MSK Flashcards
What is the definition of sign?
Observable findings detected during objective exam (e.g., swelling, skin colour changes, clubbing)
What is the definition of symptom?
Subjective reports that are perceived by a person and cannot be observed (e.g., pain, numbness, tingling, burning, nausea, dizziness)
What alerts a PT to the need for referral? What key factors create the need to screen? When may the PT know to screen or refer?
-Red flags
-Screening questions
-Screening tests
-Side effects of meds
-comorbidities
-visceral pain mechanism
-patient doesn’t get better, or initially gets better than worse, other S + S develop
How can a PT improve the screening process?
-Know what questions to ask
-Know what medical conditions can cause pain superficially and in what areas
-Become familiar with risk factors for various conditions and diseases
What are red flags?
-indicate serious pathology needing immediate attention for further screening questions and/or tests for referral
-if after screen.. PT decides physio is appropriate… continue objective, if not appropriate..referral to appropriate health care practionner
can continuously screen
What are constitutional symptoms?
-Cluster of symptoms that typically present with a systemic disease
-Diaphoresis
-Dizziness/syncope
-Fatigue
-Fever
-Nausea
-Night sweats
-Pallor
-Unexplained weight loss
-Vomiting / Diarrhea
When to refer out?
-require medical intervention
-interventions do not fall in scope of practice
-findings remain inconsistent with what is expected
-no apparent movement dysfunction, causative factors or syndromes can be identified
-client fails to improve with intervention
Immediate medical attention (emergencies) is advised when…?
Angina - not relieved (20 minds) with rest and/or NTG
- has nausea, vomiting or profuse sweating
CES-b/b incontinence, saddle anesthesia
Respiratory - inadequate ventilation, respiratory acidosis
Anaphylactic shock
Stroke - FAST
Chest - throbbing in chest, back or abdomen that increases with exertion with sensation of heart beat when lying down
-pulsating palpable abdominal mass possibly indicating an aneurysm
Explain the applied anatomy for the TMJ
Joint
-Mandibular condyle
-Glenoid fossa
-Articular disc (helps with congruency and lubrication)
Ligaments
-Lateral ligament - strongest, thickening of capsule
-Sphenomandibular and stylomandibular ligament
Movement
-Opening - lateral ptyergoid
-Closing- medial pterygoid, temporalis and masseter
-Protrusion - medial and lateral pterygoid
-Retrusion - temporalis
-Lateral deviation - contralateral - medial and lateral pterygoid and masseter, ipsilateral - temporalis
Innervation
-Trigeminal nerve (CN5), V3 branch - mandibular branch
Blood supply
-Secondary arteries of the external carotid arteries
Differential diagnosis
-trigeminal neuralgia - sensory input from the V3 trigeminal nerve
What are the cardinal signs for TMD? What are the types of TMD?
-Orofacial pain
-Restricted jaw movement
-Joint noise
-Myofascial
-Discal
-Capsular
-Ligamentous
-Joint
What are the S + S of osteoarthritis TMD?
-Signs of degeneration
-Crepitus
-Reduced ROM - especially in the morning, then increases as time goes on
-Diffuse pain - especially when biting firm foods
-Muscle weakness and atrophy
Explain disc displacement in TMD?
Disc displacement with reduction
-Click 1 : Reduction of disc
-Click 2 : Dislocation of Disc
*typically anterior disc displacement
Disc displacement without reduction
-Closed locked - anterior disc displacement, can’t open
-Open locked - posterior disc displacement, can’t close
What are the S + S of hypermobile and hypomobile TMD?
Hypermobile
-increase ROM, especially excessive anterior translation
-May be joint noise at end range
-lateral deviation contralaterally
-generalized laxity
-pain with opening
Hypomobile
-decreased ROM
-potential contracture
-history of trauma
-secondary myofascial pain
-lateral deviation ipsilaterally
-localized pain at end range
What are the S + S of myofascial pain syndrome?
-increase pain in full opening, trigger points refer pain
-NO JOINT NOISE
-Traumatic or insidious (dentist, FHP, grinding)
-May result in deceased ROM
What is the objective exam for TMD?
Observation
-Cx Ax and posture
-Asymmetry of face
-Occlusion (over/under/cross bite or normal)
-Facial profile
-Teeth
AROM
-Cx
-TMJ
-Mandibular measurement
-Tongue and swallowing
-Cranial nerve function
AROM of TMJ
-Functional opening (40mm, 25mm for rotation, 15mm for translation) can do with tongue touching, when lifts off would be around 30mm, can see where the problem is
-Max opening (50mm)
-Retrusion (1-2mm), protrusion (9mm)
-Lateral deviation (9mm)
look for quality, quantity, pain, clicking
Opening - 2 knuckles = functional, 3=max - with retrusion, not protrusion = anterior disc displacement with reduction
PROM
Isometrics
Functional Ax
Special tests
-Auscultation - crepitus = OA or disc lesion, clicking = hypermobile, late = anterior disc displacement
-Knuckle test - +ve if can’t fit knuckles
What are the interventions for TMD?
