IRAT 1 Flashcards
Shoulder complaints are classified most commonly into
Sports injuries
Wear and tear repetitive stress injuries
Traumas
Certain arthridities
In the case of trauma, what damage must be suspected
Fracture Dislocation Tendon Labrum Ligament
The shoulder can also be the sight of pain from referred
Cervical spine or thoracic spine injury or subluxation and/or from visceral sources such as heart, lung, diaphragm, or gallbladder
Less common sources of shoulder pain might be from
Tumors or infection and peripheral nerve entrapments
The most common presentation of soulder complaints include
Instability - trauma/non-truama
Impingement: tendons, bursae, ligament
Tendinitis/bursitis
Osteoarthritis
Adhesive capsulitis (frozen shoulder) - esp age 40-60ish
AC joint separations (look at ligament derangement)
C/spine referred pain patterns
Arthritidies that commonly affect the shoulder are
AS and rheumatoid
In severe cases of arthritidies of the sohoulder, the ___ can rupture
Supraspinatus tendon
In seniors, ___ is common and so is ____.
OA
Adhesive capsulitis
OA can also appear in younger populations following
Truama
Always take a thorough history so as to establish
Quality of the complaint Site Trauma MOI Activities of patient ROM Past injuries Weakness Instability Sensory loss High or low-end user
High end user
Athlete
Low-end user
Sedentery office worker
Pain localization anterior traumatic
Fracture, dislocation, sub-ac bursitis, capsular spriain, tendon rupture (long head of biceps), labrum tear
Non-traumatic pain locatlization
Impingement, biceps tendinitis, sub-ac bursitis, subscapularis tendonitis, subluxation, etc
Trauma
Look for dislocation/separation and fracture.
Typical types or presentaions of trauma are
Blows (contusion)
Falls (AC separation, clavicle fractures)
FOOSA/H injuries (AC separation, dilocation, and labrum tears)
Traction of the arm (brachial plexus injuries, subluxation)
Sudden pain when lifting heavy object (tendon rupture, labrum tear
Blows
Contusions
Falls
AC separation, clavicle fractures
FOOSA/H injuries
AC separation, dislocation, labrum tears, rotator cuff tears
Arm forced into certain positions and jammed or wrenched
Dislocation and labrum tears
Traction on the arm
Brachial plexus injuries, subluxation
Sudden pain when lifting heavy object
Tendon rupture, labrum tear
Pain
Acute or chronic
Acute pain without trauma may indicate
Burisitis if ROM is decreased
Chrnoic pain without trauma
Adhesive capsulitis
Weakness or instability is highly suggestive of
Un-rehabilitated capsular ligament injury and can lead to concomitant damage to the labrum
Nerve damage will show
Evident atrophy of the associated muscle.
Brachial plexus controsl
Upper extremity and subluxation or nerve root damage will result in weakness
With weakness might also be possibility of
Inherent shoulder capsule weakness which is usually bilateral and can be determined with orthopedic testing
Stiffness and restriction must be assessed initially with
Thorough history
Acute pain without any recent trauma that lasts for weeks before eventually becoming stiff is likely to be
Adhesive capsulitis
Post-traumatic pain will lead to other obvious conclusions such as
Dislocation or separation
History of trauma and/or surgery with resultant pain/restriction leads to
OA
Restriction due to pain and weakenss is likely caused by
Bone blockage or labrum pathology
Overuse or trauma to a muscle can lead to
Scar tissue and restriction in the direction of stretch
Painful arc is considered to be
Between 70-110 degrees
X-ray is generally filmed based on
Suspected underlying condition
Most common x-ray for shoulder
AP
Utilized for AC spot shot and osteolysis of the distal clavicle
Zanca or Z view (15 degrees cephalad)
View for Bankart lesion (glenoid lip avulsions associated with labrum teras)
West Point view
view for a Hill-Sachs lesion also a labrum tear findings
Stryker-notch
Used as a tool when patients are not responding to conservative care and can be helpful in discerning labrum tears, but not entirely reliable
MRI
Views used for labrum tears and rotator cuff tears and tend to be the imaging methods of choice
CT and CT arhtrogram
Used to determine full-thickness rotator cuff tears
US
If AS rheumatoid or other arthitides are suspected based on plain film
Lab exams for HLAB27 and rheumatoid factor may be ordered but appropriate referral to rheumatologist is suggested
If x-ray reveals infeciton, fracture or tumor
Referral to orthopedic specialist
If patient is unable to tolerate an un-medicated course of care and treatment, then
Referral out is necessary
PT is beneficial in causes of
Acute pain
Therapeutic rehab might consist of
PNF stretching, cross friction massage, myofscial release, isometrics, stabilization (strapping/taping) and strenghtening
Stability and technique must be strong considerations to adjustments to
Shoulder and upper extremity kinetic chair
The shoulder joint type
Ball and socket joint
Shoulder joint complex
Articulation of the humerus and the glenoid fossa of the scapula
4 joints in shoulder joint complex
Gleno-humeral
Acromio-clavicular
Sterno-clavicular
Scapulo-thoracic
Nerve supply shoulder joint complex
Fifth through seventh cervical nerve roots via its formation into the brachial plexus.
