Midterm: Ortho 1 Fall 2022
which RTC tear characteristics put someone in a at risk category for irreversible change?
- <65 yrs - symptomatic full thickness tears - acute tear of any size - tears with recent loss of function
what are the basic steps of acute management of a non-operative, simple elbow dislocation?
- Acute care post closed reduction: assess stability, recheck neurovascular status, immobilize at 90 degrees for 7-10 days, limit full extension if grossly unstable - Therapy: as soon as day 2 depending on stability begin with AROM gripping, finger & wrist flexion/extension supervised AAROM in stable arc (avoid full extension)
at what GHJ angles do you test GH ligaments' integrity during A/P joint play?
- Anterior Joint play: 0-30 deg. ABd for superior GHL 30-60 deg ABd for mid GHL 90 deg ABd for inferior GHL - Posterior joint play: 90 deg. in scapular plane, posterior band of IGHL
what are the potential causes of thoracic outlet syndrome?
- Anterior scalean syndrome - cervical rib syndrome - costoclavicular space syndrome - hyperabduction syndrome (abd, ext, ER) *true thoracic outlet syndrome is not common.
what muscles do you test for upper limb reflexes?
- Brachioradialis - Biceps - Triceps
what is an AC joint step deformity?
- Clavicle is higher than it should be, GH is intact but AC joint has been sprained - If contour of deltoid is normal than dislocation is unlikely
what are the three tests for lateral epicondylitis? what order do we do them in?
- Cozen's first (pictured, but keep elbow straight) - Mill's passive stretch to extensor group - Tennis elbow last as it is the most provocative (finger extensor test)
describe how dysfunction of the force couples on the shoulder can lead to extrinsic impingement?
- Deltoid/RTC force couple: Dysfunction/fatigue can lead to superior migration of humeral head into subacromial space, can lead to compression of structures in subacromial space such as supraspinatus, bursa....
what motion/muscles are innervated by C7 primarily?
- Elbow extension and wrist flexion Serratus anterior, latissimus dorsi, pectoralis major (sternal head), pectoralis minor, triceps, pronator teres, flexor carpi radialis, flexor digitorum superficialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, scalenus medius and posterior
what motion/muscles are innervated by C6 primarily?
- Elbow flexion and wrist extension Serratus anterior, latissimus dorsi, subscapularis, teres major, pectoralis major (clavicular head), biceps, coracobrachialis, brachialis, brachioradialis, supinator, extensor carpi radialis longus, scalenus anterior, medius and posterior
what are effective strategies of motivational interviewing that can enhance satisfaction and patient autonomy?
- Empathy: showing evidence of understanding patient's point of view - Evocation: elicit patient's own reasons for change - collaboration: acting as partners with patient - autonomy: conveying that change comes only from patients - open-ended questions - complex reflections: conveys understanding and adds meaning - Behaviors such as asking permission, affirming, providing supportive statements, and emphasizing control.
what is the cervical compression test? what does it test for?
- Examiner exerts downward pressure on the subject's head - Positive test: Increased pain or altered sensation indicates pressure on a nerve root. *Use this position (neutral CS) if motion testing indicates extension is contraindicated.
what are the techniques of reducing nursemaid's elbow?
- Full extension -> supination -> traction -> flexion - OR: extension -> hyperpronation
what is rotator cuff arthropathy?
- GHJ arthritis with RTC dysfunction, defines as combination of: massive RTC tear GH cartilage destruction subchondral osteoporosis humeral head collapse
what are the 3 kaltenborn joint mob grades?
- Grade I: small amplitude distraction is applied, no stress to capsule - Grade II: enough glide or distraction is applied to tighten tissues. "Taking up the slack" - Grade III: a glide or distraction is applied with an amplitude large enough to place a stretch on capsule and surrounding tissues
what motion/muscles are innervated by T1 primarily?
- Hand intrinsics Flexor digitorum profundus, intrinsic muscles of the hand (except extensor pollicis brevis), flexor pollicis brevis, opponens pollicis
what do you learn when taking a patient's history?
- Hx*: provides info about disorder, who the patient is and guides in formulating a working diagnosis. - Past medical history: major illness, surgery, accidents, allergies. - History of present illness: • info about disorder • its present state • determine who the patient is as a person • how the condition effects the patient's life
what are the grades of maitland oscillation techniques?
- I: Small amplitude rhythmic oscillations performed at the beginning of the range. - II: Large amplitude rhythmic oscillations performed within the range but not reaching the limit. It can occupy any part of the range that is free of any stiffness or muscle spasm. - III: Large amplitude rhythmic oscillations performed up to the limit of the available motion and are stressed into tissue resistance. - IV: Small amplitude rhythmic oscillations performed at the limit of the available motion and are stressed into resistance.
what are the upper extremity myotomes to test for an orthopedic exam?
- Neck flexion (C1, C2) - Neck side flexion (C3) - Shoulder elevation (C4) - Shoulder abduction (C5) - Elbow flexion (C6) - Wrist extension (C6) - Elbow extension (C7) - Wrist flexion (C7) - Thumb extension (C8) - Finger abduction (T1)
what motion/muscles are innervated by C3 primarily?
- Neck lateral flexion Longus capitis, longus cervicis, trapezius, scalenus medius
when is the radial collateral ligament taught? (RCL)
- RCL is taut through flexion & extension, tension is increased in supinated position
what is a red flag S/S?
- Red flag signs and symptoms: indicates the cause of the problem is not neuromusculoskeletal and/or requires referral to other health care provider. Indicates things that are outside our scope of practice - One (1) of these symptoms is not cause for extreme concern, but it should raise a red flag for the alert therapist. - put a red flag in the context of other things that are going on, signs and symptoms do not mean a diagnosis
what is Obrien's (Active compression) test used for?
- SLAP tear - positive if pain in the GHJ when pronated but not when supinated, if both positions are positive, it is an inconclusive test - high snout, better for ruling out if negative
what motion/muscles are innervated by C5 primarily?
- Shoulder abduction Rhomboid major and minor, deltoid, supraspinatus, infraspinatus, teres minor, biceps, scalenus anterior and medius
what motion/muscles are innervated by C4 primarily?
- Shoulder elevation Diaphragm, trapezius, levator scapulae, scalenus anterior, scalenus medius
what are the different sizes of RTC tears?
- Small tear: <1cm - medium: 1-3 cm - Large: 3-5 cm - massive: >5cm (sometimes defined as 2 or more tendons)
Give general differences for systemic and musculoskeletal pain
- Systemic: • Disturbs sleep • Deep aching or throbbing • Reduced by pressure • Constant waves of pain and spasm • Is NOT aggravated by mechanical stress - Musculoskeletal: • Generally lessens at night/with rest • Sharp or superficial ache • Usually decreases w/cessation of activity • Continuous or intermittent • IS aggravated by mechanical stress
what is the purpose of a spinal scan?
- The purpose of scanning is to rule out symptoms which may be referred from one part of the body to another. - Clear the spine to make sure it's not the source of pain/problems, same principles can apply to other joints - clear the joints above and below the joint in question, even if there aren't neurological symptoms, including spine exam will give you a better picture of what is going on. - C spine scan for UEs Lumbar scan for LEs
what motion/muscles are innervated by C8 primarily?
- Thumb extension and ulnar deviation Pectoralis major (sternal head), pectoralis minor, triceps, flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, pronator quadratus, flexor carpi ulnaris, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, extensor indicis, abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, scalenus medius and posterior
what are the benefits of using reflective statements and showing empathy with patients?
- When physicians used reflective statements, patients were more likely to perceive high autonomy support. - When physicians were empathic, patients were more likely to report high satisfaction with the physician.
what are beighton's criteria?
- a total score of >5 points defines hypermobility
how do you do the Jobe's Empty can test?
- abduct arm to 90, angle forward 30 degrees to scapular plane, internally rotate arm to point thumb at the floor - press on arm while patient tries to maintain position - weakness or pain is a positive test
what is a GH inferior glide progression to improve GH abduction?
