WEEK 3: 3.3 SHOULDER BIOMECHANICS Shoulder Mobility

● Osseous components of functional shoulder: ○ AC joint: articular surface of clavicle is convex in all planes of motion ○ SC joint: clavicle is convex frontal and concave sagittal plane

■ Very strong, stable joint ● Shoulder characteristics that benefit mobility:

○ Healthy articular surface ○ Supple capsuloligamentous restraints ○ Glenoid fossa is flat

■ Helped by labrum ○ ⅓ to ¼ articulation with humeral head

■ Not a lot of joint congruency ○ Inferior capsule is lax ○ Recess in inferior capsule allows for more mobility ○

Non-Contractile Stability Dynamic Stability

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Labrum

● Motions with significantly reduced contact between humerus and labrum: ○ Max flexion, adduction, and IR ○ Max abduction and flexion ○ Adducted at the side, with the scapula rotated downward ○ *least amount of joint congruency

Shoulder Osteology ● Scapular Structure :

○ Scapula wide and thin structure ■ Easy gliding on thoracic wall ■ Multiple sites for muscle attachments

○ Overhanging acromion and coracoacromial ligament ■ Provides improved mechanical advantage of deltoid

○ Scaption plane: loose pack position → less impingement and stress ● Acromion types:

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○ ○ Acromion type is a strong predictor of rotator cuff impingement

■ Type I: 3% incidence of rotator cuff tears ■ Type III: 70% incidence of rotator cuff tears

● Coracoid process: ○ Long lever → allows pec minor to provide scapular stability ○ Site of attachment for coracobrachialis and short head of biceps

● Close/Open Packed Position : ○ Close Pack: full abduction and ER ○ Open Pack: 39 degrees of abduction in the scapular plane

Shoulder Ligaments

● ● Glenohumeral ligaments:

○ Distinct thickenings in the anterior capsule ○ Superior GH ligament:

■ Torn SGHL allows inferior subluxation of humerus ■ Contracture limits ER and flexion ■ Taut: adduction, inferior and AP translations of humeral head

○ Middle GH ligament:

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■ Blends with the subscapularis tendon ■ Taut: anterior translation of the humeral head, esp in ~45-60 degrees of

abduction, ER ○ Inferior GH ligament:

■ Most important ligament for GH stability ■ Divided into anterior and posterior band with a axillary pouch in between

that acts like a hammock to support the humerus during abduction and ER

■ Primary static stabilizer when the arm is abducted from 45-90 degrees ■ Taut:

● Anterior band: 90 degrees abduction and full ER, anterior translation of humeral head

● Posterior band: 90 degrees abduction and full IR ● Axillary pouch: 90 degrees abduction, combined with AP and

inferior translations ○

● Coraco-humeral ligament: ○ Has a similar restraint to GH motion as the superior gleno-humeral ligament ○ Coraco-humeral ligament is taut with adduction providing significant restraint to

inferior translation and ER of the humeral head ● Capsular Patterns:

○ Adhesive capsulitis: ER limited > Abd > IR > Flex ○ Selected capsular hypomobility: IR > Abd > ER

Coracoacromial Arch ● Structures under the arch:

○ Long head biceps ○ Superior JC ○ Supraspinatus, infraspinatus, subscapularis ○ Subdeltoid, subacromial bursa

Subacromial Space ● Arm adducted suprahumeral space 10-11mm ● 60-120 degrees of scaption space is at its narrowest ● With overhead motion, supraspinatus tendon passes under the coracoacromial arch

○ With the addition of IR, the supraspinatus tendon passes under the coracoacromial ligament

○ With the addition of ER, the supraspinatus tendon passes under the acromion ● Weak/injured RTC allows increased humeral head translation

○ Increased wear labrum ○ Overuse of static restraints ○ Overuse of dynamic restraints

Muscle Functional Classification ● Scapular Pivoters:

○ Traps, serratus anterior, levator scap, rhomboids major and minor

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○ Functions at the scapulothoracic articulation ○ Serratus anterior: protracts, upwardly rotates scapula, and maintains scapula on

thorax ■ Works in synergy with traps (force couple) ■ Active with all shoulder movements, esp flex and abd ■ Lower fibers draw inferior angle of the scapula forward upwardly rotating

scapula ● Humeral Propellers:

○ Lats, teres major, pec major, pec minor ○ IRs have larger mass than external rotators

● Humeral Positioners: ○ Deltoid: anterior, lateral, posterior

● Shoulder Protectors: ○ Rotator cuff

■ Actively move and fine tune humeral head positioning during arm elevation

■ During abd, the greater tuberosity must pass under the coracoacromial arch

● Humerus must ER (infraspinatus, teres minor) ● Acromion must elevate

■ Contractile ligaments ■ Reinforces coracohumeral and glenohumeral ligaments ■ Controls GH arthrokinematics

● Horizontally oriented supraspinatus produces a compressive force into the glenoid fossa

● Holds humeral head in glenoid fossa during superior roll ● Provides:

○ Stability ○ Efficient fulcrum ○ Balances vertical force of deltoid avoiding impingement ○ In mid range arm elevation, passive restraints are lax

● Force Couples: ○ Subscap co-contracts with infra and teres minor to depress and compress the

humeral head during overhead movements ○ Deltoid co-contracts with interior RTC muscles

■ Creates a compressive force and downward rotation force to counterbalance the deltoid

■ injury/weakness of the RTC allows deltoid to elevate humerus causing impingement of the RTC on the anterior acromion

WEEK 5: SHOULDER PT. 2

Supraspinatus Tendonitis vs. Calcific Supraspinatus Tendonitis

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● Supraspinatus tendon is susceptible to tendinous pathology: ○ With the arm along the side of the body, the tendon is pulled down and over the

greater tuberosity of the humerus → compressive force of the tendon into the tuberosity and creates a zone of avascularity

■ Decreased blood to tendon → pathology ■ Tensile stress + compressive force = flushes out blood and fluid =

avascular ○ Shoulder tendinopathy:

■ Reactive or degenerative : ● Reactive: acute, just occurred ● Degenerative: chronic, takes time to happen/usually later in life

■ Etiology: ● Traumatic ● Overuse/repetitive (unaccustomed activity for that individual)

○ Is their body ready to handle the stresses? ● Insidious

■ Presentation : ● Acute/subacute: signs of inflammation ● Pain with contraction/activity ● Pain with passive stretch depending on tissue reactivity ● Tenderness over tendon

■ Treatment: ● PT ● Reactive/Early Stage of Condition (acute/subacute)

○ protect/reduce aggressive loading (frequency/duration) ○ Encourage healing - STM, modalities

● Degenerative/Late Stage of Condition (Chronic Condition) ○ Normalize load ○ Transverse/Cross friction massage ○ Exercise with heavy loading ○ Modalities

● Supraspinatus can be traditional tendonitis or calcific tendonitis: ○ But have same patient complaints and presentation

■ Difference: calcific tendonitis needs radiography to identify it ○ Calcific tendonitis: from local areas of necrosis within the tendon

■ Necrosis causes calcium to be deposited within the tendon ● But not as bone → has a toothpaste consistency ● Can be slow or fast

○ Fast → acute ○ Slow → chronic

■ Men > women ■ Same symptoms as non-calcific tendonitis ■ Radiograph to diagnose it

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■ Positive exam findings: ● Step 7: PFC → warmth and swelling over the supraspinatus

tendon ● Step 8: AROM → painful arc ● Step 9: PROM → painful in IR and adduction ● Step 10: MSTT → strong and painful with ER and abduction

○ Good for diagnosing tendinopathy ○ Don’t move onto MMT because pain

● Step 11: MLT → decreased length and painful with IR and adduction

● Step 15: PFT → painful over the supraspinatus tendon ● Step 17: Imaging → brightness (opaque area) noted within the

supraspinatus tendon location ■ Treatment:

● Anti-inflammatories or aspirate calcium deposit ● Maybe surgery if severe enough

○ Osteophytes forming on the underside of the acromion - tendon is squeezed every time patient raises arm

○ Keep GH joint slightly abducted after surgery ■ Increase blood supply and promote healing

● Lifestyle modification ○ Supraspinatus Tendonitis: arm at side of body causes a downward pull on

supraspinatus tendon over the greater tubercle ■ Compressive force causes zone of avascularity

