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Flashcards in MS Disorders Deck (156)


nonprogressive, nongenetic, congenital disorder

characterized by rigid joints of the extremities (usually symmetrical), sausage-like shapeless limbs and weak or nonfunctioning muscles

hip dislocations and contractures (flex, abd, ER), shoulder contractures (add, and IR) and club feet can result

tx: surgery, ROM, splinting, positioning, ADL training, use of ADs


complex regional pain syndrome

abnormal sympathetic reflex resulting from a persistent painful lesion

results in dysfunction of SNS to include pain, circulation and vasomotor disturbances

clinical signs: pain, edema, decreased circulation, osteoporosis, skin dryness, decreased proprioception and atrophy of muscles in close proximity to the involved area

type I: frequently triggered by tissue injury;term describes all patients with the above symptoms but no underlying nerve injury

typeII: experience the same symptoms but clearly associated with nerve injury

tx: modalities to decrease pain, joint mob, WB or closed chain exercises, massage, manual lymphatic drainage, splinting

meds: sympathetic nerve block, surgical sympathectomy, SC stimulation, intrathecal drug pumps

Tx: education for injury prevention, desensitization activities that focus on return to normal activities, flexibility exercises, TENS for pain relief


Colles' fracture

most common wrist fracture resulting from FOSH

the distal fragment of the radius has a dorsal displacement with a radial shift of the wrist and hand.

tx: casting, early AROM and PROM are essential for ultimate functional recovery, progressive resistance exercises, mobs, closed chain stabilization exercises


Degenerative joint disease (osteoarthritis)

a nonrheumatoid, nonsystemic disease

often affects WB joints by the degeneration of the articular cartilage

any stiffness may be improved with exercise

the onset is usually gradual, initially involving one or a few joints

as the disease progresses, joint motion becomes diminished, flexion contractures occur, tenderness and crepitus or grating sensations appear.

differential dx: normal ESR, abnormal joint radiographs , problems in WB joints

-functional training and education
-ROM exercises
-isometric, isotonic, isokinetic and postural exercises
-ADL training
-continue physical activity
-surgery or joint replacement
-joint protection strategies



classified as an immune system disorder of unknown origin that causes tenderness, pain and stiffness in the muscles

often relates to stress, anxiety, fatigue and sleeplessness in women>men

characterized by aching burning in the muscles, "a migraine headache of the muscles," diffuse pain, or tender points on both sides of the body

differential dx:
-widespread pain in at least 11/18 tender points
-recognition of typical pattern of non rheumatic symptoms and sleep deprivation
-exclusion of other systemic diseases

-holistic and multidisciplinary approaches are necessary
-ADL education and training
-stress managemet
-meds: analygesics and antidepressants
-local modalities and techniques for muscle pain relief
-aerobic/conditioning exercises
-improve sleeping patterns


Gout or gouty arthritis

metabolic disease marked by elevated level of serum uric acid and deposition of rate crystals in the joints, soft tissues and kidneys

most often affects the feet (* great toe, ankle and mid foot)

severe joint pain commonly at night with warmth, erythema, and extreme tenderness/hypersensitivity

-anti-inflammatory meds
-daily use of colchicine
-lowering of rate concentration in body fluids with diet, weight loss, and moderation of alcohol
-allopurinol to reduce hyperuricemia
-rest, elevation and joint protection during acute phase



hemorrhagic disorder that is hereditary

results from a deficiency of specific clotting factors

PT concerns:
-muscle bleeds: can cause pain, swelling, extreme tenderness and possibly permanent deformity. bleeding near peripheral nerves can cause peripheral neuropathies, pain, paresthesia and muscle atrophy. f bleeding impairs a major vessel, ischemia and gangrene can occur.

-ice, rest and elevation in acute phase
-chronic- joint protection, maintaining joint function, daily ROM, endurance and strength, ADL training and use of appropriate splints and AD


ITB friction syndrome

an irritation caused by the rubbing of the ITB over the lateral epicondyle of the femur

often occurs in runners from an overuse syndrome

differential dx:
- positive ober's test
-excessive hip IR in stance
-palpation over ITB insertion
- positive noble compression test

-modalities for pain and inflammation
-shoe orthosis


myositis ossificans

often caused by trauma to a muscle resulting in hematoma that may calcify or ossify - painful

can be induced by early mobilization and stretching with aggressive PT following trauma to the muscle

frequent locations: quads, brachialis, biceps

dx: radiographs will show calcium deposits

-conservative with gentle active and AA ROM
-passive stretching or manual overpressure is NOT indicated


osteochondritis dissecans

separation of the articular cartilage from the underlying bone (osteochondral fracture)

usually involving the medial femoral condyle near the intercondylar notch and humeral capitulum and observed less frequently at the femoral head and talar dome

-if displaced surgery is indicated
-gait training
-functional strengthening



decalcification of bones

results from vitamin D deficiency, which may cause deformities, fractures and severe pain

tx: pain control and functional mobility training
maintain/improve joint mechanics and CT functions
implement aerobic capacity/endurance conditioning (aquatics)

meds: calcium, vit D, vit D injections



acute or chronic bone infection

commonly the result of combined traumatic injury and acute infection

in adults, the disease commonly localizes in the pelvis and vertebrae and is usually a result of contamination related to surgery or trauma

more common in children and immunosuppresed adults

-high doses of antibiotics
-infected limb is immobilized by cast
-traction or best rest
-sometimes surgical intervention to drain infection
-chronic infection may require amputation



the most common metabolic bone disease
affects white females most commonly

depletes bone mineral density, which may predispose the individual to fracture

common sites of fracture include thoracic and lumbar spine, femoral neck, proximal humerus, proximal tibia, pelvis and distal radius

primary postmenopausal osteoporosis is directly related to a decrease in the production of estrogen

pain management
postural education
breathing exercises
general conditioning
pec stretching
WB exercises
abdominal strengthening (with caution- don't want excessive and repeated flexion of spine as can lead to wedge fractures)


Paget's disease (osteitis deformans)

a slowly progressive metabolic bone disease

characterized by an initial phase of excessive bone reabsorption followed by a reactive phase of excessive abnormal bone formation. The new bone structure is fragile and weak and causes painful deformities of the external contour and the internal structures.

abnormal osteoclastic and osteoblastic activity

Usually affects several skeletal areas- spine, pelvis, femur and skull
-can result in spinal stenosis, facet arthropathy,

involved sites can fracture easily and heal slowly and usually incompletely

vertebral collapse or vascular changes can lead to paraplegia

-if asymptomatic: no tx
-symptomatic: drug therapy for pain
joint protection, joint mechanics and CT function, aerobics- aquatic


patellofemoral dysfunction

the patella fails to track properly in the trochlear groove of the femur

instability or pain usually occurs at the first 30 deg of knee flexion

stair climbing, prolonged sitting (moviegoer's sign), squatting, or jumping may aggravate the condition

differential dx:
-Q angle >18 deg
-positive chondromalacia test: pain under patella with compression of patella and quad contraction
-abnormal tracking of patella during knee flex/ext

-McConnell's taping
-VMO strengthening
-ITB and TFL stretching
-shoe inserts to decrease genu valgum and pes planus
-on track brace to reposition patella
-transverse friction massage over lateral retinaculum
-patellar mobs: medial patellar glide and stretching deep fibers of lateral reticulum to decrease patellar tilt


patella positions

normal: patella articular surface is evenly against anterior femur

Patella baja = lower placement

Patella alta = higher placement
a "camel sign" ma be present from a high patella (one hump) and the infrapatella fat pad (second hump)
-less efficient in exerting forces for knee extension

*mob techniques:
-inferior glide for patella alta
-superior glide for patella baja


progressive systemic sclerosis (scleroderma)

a chronic disorder characterized by fibrosis and changes in the internal organs and skin

frequently, accompanied by Raynauds

polyarthralgia is a common early symptom-

heartburn and dyspnea occasionally are the first manifestations

differential dx:
-positive rheumatoid factor test
-multiple system problems in the skin, GI tract, cardiorespiratory system and kidneys

