Final Cards Flashcards
Wrapping definition
- application of non-adhesive cloth wrap or tensor
- tensors provide excellent compression, but not support
- focus on reducing by-products of inflammation, initially
Taping definition
- application of adhesive backed tape
- provide support and compression
- does not allow for underlying swelling
- used in later stages of injury
KT tape
- first developed in 1979
- adopted by high performance athlete (athletes only represent about 15% of users)
- requires training for application: costly
KT tape effects
- lifts skin increasing space between epidermis and fascia - helps with lymph circulation and blood flow
- relieves pain by releasing compression on nociceptors (sensory receptor for pain)
- simulates neuroreceptors in skin and fascia stimulating proprioception
- mechanical correction of underlying soft tissue (corrects positional errors)
- increase ROM and improves muscle contraction
Tensor (compression) key ideas
- don’t impair circulation distal to site of compression
- never wear to bed
- overlap layers by 1/2
- keep roll firmly wound and roll off bottom of tensor
- begin distally and progress proximally
- do not use excessive tension
- test for circulation, no tingling or numbness
Cloth wrap key ideas
- economical and reusable protection for an ankle that has not recently been sprained
- it will not prevent all ankle sprains but may reduce severity of a sprain
- allows practice of the heel lock (designed to lock the ankle bones of the sub-talar joint)
Purpose of taping
1) support:
- supports ligaments and joint capsules of unstable joints
- limits excessive or abnormal movements
2) enhance:
- enhance proprioceptive feedback
3) support (injuries)
- support injuries to musculotendinous unit by compression and limiting movement
When to tape
- injury prevention
- acute injury management (only for support- when acute management do not use for return to play)
- return to activity (after rehab)
When not to tape
- when further assessment is required
- after an acute injury has occurred
- functional disability/limited ROM
- swelling
- after cold application
- pre-puberty (10-14 years of age)
- for certain sports
- if you are unsure/unfamiliar with athlete’s condition
General considerations of taping
- familiarity with athletes condition
- familiarity with severity of injury
- familiarity with the stage of healing of the injury
- understanding of the physical requirements of the sport/activity
Skin preparation when taping
- hair should be shaved
- Skin: clean, dry, free from oil, etc. covered irritation with a bandage before taping
- underwrap should be used if skin is irritated by the tape
- tufskin for better adhesion (avoid fingers and toes)
Positioning of the athlete when taping
- support structure to be tapes
- should be comfortable
- should pay attention and hold body part in an appropriate anatomical position
Positioning of taper during taping
- should be comfortable
- watch for excessive postural strain on back
Common taping mistakes
Shadows, windows, wrinkles
How to avoid common taping mistakes
- constant tension
- overlap by 1/2
- reapply if you mess up
Tape removal
- use sharks/tape cutters and take care of skin and other delicate structures
- cut tape on the medial side of the leg, posterior medial malleolus
- apply counter pressure to protect skin
Three different tape strips
Anchors, functional tape strips, close off strips
Types of functional tape strips
- figure 8s
- heel locks
- spicas
- spirals
- stirrups
- fans
Describe the evaluation of an athletic injury
- begins when the injury occurs
- continues through the healing process
- goes until injured area has been rehabilitated and athlete returns to activity
- ongoing process
KEAP
Requirements of athletic injury assessment/evaluation
Knowledge
Experience
Acquired skill
Practice
When should you assess the injury? Why?
- ASAP after occurrence
- not assessing quickly could lead to misjudgement in referral mode
- ongoing process
- constant assessment and reevaluation
Where should you assess the injury?
- ideally the location at which the injury occurred
- depends on severity of injury
What should not be done during an on-field assessment?
Recovering clothing or equipment - this can be done off field when necessary to assess
In what circumstances should you not move the athlete?
If you suspect:
- head or neck injury
- fractured spine or long bone
- major joint dislocation
- if athlete is unwilling to move
Assessment considerations (4 points with specifications)
Personal assessment skills:
- be alert during athletic activity
- observe all athletes
- remain calm and use good judgement
Know the sport:
- fundamentals/ injury patters
Know your athletes:
- medical history and personalities
Experience
Assessment procedures
Primary survey
Secondary survey
Documentation
What is included int he primary survey of an injury?
ABCs
What is included in a secondary survey?
HOPS
HOPS
History
Observation
Palpitation
Special tests
History on field vs off field
On field:
- mechanism of injury
- noises
- done this before?
