MSK I UE

Good steps for Nerves

Mixed/Motor = MMT (MSTT can give you FP) NV, PFT if its a superficial nerve Sensory = Neg. MSTT, and Neg. MTT; Nerovascular step = best, then PFT

What step would be different for Tendonosis vs. itis?

PFC! itis = inflammation

Dupuytren's contracture -Diagnosed with?

Diagnosed with palpation, for skin and fascia changes (skin gets retracted or has dimples

Trigger Finger -Treatment

RX: splinting up to 4 months, cortisone up to 3, surgery releasing pulley (low re-ocurrence) Magee pg. 365

Results for MSTT if nerve involved?

(??) Weak and Painful - Tendon must be injured (partial tear) Strong and Painless - 2 fingers may not be strong enough; may just say okay contractile tissue is not involved and move on! don't need to document anything other than "Strong and painless" Weak and Painless - Why? (motor nerves are painful, so don't think that way); Nerve that supplies muscle = non-contractile; the muscle itself is not injured its the non-contractile tissue thats causing the weakness and no pain; this can give you a false positive from MSTT because you may think that its a complete tear; Its a "False positive" for tendons Strong and Painful - ? not sure

Why would you want to look up the kinetic chain?

-kinetic chain - any symptoms of shoulder or elbow that could result in excessive stressing in this area causing the irritation - NEED TO FIND THE CAUSE!

SC & AC joint pathologies were the 2 what?

"Ligament" Injuries

Area cod for Carpal tunnel = 921

FDS, FDP, FPL = 9 tendons Ulnar Bursa (covers FDS and FDP), Radial Bursa (covers FPL) = 2 Bursas Median Nerve = 1 nerve

f. Pseudoarthrosis

Fake joint at fx site that results in you thinking theres a joint there fx site will create a synovial capsule around it and makes a fake unhealthy joint; its rare but can still occur

De Quervain's is also called _________

New mother thumb - new mom is constantly cradling head with their lax joints from pregnancy can irritate these tendons

g. Undisplaced Clavicular Fracture -What kind of treatment?

No Open Reduction Internal Fixation needed; Able to position the arm/scap. so that the ends are in alignment but the ends of bone at fracture sites are still touching each other -better luck with healing in children

1. list the physical therapy musculoskeletal examination findings which would be positive for the following dysfunctions: a. adhesive capsulitis

Not on PPT, just speculating. Would depend on stage? Acute stage: -Hx of traumatic event? -PFC - Inflammation? -AROM = painful but normal ranges -PROM C= painful but normal ranges -PROM A =? Chronic/more frozen stage: -present in tight jc pattern

3. Define Heterotropic Bone Formation

1) Bone formation in non-osseous tissue 2) Most common example = Myositis Ossificans 3) Elbow is notorious for this!

Benidict sign vs. Bishop's deformity -Appearance of the hand with the 4th and 5th digits flexed

They look very similar *Benediction Sign *- ACTIVE its a sign (So something have to see) Have patient make a *fist* and *won't be able to flex thumb, index or middle finger* b/c don't have ability to control flexors to bring into a fist due to Median n. damage *Bishops Deformity* - Same appearance. Ulnar nerve problem. *Can't use lumbricals to help extend over power of extrinsic flexors flattened thenar eminence* ('ape hand') because of an atrophy. of thenar muscles

Dorsal scapular

Think about is it mixed, motor, sensory etc. & what steps would give you results

1. Cozens Test

This exam resembles an MMT -Pt. makes a fist, radially deviates and extends while examiner resists motion (+) = pain around lateral epicondyle

T/F They may never get the mobility back after an AC joint pathology (biomechanics wise)

True

DIAGNOSTIC IMAGING - NOT ON 2ND TEST!! -Watch YouTube Video!

.

SC joint pic

Anatomy- cross sectional view of meniscus on R. side #9 disc . Very difficult to manage as they are very hard to stabilize.

What else ends up with a presentation like this? How do you differentiate Dupuytren's contracture from a nerve injury?

Benediction Sign and Bishops Deformity With a nerve injury there should be motor or sensory changes in the correct distribution of the nerve, but with Dupuyten's there are no motor or sensory changes

6. discuss the significance of lunate mobility impairments to wrist symptoms.

Could see *median nerve compression* (Carpal tunnel) bc displaced lunate can cause compression If you want to treat this you'd want to support pt. wrist in slight flexion

2. describe the etiology, clinical appearance and appropriate management/intervention of *Volkman's Ischemic Contracture.* -What kind of syndrome? -What are 3 causes/Etiology?

Its a *compartment syndrome* - increased pressure within the compartment of the forearm *Etiology* 1) Direct trauma 2) Cast too tight 3) Swelling

2. describe the three (3) methods of detecting *lateral elbow tendinopathy*, (epicondylitis, epicondalgia) according to Magee, and discuss each method for specificity of examination for dysfunction. (p 379-380 Magee)

Lateral Epicondylitis Special Tests: 1 Cozens- resembles MMT (force is maximal) 2 Mills - resembles MLT with PFT 3 - resembles more MSTT (force not maximal) If tests are inconclusive, Imaging can help diagnose; usually don't need it though

What motions would you want to avoid?

Overhead movements (because not a lot of stability); start rehab with arms by side etc., Also Elbow Flexion if it is a SLAP lesion b/c long head of biceps involved

Scaphoid Fracture -PT Treatment

Physical therapy treatment will involve treatment of impairments that result from the fracture or the medical treatment. -Seeing them after their surgery or casting they may be tight or still lax, may have swelling (edema or effusion), may have tight extrinsics from being immobilized We don't fix fracture but after surgery they will have ROM limitations etc.

1. SLAP Lesion pic 2:00 - 10:00

Superior Labrum present with Anterior and Posterior Instability = SLAP

AC jt. pathology Pic

Superior ligament (13) mostly affected; Yellow = joint capsule Blue = articular cartilage?

1. describe the function of the labrum.

The labrum helps hold the humeral head in the glenoid fossa for proper stability and movement to occur. The glenoid fossa is a lot smaller than the humeral head and the labrum generates a sort of suction cup action that helps keep the humeral head in place.

Scaphoid Fracture -Medical Treatment

The medical interventions for Avascular Necrosis: Medical treatment can involve 1) immobilization in a cast covering thumb 2) ORIF 3) pharmacology 4) bone stimulator to encourage the rate of healing (Bone Stimulator built into cast) When they can't create healing they will *excise completely and replace it with other tissues* (palmaris longus tendon rolled up, artificial implants)

MMT for mixed nerves? What would you expect if nerve involved with MLT?

Write the muscles and their weakness; would there be pain in MMT? (didn't answer) What would you expect if nerve involved with MLT? -Tingling/numbness because you are stretching the nerve

n. Rowe test (p.281)

.

c. Supraspinatus test (Empty Can) (p.310)

Impingement Test (+)/Pain = tear of supraspinatus tendon or muscle, or neuropathy of supra scapular nerve

More Details on External Fixation from voice over -What can surgeons do that makes this treatment advantageous? -How long do pt. wear it?

*External Fixation: (pic)* 1) Surgeons can tweak it to add traction to help alignment 2) Helps prevent shortening of the radius with alignment 3) 8-12 weeks its removed

3. a) define ulnar tunnel syndrome -What is it? b) describe signs/symptoms

*What is it?* = Compression of ulnar n. at Guyon's canal (ulnar tunnel, pisohamate canal)

*Ulnar nerve damage* results in what deformity?

1. Bishop's Deformity = Wasting away/atrophied/flatness of *hypothenar eminence*

To make treatment need to know 5 things

1. SOC 2. TSI 3. TR 4. SR 5. Goal

f. Displaced Clavicular Fracture

2 ends do not align, over-riding of margins, locations are different, end of bones are not touching

HMWK: A pt. presents to you with an ulnar nerve entrapment due to edema in cubital tunnel. The SOC for both impairments is sub-acute and the tissue reactivity is moderate. Describe the expected physical exam findings from steps 5-14 of the clinical exam per patla.

5. PFC: Edema present in posterior medial epicondyle area of elbow - Cubital tunnel 6. AROM: -Thumb: limited adduction -Ring: limited flexion of DIP, extension, abduction and adduction -Pinky: limited flexion, extension, abduction and adduction -Elbow flexion due to edema 7. PROM C: Unremarkable 7. PROM A: Unremarkable 8. MSTT: Weak and painless or weak and painful (false positive) 9. MLT: Unremarkable -Be consistent for prom classical & MLT; if you said limited in PROM C then you'd need the same restrictions for MLT even though it may be a false positive 10. MMT: weak grip strength + weakness in FCU, FDP, ADD Poll, Palmar and Dorsal Interossei, Hypothenar mm and 3 and 4th lumbricles 11. ST: (+) Tinels also whataburger test 12. MA: Unable to grip objects or pick them up (have them do anything that uses their hands) 13. PFT: Symptoms reproduced/Pain when palpated in the cubital tunnel at moderate to deep depth *PFT stresses nerve the most for MSKI for tissue reactivity 14. Neurovascular: Light touch sensation loss over unbar nerve distribution; -Dermatomes = spinal cord levels -Peripheral nerve distribution = ulnar nerve -on test you'd need to write out where ulnar nerve distributes

3. describe the clinical exam findings for a capsular pattern restriction at the shoulder and apply to a clinical case.

A capsular restriction pattern at the shoulder would give you particular findings during the exam. During AROM and PROM Classical, pt. would have limited ER>ABD>IR. They would also have limited anterior glide>inferior glide>posterior glide in PROM Accessory. The end-feel for both PROM classical and PROM Accessory would be found as tight joint capsule. This joint pattern is one of the clinical manifestations of several conditions, including Adhesive Capsulitis. If you are finding more severe limitations in ROM, the pt. is most likely in the Frozen stage. At this stage, joint mobilizations that produce mechanical effects should be used for treatment and Coddmans exercises can also be used to help the pt. with functional movements/ADLs.

What are the ABCS of Imaging?

A:Alignment B:Bone density C:Cartilage space S:soft tissue

What type of things would you work on?

Decompress area, work on posture, work on force coupling muscles (i think she said same general things for AC joint)

d. Radial Nerve Entrapment - Elbow Superficial vs. Deep

After elbow they split into: *1. Superficial Radial Nerve* -Is around the tendinous origin of ECRB - this is where it would be entrapped and you would see SENSORY loss only (in dorsum of the hand and where the anatomical snuff box is) *2. Deep Radial Nerve* = MOTOR loss only! -Entrappment at supinator mm = finger and wrist extensors that are innervated distal to the supinator

5. identify common soft tissue injuries and complications following a *Posterior Elbow Dislocation*

Be aware of the complications if you see someone with a posterior dislocation and got it from *Hyperextenstion injury or fall* on hand *with elbow flexed* Complications: *1) Brachialis mm trauma* 2) Joint capsule damage 3) Nerve injury 4) Brachial artery *5) MO (myositis ossificans)* 6) Minor Fractures

Biomechanics on scaphoid

Biom,echanics: Ext: distal row moves dorsal and proximal row moves volar until 60 degrees. At ~60 degrees the hamate, capitate, trapezoid and scaphoid come into close packed position forming a rigid mass and radial dieviation occurs. Midcarpal moves as whole. Triquetrum and lunate move volar on radius until full extension where all but trapezium is in CPP. Flex - scaphoid doesn't become in closed pack positoin

e. Swan Neck Deformity -Etiology

Causes include 1) volar plate deficiency at the PIP jt 2) FDS tendon incompetence 3) intrinsic muscle contracture 4) chronic mallet finger 5) excessive traction by extensor apparatus

4. define and describe the clinical use of the following: a. Yergason's test (p.309)

Checks if the transverse humeral ligament is holding biceps tendon in groove: (+) = If tendon felt like it popped out of groove then transverse ligament is torn

2. explain etiology, management, outcome and P.T. treatment of Colles' fracture -MOI = Foosh, what kinds of forces? -How might it look?

