AXTER - gpreview.kingborn.net · Dermatomes 160 Appendix B Sclerotomes Appendix C Auscultation ... Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997

AXTER

POCKET GUIDETO MUSCULOSKELETALASSESSMENTJRICHARD f. BAXlfR, MPl

.::;Chief of Physical Therapy

Munson Army Health Center

Fort Leavenworth, Kansas

W.B. SAUNDERS COMPANYA Division of Harcourt Brace & Company

Philadelphia London Toronto Montreal Sydney Tokyo

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Chapter 11Respiratory Evaluation .

Chapter 8Hip..... 93

Chap,ter 9Knee 107

Chapter 10Foot and Ankle .

Chapter 12Inpatient Physical Therapy Cardiac Evaluation 141

Chapter 13Lower Extremity Amputee Evaluation 145

Chapter 14Neurologic Evaluation 149

Chapter 4Elbow 41

Chapter 5Wrist and Hand 55

Chapter 6Thoracic Spine 69

Chapter 7Lumbar Spine. . . . .. . . . ... . . . . .. .. . . . . . . . . . . . . . . . . . 77

Chapter 2Cervical Spine

Chapter 3Shoulder

Chapter 1Introduction

CONTENTS

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1

DINTRODUCTION

KISS: "Keep It Super Simple." KISSis the essence of this quick reference guide to neuromusculoskeletalevaluations and treatment optionsfor some common conditions encountered in the clinic. This is neither a comprehensive text nor an at-tempt to capture all aspects of

physical therapy and reduce them to fit a pockethandbook. This guide is meant to provide only aframework for a thorough neuromusculoskeletal evaluation and treatment. I hope you will use this guide,as I do, to keep patient examinations organized, efficient, and thorough. When examining a patient, youmay find it helpful to open the guide to the body region in question and lay the book on the nearestavailable flat surface.

Located at the beginning of each section is S/PtHx for subjective/patient history/profile and 0 forobjective, which are portions of the SOAGP note format. The A (assessment), G (goals), and P (plan) areleft up to you, the evaluator, but the treatment options portion of each section is meant to assist inthese areas. While examining a patient, you may findit necessary to glance at the outline to maintain anefficient, organized thought flow. If the correct procedure for performing a special test slips your mind during the examination, turn to the material after the outline to refresh your memory. Although there are manymore special tests and modifications of the tests Ihave included, this handbook provides a basic groupof commonly used special tests; you should feel freeto write in other tests that you use in your practice.

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Chapter 15Inpatient Orthopedic Evaluation 151

Appendix ADermatomes 160

Appendix BSclerotomes

Appendix CAuscultation

Appendix 0Normal Range of Motion 163

Appendix ELigament Laxity Grading Scale 161

Appendix FCapsular Pattern and Closed Pack Positionsfor Selected Joints 168

Appendix GRadiology 169

Appendix HPhysical Agent and Modalities 111

Appendix ITypes of Traction 180

Appendix JNormal Values for Commonly EncounteredLaboratory Results 183

Appendix KAbbreviations and Definitions 185

Index 189

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The treatment options are, in fact, options; they offer only a starting point. There are many more treatment regimens, protocols, and techniques than couldbe presented in this text. In some cases, I includedtools for diagnosis or treatment that may be beyondthe scope of practice for the providers using thistext. For example, physical therapists within myscope of practice are credentialed to order radiographs, although this is outside the scope of practicefor many, as may be the case for treatment optionsthat include the prescription of NSAIDs. In some instances, I have included options that only a physicianor surgeon may consider, such as injection or surgery. These ideas about the continuum of care maybe helpful in patient education or useful as a reminder of the various options available to the patientwho is referred for further intervention.

Basic outlines for respiratory, cardiac, amputee,neurologic, and acute inpatient evaluations are givento help in acute care settings. To save space, manystandard terms are abbreviated throughout the book.These are explained in Appendix K.

My sincere hope is that this guide is a useful toolfor you in the clinic and that it motivates you to continued study, learning, and growth. Many physicaltherapy and physician assistant students, as well aspracticing physical therapists and physician assistants, have found it to be helpful, and I believe youwill too!

Subjective Examination

Although not exhaustive, the following is theframework for the subjective examination used inthe evaluation outlines throughout the text. Onlythose items that are most pertinent to each regionhave been included in an abbreviated format in thespecific body region subjective examination outlines.

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• Age

• Sex• Chief complaint• Onset of Sx (insidious, from trauma or overuse)

• Body chart (body diagram with location of Sx,depth/quality/type of pain, whether pain is constant/intermittent, interaction between pain sites,presence of paresthesia)

• Duration of Sx (if insidious)

• MOl (if due to trauma)• Nature of pain (constant/intermittent, deep/super

ficial, boring/sharp/stabbing/hot!ache, AM/PM difference in the Sx, sclerotomal or dermatomal pattern)(see Appendices A and B)

• AGG (positions or activities, how long it takes toaggravate Sx and how long to recover)

• Easing factors (what relieves Sx)

• Radiographs/CT scans/MRI/lab results

• Meds• Occupation/recreation/hobbies

• Diet/tobacco/alcohol

• Exercise• PMH x (e.g., H/O cancer, cardiovascular disease,

HTN, adult/child illnesses)

• PSH x

• Family history

• Review of systems and SOI General health/last physical examination

I Unexplained weight loss

I Night painI Bilateral extremity numbness/tingling

I Systems*

*Region-specific questions are located in applicableevaluation outlines.

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*For the musculoskeletal screening examination of adjacentjoints, apply only the most sensitive tests for the most common musculoskeletal abnormalities. Check AROM, PROM,GMMT. The purpose is to assist in detecting all areas ofinvolvement or additional findings that may alter the diagnosis.

Position Sequence

I. Standing

II. Sitting

III. Supine

IV Sidelying

V Prone

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B. PostureC. Abnormalities, deformities, muscular

atrophy

D. Function

III. AROM (see Appendix OJ

IV GMMT or myotomal screenV Special tests (per specific region)

VI. Sensation (e.g., light touch, vibration, hot/cold,sharp/dull, two-point discrimination)

VII. Palpation (e.g., defects, pain, spasm, edema/effusion, tissue density)

VIII. Joint play (per Magee' and Maitland2)

References

1. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997

2. Maitland GD: Peripheral Manipulation, 3rd ed. Boston,Butterworth-Heinemann, 1991.

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Musculoskeletal

Pulmonary

Lymphatic

Neurologic

Skin

Endocrine

Cardiovascular

Gastrointestinal

Urinary/reproductive

t Patient's goals

Objective ExaminationAlthough not exhaustive, the following is the framework for the objective examination used in the evaluation outlines throughout the text. Only those positions and items that are most pertinent to eachregion have been included in an abbreviated formatin each region-specific evaluation outline.