- pain scale
Off field:
- detailed open ended questions
- listen to athlete explain the injury in exact detail
- good communication with the athlete is the key
Observations on vs off field
On field:
- quickly survey entire scene
- obvious fractures/dislocations
- swelling of exposed area
- bleeding
- deformity
- compare both sides
Off field:
- swelling
Redness
Discolouration
Look at athletes reactions to questions and palpitations
Palpitation on vs off field
On field:
- fracture/dislocation
- pain on palpitation, assist with localizing the injury
- feel swelling/temperature
Off field:
- fracture/hot spot
- Pain on palpitation
- crepitation: grating, grinding sensation
Special tests on vs off field
On field:
- active ROM
- weight bearing
Off field:
- functional tests: active/passive/resistive ROM
- specific stress tests evaluating joint stability
- bilateral comparison
Active ROM
Athlete initiates movement through as much range as possible
Tests: strength of surrounding
- contractile structures (muscle/tendon)
- inert structures (bone/ligament)
- ROM of joint
- athletes willingness to move
Passive ROM
Examiner moves the joint through entire ROM (athlete is relaxed)
- go until “end feel” is reached
- do not force the joint if athlete is unwilling to move due to pain or spasm
Tests:
- inert (bone/ligament)
- severity of structure injured
Resistive ROM
Examiner provides resistance
(Counter-pressure) against a joint and the athlete attempts to move
Tests:
- contractile structures: strength/weakness of joint contraction with or without pain
Testing sequence
1) always perform active testing first
2) if athlete is unwilling to move or feels pain on active movement then do not perform passive an resisted
Special testing: stress testing
- stress testing is used to test joint integrity
- examiner determines which tests will assess the condition most effectively
- only those test that are deemed to be absolutely necessary should be performed
Referral
- pain and muscle spasm can restrict motion and cause an inaccurate result
- once HOPS is complete, make an assessment of injury severity and what you think the problem is (Not a diagnosis) and decide on your method of referral
Label the joints of the shoulder
A - acromioclavicular joint
B - sternoclavicular joint
C - gleno-humeral joint
Label the anatomy of the shoulder
A - humerus
B - tendon of biceps brachii
C - subacromial space
D - coracoacromial ligament
E - acromion process
F - superior acromioclavicular ligament
G - coracoclavicular ligament
H - clavicle
I - costoclavicular ligament
J - anterior sternoclavicular ligament
K - interclavicular ligament
L - articular disk
M - manubrium of sternum
N - Coracold process
O - scapula
Label the structures within the glenohumeral joint
A - acromion process
B - Coracoid process
C - articular capsul
D - glenohumeral ligaments
E - glenoid labrum
F - glenoid cavity
G - tendon of subscapularis
H - long head of biceps brachii
Label the structures of the glenohumeral joint
A - coracohumeral ligament
B - anatomical neck
C - greater tubercle
D - lesser tubercle
E - humerus
F - bicep brachii
G - scapula
H - glenohumeral ligaments
I - coracoid process
J - acromion process
Label the yellow nerve
Brachial plexus axillary nerve
Label the purple
Subdeltoid bursa
Label the muscles
A - subscapularis
B - teres major
C - latissimus dorsi
Label the muscles
A - subclavius
B - pectoralis minor
C - pectoralis major (cut)
D - abdominal fibres
E - costal section
F - sternal section
G - pectoralis major and clavicular section
H - anterior deltoid
Label the muscles
A - anterior deltoid
B - middle deltoid
C - posterior deltoid
Label the muscles
A - trapezius
B - serratus posterior inferior
C - latissimus dorsi
D - teres major
E - rhomboid major
F - deltoid
G - rhomboid minor
H - levator scapulae
Label the muscles
A - supraspinatus
B - infraspinatus
C - teres minor
Label the muscles
A - serratus posterior superior
B - teres minor
C - levator scapulae
D - supraspinatus
E - infraspinatus
F - teres minor
G - teres major
Label the muscles. What region of the body is this?
A - supraspinatus
B - teres minor
C - infraspinatus
D - subscapularis
Rotator cuff
SITS
Rotator cuff muscles:
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What are the rotator cuff muscles responsible for?
