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DPT 681 - MSK 1 > Evaluation - E/W/H > Flashcards

Evaluation - E/W/H Flashcards

1
Q

Evaluation - Diagnostic Classification:

  • Patho-anatomical = ?
  • Movement System = ?
  • Treatment Response = ?

Evaluation - E/W/H

A

Evaluation - Diagnostic Classification:

(a) Patho-anatomical:

  • Health conditions are discussed in a manner similar to a physician visit.

(b) Movement System:

  • Where impairments or syndromes are listed that impact the musculoskeletal, nervous, integumentary, cardiovascular, pulmonary, or endocrine systems.

(c) Treatment Response:

  • Clinical prediction rules and patterned treatments classify the patient.

(d) Notes:

  • Generally, the more proximal the condition, the more apt our profession is to discuss that malady in terms of movement system and treatment-based classifications.
  • The more distal we get, the more we still use pathoanatomical terms and clinical prediction rules for screening.
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2
Q

Evaluation: Personnel

  • Who’s envolved = ?

Evaluation - E/W/H

A

Evaluation: Personnel

(a) Who’s envolved… ?

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3
Q

The Patient’s Story:

  • Five components to consider = ?

Evaluation - E/W/H

A

The Patient’s Story - Five components:

(1) Positives:

  • Young Age
  • Healthy Lifestyle
  • No Red Flags
  • Decrease Comorbidities
  • Decrease Severity
  • Decrease Irritability

(2) Impairments:

  • Strength
  • Mobility
  • Coordination
  • Muscle Tightness
  • Pain Guarding

(3) Chief Complaint:

  • Patient’s description of what brought them for therapy.

(4) Treatment:

  • Two or three general types of treatment to address your selected impairments.

(5) Participation:

  • Patient’s Goal for Therapy
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4
Q

Epicondylopathy

  • Inner tendon’s three phases = ?
  • The outer remains = ?
  • What is usually effected more, extensors or flexors = ?

Evaluation - E/W/H

A

Epicondylopathy:

(a) Inner tendon’s three phases:

(1) Reactive

  • 20’s
  • Inflammatory
  • Increase in proteoglycans

(2) Disrepair

  • 30’s
  • Separation & type-III collagen
  • Neural ingrowth

(3) Degenerative

  • 40’s+
  • Breakdown
  • Cell death

(b) Outer Remains Metabolically Active:

  • Focus on the Donut, Not the hole!
  • Increase tendon thickness on the outside
  • Improve capacity to manage load

(c) Commonly:

  • Extensors > Flexors
  • Extensor Carpi Radialis Brevis
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5
Q

Epicondylopathy:

  • Classifications = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Epicondylopathy:

(a) Classifications:

  • Epicondylitis
  • Epicondylosis
  • Epicondylalgia
  • Tennis Elbow (Most Common)
  • Golfer’s Elbow

(b) Characteristics:

- Pain Pattern

  • Localized, Distal Epicondyle

- Risk Factors

  • 35-50 Years Old
  • Repetitive Movements
  • Women > Men

- Observation

  • Avoidance of grasping or active wrist flex/ext

- Examination

  • Pain: Palpation / contraction
  • (+) Cozen, Maudsleys, Mills, or Medial Epicondylitis test
  • (-) C Spine, nerve entrapment, & chair push-up test
  • Decrease grip strength
  • Patient-rated tennis elbow evaluation

(c) Manual Therapy:

- Patient Education:

  • Activity reduction
  • Ice ( if inflammatory )
  • Orthotics
  • Wrist extension
  • Counterforce

- Joint Mobilization:

  • Humeroradial Joint
  • PRUJ
  • DRUJ

- STM/MFR:

  • Cross-friction Massage
    • 1 Direction
    • 2 min light, 2 min heavy
  • Extensor Muscles
    • Instrument Assisted

(d) Therapeutic Exercise:

- Motor

  • Scapular Strengthening
  • Hand Intrinsic Strengthening

- Tendon:

  • Pain should not exceed 5/10
  • Isometrics
    • If pain reducing, 4-5 sets of 45 sec hold
  • Eccentric Training
    • 2 sets of 15, with 2RiR
    • 48 Hour Rest
  • Energy Storage
    • Rapid Eccentrics
  • Energy Release
    • Rapid Concentrics

- Neurodynamics:

  • Radial Nerve Glides
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6
Q

Distal Biceps Tear:

  • Mechanism of Injury = ?
  • Often Preceded by = ?