Items to Assess in Each Position as Applicable

I. R/O other pathology by "clearing" joint aboveand below or other areas that refer similar Sx*

II Observation

A. Gait (e.g., cadence, stride length, weightbearing, antalgic, base of support,sequence)

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SubjectiveExamination

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t Pt Hx (region specific): nature ofpain (dermatomal or sclerotomal)?(see Appendices A and B)

t Does coughing, sneezing, straining, or anything that increases intradiscal and intrathecal pressure aggravate the Sx?

t SQ: bilateral UE numbness and tingling, recent onset of headache, dizziness/visual disturbance/nausea, difficulty swallowing

t Type of work and posture/positions assumed atwork, sleeping positions, type and number of pillows used

t Trauma? If so, was there loss of consciousness?

t Review of systems (endocrine, neurologic, cardiovascular, pulmonary, gastrointestinal)

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Objective ExaminationI. Standing

A. Observation

1. Posture: structure and alignment in threeplanes

II. SittingA. R/O shoulder or thoracic spine pathology

B. Observation

1. Posture (C5 or C6 radiculitis/radiculopathytends to feel better with the arm restingoverhead; C7 radiculitis/radiculopathytends to feel better with the arm cradledagainst the abdomen)

a. Forward head

b. Rounded shoulders

c. Protracted scapulae and other signs

C. AROM (note quality, rhythm, pain, assessedby estimation, inclinometer, or othermethods; apply overpressure, if necessary, tothese motions)

1. Cervical flex

2. Cervical ext

3. Cervical sidebending

4. Cervical rot

5. Combined motions (e.g., chin tuck,sidebending with rot)

D. Myotomal screen and GMMT

1. Neck flex (C1-C2)

2. Shoulder elevation/shrug (C3-C4)

3. Shoulder abd (C5)

4. Elbow flex/wrist ext (C6)

5. Elbow ext/wrist flex (C7)

6. Thumb IP joint ext/finger flex (C8)

7. Finger add (T1)

E. MSRs

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1. Biceps (C5)

2. Brachioradialis (C6)

3. Triceps (C7)

F. Pathologic reflexes: Hoffmann's sign

G. Special tests (as applicable)

1. Foraminal encroachment: compression(Spurling's) test, distraction test

2. Thoracic outlet syndrome: Adson'smaneuver, costoclavicular syndrome test,hyperabduction test, Halstead's maneuver,Allen's test

3. VA test

H. Sensation: dermatomes (see Appendix A)

III. Supine

A. Special tests: upper limb tension testing

B. Joint play: lat and anterior glides, cervicaldistraction

IV. Prone

A. Palpation: bony landmarks and soft tissue

B. Joint play

1. PACVP

2. PAUVP

3. Transverse pressure

4. Lat glides

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• SPECIAL TESTS FOR THE CERVICAL SPINE

Test Detects Test Procedure Positive Sign

Compression (Spurling'sl test' Foraminal encroachment Pt sitting and laterally flexes cervical Pt experiences radicular pain thatspine to one side. Examiner presses radiates into arm toward which head/straight down on PI's head. This cervical spine is flexedprocedure is repeated on opposite side.

Distraction test' Foraminal encroachment PI sitting. Examiner places one hand Pain in neck and into UE is relieved orunder PI's chin and other hand around decreased when cervical spine isocciput. Examiner slowly lifts PI's head. distracted

Ouadrant position' Foraminal encroachment PI sitting. PI performs combined ext, lat Pain radiates into arm toward whichflex, and rot. This reduces size of head/cervical spine is extended, laterallyintervertebral foramen. flexed, and rotated

Reproduction of PI's Sx

Have PI keep eyes open to observenystagmus if it occurs (indicative of VAcompression, causing lack of bloodsupply to brain stem and cerebelluml

Vertebral artery test/neck ext-rot test'

..........

Test 1

Test 2

Upper limb tension test (brachial plexustension testl' (median nerve biasl

VA compression or occlusion

Rules out inner ear as cause ofdizziness

Dural/meningeal irritation or nerve rootimpingement (similar to SLR test in LEI

Pt sitting and places cervical spine incombined ext and rot such that PI islooking back over shoulder. Pt must keepeyes open. This is performed to eachside for 20 sec.

PI standing. Examiner stabilizes PI'shead by holding PI's head with hands.PI then rotates trunk and holdsmaximum rot for 20 sec to each side.

PI supine. Examiner takes PI's UE intoglenohumeral abd (110 deg approxl,forearm supination, wrist and finger ext,shoulder ER 190 deg approxl. elbow extand neck lat flex away from testingside.

Rapid eye movements, pupils dilate,dizziness, syncope, IightheadednessControversy exists in medical communityconcerning this test. Some suggest thatit possesses low sensitivity' Apply atyour own risk, and use caution with thistest. Examiner should first have Ptperform cervical rot to see if thisproduces Sx of VA insufficiency beforeproceeding to described test position.

Same as for test 1

If Sx were not induced, cause ofdizziness was most likely not an innerear problem

Radicular pain/paresthesia into testedUE

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• SPECIAL TESTS FOR THE CERVICAL SPINE Continued


Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root Pt supine. Examiner depresses PI's Radicular pain/paresthesia into testedtension testl' (Radial nerve biasl impingement (similar to SLR test in LEI shoulder, extends elbow, flexes PI's UE

thumb into palm, pronates forearm, andulnarly deviates wrist.

Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root Pt supine. Examiner depresses PI's Radicular pain/paresthesia into testedtension test)' (ulnar nerve bias) impingement (similar to SLR test in LEI shoulder, pronates forearm, extends UE

wrist. flexes elbow, and abducts arm.

Hoffmann's sign' (pathologic reflex for Corticospinal tract lesion of spinal cord Examiner grasps and stabilizes PI's hand Induced flex of thumb and other fingersUE similar to Babinski sign for LEI and "flicks" distal phalanx of middle

finger in direction of ext (causing aquick stretch of finger flexors)

Thoracic outlet syndrome See Shoulder Special Tests andThoracic Outlet Syndrome Tests table inChapter 3

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Special Condition

Acute cervical radiculitis orradiculopathy (may be caused by discbulge/HNP or narrowing ofintervertebral foramenl

Hx/Symptoms

CS-C6 and C6-<::7 nerve rootscommonly involved

Radicular Sx in UE with distalparesthesia

Usually distal Sx worse than proximal

Signs/Objective Findings

If in lower cervical spine, Pt feels betterwith arm held close to abdomen. If inupper cervical spine, Pt feels better withforearm resting overhead.