Supraspinatus = abduction
Infraspinatus = external rotation
Teres minor = external rotation
Subscapularis = internal rotation
Movements of the shoulder
Flexion/extension
Abduction/adduction
Horizontal abduction/adduction
Internal/external rotation
Circumduction
Active ROM ranges (degrees) in shoulder
Flexion = 0 -180
Extension = 0 - 60
Abduction = 0 - 180
Adduction = 0 - 50 - 70
Horizontal abd/adduction = 0 - 130
Internal rotation = 0 - 60 - 100
External rotation = 0 - 90
Scapulohumeral movments explained
Scapulohumeral rhythm = once the arm gets above a certain degree of movement, the humerus and scapula move continuously and synchronously at a 2:1 ratio which allows increased range of motion at the glenohumeral joint (avoids impingement)
- coordinated movement
- 1 degree of scapular rotation for every 2 degrees of humeral movement is needed to facilitate full, normal shoulder motion
Degrees of scapulohumeral movement
- initial 30 of glenohumeral abduction does not incorporate scapular motion(setting phase)
- 30 - 90 the scapula abducts and upwardly rotates 1 for every 2of humeral elevation
- above 90 the scapula and humerus move in 1:1 ratio
What range does scapulohumeral rhythm movement occur?
30-90 degrees
What movement does the yellow depict?
Scapulohumeral movement/ rhythm
Movements of the scapula
Abduction/adduction
Elevation/depression
Upward/downward rotation
Protraction/retraction
What point of reference is used for upwards/downward rotation of the scapular
Glenoid fossa
Movements that create protraction of the scapula
Downward rotation
Abduction
Anterior tilt
Moments that create retraction
Upward rotation
Adduction
Posterior tilt
Label the muscles
A - sternocleidomastoid
B - deltoid
C - pectoralis major
D - sternum
E - biceps brachii
F - subclavius
G - clavicle
H - subscapularis
I - pectoralis minor
J - coracobrachialis
K - serratus anterior
L - humerus
What movements is the deltoid responsible for?
Anterior deltoid = flexion
Middle deltoid = abduction
What movement is the pectoralis major responsible for?
Flexion
What are the major anterior chest muscles
Deltoid
Pectoralis major
Serratus anterior
What movement is the serratus anterior responsible for?
Scapula abduction
What is the coracoid process a critical anchor for?
- pectoralis minor
- coracobrachialis
- short head of biceps brachii
Label the ligaments attached to the coracoid
A - transverse scapular ligament
B - coracoacromial ligament
C - trapezoid ligament
D - consider ligament
E - coracoclavicular ligaments
F - pectoralis minor
G - coracobrachialis
H - short head of biceps
What are the major muscles of the posterior neck/back?
Trapezius
Rhomboids
Latissimus dorsi
Posterior deltoid
Movements of the trapezius
Separated into 3 regions:
Upper fibres = extend neck, elevate scapula
Middle fibres = adduction scapula
Lower fibres = depress scapula
Rhomboids muscles description
Deep to trapezius muscle
Responsible for scapular retraction
Label the muscles of the rhomboids
A - acromion process of scapula
B - deltoid
C - trapezius
D - rhomboid major
E - rhomboid minor
Label the muscle and the movement its responsible for
Latissimus dorsi for adduction
Label the minuscule and the movement responsible
Posterior deltoid for extension
Anterior palpitations in the upper body
- stern also notch
- sternoclavicular joint (ligament)
- clavicle
- lesser tuberocity
- bicipital grove
- greater tuberocity
Posterior palpitations of the upper body
- acromion process
- acromioclavicular joint
- scapular spine
- medial border of scapula
- inferior ankle of scapula
- lateral border of the scapula
Clavicle fractures sign and management
- tent deformity at fracture site
- managed with figure 8 brace or some need surgery
Label the type of clavicular fractures and the chances of it occurring
Left to right:
Lateral: 15%
Middle: 80%
Medial: 5%
Sprain and separations of the AC joint mechanism, signs, and symptoms
Most common
- forced blow to tip of shoulder
- pain with forced motion
- swelling
- decreased ROM
- joint instability
What is occurring in the two photos
Direct vs indirect AC sprain
Classification of acromioclavicular joint sprains
Type I: first degree
- stretch or partial damage of AC ligament and capsule
Type II: second degree
- rupture of
Ac ligament and partial train of coracoclavicular ligament
Type III: second degree
- rupture of AC ligament and coracoclavicular ligament
TYPE IV-V: third degree
- rupture of AC ligament and coracoclavicular ligament and tearing of deltoid and trapezius fascia
Shoulder dislocations
- glenohumeral most commonly dislocated joint
- forced abduction and external rotation
- humeral head is anterior to glenoid fossa (95%)
- avulsion fracture common with first dislocation
- always refer to physician for reduction and x-rays, never reduce yourself (don’t put it back yourself)
Label the different shoulder positions
Left to right:
Normal anatomy
Anterior dislocation
Posterior dislocation
Glenoid labrum
Fibrocartilage rim that lines the glenoid fossa
SLAP lesion
Superior Labrum Anterior to Posterior injury
- may include long head of biceps tendon
What injury is pictured?