On the lateral aspect of the shoulder, the skin is innervated by a cutaneous branch of the axillary nerve
ROM shoulder
Ext rotation 108
Int rotation 72
With the arm at 90 of abduction, total rotational arc is 120
Primary muscles in shoulder joint complex
Trapezius Levator scapulae Rhomboid major and minor Serratus anterior Deltoid provides shearing force, pushing humerus upward on the glenoid labrum at abduction
Rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Protector muscles helping compress the humeral head into the glenoid
Impingement syndrome
Typical signs and symptoms
***Pain with overhead activites
Medial AC joint osteophyte formation commonly associated
Impingement Syndrome
Anatomy/structures involved
Biceps tendon Superior labrum Supraspinatus tendon Subacromial bursa Above all antero-lateral type
Subscapularis
Subcoracoid
Infraspinatus or teres minor
Posterior impingement type above
Impingement syndrome
Causes/etiology
***Over use
Degenerative changes
Inflammatory processes
Variant structure
Impingement syndrome co-exists with
Instability and excessive superior movement of the humeral head
Impingement evaluation
***Hawkins-Kennedy and Neer test for impingmeent assessment
***Relocation test for underlying accompanying instability
Impingement sign to rule in tendinitis or supra-spinatus overuse injuries
Hawkins-Kennedy test
Supraspinatus tendon jammed up against the anterior surface of the coraco-acromial ligament due to the narrowing of the subacromial space. Posterior pain implicates stretch of the teres minor and infraspinatus tendons
Indicates: local pain indicates supraspinatus tendinitis and impingement
Anterior pain = anterior impingement syndrome
Posterior pain = posterior impingement syndrome
Neer test
End range pain causes the greater tuberosity to jam up against the anterior inferior border of the acromion
Indicates impingement with overuse injury of the supraspinatus muscle or biceps tendon
Instability tests
Anterior apprehension with relocation
Jobe relocation test confirms the
Anterior instability of the GH joint
Painful arc test
Pain between 70-110 degrees is impingement syndrome with supraspinatus pathology
Pain worse with 160 or above is AC joint involvement
Shoulder impingement management protocols/goals
Care plan based on severity of symptoms - acute vs sub-acute vs chronic
Stability, progressive rehabilitation, stretching and strenghtening and modification of activity
Open chain v closed chain exercise, proprioceptive training
Chiro spinal adjustments
Chiro extremity adjustments
Modalitis - cryotherapy
2 week out assessment
Re-exam and re-eval
Prognosis/outcomes assessment
Traumatic instability
Presentation/signs/symptoms
***past history of shoulder dislocation
*** pain/weakness when arm placed overhead or in apprehension position of 90 degrees flexion coupled with external rotation and horizontal extension
Traumatic instability
Anatomy/structures involved
Gleno-humeral joint dislocation causes damage to the glenoid labrum and the humerus itself. The glenoid capsule will also incur damage along with teh intrinsic ligaments (coracohumeral and coracoacromial)
Traumatic instability
Pathophysiology/etiology
Acute/subacute anterior dislocation of the GH joint in 90-95% of cases. Posterior instability can be found in patient who chronically dislocate or those who suffer seizures
Clavicular fractures, muscle contusions and direct blows to the base of the neck can also be included as trauma
Traumatic instability evaluation
Apprehension test and it’s variants
** sulcus sign with L &S test
SUlcus sign with L & S test
A sulcus that appears on teh antero-lateral aspect indicates shoulder instability that is graded
\+1 = 1 cm \+2 = 1-2 cm \+3 = >3 cm
Labrum tears
Presentation
Presents with reported painful clunking and locking with specific movments. Loss of strength, decreased ROM and pain at night.
