UE Practical Flashcards
(288 cards)
1
Q
Scanning Cervical Exam Requirement
A
-VBI
-Alar Ligament
-Transverse Ligament
2
Q
5 Ds
A
-Dizziness
-Dysarthria
-Dysphagia
-Diplopia
-Drop Attacks
3
Q
3 Ns
A
-Numbness/tingling
-Nystagmus
-Nausea
4
Q
Cervical Physical Examination Components
A
- Pt Hx
- Systems Review
- Observation (body, face and eyes)
- Screening (VBI/TL/AL)
- Scanning Exam (if needed)
- Upper and lower c-spine/UE/Thoracic AROM>PROM>RROM
- Flexibility
- Muscle
- Joint Play
- Palpation
- Special Tests
5
Q
3 Mandatory Qs for Neck Pain
A
- Dizziness, blackouts or drop attacks?
-Ds and Ns
-VBI - Hx of RA/arthritis or steroids?
- Any neuro in legs?
Optional: Down Syndrome
-ligamentous laxity
6
Q
Canadian Cervical Spine Rule
A
-guidlines for immobilization and/or imaging after trauma to neck
-positive= refer
- High risk factor for immobilization (any of these)
->65
- dangerous MOI
-Numbness and tingling in extremities - Low risk factor for assessment of ROM
-Complex rearending
-cannot sit up in ED
-cannot ambulate
-immediate neck pain
-pain at midline of c-spine - Can Pt voluntarily actively rotate 45deg
-yes: treat
-no: immobilize and image
7
Q
Modified Sharp Purser Test
A
-1st test done for Transverse lig and AA stability
-relocation test
- Pt in sitting
- Chin tuck to move C1 on C2 for 5s
- Ask about Ds and Ns and “clunk”
- Pt Pincer’s C2 SP and post/sup pressure on forehead
(+): S/s are reduced
8
Q
Supine Lift-Off Test
A
-secondary test for Transverse lig and AA stability
- Pt supine
- PT finger in squish of C1 and push anteriorly
(+): Pt has excessive upper cervical mobility of C1 w/o movement of C2 and below
9
Q
Alar Ligament Test
A
-assess alar ligs and OA stability
- Pt in supine
- PT pincer on C2 SP
- PT passively SB or Rot
(+): immediate CONTRA movement of C2 not felt
10
Q
Vertebral Basilar Screen
A
-assess VBA
- Pt supine
- PT passively Extends head
- Rotate L
- Rotate R
- Ext w/ Rotation R
- Ext w/ Rotation L
ask about Ds and Ns for Each
If (+) w/ extension, test ROT to determine side
(+): Presence of Ds and Ns in any position
11
Q
Cervical Spine Exam
A
AROM>(measure)>PROM
-seated
Upper Cervical 1st (5-10dg flx and 45 rotation):
-Flexion (chin tucks)/Extension
-Pt uses 2 hands to stabilize w/ overpressure
Lower Cervical 2nd (70-90 flx and 70-90 rot and 30-40 SB:
-Flx/Ext/LSB/Rotation
-Quadrant testing
12
Q
Cervical MMT
A
-test in neutral
Flexion:
-C1-C2 and CN 11
Extension
Side Bending:
-C3 and CN 11
Rotation:
-C2
13
Q
Facet Joint Dysfunction Thoracic HVLAT CPR
A
CPG:
1. S/s <30 days
2. No s/s distal to shoulder
3. Looking up doesn’t agg s/s
4. FABQ physical activity <12
5. Diminished upper t-spine kyphosis
6. Cervical ext ROM <30deg
(+) > or = 3, successful outcome w/t-spine HVLAP in 86% of Pts
14
Q
ICF Model: Neck Pain w/ Mobility Deficits
A
-hypomobility
S/s:
-Pain in central (older stenosis) or Unilateral (younger foramena)
-limited ROM that constantly reproduces s/s
-possible referred pain
Exam:
-Dec ROM
-Neck pain at end ranges
-Restricted mobility in c and t-spine
-referred pain reproduced w/ provocation
-deficits in cervico-scapulo-thoracic strength
Treatment:
-T-spine manips
-C-spine manual
-Cervical ROM
-Strengthening
15
Q
ICF Model: Neck Pain w/ Movement Coordination Impairments
A
-Instability
S/s:
-MOI linked to trauma/whiplash or hypermobility
-referred shoulder pain
-HA, concussion, confusion, hypersensitivity
Exam:
-(+): cranial cervical flexion test
-(+): Neck flexor muscle endurance test
-(+): Pressure algometry
-Neck pain at midposition to end
-Dec strength
-Point tenderness
Treatment:
-Pt education and prognosis
-Increase ROM
-Manual or exercise
-Pain science
16
Q
ICF Model: Neck Pain w/ Headaches
A
S/s:
-non-continuous, unilateral neck pain (facet joint) and referred HA
-HA precipitated or aggravated by neck movements or positions
Exam:
-(+): Cervical flexion rotation test
-HA reproduced w/ provocation
-Limited ROM
-Strength and endurance deficits
Treatment:
-Mobility
-Self SNAGs to AA joint
-Manual therapy c and t-spine
17
Q
ICF Model: Neck Pain w/ Radiating Pain
A
-Radiculopathy
S/s:
-neck pain w/ UE radiating pain
-UE neruological signs
Exam:
-(+): Cervical radiculopathy CPR
-UE sensory, strength deficits
Treatment:
-Exercise and MT
-Cervical collar for short term
-Intermittent traction
-Pt education
18
Q
Trapezius Muscle Length
A
-only check if motion IS limited
must check length if you prescribe stretch later
- Pt supine
- Flex head > contra SB
- PT depresses ipsi shoulder
Normal: 45deg of rot w/ soft end range
Decreased:<45 or hard end range
19
Q
Levator Muscle Length
A
-only check if motion IS limited
must check length if you prescribe stretch later
- Pt supine
- Flex head > contra SB and contra rotation
- PT depresses ipsi shoulder
Normal: 45deg of rot w/ soft end range
Decreased:<45 or hard end range or TTP
20
Q
SCM Muscle Length
A
-only check if motion ISN’T limited
must check length if you prescribe stretch later
- Pt supine w/ head off plinth
- CONTRA SB and extension and rotate IPSI
- PT stabilizes ipsi shoulder
Normal: Equal range Bilat
Decreased: Unequal range bilat
21
Q
Scalenes Muscle Length
A
-only check if motion ISN’T limited
must check length if you prescribe stretch later
- Pt supine w/ head off plinth
- Extend and contra SB while stabilizing ipsi
- PT stabilizes ipsi shoulder
Normal: 45deg of SB
Decreased:<45 of SB
22
Q
OA Joint Mobilization Opening/Closing
A
-Normal, Hypo, Hyper
-Push C1 TP
Opening R:
-CV flexion w/ L Sideglide
Opening L:
-CV Flexion w/ R sideglide
Closing on R:
-CV ext w/ R sideglide
Closing on L:
-CV ext w/ L sideglide
23
Q
AA Joint Mobilization
A
-rotation only
-Normal, hypo, hyper
- Pt flexes mid-cervical to lock out upper
- Pt rotates neck to each side
24
Q
Cervical PA Springing Joint Mobility
A
-assess C2-T1
-Can be SP (central) or facet joint (unilateral)
-Pt in prone
-Down and medial force
C7 will disappear w/ ext
25
Cervical Sideglides Joint Mobility
-C2-T1
-Sideglides on facet joints
-Normal, hypo, hyper
Flexion (Opening Restriction):
1. PT Flex neck at segment assessed
2. Sideglides to L to open R
3. Sideglides to R to open L
Extension (Closing Restriction):
1. PT extends neck at segment assessed
2. Sideglides to L to close L
3. Sideglides to R to close R
26
Cervical Closing Restriction
Issues with:
-extension, SB, Rotation
-IPSI side of pain
27
Cervical Opening Restriction
Issues with:
-flexion, SB, rotation
-CONTRA side of pain
28
Cervical Compression and Distraction
Normal: flx/ext, LSB, rot
Provocation: compression and distraction, 5-8s