SLAP lesion
What injury is pictured? What is the mechanism?
Bankart lesion:
- a bogey bankart occurs when the labrum is avulsed and the glenoid has been fractured
- associated with recurrent anterior shoulder instability
- tears may also come from degeneration or trauma
Label the anatomy
A - labrum
B - long head of the biceps muscle
C - glenoid cavity
What injury is this? Label the anatomy
Glenoid labrum tear
A - tear
B - glenoid cavity
C - glenoid labrum
Common chronic injuries in the shoulder
Strains and impingements:
- rotator cuff strain
- rotator cuff impingement
Impingement syndrome
- tendons of the rotator cuff are pinched as they pass between the top of the humerus and the acromion
- progressive degeneration changes to the supraspinatus, bicep tendon, and/or bursae
- trauma causing swelling in increased friction in the area
- deep pain around acromion
Biceps brachii rupture
Rupture can occur when an unexpected force applied to the bicep muscle
- attempting to catch morning, fall with elbow in flexed position
Tendonitis in the shoulder aka throwers arm
- overuse from throwing
- rapids overhead move et involving excessive elbow flexion and supination
- irritates rotator cuff tendon of biceps tendon (bicipital tendonitis)
Thoracic outlet syndrome
- thoracic outlet: anterolateral aspect of neck
- compression of neuromuscular structures at the thoracic outlet (vein, artery m nerves)
- compression at three locations:
1) scalene triangle
2) costoclavicular space
3) sub coracoid space
Label the locations of the thoracic outlet
A - scalene triangle
B - subcoracoid space
C - costoclavicular space
TOS: mechanisms, signs, and symptoms
Overhead rotational stresses with muscle leads aggravate:
1) nerves compressed:
- aching pain
- pins and needles sensation
- numbness into arm (medial side into ulnar nerve aspect)
- weak grip strength and muscle atrophy
2) vein compressed:
- deems, stiffness into hand
- cyanosis in arm
3) rapid onset of coolness, numbness in entire arm, fatigue after overhead activity
4) seen in overhead athletes
- swimmers, weightlifting, volleyball
Another name for effort thrombosis
Paget-Schroetter syndrome
Treatment of acute injuries in the shoulder
- signs for immediate referral
- control inflammation (ice packs, spica)
- immobilize and transport to hospital
- vigorous rehab will be required to reduce chance of more dislocations
What situations should immediate referral be conducted in the shoulder
- obvious deformity suggesting fracture, separation, or dislocation
- significant loss of motion or weakness in myotomes (group of muscles innervated by the motor fibres of a single nerve root - cervical region for shoulder)
- joint instability
- abnormal sensation in shoulder, arm, hand
- absent or weak pulse distal to injury
- any significant unexplained pain
Painful arc sign
- active abduction of shoulder through full range and pain between 60-120 degrees
- positive for impingement
- pain between 170-180 degrees is positive for AC joint injury
What test is this? What does it assess?
Apley’s scratch test
A - medial rotation and adduction
B - medial rotation, extension, and adduction
C - abduction, flexion, and lateral rotation
Special tests for acromioclavicular instability
- piano key sign
- AC distraction and compression
Special test for glenohumeral instability
- apprehension test (crank test) - shoulder subluxation
- sulcus test - glenohumeral instability
Rotator cuff special tests
- drop arm/empty can test - supraspinatus
- open door test/lateral rotation - teres minor, infraspinatus
- lift off test/internal rotation - subscapularis
Special tests for bicipital tendonitis
Speeds and yergasons
Thoracic outlet syndrome special tests
Addison test
Two aspects of rehab of shoulder complex
Immobilization and general body composition
Immobilization during rehab of the shoulder complex
- will vary depending on injury
- isometrics can be performed during immobilization
- time in brace or splint are injury specific
- ROM and strengthening are dictated by healing
General body conditioning for rehab of shoulder complex
Maintain cardiovascular endurance through sucking, running and walking
Flexibility in shoulder rehabilitation
- Codman’s pendulum exercises should begin early
- progress to active assisted ROM in pain free range
- should be performed in conjunction with rotator cuff and scapula strengthening exercises
Strengthening for shoulder rehab
- isometric exercises first
- progress to more dynamic exercises
- neuromuscular control (must regain appropriate firing sequence for specific mercies, proprioception, CKC and OKC are necessary in complete rehab plan)
Functional progress of shoulder rehab
- incorporation of sport specific skills
- strengthening that involves PNF patters (resembles throwing)
- gradual and progressive increase in angular velocities
Return to activity for shoulder rehab
- based on pre-established criteria
- functional performance testing
- object measures of strength and performance
Movements of the elbow
Flexion/extension
Pronation/supination
Label the bones of the elbow
A - humerus
B - radius
C - ulna
Label the elbow
A - humerus
B - radius
C - ulna
Label the elbow. Is this the anterior or posterior side?