Colle's Fracture: Fracture of Distal Radius *Etiology/MOI:* FOOSH -Remember that when hand in ext. carpals are in a locked position; So forces transmitted to the dorsal aspect of the radius (in this case) and drives the radius dorsally (if you have any mal-alignment its usually the radius displaced dorsally) *Classic deformity* -"Dinner fork" = *Dorsal angulation* of distal fragment -You'd see this before they went to the surgeon (and typically they always get surgery due to such a mal-alginment)

c. Comminuted Fracture Radial Head -Treatment?

Comminuted = MORE THAN 2 PEICES of fracture/bone segments Treatment = May need *Radial head prosthesis*

Force couples:

Deltoid & RTC Subscapularis, infraspinatus and teres minor - prevent superior migration of humeral head Rotator cuff stabilizes shoulder - allows prime movers to function without excessive humeral head translation

Adhesive Capsulitis -Management MD vs PT PT - acute vs. chronic

Depends on health care provider; MD: Prescribe Injections (good for early stages w pain) PT: -If we catch them early on in acute we want to limit the worsening, decrease inflammation, teach them functional exercises, teach them ways to gait pain, AROM maintaining pain free range so the loose less range. Want to manage more on pt. education and teaching them things they can go home and do to prevent it further, you don't want to keep seeing this person and keep tearing at their shoulder (don't want to hit tendon and cause tendonitis); if caught early want to pt. education and send them on their way; tell them to comeback when they are less painful and you can work to get motion back; If we catch them in chronic: we help with mechanical effects with joint mobs, more stretching, etc.

Scapular movement Tests -Repeated motions

Elevation (flexion and abduction) 5-10 reps, may need to add small hand weight Look for consistent winging and/or dysrhythmia

h) explain both open and endoscopic surgical interventions.

Endoscopic would be preferable but its a lot more expensive, takes a more skilled surgeon -had less pain, but still have same amount of functional outcomes (i.e. still missed same days of work etc)

i. Sprengel's Deformity. -Etiology? -What happens to muscles? -What ROM are decreased? -How do scapula usually look?

Etiology: Congenital deformity of the shoulder complex particular scapula. Scapula is *underdeveloped and undescended*. Scapula is raised up as u see in the pic and smaller. Scapular muscles are *poorly developed* or replaced by *fibrous band* May be unilateral or bilateral Range of motion - decreased *ABD/Elevation* Scapula usually *smaller and medially rotated*

How do you know its a FP and its a never thats giving you that? What other steps?

For complete tear - Find lots from Hx; might find trauma; MLT would be excessive etc. For nerve - may occur over time and just gets weaker and weaker so may not necessarily find in Hx If you write Weak and Painless you need to write FP (if its not complete tear) Any positives for MSTT for nerves, you must say/write you got a FP because the intention of MSTT is to test for contractile tissue

Scapular Retraction & Reposistion Test

Force gauge on R. how they would measure Jobe's position to measure the strength change. One person retracting and other measuring the force. Two very similar tests: in retraction test u actually put the scapula in retracted position and in rep.1st pic is both hands to retract and second pic is just cue with hand and arm and not actively retract but just a cue. The reason they have two very similar tests is as they measured the force with the gauge all they needed was repositioning/cuing to get results- stronger strength change.

g. Bennetts Fx -Pic and description

Fracture AND dislocation injury at the *first carpometacarpal (CMC) joint* - THUMB (needs both fracture and dislocation)

d. Supracondylar Fracture -Where is this fracture? -Etiology/MOI (2) -Who does it commonly occur in?

Fracture through epicondyles of humerus (many types, don't need to memorize them just know what it is) *Etiology/MOI:* 1. Extension injury - i.e. arm forced into hyperextension of elbow - too much stress to distal part of humerus can break and result in fx. 2. Crush injury i.e. MVA Commonly occurs in "youngsters" May see swelling, may be harder to heal etc., may see deformities if bad enough?

d. Non-Union of the Fracture

Fx never really healed; 2 types = Fibrous non-union and psuedoarthrosis

j. Galeazzi fracture - dislocation (need both fracture and dislocation) -Fracture of what causing dislocation of what?

Galeazzi fracture consists of a fracture of the radius *with angulation* and associated *dislocation of the distal ulna* 1. Displaced fx of *distal 1/3* of radial *shaft* -Distal fragment of radius *tilted posterior* 2. Dislocation of distal radioulnar joint Raidograph - most evident in lateral viewRX with sx with plate or screws

What kinds of things would they still be able to do/work on during the 4-6 weeks of immobilization?

Give them supportive treatments to minimize their losses! 1. Start immediately on scapular firing and ther ex! No reason why they can't do scapular depression and retraction 2. They can move wrist around, do gentle stretches of the fingers/hand 3. Work on posture

c. Adhesive Capsulitis (Frozen shoulder) -Etiology -Mechanical/Poorly related factors: (8)

Idiopathic Mechanical/Poorly related factors: 1. Tendon partial tear 2. previous trauma or fx to the area 3. calcific supraspinatus tendonitis (chronic) 4. prolonged immobilization 5. DJD 6. type I diabetes mellitus 7. cervical dysfunction 8. postural - increased thoracic kyphosis

MSTT for bursitis can give you a FP? I think?

If findings are positive, they are FP because they really only test for tendons

d. Supracondylar Fracture -Treatment

If its Displaced (2 pieces are not aligned and are off) - need screws to hold them = *ORIF*

Findings are only different from tendonitis in which step?

Imaging

Process of Volkmans Ishcemic contracture Satler pg. 470 -more notes

Increased tissue pressure results in decreased blood flow that results in ischemia. Compartment pressures of 50mm Hg are associated with a 70% decrease in blood flow. Compartment pressures may return to normal after a fasciotomy. The most serious consequence of increased compartment pressures is Volkmann's ischemia of nerves and muscles. How long can a muscle last without a blood supply before it starts to demonstrate changes? Click here for answer (6 hours) How will you check the blood supply? Click here for answer (capillary refill) Allen's test

h. Sulcus sign (p.290)

Indicates Inferior Instability or GH Laxity -ST used for SLAP and Bankhart lesion i think? (+) = presence of a sulcus when pulling forearm away

e. Drop Arm test (p.311)

Indicates RTC tear (+) = unable to rerun the arm down slowly or has severe pain when attempting to do so

SC joint - Saddle joint If lateral clavicle is elevated and moved anteriorly, how does the medial clavicle move?

Inferior and anterior vex on cave = elevation/depression (glide opposite roll) cave on vex = protraction/retraction (glide same as roll)

Apprehension test (Crank test) (p.279)

Instability test; Assessing for Anterior Shoulder Dislocation (+) when pt. looks apprehensive or alarmed and resists further motion -Push humeral head anteriorly to matt -Posterior pain? = (+) for impingement

d. *Fracture of the Neck of the Humerus*: -whats the MOI? -what are the demographics? -what are some other complications?

Intracapsular: displaced/non-displaced MOI: FOOSH with forces being transmitted up the extended UE, usually via traumatic event Demographics: older women with osteoporosis or young athletes Other complications: stiffness, anything that the trauma could have affected - humeral circumflex arteries, axillary nerve damage - deltoid and t. major

How would you treat lunate displacement?

Joint mobilization - to decrease compression?

Mallet Finger Treatment

Keep DIP in extension or hyperextension during healing to avoid "lag"; you can tell in people who have poorly managed it they will not be able to achieve full extension bc it healed in a little bit of flexion

Calcific Supraspinatus Tendinitis Treatment: MD vs. PT

MDs: -Prescribe oral non-steroid anti-inflammatorys, -Injections -Aspirate and draw minerals out -Arthroscopy to excise it, may need to repair RTCs PT: don't do any of those, more search and treat, decrease inflammation, swelling and irritation

4. describe the mechanism of injury and description of tissue damage of a Hills Sachs Lesion.

MOI of Hill Sachs Lesion: Usually when there is an anterior dislocation when the humeral head slides forward and when the soft posterolateral portion of the head hits the rim of the glenoid fossa it makes a dent in the head. I think it may be associated with bank-hart lesions

Hill Sachs Lesion MOI

Mechanism of Injury 1. Traumatic event: Compressive force with dislocation. 2. Usually dislocates anterior/inferiorly and contacts posterolateral aspect of humerus 3. "Soft" humeral head contacts 'hard' glenoid rim and a cortical compression Fx is caused in that posterolateral aspect

SLAP lesion

Mechanism of Injury 1. Traumatic event: Compressive force with subluxation 2. Repetitive micro-trauma: Eccentric biceps load, "peel back" full external rotation-overhead athlete population i.e. baseball player 3. Click/popping (laburnum is fibrocartilage, so you'd hear these things) *labrum is really just a continuation of the long head of the biceps tendon

Median and Ulnar Sensory innervation

Median nerve goes dorsally and covers the tips of the fingers

Adhesive Capsulitis -Epidemiology/ Demographic:

Middle aged Caucasian women whole process may take 1-2 years; may be bilateral (develop on both shoulders)

Who usually gets trigger finger? Which fingers does it usually affect? What is it associated with? Where wold it be tender?

Middle aged women Occurs usually in third of fourth finger Associated with RA, gout, DM, CTS, De quervains, Dupuytren, HTN worse in morning Tender over MCP, catching sensation

Bennetts Fx -PT Treatment

Often *closed reduction* (proper alignment), may have to have a traction outrigger loop/cast to maintain position -If not a screw or wire used (ORIF?) 1. PT treatment depends on the impairments that you find: i.e. you will probably find laxity bc there was a dislocation (however we can't really treat laxity -Once a laxity always a laxity) 2. We may be treating the impairments that result from the medical treatment of surgery or immobilization.

ELBOW 2

On test cant just say FOOSH- need direction of FOOSH!

What would you find during PROM Accessory for a SLAP lesion? (Quality and Quantity)

PROM Accessory = Positive findings Qual? - Displaced meniscus Quan?- Hypomobility You could also get hypermobility with laxity endfeel Lesson here: you can get either hyper or hypomobility! But cant have hypermobility with springy rebound Really bad tear - pushing you back - hypo

What steps would be painful for bursitis? (vs. tendon)

PROM classical at end would be painful MMT would be painful Active ROM would be painful at any range Same direction and opposite direction = pain (pain in all directions) vs. Tendon: if you do MMT for action or stretch them in opposite direction = pain

Usually we would see pt. post-op after External Fixation device is removed; But if you do see them, what should you emphasize? What would be a possible complication and why?

PT. EDUCATION - to keep away from any INFECTION - keep it clean!! *Why?* B/c the pins are outside and reach into the bone - because bone is technically exposed to the outside world - they could have *pyogenic infections* *Complication?* Pyogenic Infections such as *Osteomyletis * -They could loose their whole arm; (pt. education very important)

What exam steps would you use and what findings for a scaphoid fracture?

Palpation condition - swelling but only slight. Palpation tenderness over snuffbox Imaging

Adhesive Capsulitis -Clinical Manifestation

Presents the same as "Tight GH joint capsule" (its the same capsular pattern) Always these 5 things that confirm! 1. Decreased Classical AROM: ER>ABD>IR 2. Decreased Classical PROM: ER>ABD>IR 3. Decreased Classical PROM: Tight Capsule end feel 4. Decreased Accessory PROM: Tight Capsule endfeel 5. Decreased Accessory PROM: (match the component motions w osteo motions) Anterior glide (ER) >Inferior glide (ABD) >Posterior glide (IR) *ABD is talking about scapular elevation or "Scaption"

d. Jerk test (p.288)

Pt arm IR and flexed at 90; Examiner grasps pt. elbow and axially loads humerus in proximal direction (+) = sudden jerk/clunk as the humeral head moves off the glenoid Indicates Posterior instability

What movements load the APL and EPB the most? -What would this movement lead to?

