Midterm 2 Flashcards
(20 cards)
- A person with GH instability has an excessive amount of anterior humeral translation on the glenoid. Describe an isometric resistance exercise that directly emphasizes the muscle responsible for reversing this translation.
-ISO internal rotation: Stand with arm and palm pressed against the wall with the shoulder in an adducted position. Press into the wall with the hand for 3-30 seconds at 70-75% MVC for a total volume of 80-150 seconds. The muscle preventing excessive anterior translation is the subscapularis muscle as it runs across the front of the GH joint stabilizing the humerus in place.
- Thoracic spine motion is coupled/partnered with shoulder motion. For each of the following shoulder motions, state the thoracic spine and a scapular motion that pairs with it—flexion,extension, rotation and abduction. For two of these, provide a thoracic mobility exercise to increase that motion.
FLEX:
-Scap: Posterior tilt and superior rotation
-T-spine: Extension
Foam roller thoracic extension
EXT:
-Scap: anterior tilt and inferior rotation
-T-spine: Flexion
Cat pose
ROT:
Purely a GH joint movement- but common to see compensation through the scapula and t-spine as listed below
-Scap: protraction (IR), retraction (ER)
-T-spine: Rotation
ABD:
-Scap: superior rotation
-T-spine: Lateral flexion (CL)
- For each of the following scapular positions, indicate which specific muscle(s) need to be lengthened and which need to be strengthened, to help reverse the position.
a) Anterior scapular tilt:
b) Inferiorly rotated scapula:
c) Protracted scapula:
a) Anterior scapular tilt:
Strengthen: Serratus anterior, LFT
Lengthen: Pectoralis minor
b) Inferiorly rotated scapula:
Strengthen: Serratus anterior, LFT
Lengthen: Rhomboids, Levator scapula
c) Protracted scapula:
Strengthen: Rhomboids, MFT
Lengthen: Serratus anterior, Pectoralis minor
- Explain the difference between scapular winging and excessive anterior tilt and include what you would this would look like on a patient. Which muscles are responsible for reversing a winging scapula? For each one, list two different resistance exercises you could prescribe (four exercises in total).
Scapular winging is the lift off of the medial boarder and inferior edge of the scapular from the thorax. This would present as being able to see the medial boarder and the inferior edge of the scapula which can become even more apparent during certain exercises such as a push up (requires scapular movement-PRO/RETRACT). Excessive anterior tilt occurs when the anterior portion of the scapula translates forward over the thorax. This would present as rounded shoulders, (excessive thoracic kyphosis), a forward head posture and the acromion becomes more apparent.
Muscles responsible for reversing the winging: Serratus anterior and rhomboids
-Wall angles
-Prone W’s
-Forward facing wall slides
-Scap push ups
- Describe how you would perform the hold-relax technique to increase medial rotation of the GH joint. Which shoulder injury or condition is this most likely to be associated with? If this approach was not effective, what static stretches would you try and how could you use SMR instead?
Want to target the ER since limiting MR
-Bring the ER into a stretched position (feel stretch but no pain), by bringing the arm into medial rotation
-ISO contract the ER to 10-30%MVC for 5-10sec by providing resistance on the inner portion of the arm (have them resist medial rotation).
-Bring into new MR ROM
Associated with posterior internal impingement (PII)- structures of the posterior shoulder (ie Infraspinatus and teres minor) get pinched and limit MR.
Static stretches to try:
-Modified sleeper (side lying position arm ABD and elbow flexed (supported by the table)- bring arm into MR)
-Modified cross body: side lying position arm ABD and elbow flexed (supported by the table)- guide arm into cross flexed position using the other arm.)
Both these SS target IR muscles which if excessively tight would limit MR
SMR: posterior shoulder roll with LAX ball. Stand with back to wall, cross flex arm (cross body position), place LAX ball inferior to spine of scapula and roll)- targets muscles of posterior shoulder which would limit MR if tight.