A - humerus
B - lateral epiconcyle
C - capitulum
D - radial head
E - radial tuberosity
F - radius
G - ulna
H - coronoid process
I - trochlea
J - medial epicondyle
K - coronoid fossa
L - medial supracondylar crest
Anterior
Label the elbow. Is this the anterior or posterior side?
A - humerus
B - olecranon
C - radial head
D - radius
E - ulna
Carrying angle
- formed by long axis of humerus and midline of forearm
- larger angles are considered abnormal
- disappears when the elbow is extended and the forearm is pronated
Carrying angles in males vs females
Females > males
Male norms: 11-14 degrees
Female norms: 13–16 degrees
Cubical valgus
Formed by long axis of humerus and midline of forearm
Cubical varus
Usually develops secondary to condylar humerus fracture
Two ligaments of the elbow
Ulnar (medial) collateral ligament:
- anterior part
- oblique part
- posterior part
Radial (lateral) collateral ligament
Bursa in elbow
Olecranon bursa
Origin, insertion, innervation, and action of biceps brachii
Origin:
- Long head - supraglenoid rim
- Short head - coracoid process
Insertion:
- Radial tuberosity
Innervation:
- Musculocutaneous nerve
Action:
- Elbow flexion, forearm supination, shoulder flexion
Origin, insertion, innervation, and action of brachialis
Origin:
- distal anterior humerus
Insertion:
- ulnar tuberocity and coronoid process
Innervation:
- musculocutaneous nerve
Action:
- elbow flexion
Origin, insertion, innervation, and action of coracobrachialis
Origin:
- coracoid process
Insertion:
- medial humerus opposite deltoid tuberosity
Innervation:
- musculocutaneous nerve
Action:
- shoulder flexion
Origin, insertion, innervation and action of brachioradialis
Origin:
- lateral supercondylar ridge of humerus
Insertion:
- lateral aspect of radial style I’d process
Innervation:
- radial nerve
Action:
- elbow flexion, especially with forearm in neutral position
Label the muscle
Triceps brachii
Label the muscle
Anconeus
Label the anatomy
A - wrist extensors
B - lateral epicondyle
C - common extensor tendon
Label the anatomy
A - wrist flexors
B - common flexor tendon
C - medial epicondyle
Arm arteries from top to bottom
Subclavian
Axillary
Brachial
Radial
Ulnar
Palmar arches
Palpitations of the elbow
Olecronan process
Olecronan fossa
Lateral epicondyle
- common extensor tendon
Wrist extensor
Medial epicondyle
- common flexor tendon
Wrist flexors
Pulse
Common acute injuries in the elbow
Fractures:
- humerus
- radius: radial head
- ulna: Olecronan process
- medial epiphyseal plate
Supracondylar fractures
Humerus fractures:
- most common in children/adolescents
- fall on flexed elbow or hyper extension mechanism
Deformity present if displaced, often missed on initial evaluation if non-displaced
Ulnar fracture
- coronoid process fracture
- may be associated with posterior elbow dislocation
Radial fractures classifications
- radial head fracture
Type I: nondisplaced
Type II: fracture with displacement, depression or angulation
Type III: comminuted fracture of head (3 or more pieces)
Type IV: comminuted fracture associated with elbow dislocation
Elbow sprain
- ligament injury
- usually from forced hyperextension or varus/valgus force
- athlete may hear “click” or “ pop” along with sharp pain at time of injury
- pain relieved by flexing elbow
- may also involve avulsion fracture
Elbow dislocation
- uncommon, but serious
- ulna/radius displaced
- always accompanied by MCL sprain
- immobilize and refer to a physician
Directions of elbow dislocation
Posterior
Posterolateral
Posteromedial
Lateral
Medial or divergent
Posterior elbow dislocation
- typically results from hyperextension, trochlea levered over coronoid process
- most common direction is posterolateral
- involved injustice or most ligament structures
- may present with subsequent myositis ossifications
Elbow dislocation and nerves
Potential for injury to brachial artery and medial/ulnar nerve
Olecranon bursitis
- typically due to direct trauma
- immediate swelling, pain, reduced ROM
- usually easily treated with rest and compression
- if persists, may be aspirated - risk of infection
Common chronic injuries of elbow
Tendinopathy, epicondylitis
Tendinopathy
- triceps Tendinopathy
- lateral epicondylitis = tennis elbow
- medial epicondylitis = golfers elbow
Epicondylitis
- local tenderness over epicondyle
- pain when using involved muscle and in resistive exercises
- swelling, pan, redness
