent, and low back flat on table. Observe the position of the shoulder girdle relative to the top of the table. A tight pectoralis minor will keep the shoulder from contacting the table. Measure the distance between the acromion and the surface of the table

(Anterior posterior glide of the radius and ulna - can help to release ___________

the supinator (if applied more proximally) as well as the pronator teres and pronator quadratus (illustrated here)

Middle trapezius strengthening

theraband horizontally

RROM of pronator teres

therapist resist pronation

Triceps Stretches

think field hockey

thoracic outlet issues can be caused by ...?

tight anterior scalene compression by clavicle or first rib tight pectoralis minor cervical rib

what do these exercises work on ? forward flexion in side-lying side-lying external rotation prone extension

trapezius muscle re-balancing exercises that will help to resolve these imbalances because they recruit the lower and middle traps more so than the upper trap

A _____________________ is a hyperirritable focus of soft tissue, usually found within a taut band of skeletal muscle that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena.

trigger point (TP)

When therapists assess the active and passive motions (AROM and PROM) at joints, they should note if the motion is ________, ___________, or _______________

typical/"normal" or hypermobile (too much mobility) or hypomobile (not enough mobility).

Up to 90 degrees of elevation (both abduction and flexion) The force couple created by the _____, _____ and ______ causes the scapula to rotate upward, axis of motion is at the SC joint.

upper and lower trapezii and the serratus anterior

strains of muscle

use RROM grade 1 - strong and painful grade 2 - weak and painful grade 3- weak and painless(muscle is probably balled up)

flexor tendon gliding

use for carpel tunnel palm open --> palm in fist

Joint Motion with Typical Ranges Scapulothoracic - Glenohumeral Horizontal adduction () Extension () Medial rotation () Lateral rotation ()

Horizontal adduction (0 - 45) Extension (0 - 60) Medial rotation (0 - 70) Lateral rotation (0 - 90)

Thoracic Outlet Test for Tight Anterior Scalene / Adson Maneuver:

"adson --> at them" The patient is sitting or standing. The therapist continuously palpates the radial pulse on the side being tested. While still palpating the radial pulse, the therapist abducts the arm to 45 degrees and extends the shoulder to 45 degrees. The patient is then asked to fully turn his/her head toward the side being tested, extend the cervical spine, and take a deep breath and hold it for 15 to 30 seconds. A positive test implicates a tight anterior scalene muscle. adson = look "at them"

MFR techniques operate from the theory that fascia can become _________ to the muscle, resulting in loss of gliding between the muscle and its fascia and the development of bands of tightness in the muscle and/or "trigger points"

"bound"

Note that the postural impairments of the scapula and the humerus involve muscles that are ________________

"imbalanced": some are short and stiff/tense and others are long and usually weak (although there are exceptions). Developing clinicians such as yourself can use manual therapy techniques to lengthen short muscles and prescribe exercise/activity to strengthen long muscles. As we work through the various manual therapy techniques, consider how you can apply them to gain "balance" of the tissues, thus achieving improved posture, which typically leads to decreased pain and improved function.

Distal median nerve gliding exercise (particularly helpful with carpal tunnel syndrome):

1. wrist in neutral, fingers and thumb in flexion 2. wrist in neutral, fingers and thumb extended 3. thumb in neutral, wrist and fingers extended 4. wrist fingers and thumb extended 5. same as in position 4 with fingers in supination (palm up) 6. same as position 5 other hand gently stretching thumb

placing the three tapes for postural correction

1. external rotation and put scapula into adduction and depression put tape anteriorly on humerus, just inferior to greater tubercle, along lateral border of scapula 2. taping to inhibit upper trap above clavicle and then angled to opposite illiac crest 3. taping to facilitate lower trapezius inferior angle of scapula towards oppistie illiac crest

Kinesiotaping for postural correction:

incrementally improve posture < Think about how taping should be initiated at the first or second visit to provide physical cueing when the patient slumps, then tapered off, transitioning to exercise prescription to stretch and/or strengthen muscles that contribute to improved posture.

Check accessory motions only at joints that appear to be

limited based on functional movement assessment and/or PROM assessment, or your knowledge of the mechanism of injury. Note those motions that are hyper or hypo-mobile. If hypomobility is apparent, indicate in the notes section whether it is part of a capsular pattern.

For instance, a muscular end-feel indicates that a tight muscle is _________

limiting full ROM,

sleep positions for carpel tunnel

wear a brace or if you dont want to then you can do prayer hands under the pillow to prevent wrist flexion

Active assisted reaching (this works toward neuromuscular coordination and conscious muscle control from the previous algorithm):

o Shoulder flexion in quadruped o Thompson's AAROM exercise for re-establishing reaching synergies o Wax-on, Wax-off exercise o Wall slide

Practice median nerve gliding exercise for the entire nerve (this will also treat anterior interosseous), as well as at the wrist/hand: instructions

1) Sit up straight, shoulders back, chest up, chin tucked in. 2) Extend your right arm back, and turn your arm outward so that your thumb is pointing away from you, and your fingers are pointing behind you. Press your hand downward onto the table (or surface you're sitting on) and pull your right shoulder blade down and back toward your left buttock. Hold this position. 3) Advance from position two by turning your head to the left as far as you can, looking up toward the ceiling, then bending your neck, bringing your left ear toward your left shoulder. Hold this position for 30 seconds. 4a and b) Gliding: begin in position three (above). Gently bring your left ear up from your left shoulder (keep looking up at the ceiling), then lower your ear back down toward your shoulder. Repeat 10 times. 5a and b) Gliding II: begin in position three (above). Gently bring your right shoulder forward, allowing it to round toward your left hip, then pull your right shoulder blade down and back toward your left buttock. Repeat 10 times. Perform often, not to exceed five times a day.

Allen Test / Test of Ulnar and Radial Arteries:

The patient completely opens and closes the hand four to five times, then makes a tight fist. The therapist firmly compresses the ulnar and radial arteries at the wrist. The patient then opens the hand, which should be pale. The therapist then releases compression of the radial artery and observes for blood return to the hand, indicated by a "blush" or reddening of the palm. The therapist then repeats the test, releasing pressure over the ulnar artery, while the radial artery remains compressed. If the palm remains pale after pressure is released over one artery, the test is positive for compression of that artery.

Finkelstein Test / Test for Stenosing Tenosynovitis of the Abductor Pollicis Longus and Extensor Pollicis Brevis:

The patient flexes the thumb toward the palmar base of the fifth finger, then flexes the fingers over the thumb. The patient then actively ulnarly deviates the wrist. A sharp, significant pain is indicative of a positive test. A mild degree of discomfort is normal. -4 fingers and thumb in

< Ward-Greenman MFR technique for the upper trapezius muscle.

Therapist introduces compression by moving hands downward, separates hands to introduce the fascial stretch (Greenman, 1996).

< Ward-Greenman MFR technique for the thoracolumbar junction.

Therapist is "tethering" the thoracolumbar fascia with forearm, uses the other hand to distract the more cephalad tissues (Greenman, 1996).

The "Courtesy stretch"

Therapists can use this technique to end their manual therapy treatment sessions to the cervical spine and/or upper extremity.

The "Courtesy stretch" variations

Try different variations of the hand-hold to see what works best for you: - One hand on occiput, one on forehead (depicted in photo) - Both hands on either side of the occiput - Fingertip traction with hooked fingers on either side of the occiput - Cradling the head/occiput in the bend of your elbow.

Elastic/muscular end-feel: may be normal or pathologic

a rubbery end-feel where a tight muscle limits further motion at a joint. Many people will produce these end-feels. Correlate your findings with postural assessment.

anterior pelvic tilt:

a sagittal plane motion that causes the ASIS to move anteriorly/inferiorly.

Posterior pelvic tilt:

a sagittal plane motion that causes the ASIS to move posteriorly/superiorly

Soft-tissue approximation end-feel: may be normal or pathologic

a soft end-feel where two soft tissue structures contact on another, limiting further motion.

capsular pattern Wrist joint:

equal loss of flexion and extension

capsular pattern Elbow/humeroradial joint:

equal loss of pronation and supination

UE deep tendon reflexes grading scale

evaluate and compare DTR's bilaterally and grade correlate diminished DTRs with dermatome and myotome findings grade the briskness/sluggishness of the DTR using this 0-4 scale 0/4 no reflex (could indicate a lower motor neuron lesion) 1/4 diminished/sluggish 2/4 brisk/average/normal 3/4 exaggerated/hyper-reflexive 4/4 pathological/clonus (could indicate an upper motor lesion) biceps : C5 spinal nerve root brachioradialis: C6 spinal nerve root triceps: C7 spinal nerve root

Be cognizant that most neural compression/entrapment issues are related to ___________

poor posture, sustained postures (even if in good alignment), and repeated motions, compression, vibration, etc. related to work or leisure activities.

practice the ulnar nerve gliding exercises: 2 postoperative ulnar nerve gldiing

pos 1: arm adducted and flexed to 90 degrees at the shoulder, the elbow also flexed to 90 degrees and wrist and fingers are in gentle flexion pos 2: wrist and fingers extended pos 3: elbow extended pos 4: arm abducted and elbow flexed to 90 and wrist and fingers are flexed pos 5: arm externally rotated pos 6: lateral cervical flexion added

practice the ulnar nerve gliding exercises: 1 conservative management of ulnar neuropathy

pos 1: arm extended with elbow straight and wrist and fingers flexed pos 2: wrist and fingers extended pos 3: elbow flexed pos 4: second half - arm abducted and wrist and fingers flexed pos 5: external rotation pos 6: lateral cervical flexion to maximize tension

Cubital Tunnel Syndrome Test / Pressure Provocative Test:

ulnar nerve tests The patient is sitting with the elbow in 20 degrees of flexion and forearm supination. The therapist applies pressure to the ulnar nerve just proximal to the cubital tunnel for 60 seconds. The test is positive if the patient reports symptoms (pain, tingling, and/or numbness) in the distribution of the ulnar nerve.

Consider whether the mechanism of injury warrants assessment for injury to the musculotendinous unit (if yes, use _________ to assess)

use RROM to assess).

Anterior scalene stretch: do this if adson test is positive, want to lengthen tight anterior scalene

use the hand of the opposite side to stabilize/depress the first rib, then look up and slightly side-bend away from the side being stretched.

Deviation from Typical: Abducted scapula: Short muscle(s) Long (potentially weak) muscle(s)

vertebral border of Scapula is greater than 3" from the spine short: serratus anterior, pectoralis major long: rhomboids, middle trapezius

0 - 30 degrees of abduction/ 0 -60 degrees of flexion what two things happen?

"Scapular setting" occurs: Most motion is at the glenohumeral joint Supraspinatus is the primary abductor, then middle deltoid begins to become prime mover at 15 - 30o. Anterior deltoid is the primary flexor

Therapists use these differential diagnosis tests to rule in or rule out specific pathologies that they hypothesize might be the source of the patient's problem. The therapist should have rationale for performing the test (link with findings from history, mechanism of injury, etc.) and not simply throw a lot of tests at the patient (ie: the _________________ approach.)

"kitchen sink" students should be able to use their knowledge of anatomy and biomechanics to figure out how the tests work

Accessory motions relate to the

"roll and glide" (as well as spin, compression, and distraction) motions of one joint surface against another as a physiological motion (flexion, extension, etc.) is happening. Accessory motions are produced by the anatomy/shape of the articulating bones, ligaments, and direction of the fibers in the joint capsule, and are necessary for full, normal range of motion to occur.

Clinicians who are skillful in manual therapy have honed their proficiency with palpation (they ________ the tissues with their hands), they skillfully use their hands to apply tension/force to the tissues, and they have an aptitude for assessing the patient's response and adjusting the intervention accordingly

"see"

Mallet Finger

(avulsion of the insertion or a tear of the distal portion of the extensor mechanism into the distal phalanx. fracture and tendon disruption at the DIP joint DIP flexion? extensor tendon has come off

radial tunnel syndrome

(entrapment of the radial nerve at the Arcade of Frohse)

PROM: UE Muscle Length /Flexibility Assessment Subscapularis

(measure shoulder flexion with goniometer)

manual muscle testing Further, you will also want to assess the strength of the muscles involved with the key components of elevation Muscles associated with scapular setting

(primarily upper, middle, and lower trapezius) upper -shoulder shrug middle - t position thumbs up lower- y position

Active Compression Test / O'Brien's Test for SLAP Lesion:

(superior labrum - anterior to posterior) The patient is standing and flexes the shoulder to 90 degrees with the elbow fully extended. The patient then adducts the arm 10 degrees and maximally internally rotates the humerus. The therapist applies a downward force to the arm as the patient resists. The patient then fully supinates the arm and repeats the procedure. The test is positive if the patient has pain or painful clicking in the area of the glenohumreal joint with the first maneuver (10 degrees adduction with full internal rotation) and reduced with the second maneuver (full supination). This can also be a test for AC sprain, in which case instability and/or pain localized to the AC joint would be associated with a positive test. for the second position

manual muscle testing Further, you will also want to assess the strength of the muscles involved with the key components of elevation The synergy created by the infraspinatus, teres minor, and subscapularis

(which causes depression/downward glide of the humeral head in the glenoid fossa with abduction and/or flexion of the shoulder) infraspinatus/ teres minor - lateral rotate subscap -medial rotation

manual muscle testing Further, you will also want to assess the strength of the muscles involved with the key components of elevation The force couple created by the upper and lower trapezii and the serratus anterior

(which causes the scapula to rotate upward with the axis of motion at the SC joint). upper -shoulder shrug lower- y position serratus anterior - punching position

Humerus: optimal alignement

- Less than one-third of the humerus protrudes in front of the acromion - The humerus is in neutral rotation so that the antecubital crease faces anteriorly and the olecranon faces posteriorly, with the palm of the hand facing the body - The proximal and distal ends of the humerus are in the same vertical plane when viewed from the side, the front, or the back

Test of the Anterior Interosseus Nerve / Pinch-grip Test:

- branches off of median nerve The anterior interosseus is a branch of the median nerve with a motor component to the lateral half of the flexor digitorum profundus and the flexor pollicis longus. The patient is asked to pinch the tips of the index finger and thumb together. The patient should be able to achieve a tip-to-tip pinch, however if there is not involvement of the anterior interosseus nerve (due usually to entrapment of the nerve as it passes between the two heads of the pronator teres muscle) the patient will exhibit an abnormal pulp-to-pulp pinch (resulting in a positive test). A positive test for the anterior interosseus nerve may exist without a positive test for the median nerve (pronator teres syndrome).

Make note of mechanical interfaces and structures that may entrap or compress the median nerve (or its branch, the anterior interosseous nerve). We will cover these in greater detail in a subsequent lecture and lab.

- subscapularis -pectoralis minor -ligament of stuthers -pronator teres -bicipital aponeurosis/lacertus fibrosis -proximal arch of the flexor digitorum superficialis -transverse carpal ligament

Contraindications for manual therapy

-acute injuries -acute inflammation (and swelling) -tissues that are extremely painful -other common sense problems -fractures -if it is healing -if patient doesnt like your hands on them for friction massage - if active movement is more than mildly uncomfortable dont perform friction massage

Neural Tension Test: Median nerve (Method 2 or "Upper limb tension test 2"/ULTT2)

1. Start with the patient supine, arm abducted about 30 degrees, elbow flexed 2. Depress the shoulder girdle by gliding the shoulder down/toward the foot of the table. 3. Keeping the shoulder girdle depressed, extend the elbow, move the forearm into full supination, then extend the wrist and fingers. 4. < Maintaining all the previous positions, have the patient sidebend the neck away from the side you are assessing. (Make sure this is mainly cervical side-bending; many people will try to rotate the neck instead.) If the patient experiences any neural symptoms, ask them to try and localize where along the course of the nerve they feel it most. Note that more than one area may be involved.

