MSPT I - EXAM 1 Flashcards
(375 cards)
1
Q
What is the open packed position of the glenohumeral joint?
A
40-55 deg. abduction
20-30 deg. horizontal adduction
2
Q
What does open packed mean?
A
Ligaments and capsule are on slack.
3
Q
What does close packed mean?
A
Ligaments and capsule are in tension; position of most bony congruency of a joint.
4
Q
What impairments may evolve at the shoulder due to immobilization and subsequent protective positioning? (4)
A
Loose structures tighten –> loss of ROM
Cartilage degeneration (lack of mvmt)
Muscle changes (atrophy)
Nerve changes (muscle guarding)
5
Q
What makes for healthy cartilage?
A
“Motion is lotion”
Cartilage relies on synovial fluid and compression forces to remove wastes and nourish the tissue.
6
Q
Why is the neurological response to prolonged immobilization?
A
Limited ROM.
Nerves adapt to the new limited ROM. Passively stretching the joint beyond this will trigger muscle spindles to think it is going beyond its capacity and cause a muscle guarding response.
7
Q
What impairment may evolve at the elbow due to the immobilization and protective positioning?
A
Flexion contracture.
8
Q
Why does the entire UE need to be considered when pathology of just one joint is present?
A
Decreased mobility at one joint will cause extra movements (compensations) at over joints leading to secondary dysfunction.
9
Q
Carlos has 130 deg. of elbow flexion. How is he able to eat or brush his teeth? (2)
A
Move the neck forward
Hike the scapula
10
Q
What types of problems can occur with constantly hiking the shoulder?
A
Overuse injuries to the trapezius and levator scapulae which leads to spasm, pain, and/or neck problems.
11
Q
What is the key role of the rotator cuff?
A
Stabilize and control the position and movement of the humeral head during active motions of the arm.
12
Q
What is the balancing act between the rotator cuff and the deltoid?
A
Rotator cuff (subscap/infrasp/teres minor) - pulls the humeral head inferior and into the glenoid fossa
Deltoid - pulls the humeral head up
13
Q
What happens if you lose control of the rotator cuff muscles?
A
Humeral head won’t stay in the glenoid fossa which leads to GHJ instability and impingement.
14
Q
What is the close packed position of the glenohumeral joint?
A
Full abduction and full external rotation
15
Q
During active elevation of the arm overhead, what motions normally occur at the scapulothoracic joint?
A
UPWARD ROTATION
Elevation, protraction, posterior tipping
16
Q
Where are the superior and inferior angles of the scapula in relation to the spine (at rest)?
A
Superior: T2
Inferior: T7-T9
17
Q
What portion of the abduction arc is upward rotation of the scapula most critical?
A
From 60-140 degrees
18
Q
When should the scapula start to move during arm elevation?
A
At about 60 degrees abduction
19
Q
What are the force couples of scapular elevation?
A
Upward: upper trap, levator scap
Downward: serratus ant, lower trap
20
Q
What are the force couples of scapular depression?
A
Downward: serratus ant, lower trap
Upward: upper trap, levator scap
21
Q
What creates concavity compression of the humeral head against the glenoid fossa?
A
Co-contraction of the subscapularis, infraspinatus, and teres minor pulling the humeral head inferiorly into the glenoid fossa.
22
Q
What happens if you lose concavity compression (damage to subscap/infra/teres)?
A
Lose function of the shoulder; cannot elevate the arm.
23
Q
Why is it that some patients with supraspinatus tears can still elevate their arm?
A
Supraspinatus does not contribute to concavity compression. The deltoid can produce the full arm elevation force.
24
Q
What is SICK scapula?
A
Malposition of the SCAPULA
Prominence of the INFERIOR border of teh scapula
CORACOID pain and malposition
Scapular DYSKINESIA
25
What becomes tight with forward head posture?
Posterior capsule (anterior translation of humeral head)
Pectoralis, upper trap, levator scap
26
What becomes weak with forward head posture?
Lower scapular stabilizers and deep neck flexors
27
What is a step deformity? How can it be accentuated? What does it indicate?
Depression where the clavicle lies superior to the acromion (seen at rest)
Indicates ACJ dislocation - torn AC and coracoclavicular ligaments
Accentuated with horizontal adduction or medial rotation (hand behind back).
28
What is a sulcus deformity? What does it indicate? What are possible causes?
Depression lateral to acromion that appears when traction is applied to the arm.
Indicates an inferior dislocation of the GHJ
Causes: multidirectional instability or loss of muscle control due to nerve injury or stroke.
29
What is the difference between dynamic and static scapular winging?
Dynamic - occurs with movement; secondary to nerve lesion or instability
Static - occurs at rest; indicates a structural deformity of the scapula, clavicle, spine, or ribs.
30
Dynamic winging is caused by a Long Thoracic Nerve lesion. How does it present?
Occurs on abduction and forward flexion.
Scapula elevates and moves medially. Inferior angle rotated medially.
31
Dynamic winging is caused by an Accessory Nerve lesion. How does it present?
Occurs before 90 deg. abduction and not much on forward flexion.
Scapula depresses and moves laterally; inferior angle rotated laterally.
32
What is reverse scapulohumeral rhythm?
Rotator cuff muscles move the scapula instead of the humerus (shoulder hike).
33
What is paratenon?
Fatty or synovial tissue between a tendon and its sheath. Inflammation can be mistaken for tendonitis.
34
What are sources of referred pain in both shoulders?
Neck
Heart
35
What are sources of referred pain in the right shoulder?
Diaphragm
Gallbladder
Other GI organs
36
What is the difference between constant pain and intermittent pain?
Constant - indicates acute injury with an inflammatory and chemical process.
Intermittent - indicates mechanical problem that generally only hurts with positioning or activity.
37
How would you treat tendinitis vs. tendinosis?
Tendinitis - treat with anti-inflammatories
Tendinosis - treat with eccentric exercise, stress/shear the structures to build good collagen
38
What is tendinosis?
Failed healing process that is headed toward immature, improper degenerative collagen.
Tendons become thickened, weaker, and more likely to rupture or break down.
39
What is the purpose of the Apley's Scratch test?
Combines movements to decrease assessment time and assess functional capacity of the patient.
40
What motions are used to reach for your wallet?
IR and ext.
41
What motions are used to comb your hair?
ER and flexion
42
Which arm is usually tighter (dom/nondom)?