Evaluation - E/W/H

A

Distal Biceps Tear:

(a) Mechanism of Injury

  • Rapid High Force
  • Eccentric Loading
  • Flexed and Supinated Forearm

(b) Often Preceded by:

  • Prior Degeneration
  • Repetitive Pronation
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7
Q

Distal Biceps Tear:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Distal Biceps Tear:

(a) Classification:

  • Distal biceps tear

(b) Characteristics:

- Pain Pattern

  • Localized, Non-Radicular Pain over the Biceps

- Risk Factors

  • > 45 Years Old
  • Repetitive Pronation
  • Smoking
  • Heavy Eccentric Loading

- Observation

  • Displaced Biceps mmBelly
  • Swelling
  • Ecchymosis

- Examination

  • Pain: Resisted elbow flexion
  • Decrease flexion/supination strength
  • (+) Biceps Squeeze Test

(c) Manual Therapy

- Patient Education

  • Adherence to Protocol
  • Importance of Protected Phase

- Joint Mobilization

  • Humeroulnar Joint
  • Humeroradial Joint
  • PRUJ

(d) Therapeutic Exercise:

- Protected Phase

  • Orthotic Bracing
  • Spot-Treat Movement System

- Progressive Motion Phase

  • ROM Exercise
  • Stretching

- Strengthening Phase

  • Isometric
  • Isotonic
  • Sport/Work-Specific
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8
Q

Ulnar Collateral Ligament - Injury of the Elbow:

  • Common mechanisms of injury = ?
  • Three bundles = ?
  • Muscularly stabilized by = ?

Evaluation - E/W/H

A

Ulnar Collateral Ligament - Injury of the Elbow:

(a) Mechanism of Injury:

  • Repetitive Trauma
  • Overhead Athletes

(b) Three Bundles:

(i) Anterior Bundle:

  • Anterior (0-60) and Posterior Band (60-120)

(ii) Posterior Bundle:

(iii) Transverse/Oblique Bundle:

(c) Muscularly Stabilized:

  • UCL Fails at 260N
  • Throwing Generates 290N
    • Flexor Carpi Ulnaris
    • Flexor Digitorum Superficialis
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9
Q

Ulnar Collateral Ligament Injury of the Elbow:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Ulnar Collateral Ligament Injury of the Elbow:

(a) Classifications:

  • UCL Reconstruction
  • Tommy John Surgery

(b) Characteristics:

- Pain Pattern

  • Localized, distal epicondyle

- Risk Factors

  • Repetitive movements

- Observation

  • Decrease throwing velocity

- Examination

  • Pain: Palpation
  • (+) Moving Valgus Stress Test
  • (-) Medial Epicondylitis Testing,

(c) Manual Therapy:

- Patient Education

  • Activity Reduction

- Joint Mobilization

  • Humeroulnar Joint
  • Humeroradial Joint
  • PRUJ
  • DRUJ
  • Shoulder External Rotation
  • Scapula
  • Thoracic Spine

- STM/MFR

  • Cross-friction Massage
    • 1 Direction

(d) Therapeutic Exercise:

- Motor

  • Ant Core/Subscap/Grip Strength
  • Flexor/Pronator Strength

- Surgical Protocol:

(i) Immediate Motion

  • Pain Control
  • PROM/AAROM/AROM

(ii) Intermediate

  • Resistance Training = Strength/Control
  • Mobilization

(iii) Advanced Strengthening

  • Progress Resistance
  • Power/Endurance
  • Plyometrics

(iv) Progressive Return to Activity

- Neurodynamics:

  • Ulnar Nerve Glides
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10
Q

Lateral Collateral Ligament Injury:

  • Mechanisms of injury = ?
  • The radius and ulna act as a unit, which results in = ?
  • Frequency = ?

Evaluation - E/W/H

A

Lateral Collateral Ligament Injury:

(a) Mechanism of Injury

  • Hyperextension force in olecranon fossa
  • Levers trochlea past coronoid process

(b) Typically, Annular Ligament Remains Intact

  • Radius and Ulna Act as a Unit
  • Results in Posterolateral Instability

(c) Frequency

  • Most Common Dislocation in < 10 yo
  • 2nd Most Common > 10, After Shoulder

(d) Different From Nursemaid’s Elbow

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11
Q

Lateral Collateral Ligament Injury:

  • Classifications = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Lateral Collateral Ligament Injury:

(a) Classifications:

  • Posterolateral Rotary Instability
  • Radial Head Subluxation

(b) Characteristics:

- Pain Pattern

  • Localized, Distal Epicondyle
  • Reports: Elbow “Giving way”

- Risk Factors

  • Hx: Radial Dislocation
  • Hx: Lateral Epicondylitis

- Observation

  • Apprehension of Supination + Loading

- Examination

  • Pain: Palpation
  • Decrease in extension ROM
  • (+) Chair Push-up Test
  • (-) Lateral Epicondylitis Testing

(c) Manual Therapy:

- Patient Education

  • Activity Avoidance
  • Bracing

- Joint Mobilization

  • Humeroradial Joint
  • PRUJ
  • DRUJ
  • Shoulder Internal Rotation

(d) Therapeutic Exercise:

- Motor

  • Grip/Extensor Strength

- Surgical Protocol:

(i) Immediate Motion

  • Pain Control
  • PROM/AAROM/AROM

(ii) Intermediate

  • Resistance Training = Strength/Control
  • Mobilization

(iii) Advanced Strengthening

  • Progress Resistance
  • Power/Endurance
  • Plyometrics

(iv) Progressive Return to Activity

- Neurodynamics

  • Radial Nerve Glides
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12
Q

Annular Ligament Injury:

  • Mechanisms of injury = ?
  • Radial head / annular ligament configuration is more susceptible, when = ?