-Education
-Fascial muscle relaxation
-Tongue and jaw proprioception and control
-Strengthening
-Manual therapy - passive stretching, ST techniques, mobilization, joint manipulations
-Modalities
Joint manipulations - if anterior, can pull caudal and anterior to relocate disc (J-stroke), often hear click
Postural - education, jaw posture, TMJ mobilization/manipulations, SOM interventions, mandibular and tongue proprioception
What is the applied anatomy for the Cspine?
7 vertebrae - C1/C2 - upper, C3-C7 is lower
8 nerves - go out above, with extra C8 between C7 and T1 then they go out below
Discs - not between C1/C2, C2/C3 is starts and continues
-Thick anterior for flexion, thin to maintain mobility
What is cervical radiculopathy? What is the etiology?
Compression or irritation of the spinal nerves
- Disc herniation -
-Typically goes postero-lateral since weakest part of annulus fibrosus
-For people in flexion with weight usually as less pressure posterior and it ruputres
-*if compresses straight posterior - more likely on to SC = UMNL - Stenosis
-Osteophyte formation
-Spondylosis - degeneration plus decrease hydration = thin = compress IVF
-Ligament thickening - ligamentum flavum - get central compression because of the area of that ligament - Swelling / inflammation (from local trauma)
What are the components for neuro scan for physical exam of cervical spine? What is it testing?
-Myotome - group of muscles or muscle supplied by spinal nerve
-Dermatomes - area of skin supplied by spinal nerve
-Reflexes - involuntary and instant response to a stimuli
-Special tests
What is myotomal testing comprised of for cervical spine? Including each myotome
Test bilaterally, hold for 5-8 secs as fatigable, testing in comfortable, neutral position
C1/C2 - neck flexion
C3 - SLF
C4 -shoulder elevation
C5 - shoulder abduction
C6 - elbow flexion, wrist extension
C7 - elbow extension, wrist flexion
C8 - thumb extension, ulnar deviation
T1 - finger abduction/adduction
What is dermatomal testing comprised of for cervical spine? Including the main testable dermatomes
Area of skin supplied by one nerve
Needs to be on bare skin, relaxed, testing bilaterally, demonstrate on non-affected area, eyes closed
Start light touch, if impaired do sharp/blunt, hot/cold
see book for pictures
C5, C6,C7,C8,T1 - most important - think of the spock hand
What are the upper region LMN reflexes? What can be included with testing? What is the rating scale?
C5 - deltoid
C6 - biceps/ brachioradialis
C7 - triceps
C8 - pronator quadratus
T1 - abductor digiti minimi
*Use jendrassik - pull legs apart for upper, hands apart for lower
Put tendons on slight stretch
Rating 0-4 with increasing response - 0, no, 1, decreased, 2, normal 3, exaggerated 4, is clonus/very brisk
What are the UMNL reflexes?
Potential lesion in brainstem, brain or spinal cord
Babinski - lateral across foot - abnormal, splaying of toes or great toe extension
Clonus - more than 5 times - hold DF
What are the neuro special tests for cervical radiculopathy?
-Cervical distraction test
-Spurlings (foraminal compression) test
-Upper limb tension (neuro provocation tests)
Cx distraction test - decrease symptoms +ve
Foraminal (spurlings) compression
-Compress in neutral, no symptoms - then with extension and rotation of unaffected, then of affected then side flexion to affected
-+ve if increased symptoms on affected
ULNT
-Unaffected side first - so they know what it feels like and compare
-Order → shoulder, forearm, wrist, fingers, elbow
-Added sensitizing and desensitizing movements to see if makes a difference
+ve if symptoms
Describe how you would do the ULTT for each nerve?
Median 1 - ULNT 1
-Shoulder depression, abduction, supination, wrist and finger extension, elbow extension
Median 2 - ULNT 2
-Shoulder depression, shoulder lower abduction, forearm supination, wrist and finger extension, elbow extension
Radial - ULNT 3
-Shoulder depression and abduction (10 degrees), forearm pronation, wrist flexion and ulnar deviation, finger and thumb flexion, elbow extension
Ulnar - ULNT 4
-Shoulder depression and abduction, forearm pronation, wrist extension and radial deviation, and finger extension, elbow flexion
What is the intervention for cervical radiculopathy?
