Ortho Final Written Exam

Ligament Injuries of Wrist/Hand

*TFCC (triangular fibrocartilage complex)* -radioulnar disc -pain in ulnar side of wrist -fall on palm with forearm pronation -WB/gripping with axial force Exercise guidelines: -begin in supination, neutral, pronated gripping, WB

Anklyosing Spondylitis Etiology

-chronic polyarthritic process -causes joint sclerosis and ligament ossification -more common in males with onset by the 30s -generally a progressive disease

General Treatment Guidelines: Max. Protection Phase

*centralize radicular pain first* -patient education -posture education -work or activity modification -directional bias with movement -increase neutral upper spine mobility -increase anterior chest/shoulder flexibility -pain free ROM -STM, joint mobs -supportive modalities to decrease pain and edema and increase tissue mobility

RX for SI Dysfunction

*educate pt to not be asymmetrical in movements* -muscle stretching: >anterior rotation= iliopsoas, quads >posterior rotation= gluts, hamstrings, and piriformis -muscle strengthening: >anterior rotation= gluts and hamstrings >posterior rotation= iliopsoas and quads >general core stabilization -modalities to painful areas; ice following mobilization -STM/joint mobs to restricted areas -SI belt may be an option to assist with stabilization

Shotgun Technique

*for pubic symphysis* -patient lies in hook lying position with knees together -therapist resists abduction (maximal contraction) for 7-10s -passively abducts hips -therapist resists adduction (maximal contraction) for 7-10s -may hear audible pop when pubic symphysis separates, allowing for it to reposition itself into a correct alignment

Muscle disorders of the cervical spine

*muscles surrounding cervical spine are both the most common cause and source of neck pain* Cause: -trauma -postural -tension/stress -tightness/weakness -muscle imbalance Associated Complaints: -headaches -radiating pain

Fracture Classification

-classified by site of injury -epiphyseal fracture: occurs at the epiphysis -intra-articular fracture: occurs any where from the joint surface to the deep zones of the epiphysis -diaphyseal fracture: occurs in the shaft (further classified as; proximal, middle, or distal)

PT for Wrist/Hand: Controlled Motion Phase

- Criteria: resolving edema, minimal to no pain with ROM and isometrics - Increase strength, gain full ROM - Return to functional activities with protection - OKC>CKC if appropriate

Maximal Protection Phase Post Op

- Edema control - Pain control - Prevent infection - Circulation, prevent DVT, PE, bed rest co-morbities - ROM, joint mobility - Gait and mobility training - Well joint mobility - 1 day up to 6 weeks

Elbow Basics: End Feels

- Extension: Cartilaginous (olecranon process in the olecranon fossa) - Flexion: Soft Tissue approximation or bone to bone if patient is very thin (coronoid process hitting coronoid fossa and radial head hitting radial fossa)

Describe the capsule of the TMJ

-composed of fibrous connective tissue -contains articular mechanoreceptors that provide kinesthetic awareness of the mandible

Elbow Basics: Capsular Pattern

- Flexion usually more restricted than extension, 10 degrees limitation of extension for each 30 degrees limitation of flexion - Pronation / supination generally not affected except in severe long-standing cases - Conditions presenting a capsular pattern: OA and RA Conditions presenting a non- capsular pattern: -loose body in joint -OA with loose body -ligamentous sprains

Elbow Basics: ROM

- Flexion: 0-140 - Supination: 0-90 - Pronation: 0-90 - Carrying Angle (Physiological valgus) >Men 5-10 degrees >Women 10-15 degrees

Minimal Protection Phase Post Op

- Full AROM - Return to previous strength, flexibility, balance - Functional abilities - Job specific tasks to include high level training - Prevention/wellness training - 12 weeks to 6 months

Moderate Protection Phase Post Op

- Gain full ROM, scar/tissue mobility - Begin strengthening - Begin stretching - Begin neuromuscular training - Usually from 4-12 weeks

Psoas Bursitis

- Pain anterior thigh or groin to patellar area - Overuse of hip flexion

Management of Medial Valgus Stress Overload

- Same as overuse syndromes - No valgus stress with stretching - Stop activity - Strengthening: no valgus stress or pain at end range elbow extension - May need surgery especially if Grade III • "Tommy Johns surgery" - LimitedROMx3-4weeks, full by 4-6weeks - Functional training resumption in 2-4 months - Return to sports 10-12months

General Treatment recommendations: Max. Protection Phase

- Soft tissue mobilization - Joint mobilization - Muscle isometrics - Reducing inflammation/pain - Improve ROM - Well joint mobility - Supportive techniques - Patient education

Physiological Movements: Osteokinematics

- biomechanical description of the motion of the bone as it swings through a ROM (ie: shoulder flexion) -movements of a joint that occur with active or passive ROM -can be measured goniometrically *roll of the joint is always in the same direction of the osteokinematic motion*

Colles' Fracture

-"dinner fork" deformity -caused by a fall on outstretched hand -distal radius is *displaced in dorsal direction*

Sprengel's Deformity

-congenitally high/undescended scapula bilaterally or unilaterally (smaller, medially rotated) -most common congenital deformity -scapular muscles poorly developed and/or replaced by fibrous band -shoulder ABD is decreased and slight functional disability (due to poor scapulothoracic motion)

LCL Injury: Special Treatment Considerations

-*Hinged brace 30-90 initially, then progress to full ROM* -*Slow progression of forearm supination and elbow extension* -Usually begin return to function phase 2-8 weeks, depending on severity

DeQuervains Tenosynovitis

-*abductor pollicis longus and extensor pollicus brevis tendon and sheaths* -pain on radial side of wrist *aggravated by use of thumb* -pain increased by ulnar deviation of wrist Special tests: finkelstein test

Spinal Anatomy Review

-2 Lordotic Curves -2 Kyphotic Curves -Shock absorption and balance of COG

Scapulohumeral Rhythm

-2:1 ratio -for every 2 degrees of flex/ABD of the humerus the scapular upwardly rotates 1 degree (first 30 degrees is pure GH motion; mid range is mostly scapular motion; later motions are primarily GH motion) -improves efficiency of humeral muscles

What is articular cartilage?

-60 to 80% water; 20% type 2 collagen; 10% proteoglycans (give compressive strength), 5% chondrocytes -permeable to allow for nutrition (via joint motion and weight bearing; diffusion/convection) -located on epiphysis of bone and joint joint surfaces -functions to allow bones in a joint to move without causing excess friction/damage -injured by: degeneration, trauma, repetitive overloading, blunt trauma, superficial lesions, and deep lesions *Note: superficial lesions of cartilage do not heal as well as deep lesions of cartilage*

Treatment Ideas for Moderate Protection: Shoulder Post Op

-AROM supine, seated and prone -Flexibility (all tight muscles) -Strengthen (manual, free weights, tubing, RTC muscles, scapular muscles, functional activities)

Clinical Signs of Posterior Rotated Innominate

-ASIS is higher -Pubic symphysis is higher -Iliac crest may be higher -PSIS is lower -Ischial tuberosity is lower -Supine to sit test= leg appears to lengthen (P>S>L) -Tight gluts and hamstrings -Lengthened and weak hip flexors

Clinical Signs of Anterior Rotated Innominate

-ASIS is lower -Pubic symphysis is lower -Iliac crest may be lower -PSIS is higher -Ischial tuberosity is higher -Supine to sit test = leg appears to be shorter (A>L>S) -Tight Iliopsoas and quads -Lengthened and weakened gluts and hamstrings

Anterior Compartment Syndromes

-Acute or chronic elevated tissue pressure within closed space leads to occlusion of vessels, neuromuscular function -tibialis fx, muscle rupture, muscler hypertrophy, circumferential burns *considered a medical emergency, irreversible damage after 12 hours* Chronic Compartment Syndrome: -could be due to hx of trauma of fibrosis to fasica

Traction Neuropathy

-Acute traction in sports, activity -Prolonged surgery or stretching -PT that is too intense after immobilization

PT Management of FM

-Aerobic exercise -Resistive exercises -Walking at low intensity (20-60% target heart rate) -Pacing activities -Avoidance of stress factors -Decreasing alcohol and caffeine consumption -Diet modification -Medications

Factors that affect balance

-Age (80+) -Medications -Perception -Behavior (history of falls, fear, depression, cognitive impairment) -ROM -Biomechanical alignment -Weakness -Sensory -Gait deviation -Assistive devices -Balance system deficit -Co morbities (DM, arthritis,CVA, MS, etc.) -Task characteristics (well learned vs. new; single vs. multi-tasking) -Coordination -Adaptability -Environment (shoes, slippery vs. dry, lighting/colors,open/closed environment)

Treatment of Carpal Tunnel Syndrome

-Altering lifestyle -Avoid extreme wrist flexion/extension -Avoid wrist constriction (watch, bracelet, sleeve) -Tendon gliding exercises -Supportive modalities -Cock-up splint (0-20 wrist extension)

Balance strategies

-Ankle -Hip -Weight shifting (lateral plane) -Stepping -Suspension -Combination of all of above

Lateral Ligaments of the ankle

-Anterior Talofibular Ligament: >horizontal from tip of fibula to talus >1st to be injured in an ankle sprain -Posterior Talofibular Ligament: >from lateral malleolus to talus >rarely injured with sprain -Calcaneofibular Ligament: >from lateral malleolus to calcaneus >2nd to be injured in an inversion ankle sprain

Key muscles during gait

-Anterior tibialis >eccentrically controls foot as it lowers to the ground after heel strike >concentrically keeps foot from dragging during swing phase -Posterior tibialis >controls pronation during mid-stance -Gastroc-soleus group >push-off >eccentric control of tib/fib advancing forward over fixed foot

Rheumatoid Arthritis

-Autoimmune disease which affects connective tissue, causing joint effusion and synovial thickening -Periods of exacerbation and remission -Causes deformity of joints and disability -May cause changes in the tendon sheath

Rehab s/p ACL Reconstruction: Maximal Protection Phase (0-8 weeks)

-Avoid excessive loads and stress -*Range limiting hinged brace is used to avoid anterior tibial translation, shear forces, and rotation* -RICE, CPM (for limited time) to control edema -Patellar mobility -FWB at approximately 2-6 weeks post op -Isometric co contractions of quadriceps and HS *HS strengthening to prevent anterior shearing*

Balance in relation to Coordination

-Balance is simply one component of coordination -Coordination uses sensory information regarding joint position, movement and movement resistance; this is called proprioception (from mechanoreceptors) Coordination is ability to perform: -fine motor skills -tasks requiring postural control and reciprocal motions

Hip Joint

-Ball and Socket (convex femoral head moves on concave acetabulum of pelvis) -Tri-axial -ROM needs for functional activities: 120 flexion, 20 abduction and ER -Supported by strong articular capsule and 3 ligaments *the capsule is particularly strong anteriorly*

Rehab s/p TKA

-Based on protocol -Immediately post op: may use immobilizer and/or CPM -Long term restrictions (ie: high impact activities and kneeling) depend on MD recommendation -Therapy goals: improve mobility, ROM, and strength

General PT Post-Op Guidelines for Knee

-Bed mobility, transfers, ambulation with AD, environmental barrier negotiation -CPM, compression, CP's, DVT prevention -Hospitalized 1 to 4 days (if no complications) -OKC exercise program (follow MD protocol) *if femoral nerve block or lack of quadriceps control is present; use a knee immobilizer to prevent buckling at knee until control is developed*

Aerobic Exercise for Orthopedic Patients

-Beneficial -Consider the soft tissue healing guidelines when implementing a program

Anatomy Review: Tibiofemoral Joint

-Biaxial, modified hinge joint -Distal femur (convex) >medial and lateral condyle >medial condyle is LARGER -Proximal tibia (concave) >2 tibial plateaus >medial plateau is LARGER than lateral >fibrocartilagenous menisci attached to each plateau

Diagnosis of Osteomylitis

-Blood tests for increased WBC's, increased sedemtation rate or C-reactive protein (all to detect inflammation) -Blood culture to detect bacteria -Needle aspiration to sample fluid for bacteria -Biopsy of the bone -Bone scan

Referred Pain

-C6 -C7 -C8

MTP/IP Joints

-CONCAVE on CONVEX (just like in the hand) -motion: flexion/extension; abduction/adduction at MTP

Anatomy Review: Midcarpal Joint

-CONCAVE proximal row (scaphoid, lunate, triquetrum, pisiform) -CONVEX distal row (trapezium, trapezoid, capitate, hamate)

Anatomy Review: Distal Radioulnar Joint

-CONCAVE ulnar notch on the distal radius articulates with the CONVEX head of the ulna -Motions: forearm pronation and supination

Anatomy Review: Radiocarpal Joint

-CONVEX proximal row of carpals articulates with the CONCAVE radius and ulna -Motions: wrist flexion and extension; radial and ulnar deviation -contains radioulnar disc; >triangular fibrocartilage complex >load bearing: 60% radius; 40% ulna (w/out disc= 95% radius; 5% ulna) > provides majority of joint stability

Cardiovascular Training

-Carbs, proteins, and fats convert into ATP -Energy metabolism may occur either with (aerobic) or without (anaerobic) the presence of O2 *Types:* 1. Anaerobic Systems: ATP-CP and Glycoloysis 2. Aerobic Systems: Oxidative -Initially, O2 isn't necessary, but to continue past *2 minutes* the body requires a constant supply of oxygen -Order of use: 1. ATP-CP 2. Glycolysis 3. Oxidative

Scapulothoracic Dysfunctions

-Caused by: muscle imbalances or abnormal tone *Signs & Symptoms:* -pain in posterior shoulder -RC impingement -abnormal scapulothoracic rhythm *Goals of PT:* -depend on condition -maintain/increase ROM, -strengthen -postural and movement education

Treatment of Painful Shoulder Syndromes

-control inflammation, promote healing, and gain ROM -patient education; may need to restrict activities (to give inflammation a chance to settle down) -posture education with functional activities -pain free motion; P/AA/AROM -cervical mobility (really involved in shoulder injuries) -soft tissue techniques -normalize biomechanics entire shoulder girdle -joint integrity -isometrics -scapular stability -supportive techniques (taping, modalities)

Rehabilitation for Tendon Healing

-control pain and swelling -perform gentle range of motion and strengthening (per MD protocol) -protect joint (if needed) *eccentric exercises found to give best results for achilles and patellar tendon injuries*

What are the benefits of exercises on ligament injuries?

-controlled motion and exercise stimulates ligament repair -improves matrix organization and composition -increases hypertrophy of ligament and ligament-bone complex -increases tensile strength -tendons and ligaments respond to not only frequency, intensity, and duration of exercise, but also to the specific type of load applied to the tissue (*repeated compressions better than tension loads*)

Cartilaginous End Plates

-cover the nucleus pulposus superiorly and inferiorly -lies between the nucleus pulposus and the vertebra -nutrition diffuses from bone marrow to the disc -can be damaged with highly compressive traumatic injury

Brachial Plexus Injuries

-damage to *C5-T1* nerve roots -can cause TOS (thoracic outlet syndrome) *Thoracic Outlet Syndrome* -insufficient vascular supply, interscalene triangle (anterior and middle scalene and first rib) -costoclavicular space (clavicle and first rib) -axillary (pectoralis minor, coracoid process, and deltoid fascia) -neural tension (adhesive scar tissue formation)

Fibromyalgia

-Chronic pain syndrome -Patients process nociceptive signals differently -Covers 1⁄2 of body, lasted more than 3 months -11 of 18 specific tender points -Non-restorative sleep -Morning stiffness -Chronic fatigue -Fluctuation of symptoms: pain free to inability to carry out normal activities -Higher incidence of headaches, tendonitis, irritable bowel, TMJ, restless leg syndrome, mitral valve prolapse, anxiety, depression, memory problems -Environmental stressors -Weather changes -Diminished exercise tolerance -Less than 30% after physical trauma -Pain is muscular in origin -Fluorescent lights -Physical stressors -Repetitive activities -Emotional stressors

Lesser Toe Deformities

-Claw Toe: >MTP dorsiflexed, PIP plantarflexed, DIP plantarflexed -Hammer Toe: >MTP dorsiflexed or neutral, PIP plantarflexed, DIP neutral, hyperextended, or plantarflexed -Mallet Toe: >MTP neutral, PIP neutral, DIP plantarflexed

General PT of Knee: Moderate Protection Phase

-Criteria: (I) SLR, decreasing edema, improving ROM, full WB -Wean from AD -Maximize ROM -Maximize strength: OKC, CKC -Maximize mobility and tissue -Maximize balance -Functional activities -Environmental barriers

General Hip Rehab Guidelines: Controlled Motion Phase

-Criteria: decreased pain, improving pain-free ROM, ability to fully WB -Return to full WB with minimizing gait deviations -Gain maximal ROM -Increase strength—function patterns -muscle flexibility and strength balance -Balance strategies -Return to functional activities/training

General Hip Rehab Guidelines: Return to Function Phase

-Criteria: maximal ROM and strength, appropriate balance strategies, No gait deviations -Gain maximal strength -Maximal functional activities -Plyometrics -Sports related activities if appropriate

Management: Controlled Motion and Return to Function Phase of wrist/hand

-Criteria: pain free ROM, muscle testing, edema resolution -Gain full ROM, strength of all joints -Return to functional activities -Modify ADL's

General PT of Knee: Return to Function Phase

-Criteria: weaned from AD if appropriate, appropriate balance strategies, normalized gait on level surfaces and environmental barriers, resolved edema, nearly full ROM, minimal to no pain -Functional activities -Return to recreational activities with support of new joint limitations -If applicable: plyometrics and return to sport activities

Thromboembolic Disease

-DVT that turns into PE -The probability of a TKA patient developing a DVT without additional risk factors or prophylactic anticoagulation is between 40-70% Risk Factors: -Surgery, trauma, obesity, pregnancy, age >40, use of oral contraceptives, immobility, hx DVT, varicose veins, smoking, family history, CHF *MONITOR!*

RX of Trochanteric Bursitis

-Decrease inflammation with CP and modalities -Remove causative factors -Address running mechanics if needed

Patellofemoral Pathologic Conditions

-Decreased gastroc and soleus flexibility -Decreased hip ER and ABD strength -Increased hip IR with CKC activities such as running -Patient typically c/o anterior knee pain with prolonged sitting, stair climbing, and squatting

Determining what grade of Joint Mobs to use

-Determine the goal of the treatment -Pain may be the indicator of the type of treatment to initiate: •Pain before tissue limitation: Gr I, II •Pain concurrent with tissue limitation: use judgment •Pain after tissue limitation: Gr III, IV If joint capsule is limiting motion: Gr III, IV --PROM is limited in a capsular pattern --Firm capsular end feel with overpressure --Decreased joint play movement when mobility testing is performed --Adhered or contracted ligament is limiting motion—apply to specific lines of stress

Hip Pointer

-Direct trauma to *subcutaneous tissues of iliac crest* -PWB, Compression, RICE

Treatment Goals/POC of RA

-Educate (rest, joint protection, energy conservation, ROM) -Exercise cannot alter pathology, but may slow, prevent or correct mechanical limitations -Modalities for pain, gentle massage, relaxation techniques -Splint immobilization -PROM/AROM (minimize joint stiffness and maintain available ROM) -Gentle strengthening: pain free positions, protect joints -Assistive devices, positioning (avoid activities stress joints) -Non-impact/low impact conditioning

Treatment goals of Osteoarthritis

-Educate on joint protection -ROM/Joint Mobs -Splinting/bracing/assistive equipment -Stretching -Strengthening -Balance -Aerobic conditioning -Aquatic programs

Rehabilitation of Soft Tissue Injuries

-Education (protection with function, anticipated recovery time) -Control pain, edema, spasm (RICE) -Maintain soft tissue, joint integrity, and mobility (ROM, muscle activity, massage) -Reduce joint swelling (modalities, medical intervention, compression) -Maintain integrity and function (AD and bracing) -Functional training -Progressive exercise programs to include balance -Prevention/Reduce risk of re-injury

Recommendations for Individuals with Osteoporosis

-Encourage weight bearing activities (increases osteoblastic activity) *may not see change for 9-12 months* -Progress activity as tolerated by integrity of bone -Educate on fall prevention (higher risk for fractures if they do fall) *Avoid: trunk flexion, combined trunk flexion and rotation* *Caution: torsional trunk movements in hip and femur patients*

Stretching Benefits

-Enhanced flexibility -Relief of muscle soreness -Muscle relaxation -Injury prevention -Performance enhancement

Capsular & Non-Capsular Patterns

-Every joint has pattern *Reasons for non-capsular pattern restrictions:* 1. Ligamentous adhesions -injury to capsule or accessory ligaments cause restriction in one direction 2. Internal derangements -displaced or loose cartilage/bone/ligament. 3. Extra-articular lesion -bursitis, muscle strains, neural irritation

Therapy guidelines for exercise of a healing ligament

-decrease in pain and edema doesn't mean the ligament is healed -ligament will remodel and mature for up to 1 year post injury -joint protection is critical to healing -be careful to not overstress the ligament when progressing exercise *avoid movements that place unwanted force on the ligaments*

Strength Training for Geriatrics

-decrease muscular strength and force generating capability -focus on delaying muscle atrophy, improving function, increasing force generating capabilities, and stimulating muscle hypertrophy -get MD approval -supervise closely -start with low resistance, low reps, and increase slowly -train 2-3x a week with 48 hours of rest in between sessions *avoid high resistance to decrease stress on the joints; keep in mind co-morbidities*

Plantar Fasciitis

-degeneration and microtears in plantar fasciitis at its calcaneal attachment (may be associated with heel spur) -MOI: repetitive forces (may be due to pes planus or cavus; excessive foot pronation, tight achilles, excessive training, poor footwear)

How do ligaments repair?