- abduct humerus to about 90 degrees, apply grade 1 GH distraction using your trunk - apply inferior glide to humerus
what do you look for during skin observation?
- abnormal/normal skin color and texture - appearance of skin different in location of symptoms compared with other areas of the body - scars indicating injury or surgery - signs of infection, swelling, redness, heat etc...
where might ulnar nerve compression occur?
- above the elbow in the region of the intermuscular septum - medial epicondylar region - ulnar groove - cubital tunnel - where the ulnar nerve exits from the flexor carpi ulnaris, usual cause for compression is the deep flexor pronator aponeurosis
what is a simple elbow dislocation?
- absence of fractures
what bony structures provide stability to the elbow during flexion?
- abutment of the radial head against the capitulum - coronoid process against the trochlea
what are tests for a SLAP tear?
- active compression test (O-brien's), crank test, compression rotation, biceps tendon tenderness, Internal rotation dysfunction, anterior GH apprehension test
when should non-operative treatment be considered for RTC malfunction?
- all patients with tendinopathy, partial thickness tears, small (<1-1.5 cm) full thickness tears, all chronic tears in older age group, all large irreparable tears with chronic irreversible muscle changes.
What is little league elbow?
- an overuse injury of the medial epicondyle, usually caused by a repetitive throwing motion. It is seen in younger baseball players who have not reached skeletal maturity - repetitive valgus loading during throwing motion
S/S of little league elbow syndrome?
- apophysitis and fragmentation, medial elbow pain
describe how to perform RROM for the C-spine?
- apply manual resistance with your hand in each direction, stabilizing the patient with your other hand. Cue patient to not let me move you. A Flexion. Note slight flexion of neck before giving resistance. B Extension. Note slight flexion of neck before giving resistance. C Lateral flexion D Rotation
how do you perform the moving valgus stress test for the elbow?
- arm abducted to 100 deg and full elbow flexion, create and maintain valgus stress, quickly extend patient's elbow - reproduction of pain between 120-70 deg indicates positive test for MCL injury
what is the hook test for the elbow?
- assess for distal biceps tendon rupture - have patient flex elbow to 90 and fully supinate - approach from lateral side of elbow to try and hook the distal biceps tendon with your finger, positive test is no cordlike structure to hook
what are normal end feels?
- bone to bone: hard - soft tissue approximation: soft - tissue stretch: firm
what does clearing the C-spine mean?
- brief exam of the CS to rule out involvement that may contribute to shoulder dysfunction. - Clearing the joint above and below is done for exams of every joint in the body. - clearing is not a neurological exam or the CS scan exam, results may indicated the need for a CS exam.
what are the characteristics of intrinsic rotator cuff disease?
- caused by properties in the tendon itself: vascular changes, collagen disorientation & degeneration, alterations in growth factors - results of tendon overload - tendon degeneration results in altered biomechanical properties of the tendon - referred to as "intrinsic impingement"
what are the extrinsic causes of extrinsic impingement of the shoulder?
- caused by properties outside the tendon - Primary causes: angle of acromion, deformity or biomechanical abnormalities of the humeral head, AC joint deformity - secondary causes: same effects on tendon but caused by multidirectional or unidirectional stability
what are general things to look for during the observation stage of a patient exam?
- check for symmetry - check for visible signs of injury/infection/inflammation - assess their resting posture/position/alignment - observe their natural movement/gait without them being cued, see how they move when they don't think they are being observed. (this begins as soon as they walk into the clinic). - look for willingness to move and abnormal/normal patterns of movement
what is a hill sachs defect?
- chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim - common in traumatic dislocations and subluxations
what are aspects of motivational interviewing that does not enhance patient satisfaction or autonomy?
- close ended questions - simple reflections: conveys understanding but adds no new meaning. - behaviors such as advising without permission, confronting and directing.
how do you differentiate between blood in a joint vs synovial effusion in a joint?
- comes on soon after injury -> blood - comes on 8-24 hours after injury -> synovial - boggy/spongy feeling -> synovial - harder/tense feeling with warmth -> blood
what is a full thickness RTC tear?
- complete defect in the tendon, extending from articular surface completely through to the bursal surface
what are the general uses for special tests?
- confirm a tentative diagnosis - make a differential diagnosis - differentiate between structures *often takes a joint into end ROM so be careful you don't irritate an injury
how do you test contractile tissue during an exam?
- contraction or stretch of muscle and tendon - tested by: AROM and MMT
PT interventions for little league elbow?
- core strengthening program at beginning of PT - ROM exercises and joint MOBs to prevent hypomobility - joint stabilization exercises if joint is hypermobile - biomechanical throwing analysis - progressive throwing program: beginning approx. 4-8 weeks into treatment
what fractures are common with severe elbow dislocations?
- coronoid fractures with more severe dislocations
what bony structures provide stability to the elbow during extension?
- coronoid process impacts against the trochlea - olecranon process locks into the olecranon fossa
what do you listen for when observing a patient during the exam?
- crepitus, snapping, abnormal sounds in the joint when the patient moves
what are symptoms of radial tunnel syndrome?
- deep aching distal to the lateral epicondyle - pain at belly of brachioradialis - pain with resisted supination - pain with repetitive wrist flexion, and/or pronation - pain intiated/intensified by repetitive motion with pronation (racket sports)
what is the examiner assessing for when palpating a patient?
- differences in tissue tension and tone - differences in tissue texture - abnormalities - tenderness - temperature variation - pulses/tremors/fasciculations - pathological state of tissues - abnormal sensation
what are S/S of myopathy?
- difficulty lifting/walking - myotonia - cramps - pain (myalgia) - progressive weakness
what movements does dorsal/volar radial head glides help with at the elbow?
- dorsal glide of radial head to increase extension of the elbow - volar glide to increase extension
what movements do joint mobs to distal radio/ulnar joint help improve?
- dorsal glides to increase supination, palmar glide to increase pronation - sitting with forearm, begin in resting position, progress to end range
what are the abnormal end feels?
- early muscle spasm - late muscle spasm - spasticity - hard capsular - soft capsular - bone to bone - empty - spring block - any normal end feel in an abnormal point in the ROM
what is the mechanism of lateral epicondylitis?
- eccentric overload to the ECRB - repetitive pronation/supination with elbow extension - common with repetitive hand/elbow/wrist movements
what are benefits of expressing empathy with patients?
- effective at decreasing anxiety, building compliance, and improving patient satisfaction. - Recognize expression of emotions: • Allow pt to express feelings • Acknowledge the feelings make sense • Offer assistance - Phrases that demonstrate empathy: • "Tell me more about that" • "Is there anything else?" • "Let me see if I understand"
how do you perform the belly press test?
- elbow 90, hand on abdomen, examiner applies force into external rotation on palmar side of forearm - positive test = weakness compared to the other side or compensation with shoulder extension.
how do you perform the external rotation lag sign test?
- elevate arm 20 degrees in scapular plane, passively flex the elbow to 90, rotate shoulder 5 degrees from full ER. Ask patient to hold arm in externally rotated position - positive test is arm starts to drift into IR
how does the clavicle move during shoulder elevation?
- elevates, retracts, and posteriorly rotates at the SC joint
what are primary clinical reasoning errors PT students make during patient encounters?
- failing to generate a key hypothesis - retaining a hypothesis in the face of conflicting findings.
S/S of LMN lesions
- flaccid paralysis - loss of reflexes - muscle wasting and atrophy - loss of synergistic action of muscles - fibrosis, contractures, adhesions - joint weakness & instability - decreased ROM and stiffness - affected growth
How do you perform Obrien's test (active compression test)?
- flex arm to 90 w/elbow extended - adduct 10 degrees across body - supinates the forearm so palm is up and PT applies force while patient resists - then the patient pronates and IR's the shoulder so thumb is pointed down, resistance is applied here - positive if painful in thumb down position but not in palm up position
RROM to perform for elbow exam
- flexion/extension - supination/pronation - wrist flexion/extension - grip strength (dynamometer)
what are potential complications of an elbow dislocation?