Stenosis - unload the nerve - SLF and rotation away, flexion based exercises, traction
-Can also floss / tension
Disc - graduated retraction, then add extension when ready being careful not to make things worse
-The UCS in to flexion - no discs so don’t worry, LCS in to extension
Name and describe the two brachial plexus injures
Erb- Duchenne’s Palsy
-C5/C6 injury
-Shoulder and elbow effected, not hand
-Elbow extension, shoulder internal rotation, forearm pronation
-Sensation - limited on deltoid area and along radial side
-From traumatic birth traction of head when shoulder gets stuck
Klumke’s Palsy
-C8/T1
-Present with Horner’s syndrome - drooping eyelids (ptosis) and small pupils (miosis)
-Effects the forearm, wrist and hand - elbow flexion, forearm supination, wrist and MCP extension, finger flexion
-Sensation on ulnar side of forearm and hand
-Hyperabduction injury on birth or grabbing something and hanging off of it
Explain facet syndrome
Pain with extension, SLF (ipsilateral) and rotation (ipsilateral) - all compression stress
May refer to neck or scapula
Direction of Cx is 45 degrees towards eyes - able to get more rotation
Tested using coupled or combined movements
Physiological coupled - SLF and rotation to same side
Can use manual therapy of either because they are the same arthrokinematics
Non-physiological coupled - SLF and rotation to opposite side - more provocative
Explain vertebrobasilar insufficiency (VBI) and the 5 D’s and 3N’s
Compression of vertebral artery = decrease BF to brain
Dizziness
Drop attacks
Dysarthria
Dysphagia
Diplopia
Nausea
Nystagmus
Other neurological signs
What are the vertebrobasilar insufficiency special tests?
Vertebral artery (cervical quadrant) test
Bring patient in to extension and SLF holding for 10-30 sec
The into ipsilateral rotation holding for 10-30 sec
Dizziness or nystagmus = +ve on contralateral side artery is being compressed
keep eyes open
What is SCM innervation?
Accessory nerve (CNXI)
Branches of cervical plexus C2,C3
What is torticollis?
Can be congenital or acquired
-Congenital - unknown etiology - trauma during birth or positioning in utero
-Positional plagiocephaly - flattened head cause of positioning - change positions or wear a helmet (cranial remodeling orthosis)
Primarily tightness of SCM causing ipsilateral SLF and contralateral rotation
-Cause and decrease AROM and PROM the opposite way
Postural education, stretch muscles and strengthening opposite side for treatment
What is postural dysfunction within the c-spine? Including interventions
Upper cross syndrome
Weak - lev scap and upper trapezius, DNF
Tight - pects and lower trapezius and lev scap
Chin poking leads to tight upper extensors and lower flexors which lead to weak DNF
Puts more stress on posterior structures (discs and facet)
good alignment when sitting at desk
Interventions - stretch tight muscles, strengthening of weak ones, appropriate positioning
What is cervical instability? Including contraindication for treatment
Excessive motion between two adjacent vertebrae
Due to joint damage, muscle weakness, fracture, dislocation, ligament damage
Caused by trauma, long term corticosteroid use, congenital or secondary to other conditions (RA,OA, downs syndrome)
*DO NOT MOBILIZE OR MANIPULATE
What are the S + S of cervical instability
Severe headaches especially with movement
Fear to movement head or neck especially in to flexion
Dizziness
Pupil dysfunction
Nystagmus
Lip or facial paraesthesia
Lump in thorat
Nausea/committing
Severe muscle spasm
Soft end feel
*may have SCI S + S as well
What are the special tests for cervical instability?
Anterior shear or sagittal stress test
Test: anterior ligaments and capsular tissues
How: stabilize at TP below, anterior force on adjacent vertebrae above through SP or posterior arch (lamina)
Positive: excessive motion or S + S
Lateral flexion alar ligament stress test
Test: contralateral alar ligaments
How: stabilize C2 at SP and lamina, side flexes C1 and head
Positive: excessive side flexion
Lateral (transverse) shear test
Test: lateral ligaments and capsular tissues
How: radial aspect of one hand on one vertebrae, other side radial aspect of one hand on another vertebrae and push together
Positive: excessive motion or symptoms of instability, SC or vascular pathology
Sharp purser test
Test: Determine subluxation between C1 (atlas) and C2 (axis) - potentially torn transverse ligament as stops C1 moving forward on C2 in flexion
How: Hand on forehead and thumb on C2, patient to flex forward and to push forehead back
Positive: head slide backwards during the movement, potential clunk
Cervical flexion-rotation test
Test: Determines C1/C2 dysfunction or CGH
How: full Cx flexion then rotate to right and left
Positive: increased or decreased ROM 45 UCS rotation = C1/C2 dysfunction or headaches = CGH
What is segmental instability?What are the interventions?