Sense of instability in the shoulder
Labrum tears
Anatomy and structures involved
Soft fibrous rim surrounding the head of the humerus where it articulates with the glenoid fossa. Stabilizes the joint and deepens the rim to add extra support. Important attachment site for several ligaments.
Labrum tears
Cause/etiology
**SLAP lesion
Acute trauma, blow or fall on outstretched arm. Sudden pulls such as lifting heavy object. Repetitisve motions such as weight lifting or throwing
**tears of the rim below the middle of the glenoid socket involving the inferior GH ligament are called Bankart lesions
***tears of the labrum often accompanying dislocation
SLAP lesions
Superior labrum anterior to posterior tear above the middle of the socket that involves the biceps tendon in some cases
Bankart lesions
Tears of the rim below the middle of the glenoid socket involving the inferior GH ligament
Tears of the labrum often accompany
Dislcoation
Labrum tears
Evaluation
Clunk test, O’Brien sign, anterior slide test and biceps load test to rule in a labrum tear
Rule out dislocation using apprehension, dugas tests
Speed, abbotts saunder and yergason tests to confirm any bicep tendon tears that might accompany a labrum tear. Can do apley adn codman if tolerable to R/O rotator cuff teras
Assess both spinal and extremities
Medical assessment for labrum tears includes
MRI
CT
Arhtroscopic surgery
Glenoid LAbrum testing
***O’Brien sign
O’Brien, anterior slide test for pain or determine snapping or clunking felt in the joint
O’Brien Sign
Pain deep in the joint indicates labrum tear. Pain felt superficially indicates AC joint issue
Anterior slide test
Popping, cracking, and crepitus is noticed with pain on the antero-superior aspect of the shoulder = superior or anterior glenoid labrum tear
Labrum tears management
Referral to an orthopaedic surgeon for assessment - most severe tears will require surgery for repair especially if the biceps tendon is involved.
Small tears will respond to conservative treatment including rest (sling), rehab, strengthening and mobilization after acute pain subsides.
Chiro adjustments to restore functional proprioception and alignment
Traumatic instability management protocols/goals
Initial/intermediate/advanced Stabilize/rehabilitation/strengthen Chiro adjustments Chiro extremity adjustments Open v closed chain exercises Cryotherapy 2 week out assessment Re-exam/re-eval Prognosis/outcome assessments Lifestyle modifications
Non-traumatic instability/looseness
Signs/symptoms and presentations
***usually asymptomatic. Pain is felt when there is sudden traction or pulling on the arm. Supporting the arm provides relief.
***Patient reports fatigue and discomfort when working overhead rather than actual pain
Non-traumatic instability/looseness
Anatomy and structures involved
Inherent looseness in the shoulder capsule - born that way
Non-traumatic instability/looseness
Etiology
Patients asymptomatic unless distraction force subluxates the shoulder. Aggravated by sports/activity that continuously stretches the capsule.