Dominant, unless it is an overhead athlete.
43
What symptoms indicate a spinal accessory nerve lesion?
Inability to abduct arm beyond 90 deg. Inability to shrug shoulder.
Pain in shoulder with abduction
44
What symptoms indicate a long thoracic nerve lesion?
Pain on flexing fully extended arm
Inability to flex fully extended arm
Winging starts at 90 deg forward flexion
45
What symptoms indicate a suprascapular nerve lesion?
Increased pain on shoulder flexion, scapular abduction, and contralateral CS rotation
Shoulder weakness
46
What symptoms indicate an Axillary nerve lesion?
Inability to abduct arm with neutral rotation
47
What symptoms indicate a musculocutaneous nerve lesion?
Weak elbow flexion with forearm supinated.
48
How much testing should you perform on a patient?
Enough to get the information you need without putting the patient at risk for further injury.
49
When do you NOT have to perform diagnostic special tests?
If a correct diagnosis is already known or if the patient is post-op.
50
Half of shoulders with this type of fracture have a brachial plexus injury?
Proximal humerus fracture
51
What is the painful arc of the glenohumeral joint?
Between 60-120 degrees abduction
52
What is the painful arc of the acromioclavicular joint?
Between 170-180 degrees abduction
53
What is a subscapular pattern? What does this indicate?
When a patient lifts their arms with the dorsum side of the forearm (shoulder IR). This indicates the pt is lifting primarily with the subscapularis muscle.
54
What is the strongest RC muscle?
Subscapularis
55
Why does a subscapular pattern lead to pathology? What can be done to correct this?
The greater tuberosity is being pulled under the acromion (impingement).
Give pt ER exercises to counteract muscle imbalance. Teach to lift in full-can scaption
56
Difficulty pushing elbow back against resistance (with hand on hip) indicates a strain in which muscle(s)?
Rhomboids
57
If a patient has limited IR, why wouldn't you MMT the subscapularis? What should you do?
Generates a false positive because you can't work in the full ROM. Perform special subscapularis tests for integrity.
58
When would you accelerate or slow down rehab: hypermobile vs. tight post-op patient? Why?
Accelerate: tight patient because joint mobility is needed for activity
Slow down: hypermobile patient because you might get too much mobility too soon (possibly overstretch a repair)
59
Cyriax: strong and painless means?
Normal
60
Cyriax: strong and painful means?
Tendon/muscle intact but irritated (tendinitis/osis)
61
Cyriax: weak and painful means?
Partial tear, compromised structure, pain overrides strength, long-term tendinosis
62
Cyriax: weak and painless means?
Complete rupture
63
What would you observe if a patient had weak infraspinatus/teres minor and you performed a resisted ER with arm at the side?
Abduction of the shoulder would occur
64
What could ER weakness indicate?
Pain, possible RC tear, neuro issue
65
Where do RCT's start and end?
Usually starts at the supraspinatus and travels backward toward infraspinatus.
66
What is the significance of the RC interval on RCTs?
The subscapularis is below and supraspinatus is above the coracoid process (united by coracohumeral l.)
This is why subscapularis is usually not involve in a RCT.
67
When does a RCT require surgery?
Small supraspinatus tear might be ok to treat without surgery, but once it starts to involve the infraspinatus, the tear is very large and requires surgical intervention.
68
What could IR weakness indicate?
Pain, possible subscapularis tear
69
If you get a painful response to RROM, what muscles do you suspect are involved?
The muscles that are stretched (muscles that do the opposite motion)
70
When is MMT/HHD contraindicated?
When pain will inhibit force generation capability. Patients that are acute, subacute, or highly irritable are contraindicated.
71
What are some reasons for inconsistencies by patients during a palpation examination?
They want to give you the right answer
You aren't testing properly
They are faking it
Neurological issue where everything is painful
72
What is the best test for ACJ pathology?
Palpating the ACJ (tenderness is best indication).
73
What are signs/symptoms of a shoulder separation injury (ACJ)?
Pain at ACJ
Trouble with end range elevation (shoulder retraction compresses the ACJ)
74
A patient is in IR so you can palpate the supraspinatus tendon. The area is tender to palpation. How do you know if it is a tendon issue or subacromial bursa issue?
If the pain goes away when the arm goes back to neutral, the tendon is indicated (tendons move, bursa does not).
75
You feel a "clunk" of the biceps tendon during external rotation. What does this indicate?
The biceps tendon is subluxating over the lesser tuberosity.
76
Where is the subacromial/deltoid bursa?
Adherent to the underside of the deltoid and acromion.
77
How can you tell between bursitis and tendinosis?
Bursitis is indicated if there is pain throughout positioning.
Tendinosis is indicated if pain goes away with repositioning.
78
What is the difference between laxity and instability?
Laxity - pathological looseness so that ROM is greater in 1+ directions but jt functions normally
Instability - pt unable to stabilize or control joint during rest/activity. Static restraints injured, weak muscles, or unbalanced force couples.
79
What should you do if you are performing PROM and can't tell if you feel capsular or muscle tightness?
Tell patient to slightly contract muscles acting in the opposite direction and then relax.
If range increases, problem was muscular and not capsular.
80
What are special tests for?
To confirm findings or a tentative diagnosis
81
Positive Hawkins-Kennedy
Painful arc
Positive infraspinatus test
Indicates?
Impingement
82
Painful arc
Positive drop arm test
Positive infraspinatus test
Indicates?
Full thickness RC tear
83
How does the Neer Impingement test cause impingement?
Passive stress causes the greater tuberosity to jam against the anteroinferior acromion.
84
How does the Hawkins-Kennedy test cause impingement?
It pushes the supraspinatus tendon (greater tuberosity) against the anterior surface of the coracoacromial ligament and coracoid process.
85
How does the posterior internal impingement test cause impingement?
Rotator cuff impinges against the posterosuperior edge of the glenoid when the arm is abd, ext, and ER
86
Is the full can test better than the empty can test for detecting full thickness rotator cuff tears?
No, but full can might be more comfortable
87
What is subacromial impingement?
Painful compression or friction of the subacromial contents due to reduced space in the subacromial region.
88
What are the 3 anatomical structures that form the coracoacromial arch.
Acromion
Coracoid process
Coracoacromial ligament
89
What structures are vulnerable to SAIS?