- A person with long head of bicep tendinopathy needs a static stretch and a resistance exercise to emphasize the biceps. Briefly describe two static stretches you would consider, and two resistance exercises (with different levels of difficulty).
Static Stretches:
-L wall stretch: Make an L with the hand to put arm into a pronated position. Facing a wall place the L against a wall. Turn away from the wall (chest can pop off but elbow stays planted)- elbow and shoulder extended.
-Scotch stretch: Sit on floor as if would scotch on bum. Place hands behind bum in pronated position (hands facing back). Extend elbows and shoulder by pressing the sternum forward.
Resistance exercises:
-ECC lower: Secure a band behind self. Start with arm and shoulder extended and band out in front with arm raised. Slowly lower the arm. Easy level of difficulty as it just requires the ECC postion of the movement.
-Bicep curl: Hold a pair of dumbbells 1 in each hand. Elbows extended arm supinated- quickly bring the arms up by bending at the elbows- watch for swinging/torso movement as compensation. Slowly lower the weights back down. This is more complex as it includes the CON and ECC portion of the movement.
- Describe how you would perform the hold-relax technique to reduce excessive shoulder girdle elevation. Why would a patient adopt this pattern (what are they compensating for)? Briefly describe two different resistance exercises you could use to address this.
-Want to target the UFT as they are overly active and causing this excessive elevation
-Bring UFT into a stretched position (no pain but feel stretch) by pressing down on the shoulders
-ISO contraction of UFT by having person resist against a downward force onto the shoulders of 10-30% MVC for 5-10s
-relax
-Bring into new ROM (increased depression)
-Compensating for lack of GH mobility: Lacking flexion and abduction
-Address this with
Flex: Forward facing overhead press- Staggered kneeling position, arm adducted elbow bent, straighten arm as press weight up until elbow extended and shoulder is in a flexed position prior to slowly lowering back down into the starting position.
ABD: Step on band with foot- band in CL hand. Cross flex into scapular plane (30-40deg ant of frontal plane), then abduct (only to 90 deg to keep it isolated to GH musculature) with thumb up (ER)
- List four different GH ROM exercises you could prescribe for a patient one-week post shoulder surgery—in addition to general mobility, the surgeon has asked you to include work on shoulder flexion.
-Rock the baby - focus on general ROM
-Codman’s pendulum- focus on general ROM
-Table slides (use towel to help ease movement within pain free ROM)- flexion
-dowel assisted Flexion- uses unaffected arm to help get a bit more range- flexion
- Briefly describe four exercises you could prescribe, to help a patient improve their mobility into abduction and lateral rotation—use static stretch and SMR only (two each). Which two muscles are you targeting with these exercises?
Pectoralis major and lat dorsi
-Executive stretch: sitting in chair place hands on back of head (GH and shoulder flexed arm abducted), have partner take arms and pull them further back behind the head, using their hip as an anchor point to prevent compensation through he spine (extension)
-Child’s pose with CL reach: Place hands up on an elevated surface, kneeling on the ground. Press sternum down into the ground. Reach both arms to one side to add emphasis to the contralateral lat. Add ER (thumbs up) to increase tension on lats.
-Side lying foam roller: In side lying place the foam roller under the side. Roll up and down the muscle belly of the lat starting at the anterior axillary wall (armpit) region.
-Pec LAX ball: Find a wall space, preferably by a corner and place a LAX ball on the wall. Place the muscle belly of the pectoralis major on the ball and roll over the region.
- Explain the cueing strategies you can use to help address base position for a patient with a shoulder injury. Provide three specific examples.
Verbal: use verbal description of exercise to cue the base positon. Should be specific enough that the client can visualize the exercise based on the description. Ie. “press your chest into the ground”.
Visual: give a demonstration of the desired base position. Ie doing a bicep curl to show body position to the client prior to asking them to try it themselves. Can recreate the positon that you demonstrated
Physical: Cue the base position using tactile feedback. This could be in the form of touch ie placing hand on back to cue pressing through, using al wall or lax balls to cue tactile feedback to acheive desired postion.