-maintain joint ROM


pronator teres syndrome

median nerve entrapment in the pronator teres muscle

pronator teres syndrome test: PT strongly resists pronation of the elbow as it extends from 90 deg flexion
+ test = tingling/paresthesia provoked in the forearm and hand in a median nerve distribution

-manual nerve glides
-NMES for nerve healing


Rheumatoid arthritis (RA)

chronic, systemic inflammatory disease

unknown etiology, although an immunological mechanism appears to play an important role

more often in women- peak onset 30-40 y/o

usually involves a symmetrical pattern of dysfunction in the synovial tissues and articular cartilage of the joints of the hands, wrists, elbow, shoulders, knees, ankles and feet

joints of the cspine are commonly involved, potentially leading to subluxation and SC compression

extra articular systems may be involved- cardiovascular, pulmonary, and GI

additional manifestations: eye lesions, infection and osteoporosis

Juvenile RA: onset prior to 16 y/o with complete remission in 75% of children. may affect any number of joints but is characterized chiefly by fever and rash.

differential dx:
- + blood test for a rheumatoid factor
-symptoms usually begin insidiously and progress slowly
-complaints of fatigue, weight loss, weakness and general diffuse MS pain are often initial presentations
-pain is localized to specific joints with symmetrical bilateral presentation
-after periods of rest, intense joint pain and stiffness can last 30 minutes to several hours with the initiation of activities
-deformities of the fingers are common and can include ulnar deviation and swan neck or boutonniere deformities
*MCP and PIP joints are mainly affected, with characteristic pannus formation (inflammatory granulation tissue that covers joint surface), ulnar drift and solar subluxation of MCP joints.

-reduce pain
-maintain mobility
-minimize joint stiffness, edema and destruction
-prevent deformities with orthoses
-patient education and continual adherence to tx program; energy conservation is stressed
-meds, rest, ADs, and ice in acute phases



unknown etiology for most cases

can also be caused by structural abnormalities (LLD or herniated lumbar disc)

structural scoliosis is an irreversible curvature with a rotational component demonstrated upon forward flexion of the spine

nonstructural scoliosis is a reversible lateral curve without rotation that straightens as the individual flexes the spine

diff dx:
-postural analysis
-forward flexion test

-structural: bracing and/or surgery for placement of Harrington rods along the spine; conservative tx for 45 deg
-nonstructural can be managed with stretching, shoe lifts and postural re-education
-respiratory care may be needed if Cobb's angle >40 deg

-flexibility, strengthening, estim to improve muscle performance, education for spinal orthoses


Sjogren's syndrome

a rheumatoid like disorder characterized by dryness of the mucous membranes, joint inflammation and anemia

more common than systemic lupus erythematous (SLE) and less common than RA

differential dx:
-dryness of the eyes and mouth along with joint inflammation
-arthritis occurs in ~33% of the patients and is similar in distribution to RA, but milder and without joint destruction

-sipping fluids t/o the day
-chewing sugarless hum
-using a mouthwash for dryness
-meds for pain and inflammation
-maintain mobility and function through a regular exercise program




an injury to a ligament or joint capsules from over stress that damages the fibers either partially or completely

1st degree: some fibers are torn; a small amount of hemorrhaging is present and joint remains stable
-prevent joint hypo mobility and disuse atrophy with movements within pain free AROM
-modalities to decrease pain, reduce edema and promote healing
-gradual return to normal functional level

2nd degree: a portion of the ligament or joint capsule is torn, moderate amount of hemorrhaging, some functional loss is present and joint stability remains intact
-guard against rein jury with limited WB and bracing as needed
-pain free AROM and joint mob should be integrated into the treatment, which includes physical agents to reduce pain and edema

3rd degree: complete disruption or avulsion of the ligament or joint capsule with loss of function, joint instability and pronounced hemorrhaging and swelling in the area. WB is undesirable
-After 2-3 weeks, the joint has usually healed (is pain free and has normal mobility) and strengthening exercises are used to reduce chance of re-injury
-may require surgical repair to avoid permanent joint instability
-bracing or splinting used to immobilize the joint and allow healing
-proprioception exercises and controlled motion exercises followed by gradual return to functional activities
-strength and mobility exercises used to complete rehab process- can take up to 5-6 months following

differential dx:
-joint palpation
-joint stability tests specific for injured area
-amount of swelling and ecchymosis
-functional/strength tests


systemic lupus erythematosus (SLE)

a chronic, systemic, rheumatic, inflammatory disorder of the CTs

affects multiple organs including skin, joints, kidneys, heart, blood-forming organ, nervous system, and serous membrane. also may affect membranes lining the walls of the body cavities and enclosing contained organs.

unknown etiology

differential dx:
-symptoms include malaise, overwhelming fatigue, arthralgia, fever, arthritis, skin rashes (butterfly rash over nose and cheeks), photosensitivity, anemia, hair loss, raynaud's, kidney involvement
-other skin manifestations can indicate vasculitis, resulting in lesions in the digits, necrotic leg ulcers, or digital gangrene

-topical corticosteroid creams for skin lesions
-patient education for energy conservation, good nutrition, and skin care
-ergonomic and postural training


TMJ syndromes

dysfunctions of this joint can be divided into 3 diagnostic categories
1- joint abnormalities that result from trauma, arthritis, disease or neoplasm
2- congenital structural defects. may include- meniscus, ligaments that control movement of the disc, the condyles, the fossa or the articular tubercles
3- loss of functional mobility of unknown etiology. may result from increased activity in the muscles of mastication as the result of stress and anxiety

differential dx: exam for joint noise, joint locking, AROM of the jaw, lateral deviation of the mandible during depression or elevation, decreased strength, tinnitus, headaches, FHP, and pain with movement


1-Synovitis and capsulitis:
-pain located in pre auricular (anterior to ear) area
-unable to fully close back teeth together
-opening 40 mm and deviates toward the noninvolved side

3-Disc displacement with reduction
-patient reports joint noises with opening and closing equal to "pops" or "clicks"
-palpation over lateral poles reveals an opening click (the reduction of the disc) and a closing click (the disc displacing anterior to the condyle). these noises = the "reciprocal click"

4- disc displacement without reduction
-patient reports intermittent locking without joint noises
-opening of mandible is limited to 20-25mm with deflection toward involved side
-limited lateral excursion toward the opposite side of the involved joint

-postural re-ed
-modalities for pain
-inflammation reduction
-joint mob
-AROM and muscle strengthening exercises
-patient education for eating soft foods and decreasing habits that stress TMG (biting nails or pencils)
-instruct patient in maintaining the rest position of the tongue (upright postural position of the tongue on the hard palate


tibial fracture

-march fractures of the inferior 1/3 of the tibia, common in persons who take long walks when they aren't used to this activity
-spiral factures occur at the junction of the middle and inferior thirds resulting from severe tibial torsion during skiing
-compound fractures can occur from a direct blow to the tibia

*most common long bone to be fractured and suffer compound injury

- possible ORIF with hardware
-poor blood supply- even stable fractures may take up to 6 months to heal
-after healing is complete, early AROM and PROM are essential for ultimate functional recovery.
-progressive resistance exercises, mobs and closed chain stabilization exercises are needed to complete the rehab process


torticollis (wryneck)

occurs when the SCM continuously contracts (spasm and/or tightness). Results in the lateral bending of the head to the affected side with rotation of the chin to the opposite side

usually develops in utero and is considered congenital. May also be acquired by pressure on the spinal accessory nerve, inflammation of the glands of the neck or muscle spasm

-modalities to reduce spasm
-postural education and training


Total hip replacement precautions

avoid excessive hip flexion and adduction past neutral

avoid ER with an ant/lat approach and IR with a post/lat approach

avoid low chairs and crossing involved leg

WB orders and precautions determined by surgeon
-cemented,- exercise and WB usually can proceed more rapidly than if cements

sleep with abduction pillow and avoid vigorous stretching

need to increase extensor and abductor strength for efficient gait pattern


Rheumatoid conditions

ankylosing spondylitis


psoriatic arthritis



ankylosing spondylitis

"Marie-Strumpell disease, Bechterew's disease, rheumatoid spondylitis"

progressive inflammatory disorder of unknown etiology that initially affects the axial skeleton

initial onset (usually mid and LBP >3 months) before 40 y/o

1st symptoms include back pain, morning stiffness and sacroiilitis

results in kyphotic deformity of the cervical and thoracic spine and a decrease in lumbar lordosis

degeneration of peripheral and costovertebral joints may be observed in advanced stages

affects men 3x more than women



genetic disorder of purine metabolism, characterized by elevated serum uric acid (hyperuricemia). Uric acid changes into crystals and deposits into peripheral joints and other tissues (kidneys).