Pain Reproduced w/ Compression:
-herniation
-end plate/fx
-arthritis
-nerve root
Pain Reproduced w/ Distraction
-spinal lig tear
-tear of annulus fibrosis
-spasm
-dural irritability
-cervical instability
29
Cervical Quadrant Testing
-spine pathology
-Flx and RSB: disc on left or LOR
-Flx and LSB: disc on right or ROR
-Ext and RSB: foramen on right or RCL
-Ext and LSB: foramen on left or LCL
30
Spurling Test
-test for cervical radiculopathy
-Compresses foramina
1. Pt seated
2. PT asked Pt to SB > applies overpressure for 5-8s
3. Repeat on opp
(+): reproduction of s/s into Ipsi shoulder
31
Cervical Radiculopathy CPR
1. C-spine rot to painful side <60deg
2. (+) Spurling test
3. (+) ULLT#1
4. (+) Cervical Distraction (relieves)
4/5: 90%
3/5: 65%
32
Cranio-Cervical Flexion Test
-assesses neck endurance of deep flexors
-for movement coordination deficis
1. Pt in supine hooklying w/ biofeedback cuff behind head
2. Cuff inflated to 20 mmHg
3. Pt nods for 10s at 22mmHg
4. Rest for 10s and start again adding 2 mmHg
5. Test ends when Pt can no longer hold
Activation Score: max pressure held for 10s
Performance Index: max pressure held for 10s x reps
33
Neck Flexor Endurance Test
-assesses neck flexor endurance and motor control
1. Pt in supine in hookyling
2. Pt tucks chin and lifts head 1 inch off the table
3. Test ends when you can no longer hold up head
(+) for women: <38.9s
(+) for men: <29.4
34
Cervical Flexion-Rotation Test
-assesses for presence of cervicogenic HA
-provocation test
1. Pt in supine w/ maximal neck flx and hold
2. Apply pressure through rotation to both sides and note any change in s/s
(+): Rotation ROM loss to 1 side >10deg compaired to opp OR reproduction of s/s
35
Shoulder Abduction Test
-assess for presenve of radicular s/s
-usually rules out shoulder
1. Pt seated w/ hand on top of head
(+): s/s arre reduced or relieved
*not a good screening test*
36
Canadian C-Spine Rule Not Applicable
-non trauma
-<15 GCS
-unstable vitals
-<16 years
-Acute paralysis
-known vertabral disease
-previous c-spine surgery
-pregnant
37
Median Nerve ULTT 1
1. Use elbow to depress scap
2. Abduct
3. Extend wrist and fingers
4. ER
5. Elbow extension
6. Lat sidebending
+ Findings: differences btw sides, distant component, reproduction of s/s
C5-T1
38
Contraindications for Neurodynamic Mobilizations
-Recent repair
-Malignancy
-Active Inflammatory Disorders
-Acute Inflammatory Demyelinating Disorders
39
Neurodynamic Mobilization Techniques: Tension
-load opposite ends of nerve
-both "on" or "off"
-when glides no longer help
ex: head flx and ankle DF, the head ext and ankle PF
40
Neurodynamic Mobilization Techniques: Gliding
-load one end of nerve while relieving stress on opposite end
- 1 "on" and 1 "off" then switch
ex: head flx and ankle PF, the head ext and ankle DF
41
Neurodynamic Mobilization Techniques: Stretching
-load opposite ends of nerve and hold
-7-30s
-both "on" or "off"
-most aggressive
ex: head flx and ankle DF (hold), the head ext and ankle PF (hold)
42
Radial Nerve ULTT 2
1. Use hand to depress scap
2. GH IR
3. Flexion wrist and fingers
4. Forearm pronation
5. Elbow extension
6. GH ABD
7. Lat sidebending
+ Findings: differences btw sides, distant component, reproduction of s/s
C5-T1
43
Ulnar Nerve ULTT 3
1. Use hand to depress scap
2. Abduct
3. GH ER
4. Forearm pronation
4. Extend wrist and fingers
5. Elbow flexion
6. Lat sidebending
+ Findings: differences btw sides, distant component, reproduction of s/
C8-T1
44
OA Joint Mobilization (PT up)
-Flexion 5-10deg supine
1. Pt in supine
2. PT fingers in occiput and shoulder on forehead with downward force
3. PT flx OA and oscilate or sustain
45
OA Joint Traction
1. Pt in supine
2. PT fingers in occiput and shoulder on forehead for sttability
3. PT distracts OA for 5-10s
46
AA Joint SNAG
-rotation self mobilization
1. Pt in sitting
2. Towel around upper neck
3. Grab across w/ contra towel and pull towars shoulder and up
4. Other hand pulling towel
47
AA Joint MET
1. Pt in supine
2. PT move head into contra (restricted side) SB and ipsi rotation
3. Tell Pt to look to SB side (contra)
4. Hold for 6 seconds
5. Rotate more
48
Cervicogenic HA OA>AA>C2-C3
1. Pt head in neutral; PA mobilization to C1 Lamina on affected side until point of pain
2. Oscilate for 10s until s/s reduce
3. Pt in ~30 ipsi rot (to pain); PA mobilization to C2 Lamina on affected side until point of pain
4. Oscilate for 10s until s/s reduce
5. Pt head in neutral; PA mobilization to C2 and C3 Lamina on affected side until point of pain
49
Seated Cervico-Thoracic Juntion Manipulation
1. Pt in sitting at edge of mat toward PT
2. PT behind Pt w/ arms around PT w/ hands on forearm
3. Pt relaxes
4. PT leans back to take up slack and HVLAT
50
Prone Cervico-Thoracic Juntion Manipulation
-gapping of C7-T1
1. Pt in in prone w/ chin resting on table
2. PT in on contra side of treatment
3. PT has pisiform on TP of C7/T1
4. Pt head SB to contra, rotated to ipsi
51
Contraindications for Manual Therapy
-infection
-Fever
-Cancer
-Acute Circulatory Condition
-Open Wound
-Fracture
-Hematoma
-Advanced DM
-Hypersensitivity
-Abnormal Endfeel
-RA
-Cellulitis
-Constant, Severe pain
-Extensive radiation of pain
-Condition not evaluated
52
Cervical Hx Questions
1. MOI (trauma/cspinerules/concussion)
2. Pain (referral/radiate/neuro/headaches)
3. Pain behaviors
4. PMHx
53
Joint Manipulation Contraindications
-Serious pathology
-fracture*
-lack of skill
-Ligament rupture*
-No working hypothesis
-Worsening neuro function*
-Unremmitting night pain*
-Severe multi directional spasms
-UMN Lesions*
54
Cervical Nerve Referrals
C1-C3: refers to head and neck
C4-C8: refers to shoulder, ant chest, UE, Scaps
-CN 11
55
Closing Restriction
Issues with:
-extension, SB, Rotation
-IPSI side of pain
56
Opening Restriction
Issues with:
-flexion, SB, rotation
-CONTRA side of pain
57
Cervical AROM Values
Flx: 80-90
Ex: 50-70
LSB: 22
Rot: 70-90
58
Whiplash-Association Disorders
-rapid deceleration or acceleration
-damage to soft tissue structures/joints/nerve issues
Common Mechanism:
-MVAs
-Sport-related
-pulls and thrusts on arm
-falls, landing on trunk or shoulder
59
Cervicogenic HA
-Any age
-Variable
-Mild
-Unilateral/dec ROM/Rams's horn
Treatment:
-C2-C3 in neutral
-C2 under C1 in rotation
-C1 under occiput
60
Differential Diagnosis for Thoracic
-Visceral
-Serious Origin
-T-spine dysfunction
-Rib dysfunction
61
Thoracic Pt Hx
-trauma
-breathing/smoking
-eating
-central vs lateral pain
-posture
-Heart issues
62
Thoracic Observations
-Respiration
-Posture
-Spinal Curves