- Describe the pathological tissue changes associated with osteoarthritis. Include clear connections to the structure and function of articular cartilage, and a specific sign you might find on x-ray.
-Hyaline cartilage and meniscus- thinning of these structures results in decreased ability to absorb shock. Cartilage has many layers each with an important function. In OA get thinning of all these layers. Get loss of “French press” mechanism when the middle gel-like layer of cartilage would typically be pressed through the outer more porous layer of cartilage. This results in decreased cartilage health and nutrition to the cartilage.
-Subchondral bone- calcification of subchondral bone. Get bone spurs around the joint; margins get thicker and denser- visible on the X-ray (loss of nice margins)
-Synovial membrane: thicker in OA- can see this on an x-ray as loss of nice margins in the joint space.
-Synovial fluid: decreased viscosity- decreased resistance to flow and decreased lubrication.
- Full knee extension can be challenging to recover in rehabilitation—describe the complex of motions that combine to allow full knee extension to happen. Outline a progression of three resistance exercises to help a patient strengthen near full extension—briefly describe each one.
-Superior translation of the patella and external rotation of the tibia allows full extension of the knee
-SAQ Towel: short arc quad in seated position with a rolled towel under the knee joint press down into the towel to train full extension (activating the quad) this exercise is NWB and is very gentle, making it ideal for early rehab
-SAQ foam roller: SAQ movement can be progressed by integrating gravity into the movement. Place a foam roller under the femur just above the knee joimt and have the client press the knee down into extension by activating the quad. This exercise requires the cleint to fight gravity as the leg is elevated and provides a larger range available for them to work through
-TKE: terminal knee extension: a band secured in front of the cleint is looped around the back of the front knee (in split stance). Press into the band to allow the knee to go into full extension. This exercise is a progression as it integrates the WB postion and uses resistance to help cue a full extension by providing some resistance.
-Spanish squat: Band secured in front, step into band and have it looped around both knees. Press into the band as lower into a squat slowly. Come out of the squat and press the band forward as the knee drives into full extension. This exercise is a progression as it involves more joints, degrees of freedom and allows fully loading the knee through a larger ROM
- Full knee extension can be challenging to recover in knee rehabilitation—describe the complex of motions that combine to make full knee extension ROM happen. List three different mobility/ROM exercises you can use to increase this end range—one for early rehab, and two for later stages. For the two later stages, use different ROM strategies.
Superior translation of the patella and internal rotation of the tibia
-Patella translates superiorly and tibia externally rotates
-Heel prop (no overload)- NWB and relies on passive stretching
-Stationary bike (CM)- adjust seat height to accommodate available ROM
- Straight leg raise (SS)- more ROM- more advanced
- Explain the three biomechanical sources of patellofemoral joint stress that can result in overload—include the specific anatomic tissues/structures involved.
-Transverse: many forces are acting on the patella (quad tendon-lateral and medial pull from VM and VL, patellar tendon, and retinacula (medial and lateral) each pulling in a specific force vector on the patella. Uneven tension/strength throguh any of these forces can pull the patella (tracking) into an unnatural alignment and cause increased pressure points. Ie lateral tracking can result in increased compression from the lateral femoral condyle which protrudes more than in medial counterpart.
-Frontal: valgus postion (int roation of femur) results in the patella translating medially- the medial femoral condyle therefore applies a large compression force on the patella as it sticks out.
-Sagittal: The quad and patellar tendons apply a compressive force in the sagittal plane (bow and arrow), as flexion increases (deeper squat) this compressive force increases.
- What you need to be cautious of (or minimize) when choosing exercises for each of the following knee injuries/conditions: osteoarthritis of the lateral compartment of the tibiofemoral joint, PCL sprains, ACL sprains.