-Extraarticular ligaments heal in a highly structured, organized and predictable fashion Phase I: Homeostasis and degeneration Phase II: Inflammation Phase III: Proliferation and migration Phase IV: Remodeling and degeneration -Intraarticular ligaments do not heal spontaneously -Healing is limited by the environment of intraarticular synovial fluid *NOTE: Intrinsically repaired extraarticular ligament does not return to normal. Even after considerable time and remodeling of dense connective tissue, ultimate tensile strength may approach only 50-70% normal up to 1 year after injury*

Spondylosis

-degeneration of the spine -progressive hypomobility -osteophytes

Spinal Stenosis Etiology

-degenerative arthritic changes -poor posture -repeated stress to the body -most common in the lumbar spine

What is Convex/Concave?

-describes the shape of the joint -moving segment is described first (i.e. GH joint is convex on concave)

Rehab s/p ACL Reconstruction: Moderate Protection Phase (6-12 weeks)

-FWB -Proper gait mechanics -Immobilization can discharged approximately 5-6 weeks -RICE to continue to control pain and swelling -CKC initiated and progressed (initially with brace on) -Maintain patellar, HS, and quad stretching exercises -General conditioning

Special Tests for the Hip

-Faber test -Trendelenburg sign -Anterior labral tear test -Posterior labral tear test

Foot and Toes

-Flexion of 2nd through 5th toes >antagonists of extension of toes >flexor digitorum brevis and longus >lumbricals >quadratus plantae (assists) >dorsal interossei (2nd-4th) >plantar interossei (3rd-5th) >abductor digiti minimi (5th) >flexor digiti minimi -Extension of 2nd through 5th toes: >extensor digitorum longus >extensor digitorum brevis (2nd-4th) >lumbricals

Muscles of the hip

-Flexors -Extensors -Adductors (pectinus, adductor group, gracilis) -Abductors (glut med, TFL) -Internal Rotators (glut minimus, TFL) -External Rotators (piriformis, gemellus superior, inferior, obterator internus and externus, quadratus femoris, sartorius)

Proximal Femoral Osteotomy

-Follow MD orders, usually restricted 8-12 weeks -May be able to use water environment after incision healed -Slowly add CKC exercises with limiting shear forces

ACL Reconstruction

-Follow MD protocol -Graft Options: 1.) autograft of either gracilis, TFL, semitendinosis, or quad tendons 2.) allograft from a cadaver -Protective bracing locked into full knee extension during WB and sleeping (full ROM unlocked = 3 wks) -Gradually increase knee flexion as pt gains CKC control -Slower progression with knee if HS graft is used *Avoid: CKC flexion greater 60-90 degrees early; NO OKC TKE from 15-45 degrees; NO additional resistance to distal tibia with quadriceps strengthening*

Hip Hemiarthroplasty

-Follow MD protocol -Similar to THA but only half the joint is replaced

PCL Reconstruction

-Follow MD protocol -Slower WB progression *Avoid:* 1. excess posterior shear forces and posterior tibial displacement 2. OKC AROM knee flexion against gravity (prone or standing) for 6-12 weeks 3. excessive trunk flexion during squatting 4. resistance training on machines for HS for 5-6mo 5. down hill inclines 6. activities that cause rapid deceleration with (B) feet planted 7. vigorous sports for 9-12mo

ORIF after Hip Fractures

-Follow WB precautions -Similar to THA program, usually no hip precautions -Complications: • Non-unionavascular necrosis • DVT

Key Postural Terms

-Foot equinus: fixed position of PF of foot -Calcaneus deformity: fixed position of DF of the foot -Pes Cavus: high arched foot -Pes Planus: low arched foot -Calcaneus Varus: varus position of the calcaneus in stance -Calcaneus Valgus: valgus position of the calcaneus in stance -Forefoot Varus: present when the plane of the metatarsal heads is inverted in relation to the plane of the calcaneus (commonly associated with increased pronation of the foot) -Forefoot Valgus: present when the plane of the metatarsal heads is everted in relation to the plane of the calcaneus (commonly associated with decreased pronation of the foot)

Carpal Tunnel Syndrome

-Formed by carpal bones and transverse carpal ligament -Contains median nerve and 9 flexor tendons Common causes: -arthritis -fractures -cysts -diabetes -hypothyroidism -aging -pregnancy -alcohol abuse -extreme temperatures -occupational factors -vibration Signs and symptoms: -Numbness and tingling of thumb and radial digits -Pain worse at night -Atrophy of thenar muscles -Swelling in hand and forearm

Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)

-develops after noxious event *S&S:* -spontaneous burning pain hyperalgesia -edema, vascular abnormalities -trophic changes -autonomic dysfunction -impairment of motor function *Types:* type 1= non nerve injury type 2= nerve injury *note: may have spontaneous recovery in 18-24 months*

Compartment Syndrome

-develops in anatomic compartments -increased fluids in an area of tightly bound fascia -can compress nerves and blood vessels (leads to nerve damage and ischemia) *Medical Emergency: alert PT/MD*

Clinical Signs of Compression Fracture

-diagnosed by xray -pain at fracture site

Clinical Signs of Anklyosing Spondylitis

-diagnosed by xray; "bamboo spine" -patient presents with flat lumbar spine, severe kyphosis in thoracic and cervical spine and increased hip flexion

Anatomy Review: Carpometacarpal (digits 2-5)

-digits 2-5 uniaxial; 5th digit biaxial -CONCAVE metacarpals on CONVEX carpals

Anatomy Review: Patellofemoral Joint

-Formed by patella and anterior distal femur -Increases momentum arm of quadriceps muscle and redirects force -Patella is a sesmoid bone that articulates with the trochlear groove on the anterior distal femur (articular surface is covered in smooth hyaline cartilage) and is embedded in the anterior joint capsule -The patella is connected to the tibia via the patellar tendon and slides superior during extension and inferior during flexion

Compression Fractures

-Fracture of the anterior vertebral body -Causes the vertebra to become "wedge" shaped

What are some considerations that should be made concerning WB and Functional Activites?

-Gait: 0-60 degrees flexion, medial rotation of femur as knee extends during initial contact and prior to heel off -Hip flexion contractures: prevents full locking into knee extension -Leg length imbalances -Obesity -Foot impairments *consider affect down the kinetic chain*

Goals of PT for Ligament Sprains

-Grade III can be solved non operatively; however some pt's require stabilization -Special considerations after ligament repair: >NWB usually 6 weeks, CAM walker for 8-12 weeks >protect ligament throughout rehab

Hallucis Deformities

-Hallux Valgus: 1st MTP shifts laterally -Hallux Rigidus: narrowing and eventual obliteration of 1st MTP space

Myositis Ossificans

-Heterotopic bone formation after blunt trauma to muscle -Calcification in the muscle Signs and Symptoms: - Within a few weeks following an injury, further symptoms may start to develop -A noticable lump or "woody" feeling in the belly of the injured muscle -An increase in morning pain -Pain with activity -Night pain -Clinical improvement in ROM following by regression *Contact PT and/or doctor*

Arthrokinetmatics: Humeroradial Joint

-Hinged pivot joint -Motions: Flexion/extension -Concave radial head slides on convex capitulum of humerus with flexion/extension -Pronation/supination (radial head spins on capitulum)

Slouched Posture

-Hip extensors and trunk flexors -weak: hip flexors and back extensors -tight trunk flexors -hanging on Y ligaments -short hamstrings -weak iliopsoas -weak gluteus medius -weak gluteus maximus *LE Compensations:* -hip extension -hip IR occasionally -genu recurvatum, genu varum -pes planus

Contraindications to Joint Mobs

-Hypermobility -Joint effusion -Inflammation

Treatment of Osteomylitis

-I & D (Incision and Drainage): surgery to open infected area and drain -Needle aspiration -Antibiotics -Immobilization to prevent further bone trauma -Surgery to scrape infected bone or amputate

Exercise Selection and Progression

-Implement multiple muscle contraction types during all phases of rehabilitation -Progression is dictated by protocol, pain tolerance, or graduation from one phase

Pronation

-In WB: >eversion: outward and upward, sole away from the body >abduction: away from the body >dorsiflexion: toes up, flexing the upper or dorsal surface of the foot

What are the indications and contraindications for TKA?

-Indications: 1. eliminate or reduce pain 2. improve functional activities in patients with arthritis -Contraindications: 1. recent septic arthritis 2. lack of extensor control

Plyometrics

-Intense, power generating exercises -Sport specific functional training near end of rehab program -Uses ballistic, high velocity movement patterns -Based on GTO and Muscle spindle responses, causing a reflex muscular contraction -Used only for patients with goals that require this type of training

Medial/Lateral Foot Motion

-Invertors >posterior tibialis >anterior tibialis >flexor digitorum longus >flexor hallucis longus >extensor hallucis longus -Evertors >peroneals >extensor digitorum longus

Shoulder Stability

-due to poor bone to labrum congruency -provided by: >GH ligaments (at end ROM) >coracohumeral ligaments >negative joint pressure >scapular upward rotation >RC muscles stabilizing humeral head

Rehab Considerations after Hip Resurfacing

-Keep leg in neutral position (when sitting or supine foot towards ceiling, not rotating out to the side) for the first 6 weeks -Prone lying allowed to address hip flexion contracture -Active hip abduction allowed immediately -Emphasis on strengthening extensors and abductors -Progression into an outpatient physical therapy setting should be initiated as early in rehab as tolerable when appropriate. -High impact activities (ie-running or jumping) not recommended

Rehab s/p PCL Reconstruction: Maximum Protection Phase

-Knee brace fully locked in extension -Crutches (FWB or PWB x 4-6 weeks) -Quad sets, SLR's, HS sets at angles >30 degrees, minimize knee flexion >60-90 degrees -Patellar mobilizations -ROM to gain full extension

Joint Shapes: Sellar

-each side of the joint is both convex and concave

Clinical Presentation of RA

-effusion/swelling in joints -onset usually in small joints -progression may cause joints to sublux or ankylose -pain in muscles may lead to atrophy and weakness -patient easily fatigues

Effect of Movement on the Menisci

-Knee extension: >femoral condyles tend to push to menisci anteriorly >menisci are pulled anteriorly by anterior attachments of quadriceps -Knee flexion: >femoral condyles pull meniscus posteriorly >menisci are pulled posteriorly by semimembranosus and popliteus tendons -Medial and lateral tibial rotation: >menisci move with the femoral condyles

Referred Pain at Ankle/Foot

-L5 -S1

What is the MOI for an MCL Injury?

-LE fixed with ER of tibia -Direct contact to lateral knee -Valgus stress to knee = isolated tear of the MCL *most common ligament injury of the knee*

Rehabilitation Guidelines s/p Cartilage Repair

-Larger lesions take longer to heal -RICE, NSAID's, and CPM -Early, controlled ROM (ROM is not usually impaired but cautious use of WB required due to compressive forces at the joint) -Can take 8-12 weeks -Protective bracing is usually locked into extension

Miserable Malalignment Syndrome

-Leads to an increased Q-angle 1. Femoral anteversion (femoral IR) 2. "Quinting" (patellae face each other) 3. Proximal external tibial torsion (bayonet sign) 4. Foot pronation

General Hip Rehab Guidelines: Maximum Protection Phase

-Limit aggravating activities -Alter lifestyle -STM, joint mobilization for pain relief, improve motion -Control WB forces (assistive devices) -Posture -Well joint mechanics -Progressive ROM -Flexibility -Stationary biking, pool -Multi-plane isometrics -Supplemental modalities for inflammation control

Bony Anatomy of the Knee, Leg, and Foot

-Lower leg >tiba and fibula (bound together by interosseous membrane -Rearfoot >talus/calcaneus -Midfoot >navicular, cuboid, and 3 cuniforms -Forefoot >5 metatarsals and 14 phalanges

Referred Pain

-Lumbar spine=L3 (groin to front of thigh to knee) -Sciatic nerve—passes deep under pirformis musculature -Obturator nerve—after pregnancy or labor -Femoral nerve—fractures from upper pelvis, dislocation of hip, pressure from labor/delivery

Special Tests

-MCL: valgus stress test -LCL: varus stress test -PCL: posterior sag sign -ACL: lachman, drawer sign, active drawer sign, lateral pivot shift maneuver -Meniscus: McMurray, Apley's, bounce home -PFS pain/chondromalacia: clarke's sign -Measure Q angle -Dislocation: apprehension test

Achilles Tendonitis

-MOI: excessive or sudden change in training intensity, direct microtrauma, repetitive microtrauma, predisposing factors -S&S: >pain along the achilles tendon during and after activities >progression of injury consistent with tendinitis >local swelling

Tibialis Anterior Tendinitis

-MOI: excessive repetitive stress applied to muscle attachment due to poor alignment (excessive pronation), excessive, rapid increase, poor or change in training regimen -S&S: > tenderness to palpation of the anterolateral aspect of the tibia (upper 1/3) >painful resisted DF/INV

Tibialis Posterior Tendinitis

-MOI: excessive repetitive stress applied to muscle attachment due to poor alignment (excessive pronation), excessive, rapid increase, poor or change in training regimen -S&S: >tenderness to palpation of the posteriomedial aspect of the tibia (lower 1/3) >painful resisted PF/INV

Subluxing Peroneal Tendinitis

-MOI: passive DF with the foot slightly everted -Acute Subluxation: >can be misdiagnosed as a lateral ankle sprain >may be in combination with sprain >described as "popping sensation" >pain produced with active DF and EV >when subluxation occurs; peroneal tendons normally dislocate anteriorly over the lateral malleolus with DF -Treatment: >treated conservatively first (rigid cast, NWB x 6 wks) successful ~50% >may need surgery

Supracondylar Fracture: Treatment/Complications

-May be treated with open or closed reduction with or without internal fixation. Cast or sling x 4-6 weeks with elbow in flexed position Possible Complications: -Nonunion, malunion, joint contracture *Could potentially be limb threatening due to potential injury to median and ulnar nerves and brachial artery* Most common complications: 1. Volkmann's ischemic contracture (See next slide) 2. Myositis Ossificans (due to tearing of brachialis off humerus)

Pelvic Fractures

-May or may not have protective WB -If stable, no surgery; may have ORIF -Bed mobility—painful and difficult

Fracture Management

-May require ORIF and LE immobilizer -Generally NWB or PWB -Progress per MD orders

Arches

-Medial Longitudinal: >calcaneus, talus, navicular, cuniforms, and metatarsals >ligament support: spring ligament, long plantar ligament, short plantar ligament, and plantar aponeurosis >muscular support: posterior tibialis, FDL, FHL -Lateral Longitudinal: >formed by: calcaneus, cuboid, and 4th-5th metatarsals -Transverse Longitudinal: >formed by: navicular, cuniforms, cuboid, metatarsals >ligament support: spring ligament >muscular support: peroneous longus

Mobilization Rules...

-Mobilize initially in resting position and then "move towards" end range -Use good body mechanics -Allow gravity to assist -Your body and the mobilizing part act as one unit -Stabilize!! -Short lever arms and hands as close to joint as possible -Mobilize below the pain threshold -Avoid muscle guarding -Articulate in opposite direction if needed *DO NOT CAUSE PAIN!!*

HR Assessment

-Moderate Intensity = 50-70% max HR -Vigorous Intensity = 70-85% max HR *Max HR:* [220-age x % = target HR] *Karvonean Method:* -[HR max-HR rest x % = target HR] -more accurate due to taking into account resting HR

Arthrokinematics: Humerulnar Joint

-Modified hinge joint -Motions: flexion/extension -Concave trochlear fossa on ulna slides on convex trochlea of humerus -Medial/lateral sliding = convex on concave (carrying angle) -VALGUS angulation with elbow extension (forearm moves laterally, medial glide) -VARUS angulation with elbow flexion (forearm moves medially, lateral glide)

Morton's Neuroma

-Morton Neuroma >diffuse radiating pain into the toes and proximally to the dorsal or plantar surface of the foot >3rd to 4th interspace (ocassionally; 2nd to 3rd) >painful mass in 1/3 of cases

Arthrokinematics: Proximal Radioulnar Joint

-Motions: Pronation/supination -Convex radial head on concave radial notch of ulna -Annular ligament circles the rim of radial head

Posture

-Muscles in neck act as stabilizers -As line of gravity shifts, different muscles contract to maintain posture Forward Head Posture: (taut muscles) -upper cervical extension = tight, shortened upper posterior cervical extensors, suboccipitals, tight upper trap and levator -lower cervical flexion = anterior lower cervical and upper thoracic muscles become lengthened and weak Flat Neck: (loss of normal lordosis in C/S) -tight anterior neck muscles -posterior neck muscles lengthened and weak

Tibial plateau fractures

-NWB x 8-12 weeks -Patellar mobility -SLR, quadriceps isometrics -AROM knee flexion OKC

Compression Neuropathy

-Nerve compression injuries are acute or chronic in origin -Both result in mechanical disruption of the nerve fiber, ischemia, decreased nerve gliding -Nerves most susceptible to mechanical disruption due to anatomical layout: radial nerve within the spiral groove of the humerus; median nerve within the soft tissue confines of the carpal tunnel arch, spinal nerve roots

Relation of Bone Fragments to eachother

-Non-displaced -Displaced -Angulated -Twisted/Rotated

Osteokinematics of Lumbar Spine

-flexion -extension -rotation (minimal at LS) -side bending

Atlanto-Occipital Joint (C0-C1)

-flexion/extension = 15-20 degrees -sideflexion = 10 degrees -negligible rotation *atlas has no vertebral body*

Windlass Effect

-foot plantar flexes and supinates; MTP's extend during push-off phase -increase tension on plantar aponeurosis (helps to increase the arch)

Spondylolisthesis

-forward slipping of one vertebral segment on the one below it -most common at the L5-S1

Shin Splints

-generic term for pain in lower leg region -tibialis posterior tendinitis -tibialis anterior tendinitis -stress fracture of lower leg -anterior compartment syndrome

Plantar Fasciitis: S&S

-heel pain in morning with first few steps -pain may go away after a short distance of running but comes back quickly -pain with DF and toe extension (structures are on stretch)

Anatomy Review: Interphalangeal (IP, PIP, DIP, MCP of thumb)

-hinge joint; "little knees" -CONCAVE on CONVEX -Motions: flexion and extension

Signs of Compartment Syndrome

-history of blunt trauma -crush injury -unaccustomed exercise -severe persistent leg pain that is intensified when a stretch is applied to the involved muscles -paresthesis (tingling, prickling) -paresis (weakness, loss of voluntary mvmt) -loss of pulse

Clinical Presentation of Fracture

-history of fall or trauma -local pain/tenderness -swelling; bruising -muscle guarding with PROM -deformity/abnormal movement -loss of function

Signs of a facet joint sprain

-history of trauma -rest will relieve pain -pain with movement (especially at end range) -empty end feel or end feel is limited by muscle guarding -inflammation and swelling

Cervical Myelopathy

-hoarseness, vertigo, tinnitus, deafness -arm positions have no effect on pain -abnormal pattern of sensation effected -gait = wide BOS, drop attacks, ataxia, proprioception affected -loss of hand function -loss of bowel and bladder -spastic paresis -upper and lower limb DTR hyperactivity -positive babinski sign and/or ankle clonus *MEDICAL EMERGENCY*

What is Congruency?

-how well opposing surfaces "match" -a joint is in congruency when both articulating surfaces are in contact throughout the total joint surface area -joints are rarely in total congruence with motion

What are some factors that can contribute to bone and tissue injury?

