Shoulder 10/26/13 7:49 PMCommon Shoulder impairments1. Pain- find the source (MSTT)

Tx: activity modification, massage, modal, grade I & II mobs/Codmans Sources: C-spine (jts C3-C5; nerve roots C4-C5), dermatomes (C4 trap, C5 deltoid/lat

arm), diaphragm, heart, gall bladder, myofascial trigger points2. Posture: muscle imbalances, fwd head & shoulder

Adaptive shortening pecs, lats, subscap, upper traps Adaptive weakness delts, mid/low traps, serratus, ERs Tx: Stretch tight, then strengthen weak, pt. education & retraining

3. Mobility: joint capsule, muscle, fascia, nervous system Tx: hypermobilitystabilize dynamic or inc motor control; bracing

o Hypomobilityjt manip, stretching, soft tissue, neural mobs4. Impaired Muscle Performance: neurologic, overuse, disuse, postural imbalance

Tx: neuro: identify sourceo Muscle strain: dec load on contractions of that muscleo Weak muscle: strengthen but avoid substitutions

Shoulder Dysfunctions1. Adhesive Capsulitis: Hypomobility, decreased ROM in capsular pattern; AROM has pain & scapular/upper trap substitutions

Etiology: primary (?) and secondaryintrinsic (arthritis, RC tear), extrinsic (trauma, disease), systemic, thoracic kyphosis, altered GH jt. mechanics, hormonal influence, immobilization

Inflamed, fibrotic, shrunken jt. capsule with adhesions

Shortened RTCs Biceps tendon adheres to the sheath PROM classical: ER>ABD>FL>IR PROM accessory: ant>inf>post glides MLT: tight muscles pecs, teres major, latissimus dorsi, subscap

o Tx: manual stx w/ inhibition techniques MMT: normal in ROM; as gain ROM, weakness in new range due to adaptive

shorteningo Tx: strengthen with isotonics

Stages (4): pain, pain & stiffness, stiffness w/min pain, recovery Precautions: in acute, low grade oscillations, mechanical manips only after

inflammation resolved, monitor for substitutions in scap during ROM

2. Acromioclavicular Dislocation MOI: direct blow/FOOSH, pain over AC, TTP @AC, pain with all motion, prominent

clavicle 1st Degree/Type I: swelling, bruising, painful, no deformity

o Tx: symptomatic, early ROM in pain free range, avoid: dips, wide grip bench, dead lifts >6 wks (triceps, pecs, lats)

2nd Degree/Type II: AC Lig. tear, partial CC, widening AC jt, some AP instability (most painful)

o Tx: protect, sling 2 wks w/ MEAT, no activities until full ROM & strength 3rd Degree/Type III-VI: complete AC & CC ligs, step deformity, instability, wider

area of TTP, tearing of deltoid attachments (less painful)o Tx: conservative for Type III, sling & swath 2 wksrehab; Type IV-VI

surgical benefit3. AC Osteoarthritis: repetitive motor stresses, grade I & II separations, clavicular fractures

S&S: minor ache with throwing, pain lying on side, crepitus, + horizontal flexion test

Tx: Pt. education, NSAIDS, steroid, surgery SC/AC due to repeated stressful movement overhead, diagonal ext, IR, horizontal

add, overhead lifting, lack of dynamic control of humerus, FOOSH, faulty postureTOS

4. Tendonitis: find the source and address that Younger ptoveruse in overhead activities Older ptdegenerative lesions so poor blood supply to supraspinatus AROM: painful arc

o Tx: modalities, massage to dec inflammation, pt. education PROM classical: full, may have pain at end range or guarding

o Tx: dec pain & inflammation, inc ROM with stretching PROM accessory: capsule not involved, but may be a cause or result

o Tx: inf/post glide for hypomobile; strengthen dynamic stabilizers

5. Bursitis: Subacromial/Subdeltoid bursa most commonly involved btwn deltoid & RTC to reduce friction

Etiology: acute (spontaneous w/ debilitating pain) or chronic (impingement) Acute: AROM, PROM classical severely limited (non capsular), empty end feel,

subacromial TTP, unwilling to perform motions Chronic: impingement signs, painless resisted motions, mild capsular restrictions Tx: Acutepain relief & modalities; Chronictreat symptoms like impingement