Neural Tension Test: Radial nerve ("Upper limb tension test 2b"/ULTT2b)

1. Start with the patient supine, arm abducted about 30 degrees. 2. Depress the shoulder girdle by gliding the shoulder down/toward the foot of the table (elbow can be flexed or extended). 3. Keeping the shoulder girdle depressed, extend the elbow, move the forearm into full pronation, then flex the wrist and fingers. 4. < Maintaining all the previous positions, have the patient sidebend the neck away from the side you are assessing. (Make sure this is mainly cervical side-bending; many people will try to rotate the neck instead.) If the patient experiences any neural symptoms, ask them to try and localize where along the course of the nerve they feel it most. Note that more than one area may be involved.

Neural Tension Test: Ulnar nerve ("Upper limb tension test 3"/ULTT3)

1. Start with the patient supine, arm abducted about 30 degrees. Depress the shoulder girdle by gliding the shoulder down/ toward the foot of the table. 2. Keeping the shoulder girdle depressed, fully flex the elbow and move the arm into lateral rotation. 3. Extend the wrist and fingers and bring them to the side of the patient's head. 4. < Maintaining all the previous positions, have the patient sidebend the neck away from the side you are assessing, moving the upper extremity along with it. (Make sure this is mainly cervical side-bending; many people will try to rotate the neck instead.) If the patient experiences any neural symptoms, ask them to try and localize where along the course of the nerve they feel it most. Note that more than one area may be involved.

Neural Tension Test: Median nerve (Method 1 or "Upper limb tension test 1"/ULTT1)

1. Start with the patient supine, arm abducted to 90 degrees. 2. Depress the shoulder girdle by gliding the shoulder down/toward the foot of the table 3. Keeping the shoulder girdle depressed, flex the elbow and move the arm into lateral rotation. 4. Maintaining all the previous positions; extend the elbow, moving the forearm into full supination, then extend the wrist and fingers. 5. Have the patient side-bend the neck away from the side you are assessing. (Make sure this is mainly cervical side-bending; many people will try to rotate the neck instead.) Symptoms that are most often described during this test include: stretch (69%), burning (56%), tingling (39%), and numbness (26%) If the patient experiences any of these, ask them to try and localize where along the course of the nerve they feel it most. Note that more than one area may be involved.

Brachial Plexus /Thoracic Outlet Tests: positive test

A test is positive when the radial pulse is significantly diminished or obliterated and is accompanied by pain or numbness of the upper extremity.

Test of the Wrist Flexors / Medial Epicondylitis (Golfer's Elbow) Test:

Also an overstretch test with the starting position of elbow flexion. With the patient's forearm fully supinated and the wrist completely extended, the therapist passively extends the patient's elbow. A positive test is pain in the wrist flexors, frequently at their origin at the medial epicondyle.

Test of the Wrist Extensors / Tennis Elbow Test (method 2):

Also known as the overstretch method. Starting position is elbow flexion. The therapist fully pronates the forearm, completely flexes the wrist, then extends the elbow. Pain in the wrist extensors is a positive test. Again, the therapist should palpate the involved muscles to determine the exact location of pathology. Routinely the problem is noted at the origin of these muscles, the lateral epicondyle.

Be mindful that muscles can be weaker in certain parts of the ROM than others. For instance, the serratus anterior can be weak in parts of the range of abduction as the arm returns to the side from elevation (noted by the scapula lifting off the thorax or "stuttering" or "hitting a hitch" at that part of the range). Given this, consider modifying the standardized MMT position and test the muscle in that part of the ROM where the lifting or "stuttering" occurs.

Also think about how the weakness may be related to poor endurance... ie, the muscle becomes weaker the more it is used. In this case, consider performing a series of about 5 MMTs of the same muscle to see if it gets progressively weaker with each application of resistance.

if a person has wrist sprain and or fracture - what should you ask them?

An important line of questioning to pursue during the initial intake process relates to the person's balance and whether they have a history of falls. The literature shows that a person who has fallen in the last six months is at greater risk for future falls. As such, it is important to determine what caused the person's fall, and whether it was an isolated incident or not. Key questions to ask: What caused you to fall? How many other times have you fallen or nearly fallen in the past month? Two months? (Etc.) Another key problem to screen for, particularly with people who have fractured their wrist, is whether they've had a bone scan performed, and if yes, when it was conducted and what were the results. Bone scans assess an individual's bone density and serve as the standard for diagnosing osteoporosis. The top three types of fractures associated with osteoporosis are of the distal radius (Colles' fracture), the neck of the femur, and the vertebral bodies.

Muscles assessed in this general assessment are:

Anterior Deltoid - push front Posterior Deltoid push back Supraspinatus & Mid. Deltoid Triceps Brachii Biceps Brachii Extensor Carpi Radialis Longus & Brevis Grip: flexors digitorum (profundus and superficialis) Gluteus medius* -push knees apart Gluteus maximus* - push legs down Quadriceps femoris - have them extend the leg Anterior tibialis (important to assess clearance of the foot during the swing phase of gait) Plantar flexors as a group* *Test positions modified to seated position for the general assessment. Note: when performing a specific manual muscle test, students should use the standardized test positions as described by Kendall, McCreary, Provance, Rodgers, and Romani (2005).

Special Tests for Neural Compression Compression of the nerves that comprise the brachial plexus (Thoracic Outlet Syndrome)

Anterior Scalene (Adson Maneuver) Costoclavicular Pectoralis Minor (Hyperabduction test) Cervical Rib (Halstead Maneuver)

Hypermobility and/or dislocations can cause injuries to the glenoid labrum, for which you have the following special tests in your toolbox:

Anterior Slide Test for Glenoid Labral Tear Active Compression Test / O'Brien's Test for SLAP Lesion: Crank Test for Glenoid Labral Tear:

Ligamentous Stress Testing for glenohumeral joint

Anterior and middle glenohumeral ligaments (Anterior apprehension & Jobe Relocation test) Inferior glenohumeral ligament (Sulcus sign & Faegan test) Posterior joint capsule (posterior apprehension test)

Treating Ulnar Collateral Ligament Sprain/ "Game-keeper's Thumb"

Applying the PRICE approach (Protection, Rest, Ice, Compression, and/or Elevation) will likely address this problem, along with removing the MOI. With regard to protecting the UCL of the thumb, here is your challenge: With no direction from your lab instructor, figure out a way to use Kinesiotape to support this ligament without interfering with a person's daily activities. Hint: 100% tension on the Kinesiotape is typically used to support sprained ligaments. Note: patients with greater degrees of instability would require a more permanent solution, such as a splint.

how do you prepare a person with la

As you prepare the person for return to work, strive to foster in them the "athlete mentality"... of thinking of themselves as "industrial/office athletes." What this means is that they should approach their job as an athlete might approach a sporting event: Begin with a warm-up to prepare for the activity, perform stretches, then ease into the activity. End with a cool-down, more stretches, possibly self-treatment manual therapy, and ice if indicated.

Ligamentous Stress Testing:

Assess stability (and degree of sprain) reported by the patient to be unstable or painful with movement, or based on the mechanism of injury. Depending on the degree of injury, some instability or laxity of the joint may be noted (compare to opposite side). Use the notes/comments section of the table in the evaluation form to record the grade of sprain (if present) and signs and symptoms that support your determination of grade of sprain.

Recall these key aspects of treating patients with glenohumeral hypermobility:

Begin with single-plane motions, avoiding the extremes of motions associated with the position of dislocation Strengthen active stabilizers that limit humeral head translation in the direction(s) of instability and allow them to become shortened to some degree Be alert to areas of hypomobility related to the immobilization - be thoughtful about any joint mobilization you might consider performing. For most people with instability, having a "tight" shoulder is better than one that is too "loose" (hypermobile) - however, this is a fine line to walk. Movements progress to multi-plane motions. Instruct the patient to avoid positions of dislocation / pay attention to feelings of apprehension.

Palpation One's hands are among the occupational and physical therapist's most important instruments - exceeded only by their minds.

By palpating (touching and feeling) an area of injury or discomfort on the body, we are not only gathering information and evaluating the area, we are simultaneously establishing a physical connection with our patients and conveying nonverbal messages to them about our empathy for their condition, our knowledge of the structure(s) beneath our hands, and confidence in our ability to help them. In addition to conveying to the therapist sensory information about tissue tension, temperature, and tenderness, placing one's hands on a patient establishes a physical connection that can be both physically and cognitively therapeutic. As such, how we place our hands on a person is of extreme importance. Novice practitioners must learn to touch their patients with intelligent - and compassionate- hands.

Treating Carpal Tunnel Syndrome

Clinical practice guidelines and systematic reviews of the literature concur on the following course of treatment: 1. A course of non-operative treatment (Grade C): PT or OT for activity modification (remove/alter MOI) Night splint as "first line of care" with wrist in neutral Early mobilization: Median nerve gliding, tendon gliding Postural exercises Ergonomic modifications and return-to-work conditioning 2. Local steroid injection (cortisone) or splinting (Grade B) 3. Oral steroids or ultrasound at 20% duty cycle (Grade C) 4. Carpal tunnel release surgery if non-operative course not successful (Grade A) Obviously addressing the MOI is the crucial step to addressing CTS, whether via cessation or modification of the activity, along with rest (which could include resting splint at night).

Taping to correct humeral and scapular positioning:

Clinicians can also augment a person's posture by using various types of elastic tape. Tape that has some degree of flexibility (such as Leukotape, Kinesiotape, etc.) provides proprioceptive input when the person moves from a corrected position to a sub-optimal position, inhibiting muscle by means of low-load prolonged stretch, and/or facilitating weak muscles by increasing motorneuron excitability In this section of the lab, tape both sides of your lab partner and wear the tape throughout the day to appreciate how it can provide postural cues and awareness. Apply the tape such that it produces a lateral rotation moment on the humerus and moves the scapula into adduction and depression. First, position the humerus and scapula into a 'normal' position. Anchor the tape anteriorly on the humerus just inferior to the greater tubercle (a); stretch the tape to about 80% full tension and smooth onto skin moving around the humerus posteriorly, being sure not to cause wrinkles in the skin as you adhere the tape (b); pull the tape along the lateral border of the scapula angling it toward the opposite iliac crest, and anchor the last one inch of tape with no tension (c). Taping to inhibit the upper trapezius: apply the tape perpendicular to the fibers of the upper trapezius. Anchor the tape with no tension just above (not on) the clavicle (a); stretch the tape to about 90% full tension and smooth onto the skin being sure not to cause wrinkles in the skin (b); pull the tape toward the opposite side (the tape should point toward the opposite iliac crest) and adhere the last one inch of the tape onto the skin with no tension (c). Taping to facilitate the lower trapezius: (Note- the tape should be applied directly to the skin, it is placed over clothing in the images below only for demonstration purposes.) First, position the humerus and scapula into a 'normal' position. Anchor the tape to the inferior angle of the scapula with about 80 % tension (a); angling toward the opposite iliac crest, smooth the tape onto the skin with no tension, being sure not to cause wrinkles in the skin (b); anchor the last inch of the tape onto the skin with about 80% tension (c).

if spinal nerves are involved, compression of cervical spine________________ and distraction________________

Compression narrows the neural foramen through which the spinal nerve roots exit and may cause pain if some type of neural involvement is present (note that this can be from many causes, including disc herniation, spinal stenosis, etc.). Distraction increases the size of the neural foramen and typically decreases pain if neural irritation is present.

Special tests for neural tension and compression

Considering that nerves are continuous structures from the spinal cord to the periphery, it is not uncommon for them to become compressed, entrapped, or impinged upon by various soft (and sometimes hard) tissues. When this happens, the nerve(s) cannot glide along their course, experience tension and thus irritation resulting in pain, tingling, and/or numbness. Clinical tests exist that assess the mobility of the peripheral nerves along their courses and whether any structures are compressing on them: these are called 'neural tension tests.' Clinicians can use these tests to implicate a nerve that is being compressed. Pay particular attention to the area where the person feels discomfort along the course of the nerve and correlate this by palpating for tissue tightness, as well as note postural and movement deficits.

Treatment of Soft Tissue Trigger Points: The Direct Method of MFR

Direct Method: directly loading the fascia at the trigger point. This technique is best applied to one to three TP's per treatment, followed by modalities and stretching. Palpate and treat the most active trigger points, starting with the one that most closely recreates the pain that the person is experiencing. Slowly compress the trigger point with your finger or thumb, being careful not to hyperextend the joints. Using your palpation skills and feedback from your patient, slowly push: upward and downward left to right clockwise and counterclockwise.

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Radio-Humeral Distraction or Distal Shift of Radius on Ulna what does it restore?

Direction of force: Along the shaft of the radius. Action: Distract the radius from the humerus. Positioning: The therapist stands on the inside of the person's arm. Stabilize the humerus with the elbow flexed 20 to 30 degrees. Movement: Place traction on the radius, pulling it away from the humerus and causing a distal shift of the radius on the ulna. *Assists in restoring elbow extension.

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Anterior-Posterior Glide of the Inferior Radio-Ulnar Joint what does it assist to restore?

Direction of force: Anterior and posterior. Action: Glide of ulna and radius on each other. Positioning: Firmly grasp the distal end of the radius with one hand; the other hand grasps the distal end of the ulna. Movement: Move the radius anterior then posterior on the stationary ulna; then move the ulna anterior then posterior on the stationary radius. Then move both radius and ulna in opposite directions of one another. *Assists in restoring forearm pronation and supination.

Hand Accessory Motion Testing Anterior-Posterior Metacarpal Glide what does it assist with?

Direction of force: Anterior-Posterior Action: Move one metacarpal on another metacarpal. Positioning: Each hand stabilizes a metacarpal. Movement: One hand stays motionless while the other hand moves the metacarpal in an anterior and posterior (palmar and dorsal) direction. *Restores/enhances grasping motions of the hand.

Glenohumeral Accessory Motion Testing Anterior Glide of Humerus what does it assist to regain?

Direction of force: Anterior. Action: Glide the humerus anteriorly. Positioning: The key is to make sure that your proximal hand is as close as possible to the head of the humerus. A common error is misplacement of the proximal hand (either too far from the humeral head or positioned over the spine of the acromion). The distal hand is at the distal end of the humerus to stabilize it. Movement: Create a downward movement of the proximal hand resulting in an anterior glide of the humerus. The therapist should be careful not to allow the distal portion of the humerus to move. *Assists to regain extension of the humerus.

Wrist Accessory Motion Testing Backward Tilt Of The Distal Row Of Carpals On The Proximal Row what does it assist

Direction of force: Backward/dorsal tilt Action: Tilting the distal row of carpals backward. Positioning: The proximal hand stabilizes the proximal row of carpals on the plinth. The other hand grasps the distal row of carpals. Movement: Apply a slight distraction to the joint, then tilt distal row of carpals backward on the proximal row. *Assists in restoring wrist extension.