- fracture, neurovascular complications are also possible - ulnar and median nerve injury is possible with simple dislocations - radial nerve is possible with complex radial head injuries - shoulder/wrist/hand involvement is also possible
what are common GH injuries after a FOOSH?
- fracture/dislocation of the GH joint - RTC tear also a possibility - fall onto shoulder or elbow can drive the humerus against the AC joint and can lead to AC dislocation or sublux
how do you perform the tennis elbow test?
- have patient extend fingers, have them resist you pushing fingers into flexion - palpate lateral epicondyle, pain over lateral epicondyle is positive test for tennis elbow
how do you perform Cozen's test?
- have pt. extend wrist and resist your force into flexion - pain at lateral epicondyle is a positive test
what are indications for tommy john's surgery?
- high level throwers that want to continue competitive sports - failed non-operative management of patients willing to undergo extensive rehab
compared to in full extension, what structures provide resistance to varus/valgus stress at the elbow when it is in flexion?
- in full extension, and in full flexion bone provides the majority of resistance to varus stress - the MCL provides most of the resistance to valgus stress when the elbow is flexed to 90 degrees
what are maitland grade 3 and 4 used for?
- increase joint play • Grade III- 2-3 per second • Grade IV - rapid motion
what are positive results of implementing patient centered medicine?
- increased patient knowledge - more accurate risk perceptions - greater number of decisions consistent with pt. values - reduced level of internal decision conflict for patients - fewer patients remaining passive or undecided.
what are some benefits of patient centered-medicine?
- increased patient knowledge - more accurate risk perceptions - a greater number of decisions consistent with patients' values - a reduced level of internal decision conflict for patients - fewer patients remaining passive or undecided
what alterations in muscle activity/latency observed in subjects with shoulder impingement or shoulder pain consistent with impingement?
- increased upper trap activity - reduced serratus anterior activity - reduced RTC activity - delayed RTC activity - delayed mid and low trap activation
What is kibler type 1? why does this occur?
- inferior angle scapular dysfunction: inferior medial border is prominent at rest - occurs from anterior tipping of the scapula, commonly seen in patients with RTC impingements as acromion is closer to humeral head during humeral elevation
what are interventions for lateral epicondylitis during the protected function phase?
- limit pain provoking activities - keep limb mobile - MWM's are supported by evidence
What is osteochondritis dissecans?
- localized fragmentation of the bone and overlying cartilage
what are prognostic indicators of worse shoulder outcomes?
- longer duration of symptoms - gradual onset of symptoms - high pain intensity - 45-54 yrs - WC claim - higher DASH score - catastrophizing (psychological factors)
What in you examination do you look for if you find a red flag sign/symptom?
- look for a pattern that suggests a viscerogenic or systemic origin of pain and/or symptoms. - Look for associated signs and symptoms. - The therapist will proceed with the screening process depending on which symptoms are grouped together.
clicking and locking in the elbow can indicate what?
- loose bodies, chondral injury, osteophytes, instability
what are interventions for lateral epicondylitis during the return to activity phase?
- maintain/assess for tolerance to resistance exercises in phase 2 - functional ROM - get strength = to the non involved side for return to activity
what is hornblower's sign? what is this test used for?
- massive tear of Teres Minor - positive if arm falls into IR - Snout = 1 spin = .93
how can microtrauma lead to posterior GH instability?
- may lead to labral tear, incomplete labral avulsion, or erosion of posterior labrum - microtrauma leads to gradual stretching of the capsule - present in lineman, weightlifters, and overhead athletes
what is kibler type II? why does this occur?
- medial border scapular dysfunction - entire medial border is posteriorly displaced from thoracic wall
what is a crescent RTC tear? how can it be repaired?
- medial lateral length is less than anterior posterior length *can usually be repaired tendon to bone which has better outcomes?
symptoms of little league elbow
- medial pain in throwing arm - decreased throwing speed, accuracy, and/or distance
what is the sulcus sign a test for?
- multidirectional instability - positive test is if a sulcus (divot) forms at the superior aspect of the humeral head between the humeral head and acromion, may indicate multidirectional or inferior instability - no sulcus = negative test, some movement of the humeral head is normal
what are indications for a C-spine scan exam?
- no history of trauma - radicular signs - trauma with radicular signs - altered sensation in the limb
what movements can lead to posterior (internal) impingement of the shoulder? why?
- occurs during ABD/ER (throwing) - humeral head translates posterior and superiorly trapping the post. portion of the supraspinatus between the humeral head and the labrum.
what populations is AMBRI instability common in?
- overhead athletes, causes microtrauma from repetitive use (volleyball, swimmers, gymnasts) - generalized ligamentous laxity associated with connective tissue disorders (e.g. marfans or EDS)
what are kaltenborn grade 1 mobs used for?
- pain relief = intermittent distraction 7-10 seconds, rest, repeat 3-5xs. Note response.
S&S of osteochondritis dissecans in elbow
- pain usually lateral, insidious onset, may have click or catch, loss of elbow extension - common in youger patients, 12-20 years
how do you perform the medial epicondylitis test? (Golfer's elbow)
- palpate medial epicondyle - passively supinate the forearm and extend the elbow and wrist - positive sign for medial epicondylitis is pain over the medial epicondyle
what are signs of generalized hypermobility?
- patella hypermobility, genu recurvatum, elbow hyperextension, MCP hyperextension, thumb abduction to the ipsilateral forearm
what are the steps to a total MSK assessment?
- patient history - Observation - Movement examination - Palpation - joint play movements - reflexes, cutaneous distribution - special tests - diagnostic imaging
how do you perform the crank test?
- patient in supine, elevate arm to 160 degrees in scapular plane, apply axial load, rotate into IR and ER - positive if clicking with pain in the GHJ
what are MOIs to the long thoracic nerve?
- penetrating force (knife/chest tube) - stretch injury: head tilted away with involved arm overhead - compression from trauma, sports - repetitive overhead use (overhead sports)
what are the components of clearing the C-spine?
- perform AROM for cervical lateral flexion, flexion, rotation, then overpressure in each direction - AROM cervical extension, extreme care if applying overpressure into extension - for overpressure: Push into initial resistance that is felt: lengthen connective tissue and approximate facet joints
what is posterior RTC impingement?
- posterior portion of the supraspinatus & infraspinatus rub on the posterior/superior glenoid lip causing the RTC to be pinched between the humeral head and the rim - provoked in 90/90 position, maximal ER and abduction
what is mechanism of anterior shoulder dislocation?
- posteriorly directed force on the arm (near the elbow) when the shoulder is abducted and externally rotated
what is the most common direction and mechanism of elbow dislocation?
- posterolateral is most common direction - MOI: FOOSH w/axial loading, supination of the forearm
when is true scapular winging present? why does it occur?
- present at rest and with movement - result of long thoracic N. involvement and resultant dysfunction of the serratus anterior. - true winging is not common
what things help inform your evaluation of the data post examination?
- progression and/or stage of signs and symptoms - stability of condition - presence of preexisting conditions - presenting impairments and how they relate to functional limitations - current overall level of physical functioning (limitations and abilities) compared with their desired level of functioning
what are the phases of lateral tendinopathy (epicondylitis) rehab?
- protected function phase - total arm strength rehab phase - return to activity phase
what are strategies to promote information retention in patients?
- provide important information first - stress its importance - use short words and sentences to be specific - repeat key points
function of the UCL?
- provides greatest resistance to valgus stress at the elbow - 1 ant. portion of the UCL is the strongest, ant. portion of ant. UCL is taught at 0-60 degrees, post. part of ant. UCL is taught at 60-120 degrees of flexion
what are interventions for lateral epicondylitis during the total arm strength rehab phase?
- proximal stability before distal mobility - serratus/lower trap strengthening - RC/posterior cuff muscles - Eccentric, endurance, stretching of forearm extensors
What are Mennell's Rules for Joint Play testing?
- pt should be fully relaxed and supported - examiner should be relaxed and should use a firm/comfortable grasp - examine one joint at a time - test unaffected side first - one articular surface is stabilized while the other is moved - movements must be normal and not forced - movements should not cause undue discomfort
how do you perform the GH apprehension test?