-Position of scapula
-Chest shapes
63
UQ and Thoracic Scan
1. Vitals (HR and BP)
1. Observation: posture, plumb line, head, face, neck, mouth
2. CNs (optional)
3. Respiratory Excursion
3. Gait: look for gross abnormalities
5. Clear the spine (Cervical and Thoracic)
6. UE ROM: All 6 w/ overpressure
7. Dermatomes (C4-L1)
8. Myotomes (C5-T1)
9. DTR: bicep, brachioradialis, tricep, Abdominal
10. UMN Testing: Hoffman's, Babinski, Lhermitte
11. Upper Limb Tension Testing (Median)
12. Pulses (carotid, axillary, brachial, radial, ulnar) (optional)
13. Thyroid (optional)
14. Chest Auscultation (optional)
64
Respiratory Assessment: Superior Ribs
1. Pt supine, PT behind head
2. PT hands inferior to clavicle
3. Instruct them to breathe in, hold it, then breathe in again
(+): expansion is asymmetrical, 1 rib rises when another doesn't
65
Respiratory Assessment: Inferior Ribs
1. Pt supine, PT on side
2. PT hands in intercostal spaces of ribs of lateral rib cage
3. Instruct them to breathe in, hold it, then breathe in again
(+): expansion is asymmetrical, 1 rib rises when another doesn't
66
Thoracic AROM
1. Pt is seated and arms crossed
2. Flx/ext, SB, ROT, Qudrant (if needed)
3. Resist in lengthened position if not painful, if painful, assess in neutral
67
Thoracic Spine ROM Norms
Total:
-Flx: 20-45
-Ext: 15-20
-Rot: 35-50
-SB: 25-45
68
Thoracic PA Springing
-C7-L1
1. Pt prone
2. Use hypothenar eminence on SP
3. Assess TP and press on Lamina
69
Thoracic PA Rib Springing
-T1-T12
1. Pt Prone
2. Use hypothenar eminence on Rib
70
Thoracic AP Rib Springing
-T1-T7
-Only performed when Pt has anterior chest pain
1. Pt supine
2. Assess sternum (upper, mid, lower) or Costocartilage
71
1st Rib Dysfunction Dx
1. Height: 1/2 inch elevation
2. (+) Spring test
3. (+) Inc scalene tone ipsi
4. (+) Cervical Rotation lateral flx test
72
1st Rib Elevation Assessment
-palpate 1st rib posteriorly
(+): elevated if 1 side is 1/2 inch higher
73
1st Rib Spring Test
-Place webspace on 1st rib and SB ipsi
74
Cervical Rotation/Lateral Flexion Test
-for 1st rib
1. Pt in sitting
2. Head rot contra
3. Flex head
(+): flx blocked when rotation is contra
75
2nd Rib Elevation Assessment
-palpate 1st rib
-move thumbs done 1 thumb length and 45 deg laterally
-NOT on scap
(+): elevated if 1 side is 1/2 inch higher or more posterior
76
2nd Rib Spring Test
1. Pt in sitting
2. PT facing away from Pt
3. Use pisiform on superior surface of 2nd rib
4. Provide inferior force
77
Thoracic Palpation: Anterior Structures
-Sternum
-Infrasternal angle
-Ribs
-Costal cartilage junction
-Intercostal muscles
-Abs
-Aortic pulse
78
Thoracic Palpation: Posterior Structures
-SPs
-TPs
-Costo-transverse joints
-Ribs
-Multifidi
-Erectors
79
Palpation: Abdomen
-superficial to deep
RUQ: Liver, gallbladder, pancreas, R kidney
LUQ: stomach, spleen, L kidney, pancreas
RLQ: appendix, R ovary
LLQ: Sigmoid colon, L ovary
80
Compression Tests
1. Pt in sitting
2. PT behind with pressure through shoulders
(+): provocation of s/s
81
Distraction Test
1. Pt in sitting w/ arms crossed
2. PT behind with arms wrapped around
3. Lift trunk
(+): relief of s/s
82
Thoracic Outlet Syndrome Tests
(+): disappearance of pulse
(+): Reproduction of neuro s/s
83
Thoracic Treatment Prioritization
1. Manual Therapy
2. Mobility Exercises
3. Stabilization Exercises
4. Traction
84
Seated Cervico-Thoracic Juntion Manipulation
1. Pt in sitting at edge of mat toward PT
2. PT behind Pt w/ arms around PT w/ hands on forearm
3. Pt relaxes
4. PT leans back to take up slack and HVLAT
85
Prone Cervico-Thoracic Juntion Manipulation
-gapping of C7-T1
1. Pt in in prone w/ chin resting on table
2. PT in on contra side of treatment
3. PT has pisiform on TP of C7/T1
4. Pt head SB to contra, rotated to ipsi
86
Supine Thoracic Spine Gapping HVLAT
1. Pt supine close to PT
2. Pt interlaces fingers behind head (UPPER); Pt hugs shoulders (LOWER)
3. SB away from PT
4. Rotate towards PT
5. PT uses pistol grip on level of spine
6. PT rolls Pt back onto hand
7. Take up slack by telling them to take a deep breath and push down
8. Quick thrust
87
Prone UPPER Thoracic Spine Gapping HVLAT
1. Pt in prone w/ arms by head
2. PT places both pisiforms on TPs of segment (check level)
3. Pt breathes in while PT pushes down to take up slack
4. Quick thrust
88
Prone LOWER Thoracic Spine Gapping HVLAT
1. Pt in prone w/ arms by head
2. PT places hands on SPs of segment (check level)
3. Arms locked out, take up slack in skin
4. Pt breathes in while PT pushes down to take up slack
4. Quick thrust
89
Supine Rib Gapping HVLAT
1. Pt supine close to PT
2. Pt interlaces fingers behind head (UPPER); Pt hugs shoulders (LOWER)
3. SB away from PT
4. Rotate towards PT
5. PT uses pistol grip on level of RIB and hand on crossed arms
6. PT rolls Pt back onto hand
7. Take up slack by telling them to take a deep breath and push down
8. Quick thrust
90
Prone Rib Gapping HVLAT
1. Pt in prone w/ arms by head
2. PT places hands on RIB of segment (check level)
3. Arms locked out, take up slack in skin
4. Pt breathes in while PT pushes down to take up slack
4. Quick thrust
91
Prone Segmental PA Mobilization
1. Pt in prone
2. Hypothenars on SP of segment
92
Prone Rib PA Mobilization
1. Pt in prone
2. Hypothenars on costo-transverse joint of segment
3. PT provides lateral force
93
Seated 1st Rib Mobilization
1. Pt seated with arm on PT leg
2. PT behind Pt with CONTRA leg up
3. PT cradles head in IPSI direction
4. PT mobilizes 1st Rib with MCP toward contra hip
94
Seated 2nd Rib Mobilization
1. Pt in sitting
2. PT facing away from Pt
3. Use pisiform on superior surface of 2nd rib
4. Provide inferior force
95
Adson's Vascular Test
-TOS
1. Pt seated
2. Pt hold arm into 15deg of abduction
3. Pt asked to inhale and hold breath
4. Then extend head and rotate away
5. Check for dimished pulse or increased s/s
96
Costo-Clavicular Test
-TOS
1. Pt seated w/ arms at side
2. Pt retracts arms/shoulders and protrudes chest and hold for 60s
3. Check for dimished pulse or increased s/s
97
Hyperabuction Test
-TOS
1. Pt seated
2. Pt asked to turn away from tesing side
3. Pt asked to raise arm into hyperabd/ext for 1-2min
4. Check for dimished pulse or increased s/s
98
Roo's Test
-TOS
1. Pt seated w/ both arms in 90/90
2. Asked to open and close fingers for 3 min
3. Check for diminished pulse or inc s/s
*stop test if s/s present*
99
Seated Exam- NO GLOVES
1. Check Jaw Opening/Saggital Plane/Resting Occlusion
2. Auscultation
3. Palpate While Opening
4. C-spine/T-spine/UQ screen
5. Posture
100
Jaw Opening Observation
C-Shaped:
-comes out them back in
-doesn't pass midline
-Capsular pattern=Hypomobility
S-Shaped:
-deviates in multiple ways
-crosses midline
-Dec NM control
Deflection:
-Anterior disc displacement
-typical toward side of displacement
101
Supine Exam- NO GLOVES
1. Muscle palpation
2. Mandibular Neurodynamic Testing (if neuro suspected)
3. Muscle Length Tests
4. Muscle strength testing
5. C-spine joint play
102
Muscle Palpation (NON-ORAL)
-masseter
-temporalis
-Pterygoid (external auditory meatus)
103
Mandibular Neurodynamic Testing
-done if suspected neuro cause of pain
1. Pt in supine w/ head over plinth supported by PT
2. PT performs capital flexion; ask
3. Then full cervical flx; ask
4. Then SB contra; ask
5. Open Pt mouth, Laterally glide to contra side and hold; ask
6. Then do in neutral
Neutral + Deviation pain= Joint
Flx/SB + Deviation pain= Neural
104
Supine Exam- GLOVES
1. ROM
2. Joint play
3. Muscle Palpation
4. Centric Relation Provocation Test
105
ROM of TMJ
Opening:
-functional 35mm
-40-60mm
Lateral Deviation:
-1/4 of opening
~10mm
Protrusion:
-5-10mm
Retrusion:
-3mm
106
TMJ Joint Play
Distraction
Anterior Translation
Lateral Translation
Anteromedial Rotation (rotation on ipsi)
107
Centric Relation Provocation Test
-identify discal issues
1. Grasp mandible
2. Scoop jaw into space
(+): pain recreated anterior to tragus
108
Muscle Palpation (ORAL)
Medial Pterygoid:
-rope like bundle behind molars
109
Prone Exam- NO GLOVES
-Assess CT and thoracic
110
MET for TMJ Opening
-resist closing
1. Pt in supine w/ neutral head
2. Depress mandible
3. Have Pt hold against for 8s
4. Then take a deep breath and open mouth
5. Use new ROM to start over until no new movement
111
MET for TMJ Protrusion
-resist protrusion
1. Pt in supine w/ neutral head
2. PT press on lower teeth into retrusion
3. Have Pt hold against for 8s
4. Then take a deep breath and relax
5. Use new ROM to start over until no new movement
112
MET for TMJ Lateral Excursion
-resist contra lateral excursion
1. Pt in supine w/ neutral head
2. PT press jaw into contra lateral excursion
3. Have Pt hold against for 8s
4. Then take a deep breath and relax
5. Use new ROM to start over until no new movement
113
MET for Suboccipitals
-resist cevical extension
1. Pt in supine w/ head at furthest upper cervical flexion
3. Have Pt look up as far as they can for 10s
4. Then take a deep breath and look down
5. Use new ROM to start over until no new movement
114
TMJ Mobilizations
*oscillatory*
-distraction
-ant mobilization
-lateral mobilization
-Posterior mobilization
115
TMJ HEP
-Self Resisted METs
-Soft tissue massage
116
Discal Intervention: ADD w/ Reduction
ADD w/ Reduction
1. Open mouth until opening click
2. Close teeth while protruding
3. The retrude before opening click
4. Repeat
117
Tongue Depressor Exercises
1. Bite down on tongue depressors held together
2. Move into closing, lateral excursion, protrusion/retrusion
118
TMJ Neuromuscular Re-Ed Exercises
-use a mirror and self correct with hand on side of deviation
-switch to other side
-then use only mirror
119
TMJ Inferior Joint
Functions as a hinge joint
-Rolls posterior during opening
120
TMJ Superior Joint
Functions as a plain joint
-Slides anterior during opening
121
Normal depression
– 40-60 mm
40-45 mm in males
45-50 mm in females
-Two fingers or 35mm are functional, three fingers are normal
122
Normal translation and rotation
First rotation: 20 to 25 mm of anterior rotation with a posteriorr roll
Translation: both condyle and disc have anterior slide
123
Normal protrusion
5-10 mm
124
Normal retrusion
3 mm
125
Normal Lateral Excursion
10mm
1/4 opening
-Ipsilateral condyle spins
-Contralateral condyle translates anteriorly
126
Mandibular deviation
Mandible moves away from midline during depression, and stays there
127
Mandibular deflection
Mandible moves away from midline during depression, but returns
128
Muscles involved with depression
Digastric, suprahyoids, lower lateral pterygoid
129
Muscles involved with elevation
Temporalis, masseter, medial pterygoid, superior lateral pterygoid
130
Muscles of protrusion
Masseter, med and lat pterygoids
131
Muscles of retrusion
Temporalis, with anterior digastric
132
Muscles of lateral deviation
Contralateral Pterygoids, ipsilateral temporalis
133
Elbow AROM Exam
-Flexion: 140-150 deg
-Extension: -10-0
-Pronation: 75 deg
-Supinaton: 80 deg
Capsular Pattern: Flx > Ext
*overpressure if pain-free*
*Resisted test in mid-range EVEN if painful*
134
Elbow Palpation
Medial:
-Medial epi
-joint line
-ulnar nerve
-UCL
-Pronators and Flexors
-olecranon
Lateral:
-lateral epi
-Joint line
-radial head
-RCL
-annular lig
-wrist extensors
Anterior:
-Biceps/brachialis/brachiorad
Posterior:
-triceps
-bursa
135
Elbow Hx: Subjective
-Pain (location, duration, quality and behavior/other pain)
-Neck/back issues
-Movement/functional limitiations
-MOI (traumatic/overuse/change in activities)
-Work
-Handedness
-Aggs/Eases
-Duration
-Age
136
Carrying Angle
-valgus angulation at elbow
Males: 11-14
Females: 13-16
137
Pain with Resisted Testing: Elbow Flexion
-biceps
-brachialis
-Brachioradialis
-wrist extensors
138
Pain with Resisted Testing: Extension
-triceps/anconeus
139
Pain with Resisted Testing: Supination
-biceps
-wrist extensors
-radial nerve
-supinator
140
Pain with Resisted Testing: Pronation
-wrist flexors
-median nerve
-pronator teres
-pronator quadratus
141
Pain with Resisted Testing: Wrist Ext
-wrist extensors
-radial nerve
142
Pain with Resisted Testing: Wrist Flx
-wrist flexors
143
Humero-Ulnar Joint Play
OPP: 70 deg flx; 10 sup
Concave on convex
Distraction (whole capsule):
1. Pt elbow flx and sup (or start at missing range)
2. PT stabilizes humerus and scoop/pull on medial side
Medial Glide (Valgus/FLX):
1. Joint Play: Pt elbow flx and sup
2. Pt stabilizes humerus and pushes on lateral side of radius into ulna medially
Lateral Glide (Varus/EXT):
1. Joint Play: Pt elbow flx and sup
2. Pt stabilizes humerus and pushes on medial side of ulna laterally
144
Humero-Radial Joint Play/Mobilizations
OPP: full ext; full sup
Concave on Convex
Dorsal Glide (Ext):
1. Pt elbow in ext and sup
2. PT in book-end grip on radius mobing downward; perpendicular to joint
Volar Glide (FLX):
1. Pt elbow in ext and sup
2. PT in book-end grip on radius mobing upward; perpendicular to joint
145
Proximal Radio-Ulnar Joint Play/Mobilizations
OPP: 70 deg flx; 35 sup
-Convex on Concave
Dorsal Glide (PRO/will SEE sup):
1. Pt elbow in flx and sup
2. PT in pinch grip on radius mobing downward
Volar Glide (SUP/will SEE pro):
1. Pt elbow in flx and sup