Radial Deviation - if someone is picking things up in RD position a lot it could result in *irritation* to this area

Differentiate Reactive vs. Degenerative b/c treatment is different

Reactive = Activity modification Degenerative = Heavy loading

If you write tendonOSIS you need to further divide it into ___________ or _________

Reactive or Degenerative; Correcting the biomechanics is overall baseline but these have different treatment stressing of the tissue wise

Big picture for Diagnosing Nerve Entrapments, really want to use which step?

Really use the neuromuscular step where you look at sensation and motor loss; Those will be your key clinical findings for diagnosing these problems!

d. Labral pathology -PT management: POST OP

Rehabilitation will be driven on the *size and position of the lesion* and *overall stability* of the shoulder after the repair. 1. Protect the repair 2. Minimize the effects of immobilization - AROM of surrounding joints and structures that your allowed to move i.e. wrist scapula etc. 3. Restore ROM 4. Restore scapular strength 5. Restore posterior cuff strength -ER strength (infraspinatus, t. minor etc.) seats head in GF - need this stability 6. Restore function

2. Mills Test

Resembles more of an MLT -Putting tendon in stretched position

What is the SICK scapula?

SICK scapula - the pathological state of the scapula characterized by: 1. *S*capula mal position-lat. Slide test 2. *I*nferior border prominence-ant. tipping 3. *C*oracoid pain-ant. shoulder pain 4. *k*inesis abnormalities of the scapula.

What is the exact opposite of a colle's fracture? -How do you get this fx? (MOI) -How is it displaced?

SMITHS Fracture! MOI: Fall on *flexed wrist* Distal fragment *displaced anteriorly* (opposite from collies) Lecture: -see opposite effects instead of most problems with ext (collies) you have more problems with flexion

c. Posterior tendinopathy - triceps tendonitis

Same exact thing but these muscles are involved -Triceps -Aconeus

If some one needs treatment here (i.e. they have developed adhesions in the area after surgery), what can we do??

Say its well healed and TR is low 1) Fluidotherapy (good but general, we want to be specific and focus on adhesions; 2) adhesions are common in this area due to lots of fascia and tendons = CFM good treatment! 3) ROM to restore normal gliding of tendons

Adhesive Capsulitis -Treatment

Self-limiting - pt. education; Codmans exercises, maybe grade I and II for pain

2. define and describe the Bankart lesion and surgical procedure including: a. open surgical b. arthroscopic

Should have already covered this!

e. Fibrous Non-Union

Soft tissue, fibrous tissue or scar tissue that never ossifies and that is the consistency of the tissue at the fracture site Think of scar tissue that never ossifies around fx site;

Special Test Finklestein's

Step 1: Active thumb flexion Step 2: Active finger flexion Step 3: Passive ulnar deviation (+) = Pain with any of these movement; all components must be preformed and pain is felt in anatomical snuff box area

What would you want to strengthen for AC joint pathology? (Think about force couples and which ones are more likely to be weak)

Strengthen: 1. ABDs: Supraspinatus (ABDs) 2. Upward scap rotation: MT, LT, SA and Rhomboids Don't necessarily strengthen Deltoids, UT , ADDs (Pecs, subscapularis) b/c they are hardly ever weak and usually hypertonic

Suprascapular Nerve

Suprascapular = Mixed -Motor = Infra and Supraspin -Where can you do sensory testing? Suprascap notch PFT -What positions cause more irritation b/c mixed fibers still at notch? Protraction (pulling on nerve);

Surgical zones/no man's land

Surgeons split hand up into zones; depending on what zones your outcomes will change; we will be focusing on flexor tendon zone 2 aka no mans land

d. Labral pathology -Physician management (2 types of repairs)

Surgical Repair - put screws in *1. Arthroscopic repair* - less scaring/impairments due to scar tissue etc. -when port holes fill with scar tissue - keep in mind it went though everything; they are basically scar-tissue anchors; probably need to do some myofascial release and keep it mobile etc. *2. Open* - not as common anymore; theres longer healing time and more scarring

1. compare and contrast the etiology, physical examination tests and findings, physical therapists management and medical management for: a. Lateral Tendinopathy/Lateral Epicondyl-itis, osis,-algia

Swelling/degeneration of proximal wrist extensors -ECRB, ECRL, ED, (I think she added ECU) -Want to be specific on which muscle is affected!

a) define carpal tunnel syndrome (CTS)

Syndrome = not a TSI

d) Explain physical therapist management of ulnar tunnel syndrome.

Take the pressure off! 1) Patient education 2) UE orthotic, bracing, gloves, equipment (grips) etc. 3) Treat soft tissue impairments

f. Posterior Apprehension test (p.285)

Tests for Posterior Shoulder Instability (+) = look of apprehension or alarm on pt. face, pt. resistance to further motion, or the reproduction of pt. symptoms

i. Adson maneuver (p.322)

Tests for Thoracic Outlet Syndrome -Locate pulse -pt. head rotated to test shoulder -pt. extends head while you laterally rotate and extend shoulder (+) = disappearance of the pulse

b) describe the patient complaints with carpal tunnel diagnosis.

Three best examination findings 1) Sensory changes in median nerve distribution 2) Muscle weakness/motor changes median nerve -may be dropping things 3) c/o night pain -Difficulty typing, gripping etc. -Phalens ST? (prayer) Use of splint Why might splint not work? 1) Does not fit 2) Patient compliance

3. describe the clinical exam findings for a *capsular pattern restriction at the elbow* and apply to a clinical case.

Tight elbow joint capsule (More common at humeroulnar?) 1. Common occurrence post elbow immobilization/injury/surgery -gets tight pretty easily b/c elbows already pretty stable 2. Classical: flexion limited more than extension 3. Accessory: P/A glide radial head limited more than A/P (Anterior glide of radius = flexion; Posterior glide of radius = extension)

PROM Accessory findings for tendinopathy?

Unremarkalbe? its outside capsule I think unremarkable for bursitis too

g. Allen maneuver (p.321)

Used to detect compression in the costoclavicular space/Thoracic outlet syndrome (+) = radial pulse disappears when head rotates to the side

e. Swan Neck Deformity -Treatment

Usually does not respond to conservative spilinting or exercise May effect ability to bring tips of fingers into a grasp Intervention varies - may be silver ring splint to correct pip hyperextension Don't really responsd well to brancing? What would be due as PTs? -pt education on how they are using hands, not to load it in that position/space, not really mobilizations

Instabilities can take the form of *Traumatic* Instabilities which result in what 3 lesions?

bankart/SLAP/Hillsachs lesion

ELBOW 1 OBJECTIVES

https://www.youtube.com/watch?v=Fe_d0RS2TD0&feature=youtu.be

e. bankart/SLAP/Hillsachs lesion

https://www.youtube.com/watch?v=a6BWiufgmsc

What are some osteokinematic movements that could irritate these tendons?

over extension of thumb or UD or RD of wrist

6. compare and contrast the medical examination of an unstable glenohumeral joint with the physical therapy evaluation.

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SHOULDER 1 LECTURE/OBJECTIVES

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SHOULDER 3 OBJECTIVES

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WRIST AND HAND 1

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What step confirms/tells you Keinbocks?

Imaging

Adhesive Capsulitis -How do pain and ROM change during 4 stages?

"Becomes inflamed then adheses/freezes then you get significant loss of motion" *1. Pre-freezing:* inflammation, painful, normal ROM *2. Freezing:* Maximally painful, some ROM limitation bc some scar tissue develop -pain is what will bring them to see you *3. Frozen:* ROM most limited, less pain *4. Thawing:* scared down capsule remains, ROM returning, decreased pain

m. scapular assistance test (p. 306)

(A scapular motion test/Symptom Altering Test) Positive findings here mean decreased pain and/or increased ROM -Positive finding is a GOOD thing here! If they do better with this then they will probably get better in rehab

l. scapular reposition test

(Symptom Altering Test) Scapula Reposition Test (post. Tilt and ER-proprioceptive cue: re-check pain and strength)

k. scapular retraction test

(Symptom Altering Test) Scapula Retraction Test (full retraction-check pain and strength)

Median Nerve Entrapment - Elbow *Signs & Symptoms of Clinical Exam:* Motor (8) Sensory

*Signs & Symptoms of Clinical Exam:* Every mm. thats innervated distal to the median n. location at pronator teres will be weak; and Sensory impairments *Motor:* 1. ABD Pollicis Brevis 2. Opponens Pollicis 3. FPL 4. FPB 5. Lumbricals 1 & 2 6. Palmaris Longus 7. FDS 8. FDP 1 & 2 - Looking for specific pattern of muscle weakness; if you see all of these then thats pretty diagnostic of median nerve damage *Sensory:* Palm/radial half through half of ring finger -if you see diminished sensory here and impaired muscle performance of the mm listed you know if median nerve involvement

Keinbock's Disease -Treatment Surgery vs. Conservative

*Surgery* -Incision of this bone *Conservative* -Short artm cast 6-10 weeks then start with ROM with splinting in between sessions and at night

What are some special tests for SLAP lesion? (2)

-Always want more that 1 to be positive (the more the better) 1. Sulcus sign would be positive 2. Load and shift: Anterior and Posterior would be positive

j. scapular slide test

-Lateral Scapular Slide Test 3 positions: Rest, Hands on hips, 90 deg. ABD (>1.5 cm diff.)

Where are Volkman's Ischemic Contracture most common?

-Most common acute involves the forearm and leg -Measurements of pressures remains controversial

Complex Regional Pain Syndrome -PT Treatment -may want to re-listen to this slide; everything on this is his texts in the notes section but his voiceover talks about other things too

1.) Fluidotherapy or different types of *materials to rub over the involved regions* to help *DESENSITIZE*and increase sensation will be used. 2.) As PT's we want to *increase motion with ROM activities*. 3.) Massage may help with the desensitization, but will address the edema and swelling. (kinda contradicted in lecture..) 4.) *Muscle pumping* exercises will also help with the edema. 5). Treat all tissue impairments as tissue reactivity permits. 6) TENS, loading the tissue (carrying heavy objects) has been proven in literature, edna massage pulse US Compression sleeves etc. Mirror training to get somatosensory re-organization

What is the Prognosis of CRPS? (4)

1.) ~ 80% have complete spontaneous relief of signs + symptoms within 18 months 2.) No criteria have been established to predict outcome 3.) 50-80% have disability secondary to pain and or limited ROM 4.) Long duration of symptoms, presence of tropic changes, presence of cold RSD are associated with higher chances of poor outcomes

3. Bankhart Lesion pic

3:00 to 6:00

Mobilizations and AC joint pathology?

Mobilize maybe I and II at AC; but if its a sprain you don't want to do III and IV there; You would do III and IV for mechanical effects at the cervical thoracic junction

*Clavicular Fractures* -Classified as (3)? -MOI? -What does pt. present with? -Possible complications? -Most common location?