Little league elbow
- lesions resulting from excessive throwing in young athletes (valgus stress)
- tendonitis/tendinosis
- medial humeral growth plate
- avulsion fracture
Tommy john surgery
- ulnar collateral ligament reconstruction
Issues to consider with tommy john surgery
- conservative treatment plan
- fail that, then do surgery
- only if they want to continue baseball then do surgery
- 9 month - a year for recovery
- factors that lead up to surgery aren’t addressed
- likelihood of it breaking down again
Movements of wrist
Flexion/ extension
Radial/ulnar deviation
Movements of fingers
Metacarpals:
Flexion/ extension
Abduction/adduction
Proximal/distal phalanges:
Flexion/extension
Thumb:
Opposition/reposition
Label the bones
A - 4 proximal carpals (scaphoid)
B - radius
C - ulna
D - 4 distal carpals
E - 5 metacarpals
F - 14 phalanges
Label the dorsal ligaments of the wrist
A - dorsal inter carpal ligament
B - dorsal radiocarpal ligament
Label the palmar ligaments of the wrist
A - v-deltoid ligaments
B - lunotriquentral ligament
C - UCL and ulnocarpal meniscus homologue
D - ulnolunate ligament
E - radioscapholunate ligament
F - radiolunate ligament
G - scapholuntate ligament
H - radial collateral ligament
I - radioscaphocapitate ligament
Carpal tunnel
Created by arched carpal bones and carpal ligament
All wrist flexor tendon run through the tunnel
Label the carpal tunnel
A - ulnar artery
B - median nerve
C - transverse carpal ligament
Ligaments in the finger
Collateral ligaments
Palpitations of hand
Approach as if a fracture
- radial style I’d process
- ulnar style I’d process
- scaphoid: anatomic snuffbox
- metacarpals
- phalanges
Common acute injuries in hand
Fractures:
- colles fracture
- scaphoid fracture
- metacarpals bones
- phalanges
Subungual hematoma
- from crush injury
Sprains and dislocations:
- skiers thumb
- mallet finger
- boutonnière deformity
- jersey finger
Management of subungual hematoma
- sterilize
- use heated paper clip
- drain blood to relieve pressure
- pad and protect
Management of finger dislocations
- hyperextension or shearing mechanism
- PIP most common
- in DIP or MCP dont let athletes reduce - watch digital nerve and vessels
- MD reduces with nerve block and may require surgery if instability persists
Common chronic injuries
- carpal tunnel syndrome
- de quervains disease
- ulnar neuropathy
Ulnar neuropathy symptoms
- numbness and tingling
- pain on the outside or middle of the forearm
Ulnar nerve: - may become compressed due to swelling of surrounding muscles and connective tissues
- its ability to transmit messages to the muscles of the forearm may be significantly reduced
Special tests for wrist, hand, and fingers
- active/passive/ resistive ROM
- valgus stress
- varus stress
- finklestein test
- phalen’s test
- tinel’s test
Finkelstein’s test
- tuck thumb under fingers by making a fist
- ulnar deviate wrist
- positive test increased pain all over radial styloid process and length of extensor pollicis breves and abductor pollicis longus
- implication of dequervians syndrome
Phalen’s test
- examiner applies overpressure during passive wrist flexion and holds for 1 min
- positive test tingling in distribution of median nerve
- implications median nerve compression
Tinels test
- examiner taps nerve over wrist
- positive test tingling distribution of median nerve
- implications median nerve compression
Functional anatomy of ankle: bone stability
- tibia (medial malleolus)
- fibula (lateral malleolus)
- talus - main weight bearing bone
Label the ankle
A - subtalar joint
B - calcaneus
Label the ankle
A - tibia
B - fibula
C - talus
D - talocrural joint
Functional anatomy of ankle: articulations
- talocrural joint (hinge - plantar/dorsi)
- subtalar joint (gliding - inversion/eversion)
Movements of ankle
Dorsi flexion 20 degrees
Plantar flexion 30-50
Eversion 0-35
Inversion 0-35
Pronation 15-30
Supination 45-60
Label the ligaments and name their function
A - posterior talofibular
B - calcaneofibular
C - anterior talofibular
Resist inversion
Label the ligaments and name their function
Deltoid, resist eversion
Functional anatomy of the ankle: muscles
- weakest aspect of ankle stability
- 3 peroneal muscles: longus, breves, tertius
- these resist inversion
Inversion ankle sprain mechanism
- most common
- sports with running, jumping, landing
- fibula causes a longer lever arm on lateral side of ankle