most frequently at knee and great toe

dx tests identify monosodium rate crystals in synovial fluid and/or CT samples


psoriatic arthritis

chronic, erosive inflammatory disorder of unknown etiology, associated with psoriasis

erosive degeneration usually occurs in joints of digits as well as axial skeleton


coxa vara

femoral neck shaft angled inward


coxa valga

femoral neck shaft angled outward
>125 deg
(normal 115-125)

may result from necrosis of femoral head occurring with septic arthritis


femoral antetorsion/anteversion

femoral neck angles anteriorly 10-15 deg from frontal plane to form anterior anteversion angle

excessive anteversion >25-30 deg
femoral neck rotated forward --> execessive IR "toe in"


femoral retroversion

femoral neck angles anteriorly 10-15 deg from frontal plane to form anterior ante version angle

excessive retroversion= excessive ER "toe out"


Internal tibial torsion:

distal aspect of tibia rotated or twisted medially as compared to its proximal end


Genu varum

knees are lateral in relation to the ankle


Genu valgum

knees come together or almost touch
"knock kneed"


Talipes Equinus

DF limitation, the toe is in a down position


Talipes Calcaneous

the heel down position
PF is limited


talipes equinovarus

ankle and foot are down and in "club foot"


Pes cavus

high arched or supinated foot


Pes planus

low arched foot, pronated "flat foot"


valgus heel

the rearfoot is deviated toward the outside resulting in a pronated heel


hallux valgus

the 1st MT has an abduction deformity "bunion"


osteogenesis imperfecta

inherited disorder transmitted by an autosomal dominant gene

characterized by abnormal collagen synthesis, leading to an imbalance between bone deposition and reabsorption

cortical and cancellous bones become very thin, leading to fractures and deformity of WB bones

tx: bone/joint protection, joint mechanics and CT functions, aerobic apacity/endurance- aquatics


osteochondritis dissecans

a separation of articular cartilage from underlying bone (osteochondral fracture)

usually involves medial femoral condyle near intercondylar notch or humeral capitulum; less observed at femoral head and talar dome.

surgical intervention if fracture is displaced

tx: joint/bone protection, flexibility exercises, aerobic endurance, strengthing


myofascial pain syndrome

"trigger point" = focal point of irritability within a muscle

=taut, palpable band within a muscle

Active: tender to palpation and have a characteristic referral pattern of pain when provoked

Latent: palpable taut bands that are not tender but can be converted into an active TP

onset: sudden overload, overstretching and/or repetitive/sustained muscle activities

tx: flexibility exercises, manual therapy (STM, joint mobs), spray and stretch, dry needling, hot, cold, TENS, desensitization with manual pressure, strengthening



common tendon dysfunction whose cause and pathogenesis are poorly understood
-often referred to as tendonitis although no inflammatory response noted

histological characeristics: hypercellularity, hypervascularity, no indication of inflammatory infiltrates, and poor organization and loosening of collagen fibrils

meds: acetaminophen, NSAIDS, steroid injection

tx: flexibility, manual therapy (STM, joint mobs), endurance, strengthening with emphasis on eccentrics, aerobic capacity, thermal agents for pain, education



inflammation of ursa secondary to overuse, trauma, gout or infection

S&S: pain with rest, limited A&P ROM due to pain but not in capsular pattern

meds: acetaminophen, NSAIDS, steroid injection

tx: flexibility, manual therapy, aerobic capacity, thermal agents, education


muscle strains

inflammatory response within a muscle following a traumatic event that caused micro tearing of the musculotendinous fibers

pain and tenderness

meds: acetometophen and NSAIDs

tx: flexibility, manual therapy, aerobics, thermal agents for pain, education


List of shoulder conditions

glenohumeral subluxation and dislocation


labral tears

thoracic outlet syndrome

acromioclavicular and sternoclavicular joint disorders

subacromial/subdeltoid bursitis

rotator cuff tendonosis/tendonopathy

internal (posterior) impingement

bicipital tenonosis/tendonopathy

proximal humeral fractures

adhesive capsulitis


glenohumeral subluxation and dislocations

95% occur in anterior-inferior direction
-occurs when abducted UE is forcefully ER, causing tearing of inferior GH ligament, anterior capsule and occasionally gleaned labrum

posterior dislocations are rare- occur with multidirectional laxity of GH joint
-occurs with horizontal adduction and IR

complications include:
-compression fracture of posterior humeral head- Hill sachs lesion
-tearing of superior gleaned labrum from anterior to posterior- SLAP lesion
-avulsion of anterior inferior capsule and ligaments associated with glenoid rim- Bankart's lesion
-bruising of axillary nerve

following surgical repair avoid apprehension position


shoulder instability

1- traumatic- common in young throwing athletes

2- atraumatic- congenitally loose CT

characterized by popping/clicking and repeated dislocation/sublux of GHJ

unstable injuries require surgery to reattach the labrum to glenoid (bankart)

-restore function without pain
-functional training- restore strength, endurance, coordination, flexibility
-joint mobs
-surgery- sling 3-4 weeks, after 6 weeks more specific training; full fitness 3-4 months


GH labral tears

classified as superior, inferior, SLAP or bankart
-SLAP- tear of the rim above the middle of the socket that may also involve the biceps tendon
-Bankart- tear of the rim below the middle, also involves the inferior GH ligament

-shoulder pain can't be localized to a specific point
-pain made worse by OH activities when arm is behind the back
-pain on resisted flexion of biceps
-tenderness over front of shoulder

unstable injuries require surgery to reattach labrum to glenoid; bankart requires sx

dx: exam, MRI or arthroscopic surgery (gold standard)

-return of function without pain
-functional training- strength, endurance, coordination, flexibility
-underlying causes addressed- instability
-joint mobs
-following surgery: sling 3-4 weeks, after 6 weeks more sports specific training, full fitness 3-4 months


Thoracic outlet syndrome

compression of neuromuscular bundle (brachial plexus, subclavian A and V, vagus and phrenic nerves and the sympathetic trunk) in thoracic outlet between bony and soft tissue structures

common areas of compression:
-superior TO
-scalene triangle
-between clavicle and 1st rib
-between pec minor and thoracic wall

surgery may be performed to remove a cervical rib or release ant/middle scalene

special tests: adson's, roos, wright, costoclavicular

-depends on cause of compression
-postural re-ed
-functional training
-correct biomechanical faults
-manipulations- 1st rib to diminsh pain and soft tissue guarding


acromioclavicular and sternocalvicular joint disorders

MOI: fall onto shoulder with UE adducted or collision with another individual during sport

3 grades

UE is positioned in neutral with use of sling in acute phase to avoid shoulder elevation

surgery is rare due to tendency of AC joint degeneration following repair

-return of function without pain
-functional training
-manual therapy to AC and SC joints and surrounding tissues : STM, joint mobs


rotator cuff tendonosis/tendonopathy

tendons of RC are susceptible to tendonitis, due to relatively poor blood supply near insertion of muscles

results from mechanical impingement of the distal attachment of the RC on the anterior accordion and/or coracoacromial ligament with repetitive OH activities

special tests: supraspinatus test, Neer's impingement test


Impingement syndrome- shoulder

characterized by soft tissue inflammation of the shoulder from impingement against the accordion with repetitive OH AROM

special tests: Neer's impingement, supraspinatus, drop arm

surgical repair: avoid shoulder elevation >90

-restore posture
-correct muscle imbalances and biomechanical faults


Internal (posterior) impingement -shoulder

characterized by an irritation between the RC and greater tuberosity or posterior glenoid and labrum