Inner unit muscles - attach segmental - postural control, not that strong but have good endurance
DNF, deep neck extensors and SOM
Global muscles - strong but don’t have good endurance
if IUM are weak or inhibited by pain then the global muscles take over to work but they are not meant for that task
This leads to segmental instability - aberrant movements between segments and causing pain
Strength DNF - coordination and timing, analgesic effect
What is the special test for segmental instability?
Craniocervical flexion test
Use blood pressure cuff - inflate to 20mmHg, continue to add by 2’s if patient successful. See if they can perform upper cervical flexion and hold is for 10 sec getting it up to 22mmHg
Most can get it up to 26mmHg
Positive: unable to get to 26mmHg, hold it, raise pressure in small increments, uses compensatory patterns (using superficial neck muscles - SCM, extends the head)
What is the applied anatomy for the Tx? Including thoracic rib movements
Costochondral
Costovertebral
Facet joints
Transitional vertebrae
Thoracic rib motion
Pump handle action- ribs 1-6 - up and forward
Bucket handle action - ribs 7- 10 - lateral and forward
Caliper action - ribs 8-12 - lateral
Where does the typical line of gravity travel?
From external auditory meatus
Acromion
Greater trochanter
Posterior to patella
Anterior to lateral malleolus
Name and explain the types of kyphosis deformities
Round back
-Entire spine is kyphosis - decreased pelvic inclination (20 degrees) with thoracolumbar and thoracic kyphosis
-Associated with FHP and rounded shoulders
Scheuermann’s disease
-Uneven growth = excessive wedge shape increasing kyphosis
-Typically T10-12
-Rare congenital and/or degenerative weakening of vertebral end plate
-Most common deformity in adults, 2nd decade, “growing pains”
Hump back
-Gibbus (localized, sharp, posterior angulation) in Tx caused by structural deformity (e.g., anterior wedging) due to fracture, tumour or bone disease
-May or may not have pelvic inclination
Flat back
-Decrease pelvic inclination and decrease curve in Tx - mobile though
Dowager’s hump
-Increased kyphosis, typically postmenopausal OP with older women creating anterior wedge fracture across several vertebrae (result from trunk flexion)
-Happens in upper and middle Tx, decreases height
What are the interventions for kyphosis deformities?
Posture education
Extension approach
Stabilization exercises
Stretching as needed
Mobilization as needed
* DO NOT JOINT MANIPULATE AND AGGRESSIVE MOBILIZATION IN SCHEUERMANN’S DISEASE AND DOWAGER’S HUMP*
Explain compression fracture
Secondary to OP, F>M (post-menopause), 60-70 yo
Most common in thoracolumbar region, typically anterior vertebral body (wedge shaping)
Causes - falls, trauma, trunk flexion
Increased kyphosis (multiple fractures = increase)
What are the interventions for compression fracture?
Posture education
Extension approach
Stabilization exercises
Scapular stabilization exercises
Weight bearing activity and exercises
Light mobilizations as needed with precautions
JOINT MANIPULATIONS AND AGGRESSIVE MOBILIZATION, TRUNK FLEXION EXERCISES ARE CONTRAINDICATED*
Explain scoliosis including how it is named and the different types
Named based on the direction of the convexity, and level of apex
-If two - minor and major names
-Cobb angle - >10 is significant, <10 is not
Non-structural
-Based on muscle guarding or spasm, nerve irritation, inflammation, postural, leg length discrepancy
-LLD - if R higher- pelvis, sacrum, Lx all shift to R then thoracic shifts to L in order to compensation. Adducted on R, abducted on L - more stress on hip joints
-Easy to correct once you know the difference
-Adam’s test - disappears with forward flexion
Structural
-Due to the bony structures - congenital or acquired
-Severe (>60 degrees) - cardiopulmonary system compromised
-Rotation of vertebrae is towards the convexity, creates a rib hump
-This is palpable along back, might be confused with SP
-If severe = razor back spine
-Can’t fix bones but can manage that non-structral doesn’t exacerbate structural
What are the interventions for scoliosis?
Posture education
Stretch concavity
Strengthen convexity
Stabilization exercises
Scapular stabilization exercises
Mobilization as needed
Bracing as needed - boston, milwaukee
Surgery if severe
What is herpes zoster?
AKA shingles
Viral infection of nerve causing skin rash along the typical dermatomal pattern (stripe like in Tx, just on one side)
May be with fever
Names the visceral referral pain patterns for all organs
Right
Liver and gallbladder - right neck and shoulder, right upper quadrant
Appendix - right lower quadrant
Left
Lung and diaphragm - left neck and shoulder
Heart - Left chest and arm and between scapula
Pancreas - left upper quadrant
Center
Stomach - center of chest and back
Small intestine - center of abdominal area
Colon - center of groin area
Both
Kidney - left and right lower quadrants and upper legs
Bladder - lower groin, inner legs
What is the applied anatomy for the Lx?