-imbalance of strength and length of muscles surrounding joint (dominant vs. non dominant; faulty posture) -rapid or excessive eccentric loading -muscle weakness -bone mal-alignment -change in intensity or duration of exercise -returning to activity too soon after injury -poor body mechanics -age, environment, training errors

Treatment for Shoulder Dislocations

-immobilize for 1 to 3 weeks -restricted activity for 6 to 8 weeks -avoid positioning in direction of dislocation Phase 1: decrease pain/edema, prevent recurrence, initiate isometric exercise Phase 2: pain control, maintain/increase ROM, continue isometric exercise, initiate isotonic exercises, and avoid end-range ABD, ER, and horizontal ABD Phase 3: strengthen in partial ROM and avoid stretching anterior capsule Phase 4: strengthen in full ROM Phase 5: return to play/function *high risk of recurrence in young patients*

Total Elbow Arthroplasty

-Not as good as THA, or TKA, 10-16 years -Joint instability, triceps insufficiency, implant loosening *Precautions:* -Follow MD orders carefully -Avoid end range flexion ROM x 3-4 weeks -Strength: no resisted elbow extension x 6-12 weeks -Low load CKC allowed after 6 weeks (standing CKC) -If able to strengthen shoulder :resistance above elbow -No moderate or high loads of weight placed on elbow long term -No moving or carrying objects x 6 weeks -Unable to use AD or push activities x 6 weeks -Avoid full elbow extension and lifting objects long term -Never lift more than 10-15# -No more than 1 lb x 3 months, 2 lb x 6 months, 5 lb with repetitive lifting -Not allowed to play golf or tennis, throwing, racquetball * VERY RESTRICTIVE*

Tendon Healing

-Occurs in stages: 1. Inflammation 2. Repair 3. Remodeling -Collagen, granulation tissue and fibroblasts can sometimes fill the gap with scar tissue (with extensive injury) -Tendon healing is a slow process *60 days for max strength gain* -Controlled stress required to develop strength Surgical repair: *weakest 7 to 10 days post op* -strength regained 3-4 weeks post op *max strength regained 6 months post op*

Arthrokinematics/Osteokinematics during AROM

-Optimal kinematics allow fully stable closed packed position -Optimal ground reaction and gravitational forces distributed through the joint allow minimal stress and work with particular muscles -Altered biomechanics lead to muscle overuse injuries and arthritis -Other joint breakdown leads to pain

Typical Findings in Pt's with General Shoulder Dysfunction

-impaired posture (fwd head-thoracic kyphosis-abducted and fwd tipped scapula) -restricted thoracic extension mobility -neuropathy -hypomobile GH joint capsule (posterior, inferior) -muscle imbalances (shortened, stretch weakness, poor scapulohumeral rhythm)

Strength Training with Children

-PRE is safe and effective -Injuries specific to this group include disruption of growth centers of ossification American Academy of Pediatrics position: -against power lifting, body building, and weight lifting -approves strength training programs for children and teens with use of free weights, body weight, machines, and other resistance devices

Partial Meniscectomy

-PT can begin post op day 1 -Slow return to full WB, motion, and functional activities

PT/PTA Relationship

-PT has the ultimate responsibility for the interventions provided -PTA does NOT change treatment plans or protocol without the PT's approval -PTA should make decisions about care that fall within the existing POC *Professional communication is the key*

Patient Supervision

-PTA gathers relevant information and develops objective assessments using scales and measurements -establish rapport, trust, and confidence -facilitates understanding of the patient's problem -assists with patient management -allows the patient to voice their concerns -assists the PT in helping the patient understand the problem, plan of care, and the interventions

Spinal Instability

-increase in neutral zone mobility -disc degeneration, spondylolysis, spondylolisthesis, ligamentous laxity, poor neuromuscular control of core stabilizers

Clinical Signs of Bursitis'

-Pain in area of inflammation -Pain with muscle stretching and resisted testing -Gait deviations -Imbalance in flexibility and strength -Decreased muscle endurance -Balance deficits

Treatment Idea's for Minimal Protection Phase: Shoulder Post Op

-increase weights -against gravity -functional patterns (UE D1 and D2) -WB using body weight -speed drills -plyometrics -functional return to high level activities

Inflammation and Intervention

-inflammation is a reaction to tissue trauma or injury -if inflammation occurs after an intervention it may indicate that the intervention was too aggressive or contraindicated (can result in new tissue damage or trauma)

Trochanteric Bursitis

-inflammation of the trochanteric bursa -due to trauma (falls, contact) or repetitive trauma (excessive compression of IT band snapping over bursa -could also be due to weak hip ABD and trendelenberg, LLD, and tightness of TFL

Lateral Epicondylitis (Tennis Elbow)

-Pain in common wrist extensor tendons with gripping activities -Activities require repetitive wrist extension (with gripping component) - Special tests: •Pain with palpation on lateral epicondyle •Pain with resisted wrist extension with elbow extended •Pain with resisted finger extension with elbow extended •Pain with passive wrist flexion with elbow extended and forearm pronated *May mimic other disorders*

Medial Epicondylitis (Golfer's Elbow)

-Pain in common wrist flexor/pronator -Activities require repetitive wrist flexion *Also may involve ulnar neuropathy* - Special tests: •Pain with palpation on or near medial epicondyle •Pain with resisted wrist flexion with elbow extended •Pain with passive wrist extension with elbow extended

Clinical Signs of Trochanteric Bursitis

-Pain over lateral hip, lateral thigh to knee -Initially with activity only, progressing to pain at rest -Pain with palpation and ROM

Clinical Presentation of Gout

-Painful joint, increased warmth, usually red -Men>women, men after puberty (peak age 75), women after menopause -Risk factors include obesity, excessive weight gain, moderate to heavy alcohol intake, HTN, abnormal kidney function, leukemia, lymphoma, and blood disorders -Other risk factors: certain meds including diuretics, aspirin, TB meds, niacin and cyclosporine -Can be brought on by dehydration, joint injury, fever, excessive food intake, heavy alcohol intake, recent surgery -Can re-occur after successful treatment

Patient Interaction

-interpersonal communication skills -initial contact (rapport, confidence, capability, and sensitivity)

Mallet Finger

-interruption of *extensor tendon DIP zone I* -may result in swan neck deformity if not treated -6 weeks: DIP hyperextension with PIP free in uninterrupted splinting -after 6 weeks: 20 degrees flexion allowed, extension splint at night x 4 weeks -*passive flexion contraindicated, no strong muscle effort* -any extension lag= resume splint -full active flexion avoided x 3 months -6 to 9 months recovery usual

Osteoarthritis

-joint enlargement -*most common in trapezioscaphoid articulation, CMC thumb, DIP digits* -Heberdon nodes: PIP -Bouchard nodes: DIP

Other Dysfunctions of the SC Joint

-joint may be hypomobility after immobilization or injury (treat with joint mobs) -impingement of intra-articular meniscus (treat with joint mobs)

Joint Shapes: Ovoid

-joints are made up of a concave and a convex surface -other structures (i.e. mensicus/labrum) often help congruency

Chronic Inflammation

-last *6 months to a year* -may need to educate the patient about the time frame for chronic inflammation during rehab -example: s/p TKA

RX s/p Spinal Surgery

-Patient will initially be splinted or braced in some manner >cervical fusion-rigid collar like an ASPEN or miami collar >lumbar will likely have a TLSO or corset -PT will initially focus on returning to (I) functional mobility level with transfers, gait, and stairs >log roll technique should be taught for bed mobility -Posture and body mechanic training once approved my MD, ROM can be gradually increased >full ROM may not be achieved >fusions-body does not adapt in levels fused, must teach education to protect fusion, avoid hypermobility of non affected segments -Scar mobilization/soft tissue mobilization -Muscle flexibility program of UE/LE -Trunk stabilization program -Generalized conditioning for whole body -Endurance program

Post Surgical Maximal Protection Phase

-Post Op Day 1-4 weeks -sling 1 to 2 weeks, depending on surgeon -peripheral joint awareness

Rehab s/p PCL Reconstruction: Minimum Protection Phase

-Progress strengthening (bilateral to unilateral) -Running and plyometric exercises -Return to sport at 6 to 9 months post op

General PT of Knee: Maximal Protection Phase

-Pt education of procedure and long term outcomes -Joint mobility -Knee ROM (*0-90 degrees ASAP *; goal maximal 0-full flexion) -Patellar mobilization -STM -Gait training, progressive AD weaning -Strengthening: isometrics, isotonics, OKC, CKC -Balance -Supportive modalities: decrease edema, pain and gain strength

Rheumatoid arthritis

-RA in cervical spine presents special problems because of erosion to the bone and ligament laxities -can lead to instabilities -increases risk for atlantoaxial subluxations or C4-C5 and C5-C6 dislocations

Goals of PT for Post. Tib and Ant. Tib Tendinitis

-RICE -flexibility: stretching of achilles (tightness promotes excessive pronation at foot and early heel rise in gait) -strength: anterior tibialis, posterior tibialis, foot intrinsics -mechanics: >address LE dynamic function, dynamic hip/foot control >footwear >orthotics if necessary

Treatment for facet joint sprains

-RICE and modalities -gentle progressive ROM exercises *joint mobs are not appropriate initially (time to heal is important); if excessive movement is allowed, hypermobility might result and vice versa*

High Tibial Osteotomy

-Realigns the tibiofemoral joint by surgically creating a wedge in the proximal tibia or distal femur -Rehab s/p: immobilized with performance of knee exercises out of immobilizer; WB progression, wean from AD 8-12 weeks *No functional CKC exercises until bone union is verified*

Scapular Fractures

-Result of dysfunction or trauma *Goals of PT:* -immobilize 2 to 3 weeks -PROM dictated by MD -progress via MD protocol *note: glenoid fractures may require sx if scapular fx causes glenoid humeral instability*

Rehab s/p ACL Reconstruction: Minimal Protection Phase (12-24 weeks)

-Return to more normalized activities -Isokinetic testing -Progress CKC and balance exercises -Plyometrics: jump training and landing mechanics

Rotator Cuff Muscles

-SITS: supraspinatus, infraspinatus, teres minor, and subscapularis *RC acts to:* -primary mover of humerus -eccentric deceleration -depress humeral head in glenoid fossa -dynamic stabilizer of GH joint

Grading for Pitting Edema

-Scale of 1 to 4 -Based on both depth and time Grade 1: 2mm deep; rapidly disappears Grade 2: 4mm deep; 15 seconds to disappear Grade 3: 6mm deep; > 1 minute to disappear Grade 4: 8mm deep; > 2 minutes to disappear

Contracture Management

-Scar tissue may be limiting ROM -Low load; long duration -Preheating the area AND maintaining moist heat before and while stretching is helpful -Position of comfort (not maximal stretch) -Allow rest breaks -Maintain heat 5-10mins after load is removed -Begin isometric contractions afterward to enhance strength gains at new end range of motion

Flat Back Posture

-Shortened hamstrings, IT band and glut maximus

Speed of Contraction

-Slower speed of contraction can produce greater force and tension; also increases joint compressive forces -Isometrics spare the negative effects of excessive joint motions, torque, and compressive forces -Higher speed isokinetic exercise improved functional speeds of contraction with lower compressive forces and accommodates for patient pain

Factors that affect the balance strategy used

-Speed and intensity of displacing forces -Characteristics of support surface -Magnitude of displacement of COM -Subject's aware of disturbance -Subject's posture at time of disturbance -Subject's prior experiences

Pt. Response to Mobs

-Stretching maneuvers usually cause soreness -Perform the maneuvers on alternate days -If increased pain after 24 hours decrease dosage or duration -Joint and ROM should be assessed after treatment and again before the next treatment

Pain

-Subjective -Make note of: changes in pain, response to intervention, patterns, description, and subjective statements *Be sure to observe the patient's response and behaviors (ie: grimacing, compensating, etc)*

Grade 3 AC Sprain

-Superior subluxation of clavicle (due to sublux btw acromion and distal clavicle) -Rupture of both AC ligaments and coracoclavicular ligaments *Signs and Symptoms:* -notable pain -"step off deformity" -severe ROM limitations (shoulder ABD and ADD) *Goals of PT:* -Sx repair or immobilization -controlled phase 4-6 weeks -progress via general rehab phases (protect AC joint)

Loose Bodies

"Articular Mice" Due to *degeneration or trauma* S&S: -Pain, effusion of the joint -Elbow "locks and unlocks" in various positions TREATMENT: Removal through arthroscopic surgery

Legg-Calve-Perthes Disease

"Coxa Plana" -avascular necrosis of the femoral head (WB causes deformation) -affects children 3-12 years old -RX: positioned in ABD with abductor orthosis, traction at night, crutches, NWB, pool, and/or surgery *must keep hip in abduction during ROM and strengthening exercises*

Osteoarthritis

"Degenerative Joint Disease" -chronic, degenerative disease which affects the articular cartilage of synovial joints -causes eventual bony remodeling and overgrowth (spurs) -increase synovial/capsular thickening -increase joint effusion

Unicate Joints

"Joints of Lushka" -saddle form to upper aspect of cervical vertebrae -not fully developed until age 18 *limit side flexion*

Balance

"Neuromuscular Control" -subconscious activation of muscles occurring in preparation for and in response to joint motion and loading -ability to maintain equilibrium -ability to maintain COG within BOS -not constant

Atlanto-Axial Joint (C1-C2)

"Odontoid Process C2" -flexion/extension = 10 degrees -sideflexion = 5 degrees -rotation = 45 to 50 degrees *C2 is the first palpable spinous process*

Protrusion

"Prolapse" Annulus bulges but nucleus is contained within the annulus and supporting ligamentous structures

Radial Nerve

"Saturday night palsy; Drop Wrist Deformity" -extensor muscles are paralyzed -sensory loss: dorsal hand (digits 1--medial side of 4th finger) and medial thumb -motor loss: wrist and finger extension, thumb extension

Ischiogluteal Bursitis

"Tailor's or weaver's bottom" -Pain around ischial tuberosity, especially with sitting -May experience symptoms of sciatica

Innominate Shear

"Upslip" -entire innominate slips upward -usually from traumatic incident; like a fall on a ischial tuberosity or vertical thrust onto an extended leg

Etiology of torticollis

"Wryneck": Asymmetrical strength or length of SCM -congenital (injury in utero or at birth) -hemiplegia possible -hysterical torticollis (person turns away from unpleasant situation)

Adhesive Capsulitis

"frozen shoulder" -tight capsule and severe loss of ROM -causes: age (40-60), gender (f>m), diabetes, menopause, trauma, RA/OA, and prolonged immobilization -stages: freezing, frozen, and thawing -may last up to 2 years; may never regain full ROM

Accessory Motion: Roll

-Surfaces are incongruent -New points on one surface meet new points on the opposing surface (like a tire rolling on the pavement) -Rolling is ALWAYS in the same direction as the osteokinematic motion -In normal joint, a pure roll does NOT occur alone, rather occurs in conjunction with either a glide or spin *If rolling occurs alone, will cause compression on the side to which the bone is angulating, and separation on the opposite side (ie: passive stretching with poor arthrokinematics)*

PT after Meniscal Repair

*After partial or total meniscectomy:* -removal of part or all of meniscus -Rx focus on pain management and edema control -increase ROM, strength, and aerobic endurance *After meniscal repair:* -may have ROM or WB restrictions -usually FWB not allowed until 4-6 weeks -ROM restricted to protect the repair site

Acromioclavicular Joint

*Arthrokinematics of the AC Joint:* -the convex lateral end of the clavicle moves on the concave acromion process of the scapula *Other:* -stabilized via ligaments (AC ligaments and coracoclavicular ligaments) -coracoclavicular ligaments (coronoid/trapezoid) prevent superior subluxation of clavicle

Treatment for disc herniation

*Avoid aggravating positions* -manual or mechanical traction -cervical ROM or gentle stretching -active protraction/retraction -promote centralization; avoid peripheralization -educate patient on proper posture -isometric strengthening/stabilization -flexibility of anterior chest wall -thoracic flexibility -UE strength/stabilization, scapular stabilization

Finger Fractures

*Boxer's fracture:* -strike object with closed fist -neck of 4th and 5th fingers *Bennet Fracture:* -palmar base of proximal 1st metacarpal *Phalanx Fractures:* -buddy taping -immediate AROM

Normal Signs and Symptoms of Inflammation

*Cardinal signs of inflammation* 1. Localized heat 2. Redness (erythemia) 3. Swelling (edema) 4. Pain 5. Loss of Function *Be concerned if these s&s are SIGNIFICANT*

Red Flag Pain Symptoms

*Cardiovascular:* -pain or heaviness in chest -pulsating pain anywhere in the body -constant and severe pain in LE *Cancer:* -persistent pain at night or pain that awakens the patient *Musculoskeletal:* -constant pain that is unrelieved by change in position or activity (musculoskeletal pain can be alt.) *Gastrointestinal:* -frequent or severe abdominal pain *Neurologic:* -frequent or severe headaches

Lateral Collateral Ligament Injury

*Common after dislocations* Special tests: - Varus stress test - Lateral pivot shift test - Posterolateral rotary drawer test - Posterolateral rotary apprehension test

General Treatment Guidelines: Controlled Motion Phase

*Criteria: improved postural awareness, improved ROM, flexibility, strength at upper body, pain and edema are controlled, no peripheralization of symptoms* Goals/Interventions: -maximize ROM, flexibility of C/S, T/S, and upper body -maximize strength of upper body -maximize toward neutral body postures -initiate multi plane activities

General Guidelines for PT: Controlled Motion Phase

*Criteria: no peripheralization of symptoms, decreasing pain and edema, increasing ROM* -return to functional activities -ergonomics training -trunk stabilization/UE/LE exercises with neutral spine -progressive LE flexibility without aggravating symptoms -initiate multi plane movements -increase excursion of body movements -cardiopulmonary endurance program

General treatment guidelines: Return to Function Phase

*Criteria: no peripheralization, max ROM, flexibility and good strength and posture positions* Goals/Interventions: -return to full functional activities -full return of all planes of motion -full return to full lifting, multi planar movement -increase speed with activities -plyometrics -alter activities to prevent re injury

Closed-pack positions of joints of the ankle/foot

-Talofibular: >max DF -Talocrural: >max DF -Subtalar: >supination -Midtarsals: >supination -Tarsometatarsal: >supination -Metatarsophalangeal: >full extension -Interphalangeal: >full extension

Capsular patterns of joints of ankle/foot

-Talofibular: >pain on stress -Talocrural: >PF-DF -Subtalar: >varus-valgus -Midtarsal: >DF-PF-ADD-Medial rotation -Tarsometatarsal: >none -Metatarsophalangeal: >great toe= extension-flexion >2nd thru 5th toes= variable -Interphalangeal: >flexion-extension

Open-pack positions of joints at ankle/foot

-Talofibular: >plantarflexion -Talocrural: >10 degrees PF and midway between inversion and eversion -Subtalar: >midway between extremes of ROM -Midtarsal: >midway between extremes of ROM -Tarsometatarsal: >midway between extremes of ROM -Metatarsophalangeal: >10 degrees of extension -Interphalangeal: >slight flexion

Signs of TOS

-UE radicular pain -numbness -paresthesia -weakness *in severe cases: discoloration, swelling, and impaired circulation in hand and lower arm*

General Guidelines for PT: Return to Function Phase

*Criteria: no radiculopathy symptoms, minimal to no pain, maximized ROM, and trunk stability* -full functional activity motions -increased speed with activities -multi planar full functional lifting -job simulation activities -plyometrics -if disc--must return to flexion program to allow full mobility

Nerve Disorders: Ulnar Nerve

*Cubital tunnel syndrome* -compression along medial elbow Special tests: -Elbow flexion test -Tinel's sign

Retroversion

*Decreased* angle of torsion. -Femoral shaft is ER (decreased IR and toed-out gait) -Could lead to *internal tibial torsion and compensatory supination* -Congenital condition

CMC, MCP, PIP Arthroplasty

*Dynamic splint with rehab* Guidelines of *boutonniere deformity* correction: -avoid DIP hyperextension -avoid resisted ex and stretching of extensor mechanism of PIP joint 6-12 weeks Guidelines of swan neck deformity correction: -avoid extreme flexion of DIP joint Guidelines of CMC thumb correction: -avoid forceful pinch and grasp for 3 months s/p sx -limit heavy lifting; advise wearing protective splint

Rheumatoid Arthritis and Osteoarthritis

-Wearing of joint surfaces -May cause genu valgum or varum deformities

General Ligament Injury: Post-Surgical Management

-Weeks 0 to 3 = 90 elbow brace with forearm pronation, no elbow ROM -No supination x 4-6 weeks -No shoulder IR/ER isometrics x 3 weeks -May begin gentle hand gripping -Other shoulder isometrics x IR/ER -Shoulder/wrist PROM--AAROM--AROM (no pain in elbow) -Supportive techniques -Well joint mobility

What are the two laws of bone remodeling?

-Wolff's Law: intermittent physiologic loads applied to bone stimulate adaptive responses -Hueter-Volkmann Law: (reverse of wolff's law) compression forces limit bone growth and tensile stress stimulates growth *bone remodeling is a lifelong process that responds to mechanical stress*

Spondylolysis

-a bony defect in the pars interarticularis -fracture seen on xray

Abnormal End Feels

*Empty:* -motion is limited by pain without muscle spasm *Guarded/Spasm:* -pain accompanied by a halt of movement that prevents full ROM -rebound *Springy block/internal derangement:* -full ROM is limited by "springy" sensation -sometimes accompanied by pain *Loose end feel:* -joint hypermobility -no resistance at end of ROM-signifies excessive joint looseness *Boggy:* -mushy due to joint effusion *Capsular:* -if felt before normal ROM

Orthopedic Conditions

*Fractures and Dislocations are most frequent* -the elbow is the 2nd most dislocated joint in the body -rehab is difficult following traumatic injury due to extensive bleeding and the resulting fibrosis (lack of terminal elbow extension is not uncommon) -elbow is the most frequent site of abnormal bone on bone end-feel

Treatment for Adhesive Capsulitis

*Goals of PT:* -ROM -passive joint mobs, distraction, and traction -HEP of self traction and mob techniques -muscle setting -isotonic exercises in pain free range -soft tissue mobility -postural and mechanical re-education -peripheral joint mobility -progress pt via rehab phases -stretching anterior musculature (too aggressive may worsen symptoms) -use new ROM or you'll lose it

Sx Managment: Rotator Cuff Impingement and Tears

*Goals of PT:* -based on MD protocol, sx approach, and size of tear -small tears= immobilization, min AROM for 5-6 weeks, then progress via MD or as tolerated -large tears= RICE, immobilization for 6 weeks (PROM only), avoid ADD (immob. at degrees ABD), AAROM and progress to AROM, strengthen at 6-12 weeks,vigorous PROM at 8-12 weeks, return to play at 16-20 weeks

Treatment of Complex Regional Pain Syndrome

*Goals of PT:* -gentle, brief bouts of exercise throughout day -AAROM/AROM to maintain joint mobility (will not tolerate touch) -facilitate muscle activity (via isometric/dynamic exercises with minimal joint motion) -compression/distraction activities -cardiovascular activities -desensitization -treat symptoms (vary day to day) -watch for S&S of inflammatory period -use supportive techniques (emotional component) -use caution with stretching, joint mobility, and resistive exercises (due to osteoporosis)

No-Operative Treatment of Rotator Cuff Impingement

*Goals of PT:* Phase 1= symptom relief, ROM exercises, ADL modification Phase 2= PRE and advanced scapular stability Phase 3= return to play/function

Speed, Rhythm & Duration

*Grade I and IV:* rapid oscillations *Grades II and III:* smooth oscillations, 2-3 second for 1 to 2 minutes *Sustained:* Pain, distraction 7-10 seconds

Distraction Grades

*Grade I:* -unweighting or barely supporting the joint surfaces (picolo) -equalizes cohesive and atmospheric forces of the joint -alleviates pain by unloading and decompressing -nullifies normal compressive forces *Grade II:* -slack of the capsule taken up (eliminates joint pain) *Grade III:* -capsule and ligaments stretched

Graded Oscillations

*Grade I:* Small oscillations performed only at the beginning of the available range *Grade II:* Larger amplitude motion occurring from the beginning of the ROM to mid-range *Grade III:* Larger amplitude motion occurring from the mid- range of the motion to the end of the available range *Grade IV:* Small oscillations that occur at the very end of the available range *Grade V:* A small amplitude, high velocity thrust technique at the limit of the available range

Intermittent Claudication

-activity related discomfort associated with peripheral arterial disease (PAD) -aching or cramping that is localized in the region affected by impaired circulation (ie: LE's) *Assessment of Intermittent Claudication:* 1. Determine claudication time 2. Max walking time 3. Pain free walking time 4. Walking time to severe claudication

Moderate Protection Phase Shoulder Post Op

-acute Symptoms are under control -minimal discomfort when shoulder is unsupported -nearly complete pain-free PROM -supine AROM>120 -pain-free AROM ER 45 -at least 3/5 strength at shoulder girdle -patient education (HEP) -develop balance and length of shoulder girdle musculature -develop scapular stability -develop shoulder girdle muscle stability and endurance -progress shoulder function

Skier's Thumb

-acute sprain *ulnar collateral ligament of thumb* -sudden valgus stress and hyperextension of thumb -*unrestricted use delayed until 3 months post injury*

Peripheral Nerve Rehabilitation

-aggressive range of motion too early can disrupt healing of fascicle sutures and axonal regeneration -post op splinting is used to maintain appropriate amount of tension -compressive dressings -conservative range of motion exercises -superficial heat, electrical stimulation, and sensory stimulation tactics can be used

Rehabilitation Guidelines: Protective Phase

-alter activity -supportive modalities -alter foot mechanics -decrease stress on tendon in WB -low load eccentric exercises found to assist with healing -DFM, STM -joint mobs -strength and flexibility -multi angle isometrics -AD if needed -modalities for pain and edema

Hip Resurfacing

-alternative to THA -cap is placed over the femoral head and in the acetabulum to replace the articulating surfaces -very little bone is removed

What does the ACL limit?