2. PT in pinch grip on radius mobing upward
146
Elbow Ligamentous Instability Tests
-tests stability, not specific ligament integrity
-do all 3 tests
-Valgus Stress Test
-Varus Stress Test
-Moveing Valgus Stress Test
147
Elbow Tendinopathy Tests
-Cozen's Test
-Mill's Test
-Golfer's Elbow Test
148
Elbow Neurological Dysfunction Tests
-Tinel's Sign at Elbow
-Elbow Flexion Test
149
Elbow Valgus Stress Test
-UCL intetgrity
1. Arm EXT
2. PT on outside and stabilize humerus
3. Move wrist
4. Arm slight FLX & repeat
(+): reproductiton of pain or excess movement
150
Elbow Varus Stress Test
-RCL intetgrity
1. Arm EXT
2. PT on inside and stabilize humerus
3. Move wrist
4. Arm slight FLX & repeat
(+): reproductiton of pain or excess movement
151
Elbow Moving Valgus Stess Test
-UCL intetgrity
-mimics throwing motion
1. UE 90/90
2. PT on outside and stabilize humerus
3. Move into max ER while EXT elbow
(+): reproductiton of pain w/ ROM btwn 120-70
152
Cozen's Test
-Lateral tendinopathy
-primary test
1. Pt moves into pronation, wrist ext, rad dev against resistance
2. PT pushes into supination, wrist flx, ulnar dev
(+): pain at lat epi
153
Mill's Test
-Lateral tendinopathy
-passive stretching test of ECRB and ECRL
1. PT moves arm into pronation, elbow ext, and wrist flx
(+): pain at lat epi
154
Golfer's Elbow Test
-medial tendinopathy
1. Pt arm slightly flexed
2. PT resists wrist flexion
(+): pain at medial epi
155
Tinel's Sign at Elbow
-neuro test for ulnar nerve
1. UE slightly flexed
2. PT taps over ulnar nerve 4-6 times
(+): reprodiction of s/s in ulnar nerve distribution
156
Elbow Flexion Test
-neurological dysfunction test of ulnar nerve
1. Pt confused position: elbow flx, wrist ext, finger ext
2. Hold position for 3-5 mins
3. Stop after s/s
(+): tingling and parasthesiad in ulnar nerve distrtibution in forearm and hand
157
Elbow Hx: MOI
Trauma:
-fracture/dislocation
-strain/sprain
-growth plate injury
-bursitis
-neuro
Overuse:
-tendinopathy
-stress fracture
-growth plate
-neuro
Arthropatthies:
-OA/RA
158
Humero-Ulnar Mobilizations
OPP: 70 deg flx; 10 sup
Concave on convex
Distraction (whole capsule):
1. Pt elbow flx and sup (or start at missing range)
2. PT stabilizes humerus and scoop/pull on medial side
Medial Glide (Valgus/FLX):
1. Mobilization: Pt elbow flexed with forearm across stomach
2. Pt stabilizes humerus and pushes on lateral side of radius into ulna medially
Lateral Glide (Varus/EXT):
1. Mobilization: Pt elbow flexed with forearm across stomach
2. Pt stabilizes humerus and pulls on medial side of ulna laterally
159
Median Nerve: Elbow
-Medial and Lateral Cords of BP
-C5-T1
Anterior Interosseous N. (AIN)
-C8-T1
-Median after cubital tunnel
-FDP (2-3), FPL, PQ
-Superficial layer of anterior forearm (except FCU) , intermediate layer of anterior forearm, Deep layer of flexors (AIN), thenar muscles (recurrent branch), lumbricals (digital Branch)
160
Radial Nerve muscles: Elbow
-Posterior Cord of BP
-C5-T1
Posterior Interosseous Nerve
-deep branch
-ECRB/ECU/ED/EU/EDM/APL/supinator
-Brachialis, triceps brachii, Anconeus, brachioradialis, superficial layer of posterior forearm, outcropping of the deep layer of posterior forearm (PIN),
161
Ulnar Nerve muscles: Elbow
-Medial Card of brachial Plexus
-C8-T1
-Medial part of FDP (regular), FCU
hypothenar muscles, adductor pollicis, Palmsr interossei, dorsal interossei, 4th and 5th lumbricals (deep branch)
162
Musculocutaneous Nerve: Elbow
-Lateral Cord of Brachial Plexus
-C5-C7
163
UCL Sprain
Hx:
-pop or acute pain over medial elbow
-progressive pain w/ throwing
MOI:
-acute valgus stress to flexed elbow (acceleration phase MC)
Imaging:
-bone spurs
-epipheseal separation
-loose bodies
-leaking dye from torn capsule (arthrogram)
-complete rupture (MRI)
164
LCL/RCL Sprain
-results in posterio-lateral rotary instability at elbow
-MC recurrent instability at elbow
-Conservative Tx not often effective
Hx:
-clicking of radial head slipping
-Lateral Elbow pain
MOI:
-Compression + Shouler ER + valgus
-Latrogenic: agressive debridement
165
Lateral Elbow Tendinopathy
-tennis elbow
Hx:
-35-50 yrs
-pain at lat elbow
-TTP 1cm disal to lat epi
-pain w/ passive flx, gripping, resisted ext
MOI:
-repetitive strain
-high physical work
DDx:
-Radial Nerve entrapment
-Instability
166
Disal Biceps Tendon Rupture
-must have surgery (5-6m recovery)
S/s:
-popping sensation w/ swelling
-visible/palpable defect
-dec grip sttrength
-dec ability to feel
MOI:
-single traumatic event w/ resistance against arm in 90 flx
167
Medial Elbow Tendinopathy
-golfer's elbow
Hx:
-dull aching pain
-pain at med elbow
-pain w/, weak gripping, resisted flex
MOI:
-repetitive strain
-high physical work
DDx:
-Ulnar Nerve entrapment
168
Cubital Tunnel Syndrome
-2nd MC nerve entrapment
-inflammaion of ulnar nerve
S/s:
-ulnar nerve s/s
MOI:
-traction
-valgus deformity
-sustained flexion posture (bicyclists)
DDx:
-Cervical Radic
-TOS
169
Radial Tunnel Syndrome
-compressuon of PIN from radial nerve as it passes btwn supinator
-NO sensory involvement
Test:
-use extensor indicis or EPL to test for weakness
S/s:
-pain distal to lateral epicondyle; at supinator
170
Pronator Teres Syndrome
-compression of median nerve btwn pronator teres
-rare
Test:
-pain w/ resisted pronation
DDx:
-Carpal tunnel
-Palmar sensory changes
-FDS weakness
-cervival root compression
171
Anterior Interosseous Nerve Syndrome
-motor only
-FPL, pronator quadratus, FDP of 2-3
Hx:
-difficulty gripping
-issue buttoning shirt
-difficultty making fist
Test:
-difficulty making ok sign
-weakness
-Positive Pinch Grip Test
172
Wrist/Hand Observations
-Posture
-Willingness to move
-Dominant hand; functional status
-Muscle spasms, wasting
-Palmar/Dorsal sides of hands
173
Wrist AROM Exam
-Flexion: 80-90 deg
-Extension: 70-90
-Rad Dev: 15
-Ulnar Dev: 30-45
-Supination: 85 deg
-Pronation: 75 deg
*overpressure if pain-free*
*Resisted test in mid-range EVEN if painful*
174
Wrist Resisted ROM
-hold for 5s
FCR/FCU: Flex + rad/ul dev
ECRL/ECRB: Ext + rdev
ECU: Ext + ul dev
175
Hand/Wrist Palpation
Dorsal Surface:
-Snuff box
-scars
-scaphoid
-radial styloid
-ulnar styloid
-Bones
Palmar/Volar:
-pulses
-tendons
-arches
176
Wrist/Hand Hx: Subjective
-Pain (location, duration, quality and behavior/other pain)
-Neck/back issues
-Movement/functional limitiations
-MOI (traumatic/overuse/change in activities)
-Work
-Handedness
-Aggs/Eases
-Duration
-Age
177
Wrist/Hand Hx: MOI
Trauma:
-fracture/dislocation
-strain/sprain
-growth plate injury
-bursitis
-neuro
Overuse:
-tendinopathy
-stress fracture