OH athletes

special tests: posterior internal impingement test


Bicipital tendonosis/tendonopathy

most commonly an inflammation of the long head of biceps

results from mechanical impingement of proximal tendon, between anterior accordion and bicipital groove of humerus

special test: speed's test


proximal humeral fractures

Humeral neck fractures:
frequently occur with a fall onto outstretched UE among older osteoporotic women. Generally doesn't require immobilization or surgical repair; fairly stable fracture

Greater tuberosity fractures
more common in middle aged and elder adults. usually related to a fall onto the shoulder, doesn't require immobilization

-early PROM important in preventing capsular adhesions
-functional training without pain


Adhesive capsulitis

"frozen shoulder"

characterized by a restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule, usually due to disuse following injury or repetitive micro trauma

restriction follows capsular pattern of limitation:
-greatest limitation in ER, following by abduction and flexion and least restricted in IR

commonly seen in associated with DM

-return of function w/out pain
-functional training
-biomechanical faults


List of elbow conditions

elbow contractures

lateral epicondylosis/epicondylopathy
"tennis elbow"

medial epicondylosis/epicondyylopathy
"golfer's elbow"

Distal humeral fractures

osteochondrosis of humeral capitulum

Ulnar collateral ligament injury

Nerve entrapments

elbow dislocations


elbow contractures

loss of motion in capsular pattern (flexion>extension)

los of motion in non capsular pattern as the result of a loose body in the joint, ligamentous sprain, and/or complex regional pain syndrome

-joint mobs
-STM, modalities, flexibility, functional exercises


lateral epicondylosis/epicondylopathy

"tennis elbow"

most often a chronic degenerative condition of the ECRB tendon at its proximal attachment to the lateral epicondyle of the humerus

gradual onset, usually the result of sports or occupations that require repetitive wrist extension or strong grip without the wrist extended- overloading the ECRB

special tests: lateral epicondylitis test

-correct muscle imbalances & biomechanical faults
-endurance and strengthening with emphasis on eccentrics
-prevention education
-thermal agents and TENS


medial epicondylosis/epicondylopathy

"golfer's elbow"

usually a degenerative condition of the pronator teres and FCR tendons at their attachment to the medial epicondyle of the humerus

occurs with overuse in sports- baseball, pitching, golf swings, swimming or occupations that require a strong hand grip and excessive pronation of the forearm

special tests: medial epicondylitis test

-correct muscle imbalances & biomechanical faults
-endurance and strengthening with emphasis on eccentrics
-prevention education
-thermal agents and TENS


distal humeral fractures

complications can include: loss of motion, myositis ossificans, malalignment, neurovascular compromise, ligamentous injury and CRPS

supracondylar fractures:
-must be examined quickly for neuromuscular status due to high # of neurological (typically radial nerve involvement) and vascular structures that pass through this region (may lead to Volkmann's ischemia).
-in youth- important to assess growth plate as well
-high incidence of melanin

Lateral epicondyle fractures:
-fairly common in young people and typically require ORIF to ensure absolute alignment

-pain reduction and limiting inflammatory response following trauma/surgery
-improve flexibility of shortened structures, strengthening and training to restore functional use of UE


osteochondrosis of humeral capitulum

osteochondritis dissecans affects central and/or lateral aspect of capitulum or radial head. An osteochondral bone fragment becomes detached from articular surface, forming a loose body in the joint.

Caused by repetitive compressive forces between radial head and humeral capitulum.

occurs in adolescents 12-15 y/o

Panner's disease= a localized avascular necrosis of capitulum leading to loss of subchondral bone, with fissuring and softening of articular surfaces of radiocapitellar joint. children >10 y/o

-rest with avoidance of throwing or UE loading activities (gymnastics)
-when painfree, initiate flexibility and strengthening/endurance/coordination exercises
-during late phases of rehab: program to slowly increase load on joint is initiated. If symptoms persist, surgical intervention is necessary
-after surgery: initial focus of rehab is to minimize pain and swelling using modalities. Flexibility exercises begun immediately after surgery. progressive strengthening.
-biomechanical faults- joint mobs


Ulnar collateral ligament injuries- elbow

occurs as a result of repetitive values stresses to medial elbow with OH throwing

clinical signs: pain along medial elbow at distal insertion of ligament. In some cases- paresthesias in ulnar nerve distribution with + Tinel's sign

special tests: MCL instability test

-initially rest and pain management
-after resolution of pain and inflammation- strengthening exercises that focus on elbow flexors are initiated. Taping can also be used for protection during return to activities.


Nerve entrapments- elbow

Ulnar nerve
Radial nerve
Median nerve

-neurontin for neuropathic pain

-early intervention: rest, avoiding exacerbating activities, NSAIDs, modalities and STM to reduce inflammation and pain
-if abnormal neurotension is present, neurodynamic mobs may be indicated
-protective padding and night splints to maintain slackened position of involved nerves
-with reduction in pain and paresthesias- rehab program should focus on strengthening, endurance, coordination exercise of involved muscles to achieve muscle balance, normal flexibility of shortened structures and normalizations of strength, etc.
-functional training, patient education and self management techniques


Ulnar nerve entrapment

Various cases:
-direct trauma at cubital tunnel
-traction due to laxity at medial aspect of elbow
-compression due to a thickened retinaculum or hypertrophy of FCU
-recurrent subluxation or dislocation
-DJD that affects cubital tunnel

Clinical findings:
-medial elbow pain
-paresthesias in ulnar distribution
-positive Tinel's sign


Median nerve entrapment

occurs within pronator teres muscle and under superficial head of FDS with repetitive gripping activities required in occupations (electricians) and with leisure time activities (tennis)

Clinical signs
-aching pain with weakness of forearm muscles
-positive Tinel's sign with paresthesias in median nerve distribution


Radial nerve entrapment

entrapment of distal braces (posterior interosseous nerve) occurs within radial tunnel (radial tunnel syndrome) as result of OH activities and throwing

Clinical signs:
-lateral elbow pain that can be confused with lateral epicondylitis
-pain over supinator muscle
-paresthesias in a radial nerve distribution
-Tinel's sign may be positive


elbow dislocations

posterior dislocations account for most elbow dislocations
-defined by position of olecranon relative to humerus
-posterolateral dislocations are most common and occur as the result of elbow hyperextension from a fall on outstretched UE
-frequently cause avulsion fractures of medial epicondyle secondary to traction pull of MCL

anterior and radial head dislocations account for only 1-2%

with a complete dislocation, UCL will rupture, with possible rupture of anterior capsule, RCL, brachialis muscle, and/or wrist flexor and extensor muscles

Clinical signs:
-rapid swelling
-severe pain at elbow
-deformity with the olecranon pushed posteriorly

-initial intervention: reduction of dislocation
-once stable, there is an initial phase of immobilization, followed by rehab focusing on regaining flexibility within limits of stability and strengthening
-surgery indicated if unstable dislocation


List of wrist and hand conditions

carpal tunnel syndrome

De Quervain's tenosynovitis

Colles' fracture

Smith's fracture

Scaphoid fracture

Dupuytren's contracture

Boutonniere deformity

Swan neck deformity

Ape hand deformity

Mallet finger

Gamekeeper's thumb

Boxer's fracture


Carpal tunnel syndrome

"repetitive stress syndrome"

compression of median nerve at the carpal tunnel due to inflammation of the flexor tendons and/or median nerve

commonly occurs as result of repetitive wrist motions or gripping, with pregnancy, diabetes and RA

must rule out potential of cervical spine dysfunction, TOS, or peripheral nerve entrapment that mimics condition

Common clinical findings:
-exacerbation of burning, tingling, pins and needles and numbness into medial nerve distribution at night
-positive Tinel's sign and/or Phalen's test
-long term compression causes atrophy and weakness of thinner muscles and lateral two lumbricals

--correct biomechanical faults
-STM, modalities, flexibility, functional exercises


De Quervain's tenosynovitis

inflammation of extensor policies brevis and abductor pollicis longus tendons at first dorsal compartment

results from repetitive micro trauma or as a complication of swelling during pregnancy

clinical signs:
-pain at anatomical snuffbox
-decreased grip and pinch strength
-positive Finkelstein's test - places tendons on stretch