Objective neurologic signs withradiculopathy (decreased MSRs, UEmuscle weaknessl

Treatment Options

Acute: relative rest, ice/heat. mayconsider cervical collar for 2-3 days forPt comfort (but not more than a fewdays). sustained cervical traction, Pteducation (neck carel

Goal is to centralize Sx

Check neurologic system each visit

Advise Pt that Sx may not improve for7-10 days

Address posture

Subacute: Begin AROM in a painfreerange

Chronic: AROM, cervical isometrics

Refer Pt to orthopedic surgeon orneurosurgeon for progressive neurologicdeficit

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• TREATMENT OPTIONS FOR THE CERVICAL SPINE Continued

Special Condition Hx/Symptoms Signs/Objective Findings Treatment Options

Cervical spondylosis (ODD) C5-C6 and C6-C7 most commonly AM stiffness that is eased with AROM exercises several times per dayinvolved movement but worsens later in day with

Cervical isometrics (painfree)Nerve root/spinal cord pressure continued activity

Cervical traction (intermittent)common from foraminal encroachment Radiograph may confirm and showand spinal stenosis, resulting in decreased disc space and osteophytes/ Moist heat

radicular Sx spurring Pt education (neck carel/self-treatment

Cervical DJO (involves facet jointsl Upper cervical Pain and stiffness with rest that AROM exercises several times per day

Gradual onset improves with movement Cervical isometrics (painfreel

Forward head posture AROM rot and lat ftex most limited Cervical traction (intermittentl

Crepitus Palpable thickening of facet joint Moist heatmargins

Pt education (neck carel/self-treatmentRadiograph may confirm

Soft tissue mobilization

Muscle strain or contusion

Acute torticollis ("wry neck"l

From acute facet locking

Muscle pain/soreness

Hx of trauma/overuse

Hx of unexpected movement or prolonged prone lying with head rotated toone side

Sharp pain that is unilateral and welllocalized

Tender soh tissue with palpation

ARDM limited by pain

Protective deformity of lat flex and rotaway from pain

Muscle guarding

Neurologic system: normal

First, ensure PI is stable/no Fx

Acute: Relative rest, ice for first 48-72hours, moist heat with interferentialelectrical stimulation or ultrasound withelectrical stimulation after initial 72hours, add ARDM to tolerance

Subacute/chronic' ARDM, SCM and upper trapezius stretching, shoulder rolls,cervical isometrics (painfreel. posturaleducation

Acute: supine lying to unload facet, ice,gentle manual distraction in line with deformity

Gentle PROM away from painful side

Cervical collar for 2-3 days to unloadfacets

Subacute/chronic: muscle energy techniques to regain ARDM, progress to cervical isometrics

Continu"d ...

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17

Bihliography

References

1. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

2. Bland JH: Disorders of the Cervical Spine: Diagnosis andMedical Management, 2nd ed. Philadelphia, WB Saunders, 1994.

3. Maitland GD: Vertebral Manipulation, 4th ed. Boston,Butterworths, 1973.

4. Cote P, Kreitz BG, Cassidy JD, Thiel H: The validity of theextension-rotation test as a clinical screening procedure beforeneck manipulation: A secondary analysis. J Manipulative PhysiolTher 19:159-164,1996.

5. Butler DS: The upper limb tension test revisited. In Grant R(ed): Physical Therapy of the Cervical and Thoracic Spine, 2nd ed.New York, Churchill Livingstone, 1994.

6. Kandell ER, Schwartz JH, Jessell TM (eds): Principles ofNeural Science, 3rd ed. New York, Elsevier Science Publishing,1991 .

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy PrinCiples andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Highland TR, Dreisinger TE, Vie LL, et al: Changes in isometricstrength and range of motion of the isolated cervical spineafter eight weeks of clinical rehabilitation. Spine17(Supplement 6)S77-S82, 1992.

Jones H, Jones M, Maitland GD: Examination and treatment bypassive movement. In Grant R (ed): Physical Therapy of theCervical and Thoracic Spine, 2nd ed. New York, ChurchillLivingstone, 1994.

Kisner C, Colby LA: Therapeutic Exercise: Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Magarey ME: Examination of the cervical and thoracic spine. InGrant R (ed): Physical Therapy of the Cervical and ThoracicSpine, 2nd ed. New York, Churchill Livingstone, 1994.

Saunders HD, Saunders R: Evaluation, Treatment and Preventionof Musculoskeletal Disorders: Spine, 3rd ed, vol 1. Chaska,Minnesota, Educational Opportunities, 1993.

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SQ, if applicable: night pain, bilateral UE numbness/tingling, unexplained weight loss)

• Review of systems (cardiovascular, pulmonary, gastrointestinal)

• Pt Hx (region specific): which isthe dominant UE, radicular Sx (dermatomal or sclerotomal)? (see Appendices A and B)

• Functional limitations

•

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A. Observation

1. Posture2. Abnormalities, deformities, atrophy

B. AROM (note quality, scapulohumeral rhythm,pain, and common substitutions)

1. Shoulder flex (165-180 deg)

2. Shoulder ext (50-60 deg)

3. Shoulder abd (170-180 deg)

4. Shoulder horizontal abd and add

C. PROM if lacking AROM in any motions

D. Special tests (as applicable)

1. Impingement: impingement relief test

II. SittingA. R/O cervical pathology (see Special Tests for

the Cervical Spine in Chapter 2)

B. Observation

1. Posture2. Abnormalities, deformities, atrophy

C. AROM may also be assessed in sitting

D. PROM if lacking AROM in any motions

E. GMMT and myotomal screen



3. Shoulder flex (C5-C7)

4. Shoulder ext


6. Elbow ext/wrist flex (C7)


8. Finger add (T1)

F. MSRs, if applicable

1. Biceps (C5-C6)

2. Brachioradialis (C5-C6)

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3. Triceps (C7)G. Special tests (as applicable)

1. Instability: anterior/posterior apprehensiontests, relocation test. sulcus sign

2. Biceps tendinitis/tendon instability:Yergason's, Speed's, Ludington's, and THLtests

3. Impingement: painful arc test, Hawkin'simpingernent test, impingement relief test,Neer's impingement test

4. Rotator cuff tear: drop-arm test,supraspinatus test (empty can test)

5. Thoracic outlet syndrome: Adson'smaneuver, costoclavicular syndrome test.or Halstead's maneuver; hyperabductionsyndrome test

H. Sensation: LT and 2-point discriminationI. Palpation

1. Tendons of the rotator cuff2. Bicipital groove/biceps tendon3. Bony landmarks

III. SupineA. Special tests (as applicable)

1. Impingement: impingement relief test(may be performed standing or supine)

2. Joint playa. AP glideb. Long-axis distractionc. AP motions of the clavicle at the AC

and SC jointsIV. Prone

A. AROM1. Shoulder IR (70-80 deg)2. Shoulder ER (80-90 deg)

B. GMMT1. Shoulder IR2. Shoulder ER

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• SPECIAL TESTS FOR THE SHOULDER


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Neer's impingement test' 2 Impingement of long head of biceps PI sitting or standing. PI's arm is passively Reproduction of PI's Sxtendon and/or supraspinatus tendon elevated through forward flex by examiner,

forcing greater tubercle of humerus againstacromion.