-anterior displacement of tibia on the femur -hyperextension -extreme varus, valgus, and rotation movements

Vital Signs

*HR =* 60-100bpm -abnormal: increase in bpm greater than 20 that lasts for more than 3 minutes after rest *Respiration=* 12-20 breaths per min -monitor for 30s (x2) or 60s if abnormal *BP=* 120/80 -abnormal systolic: > 250mmHg -abnormal diastolic: > 110mmHg -abnormal if systolic rises > 20mmHG with min to mod and > 40-50mmHG with intensive exercise -abnormal if diastolic rises >10mmHg -watch for orthostatic hypotension and valsalva maneuver *Pulse Ox=* 95-100% -discontinue treatment if it drops below 90% in healthy individuals or below 85% in lung patients

Sensation/Strength Testing of Shoulder Joint

-assists in ruling out cervical or peripheral nerve entrapment C4: dermatome: upper trap to tip of shoulder myotome: scapular elevation C5/C6: dermatome: deltoid region and lateral arm myotome: shoulder abduction deltoid, teres minor, biceps

What are the types of bones?

*Long Bones:* -Diaphysis: tubular shaped midportion that houses compact bone -Epiphysis: end of long bones that house cancellous bone (aka trabecular bone, 50-90% porous) and the intermedullary canal where blood cells are formed -Metaphysis: wide ends *Short Bones:* -Composed of spongy inner bone enclosed in a thick layer of compact bone (aka cortical bone, <30% porous) *Flat Bones:* - Larger; purpose of protecting organs - Two layers of compact bone with spongy bone between *Irregular Bones:* - Skull, vertebrae, pelvis

Observations to make note of

*Lymph Nodes:* -tender or enlarged *Redness or Skin Color changes:* -rashes or streaking may indicate bacterial infection; leading to acute inflammation of lymph nodes *Redness with superficial tenderness and hardness:* -indicate blood clot in vein(thrombophlebitis) *Loss of skin color (pallor):* -associated with temperature changes, pain, or edema may indicate an occlusion of a blood vessel

Special tests for long thoracic nerve damage

-at wall or supine, arm flexed at 90 degrees -therapist applies backward force to arm or fist -positive if= scapular medial border wings

Effects of Immobilization

-atrophy -decrease number of sarcomeres (up to 40% loss) -Type I fibers (marathon) atrophy more than Type II fibers (sprint) -decrease in muscle weight by 17% in 3 days

Extensor Tendon Transfer/Reconstruction of RA Hand--Precautions

-avoid activities or hand postures that combine finger flexion/thumb flexion and adduction with wrist flexion -avoid WB on dorsum of hand -avoid vigorous grasping activities

Anatomy Review: Metacarpal Phalangeal (digits 2-5)

-biaxial, condyloid joint -CONCAVE phalanages on CONVEX metacarpals -Motions: flexion, extension, abduction, adduction >not able to perform abd/add in full flexion due to ligaments >3rd digit can ABD but not ADD since it is considered midline -Oblique flexion of digits 3-5

Signs of TMJ

-biting or chewing difficulty or discomfort -clicking sound while chewing or opening of the mouth -dull aching pain in the face -ear ache -grating sensation while chewing -headache -jaw pain -loss of TMJ ROM

What is the structure of bone and what are the two types of bone?

-bone tissue is a metabolically active tissue *65% mineral and 35% organic (type 1 collagen)* -Two forms of bone: 1. mature bone: comprises most of skeleton by age 4; highly organized collagen arrangement 2. immature bone: disorganized collage arrangment; seen in newborns and adults with fx repairs, bone tumors, or pathologies

Treatment for tension headaches

-break cycle of pain and muscle spasm -STM, joint mobilization -stretching tight musculature (suboccipital release, cervical and shoulder musculature) -strengthening shoulder and scapular musculature -posture education

RX for Compression Fracture

-can be very slow to heal -in severe osteoporotic patients, more fractures may occur while they are trying to heal -pain control (meds, positioning, binders, corsets, jewett brace to maintain extension) -avoid flexion activities (can cause impingement) -caution with rotation -gentle stabilization exercises if tolerated -increase mobility (wolfe's law) -kyphoplasty (pump hardening agent into fracture site) -affects of synovial joints of spine and ribs -cervical spine is mostly affected -pain or neurological s&s originating in spine may be related to subluxation (consider effect of inflammation/acute response)

Uni-directional GH Dislocation

-can occur anterior, posterior, or inferior (anterior is most common) -occurs with other issues: rotator cuff tears, capsule or ligament damage, trauma, or lax CT's -caused by: anterior instability or FOOSH in ABD or ER position

Anterior Rotated Innominate

-can occur from baseball, golf swing, knee to dashboard injury, or a forceful diagonal PNF pattern such as chops or repeated PNF pattern when getting in and out of the car

Calcaneal Fractures

-casting or ORIF depending on type and severity of fracture -long term importance gaining strength of plantar flexors

Bankart Lesion

-caused by anterior dislocation of GH joint -anterior portion of labrum and GH ligaments are torn from their attachment on the glenoid fossa

Hill-Sachs Lesion

-caused by anterior dislocations of GH joint -indentation fracture on humeral head occurs during anterior dislocation as posterior portion of humeral head hits the anterior portion of the glenoid rim *recurrent anterior dislocations*

Proximal Humeral Fractures

-caused by: FOOSH -may be displace or non displaced *Rx:* -immobilization, conservative PT after 2-3 weeks -ORIF *Goals of PT:* -follow MD orders -progress via rehab stages *Risks:* -avascular necrosis -radial nerve entrapment or damage

Mobilization vs. Manipulation

*Mobilization:* -a low velocity, passive movement applied within or at the limits of ROM -applied at a speed low enough to allow the client to stop the movement *Mobilization with movement:* -concurrent application of sustained accessory mobilization applied by the therapist with active physiological movement to end range applied by the patient *Manipulation: "thrust"* -a sudden, high velocity technique applied at end of ROM -cannot be stopped by the client *PTA's do not perform!*

Suprascapular Nerve Disorder

-caused by: stretched by carrying heavy book bag over shoulder -supraspinatus/infraspinatus weakness or atrophy (due to loss of innervation) *Goals of PT:* -allow nerve to recover (avoid over stressing) -protect through out rehab phases -place some traction on nerve to facilitate healing

Therapeutic Intervention: Monitor for Vascular Obstruction

*Monitor for Volkman's Ischemia* -Hemorrhage beneath deep fascia produces ischemic injury creates arterial and venous obstruction (brachial artery) Signs and Symptoms: -Severe pain in the forearm muscles -Limited and extremely painful finger movements -Purple discoloration of the hand with prominent veins -Initial paresthesia followed by loss of sensation -Loss of radial pulse and lateral loss of capillary return -Pallor, Anesthesia, paralysis *Passive stretching is contraindicated in protection phase* -Follow MD orders closely -Initial restoration of function focuses on motion exercises that do not stress the fracture site -Exercise shoulder and wrist as permitted by doctor

Long Thoracic Nerve Disorder

-causes: *serratus anterior weakness* *S&S:* -scapular winging (when humerus flexed to 90 degrees) -inability to stabilize scapula against thorax -may be unable to abduct or flex arm greater than 90 degrees (due to impaired scapulothoracic rhythm)

Indications for Joint Mobs: Grade I & II

*Neurophysiologic Effects:* -inhibit transmission of pain stimuli at the spinal cord -stimulates mechanoreceptors in joint capsule and ligaments (those that sense touch and pressure) that can inhibit transmission of pain *Mechanical Effects:* -joint motion stimulates biologic activity by moving synovial fluid -brings nutrients to the avascular portions of cartilage -helps maintain nutrient exchange and prevent degenerating effects of immobilization

Spinal Fusion

-cervical or lumbar -one or more vertebral segments of the spinal column are surgically fixated or fused to prevent movement at the particular segment -fusion can be by internal fixation methods (rods/screws) and/or bone grafts -surgical approach may be from an anterior or posterior direction *make note of what procedure was used*

Peripheral Nerve Repair

*Neurorraphy:* surgical repair for neurotmesis (severe nerve injury) -repairs with minimal tension show better results than repairs with NO tension -without repair; denervated bone becomes osteoporotic, joint capsule and periarticular soft tissues become fibrotic, and muscle atrophies *excellent results are expected 50% of the time* *sural nerve is commonly used in nerve repairs*

Scapulothoracic Joint

*Not a true joint* -scapula slides along the thorax -joint is stabilized via strength and flexibility of muscles (RC holds humeral head in glenoid fossa preventing superior migration) -balance of muscular forces of: upper and middle trapezius, levator scapula, pec minor, serratus anterior, rhomboids, lat dorsi, and weight of arm

Rehab s/p PCL Reconstruction: Moderate Protection Phase (6-12 weeks)

*Quadriceps should be emphasized* -Restore full ROM -Progress strength

Treatment Ideas for Shoulder Post Op

*ROM:* -table top dusting, ball rolling without gravity, wand exercises, pendulum, pulleys, scapular ROM, P/AA/AROM without gravity *Stretching Tight Tissues:* -pectoralis stretching, sleeper stretch, into flexion/abd without pain *Strength:* -multi angle isometrics -manual resistance exercises without gravity -scapular stability exercises -prone exercises -closed chain WB (standing,

Wrist Arthoplasty

*Rehab through hand specialist or OT* Special Guidelines: -avoid WB on hand with transfers and ambulation with AD or with ADL's -forearm supported walker or crutches -avoid functional activities that place more than 5-10# on wrist -wear wrist splint for additional protection with functional ctivities -no high-impact vocational and recreation activities -usual gain in ROM following rehab = 15-30 wrist flexion/extension, 5-10 RD/UD, 100 pronation/supination *revision common after 5 years*

Final Notes to Remember

*Remember: use new ROM* -stretching -ROM exercises -strengthening -balance -functional activities Definition of Grades of movement related to a joint Ankylosis (stiffening) Greatly decreased ROM Minimal decrease in ROM Normal Slight increase in ROM Significant instability Total instability

1st Degree SC Sprain

*Signs and Symptoms:* -little pain or disability -point tenderness -pain at end range of horizontal ADD *Rx:* -relative rest -ice -modalities

3rd Degree Sprain

*Signs and Symptoms:* -notable deformity -pain and swelling -point tenderness -disability *Rx:* -MD will reset -immobilize for 3-5 weeks -ice, rest, modalities -gradual return to play/function *higher risk of re-injury with contact sports*

2nd Degree SC Sprain

*Signs and Symptoms:* -notable deformity -pain and swelling -point tenderness -pain at end range of hor. ADD and end range shoulder ABD *Rx:* -immobilized for 1-2 weeks -rest, ice, and modalities -return to play/function after 4-6 weeks *higher risk of re-injury with contact sports*

Inflammation

-protective, first response to injury or disruption of homeostasis -if left UNRESOLVED: it may become chronic -chronic inflammation can lead to secondary complications or permanent changes in tissue *Monitor changes in inflammation*

What is the function of connective tissue?

-provide stability and shock absorption in joints -mechanical link system between bones -transmits muscle forces

Tibia and Fibula

-proximal and distal tibiofibular joint >accessory motion >CONVEX fibular head moves on CONCAVE tibia

Rehabilitation of Muscle Injuries

-reduce pain and swelling -minimize muscle atrophy -maintain or regain strength and range of motion (if ROM is restricted may need protective bracing) -progression through comprehensive exercise program

Smith Fracture

-reverse Colles' fracture -caused by fall on dorsum of hand -*displaced fracture of radius in palmar direction*

Anatomy Review: CMC of Thumb

-saddle joint -frontal plane: CONCAVE on CONVEX in flexion/extension -sagittal plane: CONVEX on CONCAVE in abduction/adduction

Causes of Secondary Rotator Cuff Impingement

-scapular weakness decreases subacromial space and leads to impingement -faulty biomechanics secondary to hypomobility or instability in GH joint -weakness of serratus anterior, traps, levator scapula, and rhomboids allow superior humeral head migration

Special tests for TOS

-sensation test -muscle test -reflex test -upper limb tension tests -radial, median, ulnar nerves -provocative tests: roos, adson's, allen, reverse adson

Upper Limb Tension Test: Median Nerve Bias (2)

-shoulder girdle depression -shoulder joint abduction -elbow extension -lateral rotation of the whole arm -wrist, finger, and thumb extension

Upper Limb Tension Test: Radial Nerve Bias

-shoulder girdle depression -shoulder joint abduction -elbow extension -medial rotation of the whole arm -wrist, finger, and thumb flexion

Upper Limb Tension Test: Median Nerve Bias (1)

-shoulder girdle depression -shoulder joint abduction -forearm supination -wrist and finger extension -shoulder joint laterally rotated -elbow extension

Goals Post Immobilization during Fracture Healing

-slow, careful, initiation of ROM and strengthening -mobilize scar tissue -joint mobilization -normalize biomechanics as much as possible, if not, include appropriate bracing, compensation techniques -return to functional goals

Etiology of tension headaches

-soft tissue injury -faulty or sustained postures -sustained muscle contractions -emotional stress -migraines, allergies, and sinusitis

Treatment of TOS

-soft tissue stretching (pectoralis, scalenes) -first rib mobilizations -posture *in severe cases: surgery to remove first rib*

Management: Protective Phase of wrist/hand injuries

-splints -supportive modalities -STM, joint mobilization -tendon gliding exercises -pain free ROM -multi angle isometrics -joint biomechanics normalized

Eversion Ankle Sprain

-sprain of medial ligament (deltoid ligament) -more rare (more force is required to tear deltoid ligament) -often associated with avulsion fracture of the medial malleolus and/or fracture of the lateral malleolus and sprain of the tibiofibular ligament -watch for posterior tibialis dysfunction

Treatment for muscle disorders of cervical spine

-stretching and ROM -strengthening -education on posture -relaxation -addressing poor work habits or conditions (evaluate work space)

Treatment for torticollis

-stretching tight SCM -strengthening supportive musculature -educate parents to do HEP

What are the functions of intracellular exchange?

-supplies tissues with nutrients and oxygen -provides removal of extracellular waste and gases *Relies on circulation of the blood*

Posture Syndrome

-sustained flexed posture in spine -disc/facet/joints and ligaments placed under sustained loading -creep and fluid transfer occur with increased intradiscal pressure -sudden change in postures can cause pain

Subtalar Joint

-synovial joint -CONVEX calcaneus moves on CONCAVE talus -motions: inversion; eversion

Facet Joints

-synovial joints -have different orientation in the CS, TS, and LS -functions: >guides and limits movement >handles 20-30% of compressive loads (can increase to 70% with degeneration) >40% of torsional and shear strength

Goals of Immobilization Phase of Fx Healing

-teach safe gait and transfers -protect healing structures -minimize muscle atrophy -maintain or increase muscle strength -promote/maintain movement of unaffected joints -increase overall fitness

High Ankle Sprain/Ankle Syndesmosis Injury

-tear or the medial ligamentous structures supporting the distal tibiofibular joint -MOI: forced excessive DF, IR of tibia with foot in WB, severe impact on heel (often associated with severe eversion or inversion ankle sprain) -S&S: >pain over distal tib/fib ligaments >pain in WB

S&S of Rotator Cuff Impingement/Tear

-tendonitis/bursitis/inflammation of tissues in the subacromial space -palpation of: >supraspinatus= place hand behind and inferior to acromion >infraspinatus= in bicipital groove

What are the signs of tension headache

-tension in posterior cervical muscles -pain at the attachment of the cervical extensors -pain radiating across top and side of scalp

Trigger Finger

-thickened flexor sheath, sticking of tendon with finger flexion -PROM to straighten -may need surgical intervention

Muscle and Soft Tissue Lesions Etiology

-trauma -poor posture -emotional stress -repeated stress to the body

Gout

-uric acid crystals deposit in tissues through out the body (*great toe especially) -crystals deposit specifically in the synovial fluid and lining and cause painful joint inflammation as white blood cells attempt to engulf the crystals and begin the inflammatory process -related to the body's ability to process uric acid -can result in: arthritis attacks, kidney stones, and kidney failure

Intraarticular Fractures

-use caution with closed chain activities -external support -avoid stressful activities -light eccentric and concentric activities

Stage 3 Rotator Cuff Impingement/ Tear

-usually 40+ years -tendon degeneration, rotator cuff tears, rotator cuff rupture -associated with a long history of repeated shoulder pain/dysfunction and significant muscle weakness and atrophy

Compression Fracture Etiology

-usually from osteoporosis -may be traumatic may be from prolonged steroid use, which can cause osteoporosis

Ulnar Fracture

-usually occur with radial fractures -persistent pain with rotation or WB (rule out TFCC tear)

Return to Function Phase: Shoulder Post Op

-very patient specific; based on their needs -pt has developed control of posture and basic components of functional activities without an increase in symptoms -criteria for this phase: no impingement signs, full pain free AROM with good mechanics, 4/5 or greater strength shoulder girdle m. -increase muscular strength and endurance -specificity of training (working according to goals of pt) -speed and plyometric training

Temperature and Inflammation

-warmth isn't necessarily a bad thing -be concerned if the involved limb is SIGNIFICANTLY warmer than contralateral limb (edema may be present) -note if the patient's WHOLE body is running significantly warmer (ie: fever or flu) *contact PT or MD in emergency! use judgement based on degree of temperature elevation and other symptoms (malaise, etc.) to determine if PT intervention should be continued*

Sacrum

-wedge shaped -suspended by strong ligaments -piriformis is the only major muscle that influences it

What are the benefits of Continuous Passive Motion (CPM) on ligament injuries?

-well organized and oriented collagen fibers -enhances connective tissue strength -increases joint nutrition -minimizes adhesions -decreases negative effects of immobilization *Studies showing no substantial advantage, no difference in long term outcomes*

Upper Limb Tension Test: Ulnar Nerve Bias

-wrist and finger extension -forearm pronation -elbow flexion -shoulder girdle depression -shoulder lateral rotation -shoulder abduction

Bony Landmarks

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Supracondylar Femur Fractures

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Various Tibiofemoral Fractures

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Ankle Fractures

-lateral/medial malleolus, bimalleolar, trimalleolar (bimalleolar + posterior margin of tibia) -ORIF typically needed >placed in semirigid post-op removable splint for 2 weeks; can be removed to allow for active DF and PF ROM exercises (surgeon specific, check with MD) >walking cast is applied once the pt achieves full PF and DF ROM >once cast is removed, initiate ROM exercises, isometric strengthening, stationary bike, WB ex, progress -Distal tibia compression fracture >AKA: pilon fracture >vertical load compresses tibia onto talus >ORIF or external fixation >NWB activities protected x12 weeks >after immobilization, slowly progress through NWB strengthening and ROM to resisted exercise to PWB repetitive motion activities (stationary bike)

Warm-up

-light exercise and dynamic stretching -increases blood flow and temperature -increased core body and intramuscular temperature leads to increased ROM -warmed muscle will be able to contract more forcefully and relax more quickly -increased cardiovascular response and 02 delivery to working muscles

Claw Fingers = Intrinsic Minus Hand

-loss of intrinsic muscle action and over-action of extensor muscles -*combined loss of median and ulnar nerve*

Subacromial Space/Coracoacromial Arch

-made of acromion and coracoacromial ligament overlying subacromial/subdeltoid bursae, supraspinatus tendon and muscle -humerus must ER during ABD to clear the coracoacromial arch (preventing impingement; the greater tubercle from hitting the acromion) -this area becomes compromised with rotator cuff impingement

Talocrural Joint

-made of distal tibia, distal fibula, and talus -synovial hinge joint -CONVEX talus articulates with CONCAVE distal tibia/fibula (together= ankle mortise) -dorsiflexion/plantarflexion

RX of Facet Joint Impingement

-manual or mechanical traction -mobilization techniques -treatment of muscle spasms (calm the muscles down)

Treatment Contraindications for RA

-maximum resistive exercises should not be performed -stretching should not be done (gentle ROM only) -manipulative techniques

Clinical Signs of Spondylolisthesis

-may have pain and/or neurological symptoms -s&s tend to be aggravated by extension activities (increases angle and likelihood to slip forward) -s&s aggravated by prolonged standing and walking (due to gravity on that angle) -relieved pain with lying down -may be completely asymptomatic

RX s/p Laminectomy

-may need to be seen initially for functional mobility training -patient education -posture and body mechanic training -once approved by MD, OT to restore ROM, LE flexibility (with lumbar lami's) -scar mobilization, STM -joint mobilization once approved by MD (non affected segments) -spinal ROM -UE/LE flexibility -trunk LE/UE strengthening -endurance -overall conditioning

Clinical Signs of Slipped Capital Femoral Epiphysis

-mild to moderate pain at hip and sometimes knee -may demonstrate trendelenberg gait as slippage progresses -diagnosed via xray

What is collagen?