-growth plate
-neuro
Arthropatthies:
-OA/RA
178
Finger AROM Exam
-Flx:
MCP: 80-90
PIP: 100-115
DIP: 80-90
-Ext:
MCP: 30-45
PIP: 0
DIP: 20
-ABD: 20-30
-ADD: 0
-Thumb Flx:
CMC: 45-50
MCP: 50-55
IP: 85-90
-Thumb Ext:
CMC: 20
MCP: 0
IP: 0-5
-Thumb ABD: 60-70
-Thumb ADD: 30
*overpressure if pain-free*
*Resisted test in mid-range EVEN if painful*
179
Functional ROM for Power Grips
-Hook
-Speherical
-Cylinder
-Fist
180
Functional ROM for Percision Grips
-Pinch (pad to pad; tip to tip)
-5 Finger Pinch
-Tip Pinch
-Lateral Key Pinch
-3 Fingered Pinch
181
Thumb Resisted ROM
-hold for 5s
APL/APB: Thumb abduction
Opponens Pollicis: Resist both sides of opp
FPL/FPB: Thumb flx
Adductor Pollicis: Thumb ADD
EPL/EPB: Thumb ext
182
Instrinsics Resisted ROM
-hold for 5s
Lumbricals: lumbrical grip
Palmar Interossei: PADs
Dorsal Interossei: DABs
183
Finger Resisted ROM
-hold for 5s
FDP: DIP flx
FDS: PIP Flx
EI/ED: Finger ext
Flexor Digit Minimi: pinky flx
Opponenns Digiti Minimi: Pinky opp
184
Hand Dynamometer
-measured in functional positions
-10% differrences from R to L
->20% differences may be an issues
-mean of 3 trials
185
Distal Radio-Ulnar Joint: Joint Play
-concave rad + convex ulna= same
-OPP: 10 SUP
Volar Glide (PRO):
-book end grip; move radius
Dorsal Glide (SUP):
-book end grip; mvoe radius
186
Radio-Carpal Joint: Joint Play
-Convex carpals + Concave radius= opp
Distraction (All movement):
-Move carpals; hand distal to radius
Palmar Glide (Ext)
Dorsal Glide (Flx)
Ulnar Glide (Radial dev)
radial Glide (Ulnar Dev)
187
Mid-Carpal Joint: Joint Play
-Convex on Concave= opp
Distraction (All movement):
-Move carpals; hand distal to radius
Palmar Glide (Ext)
Dorsal Glide (Flx)
Ulnar Glide (Radial dev)
radial Glide (Ulnar Dev)
188
Carpo-Metacarpal (CMC) Joint: 2-5 Joint Play
2nd-5th Joints: Concave metacarpal on convex carpal= same
Ant glide (FLX)
Post Glide (EXT)
Distraction (ALL)
189
Carpo-Metacarpal (CMC) Joint: Thumb Joint Play
Anterior/Posterior: Convex on concave= opposite
Medial/Lateral: Concave on convex= same
Ant glide (ADD)
Post (ABD)
Ulnar/Medial glide (FLX)
Radial/Lateral glide (EXT)
Distraction (ALL)
190
Metacarpo-Phalangeal (MCP): Joint Play
Concave on Convex= same
Ant glide (FLX)
Post glide (EXT)
Ulnar/Medial glide (ADD)
Radial/Lateral glide (ABD)
Distraction (ALL)
191
PIP and DIP: Joint Play
Concave on Convex= same
Ant glide (FLX)
Post glide (EXT)
Distraction (ALL)
192
Hand Special Test for Tendon and Muscles
-Finkelstein Test
193
Special Test for Ligaments, Capsule, and Joint Stability
-Liagmentous instability of fingers
-Thumb UCL Instability
-Watson Shift Test
-Ballotement Test
-Murphy's Sign
-Piano Key Test
194
Special Tests of Neurological Dysfunction
-Tinel's
-Phalan's Test
-Reverse Phalen’s Test
-Fromment's Sign
195
Special Test for Circulation and Swelling
-Allen's Test
196
Ligamentous Instabilty of Fingers Test
1. Hold distal and pxovimal joints
2. Provide Valgus and varus stress
3. Test both sides
*relative to middle finger*
197
Thumb UCL Instability Test
Gamekeeper's/Skier Thumb
1. Flex MCP to 30deg and apply VALGUS (ulnar) stress
(+): excess ABD
198
Watson/Scaphoid Shift Test
-Scapho-lunate instability
1. Pt hand in pronation
2. PT graps radial side with thumb over scaphoid and other hand on ulnar side carpals
3. Start in ulnar deviation + ext
4. Move to radial dev + flex
(+): subluxation or clunk over thumb w/ pain= tear of scapho-lunate ligament
199
Ballotement Test
-luno-triquetral Instability
1. Grasp triquetrum and lunate
2. move lunatee palmarly and dorsally w/ respect to triquetrum
(+): laxity, crepitus or reproduction of pain= luno-triquetral ligament tear
200
Murphy's Sign
-lunate dislocation
1. Inspect dorsal of hand in fist
2. check if 3rd knuckle is level with the rest
(+): 3rd knuckle same level= lunate dislocation
201
Piano Key Test
-TFCC tear
1. Press on ular styloid
(+): reproduction of pain or laxity
202
Finkelstein Test
-De Quervain's
1. Make a fist enclosing thumb
2. Ulnar deviate slowly
(+): pain over APL/EPB tendons
203
Tinel's Sign at Wrist
-carpal tunnel (median nerve)
1. Tap over carpal tunnel
(+): N/T into thumb/index/middle/half of the ring finger; can determine most distal degeneration
204
Phalan's Test
-carpal tunnel
-wrist flexion
1. Pt wrists in max FLX for 1 min
(+): tingling in 1-3 finger and half of 4th
205
Reverse Phalen's Test
-carpal tunnel
-wrist extension
1. Pt wrists into full EXT for 1 min
(+): tingling in 1-3 finger and half of 4th
206
Fromment's Sign
-tests ulnar palsy
-uses Adductor Policis
1. Try to grasp a piece of paper in lateral pinch grip
2. PT tries to pull it away
(+):
-Flexion at IP to hold on using FPL
-Thumb hyperextends (Jeanne's Sign)
207
Allen Test
-if suspecting radial or ulnar artery deficencies
1. Open and close hand 5x quickly
2. Keep fist closed and PT pinches ulnar AND radial artery
3. Open hand and observe each when letting go of artery
(+): Color returnns to hand in 6-10s
(-): Pallor remains after10s = comprimised blood flow on released side
208
Order of Exam
1. Subjective
2. Observation of Hand
3. Scan if needed
4. Palation
5.ROM
6. Muscle
7. Joint Play
8. Special Tests
209
1st CMC OA CPR
1. Hand pain or stiffness
2. Hard tissue enlargement of >2 joints AND 2nd/3rd DIPs and PIPS and 1st CMC
3. <3 swollen MCPs
4. Hard tissue enlargement of >2 DIPs
5. Deformity of >2 selected joints
*>2 = greater than or equal to*
210
Distal Radio-Ulnar Joint
Conave radius on Convex Ulna head
CPP: 5 supination
OPP: 10 supination
Capular Pattern: pain at extremes of SUP/PRO
211
Ulnar Variance
-ulnar head in relation to radius in DRUJ
-changes in % of load bearing
(+): ulna >2mm distal to radius= longer
-TFCC and scaphulolunate instability tears
(-): ulna >2mm proximal to radius= shorter
-Kienbock Malacia
212
Radio-Carpal Joint
Convex carpals on Concave radius = opp
CPP: full ext with rad dev
OPP: neutral with slight ulnar dev
Capular Pattern: flexion= ext
213
Carpal Bones
-8
Proximal Row: scaphoid, lunate, triquetrum, pisiform (palmar) (Slow loris takes poops)
Distal Row: Trapezium, tappezoid, capitate, hamate (toe taps cause hemroids)
214
Intercarpal Joints
-plan joints btwn carpals
CPP: full ext
OPP: neutral to slight flx
215
Mid Carpal Joints
-joints between proximal and distal rows
CPP: full ext w/ ulnar deviation
OPP: neutral to slight flexion w/ ulnar deviation
Capsular Pattern: flex= ext
216
Thumb CMC Joint
-saddle joint
CPP: full opposition
OPP: midway ABD/ADD and flx/ext
Capsular pattern: ABD loss > ext
217
Finger CMC Joint
-plane joints
CPP: full flx
OPP: midway flx/ext