Evaluation - E/W/H

A

Annular Ligament Injury:

(a) Mechanism of Injury:

  • Longitudinal Pull on the Radius
  • Full Extension and Supination

(b) Radial Head/Annular Ligament Configuration

  • Children Not as Congruent and Stable as Adults
  • Looser and Even More Susceptible After Injury
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13
Q

Annular Ligament Injury:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Annular Ligament Injury:

(a) Classifications:

(b) Characteristics:

- Pain Pattern

  • Localized, Distal Epicondyle

- Risk Factors

  • Age 2-4

- Observation

  • None

- Examination

  • Pain: Palpation/ROM
  • Decrease in ROM
  • (+) Chair Push-up Test
  • (-) Lateral Epicondylitis Testing

(c) Manual Therapy:

- Patient Education

  • Referral For Imaging and Potential Relocation

(d) Therapeutic Exercise:

- Motor

  • Grip Strength
  • Wrist Extension Strength
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14
Q

Elbow Arthropathy:

Evaluation - E/W/H

A

Elbow Arthropathy:

(a) Osteoarthritis:

  • Secondary to Prior Trauma
  • Chondral Degenerative Process
  • Not as Common as other Large Joints

(b) Panner’s Disease:

  • Disruption of Blood Supply to the Capitulum
  • Repetitive Valgus Stress or Trauma (6-11)
  • No Chondral Flaking
  • Good Prognosis

(c) Osteochondritis Dissecans:

  • Genetic Predisposition to Poor Subchondral Health / Blood Supply
    • Repetitive Valgus Stress or Trauma (10-20+)
    • Chondral Flaking
    • Guarded Prognosis
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15
Q

Elbow Arthropathy:

  • Classifications = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Elbow Arthropathy:

(a) Classifications:

  • Osteoarthritis (OA)
  • Osteochondrosis
  • Panner’s Disease
  • Osteochondritis Dissecans (OCD)

(b) Characteristics:

  • Pain Pattern
  • Deep in Elbow Joint

- Risk Factors

  • Age > 55 (OA)
  • Girls > Boys (OA)
  • Age 6-11 (Panner’s)
  • Boys > Girls (Panner’s/OCD)
  • Girls > Boys (OA)
    • Hx: Joint Trauma
    • Hx: Heavy Joint Loading

- Observation

  • Swelling
  • Nodules (Osteoarthritis)

- Examination

  • Pain: ROM
  • Decrease in ROM
  • Joint Crepitus (OA)
  • Loose Bodies (OCD)

(c) Manual Therapy:

- Patient Education

  • Joint Protection Principles
  • Rest/Immobilization (Panners)
  • Anti-inflammatory Diet (OA)
  • Ice – Acute | Heat Recurrent
  • Referral for Medical Management

- Joint Mobilization

  • Humeroulnar Joint I-II
  • Humeroradial Joint I-II
  • PRUJ I-II
  • DRUJ I-II

(d) Therapeutic Exercise:

- Motor

  • Daily AROM
  • Pain-free Grip and Elbow Strengthening

- Modalities

  • Ultrasound = (1 MHz; 1W/cm2 for 5 min)
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16
Q

Cubital Tunnel Syndrome:

Evaluation - E/W/H

A

Cubital Tunnel Syndrome:

(a) Nerve Compression Injury

(i) Medial Intermuscular Septum

(ii) Cubital Tunnel

  • Medial Epicondyle of the Humerus
  • Olecranon of the Ulna
  • Cubital Retinaculum & Flexor Carpi Ulnaris

(b) In Flexion, Olecranon Moves 1.5cm Away:

(i) ‘Roof Collapses’ as Space Becomes Narrow Oval

(ii) Pressure Goes Up Inside Space

  • x7 in Full Flexion
  • x20 in Full Flexion + Active Ulnar Deviation

(c) Prolonged Exposure:

  • Thickening of Epineurium and Perineurium
  • Microvascular Proliferation of the Endoneurium
17
Q

Cubital Tunnel Syndrome:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Cubital Tunnel Syndrome:

(a) Classification:

  • Ulnar Nerve Entrapment
  • “Funny Bone”

(b) Characteristics:

- Pain Pattern

  • Radicular Pain and Paresthesia from Medial Elbow to Medial Hand

- Risk Factors

  • Prolonged Elbow Flexion
  • Work/Sleep (7-20xmmHg)
  • UCL Inflammation

- Examination

  • (+) Tinel’s Sign
  • (+) Elbow Flexion Test
  • (-) C Spine, Medial Epicondylitis Testing
  • Decrease in Grip Strength
  • Wartenberg Sign (↓ Intrinsic)
  • Froment Sign (↓ Add Pol)
  • Claw Hand

(c) Manual Therapy:

- Patient Education

  • Activity Reduction
  • Heat
  • Night Orthotics

- STM/MFR

  • Flexor Carpi Ulnaris
  • Cubital Tunnel Retinaculum

(d) Therapeutic Exercise:

- Stretch

  • Flexor Carpi Ulnaris

- Neurodynamics

  • Ulnar Nerve Glides
18
Q

Elbow Fracture:

  • Mechanisms of Injury = ?
  • What complications does surgery present = ?