Hawkin's impingement test' Impingement of inflamed supraspinatus Pt sitting or standing. Examiner forward Reproduction of PI's Sxtendon flexes PI's arm to 90 deg, and flexes PI's

elbow to 90 deg, then passively internallyrotates shoulder, forcing supraspinatustendon against coracoacromial ligament.

Painful arc' test Pathology of subacromial origin (e.g., Pt sitting or standing. Pt abducts arm in Reproduction of Sx in a 60-120 deg arc.impingement, rotator cuff tendinitisl neutral position (no IR or ERI Pain stops or is dramatically reduced when

humeral head glides inferiorly.

"No pain --> pain --> no pain"

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Impingement relief test' Helps confirm Ox of impingement Pt standing, performs active flex and abd3-5 times while examiner records locationof onset of painful arc range. Pt asked togive a subjective indication of amount ofpain. Test is then repeated while examinerapplies a gentle inferior or posteroinferiorglide just before onset of recorded painfularc. PI is then asked again to give asubjective indication of amount of pain.Test may be modified to a supine position

Outcomes and their interpretations are asfollows:

Complete relief of pain: indicates thathumeral head is capable of moving undersubacromial arch without impinging. Thisindicates contractile tissue as primary causeand recommend a Rx regimen aimed attraining contractile tissue to balance forcecouple and scapulohumeral rhythm le.g.,strengthening, proprioception, scapularstabilizationl.

Partial relief of pain at same point in rangeof motion: suggests that, in addition tocontractile tissue weakness, noncontractiletissue is involved. Joint mobilization inaddition to strengthening and re-educationshould be part of Rx regimen.

No relief or reduction of pain: indicatesinability of humeral head to depress becauseof noncontractile tissue tightness. As part oftreatment program, perform jointmobilization to restore accessory motions toachieve inferior and posteroinferior glide ofhumeral head. Inability to reduce pain bystretching and joint mobilization mayindicate pathology other than impingementas source of pain.

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~ • SPECIAL TESTS FOR THE SHOULDER Continued


Stability Tests

Anterior apprehension test' Anterior instability PI sitting, standing, or supine. Examiner Pt has look of alarm or apprehension andplaces PI's shoulder in abd and ext rot (90 resists further motion. PI may also have paindeg/90 deg). Then examiner applies an ext with this movement.rot force.

Relocation test' Anterior instability PI supine. Same procedure as apprehension PI's alarm or apprehension disappears, paintest. Upon finding a positive anterior may be relieved, and further ext rot isapprehension test, maintain that position allowedand apply a posterior force with one hand tothe PI's arm.

Sulcus sign' Inferior instability Pt standing or sitting with arm by side and Sulcus (gapl appears at glenohumeral jointwith shoulder muscles relaxed. Examiner Must compare with uninvolved shouldergrasps PI's forearm below elbow and pullsdistally/inferiorly.

Posterior drawer sign' Posterior instability PI supine. Examiner grasps PI's proximal Posterior displacement can be felt as thumbforearm with one hand and flexes elbow 120 slides along lat aspect of coracoid processdeg. Then examiner positions PI's shoulder PI may also have apprehensionin 80-120 deg abd and 20-30 deg flex.With other hand, examiner stabilizes PI'sscapula. As PI's arm is internally rotated andflexed, examiner attempts to sublux humeralhead with thumb.

load-shift test'

Miscellaneous Tests

Cross-arm adduction test'

AC joint shear test'

Yergason's test"

Speed's test'

Anterior, posterior, or multidirectionalinstability

AC joint pathology

AC joint lesion/DJD

Unstable biceps tendon due to THl tear

Could also detect biceps tenosynovitis

Bicipital tendinitis

Pt sitting. First, examiner places one handover PI's clavicle and scapula for stability.Then, grasping proximal arm near humeralhead, examiner "loads" humeral head suchthat it is in a neutral position in glenoidfossa. Examiner then applies an anterior orposterior force, noting amount of translationand end-feel.

Pt sitting. Examiner horizontally adducts(passive) PI's arm across chest wall.

PI sitting. Examiner cups hands, with onehand on PI's scapula and other hand overclavicle and then squeezes, causing a shearforce at AC joint.

Pt sitting or standing. PI's elbow flexed 90deg, with arm at side of body. Examinerresists at wrist while PI attempts tosupinate a pronated forearm.

Pt sitting or standing. PI's shoulder is flexedwith forearm supinated, and elbow iscompletely extended. Examiner palpatesbiceps tendon in bicipital groove and forcesarm down in ext as PI resists.

Excessive displacement anteriorly,posteriorly, or both compared withuninvolved shoulder

Reproduction of PI's Sx at AC joint

Reproduction of Pt's Sx at or excessivemotion in AC joint

localized reproduction of PI's Sx in bicipitalgroove

Reproduction of PI's Sx localized to bicipitalgroove

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1 SPECIAL TESTS FOR THE SHOULDER Continued

Test I Detects Test Procedure Positive Sign

Ludington's test" I Rupture of long head of biceps tendon Pt sitting or standing. Pt clasps both hands Examiner feels tendon on uninvolved sideon top of head and interlocks fingers. Pt but not on involved side during contractionthen simultaneously contracts and relaxes of biceps muscle

I biceps muscles while examiner palpatesbiceps tendon proximally at bicipital groove.

Apley's scratch test' Functional method of assessing shoulder Pt performs combined IR with add in Gives examiner an idea of functionalin IR and ER attempt to touch or "scratch" opposite capacity/AROM of Pt's shoulders

scapula. Second motion involves combined This is recorded by the anatomic landmarkER with abd in attempt to place hand that Pt is able to reach and touch (e.g., tobehind head and touch top of opposite inferior angle of scapula1shoulder.

Drop-arm test' Rotator cuff tear (specifically, Pt sitting or standing. Examiner passively Arm drops suddenly to side because ofsupraspinatus tendon) abducts PI's shoulder to 90 deg. Pt is then weakness and/or pain

instructed to maintain arm in that position.Examiner then presses inferiorly on PI's arm.

Supraspinatus test (empty Torn supraspinatus muscle or tendon Pt sitting or standing. Pt in "empty can .. Reproduction of PI's Sx or weaknesscan testI' Supraspinatus tendinitis position 90-deg shoulder abd, 30-deg Compare with uninvolved side

Neuropathy of suprascapular nervehorizontal abd, and maximum IR. Examinerresists PI's attempt to abduct.