- vertical load on uneven surfaces
- tight Achilles’ tendon
- weak peroneal muscles
Ethology of inversion ankle sprain
- combo of plantar and excessive supination when foot contacts the ground
- common changing directions quickly
- fast injury mechanism— muscles cannot contract to control the excessive supination
- ligaments become the only absorbers
- ATFL is primary lateral stabilizer and is most commonly damaged
- CFL can be damages
- PTFL injured in severe injuries
Label the ligaments
A - deltoid
B - calcaneofibular ligament
C - posterior talofibular ligament
- sitar posterior tibiofibular ligament
Signs and symptoms of inversion ankle sprain
First:
- pain and swelling anterolateral aspect of lateral malleolus
- point tenderness over ATFL, no laxity with stress test
Second:
- tearing or popping felt on lateral side
- pain and swelling on anterolateral and inferior aspects of lateral malleolus
- painful palpitation over ATFL and CFL: may be tender over PTFL and deltoid ligament
- positive anterior drawers and Tamar tilt
Third:
- tearing and popping sensation felt on lateral aspect
- diffuse swelling
- painful or no pain
- positive drawer and tilt
Eversion/medial ankle sprain mechanism
- rare
- strong deltoid ligament
- may be associated with avulsion fracture
- lateral malleolus can fracture
- deltoid ligament can avulsion the medial malleolus
- distal tibiofibular joint can be disrupted
Grades of ankle sprains
Grade I - mild
- a stretch of the involved ligament
GRade II - moderate
- a partial tear of the ligament with part of the ligament remaining intact
- joint suffers minimal instability
Grade II - severe
- a complete tear of the involved ligament
- ligament may separate completely from the bone and the joint will lose stability
High ankle sprain (syndesmotic)
- damage to ligaments holding tibia and fibula together
- more common than eversion ankle sprains
- most debilitation of any sprains in the foot and ankle
High ankle sprain mechanism
- dorsifelxion and pronation most common
- foot is planted fixed on the ground with internal rotation of the tibia
- fibula separated from the tibia disrupting the distal tibiofibular ligament
- cutting and pivoting sports
- longer to heal than lower ankle sprain — 6-8 weeks
Observation of ankle
- postural deviations
- valgum or varum
- difficulty walking
- deformities, asymmetries, or swelling
- skin condition
- pain
- ROM
Palpitation of bony anatomy in ankle
- fibular head and shaft
- lateral malleolus
- tibial plateau
- tibial shaft
- medial malleolus
- Tamar dome
- calcaneus
Palpitation of soft tissue anatomy in ankle
- peroneus longus, brevis, tertius
- flexor digitorum longus
- flexor hallucis
- tibialis posterior
- tibialis anterior
- extensor hallucis longus
- extensor digitorum longus
- gastrocnemius
- soleus
- Achilles’ tendon
Fracture test of ankle
Potts compression (squeeze test)
Percussion or bump test (malleolus fracture)
Joint stability test of ankle
Anterior drawer test
- determine damage to anterior talofibular ligament primarily
Tamar tilt test
- ATFL, CFL, PTFL
- determine extent of inversion or eversion injury
Kleiger’s test (external rotation)
- to determine the extent of damage to the deltoid ligament
- syndesmosis
Other special tests for the ankle
Thompson’s test:
- detects Achilles’ tendon rupture
- positive is no movement in the foot
Syndesmotic sprain
- squeeze tibia and fibula together
- positive if pain
Tap test (tinels test)
- possible tarsal tunnel syndrome
Mortons test
- Morton’s neuroma
- squeeze metatarsals together
- positive if pain
Movements of the hip
Flexion/extension
Abduction/adduction
Internal/external rotation
Joints of the hip
A - sacroiliac joint
B - iliofemoral joint
C - L5/S1 joint
Muscles of the hip flexors
A - psoas minor
B - illiacus
C - psoas major
Label the muscles and what movement they produce
A - pectineus
B - adductor longus
C - gracilis
D - adductor brevis
E - adductor magnus
Label the muscles
A - gluteus Maximus
B - illiotibial tract
C - gluteus medius
Label the muscles of the posterior thigh
Left to right:
Bicep femoral
Semitendinosus
Semimembranosus
Label the ligaments
A - pubofemoral ligament
B - iliofemoral ligament (superior and inferior bands)
C - iliofemoral ligament
D - ischiofemoral ligament
Palpitation of the hip
Supine:
- anterior superior iliac spine
- iliac crest
- quads
- groin (muscles, lymph swelling, femoral pulse)