-correct biomechanical faults
-STM, modalities, flexibility, functional exercises


Colles' fracture

most common wrist fracture


immobilized for 5-8 weeks

characteristive "dinner fork" deformity of wrist and hand results from dorsal or posterior displacement of distal fragment of radius, with a radial shift of wrist and hand

-median nerve compression can occur with excessive edema
-loss of motion
-decreased grip strength
-carpal tunnel syndrome

-early PT focuses on normalizing flexibility is paramount to functional recovery of wrist and hand
-correct biomechanical faults
-STM, modalities, flexibility, functional exercises


Smith's fracture

similar to Colles' except distal fragment if radius dislocates in a polar direction, causing a characteristic "garden spade" deformity

results from a fall onto a flexed wrist


scaphoid fracture

results from FOSH in a younger person
most commonly fractured carpal bone.

because of poor vascular supply to this bone, there is high risk of avascular necrosis of proximal fragment of the scaphoid

-immobilized 4-8 weeks
-early maintenance of AROM of the distal and proximal joints while the UE is casted
-later tx emphasis is on regaining full functional use of the wrist and hand


Dupuytren's contracture

observed as banding on palm and digit flexion contracture of palmar fascia that adheres to skin


contracture usually affects the MCP and PIP joints of digits 4 and 5 in non diabetic individuals and digits 3&4 most often in people with diabetes

-flexibility exercises to prevent further contracture and splint fabrication/application
-once contracture is under control, promote restoration of normal hand function through functional exercises
-PT after surgery includes wound management, edema control and progression of functional exercise


Boutonniere deformity

results from rupture of central tendon slip of extensor hood

observed deformity is extension of MCP and DIP with flexion of PIP

commonly occurs following trauma, or in RA with degeneration of central extensor tendon

-edema management
-flexibility exercises
-functional strengthening


Swan neck deformity

results from contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons

observed deformity is flexion of MCP and DIP with extension of PIP

commonly occurs following trauma or with RA following degeneration of lateral extensor tendons

-edema management
-flexibility exercises
-functional strengthening


Ape hand deformity

observed as thenar muscle wasting, with 1st digit moving dorsally until it is in line with 2nd digit

unable to flex digits 1-3, and oppose thumb

results from median nerve dysfunction

-edema management
-flexibility exercises
-functional strengthening


mallet finger

rupture of avulsion of extensor tendon at its insertion into distal phalanx of digit

observed deformity is flexion of DIP

-edema management
-flexibility exercises
-functional strengthening


Gamekeeper's thumb

a sprain/rupture of UCL of MCP joint of thumb resulting in medial instability

frequently occurs during a fall while skiing, when increasing forces are placed on the thumb through ski pole

immobilized 6 weeks

-edema management
-flexibility exercises
-functional strengthening


Boxer's fracture

fracture of the 5th metacarpal

frequently sustained during a fight, or punching a wall

casted 2-4 weeks

-edema management
-flexibility exercises
-functional strengthening when flexibility is restored


List of hip conditions

avascular necrosis of the hip (osteonecrosis)

Legg calve perches disease (osteochondrosis)

slipped capital femoral epiphysis

femoral anteversion

coxa vara or valga

trochanteric bursitis

ITB tightness/friction disorder

piriformis syndrome


avascular necrosis of the hip (osteonecrosis)

impaired blood supply to femoral head

hip ROM is decreased in flexion, IR and abduction

-pain in the groin and/or thigh
-tenderness with palpation at hip joint
-coxalgic gait

-corticosteroids contraindicated since that may be causative factor- if already taking, decrease dosage needed

- joint/bone protection strategies
-maintain/improve joint mechanics
-implement aerobic capacity/endurance (aquatics)
-postsurgical intervention includes regaining functional flexibility, improving strength/endurance/coordination and gait training


Legg-Calve-Perthes disease (osteochondrosis)

age of onset: 2-13 y/o (average=6)
males 4x> females

characteristic psoatic limb due to weakness of posts major; affected LE moves in ER, flexion and adduction

gradual onset of "Aching" pain at high, thigh and knee

AROM limited in abduction and extension

Dx: MRI;
-positive bony crescent sign (collapse of subchondral bone at femoral neck/head)

-joint/bone protection strategies
-maintain/improve joint mechanics and CT functions
-implement aerobic capacity/endurance
-postsurgical interventions: regain functional flexibility, improve strength/endurance


slipped capital femoral epiphysis

most common hip disorder observed in adolescents
unknown etiology

onset in males: 10-17 y/o (avg=13)
onset in females: 8-15 y/o (avg=11)
males 2x >females

AROM is restricted in abduction, flexion and IR

patient describes pain as vague at knee, thigh and hip

chronic conditions- patient may demo Trendelenburg gait

dx: plain film shows a + displacement of upper femoral epiphysis

- joint/bone protection strategies
-maintain/improve joint mechanics
-implement aerobic capacity/endurance (aquatics)
-postsurgical intervention includes regaining functional flexibility, improving strength/endurance/coordination and gait training


trochanteric bursitis

an inflammation of deep trochanteric bursa from a direct blow, irritation by ITB and biomechanical/gait abnormalities causing repetitive micro trauma

common in patients with RA

differentiate from contractile condition by comparing A&P ROM and resistive tests


ITB tightness/friction disorder

tight ITB/abnormal gait patterns

results in inflammation of trochanteric bursa

Special tests:
-noble compression test is positive when friction is introduced over the lateral femoral condyle during knee extension
-Ober's test

-reduce pain and inflammation with modalities, STM and manual therapy
-correct muscle imbalance and biomechanical faults
-flexibility: ITB, hamstrings, quads, and hip flexors
-joints mobs
-gait training and patient education regarding running shoes and surfaces, orthoses


piriformis syndrome

piriformis: ER of the hip- can become overworked with excessive pronation of the foot, causing abnormal femoral IR. considered a tonic muscle that is active with motion of SI joint, particularly sacrum.

tightness or spasm of performs muscle can result in sciatic nerve compression and/or SI dysfunction

-restriction in IR
-pain with performs palpation
-referral of pain to posterior thigh
-weakness in ER, positive piriformis test
-uneven sacral base

perform LE biomechanical exam to determine if abnormal biomechanics are the cause. must rule out involvement of lumbar spine and/or SIJ

-reduce pain- modalities, STM
-joint oscillations to hip or pelvis to inhibit pain
-correct muscle imbalances and biomechanical faults
-restore muscle balance and patient education to protect SIJ (not to step off curb onto bad LE)


List of knee conditions

Ligament sprains

meniscal injuries

abnormal patella positions
-lateral tracking

patellofemoral pain syndrome (PFPS)

patellar tenonosis/tendonopathy
"jumper's knee"

pes anserine bursitis

Osgood-Schlatter disease

Genu varum and valgum

knee joint fractures
-femoral condyle
-tibial plateau
-epiphyseal plate


Knee ligament sprains

injury to the ligaments may result in a single plain or rotary instability

ant, post, med, lat, ant/med, ant/lat, post/med, post/lat

"Unhappy triad" includes injury to MCL, ACL and medial meniscus-- results from a combo of valgum, flexion and ER forces applied to knee when the foot is planted

MRI difficult to visualize complete ACL; often misdiagnosed

reconstruction frequently involves combo of intra-articular and extra-articular procedures

Special tests:
-ACL: lachman's, pivot shift,
-PCL: posterior sag, posterior drawer, reverse lachman's

-varied based on need for surgery
-reduce pain and inflammation- modalities, STM, oscillations
-post-op: CPM to maintain flexibility
-correct muscle imbalances and biomechanical faults, joint mobs
-progress to functional training

ACL rehab:
-immediately following surgery a CPM is used with PROM 0-70 flexion; increased to 120 by week 6
-protected with a hinge brace set at 20-70 flexion initially; weaned from brace weeks 2-4
-NWB ~1 week

PCL rehab:
-same as ACL except hinge brace at 0 during ambulation

6 phases of rehab: preoperative, max protection, controlled motion, moderate protection, min protection and return to activity