Evaluation - E/W/H

A

Elbow Fracture:

(a) Mechanism of Injury:

  • High-force Impact
    • Fall or Car Accident

(b) Multiple Classification Schemes

  • Surgery is Most Common Treatment (ORIF)
  • Stiffness is Common
  • Early Mobility Helps
  • Varus Deformity is Expected

(c) Difficult Surgery:

  • Altered Kinematics
  • Decreased ROM
  • Close Proximity to Neurovascular Structures
    • Iatrogenic Nerve Involvement
19
Q

Elbow (Humerus) Fracture:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Elbow (Humerus) Fracture:

(a) Classification

  • Extra-articular (A)
  • Articular with Shaft Continuity (B)
  • Articular without Shaft Continuity (C)

(b) Characteristics:

- Pain Pattern

  • Diffuse Pain

- Risk Factors

  • Men aged 12-19
  • Women > 80
  • Fall History

- Observation

  • Swelling
  • Obvious Deformity

- Examination:

  • (↓) ROM
  • Significant Stiffness
  • (↓) Grip Strength
  • (+) Elbow Extension Test

(c) Manual Therapy:

- Patient Education

  • Ice
  • Orthotics
  • Static Progressive
  • Joint Active System (JAS)

- Joint Mobilization

  • Humeroulnar Joint
  • Humeroradial Joint
  • PRUJ
  • DRUJ

- STM/MFR

  • Biceps
  • Triceps
  • Forearm Musculature

(d) Therapeutic Exercise

Protocol:
(I) Inflammatory Phase

  • 0-2 Weeks
  • Manage Pain/Inflammation
  • Light ROM

(II) Fibroplastic Phase

  • 3-8 Weeks
  • Increase ROM
  • Begin Light Strengthening

(III) Remodeling Phase

  • 2-6 Months
  • Progress Strength
  • Mobilizations
  • Static-Progressive Orthotics

- Neurodynamics:

  • Nerve Glides (Check All)
20
Q

Carpal Tunnel Syndrome:

Evaluation - E/W/H

A

Carpal Tunnel Syndrome:

(a) Most Common UE Nerve Compression

(b) Etiology

  • Fractures, Carpal Arthritis, Synovitis
  • Forceful Grip with Wrist Flexion (Lumbricals)

(c) Pathogenesis

(i) Extra-neural Compression - Endoneurial Swelling

  • 2+ Hours Extra-neural - 24 Hours Endoneurial

(ii) Prolonged Swelling

  • Endoneurial Breakdown
  • Nerve Fibrosis
  • Demyelination
  • Wallerian Degeneration

(d) Associated with Double Crush Phenomenon

21
Q

Carpal Tunnel Syndrome:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Carpal Tunnel Syndrome:

(a) Classification:

  • Median Neve Entrapment

(b) Characteristics:

- Pain Pattern

  • Pain/paresthesia
  • Lateral Hand
  • Pain Worse at Night

- Risk Factors

  • Age > 45, Women > Men
  • Diabetes

- Observation

  • Flick Sign - Shaking (↓) Sx
  • Wrist Ratio > 0.7
  • Thenar Atrophy

- Examination

  • (+) Phalen’s, Tinel’s, Wainer CPR, Durkan’s (Compression)
  • (-) Scaphoid Fx, Finkelstein, TOS, Cervical Spine
  • (↓) Grip Strength/Sensation
  • (↓) Coordination (Moberg)

(c) Manual Therapy:

- Patient Education

(i) Possible Injection Consult

(ii) Possible Surgical Consult

(iii) Heat

(iv) Activity Modulation

  • (↓) Full MCP Flexion and Ulnar Deviation
  • Work in 0-45° Pronation
  • Work in slight Ext/Ulnar Dev.

(v) Orthotics

  • 2 degrees Ext/Ulnar Deviation
  • Night, During Heavy Work Activities, or Pregnant (not mouse work)

- STM/MFR

  • Flexor Retinaculum
  • Medial Arm

(d) Therapeutic Exercise:

- Neurodynamics

  • Distal Median Nerve Glides

- Flexibility

  • Flexor Retinaculum Stretch
  • Hand Intrinsic Stretch
  • Finger Flexor Stretch

- Post-Surgical (Only a few visits over 2-3 weeks are needed)

  • Activity Avoidance Education
  • Light Paper Taping Over the Incision
  • Light Isometrics progressing to tendon glides
  • Distal Median Nerve Glides
22
Q

Distal Radius Fracture:

  • Mechanisms of Injury = ?
  • Types of Fracture = ?