-most abundant component of the connective tissue -properties of connective tissue are dependent on the specific types of collagen found within the matrix *fibroblasts stimulate collagen synthesis*

Shoulder Arthroplasty (TSA)

-not as common as hip/knee arthroplasty -usually release of *subscapularis tendon* (rotator cuff repair precautions) *Goals of PT:* -can begin day 1 post op -immobilize for 6 weeks -follow MD protocol -progress pt via rehab phases -do not expect full ROM (ask MD how much to expect) -functional shoulder ROM: flexion=130-140, abd= 120, ER= 60, and IR= 70 -can expect at least 4/5 mmt strength *reverse shoulder replacement: reversing the normal concavity/convexity of GH joint*

Sacroiliac Joint

-one articulation but described as two joints 1. iliosacral: inominates move on sacrum 2. sacroiliac: sacrum moves on inominates

Clinical Signs of Facet Joint Impingement

-onset begins with unusual movement -person may awaken from symptoms -lose specific motions and attempted motions induce pain ("locked back") -muscle guarding

Common causes of overuse syndromes

-overuse -abnormal foot mechanics -muscle tightness -muscle imbalances -hip and knee abnormalities -gait deviations

Stress Fractures

-overuse/unrelenting stress -S&S: >pain over affected area >increases with activity, decreases with rest -Tests: >vibration, US >Xray may not see initially; can use a bone scan -Areas at risk: >5th toe, navicular, sesamoids, intraarticular fractures

Clinical Signs of Muscle and Soft Tissue Lesions

-pain -localized swelling -tender to palpation -protective muscle guarding which further increases pain -no true neurological signs (can cause impingement= acute neuro signs) -postural strain may increase s&s -emotional stress may cause increase tension in cervical or lumbar area

S&S: Thoracic Outlet Syndrome

-pain -vascular changes, swelling -numbness, weakness *Causes of TOS:* -poor posture and postural endurance -muscle imbalances -poor clavicular and rib mobility -shallow upper chest breathing

Scaphoid Fracture

-pain and swelling in anatomical snuffbox, pain with wrist extension, decreased grip strength -proximal portion of scaphoid no direct circulation with fracture; 12-24 weeks immobilization

Clinical Signs of Spinal Stenosis

-pain in back or neck -may have radicular pain, paresthesia, weakness, impaired sensation, and diminished reflexes -s&s frequently increased with extension -often can be progressive -can cause patients to fall due to LE weakness

Clinical Signs of Osteomylitis

-pain in infected area -swelling and increased temperature -drainage or pus through the skin -foul odor if an open wound is present -general feeling of illness, nausea, etc. People with the following diagnosis are at risk: -diabetes -patients on dialysis -people with weakened immune systems -sickle cell disease -IV drug abusers -the elderly

Ligament Sprains: S&S

-pain over tissue (especially when stressed) -excessive motion or instability of joint -decreased ROM -decreased/intolerance with strength testing -edema -functional WB limitations -antalgic gait -ecchymosis (bruising, discoloration)

Overuse Syndromes: S&S

-pain with palpation over affected tissue -pain with resisted strength testing -pain with stretching involved tissues -functional WB limitations -edema

S&S: Adhesive Capsulitis

-pain, muscle guarding -capsular pattern (ER>ABD>IR>Flexion) -pain radiating below elbow, back of shoulder, and neck -poor joint mechanics and posture -restricted joint play and ROM -muscle weakness

Signs of Peripheral Arterial Disease

-pallor -decreased peripheral pulses -sensory changes -weakness of the involved area (distal to site of blocked circulation) -associated with DM and non-healing wounds

Stage 2 RC Impingement/ Tear

-patient 25 to 40 years -tendonitis, bursitis, fibrosis -irreversible (without surgical intervention) -repetitive microtrauma -supraspinatus and biceps most commonly involved

General Guidelines for PT: Maximal Protection Phase

-patient education -posture/body mechanic training (bed mobility, sitting, standing) -directional bias treatment program -walking program (might not be able to do ROM but can do functional mobility) -decrease pain (movement patterns) -initiate movement in single planes -taping/splinting/bracing -supportive modalities *functional mobility*

RX of Spondylolisthesis

-patient education to avoid progression of slippage >grade 1: patient education >grade 2: avoid ballistic lumbar extension, vertical loading while seated or standing >grade 3 and 4: may need surgical intervention -flexion and neutral bias -lumbar stabilization exercises/abdominal strengthening (to maintain better posture) -may require surgical intervention (fusion) to gain stability (for higher grades, patient with neuro issues, etc)

Treatment of Thoracic Outlet Syndrome

-patient education; modify activities -postural correction and re education -nerve tissue mobility (neural glides) -joint and tissue mobility -respiration patterns -supportive techniques

Precautions Regarding Treatment of Rheumatoid Arthritis

-patient fatigues easily -avoid stress and fatigue -be conservative during periods of exacerbation -joint capsule, ligaments, and tendons are structurally weakened by the rheumatic process and steroids -cervical spine displays ligament laxity

Leg Pull for Upslip

-patient lies prone -therapist stands at foot of table and grasps ankle -therapist extends hip 30 degrees, abducts hip 30, and internally rotates hip (closed pack position of hip) -patient holds table and breaths in/out -when patient breathing out, the therapist pulls caudally on leg -causes downward pull on innominate and not hip since hip is in closed pack position (alt position: supine with LE in ER. add cough)

Stage 1 RC Impingement/Tear

-patient usually <25 years old -edema, hemorrhage -pain is worse with ABD > 90 degrees -reversible lesion -responds to conservative PT interventions

RX of Ankylosing Spondylitis

-patients must exercise the rest of their lives -avoid flexion activities; promote extension -posture education -positioning -deep breathing exercises -extremity flexibility

Etiology of disc bulges and herniations

-poor posture -heavy lifting -trauma

What does the PCL limit?

-posterior translation of tibia on the femur -tibial varus, valgus, and ER

RX of Muscle and Soft Tissue Lesions

-postural education -body mechanic training -patient education -pain free AROM -isometrics (neutral spine) -LE flexibility -LE and progressive trunk strength -alter lifestyle to prevent re-injury

RX of Spinal Instability

-posture education -core and LE strength/stabilization -taping/splinting -surgical fusion if therapy unsuccessful

RX for Posture Syndrome

-posture education -modify sustained postures (move more) -opposite movement of spine

RX for Spinal Stenosis

-posture education to decrease pinching -overall flexibility and strengthening >patient may have impaired LE strength, so gait training, balance >training, safety education and LE strengthening may be necessary -steroid injections -may need surgery (ex: decompression laminectomy)

Clinical signs of herniation

-pressure on nerves -radiating pain, numbness, tingling, weakness *C4 to C5 and C5 to C6 are most commonly affected*

Effects of Exercise on Bone Healing

-promotes edema absorption -prevents blood clots -prevents loss of muscle elasticity -promotes formation of scar tissue -improves circulation, strength, and joint motion

Arthrokinematics of the cervical spine

1. Flexion/Extension: -upper and lower cervical work together 2. Rotation and Sidebending: -coupled movement -sidebending and rotation occur in the same direction when in neutral -sidebending to right = facets close, foraminal opening decreases -rotation to right = posterior facets glide down, closing foramina on right *if spine is flexed; rotation and sidebending occur in opposite directions*

Osteokinematics and Resultant Disc Movements

1. Flexion: - 2. Extension: - 3. Sidebending:

RX s/p Total Ankle Arthroplasty

1. Follow guidelines of protocol 2. Immobilize ankle 3. NWB>PWB>FWB 4. IP mobility 5. Isometrics of LE 6. ROM restrictions initially and should be progressed via protocol

Incomplete Fractures

1. Hairline: -not completely through bone 2. Greenstick: -bone bends and breaks like twig (peds; linear fx thru one cortical surface and flexion deformity on opposite surface 3. Buckle: -bending of the cortex on one side of bone (ped;soft bones) 4. Bowing: -multiple microfracture along length of long bone; entire bone is bent/curved

What are the phases of tissue healing?

1. Inflammatory Response: -lasts approximately 5-7 days 2. Proliferation: -5 to 7 days after initial injury -fibronectin, laminin, collagen, and GAG's are synthesized and deposited -angiogenesis occurs 3. Remodeling and Tissue Maturation: -collagen matures and is organized -extra collagen is broken down -regression of inflammatory cells *Note: stages overlap each other*

Types of Muscle Contractions

1. Isometric 2. Concentric 3. Eccentric 4. Isokinetic 5. Isotonic

Surgical Management of Patellofemoral Pain

1. Lateral Retinacular Release: -release of lateral retinaculum to improve neutral patellar tracking and reduce lateral pull -RX: RICE, temporary immobilization, NSAIDS, early knee flexion exercises to prevent scarring -may be accompanied by a repositioning of the VMO (extreme caution is needed when moving; quad strengthening is delayed 2. Distal Realignment: -reduces compression loads and subluxation at patella by removing insertion point of patellar tendon and repositioning it -RX: immobilized in a hinged range limiting brace for 4-6 weeks -isometrics and SLR once pain and swelling subside (after a few weeks healing) -progress appropriately in moderate protection phase (6 weeks post op)

How is patellar alignment maintained?

1. Laterally by the IT band and Lateral Retinaculum 2. Medially by the VMO (vastus medialis) 3. Inferiorly by the Patellar tendon 4. Superiorly by the Quadriceps tendon

Posterior cervical spine musculature

1. Levator Scapula -transverse processes of C2 to C4 to superior angle of scapula -downwardly rotates and elevates scapula 2. Trapezius -occiput and spinous process of vertebra to clavicle and spine of scapula -upwardly rotates and elevates scapula 3. Occipitals -extends the occiput

What are the osteokinematic motions of the TMJ?

1. Mandibular Depression 2. Protrusion 3. Lateral Excursion

What are the arthrokinematic motions of the TMJ?

1. Mandibular depression -posterior glide of condyle -anterior translation of the condyle 2. Protrusion -anterior translation of the condyle 3. Lateral excursion -anterior translation of the contralateral side -spin on the ipsilateral side

Upper Limb Tension Tests

1. Median 2. Radial 3. Ulnar

Surgical Procedures for Articular Cartilage Repair

1. Microfracture: -penetrate subchondral bone and expose bone marrow -stimulates a marrow-based repair response local ingrowth of cartilaginous repair 2. Chondroplasty: -damaged cartilage is removed; allowing healthy cartilage to grow it its place 3. Abrasion Arthroplasty: -high speed burrs are used to remove the damaged cartilage and reach the subchondral bone

Motions of the Sacrum

1. Nutation: sacral flexion -occurs in transverse axis 2. Counternutation: sacral extension -occurs in transverse axis 3. (L) or (R) Rotation on a vertical axis 4. (L) or (R) sidebending on a central axis 5. Movement on an oblique axis (torsions) -defined by direction of the face of the sacrum an on which axis it turns -(L) forward torsion on left axis; (R) backward torsion on left axis -(R) forward torsion on (R) axis; (L) backward torsion on right axis

Evaluation of SI Dysfunction

1. Palpate in standing 2. Palpate in supine 3. Palpate in prone -ASIS -PSIS -Ischial tuberosity -Pubic symphysis -Iliac crests -Greater trochanters -Sacrum

Fiber Types

1. Slow Twitch: -aerobic work, muscle endurance -fatigue resistant -contract slowly -efficient for prolonged aerobic events 2. Fast Twitch: -anaerobic work, speed -contract at higher speed and with greater force -larger in diameter than slow twitch -used mainly for speed, strength, and power activities

Types of balance control

1. Static: -ability to maintain stable anti gravity posture during non movement activities 2. Dynamic: -ability to maintain body mass over base of support while the body or support is in motion -response to external perturbations

Anterior cervical spine musculature

1. Sternocleidomastoid (SCM) -from mastoid process to clavical and sternum -sidebends toward origin; rotates away from origin 2. Scalenes -transverse processes of cervical vertebra to 1st and 2nd rib -sidebends cervical spine -elevates rib cage with forced inspiration

Nerves of the Knee

1. Tibial nerve 2. Common peroneal nerve (lateral fibular head) 3. Saphenous nerve: provides sensory to medial side of knee and leg; cutaneous branch of the femoral nerve *in the popliteal fossa the sciatic nerve divides into the tibial and common peroneal nerve*

Traction vs. Distraction

1. Traction applied to the shaft of the humerus results in caudal gliding of the joint surface. 2. Distraction of the glenohumeral joint requires separation at right angles to the glenoid fossa.

Complete Fractures

1. Transverse: -fracture extends horizontally through the bone 2. Oblique: -fracture crosses the bone diagonally 3. Spiral: -fracture spirals around the bone (torsional injury) 4. Comminuted: -fx with more than 2 fragments (sx repair needed) 5. Impacted: -fragments are driven into one another and remain locked 6. Avulsion: -tendon/ligament rips off a piece of bone at insertion (excessive stress on tendon/ligament)

Capsular Ligaments

1. Ulnar collateral ligament (Medial) -Anterior, posterior and transverse - Provides support against valgus stresses -*Limits end range elbow extension* -*Keeps joint surfaces approximated* -Stressed most with golfing and throwing 2. Radial collateral ligament (Lateral) -Fan shaped ligament -Provides stability against varus forces -Prevents *posterior translation of radial head*

Challenges to Balance

1. Unexpected perturbations: -open loop motor control -example: stumbling over an unseen object 2. Anticipated motor activities: -ie: climbing stairs, picking up groceries

Three systems affecting postural control and equilibrium

1. Vestibular System: -ears and eyes (gaze stabilization) -mechanoreceptors neck -postural system feedback 2. Somatosensory -primary muscle receptors -joints play role regulating muscle stiffness and tone for postural adjustments 3. Vision -orientation of the head -speed of head and surrounding objects -second fastest *Together called, "postural control system"* Sensory Organization: -damage to one area; cerebellum suppresses it -other senses can compensate for damaged system

What are some special rehab precautions with meniscal repairs?

1. WB precautions (if pt has clicking in knee with exercise or WB activities) 2. Gradually progress knee flexion 3. Limit knee flexion on stationary bike 4. WB lunges = no flexion >45 degrees x4 weeks; >60-70 degrees x8 weeks 5. No leg press x 8 weeks 6. No twisting motions with WB 7. No HS curls x8 weeks 8. No deep squatting, lunges, or pivoting x4-6 mo 9. No jogging/running x 5-6mo 10. No recreational sports or activities that involve repetitive joint compression and shear forces 11. No prolonged squatting in full flexion

RX s/p Arthrodesis

1. WB status= NWB for 6 to 8 weeks; progress to FWB in 12-16 weeks 2. Maintain ROM of uninvolved joints (be sure to protect the fusion) 3. Follow protocol closely as it is dependent on what bones were fused in surgery 4. Similar rehab goals as THA and TKA (maintain WB precautions, IP mobility, RICE

Disc Lesions Etiology

1. Wear and tear of annular fibers over time -usually caused by repeated flexion and/or rotational movements -poor circulation to the disc prevents healing of microtears -any microtears that do heal are weaker once healed 2. Degenerative Changes -nucleus becomes more fibrotic over time -less water content 3. Traumatic rupture of annular fiber

What is the anatomy of a ligament?

1. dense connective tissue Made of: -type 1 collagen -fibroblasts -extracellular matrix -various amounts of elastin 2. Hypovascular (relative uniform microvascularity at origin and insertion sites) 3. Contains mechanoreceptors and free nerve endings that contribute to proprioception and pain sensation

Causes of Patellar Tracking Dysfunction

1.) Large Q-angle 2.) Muscle/Fascial tightness 3.) Pronator forces at the foot 4.) Hip muscle weakness -Lateral dislocation prevented by: >lateral ridge of patellar groove >vastus medialis >lateral retinaculum

Arthrokinematics of the Knee

1.) Open kinetic chain -CONCAVE tibial plateau slides on CONVEX femoral condyle 2.) Closed kinetic chain -CONVEX femoral condyle slides on CONCAVE tibial plateau

Bone Healing

1.Bleeding occurs and hematoma results 2.Granulation tissue is formed by the hematoma (soft callus formation) 3.Osteoblasts produce new bone and a hard callus is formed 4.Callus is gradually reabsorbed, and the anatomical contour of the bone is regained

Discs

1. Annulus Fibrosis -made of dense layers of collagen and fibrocartilage -fiber orientation change obliquely from layer to layer to give it tensile strength to resist compression, twisting, and bending -outer fibers neurally innervated; otherwise disc is avascular and anneural -fibers of the innermost layer blend with the nucleus pulposus 2. Nucleus Pulposus: -gelatinous mass -located centrally in disc (more posterior in LS) -recieves nutrition via cartilaginous end plates -hydrophyllic (nucleus imbibes H2O when pressure is reduced on disc; water is squeezed out under compressive loads; transport for nutrients and help maintain tissue health in disc -asymmetrical loading in flexion results in distortions of nucleus toward contralateral posteriolateral corner; fibers of annulus are more stretched)

What are the ligaments that stabilize the knee?

1. Anterior Cruciate Ligament: provides anterior stability 2. Posterior Cruciate Ligament: provides posterior stability 3. Lateral Collateral Ligament: provides lateral stability 4. Medial Collateral Ligament: provides medial stability

Ligaments

1. Anterior Longitudinal Ligament -attaches to anterior vertebral bodies and discs -helps limit extension 2. Posterior Longitudinal Ligament -attaches to posterior vertebral bodies and discs -helps to limit flexion 3. Ligamentum Flavum -helps to limit flexion -forms anterior portion of facet

Motion of the Ilium

1. Anterior Rotated Innominate 2. Posterior Rotated Innominate 3. Innominate Shear or Upslip

What are the dermatomes in the knee for referred pain?

1. Anterior knee: L3 2. Posterior knee: S1 and S2

Goals for Anterior and Posterior GH Dislocations

1. Anterior: -ER at side (no greater than 10-30 degrees for 3 weeks) -Progress ER over 12 weeks (6wk= 30-45, 9wk= 45-75, 12wk= 75-90) -no ABD at 90 degrees; -no extension greater than 0 degrees -flexion, IR at side in front of trunk, -avoid mobilizing joint in anterior direction *anterior glide is contraindicated* 2. Posterior: -sling may be more uncomfortable than resting arm at side, avoid mobilizing joint in posterior direction *posterior glide is contraindicated*

Types of Surgical Approaches for THA

1. Anterior: -precautions: *limit extension, ER, or a combo of both at end range* 2. Anteriolateral: -precautions: *hip flexion >90, extension, add, ER past neutral* -step to gait pattern -if glut medius incised= no anti gravity hip AROM for 6-8 wk 3. Posteriolateral: -precautions: *hip flexion >90, IR, add past neutral* 4. Minimally Invasive: -smaller incision -less muscular damage

Displaced Fractures: 4 Sub-Classifications

1. Avulsion fracture, displaced 2. Oblique or transverse fracture 3. Comminuted fracture 4. Fracture-dislocation • RX: ORIF (80% can be removed without losing joint stability) • No flexion greater than 90 x 8 weeks • No active resistive elbow extension x 8 weeks (may begin gentle isometrics once bony union verified) • Recovery may take 6 months to 1 year

Surgical Interventions for Recurrent GH Dislocation

1. Bankart Repair= labrum is reattached to glenoid rim (may involve RC muscles) -*limit ER, Ext, and Hor ABD* 2. Capsulorrhaphy Capsular Shift= tightening of capsule with anchors, suture, tacks, and staples 3. Electrothermally Assisted Capsulorraphy= thermal energy used to shrink capsule, rarely used 4. SLAP Lesion Repair= labrum is reattached to glenoid rim (may involve biceps tendon)

Assessing Intensity

1. Borg Scale (6-20) 2. RPE (rate of perceived exertion) (1-10) 3. Talk Test

Treatment of Fractures

1. Closed Reduction -manual manipulation, usually under anesthesia -no surgery needed (fixated with casts, splints, braces, etc.) 2. ORIF: Open Reduction Internal Fixation -internally held together with screws, pins, plates, wires 3. External Fixator -external hardware to maintain proper alignment

Potential Complications of Fracture Healing

1. Compartment Syndrome 2. Fat embolism -long bones and pelvis most common -marrow migrates to the lungs and blocks pulmonary vessels 3. Displacement of fixation devices 4. Infection -locally or systemically 5. Re-fracture 6. Joint, tissue stiffness 7. Avascular necrosis (AVN) 8. Problems w/union of fractures -delayed union, nonunion, or malunion

Non-Operative Rehab of Anterior Knee Pain

1. Control pain (activity modification, RICE, NSAIDs) 2. Strengthen: -initially with sub-max quad isometrics -focus on VMO to counter lateral tracking -strengthen hip abductors, ER's, and extensors -after acute inflammation subsides; begin CKC exercises to progress functional strength 3. Manually treat lateral structures and tightness in quad and gastroc/soleus 4. Evaluate LE mechanics related to running, jumping, and cutting activities during return to function phase

Anatomy Review: Medial Meniscal Attachments

1. Coronary ligaments 2. MCL 3. Semimembranosus tendon 4. Some fibers of the ACL 5. Anterior attachment of the quadriceps mechanism

Anatomy Review: Lateral Meniscal Attachments

1. Coronary ligaments: extension of the joint capsule and attaches the menisci to the tibia 2. Popliteus Tendon: attaches to the posterior horn of the menisci 3. Anterior attachment of the quadriceps mechanism

Performing Joint Mobilization

1. Determine grade to be used 2. Position the patient 3. Joint position 4. Stabilization

Initiate & Progress Joint Mobs

1. Determine patient's ability to relax 2. ALWAYS unload the joint first (gr I-II) 3. Treat with chosen grade of motion 4. Re-assess continuously -adjust appropriately -increased pain and sensitivity = reduce amplitude -same or better = repeat same maneuver or progress 5. Re-assess the next treatment session *Warm-up exercises or heat prior to Grade III or IV may help*

Annular Tissue Breakdown

1. Fatigue Breakdown -overtime annulus breaks down due to repeated overloading of the spine -possible for self sealing of defect with nuclear gel or proliferation of cells of annulus, however repair is weaker and takes a long time to heal due to poor vascularity 2. Traumatic Rupture -common with sudden hyperflexion activities -ages= 30-45 years 3. Degenerative Changes -loss of integrity of disc from infection, disease, herniation or end plate defect -possible to have protrusions of annulus fibrosis without bulging from nucleus pressure