Rotator cuff tendons
Subacromial/subdeltoid bursa
Long head of biceps tendon
90
How does the long head of the biceps tendon help stabilize the GHJ during over-hand throwing motion?
It pushes the humeral head inferiorly into the glenoid fossa
91
Why should you strengthen the subscapularis for biceps tendon pathology?
To prevent the tendon from subluxating over the lesser tuberosity which promotes shoulder instability.
92
Why is it rare to surgically repair a long head of biceps tendon rupture?
People don't lose function because of it - can still do bicep curls and can still supinate. It is only surgically repaired for cosmetic reasons or for someone like a young baseball player.
93
If all motion is painful, pushing the acromion is painful, and even passive motion is painful, what is indicated?
Subacromial/subdeltoid bursitis
94
Repeated forceful overhead or shoulder height UE activities are risk factors for what?
Sub-Acromial Impingement Syndrome (SAIS)
95
What is primary impingement?
Mechanical compression/friction between the acromion and RC/bursa, associated with the shape of the acromion process and repeated overhead activity.
96
What are the 3 types of acromion?
Type I - normal
Type II - curved
Type III - beaked
97
What morphological type(s) of acromion process are a risk factor for primary impingement?
Type II and Type III (70%)
98
What is secondary impingement?
SAIS associated with dysfunction of other shoulder tissues that cause either excessive upward translation of the humeral head or altered kinematics of the humeral head during functional activity.
99
What portions of the GH capsule would cause secondary impingement when tight?
Posterior capsule drives humeral head anteriorly during arm elevation
Inferior capsule drives humeral head superiorly during elevation (posterior band)
100
Why are you unable to elevate your arm when you have a torn RC?
Humeral head is translated superiorly by the unopposed deltoid
101
What is the difference between extrinsic and intrinsic RC disease?
Extrinsic - caused by repetitive irritation or wear and tear on the bursal side due to repeated or chronic compression against the CA arch
Intrinsic - caused by lesion on the inferior side of the tendon itself, often related to aging and degeneration (at the hypovascular critical zone)
102
What motion stretches the supraspinatus, infraspinatus, and teres minor?
Hand Behind Back (HBB)
103
What kind of deficit would you see with a tight posterior capsule?
GIRD - Glenohumeral Internal Rotation Deficit
104
What movements do you test to differentially diagnose LHB vs. RC?
RROM shoulder flexion and elbow flexion/supination.
105
What are typical findings of bursitis?
Tenderness/swelling of bursa noted on palpation (acute inflammation co-existing with RC and/or LHB tendinopathy)
Active elevation very painful
ROM limited by pain
Hurts despite repositioning
106
How is internal RC impingement different from SAIS?
Unique to throwing athletes
Location of irritation is different (greater tuberosity against posterior glenoid rim)
Occurs in late cocking phase of throwing
107
What is a small full-thickness tear of the RC?
< 3 cm
108
How long does the inflammatory phase usually last?
12-14 days
109
How many cortisone injections can you get each year?
No more than 3
110
What does joint mobilization do for tendons?
Breaks up granulation and stimulates type I collagen production by fibroblasts
111
What does stretching do for muscle?
Re-educates muscle spindles as to their appropriate length.
112
Why are eccentrics such a great exercise for chronic tendinosis?
Shears the tissue more to stimulate type I collagen.
113
Why is low load / high rep a good idea for a painful shoulder?
Brings blood to the area (healing)
Protects weak tissue
Mechanoreceptors get a lot of stimulation and override pain messages (as long as in pain-free movement arc)
114
How long does it take to recover from shoulder surgery?
About a year for full recovery, but return to activity can be within a few months.
115
What size RC tears get arthroscopic surgery?
Small/moderate (< 3 cm)
Mobile large (3-5 cm)
Large (> 5) tears that can't be repaired - for debridement only
116
What kind of RC tears get open surgery?
Large tears that can be repaired
Large tears involving subscap or TM
Tears of musculotendinous junction
117
How long does the pain of bone healing usually take?
3-4 weeks
118
When is an acromioplasty performed (without repairing an RC tendon)
To create more space under the coracoacromial arch to reduce impingement on the RC.
Typically for patients with Type II or III acromions
119
What is the best way to metabolically "clean up" a joint?
Move it
120
Why do you want to fully elevate the arm after a supraspinatus tendon repair (phase I)?
Takes pressure off of the tendon.
121
What is the cause of shoulder pain if you do passive elevation of the arm after a supraspinatus tear? How do you fix this? What if they get stuck in elevation?
It hurts because of impingement. Take them up to pain level, have them use lat to push humeral head down, keep elevating arm this way until reach full range.
They get stuck in full elevation because the deltoid is raising the humeral head up. Grab their hand and tell them to use their lats to pull your hand down.
122
What is a Type I SLAP lesion?
Degenerative changes of labrum
Peripheral fraying
123
What is a Type II SLAP lesion?
Degenerative changes of labrum
Peripheral fraying
Anterior superior and posterior superior portions of labrum detached from rim
LHB tendon instability
124
What is a Type III SLAP lesion?
Free margin of superior labrum displaced into joint
Insertion of LHB is stable
125
What is a Type IV SLAP lesion?
Superior portion of labrum displaced into joint
LHB tendon partially ruptured
126
What type of SLAP lesion is most common?
Type II: 41-45%
127
What are the MOI for SLAP lesions? (5)
FOOSH
Traction injury
Throwing injury
Peel-back phenomenon
Posterior inferior capsule tightness
128
What is the peel-back phenomenon?
In the throwing position (abd 70-90 deg, progressive ER), torsional load is transmitted to the superior labrum via LHB tendon. Repeated stress causes failure of attachment of labrum and LHB tendon.
129
What is Dead Arm Syndrome?
Patient unable to recruit muscles in the arm for a temporary period of time.
Occurs with SLAP lesions or other forms of instability.
130
What are the two types of shoulder instability?
TUBS (torn loose)
AMBRII (born loose)
131
What does TUBS stand for?
Traumatic etiology
Unidirectional instability
Bankart lesion (detached anterior labrum)
Surgery is required
132
What does AMBRII stand for?
Atraumatic or microtrauma
Multidirectional instability
Bilateral (opp. shoulder also loose)
Rehabilitation is treatment of choice
Inferior capsular shift (surgery)
Interval closure between suprasp & subscap
133
What is the cause of pain in an AMBRII patient typically?