- pt supine, abduct arm and flex elbow to 90, then slowly put shoulder into ER. - stabilize with the other hand and place posterior force on anterior shoulder, also use this hand as a sensor - if no symptoms are produced, can apply anterior directed force on posterior shoulder to stress ant. capsule further. - positive if patient feels pain, instability in the anterior shoulder, or apprehension with further ER. - if patient feels symptoms with removal of posterior stabilization force, apply force again before taking the patient out of this position
how do you provide GH distraction?
- pt supine, support their arm, place hand in axilla as close to joint as possible, other hand is supporting humerus - move humerus laterally with the hand in the axilla
How do you perform the compression rotation test?
- pt. supine, arm abducted to 90, elbow flexed to 90, apply axial compression to the shoulder, then circumduct and rotate the humerus - circumduct first then rotate - positive for SLAP or other labral tear if there is pain and a click
when could putting arm over head relieve shoulder pain/symptoms?
- puts nerves on slack, may indicate cervical referral rather than subacromial issues.
MOI of biceps rupture
- rapid eccentric contraction of the biceps - load takes the elbow into extension in a supinated position
what is the pathoanatomy of lateral epicondylitis?
- repetitive activities lead to histopathologic changes usually begins as a microtear of the origin of ECRB may also involve microtears of ECRL
what movements tend to reproduce GH joints symptoms?
- reproduced by rotation and/or compression of the joint - pt. reports symptoms deep in the joint, may radiate down arm into elbow
provocative tests for lateral epicondylitis
- resisted wrist extension with elbow fully extended - resisted extension of the middle finger (may include index) - maximal passive flexion of the wrist (stretch)
how to test tricep length
- sitting, passively elevate shoulder to end range then flex elbow - normal = same ROM as active movement
S/S of UMN lesions
- spasticity - hypertonicity - hyperreflexia (deep tendon reflexes) - positive pathological reflexes (babinski's sign) - absent or reduced superficial reflexes - extensor plantar response (bilat.)
what are common pathoanatomical findings associated with multidirectional GH instability?
- spread or expanded inferior capsule - rotator interval deficiency - reverse bankart lesion: posteroinferior labral tear
How do you do the gerber lift off test?
- standing, hand behind back with dorsum on their back, raise dorsum of hand with internal rotation of the shoulder
what are grade 3 kaltenborn joint mobs used for?
- stretches joint structures/increases joint play. Distraction or glide 10 seconds, partial release, repeat 3xs. Note response, repeat.
what is kibler type 3? why does this occur?
- superior scapular dysfunction - early and excessive superior scapular elevation during arm elevation - results from RC weakness and force couple imbalances
how to test biceps length
- supine, shoulder extended off edge of table to end range, extend elbow - normal: elbow extension the same range as active movement (full extension)
tinnel's sign at elbow
- tap the ulnar groove between olecranon and medial epicondyle - positive sign is indicated by tingling sensation in the ulnar distribution of the forearm and hand distal to the point of compression in the nerve.
physical exam findings with little league elbow
- tender medial epicondyle with palpation - pain with valgus stress -> potentially instability (examine in varying angle of elbow flexion) - perform Tinel's test, check for ulnar nerve motor & sensory testing
what are common sites of radial nerve entrapment?
- tendinous margin, origin of ECRB - arcade of Frohse - distal border of the supinator
tension overload to what structures causes little league elbow syndrome?
- tension overload to the: 1. medial epicondyle: results in delayed or accelerated growth of the epicondyle, traction apophysitis (medial epicondyle fragmentation), stress fractures 2. ulnar collateral ligament (UCL) anterior band 3. flexor-pronator mass *younger athletes are more likely to have traction apophysitis than UCL sprains
What is the apprehension test used for?
- tests for anterior glenohumeral instability, not used for traumatic dislocation as we would already know they are unstable in that case - positive test is experience of pain, apprehension, or instability at the anterior shoulder - Spin = .96 for anterior shoulder instability
what is the drop arm test (sign)? why would you use it? is it better for ruling in or out?
- tests for function/integrity of the supraspinatus - positive sign is weakness or pain that causes the patient to drop their arm to their side - may also observe this same phenomenon when doing the AROM portion of your exam. - Spin .88
what is the external rotation lag sign used for? is it better for ruling out or in?
- tests for infraspinatus pathology - positive test is arm drifts into internal rotation - Spin = .94, good for ruling in infraspinatus pathology - might get positive test with massive RTC trauma or with chronic degeneration
What is the gerber lift off test? what is it used for?
- tests for subscapularis pathology - positive test is hand can't be lifted off the back or if compensating with shoulder or elbow extension - Spin = 1.0
how does a tight posterior GH joint capsule affect positioning of the humeral head?
- tight post. capsule relates directly to anterior and superior translation of the humeral head - increased subacromial contact of RTC - equates to decreased subacromial space and possible RTC injury
how do you perform humeroulnar distal glide joint mob?
- to increase flexion - in supine, elbow over the edge of treatment table, elbow in resting position place fingers around proximal ulna with both hands - apply distraction force at 45 deg. angle, while maintaining distraction, direct force in distal direction along long axis of ulna using a scooping motion. - progress by positioning at end-range of flexion
what is a common history of anterior GH instability?
- traumatic event causing dislocation - feeling of instability "out of the joint" - shoulder pain caused by dislocation
what are the SLAP tear classifications? which ones are surgically treated?
- type 1 not surgically treated - type 3/4 more troublesome, can move or obstruct joint motion, cause more instability.
what are kaltenborn grade 2 mobs used for?
- used as an assessment to determine sensitivity of joint. - Also used as a treatment: pain relief = use of distractions (dose as above) maintains joint mobility = use of glides
what is the compression rotation test used for?
- used for SLAP tears and general GH labral tears - positive for SLAP or labral tear if there is pain and a click - Spin: .76, better for ruling in
what are scapular mobilizations used for?
- used to educate, stretch, increase scapular motion
What is PROM used to assess?
- used to find the anatomical barrier to further motion vs AROM which finds physiological barrier
what are symptoms of a SLAP tear?
- vague/deep shoulder pain - mechanical symptoms of popping and clicking - weakness/easy fatigue/decreased athletic performance
what are intrinsic factors that can cause stress to the RTC?
- vascular changes, collagen disorientation and degeneration, alteration in growth factors - intrinsic factors are reflection of change over time and may be influenced by repetitive tension overload.
what is the examiner observing for during PROM?
- when and where symptoms begin - does movement increase the intensity or quality of symptoms - the pattern of limitation of movement - the end feel which is the barrier to further movement -movement of associated joints - ROM available - are symptoms being changed in general, worse/better/reproduced
what are the grades for deep tendon reflex testing?
0 - absent (areflexia) 1 - diminished 2 - average (normal) 3 - exaggerated (brisk) 4 - clonus, very brisk (hyperreflexia)
at what elbow angles should you do varus/valgus stress tests? what end feel is expected at each angle?
- 5 deg. flexion for bony integrity of the elbow (bone to bone end feel expected at this angle) - 25 deg. of flexion for soft tissues/UCL (tissue stretch end feel expected here)
what motion/muscles are innervated by C1-2 primarily?
- Neck flexion Rectus lateralis, rectus capitis anterior, longus capitis, longus coli, longus cervicis, sternocleidomastoid
What is the terrible triad of the elbow?
- a posterior dislocation with intra-articular fractures of the radial head and coronoid process
what are functional assessments?
- measurement of whole body task performance ability as opposed to isolation of a single joint - determine if the isolated impairment affects ability to perform activities - establish what functional factors are important to the patient - functional test must relate to the activity the patient is limited in and should be used in combination with a complete exam.
what is the relocation test?
-Test for anterior instability, perform apprehension test then apply posterior force to the anterior GHJ - positive test is if pain/apprehension decreases with posterior force - Spin = .90
describe how to do Spurling's test? what does this test for?