Evaluation - E/W/H

A

Distal Radius Fracture:

(a) Mechanism of Injury

  • FOOSH
  • Old Age
  • Activity (Skateboarding, skiing, snowboarding…etc.,).
  • Contact Sports

(b) Type of Fracture

  • Extra-articular is Most Common
  • Colles’ = Distal Radius Displaces Dorsally
    • Likely to be oversimplified
    • Multitude of potential fracture patterns and classifications
  • Smith’s = Distal Radius with Volar Displacement
23
Q

Distal Radius Fracture:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?

Evaluation - E/W/H

A

Distal Radius Fracture:

(a) Classification:

(I) Extra-Articular

  • Colle’s Fracture (Dorsal)
  • Smith’s Fracture (Volar)

(II) Intra-Articular

(b) Characteristics:

- Pain Pattern

  • Diffuse Wrist Pain

- Risk Factors

  • (>) 50 Years Old
  • Fall Risk
  • Women > Men

Observation

  • Avoidance of grasping or active wrist flex/ext

- S/P Examination

  • (↓) ROM
  • (↓) Grip/Pinch Strength
  • (↓) Push-off Test Strength

(c) Manual Therapy:

- Patient Education

  • Ice/Heat
  • Orthotics

- Joint Mobilization

  • Humeroradial Joint
  • PRUJ
  • DRUJ
  • Radiocarpal Joint
  • MCP/IPs

- STM/MFR

  • Forearm Musculature

(d) Therapeutic Exercise:

- Protocol

(I) Protective Phase

  • 1-6 Weeks
  • Wrist Immobilization
  • Monitor Pain/CRPS
  • Finger/Elbow/Shoulder ROM

(II) Motion Phase

  • After Immobilization
  • Wrist AROM (Priority: Wrist Ext/Sup/Pro and Finger Flexion)
  • Tendon Gliding

(III) Function Phase

  • Starts at Bone Healing
  • Strength = Isometric - Isotonic
  • Mobilization

- Neurodynamics:

  • Nerve Glides (Check All)
24
Q

Triangular Fibrocartilage Complex (TFCC) Injury:

  • Articular Disc is Mostly = ?
  • Mechanisms of Injury = ?
  • Causes of degeneration = ?
  • Treated with = ?

Evaluation - E/W/H

A

Triangular Fibrocartilage Complex (TFCC) Injury:

(a) Articular Disc is Mostly Avascular

(b) Mechanism of Injury

  • Trauma
  • Fall Onto an Outstretched Hand
  • Forced Rotation While Gripping

(c) Degeneration

  • Wear - Chondromalacia - Puncture - Arthritis
  • Secondary to Ulnar Malposition
  • Prior Trauma
  • Positive Ulnar Variance

(d) Treated With:

  • Active Stabilization
  • Bracing
  • Injection
25
Triangular Fibrocartilage Complex (TFCC) Injury: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Triangular Fibrocartilage Complex (TFCC) Injury: (a) **Classification**: * Acute * Degenerative (b) **Characteristics**: **- Pain Pattern** * Localized, Distal Ulna **- Risk Factors** * Hx: Distal Forearm Injury * Ulnar Variance (+)or(-) * Advancing Age * Repetitive Movements **- Observation** * Localized Swelling * Clicking/Crepitus **- Examination** * **Pain**: Palpation/ROM * (+) Ulnomeniscotriquetral Sweep * (↓) Grip Strength (c) **Manual Therapy**: **- Patient Education** * Ice * Orthotics - *Night + Vigorous Activity* * Possible Referral if Bracing/Strength are Unsuccessful - *Injection or Surgery* **- Joint Mobilization** * Humeroradial Joint * PRUJ * DRUJ **- STM/MFR** * Cross-friction Massage - *1 Direction* * ECU + FCU (d) **Therapeutic Exercise**: **- Motor** * Grip Strength * Wrist Strength **- Sensory** * Angle Reproduction - *Laser on a Bat* * Reflex Reactivation - *Lighter Perturbations* **- Neurodynamics** * Ulnar Nerve Glides
26
Stenosing Tendovaginitis: * Mechanisms of Injury = **?** * Pathogenesis = **?** * Common Sites of Pathology = **?** ## Footnote *Evaluation - E/W/H*
Stenosing Tendovaginitis: (a) **Mechanism of Injury** * Trauma and repetitive Stress * Possible Predisposition (b) **Pathogenesis** (**i**) Metaplasia of Collagen and Extracellular Matrix * Limited to No Inflammatory Element (**ii**) Thickening of the Retinaculum * Up to 3-4x its thickness (**iii**) Adhesions Form Between Tendon and Sheath (c) **Common Sites of Pathology** (**i**) De Quervain’s Tenosynovitis * 1st Dorsal Compartment * Abd. Pollicis Longus & Extensor Pollicis Brevis (**ii**) Trigger Finger * A1 Pulley
27
Stenosing Tendovaginitis: * Classifications = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Stenosing Tendovaginitis: (a) **Classifications**: * Stenosing Tenosynovitis * De Quervain’s Tenosynovitis * Trigger Finger (b) **Characteristics**: **- Pain Pattern** (**i**) Localized Pain * De Quervain’s: Radial Styloid * Trigger Finger: Pulley **- Risk Factors** * Repetitive /Forceful Jobs * Women > Men **- Observation** * Local Nodule * AROM: Catching/Crepitus **- Examination** * **Pain**: Palpation/AROM * (+) Finkelstein’s * (↓) Strength * (-) Scaphoid Fracture (c) **Manual Therapy**: **- Patient Education** * Activity Avoidance * Ergonomic Modifications * Ice * Ultrasound * Orthotics - *Rigid* * Refer for Injection - *Failing Conservative Care* **- STM/MFR** (**i**) Cross-friction Massage * 2-Direction * 2 min light (**ii**) Involved Musculature (d) **Therapeutic Exercise**: **- Motor** * Grip Strength * Gentile Tendon Glides * Stretching * Strengthen Kinematic Chain
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Scaphoid Fracture: * Mechanisms of Injury = **?** * Vascular Supply = **?** ## Footnote *Evaluation - E/W/H*
Scaphoid Fracture: (a) **Mechanisms of Injury**: * Most Common Carpal Fracture * Vulnerable Due to 45 Angulation * Compression in Extension & Radial Deviation - Radioscaphocapitate Ligament Fx Waist (70%) (b) **Vascular Supply**: * Most Vascularization at or Distal to Scaphoid Waist * Proximal Pole Supplied by Retrograde Intraosseous Flow/
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Scaphoid Fracture: * Classifications = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Scaphoid Fracture: (a) **Classifications**: * N/A (b) **Characteristics**: **- Pain Pattern** * Localized, Distal Radius **- Risk Factors** * 15-30 Years Old * Men > Women **- Observation** * Focal Swelling **- Examination** * **Pain**: Palpation * (+) Scaphoid Compression * (+) Snuffbox Tenderness * (-) Finkelstein’s Test * (↓) Grip Strength (c) **Manual Therapy**: **- Patient Education** * Screening and Referral * Ice * Orthotics - Thumb Spica (long/short) ***and*** Progressive Orthotics **- Joint Mobilization** * Radiocarpal Distraction * DRUJ * Light Carpal Mobilization * MCP Mobilization * IP Mobilization (d) **Therapeutic Exercise**: **- Protocol**: *Can vary greatly depending on location of fracture and surgical intervention*. (**I**) Protective Phase * 2-4 Weeks * Wrist Immobilization * Monitor Pain/CRPS * Finger/Elbow/Shoulder ROM (**II**) Motion Phase * After Immobilization * Finger/Wrist AROM * Stretching/Tendon Gliding (**III**) Function Phase * Starts at Bone Healing * Strength (Isometric - Isotonic) * Mobilization **- Neurodynamics**: * Median Nerve Glides