Impingement due to inability to stabilize scapulothoracic or glenohumeral joint due to:
RC pathology
Capsular laxity
Altered proprioception
Primary instability --> secondary impingement
134
What age group has a higher incidence of TUBS?
< 30 yo
135
What is a Bankart lesion?
Anterior GH capsule and glenoid labrum are damaged. Results from traumatic dislocation.
136
What is a Hill-Sachs lesion?
Compression fracture of the posterior lateral humeral head due to traumatic impact on the anterior inferior glenoid rim
137
If a patient has posterior instability? What range of motion extremes should be avoided during exercise?
Horizontal adduction, internal rotation
138
What range of motion extremes should be avoided during exercise for patients with anterior instability?
Horizontal abduction, external rotation
139
What is the shoulder capsular pattern? What about for a diabetic patient?
ER > ABD > IR > FLEX
Diabetic: IR has greatest restriction and occurs early.
140
What are the two types of primary frozen shoulder? Describe.
Idiopathic: mostly females; 30-60 yo
Systemic: commonly bilaterally in diabetics (> 10 years) or other endocrine diseases
141
What is secondary frozen shoulder?
Due to immobilization from trauma/surgery or may develop after something like tendinitis or bursitis.
142
What are the 3 phases of frozen shoulder? How long do they last?
Freezing, Frozen, Thawing
Last 3-4 months each
143
What are the pathological characteristics of frozen shoulder?
Capsular thickening
Loss of inferior capsular fold (axillary recess)
Decreased synovial fluid
Absence of synovial or capsular inflammation during frozen stage.
144
Where do 80-85% of proximal humerus fractures come from?
Low energy trauma from osteoporotic bones in the elderly. Usually a minimally displaced fracture.
145
Where do 15-20% proximal humerus fractures come from?
High energy trauma in the active adult
146
What is the most common and the second most common fracture type in the UE?
1: distal radius
2: proximal humerus
147
What are the MOI of proximal humerus fractures? (3)
FOOSH
Fall on shoulder
Direct blow to shoulder
148
What is Neer's one-part proximal humerus fracture?
No fragments displaced > 1 cm or > 45 deg. angulation
| 85% of fractures
149
What is Neer's two-part proximal humerus fracture?
> 1 cm displacement or fragment angulation of 45 deg.
Usually involve humeral head and surgical neck or head and greater tuberosity.
150
What is Neer's three-part proximal humerus fracture?
Greater tuberosity
Lesser tuberosity
Surgical neck
Blood supply to humeral head is at risk
151
What is Neer's four-part proximal humerus fracture?
Fracture-dislocation involving the articular surface.
High risk of avascular necrosis - requires hemiarthroplasty.
152
What is the most common complaint with OA?
Pain
153
Stretch the posterior capsule
Horizontal adduction, Genie stretch
154
Stretch to increase ER
Doorway/corner with arms at sides
Cane - standing or supine
155
Stretch to increase IR
Sleeper stretch, HBB, Genie
156
Stabilized shoulder elevation
Roll weighted ball up wall
| Weighted shrugs
157
How often should you re-eval your patient? Why?
Roughly every 2 weeks to make sure you're on track.
158
What are the 7 elements of patient/client management leading to optimal outcomes?
1. Examination
2. Evaluation
3. Diagnosis
4. Prognosis
5. Intervention
6. Re-examination/outcome assessment
7. Discharge planning
159
What is an evaluation?
Dynamic process in which the PT makes clinical judgments based on data gathered during the examination. Time to formulate a hypothesis.
160
When is a plan of care established?
During the prognosis. Goals and outcomes are clarified.
161
What 3 elements are required of a plan of care (goals and outcomes)>
Measurable
Time-sensitive
Specific
162
What are the 3 elements of an examination?
History
Systems review
Tests and measures
163
What is the clinical implication of beta blockers?
They prevent the heart rate from rising despite exercise.
164
What is the clinical implication of coumadin?
Aggressive techniques can cause bruising or bleeding.
165
What are the general time lines for acute, subacute, and chronic pathology?
Acute: 7-10 days
Subacute: 10 days to 7 weeks
Chronic: > 7 weeks
166
Pain that is sharp, burning, radiating, shooting, stinging indicates...?
Nerve pain
167
Pain that is deep, boring, dull, localized ache indicates...?
Bone or joint pain
168
Pain that is dull, unlocalized, or cramping indicates...?
Muscle pain
169
Clicks/pops indicate?
Dyskinesia, loose bodies, scar tissue, tears, or hypermobility (subluxation)
170
Snapping indicates?
CT structures causing friction
171
Grinding indicates?
DJD
172
What are 3 reasons for giving way?
1. Weakness/fatigue of muscles
2. Laxity --> instability and subluxation
3. Pain --> reflex inhibition of muscles
173
What is the SF-36?
A generic self-report outcome tool that can be used for any patient.
174
What is the PSFS?
Patient Specific Functional Scale
Patient identifies 5 functional activities that they have trouble with. Relevant specifically to that patient.
175
Why use a self-report tool if it is a subjective measure?
Allows us to focus on what is important to the patient.
176
What is an SEM?
Standard Error of Measurement
177
A Roland-Morris SEM is (95% CB) = 3 pts. Helen got a score of 20. Accounting for measurement error, you can be 95% confident that her true score...?
Lies between 17 and 23.
178
What is an MDC?
Minimal Detectable Change Score
Derived from the SEM. Used to determine meaningfulness of change over time.
179
A Roland-Morris MDC is (95% CB) = 5 pts. Helen has a score of 13 which is 7 points less than it was 3 weeks ago. What does this mean?
Since the MDC is 5 points, and she improved by 7 points, this means that you can be 95% certain that she has truly improved.
180
What are self-reported outcome tools for the spine? (3)
Roland-Morris Quesitonnaire
Revised Oswestry
Neck Disability Index
181
What are self-reported outcome tools for the upper extremity? (4)
DASH (Disabilities of Arm, Shoulder, and Hand)
SPADI (Shoulder Pain and Disability Index)
ASES
Penn Shoulder Scale
182
What are self-reported outcome tools for the lower extremity? (3)
LE Functional Scale
Lysholm Scale (Knee ACL)
WOMAC (hip or knee osteoarthritis index)
183
What is the Global Rating of Function?