5 vertebrae
5 spinal nerves coming out below
5 discs
-Thicker anterior - why lumbar lordosis
-Posterolateral weaker - that is why it herniations here
-Also not posterior cause of the posterior longitudinal ligament
Motion segment - disc + above and below vertebrae
What is the neural exam for Lx radiculopathy? Including how to test for each
Dermatomes - same procedure as cervical
-L4 - patella, and to great toe
-L5 - plantar and dorsal digits, lateral ankle
-S1 - 5th digit
Myotome - same procedure as cervical
-L1/L2 - hip flexion
-L3 - knee extension
-L4 - Ankle DF
-L5 - Great toe extension
-S1 - PF, hip extension and eversion at ankle
-S2 - PF, hip extension and knee flexion
Reflexes - same procedure as cervical (and same rating)
-L3/L4 - patella
-L4/ L5 - tibialis posterior
-L5/S1 - medial hamstring
-S1/S2 - lateral hamstring
-S1/S2 - achilles
UMN - same as cervical spine as this doesn’t change
What are the special tests of Lx radiculopathy?
Slump - get patient to slump down and tuck chin then passively extend their unaffected leg, then their affected
If no symptoms - add DF
If symptoms - ask them to lift head without moving from slump
Positive - symptoms become worse with DF, or better when lifting head indicated neural tension/restriction of lumbosacral roots or dura/neural tissues
*If symptoms at any stages - don’t add movements
SLR - testing unaffected side first, add medial rotation and adduction, then flex at hip, if pain/tightness lower slightly until disappears, then DF or flex patient’s neck to see if symptoms or reproduced
ROM - 35-70 = sciatic nerve
-Before 35 - slack taken up
-35- under tension
-60-70 sciatic roots tense over disc
->70 - pain is likely MSK (hamstring stretch)
Further stress nerves
-SID - sural, inversion, DF
-TED - tibial, eversion, DF
-PIP - peroneal, inversion, PF
Crossover sign - if when doing unaffected side they feel it in affected - suggests a large disc bulge as pulling the nerves into the disc
Sign of the buttock - do after SLR - go to point of restriction then back off, add knee flexion and see if can get further hip flexion
Positive - hip flexion does not increase - pathology behind hip joint (bursitis, tumour, abscess) - refer to GP
Bow-string test - SLR produces symptoms, slightly flex the patient’s knee (20 degrees) to reproduce symptoms, pushing then in to popliteal area
Positive - reproduces radicular symptoms, pressure or tension on sciatic nerve
What is spinal stenosis? How does it present in Lx?
Narrowing of the central canal (central stenosis) or lateral canal (lateral stenosis) which may compress the nerve roots or spinal cord
Onset is insidious and usually >60
Due to osteophytes, spondylosis, ligament thickening
May result in neurogenic claudication - neural leg pain
Better with flexion, worse with extension
How do you differentiate between neurogenic claudication and intermittent claudication?
IC is similar leg pain symptoms but more to do with the use of muscles. Increase pain leads to increase activity and it is relieved by rest
*see chart to differentiate between NC and IC *
Use bicycle test as main measure to differentiate the two
What are the intervention for spinal stenosis in Lx?
Flexion based exercises initially and positioning (e.g., z-posture)
Avoid aggravating movements
Surgical management - laminectomy
What is a disc herniation? What are the types? How does it present?
Disc herniations posterolateral - due to PLL and weak annulus fibrosis, may compress nerve root
Typically acute onset, 30-50
Levels
-Protrusion
-Prolapse
-Extrusion
-Sequestration
Happens with flexion MOI, hurts in flexion, better in extension
Worse in morning - due to larger disc = more herniation, worse with cough, sneeze, Valsalva
May present with lateral shifting away from bulge (named based on the shoulders shift)
What are the interventions for disc herniation in Lx?
Postero-lateral bulge
-Extension based exercises with progressions
-Lumbar roll to promote extension when sitting
Lateral bulge
-Shift back towards the affected side
Anterior bulge
-Happens when bulge comes out anteriorly - less common, but there is no spinal nerves but the disc has nociception therefore can still feel pain
-Flexion based exercises
May be painful initially but complete entire set to evaluate the effect
CENTRALIZATION is the priority
Green (centralized or with an increase in pain), yellow (no change), red (no change and increase pain and peripheralized)
Avoidance of aggravating movements and positions
Surgical - laminectomy, discectomy
What is schmorl’s node?
The nucleus goes up or down, typically from a compression force, which goes through the cartilaginous end plate and vertebral body
Typically in higher lumbar levels
What is the postural dysfunction in Lx? What is the intervention for this?
Lower cross syndrome
Tight hip flexors, hamstrings, ES
Hamstrings tight from trying to correct pelvis and compensating for glutes
Weak glutes and core
Anteriorly rotates the pelvis = more lumbar lordosis
Intervention
Strengthening weak, stretch tight
What is spondylosis in Lx?