More common in children Classified As: *1. Displaced Clavicle* (its moved location wise due to fracture) *2. Undisplaced Clavicle* (where it should be) *3. Greenstick fracture *(splinters and freys; bone is so young and pliable its not a ridged break it freys on convex side) *MOI:* traumatic event, FOOSH injury, Fall on elbow where shoulder goes up and shears and compress on clavicle *Pt presents* with pain, swelling, cluncking at clavicle where parts collide with one another *Possible Complications:* neruovascular compromise, brachial plexus, pneumothorax *Most common location:* within the first 3rd

c. Delayed Union - "Slow healing"

Most common that you will see in clinic: About 6 weeks is pretty standard for healing, but some people take 14 - 20 weeks to heal! Could be due to: 1. Collagen deficit 2. Pt. could be diabetic 3. Other factors: meds, smoker, old age = delayed healing Management: -Slow them down, let them heal, try not to be aggressive in beginning, very cautious with these people and they need longer immobilization

b. Medial Tendinopathy - golfer's elbow

Muscle involved: Pronator Teres, FCR, FCU; -Inflammation at Wrist flexor attachment -not something you see too often for golf injuries its just a slang term Same diagnosis as lateral epicondylitis; -Contract, put them in stretch, palpate medial epicondyle

If the pt. has a fracture and dislocation, is it still a colle's fracture?

NO, its become Galezzi's Fracture; But the fracture in the galezzis fracture is the same as colles fracture

Colle's Fracture Post-OP (after the device is removed) -What things could be tight/possible TSIs? -Where does the most amount of tendon excursion happen/where should your focus on rehab be?

Possible TSIs: 1) Tightness of muscles - intrinsic or extrinsic (because no normal excursion of tendons in area); 2) Wrist joint capsule, carpals and digits may also be tight (mainly wrist joint is what you need to treat) The greatest amount of tendon excursion happens with wrist movements so need to work on wrist motions early on;

3. Lateral Epicondylitis Test 3

Resembles more of an MSTT Examiner resists extension of 3rd digit distal to PIP, stressing the extensor digitorum muscle and tendon (+) = pain over lateral epicondyle

b. Trigger Finger AKA digital tenovaginitis stenosans

Result of thickening of flexor tendon sheath Causes sticking of tendon with flexion They can actively flex but every time they flex it it will get stuck there - you can passively extend but they cannot extend actively

*Median nerve damage* results in which deformities?

*1. Ape Hand* -Median nerve innervates the thenar mm and with damage you get *wasting away of the thenar eminence*; -Apes still have opposable thumbs but its more that the bulk of the palm is gone and its flat *2. Benidict SIGN* indicates median nerve damage

Following reading of the Gaunt article, the student will be able to: 7. a. discuss the four guiding principles used by the rehabilitation professional for a successful outcome following shoulder instability surgery. b. interpret the principle of gradual application of stress as it applies to the post-operative rehabilitation weeks 0-24.

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b. Radial Head Fracture -Treatment Approach (depends on size of fracture)

*1) Small fx *(barely seen on radiograph) = pt. should take it easy and it should heal on its one *2) Displaced fx* = need cast, closed reduction or ORIF *3) For Comminuted Fx* = radial head prosthesis (usually for comminuted) - cut off old head and replace it with prosthetic head; this will make the radius shorter (chop off the top part) *may affect the distal RU joint as well* bc the radius may slide up

Following viewing of the Anterior Instability video, lecture presentation, and independent study the student will be able to: 8. identify the three radiographic views for viewing of the Bankart lesion: a. A/P at right angle b. lateral scapula view c. axillary view (* most important)

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If PIP joint cannot flex in 2nd step what are possible tissue specific impairments at the PIP causing this?

(These are not TSIs) 1) Hypomobile capsule 2) Joint capsule adhesion -TSI = Right PIP joint capsule adhesion in P/A direction 3) Hypermobile capsule (capsule laxity) ^ This could be a false positive for tight intrinsics 4) Effusion/edema ^This could be a false positive also, you never really know whats join on 5) Bone spur 6) Tight extrinsics ^This could also be a false positive - they may be the ones that are giving you test results as apposed to the intrinsics -Also mal-algnment could give you a false positive

h. Green-stick Fracture of Clavicle. -pic

(splinters and freys; bone is so young and pliable its not a ridged break it freys on convex side) -Common in kids (younger than 10)

If a scaphoid fracture is present, what motions of the wrist will be painful?

(wrist extension and radial deviation. The same position that causes the fracture)

d) describe nine (9) possible causes/"associations" of CTS.

*1) Trauma* Fracture/fall on area Disease Space occupying lesion *2) Ergonomics* Treatment *3) Tight Wrist Flexors* Treatment *4) Displaced Lunate* Hypomobility Hypermobility Treatment *5) Retinaculum tightness* Pisiform mobility Treatment *6) Edema* Treatment *7) Effusion* Treatment *8) Pronator Teres Syndrome* *9) C5-T1 Nerve Roots*

What are 3 forms of treatment for Colle's Fx? -Which is least common and why?

*1) Cast for immobilization* to realign fragments -not common bc most time theres a lot of mal-alignment; unless the fx is not displaced or comminuted it will be hard to get normal fixation with just immobilization *2) ORIF* *3) External Fixation (pic)* -pins through skin into bone;

B:Bone density Normal vs. Abnormal for 1) General Bone density 2) Texture 3) Local bone density

*1) General Bone Density* *-Normal:* Contrast between soft tissue & bone, contrast between cortical & cancellous bone *-Abnormal:* loss of density thinning cortical margins or increased density *2) Abnormal Texture* *-Normal:* normal trabeculae *-Abnormal:* thin, fluffy, coarse. Local changes in bone density *3) Local Bone Density* *-Normal:* sclerosis at wt. surface or attachments *-Abnormal:* excess sclerosis, osteophyetes Reactive Sclerosis: surrounding tumor/infection

A: Alignment - General Architecture Normal vs. Abnormal for 1) General 2) Contour of bone 3) Bones relative to adjacent bones

*1) General:* *-Normal:* size & number of bones *-Abnormal:* Aberrant size, Supernumeray, Congenital anomalies, absent bones *2) Contour of Bone:* *-Normal:* smooth and continuous cortical outlines *-Abnormal:* Fractures, spurs *3) Bones relative to adjacent bones:* *-Normal:* joint articulation, normal spaces *-Abnormal: Fx, joint subluxation/dislocation, marking of past surgical sites

C:Cartilage space (Do not see it)

*1) Joint Space Width* *-Normal:* well preserved joint space *-Abnormal:* decreaed jt. space - degeneration or trauma *2) Subchondral bone* *-Normal:* smooth surface *-Abnormal:* inc. sclerosis *3) Epiphyseal plates* *-Normal:* normal size for skeletal age, smooth *-Abnormal:*changes in thickness compared to opposite side

SHOULDER 2 OBJECTIVES - LISTEN TO PP!!

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What is unique about the scaphoid? (3)

*1. Blood supply only enters from the DISTAL pole* -no proximal blood supply; if you have a transverse fx that splits it in 2 you are devascularizing the more proximal segment *2. No muscle attachments* -cant stress it via wolfs law to cause a stronger healing bony fracture *3. Covered with articular cartilage* - little periosteum (which has good blood supply, articular cartilage has little) impeding/slowing healing

j. *Fractures of the Shaft of the Humerus.* -MOI? -Clinical Manifestation? -Possible complications? (2 vascular structures) -Treatment? -What is it prone to?

*1. MOI:* Transverse forces (not shear), direct blow i.e. car crash 2. Extracapsular, outside of joint so any bleeding/swelling will be outside of joint = ("edema") *3. Clinical Manifestation:* This Fx won't hide itself well; they will have *"flail arm"* they will guard and brace/hold arm; lots of *muscle guarding* of mm tying to stabilize *4. Possible Complications:* lots of risk to *radial nerve*: most concerned about sharp edges of Fx lacerating the radial nerve; Also the *brachial artery* *5. Treatment:* open reduction internal fixation, closed reduction and cast; 6. Heals well its just prone to *alignment issues* and subsequent *stiffness at elbow* due to immobilization

c. causes of impingement: -6. GH jt. dislocation Complications of Anterior Glenohumeral Dislocation: (4)

*1. Neurovascular comprmise:* -Axillary Nerve injury- atrophy and wasting of Deltoid -Humeral circumflex arteries could be compromised *2. Instability afterwards* -After you dislocate you are definitely lax, thats why immobilization is super important after *3. Rotator cuff tear* *4. Long head biceps tear*

1. describe the following fractures in regard to etiology and treatment (medical and physical therapy): a. Olecranon Avulsion Fracture

*2 common MOI:* 1. Blunt force trauma - falls right on olecranon 2. Avulsion fracture - triceps contract and it pulls a part of the olecranon away from the main bone Any time you see avulsion = think of tendon/ligament pulling bone away from main part

SHOULDER SURGERY OBJECTIVES

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1. identify five (5) possibilities for etiology of *Complex Regional Pain Syndrome (CRPS)* type I (Sudeck's atrophy) identify three (3) characteristic features and discuss the Physical Therapists management.

*5 Etiologies* 1) Direct trauma to sympathetic nerves 2) Immobilization causing edema 3) Direct trauma to peripheral nerves 4) Immobilization 5) Psychological predisposition *3 Characteristic Features*

Adhesive Capsulitis -Pathophysiology - Acute vs Chronic

*Acute vs. Chronic:* -Acute may be missed, harder to diagnosed because it generally just presents itself as this dominating shoulder pain -Chronic stage: frozen/ begining to thaw *Pathophysiology:* self-limiting pathology/process where you go through phases of change at joint and you get impairments Key words: Self limiting = phases of change = changes at joint = impairments

TSI = (name of nerve) irritation; There will be another TSI causing that TSI; i.e. Limited in PROM Accessory, or Edema

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WRIST & HAND 2

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Always find/treat the cause, basically =

*CORRECT THE BIOMECHANICS* -could be tightness/limitations - anything thats causing the abnormal biomechanics Find the cause & treat the cause

What are the 2 types of CRPS?

*CRPS 1* 1) pain syndrome, previously RSD 2) triggered by *noxious event that is not limited to a single peripheral nerve.* 3) Sympatheltically maintained pain abnormal reaction of the sympathetic nervous system 4) 3 phases acute phase 1- days to 3 mos. Reversable. Phase 2 vasomotor instability 3-6 mos Phase 3 cold 2-3 mos *CRPS 2* 1) pain previously causalgia 2) involves direct partial or complete injury to a nerve or one of its major branches 3) there is objective nerve injury!

WRIST & HAND 3 - Didn't listen! all notes are from PPT and lecture

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Volkman's Ischemic Contracture *Clinical Appearance (signs & symptoms) & Treatment* -5 Ps: Pain, Pressure, Paralysis, Pulses, Paresthesia

*Clinical Appearance:* 1. Swelling and c/o tightness 2. Severe pain exacerbated with passive stretch of fa muscles 3. Motor weakness or paralysis 4. Absent radial and ulnar pulses 5. Diminished pulses and capillary refill *Treatment:* How is a compartment syndrome treated? the pressure needs to be relieved, this can be done through a fasciotomy or removal of the cast) -removing fascia so that things have a place to go and release pressure -surgical intervention needed if they reach a point of no return

a. Olecranon Avulsion Fracture -Treatment: ORIF vs. *Closed Reduction/Immobilization*

*Closed Reduction/Immobilization* 1) Usually pt. gets cast, surgeon tys to pull pieces together in alignment the best way possible and they use a plaster; 2) Now a days immobilization devices are used for about 6 weeks 3) Only possible if NOT highly displaced - if there are pieces of bone floating around you probably have to do ORIF 4) Factors that influence healing time? age, how bad fx, pt. normal health etc; but 6 weeks is clinically classical time for bone healing; but can go up to 10-8 weeks depending on factors

What is De *Quervain's Tenosynovitis?* = Inflammation of SHEATH Where is this condition located/which tendons are involved? What structure(s) would you treat?

*De Quervain's:* Common tendon condition seen on radial side characterized by *thickening and inflammation* of *APL and EBP tendon sheaths* (needed to flex, extend and grip object) Located = @ 1st extensor tunnel/volar side of anatomical snuff box; Clinically you can't tell if its just the *tendon or sheath* so you treat both!