Ex: swimming or throwing
Non-traumatic instability/looseness
Evaluation/assessment
L&S tests*** most appropriate and practical
- **apprehension test if accompanied by impingement
- **pain is reduced by the relocation test (jobe test) where an AP force is placed on the proximal humerus as the arm is abducted and ext. rotated
Non-traumatic instability/looseness management
Strengthening rotator cuff and serratus anterior for stability. Taping can help
Adhesive capsulitis
Frozen shoulder
Adhesive capsulitis
Signs/symptoms and presentations
Usually over 40 years of age
Adhesive capsulitis
Acute phase
Moderate to severe pain that limits all shoulder use, pain when sleeping or with minimum activity
Adhesive capsulitis
Middle phase
Possible past history of acute phase 1-3 months prior, pain has decreased but discomfort and restricted motion persists when liftin garm or turning out
Adhesive capsultiits
Final phase
Very slow increase in ROM but still significantly reduced
Adhesive capsulitis
Anatomy and structures involved
Inflammation and swelling of the shoulder capsule
Adhesions develop which stiffen the jhoint
Synovial fluid decreases and joint lubrication is hampered
Adhesive capsulitis
Cause/etiology
The cause remains unkown
More common in patients with diabetes, thyroid pathologies, and COPD.
The acute phase is inflammatory in nature leading to a stiffening stage and finally a thawing phase months or years later. In stage 3, some ROM is restored.
Adhesive capsulitis
Evaluation/assessment
Positive mazion shoulder maneuver - most pts present in the stiffening phase or stage 2***
***restriction and pain are reliable indicators especially in abduction and ext. rotation. Muscle tests are strong within the range the patient can tolerate
Confirmatory test is improvement in motion following reciprocal contraction or rhythmic stabilization.
If the patient does not improve at all, a bony blockage is suspected due to possible OA.
Mazion shoulder maneuver
Adhesive capsulitis
Inabiilty to actively raise the elbow to the forehead due to pain and of stiffness indicates early adhesive capsulitis or non-inflammatory capsular adhesions
Adhesive capsulitis management
Cryotherapy
Extremity adjustment to improve ROM (later stages)
Modalitis - E-Stim and TENS. US in stiffening stage
Rhythmic stabilization
TENS
Transcutaneous electrical nerve stimulation
Rhythmic stabilization
Passive nad active therapy with contraction and ROM while alternating patterns
Rotator cuff tears
Presentation
Typically following an **acute trauma such as heavy lifting, a fall or high impact injury. Older patients might not recall an event. *pain and or weakness is experienced while *lifting the arm or performing overhead activities
Rotator cuff tears
Anatomy/structures involved
Most commonly associated with tears of the supraspinatus articular and bursal sided tears are generally involved, while the articular type are more frequently partial
Rotator cuff tears
Cause/etiology
Trauma, can occur secondary to chronic degenerative changes in the tendinous attachments
Rotator cuff tears
Evaluation/assessment
Supraspinatus: weakness with empty can test or codman’s drop arm (unabl eto perform) and a positive apley test
Subscapularis: lift-off test weakness. Radiograph: superior head migration on AP view
EMpty can test
Resistance to the abduction and downward pressure stresses the supraspinatus muscle and tendon insertion, indicates tear or rupture of the supraspinatus muscle or tendon with possible suprascapular neuropathy
Rotator cuff tears management
Rehab gradually with isometrics then progressing ot strengthening. Rotator-cuff full thickness tears might need surgical repair
AC joint separation
Presentation
Taruma/fall/high impact injury on an outstretched arm or on top of the shoulder type onset. Very common in atheltes such as football or rugby players. Pain, tenderness and swelling over the AC joint.
AC joint separation
Anatomy/structures involved
Grade 1
Some tearing of the acromio-clavicular ligament without instability.
AC joitn separation
Anatomy
Grade 2
Rupture of AC ligmaent
AC joint separtion
Anatomy
Grade 3
Torn AC ligament with a tear of the coraco-clavicular (conoid and trapezoid) ligament. Both grade 2 and 3 are considered unstable
AC joint separation
Anatomy
Grade 4
The clavicle is pushed posterior to the AC joint, fairly unusual in presentation
AC joint separation
Grade 5
This is an exaggerated grade 3 with the muscles above the AC joint punctured by the clavicle causing a significant bump over the injury site
Grade 6 AC joint separation
Fairly rare, this type of injury sees the clavicle pushed or forced interior where is becomes lodged below the corocoid
AC joint separation
Etiology/cause
Trauma/fall/high impact sports injury that tears partially or completely the AC or coraco-clavicular ligaments
AC joint separation
Evaluation/assessment
** positive o’brien sign
X-ray to rule out distal clavicular fracture and determine severity of injury. More than 1.3cm** widening of hte coraco-clavicular space would indicate a grade 3 separation
Weighted and non-weighted bilateral views would be ordered
AC joint separation managment
Support with kinney-howard sling for short period. Mild isometrics followed by isotonics. Emphasis on deltoid and upper trap exercises incorporating biceps and pectoral exercises to restore near proper function.