----~

Test*

Adson's maneuver"

Costoclavicular syndrome test"

Hyperabduction syndrometest 14

Halstead's maneuver'

L

Detects

Entrapment in scalene triangle

Entrapment between 1st rib and clavicle

Entrapment between coracoid processand pectoralis minor

Entrapment in scalene triangle

Test Procedure

Pt sitting. Examiner locates Pt's radial pulse.Pt then rotates head toward test shoulderand extends head/neck. Examiner thenexternally rotates and extends Pt's shoulderas Pt takes a deep breath and holds it.

Pt sitting. Examiner palpates radial pulseand then draws PI's shoulder down andback (depression and retractionI.

Pt sitting. Examiner palpates radial pulseand hyperabducts Pt's arm so that PI's armis overhead. Pt takes a deep breath andholds it.

Pt sitting. Examiner palpates radial pulse. Ptthen rotates head away from test shoulderand extends head/neck. Examiner thenexternally rotates and extends PI's shoulder,applying downward traction as Pt takes adeep breath and holds it.

Positive Sign

Reproduction of pain and paresthesia intested UE with diminished or absent pulse




'These tests detect subclavian artery and brachial plexus entrapment.

Nco

• TREATMENT OPTIONS FOR THE SHOULDER


Impingement syndrome Pain with overhead motion or when Positive painful arc Acute: relative rest, ice, NSAIDshand is placed behind back Positive Hawkin's impingement test Gentle ROM ICodman's/pendulum, wandPain may refer down lat arm or anterior Positive Neefs impingement test exercisesIhumerus Must R/O cervical pathology Subacute/chronic: isometric shoulder flex!

Check for instability that may be allowing exVIR/ER exercises progressing to isotonicimpingement (tubing or free weights) as Sx improve

Check for tight posterior and/or inferior May consider ultrasound to aid in healing/capsule or muscle imbalance improve blood flow

PI may have poor posture as a causative Shoulder proprioception exercisesfactor Closed chain shoulder stabilization leg.,

quadruped position and examiner appliesperturbation to Pt)

Work on neuromuscular control of rotatorcuff/shoulder girdle musculature

Scapular stabilization exercises le.g., push-up with a plus, seated press-upsIPosterior/inferior capsule stretch ifindicated

Avoid overhead activities/work thataggravates Sx

Nto

Supraspinatus tendinitis Pain with overhead motion or whenhand is placed behind back

Pain may refer down lat arm or anteriorhumerus

Key finding is exquisite pain with resistedmovement involving supraspinatus muscleipositive supraspinatus/empty can test)

R/O cervical pathology

Will also have positive impingement tests

Acute: relative rest. ice, NSAIDs

Gentle ROM iCodman's, wand exercises)

Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsl as Sx improve

Supraspinatus-specific exercises

May consider ultrasound to aid in healing/improve blood flow

Closed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt)


Scapular stabilization exercises le.g., pushup with a plus, seated press-upsIPosterior/inferior capsule stretching ifindicated

Avoid overhead activities/work thataggravates Sx

COli till "I'd ...

~ TREATMENT OPTIONS FOR THE SHOULDER Continued


Bicipital tendinitis Pain over anterior shoulder Exquisite tenderness to palpation over Acute: Relative rest, ice, NSAIDs

Does Pt perform repetitive curls/elbow bicipital groove Gentle ROM ICodman's, wand exercisesIflex against high resistance at work or Mayor may not have positive Vergason's Avoid AGG and initiate Pt educationrecreation/weight lifting? or Speed's tests

Pt may report "snapping" in region of May have exquisite pain with resisted Subacute/chronic: isometric shoulder flex/

bicipital groove horizontal add of shoulder that is in 90 ext/IR/ER exercises progressing to isotonic

deg ER Itubing or free weightsl as Sx improve(avoid strenuous resistance in early

Check for posterior capsule tightness phaseslR/O cervical pathology IR stretch (towel/door stretch)

May consider ultrasound to aid in healing/improve blood flow or phonophoresis/iontophoresis for pain relief and todecrease inflammation

Shoulder proprioception exercises

Closed chain shoulder stabilization le.g"quadruped position and examiner appliesperturbation to Pt)


Scapular stabilization exercises (e.g., push-up with a plus, seated press-ups)

w....

Subacromial/subdeltoid bursitis Pain at superior portion ofglenohumeral joint

Pain at night with difficulty sleeping

Paln may radiate down arm

Marked restriction of shoulder flex andabdTenderness to palpation over deltoidaround acromion

Distraction of glenohumeral joint inferiorlymay relieve Sx

R/O cervical pathology

Acute: relative rest. ice, NSAIDs,phonophoresis or iontophoresis

Subacutelchronic: gentle prom (Codman's)progressing to AAROM (wand, pulleyl

Isometric shoulder flex/ext/IR/ER exercisesprogressing to isotonic (tubing or freeweightsl as Sx improve

Joint mobilizationMay consider ultrasound

Closed chain shoulder stabilization (e.g.,quadruped position and examiner appliesperturbation to Pt)


Scapular stabilization exercises (e.g., pushup with a plus. seated press-upsI

Pt education to avoid overhead activities/work

Avoid overhead work/activities thataggravate Sx

WN

• TREATMENT OPTIONS FOR THE SHOULDER Continued


Anterior shoulder instability (after Hx of acute traumatic abd-ER injury Positive apprehension and/or relocation Acute: radiographs to R/O Hill-Sach's orsubluxation or dislocation) Ifall on outstretched arm or grasp of test Bankhart lesion (if Pt being seen for the

arm during throwing motion! Positive load-shift test (with anterior first time!

translation! Protection (immobilization and PI educationto avoid shoulder ER with abdl. ice, NSAIOs

Gentle ROM (Codman's, wand exercisesi inpainfree and apprehension-free range

Subacute/chronic: isometric shoulder ftex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsI as Sx improve


Closed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Ptl


Scapular stabilization exercises le.g., push-up with a plus, seated press-ups!

Pylometrics progressing to least stableosition

ww

Posterior instability (aftersubluxation or dislocation)

Hx of trauma Positive posterior drawer sign

Positive load-shift test (with posteriortranslation)

Refer PI to orthopedic surgeon if stabilitynot improvingAcute: radiographs lif PI being seen forfirst timelProtection (immobilization and Pteducation), ice, NSAIDsGentle ROM (Codman's, wand exercises) inpainfree and apprehension-free range

Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsl as Sx improve


Closed chain shoulder stabilization (e.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises (e.g., pushup with a plus, seated press-upsI

Pt education to avoid overhead activities/work that aggravates SxRefer Pt to orthopedic surgeon if stabilitynot improving

COlltllllU'd T

TREATMENT OPTIONS FOR THE SHOULDER Continued

Special Condition

Multidirectional instability

Hx/Symptoms

Pt C/O instability and may be able todemonstrate

Pt may have pain or impingement typeSx due to excessive movement/laxity ofglenohumeral joint


Positive sulcus sign

Positive load-shift test (with both anteriorand posterior translation!