Shoulder tendinopathy -PT management *Degenerative tendonOSIS (late SOC)*

*Degenerative tendonosis (late SOC)* 1. Normalize load aka "Correct the biomechanics" 2. Transverse friction massage -also may be later on because pt. may not be able to handle it early on 3. Exercise with eccentric loading - Heavy loading -This is our goal; don't start out with it; -Heavy loading breaks down degenerative cycle 4. Ultrasound -can be done in both; intent of US is different

DIDNT LISTEN TO LAST SLIDE!! Pisiform Mobility

*Medial glide lengthens flexor retinaculum* Glides named in relation to anatomical man standing *Restricted medial glide may be a cause of carpal tunnel syndrome* Compresses median nerve under flexor retinaculum *What is the treatment for a hypomobile pisiform?* -Joint mobilization

Colle's Fracture - Post-OP What kinds of treatment would you do? -Early on (3) vs. Later on (3)

*Early on* 1) Modalities - US 2) Mobilizations grade I and II for pain 3) Soft tissue work *Later on- More aggressive* 1) Mobilizations grade III and IV, maybe thrust after adequate healing 2) Strengthening weak tendons 3) Stretching tight tendons

c. Ulnar Nerve Entrapment - Elbow

*Etiology* -Entrapment in Cubital Tunnel - if you rest your elbow on desk too long, if you hit your "funny bone" *Signs & Symptoms of Clinical Exam:* -*Motor loss* in: FCU, FDP (Medial half), Hypothenar, ADD Pollicis, Lumbricles 3 & 4, Palmar & Dorsal Interossei -*Sensory loss* to: Ulnar half of 4th and 5th digits

Bennetts Fx -Etiology

*Etiology* 1) A *longitudinal force* applied to a *partially flexed thumb* dislocates the metacarpal base while leaving a fragment (avulsion) of bone from the anterior aspect of the base of the metacarpal. - FOOSH but hitting thumb first 2) A small piece of metacarpal remains in place with the trapezium while the rest of the metacarpal is dislocated and ends in a flexed position/appearance 3) With the dislocation that is also present, what is the tissue specific impairment that results? (capsule laxity) Seen more in people who are athletic, catching a ball etc.

2. describe the etiology and medical treatment for: a. Post-Traumatic Degenerative Joint Disease

*Etiology* 1. *Anytime you have an injury* and you damage osseous or soft tissue around joint, or you have a break in the bone, you are at *risk for developing post traumatic DJD* 2. Due to the *potential of abnormal biomechanics* leading to DJD (i.e. when they fractured the bone it could compress jt in a way that it can damage cartilage) 3. Big picture as a complication of Fracture: Fracture bone -->bones may not heal correctly-->abnormal biomechanics at jt-->result in early break down at joint 4. A concern for any fracture

b. Mal-Union Fracture -How does it heal? -What is it associated with? (2 examples) -How does it present?

*Etiology* 1. *Heals in abnormal position* - Forces are still going fx site when fx should be healing 2. POOR MANAGEMENT! 1) Immobilization period was not effective - cast taken off to early, cast not set in correct position etc. 2) Person needed surgery/ORIF but they had closed reduction instead *Presentation* Heals in an abnormal position; some sort of angulation due to abnormal healing and bone is not in normal position

4. Various shoulder bursitis: subacromial, sub deltoid -Etiology & Clinical Presentation "Everything need to know is on slide"

*Etiology* 1. Acute or chronic 2. Mechanical cause: trauma or secondary to other pathology such as DJD 3. Systemic: rheumatoid arthritis, 4. This is the largest continuous bursa in the body *Clinical Presentation* 1. Acutely very painful and signs of inflammation 2. Pain with any AROM or muscular contraction 3. Pain with end range PROM: ABD, IR, Horizontal ADD 4. Palpable tenderness-PFT

What do we as PTs want to do? Need to be more specific than "desensitize" Do you think they will let you massage their hand? (no) Start slower, small towel and rub their own hand

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*2. SC jt. pathology:* Etiology & Clinical Presentation -What type of dislocation dangerous? -How many grades of sprains? -What might you see during Structural Inspection/PFT? -What type of symptoms are SC joint path similar to?

*Etiology* 1. Sprain/dislocation from shoulder girdle trauma 2. MVA (most common) or sports injury or (FOOSH) -Posterior dislocation is very dangerous: i.e. brachial plexus, heart, etc. lots of important structures *Clinical Presentation* 1. IV grades of sprain 2. Deformity/mal alignment 3. Local pain/tenderness 4. Meniscus type symptoms -Clicks, pops (ask from Hx);

*3. Peripheral neuropathy of the shoulder:* Etiology & Clinical Presentation -How would pain present? -If sensory fibers were involved? -If motor fibers were involved? -Reflexes?

*Etiology* 1. Traumatic Injury: direct blow, traction, dislocation etc. 2. Compressive *Clinical Presentation* 1. Symptoms: painful *changes at location* or *radiating through area* of innervation (proximal or distal) 2. If *sensory* fibers: paresthesia, sensory alteration distal to injury site. 3. If *motor* fibers: weakness in distribution distal to injury site. 4. *Reflex* affected: triceps, biceps, etc.

5. Shoulder tendinopathy = Tendonitis or Tendonosis (itis has inflammation) -Etiology & Clinical Presentation

*Etiology* 1. Traumatic MOI 2. Overuse 3. Insidious onset *Clinical Presentation* 1. Tendonitis-signs of inflammation-PFC 2. Pain with activity 3. Depending on tissue reactivity may have pain with: PFT, MLT, PROM Classical (stretching muscle), MSTT -I think she may have said Active when compressing muscle too?

3. describe the etiology, pathophysiology, medical physician management and PT management for the following conditions: *1. AC jt. pathology*: Etiology (3) & Clinical Presentation -What special test? -What ROM in particular are painful? (what happens above 90?) -What about mobility of movement?

*Etiology* 1. Traumatic event causes sprain/dislocation (most common) 2. OA/Arthrosis 3. FOOSH -AC jt. ligaments and capsule provide horizontal stability - Graded I-VI (by MDs?) *Clinical Presentation* 1. Visual or palpable *mal alignment* -piano key sign (Special Test) = press on proximal clavicle and distal end moves up; may not see in lower grades 2. *Palpable tenderness* 3. Pain with *end range* motions especially *flexion or horizontal ADD* -Above 90 there is rotation of clavicle so movements above this may be especially painful 4. May see jt. *hypermobility* (sprain) FYI: Observe or view radiograph of Bil. shoulder shrug (Zanca view) or horizontal ADD (Basmania)

6. Rotator cuff tears -Etiology (2) & Clinical Presentation (3)

*Etiology* 1. Traumatic event-ecc. Overloading of tendon 2. Degenerative-overhead athlete or elderly *Clinical Presentation* 1. Night pain-hallmark, uncomfortable 2. Pain at rest 3. Significantly worse with volitional movement/contraction

3. describe the etiology, pathophysiology, medical physician management and PT management for the following conditions: a. External (Mechanical) Impingement -Etiology: Predisposing factors (7) & Extrinsic factors (4)

*Etiology- predispoising factors* 1. Excessive exposure: repetitive overhead activities -i.e. someone hammering overhead 2. Structure-boney and soft tissue 3. Instability/laxity: i.e too much anterior translation; 4. Capsule tightness: i.e. not letting humeral head glide inferiorly and ends up pinching 5. Muscle imbalance (tight/weak) 6. Postural - functional-slouched increases the pain: these are things you can fix right away 7. Impaired scapular kinematics *Extrinsic factors* 1. Nerve - palsy of long thoracic nerve = severe scapular winging 2. Trauma 3. Disease 4. Cervical

b. Radial Head Fracture -Etiology

*Etiology/MOI* 1. Usually Compression of radial head into capitulum -i.e. fall on hand FOOSH injury could load radial head and jam it into capitulum 2. Severe Valgus Force - someone could fall in a way that makes this force

c) describe the possible causes of ulnar tunnel syndrome

*Etiology:* 1) Trauma 2) Chronic pressure -Cycling, crutches, vibration and gripping (jackhammer) 3) Pisohamate Ligament/ Flexor Retinaculum -Tight or pathological thickening Didn't have this pic on slide but talked about zones around guyons canal -Zone 1 = have both motor and sensory changes- may see that flattening of hand? -Zone 2 = motor only -Zone 3 = sensory only Which is most common? Zone 2 - picking things up the objects really hit more on 2 zone than we do on 2 or 3; so 2 is most common and you get those motor deficits

Median nerve entrapment/*Anterior interosseous nerve entrapment*

*Etiology:* 1. Median nerve splits at Pronator Teres and gives off anterior interosseous nerve 2. Can get entrapped in deep volar forearm (Pronator Teres entrapment) *Signs & Symptoms of Clinical Exam:* 3. Only loose motor to these 3 mm: FPL, FDP, and Pronator Quadtratus - NO sensation loss 4. Pinch Grip Test: come in pad to pad because FDP inst flexing DIPs and FPL isn't flexing IP of thumb

b. *Median nerve entrapment*/anterior interosseous nerve entrapment -Median nerve entrapment can occur in a number of locations (6)

*Etiology:* 1. Scalenes (anteriomedial scalene) 2. Cubital fossa 3. Ligament of Struthers (not very common, many people don't have this ligament) 4. Biceps Aponeruosis *5. Pronator Teres* -hypertorphy will give you entrapment *6. Carpal Tunnel* ^^ 5 and 6 should be more of the common ones/ones that we would see and should be focused on

5. describe the etiology, symptoms and signs of the clinical examination for: a. Elbow Medial Collateral Ligament Injury

*Etiology:* 1. Valgus stress through MCL creates injury to collagen fibers 2. MCL more vulnerable to injury 3. See a lot in overhead throwing athletes, baseball in particular (pitchers); ligament can't handle the force (baseball players are getting stronger) *Sings & Symptoms of Clinical Exam:* 1. ST: Valgus stress test - you will find increased valgus joint mobility (diagnostic for MCL sprain) 2. PFT: Palpable tenderness depending on tissue reactivity and severity of sprain; between medial epicondyle and ulna = tenderness around that ligament is also diagnostic

d. Radial Nerve Entrapment (superficial and deep branches) - Elbow -Etiology

*Etiology:* Radial nerve can get entrapped if you have a -Mid-Shaft Humeral Fx - due to swelling -Neck of Radius Fx -Tight Cast @ Elbow - may compress radial nerve around elbow

Lateral Tendinopathy - tennis elbow -Etiology & Exam findings

*Etiology:* Biomechanical over-use (micro trauma) -They are putting abnormal stresses on the tendons and it causes inflammation *Exam* = most specific tests for tendons 1) Muscle Contraction/MSTT: you want to contract that tissue, if its strong and painful then you know its tendinitis or osis (then you'd go back to PFC and see if there was inflammation) 2) Stretch/MLT: if it reproduces pain it can be diagnostic 3) Specific palpation for tenderness at lateral epicondyle can be diagnostic as well

Fracture of the Neck of the Humerus. -Examination & Treatment -Intracapsular: Displaced vs. Non-displaced

*Examination* 1. There will me minimal evidence of fracture bc everything is contained in joint, you may think joint pathology 2. Local tenderness in axilla 3. Could have normal PROM bc the joint capsule is holding everything together *Treatment* 1. Sling- non-displaced- 4 wks, P/AA ROM at 2 weeks 2. TSA-older, displaced, poor prognosis

Compare and contrast External (Mechanical) vs. Internal Impingement

*External (Mechanical)* 1. Anything that causes compression or mechanical abrasion ocurring in subacromial space: RTC tendons (supra, infra long head biceps), Subacromial bursa, coracohumeral ligament etc. 2. Demonstrate classic 'painful arc'-mostly 60-120 deg. -this is when there is lease amount of space between humeral head and scapula (60 degrees at most risk because space is smallest); pt. experience pain 3. Greatest risk at *BELOW < 90 degrees* ABD *Internal* 1. Entrapment of tendon undersurface in glenoid-labrum complex (pinched) 2. Most common in overhead athletes 3. Rare - needed that activity over and over again for it to happen 4. Greatest risk *ABOVE > 90 degrees* ABD and ER

c. Heberden's Nodes & d. Bouchard's Nodes -Whats the difference in where they appear? -Etiology? -Clinical Appearance?