-STM to quads and hamstrings to reduce guarding
-joint oscillations to inhibit joint pain and muscle guarding
-correct muscle imbalances
-joint mobs
-progress to functional training


classification of ligament injury

1st degree: little or no instability

2nd degree: minimal-moderate instability

3rd degree: extreme instability


Meniscal injuries

result from a combo of forces to include tibiofemoral joint flexion, compression and rotation, which places abnormal sear stresses on the meniscus

-lateral and/pr medial joint pain
-effusion (swelling w/in a joint)
-joint popping
-knee giving way
-loss of ROM
-joint locking

special tests:
-mcmurrary's, apleys

-reduce pain and inflammation
-correct muscle imbalances and biomechanical faults
-progress to functional training

Partial meniscectomy: PWB as tolerated when full knee ext is obtained
-initial focus on edema/effusion control
-AROM urged surgical day 1
-isotonic and isokinetic strengthening by day 3
-jogging on ball of the foot or ties is recommended to decrease loading of knee joint

Meniscal repair:
-NWB 3-6 weeks
-rehab beings 7-10 days


abnormal patella positions

Patella alta:
-patella tracks superiorly in femoral intercondylar notch
-may result in chronic patellar subluxation
-positive camel back sign (2 bumps over anterior knee region instead of 1- patella superiorly and tibial tuberosity)

Patella baja:
-patella tracks inferiorly in femoral intercondylar notch
-results in restricted knee extension with abnormal cartilaginous wearing, resulting in DJD

Lateral patellar tracking:
-could result if there is an increase in Q angle with a tendency for lateral subluxation or dislocation

-regain functional strength of structures surrounding knee, particularly VMO, regain normal flexibility of ITB and hamstrings, orthoses (if appropriate) and patellar bracing/taping

lateral reticular release to restore tacking of patella during contraction of quads
PT: emphasize closed chain exercise to strengthen quads and regain dynamic balance of all structures surrounding knee; normalize flexibility of hamstrings, triceps sure and ITB ; mob patella to maintain nutrition and decreased adhesion


Patellofemoral pain syndrome (PFPS)

common dysfunction that may occur on its own or in conjunction with other entities. May have been caused by trauma or by congenital/developmental dysfunction

may be interrelated with chondromalacia patellae and/or patella tendonitis

common result is an abnormal patellofemoral tracking leading to abnormal patellofemoral stress

occasionally, surgery is indicated

-patellofemoral (McConnell) taping is helpful to inhibit pain during rehab
-patella mobs
-correct muscle imbalances and biomechnaical faults


patellar tendonosis/tendonopathy

"Jumper's knee"

degenerative condition of the patellar tendon, typically of the deep aspect

may be related to overload and/or jumping related activities

may also be interrelated to patellofemoral dysfunction



Pes anserine bursitis

typically caused by overuse or a contusion

must be differentiated from tendonitis


PT: general bursitis treatment


Osgood-Schlatter disease

mechanical dysfunction resulting in traction apophysitis of the tibial tubercle at the patellar tendon insertion

often surgery
*early flexibility is important in preventing

-modify activities to prevent excessive stress to irritated site


Genu varum and valgum

normal tibiofemoral shaft angle= 6 deg of valgum

Genu varum= excessive medial tibial torsion
-results in excessive medial patellar positioning and the pigeon-toed orientation of the feet

Genu valgum= excessive lateral tibial torsion
"knock knees"
-results in excessive lateral patellar positioning

PT: decreased loading of knee while maintaining strength and endurance


Femoral condyle fractures

medial femoral most often involved d/t anatomical design

numerous etiology factors: trauma, shearing, impacting, and avulsion forces

common MOI = fall with knee subjected to a shearing force


tibial plateau fractures

common MOI= combo of valgum and compression forces to knee when flexed

occurs in conjunction with MCL injury


epiphyseal plate fractures

MOI frequently WB torsional stress

presents more frequently in adolescents where an ACL injury would occur in an adult


Patella fractures

common MOI- direct blow to patella due to fall


List of conditions to the lower leg

Anterior compartment syndrome (ACS)

anterior tibial periostitis (shin splints)

medial tibial stress syndrome

stress fractures


Anterior compartment syndrome (ACS)

increased compartmental pressure resulting in a local ischemic condition
-resulting from direct trauma, fracture, overuse, and/or muscle hypertrophy

symptoms of chronic or exertion compartment syndrome are produced by exercise or exertion and described as a "deep, cramping feeling"

symptoms of acute ACS are produced by sudden trauma causing swelling within the compartment
* considered a medical emergency and requires immediate surgical intervention with fasciotomy


Anterior tibial periostitis

"shin splints"

musculotendinous overuse condition

3 common etiologies:
1-abnormal biomechanical alignment
2-poor conditioning
3-improper training methods

muscles involved: anterior tibialis and extensor hallucis longus

pain elicited with palpation of lateral tibia and anterior compartment

-correct muscle imbalances and biomechanical faults
-flexibility for anterior compartment muscles as well as triceps surae


medial tibial stress syndrome

overuse injury of the posterior tibias and/or the medial soleus, resulting in periosteal inflammation at the muscular attachments

thought to result from excess pronation

pain elicited with palpation of the distal posteromedial border of the tibia

-correct muscle imbalances and biomechanical faults
-flexibility exercises for anterior compartment muscles as well as triceps sure to gain restoration of normal function


lower leg stress fractures

overuse injury resulting most often in micro fracture of the tibia or fibula

49% involve tibia, 10% involve fibula

common etiologies:
1-abnormal biomechanical alignment,
2- poor conditioning
3-improper training methods

-correct muscle imbalances and biomechanical faults
-flexibility exercises for anterior compartment muscles as well as triceps sure to gain restoration of normal function


List of foot and ankle conditions

Ligament sprains

Achilles' tendonosis/tendonopathy

fractures of the foot/ankle

Tarsal tunnel syndrome

flexor hallucis tendonopathy

pes cavus -"hollow foot"

pes planas -"flat foot"

talipes equinovarus - "clubfoot"


hallux valgus


metatarsus adductus

Charcot-Marie-Tooth disease

Plantar fasciitis

forefoot/rearfoot deformities


ligament sprains- foot and ankle

95% of all ankle sprains involve lateral ligaments
-foot is PF and inverted at time of injury

instability evaluated with anterior drawer and talar tilt special tests

-varied depending whether surgery is needed
-reduce pain and inflammation
-correct muscle imbalances and biomechanical faults
-progress to functional training


Ankle ligament sprain grading

Grade I:
-no loss of function
-minimal tearing of ant talofibular ligament

Grade II:
-some loss of function
-partial disruption of anterior talofibular and calcaneofibular ligaments

Grade III:
-complete loss of function
-complete tearing of the anterior talofibular and calcaneofibular ligaments and partial tear of posterior talofibular ligament


Achilles' tendonosis/tendonopathy

degenerative condition

special test: Thompson's test


general tx for tendonopathy


fractures of foot and ankle

trimalleolar: medial, lateral and posterior tubercle of distal tibia

concern for growth plate fractures

-return of function w/out pain
-functional training and restoration of muscle imbalances
-early PROM to prevent capsular adhesions


tarsal tunnel syndrome

entrapment of the posterior tibial nerve or one of its branches within the tarsal tunnel

excessive pronation, overuse problems resulting in tendonitis of the long flexor and posterior tibialis tendon, and trauma may compromise space in the tunnel

special test: Tinel's

-orthoses to maintain neutral alignment
-if abnormal neurotension is present, neurodynamic mobilization may be indicated


flexor hallucis tendonopathy

identified as tendonitis in the acute stage, or can present as chronic

commonly seen in ballet performers



Pes cavus

"hollow foot"

results from:
-neurological disorders resulting in muscle imbalances and contracture of soft tissues

deformity observed includes:
-an increased height of longitudinal arches
-dropping of anterior arch
-MT heads lower than handoff
-plantar flexion
-splaying of forefoot and claw toes

function is limited due to altered arthrokinematics, reducing ability to absorb forces through foot

PT education: limit high impact sports, use of proper footwear and fitting orthoses