● Tensile stress + compressive force = flushes out blood/fluid → avascular

■ Examination : ● Step 7: PFC supraspinatus tendon → warmth and swelling ● Step 8: AROM: Painful arc → pain in mid range ● Step 9: PROM IR, Add = pain → lengthening tissues causes pain ● Step 10: MSTT ER and Abd = strong and painful → don’t do

MMT ● Step 11: MLT IR and Add = Decreased length and painful ● Step 15: PFT supraspinatus tendon → pain

■ Treatment: ● MD: inflammatories, lifestyle modification ● PT:

○ Exercises in slight abduction to avoid wringing out of tendon

○ Put into areas of vascularity (ex. Scaption plane, loose pack)

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● Adhesive Capsulitis: the capsule becomes inflamed and adheres to the humeral head → fibrotic

○ Idiopathic ○ AKA frozen shoulder ○ Will go through the stages of condition and will often result in chronic condition ○ ROM decreases over time ○ Self limiting condition ○ Entire capsule is involved ○ Predisposing factors:

■ Women who are perimenopausal are most often affected ■ No known cause but could be hormonal ■ Diabetes ■ Thyroid disease ■ Shoulder pathology ■ immobilization

○ Clinical Features: ■ Onset is gradual and insidious

● Could be because of immobilization or pathology ■ Could resolve on its own - could take up to 24 months ■ Entire capsule is involved ■ Primary findings: decreased ROM → capsular pattern

● Shoulder capsular pattern: ER>ABD>IR ■ Self-limiting condition

○ Exam findings resulting in capsular pattern : ■ Step 8: AROM - decreased ER>ABD>IR ■ Step 9: PROM

● PROM Classical Quantity - decreased with limitations of ER>ABD>IR

● PROM Classical Quality - tight capsule end-feel all directions ● PROM Accessory Quantity - decreased P/A>inferior>A/P ● PROM Accessory Quality - tight capsule end-feel all directions

○ Treatment: ■ Medical tx: surgical manipulation, rest, pain meds, or NSAIDs ■ PT tx: increase ROM by oscillations

Fractures ● Humeral Neck Fractures:

○ Can be extracapsular or intracapsular ■ Extracapsular fracture: fracture outside the joint capsule

● With edema ■ Intracapsular fracture: fracture inside the joint capsule

● May be bleeding in the actual joint - hemarthrosis ○ Can lead to malalignment

● With effusion

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○ Predisposing factors: ■ Most occur secondary to a minor fall and related to a FOOSH injury

● FOOSH injury: Fall On an Out Stretched Hand ■ Elderly women > men ■ Can sustain humeral head trauma from compressive forces into glenoid

○ Treatment: ■ MD:

● usually immobilization in a sling ■ PT:

● Early PROM ● Decrease swelling and ecchymosis

● Humeral Shaft Fractures: ○ Usually because of direct trauma to the arm ○ ex) direct blow to the arm in a car accident or falling without an outstretched arm

and landing on a hard, elevated object ○ Tend to heal well due to good blood supply ○ Treatment:

■ Depending on severity, can be treated with a closed reduction or an open reduction internal fixation (ORIF)

● Closed: cast or splinting ○ Used when bones are still aligned with each other

● ORIF: used when bones are malaligned to some degree ● Clavicular Fractures:

○ Predisposing factors: ■ More common in kids ■ FOOSH ■ Person falls directly onto the outside of their shoulder - direct trauma

○ Presentation : ■ Most common location: middle ⅓ ■ Most lateral aspect is usually pulled inferomedially due to the weight of

the UE ■ Not considered a serious injury as long as the fracture is allowed to heal

○ Greenstick fracture : when the bone does not break all the way ■ Apply a load that creates a concavity on one side and a convexity on the

other side ■ Only one cortex disrupted ■ Convex side will break but the concave side does not ■ Intervention: figure 8 brace

● Attempts to allow the bone ends to align Sprengel’s Deformity

● Not a fracture ● Predisposing factors:

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■ Scap did not descend appropriately during embryonic development and sits too high on the thorax

● Presentation : ○ Is a “high scapula”

■ Too high on the thorax ■ Scapula elevated and rotated inferiorly → can cause lots of

biomechanical problems ○ Scap tends to be smaller than the contralateral side ○ Can cause abnormalities of the cervical spine and the ossification of ligamentous

connections ■ Can also have brachial plexus and muscular imbalance dysfunctions

○ Overhead function limited Codman’s Exercises

● AKA pendulum exercises ● Purpose: used to assist people in the performance of ADL’s for shoulder injury ● Patient bends forward at the waist allowing the trunk to be positioned in front of the legs

○ Allows the UE to hang towards the ground ■ Positions the shoulder into some amount of flexion and slight abduction

○ Then patient flexes their elbow without having to lift their shoulder ○ Perform ADLs in this position avoiding having to elevate arm

■ Can simply flex elbow without lifting shoulder ■ Loose pack position so less stress on shoulder

● Creates less pain and requires minimal muscular effort ● As an exercise, use trunk to perform UE circles, forward/backward and lateral

movements ● Allows joint separation and repetitive movement gaits pain → neurophysiological effect ● Used as therex

AC Joint Sprain ● Predisposing factors:

○ MOI: FOOSH ○ Force: clavicle against rib cage

■ Acromion down, back, and in ● Types:

○ Type I: sprain of the AC ligament ○ Type II: rupture of the AC ligament ○ Type III: AC joint disrupted (clavicle elevated above acromion) and

coracoclavicular ligament ruptured ● Rockwood Classification :

○ Grade I: Clavicle not elevated ■ AC ligament: mild sprain

○ Grade II: Clavicle elevated but not above superior border of acromion ■ AC ligament: ruptured ■ CC ligament: sparin

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○ Grade III: Clavicle elevated above superior border of acromion ■ AC ligament: ruptured ■ CC ligament: rupture ■ Joint capsule: ruptured ■ Deltoid: detached ■ Trapezius: detached

○ Grade IV-VI: essentially different variations of Grade III ● Subjective :

○ Localized pain ● Examination :

○ Step 7: PFC → acute condition and those with deformity ○ Step 8 and 9 → pain with A/PROM ○ Step 15: PFT

● Assessment: ○ Piano key sign ○ Imaging: X-ray

● Treatment: ○ MD:

■ Grade I and II conservative: immobilization ■ Grade >3: surgical candidate

○ PT: ■ Acute : fit with sling, ice, and compression 24-48 hours ■ Subacute : ROM after sling is removed, pendulum, pulley, L-bar exercises,

wall climb ■ Settled :

● Strength: GH cardinal planes, biceps/triceps, scapular stabilization (superman’s seated push-ups)

● Advanced strength: endurance, high speed, eccentrics, PNF diagonals, bird dog rhythmical stabilization, return to sport

SC Joint Injury ● Anterior dislocations more common ● Posterior dislocations rare

○ Difficult to diagnose ○ May be life-threatening due to pressure placed on vital structures between

sternum and cervical spine ● Biomechanically proper alignment is essential for normal UE movement ● Presentation: meniscus type symptoms of clicking, popping, and/or locking ● Grades:

○ Type I: sprain of SC ligament

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○ Type II: subluxation, partial tear of capsular ligaments, disk, or costoclavicular ligaments

■ Type IIA: anterior subluxation (most common) ■ Type IIB: posterior subluxation

○ Type III: dislocation ■ Type IIIA: anterior dislocation ■ Type IIIB: posterior dislocation

○ Type IV: habitual dislocation - rare Bursitis

● Types: subacromial, subdeltoid, subscapular ● Presentation :

○ Inflamed and irritated ○ Pain lateral brachial region ○ Gradual onset with previous history of tendonitis/osis ○ Patient support arm in loose pack position

● Examination : ○ Step 7: PFC → warmth and swelling over bursa location ○ Step 8: AROM → pain with any motion that compresses bursa ○ Step 9: PROM → pain with any motion that lengthens the muscle over the bursa

or compresses the bursa ○ Step 15: PFT → painful with direct palpation of bursa

● Treatment: ○ MD:

■ anti-inflammatory/anesthetic - oral or injection ■ Excision

○ PT: ■ Acute: modalities to decrease swelling, lifestyle modification ■ Subacute: massage to mobilize fluid ■ Settled: retrain functional movements

Rotator Cuff Pathology ● Etiology:

○ Most often supraspinatus ○ Least often subscapularis ○ Young = traumatic etiology ○ Old = degenerative with insidious/gradual onset

● Presentation : ○ Pain at rest and at night ○ Worse with volitional movement ○ Weakness and loss of ROM ○ Painful arc

● Examination : ○ Step 7: PFC → warmth and swelling ○ Step 8: AROM → painful in direction muscle contracts

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○ Step 9: PROM → painful when muscle lengthens, opposite direction of contraction

○ Step 10: MSTT → findings depend on severity of injury ■ Strong and painful = strain/degeneration/inflammation ■ Weak and painful = partial tear ■ Weak and painless = complete tear

○ Step 11: MLT → painful with lengthening of involved muscle (if not deferred due to MSTT findings)

○ Step 12: MMT → weakness of involved muscle (if not deferred due to MSTT findings)

○ Step 13: Special tests → multiple test, combination of painful arc, drop arm sign, and infraspinatus muscle test had high probability of full thickness tear

○ Step 15: PFT → painful with direct palpation of injury ● Treatment:

○ MD: acute with large significant tears → surgical candidate ○ PT:

■ Chronic degenerative and/or small tears: conservative care ■ Stage I: pain/inflammation reduction :

● Decrease pain and inflammation: modalities, activity modification, NSAIDS

● Improve depressor effect on humeral head → strengthen RTC (IR/ER isometrics) and scapula pivoters

○ Inhibit delotoid ● Avoid positions that may exacerbate supraspinatus impingement ● Manual techniques to improve capsule mobility

■ Stage II: ROM restoration : ● Restore ROM → stretching/self mobilization ● Strengthening → free weights, concentrics RC, push up + ● Neuromuscular training → quadruped rocking, fitter board ● Plyometrics → medicine ball, push up with a clap ● Manual neuromuscular techniques PNF → quick reversals

■ Stage III: Strengthening : ● PNF diagonal patterns, eccentrics RC, military press, reverse flys,

push ups ■ Stage IV: Return to normal activity:

● Advanced plyometric training, sport specific training Shoulder Impingement

● External vs. Internal : ○ External impingement: acromial side of RTC

■ RTC with coracoacromial ligament or acromion ■ Type III acromion ■ Older non-athletic population ■ Superior surface of RTC fraying, abrasion, inflammation

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■ Degenerative changes: fibrosis, decrease in joint space, spurring ■ Decreased vascularity ■ Arthrokinematics: too much roll without enough inferior glide ■ Infraspinatus (ER) training at 90 degrees abduction will be the most

effective muscle to train ○ Internal impingement: glenoid side of RTC

■ Young overhead athlete ■ Extreme ranges of abduction and ER ■ Weak scapula retractors causes decreased force couple of RTC and

stretching of capsular ligaments ■ Greater tubercle impinges the glenoid side RTC against the

posterior/superior glenoid labrum ■ Biomechanical problem

● Importance of Scapular Upward/Rotation : ○ Patients with internal impingement had decreased scapular upward rotation with

shoulder abd ■ Puts the underside of the RTC in danger of being impinged between the

greater tubercle and the glenoid rim ■ Leads to inflammation of underside of RTC tendon, labrum posterior

superior tears, humeral head posterior defect ● Assessment:

○ Predisposing factors: ■ Scapula dyskinesia ■ Osteophytes (more likely with age) ■ RTC thickening ■ Labral injury ■ Multidirectional instability ■ Biceps tendinopathy ■ Type II or III acromion

○ External Impingement: ■ Primary: Type III acromion, bone spurs, calcified coracoacromial ligament ■ Secondary: superior migration of humerus due to RTC weakness/tear,

instability, anterior/posterior capsule contracture (adhesive capsulitis), reduced upward rotation of scapula, posture, T-spine hypomobility, poor form, stiff/short lats, inefficient breathing

○ Internal Impingement: ■ Extreme ER and abd

○ Subjective : ■ Reaching behind back, overhead, and night pain ■ External Impingement: pain ant/lat with overhead activity (ex. throwing,

swimming) ■ Internal Impingement: pain post/lat with max abd and ER

○ Assessment:

■ Painful arc, yocum, empty can, neer’s, hawkins-kennedy ■ Imaging: X-ray, MRI

● Stages: ○ Stage 1 :

■ Age <25 y/o ■ Localized hemorrhage and edema with tenderness at supraspinatus

insertion and anterior acromion ■ Painful arc 60-120 degrees (increased with resistance at 90 degrees) ■ Weakness secondary to pain ■ + Neers, Hawkins-Kennedy ■ - Radiography ■ Reversible with rest, activity modification, and rehab

○ Stage 2 : ■ 25-40 y/o with repetitive overhead activity ■ Same clinical findings as Stage 1 ■ Symptom severity increased to pain with activity and at night ■ Soft tissue crepitus or catching at 100 degrees ■ Fibrosis restricts PROM ■ + radiograph may show osteophytes under acromion, degenerative AC

changes ■ No longer reversible with rest, possibly helped by a long-term rehab

program ○ Stage 3 :

■ Age >40 y/o ■ Same clinical findings as stage 2 ■ Tear in RTC usually less than 1 cm ■ Increased limitations in A/PROM ■ Prominent capsular laxity with multidirectional instability seen on

radiograph ■ Atrophy of infraspinatus and supraspinatus ■ Surgery following a failed conservative approach

● Treatment: ○ Goal:

■ Inhibit middle deltoid ■ Facilitate ER: infraspinatus, teres minor, supraspinatus, subscapularis to

depress and compress GH joint ■ Stretch posterior and inferior joint capsule ■ Protect anterior joint capsule ■ Strengthen muscles that abduct, elevate, and upwardly rotate scapula:

● SA, upper trap, lev scap ■ Eccentrically strengthen middle trap and rhomboids to help decelerate

arm with throwing ■ Strengthen lower trap tp balance force couple with upper trap

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■ Mobilize SC and AC in any planes that are limited ■ Strengthen LE and core to decrease stress on shoulder joint

○ Neuromuscular Control Phase: ■ PNF diagonals, bird dog rhythmic stabilization

○ Return to sport ■ Consistency with program important to avoid recurrence

○ External Impingement: ■ Focus on scapula position → improve upward rotation ■ Work on shoulder instabilities

● Rhythmic stabilization GH Joint Multidirectional Instability

● Assessment: ○ Predisposing factors:

■ Atraumatic: congenital laxity, stabilizing muscles unable to control laxity especially during deceleration throwing

● Humeral head translates anteriorly and inferiorly stretching capsuloligamentous structures

● Proprioceptive deficits ■ Traumatic

○ Subjective : pain and clicking ○ Assessment: load and shift, sulcus sign, crank test

● Treatment: ○ Early phase: improve muscle tone and scapulothoracic posture

■ Provides steady base with proper length tension relationship of ant/post muscles

○ Strength phase: RTC begins at 0 degrees of elevation ○ Neuromuscular control phase: PNF diagonals, bird dog rhythmical stabilization ○ Return to sport: consistency with program important to avoid recurrence

WEEK 6: ELBOW

Elbow Tendinopathy ● Tendinopathy/itis/osis:

○ Tendinopathy: pathology of tendon ○ Tendonitis: inflammatory process occurring within the tendon ○ Tendonosis: tendon degeneration

● Predisposing factors: ○ Joint restriction or hypermobility → alters length tension relationship → increases

stress on tendon ○ Muscle imbalance → increases stress on tendon ○ Faulty ergonomics (sport/ADL) increases stress on tendon ○ Unaccustomed stress (joint dysfunction, insufficient strength, tight muscles,

wrong racket, holding racket wrong ● Locations:

○ Lateral tendinopathy → lateral epicondyle ○ Medial tendinopathy → medial epicondyle ○ Posterior tendinopathy → posterior elbow (triceps tendon) ○ Bicipital tendinopathy → anterior elbow (biceps tendon)

● Examination : ○ Step 2 : initial observation → may note some swelling ○ Step 3 : history → gradual onset, repetitive use

■ Lateral/medial: middle age ■ Biceps/triceps: younger

○ Step 6 : structural inspection → muscle atrophy/hypertrophy ○ Step 7 : PFC → warmth and swelling ○ Step 8 : AROM → painful with muscle contraction ○ Step 9 : PROM → painful with lengthening tissue ○ Step 10 : MSTT →