*Heberden's* - dorsal surface of *DIP* and associated with OA *Bouchard's* - dorsal surface on *PIP* and associated with OA (Page 361 Magee) *Etiology:* 1. Thickend fibrous part of joint capsule and it ossifies and becomes a node *Clinical Appearance* 2. Finger joints appear bony and and become less stable and less functional 3. May lead to effusion and fusion 4. Decreased ability to grip small objects and make a tight fist

What is Keinbock's Disease? Who is it most common in?

*Keinbock's Disease* 1) Osteochondrosis of lunate; 2) Avascular necrosis of lunate (death of bone tissue due to decreased blood flow) *Common in* 1) Young adults or ppl who have jobs with repetitive motions - (can cause microftracutres that can obscure the blood flow) i.e. someone working with a jack-hammer

Bankart Lesion MOI & Clinical Exam

*MOI:* Traumatic (TUBS injury) 1. Avulsion of anterior inferior labrum from the glenoid rim 2. Could be called *bony bankart* if glenoid rim is involved as well. 3. Usually occurs with anterior dislocation acutely or repetitive subluxation. *Clinical exam:* -PROM ACC: Findings: not sure?? -Special Tests: Sulcus sign & Load and Shift

Complex Regional Pain Syndrome -Medical Treatment

*Medical Treatment* 1. Focus on functional restoration. 2. Use of drugs, sympathetic blocks, and psychotherapy helps to achieve *good pain control* during physical therapy. i.e. *sympathetic or somatic blocks*, if performed, should be integrated into a good rehabilitation program. 3. Other surgical intervention include: 1) A spinal cord stimulator (SCS) can be an effective treatment for the pain of RSD 2) intrathecal infusion 3) baclofen pump: Morphine pump, Sympathectomy, and Radiofrequency. 4. They may refer to hand therapists -end result is the same = want to desensitize tissue

Treatment of De Quervain's (similar to any other tendonitis) -Medical -PT

*Medical* 1) Injections to reduce inflammation 2) Oral meds 3) "resting splint" - wrist is in ext and thumb mid way btwn ABD and ADD and MCP are in flexion 4) Surgery to release tunnel and clean out any scar tissue/swelling - no longer have tight space on tendon *PT Treatment* 1) Anti-anflammatory modalities - US to decrease adhesions 2) CFM area, with tendon in taut position (bc it has a sheath) = (UD, ADD, and flex of thumb) 3) Modified CFM -position is similar to Finklestein's so likely that pt. will have pain-->have them do just the 1st 2 passive steps and no UD; 4) Pt. education - alter the load on tendon 5) Strengthen weak mm. 6) Stretch tight mm. 7) Splint to decrease stress/strain on tendons

Colle's Fracture- Post-OP What might you find for PFC? SI? AROM? PROM C? (3 end-feels) PROM A? NV?

*PFC:* Atrophy or edema *SI:* check for alignment *AROM:* limited MCP Flex, IP ext, wrist flex/ext, ulnar dev - pretty much limited everywhere *PROM C:* could have bony, adhesion, or tight capsule end-feels *PROM A:* all decreased tight joint cap or adhesions *NV:* compression of nerve passing through area (median or ulnar due to compression); decreased sensory of median nerve distribution?

d. Labral pathology -PT management

*PT Management: Non Operative* 1. *Conservative* management can work! -Success depends mainly on recurrence of dislocation, pain report and functional loss. 2. *Control pain and inflammation* with modalities 3. Immobilize to decompress labrum: *4-6 week minimum* 4. Immediately start *scapular therex in sling* -ABD sling! want humeral rotation in neutral to slight ER (puts least amount of pressure on labrum), best type of sling -Traditional sling? too much IR = too much pressure on posterior labrum 5. Respect *tissue healing* and follow load progression as tissue heals and stability/control is created

2. explain the difference of signs/symptoms of nerve irritation versus regeneration according to Tinel.

*Pain is sign of nerve irritation* -Local -Painful cutaneous hyperesthesia *Tingling is sign of nerve regeneration* -Over cutaneous area of innervation -Hypoesthesia and dysesthesia Regeneration: -1 inch/month -Will not see positive Tinel's for up to 4-6 weeks

What would be some positive exam findings For De Quervain's? -Reverse Case: TSI = De Quervain's SOC = Sub-Acute TR = Moderate

*Palpation for Condition:* Inflammation (its an -itis) warmth, pain, redness, edema, loss of function *AROM:* ACTIVE MOVEMENTS (pain would in in the motions it does) Painful and limited for: -Wrist RD -Thumb ABD, and ext; *PROM C:* PASSIVE MOVEMENTS (so pain would be in opposite directions painful and limited for: -Wrist UD -Thumb ADD, and Flex *PROM A:* Unremarkable *MSTT:* Strong and Painful for thumb ABD and EXT (movements it does) (name/document according to action) *MLT:* PASSIVE MOVEMENTS (so pain would be in opposite directions Pain at end-range for: - same as PROM C! -Wrist UD -Thumb ADD, and Flex *Special Test:* Finklestein's? *may need to use imaging to rule out bony pathologies that produce similar symptoms

Various shoulder bursitis: subacromial, sub deltoid -Physician & PT Management

*Physician Management* 1. Excision 2. Anti-inflammatory injection 3. Oral anti-inflammatory medication *PT Management* 1. Control pain and inflammation with modalities 2. Immobilize to decompress (variable) 3. Pt. education to avoid exacerbation (rest) *4. Mobilize fluid in latter SOC* -MELT the Bursa; want fluid to dissolve/leave sac;

SC jt. pathology -Physician (2) & PT Management (4)

*Physician Management* 1. Local injection 2. Surgery for higher grades *PT management* - Same general management 1. Initial immobilization 2. Treat surrounding hypomobilities- stress SC -CT junction and AC joint may be tight and may need to work on them first 3. Protected motion 4. Stabilize through strengthening of muscles that attach to clavicle and scapular stabilization -we usually don't strengthen these surrounding muscles (pecs, etc. because they are already overworking/tight), need to decompress these and strengthen opposing mm.

*AC jt. pathology*: Physician vs. PT Management (4) -When would surgery be indicated? -What does research say? -Initial PT treatment? -Focus on? -Early intervention of what?

*Physician Management* 1. Not every grade V requires surgery 2. Surgical indications: *Acute Grade V/VI or failed conservative management* 3. AC jt. *Injection* *PT management* 1. Research shows that *all grades* of dislocation can be *managed successfully* 2. Initial *immobilization* and avoid stressful/painful positions- *ABD sling* because you want the humeral head more in neutral direction (don't want to stress one way of capsule more than the other) 3. Focus on *scapular stability* 4. Early intervention of *correct therex*

Rotator cuff tears -Physician (1) & PT Management (4)

*Physician Management* 1. Surgical Repair *PT Management* 1. Initial PRICE 2. Appropriate loading as T. heals 3. Avoid abnormal stresses on tendon to promote healing 4. If post surgical initially immobilization in sling followed by PROM --> AAROM ---> AROM -Important to read referral prior to evaluation; if it says no PROM or no AROM you can't do those things in the eval;

Peripheral neuropathy of the shoulder -Physician (3) & PT Management (6)

*Physician Management* 1. Surgical debridement 2. Transposition 3. Injection *PT Management* 1. Relieve compression 2. Protect nerve 3. E-stim to help neural action potentials if needed (keep fibers going) 4. Strengthening (if motor or mixed) 5. Desensitization 6. Sensory Re-education

Shoulder tendinopathy -Physician & PT Management

*Physician Management* 1. Tendonosis- excise abnormal tissue, injections: prolotherapy or sclerosing, extracorporeal shock wave therapy. 2. Tendonitis- Rx oral medications, corticosteroid injections *PT management* 1. Depends on type-osis or itis, and stage of condition 2. Always find/treat the cause 3. Change load 4. Manage any inflammation if present

Peripheral neuropathy of the shoulder -Common nerves affected: Primary (4), Secondary (3)

*Primary* 1. Suprascapular 2. Axillary 3. Long thoracic 4. Dorsal scapular *Secondary* 1. Median 2. Radial 3. Ulnar

Shoulder tendinopathy -PT management - *Reactive TendonOSIS (early SOC)*

*Reactive tendonosis (early SOC)* 1. Protect and reduce aggressive loading = aka activity modification reduce frequency/duration 2. Encourage healing -Modalities - US, Estim, RICE -Remember baseline = correct the biomechanics 3. Early stage = Hx step may give you this info

3. define and describe the following: (H&K p 187) a. SLAP b. TUBS c. AMBRII

*SLAP* = Superior Labrum Anterior to Posterior *TUBS* = Traumatic Unilateral Bankhart Surgery; TORN LOOSE *AMBRII* = Atruamatic Multiaxial Bilateral Rehabilitaion Inferior Interval shift

7. describe the significance of the pisiform mobility and soft tissue attachments to wrist mechanics.

*Six (6) Soft Tissue Attachments* (2 muscles, 2 retinaculum, 2 ligaments) 1) Abductor digiti minimi 2) FCU 3) Flexor retinaculum 4) Extensor retinaculum 5) UCL 6) Piso-hamate ligament Decreased mobility or any problems with pisiform? 1) movements affected at wrist and hand because it acts like a pulley for FCU 2) Potential Ulnar nerve and artery damage; Big picture, Pisiform should be able to move freely and do its job; if anything goes wrong with it it can affect our wrist big time by affecting any of the structures its associated with!

4. explain the *intrinsic tightness* test = Bunnel-Littler Test (hypothenar, thenar, lumbricles, interossei mm.)

*Step 1* -MCP extension with passive PIP flexion -If unable to flex PIP progress to 2nd step *Step 2* -MCP flexion with passive PIP flexion -If PIP flexes then tight intrinsics -If PIP does NOT flex then problem with PIP joint -Distinguish between if its capsule or intrinsic tightness

3. describe symptoms, signs and treatment of De Quervain's.

*Symptoms* - (not on slide, info is from me) 1) Pain and swelling near anatomical snuff box 2) Difficulty in grasping objects *Signs* 1) More common in women 2) Occupation involving repetitive movements

5. describe *Lunate dysfunction(s)* symptoms and signs.