1. Patient is seated, PT standing behind them. 2. Place patient's head in slight extension, then laterally flex patient's neck 30 degrees to the affected side. 3. Apply a downward* axial compression. *Can apply multiple slow compressions or slow build up of force - Positive: when the pain arising in the neck radiates in the direction of the corresponding ipsilateral dermatome. *Be sure not to laterally flex the patient's neck any further when compression is being applied to avoid collapse of spine.
explain the process of examining specific joints
1. Systematic approach 2. Detailed exam for the joint in question and brief check for adjacent joints to "clear" the joints. If referral from adjacent joints creates symptoms in the primary joint, then the adjacent joints will need to be examined as well. 3. Looking for patient's subjective response and objective findings 4. Include scan exam of the spine if uncertain about where the origin of the pathology lies. 5. Acute injury may preclude complete exam process 6. Exam needs to be extensive enough to allow pattern to emerge
how often does fracture occur with GH dislocation?
18% of the time
what is loose packed position of the knee?
25 degrees flexion
pain with movement and movement is weak, what tissue damage is this a classic presentation of?
2nd degree or greater strain, or a significant lesion around the joint like a fracture
what ages does internal shoulder impingement commonly occur in?
40-60 yrs, due to degeneration of RC tendons
what ages is atraumatic adhesive capsulitis common?
45-60 years
what is normal carrying angle of the elbow?
5-15 degrees - males: 5-10 - females: 10-15
what is a bankart lesion?
A Bankart lesion is avulsion of the glenoid labrum - bony bankart includes fracture of the anterior inferior glenoid with anterior dislocation
C4 dermatome
AC joint
what is the referral pattern of the coracobrachialis?
Anterior shoulder & down posterior arm
what is a functional test for IR AROM?
Apley's scratch test
which direction does the GH joint have to rotate to get full elevation?
ER required for full elevation
what is the capsular pattern of the shoulder?
External rotation Abduction Internal rotation Flexion
how do you perform Mill's test?
Fingers, wrist, and elbows flexed with forearm supinated, passively extend elbow while pronating forearm to full extension keeping wrist in flexion. - pain at lateral epicondyle is positive for lateral epicondylitis
what is the grading of GH translation during joint play examination?
Gd 1: humeral translation within the glenoid Gd 2: humeral translation rides up on rim of glenoid, returns when stress is removed with no symptoms Gd 3: humeral head rides over rim, fails to return when stress is removed (DO NOT PROVOKE TO Gd 3, unstable joint)
is Mill's test better for ruling out or in?
In, high specificity
what type of deformities or deviations should you look for during the exam?
Is there any obvious deformity or a deviation from normal? - Structural deformity: present even at rest ex. fracture, bony symmetry, soft tissue contours, atrophy, muscle size - Functional deformity: result of a particular posture and disappears when posture is changed ex. scoliosis due to a short leg, equal limb position - Dynamic deformity : caused by muscle action ex. valgus moment at knee secondary to weak hip abduction
anteroposterior translation grading scheme
Move slowly and detect amount of give/translation/resistance there is in the joint. DO NOT push them too far, if no resistance is felt where there should be that is abnormal, do not push so far it dislocates or injures the patient.
is Cozen's test better for ruling out or in?
Out, has high sensitivity
what is the referral pattern of the deltoid?
Over muscle & posterior glenoid area
what is the referral pattern of the subscapularis?
Posterior shoulder to scapula and down posteromedial and anteromedial aspects of arm to elbow
shoulder pain when lifting any kind of weighted object can indicate what?
RTC or long head of biceps injury
shoulder pain at night and when resting can indicate what?
RTC tear, tumor
What is Tommy John surgery?
Reconstruction of the ulnar collateral ligament with the tendon from the palmaris longus
what is the referral pattern of the teres major?
Shoulder cap down lateral aspect of arm to elbow
what is the rotator cuff interval?
The triangular space between the tendons of subscapularis and supraspinatus and the base of the coracoid process.
what is neuropraxia?
Type I nerve injury. A local conductive block (nerve pressure or blunt trauma) with no physical disruption of the axon results in transient paralysis, slight sensory changes, and no reaction of degeneration. Recovery is usually in hours to days.
which is the most commonly injured ligament in throwing athletes?
UCL, anterior band is most common
what nerve innervates the palmar and dorsal interossei? (abduction/adduction of the digits)
Ulnar nerve
what is pitting edema?
When finger pressure applied on the swollen extremity leaves an indentation mark on the skin.
radiocapitellar line
a line drawn down the neck of the radius should intersect the capitulum
anterior humeral line
a line drawn parallel to the anterior humerus should pass through the middle third of the capitulum
what is a spinal scan
a quick check of the portion of the spine that relates to the limb in question.
How do you test non-contractile tissue during an exam?
affected by loading, compression, and/or pinching of: ligaments, capsule, cartilage, blood vessels, bursae, and skin - tested by PROM and special tests
What does Jobe's test test for?
also called Empty can test, decreases the subacromial space - tests for supraspinatus weakness - .87 spin for impingement - weakness or pain is a positive test, pts are often painful just getting into this position - Use this test if you suspect the pt has some form of RTC dysfunction, don't use if you suspect a tear
what determines your ability to return to activity post elbow dislocation?
based on soft tissue damage (assuming no fractures or other complications) - light use at 2 weeks is best scenario - sports up to 3-4 months
how do you do hornblower's test?
bring shoulder to 90 degrees of abduction, 90 ER, and ask the patient to hold this position
what does a flattening of the deltoid indicate?
complete dislocation: you'll see a flattening of the deltoid because it no longer wraps over the humeral head
which part of the elbow gets compressed with a varus deformity? what complication can this cause long term?
compresses medial joint space - could lead to ulnar neuropathy over time
elbow flexion test
cubital tunnel test; hold elbow in flex for >60 sec with wrist neut to elicit symptoms
What does the glenoid labrum do?
deepens the glenoid fossa and increases the size of the articular surface - acts as a chock block to subluxation - helps create joint cavity compression - anterior labrum anchors the IGHL - superior labrum anchors the long head of the biceps tendon
what forces is bone affected by?
direct pressure, compression, torsion - these forces tend to bring out symptoms of bony injuries during exams
for contractile lesions, AROM and PROM are usually painful in what directions?
directions opposite eachother, PROM that stretches the injured muscle/tendon or AROM that contracts the injured muscle/tendon
what motion often causes tensile overload of the shoulder ERs?
eccentric overload, slowing down throwing motion on the follow through.
what is close packed position for facet joints of the spine?
extension
what position of the shoulder puts the posterior capsule in a compromised position?
flexed, adducted, internally rotated arm is in a high risk position
what position should you avoid in acute treatment of an elbow dislocation?
full extension
what is close packed position for the hip?
full extension, IR
what is close packed position of the knee?
full extension, lateral rotation of tibia
panner's disease
ischemia and subsequent necrosis of the capitulum
what is the difference between kaltenborn and maitland joint mobs?
kaltenborn = Sustained, Translatory Joint-Play Maitland = small amplitude rhythmic oscilations
S1 dermatome
lateral heel
pain and limitation with passive movement is some directions but not others, what tissue injury(ies) is this a classic presentation of?
ligament sprain, capsular adhesion, non-capsular pattern, internal derangement (e.g. meniscus tear, loose body)
what is the referral pattern of the rhomboids?
medial border of the scapula
L2 dermatome
mid anterior thigh
C7 Dermatome
middle finger
at what elbow angle should you palpate the UCL?
palpate with 50-70 degrees of flexion
observation of posterior dislocation
prominent posterior shoulder and coracoid - common to be locked in IR
glenoid labrum anatomy
rim of fibrocartilage around glenoid cavity
what are sagittal plane landmarks for body alignment?
should be a straight line from mastoid, medial iliac crest, through lateral malleolus
if pain is posterior on the GH apprehension test, what is that a sign of?
sign of posterior (internal) impingement
which RTC tear characteristics put someone in a low risk for irreversible change category?
small, partial thickness tears
atrophy of the upper traps can indicate what injury?
spinal accessory nerve palsy
what is the best way to measure AROM for the GH joint?
supine
what are indications for GH inferior glides?
to increase abduction(sustained grade 3), to reposition the humeral head of superiorly positioned
extensor plantar response
toes pointing up with plantar stimulation
during elevation of the arm in healthy subjects, what should the scapula do?
upwardly rotate and posteriorly tilt
what are other miscellaneous red flag symptoms that don't apply to a certain condition?