■ Strong painful: tendonitis/osis or muscle strain (don’t do MMT) ■ Weak painful: partial tear (do not do MLT/MMT) ■ Weak painful: complete tear

○ Step 11 : MLT → pain with lengthening tendon and may have decreased length ○ Step 12 : MMT → pain with contraction ○ Step 13 : special tests ○ Step 15 : palpation for tenderness → pain with palpation of involved tendon ○ Step 16 : movement analysis → recreate functional task that reproduces

symptoms ○ Step 17 : imaging → MRI or CT scan may be useful in narrowing down involved

tendon ● Treatment:

○ Acute : prevent condition from worsening, decrease inflammation ■ PRICE ■ Gentle PROM in pain free range = top preserve ROM ■ 50% 1RM exercise (31+ reps without fatigue) for vascularity/pain ■ Look at joints above and below

○ Subacute : maintain range and begin to reintroduce tendon stress ■ Progress to AAROM and then to AROM as tolerated to preserve ROM

and being to reintroduce stress to tendon ■ Manipulations to address any joint restrictions ■ Gentle PRE (progressive resistance exercises) at end of subacute 60%

1RM (25-30 reps) for coordination ■ Eccentrics for tendon healing - low grade muscle contraction

○ Settled : progress strengthening ■ To more aggressive forms ■ 80% 1RM (8-12 reps) for strengthening ■ Stretch tight muscles ■ Progress

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○ Additional Elbow Treatments: ■ Bracing/splinting for lateral tendinopathies → changes origin ■ Eccentrics for degenerative tendinopathies ■ Surgery if conservative management not successful

● Goal is to stimulate improved vascularization to create a new healthy scare

● Post op therapy important to promote proper healing and scar formation

Elbow Capsular Pattern ● Entire joint capsule is restricted (hypomobile) ● All directions that the joint move are hypomobile with a tight capsule end feel ● Elbow Capsular Pattern : Flex/ext

○ Decreased AROM with flex, more limited than ext ○ Decreased PROM classical flex more limited than ext ○ Tight capsule end feel with PROM classical ○ Decreased PROM accessory: P/A glide radial head more limited than A/P glide of

radial head ○ Tight capsule end feel with PROM accessory

Medial Collateral Ligament Sprain ● Predisposing factors:

○ Overhead athlete → throwing, tennis serve ○ Trauma → direct trauma to medial elbow

● Examination : ○ Step 3 : history → pain medial elbow ○ Step 7 : PFC → warmth and swelling ○ Step 13 : special tests → pain and increased mobility with valgus stress test ○ Step 15 : PFT → pain in MCL

● Treatment: ○ MD:

■ Surgery for competitive throwing athletes ■ Use of palmaris longus, plantaris, or toe extensor tendons

○ PT: ■ PRICE, modify activities ■ Increase ROM and strength ■ Strengthen/stabilize above and below ■ Supervised throwing progression

Olecranon Bursitis ● Predisposing factors:

○ Direct trauma ○ Repetitive weight bearing

● Examination : ○ Step 7 : PFC → warmth and swelling posterior elbow ○ Step 8 : AROM → Pain with AROM ext (triceps)

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○ Step 9 : PROM → pain with PROM flex (triceps) ○ Step 11 : MLT → pain with lengthening triceps ○ Step 15 : PFT → pain over olecranon bursa

● Differential diagnosis: ○ Infection within joint ○ RA ○ Gout ○ Fracture

● Treatment: ○ MD:

■ Aspiration, cortisone injection, antibiotics ■ Sling

○ PT: ■ Modalities to decrease inflammation and pain ■ Education for repetitive stress ■ stretch/strengthen as indicated by clinical exam

Heterotopic Ossification and Myositis Ossificans ● Heterotopic ossification : bone formation in location other than bone ● Myositis ossificans: bone formation in inflamed muscle

○ Predisposing factors: ■ Trauma ■ Burns ■ Genetic disorders

○ Examination : ■ Step 8 : AROM → limited in flex and ext ■ Step 9 : PROM → classical limited in flex and ext ■ Step 10 : MSTT → weak ■ Step 11 : MLT → decreased length ■ Step 12 : MMT → Weak ■ Step 17 : imaging → as early as 2 weeks post injury may see bone

formation in muscle ○ Treatment:

■ PT: ● Maintain ROM ● Don’t be too aggressive - don’t want to reinjure

○ Avoid bleeding into muscle Nerve Entrapments

● Predisposing factors: ○ Trauma ○ Tight muscles ○ Soft tissue restrictions ○ Joint mobility restrictions ○ Swelling

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○ Bony changes ○ Ergonomics

● Examination : ○ Motor and sensory changes distal to the site of entrapment ○ Stress the site of entrapment to confirm location

● Treatment: ○ Address pressure that is on the nerve

■ Soft tissue: soft tissue manipulation ■ Tight muscle: stretch muscle ■ Joint mobility: joint manipulation ■ Ergonomics

○ Cannot strengthen muscles until pressure relieved off the nerve ● Median Nerve Elbow Entrapment Sites:

○ Ligament of Struthers → becomes irritated between ligament and humerus ○ Bicipital aponeurosis:

■ Fascia where the biceps tendon attaches to radius ■ Median nerve becomes adhered to fascia

○ 2 heads of pronator teres: ■ Runs between the 2 heads ■ Compressed due to tightness, hypertrophy, swelling of pronator teres ■ Anterior interosseous nerve is a branch of the median nerve that can be

entrapped at pronator teres ● Only motor so use that to differentiate median nerve from AIN

entrapment ○ Median nerve muscle innervations:

■ Pronator teres, FCR, PL, FDS, lumbricals, sensory - volar of digits 1,2,3,½ 4

■ Anterior interosseous: FDP, FPL, pronator quadratus ■ Recurrent branch: OP, APB, FPB

● Ulnar Nerve Elbow Entrapment Sites: ○ Cubital Tunnel behind the medial epicondyle :

■ Sharp turn behind the medial epicondyle can aggravate the nerve ■ Large carrying angle increases susceptibility to nerve irritation ■ Forearm flexor mass may become hypertrophied or tight causing

compression on nerve ○ Ulnar Nerve Muscle Innervations:

■ FCU, FDP, Sensory ½ 4, 5, FPB (deep head), AP, Interossei, lumbricals 3 and 4, ODM, ADM, FDM

■ Superficial ulnar: palmaris brevis ● Radial Nerve Deep and Superficial Branch Elbow Entrapment Sites:

○ Direct trauma to the area or radial head or neck fracture can damage the nerve ○ Deep branch within muscle belly of supinator due to muscle hypertrophy or

tightness

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○ Superficial branch fibrous angle of ECRB ■ Main complaint is pain over dorsal aspect of 1st CMC joint

○ Radial Nerve Muscle Innervations: ■ Brachioradialis, ECRL, anconeus, triceps, sensory to dorsum of digits

1,2,3,½ 4, supinator, ECRB, ED, EDM, ECU, APL, EPB, EPL, EI Elbow Fractures

● Supracondylar Fracture : ○ Fracture through the epicondyles of the humerus ○ Can be intra or extra-articular depending on location ○ Predisposing factors:

■ Children ■ Hyperextension or fall on flexed elbow ■ Severe comminuted fracture possible

● Jagged ends can be driven into anterior periosteal tissue and the brachialis

● Bone fragments may damage the median nerve or brachial artery ○ Treatment:

■ MD: ● Based on the amount of displacement and nerve/arterial damage

○ If no displacement or neurovascular damage than the fracture is immobilized with the elbow flexed

○ If displacement, a closed reduction can be done ○ But if neurovascular damage → ORIF needed

■ PT: treat secondary complications from the fracture, surgery, immobilization

● Radial Head Fracture : ○ Compression of radial head in capitellum due to FOOSH ○ Can be comminuted or non-comminuted ○ In this area, malunion is highly likely ○ Treatment:

■ MD: ● Closed reduction and casting

○ Often associated with high rates of stiffness ● Closed reduction and early motion

○ May have bony malunion and malunion especially with comminuted and unstable fractures

● ORIF or replacement or excision depending on fracture ○ Improved long term functional outcomes

■ PT: ● Treat secondary complications due to the fracture, surgery,

immobilization ● Avulsion Fracture of Olecranon :

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○ Sudden passive flexion with a powerful contraction of the triceps or a fall backwards onto elbow