6. Instability/Laxity-Dislocations Instability: loss of neuro control (ex: scapulohumeral rhythm off) Hypermobility: leads to instability

Contraindications: inc mobility of GH jt (joint manipulation Gr III & IV), manual stretching, end ROM activities

7. Impingement/Instability/RTC tear: >35 yrs degenerative aging process; <35microtrauma to muscles, tendons, capsule, ligaments due to laxity & overuse

Classificationso Group I: Pure Impingement, no instability, >35 yrs due to overuse, posture,

acromion shape, DJD, post/inf capsule tightness, weakness of RTC/biceps Lack IR, ER, horiz add, dominant supraspinatus, hooked acromion,

AC DJD Tx: maximize subacromial space, improve capsular extensibility,

strengthen other RTCs & Bicepso Group II: primary instability due to microtrauma & impingement

IIa: internal impingement under surface of RTC when in abd/ER from glenoid fossa

IIb: Subacromial impingement Many different laxity test and some subtle instability Tx: strengthen & increase endurance of RTC, biceps, scap stabilizers,

NM training, functional techniqueso Group III: Primary instability due to hyperelasticity w/ impingement

Ectomorph, <35, multijoint hypermobility & instability (AMBRI) Tx: strengthen & inc endurance of RTC & Scap stabilizers

o Group IV: pure instability (traumatic), no impingement Younger usually, TUBS, trauma, unidirectional laxity, apprehension + Associated problems w/ dislocation: nerve injury, Fx, labral tears,

capsular injury, RTC tears, high recurrence in young Hill Sachs lesion on head of humerus Bankart Lesion of glenoid labrum

Tx: non-opimmediate motion & strengthening w/in guarded range to prevent atrophy and NM shutdown

Neer’s Classificationo Stage I: Edema & Inflammationpainful 60-120 deg, decreased ROM,

subacromial inflammation, conservative tx (<25yrs)o Stage II: Fibrosis & Tendonitiscrepitus due to scaring, ‘catching’ sensation,

limited AROM, PROM, not reversible (25-40yrs)o Stage III: Bone spurs & tendon ruptureAROM worse than PROM, atrophy,

weakness in abd/ER, biceps T involved, not reversible, Sx needed (>40yrs)8. RTC Tear & Repair

9. Thoracic Outlet Syndrome 1st rib, clavicle, ant/middle scalenes due to hypertrophy, overuse, fx, or poor posture

can result in entrapment of the Ulnar nerve (C8-T1)o affects Subclavian vasculature or Axillary A if pec minor is tight

Exam: UE pain/paresthesias, vasomotor changes, chest/shoulder pain, poor posture Tx: based on cause, posture education, stretchingstrengthening, manipulations

10. CRPS: Ther Ex depends on stage of disease, main goal is AROM to prevent DVT, edema contracture, & osteoporosis11. Peripheral Nerve Injuries

Pain control, maintain ROM/strength, monitor posture/compensations, support bracing

Classification of nerve injuries: Neuropraxia (pressure neuropathy), axonal tenesis (axon dies, degeneration), Neural tenesis (Neural tube gone, so cannot regenerate)

Long Thoracic Nerve: trauma, weight lifting, idiopathicserratus anteriorscap winging

o Findings: winging with flex/abd/scaption, dec AROM due to weak serratus (flex)

o Tx: maintain ROM, strengthen surrounds mms, maintain RTC strength, strengthen agonists & SA when signs of reinnervation

Suprascapular Nerve: excessive protraction of scapula (cyts, direct trauma, volleyball)

o Findings; deep burning esp in horizontal add, TTP, atrophy, decreased abd & ER

o Tx: avoid scap protraction, correct posture, calm down inflammation, normalize muscle tone, maintain ROM, stretch IRs, strengthen ERs

Axillary Nerve: due to anterior shoulder dislocation or shotso Findings: weak deltoid & RTCo Tx: strengthen deltoid & RTC, maintain ROM

Elbow/Forearm 10/26/13 7:49 PMElbow Joint: 1 anatomical joint, 3 functional joints

Flex(biceps, brachialis, brachioradialis)/ext (triceps, anconeus) and pron (pronator teres & quadratus) /sup (supinator, biceps, brachioradialis)

Sensation provided by Musculocutaneous and Radial N.