Wrist Accessory Motion Testing Side Tilt of the Navicular (Scaphoid) from the Radius (aka Stress Test of Radial Collateral Ligament of the Wrist) what does it assist with?

Direction of force: Curved Action: Distracting the scaphoid from the radius, stressing the radial collateral ligament. Positioning: The proximal hand stabilizes the radius on the plinth. The distal hand grips the proximal row of carpals. Movement: Apply separation to/gap the radio-carpal joint. *Assists with restoring radial and (mostly) ulnar deviation

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Rotation of Radius on Ulna what does it assist to restore?

Direction of force: Perpendicular to glenoid fossa. Action: Rotation of the radial head on the ulna. Positioning: The stabilizing hand is blocking the radial head. This is easiest to achieve by palpating the radial head and then slowly flexing the elbow until the hand over the radial head blocks the motion. Movement: The therapist grasps the distal end of the radius and ulna and pronates or supinates the forearm depending on the desired motion. *Assists in restoring forearm pronation and supination.

Restore Joint Mobility Deficits particularly important with regard to the biomechanics of elevation and offsetting impingement and provide treatment progression Inferior Glide of the Humeral Head with Abduction

Direction of force: Inferior and parallel to floor. Action: Assists depression of the humeral head during the first 90 degrees of abduction. Positioning: The thenar and hypothenar eminences of the proximal hand are over the humeral head. The other hand is supporting and moving the distal humerus. Movement: The therapist uses their body to cause abduction of the client's arm up to ninety degrees. The therapist's proximal arm is perpendicular to the patient's arm throughout the motion and gently pushes the humerus downward. This facilitates an inferior glide of the humerus with abduction. Treatment progression: practice performing downward glide in parts of the ROM above shoulder level - which is what you would do as you make gains in ROM during your treatment (see image at left). This mobilization can also be done in sitting.

Glenohumeral Accessory Motion Testing Inferior or Downward Glide of Humerus what does it work to regain?

Direction of force: Inferior/toward foot of table Action: Glide the humerus inferiorly along the glenoid fossa. Positioning: The therapist's hands are at the proximal humerus. The client's elbow is resting on the therapists shoulder. Movement: Exert a downward force with your hands along the midaxillary line, gliding the humeral head downward/toward the foot of the table. * Assists to regain elevation (flexion and/or abduction) of the humerus.

Glenohumeral Accessory Motion Testing Medial Rotation of Humerus what does it restore?

Direction of force: Inward/medial rotation Action: Stretch the posterior-lateral joint capsule. Positioning: Notice how the proximal forearm is across the client. The proximal hand is on the head of humerus or as close as possible (minor adjustments or position of the hand are often necessary for the client's comfort). The distal hand stabilizes the distal humerus. Movement: Rotate the humerus inward; the motion occurs along the long axis of the humerus. *It is typically useful to perform both medial and lateral rotation glides to restore humeral rotation.

Restore Joint Mobility Deficits particularly important with regard to the biomechanics of elevation and offsetting impingement and provide treatment progression Lateral Rotation of Humerus

Hand Accessory Motion Testing Anterior-Posterior Phalangeal Glide what does it assist with

Direction of force: Parallel to the metacarpal. Action: Anterior and posterior glide. Positioning: The proximal hand stabilizes the metacarpal. The distal hand grasps the proximal end of the phalanx. Movement: Apply a small amount of traction, then glide the phalanx anterior or posterior. Perform at MP, PIP, and DIP joints of the fingers and MP and IP joints of thumb. *Enhances flexion and extension of the phalanges.

Wrist Accessory Motion Testing Anterior-Posterior Mid-Carpal Glide what does it assist?

Direction of force: Parallel to the radius / upward and downward Action: Glide the distal row of carpals parallel to the proximal row of carpals. Positioning: The proximal hand stabilizes the proximal row of carpals on the plinth. Movement: Separate/distract the distal row of carpals from the proximal, then perform an anterior or posterior glide. Moving the distal row of carpals along the proximal row. *Assists with restoring both wrist flexion and extension.

Wrist Accessory Motion Testing Anterior-Posterior Radio-carpal Glide what does it assist with?

Direction of force: Parallel to the radius / upward and downward. Action: Gliding the proximal row of carpals parallel to the radius and ulna. Positioning: The proximal hand stabilizes the radius and ulna. The distal hand grips the proximal row of carpals. Movement: Distract (traction) the distal row of carpals from the proximal row/ hands move in opposite directions, then perform anterior glide of one row and posterior glide on the other Once you have distraction of the joints, you can perform an ANTERIOR or POSTERIOR glide. * Assists with restoring flexion-extension at the wrist.

Wrist Accessory Motion Testing Anterior-Posterior Glide of the Triquetrum and Pisiform on the Ulna what does it assist with

Direction of force: Parallel to the ulna / upward and downward. Action: Glide the triquetrum/pisiform parallel/ up and down to the ulna. Positioning: The proximal hand stabilizes the radius and if possible the ulna (not shown in this picture). The distal hand grasps the triquetrum and pisiform. Movement: Once you achieve a slight distraction, perform an anterior or posterior glide. *Assists with restoring flexion-extension at the wrist.

Elbow and Forearm: Humero-ulnar and Radio-Ulnar Accessory Motion Testing Humeral-Ulnar Distraction

Direction of force: Perpendicular to Trochlea. Action: Distract the ulna from the humerus. Positioning: The therapist stands on the outside of the patient's arm. Grasp the ulna with one hand while stabilizing the humerus as shown. Bend the elbow to about 30-degrees to prevent the olecranon from locking in the olecranon fossa. Movement: Place traction on the ulna, moving it away from the humerus.

Glenohumeral Accessory Motion Testing Glenohumeral Distraction

Direction of force: Perpendicular to and away from the glenoid fossa. Action: Distract the humerus from the glenoid fossa. Positioning: The left hand is cupped and as close to the humeral head as possible (you may choose to use a washcloth to protect your hand). The right hand is over the lateral epicondyle. Minor hand adjustments are often necessary to prevent impingement of the radial and/or median nerve. Movement: Create a coupled force at the head of the humerus and at the lateral epicondyle. The solid arrow that is curved represents movement of the hips. Remember that you generate this movement with your hips and transfer the power through your arms to the humeral head as you press it laterally.

Direction of force: Perpendicular to humerus. Action: Assists depression of the humeral head during the first 90 degrees of flexion. Positioning: The thenar and hypothenar eminences of the proximal hand are over the humeral head. The other hand is supporting and moving the distal end of the humerus. Movement: This is a passive technique. The therapist uses their body to cause flexion of the client's arm up to ninety degrees. The therapist proximal arm is approximately perpendicular to the client's arm throughout the motion and gently pushes the humerus toward the foot of the table. This facilitates an inferior glide of the humerus with flexion. Treatment progression: practice performing downward glide in parts of the ROM above shoulder level - which is what you would do as you make gains in ROM during your treatment (see image at left)

Hand Accessory Motion Testing Phalangeal Distraction

Direction of force: Perpendicular to the metacarpal. Action: Distraction. Positioning: The proximal hand stabilizing the metacarpal. The distal hand grasps the proximal end of the phalanx. Movement: Traction / distraction. Perform at MP, PIP, and DIP joints of the fingers and MP and IP joints of thumb.

Wrist Accessory Motion Testing Radio-carpal Distraction

Direction of force: Perpendicular traction away from the radius. Action: Distract the proximal row of carpals from the radius and ulna. Positioning: The proximal hand is stabilizing the radius and ulna. The distal hand grips the proximal row of carpals. Movement: Distract (traction) the proximal row of carpals from the radius and ulna / hands move in opposite directions.

Posterior Glide of Distal/Lateral Clavicle Sternoclavicular and Acromioclavicular Accessory Motion Testing

Direction of force: Posterior Glide Action: Moving the clavicle posterior on the acromion. Positioning: The thumbs are overlapping and on the distal end of the clavicle. Movement: Slowly and carefully depress the distal end of the clavicle

Glenohumeral Accessory Motion Testing Posterior Glide of Humerus what does it restore?

Direction of force: Posterior. Action: Gliding humerus posteriorly. Positioning: The client's arm is resting against your body (some may prefer a pillow between the client and therapist). The therapist's hands are resting on the client's olecranon (elbow). Movement: Make sure the client is at rest (observe if they have allowed full elbow flexion or if they are keeping the triceps active). *Assists to restore elevation

Wrist Accessory Motion Testing Wringing the Proximal Row of Carpals on Distal Row what does it assist?

Direction of force: Rotation Action: Pronation and supination of the midcarpal joint. Positioning: The proximal hand stabilizes the proximal row of carpals on the plinth. The other hand grasps the distal row of carpals. Movement: Apply a slight distraction force. The proximal hand stabilizes the proximal row of carpals and the distal hand pronates and supinates the distal carpals. *Assists with restoring flexion and extension, radial and ulnar deviation, and some degree of pronation-supination.

Hand Accessory Motion Testing Phalangeal Rotation what does it assist?

Direction of force: Rotation of the metacarpal. Action: Rotation. Positioning: The proximal hand stabilizes the metacarpal. The distal hand grasps the proximal end of the phalanx. Movement: Rotate the phalanx on the metacarpal. Perform at MP, PIP, and DIP joints of the fingers and MP and IP joints of thumb. *Enhances flexion, extension, and ab-adduction of the phalanges.

Hand Accessory Motion Testing Metacarpal Rotation what does it assist with?

Direction of force: Rotation. Action: Rolling one metacarpal on another. Positioning: Each hand stabilizes a metacarpal. Movement: One hand stays motionless while the other hand rolls the other metacarpal towards or away from the other metacarpal. Remember the body is generating the force. * Restores/enhances grasping motions of the hand.

Rolling the Clavicle Sternoclavicular and Acromioclavicular Accessory Motion Testing

Direction of force: Rotational motion, anterior and posterior Action: Rotation of the clavicle. Positioning: The therapist achieves as much contact as possible with the fingers along the upper back edge of the clavicle and the thumbs along the anterior/inferior edge of the clavicle. Movement: Directed upwards and backwards to create a posterior roll. Change direction to create the anterior roll. *The clavicle is quite tender. Distribute your forces as widely as possible with the contact of your fingers and thumbs. **Recall that posterior rolling of the clavicle increases the subacromial space with elevation and helps to decrease the possibility of impingement -do it in the middle of clavicle or near SC

Restore Joint Mobility Deficits particularly important with regard to the biomechanics of elevation and offsetting impingement and provide treatment progression Posterior Rotation of the Clavicle

Direction of force: Rotational motion, posteriorly Action: Rotation of the clavicle. Positioning: The therapist achieves as much contact as possible with the fingers along the upper back edge of the clavicle and the thumbs along the anterior/inferior edge of the clavicle. Movement: Directed upwards and backwards to create a posterior roll. Change direction to create the anterior roll. *The clavicle is quite tender. Distribute your forces as widely as possible with the contact of your fingers and thumbs.

Wrist Accessory Motion Testing Palmar glide of the Capitate what does it assist with?

Direction of force: Toward the palm. Action: Mobilize the capitate between the proximal row of carpals, hamate, and trapezoid. Positioning: The therapist's thumbs are over the capitate on the dorsum of the hand just distal to the scaphoid / proximal to the third metacarpal. The fingers on the palm side are at the thenar and hypothenar eminences. Movement: Use the thumbs to push the capitate downward. You can use this technique for any of the carpal bones. *Assists in restoring wrist extension.

Wrist Accessory Motion Testing Palmar glide of Scaphoid what does it assist with?

Direction of force: Toward the palm. Action: Mobilize the scaphoid between the radius and distal row of carpals. Positioning: The therapist's thumbs are on the dorsal aspect of the scaphoid. The fingers are on the palmar side of the scaphoid. Movement: Glide the scaphoid up and down / dorsally-palmarly. This technique can be used for any of the carpal bones. *Assists with restoring wrist flexion.

Hand Accessory Motion Testing Medial - lateral tilt (aka Stress Tests of Phalangeal Collateral Ligaments or Valgus/Varus Stress) what does it assist?

Direction of force: Valgus or varus stresses Action: Tilting of the joint. Positioning: The hands create a fulcrum on the opposite side of the joint to achieve the desired gapping. Movement: Gap the medial and/or lateral side of the joint. Perform at MP, PIP, and DIP joints of the fingers and MP and IP joints of thumb. *In addition to testing the ligaments, this technique also assists with restoring (some) flexion, (some) extension, (more) abduction and (more) adduction of the phalanges.

Posterior Glide of Stenoclavicular Joint (SC Ligament Stress Test) Sternoclavicular and Acromioclavicular Accessory Motion Testing

Direction of force: posterior/downward toward table Action: Moving the clavicle posterior on the sternum Positioning: The thumbs are overlapping and on the proximal/medial end of the clavicle. Movement: Slowly and carefully depress the proximal end of the clavicle. *There is no anterior mobilization of the clavicle. It is too painful for the client to grasp behind the proximal end of the clavicle. The rolling motion described below will glide the clavicle anteriorly.

Wrist Accessory Motion Testing Mid-Carpal Distraction

Direction of force: traction/ distal Action: Distraction of the distal row of carpals from the proximal row. Positioning: The proximal hand stabilizes the proximal row of carpals. The hand position is similar to distraction at the radio-carpal joint except the stabilizing hand has moved one thumb width distal to stabilize just distal to the radius at the joint line. The mobilizing hand is just distal to stabilizing hand over the distal row of carpals. Movement: Separate/distract the distal row of carpals from the proximal.

From 90 degrees of elevation to 180 degrees

Disassociation of humeral and scapular motion is apparent Ratio of glenohumeral to scapulothoracic motion is 2 : 1

Deviation from Typical: Humeral superior glide: Short muscle(s) Long (potentially weak) muscle(s)

Distal end of the humerus is lateral to the proximal end; subacromial space may be lessened short: Deltoid, infraspinatus, teres minor, teres major, and subscapularis; joint capsule is stiff long: Rotator cuff muscles are weak, but not necessarily long

Soft tissue manual therapy: use for lateral/medial epicondylitis

During your physical examination in which you palpated the various muscles that could be involved with epicondylitis, you likely noted any changes in tissue tension, as well as the existence and location of trigger points. Choose a few of the structures associated with lateral and medial epicondylitis and treat via the following manual therapy techniques: Bowstrining MFR direct release of any noted trigger points MFR along fascial lines Ward-Greenman Remembering the cardinal rule of manual therapy (always prescribe at least one exercise), be sure to do so in conjunction with the soft tissue work.