Pes planus

"flat foot"

etiologies: genetics, muscle weakness, ligamentous laxity, paralysis, excessive pronation, trauma or disease (RA)

normal in infant and toddlers

deformity observed: reduction in height of medial longitudinal arch

decreased ability of foot to provide a rigid lever for push off due to altered arthrokinematics

PT education: proper footwear, orthoses


Talipes equinovarus


1-postural- results from intrauterine malposition
2- talipes equinovarus is an abnormal development of the head and neck of the talus, due to heredity or neuromuscular disorders (myelomeningocele)

deformity observed:
- postural: PF, adducted, inverted foot
- TE: 3 components- PF at talocrural joint; inversion at subtler, talocalcaneal, talonavicular and calcaneocuboid joints; and supination at mid tarsal joints

-manipulation followed by casting or splinting for postural condition
-TW requires surgery to correct deformity followed by casting/splinting


talipes equinus

etiology: congenital bone deformity, neurological disorders (CP, contracture of calf, trauma, or inflammatory disease)

deformity observed: PF foot

compensation secondary to limited DR includes subtler or mid tarsal pronation

PT: flexibility, joint mobs, strengthening to foot muscles and orthotic mgmt


hallux valgus

-biomechanical malalignment (excessive pronation)
-ligamentous laxity
-weak muscles
-tight footwear

deformity observed:
-medial deviation of 1st MT head
-MT and base of proximal phalanx move medially
-distal phalanx then moves laterally

normal MTP angle= 8-20 deg

-early orthotic fitting and patient education
-lateral management- surgery followed by flexibility and strengthening



-mechanical: tight triceps sure group and/or achilles tendon, collapse of transverse arch, short 1st ray, pronation of forefoot
-structural changes in transverse arch, possibly leading to vascular and/or neural compromise in tissues of forefoot

complaint frequently heard is pain at 1st and 2nd MT heads after long periods of WB

-correct biomechanical abnormalities- improve flexibility of triceps surae, modalities to decrease pain
-footwear education


metatarsus adductus

etiology: congenital, muscle imbalance, or neuromuscular diseases (polio)

1- rigid: results in a medial subluxation of tarsometatarsal joints. Hindfoot is slightly in values with navicular lateral to head of talus.
2- flexible: observed as adduction of all 5 MT at the tarsometatarsal joints.

-strengthening and regaining proper alignment of foot, orthoses


Charcot-Marie-Tooth disease

peroneal muscular atrophy that affects motor and sensory nerves

child or adulthood

initially affects muscles in lower leg and foot, but eventually progresses to muscles of hands and forearm

slowly progressive disorder with varying degrees of involvement, depending on degree of genetic dominance

neurontin for neuropathic pain

-no specific tx to prevent, inherited disorder
-intervention centers on preventing contractures/skin breakdown and maximizing patient's functional capacity to perform activities
-education/training for braces and ADs


plantar fasciitis

mechanical etiology:
-chornic irritation of plantar fascia from excessive pronation
-limited ROM of 1st MTP and talocrural joint
-tight triceps surae
-acute injury from excessive loading of foot
-rigid caves foot

results in microtears at attachment of plantar fascia

differentiate from tarsal tunnel by (-) tinel's

-regain proper mechanical alignment
-modalities for pain and inflammation
-flexibility of plantar fascia for pes cavus foot
-careful flexibility for triceps sure
-joint mobs
-night splints
-strengthen inverters
-patient education of footwear and orthotic fitting


Rearfoot varus

-abnormal mechanical alignment of tibia
-shortened rearfoot soft tissues
-malunion of calcaneus

deformity observed: rigid inversion of calcaneus (medial side elevated) when subtalar joint is neutral

compensated-subtalar pronation

-regain alignment
-improve flexibility
-orthotics and footwear


Rearfoot valgus

-abnormal mechanical alignment of the knee (genu valgum) or tibial valgus

deformity observed: eversion of calcaneus with a neutral subtalar joint

due to increased mobility of hindfoot, fewer MS problems develop from this than with rearfoot varus

-regain alignment
-improve flexibility
-orthotics and footwear


forefoot varus

-congenital abnormal deviation of head and neck of talus

deformity observed: medial forefoot elevated/inverted when subtalar joint is neutral

-regain alignment
-improve flexibility
-orthotics and footwear


forefoot valgus

-congenital abnormal development of head and neck of talus

deformity observed: eversion of forefoot when the subtalar joint is in neutral

-regain alignment
-improve flexibility
-orthotics and footwear


List of spinal conditions

muscle strains


spinal or intervertebral stenosis

disc conditions
-internal disc disruption
-posterolateral bulge/herniation
-central posterior bulge/herniation
-anterior bulge/herniation

facet joint conditions
-facet entrapment- acute locked back

acceleration/deceleration injuries or cervical spine- "whiplash"

hypermobile spinal segments

SI joint conditions

repetitive/cumulative trauma to back

bone tumors

visceral tumors

GI conditions

cardiovascular and pulmonary conditions


muscle strain- spine

may be related to sudden trauma, chronic or sustained overload, or abnormal muscle biomechanics secondary to faulty function

-muscle relaxants- flexeril, valium
-trigger point injections

-correct biomechanical faults- joint mobs
-patient education- harmful positions and postural re-ed
-spinal manipulation for pain inhibition



ankylosing of a vertebral

degenerative changes >stiffness>immobility


spondylolysis and spondylolisthesis

etiology: thought to be congenitally defective pars interarticularis

Spondylolysis= a fracture of the pars interarticularis with positive "Scotty dog" sign on oblique radiographic view of spine

Spondylolisthesis= the actual anterior or posterior slippage of 1 vertebra on another, following bilateral fracture of pars interarticularis
-can be graded according to amount of slippage from 1 (25% slip) to 4 (100% slip)

dx: plain films (oblique and lateral)

special tests:
-stork test

-correct mechanical faults
-exercise focused on dynamic stabilization of trunk with particular emphasis on abdominals
-avoid extension and/or other positions that add stress to defect (extension, ipsilateral side bend, contralateral rotation)
-patient education- eliminate positions of ext and postural education
-braces- boston brace and TLSO (thoracolumbarsacral orthosis)
-spinal mani may be contraindicated particularly at level of defect


spinal or intervertebral stenosis

etiology: congenital narrow spinal canal or intervertebral foramen, coupled with hypertrophy of the spinal lamina and ligamentum flavor or facets, as the result of age related degenerative processes or disease

results in vascular and/or neural compromise

-bilateral pain and paresthesia in back, buttocks, thighs, calves and feet
-pain decreases in spinal flexion, increases in extension
-pain increases with walking
-pain relieved with prolonged rest

Dx: plain films, MRI, CT, myelography

special tests: bicycle/Van gelderen's test helps differentiate from intermittent claudication
*if stenosis pain will alleviate with slouched/flexion position

-correct biomechanical faults
-perform flexion-based exercise and exercise that promotes dynamic stability t/out trunk and pelvis
-avoid extension and/or other positions that narrow spinal canal or intervertebral foramen (ext, ipsilateral SB, ipsilateral rotation)
-manual/mechanical traction
---c-spine positioned to 15 deg of flexion to provide optimum intervertebral foraminal opening
---contraindications include joint hyper mobility, pregnancy, RA, down syndrome, or any other systemic disease that affects ligamentous integrity


internal disc disruption

internal structure of disc annulus is disrupted; however external structures remain normal
* most common in lumbar region

-constant deep, achy pain
-increased pain with movement
-no objective physical findings although patient may have referred pain in LE

dx: CT discogram or MRI

-correct biomechanical faults
spinal manipulation may be contraindicated
-patient education - proper body mechanics, positions to avoid limiting repetitive bending and twisting, limiting UE OH and sitting activities and carrying heavy loads