Treatment Options ~

Acute relative rest. Ice, NSAIOs

Gentle ROM ICodman's, wand exercises)

Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weights! as Sx improve


Closed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt!


Scapular stabilization exercises le.g., pushup with a plus, seated press-upsl

Pt education to avoid activities/work thataggravates Sx or places PI in an unstableposition

If stability does not improve over severalmonths of aggressive rehabilitation, referPt to orthopedic surgeon

w(Jl

Rotator cuff tear May have Hx of FOOSH, throwing, orlifting injuryMay be seen in older individuals as aresult of degeneration of rotator cuff

Positive drop-arm test

Positive impingement signs

Positive painful arc test

Weakness of specific rotator cuff muscles

May observe abnormal scapulohumeralmotion li.e.. scapular hiking before upwardrotl

Acute: relative rest, ice, NSAIDs

Gentle ROM ICodman's exercisesI

Subacute/chronic: isometric rotator cuffstrengthening progressing to isotonicItubing or free weights) as Sx improve

Shoulder proprioception exercisesClosed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculature

Scapular stabilization exercises le.g., pushup with a plus, seated press-ups)

If severity of tear warrants, surgicalintervention/repair may be necessary

C lit III ...

wOl

• TREATMENT OPTIONS FOR THE SHOULDER Continued


AC joint separation Hx of fall onto shoulder Depending on severity of injury, Pt mayor Immobilization in Kenny-Howard/AC jointmay not have a noticeable "step-off" from sling (type I. 1 wk; type II, 2 wks; type III,clavicle to acromion IV, or V. until Sx subsidel

Positive AC joint shear test Ice

Positive cross-arm adduction test Early ROM within limits of pain

Tenderness to palpation over involved AC Progress to general rotator cuff andjoint shoulder strengthening as Sx subside

Rx of type III still controversial; somerecommend surgical Rx, and others haveobtained good results with nonoperativeRx. However, acute Rx of type III shouldbe the same as for a type II injury. Seethe Cook, Dias, and Mulier entries in theBibliography for treatment options.

For type IV and V injuries, surgery is moreof a consideration. See the Cook and Diasentries in the Bibliography for treatmentoptions.

Adhesive capsulitis

Thoracic outlet syndrome

Common for ages 40-60 yr

Several weeks' Hx of shoulder pain andrestriction

Pt may not be able to pull wallet fromback pocket or fasten clothes thatfasten in back

Sx include pain and paresthesia andpossibly muscle weakness in shoulder,arm, and/or hand

Very similar to cervical radiculitis/radiculopathy

Restricted ARDM in a clear capsularpattern IER > abd > IRI

Positive thoracic outlet syndrome tests

Must differentiate from cervical pathology

Acute: ice, NSAIDs, pain-relievingmodalities in initial stages

Codman's exercises for 2-3 min every 1-2hr

Subacute/chronic: after pain subsidessomewhat. begin stretching to increaseER, abd, and IR through wand exercisesand joint mobilization

Ultrasound to axilla to heat joint capsulebefore joint mobilization and AAROM/stretches (remember to addressglenohumeral, scapulothoracic, and ACjoints)

NSAIOs

Avoid AGG

Stretch appropriate structures causing Sx

Neural stretch (scalenes, levator scapulae,pectoralis minorl

Strengthen scapular stabilizers

(f)

IoCrom:JJ

38 -------------

References

1. Neer CS, Welsh RP: The shoulder in sports. Orthop ClinNorth Am 8583-591,1977.

2. Neer CS: Impingement lesions Clin Orthop 173:70-77,1983.

3. Hawkins RJ, Bokor DJ: Clinical evaluation of shoulderproblems. In Rockwood CA, Matsen FA (eds): The Shoulder.Philadelphia, WB Saunders, 1990.

4. Kessell L, Watson M The painful arc syndrome J BoneJoint Surg Br 59:166-172,1977.

5. Corso G: Impingement relief test: An adjunctive procedureto traditional assessment of shoulder impingement syndrome. JOrthop Sports Phys Ther 22: 183-192, 1995.

6. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

7. Gerber C. Ganz R: Clinical assessment of instability of theshoulder. J Bone Joint Surg Br 66:551-556, 1984.

8. Silliman JF, Hawkins RJ: Clinical examination of theshoulder complex. In Andrews JR, Wilk KE (eds) The Athlete'sShoulder New York, Churchill Livingstone, 1994.

9 Davies GJ, Gould JA, Larson RL Functional examinationof the shoulder girdle. Phys Sports Med 9:82-104, 1981

10. Yergason RM: Supination sign. J Bone Joint Surg Am13160,1931.

11. Ludington NA: Rupture of the long head of the bicepsflexor cubiti muscle. Ann Surg 77:358-363, 1923.

12. Adson AW, Coffey JR Cervical rib: A method of anteriorapproach for relief of symptoms by division of the scalenusanticus. Ann Surg 85:839-857, 1927.

13 Falconer MA, Weddell G: Costoclavicular compression ofthe subclavian artery and vein. Lancet 2539-544, 1943

14. Wright IS: The neurovascular syndrome produced byhyperabduction of the arms Am Heart J 29: 1-19, 1945.

Bibliography

Boissonnault WG, Janos SC Dysfunction, evaluation, andtreatment of the shoulder. In Donatelli R, Wooden MJ (eds):Orthopaedic Physical Therapy. New York, Churchill Livingstone,1989.

Cook DA, Heiner JP: Acromioclavicular joint injuries: A reviewpaper. Orthop Rev 19510-516,1990.

Dias JJ, Gregg PJ: Acromioclavicular joint injuries in sport:Recommendations for treatment: Sports Med 11:125-132,1991.

-------------- 39

Ellman H: Diagnosis and treatment of rotator cuff tears. ClinOrthop 25464-74, 1990.

Hawkins RJ, Abrams JS: Impingement syndrome in the absenceof rotator cuff tear (stages 1 and 21. Orthop Clin North Am18373-382, 1987.

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders. Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Itoi E, Tabata S: Conservative treatment of rotator cuff tears. ClinOrthop 275:165-173,1992.

Karas SE: Thoracic outlet syndrome. Clin Sports Med 9:297-310,1990.

Kisner C, Colby LA: Therapeutic Exercise. Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Mulier 1. Stuyck J, Fabry G: Conservative treatment ofacromioclavicular dislocation: Evaluation of functional andradiological results after six years' follow-up. Acta Orthop Belg59255-262, 1993.

Neviaser RJ, Neviaser TJ: The frozen shoulder Diagnosis andmanagement: Clin Orthop 223:59-63, 1987.

Pink M, Jobe FW: Shoulder injuries in athletes. Orthopedics1139-47, 1991.