Elbow Joint Capsule Dysfunction-Common source of referred pain by C8-T1-Nerve disorders: Ulnar N (cubital tunnel), Radial N (deep branch in ECRB/ sup or sup branch by direct trauma, Median N (pronator teres syndrome)-Carrying Angle: abd position of forearm, F: 10-15, M: 51. Capsular tightness

Result of immobilization, pt. will go to clinic after removal of cast/splint with adhesions & scar tissue already formed

Determine using PROM class/acc if loss of ROM due to muscle length or capsular tightness

Capsular pattern: flex>ext, pron=sup Functional Limitations: turning doorknob/key, pushing/pulling, hand to mouth

activities, carrying objects w/ straight arm, limited reach Tx: may require aggressive, prolonged stretching Post-op of Fx: head & neck of radius 33% of all fxs due to FOOSH

o Total Elbow Arthroplasty Precautions: avoid stress on triceps at end range, no resisted elbow ext for 6-12 weeks, limit repetitive lifting, no rec sports

2. Myositis Ossificans: heterotropic ossification seen with supracondylar fx, pos dislocation of elbow, stretching of elbow flex, brachialis muscle trauma

Exam Findings:o PFC: inc warmth, firm brachialiso PROM: elbow ext limit>flex, flex end range painfulo MSTT/MMT: pain with resisted elbow flexo PFT: palpation may be painful, may feel mass

Contraindications after trauma: massage, passive stx, resistive ex Tx: rest in splint until bony mass resorbed; only remove for ROM

3. Overuse Syndromes (tendonitis): Lateral Epicondylitis: extensor muscles of forearm (ECRB >ECU>ECRL) Medial Epicondylitis: flexor muscles of forearm, mostly FCR & pronator teres Triceps Tendonitis: distally Find the cause, usually a symptom of another impairment; must balance stress & rest

o Too much stressimmature collagen broken down before matures chronic inflammation

o Too much restcomplete immobilizationinadequate stressfail to strengthen mature collagenbreakdown of collagen in return to activity

o Pain with lengthening due to inflammation/damage & micro tears to tendon, and pain with gripping activities

4. Cubital Tunnel: entrapment/irritation of Ulnar N in cubital tunnel Pain/numbness, and parasthesia in ulnar side of forearm and hand Symptoms inc with functions requiring elbow flex Max shldr abd, elbow flex, forearm pron, wrist ext, will maximally stretch Ulnar N.

Wrist/Hand 10/26/13 7:49 PMHand Function-Muscles of wrist and hand work together

Wrist ext for stronger grip Wrist flex for stability of finger ext Extensor mechanism

o ED: MCP hyperext w/ IP flex Must have tension to get IP ext

o PIP & DIP ext together from pull of interossei/lumbricals one extensor hood Grip patterns:

o Power: clamping with partially flexed flingers against palm with counter pressure from add thumb (cylindrical, spherical, hook, grip, lateral prehension

o Isometric control of: extrinsic flexors, ED compression to MCP, interossei, thenar & add pollicis

Prehension: grasping of objects btwn any 2 surfaces in hand that isn’t the palmo Muscular control: extrinsic provide compression btwn fingers & DI w/

intrinsic interossei, thenar mms, lumbricals (hold obj away from palm) Combined grips: involved D1 & D2 for precision, D3, D4, D5 for power Wrist capsular pattern: flex=ext Finger capsular pattern: flex>ext

Wrist and Hand Dysfunctions1. RA: associated with tenderness/warmth over joints, muscle guarding/pain with motion, joint stiffness & dec ROM, muscle weakness, deformity, restricted ADLs

Chronic systemic disease affecting synovium I joints S&S: volar sublux triquetrum, Ulnar sublux of carpalsradial dev of wrist, ulnar

drift of fingers w/ volar sublux of prox phalanxstretch/rupture of collateral ligaments at MCP

Contraindication: stretching of swollen joints Work on cardiopulmonary endurance and low/non impact conditioning (aquatherapy,

biking) Swan Neck deformity: dorsal displacement of lateral bandsDIP, MCP flex, PIP

hyperext Boutonniere deformity: volar displacement of lateral bandsDIP, MCP hyperext,

PIP flex Educate pt on balancing work & rest, avoiding deforming positions, using adaptive

equipment, energy conservation

2. Joint Hypomobility OA & post-traumatic arthritis, post-immobilization

o Protection phase: control pain, protect joints, grade I, II distractions & oscillations, PROM, AAROM, or AROM to maintain muscle integrity & tendon mobility, tendon gliding (5positions)

o Controlled motion/return to function phase: inc joint play & acc motions with Grade III, IV manipulations