*2nd/3rd immobile*
*4tth/5th mobile for grip*
218
MCP Joints
-coondyloid
CPP: full opposition (thumb); full flx (2nd-5th)
OPP: slight flexion
Capsular Pattern: flx >ext
219
PIP/DIP Joints
-hinge
CPP: full ext
OPP: slight flx
Capsular Pattern: flx > ext
220
Ulnar Nerve Hand Distribution
Sensation:
-medial palm and dorsum
-pinky finger (tip is eclusive)
-medial half of ring finger
-bottom half of middle finger
Motor:
-Mmedial 2 lumbricals
-Adductor Policis
-Interossei
-Palmaris Brevis
221
Median Nerve Hand Distribution
Sensation:
-lateral palm
-top half of fingers 2 and 3 (exclusive)
-palmar side of thumb
Motor:
LOAF
-lateral lumbricals
-Opponens pollicis
-Abd policis brevis
-Flexor policis brevis
222
Radial Nerve Hand Distribution
Sensation:
-Lateral dorsum of hand excluding top half of digits 2 and 3
-dorsum and lateral of thumb
Motor:
-wrist and finger extensors
223
Dermatomes of Hand
C6: palmar and dorsal thumb
C7: palmar and dorsal fingers 2 and 3
C8: [palmar and dorsal fingers 4 and 5
224
DDx Wrist Injuries
Fx:
-Distal Radius (Colles' vs Smith)
-Scaphoid
-Hook of Hamate
Sprains:
-TFCC
-Radioscapholunate Ligament
-Lunotriquetral
Volkmann's Ischemic Contracture
OA
Tendinopathy/Tenosynovitis:
-De Quervains
-EPL, EI, ECU
-FCR, FCU
Carpal Instabilities
Peripheral Nerve Injuries
225
TFCC Tear
MOI:
-FOOSH
-repettitive loading
-ulnar distraction
S/s:
-wrist pain on ular side
-click or crepitus during gripping or rotation
Test:
-Piano Key Test
Tx:
-bracing 4-6w
-activity modification
226
De Quervain's Tenosynovitis
-inflammation of synovial shealth of APL and EPB
MOI:
-over use (MC)
-direct trauma
S/s:
-TTP radial styloid
-TTP of snuffbox
-Pain with active thumb ABD
-PAin with passive thumb ADD
Test;
-Finkelstein's Test
Tx:
-spica splint
-steroid injection
-surgical release
227
Scapholunate Dissociation
-lunate MC dislocated carpal
-might take 1 year
MOI:
-FOOSH
S/s:
-schapoid shifts volarly
-lunate shifts dorsally
Test:
-Watson Shift Test
Tx:
-immobilization 6-12w
-sugery
-strengthen surrounding muscles
228
DDx Hand Diagnoses
-Heberden's Nodes
-Bouchard's Nodes
-Swan Neck
-Boutonniere
-Trigger Finger
-Mallet Finger
-Jersey Finger
-Ulnar Drift
-Ape Hand
-Boxer's Fx
-Dupuytren's Contracture
-Gamekeeper's Thumb
-Peripheral Nerve Entrapment
-1st CMC OA
229
TMJ Exam Order
1. Observation of opening
2. Palpation of joint and muscles
3. Auscultation
4. Cervical and Thoracic Screen
5. ROM
6. Joint Play
7. Special Tests
8. Treatment
230
Shoulder Observations
-Posture
-Willingness to move
-Shoulders level: atrophy, flattening of deltoid (ant dislocation)
-Scapula: winging or deformities
-Dominant arm: lower shoulder
-Muscle spasms, wasting
231
Shoulder AROM Exam
-Flexion/IR and ER @0/ABD for everyone
-Ext/Horizontal (cross arms)
*overpressure if pain-free*
*Resisted test in mid-range EVEN if painful*
232
Shoulder Resisted ROM
-hold for 5s
Flx: at wrist
ABD: elbows bent
IR/ER: bent elbows and push at wrist
Strong; painless
Strong; painful
Weak; painless
Weak; painful
233
Painful Arc Sign
-RC pathology indicator
-impingement test
-Pain in mid-range
GH: 60-120 pain
-max stress on subacromial space
AC: end range pain
-max stress on AC
234
Scapular Dyskinesis Test
-altered scapular position and motion
-only check if seen during ROM
-changes GH loads
1. Pt raises and lowers BIL 3-5x
-if needed inc reps or weight
(+) obvious deformity
SICK Scapula: Malposition of scap, inferior medial boarder, coracoid pain and malposition, scapular dykinesia
235
GH Distraction Mobilization/Assessment
-all parts of joint
1. Pt in supine
2. Pt arm to side with elbow above shoulder in OP
3. Provide distraction (sustained or oscillatory)
236
GH Inferior Glide Mobilization/Assessment
-abduction
1. Pt in supine
2. Pt arm to side with elbow above shoulder in OP
3. Use arm crotch on superior humeral head (sustained or oscillatory)
237
GH Anterior Glide Mobilization/Assessment
-Extension and external rotation, horizontal ABD
1. Pt in prone w/ arm off side
2. Pt elbow below shoulder
3. Provide anterior force to humerus
238
GH Posterior Glide Mobilization/Assessment
-Flexion and Internal rotation, horizontal ADD (FIADD)
1. Pt in supine
2. Pt arm to side with elbow above shoulder in OP
3. Use hypothenars to push posteriorly while supporting elbow
239
AC Joint Mobilization/Assessment
-only if they have pain at end range OR pain at AC joint
-Superior glide: adduction/ext
-Inferior glide: Abduction/flx
1. Pt in supine
2. Grab clavicle closest to acromion
3. Superior and Inferior glide
4. Can Assess in GH elevation
240
SC Joint Mobilization/Assessment
-only if they have pain at SC joint
-Superior glide: ext
-Inferior glide: flx
1. Pt in supine with arms at side
2. Grab patients clavicle as close to sternum
3. Inferior or superior glide
241
ST Joint Mobilization/Assessment
1. Pt in sidelying
2. Pt arm on PT forearm
3. PT holding top and bottom of scapula
4. Distraction; lift up medial boarder
-Superior/inferior/medial/lateral
242
Palpation
-muscles
-AC joint
-SC joint
-Clavicle
-Coracoid
-sternum
-Scap
243
Shoulder Impingement Tests
-provocative, 1 side only
-Neer
-Hawkins-Kennedy
-Cross-Body Adduction
-Painful Arc
244
Muscle/Tendon Pathology Tests
-BIL assessment
-look for weakness and pain
-Speed's Test
-Full can
-Empty Can
-ER Lag sign
-Infraspinatus Strength
-Belly press
-Lift off Sign
-IR lag sign
-Drop Arm
245
Neer Test
-jam greater tuberosity hits acromion
-overuse or injury to supraspinatus and possible biceps tendon
1. Pt in sitting
2. PT passively IR and FLX arm
3. Repeat with ER
(+): pain with IR relieved with ER
246
Hawkins-Kennedy Test
-supraspinatus tendinopathy
-press supra into coracoid or coraco-acromial lig
1. Pt in sitting
2. Arm flexed to 90 (slight H ADD) with elbow bent
3. PT forces into IR
(+): pain
247
Cross-Body Adduction Test
-AC joint pathology
1. Pt in sitting
2. PT elevates to 90 and Horizontally ADD to end range
(+): subacromial pain
248
Speed's Test
-long head of bicep tendinopathy
1. Pt flexion at shoulder level, elbow extended, forearm supinated
2. PT push on wrist
(+): pain in bicipital groove
249
Full Can Test
-done first, less provocative, then Empty Can
-Supraspinatus tendinopathy
1. Pt sitting
2. Arms scaption, ER, thumbs up
3. PT pushes on wrists
(+): weakness and reproduction of s/s
250
Empty Can test
-done 2nd after positive Full Can
-Supraspinatus tendinopathy
1. Pt sitting
2. Arms scaption, IR, thumbs down
3. PT pushes on wrists
(+): weakness and reproduction of s/s
251
Infraspinatus Strength test
-infraspinatus strength