○ This causes the triceps to avulse the olecranon procress ○ Immediately post injury will have decreased elbow extension ○ Complications:

■ Non-union ■ Post traumatic DJD

○ Treatment: ■ MD:

● If non-displaced or minimally displaced → immobilization with elbow flexed 90 degrees

● For any other fracture → ORIF followed by immobilization ■ PT:

● Will treat any secondary impairments from surgery and immobilization

● Fracture Complications: ○ Post traumatic DJD: articular cartilage damaged

■ Associated with: ● Intra-articular fractures ● Dislocations ● Malunion

○ Nonunion : Fails to heal with bone ■ Fibrous non union: healed by fibrous tissue but not bone

○ Pseudoarthrosis: Nonunion with continual motion at fracture site ■ Causes formation of false joint

○ Malunion : fracture has healed but incorrectly ■ Significant deformity

○ Delayed union : healing but at a slow rate ○ Greenstick fracture : failure on convex side (break of cortical surface) with only

bending on concave surface ● Possible End Feels after Immobilization :

○ PROM classical → tight muscle, tight capsule, edema, bony block ○ PROM accessory → tight capsule, effusion, bony block

Dislocation ● Severe hyperextension or a fall on the hand with the elbow slightly flexed ● Ulna and radius move posteriorly in relation to humerus which is now more anterior ● 20-25% of the time a posterior dislocation is associated with a fracture ● Complications:

○ Capsular damage ○ Injury to brachialis muscle ○ Damage to the collateral ligaments ○ Median nerve injury ○ Brachial artery damage

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○ Fractures ○ Myositis ossificans ○ Post traumatic DJD ○ Tight muscles/capsule

WEEK 7: WRIST AND HAND

Fractures and Deformities

● Mallet Finger: ○ Rupture of extensor tendon (central slip) that attaches to base of distal phalanx

or avulsion of attachment site ○ MOI: fingers actively extending while ball hits tip of finger hyperflexing DIP (bent

down) ■ Finger jam during eccentric loading

○ Presentation : loses ability to actively extend → intact flexor musculature pulls DIP into flexion

● Bennett’s Fracture : ○ Fracture at base of 1st MC ○ Common in boxers, football players ○ MOI:

■ Axial load to tip of 1st digit while it is in slight flexion ■ Drives MC into trapezium causing fracture on ulnar side ■ Often associated with dislocation of 1st CMC joint with MC moving in

radial direction ■ Strong interosseous ligament holds fragment in place against 2nd MC

while 1st MC displaced laterally ○ Treatment:

■ MD: ● Closed reduction and casting ● Percutaneous pinning ● If significant → open reduction with K wire or screws

■ PT: ● Often see them after surgery or immobilized ● May present with CMC laxity or hypomobility

○ Treat what you find ○ Joint capsule stiffness, muscle atrophy

● Boxer’s “Street Fighter’s” Fracture : ○ Fracture at neck of 5th MC ○ Unskilled in fighting ○ MOI:

■ Poor technique striking force through ulnar side of fist vs. radial side ■ MC 4 and 5 are mobile whereas 2 and 3 are more rigid

● Because adductors are on the 2nd and 3rd so more rigid

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■ Ulnar nerve can be damaged - weakness in adduction ○ Treatment:

■ MD: ● Close reduction ● ORIF with plating

● Scaphoid Fracture : ○ MOI:

■ FOOSH with wrist in ext and slight radial deviation ■ Causes scaphoid and lunate to approximate with radius

○ Subjective : pain in anatomical snuff box ○ Radiography: acute injuries are often missed on radiographs ○ Complications:

■ Avascular necrosis ■ Delayed healing and non-unions

○ Treatment: ■ MD:

● Medical treatment mandatory ● Casting, surgery, bone stimulators

■ PT: after immobilization ● Hyper/hypomobilities ● Swelling ● Tight extrinsics

● Colles Fracture : ○ Transverse distal radius fracture with dorsal displacement ○ Predisposing factors:

■ Age > 50 ■ Females > Males

○ MOI: ■ FOOSH with wrist in extension (often supinated)

● Force travels dorsally though the distal radius ○ Presentation :

■ Distal segment will have a dorsal displacement ■ “Dinner fork deformity”

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● ○ Complications:

■ Median and ulnar nerve injury ■ Malunion “dinner fork deformity” ■ Post-traumatic arthritis ■ Soft tissue adhesions ■ Complex regional pain syndrome ■ Shortening or lengthening of radius due to poor alignment

● Smith’s Fracture : ○ Transverse distal radius fracture with palmar displacement volarly ○ MOI:

■ FOOSH with wrist in ext (often pronated) ■ FOOSH with wrist flexed

● Force travels palmarly through the distal radius ○ Presentation :

■ Distal segment will have a volar displacement ■ Muscle atrophy ■ Joint laxity

● Galeazzi Fracture : ○ Fracture of distal radius with dislocation of distal radio-ulnar joint ○ Open fracture: bone through skin ○ Can have non-union ○ Treatment:

■ MD: ● Best results with ORIF of radius and distal radioulnar joint

● Monteggia Fracture : ○ Fracture of proximal ulna with dislocation of distal radio-ulnar joint ○ Treatment:

■ MD: ● Closed reduction: realign by traction/cast

● Dupuytren’s Contracture : ○ Contracture of palmar fascia of hand ○ Cellular level formation of nodules on palmar fascia

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■ Thickens and shortens palmar fascia pulling MCP and PIP joints into flexion

○ Digits 4 and 5 most common ○ Predisposing factors:

■ European Caucasian males ○ Treatment:

■ MD: ● Resting hand splint ● Excise tissue with Z incision ● Tenolysis - make room for tendon

■ PT: ● Scar management ● ROM

● Kienbock’s Disease : ○ Osteochondrosis of lunate bone ○ Predisposing factors:

■ Trauma from FOOSH or laxity of lunate bone ● Causes avascular necrosis

● Bouchard’s and Heberden’s Nodes: ○ Fibrous part of capsule thickens laying down ossification forming bony node ○ Bouchard’s = at the PIP joint

■ May be associated with RA ○ Heberden’s = at the DIP joint ○ Presentation :

■ Decreased joint space ■ Sclerosis of subchondral bone ■ Osteophytes at articular margins ■ Joint deformities

● Swan Neck and Boutonniere Deformity: ○ Displacement of the lateral bands of the extensor mechanism at the PIP joints ○ Swan Neck: lateral bands displaced dorsally

■ PIP pulled into hyperextension ■ MCP and PIP pulled into flexion

○ Boutonniere : lateral bands displaced volarly ■ PIP flexed ■ MCP and DIP extended

● Digital Tendovaginitis Stenosans “Trigger Finger”: ○ Thickening of flexor tendon sheath causing finger to be stuck in flexion and

unable to extend ○ With active flexion, tendon becomes stuck proximal to A1 pulley ○ Individual must passively extend finger to pass tendon through pulley ○ Predisposing factors:

■ Swelling around the flexor tendons

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■ Nodule within flexor tendons ■ Thickening of fibrous sheath of flexor tendons

● Z Deformity: ○ 1st digit

■ CMC flexed ■ MCP hyperextended ■ IP flexed

○ Predisposing factor: ■ Laxities from RA

● Opera Glove Anesthesia : ○ Loss of sensation from wrist down to fingertips ○ Is not correlated with any neurologic cause ○ Predisposing factors:

■ Hysteria ■ Leprosy ■ Diabetes ■ CRPS

● Benediction Sign and Bishop’s Deformity: ○ 4th and 5th digits are flexed while rest of hand is extended ○ Benediction Sign : ask patient to make a fist and only able to flex 4th and 5th

digits ■ Indicates loss of median nerve and therefore ability to flex 2nd and 3rd

digits ○ Bishop’s Deformity: patient holds their hand with the 4th and 5th digit flexed due

to loss of ulnar nerve and medial two lumbricals that assist with PIP extension ■ Patient unable to extend digits fully

Pathologies ● Complex Regional Pain Syndrome :

○ Regional pain and hypersensitivity disproportionate to any specific event ○ Theories on Etiology:

■ Direct trauma to sympathetic nerves ■ Direct trauma to peripheral nerve ■ Immobilization ■ Immobilization in the presence of edema ■ Psychological predisposition

○ Miscommunication between ANS and CNS: ■ S&S associated with miscommunication between ANS and brain