Patient rates a functional activity from 0 to 100 (0 = no function, 100 = full function)
184
What are concerning HR, BP, and RR?
HR: < 60 or > 100 bpm
BP: > 140/90
RR: < 12 or > 20 bpm
185
Distal extremity swelling or discoloration indicates...?
Cardiac issue
186
What should you do if you see evidence of a DVT?
Send immediately to a doctor for anticoagulants. Do not workout or stretch!
187
What is orthostatic hypotension?
Dizziness caused by a drastic BP drop when patient stands up.
188
What is the difference between major and minor criteria for the Beighton scale?
Major - strongly suspects
Minor - may suggest
Generalized joint hypermobility
189
What are the 2 major criteria for the Beighton scale?
Beighton score of 4 or more
Arthralgia for > 3 months or in 4 or more joints
190
Which disorders are associated with generalized joint laxity? (5)
Ehlers-Danlos, Marfan's, osteogenesis imperfecta, RA, Down's
191
What is BJHS?
Benign Joint Hypermobility Syndrome
Patient has some Beighton criteria but no systemic disease attached.
192
What is the difference between hypermobility and instability
Hypermobility is excessive motion at a joint
Instability is a clinical problem in a joint that results from being hypermobile or from trauma
193
What are the 6 abnormal end feels?
Muscle spasm (guarding)
Abnormal capsular (early ROM)
Hard
Empty
Springy block
Boggy
194
What is an empty end feel?
Absence of end feel. Patient is in pain or won't let you finish.
195
What is a springy block end feel?
Restriction of joint motion in non-capsular pattern. Something is in the way blocking full motion.
196
What is a boggy end feel?
Feels like resistance or fluid drag as you move the joint. Due to effusion in the joint (fluid pressure increase).
197
What is a capsular pattern?
Predictable pattern of ROM loss when the entire capsule is restricted and tight.
198
What is a non-capsular pattern?
When parts of the capsule are restricted and tight, but not the whole capsule.
Can be due to adhesions, bursitis, neoplasm, lesion, loose body.
199
What is the Cyriax classification system?
Strong and Painless
Strong and Painful - mild lesion
Weak and Painful - greater injury
Weak and Painless - total rupture or interrupted nerve supply
200
What is sensitivity vs. specificity?
Sensitivity - should pick up what you are testing for (poor sensitivity = false negative)
Specificity - should be specific for the pathology it was designed for (poor specificity = false positive)
201
What are some things that you look for during a palpation exam?
```
Tenderness
Temperature
Moisture
Soft tissue mobility
Scar mobility
Edema
Effusion
Pulses
```
202
What is tested in a neurologic screening?
Myotomes
Dermatomes
Deep tendon reflexes
Neural tension tests
Abnormal reflexes (Babinski, Hoffmann, clonus)
203
Why do radiculopathies typically cause only partial numbness or paresthesias?
Dermatomes overlap so they are unlikely to result in complete anesthesia.
204
What are autonomous sensory zones?
Small patches of skin in the LE where dermatomes do not overlap and where it is possible to have complete anesthesia from radiculopathy.
L3 - anterior mid thigh
L4 - anterior distal thigh/knee
L4 - lateral/proximal leg
L4 - dorsal web space D1-D2
205
What can cause a depressed reflex?
Radiculopathy or pain
206
What are joint mobilizations for?
Pain management - stimulating the mechanoreceptors; gate theory - pain transmission blocked at the dorsal root ganglion
Improve mobility - reflex relaxation of related musculature, elongation of CT, facilitation of ROM and function
Tests and measure to assess accessory motions
207
What is gliding vs. traction in regards to the treatment plane?
Gliding - parallel to treatment plane
Traction - perpendicular to treatment plane
208
If the moving joint surface is concave and bone movement is restricted in an upward direction, what is the treatment direction?
Upward
209
If the moving joint surface is convex and bone movement is restricted in an upward direction, what is the treatment direction?
Downward
210
Does the glenohumeral joint follow the concave-convex treatment rule?
No! Treatment direction should be opposite of restriction, but it's actually in the same direction.
211
What is grade 1 traction?
Not enough tension is applied to take all slack out of tissues of joint. Used for pain reduction and reduction of muscle spasm.
212
What is grade 2 traction?
Therapist takes all slack out of tissues of joint. Used for pain reduction, reduction of muscle spasm, and mild stretching of soft tissues.
213
What is grade 3 traction?
Therapist applies enough tension to cause joint distraction. Used for joint decompression and more aggressive stretching of soft tissues.
214
What is a low grade gliding mobilization?
Large or small oscillations at the beginning or mid-range of available joint motions. Used for relaxation and pain control.
215
What is high grade gliding mobilization?
Large or small oscillations or sustained stretch near the end of available range of motion. Used to assess accessory motions during exam or improve soft tissue and joint mobility.
216
What is deep friction massage used for?
Remodeling tissue. It takes hypomobile or scarred tissue and helps restore normal collagen alignment and mobility. It also enhances blood flow to area.
217
What is normal ROM for GHJ?
0-120 degrees
218
What does the glenoid labrum do?
Deepens the glenoid cavity 50% and prevents excessive rotation/translation of the humeral head.
219
What does the superior glenohumeral ligament limit?
Inferior and anterior translation and external rotation
220
What does the middle glenohumeral ligament limit?
external rotation
221
What does the inferior glenohumeral ligament limit?
Supports humeral head above 90 degrees abduction
Anterior band - limits external rotation (throwing)
Posterior band - limits internal rotation
222
What does the coracohumeral ligament limit?
Inferior translation
ER below 60 deg abd
223
What does teh coracoacromial ligament do?
Forms an arch over the humeral head and blocks superior translation
224
Why is the coracoacromial ligament so hard to treat when it becomes fibrotic?
The ligament connects to the same bone - there's nothing to mobilize.
225
What does the transverse humeral ligament do?
Forms roof over the bicipital groove to hold the LHB tendon.
226
What forces play on the shoulder at rest?
Low firing RC pulls head into glenoid fossa
Coracoacromial ligament, coracohumeral ligament, and subscapularis tendon support against gravity.
227
What ligament is the first to tear when acromioclavicular joint is stressed?
Acromioclavicular ligament
228
What does the coracoclavicular ligament do?
Primary support of ACJ. Limits elevation/excursion between the coracoid process and the clavicle.