*Symptoms* - Extension activités that lower the wrist 1) Can't push up off chair, or reach for door -anythign with extension 2) Possible numbness/tingling (median nerve) - if lunate is going too volar it could compress nerve *Signs* 1) PROM A: Hypermobility of lunate articulation(s) -usually with scaphoid but could be with triquetrum -end-feel is lax for PROM A (makes sense bc you see hyper mobility) 2) PROM C: Decreased wrist extension with bony block end-feel -end-feel makes sense because you are seeing limited motion as a result of the laxity

2 types of instability -TUBS -AMBRI

*TUBS:* "Traumatic Unilateral Bank-hart Requiring Surgery" =*Torn loose* -traumatic event caused instability and its in 1 direction -Bank-hart lesion is example of TUBS *AMBRII* = Atraumatic Multiaxial bilateral Requiring/ (Rehabilitaion) Inferior Interval shift = *Born loose* -Born with it; laxity in multiple directions

c. causes of impingement: -5. Capsular tightness or adhesion

*Tightness - Capsular pattern* AROM Limited ER>ABD>IR PROM Classical Limited ER>ABD>IR ^^same pattern for AROM and PROM PROM Classical Tight Capsule *End-feel* PROM Accessory Limited *Ant.(ER)>Inf (ABD)>Pos. (IR)* PROM Accessory Tight Capsule *End-feel* *Adhesions* What would findings be for adhesion (scar tissue) in posterior direction? Qual - Adhesion end-feel Quan - hypomobility -wont have a pattern, mainly just limited in 1 direction (depending on where adhesion is) -Think of all the motions that would require a posterior glide, they would be affected! -Pain? depends on tissue reactivity of that tissue

c. causes of impingement: -3. Muscle imbalance -Weakness -Tightness

*Weakness:* *1. RTC external rotators* weakness?-linked to decreased acromial humeral distance (AHD) and disability. 2. Humeral head "seaters"-not depressors; don't necessisarly pull it down but more about pushing into glenoid to maintain that space *3. Scapulothoracic musculature -LT, MT, SA* -if LT MT fire normally= keep scapula in ER and allow it to upwardly rotate w/o winging or without tipping anteriorly *Tightness:* *1. Pect minor/major* -P. minor (att. to coracoid) can tilt whole scapula anteriorly *2. Shoulder internal rotators* -Tilt the whole scapula anteriorly -IRs pull whole scap into IR (in addition to IR of the Humerus)

2. discuss the use of Codman's exercise for: a. functional movement. b. pendulum exercise.

*a) functional movement:* bent over in flexed position allows *gravity to distract the joint*; they can now do their functional movements/ADLs i.e. put shirt on, wash hair etc. with less pain without aggravating tissue -need *momentum to stimulate*, no active movement -Codmans is a functional exercise/position for ADLS -in clinic may see people holding weight but they have to activate things to hold the weight, not as good

Additional Information under notes section, kinda repetitive didn't mention it in voice over

-Result of contracture of intrinsic muscles or tearing of the volar plate and is often seen in patients with RA or after trauma -*Can be from RA*, extensor tendon injuries, spastic conditions, fractures to middle phalanx that heal in hyperextension, generalized ligamentous laxity -Destruction of oblique retinacular ligament of extensor mechanism leads to possible displacement of lateral bands of extensor mechanism which increased extensor force at pip which stretches the fds and ddp tendons. The pull on fdp tendon causes passive flexion of dip joint.

Age and quality of bone for Colles Fx. (lec notes)

-Seen more with osteoporotic old female more so than young people; -the young people are more likely to fracture their scahoid or carpal bones -If really young you may see that green-stick type of fx

3. describe and apply a systematic approach to interpreting plain film radiographs which includes: A:Alignment B:Bone density C:Cartilage space S:soft tissue

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3. describe the etiology, anatomical injury / abnormality, and treatment for: Not mentioned in slides: h. De Quervian's tenovaginitis i. Kienbock's disease k. dinner fork deformity

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5. interpret possible rehabilitation problems given soft tissue invasion/trauma from the above surgical procedures.

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8. apply intervention tactics for selected impairments based on analysis of reactivity and condition of the impairment and/or the subjective state, for interventions which include palliative, preparatory, corrective, supportive for the following: a. immediate stage. (high, moderate, low reactivity) a. acute stage. (high, moderate, low reactivity) b. subacute stage. (high, moderate, low reactivity) c. settled stage. (high, moderate, low reactivity) d. chronic stage. (high, moderate, low reactivity)

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9. The student will be able to explain why the four (4) indications exist for Bankart repair as: a. post traumatic instability b. unidirectional c. describe Bankart lesion d. no ligamentous laxity

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How do repetitive movements or over-use of these tendons cause De Quervain's?

. increased friction = more fluid in tendon sheath = thickening of retenaculum = narrowing of canal = entrapment/compression of tendons especially in RD: leads to degeneration and thickening of the 2 tendon sheaths (similar to normal tendonopathoy)

What things would you need to rule out/differentially diagnose for De Quervain's?

1) Superficial Radial nerve entrapment 2) 1st CMC arthritis or hypomobiliy -Rule out with PROM A; --if tendon problem it should be unremarkable --but if joint capsule prob then PROM A would be positive 3) Scaphoid fx

Keinbock's Disease

1) Causes mal-alighnmacny 2) Can cause OA (secondary) 3) Person is tender over area (PFT/C) 4) Decreased ROM 5) Decreased Grip Strength

What would your end-feel be? -What motions would the laxity present as limited movement and why (biomechanically)? -Why is it hard to get carpal bones in alignment?

1) End-feel = ligamentous or capsular laxity 2) Wrist extension (PROM C) = Laxity can be limiting -b/c thats the most 'provocative' movement of wrist; either lunate moving too much or its in mal-alignment that results in the close-pack position too soon and you feel the bony block which shows up as limitation 3) Hard to get alignment in carpal bones due to anatomical variability

Mallet Finger can result in (2) Physical Exam?

1) Extensor tendon may rupture just proximal to the insertion 2) Avulsion fx of base of distal phalanx where tendon inserts Physical Exam: flexion deformity of DIP joint. Can be extended passively but not passively b/c of no tension in extensor and often increased tone in Flexor

1. describe "no man's land" and discuss the anatomical rationale for poor outcomes of surgery in this region. -Where is the region? -What is located here?

1) Location = Distal palmar crease to mid portion of middle phalanx 2) Contains *Flexor tendons* in their tendon sheaths; -not a lot of adipose in this area- more skin, fascia and tendon; Poor outcomes of surgery in this region? -This area contains tendons and lot of fascial tissue, which do not receive a dense amount of blood supply. Adhesions can develop easier and the tendons can become ischemic and the body responds by laying down scar tissue. In this region the healing is slow and there is a high probability for developing scar tissue at an increased rate.

*Lunate Displacement* -Biomechaically, how does the FOOSH impact/injure the lunate? -Which is more rare displacement or laxity? -What ligament is most commonly responsible for this laxity and displacement? -What bone is most commonly displaced and in what direction(s)?

1) MOI: FOOSH -Lunate is proximal row; with *extension* it goes volarly, when you hit the ground it may injure the ligaments and create the laxity 2) Lunate displacement is more rare than someone having a lunate laxity 3) Scaphoid-Lunate Ligament is most commonly ruptured in UE - this ligament is most commonly responsible for the displacement of the lunate due to this laxity 4) Lunate is the most commonly displaced bone and is usually displaced in the *volar direction* (could be dorsal also, but def volar due to MOI)

h. Scaphoid Fx -How is hand placed during FOOSH?/and biomechanically why (what happens to carpal bones in this placement)? -Why is is overlooked? -Why are there complications?

1) MOI: Fall *open hand, wrist extended, wrist radially deviated* (FOOSH); when you extend your wrist you have some radial deviation; forms a close-pack position between radial side carpals & radius so force goes directly through the scaphoid - thats why its the most common 2) It is the most common carpal fracture. 3) this fracture is often overlooked and dismissed as a sprain as it is not often visible on a radiograph 4) There is a high incidence of complications with this fracture because of limited vasularity.

What are some complications to a colle's fracture? (6)

1) Median/Ulnar nerve irritation due to compression (mentioned earlier) 2) Deformity could happen due to non-union of area 3) Post traumatic arthritis 4) Soft tissue adhesions 5) Shortening or lengthening of radius 6) Decreased ROM - pronation and supination (most affected at that joint); also extension and flexion Lect: -CRPS may present similar symptoms? -Listers tubercle could be impacted -poor excursion

k. Monteggia fracture - dislocation -Fracture of what? and associated dislocation of what? -Etiology (2) -Treatment? Be able to tell her what direction it goes in

1) Monteggia fracture consists of a *fracture of the ulna (red arrow) with angulation* and associated *dislocation of the radial head*. 2) A line drawn through the shaft of the radius (blue line) should always intersect the capitellum, no matter what the position of the arm *Etiology:* 1) *Hyperextension and pronation injury* or 2) direct blow over ulnar border of forearm Treatment: -Surgery

Dupuytren's contracture -Management/Treatment

1) No good conservative rx 2) Can be treated with surgical release when get 30 degrees mcp flex b/c then functional 3) 50% of post surgical results depend on exercises and Bracing 4) Scar mobility, AAROM, PROM and AROM in first treatment Be aggressive with it because its not "IF" scar adhesions will for its "WHEN" and how much motion can you get maintian/get back until the scar tissue is finally laid down

Significance of No Mans Land

1) Not a lot of blood flow, area can't heal easily = Injury to flexor tendons in this area requires surgery -they retract up to the distal forearm 2) Adhesions typically form; theres not a lot of blood flow to this facsical tissue -- it becomes avascular which can lead to more formation to scar tissue 3) Tendons may become ischemic and when this happens the body replaces with scar tissue

m. Claw finger -What finger joint is hyperextended? -Which are flexed?

1. *Loss (wasting or atrophy) of intrinsics* - lumbricles and interossei which are *important in balancing* the loads between flexors and extensors; loss of these results in poor regulation and you get deformities like this 2. Overaction of extrinsic extensor muscles on proximal phalanx of fingers 3. MCP hyperextended 4. Proximal and DIP flexed

Myositis Ossificans -Management (different from traditional PT treatment 10 years ago) -Early treatment? -What was the old-school method of treatment?

1. *Early:* NSAID's (first 3 weeks)/PRICE to calm down the tissue - reduce swelling, edema, bleeding etc. 2. Old school/traditional thought was = don't move the limb (no interventions because you were afraid it would tear mm, based on no research) -Still have limited evidence but there is some research that says GRADUALLY doing the things below will help 3. Depending on location and severity (case by case basis) you may progress 1) gentle AROM and PROM exercises 2) dynamic splinting 3) strengthening to regain lost motion and facilitate healing 4. Biggest thing - no pain or inflammation, if you see it then slow down and take it easy; GENTLE progression is key!! 5. NO forcible manipulation/stretching -no us due to vibration effects (may or may not matter) 6 *Severe Cases:* pt. need Radiation Therapy

Clavicular Fx Management -Figure 8 brace vs. ORIF -when can you begin PROM/AROM

1. *Figure of 8 brace*- pulls scap in *retraction* and unloads clavicle at AC; create *good alignment* of clavicle and held in this position -btween 8 weeks in children and 12 weeks in adults; -once they get *callus formation* start AROM and PROM but careful not to aggregate site 2. *ORIF*- much more stable?; much more limited in loading the area, surgeon will give you amount; -begin AROM and PROM *immediately*, no external bracing

Associated Signs and Symptoms for CRPS (11)

1. *Atrophy of hair, nails, and other soft tissue - thicker hair and nails etc.* 2. Alterations of hair growth. 3. Loss of joint mobility. 4. Impaired motor function (weakness, tremor) 5. Sympathetically maintained pain (may be present) 6. Pain described as *burning, throbbing, shooting or aching* 7. Hyperalgesia 8. Allodynia (perception of pain with normally innocuous stimuli - sympathetic mediated pain) 9. Abnormal sweating or anhydrous 10. Redness or bluish discoloration 11. Heat or cold sensitivity "Trophic changes" - skin, hair, nail, tissue maybe even bone changes

e. scapular dyskinesis What is scapular dyskinesis?

1. Altered dynamic scapular movement 2. Exists in the presence of shoulder injury 3. Not directly linked to pain. Can be present in non-painful conditions of the shoulder 4. Can be effectively treated through conservative treatment

Scaphoid Fracture Complications (3)

1. Avascular Necrosis -death of bone; its starved of blood and dies 2. Non-Union -both alive they just don't heal together 3. DJD -Very difficult for scaphoid to heal itself! -A scaphoid fracture can take up to 3 months to heal because of the factors previously discussed

Why an ABD sling for AC joint pathology? -How would you want the humerus? -How would you want the supraspinatus tendon?