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Ulnar Collateral Ligament Tear of the 1st: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Ulnar Collateral Ligament Tear of the 1st: (a) **Classification**: * Skier’s Thumb - Trauma * Gamekeeper’s Thumb - Repetitive Stress (b) **Characteristics**: **- Pain Pattern** * Localized, Medial 1st MCP **- Risk Factors** * Fall Risk **- Observation** * Focal Swelling **- Examination** * **Pain**: Palpation * (+) Ulnar Collateral Ligament Test (c) **Manual Therapy**: **- Patient Education** * Screening and Referral * Ice * Orthotics - Thumb Spica (short) **- Joint Mobilization** * DRUJ * Carpal Mobilization * CMC Mobilization * IP Mobilization (d) **Therapeutic Exercise**: **- Motor** * 2-8 Weeks after Immobilization * Pinch and Grip Strength * Wrist Strength * Stretching **- Neurodynamics** * Median Nerve Glides
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Metacarpal Fractures: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Metacarpal Fractures: (a) **Classification**: * Boxer’s Fracture (b) **Characteristics**: **- Pain Pattern** * Localized, Metacarpal **- Risk Factors** * Age 22-34 * High Force Loading * Men > Women **- Observation** * Focal Swelling * Ecchymosis * Guarded Movement **- Examination** * **Pain**: Palpation/ROM * (↓) Strength (c) **Manual Therapy**: **- Patient Education** * Referral * Ice * Orthotics * + ‘Rehabilitation Ready’ Splinting (MCP Flexion *and* IP Extension) **- Joint Mobilization** * Carpal * MCP * IP **- STM/MFR** * Hand Intrinsics (d) **Therapeutic Exercise**: **- Protocol** (**I**) Protective Phase: * 3-7 Days * Hand Immobilization * Monitor Pain/CRPS * Finger/Elbow/Shoulder ROM (**II**) Motion Phase: * 7-21 Days * Tendon Gliding * Finger/Wrist AROM (**III**) Function Phase: * 4-8 Weeks * Wean from Orthotic * Strength (Isometric - Isotonic) * Aggressive Stretching and Mobilization
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Dupuytren’s Contracture: * Pathogenesis = **?** * Cord Types = **?** ## Footnote *Evaluation - E/W/H*
Dupuytren’s Contracture: (a) **Pathogenesis**: * Unknown Etiology * Fibromatosis of the Palmar Ligaments and Fascia * Nodule at Distal Wrist Branches Outward * Longitudinal Ligaments Limit Function * + MCP & PIP * + 4th & 5th Digits (b) **Cord Types**: (**i**) Central Cord (Pictured) * Longitudinally Runs Palmar to Flexor Tendons (**ii**) Spiral Cord (Not Pictured) * Runs Laterally and Tethers Neurovascular Bundle (**iii**) Natatory Cord (Not Pictured) * Crosses Metacarpals, Connects Digits
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Dupuytren’s Contracture: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Dupuytren’s Contracture: (a) **Classifications**: * Progressive Fibroplasia * Dupuytren’s Disease * Dupuytren’s Diathesis (More Severe) (b) **Characteristics**: **- Pain Pattern** * Localized, Palm 4th/5th Digits * Catching/Locking **- Risk Factors** * Alcoholism * Diabetes * Smoking * Men > Women * North European Ancestry **- Observation** * Dupuytren’s Nodule * Obvious Deformity **- Examination** * **ROM**: (↓) 4th/5th MCP & IP * (+) Tabletop Test (c) **Manual Therapy**: **- Patient Education** (**i**) Wound Management (**ii**) Orthotics * Extension IP (pre-surgical) * Dorsal Orthosis (I) * Volar Orthosis (II) * Static/Dynamic Ext. (III) **- Joint Mobilization** * Carpal * MCP * IP **- STM/MFR** * Forearm Musculature * Hand Intrinsics (d) **Therapeutic Exercise**: **- Protocol ** (**I**) Wound Management: * Weeks 1-2 * Orthotics * Wound Cleaning * Mid-range ROM (**II**) Motion Phase: * Weeks 2-3 * Progressive ROM * Light Mobilization * Tendon Gliding (**III**) Discharge Phase: * 4-6 * Achieve End-range ROM * Isometric Strength * Wean from Therapy
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Wrist and Hand Tendon Pathology: * Classifications = **?** * Mallet Characteristics = **?** * Complex Considerations = **?** * Mallet Considerations = **?** ## Footnote *Evaluation - E/W/H*
Wrist and Hand Tendon Pathology: (a) **Classifications**: * Flexor Tendon Laceration * Extensor Tendon Laceration (Mallet Finger) (b) **Mallet Characteristics**: **- Pain Pattern** * Localized, DIP **- Risk Factors** * Impact Sports or Professions **- Observation** * DIP Flexion * PIP Extension * Focal Swelling **- Examination** * **Pain**: Palpation/ROM * (↓) Grip Strength (c) **Complex Considerations**: **- Dependent on Protocol ** * Indiana Hand Protocol Manual **- Protocol Types** * Immobilization * Early Passive Motion * Early Active Motion **- Protocol Dependent on** * Flexor vs Extensor Side * Zone of Injury * Severity of Injury * Surgical Intervention Type * Strength of Suture Used * Patient: * + *Age/Health* * + *Motivation* * + *Socioeconomic Factors* (d) **Mallet Considerations**: **- Mallet Finger Protocol** * 6 weeks Mallet Splint * Light ROM Exercise **- Goal** * Strong Tendon * Glides Freely
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Complex Regional Pain Syndrome: * Pathogenesis = **?** ## Footnote *Evaluation - E/W/H*