Myositis Ossificans

Heterotopic bone formation in the muscle-tendon unit, capsule or ligamentous structures -Bone formation is laid down in between muscle fibers -Sometimes bone can be reabsorbed after several months -Most common in *brachialis* muscle -Due to trauma, immobilization, or over aggressive stretching of elbow flexors after injury CLINICAL FINDINGS: -Extension limited > flexion -Resisted elbow flexion = pain -Flexion limited and painful when inflamed muscle is pinched -Muscle firm to touch TREATMENT GUIDELINES: *Massage, passive stretching and resistive exercises are contraindicated early after trauma* -Elbow is splinted with periodic AROM

Anterior Pelvic Tilt

Hip flexion and increased lumbar spine extension -tight: hip flexors and back extensors -lengthened and weak: abdominals and hip extensors (gluteus med and piriformis) -short TFL/IT band -limited ER due to excessive IR *LE Compensations:* -hip IR -genu valgum -tibial ER -pes planus -hallux valgus

Signs of whiplash

Hyperextension Injuries: -muscle strains -ligament sprain -intervertebral disc dysfunction -pharyngeal edema -pain in anterior neck area, shoulders, anterior chest/pecs -reduced ROM Hyperflexion Injuries: -posterior cervical muscle strain -ligamentum flavvum, posterior longitudinal ligament sprain -intervertebral discs dysfunction -pain in posterior neck area, shoulders, upper back

Concave ON Convex Surface

If a concave joint surface is moving on a convex joint surface, the roll and glide are in the SAME direction

Convex ON Concave Surface

If a convex joint surface is moving on a concave joint surface, the roll and glide are in the OPPOSITE direction

Effect of Exercise and Immobilization on Tendon Healing

Immobilization: -decreases tensile strength of the tendon -increases scar tissue -causes dehydration of tendon Exercise: -early protected motion -increases tensile strength -increases collagen fibers with better orientation and remodeling -produces greater tensile strength -prevents adhesion formation

Supination

In WB: -inversion: inward and upward, sole toward the body -adduction: toward the body -plantarflexion: toes down, flexing the lower, or plantar surface of the foot

Anteversion

Increased angle of torsion -Femoral shaft is IR (decreased ER, toed-in gait) -Could lead to *increased Q-angle from increased external tibial torsion and compensatory foot pronation* -Congenital condition

Osteomylitis

Infection of the bone Possible causes: - Open injury to the bone (i.e. compound fx) - Infection from somewhere else in the body - Minor trauma - Bacteria in the bloodstream - Chronic open wound or soft tissue infection

Peripheral Nerve Injury

Initial response to nerve trauma: -edema within the nerve fiber's connective tissue barriers -results in impaired O2 transport, nutrition, ion content of nerve cells and conductivity of the traumatized nerve fiber -nerve tissue is highly deformable with similar viscoelastic properties as other soft tissue -trauma to nerves can come from mechanical, thermal, chemical or vascular injury

Terrible Triad

Injury to MCL, ACL, and Medial mensicus occurs at same time

Progression Principle

Intensity must become progressively greater

Review of Myotomes

L1-2= hip flexion L3= knee extension L4= ankle dorsiflexion L5= 1st toe extension S1= ankle eversion, plantar flexion, hip extension S2= knee flexion S3- intrinsic foot muscles (not usually tested)

Review of Dermatomes

L1= groin L2= lateral and upper thigh L3= lateral mid, anterior lower thigh, medial knee L4= lateral knee, medial lower leg, 1st toe L5= lateral lower leg, dorsal foot, 2-4 toes, plantar 1st toe, lateral posterior leg S1= lateral foot, plantar foot 2-5, mid posterior leg S2= posterior lateral thigh S3= medial posterior thigh/posterior groin

Coxa Vara

Angle of inclination is < 125 degrees and results in a shorter leg on that side -*genu valgum* -*if present at birth; WB will aggravate condition; reduce WB loads whenever possible to prevent further degeneration* -RX: problem oriented approach due to LLD; strengthen ABD, stretch ABD -In severe cases; an osteotomy may be indicated to improve alignment

Coxa Valga

Angle of inclination is > 125 degrees and results in a long leg on that side. -*genu varum* -small amount of coxa valga at birth is normal; WB normalizes angle -RX: problem oriented approach due to LLD; strengthen ABD and stretch ADD

What are the ligaments of the hip joint?

Anterior: 1.) Iliofemoral (Y ligament of bigelow): limits extension and ER 2.) Pubofemoral: limits abduction Posterior: 3.) Ischiofemoral: limits IR and add

Herniation

Any change in shape of annulus causes to bulge beyond normal perimeter

Glenohumeral Joint Anatomy

Arthrokinematics of GH Joint: -CONVEX humeral head rolls in CONCAVE glenoid fossa *Other:* -contains glenoid labrum to increase joint congruency and depth of socket (only a small portion of humeral head contacts fossa) -open pack position= scaption (55 degrees ABD and 30 degrees horizontal ADD) -closed pack position= full ABD and ER -capsular pattern= ER>ABD>IR

Sternoclavicular Joint

Arthrokinematics of the SC Joint: -superiorly/inferiorly: convex on concave -anteriorly/posteriorly: concave on convex -open pack position = at side in anatomical position -close pack position = full elevation of arm (end ROM for posterior rotation of clavicle) -stabilized by ligaments (sternoclavicular, interclavicular, and costoclavicular)

Treatment Plane

At right angles to a line drawn from the axis of rotation to the center of the concave articulating surface

During OKC activities, when is there a significant increase in patellofemoral joint compressive forces?

Between 0-30 degrees of knee flexion

During CKC activities, when is there a significant increase in patellofemoral joint compressive forces?

Between 60-90 degrees knee flexion

Etiology of thoracic outlet syndrome

Blood vessels and nerves are compressed by structures in the thoracic outlet (first rib, scalenes, and pec minor) -poor posture -carrying heavy bag -congenital factors (ie: extra rib) -trauma -positive adson's, allen maneuver, or roos test

What is osteomalacia?

Bone softening caused by vitamin D deficiency -called "rickets" in children -defect in bone building process -poor calcium absorption leads to poor bone mineralization -results from poor Ca consumption or mal-absorption -t score = -1.1 to -2.4

Tectoral Membrane

Broad band covering dens and ligaments *continuation of the posterior longitudinal ligament*

Intercondylar "T" or "Y" Fractures

Direct trauma to elbow or fall on elbow -involve the articular surfaces of the elbow joint Type I: non-displaced fracture extends between two condyles RX: immobilization x 3 weeks, begin therapy, gently progression, defer RROM until union visualized on x-rays Type II: displaced fracture without rotation of fracture fragments Type III: displaced fracture with rotational deformation Type IV: severely comminuted fracture with significant separation between two condyles - RX: ORIF -Elderly: bag of bones technique »Placed in sling with maximal flexion, allowed to hang, hope to gain possible reduction of fracture fragments

What are the causes of fractures?

Direct trauma: fracture is sustained at the point of contact of the violent force Indirect trauma: fracture sustained at a distance from the point of contact Pathological fracture: can occur from tumors, osteoporosis, stress fractures, metabolic bone disease

Patellofemoral knee pain (chondromalacia patella)

Examine: -position of patella relative to the femur (patella alta, patella baja, tilting, gliding) -LE strength, flexibility, and static/dynamic alignment

Edema

Excessive pooling of fluid in the interstitial spaces -PTA should monitor edema with constant measurements -PTA should document all measurements and characteristics of the edema

Muscles of the Elbow & Forearm/Action

FLEXION: - Brachialis - Biceps Brachii - Pronator Teres - Flexor Carpi Ulnaris EXTENSION: - Tricps - Anconeous SUPINATION: - Supinator - Biceps Brachii PRONATION: - Pronator Quadratus - Pronator Teres - Flexor Carpi Radialis

Finger Muscles Review

Finger Extension: -extensor digitorum (radial) -extensor indicis (radial) -extensor digiti minimi (radial) Finger Flexion: -flexor digitorum superficialis and profundus (median) -lumbricals (1-2 median; 3-4 ulnar) -interossei (ulnar) -flexor digiti minimi (ulnar) Finger Abduction: -dorsal interossei (ulnar) -abductor digiti minimi (ulnar) Finger Adduction: -palmar interossei (ulnar)

Periodization of Strength Training

First Phase: -develop basic strength and muscular hypertrophy -small alterations in sets (3-6) and reps (8-12) in each week of rehab Second Phase: -enhances strength by increasing loads used (85% of 1 RM) -decreases volume of exercises to 3-5 sets of 4-6 reps *think of NASM phases*

Work

Force X Distance

Torque

Force X Perpendicular distance for axis of rotation

Pitting Edema

Forms sustained indentations when edemous areas are compressed

Lumbopelvic Rhythmn

Forward bending: 1. posterior pelvic shift 2. full trunk/lumbar flexion 3. anterior pelvic tilt (glut max and hs control) Return to standing: 1. hip extensors rotate pelvis posteriorly 2. back extensors lift trunk upright

Talus Fractures

Four Types: 1. Talar neck fracture, no displacement 2. Talar fracture with subtalar subluxation 3. Talar fracture with further subtalar subluxation 4. Talar fracture, head dislocates from navicular bone -requires 3 months of NWB -varied upon surgery type -follow MD protocol

Supracondylar Fracture: Type I vs. Type II

Fracture of the humerus just above the condyles -*TYPE I:* (most common) refers to an injury that occurs as a result of a fall on an extended, outstretched arm in which *the distal humerus fragment is displaced posteriorly* and is *maintained in that position because of the strong pull of the triceps* -*TYPE II:* Flexion injury; occurs after direct trauma to the posterior aspect of the elbow in which *the distal humeral fragment lies anterior to the humerus*

What are some exercise guidelines for improved bone density?

Frequency: 2-3x/week (every other day) Intensity: 80% of 1RM for UE's 1-3 sets of 8-12 reps 6-10 on RPE scale

Anatomy Review: Menisci

Functions: 1. Shock absorbers 2. Improves joint congruency and stability 3. Enhances joint lubrication/nutrition Lateral Meniscus: oval shaped and lies on the smaller tibial plateau Medial Meniscus: semi-lunar shaped and lies on the larger medial plateau

What is the treatment for ligament injuries?

Grade 1 and 2 Injuries: -pain and edema control -joint protection (bracing if needed) -muscle re-education -return to controlled, protective stress Grade 3: most likely will require surgery

Grades of Spondylolisthesis

Graded by amount of forward displacement of superior vertebrae over inferior vertebrae -diagnosed by xray -grade 1: 0-25% -grade 2: 25-50% -grade 3: 50-75% -grade 4: 75-100%

Anklyosing Spondylitis

Gradual ankylosing of the spine, SI joints, hips, and even costovertebral joints

Operative Management of PCL Injury

Graft options: 1.) Patellar tendon autograft 2.) HS tendon autograft 3.) Achilles allograft

Ulnar Nerve

Guyon's Canal -"bishops hand": flexion of 4th and 5th digits -sensory loss: dorsal and palmar 5th and lateral side of 4th finger -motor loss: thumb adduction, PIP and DIP extension of digits 4-5, MCP finger abduction, flexion of 5th digit Special tests: -tinel's sign

Clinical Presentation of Peripheral Artery Injury

Hard Symptoms: -Loss of pulse, pallor, paresthesias, pain, paralysis, rapidly spreading hematoma Soft signs: -Possible history of arterial bleeding, hematoma over a peripheral artery and a neurological deficit originating in a nerve adjacent to the injured artery *MONITOR!*

Brawny Edema

Hard, tough, thick, and leathery edema *commonly associated with chronic inflammatory or systemic conditions involving fluid shift abnormalities*

Laminectomy (cervical or lumbar)

Lamina is cut into gain access to a herniated disc with herniated material removed

Hip Muscle Imbalances: Unilateral Short Leg

Lateral pelvic drop on short side; side bend away Observe: -scoliosis -flat foot -genu valgum -coxa vara -tight hip muscles -anterior pelvic obliquity - posture -bone growth asymmetries

Q-Angle

Line of pull of the quadriceps versus the line of pull of the patellar tendon -10 to 15 degrees normally (women have a larger Q-angle) -Creates a lateral pull on the patella during extension -Measure: angle between line drawn from ASIS to center of patella and the line drawn from the center of the patella to the distal patellar tendon insertion at the tibial tubercle

Overload Principle

Load must exceed the metabolic capacity of the muscle

Treatment Guidelines: Overuse Syndromes

MAX PROTECTION STAGE: -Rest: RICE, splints -Supportive techniques, taping -Alter activities -Patient education: ergonomics, bracing, posture -Soft tissue/joint mobilization -Deep friction massage -Stretching -Multi-angle muscle setting -Elbow initially flexed, progress into extension -Pain free ranges, progress to provocative test position -Well joint mobility CONTROLLED MOTION STAGE: *Criteria: no signs of inflammation -Restore full ROM* -Initiate and increase strength UE -CKC UE -Initiate Functional activities RETURN TO FUNCTION STAGE: *Criteria: full pain free AROM and pain-free provocation tests* -Increase strength -Functional training and activities -Plyometrics -High speed activities -Activity modification

Achilles Tendon Rupture

MOI: landing from a jump, jumping, pushing off, r chronic irritation -may be very painful >extreme weakness at ankle but they can still actively PF (but not perform heel raises) -frequency is greater in men than women (30-50y) Conservative Rehab: -casted in PF (likely NWB) x 8 weeks -after 8 weeks, progressive rehab of stretching and strengthening -may upgrade to CAM boot and PWB -may start with heel lift and progressively decrease height Post Op Rehab: -NWB initially -progress to ankle immobilized neutral or 20 PF with AD >FWB 3-6 weeks >orthosis x 6-8 weeks for WB activities >shoes with heel lifts x next 8 weeks >caution with gastronemius/soleus group

Etiology of TMJ

Malocclussion of the teeth -decreased vertical dimension of the bite -other dental problems -faulty joint mechanics from inflammation, subluzation of the dic dislocation of the condylar head, joint contractures, or asymmetrical -forces from jaw and bite imbalances -restricted motion from periods of immobilization (after jaw fracture or surgery for other reasons) -sinus problems resulting in mouth breathing -poor cervical posture resulting in malalignment of the jaw -trauma -pregnancy (increased hormone relaxin causing joint hypermobility

Force

Mass X Acceleration (linear) Mass X Angular acceleration (acceleration)

Rehab s/p MCL Injury

Maximal Protection Phase: -crutches -hinged brace to decrease valgus/rotational forces -RICE, restore ROM, increase quadriceps tone -*Avoid: valgus stress during multiplanar SLR's* -progress to FWB in 1-2 weeks -Isolated grade I-III MCL injuries can be treated non operatively Moderate Protection Phase: -restore ROM -progress strength -continue protection of involved tissues -continue modalities for edema -progress CKC exercises from (B) to (U) and from sagittal>frontal>transverse) Return to Function Phase: can begin as early as 6 wks -running progression -plyometrics -return to sport at 8-12 weeks

Mechanical vs. Functional Instability

Mechanical instability: >ligament laxity >often need surgery to stabilize Functional instability: >decreased strength and/or proprioception >pt c/o feeling that ankle is going to give out >often from *chronic ankle sprains* and at risk for further sprains >chronic pain and swelling

What are the ligaments of the TMJ?

Medial and lateral collateral ligaments -serve as attachment sites for disc -reinforce the capsule medially and laterally

Nerve Disorders: Median Nerve

Medial nerve entrapment -*Between heads of pronator teres* (may mimic CTS) -Anterior cubital fossa: anterior elbow dislocations -Can be caused by *trauma, repetitive motion, or anatomical variation* Clinical signs: -pain with pronation and wrist flexion -weakness, parasthesia and/or pain in median nerve distribution Special tests: -Pinch test

CDC's Minimum Weekly Aerobic Exercise Guidelines for Adults

Moderate Intensity Activity: -adults/older adults/pregnant women: *2.5hrs per week* (30 minutes a day, 5 days a week) Vigorous Intensity Activity: -adults/older adults: *1.25hrs per week* -pregnant women: may continue activities if previously done prior to pregnancy Combination: -an equal amount of both is recommeneded

RX of SI Dysfunction

Muscle Energy Techniques: -uses patients muscle contraction of insertion on origin against resistance to mobilize restricted joints 1. Anterior Rotated Innominate: >use antagonist to pull innominate back (use hip ext) >causes muscle to assis with pulling pelvis back into alignment 2. Posterior Rotated Innominate: >use hip flexors to assist pulling pelvis anteriorly

Muscular Endurance Training

Muscular endurance training typically uses an ANAEROBIC energy system To increase muscular endurance: -high reps, low weight -15 reps at less than *67%* 1 RM with *1-2 min* rest between each set

Tendon Injuries

Musculotendinous injuries: muscle and tendon are injured together Tendonitis: acute injury to the tendon, associated with inflammatory response Tendinosis: degeneration to the tendon, not associated with inflammatory processes (age related changes, micro-trauma) Tenosynovitis: inflammation of tendon's synovial membrane

Spinal Stenosis

Narrowing of the spinal canal which can constrict and compress nerve roots (foraminal stenosis) and possibly the spinal cord itself (central stenosis)

Nerve Roots

Nerve root exits, disc pathology usually affects nerve root below -example: L4 nerve affected by L4/5 disc

Patellar Fractures

Non-Operative: -immobilization and WB limitations full extension x 6 weeks -ankle pumps -*no active quadriceps contraction early until sufficient bone healing* Operative: -knee immobilized in 20 degrees knee flexion -knee flexion limited to 100 degrees x 6 weeks -WBAT in immobilizer with AD -progress to FWB x 3 weeks -*gentle quadriceps exercises initiated after 1 week*

What is elastin?

Non-collagenous glycoprotein -deforms under stress and then returns to original orientation and shape *can elongate about 70% without sustaining injury*

Cartilage Repair

Non-operative Repair: -limit WB activities -reduce vertical compressive loads -CPM -modified exercise routines -oral Glucosamine and Chondroitin supplements -injection of synthetic synovial fluid Operative : 1. Debridement -microfracture: small holes through cartilage layers; induces inflammatory response 2. Osteochondral autographs (OATS procedure; bone plugs) 3. Chondrocyte implantation (2 surgeries; harvesting, cultured 16-18 wks, replace patch fibring glue and sutures)

Joint End Feels

Normal: 1. Bony 2. Capsular/Elastic resistance 3. Soft tissue approximation 4. Musculature

Facet Joint Impingement Etiology

Occurs from a sudden or unusual movement

Open (Loose) Packed Position

Open Pack Position = when there is the greatest amount of intercapsular space -any other joint position besides closed pack position Joint resting position = Joint capsule and ligaments are most relaxed, loose and allow maximal amount of joint play

Opposition Muscle Review

Opposition: -opponens pollicus (median) -flexor pollicus brevis (median) -abductor pollicus brevis (median) -opponens digiti minimi (ulnar)

What is osteoporosis?

Osteoclast activity is greater than osteoblast activity and results in decreased overall quality of bone tissue *Primary causes:* post menopause, low body weight, sedentary, smoking, bed rest, age *Secondary causes:* medical conditions, GI diseases, hyperthyroidism, chronic renal failure, excessive alcohol consumption, steroids Diagnosed radiologically (presence of cortical thinning, trabecular changes, fractures) Bone density testing: norm = >-1.0; osteoporotic = <-2.5

Lateral Epicondylitis: Conservative Rehabilitation

PHASE I: 1. Increase Flexibility 2. Decrease Inflammation 3. Promote Tissue Healing PHASE II: 1. Continue to improve flexibility 2. Increase Muscle Strength and Endurance (emphasize concentric and eccentric strengthening) 3. Increase Functional Activities and Return to Function - use counterforce brace, initiate gradual return to stressful activities, reinitiate previously painful movements, gradually PHASE III: 1. Continue to improve muscular strength and endurance (progress exercises) 2. Return to High-Level Sport Activities - diminish use of counterforce brace, equipment modificators

Rehab Protocol Following Lateral Epicondylitis Surgery

PHASE I: 1. protect surgical site - extremity positioned in sling (removed at 2-4 weeks) 2. Control Inflammation and Edema 3. Maintain ROM - gentle (pain-free) passive/active-assisted hand, wrist, elbow and active shoulder ROM PHASE II (weeks 2-4): 1. Increase ROM (progress ROM exercises) 2. Initiate Strengthening - active motion, submax isometrics, shoulder/scapular: D1/D2 PNF pattern PHASE III (weeks 5+): 1. Strengthening - PRE's (weights/TB), return to sport 8-12 weeks 2. Functional Training (modified activities) 3 Scar Formation (gentle massage to reduce)

Referred/Visceral Pain

Pain is felt in an area distant from the site of the lesion but is supplied by the same or adjacent neural segments -pain is usually well localized but with indistinct boundaries -tends to be felt deeply and radiates segmentally without crossing the midline Visceral Pain = specifically originates from a body organ

Centralization of Pain

Pain localizes to the causative factor -may indicate improvement of condition -example: decreased pain radiating down the leg; increased pain in the lower back due to herniated disc *This is the goal!*

Peripheralization of Pain

Pain moves away from causative factor and into the periphery -indicates a worsening or the progression of the condition -example: compression on spinal nerve roots

Pain During ROM and Inflammation

Pain occurs BEFORE tissue resistance: -acute inflammation Pain occurs at SAME time end ROM is reached: -sub acute inflammation Stretching sensation is felt at the end ROM: -chronic inflammation

Grade 1 AC Sprain

Partial tearing of ligaments *Signs and Symptoms:* -point tenderness at AC joint -minimal loss of function -no AC joint instability *Goals of PT:* -RICE -return to play/function 2-3 weeks

Vertebrae Continued

Pedicle: -connects vertebral body to lamina -help form intervertebral forament Lamina: -connect the pedicle to the spinous process Transverse Process and Spinous Process: -serve as ligament and muscle insertion sites

Conservative Treatment of Ankle Sprains

Phase I: -control pain and edema (RICE), e stim, toe curls, ankle pumps, cryotherapy Phase II: -pt can ambulate (PWB) with AD without pain, low level balance (avoid PF and INV), low level strengthening of hip and LE using theraband Phase III: -ambulate with FWB without pain, (U) balance training, progress from double heel raises to single heel raises, TM walking, progress to fast walking without heel lift Phase IV: -jog to run progression, shuttle runs and cutting maneuvers, sport specific training

Upper Limb Tension Test

Positive Test: if one or more of the following occurs... -symptoms are reproduced -side to side difference in elbow extension greater than 10 degrees -contralateral cervical side bending increases symptoms or ipsilateral side bending decreases symptoms

Surgical Pt Management

Pre-Op: -Patient education of surgery and anticipated therapy and recovery times -Optimal joint mobility/biomechanics -Optimal flexibility -Optimal ROM -Optimal strength -Minimal swelling, tissue adhesions Post-Op Surgical Management: -Inspection of surgical incision -Continually watch for signs and symptoms of infection/necrosis -As healing occurs, ensure optimal mobility -Monitor for signs and symptoms of vascular comprise

Treatment of Gout

Prevention: -Adequate fluid intake -Weight management/reduction -Dietary changes -Reduction in alcohol consumption -NSAIDs, corticosteroids -Medications to decrease uric acid blood levels (FYI Benemid and Anturane) *Avoid aspirin as aspirin prevents kidney excretion of uric acid* Other treatments: -Rest, ice and elevation -Assistive devices to assist with ambulation

What are the pro's and con's of ligament immobilization?