OA: valgus, deep flexion and sheering- lack of joint cushioing, valgus puts large compressive force on lat compot
PCL: limit hyperflexion (post transl tibia rel to femur) - ALL stress the PCL
ACL: Limit hyperextension (Ant transl tibia rel to femur), valgus, lateral rotation, - All stress the ACL
- What non-knee muscle groups are particularly important partners to consider strengthening, in a program for patellar tendinopathy? For this condition, briefly explain two knee resistance exercises that will help you focus on the target knee in a way that will optimize tendon healing.
-HIP ABD and ER; help prevent valgus position which created uneven loading through the knee
-HIP EXT; helps prevent a quad dominant approach- takes some of the load off the tendon
-PF; shock absorbtion at the ankle decreases the amount of force up the leg.
ECC step downs: Stand on elevated surface on one leg. Slowly lower down watching for caving in at the knee (valgus), until the foot touches the ground. ECC help load the tendon in a manner that helps collagen formation for tendon adaptation without overstressing it and making pain worse.
Wall squat: Stand with back against the wall and slowly lower into a squat postion keeping contact the entire time. Pause at the bottom and hold. Come out of the squat and reset to the start position. This exercise allows an emphasis on ECC and ISO portions of the squat. Loading both tendons in a way that will not overstress them but provides a stimulus for adaptation.
- Which muscle group is particularly important to train following ACL injury, and why? Briefly three resistance exercises that target this group—one for early rehabilitation for a patient who is non-weight-bearing, one for middle rehabilitation that includes an emphasis on the hip, and one for the latest stages of rehab with an emphasis on eccentric control.
Hamstrings: help prevent hyperextension which puts lots of stress on the ACL– want to prevent hyperextension therefore strengthen hamstrings
-Heel dig: lying supine with feet elevated. Stack feet one on top of the other. Press heel down into the surface to activate the hamstrings isometrically. NWV and ISO so great for early stages of recovery
-Glute bridge: Crook lying, walk feet out to emphasize hamstrings (but still get hip activation), lift hips up to form straight line knees to hips. Great for mid-stage as begins to integrate some weight and complexity.
-ECC nordic curls: kneeling on the ground with feet stabilized. Slowly lower torso to the ground keeping the hips fully extended. Have arms bent and ready to catch if needed. Watch for compensation at the hips and spine (flexion) during the movement. Complex movment therefore great for late stage.
- Hip abductor and lateral rotator strengthening may be essential in a knee rehabilitative program. Explain why and include a specific injury/condition to support your answer. Briefly describe two resistance exercises that will emphasize these muscle groups—one in weight-bearing position, one in non-weight-bearing.
-Important as they provide pelvic stability (for proper alignment) and prevent internal rotation of the femur (prevent valgus position) which results in collapsing in at the knee. This is the case for PFPS as a valgus postion results in translation of the femur and consequently the patella moving it towards the medial femoral condyle which provides large compressive forces behind the patella -resulting in pain.
-Clamshells: side lying crook position (feet aligned with hips) feet and hips stacked, resitance band around the tighs. Lift the top knee up to the top of ROM before lowering. Should have good control through the movement. Look for rolling of the hips and abd as a compensation- should be a purely hip motion (no lumbar or pelvis involvement)
-Monster walks: place a band around the ankles, soft bend/ little squat, feet shoulder width appart. Keeping tension on the band slowly walk forward. Watch for bouncing (coming out of soft knees).
- Explain the specific benefits of isometric resistance exercise in a rehabilitation program—include the specific parameters you need to include in your prescription.
-Emphasis on stability over mobility
-Emphasizes muscle activation (activates MU w/out as much muscle damage- therefore less soreness)
-Joint angle specificity- strength specific to the ROM working within
-Can work within a pain free ROM, can be modified with NWB or immobilized - great for early rehab or post-surgery
- Be the professor. Create a question you think should be on this test (and isn’t in the prep list
already).
Have a cleint that came in woth subscap sprain. What is one resistance exercise you would prescribe. What are 3 variables your could modify to increase the difficulty of the exercise.