1. Because you want the *humeral head more in neutral direction* (don't want to stress one way of capsule more than the other) for *good posture - retracted, shoulders down* 2. Stress of *Supraspinatus* tendon; If your *arm is in ADD* the tendon is more stressed - *ringing out blood* in that position; If in ABD its more relaxed and can heal

c. causes of impingement: -1. structural changes

1. Spurs off the acromion 2. Shape of acromion - Straight, curve (shorter and flatter), hook -curve and hook both encroach into space; hook would be the most likely 3. Rotator Cuff - Thickened tendon 4. Humerus- Increased prominence greater tuberosity Anything that would occupy space there!

What is Complex Regional Pain Syndrome? How is it characterized? When is the diagnosis of CRPS used?

1. CRPS is a form of hypersensitivity typically in the upper extremities, but it can also be found in the lower extremities. 2. It is characterized by *pain and hypersensitivity* that is *not proportional* to the inciting event. 3. The diagnosis of CRPS is frequently used when there is a difficult or no explanation for the various signs and symptoms that present

i. Dupuytren's Contracture -Contracture of what? With a deformity of what?

1. Contracture of *palmar fascia* with a flexion *deformity of the MCP and PIP* (4th and 5th digits) 2. Palmar fascia becomes thickened and adhered to overlying skin 3. ** Synovial jts not involved initially, eventually develop contracture and degeneration

Lateral Tendinopathy -Management

1. Correct the biomechanics impairments (elbow mobility, shoulder mobility, grip strength etc. may want to treat if thats the cause of the problem) 2. If swollen, reactive, *tendinitis* - Decrease stress, facilitate healing and improve strength ROM -cortisone injections, NSAIDs, support strap to take stress of tendon, modalities 3. If more degenerated, *tendinosis* = good stress, stimulate healing improve strength/ROM, get tendon stronger -CFM, loading exercise, PRP: platelet rich plasma (take blood, spin it in centrifuge and put it back in tendon to try and heal), surgical debridement (last resort), concentric and eccentric exercises

1. describe the etiology, clinical manifestations, M.D. and P.T. treatment for: a. Calcific Supraspinatus Tendinitis. -Etiology -Acute vs. Chronic -Clinical Manifestations

1. Etiology: *Mineral deposits* in tendon due to *local necrosis* (when body tries to heal, instead of tendons tissue it heals with calcification - Consistency like tooth paste) 2. Acute: inflammation, more pain -Chronic: becomes tendinosis, less pain, won't see typical inflammation signs; won't see warmth 3. Can lead to what other tissue specific impairments? Muscle tears? 4. Clinical Manifestations: Looks/presents just like tendonitis- thats why clinical features are going to be similar

Dupuytren's contracture -Often occurs in who? -Cause? -Most common in which finger?

1. Often occurs in men > 50 usually always caucasion of northern european descent 2. Cause is unknown but often hereditary, but often alcoholic, diabetic and eplitic populations, smokers, possibly after surgery (rare) 3. Can be bilateral, no association with hand dominance, painless. 4. Progressively gets contracture 5. Most common in little finger (but can occur in other places besides the hand as well)

Characteristic features of CRPS? (5)

1. Osteopenia - bone loss 2. Hyperalgesia - hypersensitive in affective region 3. Edema (in pic) 4. Atrophy of musculature 5. Glassy/shiny skin -Any sort of Trophic change -may have blotchiness

a. External (Mechanical) Impingement -Clinical Presentation

1. Pain reported in *lateral brachial region* (side of arm, not actual shoulder joint itself) -why this area when the pinch is some where else? thats the referral pattern of pain for this area *2. Painful arc-60-120 degrees*- Hallmark sign 3. Palpable tenderness 4. Muscular imbalance 5. Scapular dyskinesis

e. Swan Neck Deformity

1. Flexion of MCP and DIP joints and *hyper- extension of PIP* 2. *Lateral* bands *displace dorsally* - lets the PIP drop and sublux 3. Can be flexible or fixed Seen in RA hands

c. causes of impingement: -4. GH jt. Instability/Laxity

1. Humeral head does not sit with proper alignment to glenoid fossa. -sits too superiorly? will cause compression on undersurface of acromion 2. You can have laxity in any direction -Anterior, posterior or inferior capsule and /or ligamentous laxity.

f. Boutonniere Deformity -Etiology & Treatment

1. Hyper extension of MCP and DIP and flexion of PIP joint 2. Lateral bands displace volubly *Etiology* -Result of a rupture of the central tendinous slip of the extensor hood and is most common after trauma or in RA *Treatment* -Responds to specific splinting and exercise

c. causes of impingement: -2. poor posture *Try flexing your arm in good upright posture vs. bad/slouching posture

1. Increased thoracic kyphosis 2. Forward head 3. Rounded shoulders Postural imbalance like Fwd head causes impingement. Probably b/c of *changes in activation patterns of force couples* As we slouch, elevation decreased, as position of rib cage, T-spine is affected and effects scapular motion. Due to T-spine limits scapular mobility, Scapula can't do post. Tipping as it hits ribs, T-spine flexed and ribs more convexed and can't tip bkwd and u gets impingement.bkwards.

a. Mallet Finger

1. Injury of the *extensor mechanism* 2. Result of hyperflexion of the distal phalanx with extensor tendon under tension 3. Causes injury to the terminal tendon 4. Common hand injury in *athletics* (baseball catcher and football receiver, where there is lots of catching ) 5. Usually *longitudinal force* to tip of finger (they are extending the finger and they get a force putting it into flexion) 6. DIP joint remains in flexion and can't be actively extended

What would be some nerve pathology physical exam tests?

1. Light touch sensation over specific distribution 2. Motor testing for specific muscles 3. Palpable tenderness at specific location -i.e. think theres entrapment over PT and you palpate and find symptoms = can be diagnostic 4. Neural tension tests -putting arm in position where nerve is on stretch; 5. Specific Special tests Main thing = *Detect the cause of the nerve entrapment*; most times theres a mechanical cause and you want to treat that!

What is the dynamic pattern of scapular pathology?

1. Loss of upward rotation Normal: Inferior angle of scapula comes to axillary line 2. Excessive scapular IR Decreased activation of serratus ant. (SA)-winging 3. Excessive scapular anterior tilt/tipping Tight pec minor, decreased low trap/SA activation

Which of these are the best tests to use? Which is the very best to differentiate calcific deposits vs. regular tendonitis?

1. MSTT: Strong and Painful for ABD and ER 2. PFT: Tenderness over tendon 3. PFC: Inflammation, warmth, swelling over area *4. IMAGING*: The BEST to see calcific deposits, clearly see

l. Street Fighter Fracture (AKA Boxer's Fracture)

1. Phalangeal fractures are more common than metacarpal fractures -most commonly involve the distal phalanges then proximal phalanges, with the middle phalanges least likely to be fractured 2. Fractures of the metacarpal bones are predominately found on the first (thumb) and fifth (pinkie) digits. 3. The Boxer's Fracture (small arrows) is a traumatic fracture of the fifth metacarpal at the shaft and neck of the fifth metacarpal, usually brought on by punching. 4. The fracture is also called a Street-Fighter's Fracture since trained pugilists would not strike with the knuckle of their fifth digit. Treatment: Closed reduction with splint (want to stabilize it in a loose pack position) or plate structure with ORIF

What are some Fracture Complications? -Important slide, know all complications, be able to explain it to someone/what it would look like; *maybe on test??? "you would use this information and explain to me why"

1. Post-traumatic DJD 2. Delayed-Union -may be OK, but just takes longer to heal 3. Mal-Union 4. Non-Union -Fibrous -Psuedoarthrosis

Process of Volkmans Ishcemic contracture (4) -More notes on the progression/pathology

1. Result of *increased tissue fluid pressure within a fascial muscle compartment* that *reduces capillary blood perfusion* below level *necessary for tissue viability* 2. The *nerve injury* that results from the compression produces *deformed limb* known as Volkman's ischemic contracture 3. The necrotic damage that occurs due to the ischemia leads to a *fibrosis of the muscle and soft tissues*. 4. The fibrosis leads to *contracture of the muscle and possible impingement of the nerve. 5. The resulting "contracture" is the shortening of a muscle or soft tissue, including nerve, that derives from decreased blood flow.

a. Olecranon Avulsion Fracture -What will it significantly impact? -Treatment: *ORIF* vs. Closed Reduction/Immobilization

1. Significantly impact elbow functioning, can't have normal biomechanics; joint health will be affected; theres also a piece of the bone floating around in the joint capsule Treatment: *ORIF* = Make incision over skin and cut away soft tissue; insert plates, wires, screws etc to fixate bone back together; 1) Best way to insure normal healing of fx/ fixation of bone tissue 2) Needed if highly displaced fx or if you have pieces of bone in joint capsule (can't do cast, won't heal well; pieces need to be screwed in place)

Gist of using MSTT (3) =

1. Strong and painless & weak and painless are "correct" 2. If weak and painless need to write FP 3. Don't always assume weak and painless is complete tear

Calcific Supraspinatus Tendinitis - Clinical Features (9 Steps 6 with findings)

1. Structural Inspection 2. PFC: Inflammation, warmth, swelling over area, Edema 3. AROM: Pain & limited with ABD and ER 4. PROM: -Classical: pain, possible limitation due to pain with things that lengthen supraspinatus i.e. horizontal ADD and ER (in class she said normal ROM); abnormal muscle end-feel -Accessory: problem is not in joint capsule, everything should be normal (Quant, Qual, Pt. Sym) 5. MSTT: Strong and Painful for ABD and ER 6. MLT: Normal length and pain 7. MMT - defer 8. PFT: Tenderness over tendon moderate and deep depth (for moderate TR) 9. Imaging: MRI or US is more sensitive/reliable for picking it up in the early stages; then radiographs later on

Pic & info on ligaments

1. Sub deltoid Bursa. 2. Glenoid Cavity - small compared to large humeral head 3. Inferior glenohumeral ligament - has anterior and posterior band. Anterior tightens on ER Posterior band on IR rotation 4. Middle GH ligament - limits lateral rotation between 45-90 abd. 5. Biceps Brachii tendon 6. Coracohumeral Ligament - Limits inferior translatin and helps limit lateral rotation below 60 degrees of abduction. Found between anterior supraspinatus and superior subscap tendon 7. Coracoacromial ligament - formas arch over humeral head to block superior translation

n. "Z" deformity of the thumb j. "opera glove"

1. Thumb flexed at MCP joint and hyperextended at IP joint = Z shape 2. Deformity may be caused by heredity or associated with RA, could also be due to trauma

4. explain the etiology and development of *myositis ossificans* and treatment(s) -Where does it occur? -Etiology? -Clinical manifestation? -2 major muscles?

Myositis Ossificans: Occurs in injured muscle tissue *Etiology:* 1) Associated with *trauma of muscle* and bone formation inside during healing i.e. soccer player kicked hard on thigh; has hematoma black and blue, bleeding in tissue, body will create bone tissue when body is healing - big problem *Clinical Manifestations* 1. *Pain and edema* often present 2. *Motion loss continues* at a time during healing when it *should* be slowly *improving* -need imaging to truly diagnose it; but you can still make a hypothesis i.e. its been a month since soccer player injury and they should be feeling better with more ROM, but they still have significant motion loss even after sig time as past since injury *2 major muscles* that should be concerned with for Myositis Ossificans 1) Brachialis mm. around elbow joint 2) Quads mm around knee joint

What are some examples of over-use/repetitive ADLs that may result in De Quervain's? (etiology/cause)

Occupations using lots of thumb movements, Typing, Hand tools, Texting "black berry thumb", Painting, Hammering, Golfing, Fishing, Cutting etc. Lect: Anything you need a grip with and you use it repetitively