• fever or night sweats • severe emotional disturbance • swelling or redness in any joint with no history of injury
what are the 12 principles of examination?
1. Unless bilateral movement is required, the normal side is tested first. 2. The patient does active movements before the examiner does passive movements. 3. Any movements that are painful are done last, if possible. 4. If active ROM is not full, overpressure is applied only with extreme care to prevent the exacerbation of symptoms. 5. During active movements, if the ROM is full, overpressure may be carefully applied to determine the end feel of the joint. (let acuity guide this, make sure it's safe and doesn't make them worse) 6. Each active, passive, or resisted isometric movement may be repeated several times or sustained. 7. Resisted isometric movements are done with the joint in a neutral or resting position so that stress on the inert tissues is minimal. 8. For passive ROM or ligamentous tests, it is not only the degree (i.e., the amount) of the opening but also the quality (i.e., the end feel) of the opening that is important. (always compare to normal side so you know what their normal feels like) 9. When the examiner is testing the ligaments, the appropriate stress is applied gently and repeated several times. (Watch for symptoms and patterns to emerge during repeated tests, confirm what you feel at an end point so you're certain about what you feel.) 10. Myotomes: each contraction is held for a minimum of 5 seconds to see if weakness becomes evident. (Nerve requires repetition to be fatigued, check multiple repetitions/hold contraction to see if fatigue/endurance is a factor) 11. The examiner must warn the patient that symptoms maybe exacerbated as a result of the assessment. (do this 1st, set the expectations that symptoms may be recreated during exam and that's ok/normal 12. If the condition appears to be beyond his or her scope of practice, the examiner should not hesitate to refer the patient to an appropriate health care professional.
what are the 7 condensed form questions for an ortho exam history?
1. mechanism of injury 2. aggravating/relieving factors or movements 3. 24-hour history 4. improving/static/worse 5. new/old injury 6. past history (social & family) 7. diagnostic imaging
typical order of tissue damage during elbow dislocation
1. ulnar portion of LCL is disrupted 2. remaining LCL structures, A/P capsule is disrupted 3. MCL is either partially disrupted, involving the posterior MCL only or is partially disrupted *The higher level of injury-> greater tear to the capsule
4 Truisms of joint play (read)
1. when a joint is not free to move, the muscles that move it are not free 2. muscles cannot be restored to normal if the joint which they move is not free to move 3. Normal muscle function is dependent on normal joint function 4. impaired muscle function may cause deterioration in joints
what are important questions to ask yourself in a patient-centered interview?
1. who is the patient? (use the ICF) 2. what does the patient want from the provider? 3. how does the patient experience the illness? 4. what are the patient's perceptions about the disorder? 5. what are the patient's feelings about the disorder?
what is the chance of retear post RTC surgery?
20-90%
what is loose packed position of the hip?
30 degrees flexion 30 degrees abduction slight external rotation
what is loose packed position of the shoulder?
55 degrees Abduction and 30 degrees horizontal flexion
what are the components of the CS scan exam?
AROM PROM (in supine, performed if AROM is grossly limited) Over-pressure (when AROM is full or nearly full, otherwise proceed with caution) RROM (CS) UE myotomes Reflexes Dermatomes Special tests for: compression & distraction Neurodynamic tests (e.g., upper limb tension test)
what directions do you apply A/P GHJ glides in?
Anterior: antero-medial direction Posterior: posterolateral direction
what is the referral pattern of the infraspinatus?
Anterolateral shoulder and medial border of scapula; may refer down lateral aspect of arm.
What are the s/s of nursemaids elbow?
Arm is held with the elbow flexed and the forearm pronated -- the toddler will refuse to use that arm - pain and lacking supination
why can lateral elbow structures be overstressed when the UCL is impaired?
As medial strucutres become stretched out/torn/unstable, the medial part of the elbow can gap and compress the lateral aspect of the elbow
What is AMBRI instability?
Atraumatic Multidirectional Bilateral (often) Rehabilitation (often responds to) Inferior capsular shift (if surgery) - atraumatic GH instability - as RTC fatigues, it isn't able to stabilize the humerus as well and it leads to chronic instability over time
what is an alternative to the gerber lift off test?
Belly press test
what is the C-spine scan exam?
CS scan exam is used to rule out referral of symptoms from the CS to the shoulder. The CS scan exam will include all of the following
What is Sprengel's deformity?
Congenital failure of scapula to descend Elevation of the scapula, and limited humeral abduction - Not scapular dyskinesis
what can a coronoid fracture cause at the elbow?
Coronoid is an important structure for elbow stability, fracture here that doesn't fully heal can cause elbow instability later on
what is the dosage for grade 2 and 3 kaltenborn joint mobs?
Distraction or glide 10 seconds, partial release, repeat 3xs. Note response, repeat.
what is the duration of treatment for maitland oscillation techniques?
Duration of oscillation is 1-2 minutes
EDS
Ehlers-Danlos syndrome
what is radial tunnel syndrome?
Entrapment of the radial nerve in an area extending from the radial head to the supinator muscle
what is the arcade of frohse? what is it's importance to us as PTs?
Fibrous ridge at the proximal aspect of the supinator muscle that may compress the radial nerve. Near the radiocapitellar joint, the radial nerve branches into the deep, motor, posterior interosseous nerve and the superficial sensory branch. It is the deep branch that passes beneath the arcade of Frohse which is the most common site of compression of the radial nerve
Pain and limitation with ROM in every direction, what tissue injury is this a classic presentation of?
Frozen joints, immobilization -> movement loss in all directions - indicates arthritis or capsulitis
what are RTC atrophy grades an indication of?
Gives info to the surgeon about the viability of the tissue for repair. - STIR sequence: highlights fatty streaks in RTC tendon
Sulcus Test Grading Scheme
Grade 1: Acromiohumeral interval <1cm Grade 2: Acromiohumeral interval 1-2 cm Grade 3: acromiohumeral interval >2cm
What are Maitland Grades I and II used for?
Grades I & II treat pain, muscle guarding, provide synovial fluid movement. - Grade I - rapid motion (pain) - Grade II - 2-3 per second (spasm)
as you move the GHJ into greater abduction, what GH ligament provides greater resistance to rotation?
Inferior GH ligament
what is the referral pattern of the latissimus dorsi?
Inferior angle of scapula up to posterior and anterior shoulder into posterior arm; may refer to area above iliac crest.
What is Marfan's disease?
Inherited connective tissue disorder w/ventricular weakening & enlargement - can cause general hypermobility
What will I do if the scan exam reproduces shoulder symptoms?
It depends... - If the problem is completely CS related, then the CS will need to be treated. - If the problem is both in the CS and the shoulder, then both areas will be treated.
what is tennis elbow?
Lateral epicondylitis; an overuse injury affecting the musculotendonus junction of the wrists extensor muscles or the lateral epicondyle of the humerus - involves eccentric overload at the origin of the common extensor tendon
C8 dermatome
Medial arm and forearm to long, ring, and little fingers
what nerve innervates the muscles that oppose the thumb?
Median
what is the referral pattern of the teres minor?
Near deltoid insertion, up to shoulder cap, and down lateral arm to elbow
traction apophysitis
Occurs at onset of growth spurt when bones are not fully developed
what is the referral pattern of the levator scapulae?
Over muscle to post. shoulder, along medial border of scapula
what is the referral pattern of the supraspinatus?
Over shoulder cap & above spine of scapula; sometimes down lateral aspect of arm to proximal forearm.
what are the components of an orthopedic exam?