Prone:
- hamstrings
- ischial tuberosity
- posterior superior iliac spine
Side:
- gluteus Maximus
- greater trocanter
Acute injuries of hip
Fractures:
- femur, pelvis
Immature hip:
- epiphyseal plate fractures
- slipped femoral head
Dislocation
Strained
Contusions
Hip larval tear
- hip labrum — fibrous ring of cartilage around hip socket
- deep groin pain
Stress fracture of hip
- neck of femur
- deep tenderness of anterior hip
Osteitis pubis
- repetitive running/jumping, shearing movements
- inflammation and gradual onset of localized pain around pubis symphysis
Sport hernia
- strain or tear of any soft tissue in lower abdomen or groin area
- severe pain in groin
Piriformis syndrome
- tight piriformis irritates sciatic nerve
- overactive hip flexors and weak gluteals
- may include gluteal and radiating pain from sciatic compression
Illiotibial band syndrome
- repetitive running
- tenderness on lateral knee; weak hip adductors
- treatment — rices, assessment, gradual RTA
Label the anterior compartment muscles
A - extensor digitorum longus
B - tibialis anterior
C - extensor hallucis longus
Deep posterior compartment artery and nerve
Posterior tibial artery
Tibial nerve
Lateral compartment artery and nerve
Peroneal artery
Superficial peroneal nerve
Tendond of the lower limb
Posterior tibial tendon
Quadriceps tendon
Achilles’ tendon
Common injuries of lower leg
Stress fractures
Strains
Sprains
Tendinopathy
Strain and sprains of leg
Muscle spasm:
- check fluid and electrolyte intake
- Achilles’ tendon strain: forceful contractions
- rupture tear of muscle resulting in palpable mass
- sprained ankle
Achilles tendinopathy
- common in distance runners
- thickening surrounding tissue
- tenderness with palpitation, pain with activity, swelling, creputation, stiffness especially with dorsiflexion
Exertional compartment syndrome
- exercised induced pain and swelling that is relieved by rest
- increased tissue pressure
- compromised muscles, nerves, blood vessels within the space and signal to compartment
- anterior and deep posterior most common
- can result in neurological disability
Shin splints
S/S:
- pain on border of tibia
- increases with weight bearing or pressure
Leading to:
- periostitis
- stress fracture
- anterior compartment syndrome
- stress fracture
Prevention:
- check shoes and arches
- check training load and playing surfaces
- chec flexibility/strength or lower leg muscles
Bone stress injury
Load applied to the bone exceeds bone’s ability to manage this load
- bone is unable to remodel to remodel sufficiently and a stress reaction develops
- often Rene in running and jumping activities
5th metatarsal fracture
- styloid process
- common area for injury
Sand toe
Hyper planter flexion of big toe
Commonly seen in beach volleyball
Turf toe
Excessive upward bending of MTP joint
Repeated motions of running or jumping
Plantar fasciitis
- chronic inflammation of plantar fascia
- pain with initial weight bearing
- point tenderness at clacaneal portion
Mortons neuroma
- pinched/squeezed nerve that passes between metatarsals
- affect the ball of foot
- feels like standing on a pebble in your shoe
Foot conditions
- bunion (hallux valgus)
- corn
- ingrown toenail
- hammer toe
Label the toe deformities
A - hammer toe
B - claw toe
C - mallet toe
Typical tissue healing time frames
Movements at the knee
Flexion/extension
Internal/external rotation when knee is flexed
Joints of the knee
Patellofemoral
Tibiofibular
Tibiofemoral
Name a test that can be used to detect a bicep rupture
Ludington test
Avascular necrosis
Death of a bone tissue due to lack of blood supply
What is the main structural cause of medial epicondylitis
Damage to tendons that bend the wrist toward the palm
What anatomical structures and hormonal differences of female athletes put them more at risk of ACL injuries than male athletes?
-ligament laxity from hormonal fluctuations in the menstral cycle
Which group of athletes are most prone to athletic pubalgia?
Men under the age of 40
What population is more at risk for suffering heat stroke?
- people 65 years of age or older
- infant and children up to 4 years of age
-people who are overweight
- people who are on medications
- people who are working in hot environments
What is a test you can use to diagnose patellofemoral pain syndrome?
Patellar grind test
What is the main muscle where shin splints occur?
Tibialis anterior