● Atrophy of hair, nails, and other soft tissue ● Alterations of hair growth ● Glassy or shiny skin, red blotchy skin ● Loss of joint mobility ● Impaired motor function (weakness, tremor) ● Osteopenia

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● Sympathetically maintained pain ● Pain described as burning, throbbing, shooting, or aching ● Hyperalgesia ● Aloodynia: perception of pain with normally innoculous stimuli

(sympathetic mediated pain) ● Abnormal sweating or Anhidrosis (inability to sweat) ● Redness or bluish discoloration ● Heat or cold sensitivity

■ Brain responds with edema, attempts to heal and heightened sensations to protect individual from doing further harm

■ Sympathetic system responds to injury by enlarging blood vessels, onset of swelling, pain, and redness

● Sympathetic system is trying to fight ○ Treatment:

■ MD: ● Pharmacology, sympathetic blocks and psychotherapy ● This should be integrated with rehab program ● Surgical intervention: spinal cord stimulator, intrathecal infusion,

baclofen pump, morphine pump, sympathectomy, and radiofrequency ablation

■ PT: ● Sensory training: tactile habituation (fluidotherapy) ● Massage and muscle pumping for edema ● Maintain mobility and muscular functioning ● Pain science education

○ Prognosis: ■ 80% have complete spontaneous relief of signed and symptoms in 18

months ■ 50-80% have disability secondary to pain and or limited ROM ■ Poor outcomes associated with long duration of symptoms, presence of

trophic changes, presence of cold RSD ● Volkman’s Ischemic Contracture :

○ Compartment syndrome specific to the forearm ○ Predisposing factors:

■ Direct trauma to area causing edema ■ Forearm cast

○ Etiology: ■ Increased build up of pressure leads to compression of neurovascular

components ■ Causes decreased sensation and decreased blood flow → ischemia ■ Ischemic muscles and soft tissue become necrotic and fibrotic ■ Leads to contractures of muscle or soft tissue including nerves

○ S&S:

■ Swelling and ℅ tightness ■ Diminished radial or ulnar pulses and capillary refill ■ Significant motor weakness and paralysis ■ Measurement of pressure remains controversial

○ Treatment: ■ MD:

● Emergent condition ● Fasciotomy to restore compartment pressure to normal ● Remove cast ● If pressure not released in time will require further surgical

interventions ● Injury to “No-Man’s Land”:

○ Flexor Zone 2 of the hand → distal palmar crease to mid portion of middle phalanx

○ FDP and FDS pass through their fibrous tunnels ○ Laceration in this zone has poor prognosis

■ Poor blood supply and tendons are prone to adhesion formation ■ Will require surgery

● Dequervain’s Tenosynovitis: ○ Inflammation of APL and EPB tendons and sheath (1st extensor tunnel) ○ Predisposing factors:

■ Repeated action that causes friction where the tendons glide → inflammation

○ Examination : ■ Step 3 : history → pain radial side of wrist over 1st extensor tunnel

● Worse with thumb active abduction and extension and wrist ulnar deviation

● Female > male ■ Step 7 : PFC → warmth, swelling, and thickening over the APL and EPB ■ Step 8 : AROM → pain with thumb abduction and extension ■ Step 9 : PROM → pain with thumb adduction and flexion ■ Step 10 : MSTT → Abd and ext of thumb: strong and painful ■ Step 11 : MLT → pain in thumb abductors and extensors ■ Step 13 : Special tests → Finkelstein

○ Treatment: ■ PT:

● Activity modification ● Decrease inflammation ● Splint to decrease stress and strain on tendons ● Treat impairments that are causing tendon irritation

○ Hypo/hypermobilities ○ Stretching tight muscles ○ Strengthening weak muscles

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Peripheral Nervous System Pathologies ● Carpal Tunnel Syndrome :

○ Median nerve entrapment in carpal tunnel ○ Mixed efferent and afferent nerve ○ Predisposing factors:

■ Pressure on wrist from work or bicycle riding ■ Trauma: fracture/fall on area ■ Disease: diabetes or other metabolic disorders ■ Space occupying lesion: ganglion cyst ■ Tight wrist flexors: prevent neural gliding in carpal tunnel ■ Displaced lunate: more in volar direction

● Hypomobile: lunate on scaphoid restricted in dorsal direction ● Hypermobility: scapholunate ligament is lax

○ Lunate moves in volar direction ■ Retinaculum tightness: causes compression ■ Edema: interstitial fluid ■ Effusion: between carpals ■ Pronator Teres Syndrome: any median nerve entrapment at elbow ■ C5-T1 nerve root pathology

○ Examination : ■ Step 3: history → paresthesias in the median nerve distribution,

night pain, hand weakness ■ Step 9: PROM accessory → lunate mobility ■ Step 10: MSTT → weak and painful ■ Step 11: MLT → tight wrist flexors ■ Step 13: special tests → Phalen’s, Tinnel’s

○ Treatment: ■ MD:

● Endoscopic release ● Open release

■ PT: ● Depends on impairments and lifestyle that caused it ● Education in lifestyle modifications/ergonomics ● Night splint to keep patient out of flexed postures

○ Only use when acute or highly reactive ● Stretch wrist flexors ● Decrease fluid with manual techniques and modalities

○ Nerve Injuries: ■ Neuropraxia :

● Slight damage to the nerve with transient loss of conductivity ● Corresponds to a 1st degree injury to a nerve ● Demyelination with restoration in weeks ● Complete recovery is expected in approximately 12 weeks

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● S&S: ○ Pain ○ None or minimal muscle wasting ○ Some muscle weakness ○ Numbness ○ Loss of proprioception

■ Axontmesis: ● Injury damages the axons but not the body of the nerve ● Axons, myeling, and internal structures are all disrupted ● Corresponds with 2nd, 3rd, and 4th degree injury to a nerve ● Axons are disrupted and must regenerate while the epineurium is

intact ● Typically occurs with traction type injuries ● Regeneration occurs in the intact neural tubes but slowly

(1mm/day) ● S&S:

○ Pain ○ Evident muscle atrophy ○ Diminished motor, sensory, and sympathetic function ○ Recovery sensations return before motor function

■ Neurotmesis: ● The internal structural framework and the enclosed axons are

destroyed ● Corresponds to a 5th degree injury to a nerve ● An injury that results from disruption in the continuity of both axons

and all supporting structures, including epineurium ● Losing the neural tubes negates the potential for normal

regeneration ● Neurofibrils can grow out from the divided ends to produce a

neuroma ● S&S:

○ No pain ○ Muscle wasting ○ Complete motor, sensory, and sympathetic function loss

WEEK 8: CERVICAL/THORACIC

Anatomy

●

●

●

● Arthrokinematics

● Functional Anatomy: ○ Cervical Thoracic: occiput → T4 ○ Upper Cervical: C0 → C2 ○ Mid-Lower Cervical: C2 → T4

● Sub-cranial : ○ Flexion :

■ C0 on C1 → anterior roll/posterior glide (convex on concave) ■ C1 on C2 → anterior roll/anterior glide (convex on convex)

○ Extension : ■ C0 on C1 → posterior roll/anterior glide (convex on concave) ■ C1 on C2 → posterior roll/posterior glide (convex on convex)

○ R Rotation : ■ C0 on C1 → 1-3 degrees R posterior roll/anterior glide (convex on

convave) ■ C1 on C2 → R posterior roll/posterior glide (convex on convex)

● 30 degrees ○ R Sidebending (Lat Flex):

■ C0 on C1 → R roll/L glide (convex on concave) ● C1 will side glide to R ● C1 always moves with skull

■ C1 on C2 → no sidebending occurs (convex on convex) ○ *roll will go to the same side the bone is moving

■ ex) flex arm → arm goes up → roll goes up ● Mid Cervical/Upper Thoracic:

○ Flexion : Superior/Anterior ■ Up/forward

○ Extension : Inferior/Posterior ■ Down/back

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○ Sidebending/Rotation : Ipsilateral Inferior/Posterior, Contralateral Superior/Anterior

Collagen ● Type 1 Collagen : Stretch

○ Muscles, tendons, ligaments, capsule, annulus of disc ● Type 2 Collagen : Compression

○ Facet cartilage/nucleus of disc ○ Responds well to compression and cyclical loading

Myofascial Tightness and Posture ● Myofascial tightness:

○ Differential diagnosis: cervical SB with arms unsupported and supported ■ Decreased range with unsupported → tight muscle or facet ■ Decreased range with supported → tight facet

● Posture Related Neck Pain : aka Val syndrome ○ Pain in neck, upper trapezius, interscapular, suboccipital ○ Cervicogenic headaches ○ No complaint of paresthesias or neurological symptoms since source of pain is

typically facet (cartilage, capsule, or both) ○ Forward head posture :

■ Excessive upper thoracic flexion ■ Excessive mid and upper cervical extension

○ Impairments: ■ Forward head and rounded shoulders ■ Decreased cervical AROM ■ Tight upper trapezius, levator scapula, suboccipital muscles, pec major,

pec minor ■ Weak middle lower trapezius and deep neck flexors ■ Increased tenderness and tone in cervical/thoracic paraspinals,

suboccipital muscles, SCM, upper trap, levator scap, and interscapular muscles

■ Poor posture awareness and ergonomics set up ○ Treatment:

■ Identify tissue specific impairments ■ Reduce pain and muscle guarding

● Soft tissue mobilization ● Joint manip ● Light exercise (50% 1RM) ● Physical agents (thermal, electrical) only if patient can tolerate

manual treatment ■ Focus on TSI ■ Postural education and ergonomic set up ■ Ex)

● Stretching mid-upper thoracic spine into extension

● Actively stretching tight pec muscles while strengthening middle traps (cable rows)

Sprain/Strain/Synovitis and Painful Entrapment ● Sprain/Strain/Synovitis:

○ Ligament-Capsule Sprain on Right: ■ Painful movement pattern :

● In end range with all motions ● Worse with L SB/flex → gapping of facet joint ● Unilateral pain

■ Worse with up glides ■ Better with down glides ■ Ex) Tear in capsule C3-C4

● Cervical flex → bad ○ Tension in capsule

● R rotation → bad ○ Creates up glide ○ Tensions capsule

● R SB → good ○ Bunches up capsule

● Cervical ext → good ○ Puts capsule on slack

○ Capsular Entrapment: ■ Painful movement pattern :

● End range with all motions ● Worse with compression → ext, ipsilateral SB/rotation ● Unilateral pain

■ Treatment: ● Isometric multifidi contraction to pull capsule out of joint space

○ Keeps capsule from folding in and getting pinched ○ An unexpected perturbation can irritate multifidi

● R sided problem → PT stands on L ○ Facet Cartilage on Right:

■ Painful movement pattern : ● Ext ● Ipsilateral SB/rot ● Unilateral pain in R

■ Pain relieved with : ● Flexion ● Contralateral SB/rot

○ Posterior Annular Tear: ■ Painful Movement Pattern :

● + flexion ● B rotation

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● Possible ext ● uni/bilateral pain

Cervical Radiculopathy & Myelopathy ● Cervical Radiculopathy:

○ Pressure on a cervical nerve causing pain, numbness, tingling, or weakness ○ Etiology:

■ Uncovertebral (“U” or “Von Lushka”) joint spondolytic changes ■ Inflammation from annular tear ■ Inflammation from facet joint

○ Painful Movement Pattern : ■ Decreased ipsilateral SB and BB with UE symptoms

○ Neurologic findings: ■ Dermatome/myotome (muscle weakness)

● Changes movement distally ■ Distraction decreases symptoms ■ Compression increases symptoms (numbness) ■ Tenderness on side of involvement

○ Impairments: ■ Forward head and shoulders posture ■ Limited and painful BB and ipsilateral SB with pain radiating into UE ■ Neurologic signs in corresponding dermatome/myotome ■ Distraction decreases symptoms ■ Compression/Spurlings and Quadrant test all increase symptoms in the

UE ■ Tenderness on side of involvement in the upper

trap/levator/paraspinals/interscapular muscles ○ Clinical Prediction Rule :

■ + ULTT1 ■ Cervical rotation < 60 degrees ■ Distraction decreases symptoms ■ + Spurling’s Test

● Central Spine Stenosis and Myelopathy: ○ Damage to cervical spinal cord due to degeneration of cervical spine ○ Etiology:

■ Osteophytes on posterior aspect of vertebral body ■ Disc and ligamentum flavum protrusion ■ DJD and DDD in the c spine

○ Presentation : ■ Aching in neck and shoulders with occasional radiation into arms ■ Paresthesias in hands/feet, weakness in legs and imbalance

○ Impairments: ■ Forward head posture with thoracic kyphosis ■ Limited AROM

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■ Permanent or transient neurologic signs/+ Babinski and Clonus ■ General weakness of extremities ■ Muscle tightness/weakness associated with posture ■ Tenderness and increased tone in the upper traps, cervical region

○ Treatment: ■ Notify MD ■ If cleared for therapy:

● Work on tightness/weakness associated with posture ● Strengthen the extremities ● Work on balance ● Local treatment for muscle soreness ● Chin tucks with head on 2 pillows

*Read these if you have time LOL - not much will be on test

WEEK 4: MS PATHOLOGY Musculoskeletal Pathology Part 1

● Metabolic Diseases: ○ Osteoporosis: porous bone

■ Metabolic disorder ■ Bone reabsorption > bone formation ■ Osteoclast activity > osteoblast activity ■ Areas most susceptible :

● Areas rich in blood supply and trabecular: vertebrae, calcaneus, and metaphyseal area of long bones

■ Risk factors: ● Menopause ● Men 4x > women after 40 y/o ● Aging ● Heredity ● Ethnicity ● Inactivity ● Tobacco ● Alcohol ● Corticosteroid use ● Nutrition ● Depression

■ Signs and symptoms:

● Loss of height ○ Thoracic kyphosis ○ Vertebral fracture

● Postural changes ○ Protruding abdomen ○ Increased thoracic kyphosis ○ Dowager’s hump ○ Loss of lumbar lordosis ○ Forward head, internally rotated shoulders, backward

facing palms ○ Posterior pelvic tilt ○ Knee hyperextension ○ Back pain

■ Fracture site ■ Muscle imbalance ■ Paravertebral spasm

○ Fracture ■ Spontaneous fracture

● Vertebral bodies ● Femoral neck/acetabulum ● Rib ● Radius ● Shaft of femur ● Metatarsal

■ Determined by bone mineral density: ● *Radiological definition: low bone density regardless of cause

(osteoporotic or not) ● Normal : bone density within 1 SD of the young adult mean (+1 or

-1) ● Osteopenia : bone density is 1.0-2.5 SD below the young adult

mean (-1 to -2.5 SD) ● Osteoporosis: bone density is 2.4 SD or more below the young

adult mean (> -2.5 SD) ■ Radiological features of common osteoporosis:

● Cortical bone thinning (long bones) and periarticular areas ○ First areas to lose density or show loss

● Osteopenia: hallmark of osteoporosis ○ Radiolucency areas in bone

● Trabecular changes ○ Thin, sparse, and delicate ○ Easily seen in proximal femur

● Fractures

○ Vertebral bodies, proximal femur + humerus, and distal radius

●

● ■ Treatment:

● Stop bone loss ○ Estrogen replacement therapy: selective estrogen receptor

modulator (SERM) ○ Supplements: calcium, vitamin D ○ Pharmacology: calcitonin, bisphosphonates (actonel,

boniva, fosamax) ● Fracture management

○ Vertebroplasty ○ Kyphoplasty ○ ORIF ○ THA

● Proper nutrition: keep BMI above 22

● Load bearing exercise ○ Walking, jogging

■ Prevention : ● Bone density screening ● Calcium and vitamin D supplements ● Adequate nutritional intake ● Weight bearing activity ● Fall prevention ● Smoking cessation

○ Osteomalacia (soft bone): ■ Bone is built incorrectly

● It is built too soft ■ The cause may be poor nutrition, person may not be able to absorb

calcium or phosphate (GI disorder), or has a metabolic deficiency excreting too much calcium or phosphate (kidney related)

■ Similar to Rickets disease in children (poor nutrition and lack of vitamin D) ● Don’t confuse with osteogenesis imperfecta (brittle bones)

■ Risk factors: ● SLE due to photo sensitivity ● People from northern China, India, and Japan ● Long term antacid use-usually at high doses (aluminum

hydroxide)-aluminum hydroxide causes hypophosphatemia and subsequent stealing of phosphate from bones