At 180 degrees of elevation

Extension of the thorax contributes the final few degrees of GH flexion Scapular abduction contributes to the final few degrees of GH abduction

________________________ is a soft tissue that is composed of collagen, elastin, and a polysaccharide gel-like ground substance. It surrounds every muscle of the body and is believed to provide support to other soft tissues, enable adjacent structures to move upon each other, and to help absorb and disperse shock throughout the body

Fascia

International Classification of Function (ICF) model provides a helpful progression of: Body Structure & Functions > Activity > Participation

First, treat any inflammation/pain that may be present > then work to optimize ROM > enhance muscle length > enhance muscle strength > improve posture > replace habitual postures or movements with better ones > optimize normal movement patterns > return to daily routines important to the patient (those items listed/associated with the Patient Specific Functional Scale) in the appropriate contexts and environments

The Direct Method of MFR

For each direction, determine which ones place the fascia in a more-tightened position (you may feel this as increased resistance, or your patient will report that this reproduces their pain). Load the fascia by moving into each of these three positions. Gently have the patient provide a counterforce to your compression by contracting the muscle. This may be achieved by slow deep breathing or by direct contraction of the muscle. Do not let up on your compression as the patient provides counterforce. Have the patient relax. At this point you will usually feel a "release" where the tissues become more relaxed. Reevaluate the tension of the tissue as before, and repeat the process two to five more times. Hanten, Olson, Butts, and Nowicki (2000) suggest that stretching a muscle following trigger point treatment is necessary to provide longer pain relief.

rules for splint making

Forearm trough is 2/3 distance of FA and ½ width. Distal palmer crease is free for full MP motion. Thenar muscles and joints are unrestricted. Wrist is restricted from flexion and is fully supported by the splint. The straps adequately hold the extremity within the splint; proper strap widths were used. No obvious areas of pressure are noted.

The course of the Radial Nerve

Forms as a terminal branch of posterior cord (along with the axillary nerve) just distal to the coracoid process on anterior surface of subscapularis. Enters the posterior arm with the deep brachial artery just inferior to trees major, between the long & medial heads of the triceps and follows the radial groove. Upon exiting radial groove, it pierces the lateral intermuscular septum to enter the anterior compartment, where it lies between the brachialis & brachioradialis. It crosses anteriorly over lateral epicondyle (where it can be injured in epicondylar fractures). Just past this, the superficial radial n. splits off to go to wrist.

PROM: Key Accessory Motions Associated with Elevation glenohumeral joint

GH distraction* Inferior/downward glide of humerus Up to 90 degrees: Infraspinatus, teres minor, and subscapularis cause depression of the humeral head in the glenoid fossa - for this to occur, you must have length in the inferior glenohumeral joint capsule to allow inferior/downward glide of the humerus Posterior glide of humerus* (contributes to shoulder flexion) Anterior glide of humerus* Medial rotation of humerus* Lateral rotation of humerus Up to 90o: Infraspinatus and teres minor cause lateral rotation of the humeral head

Distally derived scapular dyskinesis can involve (all in red font, because we address all of these in this course):

Glenohumeral instability Labral tear or detachment Impingement Capsular hypermobility (laxity) or hypomobility (tightness) Tendonitis Adhesive capsulitis Rotator cuff strains/tears AC and SC sprains -instead of distally think "inner"

The five grades of joint mobilization as described by Maitland:

Grade I Small amplitude sustained or oscillatory movement performed at the beginning of the range of joint motion. Used to treat pain. - Grade II Large-amplitude sustained or oscillatory movement performed within the range but not reaching the limit of the range of joint motion. It can occupy any part of the range that is free of any stiffness or muscle spasm. Also used to treat pain. - Grade III Large amplitude sustained or oscillatory movement performed into resistance or up to the limit of the range of joint motion. Used to maintain ROM. - Grade IV Small amplitude oscillatory movement performed into resistance or up to the limit of the joint range of motion. Used to increase ROM. - Grade V Low amplitude, high velocity thrust performed at the limit of the joint range of motion (non-oscillatory) (This is a manipulation). Also used to increase ROM.

Test for Gamekeeper's Thumb / Test of the Ulnar Collateral Ligament of the Thumb

what type of strengthening activities should you have someone with lateral/medial epicondylitis perform?

Gripping/hand strengthening exercises/activities are also an important part of the person's rehabilitation program. With people who have epicondylitis, it is important that they consider their elbow and wrist position while performing the activity that involves gripping (a neutral position is typically recommended). Using equipment at your disposal, practice gripping exercises/activities with the elbow and wrist in various positions (neutral, flexion, extension, etc.) and palpate the target muscles to determine which joint positions increase the muscular contraction and which ones decrease it.

Test of the Wrist Extensors / Tennis Elbow Test (Cozen's test):

Have the patient pronate her forearm, then actively extend and radially deviate the wrist while the therapist applies resistance. Pain of the wrist extensors (usually the extensor carpi radialis brevis) indicates a positive sign. The therapist should palpate the entire wrist extensor group from origin to insertion to determine the exact location of pathology -pronate, extend, radially deviate

Part I: Diagnosing Glenohumeral Hypermobility __________ is greater than normal motion at a joint. Some individuals can have some degree of joint laxity, which is a normal quality of joints and is the clinical ability to passively translate the humeral head on the glenoid. ___________________ is a pathologic problem in which an individual has increased joint mobility and does not have the ability to stabilize the joint via muscular action.

Hypermobility Shoulder instability

degree of ligament sprain

I (mild) Some stretching or tearing of the ligamentous fibers Mild pain, little or no swelling, some joint stiffness, minimal loss of structural integrity, no abnormal motion, minimal bruising. PROM findings> painful, but no loss of joint integrity. Some tenderness to palpation along course of ligament. Minimal functional loss, early return to activity, some protection may be necessary II (moderate) Some tearing and separation of the ligamentous fibers Moderate to severe pain, joint stiffness, significant structural weakening with abnormal motion, often associated with hemarthrosis and effusion. PROM findings> painful with moderate to significant joint instability. Tenderness to palpation along the course of the ligament. Tendency to recurrence, need protection from risk of further injury, may need modified immobilization, may stretch out further with time III (severe) Total rupture of the ligament Severe pain initially, followed by little or no pain (total disruption of nerve fibers), profuse swelling and bruising, loss of structural integrity with marked abnormal motion. PROM findings > severe joint instability, possible pain in the surrounding tissues. Needs prolonged protection, surgery may be considered, often permanent functional instability

grade 2 sprain (moderate)

II (moderate) Some tearing and separation of the ligamentous fibers Moderate to severe pain, joint stiffness, significant structural weakening with abnormal motion, often associated with hemarthrosis and effusion. PROM findings> painful with moderate to significant joint instability. Tenderness to palpation along the course of the ligament. Tendency to recur, need protection from further injury, may need modified immobilization

ligament grade sprain Grade : II (moderate) Description : Signs and Symptoms : Implications :

II (moderate) Some tearing and separation of the ligamentous fibers Moderate to severe pain, joint stiffness, significant structural weakening with abnormal motion, often associated with hemarthrosis and effusion. PROM findings> painful with moderate to significant joint instability. Tenderness to palpation along the course of the ligament. Tendency to recurrence, need protection from risk of further injury, may need modified immobilization, may stretch out further with time

enhance posture and also begin to flex the shoulder past 90 degrees, upward facing dog

If the person has less than ideal posture (particularly a tipped scapula), you can add the upward facing dog to the quadruped rocking-back/child's pose postures. This is actually a low-level yoga "flow" series that is great at improving posture, and a good set of introductory exercises to address impingement.

The Manual Therapy Rule

In conjunction with manual therapy, you must always prescribe at least one exercise or therapeutic activity to maintain the length you've gained in the muscle you've just treated: This can be a stretch of the target muscle(s) Or, it can be an exercise to strengthen the muscle's antagonist (think muscle balance to resolve postural impairment syndromes) Or, it can be both

Interventions for Glenohumeral Hypomobility (Adhesive Capsulitis)

Keep in mind that patients with adhesive capsulitis/fibrosis of the glenohumeral joint capsule (what Sahrmann calls glehohumeral hypomobility) have little or no scapula-humeral disassociation; as the person tries to elevate the upper extremity with the fairly powerful deltoid, the humerus will 'drag the scapula along for the ride.' Typically there is little or no scapular setting phase and little or no disassociation with glenohumeral capsulitis/fibrosis/hypomobility.

Up to 90 degrees of elevation (both abduction and flexion) _______ and _________ cause lateral rotation of the humeral head during abduction.

Infraspinatus and teres minor

Up to 90 degrees of elevation (both abduction and flexion) _____, _____ and ______ cause depression of the humeral head in the glenoid fossa around 90 degrees of elevation

Infraspinatus, teres minor, and subscapularis

Wrist Sprains and Fractures

Injuries of the wrist comprise 15% of all upper extremity orthopedic problems, with the greatest amount (75%) being sprains (35%) and fractures (40%)(Ootes, Lambers, & Ring, 2012). The most prevalent mechanism of injury is a fall on the outstretched hand.

Assessing for Carpal Tunnel Syndrome

It addition to a history that reveals one or more of the preceding MOI's, the person likely will report or demonstrate a positive "Flick Sign." The physical examination for CTS includes all elements, emphasizing: MMT: strength testing of the abductor policis brevis is one of the best tests for ruling it in and ruling it out CTS (sensitivity and specificity both of 66%). Test for Abductor Pollicis Brevis Weakness: this test assesses for loss of strength in the abductor pollicis brevis, a muscle solely innervated by the median nerve. Weakness in the muscle is highly correlated with carpal tunnel syndrome, caused by compression of the median nerve. To perform this test, the patient places the touch pads of the thumb and small fingers together. The therapist then applies a strong posteriorly directed force at the thumb interphalangeal joint toward the metacarpophalangeal joint of the index finger while instructing the patient to give maximum effort to keep the touch pads together. The test is positive if the therapist detects weakness. Neural Assessment: Check cutaneous sensation in the hand. By now, you should be able to identify the median distribution for sensation of the hand. Further, a person with CTS will likely have a positive median nerve tension test in one or both positions, with the symptoms likely being experienced at the wrist. ULTT1 ULTT2 Swelling/Edema: Question - can you measure swelling/edema with CTS? If yes, what is the best method for doing so? -- volumetric or circumferential Special Tests / Differential Diagnosis Tests: abdcutor polliics brevis, sqaure shaped wrist

Knowing that people with Grade II or III sprains may have ligamentous laxity due to the injury, it is important for clinicians to be very thoughtful about whether they perform joint mobilization to gain accessory motions into radial and/or ulnar deviation.

It may be better to leave those motions somewhat "tight" or hypomobile via the scar tissue that the body has laid down along the course of the injured ligament. Otherwise, the "adhesion" that you might break free with your Grade III or Grade IV joint mobilization might very well be the only thing that was providing stability to the injured ligament. The clinician can certainly mobilize the other limited joint accessory motions as necessary to restore ROM and function. Very often, however, the person's routine activities of daily living and use of their hands will provide ample mobilization forces that will help to restore passive and active joint motion.

UE Pattern 2: what are the directions? what movements does this hit?

Lateral Rotation & Flexion "Stand in a tall position with your feet together and toes pointing forward. Take your arm and reach up and behind your head toward the top of your opposite shoulder blade." Watch for scapular dyskinesis. Able to touch spine of right/left scapula?

_________________ (a.k.a. "tennis elbow") is irritation of the common origin of the wrist extensors usually due to repetitive or sustained wrist extension, with or without combinations of pronation/supination or heavy gripping.

Lateral epicondylitis the radial tunnelsyndrome is more distal and tingling at arcade of froshe

Labral Tear Tests

Load and Shift Test for Shoulder Instability? Anterior Slide Test for Glenoid Labral Tear: Active Compression Test / O'Brien's Test for SLAP Lesion: Crank Test for Glenoid Labral Tear:

The five grades of joint mobilization as described by Maitland: Grade V

Low amplitude, high velocity thrust performed at the limit of the joint range of motion (non-oscillatory) (This is a manipulation). Also used to increase ROM.

shoulder impingement notes

MOI: posture, repeated overhead movement, acromion hurts past 90 degrees lateral shoulder hurts local pain does not tingle, if it pop means labral tear endfeel- typically muscular. capsular or empty end feel

Joint Motion with Typical Ranges hand (extension-flexion) MP (45-90) PIP (0-100) DIP (0-90)

MP () PIP () DIP ()

Testing cutaneous sensation of dermatomes Instructions for Sensory Testing (Light touch & pain/sharp-dull) grading scale

Make note of any areas of altered sensation on the dermatome chart. Give points to each area touched as follows: 2 = normal 1 = impaired/diminished 0 = absent/no sensation Divide the sum of the points attained by the sum of possible points (if you assessed ten areas, divide by 20); then record the percentage.

Positive findings on these tests could indicate median nerve or anterior interosseous nerve involvement:

Median nerve tension testing (two test positions) Test for pronator teres syndrome Tests for carpal tunnel syndrome: Square shaped wrist, abductor pollicis brevis weakness Test for compression of the anterior interosseous nerve ("a-okay" sign) Correlate differential diagnosis testing with sensory testing (numbness/tingling along median nerve distribution):

The indications for manual therapy

Mild pain A non-irritable condition Intermittent musculoskeletal pain Pain that is relieved by rest, or by particular motions or positions -trigger points -muscle tightness -adhesions (chronic inflammation, scar tissue) -lengthen short muscles -improving posture -improving function

Proximally derived scapular dyskinesis can involve (elements in red font reflects those addressed in this course):

Neural pathology (long thoracic, spinal accessory, or dorsal scapular) Postural dysfunction including head forward, thoracic kyphosis, and/or scoliosis Lumbopelvic (core) weakness Weakness in scapular synergy muscles (upper trapezius, lower trapezius, serratus anterior) Pectoralis minor shortness/contracture

Assessing the Wrist for Sprain and or Fracture

Observation. Individuals with sprains and fractures will demonstrate swelling and loss of function. Wrist fractures likely will exhibit atypical alignment or angulation. Remember that you can quantify swelling (edema) with circumferential measurements or with a volumeter. Palpation (people with sprains will have discomfort with pressure/palpation along the course of the injured ligaments, however, they are able to tolerate it; those with fractures will have significantly greater pain and likely will not tolerate palpation. Take a few moments to palpate the following structures: 1) radial and ulnar collateral ligaments, 2) the distal radius and ulna, 3) the scaphoid bone. AROM. Sprains will likely cause discomfort or pain at the end of motions that stress the injured ligaments; motions that do not stress the ligament typically are not painful or at least much less painful. People with wrist fractures will have significantly greater pain with all wrist motions. Individuals with notable atypical angulation of the wrist and/or extreme discomfort with palpation or active motion, should have radiographs taken and fracture ruled-out before further physical assessment. If a fracture is present, the person is immobilized for the proper length of time. Remember that fractures of the scaphoid bone will necessitate immobilization of the thumb as well as the wrist (thumb spica cast or splint). PROM. Ligament stress testing of the radial collateral and ulnar collateral ligaments reveal laxity or hypermobility along with some degree of discomfort with people who have sprains of the wrist. End-feel for less severe sprains are firm/leathery/ligamentous in nature, whereas for more severe injuries it is either muscular (spasm) or empty. RROM: It is not uncommon, particularly with FOOSH injuries, for patients who have ligamentous sprains to also have strains of the muscles that cross the wrist. Resisted testing of the various wrist and finger flexors and extensors will easily rule in or rule out muscular injury that exist along with the sprain(s). Activity Assessment: Always assess the impact of the wrist sprain on the person's ability to perform functional tasks that are important to them. Although important with all upper extremity injuries, it is imperative to know if the person's dominant hand/wrist is involved.

Treating finger and thumb sprains involves protecting the injured structures and allowing them to heal in the timeframe required based on the degree of sprain.