POMPJRSD Patient history with Initial hypothesis Observation: beginning to confirm or refute initial hypothesis Movement: AROM, PROM, RROM, Functional Movement Assessment Palpation Joint play testing Reflexes Special Tests = Provocative tests Diagnostic Imaging
how do you do the cervical distraction test?
Patient in supine. PT seated. Place hands around patient's mastoid processes. Slightly flex patient's neck and pull their head towards your torso, applying a gentle distraction force. - Positive test for cervical nerve root compression: when the patient's symptoms are reduced with the distraction.
what are three things that are commonly associated with patient satisfaction in orthopedic PT?
Patients are highly satisfied with musculoskeletal physical therapy care when these are met: 1. Interpersonal aspects of treatment: effective communication and empathy 2. The process of care: continuity of care and adequate treatment duration 3. Well-organized care: convenient access and low waiting times
How much time do patients typically need to disclose their primary complaint?
Patients need 32-90 seconds to disclose primary c/o with maximum requiring 2 minutes
how do you perform MWM's for tennis elbow?
Pt's palm down, stabilize humerus with proximal hand, wrist with distal hand (gently) - lateral glide to elbow just distal to the elbow joint using the strap - pt. performs gripping or wrist extension during mobilization - 10 reps at 30, 60, 90 deg elbow flexion
Potential causes for ulnar nerve entrapment?
Recent: post-fracture, from throwing baseball, new activity requiring repetitive elbow flexion or flexion w/valgus stress (pulling wire or lines) Latent: post-fracture with deformity that has become problematic over years or decades vs. months, osteophyte formation, repetitive use resulting in fibrosis
what are the normal spinal landmarks for the position of the scapula?
Scapula extends from T2/T3 to T7/T9 - scapular spines at T3
possible causes for decreased GH ER?
Short pectoralis major and/or latissimus dorsi, adhesive capsulitis
PROM elevation test for subacromial impingement
Stabilize at the scapula. • Internally rotate humerus. • In the plane of the scapula, passively elevate humerus to maximal range. - Positive test if: pain is located at the sub-acromial space or anterior edge of acromion - decent sensitivity, good for ruling a condition out
what are the time frames for the 3 stages of frozen shoulder?
Stage 1: ~3 months Stage 2: ~3-9 months Stage 3: ~9-18 months
what are tests for atraumatic instability of the shoulder?
Sulcus sign (assesses rotator interval) - apprehension/relocation test - Neer and Hawkins test: impingement or RTC tendonitis in younger people indicate possible multidirectional instability
what RTC tear size typically does not have better outcomes with surgery?
Tear of 3cm or smaller, PT outcomes are equal to surgery - More difficult to recover with PT with a tear larger than 3cm
possible causes for increased scapular protraction?
Tight pectoralis minor Weak/lengthened lower trapezius Weak/lengthened serratus anterior
what are possible causes for scapular anterior tilting?
Tight pectoralis minor; weak lower trapezius
What is TUBS injury?
Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery - common injury with gross shoulder instability - common anteriorly - high recurrence rate
what is a possible cause for excess scapular depression?
Weak upper trapezius
what are yellow flag S/S?
Yellow flag signs and symptoms: • may indicate a more severe problem • may require a more extensive evaluation • may increase level of precaution or treatment may be contraindicated - Many red and yellow flags are referred to as "non-specific" meaning they may be associated with a variety of different causes.
referral pattern of the brachialis
ant. arm, elbow to lateral thenar eminence
myopathy
any pathologic change or disease of muscle tissue
what is mechanisms of inferior shoulder dislocation?
arm forced into elevation with distraction
how do you perform the sulcus test?
arms relaxed at pt's side, hold arm above the elbow and apply inferior force - positive test is a sulcus/divot appearing between the humeral head and the acromion
what is joint play?
arthrokinematic movement that happens between joint surfaces when an external force creates passive motion at the joint, examiner creates passive motion at the joint - not under voluntary control of the patient - joint play is required for normal, pain free joint mobility
T2 dermatome
axilla
what is the most common nerve injured with GH dislocation?
axillary nerve, often a transient neuropraxia - increased risk of axillary nerve injury with increased age, vascular injury, and delay in reduction
referral pattern of the biceps
bicipital groove to anterior elbow
what are extrinsic factors that can cause stress to the RTC?
biomechanical & anatomical factors - overhead work, scapular dyskinesis, abnormal scapulohumeral rhythm, boney changes (OA, bone spurs, acromion changes) - throwing technique - hypermobility
what is brachial plexus palsy?
brachial plexus injury, often a birth trauma that causes C5/6 injury - presents as stuck in IR of the shoulder, inability to ER the arm
chondrolysis
breaking down and absorption of cartilage
What is a subluxation injury?
dislocation partially out of the socket - congruency of some of the joint but not all of the joint
why would a patient's arm be bolstered into abduction post RTC surgery?
holding them in Abducted position may indicate a large/massive RTC tear, putting slack on the repaired tendon
what are indications for GH anterior glides?
increase extension/External rotation
what are indications for GH posterior glides?
increase flexion/internal rotation
what is a sulcus deformity?
indicates subluxation, part of the joint is still congruent
what is the crank test used for?
labral tear - positive if clicking with pain in the GHJ (clicking with no pain isn't concerning) - Spin = .7 - .9 , better for ruling in
which RTC tear characteristics put someone in the "irreversible changes have already occurred" group?
large RTC tears, chronic tears >70 yo
what ages does external impingement commonly occur in?
late teens to 20s, hypermobility/instability caused by weakness in scapular or humeral control muscles or CT tissue laxity
brachioradialis referral pattern
lateral epicondyle, lateral forearm to post. web space BT thumb & index finger
C3 dermatome
lateral neck
C5 dermatome
lateral upper arm
what are risk factors for posterior GH dislocations?
ligamentous laxity, glenoid retroversion or hyperplasia
radial collateral ligament function
limits ulnar deviation of the elbow - primary lateral stabilizer followed by capsule & common extensor group
movement is relatively strong, but not as strong as it should be and movement is painful. what tissue damage is this a classic presentation of?
local strain of muscle or tendon (grade 1 or 2)
when looking at AROM, what are you examining for?
look at available range, control, power, willingness to move - when/where symptoms occur - whether the movement increases the intensity/quality of symptoms - patient reaction to symptoms - amount and nature of restriction - pattern of movement (certain issues have predictable patterns) - rhythm and quality of movement - movement of associated joints
what joint position is joint play assessed in?
loose packed/resting position
immobilization >3 weeks post elbow dislocation leads to what loss of ROM?
loss of extension
what is saddle anesthesia?
loss of sensation (anesthesia) restricted to the area of the buttocks, perineum and inner surfaces of the thighs frequently associated with the spine-related injury cauda equina syndrome
T1 dermatome
medial forearm
L3 dermatome
medial knee
L4 dermatome
medial malleolus
what is loose packed position of the facet joints in the spine?
midway between flexion and extension
for passive tissue lesions, AROM and PROM are usually painful in what directions?
movement in the same direction, pain usually occurs with limitation/end range of movement - ex. damaged post knee capsule will hurt with both PROM and AROM knee extension
if normal ROM and overpressure with C-spine clearing exam is unremarkable, then what is the result of the exam?
negative clearing exam
no pain and movement is weak, what tissue damage is this a classic presentation of?
neurologic involvement OR a 3rd degree strain
is accessory movement available in the close packed position?
no accessory movement is possible in close packed position
what is an absolute indicator for RTC surgery?
onset of acute, post-traumatic weakness in active individuals without pre-existing RTC dysfunction
what are relative indications for RTC surgery?
pain and weakness that has been resistant to non-operative management (usually considered a period of 3-6 months)
what are symptoms of atraumatic GH instability?
pain, weakness, paresthesia, crepitus, shoulder instability during sleep
how do you do drop arm test/drop sign?
passively elevate the arm in scapular plane to 90 degrees, ask patient to slowly lower back down to their side - positive test is pain or weakness causing the patient to lower their arm to their side.
what is Valgus Extension Overload? what tissue damage does it cause?