● Sedentary and institutionalized individuals ○ Osteitis Deformans:

■ Bone inflammation causing deformity ■ AKA Paget’s disease ■ Progressive metabolic bone disease :

● 2nd most common metabolic bone disease ● Origin may be genetic and/or virotic

■ Pathology: ● Greatly accelerated bone remodeling activity → presence of giant

osteoclasts that are actively resorbing bone ● Rebuilding process is at a loss to catch up

○ But when it does, it’s bad ● Abnormal bone turnover may cause unwanted bone growth

compressing nerves, spinal cord, and brain leading to headaches, cognition deficits, and hearing problems

● Increased bone turnover require increased blood circulation and overtime may cause heart related problems

■ Incidence : ● British isles and british immigrants ● Age > 50, more common in males

■ Pelvis (75%) most commonly affected ■ Bowing of the femur and tibia ■ Enlarged skill (29% to 65%)

○ Osteopetrosis: ■ Stone bone ■ Increased bone density ■ Pathology:

● Very rare disorder where osteoclasts fail to resorb bone → impaired bone modeling and remodeling

● Defect in bone turnover → skeletal fragility despite increased bone mass

○ Key points to remember about metabolic bone disorders: ■ Osteoporosis: normal bone losses density, common in caucasian

post-menopausal women ■ Osteomalacia : bone is built too soft, lack of minerals often from nutritional

intake deficit or GI disorder ■ Paget’s disease : bone turnover too high → can cause neurological

(compression) and cardiovascular (excessive blood demand) problems ■ Osteopetrosis: bone too dense → rare, weak structure

Musculoskeletal Pathology Part 2 ● Fractures:

○ Definition: defect in the continuity of a bone or cartilage ranging from a crack to a break with multiple segments

○ Classification : ■ Traumatic (impact): acute bone failure often caused by a single

application of high magnitude stress ■ Stress: insidious bone failure usually caused by repetitive application of

stress of small magnitude over time (extremely rare in sedentary people) ■ Pathologic: bone failure is caused by a pathologically fragile bone

structure caused by neoplasm or infection ■ Insufficient: bone failure caused by normal application of stress in fragile

bone weakened by metabolic bone disease or abnormal calcium metabolism

○ Types: ■ Displaced (no contact between pieces) or non-displaced ■ Open/compound (skin-breached) or closed ■ Complete (transverse, bone loss, oblique, spiral, comminuted, segmental

and butterfly) or incomplete (stress, green-stick, torus, or hairline) ■ Intraarticular (involving the articulating synovial cartilage) or extraarticular

■ ○ Special features:

■ Impacted fx: when a bone piece, generally cortical, is impacted into trabecular bone

● Common in long bones ● Traction required for reduction

■ Compression fx: when trabecular bone collapses into itself ● Common in the spine

■ Avulsion in locations where tendons or ligaments tear pieces from the bone

○ Mechanism of Traumatic Fractures: ■ Shearing loads:

● Transverse ■ Torsional loads

● Oblique ● Spiral

■ Combined loads ● Comminuted ● Segmental ● Butterfly

● ○ Risk Factors for Fractures:

■ All fractures: ● Trauma ● Age >50 yr ● Low BMI ● History of falls ● Vitamin D deficiency ● Low physical function ● Medications that interfere with calcium absorption ● Poor nutrition ● Metabolic bone disease ● Malignancy ● Infection ● Poor calcium metabolism ● Radiation treatment ● Postmenopausal women ● Long term care facilities

■ Stress fractures: ● Armed force soldiers ● High caliber athletes ● Too much physical activity without a period for adaptation,

increased training (esp in females > 40 yr because of hormonal changes)

● Leg length discrepancy ● Low muscle mass - bones have to take more of the force ● Rare in sedentary people

○ Fractures in Children :

■ Greenstick: incomplete long bone fracture ● One side of the bone is fractured, whereas a portion of the bone

and periosteum remains intact ■ Epiphyseal : cartilage on growth plate affected

● Growth abnormality may occur ○ Signs and Symptoms:

■ Traumatic: bone deformity and swelling, unable to weight bear, extreme pain, difficulty to move, grossly restricted ROM, gross weakness

■ Stress: point tenderness or pain upon palpation over fracture site, pain with repetitive weight bearing

■ Insufficient/pathologic: either one above ○ Fracture Management:

■ Non-surgical: immobilization and closed reduction ■ Surgical: open reduction and internal fixation

○ Complications: ■ Malunion, delayed union, or non-union ■ Pseudoarthrosis (non-osseous union of bone) ■ Joint instability, osteoarthritis because of abnormal joint mechanics, esp

intra-articular ■ Shortened limb, postural deformities

● Osteomyelitis: inflammation of bone marrow ○ Commonly caused by bacteria

■ Can be caused by virus, fungi, and parasites ○ Incidence :

■ Acute is rare: children, male>female ■ Chronic is more common in adults - immunosuppressed patients, elderly

○ Etiology/Pathogenesis: ■ Bacteria spreads easier on trabecular bone rich on blood supply

○ Risk factors: ■ Surgery - prosthesis ■ Open fractures/wounds ■ GI, GU, and respiratory tract infection ■ Diabetes ■ SCI ■ Malignancy ■ Chronic disease (renal, liver) ■ IV drug use ■ HIV ■ Prolonged use of oral coricosteroids

○ Diagnosis is difficult: ■ May be painless without fever ■ Sleep disturbances

○ Management:

■ IV antibiotics ■ Surgical resection of infected bone

○ Serious Complications: ■ Septicemia ■ Bone necrosis (possible amputation) ■ Impaired bone growth ■ Septic arthritis ■ Prosthetics infection (surgical revision) ■ *all require immediate care

○ Septic Arthritis vs. Osteomyelitis: ■

Septic Arthritis Osteomylitis

Acute onset of limp/non-weight bearing/refusal to use limb

Subacute onset of limp/non-weight bearing/refusal to use limb

Pain on movement and at rest Localized pain and pain on movement

Limited range/loss of movement Tenderness

Soft tissue redness/swelling often present

Soft tissue redness/swelling may not be present and may appear late

Fever +/- Fever (acute might present fever, chronic might not)

● Osteonecrosis: bone death as a result of blood insufficiency in absence of infection ○ AKA Avascular or aseptic necrosis ○ Risk factors:

■ Fractures ■ Alcoholism ■ Pancreatitis ■ Obesity, diabetes, hyperglycemia ■ HIV ■ Systemic lupus ■ Prolonged use of corticosteroids, intravenous bisphosphonates (jaw), or

contraceptives ■ Sickle cell disease

○ Pathogenesis: ■ Development of fat emboli in vessels of the bone ■ Interruption of blood supply after fractures

■ Osteoclasts inhibition: necrosis stays in bone and bisphosphonates aren’t removed

○ Incidence : ■ Femoral head (most common) ■ Humeral head ■ Tibial plateau ■ Small bones of hand and feet (lunate, scaphoid, talus), jaw

○ Signs and Symptoms: ■ Pain, especially on WB, antalgic gait pattern (hip, foot) ■ Restricted ROM or fracture (late stages) ■ Numbness or heaviness of the jaw

○ Treatment: ■ Core decompression to remove dead bone (bone graft may be added) ■ Prosthesis (THR, TSR)

○ Legg-Calve’-Perthes Disease : ■ Femoral head necrosis in children (males 3-10 y/o) ■ May have spontaneous healing, unlike adult osteonecrosis ■ Cause: unknown, possibly second hand smoke exposure in utero and in

childhood ○ Slipped Femoral Capital Epiphysis:

■ Fracture (often insidious) of the proximal epiphyseal plate of the femur (NOT osteonecrosis)

■ Affects mostly obese African-American male teens (8-13 year old) ■ It is believed to be associated with an inherited weakness of the

epiphyseal plate ● Key Points to remember:

○ Fractures: ■ Classification: traumatic, stress, pathologic, insufficient ■ Types and features: incomplete, displaced, avulsion, compression,

epiphyseal, intra-articular ■ Complications: non-union, mal-union, OA, joint instability

○ Osteonecrosis: ■ Caused by emboli or poor circulation ■ Complication of injuries, systemic, unknown ■ Initially affects the bone without changing the joint surface

○ Osteomyelitis: ■ Infection has preference for trabecular bone ■ Difficult diagnosis ■ Complication of surgery and open wound

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