Often times "buddy taping" in which the injured digit is taped to a neighboring un-injured digit is a great way to protect the part without needing a splint. Mild compression wrapping with Koban or similar elastic bandage can help with any edema that is present. trying to make the tape act as a ligament

Restore Reaching Synergies

Once you have begun to establish strength in individual muscles, you can then begin to strengthen them as groups in the context of actual reaching activities. Practice the following exercises, which provide a progression from lower level to higher level activity. Recall that the goal of these exercises is to regain/maintain normal biomechanics of elevation, which includes appropriate use and timing of scapular and glenohumeral muscles. If you are using these exercises with a patient who has had soft tissue injury (tear or post-operative), consider tissue healing times and when it would be appropriate to introduce these exercises. Also: if you have not gained adequate joint mobility or muscle length and strength, your patient will not be successful.

Precautions for joint mobilization

Osteoporosis Pregnancy History of malignancy Signs of neurological involvement (stroke, head injury, etc.)

RROM of extensor digitorum

PIP

Alternate Supraspinatus Test / Empty-can Test:

Pain and/or weakness with the Empty can test implicates impingement of the supraspinatus and/or the subacromial bursa: specific impingement test (tendon of supraspinatus and or subacromial bursa) This test is often performed to both upper extremities simultaneously and evaluates for strain of the supraspinatus. The patient is sitting or standing. The therapist places the patient's upper extremities in a position between 90 degrees of forward flexion and 90 degrees of abduction. The elbows are straight. The arms are then internally rotated so that each thumb points toward the floor. (dumping a can) The therapist applies resistance downward. Pain in the supraspinatus and/or weakness or inability to hold against resistance indicates a positive test. -scaption -thumb down -push down scaption and dumping soda

Direct Method of Myofascial Release Along Fascial Lines instructions

Palpate the muscle(s) and identify areas of restriction. You will become skilled at identifying portions of muscles that are tighter than other aspects of the same muscle. Focus your treatment on these areas. Place the muscle in a lengthened position. Place a small amount of fascial release cream ("Fascia-free," "Re-lease," etc.) over the area you are treating. Use sparingly, you're not trying to grease a pig! You should have just enough on the skin that your hands / fingers / thumbs slowly glide, but you still have traction on it. Using a finger, thumb, or the thenar eminence of your hand, apply pressure to the area of restriction and move in line with the muscle fibers. Visualize separating the muscle fibers with your pressure, and repeat the process as much as necessary (typically you won't exceed five minutes unless you're dealing with a large area). Note: This can be a fairly intense release. Watch your patient carefully for indications that you need to "back off." Repeat this process with the muscle in a shortened position. Finally, perform this process a third time. This time, have the patient actively move the part, using the involved muscle(s) while you apply pressure along the course of the restricted muscle fibers. End by removing your hands and have the patient actively move the part. Apply ice if needed. -lengthened position, shortened position, actively moving position -parallel with muscle fibers

Treating DeQuervain's Tenosynovitis

Perform the manual therapy technique of friction massage perpendicular to the tendons in the "anatomic snuff box." Then perform a variation of the "Norwegian pump" technique: apply a proximal traction on the bellies of the muscle as the patient actively ulnarly deviates the wrist. Follow up with myofascial release along fascial lines. Question: Because this pathology typically involves significant inflammation, therapists may use ice massage and/or pulsed ultrasound as an adjunct to therapy. Which modality would you use prior to manual therapy and which one would you apply following manual therapy? Certainly, the key to successfully treating DeQ's syndrome is to identify the mechanism of injury and remove or modify the activity that caused it. If the MOI is work-related, recall the "industrial athlete" approach to teaching the patient to warm up and stretch before work, stretch as needed while working, and cool-down or ice afterwards.

Special Tests for Neural Compression Compression of the ant. interosseous

Pinch-grip test

As you are performing open-chain elevation such as the preceding Scaption exercise, you can also introduce closed-chain general integration exercises (which not only benefit the upper extremity, but the core and lower extremities as well). Practice the general integration exercises below, which are higher-level versions of the quadruped rocking back > child's pose > upward facing dog exercises. These can also become a "flow series" in which you seamless transition from one position to the next to the next and back again. plank upward-facing dog -downward facing dog

Plank Hold your body in the push-up position. Be sure your hands are directly under your shoulders. Keep your legs, pelvis, and back in one straight line. Hold for 30 seconds, repeat three times. Upward Facing Dog Lying on your stomach on the floor, push up so that your back is arched (but not to the point of any pain), and your weight is evenly distributed between your thighs and your two hands. Your hands should point forward, and be directly under your shoulders, with elbows straight. Squeeze your shoulder blades together and let them slide down toward your bottom. Hold for 30 seconds and repeat three times. Advanced: bear weight through your hands and the tops of your feet. Downward Facing Dog From the upward facing dog position, push back and raise your bottom into the air. Step your feet back or your hands forward, if needed. Concentrate on bringing your heels to the floor as you push into the floor with your hands. As you breathe out, gently pull your sternum toward your thighs, allowing your shoulders to sink lower and stretch. Hold for 30 seconds and repeat three times.

Joint Motion with Typical Ranges Forearm Pronation () Supination ()

Pronation (0 - 80) Supination (0 - 80)

The Radial Nerve: Diagnosing and Treating Compression/Entrapment Positive findings from the physical exam that could indicate radial nerve involvement include:

Radial nerve tension test Weakness of the wrist extensors Numbness/tingling along radial nerve distribution

Progress to Active Exercises to maintain gained ROM through exercise/activity prescription -helps with impingement

Recall that as you gain improved postural alignment and range of motion and the patient is ready to progress from lower level and/or assisted exercises, you should begin by strengthening the scapular muscles, then progress to strengthening the glenohumeral muscles

Practice activities important to the patient

Recall that the ultimate goal of the rehabilitation process is helping patients to achieve their desired outcomes. Having patients perform the activities related to these outcomes (listed on the patient specific functional scale on the intake form) are the final phase of rehabilitation. It is possible that therapists may have to help patients modify/adapt the activities (either short term, or permanently). Future courses will help student therapists to perform an activity analysis, which helps to identify the components and requirements of various functional activities. Although we will not practice this aspect of rehabilitation in this course, please do not lose sight of its extreme importance.

De Quervain's Tendonitis/Tenosynovitis

Recall that this problem involves inflammation of the tendons and the sheath around the Abductor Pollicis Longus and Extensor Pollicis Brevis, producing distal, radial, dorsal wrist pain. Mechanism of injury is repetitive abduction and extension of the thumb (such as with cutting with scissors), and sometimes repetitive radial and ulnar deviation (as with hammering). The person will have distal radial wrist pain in the "snuffbox" that can range from dull and achy to sharp and radiating (down to the thumb or up into the forearm).

Glenohumeral Hypomobility (Adhesive Capsulitis)

Recall that typically individuals who develop glenohumeral hypomobility have an underlying pathology (impingement, rotator cuff injury, and humeral fractures are very common) that produced pain and some degree of inflammation. These two problems, combined with immobilization (whether by necessity to allow healing to occur, or simply by choice because to move the arm produced pain) leads to capsular fibrosis and loss of motion (hypomobility).

Treating Lateral and Medial Epicondylitis

Rest: can be achieved by simply removing or modifying the MOI /aggravating activity. It can also involve use of a custom or over-the-counter splint. Ice massage is a great way to provide cryotherapy with epicondylitis. radial head mobilization soft tissue manual therapy inhibitory strap/taping gripping and hand strengthening exercises

Part IV: Treating Lateral and Medial Epicondylitis

Rest: can be achieved by simply removing or modifying the MOI /aggravating activity. It can also involve use of a custom or over-the-counter splint. Ice massage is a great way to provide cryotherapy with epicondylitis. weeks 1-2 -ice and avoiding provoking activities -30-45 degrees wrist extension splint (for tennis elbow) -eccentric extensor contraction exercise, manipulation, soft tissue work -iontophoresis -steroid injections weeks 3-6 -increasing functional gains (ability to return to work) -myofascial release and manipulation of elbow structures -rapid transition to self-management using eccentric resistence contraction exercise and massage weeks 7-8 and beyond good improvement- condition should be mostly resolved and primarily self-managed if inadequate improvement - persistent pain - need more activity modification - if not then consider other diagnosis

Deviation from Typical: Elevated scapula (super angle elevated, along with acromion): Short muscle(s) Long (potentially weak) muscle(s)

Scapula sits higher than T2 - T7. short: upper trapezius

Deviation from Typical: Elevated scapula (superior angle elevated, but not acromion): Short muscle(s) Long (potentially weak) muscle(s)

Scapula sits higher than T2-T7 but acromion stays level; may have slight downward rotation. short: Levator scapula long:

series of serratus anterior strengthening exercises reflects a progression from less difficult to more difficult.

Serratus punch at 120 degrees flexion Lie on your back with a weight in your hand (use the amount of weight prescribed by your therapist). Your shoulder should be at 120 degrees of flexion (pictured). Slowly and with control, punch your hand/arm toward the ceiling. If you feel your shoulder blade "winging" or lifting off the thorax/your back, stop and correct it. Slowly return to the starting positon. Perform 15-20 repetitions, twice a day. Wall Push-up: Perform this exercise in standing, doing the push-up against a wall. In addition to straightening your elbows, be sure that a good part of the movement happens by sliding your shoulder blades forward off your trunk toward the wall. Hold for ten seconds, then bend your elbows, lowering yourself toward the wall. Work up to 30 repetitions, two times a day. Push-up plus: Start in the plank/push up position, either with knees on the floor (slightly easier) or off (more challenging). Assure that the hips are not raised toward the ceiling or sinking to the floor. As you lower your torso toward the floor, allow your shoulder blades to move toward each other (retraction); as you raise your torso up and your elbows straighten, push your hands into the floor and push your back toward the ceiling - this causes your shoulder blades to separate and your shoulders to slightly round (protraction). The key to this movement is scapular retraction and protraction to strengthen the serratus anterior muscle - the actual push up is secondary. --Variations of this exercise: You can perform this in the seated position (left) or with your forearms on the floor instead of hands (elbow push up plus, below). Note that the elbow push up plus exercise increases pec minor activity, which you may want to avoid if the person has a tipped scapula posture. Dynamic Hug Stand with resistance band or cable at shoulder level behind you. Press your arms outward and forward in a sweeping motion similar to giving someone a big hug. Hold the arms at end position for a count of five, then slowly return to the starting position. Emphasize scapular protraction (serratus anterior) and avoid shoulder elevation (upper trapezius). The first part of this exercise (moving into the hug) is concentric activity, holding the position is isometric, and returning to the starting position is eccentric. Foster smooth, controlled movement during each phase of this exercise

Pinch gauge

Similar to the hand-held dynamometer, pinch gauges can be used to assess strength of the pad/tip pinch, the lateral/key pinch, and the chuck/tripod pinch. Note where to record your findings on the Upper Extremity Orthopedic Evaluation Form. Normative values by age and gender have been for both hand-held dynamometers and pinch gauges.

goal of these exercises is to regain/maintain normal biomechanics of elevation, which includes appropriate use and timing of scapular and glenohumeral muscles. Weight-reduced Reaching:

Sit in a chair holding a dowel rod (or crutch, or broom handle) with your hand at shoulder level. Reach forward until your elbow is fully extended, being sure not to shrug your shoulder as you do so. Slowly return to starting position. Progress this exercise by placing your hand higher on the dowel rod with each repetition. If you note discomfort, discontinue this exercise until you discuss with your therapist.

0 - 30 degrees of abduction/ 0 -60 degrees of flexion __________ is the primary abductor, then middle deltoid begins to become prime mover at 15 - 30o.

Supraspinatus

rotator cuff rehab External rotation (phase V/weeks 17-26):

Sit or stand comfortably, with your back straight, arm out to your side (at a 90 degree angle or slightly less), elbow bent to 90 degrees as well, holding a piece of theraband or theratubing in your hand (the theraband should be fixed to something directly in front of you, such as in a securely closed door). Move slowly such that your arm rotates back (external rotation), hold for 10 seconds, then slowly return to the starting position. Be careful to assure the motion is happening at the humerus and avoid substitutions such as leaning backward, extension of the trunk, etc. Work up to 30 repetitions, two times a day

As you know by now, sustained postures can lead to scapular and humeral impairments. We've spent a great deal of time thinking about standing and sitting postures and it is important to think of another posture that we tend to spend about six to eight hours (some more, some substantially less) in every night:

Sleep position.

The five grades of joint mobilization as described by Maitland: Grade IV

Small amplitude oscillatory movement performed into resistance or up to the limit of the joint range of motion. Used to increase ROM. -

The five grades of joint mobilization as described by Maitland: Grade I

Small amplitude sustained or oscillatory movement performed at the beginning of the range of joint motion. Used to treat pain. -

sprain grade I (mild)

Some stretching or tearing of the ligamentous fibers Mild pain, little or no swelling, some joint stiffness, minimal loss of structural integrity, no abnormal motion, minimal bruising. PROM findings> painful, but no loss of joint integrity. Some tenderness to palpation along course of ligament. Minimal functional loss, early return to activity, some protection may be necessary

As assisted elevation/reaching becomes easier and you and the patient have eliminated substitutions, then progress to active, open-chain flexion, abduction, and scaption. From here, you can begin to add resistance (weights, bands, etc.). scaption

Standing with tubing or weight in your hand, thumb pointed upward. Position your arm at a 45-degree angle to your body (halfway between abduction and flexion). Raise the arm up to shoulder level and pause, then continue to raise it upward. If this exercise causes discomfort, discontinue it until you can speak to your therapist. When moving up to at least 120 degrees of elevation, this exercise strengthens the upper trapezius, anterior and middle deltoid, lower trapezius, serratus anterior, supraspinatus, and infraspinatus

enhance posture and also begin to flex the shoulder past 90 degrees, Quadruped-rocking-back exercise:

Start in quadruped, with your hands directly under your shoulders, knees directly under hips. Gently press both hands down into the table/floor (this facilitates a slight downward glide of the humerus and is a key part of this exercise). While maintaining your pressure into the table/floor, slowly rock back, bringing your bottom toward your heels (this automatically causes the shoulders to flex). Patients can work up to performing this exercise for two to three minutes, twice a day.

When you perform RROM via an isometric resisted test, the responses you are looking for are: grades of muscle strain

Strong and painless: no pathology Strong and painful: minor injury of the muscle-tendon unit - either exercise-induced pain, Grade I or mild Grade II strain. Use the patient history to determine if the problem is exercise-induced (related to recent increase in activity), or Grade I or mild Grade II (usually related to some type of trauma; mild Grade II strains might show very slight weakness as compared to the opposite side, or may be strong but with a patient report of greater pain). Weak and painful: major injury/ partial thickness tear of the muscle-tendon unit - either moderate or severe Grade II strain. The degree of pain and/or the extent of weakness determines moderate vs severe. Weak and painless: major injury/ full thickness tear of the muscle-tendon (Grade III strain) unit OR the person has a neural deficit (injury to the motor nerve supplying the muscle > correlate with neural testing).