Posterolateral bulge/herniation

most commonly observed disc disorder of lumbar spine due to 3 structural deficiencies:
1- posterior disc is narrower in height than anterior disc
2- posterior longitudinal ligament is not as strong and only centrally located in lumbar spine
3-posterior lamellae of annulus are thinner

etiology: overstretching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures, from high compressive forces or repetitive micro trauma

results in loss of strength, radicular pain, paresthesia and inability to perform ADLs

dx: MRI

-exercise program to promote dynamic stability t/out trunk and pelvis and to provide optimal stimulus for regeneration of disc
-positional gapping for 10 min to increase space within region of space occupying lesion
--If L posterolateral lumbar is herniated:
----have pt. SL on R side, with pillow under R trunk (accentuating trunk SB R)
----flex both hips and knees
----rotate trunk to left (or pelvis to R)
-spinal manipulation may be contraindicated
-patient education- body mechanics, positions to avoid, limiting repetitive bending and twisting movements, limiting UE OH and sitting activities, and carrying heavy loads
-manual/mechanical traction


Central posterior bulge/herniation

more commonly observed in cervical spine but also seen in lumbar

etiology: overstretching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures (posterior longitudinal log) from high compressive forces and/or long term postural malalignment

results in loss of strength, radicular pain, paresthesia, inability to perform ADLs, and possible compression of SC. Patients exhibit CNS symptoms (hyperreflexia, +babinski)

dx: MRI

-exercise program to promote dynamic stability t/out trunk and pelvis and to provide optimal stimulus for regeneration of disc
-positional gapping for 10 min to increase space within region of space occupying lesion
-spinal manipulation may be contraindicated
-patient education- body mechanics, positions to avoid, limiting repetitive bending and twisting movements, limiting UE OH and sitting activities, and carrying heavy loads
-manual/mechanical traction


anterior bulge/herniation

very rare due to structural integrity of anterior intervertebral disc


Degenerative joint disease- spine

etiology: normal aging process due to WB properties of facets and intervertebral joints

results in bone hypertrophy, capsular fibrosis, hyper/hypo mobility and proliferation of synovium

-reduction in mobility of spine
-possible impingement of associated nerve root resulting in loss of strength and paresthesias

special test: quadrant

-exercise program to promote dynamic stability t/o trunk and pelvis and to provide optimal stimulus for regeneration of facet cartilage and/or capsule
-correct biomechanical faults
-spinal mani may be useful


facet entrapment (acute locked back)

caused by abnormal movement of fibroadipose meniscoidal in facet during extension (from flexion). Meniscoidal doesn't properly reenter joint cavity and bunches up, becoming a space occupying lesion, which distends capsule and causes pain

flexion is most comfortable, extension increases pain

special test: lumbar quadrant

-positional facet joint gapping and or manipulation


acceleration/deceleration injuries of cervical spine


occurs when excess shear and tensile forces are exerted on cervical structures
-facets/articular processes
-facet joint capsules
-ant/post muscles
-fracture to odontoid process and SP
-sympathetic chain ganglia
-spinal and cranial nerves

-Early: headaches, neck pain, limited flexibility, reversal of lower cervical lordosis and decrease in upper cervical kyphosis, vertigo, change in vision and hearing, irritability to noise and light, dysesthesias of face and bilateral UEs, nausea, difficulty swallowing and emotional lability
-Late: chronic head and neck pain, limitation in flexibility, TMJ dysfunction, limited tolerance to ADLs, disequilibrium, anxiety and depression

common clinical findings:
-postural changes, excessive muscle guarding with soft tissue fibrosis, segmental hyper mobility, and gradual development of restricted segmental motion, cranial and caudal to the injury (segmental hypo mobility)

- spinal manipulation generally indicated
-correct muscle imbalances and biomechanical faults
-progress to functional training
-patient education-eliminate harmful positions and postural re-ed


hypermobile spinal segments

=abnormal increase in ROM at a joint due to insufficient soft tissue control (ligamentous, distal, muscle or a combo)

-pain reduction modalities to reduce structural irritation
-PROM within normal ROM
-passive stabilization with corsets, splints, casts, tape, collars
-increase strength, endurance, coordination, especially in multifidus, abdominals, extensors and gluteals which control posture
-regain muscle balance
-education- postural education, limit excessive overloading and sustained activities and end range postures


SI joint conditions

cause and specific pathology unknown
-joint ma become inflamed, develop degenerative changes or develop abnormal movement patterns

anatomically and functionally, SIJ is closely related to lumbar spine, so a thorough exam of both regions is indicated

special tests:
-ipsilateral anterior rotation
-long sitting

-spinal manipulations- SIJ gapping generally indicated to inhibit pain, reduce muscle guarding and restore normal joint motion
-correct muscle imbalance t/o pelvis- strengthen, endurance, coordination, flexibility
-joint mobs
-education- harmful positions and postural re-ed
-SI belts


repetitive/cumulative trauma to back

disorders of the nerves, soft tissues and bones precipitated or aggravated by repeated exertions or movements of the back

repetitive trauma- 48% of all occupational diseases

difficult dx - 85% of back pain undx

chronic disability may be reduced by enrollment in a work-conditioning program, patient education, aerobic exercise, general strengthening and functional stability exercises that promote endurance for work related activities

intervention should focus on prevention with education.


bone tumors - spine

primary tumors:
-multiple myeloma (most common primary bone tumor)
-Ewing's sarcoma
-malignant lymphoma

metastatic bone caner has primary sites in lung, prostate, breast, kidney and thyroid

S&S: pain that is unvarying and progressive, not relieved with rest or analgesics, more pronounced at night


visceral tumors related to the spine

esophageal cancer symptoms may include pain radiating to the back, pain with swallowing, dysphagia and weight loss

pancreatic caner symptoms include a deep, gnawing pain that may radiate from chest to back


GI conditions related to the spine

acute pancreatitis may manifest as mid-epigastric pain radiating through to the back

cholecystitis may present with abrupt, severe abdominal pain and R upper quadrant tenderness, nausea, vomiting and fever


cardiovascular and pulmonary conditions related to the spine

heart and lung disorders can refer pain to chest, back, neck, jaw and UE

abdominal aortic aneurysm (AAA) usually appears as nonspecific lumbar pain


urological and gynecological conditions related to the spine

kidney, bladder, ovary and uterus disorders can refer pain to the trunk, pelvis and thighs


TMJ conditions

common S&S
-joint noise
-joint locking
-limited flexibility of jaw
-lateral deviation of mandible during depression or elevation
-decreased strength/endurance of muscles of mastication
-pain with mandible movement

many patients with TMJ conditions have a component of cervical dysfunction

dysfunction categories:
1- DJD (OA or RA)
2- myofascial pain (*most common TMD)- discomfort or pain in muscles controlling jaw function, as well as neck and shoulder muscles.
3- internal derangement of joint, meaning a dislocated jaw, displaced articular disc, or injury to condyle
-loss of functional mobility may result from increased activity in muscles of mastication due to stress and anxiety
---trauma: leading to joint edema, capsulitis, hypo/hypermobility, abnormal function of ligaments, capsule and muscles
---congenital anatomical anomalies- change in shape of palate
---abnormal function- repeated chewing hard/chewy, mouth breather, FHP

-postural re-ed
-modalities to reduce pain/inflammation
-biofeedback to minimize effects of stress/anxiety
-joint mob is TMJ restriction present (primary glide is inferior which gaps joint, stretches capsule and allows relocation of anteriorly displaced disc
-flexibility and muscle strengthening exercises (rocabado's jaw opening while maintaining the tongue in contact with the palate and isometric mandibular exercises)
-patient education- foots, posture
-night splints
-resting tongue position on hard palate
-critical to normalize the cervical spine posture before patient receives any permanent dental procedures and/or appliances


surgical repairs of the spine

back protection program and early mobilization should be initiated prior to surgery

avoid prolonged sitting, heavy lifting, and long car trips ~3months

repetitive bending with twisting always avoided

microdiscectomies: rehab time is decreased bc the fibers of the annulus fibrosis are not damaged

laminectomy/discectomy: early movement and activation of paraspinal musculature (especially multifidi) is necessary

multilevel vertebra fusion:
-~6weeks of trunk immobility with bracing
-after bracing, important to regain as much normal/functional movement as possible, while restoring functional activation of muscles
-with combined ant/post surgical approach, bracing seldom used

Harrington rod placement for idiopathic scoliosis:
-rehab goals focus on early mobilization in bed and effective coughing
-begin ambulation between days 4-7
-avoid heavy lifting and excessive twisting/bending