Taping and support would be recommended for future sports activity
Chiro adjustments to assist in functional proprioception
Osteolysis of distal clavicle
Presentation
Can be secondary to AC trauma or heavy weight lifting regimens. Typically a weight lifter will present with diffuse pain felt while bench-pressing. Clean and jerking or dipping. Pain on shoulder abduction beyond 90 degrees.
Osteolysis of the distal clavicle
Anatomy/structures involved
Distal end of the clavicle
Osteolysis of the distal clavicle
Cause/etiology
Trauma/repetititive compression forces and heavy lifting that cause resorption of the distal end of the clavicle
Osteolysis of distal clavicle
Evaluation/assessment
Zanca view*** or AC spot shot looking for increased widening of the joint space and resorption. Most orthopedic tests are unremarkable. History is crucial to help rule out differential diagnosis
Osteolysis of the distal clavicle managment
Modification of exercises with some rest recommended
Chiro spinal and extremity evaluation
Acute calcific bursitis and tendinitis
Presentation
***severe shoulder pain increasing with any shoulder movement. Patients have a supportive posture holding the arm to their sides to avoid movement
Acute calcific bursitis and tendinitis
Anatomy/structures involved
Bursae include: subacromial, sub-deltoid and sub-scapular.
All shoulde tendinous attachments of the can be involved.
Acute calcific bursitis and tendinitis
Cause/etiology
Following trauma or of insidious onset**. Bursitis pain occurs often due to a resorption of calcium deposition. This is typically an inflammatory phase and is very painful. Direct rtrauma or injury assocaited iwth cuff rupture is considered another common cause.
Acute calcific burtsitis and tendinistis evaluation/assessment
All active and passive movement is painful. **dawbarn test will determine a sub-acromial bursitis
**abbott saunders, speed and yegason tests are all positive for bicipital tendinitis
**apley test will determine degenrative tendinitis while the impingement sign will assist in assessing overuse injuries to the bicveps tendon. Deep palpation is often sufficient to elicit a response.
**Patte test (hornblower sign) will be positive for infraspinatus or teres minor tendinopathy. Lift off test will be positive for subscapularis tendinopathy.
X-rays following trauma
Patte test (hornblower sign
Pain and inability to actively externally rotate against resistance due to weakness indicates infraspinatus or teres minor tendinopathy
Lift off test
Inability to actively lift the hand off or away from the back indicates subscapularis tenddinopathy
Acute calcific bursitis and tendinitis managemnet
Pulsed US to resorb calcific depostis for short term therapy can be considered.
Chiro spinal and extremity adjustments to assist with recuperative healing and functional proprioception.
In acute and inflammatory stages, referral to a medical practitioner is recommended due to severe pain.
Cryotherapy is recommended to reduce swelling and manage pain.
Little leaguer’s shoulder
Presentation
Young, 12-15 yo male baseball pitchers***
Pain felt when throwing hard and comes on gradually - sometimes up to as long as 7 months before diagnosis
Little leaguer’s shoudler
Anatomy/structures involved
**prosimal humerus pain and tenderness
Triangular metaphyseal avulsion fracture (salter-harris type 2)
Little leaguer’s shouder
Etiology/cause
Excessive rotational stresses on the growth plate of the proximal humerus from pitchers who **overptich or pitch too frequently. (Salter-harris type 1). Type 2 is less common
Little leaguer’s shoulder evaluation
Swelling/loss of ROM
***weakness on ext rotation and positive empty-can test (thumbs down abduction
X-ray shows widening of the proximal humeral physis with sclerosis of the proximal humeral metaphysis.