Degenerative changes within spinal motion segment
Increase incidence with age, typically around >50, insidious
Loss of disc height, approximation of vertebrae (initially unstable because ligaments longer = more laxity, then becomes stiff), degeneration of plates, fibrotic in discs, osteophyte formation
Presents with loss of lordosis - results in increased stiffness, muscle spasms and back pain (Ache)
Worse with prolonged flexion, specifically load. Better unloaded, position changes and gentle movement
What is facet syndrome in Lx? What are the coupled (physiological) and non-physiological movements in the Lx?
Syndrome cause by facet - worse with compression of facet joints
May refer to low back, glutes, hips, groin, thighs (not below knees)
Coupled movements
-Flexion - SLF and rotation to same side
-Extension - SLF and rotation to opposite sides
Non-physiological coupled - the opposite of this
What is the special test to determine facet syndrome in Lx?
Quadrant Test
-Patient extended Lx and side flexes and rotates to side of pain
-If increase - indicate facet involvement
What are the intervention for facet syndrome in Lx?
Flexion based exercises and positioning
Avoidance of aggravating movements and positions
What is lumbar instability? What is the intervention?
Excessive motion between two vertebrae
Can be ligament damage, fracture, dislocation,muscle weak, joint damage, poor neuromuscular control
May be caused by trauma, long term corticosteroid use, congenital or secondary to other conditions
Do not mobilize or manipulation
Control system (CNS), active system (muscles and neural control) and passive system (bones and ligaments)
Intervention = inner unit core stability training
What is clinical instability in Lx?
Inner unit muscles - stabilizers - timing and endurance is important
Transverse abdominis, PF muscles, diaphragm, lumbar multifidus
Neurophysiological connected - meaning that they all fire at once, anticipatory before movement
Often weak, trouble with timing - leads to aberrant movement and increased recruitment of global muscles to maintain stability
Active muscle systems
-Local and global - see chart in book
What are the special tests to Ax Lx instability?
H and I (*start with pain free direction first)
-If two positive - hypomobility
-If one positive - instability
-as the first movement providing stability for the second movement if this is the one that is unstable
-direction of instability is based on the first movement
Prone segmental instability test
-Upper body prone, legs on floor
-PA by therapist, if pain - lift legs - not present, then need core strengthing/stability exercises
What is inner unit core stability training for each muscle?
TA isolation
Make sure deep tension, no bulge
2 inch medial to ASIS, 1 inch inferior - then draw in abdomen and hold for 10 secs
May coactivate with multifidus and PF muscles and progress to sitting / standing
Correct
-Normal, relaxed breathing
-Slow, inward movement of lower abdomen
-Deep tension under palpated area
Incorrect - global muscle use
-No movement of lower abdomen
-Rapid contraction and/or tremor
-Visible contraction
-Swelling or bulging
-Upper abs and rib cage movement
-Breathing - unable to relax abdomen, holding breath
-Spinal movement - PPT or APT, flex or extension of spine
Multifidus
Lateral to both sides of lower lumbar SP - contract for 10 secs - swell muscle, pushing fingers away
May coactivate with TA or PF muscles
PF
Contract PF, stop urine from flowing,
NO peri-anal or glute gripping
Diaphragmatic
Breath through belly, not chest
Progression
Isolate inner unit
Train inner unit
Maintain control of inner unit while training outer unit
Integrate into function
Describe spondylolysis, spondylolithesis (and types), retrolisthesis.
Spondylolysis - fracture of one pars articularis - no slippage
Spondylolisthesis - fracture of two and get anterior slippage
-Traumatic - from trauma
-Isthmic - repetitive micro trauma - common in L5/ S1 (excess movement of L5, carry weight of body, angulation is greatest)
-Degenerative - degenerative changes - decrease joint space, increased laxity and risk of slippage
-Dysplastic (congenital) - defect in formation of vertebrae
-Pathological - secondary to another disease process or treatment
Retrolisthesis - fracture of two and get posterior slippage
What are the grades of spondylolithesis and the intervention?
1 - <25
2 - 25-50
3- 50-75
4 - >75
5 - 100
*4 and 5 - need fixation, others core stability exercises
What are the S + S of spondylolithesis?
Hyperlordotic
Pain with hyperextension
Tight hamstrings
Scotty dog with collar or decapitation
Step deformity maybe
S + S of central and lateral stenosis
What is the intervention for spondylolithesis?
Inner core stability
Education - avoid aggravating movements
Spinal fusion surgery
*don’t manipulate
What is the post-operative management of spondylolithesis?