The Patient Intake Form

Students will likely use this or a similar form in clinical practice to collect preliminary information from patients, who fill it out when they first arrive to the clinic and prior to meeting the therapist. This form contains questions that collect information about the problem(s) in the patient's own words, screening questions related to the various systems that could indicate problems that fall outside the clinician's scope of practice, as well as medications. It also contains the Patient Specific Functional Scale (PSFS), which is a standardized means of establishing activities important to the person and baseline measures of perceived ability to perform them

Locate/palpate areas of potential radial nerve compression/entrapment:

Subscapularis Triceps (lateral head) Between brachialis and brachioradialis Tendinous origin of extensor carpi radialis brevis Tendinous origin of supinator (the Arcade of Frohse) Distal aspect of supinator

pain going down arm

TOS neural entrapement cervical spine

Sprains of the Joints of the Fingers and Thumb

The MOI for finger and thumb collateral ligament sprains (sometimes called "jammed" finger/thumb) is trauma to the tip of the finger, or sometimes from a fall (usually with a varus or valgus/angulate stress to the ligament). Determine if a fracture is present, applying similar decision-making as you would use to distinguish a sprain from a fracture at the wrist. Assess via PROM/ ligamentous stress testing and grade the injury according to pain and (in)stability as compared to the uninjured side.

when these things are positive, what could be happening? Ulnar nerve tension testing Froment's sign Wartenburg's sign Correlate with numbness/tingling along ulnar nerve distribution -cubital tunnel compression test -also numb pinky and ring finger -dropping items

The Ulnar Nerve: Diagnosing and Treating Compression/Entrapment

At 90 degrees of elevation

The coracoclavicular ligaments (the conoid and the trapezoid) become tight causing the crank-like clavicle to rotate backward, which causes the distal clavicle and AC joint to elevate and allowing the second 'burst' of scapular upward rotation.

Assessing for Ulnar Collateral Ligament Sprain/ "Game-keeper's Thumb"

The differential diagnosis test for this problem is: Test for Gamekeeper's Thumb / Test of the Ulnar Collateral Ligament of the Thumb: Grasp the patient's thumb so that your index finger is just distal to the metacarpalphalangeal (MP) joint of the thumb, and your thumb is over the lateral aspect of the MP joint. Slowly yet firmly create a force couple that stresses the ulnar collateral ligament. A positive test is indicated by pain and/or laxity/sprain of the ulnar collateral ligament. This maneuver can also be performed to assess the radial collateral ligament of the thumb (reverse Gamekeeper's thumb). Grade the degree of sprain by pain and/or instability as compared to the opposite side.

Testing cutaneous sensation of dermatomes Instructions for Sensory Testing (Light touch & pain/sharp-dull)

The environment should be quiet and distraction free. The person should be on a stable surface in the seated or lying position. Instrument for light touch: either a cotton ball or a Q-tip/cotton swab Instrument for pain/sharp-dull: unfolded paper clip or a reflex hammers (some hammers actually have sharp/dull instruments built into them). Explain the purpose of the test, such as: o "I'm going to examine your sensation and your ability to feel light touch. To accurately assess this, it is important that you not guess: If you don't feel anything, please tell me." o "I'm going to examine your sensation and your ability to tell the difference between something that is sharp and something that is dull. To accurately assess this, it is important that you not guess: If you don't feel anything or can't tell the difference between sharp and dull, please tell me." With the person's eyes open and them watching you, gently touch the person with whichever instrument you are using. o For light touch, gently apply the Q-tip to the skin o For pain/sharp-dull, firmly but gently press the sharp end of the paperclip into their skin (but certainly not enough to pierce the skin) and tell them this is "sharp," then touch the subject with the dull end and tell them this is "dull." Ask the person to close their eyes and begin assessing the area to be treated, asking the person to say "yes" if they feel the light touch or say "sharp" or "dull" and have them point to where they felt it. Irregularly alternate the order in which you apply the sharp or dull stimuli. Assess ten areas with at least one being applied to each dermatome of the upper extremity.

Manual Muscle Testing (MMT) Students will learn two different approaches for assessing strength:

The first is a general strength assessment that practitioners use in any early mobility or pre-gait situations to determine if a patient has the needed strength to safely get up and move about. (The general strength assessment is faster because it is performed with the patient in one position (sitting), but this also makes it less-specific and at best is a gross estimate of actual strength in some muscles. When the goal is to evaluate/measure strength in muscles, OTs and PTs must use the standardized testing positions. Both the general and the MMT strength tests use the same application of force/resistance.) The second is a specific test of individual muscles using standardized muscle testing positions.

Up to 90 degrees of elevation (both abduction and flexion) what 4 things happen?

The force couple created by the upper and lower trapezii and the serratus anterior causes the scapula to rotate upward, axis of motion is at the SC joint. Disassociation of humeral and scapular motion is apparent and Ratio of glenohumeral to scapulothoracic motion is 2:1 The costoclavicular ligament becomes taut preventing further clavicular elevation, and the upper trapezius loses its moment arm, causing the axis to shift to the AC joint. Infraspinatus, teres minor, and subscapularis cause depression of the humeral head in the glenoid fossa around 90 degrees of elevation Infraspinatus and teres minor cause lateral rotation of the humeral head during abduction.

Test for the Sternoclavicular Joint:

The patient is sitting or lying supine with the involved arm relaxed. The examiner places one hand on the proximal end of the patient's clavicle and the other hand on the spine of the scapula. The examiner then applies gentle inferior and posterior pressure on the clavicle. The test is positive if the patient has movement and/or pain of the clavicle. Compare to opposite side.

Alternate Test of the Long Biceps Tendon / Speed's Test:

The patient is sitting or standing with the arms resting at the sides. The patient then elevates the humerus to 60 degrees of shoulder flexion with the forearm in supination and a slight degree of elbow flexion. The patient holds this position while the therapist applies resistance against elevation (shoulder flexion). The test is positive if pain is elicited (bicipital tendinitis) or if snapping or slipping is noted (instability of the tendon within the groove). -could also hear snapping of long head of biceps out of groove

Test for the Acromioclavicular Joint / Active Compression Test (O'Brien sign):

The patient is sitting or standing. Examiner asks the patient to flex arm to 90 degrees with the elbow in full extension. The patient then adducts the arm 10 degrees and internally rotates the humerus. Examiner applies downward force to the arm as the patient resists (A). "pour out the soda" Patient fully supinates the arm and repeats the procedure (B). The test is positive if the patient has pain localized to the AC joint (Cleland, 2005, p. 414). Compare to opposite side.

Thoracic Outlet Test for Pectoralis Minor Syndrome / Hyperabduction Test:

The patient is sitting or standing. The therapist continuously palpates the radial pulse on the side being tested. While still palpating the radial pulse, the therapist hyperabducts the upper extremity, placing the patient's hand behind her head, applying overpressure and holding for 30 - 45 seconds. A positive test implicates a tight pectoralis minor muscle

Alternate Test for the AC Joint /Paxino's Test:

The patient is sitting with arm by side. With one hand, the examiner places the thumb over the posterolateral aspect of the acromion and the index finger superior to the mid-portion of the clavicle. The examiner then applies compressive force. The test is positive if the patient reports pain in the area of the AC joint. Compare to opposite side.

Apprehension Test of the Annular Ligament ("Nursemaid's Elbow" Test):

The patient is sitting with the therapist supporting the arm. Gently but firmly grasp the proximal to middle part of the radius and apply a distal/traction force. The test is positive if the patient's radial head subluxes from the annular ligament, or if the patient shows signs of apprehension that it may sublux (older patients might report feelings of the radius "popping out of joint" and younger patients/children might cry or try to stop the test). Compare to the opposite side.

Stress Test of Ulnar Collateral Ligament of the Wrist (also known as Side Tilt of the Triquetrum from the Ulna):

The patient is sitting with the wrist supported on the table. Gently grasp the distal radius and ulna with one hand, and the proximal row of carpals with the other. Apply a force that passively moves the wrist into radial deviation (gapping the ulno-carpal joint). Assess for instability and/or patient discomfort and compare to the opposite side.

Load and Shift Test for Shoulder Instability:

The patient is sitting, with glenohumeral joint in neutral (support the upper extremity with pillows to avoid possible subluxation). The therapist stabilizes the scapula with one hand and seats the humeral head in the glenoid fossa with the other. The therapist then attempts to shift the humeral head anteriorly, posteriorly, and inferiorly. The amount of laxity is graded on the same zero to three scale as the sulcus sign. (The image at right depicts the anterior shift.) 0 = little/no movement 1 = humerus shifts to the edge of the glenoid 2 = humerus shifts over the edge of the glenoid and spontaneously relocates 3 = humerus shifts over the edge of the glenoid, doesn't spontaneously relocate

Anterior Slide Test for Glenoid Labral Tear:

The patient is standing or sitting with hands on hips, thumbs facing posteriorly. The therapist stabilizes the scapula with one hand and, with the other hand on the patient's elbow, applies a force directed anteriorly and superiorly through the humerus. The patient is asked to push back against this force. The test is positive if pain is elicited or a click is noted in the anterior shoulder.

Sulcus sign for Inferior Glenohumeral Instability:

The patient is standing or sitting with the unsupported arm at the side. Grasp the arm and apply an inferior distraction to the shoulder. The amount of laxity is graded on a zero to three scale: 0 = little/no movement 1 = humerus shifts to the edge of the glenoid 2 = humerus shifts over the edge of the glenoid and spontaneously relocates 3 = humerus shifts over the edge of the glenoid, doesn't spontaneously relocate

Test for Posterior Glenohumeral Instability / Posterior Apprehension:

The patient is supine and relaxed as much as possible. With one hand, the therapist passively flexes the patient's shoulder to 90 degrees and allows the elbow to flex, the other a hand is placed on the posterior aspect of the glenohumeral joint to palpate for excessive movement. The therapist then slowly performs a posterior shear of the humerus on the glenoid fossa (pushing down toward the table). Be sure the table isn't hindering posterior movement. Palpable laxity/instability (as compared to the opposite shoulder) and/or patient apprehension is indicative of a positive test. Compare to opposite side.

Crank Test for Glenoid Labral Tear:

The patient is supine while the therapist elevates the humerus 160° in the plane of the scapula. Holding this position, the therapist then applies an axial load to the humerus while passively internally and externally rotating the humerus. The test is positive if pain or a click is noted in the shoulder.

Test for Anterior Glenohumeral Instability / Anterior Apprehension:

The patient is supine with glenohumeral joint at edge of table, scapula supported by the table. The therapist places the patient's shoulder in 90 degrees abduction and 90 degrees of elbow flexion, the progressively externally rotates the humerus. The test is positive if the patient expresses a feeling that the joint might dislocate/sublux (apprehension) or if the therapist notes laxity/instability. Compare to opposite side. -will have a clunky click maybe

Differential Diagnosis Tests for Thoracic Outlet Syndrome: name the tests? when is it positive?

These tests are performed to differentiate which structures are causing an impingement of the neurovascular bundle of the thoracic outlet. A test is positive when the radial pulse is significantly diminished or obliterated and is accompanied by pain or numbness of the upper extremity. A diminished pulse in and of itself is not a positive test. When based solely on a diminished radial pulse, these tests are unreliable, since pulse alterations may be found in a high percentage of asymptomatic individuals 1. Thoracic Outlet Test for Tight Anterior Scalene / Adson Maneuver: 2. Thoracic Outlet Test for Costoclavicular Syndrome: 3. Thoracic Outlet Test for Pectoralis Minor Syndrome / Hyperabduction Test: 4.Thoracic Outlet Test for a Cervical Rib / Halstead Maneuver

Test of the Median Nerve / Test for Pronator Teres Syndrome:

The patient sits with the elbow flexed to 90 degrees. The therapist strongly resists pronation as the elbow is extended. A positive test is indicated by tingling or paresthesia in the median nerve distribution in the forearm and hand. Muscles supplied by the median nerve may also be affected, including the flexor carpi radialis, palmaris longus, and flexor digitorum muscles. If pronator teres syndrome exists, the patient will also present with a positive test for the anterior interosseus nerve / pinch grip test

Standardized Testing for Hand-held Dynamometer

The person should be in a seated position with the arm adducted, elbow flexed to 90 degrees with the wrist at 0 degrees of ulnar/radial deviation. Each position should be evaluated using positions 1 through to 5 alternating from dominant to non-dominant hands. Record the pounds or kilograms of force produced at each setting (the pounds measurements are on the outside of the force dial, while kilograms measurements are on the inside of the force dial). For a more accurate reading, it is recommended that three (3) readings be taken for each position on each hand and the average of the results be used. Observe that the person is not using accessory movements of the wrist, arm, shoulder, or trunk to produce additional effort during the performance of this evaluation.

The General Strength Assessment

This is performed with the patient in the seated position and should be conducted before getting a person up for the first time. Therapists should screen patients using this general assessment with every patient whom they suspect could have mobility issues. This screen will also help you to determine if the person might benefit from an assistive device such as a wheelchair, walker, or cane. If you identify a strength deficit in a particular muscle (such as in the gluteus maximus), you would want to follow up at some point (soon, but probably not in the same visit) with a specific MMT, placing the person in the standardized testing positions. Again, it is critical that student therapists realize that this general strength assessment should never substitute for the more-specific MMT. They should view it as a pre-mobility/gait training screen.

Observation: General mobility and postural assessment

This is the first step of any musculoskeletal assessment; adapt the motto of "Eyes wide open." Effective practitioners are always observing the people they are working with. Observe for guarding and/or use of injured upper extremity - is this the patient's dominant arm/hand? Also note color, temperature, the presence of sweating, hair growth patterns, and/or any scars.

rotator cuff rehab Body Blade Exercise (phase III/weeks 8-12)

This piece of exercise equipment uses rhythmic - oscillating motions of the plastic weighted blade to facilitate muscular co-contraction in the upper extremity and trunk. It is particularly helpful in achieving scapular stabilization. The body blade can also promote increased patient attention to proprioceptive and kinesthetic feedback. Use the body blade to maintain arm position as it oscillates; begin by holding it with both hands in the cardinal planes of motion and then work into diagonals. Progress from bilateral motions to holding the blade with one hand.

Ward- Greenman Direct and Indirect Techniques for Myofascial Release

This technique emphasizes use of the hands to introduce compressive and twisting forces on the tissues to effect a release/relaxation response. Therapists can apply this technique to any muscle or area of fascial restriction. Often times, Ward-Greenman works well after direct MFR techniques have been used, given that it is typically less intense for the patient and fosters greater relaxation prior to the conclusion of manual therapy.

Test of the Long Biceps Tendon / Yergason's Test:

This test evaluates for bicipital tendinitis and/or instability of the long head of the biceps tendon in the bicipital groove and/or tearing of the transverse humeral ligament. -could hear snapping of the tendon out of the groove The patient is standing or sitting with the elbow of the side to be tested flexed to 90 degrees. The therapist applies distraction to the glenohumeral joint by pulling downward on the elbow. The patient is then asked to flex the elbow and supinate, while the therapist resists these movements. (therapist tries to extend and pronate and external rotate) At the same time, the therapist passively moves the arm into external rotation. The test is positive if the patient has pain (indicating bicipital tendinitis), and/or if there is "slipping" (often accompanied with a "snapping") of the biceps tendon out of the bicipital groove (indicating instability of the tendon in the groove and/or a tear of the transverse humeral ligament).

Hawkins / Kennedy test for Shoulder Impingement:

This test is non-specific for impingement of the subacromial bursa, biceps tendon, or supraspinatus tendon. The patient is standing or sitting. The therapist passively places the person's arm in 90 degrees of forward flexion, then maximally internally rotates the humerus. The test is positive if the patient experiences pain in the subacromial space, which is indicative of impingement on one or more of the three structures.