0:Wo--.J::JoI(f)

-

nr-------------41

illHBOW


• Pt Hx (region specific): dominanthand, radicular Sx (dermatomal orsclerotomal) 7 (see Appendices Aand B)

• SO (if applicable)

soco.-JW

mreoo:2

42 ---------------


A. Observation

1. Posturea. Carrying angle for males (normal 5-10

deg valgus)

b. Carrying angle for females (normal 15deg valgus)

II. Sitting

A. R/O cervical or shoulder pathology

B. Observation

1. Posture2. Atrophy or deformities

3. Edema

C. AROM1. Elbow flex (140-150 deg)

2. Elbow ext (0 deg)

3. Elbow pronation (70-80 deg)

4. Elbow supination (80-90 deg)

D. GMMT and myotomal screen



3. Shoulder flex (C5-C7)


5. Elbow ext/wrist flex (0)

6. Forearm pronation/supination


8. Finger add (T1)

E. MSRs, if applicable

1. Biceps (C5)

2. Brachioradialis (C6)

3. Triceps (0)

F. Special tests (as applicable)

1. Instability: varus/valgus stress test

2. Epicondylitis: tests for lateral and medialepicondylitis

3. Nerve impingement/entrapment tests:Tinel's sign at the elbow, Wartenberg's sign,elbow flex test, test for pronator teressyndrome

G. Sensation: LT and 2-point discrimination

H. Palpation

1. Soft tissue

2. Bony landmarks

I. Joint play1. Radial and ulnar deviation (similar to valgus/

varus testing)

2. Ulnar distraction with the elbow in 90 degflex

3. AP glide of radius

43

soa:l-lW

...

... SPECIAL TESTS FOR THE ELBOW

r

Test

Varus stress test for elbow'

Valgus stress test for elbow'

Tests for lat epicondylitis'

Method 1

Method 2

Tests for med epicondylitis'

linel's sign (at elbow)'

Wartenberg's sign'

Elbow flex test'

Test for pronator teres syndrome'

Detects

Rupture of RCL

Varus instability also associated withanterior radial head dislocation andannular ligament disruption

Rupture of UCL

Lat epicondylitis

Lat epicondylitis

Med epicondylitis,

Regeneration rate of sensory fibers ofulnar nerve

Ulnar neuritis (entrapment may be atelbowl

Cubital tunnel syndrome

Impingement of median nerve bypronator teres muscle

Test Procedure

PI's arm is stabilized with one ofexaminer's hands placed at elbow andother hand placed above PI's wrist. PI'shumerus is placed in full IR, and elbowis slightly flexed (15-20 degl asexaminer applies varus force.

PI's arm is stabilized with one ofexaminer's hands at elbow and otherhand placed above PI's wrist. PI'shumerus is placed in full ER, and elbowis slightly flexed (15-20 degl asexaminer applies valgus force.

Examiner palpates lat epicondyle whilepronating PI's forearm and flexing PI'swrist fully with ulnar deviation andextending PI's elbow.

Examiner resists ext of middle fingerdistal to PIP joint, stressing extensordigitorum muscle and tendon.

Examiner palpates med epicondyle,supinates PI's forearm, and extends PI'selbow and wrist fully with radialdeviation.

Examiner taps area of PI's ulnar nerve ingroove behind medial epicondyle.

Pt sits with hand resting on table.Examiner passively spreads PI's fingersand asks Pt to bring fingers together.

Pt completely flexes elbow and holds itfor 5 min.

PI sits with elbow flexed 90 deg.Examiner then attempts to supinate andextend PI's elbow as PI resists.

Positive Sign

Laxity of involved elbow compared withuninvolved Inote amount of laxity and endfeel)

Pain/reproduction of PI's Sx over lathumeral epicondyle

Pain/reproduction of PI's Sx over lathumeral epicondyle

Pain/reproduction of PI's Sx over medhumeral epicondyle

ling ling sensation in ulnar nerve distributionof forearm and hand distal to point oftapping

Most distal point at which abnormalsensation is felt represents limit of nerveregeneration

Inability to adduct 5th digit back to otherfingers

lingling/paresthesia in ulnar nervedistribution

lingling/paresthesia in median nervedistribution

I TREATMENT OPTIONS FOR THE ELBOW

Special Condition

UCL rupture

Hx/Symptoms

Hx of elbow dislocation, throwinginjury, or chronic overloading, as in athrowing athlete


Positive valgus stress test of elbow

Mayor may not have tenderness overattachments of UCL

Treatment Options

Acute: sling/immobilizer, ice, NSAIDs

Refer to orthopedic surgeon. Surgerymay be considered

Postop: sling for a few days to 1 wk;maintain fingers/wrist AROM and gripstrength

Cast brace 130-120 degl for 4 wk;allow AROM within this ROM

Cast brace 10-120 degl for 8 wk;allow AROM within this ROM andbegin strengthening between 8-12wk postop. Begin with isometricelbow ftex/ext and wrist radial/ulnardeviation; progress to isotonic andisokinetic strengthening. In finalstages, functional/return to sportactivity should be initiated.

Resume throwing at 6 mo

,

Posterior elbow subluxation/dislocation Hx of FOOSH injury with shoulderabducted or elbow in hyperextension

Radiograph confirms subluxation ordislocation

Dislocation normally requires relocationby medical personnel

Fx are common Ibeware!)

Be sure to perform a neurovascularassessment

Cast bracing times and ROM limitationsmay vary, but AROM within allowablerestrictions noted above and progressivestrengthening should progress asclinically reasonable and as patienttolerates.

Acute: ice, elevation, NSAIDs

If cleared by orthopedic surgeon (no Fxthat require ORIF or prevent initiation ofrehabilitationl, may begin immediatemotion

Maintain wrist and hand motion andstrength

No instability: immediate unlimitedmotion without brace

Valgus instability: immediateunlimited motion in a cast brace withforearm fully pronated

Unstable In extension: immediatemotion in cast brace that blocks fullextension. Extension block may begradually eliminated over 3-6 wk.

Subacute/chronic: begin isometric elbowflex/ext!pronation/supination and wristradial and ulnar deviation. Progress toisotonic and isokinetic strengthening.

( l 11111111 cl ..