Pro's: -protects the joint -promote healing of damaged connective tissues Con's: -joint stiffness/loss of ROM -muscle atrophy -decreased afferent (sensory) neural input -articular erosion -contracture formation -adhesion formation -weakening/laxity of ligaments, cartilage, and tendons -possible loss of bone at ligament insertion site

Communication Skills

Proactive Communication: -probing questions -open ended questions will promote discussion -closed ended questions will find facts -summary statements to check understanding Goal: a balance of dominance and warmth (see Q4 model) Prompting the patient = allows the patient to decipher information; gives them the opportunity to demonstrate knowledge Cueing = giving the patient a direction

Proprioception

Proprioception is made up of position sense and kinesthesia -joint position = awareness of static position -kinesthesia (aka kinesthetic sense/kinesthetic awareness) = awareness of joint motion, deals with sensory signals from muscles, tendons, joints, and ligaments Proprioceptive system delivers input concerning: -Joint position -Joint movement -Direction -Speed and amplitude *Occurs with mechanical deformation of muscles, ligaments and joint capsule*

Nerve Disorders: Radial Nerve

Radial nerve entrapment -Passes under *extensor carpi radialis brevis* -Injury from radial head fracture -Direct trauma along lateral radius

What does Joint Mobs Address?

Restricted capsular tissue by replicating normal joint mechanics and minimizing compressive stresses on the articular cartilage in the joint -uses manual, passive, accessory joint movement -specific to articulating surfaces -uses oscillatory or sustained movement -should not be used indiscriminately -can be used in conjunction with passive stretching

Vertebral Artery

Runs along each side of the cervical spine -makes a double turn at C1 and wraps around atlas

Grade 2 AC Sprain

Rupture of AC ligaments and partial tear of coracoacromial ligaments *Signs and Symptoms:* -moderate pain -"step off deformity" -some loss of function (reduced shoulder ADD and ABD ROM) *Goals of PT:* -immobilize -modalities for pain and edema -early ROM/stability exercises -progress through general phases of rehab *avoid ligamentous stress to AC joint*

Prolapse

Rupture of nuclear material into vertebral canal 1. Extruded: nucleus extends through the annulus, beyond confines of posterior longitudinal ligament or above/below disc space, still in contact with disc 2. Free Sequestration: nucleus extends through annulus, separated from the disc and moved aways from the prolapsed area

Accessory Motion: Glide or Slide

Same point on one surface come in contact with new points on the opposing surface (tire sliding on ice) Spin: -rotation of a segment about a stationary axis -rarely occurs alone in joints, rather in conjunction with a roll or glide. -examples of spin: 1. humerus/scapula 2. femur/pelvis 3. radius/humerus

Hand Testing

Sensation: -Semmes Weinstein monofilament -two point discrimination test -stereognosis -vibration Vascular Pulses Edema: -volumeter -tape measure Nerve Innervation: -Wrinkle/Shrivel Test (fingers placed in warm water 5-20mins; *denervated fingers do not wrinkle if injury within first few months*) Functional Activities: -Doorknobs -Turning key -Pick up objects -Hold object -Open jar -Button blouse -Eating -Tie shoes -Carry items

Accessory Motions: Traction

Separation of joint surfaces •Distraction -when joint surfaces are pulled apart at right angles to the joint surface •Long axis traction -pulling on the long axis of the bone

Referred Pain

Shoulder pain may be coming from other source if it is not resolving with PT -Diaphragm= upper trapezius pain -Heart= pain in axilla, left pec, upper back, and side of neck -Gallbladder= tip of shoulder and posterior scapula

Acute Inflammation

Signs of acute inflammation persist for *4-6 days*

Trigger Points

Small, localized tender areas found within the skeletal muscles, fascia, tendons, ligaments, periosteum, and pericapsular areas -associated with musculoskeletal dysfunction such as TMJ, cervical strain, FM, myofascial pain -palpation of trigger point will result in pain directly over the affected area or cause radiation of pain

How do ligaments heal?

Sprain = injury to ligament -most common injury to joints •Healing of ligaments: -three conditions need to be present for ligaments to properly heal or remodel; 1. torn ligament ends need to be in contact with each other 2. progressive, controlled stress must be applied to healing tissue to orient scar tissue formation 3. ligament must be protected from excessive forces during remodeling phase *Note: healing is related to blood supply and degree of injury. Not all ligaments heal the same.*

Etiology of a facet joint sprain

Sprain of capsule of the posterior joint from a sudden movement or trauma

Injury to the Acromioclavicular Joint

Sprain via direct/indirect trauma -direct trauma: falling on acromion process -indirect trauma: FOOSH *Signs and Symptoms:* -point tenderness at AC joint -step off deformity (acromion sits inferior to clavicle) -pain with horizontal ADD -edema at AC joint -"piano key" sign (hypermobile clavicle at AC joint) *Test:* -Cross Over Test

Stages of Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)

Stage 1= (Acute Reversible Stage) 3wk-6mo, pain out of proportion to injury, hyperhydrosis, warmth, erythemia, rapid nail growth, edema in distal extremity Stage 2= (Dystrophic or Vasoconstriction Stage) 3-6mo, sympathetic hyperactivity, burning pain, hyperasthesia exacerbated by cold, mottling, brittle nails,osteoporosis, less reversible Stage 3: (Atrophic Stage) months-years, pain either decreasing or becoming worse, severe osteoporosis, muscle wasting and contractures *note: may have spontaneous recovery in 18-24 months*

What is TMJ disoder?

Symptoms are caused by strain to the structures around the TMJ -imbalance between head, jaw, neck, and shoulder girdle -structures potentially involved: 1. cartilage disc at the joint 2. muscles of the jaw, face, and neck 3. ligaments, blood vessels, and nerves in close proximity to the joint 4. teeth

Functional strength

ability of the neuromuscular system to produce, reduce, or control forces in a smooth coordinated manner during functional activities

Muscle endurance

ability to sustain forces repeatedly or generate forces over a period of time

Muscular power

force produced per unit time -product of strength and speed

Etiology of whiplash

hyperextension--hyperflexion--hyperextension of neck *often a component of rotation or sidebending as well* *headrest and airbag can decrease the severity of injury*

Strength

maximum force generated by a single muscle or related muscle group

Capsular Pattern of the Clavicle

pain at extreme ROM

Muscle performance

capacity of a muscle or group to generate forces

Inferior GH Instability

caused by: -inability of rotator cuff muscles to depress humeral head in glenoid fossa -hemiplegic paralysis (from CVA; gravity continually pulls inferiorly on arm) -multi directional instability

Signs of torticollis

cervical sidebending towards affected side and rotation away from affected side

Neutral Zone of Spine

several degrees between 2 vertebrae before elastic zone of tissues are reached

Facet Joint Impingements

the meniscus of the facet capsule becomes entrapped, impinged, or stressed

Radial Head Fx: Therapy Considerations

• When the radial head is excised, elbow is usually immobilized in a HINGED SPLINT to protect the healing bone and surrounding soft tissues -- protected but not completely immobilized - *Excision of radial head can lead to increased varus or valgus deformity* - Distal radioulnar pain may be reported due to added stress on ligaments During Immobilization: -RICE -Exercise hand, wrist and shoulder as allowed by MD Post Immobilization: -*Restoration of ROM is key* (pronation and supination are most affected) -Joint Mobs -RROM once pain has subsided on a radial head excision -OR- once union is secured on ORIF

Treatment Force (Hand Positions)

•As close to the opposing joint surface as possible. •The larger the contact, the more comfortable the procedure

Functional Review of Hip

•Capsular Pattern: flex>ABD>IR •Open-Packed position: 30 degrees flexion, 30 degrees ABD, slight ER •Closed packed position: end-range ext, ABD, IR •Normal ROM: -Flexion= 110-120 -Extension= 10-15 -ABD= 30-50 -ADD= 30 -IR 30-40 -ER 40-60

RX of DJD of the Hip

•Conservative management: maintain/improve ROM with exercise, joint mobs; light WB activities; maintain/ improve strength (isometrics preferred to reduce pain); decrease pain; patient education (use of AD, footwear) • Surgical management: THA

RX for Slipped Capital Femoral Epiphysis

•Conservative treatment -Ambulation with crutches, NWB •Surgical fixation -TTWB x 6 weeks

RX of THA

•Ensure no hip dislocation •Bed mobility with precautions if applicable •Prevent DVT •Early OKC program •Transfer training •Initiate ambulation with AD •Environmental barrier training ASAP •Out of hospital 1-3 days if no complications

Weight bearing s/p THA

•Follow MD orders—depending on approach, type of prosthesis and complications •Cemented-usually immediate WBAT •Non-cemented or hybrid: TTWB or PWB x 6 weeks to 3 months

Pelvic Rotation

•Forward motion of pelvis •Trunk opposite motion •Femur opposite side rotates internally

What are the grades of ligament injury?

•Grade I: (MILD) microscopic tearing of a ligament without joint laxity •Grade II: (MODERATE) tearing of ligament with moderate joint laxity •Grade III: (SEVERE) complete rupture of a ligament with severe joint laxity

Hip Orthopedic Conditions

•Joint pathologies - Osteoarthritis - RA - Aseptic necrosis - Dislocations - Congenital deformities

Acetabulum

• Acetabulum -Made up of fusion of ilium, ischium, and pubic bones -Concave fossa -Deepened by ring of fibrocartilage called acetabular labrum •Lateral portion is thicker •Central portion non articular

Olecranon Fractures

• CAUSE: Fall on the point of the elbow or a forceful contraction of triceps • CLASSIFICATION: displaced or non-displaced -RX: AROM initiated after 3 weeks *No flexion greater than 90 degrees x 6 weeks*

Joint Surgery Treatment Guidelines: Controlled Motion Phase

• CRITERIA: incisions healed, AROM pain-free - Restore full ROM (as much as possible, may need dynamic splint assistance) - Soft tissue mobilization/scar mobility - Joint mobilization • NO varus/valgus forces in terminal flexion/extension - Increase strength (OKC, CKC) - Functional activities (No holding or moving heavy objects)

General Treatment recommendations: Return to Function Phase

• Criteria: near or full AROM, strength at least 4/5, no pain/edema • CKC to WB ex if allowed • Isokinetic activities • Plyometric activities • Return to functional activities • Progressive interval program if pass strength and stability testing

General Treatment recommendations: Controlled Motion Phase

• Criteria: no swelling, minimal pain, tolerates strength testing and ROM activities • Increase to full ROM • May need dynamic brace to assist with full ROM • Progressive resistive exercises, OKC--CKC • Functional activities

Intercondylar Fx.: Therapeutic Intervention

• DURING IMMOBILIZATION: General conditioning program, but AVOIDING all stress to the affected arm - Wrist, hand, and shoulder may be exercised with AROM if prescribed by the MD • DURING EARLY POST-IMMOB. PERIOD: no passive manipulation or passive stretching can be performed (increase risk of ankylosis) - Elbow flex, ext and forearm pronation, supination as prescribed by MD - ONCE bone is secure, MD and PT may decide to implement specific joint mobs - Some ROM deficits may persist, but functional activities can be accomplished with: Elbow AROM -30-0-130 and 50 degrees pronation / supination (functional degrees for ADL's)

What is the Purpose of Joint Mobs?

• Decrease pain • Increase ROM

Pulled Elbow "Nursemaid's Elbow"

• Distal subluxation of radius; *Radial head slips out of annular ligament* • Forceful pull on hand-pick up heavy object • Common in children; lifting or jerking child by the hand with the elbow extended and forearm pronated -*When pulled by the hand, all traction forces are communicated to the radius. When pulled by the forearm, radius and ulna "share" the traction forces* •Displacement is reduced -may be followed by sling with elbow flexed and supinated

Olecranon Bursitis (Students Elbow)

• Edema in bursa along posterior elbow • Special treatment considerations: - Elbow pad with resting activities - Anti-inflammatory supportive techniques

Radial Head Fractures

• FOOSH (Fall on outstretched hand) • Fractured radial head can lead to *increased valgus deformity=GUNSTOCK DEFORMITY* - Normal carrying angle men=10, women=13 • 4 types - I: non-displaced • Rx: immobilization 1-4 weeks - II: marginal fracture with displacement • RX: ORIF or excision of radial head - III: comminuted fracture of entire radial head • Fracture area excised • May see loss of 25-30 pronation/supination if immobilized > 4 weeks - IV: any radial head fracture with elbow dislocation

Hand Function

• Gripping - Hook - Cylinder - Fist - Spherical - Testing=dynamometer • Pinching - Lateral - Tripod - Tip - Testing=pinch gauge

Ruptured Long Head of Biceps Proximal Insertion

• MECHANISM: *Due to excessive force of the biceps and progressive degeneration* • S&S: *Slight weakness* in elbow flexion (about 10% decrease in strength). Muscle belly moves distally, creating deformity. • TREATMENT: Refer to shoulder material.

Joint Surgeries

• Most common fracture: head and neck of radius-- FOOSH • ORIF • Excision of radial head—may replace with implant

Medial valgus stress overload

• Occurs to the capsuloligamentous structures • Often occur in the overhead athlete; repetitive overhead motion • CAUSE: chronic stress overload or repetitive micro- traumatic stress • Medial aspect of the elbow undergoes tremendous tensile (distraction) forces, lateral aspect is forcefully compressed - May lead to osteophyte formation, stress fractures of the olecranon or physeal injury • Clinical signs and special tests: - Pain over medial aspect of elbow, posterior olecranon - Valgus stress test - Moving valgus stress test - Milking maneuver

Joint Surgery Treatment: Protection Phase

• PT begins post up day 1-3 PROM while immobilized • Goals (follow MD orders) • Inflammation/pain control, wound care • Soft tissue mobilization • PROM/AAROM x 1-2 weeks • AROM after 2 weeks, may be in long arm splint • Well joint mobility --Initiate isometrics

Dislocations of elbow

• Posterior most common in humeroulnar joint (in hyperextension) • Mechanism of Injury: Falling on an outstretched arm with elbow hyperextension force

Pushed Elbow Syndrome

• Proximal subluxation of radius, *pushes through annular ligament*, impinges against capitulum—FOOSH (Fall on outstretched hand) • Mobilization; sustained traction to radius

Joint Surgery Treatment Guidelines: Return to Function Phase

• Return to function phase: similar to orthopedic conditions

Ruptured Biceps Tendon Distal Insertion

• Rupture of common biceps tendon near insertion on radius • MECHANISM OF INJURY: *Forceful contraction of biceps* • S&S: Weakness of elbow flexion, muscle belly of biceps moves proximally, creating deformity • TREATMENT: Surgery followed by 6-8 weeks of immobilization and progressive rehabilitation. *No heavy lifting for at least 6 months*

Nerve Disorders: Treatment

• Soft tissue/joint mobilization • Stretching • ROM • Supportive techniques • Activity alteration • *Progressive strengthening once nerve compression resolving* • If unable to resolve, may need surgical decompression

Muscle Injuries

• Strain: injury involving muscle or tendon tissue -Indirect Injury: musculotendinous junction is injured by a sudden stretch or contraction -Direct Injury: laceration, contusion, blunt trauma, etc. Injury & Healing: -muscle belly very vascular -musculotendinous junction is more vulnerable to injury *eccentric contraction more frequent cause of strain*

Hip Muscle Imbalances: Decreased Flexibility

• Tight hip flexors, extensors alter lumbar spine • Hip flexor contractures= increased stress at knee • Adductor contractures=lateral pelvic tilt opposite side of tightness, SB to tightness • Abductor contractures=lateral pelvic tilt same, SB away from tightness

Dislocations: Treatment

• Treatment - Reduction by MD - Immobilized 90 elbow flexion splint x 3-6 weeks - Hand and shoulder ROM ok if no elbow pain - NO PROM or stretching (myositis ossificans) - Caution with elbow extension (mode of injury) x 8-10 weeks - No resistance type exercises x 3 weeks • After which, focus on bicep eccentric to prevent excessive hyperextension - No aggressive elbow extension x 8-10 weeks - Flexion contracture common • Possible Complications: Volkmann's ischemic contracture, myositis ossificans, fractures (most often medial humeral epicondyle)

Reflexes of the cervical spine

C5: biceps C6: brachioradialis C7: triceps

Posterior Rotated Innominate

Can occur from: -repeated unilateral stance -fall on an ischial tuberosity -vertical thrust onto an extended leg -lifting in forward bent position with knees locked

Median Nerve

Carpal tunnel -ape hand deformity: unable to oppose or flex thumb so it falls back in line with fingers -sensory loss: fingers 1-3, medial side of 4th finger -functional loss: thumb opposition, thumb flexion, weak or no pinch, weak grip Special tests: -tinel's sign -phalen's sign -reverse phalen sign

Transfer of training

Carry over of training effect from one variation of exercise or task to another

Multi-directional GH Instability

Cause: lax CT's, trauma to capsule or ligaments, repetitive microtrauma -may cause subluxation or rotator cuff tendonitis -may cause bone spurs, tendon rupture, or capsular restrictions long term

Management of Hallux and Lesser Toe Deformities

Cause: progressive deformities, congenital, trauma, surgery, poor fitting footwear, or weak musculature *flexible deformities are correctable with conservative measures* Conservative Management: non-surgical 1. flexibility of tissues 2. alter footwear to dissipate stress 3. cortisone injections 4. modify activities to decrease stress Surgical Management: 1. NWB>PWB>CAM boot>FWB 2. PT Goals: reduce pain and edema; normalize gait pattern and ROM

Causes and Clinical Presentation of OA

Causes: - Mechanical injury - Major stress or repeated minor injuries - Poor synovial fluid movement - Joint Immobilization Clinical Observations: - Pain - Stiffness - Enlarged joints - Most commonly occurs in WB joints - Crepitus/loose bodies - Progressive weakness - Impairment of position sense

Reversibility Principle

Changes in a body's systems are transient unless training is maintained

Closed Packed Positions CPP

Closed Pack Position = when there is the least amount of intercapsular space -maximum congruency between joint surfaces -capsule and ligaments are TAUT - joint compression increases as a joint moves toward close pack position -used for testing the integrity and stability of ligaments and capsular structures

What is the MOI for an ACL Injury?

Combination of: -hip ER -valgus stress at knee -IR of tibia *can be with or without knee hyperextension while the foot is planted*

Hypertrophy

Compensatory increase in muscle fiber size due to increases in synthesis of myosin and actin -fast twitch increase more than slow twitch (ie: sprinters body type versus endurance athlete's body type)

Temporomandibular Joint

Concave mandibular fossa moves on a convex mandibular condyle -articular disc articulates with mandibular condyle and temporal bone -allows for: chewing, talking, yawning, clenching teeth, and bruxism (grinding teeth)

Anatomy Review

Consists of 3 joints: 1. Humeroradial 2. Humeroulnar 3. Proximal radioulnar

Aerobic Training

Continuous: -running, walking, etc Discontinuous: -interval training -beneficial for patients with low tolerance to exercise

General Ligament Injury: Controlled Motion/Return to Function Phase

Controlled motion phase (week 4): -Progress elbow PROM 30-100 in forearm pronation -Increase 10/week, d/c brace x 6 week -Full PROM goal 8-10 weeks -Light isometric strengthening Return to function phase (week 8) -Criteria: full PROM -Gain full AROM -Progressive resistive exercises -10 weeks: initiate aggressive strengthening, concentric, eccentric -Plyometrics -Week 16: within 15% of contralateral arm prior to returning to sports interval training

Rehab Guidelines: Controlled Motion Phase

Criteria: decreased edema, full pain free WB, ROM and resolving pain with strength testing, minimal to no edema -maximize ROM -maximize strength -resolve gait deviations -maximize flexibility entire chain -balance -functional activities -multi plane activities -environmental barrier training

Rehab Guidelines: Return to Function Phase

Criteria: full pain free ROM, good strength, balance, ambulation and environmental barrier negotiation, no gait deviations -functional training -speed drills, plyometrics -adapt return to function to prevent re injury

DJD of the HIp

"hip osteoarthritis" -deterioration of the articular cartilage of the hip -due to trauma or wear/tear -can be seen on xrays -decreased ROM

Superior Labral Anterior Posterior Lesion (SLAP lesion)

"rotator cuff tendonitis that does not get better" -caused by: repetitive OH activities (pinching microtrauma) or traumatic injury -*at biceps insertion on the superior labrum* -S&S: clicking, snapping, locking, slight GH joint instability, and pain with OH activities -difficult to diagnose (even with MRI)

Radial Nerve Disorder

"saturday night palsy" or "crutch palsy" -caused by: humeral head fracture *S&S:* -difficulty with elbow extension, wrist extension, or holding wrist at neutral -numbness, decreased sensation, tingling, or burning sensation -abnormal sensations occurring at: dorsum of hand/forearm, digits 2 and 3, and thumb side of hand -pain

Benefits of Cardiovascular Training

*-Weight reduction /control* *-Decreased risk of developing a chronic disease or reduce severity of symptoms associated with chronic disease* Other-- -Increased Mitochondria -Increased Myoglobin Content -Increase heart weight and size -Increased cardiac output and stroke volume -Improved mobilization and use of fat and carbs -Selective hypertrophy of type I slow twitch oxidative muscle fibers -Decreased resting heart rate -Decrease in adipose tissue -Increased blood volume and hemoglobin -Reduced systolic and diastolic blood pressure -Significantly improved O2 extraction rates from blood

What is the MOI for a PCL Injury?