Complex Regional Pain Syndrome: **Pathogenesis**: (**1**) Starts with overt or covert nerve injury (**2**) Genetic predisposition increases: * Pain/Inflammatory Mediators (**3**) Sympatho-afferent Coupling * Nociceptive Fibers Grow Adrenergic Receptors * Stress Response Triggers Pain * Worsened by an Elevated Stress Response (**4**) Decreased Regional Sympathetic Activity * Parasympathetic Dominance * Vasodilation (Red/Warm) (**5**) Upregulation of Sympathetic Receptors * Sympathetic Dominance * Vasoconstriction (Blue/Cold) (**6**) Prolonged Pain Produced Central Sensitization * Changes in Somatosensory Mapping
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Complex Regional Pain Syndrome: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Complex Regional Pain Syndrome: (a) **Classification**: * Type I (Reflex Sympathetic Dystrophy) * Type II ([Causalgia](https://www.uclahealth.org/medical-services/neurosurgery/conditions-treated/causalgia#:~:text=Causalgia%20is%20a%20rare%20pain,cases%20are%20called%20major%20causalgia.)) (b) **Characteristics**: **- Pain Pattern** * Unilateral, Non-dermatomal * Hyperalgesia = *increased pain from a stimulus that usually causes pain*. * Allodynia = *Pain caused by a stimulus that doesn't usually cause pain*. **- Risk Factors** * Advancing Age * Women>Men * Fracture or Crush Injury **- Observation** * Warm/Red - Cold/Blue * Edema/Sweating * Trophic Change **- Examination** * (↓) Range of Motion * Weakness/Dystonia * Anxiety/Depression * Budapest Criteria (3 of 4, 1 at eval) * + Hyperalgesia & Allodynia * + Edema/Sweating * + [Trophic Change](https://www.ncbi.nlm.nih.gov/medgen/866865#:~:text=Definition,from%20HPO%5D) (c) **Manual Therapy**: (**i**) Patient Education * Pain Neuroscience Ed. * Relaxation Exercises * Cardio Program * Ice or Heat (**ii**) Desensitization (**iii**) Retrograde Massage (d) **Therapeutic Exercise**: (**i**) Guided Motor Imagery * Limb Laterality Recognition * + Week 1 * Imagined Movements * + Week 2 (**ii**) Mirror Box Therapy * Active Movements (Week 3-6) * Two Point Discrimination (**iii**) Pain Free AROM (**iv**) Graded Exposure (**v**) Isometric Strengthening (**vi**) Push/Pull Stress Loading (**vii**) Return to Work
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Wrist and Hand Arthropathy – Osteoarthritis: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Wrist and Hand Arthropathy – Osteoarthritis: (a) **Classification**: * Osteoarthritis * Bouchard’s Nodes (PIP) * Heberden’s Nodes (DIP) (b) **Characteristics**: **- Pain Pattern** * Localized, DIPs & 1st CMC **- Risk Factors** * Age > 50 * Women > Men **- Observation** * Crepitus * Swelling **- Examination** * **Pain**: ROM * (↓) Grip Strength * (↓) ROM (c) **Manual Therapy**: **- Patient Education** * Joint Protection Principles * Anti-inflammatory Diet * Ice: Acute * Heat: Recurrent * Orthotics (OtC Support) **- Joint Mobilization** * Carpal I-II * CMC I-II * MCP I-II * IP I-II (d) **Therapeutic Exercise**: **- Pain-Free Motor** * Daily AROM * Hand Intrinsic Strengthening * Isometric Grip Strength * Forearm-Strength
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Auto-Immune Systemic Inflammation of the Synovium = **?** ## Footnote *Evaluation - E/W/H*
**Rheumatoid Arthritis**: Auto-Immune Systemic Inflammation of the Synovium (a) **Endothelial Inflammation** (b) **Synovial Hyptertrophy and Hyperplasia** * Invades Surrounding Tissue (c) **Massive Inflammatory Response** * Destroys Cartilage - Desiccation and Degradation * Destroys Bone - Elevated Osteoclastic Activity * Distends Capsular - associated Ligaments * Destroys Tendons - Matrix and Venous Disruption, Tears
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Wrist and Hand Arthropathy – Rheumatoid Arthritis: * Classification = **?** * Characteristics = **?** * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Evaluation - E/W/H*
Wrist and Hand Arthropathy – Rheumatoid Arthritis: (a) **Classification**: (**1**) Rheumatoid Arthritis * (I) Inflammatory * (II) Proliferative * (III) Destructive * (IV) Collapse & Deformity (**2**) Swan Neck Deformity (**3**) Boutonniere Deformity (b) **Characteristics**: **- Pain Pattern** * Diffuse, Fingers/Hands **- Risk Factors** * Family History * Smoking/Periodontitis * Women > Men **- Observation** * (I) Focal Swelling/Heat * (III/IV) Obvious Deformity **- Examination** * (I) Pain: Palpation/ROM * (↓) Grip Strength 2nd to: * + (I/II) Pain * + (III/IV) Deformity * + (III/IV) Tendon Rupture (c) **Manual Therapy**: **- Patient Education** (**.**) Joint Protection Principles (**..**) (I/II) Ice or (III/IV) Heat (**...**) Orthotics * Increasing Support for Each Stage * (I/II) Compression Gloves * (III/IV) Night Orthoses - * (III/IV) Swan Neck * (III/IV) Boutonniere **- STM/MFR** * Spot-treat (Contractures/Tightness) (d) **Therapeutic Exercise**: **- Motor** * Pain-free AROM * Isometric Strengthening * General Conditioning

DPT 681 - MSK 1 (17 decks)

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