Ulnar Collateral Ligament Sprain: "Game-keeper's Thumb"

Typical mechanism of injury is a fall onto thumb or from using a ski pole (both of which are more acute in nature), or weight lifting with a tight grip using the thumb (more overuse or chronic in nature). As with most sprains, the person will have tenderness to palpation along the course of the ligament. Some inflammation or swelling may be detectable as well.

Correlate findings from dermatome, myotome, and DTR testing:

Unless variables such as cognitive deficit or symptom creation/magnification are influencing the examination, involvement of one spinal nerve root causes deficits in cutaneous sensation, motor output, and deep tendon reflex (if there is one associated with the spinal nerve) that you can triangulate with one another. For example, involvement of the C5 spinal nerve would produce decreased sensation at the region of the distal middle deltoid, which would also test weak, and the patient would have an altered biceps DTR.

Testing cutaneous sensation of dermatomes -- and applying it to peripheral nerves

View the results of your dermatome sensory assessment by looking at the dermatome chart. Simply overlay the innervation chart for peripheral nerves (below) to determine if light touch and pain/sharp-dull sensation of a particular peripheral nerve is diminished.

major injury/ partial thickness tear of the muscle-tendon unit - either moderate or severe Grade II strain. The degree of pain and/or the extent of weakness determines moderate vs severe.

Weak and painful:

Restoring Accessory Motion at Joints: A Sneak Peek at Upcoming Labs

When therapists assess the active and passive motions (AROM and PROM) at joints, they should note if the motion is typical/"normal" or hypermobile (too much mobility) or hypomobile (not enough mobility). If hypomobility is noted, the therapist should measure how much motion is lost using a goniometer and then determines what is causing the limitations.

Spinal nerve assessment: Dermatomes, myotomes, and deep tendon reflexes (DTRs)

Whereas the cervical spine screen helps to identify spinal nerve involvement, assessment of dermatomes, myotomes, and DTR's can distinguish which particular spinal nerve(s)/levels you are dealing with.

Lateral Collateral Ligament Stress Testing: Medial Tilt or Elbow Varus Stress Test:

With the patient sitting, flex the elbow to 20 - 30 degrees and, stabilizing with one hand at the humeral epicondyle and the other above the wrist, apply a varus stress to the elbow (which produces an action that will gap the lateral aspect of the elbow). Note: The humerus will tend to internally rotate with this maneuver and requires the therapist to apply an external rotation force with the stabilizing hand. Assess stability by comparing to the opposite side

Medial Collateral Ligament Stress Testing: Lateral Tilt or Elbow Valgus Stress:

With the patient sitting, passively flex the elbow to 20 - 30 degrees and, stabilizing with one hand at the humeral epicondyle and the other above the wrist, apply a valgus stress to the elbow (which produces an action that will gap the medial aspect of the elbow). Note: The humerus will tend to externally rotate with this maneuver and requires the therapist to apply an internal rotation force with the stabilizing hand. Assess stability by comparing to the opposite side.

The "Courtesy stretch" instructions

With the patient supine and fully relaxed, the therapist holds the patient's head with both hands at the occiput. Be careful to have your hand on the occiput, not on the patient's cervical spine. (It is very important that the patient is relaxed, and the therapist is holding the patient's head.) The therapist then begins to apply gentle traction to the cervical spine. Adding slight cervical flexion will increase the sense of a stretch into the patient's thoracic region. Use your body weight (not your hands, wrists, or elbows) by leaning back to generate the traction force. To enhance the stretch, ask the patient to axially extend one or two times, then relax as you continue to perform axial traction.

Wartenburg's sign of ulnar nerve irritation:

With the person's hands resting on a table, ask them to actively spread (abduct) their fingers, then bring them back together (adduct them). Inability to adduct the little finger from the abducted position is due to loss of innervation of the palmar interosseous muscles.

Practice exercises that strengthen the "core" muscles (back extensors and abdominals) that can influence posture and serve a protective function against lower back pain

Yoga: Cat-cow (hands under shoulder, knees under hips) "Bird dog" exercise Variations of the plank exercise Pilates: Leg lowering / external oblique exercise

Bony end feel: may be normal or pathologic

abrupt and unyielding, gives the impression that further forcing will break something. The point in the ROM where the bony end-feel is felt usually determines if it is normal or pathologic. If at the end of the range (such as full elbow extension) it is typically normal, if earlier in the range and abrupt, it is more likely due to a bone fragment in the joint space.

Radial Head Mobilization: -use for lateral/medial epicondylitis

accessory motions/joint mobilization of the radius and radio-humeral and radioulnar joints/articulations can be very helpful in treating lateral epicondylitis. Take a few moments to revisit/practice these motions; appreciating that you can use grades I and II for pain and grades III and IV for loss of motion. Distal shift of radius on ulna (radio-humeral distraction) Rotation of radius on ulna Anterior-posterior glide of radio-ulnar joint (although distal glide is depicted here, treating the proximal aspect can be very beneficial as well )

Trigger points may be __________ (ie: they are symptomatic with respect to pain, usually causing radiating pain when compressed) or __________(clinically quiet with respect to pain until compressed).

active latent

Two of the four sources of TOS are tight muscles (______________ and _________________) A third source is posture-related (______________________). Treatment strategies for these three causes of TOS should include _____________ and ______________________:

anterior scalene and pectoralis minor costoclavicular manual therapy and exercise/activity prescription

The ___________ that the therapists palpates helps to identify the structure(s) that are producing the limitation at a joint. For instance, a muscular end-feel indicates that a tight muscle is limiting full ROM, an empty end-feel indicates that pain is limiting the motion, and a firm-leathery end-feel would suggest that a stiff joint capsule is limiting motion.

end-feel

With the five-position grip dynomometer, graphing the results should show a ______________ curve, with the greatest force being generated at positon _____ (since the patient is using both flexor digitorum profundus and superficialis). A graph that shows a flat line or non-bell curve might indicate a patient who is giving submaximal effort or potentially malingering.

bell-shaped position 3 Do note that specific job tasks performed over time can create stronger forces at different locations in the graph. In these instances, you are still looking for consistency of curve structure and the curves should be consistent in shape comparing right to left hand.

Neural Examination of the Upper Extremity As you can appreciate from your knowledge of anatomy, the spinal nerves of C5 through T1 merge into the trunks of the ___________

brachial plexus, which then differentiate into divisions that form the cords of the plexus. These cords branch into the main nerves of the upper extremity (musculocutaneous, axillary, median, ulnar, radial, etc.). All of this occurs in the space of the neck and chest between the anterior scalene and the pectoralis minor (a region referred to as the thoracic outlet). The brachial plexus then branches into nerves that course through the axilla and into the upper extremity, many of them terminating at the wrist and hand.

Ulnar Collateral Ligament Sprain: "Game-keeper's Thumb" notes

buddy taping - dont do it too tight - tape thumb to pointer finger if it is severe treat: immobilize, strengthen dynamic stabilizers - putty, thenar, adductor pollicis, put putty between thumb and squeeze

swelling/edema

check for cardinal signs of inflammation, if swelling is noted, include girth measurements and/or volumetric measurements -volumetric measurements (hand edema) amount displaced: (put hand in the water conteiner thing until reaches the bottom and measure how much water comes out compare left and right) girth measurements (use landmarks that are easility locatable for tape placement so that you can replicate from one session to the next circumferential measurements: (compare left side to right side) -5 cm down from inferior acromion/joint line -mid-belly of biceps (reflect distance from inferior acromion/joint line) - crease of the cubital fossa -10 cm down from radial head or 10 cm up from radial styloid -distal retinacular crease (base of hand) -base of thumb at CMC joint -MP joint crease -PIP and DIP joint creases

Students should be alert to pitting edema, which typically is related to

chronic swelling in which fluid accumulates in the interstitial tissue. With pitting edema, pressing into the skin produces a "pit" or depression that persists some time after the release of pressure. Clinicians grade the degree of pitting edema using the 1+ through 4+ scale below, based on the approximate number of seconds it takes for the pit to refill: 1+ barely detectable 2+ <15 seconds to refill 3+ 15-30 seconds to refill 4+ > 30 sec to refill -pitting edema is a circulatory issue

Distally derived structures include the Distally derived scapular dyskinesis can involve (all in blue font, because we address all of these in this course):

clavicle, the AC and SC joints, the subacromial space, and the glenohumeral joint. Glenohumeral instability Labral tear or detachment Impingement Capsular hypermobility (laxity) or hypomobility (tightness) Tendonitis Adhesive capsulitis Rotator cuff strains/tears AC and SC sprains

Once you've cleared or implicated the joint above and below the one(s) that you believe is/are restricted, you will then proceed to assess the

end-feel and measure (via goniometer) the ROM of the joint(s) with limited mobility, then examine all the accessory motions at the joint(s)

nerves are __________ structures that arise from the _____ and extend into _________

continuous structures spinal cord and extend into the arm, forearm, and hand. -nerves do sensory, motor and proprioception they are continuous structures from spinal cord (they change names though)

At 90 degrees of elevation The ________ ligaments (the conoid and the trapezoid) become tight causing the crank-like clavicle to rotate ________, which causes the distal clavicle and AC joint to elevate and allowing the second 'burst' of scapular upward rotation.

coracoclavicular backward

factors limiting anterior translation of GH

coracohumeral and superior glenohumeral ligaments - limit external rotation between 0-60 degrees elevation -subscapularis and middle GH ligament - effective stabilizers between 0-90 degrees elevation anterior band of the inferior glenohumeral lig - primary stabilizer above 90 degrees elevation infraspinatus and teres minor - prevent anterior translation of the humeral head in abducted, externally rotated positons (actively pulls it into socket)

Up to 90 degrees of elevation (both abduction and flexion) The ________ ligament becomes taut preventing further clavicular elevation, and the upper trapezius loses its moment arm, causing the axis to shift to the _________ joint.

costoclavicular AC joint

Potential areas of ulnar nerve compression or entrapment:

cubital tunnel via triceps ulnar groove flexor carpi ulnaris (at arcade of froshe) guyon's canal between hamate and pisiform

my elbow hurts

epicondylitis ligament injury (from fall or from throwing)

The mechanisms of neural injury can vary, including

direct trauma, compression by neighboring anatomic structures, or overuse/repetitive motions.

PROM: UE Muscle Length /Flexibility Assessment Medial humeral rotators

do lateral rotation (measure lateral rotation with goniometer)

The scapula plays a key role in upper extremity elevation. Atypical (problematic) scapular movements that occur when the shoulder is voluntarily moved is termed _____.

dyskinesia

The scapula plays a key role in upper extremity elevation. Atypical (problematic) scapular movements that occur when the shoulder is voluntarily moved is termed ___________________

dyskinesia.

myotomes C8 spinal nerve root:

finger flexors / flexor digitorum

capsular pattern Metacarpal-phalangeal (MP) joint:

flexion is most limited, followed by extension

capsular pattern Proximal interphalangeal joint (PIP):

flexion is most limited, followed by extension

i cant move my shoulder

frozen shoulder AROM = PROM ligamentous end feel no dissassocaition capsular pattern what caused it? shoulder impingement, not moving it

If joint capsule stiffness is the limiting factor, you'd address that by _________

gaining joint capsule mobility by restoring the lost accessory motions.

thumb pain what could it be?

game keepers carpel tunnel sprain (radial/ulnar collateral ligament) fracture (x-ray)

"Cat -Cow" instructions

get on your hands and knees on the floor. Make sure your knees are in line with your hips and your wrists are in line with your shoulders. Your lower legs should be parallel with each other and with your hips. Make sure your weight is distributed evenly on all fours. Smoothly round your back upward as your head curls under to create a curve that runs from your buttocks to your neck- this is the "cat with an arched back" (Figure a). Smoothly sway your back down while bringing your head up - this is the "cow with a swayed back" (Figure b). Make these two moves flow continuously back and forth from one position to the other. Do one set of ten repetitions. This exercise works the hips, spine, shoulders, and neck in coordinated flexion - extension. Do 15 repetitions, two times a day.

From 90 degrees of elevation to 180 degrees Disassociation of humeral and scapular motion is apparent Ratio of ________ to __________ motion is 2 : 1

glenohumeral to scapulothoracic

Deviation from Typical: Upwardly rotated scapula: Short muscle(s) Long (potentially weak) muscle(s)

glenoid fossa is higher than superior medial angle of scapula- Spine of scapula and glenoid fossa are oriented up/superiorly short: upper trapezius long: no long muscles

typical postural alignment

head: Neutral (LOG goes through external auditory meatus) c spine:slight lordosis t spine: slight kyphosis shoulder:LOG is just anterior to glenohumeral joint typical scapular posture > - the vertebral border is parallel to the spine and is about 3 inches from it - is situated between T2 and T7 - is flat on the thorax and rotated 30° anterior to the frontal plane. humerus: proximal & distal humeral ends in same plane, Less than 1/3 of humerus is anterior to AC joint, antecubital fossa faces anterior, olecranon faces posterior l spine: typical lordosis Pelvis:neutral - ASIS's PSIS's level, level illiac crests hips:LOG thru greater trochanter, level GTs knees: LOG just in front of knee jt ankle: LOG just in front of ankle jt, rearfoot neutral foot:normal arch

Practice performing manual therapy on the following structures as well as teaching the person how to stretch each one: Subscapularis (along fascial lines) Pronator teres (bowstringing, along fascial lines) Lacertus fibrosis/bicipital aponeurosis (focused bowstringing (aka friction massage), MFR along fascial lines) Wrist flexors and extrinsic finger flexors (MFR along fascial lines, direct TP release, bowstringing, WardGreenman)

helps with median nerve and anterior interossei nerve compression

Prolonged hip flexion can cause shortness of the __________ (combine this with sitting at a desk as another sustained posture, and suddenly you have a person who doesn't extend their hips much at all!)

hip flexors

Maintain Gained ROM through Exercise/Activity Prescription -helps with impingement

if the patient is performing the exercise incorrectly, therapists must identify the issue, then give proper cueing (physical and verbal) to help the patient correct the problem. Recall that effective patient performance of exercises and activities is a reflection of their therapist's time and effort to provide education and feedback With regard to exercise and activity instruction, better than average therapists: Place the patient in optimal posture and alignment before each exercise Give verbal instruction and feedback Give physical cues and feedback, which taper as the patient becomes more independent Emphasize patient successes (catch the patient "doing things right")

factors limiting posterior translation of GH

infraspinatus and teres minor muscles - static stabilizers in all positions of abduction subscapularis muscle - prevents posterior translation oof humeral head on the glenoid inferior glenohumeral lig - most effective stabilizer at 90 degrees abduction anteiror superior capsule - disruption necessary for posterior dislocation to occur

Pilates: Pec minor stretch, plus thoracic extension and lower trapezius strengthening (which will help to improve posture)

lay on ball with arms out

Deviation from Typical: Glenohumeral hypomobilty (Sahrmann's "frozen shoulder"): Short muscle(s) Long (potentially weak) muscle(s)

loss of range of motion in all directions with capsular end-feel. short: All scapulohumeral muscles are short; joint capsule is stiff long: Serratus anterior and lower trapezius are long; rotator cuff is weak

Weak and painful:

major injury/ partial thickness tear of the muscle-tendon unit - either moderate or severe Grade II strain. The degree of pain and/or the extent of weakness determines moderate vs severe.