1. Pt holds arm out 45 deg in scapular plane
2. PT holds elbow and pushes into ER witht resistance
(+): Pt cannot resist due to pain or weakness
252
ER Lag Sign
-infraspinatus tear
1. Pt holds arm out 45 deg in scapular plane
2. PT holds elbow and puts them in ER and ask to hold positTion before releasing
(+): Pt cannot hold position; infra tear
253
Belly Press Test (Napoleon Sign)
-subscapularis tendinopathy or tear
1. Pt sits with hand across belly
2. PT grabs Pt wrist and ttries to pull away from belly
(+): Pt hands moves away or elbow moves posteriorly to compensate
254
Lift-Off Test
-subscapular pathology
1. Pt places hand on belt line and a lift away
2. If capable, resist on wrist
(+): inability to do so; subscap
255
IR Lag Sign
-subscapular pathology
1. PT places Pt hand on belt line and a lift away
2. Ask Pt to hold
(+): inability to do so; large RC/subscap tear
256
Drop Arm Test
1. PT passively lifts arm to 90 deg of ABD and ER
2. Ask Pt to hold in space and let go
(+): Pt unable to maintain arm; significant RC pathology
257
General Rehab Principles for Shoulder
1. Pt Education:
-posture
-ergonomics
-activities to avoid
2. Proximal to Distal Tx
-T spine
-C soine
- Shoulder
258
GH Progressive Inferior Mobilization
-lacking ABD
1. Pt supine w/ arm abd 45-90 deg
2. PT provides long axis distraction AND inferior glide
3. Repeat by increasing ABD
259
GH Progressive Flexion/ABD/ER Mobilization
-for Pt who have issues with combined motions
1. Pt prone in abd/flx/ER
2. PT uses webspace to mobe into arm pit in direction of the elbow as you move
3. Increase ABD as you go
260
GH Progressive Posterior Mobilization
1. Start in normal posterior position as close to 90 as possible
2. Increase Pt horizontal ADD and scoop out AND down
3. Increase ADD as you go
261
GH Progressive Anterior Mobilization in Prone
-frozen shoulder or significant loss of mobility of volume
1. Pt in prone
2. Towel under glenoid
3. PT distracts and mobs PA on humerus
4. Can use stool to increase ER
262
GH Progressive Anterior Mobilization in Supine
- frozen shoulder or significant loss of mobility
-cannot tolerate prone
1. Pt supine with towel under humerus
2. PT distracts humerus and AP mobs at GLENOID
3. Progressively increase ER
263
GH Posterior Mobilization w/ Movement
1. Pt in sitting
2. PT on opposite side with hand on scapula and superior head
3. Have pt move with you
264
GH Inferior Mobilization w/ ER for Adhesive Capsulitis
1. Pt in supine
2. PT faces feet and holds elbow
2. PT ERs wind up of shoulder with long axis distraction
265
Shoulder Mobility HEP
1. Pendulum
2. T Bar ER from side to side
3. T Bar Elevation
4. Wall Pulleys
266
Capsular Stretching
Anterior:
-Limited ER or EXT
-ER and progress with weights
-don’t give if excessice anterior glide
Posterior:
-limited FLX or IR
- Pt lays on side and brings arm across body
- Progress with towel then pull hand
267
Instability Tests
-Anterior Apprehension
- Jobe Relocation Test
-Sulcus Sign
-Posterior Apprehension Test
268
Shoulder Pain DDx: Rotator Cuff/Impingement
(+):
-impingement signs
-painful arc
-pain w/ iso resistance (tendinopathy) (mid range)
-weakenss
-atrophy
(-):
-significant loss of motion
-instability signs
269
Shoulder Pain DDx: Frozen shoulder
(+):
-spontaneous progressive pain
-loss of motion in multiple planes
-pain at end range
(-):
-normal motion
-<40 yrs
270
Shoulder Pain DDx: GH Instability
(+):
-<40 year
-Hx of dislocations
-Apprehension
-Laxity
(-):
-No hx of dislocations
-No apprehension
271
SLAP Lesion Tests
-Active Compression/O'Brien's
-Biceps Load I
-Biceps Load II
272
Labral Test
-Clunk Test
273
Scapular Stability Tests
-Scapular Dyskinesis Test
-Scapular Assistance Test
-Wall Push Up
-Pec Minor Tightness
274
AC Joint Pathology Tests
-Step Deformity
-Palpation
-Cross-Body Adduction
-Active Compression/O'Brien's Test
275
Apprehension Test
-Anterior GH instability
1. Place Pt into 90/90 with overpressure
2. Watch for Apprehension
(+): apprehennsion or guarding
276
Jobe Relocatioon Test
-anterior GH instability
-Only if Apprehension test (+)
1. Provide Overprssure in 90/90 and should get better
(+): dec apprehension or reducttion in s/s; can ER more
277
Sulcus Sign
-Inferior or multidirectional GH instability
1. Pt seated
2. ABD arm 20-50 and provide downward force
(+): sulcus sign greater than 1 finger
Grade 1: 1 cm
Grade 2: 1-2cm
Grade 3: >2 cm
278
Posterior Apprehension Test
-posterior GH instability
1. Pt Supine or siting
2. PT stabilizes scap, horizontally ADD shoulder and proiides posterior force
(+): pain in post shoulder, aprehension
279
Active Compression/O'Brien's Test
-SLAP tear OR AC Joint test
-assess pain from Bicep NOT labrum
1. Pt in standing w/ arm flexed, elbow ext, horizontally ADD and IR
2. PT aplies resisance for 5s
3. Turn to ER and do again
(+): pain w/ IR that dec with ER OR over AC joint
280
Biceps Load I Test
-SLAP tear
-done 1st
1. Pt in supine in 90/90
2. PT resists elbow flexion
(+): reproducion of shoulder pain w/ resisted flexion
281
Clunk Test
-Labral pathology/ labral fragment caught in joint (=instability)
1. Pt in supine
2. PT holds humerus and forearm
3. PT abd arm fully and ER while pushing humeral head anteriorly
(+): clunk or grindninng sound; may cause apprehension
282
Biceps Load II Test
-SLAP tear
-done 2nd if Bicep I not positive
1. Pt in supine in 90/120 (abd)
2. PT resists elbow flexion
(+): reproducion of shoulder pain w/ resisted flexion
283
Scapular Assistance Test
-Scapular stability/dyskinesis
-oppens up subacromial space
1. Pt in standing
2. PT hands on suerior angle and inferior angle
3. Pt activiely elevates while PT helps upwardly rotates
(+): dec of shoulder s/s
284
Wall/Floor Push Ups
-scapular stability
1. Pt performs 3-5 push ups
2. Can do on floor or walk outs for stronger
(+): obvious muscle weakness noted (winging)
285
Presense of Step Deformity
-AC joint pathology
1. Gapping of AC joint to GH
286
Shoulder Hx: Age
Children: Cancer or epiphysis
10-20s: instability then secondary imingement
20:40: calcium depositis
40-60: RC or frozen shoulder
287
Shoulder Hx: MOI
Overheard Exertion/Repetitive:
-Subacromiial
-RC tear
-Biceps tendinopathy
FOOSH:
-Fx
-AC Joint separation
-GH Dislocations
Fall on Tip of Shoulder:
-AC Joint separation
-C-spine
Forced Horizontal ABD/est/ER
-anterior dislocation
Swimmers:
-Fatigue of muscles
-impaired stability
288
Shoulder Hx: Pain Relief
W/ Elevation:
-C-spine
W/ Elbow Supported:
-AC joint separation
-RC tears
Circumduction w/ click:
-GH instability
W/ Arm Distraction:
-Bursitis
-RC
Arm in dependent position:
-TOS