Max protection -
Patient education
-Expectations
-No heavy lifting >10 pounds for up to 3 months
-Signs of inflammation and infection
-No getting incision wet (1 to 2 weeks)
-Surgeons guidelines
–Based on preference and surgery dependent - no rotation and avoid hyperflexion/extension
Bed mobility
Exercise - walking, gentle exercise
C/I - extension exercises for laminectomy
Moderate and minimum
Scar tissue mobilization
Progressive stretching and joint mobilization - grade I or II for pain relief
Exercise - walking, strengthening - start with inner unit then progress
C/I - joint manipulation at level of spinal fusion, extension exercises
What are the sinister pathologies for Lx and what are the S + S to look for
CES
-Below L1 - variable nerve root damage
-Flaccid paralysis
-LMN injury - areflexic B + B and sacral anesthesia
-Leaking but don’t notice as don’t know when it is full
-Emergency
Malignancy
-Spinal pain common-
-Age >50
-Previous history of cancer
-Unexplained weight loss
-Constant unrelenting pain
-Pain unrelieved by rest
-Pain worsens at night
-Failure to improve with conservative therapy (1 month)
What is the action and innervation of serratus anterior?
A; Draws scapula anterolaterally, Suspends scapula on thoracic wall, Rotates scapula (draws inferiorly angle laterally)
N: Long thoracic nerve (C5- C7) (SALT)
What is the action and innervation of supraspinatus?
A: Shoulder joint: abduction of arm, stabilization of the humeral head in the glenoid cavity
N:Suprascapular nerve (C5, C6)
What is the action and innervation of biceps brachii
A: Flexion and supination of the forearm at the elbow joint, weak flexor of the arm at the glenohumeral joint
N: Musculocutaneous nerve (C5- C6)
What is the action and innervation of infraspinatus?
A: Shoulder joint: Arm external rotation;
Stabilizes humeral head in glenoid cavity
N: suprascapular nerve (C5, C6)
What is the action and innervation of teres minor?
A: Shoulder joint: Arm external rotation, arm adduction;
Stabilizes humeral head in glenoid cavity
N: Axillary nerve (C5, C6)
*can be injuried with axillary nerve damage from shoulder dislocation
What is the action and innervation of subscapularis?
A; Shoulder joint: Arm internal rotation
Stabilizes humeral head in glenoid cavity
N: Upper and lower subscapular nerves (C5 - C6)
What is the action and innervation of deltoid?
A: Clavicular part: flexion and internal rotation of the arm,
Acromial part: abduction of the arm beyond the initial 15°
Spinal part: extension and external rotation of the arm.
N: Axillary nerve (C5, C6)
What is the applied anatomy for the shoulder joint?
Sternoclavicular joint - attaches shoulder to axial skeleton, ligaments very strong, more likely to fracture clavicle
Acromioclavicular joint - attached scapula to axial skeleton
Glenohumeral joint
-ER>abduction>IR - closed packed
-30 degrees flexion, 60 degrees abduction, internal rotation - loose packed
Scapulothoracic joint - false joint since no capsule and no bony articulation
What are the borders and contents of the thoracic outlet?
Borders
-Anterior - pect minor, coracoid process, clavicle
-Posterior - scapula, UFT
-Medial - 1st rib, scalenes
-Lateral - axilla
Content
-Brachial plexus
-Subclavian artery
-Subclavian vein
What is Thoracic outlet syndrome? And what are the types?
Diagnosis of exclusion - results from compression of nerve or vascular structures in outlet
Types
Neurogenic (True TOS)
-From anatomical anomaly - compression of nerve
Non specific (symptomatic) neurogenic
-Most common, diagnosis of exclusion - nothing shows up on scan, muscle atrophy or anatomical anomaly
-Maladaptive postures - tight scalenes or pect minor
Vascular - arterial
-Compression of subclavian artery from anatomical anomaly
-Worse with upper arm movements
Vascular - vein
-Does not typically result in TOS complaints - result of another cause (thrombus)
What are the S + S of all types of TOS? What is the epidemiology?
Neurogenic
-Tingling, numbness, paraesthesia
-Harder fine movements
-Weak grip strength
Vascular - artery
-Cold and pale
-Decrease pulses
-Rapid fatigue of limb
-Lower BP on affected side
Vascular - vein
-Mottled skin, blueish
-Painful swelling in arm
F>M, onset 20-50 - neuro most common
Involves C8,T1 (ulnar nerve distribution)
Athletes with abduction and external rotation
What is the etiology of TOS ?
Congenital anatomical anomaly
Inflammation or scar tissue
Hypertrophy of scalenes, pect minor, subclavius
Pressure
Posture
Overhead movements
Trauma
Thrombus (vascular TOS)
Pancoast tumor
What are the classifications of TOS?