Made up of 2 ligaments: conoid (medial) and trapezoid (lateral)
229
What kind of joint is the acromioclavicular joint?
Saddle joint with articular disc (thicker anteriorly)
230
What is the difference between the anterior and posterior sternoclavicular ligaments?
Anterior is weak and allows SCJ to dislocate anteriorly
Posterior is much stronger to protect vital structures deep to clavicle
231
What does the interclavicular ligament prevent?
Superior or lateral motion of SCJ
232
What does the costoclavicular ligament do?
Maintains the integrity of the SCJ. It is extracapsular and limits all movement ranges.
233
What direction does the glenohumeral joint typically dislocate?
Anteriorly
234
What ligament tears when there is a shoulder separation due to fall on elbow?
Acromioclavicular ligament tear
235
What ligament tears when there is a shoulder separation due to fall on shoulder?
Acromioclavicular and coracoclavicular ligament tears
236
What is the most commonly injured RC muscle?
Supraspinatus
237
Where is the labrum torn most often?
Anteriorly
238
What is the dynamic between supraspinatus and deltoid for shoulder abduction?
First 20 deg: supraspinatus
Rest of range: middle deltoid
239
Latissimus dorsi and pectoralis major provide what to the shoulder?
An agonist/antagonist contraction around a common axis to maximally stabilize the joint (co-contraction principle)
240
What muscle exerts a downward force on the scapula to stabilize it against ground reaction forces when patients use crutches?
Pectoralis minor
241
ROM: flexion
180
242
ROM: extension
50
243
ROM: abduction
180
244
ROM: horizontal abduction
45
245
ROM: horizontal adduction
135
246
ROM: IR
80
247
ROM: ER
80
248
What is the clavicular movement during arm elevation? How?
Upward rotation and elevation of the distal end via conoid ligament being pulled up by the scapula.
249
What injuries occur from lateral to medial clavicular force?
ACJ separation
Clavicular fracture
SCJ separation
250
What movements make up protraction?
Scapula upward rotation and abduction
251
What kind of scapular tipping occurs during arm elevation?
Posterior tipping (upper border of scapula)
252
What is the concave/convex relationship of the humeroulnar joint?
Concave trochlear notch ON
Convex trochlea
Same direction roll and glide
253
What is the concave/convex relationship of the humeroradial joint?
Concave radial head ON
Convex capitulum
Same direction roll and glide
254
What is the concave/convex relationship of the proximal radioulnar joint?
Convex radial head ON
Concave radial notch (ulna)
Should be opposite roll and glide, but annular ligament prevents normal roll/glide mechanics
255
What is the concave/convex relationship of the distal radioulnar joint?
Concave ulnar notch (radius) ON
Convex head of ulna
Same direction roll and glide
256
An increased carrying angle puts more stress on which collateral ligament?
Medial Collateral Ligament
257
ROM/end feel: Elbow flexion
135-150 (soft)
258
ROM/EF: Elbow hyperextension
0-20 (hard)
259
ROM/EF: Forearm supination
70-90 (firm)
260
ROM/EF: Forearm pronation
80-90 (firm)
261
What is the clinical implication of a loss of more than 30 degrees elbow flexion
Drastic loss of functional reach
262
What is considered functional AROM for elbow flexion and extension?
15-130 degrees
263
What is considered functional AROM for pronation and supination?
50 degrees both ways
264
What produces cubital valgus of the elbow (carrying angle) normally?
Medial portion of trochlea expands farther distally which causes more lateral orientation of the ulna with respect to the humerus.
265
What motions increase tension of the MCL (anterior fibers)
Valgus
Extension
Flexion
266
What motions increase tension of the MCL (posterior fibers?
Valgus
| Flexion
267
What motions increase tension of the LCL?
Varus
External rotation
Flexion
268
What motions increase tension of the annular ligament?
Distraction of radius
| External rotation
269
What is the most common type of humeroulnar joint dislocation?
Lateral and posterior movement of the forearm from a valgus (lateral) force on the distal forearm.
270
Where is the elbow joint capsule loose/tight?
Somewhat loose anteriorly
Very loose posteriorly
Capsule unfolds anteriorly or posteriorly depending on flexion/extension. Most lax in mid-range.
271
What kind of force does the MCL resist?
Valgus forces (deviate forearm laterally)
272
Overhead and throwing activities increase valgus or varus stress?
Valgus
273
What kind of force does the LCL resist?
Varus forces (deviate forearm medially)
274
Rotational laxity (excessive IR/ER) of the elbow could indicate...?
collateral ligament damage
275
If you are differentiating between a tight anterior elbow capsule and a tight bicep, what should you do?
If you get more flexion at the elbow while the shoulder is put in flexion, then you know the tightness was in the biceps.
276
A tight brachialis muscle presents similar to capsular tightness in that there is decreased extension ROM despite shoulder/forearm position. How do you differentiate?
Muscle tightness: rubbery/springy end feel
Capsule tightness: harder, less springy
277
What produces stability of the elbow?
Bony congruency (50%) and extensive ligamentous support
278
Open/closed packed positions of humeroulnar joint?
Open: 70-90 deg
Closed: full extension
279
Open/closed packed positions of humeroradial joint?
Open: full extension
Closed: > 90 deg. flexion
280
Open/closed packed positions of proximal radioulnar joint?
Open: 20-35 deg. supination
Closed: 5 deg. supination
281
What is normal carrying angle (cubital valgus)?
15 degrees
282
What are the effects of excessive cubital valgus?
Increased tensile forces at MCL and CFT
Increased likelihood (+) valgus tests
Increased compressive forces at lateral elbow (radial head and capitulum)
Increased likelihood MCL tear
283
What is a gunstock deformity? Effects?
Cubital varus
Lateral structures stretched, medial structures compressed.
Reversal of normal carrying angle due to distal humeral fractures or lateral growth of humerus > medial growth
284
What is the capsular pattern of the elbow joint?
Limitation of Flexion > Extension
285
What is the oblique cord?
Fascial band that limits separation of radius and ulna
286
What is the quadrate ligament?
Reinforces the inferior joint capsule and limits spin of radial head at end ranges of pronation/supination
287
Functions of the interosseous ligament?
Binds radius to ulna throughout length
Distributes forces from radius/hand to the ulna in WB and FOOSH
288
What is the best kind of stretch for contracture of soft tissue?
Low load, prolonged stretch
289
What is lateral epicondylitis?