Unlock subluxated ulnomeniscal-triquetral joint (cannot supinate)volar glide ulna on stabilized triquetrum

Mobilizations with movement at wrist to inc joint tracking (apply lat glide while pt moves)

Improve balance & endurance3. Muscle Imbalances

Check for normal arthrokinematics (PROM acc) before initiating stretching Stretch distal to proximal to avoid joint compression (may not need to stretch over

every joint if tight)o ED: flex DIPflex PIPflex wristo Lumbricals: flex DIPflex PIPext MCPo FDS: ext PIPext MCP, ext wrist

MRE to strengthen after stretching4. Overuse Syndromes

Tenosynovitis/Tendonitis: pain, warmth, TTP, imbalance in muscle strength & length, poor endurance, pain worsens with activity

o Protection: splint, friction massage to tendon, mm setting, painfree ROM, pt tendon gliding

5. Wrist Sprain: pain with stretch force to ligament, possible hypermobility/ instability, maintain mobility while minimizing stress to healing tissue6. Tendon Repairs: must take into account MOI, location (which zone), other tissue involved

Treat conservatively but need to prevent adhesions Balance protection & movement: immobilization for tendon healing, early ROM to

prevent adhesions Surgery immediately: w/in 10 daysOK, >2wkspoor, >3-4wksdirect repair not

possible FLEXOR TENDON ZONES

1. FDP insert to FDS insert (FDP, A4&5 pulleyscan’t make fist)2. FDS insert to palmar crease (FDS, FDP tendons, annular pulleysunable to flex PIP, DIP)3. Neck of MC to distal border of Carpal Tunnel (FDP, FDS, lumbricalsMCP flex affected)4. Carpal Tunnel (FDS, FDP, FPL, Nerve injury)5. Prox wrist to extrinsic flexors (flexor tendons of digits & wristloss of wrist 7 digit flexion, Median & Ulnar N&A

o Tx: splint to prevent extension; early controlled motion with dorsal block splint in dynamic traction (passive flex to not put stress on flexor tendons, active extension to maintain ROM and strengthening

Tendon gliding (5 positions: straight, hook fist, full fist, table top, straight fist)

EXTENSOR TENDON ZONES1. DIP jt. region2. Middle Phalanx (1 & 2no active DIP ext, flex contracture, swan neck)3. PIP jt. region4. Proximal phalanx (3 & 4cannot ext PIP from 90, boutonniere)5. Apex of MCP jt (EDC, EIP, EDM damagecannot extend MCP)

6. Dorsum of hand7. Wrist (6 & 7retinaculum damage & multiple tendons, loss of ext of digits and wrist)

o Less likely to develop adhesions b/c extensors only glide at wrist joint, immobilized longer due to slower healing

Dynamic Ext splintallow for active MCP flexion but maintaining MCP ext at rest

Volar splints: short arc ex of PIP & DIP (wrist 30 deg flex) Dupuytren’s Contracture: flex contracture of 1 or more fingers from thickening of

palmar aponeurosiso Small thickened nodule preventing full MCP & PIP exto Treat with low force, prolonged stretch (splint)

Skier’s Thumb: sprain UCL of 1st MCP from hyperAB force to thumbo TTP and swelling over UCL, pain w/ pinchingo Tx: splint to stabilize, stretch of proximal MCP

7. Colles Fx: distal radial Fx due to FOOSH Complications: capsule tightness, sprain of UCL, avulsion fx, malalignmentCarpal

tunnel, limiting wrist flex & Ulnar dev RSD/CRPS Full return to ROM, strength & function may not be realistic (bony block with PROM

due to malalignment) Won’t see pt. in acute stage due to cast or external fixator

8. Scaphoid Fx: FOOSH in wrist ext TTP in anatomic snuff box, swelling, dec ROM Poor healing due to poor blood supplyavascular necrosis due to distalprox blood

supply9. TFCC: FOOSH usually wrist in pronation

Ulnar sided wrist pain, swelling, dec grip strength, click with ulnar dev

10. CRPS11. Carpal Tunnel Syndrome: night pain, tingling, numbness, insidious onset, dec strength in Median N distribution, dec sensation, pain may refer proximally