- Scalenus anterior syndrome
Compress = interscalene triangle - between scalene anterior and medius (SUPRACLAVICULAR) - Costoclavicular syndrome
Compress = costoclavicular space - between clavicle and 1st rib (subclavicular) - Hyperabduction syndrome
Compress - axillary interval - under coracoid process and behind pect minor (infraclavicular) - Cervical rib syndrome
What are the special tests for TOS?
Adson’s
Allen’s
Costoclavicular syndrome
Halstead
Wright test
above are all vascular and have to do with different positioning and decreasing the pulse
Roos - opening and closing hands - see why they stop
Shoulder girdle passive elevation - do to patient and see if they get decrease in symptoms
What is shoulder separation? What is the etiology?
The AC joint separation - the ligaments that hold the joint together (AC and coracoclavicular)
Etiology
-Downward pressure on acromion, or fall on acromion
-Fall on outstretched hand or elbow
What are the S + S of shoulder separation? What are the special tests? How do they xray?
Step deformity
-Distal end of clavicle raises
-Grade III separation
-Torn deltoid and trapezius also possible
Pain with
-Horizontal adduction - compressing together
-Elevation - causes posterior rotation of clavicle
-HBB - causes anterior rotation of clavicle
Tenderness and swelling
Horizontal adduction or cross body test
Stress view xray - provide traction (inferior pressure) to see if there is separation
What are the grades of shoulder separation?
Grade 1 (SPRAIN) - no separation, capsule intact
Grade 2 (SUBLUXATION) - increased AC joint spacing
Grade 3 (DISLOCATION) - torn AC and coracoclavicular ligaments, joint surfaces not in contact
What is the classification of glenohumeral instability? What is the epidemiology?
Direction - anterior, posterior, inferior, multidirectional
Degree - subluxation, dislocation
Etiology - traumatic, atraumatic
Timing - acute, recurrent
Epidemiology - M, <30
What is the difference between shoulder dislocation and subluxation?
Shoulder dislocation - separate of humerus from scapula, common (and common anterior - for MSK)
Shoulder subluxation - incomplete dislocation
What is the etiology of shoulder dislocation?
Traumatic - direct, indirect
-Most common abduction, ER
-Stability provide - subscapularis, GH ligaments, long head biceps
-Anterior dislocation injuries - subscapularis, long head of biceps, GH ligaments, anterior capsule, anterior glenoid labrum
Atraumatic - general laxity lead to instability
*surgery - only if recurrent - tighten subscap - no stretching or resisted activities
What are the S +S of glenohumeral joint instability?
Feeling of slippage with pain or insecurity with certain activities
Pain or apprehension when approaching extreme ROM
Decrease ROM - acute
Increase ROM - chronic
Normal on clinical examination - more apparent after repeated activities with fatigue
Atrophy due to disuse (chronic)
Sulcus sign - multidirectional instability, loss of muscle control, groove inferior/lateral of acromion
What are the complications to glenohumeral instability?
Axillary nerve injury - deltoid or teres minor
Axillary artery
Brachial plexus - posterior cord especially
Bankart lesion - anterior dislocation = labrum damage
Hill-Sach’s lesion - damage to posterolateral humerus (indentation) as humeral head is compressed against anterior-inferior glenoid rim
What is the spectrum of instability for glenohumeral instability?
AMBRI - born loose
-Atraumatic, multidirectional, bilateral, rehab, inferior capsule shift if surgery required
TUBS - torn loose
-Traumatic, unidirectional, bankart, surgery
What are the special tests for glenohumeral instability?
Anterior instability
Crank, apprehension test with relocation
Apprehension release (surprise)
Load and shift test
Posterior instability
Posterior apprehension test
Load and shift test
Jerk test
Inferior and multidirectional instability
Sulcus sign
Feagin test - push inferior with their hand on your shoulder
What are the types of glenohumeral labral tears? Including S + S
Bankart
Anterior-inferior of labrum
From anterior dislocation, common from overhead sports
S + S
Clicking and/or popping
Diffuse shoulder pain
Worse with HBB
Weakness and instability
SLAP
Superior labrum anterior, posterior
Long head of biceps attaches to superior labrum - can tear if forceful, shoulder can become unstable
From
-Repetitive throwing and overhead activity
-Deceleration when throwing
-Direct trauma
-FOOSH
-Traction injury (to biceps) in inferior direction
S + S
Clicking and/or popping
GIRD - internal rotation deficit
Pain with overhead activity (elevation) and lying on affected side
Loss of strength and endurance in RC and scapular stabilization
“Dead arm”
What are the special tests for glenohumeral labral tears?
Clunk test
Active compression test of O’brien - SLAP
Biceps load test
What is adhesive capsulitis and was is the epidemiology?
Idiopathic - pain with more decrease ROM in capsular pattern from dense adhesions and capsular thickening
F>M, 40-60 yo, non-dominant shoulder, increased with diabetes