"Tennis elbow"
Microtears in muscle fibers of wrist extensors and then the CET causing an inflammatory response.
MOI: overuse/misuse of wrist extension (back hand) / flexion (eccentric) and gripping
290
What is medial epicondylitis?
“Golfer’s Elbow”
Microtears in muscle fibers of wrist flexors and then the CFT causing an inflammatory response.
MOI: overuse/misuse of wrist flexion
291
What is olecranon bursitis?
Inflammation of the olecranon bursa
MOI: trauma, infection, or repetitive WB on elbows
292
What are the MOI for UCL/MCL tears?
Valgus and distraction forces (throwing) or FOOSH
293
When is a Tommy John surgery done?
For a full tear of the MCL. The contralateral palmaris longus or a hamstring graft is used for reconstruction.
294
What are the MOI for LCL tear?
Trauma or being overstretched from gunstock deformity.
295
What is a grade I radial head fracture?
Nondisplaced (crack in bone)
296
What is a grade II radial head fracture?
Comminuted, close to the origin
297
What do grade III and IV radial head fractures require?
Surgical intervention - external fixation
298
What is the MOI for a radial head fracture?
Compression injury, typically FOOSH
299
What is the MOI for an olecranon fracture?
Direct blow to olecranon in flexion
FOOSH hyperextension fracture
300
What is the MOI for ruptured biceps brachii tendon?
Trauma
Flexion against resistance
Hyperpronation
301
What is the MOI of elbow dislocation?
FOOSH
302
90% of simple elbow dislocations are in which direction?
Posterolateral
303
What are the signs of compartment syndrome? (5)
Extreme pain with all motions
Paresthesias with distinct pattern depending on compartment
Paresis/paralysis
Pale/bluish skin
Diminished pulses/capillary refill
304
What is ulnar neuritis?
Damage/irritation of ulnar nerve usually at the cubital tunnel.
305
What is the MOI of ulnar neuritis?
Usually from compression of ulnar nerve in cubital tunnel (direct or soft tissue compression)
306
What is median neuritis?
Anterior Interosseous Syndrome
Damage/irriation of the median nerve.
307
What is the MOI of median neuritis?
Compression of the median nerve between the heads of the pronator teres, proximal head of FDS, or enlarged bicipital tendon bursa.
Repetitive pronation in elbow flexion
Trauma: displaced fractures of ulna or radius
308
What is radial neuritis?
Posterior interosseous syndrome
Damage/irritation of radial nerve
309
What is the MOI of radial neuritis?
Compression of radial nerve under tendinous origin of ECRB or under proximal supinator (radial tunnel).
310
How can you differentiate between lateral epicondylitis and radial neuritis?
With lateral epicondylitis - strength is still intact.
Trying to do active release on a radial nerve injury will make the pain worse.
311
What is Chronic Regional Pain Syndrome?
Abnormal response to injury or immune disorder (autonomic)
312
What is Little Leaguer’s Elbow?
Instead of ligament tears as in older throwers, the same valgus and distractive repetitive forces disrupt growth plate formation in long bones of the arm.
313
What are the effects of Little Leaguer’s Elbow?
Panners Disease - decrease in blood flow with deterioration and malunion of growth plate.
Osteochrondritis dessicans of capitulum - lateral elbow pain due to compression of radius and capitulum that causes inflammation and pain. Fragmentation of cartilage and loose bodies in joints.
314
What is radiocapitellar chondromalacia?
Painful snapping of the synovial plica at the lateral elbow
315
What are 2 causes of an elbow flexion contracture?
Prolonged immobilization
CP or other neuro disorders (increased flexor tone)
316
FOOSH typically causes?
Medial soft tissue damage or lateral compression injuries.
317
What is internal RC impingement?
Compression of supraspinatus and infraspinatus tendons against the glenoid rim in the late cocking phase of throwing.
Greater tuberosity compressed against the posterior glenoid fossa rim; under surface of the supraspinatus is pinched.
318
In a post-op exam of an RC repair, what can/can’t you measure with PROM?
Yes: flexion, abduction, external rotation
No: horizontal adduction, internal rotation
319
Why is an rTSA performed?
Chronic synovitis erodes soft tissues or RCT/LHB rupture cannot be repaired.
320
What are the advantages of an rTSA?
Overcomes the breakdown of implants caused by chronic deficiency of the rotator cuff (impingement of implant).
Increases stability of the joint and increases the deltoid moment arm.
321
Why is an rTSA procedure a longer rehab than a regular TSA?
rTSA patients have to be immobilized for 4-6 weeks while the soft tissues heal.
322
Patients who have undergone successful surgical repair of a rotator cuff tear typically being active external rotation and abduction against gravity at:
8-12 weeks post-op
323
A patient who has undergone SLAP repair 6 weeks ago will most likely have which of the following ROM restrictions/precautions?
No elevation above 90 deg, no ER past 30 deg., and no IR past 60 deg.
324
What is the median nerve self glide?
Arm at side, head in neutral
Extend wrist and ulnar deviate (finger ext)
Side bend head away or abduct
325
What is the radial nerve self glide?
```
Anatomical position
Flex thumb across palm
Pronate forearm
Extend and abduct arm away from body
Side bend head away
```
326
Open/closed packed position of ACJ?
Open: arm by side
Closed: 90 deg. abd
327
Open/closed packed position of SCJ?
Open: arm by side
Closed: full elevation and protraction
328
Capsular pattern for ACJ?
Pain at extremes, especially horizontal adduction and full elevation.
329
Capsular pattern for SCJ?
Pain at extremes, especially horizontal adduction and full elevation
330
Capsular pattern for radioulnar joint?
Pronation limit equal to Supination
331
What is a Fountain sign?
Swelling at the ACJ. Indicated degeneration of the ACJ or bursitis
332
What is a snapping scapula?
Scapula sits low on the ribs. The superior/medial border snaps when placing the arm in abduction or adduction
333
What is Sprengel’s deformity?
Congenitally high scapula that is small and internally rotated. Muscles are undeveloped or fibrous. Decreased abduction capability.
334
Reasons for dynamic winging? (6)
```
LTN lesion
Accessory lesion
Rhomboid weakness
Multidirection instability
Splinting (pain)
Brachial plexus radiculopathy
```
335
What is Neer’s stage I classification of SAIS?