I TREATMENT OPTIONS FOR THE ELBOW Continued

Special Condition Hll/Symptoms Signs/Objective Findings Treatment Options

Lateral epicondylitis (tennis elbow) Hx of overuse, heavy lifting, repetitive Local tenderness to palpation over Acute: decrease inflammation lice,motions such as filing/keyboard work/ common wrist extensor origin (Iat NSAIDs, phonophoresis or iontophoresis)tennis strokes (forceful pronation and humeral epicondyle) Relative restsupinationi AGG: resisted wrist and middle finger Epicondylar splint

ext

Positive lat epicondylitis tests Subacute: stretching wrist extensors andflexors

R/O C6 radiculitis or radiculopathyTransverse friction massage

R/O posterior interosseous nerveIsometric strengthening for wrist flex/entrapmentext/radial and ulnar deviation (initiallyperformed with elbow flexed, thenprogress to performing exercises withelbow extended)

Chronic: progress isometrics to isotonics

Strength and endurance training isfocused primarily on wrist extensors

Pt education

Med epicondylitis (golfer'S elbow)

Olecranon bursitis

Hx of high-intensity flex/pronation/gripping

Pain during activity that increases afteractivity

Hx of direct trauma to olecranonprocess

Local tenderness over med humeralepicondyle

AGG: PROM into full wrist ext andresisted isometric wrist flex withforearm pronation

Positive med epicondylitis tests

Swelling and erythema over olecranonprocess

Exquisite tenderness directly overolecranon process and swollen bursa

Acute: decrease inflammation (ice,NSAIDs, phonophoresis or iontophoresis)Relative rest

Epicondylar splint

Subacute: stretching wrist flexors andextensors

Transverse friction massage

Isometric strengthening for wrist flex/ext/radial and ulnar deviation (initiallyperformed with elbow flexed, thenprogress to performing exercises withelbow extended)

Chronic: progress isometrics to isotonics

Strength and endurance training isfocused primarily on wrist flexorsPt education

Ice, NSAIOs, phonophoresis oriontophoresis

May consider padding area forprotection

Ctmtillllcd T

~ TREATMENT OPTIONS FOR THE ELBOW Contmued

Special Condition

Compression at elbow

Pronator teres syndrome (median nervecompressed at pronator teres muscle)

Anterior interosseous syndrome (branchof median nerve)

Hx/Symptoms

Paresthesia in thumb, index finger, andmiddle finger that is aggravated byactivity

Weakness in muscles of forearm andhand innervated by median nerve

Paresthesia in thumb, index finger, andmiddle finger that is aggravated byactivity

Weakness in muscles of forearm andhand innervated by median nerve

Hx of sudden severe forearm pain thatresolves in a few hours

No reported loss of sensation


Loss/weakness of pronator teres musclein addition to muscles of handinnervated by median nerve

R/D cervical pathology

Resisted forearm pronation and elbowflex reproduce Sx

Pronator teres muscle is spared whencompression is at this level vs. elbow(i.e., MMT of pronator teres reveals nodeficitlR/D cervical pathology

Weakness of FPL, PO, and FOP

Pt unable to pinch tip to tip or flex DIPjoints of digits 2 and 3 (positive pinchtestlKey is no loss of sensation


Treatment Options

Relative rest and NSAIDs

Splinting

Ultrasound and soft tissue mobilization

Phonophoresis or iontophoresis

Surgical decompression if conservativeRx fails

Relative rest and splinting for 4-6 wk

NSAIDs

Decrease AGG


Surgical decompression or steroidinjections if conservative Rx fails

Relative rest and splinting for 4-6 wk

NSAIDs

Decrease AGG


Surgical decompression or steroidinjections if conservative Rx fails

(J1....

Palmar cutaneous nerve compression

Carpal tunnel syndrome

Radial Nerve Neuropathies

Radial tunnel syndrome (compression ofradial nerve at elbowl

Superficial radial nerve compression

Posterior interosseous nerve syndrome

Pain over thenar eminence andproximal palm

See Special Tests for the Wrist andHand table in Chapter 5

Pain over lat humeral epicondyle

Tenderness reported along line of radialnerve over radial head

Numbness in radial nerve distribution inhand

Numbness/decreased sensation overdorsoradial hand

Reported normal sensation Inoparesthesia)

May have Hx of lat epicondylitis orincreased use of supinator muscles

Positive linel's sign at palmar mediannerve site

Resisted middle finger ext reproduces Sxmore intensely than in lat epicondylitis

Resisted supination may also reproduceSx

R/D cervical pathology and latepicondylitis

Positive linel's sign over superficialbranch of radial nerve


Reproduced Sx with forced wrist ext ordigital compression when wrist is in flex

Wrist may deviate radially with wrist ext.

Pt unable to extend thumb or fingers atMCP joints


R/D lat epicondylitis

Padding area of injuryPhonophoresis or iontophoresisLocal steroid injections

Relative rest

Splinting

NSAIDs


Phonophoresis or iontophoresis

Neural stretching

Remove tight wristwatch/band that maybe causing compression.

Rest and splinting

Relative rest

Splinting

NSAIDs

Address aspects of job/ADLs requiringincreased use of supinator muscles

Surgical decompression if conservativeRx fails

52

Bibliography

1. Regan WD, Morrey BF: The physical examination of theelbow. In Morrey BF (ed): The Elbow and Its Disorders, 2nd ed.Philadelphia, WB Saunders, 1993.

2. Lister G: The Hand: Diagnosis and Indications, 2nd ed. NewYork, Churchill Livingstone, 1984

3. Hertling 0, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

4. Moldaver J: Tinel's sign: Its characteristics and significance.J Bone Joint Surg Am 60:412-413, 1978.

5. Hunter JM, Schneider LH, Mackin EJ, Callahan AD leds):Rehabilitation of the Hand: Surgery and Therapy, 3rd ed. St. Louis,CV Mosby, 1990.

6. Magee OJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

7. Spinner M, Linscheid RL: Nerve entrapment syndromes. InMorrey BF (ed): The Elbow and Its Disorders, 2nd ed.Philadelphia, WB Saunders, 1993

------------53

References

Dellon AL, Hament W, Gittelshon A. Nonoperative managementof cubital tunnel syndrome: An 8-year prospective study.Neurology 431673-1678, 1993.

Fess EE, Philips CA: Hand Splinting: Principles and Methods, 2nded. St. Louis, CV Mosby, 1987

Galloway M, Demaio M, Mangine R: Rehabilitative techniques inthe treatment of medial and lateral epicondylitis. Orthopedics15:1089-1096,1992.

Hertling 0, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Kisn~r C, Colby LA: Therapeutic Exercise: Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Linscheid RL, O'Driscol1 SW: Elbow dislocations. In Morrey BF(ed): The Elbow and Its Disorders, 2nd ed. Philadelphia, WBSaunders, 1993.

Lister G: The Hand: Diagnosis and Indications, 2nd ed. New York,Churchill Livingstone, 1984.

Nirschl RP: Muscle and tendon trauma: Tennis elbow. In MorreyBF led): The Elbow and Its Disorders, 2nd ed. Philadelphia,WB Saunders, 1993.

O'Driscol1 SW: Classification and spectrum of elbow instability:Recurrent instability. In Morrey BF led): The Elbow and ItsDisorders, 2nd ed. Philadelphia, WB Saunders, 1993.

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Documents

AXTER - gpreview.kingborn.net · Dermatomes 160 Appendix B Sclerotomes Appendix C Auscultation ... Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997