Little leaguer’s shoulder management
Rest
Rehabilitation with EASY throwing and pain as the limiting factor
4 types of passive end-range or end-feels (provocation) as described by Cyriax
Soft
Muscular
Bone-on-bone or cartilaginous
Capsular
Soft type of passive end-range or end-feels
Bicep to forearm
Muscular type of passive end-range or end-feels
Hamstring stretch
Bone-on-bone or cartilagenous
Elbow extension
Capsular
Hip rotation (capsular stretch)
Abnormal end-feels include
Spasm
Springy or rebound
Empty
Loose
Spasm
Pain prevents full ROM
Springy or rebound
Mechanical blockage such as labrum or meniscus
Empty
Acute pain such as bursitis preventing movement to end-range
Loose
Capsular or ligamentous damage seen with grades of sprain
Timing of onset
acute, subacute and chronic (passive provocation)
Acute time of onset
Pain felt before end range. Therapy required
Subacute timing of onset
Pain at the same time as end-range. Stretch and mobilize
Chronic timing of onset
Pain felt after end-range. Stretch and adjust/manipulate
When a joint is not free to move, the muscles that move it
Are not free to move
Muscles cannot be restored to normal if the joint which they move
Is not free to move
Normal muscle function is dependent on
Normal joint movement
Impaired muscle function perpetuates and may cause
Deterioration in abnormal joints
Isometric
No lengthening or shortening of muscle at all. For example, shoulder flexion as when you hold an object out in front of you
Isotonic
Also called concentric by some sources. Here the muscle shortens - origin to insertion. The best example is biceps curl. Other examples include anterior deltoid shortening when lifting an object overhead.
Isokinetic
The muscle shortens and gains tension through a motion at a constant speed such as a swimming stroke
Eccentric
Here the muscle lengthens as when you place an object down or walk downshill - the quads flex and lengthen during heel strike
Passive stretch
This is also lengthening however done in a passive state such as lying on your back and having a hamstring stretch performed on you
Agonist muscles
Called prime movers, they cause movement to occur. They create a normal ROM in a joint by contracting.
Antagonist
Acts in opposition to the agonist and returns the limb to it’s initial position - it can be an extensor or a flexor
Examples of agonists and antagonists are
Biceps flexion - tricep extension
Pec major/trap - rhomboid
Deltoid flexion - latissimus dorsi
PNF techniques
Rhythmic initiation Hold relax Contract relax Rhythmic stabilization Repeated contractions Slow reversals
The one exception to active motion in PNF
Rhythmic initiation
Progression used for those who are very weak or unable to initiate a motion
Rhythmic initiation
Rhythmic motion through a desired ROM beginning with passive motion
Rhythmic initiation
Rhythmic initiation
Goals
Indications
Contraindications
Description of technique
Description of technique - rhythmic initiation
Therapist moves the patient passively through a desired ROM, using speed and verbal commands to cue movement
Patient is asked to move actively with therapist through ROM
Therapist then begins to apply resistance
Hold relax
Goals Indications Contraindications Description of technique Example
Description of technique
Patient actively contracts agonist in available ROM
Therapist provides resistance to an isometric contraction of the antagonist
Patient again actively contracts agonist to new available ROM
Example hold relax
Hamstring ROM (increase hip flexion)
Patient flexes hip using hip flexors, therapist resists a hamstring contraction, then redo
Contract relax
Goals
Indications
Contraindications
Description of technique
Description of technique contract relax
Active contraction of agonists to end of available ROM followed by concentric contraction of antagonists, then another active contraction of agonists to new available ROM
Rhythmic stabilization
Alternating isometric contraction against resistance, no motion intended
Therapist slowly increases resistance of agonist which patient resists until maximum, then slowly decrease add resistance in opposite direction
Repeated contractions description of technique
Therapist provides resistance of agonists during concentric contraction