pathology in the posteromedial elbow - common in pitchers - repetitive stress of pitching leads to excess shear force on medial aspect of olecranon tip and olecranon fossa and overload tension at the MCL - characterized by: chondrolysis, osteophyte formation (posteromedial humerus and olecranon, loose bodies, MCL attenuated with repetitive strain, radio capitellar compression -> chondrolysis
if C-Spine clearing exam reproduces their shoulder symptoms, then what do you do next?
perform a C-spine scan exam
clinical signs of avulsion fracture of the medial epicondyle
point tenderness and swelling over the medial epicondyle, lack of full extension are clinical signs
S2 dermatome
popliteal fossa
triceps referral pattern
post. shoulder, arm, elbow, & forearm to medial two fingers, medial epicondyle
what is the most common direction of dislocation for the elbow?
posterior
loss of GH IR indicates tightness where?
posterior GH joint capsule tightness
what is the best predictor of RTC integrity post op?
preoperative tear size - tears <2cm twice as likely to heal as massive tears
what is a complex elbow dislocation?
presence of fractures
function of the interosseous membrane
prevents proximal dislocation of the radius on the ulna
serratus anterior MMT
push down on arm and feel for tipping of the inferior border of the scapula - don't need to have them protract their scapula
is Maudsley's Test (tennis elbow test) better for ruling out or in?
ruling out, high sensitivity
annular ligament function
stabilize the head of the radius against the ulna - limits distraction/dislocation of the radial head
What is a SLAP tear? what other injuries is it associated with and what is it's mechanism of injury?
superior labral tear from anterior to posterior - may occur as isolated lesion or be associated with internal impingement, RTC tears, or GH instabilty - MOI: repetitive overhead activities (throwing), FOOSH with tensed biceps, traction on the arm (pull on the LH of the biceps)
atrophy of the infraspinatus and/or supraspinatus indicates what?
supra scapular nerve palsy
derangement
tear/injury to a tissue inside the joint, blocking normal movement
which elbow ROM do tennis player commonly lose over time?
tennis players may lose extension as they age
what is Cross Arm Adduction Test?
test for subacromial impingement - passively flex arm to 90, maximally adduct arm - spin .82, good for ruling in
what are indications for GH distraction?
testing/initial treatment (sustained grade 2) pain control: grade 1 or 2 oscillations general mobility: sustained grade 3
what is the belly press test? what is it used for?
tests for subscapularis pathology, Spin = .98 - positive test, weakness vs other arm or compensation with shoulder extension trying to pull arm into body.
what is end feel at a joint?
the barrier to further motion at the end of PROM - felt by the examiner - each joint has a characteristic end feel and a unique structure providing a stopping point to mobility
tightness of what part of the GH capsule can increase likelihood of SLAP lesions?
tightness of the posterior capsule/IGHL shifts the GH contact point anterior/superior and increases shear force on the superior labrum
complaints of weakness and heaviness in a limb after activity can indicate what?
vascular issues
radial nerve entrapment symptoms
wrist drop (unable to extend elbow and wrist), loss of triceps reflex, decreased sensation to posterior arm tx: adjust, increase strength, stretch
should you perform resisted isometrics in positions that cause the patient symptoms?
yes! - see if symptoms are reproduced/changed, grade the strength of the contraction, test the type of contraction that causes the problem - symptoms can be more than just pain (perform resisted isometrics after AROM and PROM)
what are neurological red flags?
• Changes in hearing • Frequent or severe headaches with no history of injury • Problems with swallowing or changes in speech • Changes in vision (e.g., blurriness or loss of sight) • Problems with balance, coordination, or falling • Fainting spells • Sudden weakness • Changes in personality
what are gastrointestinal/genitourinary red flags?
• Frequent or severe abdominal pain • Frequent heartburn or indigestion • Frequent nausea or vomiting • Change in or problems with bowel and/or bladder function (e.g., urinary tract infection) • Unusual menstrual irregularities
What is the Yocum test?
• Patient places hand of involved shoulder on contralateral shoulder. • Pt actively raises involved side flexed elbow to shoulder level. • Positive if painful at anterior shoulder. • Snout .80, good for ruling out
what are red flags for cancer?
• Persistent pain at night • Constant pain anywhere in the body • Unexplained weight loss • Loss of appetite • Unusual lumps or growths • Unwarranted fatigue
Joint Play Movements of the Shoulder Complex to check during the exam?
• Posterior glide of the humerus • Anterior glide of the humerus • Lateral distraction of the humerus • Inferior glide of the humerus • Posterior glide of the humerus in abduction • Anteroposterior and inferior/superior movements of the clavicle at the acromioclavicular joint • Anteroposterior and inferior/superior movements of the clavicle at the sternoclavicular joint • Scapular movement to determine mobility
Describe Hawkins Kennedy test
• Pt sitting, passively raise arm to 90° flexion • Flex elbow to 90° • Support arm at distal humerus w/lateral hand • Medial hand holds proximal to patient's wrist • Quickly move the arm into internal rotation holding onto wrist - Snout .55-.80 Spin .30-.60, better for ruling out
what red flags during the exam indicate immediate need for medical referral?
• Severe unremitting pain • Severe spasm • Psychological overlay
what are cardiovascular red flags?
• Shortness of breath • Dizziness • Pain or a feeling of heaviness in the chest • Pulsating pain anywhere in the body • Constant and severe pain in lower leg (calf) or arm • Discolored or painful feet • Swelling (no history of injury)
what are the steps of Median nerve testing?
• Shoulder depression and abduction (110°) • External rotation • Elbow extension • Forearm supination • Wrist extension • Fingers/thumb extension • Attenuate with contralateral lateral neck flexion, decrease intensity with ipsilateral lateral neck flexion
When should you Use the Spinal Scanning Examination? (8 reasons)
• There is no history of trauma • There are radicular signs • There is trauma with radicular signs • There is altered sensation in the limb • There are spinal cord signs • The patient presents with abnormal patterns • There is suspected psychogenic pain * Clear the joints above and below the injury/pain. Even if there aren't neurological symptoms, including spine exam will give you a better picture of what is going on.
what are miscellaneous yellow flag symptoms?
• bilateral symptoms • symptoms peripheralizing • multiple nerve root involvement • abnormal sensation patterns (do not follow dermatome or peripheral nerve patterns) • saddle anesthesia • abnormal signs and symptoms (unusual patterns of complaint) • vertigo • progressive weakness • progressive gait disturbances • multiple inflamed joints • psychosocial stresses • circulatory or skin changes • pregnancy
what are precautions for joint mobs?
• osteopenia • pregnancy • history of malignancy • protective muscle spasm to the extent that the clinician is unable to evaluate mobility in the area being examined • total joint replacement
interventions for cubital tunnel syndrome?
•Cubital tunnel split: limits flexion to decrease stress on nerve •Strengthen proximal GHJ & scapular muscular -correct proximal impairments •Manual therapies to improve soft tissue movement around area of compression (don't compress the nerve) •Selective strengthening of hand intrinsics (ulnar nerve distribution) •Refer to CHT or ortho hand surgeon (not plastic surgeon unless they only do hands) if symptoms fail to resolve or improve (4 weeks should see improvement)
signs/symptoms of lateral epicondylitis?
•Point tenderness at lateral epicondyle •Gripping and resisted wrist/digital extension is painful and weaker •Tightness in extrinsic extensors - decreased grip strength
what are indications for joint mobilization?
▪ Decrease pain, muscle guarding, and spasm ▪ Increase joint mobility in joints with hypomobile capsule and/or ligamentous tissues ▪ Maintain motion or slow loss of motion in persons with chronic diseases that effect motion ▪ Provide joint mobility and movement of synovial fluid when patient is not able to actively move body part
what are contraindications for joint mobs?
▪ Joint instability ▪ Joint hypermobility if mob is performed at end range ▪ Joint effusion: o joint infection o malignancy o rheumatoid arthritis in an active phase ▪ Fracture - recent, unstable or unhealed ▪ Joint ankylosis ▪ Osteoporosis especially if know history of fracture