*1.) Fall on a hyperflexed knee that results in a posterior translation of the tibia on the femur* 2.) Dashboard injury during MVA 3.) Hyperextension injuries (usually in combination with an ACL injury) -Less common than ACL injuries

S&S: Anterior GH Joint Dislocation

*Acute Presentation:* -UE in slight ABD, flattened deltoid, and prominent acromion -confirmed radiographically *Post-Reduction:* -hx of dislocation -pain, edema, reduced ROM, apprehension, excessive joint play

PT for Wrist/Hand: Return to Activity Phase

- Criteria: pain free ROM and strength testing - Higher level strength - Plyometrics - Speed drills - Full functional activity return - Reducing risk of re-injury with patient education

Clinical Presentation of Disc Lesions

*not all disc injuries are symptomatic* -pain starts when protrusion of disc applies pressure against pain sensitive structures (spinal nerve, ligaments, dura mater, blood vessels) -neurological signs: may result from pressure against spinal nerve roots or spinal cord >paresthesia or sensory loss in dermatomal pattern >muscle weakness in myotomal pattern >reduced reflexes >red flag: loss of bowel/bladder control (may indicate more spinal cord damage) -s&s may vary/shift -onset usually between 20-55 years of age -pain tends to increase with sitting, forward bending, coughing, straining, attempting to stand after being in forward flexion, and mornings tend to be worse -s&s tend to be better with walking -most common at L4-5 and L5-S1 -may see decrease in lumbar lordosis and lateral shift -anterior protrusions much less common and usually worsen with extension activities

Injury to the SC Joint

*posterior subluxation is more critical that other subluxations due to structures posterior to the clavicle* -can be sprain or dislocated -relatively rare injury -you should assess SC joint with every shoulder patient superior medial subluxation: force along the long axis of the clavicle posterior subluxation: force applied to anterior aspect of clavicle

RX for Disc Lesions

*primary goals is to centralize pain before moving into a full program (decrease radicular symptoms)* -ROM to promote centralization (traction, prone progression, positional distraction, postural education) -increase lumbar and LE flexibility -increase strength -increase cardiovascular fitness -improve posture -education on anatomy and prevention -supportive modalities for pain

Talonavicular Joint

*supported by multiple ligaments* -Spring Ligament: (plantar calcaneonavicular ligament) -Dorsal Talonavicular >from neck of talus to dorsal surface of navicular -Deltoid Ligament (anterior portion) >from tibia to navicular (anterior tibionavicular) and from tibia to talus (anterior tibiotalus)

Treatment for TMJ

*treat cause!* -patient education -cervical, thoracic spine treatment protocols -instruct patient to eat softer foods, avoid food that requires firm biting, chewing, or excessive jaw opening -stretching -joint mobilization -mouth guards, dentist referral -supportive modalities -NSAIDS, muscle relaxants -reconstructive surgery in severe cases

What are menisci?

*water, 90% type I collagen, 10% type II-IV, elastin* -found in knee, AC, SC, TMJ, and radiocarpal joint -provides structural integrity with tension and torsion activities *injury caused by: degenerative and combination of compression/ acceleration/deceleration* -healing is dependent on vascularity *peripheral borders are more vascular*

PT for Wrist/Hand: Maximal Protection Phase

- Any repair surgeries—follow MD orders closely - Well joint motion - Splinting/braces - Supportive modalities—control pain and inflammation - STM, joint mobilization - Pain free ROM - Regain normal hand arches - Multi-angle isometrics - Patient education, activity modification

Orthopedic Conditions: Rheumatoid Arthritis

-most common inflammation in MCP, PIP, and wrist joints, extrinsic tendon and sheaths -*joint capsule weakening, cartilage destruction, bone erosion, tendon rupture, instabilities, subluxations, deformities* Deformities: 1. flexion at wrist joint (volar subluxation of triquetrum on articular disc) 2. radial deviation of wrist (ulnar subluxation of carpals) 3. rupture/stretching of collateral ligaments at MCP (ulnar drift of fingers, volar subluxation of proximal phalanx) 4. swan-neck deformity (hyperextension of PIP, flexion of DIP joint; can also occur following trauma) 5. boutonniere deformity (PIP flexion, DIP extension, can also occur with trauma). Treatment: full PIP ext, MP/DIP free x 6 weeks, continued splinting x 4 weeks, AROM PIP initiated, 6-9 mo recovery 6. zig-zag deformity of thumb (metacarpal dislocation of thumb similar to finger deformities)

Inversion Ankle Sprain

-most common type of ankle sprain (85-95%) -anterior talofibular ligament is first affected and then calcaneofibular ligament -S&S: >pain at lateral aspect of the ankle >pain in WB >history of injury

Delayed Onset Muscle Soreness

-muscle soreness occurs 2-3 days post exercise -increased with eccentric exercise -theorized due to lactic acid accumulation, torn tissues, tonic muscle spasms, CT damage, and tissue fluid -RX: anti-inflammatories, e-stim, exercise, and stretching *important to differentiate between exercise induced soreness and an acute muscle strain*

Slipped Capital Femoral Epiphysis

-neck of the femur slips upward and anterior at epiphysis -epiphyseal plate is at risk of displacement before it fuses in adolescent years -can be congenital, idiopathic, or due to trauma -average age of onset 10-15 years; females > man; -body types at risk= tall, thin, and rapidly growing or short, stocky, and overweight

What are the effects of remobilization?

-negative effects of immobilization are generally reversible -ligament to bone insertion complexes tend to remodel and regain tensile strength more slowly than ligament tissue after immobilization

Oxford Program

1st set: 100% of 10RM x10 2nd set: 75% of 10RM x10 3rd set: 50% of 10RM x10 +warm up prior to program +accommodates for pt fatigue

DeLorme PRE

1st set: 50% of 10RM x10 2nd set: 75% of 10RM x10 3rd set: 100% of 10RM x10 3x10 with brief rest breaks +allows warm up of muscle +weight load increases progressively

Ligaments Continued

4. Interspinous Ligament -between the spinous processes -helps to limit flexion 5. Intertransverse Ligament -between transverse processes -helps to limit sidebending 6. Supraspinous Ligament -between tips of the spinous processes -can palpate -helps to limit flexion

Plantarflexor Muscles

>Gastroc-soleus -attach to calcaneus via achilles tendon >Posterior Tibialis (PF/INV) -helps control excessive pronation during gait >Flexor Hallucis Longus and Flexor Digitorum Longus -flexes toes and helps support the medial arch >Peroneus Longus and Brevis -everts the foot and supports the arches

Dorsiflexor Muscles

>antagonists to plantarflexion >Tibialis Anterior >Extensor Digitorum Longus >Extensor Hallicis Longus

RX for Morton's Neuroma

>metatarsal pad >change footwear to a wider, softer shoe >corticosteroid injections >AROM >surgical intervention: WBAT-FWB

What is Joint Mobilization?

A manual therapy techniques that specifically addresses altered joint mechanics -stretching alone addresses loss of flexibility in the contractile element of the muscle but does not address altered joint mechanics

PT Goals during Musculotendinous Healing

Acute Phase Goals: -facilitate healing -control pain and edema -initiate controlled movements to restore ROM (PROM; AAROM) -reduce loss of muscle strength Subacute Phase Goals: -progress toward full ROM (PROM-AROM as tolerated) -initiate muscular strengthening -continue to address residual swelling, reduce pain, and initiate functional movement tasks Chronic Stage Goals: -increasing endurance capacity of the muscle -progress strengthening as tolerated -exercise prescription should be functional in nature -once pain-free, plyometrics or power training may be initiated if functionally necessary

Treatment for cervical sprains

Acute Phase: -treat the symptoms -NSAIDS, muscle relaxants, rest, modalities for pain and edema, posture, and positioning Progress AROM, gentle isometrics, and cervical posture mechanics Gentle stretching to tight musculature Postural strengthening

Williams Flexion Exercises

A. Hooklying B. SKTC C. DKTC D. Crunches in Hooklying position E. Opposite UE to LE in hooklying position

Anterior Compartment Syndrome: S&S and Treatment

Acute: -pain -palpable swelling -paresthesias -skin warmth -shiny and tense skin -passive stretching of muscles produces severe pain Chronic: -dull, aching pain with exercise and progresses -symptoms disappear with rest -numbness on superior aspect of foot Treatment: -fasciotomy

Treatment of Plantar Fasciitis

Acute: -protection (crutches if needed, taping) -relative rest -anti inflammatory -heel lift if needed -modalities -night splint -determine and address the cause of injury Controlled Motion and Return to Function Phase: -stretch achilles -strengthen foot, anterior tibialis, posterior tibialis, muscles invovled in dynamic function -dynamic leg function -footwear/orthotics

McKenzie Prone Extension Program

A. Prone without pillow for support B. Prone with pillow under chest for mild thoracic/lumbar extension C. Prone on elbows for improved extension D. Prone with elbows extended for maximum extension

Goals of PT for Achilles Tendinitis

Acute: -relative rest -stretching achilles -temporary use of heel lift as needed -cross friction massage -anti inflammatory -achilles tendon strap -modalities for pain and swelling Controlled Motion and Return to Function Phase: -address improper mechanics -re establish normal ankle ROM -re establish normal LE strength and function -return to activities

What is the procedure for a TKA?

Degenerated articular cartilage is removed on the surface of the femur, tibia, and/or patella -not great depths of bone is removed -muscle is minimally damaged -*cemented TKA: can be WBAT immediately* -*non cemented TKA: TTWB to PWB for 4-8 weeks*

What is ground substance?

An aqueous gel component of the connective tissue -facilitates intercellular exchange of water, oxygen, and gases -gives mechanical support between tissues

Angle of Inclination

Angle between the axis of femoral neck and shaft of femur Normal angle= 125

Angle of Torsion

Angle comparing the traverse axis through the femoral condyles and the axis of the femoral neck.

Postural Equilibrium

Balancing all forces acting on body's center of mass (COM) to maintain COM within limits of stability with optimal joint segment alignment

Progressive Balance Exercises

Balance can be performed in a CLOSED environment, progressed to an OPEN environment Vary the environment: -empty, busy, bland, colorful, lighting, moving objects. -all motions can be performed in sagittal plane, frontal plane and progressed into transverse planes

Medial Ligaments of the ankle

Deltoid Ligament: -from medial malleolus to navicular, talus, and calcaneus -maintains medial stability

Cervical Anatomy

C3-C7: -facets are oriented at a 45 degree angle -superior facets face = up and back -inferior facets face = down and forward -as you move down the spine the facets orient more to the frontal plane *C7 is the most prominent spinous process*

Myotomes for the cervical spine

C1 and C2: cervical flexion C3: cervical side flexion C4: scapular elevation C5: shoulder abduction C6: elbow flexion C7: elbow extension C8: thumb extension T1: finger abduction

Dermatomes for the cervical spine

C3 and C4: -trapezius -spinal accessory nerves Other dermatomes: -C3: lower neck/upper shoulders -C4: outer shoulders -C5: lateral upper arm -C6: lateral lower arm to thumb -C7: palmar 3rd finger -C8: 4th and 5th fingers dorsal and palmar -T1: medial lower arm -T2: medial axillary upper arm -T4: nipple line -T10: umbilicus

Hyperplasia

Development of new muscle fibers or longitudinal fiber splitting may occur in response to high intensity strength training *not proven in humans*

Describe direct versus indirect ligament insertion into bone.

Direct insertion: gradual change of fibers Indirect insertion: attaches directly to the periosteum of the bone

ROM of the Clavicle

Elevation: 45 degrees Depression: 10 degrees Posterior Rotation: 40-50 degrees (with abduction or shoulder flexion)

Females and Ligament Injuries

Environmental: -knee braces/shoes Anatomical: -LE alignment Hormonal Differences: -estrogen/progesterone Biomechanical Risk Factors -dynamic body movements

Painful Hip Syndromes

Tendonitis/Muscle Strain *Adductor strain, Hamstring Strain, Quad strain are most common* Treatment: -Cold pack x 20 min 3-5x/day -Compression bandages -Protect muscle during healing—contraction or stretching -Progress

Overuse Syndromes of wrist/hand

Tenosynovitis, tendonitis, sprains Signs and symptoms: -Pain of related muscle contraction -Warmth and tenderness -Imbalance in muscle length and strength -Poor endurance in stabilizing muscles -Shoulder and elbow should also be examined

Modifications During Treatment

The PTA can modify a specific intervention in response to changes in pt condition after consulting with PT

Muscular Endurance

The ability of a muscle to perform at a particular level for a prolonged period of time

Cardiovascular endurance

The ability of one's cardiovascular system to allow the performance of prolonged aerobic activities

Spondylolisthesis Etiology

Type 1: congenital or dysplastic; malformation of neural arch/sacrum common in children Type 2: isthmic spondylolisthesis 5-50 years (mechanical stress causes stress fracture at pars interarticularis) Type 3: degenerative spondylolisthesis; common older population; normal aging process (loss of ligament integrity/stability results in forward slippage of vertebrae) Type 4: traumatic spondylolisthesis; usually younger population (trauma produces acute fracture of pars interarticularis; casting/bracing) Type 5: pathologic spondylolisthesis (bone tumors affect pars interarticularis)

Salter-Harris Fractures (spec. to peds)

Type I: S- straight across -separation of epiphysis from the metaphysis -often from a shearing force Type II: A- above epiphyseal line -same as type I but part of metaphysis produces triangular fragment -from shearing or bending forces Type III: L- lower than the epiphyseal line (goes along and below) -intra-articular -uncommon Type IV: T- through the growth plate (goes above and through the growth plate) -intra-articular, and extends through metaphysis -often in lateral epicondyle of humerus -can lead to reduction in bone growth Type V: ER- erasure (crush of growth plate) -crushing -usually in ankle or knee -can alter growth of bone

What are glycosaminoglycans? (GAG's)

Type of proteoglycan -responsible for the compressive strength of cartilage -90% are in cartilage -hydrophilic (attract and bind water) *Note: proteoglycans and collagen contribute to the strong, rigid, and flexible nature of connective tissue*

Meniscal Tears

Types of Tears: 1. Horizontal 2. Longitudinal (bucket handle) 3. Degenerative 4. Flap 5. Radial -Non contact WB injuries involved *combination of knee flexion, rotation, compression, and shear forces* -Traumatic tears are more common in youth -Degenerative tears can be subtle with no hx of sudden overt trauma (occur more frequently >40 years)

Vertebrae

Vertebral Body: -major weight bearing structure -handles compressive loading Vertebral (Posterior) Arch: -made up of pedicles, lamina, spines, articular processes, transverse processes, and facet joints -attachment site for muscles and ligaments -forms osseous ring that is the vertebral canal

Wrist Muscles Review

Wrist Extension: -extensor carpi radialis brevis and longus (radial) -extensor carpi ulnaris (radial) Wrist Flexion: -flexor carpi radialis (median) -flexor carpi ulnaris (ulnar)

Dorsal wrist and hand damage

Zones and Consequences of injury: I, II: swan neck deformity III, IV: boutonniere deformity V: MCP flexion contracture TI, TII: loss hyperextension of IP, weakened MCP TIII, TIV: flexion of MCP, hyperextension deformity of IP joint

Lacerated flexor tendons

Zones of fingers, palm, wrist and forearm and Consequences of injury: I: Flexor digitorum profundus; inability to make a full fist II (no man's land--limited blood supply): Flexor digitorum profundus, flexor digitorum superficialis, and annular pulleys; inability to flex PIP and DIP joints III: zones I and II and lumbricals; inability to flex MCP joints IV (carpal tunnel): zones I, II, III and flexor pollicis longus/brevis; inability to flex thumb and median nerve damage, adherence of adjacent tendons in carpal tunnel V (forearm): loss of wrist and digital flexion, medial and ulnar nerve damage, and arteries TI and TII: IP and MCP flexion is distrupted TIII: thenar muscle damage

Alar Ligaments

Two strong, round cords -located on each side of the upper dens to attach to occipital condyles *limit flexion and rotation*

Accessory Motions: Compression

The decrease of joint space between bony partners •In weight bearing •With muscle contraction Normal Intermittent Compressive Loads: -help move synovial fluid -maintains healthy cartilage

Convex-Concave Rule

The direction of gliding follows the Convex-Concave Rule -If a convex joint surface is moving on a concave joint surface, the roll and glide are in the OPPOSITE direction -If a concave joint surface is moving on a convex joint surface, the roll and glide are in the SAME direction *Joint mobilization techniques are directed toward influencing the gliding motion within the joint to restore normal joint play* The "grey" area of physical therapy: positional fault; joint capsule restrictions *Watch and listen to your patient regarding mobility*

Screw-home Mechanism in Closed Kinetic Chain Activities

The femur moves on the tibia. 1.) Extension -posterior roll and glide with IR during final 30 degrees of extension 2.) Flexion -anterior roll and glide with ER during initial 30 degrees of flexion

What prevents lateral dislocation of the patella?

The lateral ridge of the patellar groove, vastus medialis, and lateral retinaculum

VO2 Max

The maximum volume of oxygen consumed during exercise -an assessment of aerobic fitness -exercise intensity can be prescribed based on a percentage of this value *not typically done in a PT clinic unless equipment is available*

Accesory Movements: Arthrokinematics (Joint Play)

The motion of the joint surface within a joint when a bone moves through a ROM -motion specific to joint surfaces -necessary for normal ROM -if full accessory motion does not occur, will be limitation in normal osteokinematic plane movements -cannot be actively controlled by a patient but can passively be reproduced by another person -includes roll, spin, slide, and glide

Screw-home Mechanism in Open Kinetic Chain Activites

The tibia moves on the femur. 1.) Extension: locking of the knee -anterior roll and glide with ER during the final 30 degrees of extension (most rotation occurs during the last 5 degrees) 2.) Flexion: unlocking of the knee -posterior roll and glide with IR during the initial 30 degrees of flexion

Arthrokinematic Roll

There must be some combination of glide and roll -arthrokinematic roll always occurs in the same direction as bony movement regardless of whether the joint surface is convex or concave in shape *If excessive, can cause degeneration*

What is the effect of fractures, internal/external fixation devices, and prosthetic joint implants on bone?

They devitalize the microcirculation of the cortical, periosteal, and endosteal portion of the bone *Resultant ischemia of bone can lead to:* -nonunion -bone infections *important to keep in mind when prescribing WB activities*

Piriformis Syndrome

Tightness of the piriformis causing compression on the sciatic nerve -could be *caused by posture, lack of stretching, sitting on a wallet* Clinical findings: -tenderness to palpation of the piriformis -limited hip IR Treatment: -stretching of the piriformis -modalities, STM -patient education (avoid sitting with hip flexed >90; avoid sitting on wallet)

Roll/Slide/Spin with Convex/Concave Surface

Top: Convex on Concave Bottom: Concave on Convex

Specific Adaptations to Imposed Demands (SAID)

Training in a specific manner to produce a specific adaptation or outcome

Clavicle Fractures

Treatment: -immobilize for 4-6 weeks -possible ORIF (depending on severity) *no AROM flexion/ABD greater than 50-70 degrees for 4 weeks* Goals of PT: -maintain joint mobility -avoid stress to fx site -initiate submax isometric exercises when pain is controlled -initially use MRE then progress to active resistive exercise

Special Precautions for Joint Mobs

•Malignancy -potential for METS -fx risk •Bone disease/infection -i.e. osteoporosis, avascular necrosis -fx risk •Unhealed fracture/dislocations -must be able to stabilize the area and not stress fx while mobilizing •Excessive pain -especially if patient is unable to tolerate even Grade I -could indicate a bigger problem -could also be a malingerer •Hypermobility in associated joints -ex. hypermobility in the elbow when mobilizing shoulder •Total joint replacements -components could be self limiting -mobilizations could damage prosthesis •Pregnancy -hormones increase joint mobility and flexibility -increased risk for dislocation or injury •Newly formed connective tissue -after injury -if patient is taking corticosteroids -after injections -aggressive mobs can be destructive • Systemic connective tissue disease -i.e. RA or Lupus - connective tissue is weak and forceful techniques may rupture tissues and lead to instabilities -Hemophilia •Medications -Corticosteroids, tamoxifen -Anticoagulants

Relationship of Fragments to the Environment

•Open = Compound -breaks through the skin •Closed = Simple -does not break the skin

Dupuytren Disease

•Palpable firm nodules lie below skin of palm •Overactive fibroblasts—form cords,limiting finger extension •Most commonly affects *ulnar MCP digits* •50-70 year old European descent white male most common

Functional Immobility

•Patient cannot move joint for period of time •Paralysis or neurological injury -distraction or joint play

Lateral Pelvic Tilt

•Quadratus lumborum, reverse pull of gluteus medius •Passive support with weight shift: Y ligament lowered side and IT band elevated side •SLS: hip adduction, gluteus medius stabilized to prevent hip drop (trendelenberg)

Indications for Joint Mobs: Grade III & IV

•Reverse joint hypomobility •Positional faults -faulty tracking of one joint surface upon another •Progressive limitations: -progressive diseases not in active stage -distraction or joint play -cannot change disease processes -directed towards maintaining available joint play, minimize pain