Enhance posture by addressing scapular and/or humeral impairments. -helps with impingement

manual therapy techniques to gain length in short muscles and exercise/activity prescription to stretch them, along with strengthening the muscles that are long and potentially weak. patient education on good posture/alignment (sternum up, level your head, gently bring your shoulder blades together), which may initially include use of kinesiotape for postural correction. As you make gains in ROM and joint capsule extensibility with joint and soft tissue mobilization, remember the cardinal rule of manual therapy: Always prescribe one or more exercises or activities to maintain the ROM that you have gained.

Similarly, ______________ (a.k.a. "golfer's elbow") is inflammation of the muscles originating off the medial epicondyle aggravated by repetitive wrist flexion, pronation, and gripping, especially in a wristflexed position.

medial epicondylitis

Positive findings on these tests could indicate ________________ or ____________________ involvement: Median nerve tension testing (two test positions) Test for pronator teres syndrome Tests for carpal tunnel syndrome: Square shaped wrist, abductor pollicis brevis weakness Test for compression of the anterior interosseous nerve ("a-okay" sign) Correlate differential diagnosis testing with sensory testing (numbness/tingling along median nerve distribution):

median nerve or anterior interosseous nerve

Test for Abductor Pollicis Brevis Weakness:

median nerve tests (carpel tunnel) this test assesses for loss of strength in the abductor pollicis brevis, a muscle solely innervated by the median nerve. Weakness in the muscle is highly correlated with carpal tunnel syndrome, caused by compression of the median nerve. To perform this test, the patient places the touch pads of the thumb and small fingers together. The therapist then applies a strong posteriorly directed force at the thumb interphalangeal joint toward the metacarpophalangeal joint of the index finger while instructing the patient to give maximum effort to keep the touch pads together. The test is positive if the therapist detects weakness

Strong and painful:

Neer Impingement Test:

neer - arm to the ear This test is non-specific for impingement of the subacromial bursa, biceps tendon, or supraspinatus tendon. The patient is standing or sitting. The therapist places one hand on the posterior aspect of the scapula, then passively forward flexes the shoulder (elbow straight) to the end of the range, then applies overpressure. The test is positive if the patient experiences pain in the subacromial space, which is indicative of impingement on one or more of the three structures. The therapist should use other special tests to rule-in or rule-out which of the three structures is/are involved.

Review and practice the two neural tension test procedures for the median nerve. Recall that some people with have a positive finding with one test and not the other. Appreciate what motion(s) cause the person's discomfort - these will be the ones that you target with your ____________________ exercise.

neural gliding ("flossing")

will you have have a positive radial neural tension test with lateral epicondylitis?

no - but you will with radial tunnel tenderness

Strong and painless: muscle

no pathology

Lateral Epicondylitis / Epicondylalgia / Tennis Elbow notes

normally work related, joint mob distaction treatment: PRICE , ice, dry needling, compress, taping, ultrasound, iontophoresis, splint in 30-45 degrees extension slow, controlled eccentric soft tissue manipulation

Perform compression and distraction of the cervical spine as part of your cervical spine/nerves neural assessment

note if these cause or relieve pain/discomfort. Be careful to keep the cervical and thoracic spine "stacked" atop each other (avoiding cervical flexion or extension) as you perform these maneuvers. Compression narrows the neural foramen through which the spinal nerve roots exit and may cause pain if some type of neural involvement is present (note that this can be from many causes, including disc herniation, spinal stenosis, etc.). Distraction increases the size of the neural foramen and typically decreases pain if neural irritation is present.

manual stretch of levator scapula, patient supine

note: to perform bowstringing, simply use right hand to apply stretch perpendicular to the muscle fibers, to perform stretch and spray technique, use your right hand to sweep the muscle with flourimethane spray while maintaining stretch with left hand

o the joint above is the wrist - assess with AROM and overpressure of wrist flexion, extension, radial and ulnar deviation o there is no joint below. If the joint above or below is also restricted, move on to clear the next joint above or below

Carpal Tunnel Syndrome notes

pain, numbness, tingling overuse: irritation and inflammation, will lay down more tissue they will use the flick sign MOI: chronic, overuse, pregnant (swelling in the extremities) , developed over time, vibration, ergonomic, sqaure shaped wrist, trauma can cause it too limited space compression of median nerve, first three fingers rule out tests: pronator teres syndrome, cervical nerves, anterior interosseius rule in tests: abductor pollicis brevis (push MCP towards base of the index, square shaped wrsit, median nerve tension test, hoffman tinel, compression, volumetric/circumferential edema

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Medial Rotators:

patient lies supine, arms at 90° abduction, elbow flexed to 90°, forearm perpendicular to the table. Have the patient laterally rotate as far as possible, bringing forearm down toward the table. Do not allow the back to arch. Short medial rotators will keep the forearm from touching the table. Measure either the angle of rotation achieved with a goniometer, or the distance from the radial styloid to the table (Kendall, et al., 2005).

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Lateral Rotators:

patient lies supine, arms at 90° abduction, elbow flexed to 90°, forearm perpendicular to the table. Have the patient medially rotate as far as possible, bringing forearm down toward the table. Do not allow the back to arch. Short lateral rotators will keep the forearm from touching the table. Measure either the angle of rotation achieved with a goniometer, or the distance from the radial styloid to the table (Kendall, et al., 2005).

assessing passive range of motion

patient should be fully relaxed tests willingness to move

This technique is called "bowstringing" because the movement of your hands/force is _________________ to the direction of the muscle fibers. Not unlike how a violinist (or fiddler, if you're truly a Midwesterner) draws a bow along the strings of the instrument.

perpendicular Practice bowstringing the following structures: The pectoralis minor The upper trapezius The levator scapula The wrist extensors The pronator teres -typically do 3 minutes of bowstringing

^ Sensory distribution of the main nerves of the upper extremity.

photo

A common site of compression of the ulnar nerve its distal segment in the Tunnel of Guyon (formed by the retinaculum that spans the hook of the hamate and the pisiform bones). The MOI is typically ____________________ Although the evidence makes no recommendation for joint mobilization (ie: the literature is lacking in this area as it relates to efficacy), clinical experience and experts recommend mobilizing the pisiform and triquetrum (along with recommending that the person wear padded bicycling gloves). Review/practice this joint mobilization technique:

prolonged weight bearing (such as when riding a bike).

Position sense/proprioception assessment: -UE Posiiton Sense Assessment (proprioception) -how do you perform a proprioceptive exam

proprioceptive assessment is warranted if the joint capsule and/or ligaments have been injured (such as with a dislocation or sprain) or are otherwise involved - to clinically assess proprioception, the patients eyes are closed and the therapist uses the thumb and index finger to grasp the patients wrist at the region of the ulnar and radial styloids. the therapist then moves the patient UE into different positions and ask the patient to recreate the position at each joint with the opposite side. use further assessment with an isokinetic machine or other proprioceptions measurement device Record by joint the absence or presence of proprioception.

De Quervain's Tendonitis/Tenosynovitis notes

pulsed ultrasound (pain and inflammation), ice massage, remove MOI, cutting, hammering, manuel therapy, assess joint mobility, accessory muscles unloaded AROM, finkelsteins with soft manual therapy, dry needling

RROM of extensor carpi radialis brevis

radial side

The joint capsule - like ligament and sometimes bone - controls the amount of ____________ what end feel?

range of motion present at a joint. It produces a firm, leathery end-feel that is the same as the end-feel produced by ligaments.

Assess any activities that may be re-enforcing poor posture and work with the patient to _______________ and __________________ those postures or movements (beginning with taping for postural correction can help provide those cues when the patient is alone).

recognize and self-correct

Keep in mind that patients with adhesive capsulitis/fibrosis of the glenohumeral joint capsule (what Sahrmann calls glehohumeral hypomobility) have little or no ____________________________; as the person tries to elevate the upper extremity with the fairly powerful deltoid, the humerus will 'drag the scapula along for the ride.' Typically there is little or no scapular setting phase and little or no disassociation with glenohumeral capsulitis/fibrosis/hypomobility.

scapula-humeral disassociation

The Ball-on-the-wall exercise what muscle does this strengthen and what synergy does it work on

serratus anterior -helping with upward scapular rotation Hold ball against wall, make small circular motions with the ball (30 seconds clockwise, 30 seconds counterclockwise). Start with the shoulder at or below 90 degrees of flexion or abduction. Progress toward higher degrees of elevation as dictated by gains in strength, ROM, and no pain within the range of motion of the exercise.

If a tight structure (usually a muscle) is compressing or producing entrapment of a nerve, two ways to rule it in as the offending structure are to assess for ____________________

shortness of the muscles (length testing) and to palpate it to see if it has greater tension or is tight.

Ligamentous Stress Testing Ligaments serve to...

stabilize joints and articulations. In some instances (such as with the medial collateral ligament of the elbow), they are easily discernible from the joint capsule, and in other cases (such as with the anterior glenohumeral ligaments) they practically blend in with the joint capsule.

Concurrent with the ball exercise, you can also have the patient perform other active elevation exercises such as Sahrmann's wall exercise for shoulder flexion:

stand with your involved arm toward a wall. Place your hand on the wall (a little less than shoulder height) so that your elbow is straight, your thumb is pointing up, and your little finger is parallel with the floor (this is critical: It places the humerus into external rotation). Gently push into the wall so that you create a slight downward force at your shoulder joint. Maintain this pressure as you slide your hand up the wall, keep your thumb up and little finger parallel to the floor. Go as high as you can, however avoid anything more than slight discomfort at your shoulder You can also perform this exercise to emphasize abduction. Patients can work up to performing this exercise for three minutes, twice a day.

person coming out of cast

stiffness, accessory motion testing, restore motion, start with grade 1 and grade 2 -- > for pain, rate their pain (0-10) and explain the scale start with grade 3 or grade 4 is pain is at 1-2

As the acute and sub-acute phases of epicondylitis resolve, treatment progresses to __________ of the epicondylar muscles,

strengthening with the evidence supporting eccentric strengthening as being more effective. Select a resistance method you believe is appropriate (theraband, cuff weight, etc.) and practice eccentric strengthening of the various muscles associated with lateral and medial epicondylitis. A key to early eccentric training is to avoid concentric muscle activity.

Make note of potential areas of entrapment for the radial nerve (more to come in a future lecture and lab):

subscapularis muscle lateral head of triceps muscle spiral groove between brachialis and brachioradialis muscles supinator muscle arcade of froshe

Clinicians use ligamentous stress testing to assess for

tears (sprains) and resulting pain and instability. Therapists base the grade of sprain on the degree of pain noted during stress testing as well as the degree of stability or instability as compared to the uninvolved side (Dutton, 2020, p. 43):

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Latissimus Dorsi, Teres Major, and Rhomboids:

the patient lies supine with elbows flexed (in "goal post arms" position with hands fisted), knees are bent and lower back is flat on the table. The patient raises both arms overhead, elbows remain flexed to about 90 degrees, trying to keep the arms in the same plane as the table - the patient should maintain a flat back and attempt to touch fists together overhead without the arms or elbows lifting above the plane of the table. If there is normal length, the patient can bring arms overhead while keeping them in the same plane of motion as the table and back remains flat. Shortness is indicated by the inability to get the arms overhead or unable to keep the arms or elbows at table level or if the back arches. If short, measure the distance from the lateral epicondyle to the table

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Pectoralis Major (clavicular/upper portion):

the patient lies supine with knees bent and lower back flat on the table. Place the patient's arm in horizontal abduction with the elbow extended and the palm facing upward (this places the shoulder in lateral rotation). With normal length of the muscle, the arm is able to touch the table, achieving full horizontal abduction with lateral rotation, and no rotation of the trunk. This portion of the muscle is short if the arm does not drop down to table level. Document the limitations by using a tape measure to determine the distance from the lateral epicondyle to the table surface

UE Muscle Length /Flexibility Assessment -- Measure length of muscles thought to be short after postural assessment and/or functional movement assessment. Subscapularis:

the patient lies supine, knees bent and lower back flat on the table. The therapist stabilizes the patient's scapula against the thorax, then passively flexes the shoulder. Normal length of this muscle would allow full flexion of the shoulder, and the arm should touch the table. A tight subscapularis will cause the scapula to move laterally along the thorax and, if kept stabilized against the rib cage, will prevent full shoulder flexion.

manual muscle testing Further, you will also want to assess the strength of the muscles involved with the key components of elevation supraspinatus,

the primary abductor from 0-30 degrees (test at 30 degrees of abduction) -empty can test

Postural Assessment Posture is defined as

the relative alignment of the parts of the body. Good posture is "that state of muscular and skeletal balance which protects the supporting structures of the body against injury or progressive deformity" Under such conditions, the muscles will function most efficiently and the potential for pain and/or dysfunction are minimized. Assess a person's posture from anterior(plumb line midway between the heels), lateral (lateral malleolus is just posterior to the plumb line), and posterior (plumb line is midway between the heels) views:

Capsular/ligamentous end-feel may be normal or pathologic

this is a firm, "leathery" feeling. Magee (2007) defines this end-feel as soft (indicating synovitis or soft tissue edema) or hard (indicative of an intact ligament or perhaps capsular fibrosis). Some capsular endfeels are normal. Capsular end-feel is pathologic when the ROM normally available at the joint is restricted, in a stereotypical capsular pattern.

At 180 degrees of elevation Extension of the _______ contributes the final few degrees of GH flexion _____________ contributes to the final few degrees of GH abduction

thorax Scapular abduction

When therapists notice diminished motion at one or more joints with any of the above active movements (AROM), they should more closely examine

those limited joints with PROM and possibly RROM (which we'll discuss next week). Before doing so, the first step is to clear (or implicate) the joints above and below the joint(s) that you believe is/are limited.

Keep in mind that many people with impingement have weak middle and lower trapezius muscles and an over-active upper trapezius. This will be very apparent if they shrug their shoulders while performing an elevation activity/exercise. If you note this substitution with the upper trapezius, consider prescribing these trapezius muscle re-balancing exercises that will help

to resolve these imbalances because they recruit the lower and middle traps more so than the upper trap (since you practiced these last week, no need to do so again). Keep in mind that you might begin this exercise without weights, and progress to using weights as the patient's strength and form improve. forward flexion in side-lying side-lying external rotation prone extension

The MOI for people with glenohumeral hypermobility can be __________ (more common) or ___________due to repetitive motions or possibly due to paresis of surrounding musculature (such as with strokes in which case the joint may be subluxed). The most typical MOIs related to trauma leading to hypermobility include humeral dislocations:

trauma chronic

Glenohumeral Hypomobility (Adhesive Capsulitis) Notes

traumatic has better prognosis 6-8 months long prognosis - more frequent at first for pain then shift focus to HEP AROM=PROM frozen shoulder leathery or empty end feel restore ROM with joint mobs (inferior, posterior, lateral rotation) freezing, frozen, thawing capsular pattern: ex rot, abduction, in rot

posture assessment If you note deviations, begin to consider

whether they are bony abnormalities, or related to muscle length-strength imbalances, or other influences.

Patient Specific Functional Scale (PSFS),

which is a standardized means of establishing activities important to the person and baseline measures of perceived ability to perform them

with wrist sprains and fractures make sure to palpate

with sprain - it will be very tender - do stress test and compare it to the other side is there inflammation and temp change

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