Age < 25
Reversible edema and hemorrhage.
Treat with rehab.
336
What is Neer’s stage 2 classification of SAIS?
Age 25-40
Irreversible fibrotic changes, bad collagen
Treat with shear/stress, eccentrics, and manual therapy
337
What is Neer’s stage 3 classification of SAIS?
Age > 40
Bone spurs, RC and LHB tears
Treat with surgery
338
How would you treat tendinosis?
Restore ROM, mobilize/stretch capsular tightness, eccentrics, RC strength/scap stabilization, UQ posture correction, CFM
339
What motions can you examine post-op after a rotator cuff repair? What motions do you avoid?
Yes: Flexion, abduction, ER
No: Horizontal adduction, IR
340
What is a Bankart lesion?
Injury of anterior inferior labrum due to repeated anterior dislocation. Often accompanied by Hill-Sachs lesion (posterior humeral head)
341
What is a Hill-Sachs lesion?
Damage to posterior superior humeral head due to repeated anterior dislocation. Often accompanied by Bankart lesion.
342
What is the intervention for anterior instability?
Enhance stabilization of dynamic structures: RC, scap, anterior muscles (delt, pec major, lats, teres major, biceps). Stretch posterior capsule.
343
What is the intervention for posterior instability?
Enhance stabilization of dynamic structures: RC, scap, posterior muscles (delt, triceps, infraspinatus, teres minor). Stretch anterior capsule.
344
What is the intervention for multidirectional instability?
Strengthen all muscles that surround the joint. No stretching.
345
How long is a young person immobilized after dislocation? Older person?
Young: 3-6 weeks
Old: 1-3 weeks
346
Intervention for freezing stage of frozen shoulder?
Pain relief and motion as tolerated. Pendulums and AROM in good scapulohumeral rhythm
347
Intervention for frozen stage of frozen shoulder?
TERT: Total End Range Time
30 min/day of low load prolonged stress, joint mobilizations
348
Intervention for thawing stage of frozen shoulder?
TERT: Total End Range Time
30 min/day of low load prolonged stress, joint mobilizations
349
What is the surgical treatment for frozen shoulder?
Manipulation under anesthesia during thawing stage
Or arthroscopic capsular release
350
Intervention for 1-part proximal humerus fracture?
1-3 wks: PROM when head/shaft move as unit; AROM ST, elbow, wrist
4-6 wks: AAROM/AROM of ST, GH; elevation in scap plane
8-12 wks: Isometrics, open/closed chain exercises
12+: rhythmic stabilization, plyos, sport/ADL specific activities
351
What motions should you avoid if there was a fracture of the greater/lesser tuberosity?
Greater: abd with ER
Lesser: IR
352
What is the progression of treatment after a hemiarthroplasty (4-part fx)?
PROM day 1
AROM @ 3-5 weeks when stable
Strength @ 6-8 weeks
353
How does lateral epicondylitis present?
Acute tenderness at CET
Pain with resisted wrist extension
Pain with passive elbow extension and wrist flexion
354
What are the treatments for lateral/medial epicondylitis?
```
Muscle release
Progressive stretch and strength
Splint, Chopat strap
CFM, ice massage
Ionto (dexamethasone)
```
355
How does medial epicondylitis present?
Acute tenderness at CFT
Pain with resisted flexion
Pain with passive elbow extension and wrist extension
356
How does an MCL tear present?
“Pop” when throwing
Pain with throwing and extension
Medial instability (+ valgus test)
357
Treatment for MCL tear?
No throwing 3 months
Anti-inflammatory modalities
PREs (core and scap)
Tommy John Surgery
358
When can you start to throw again after Tommy John surgery?
Light toss at 3-4 months
Position players: 6 months
Pitchers: 9-12 months
359
How does an LCL tear present?
Positive varus test (lateral instability)
Reverse carrying angle, LCL pain
360
How does a radial head fracture present?
Acute pain over the lateral elbow
| Marked loss of ROM in flex/ext/pro/sup
361
How do you treat a grade I radial head fracture?
Anti-inflamm modalities
AROM to tolerated
Progress to PREs and restore ROM in 2-3 months
362
How do you treat a grade II-IV radial head fracture?
Hard cast 2-4 weeks
Hinge cast 4-6 weeks
363
How does an olecranon fracture present? Treatment?
Acute pain over the posterior elbow
Marked loss in extension > flexion
Tx: immediate AROM to tol; restore full ROM in 2-3 months
364
How does a biceps tendon rupture present?
Acute pain of anterior elbow
ROM loss of supination
Supination strength < 3/5
365
How does an elbow dislocation present?
Guarded/apprehensive to extension
| ROM limit ext > flex
366
How do you treat compartment syndrome?
Control edema with positioning, not ice
Remove cast/splint
Refer to doctor immediately
Fasciotomy
367
How does ulnar neuritis present?
```
Acute/dull aching pain over medial elbow
Pain at end range
Positive Tinel’s and elbow flexion test
Decreased grip strength
Hypothenar atrophy
Paresthesias in ulnar distribution
```
368
How does median neuritis present?
```
Acute/dull ache over medial elbow
Decreased tip to tip or pinch grip
Decreased movement of middle/index fingers
Ape hand (retracted thumb)
Unable to oppose
```
369
How does radial neuritis present?
Acute tenderness over lateral epicondyle
Pain with resisted supination
Decreased wrist strength, middle finger
+ Tinel's
370
How do you treat neuritis?
```
Rest
Eliminate provocative movement
NSAIDS, ice
Restore ROM
Nerve glides
```
371
How does CRPS present?
Severe, disabling, disproporionate pain
Hypersensitivity
Red or blue skin (hot or cold)
372
How do you treat CRPS?
```
Gentle/aggressive AROM as tolerated
Avoid end range PROM in acute stage
TENS on nerve path
Desensitization
Psychotherapy
Nerve blocks, meds
```
373
How does Nursemaid’s Elbow present? Treatment?
Avoid use of arm, painful supination
Reduced by hyperpronating; anti-inflamm modalities, promote use of arm
374
How does Little Leaguer’s Elbow present? Treatment?
Localized fatigue, diffuse pain and tenderness, ROM limits ext > pro > sup
No throwing for 3 months
375
How does radiocapitellar chondromalacia present?
Diffuse lateral elbow pain
Painful joint snapping at end range extension and supination
+ flexion-pronation test