No resistance is given to antagonists
Slow reversals
Therapist resists motion of agonist and antagonist through ROM in pattern
When to use PNF techniques
Increase ROM Increase initiation of ROM Increase strength Increase joint stability Increase relaxation
Increase ROM
Contract-relax
Hold-relax
Rhythmic initiation
Rhythmic stabilization
Increase initiation of ROM
Repeated contraction
Rhythmic initiation
Increase strength
Slow reversal
Repeated contractions
Rhythmic stabilization
Increase joint stability
Repeated contractions
Hold-relax
Increase relaxation
Hold relax
Contract relax
Diagonal patterns
Upper extremity = D1 and D2 flexino and extension
Lowe rextremity = D1 and D2 flexion and extension
Upper extremity D1 flexion starting position
Shoulder extension, abduction and int rotation; forearm pronation; wrist extension and ulnar deviation; finger extension
Upper extremity D1 flexion hand positions (for R side)
L hand in palm of patient had
R hand on distal anterior/medial arm
Upper extremity D1 flexion movements
Shoulder flexion, adduction, and int rotation; scapular elevation and abduction; forearm supination; wrist flexion and radial deviation; finger flexion
Upper extremity D1 extension - starting position
Shoulder flexion, adduction and external rotation; forearm supination; wrist flexion and radial deviation; finger flexion
D1 extension upper - hand positions (for R side)
L hand on distal, posterior/lateral arm, R hand on dorsal/ulnar aspect of hand/fingers
Upper extremity D1 extension movements
Shoulder extension, abduction and int rotation; scapular depression and adduction; forearm pronation; wrist extension and ulnar deviation; finger extension
Upper extremity D2 flexion - starting position
Shoulder extension, adduction and int rotation; forearm pronation; wrist flexion and ulnar deviation; finger flexion
Upper extremity D2 flexion hand positions for R side
L hand on dorsal aspect of hand, R hand on posterior arm
Upper extremity D2 flexion movements
Shoulder flexion, abduction and ext rotation; scapular elevation and adduction; forearm supination; wrist extension and radial deviation; finger extension
Upper extremity D2 extension starting position
Shoulder flexion, abduction and ext rotation; forearm supination; wrist extension and radial deviation; finger extension
Upper extremity D2 extension hand positions for R side
L hand around distal humerus, R hand in athlete’s palm
Upper extremity D2 extension movements
Shoulder extension, adduction and int rotation; scapular depression and abduction; forearm pronation; wrist flexion and ulnar deviation; finger flexion
Lower extremity D1 flexion starting position
Hip extension, abduction and int rotation; ankle plantarflexion; foot eversion; toe flexion
Lower extremity D1 flexion hand positions for R side
L hand on distal, anterior/medial thigh, R hand on medial dorsal aspect of foot
Lower extremity D1 flexion movements
Hip flexion, adduction and external rotation; ankle dorsiflexion; foot inversion; toe extension
Lower extremity D1 extension starting position
Hip flexion, adduction and external rotation; ankle dorsiflexion; foot inversion; toe extension
Lower extremity D1 extension hand positions for R side
L hand on distal, posterior/lateral thigh ,R hand on lateral plantar aspect of foot
Lower extremity D1 extension movements
Hip extension, abduction and internal rotation; anke plantargflexion; foot eversion; toe flexion
Lower extremity D2 flexion starting position
Hip extension, adduction and ext rotation; ankle plantarflexion; foot inversion; toe flexion
Lower extremity D2 flexion hand positions for R side
L hand on distal, anterior/lateral thigh, R hand on dorsal lateral aspect of foot
Lower extremity D2 flexion movements
Hip flexion, abduction and int rotation; ankle dorsiflexion; foot eversion; toe extension
Lower extremity D2 extension starting position
Hip flexion, abduction adn int rotation; ankle dorsiflexion; foot eversion; toe extension
Lower extremity D2 extension hand positions for R side
L hand on distal posterior/medial thigh, R hand on plantar medial aspect of foot
Lower extremity D2 extension movements
Hip extension, adduction and ext rotation; ankle plantarflexion; foot inversion; toe flexion
