SC modified side laying - SCP - CP - SH - LOC

SCP- Medial side of SC joint CP- Soft Pisiform of inferior hand SH- Support pt. head (C-spine) AND inferior knee behind scapula LOC- M-L (95%), A-P along line of clavicle (usually I-S) On female- use hand opposite side of joint (side) being adjusted to cover ( o )( o ). Dr. can place the forearm of the CP hand over pt's. hand to achieve LOC

Lab/Lecture/Ameripress and Powerpoint Notes for Midterm Flashcards by B Burr

Muscle Test for SC joint

Pec Major, Clavicular branch

-Dr. pulls out and away at 20-30 degree angle from pt.

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MC mislalignment of SC joint

Anterior/ Inferior/ Medial

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What is LOC for SC joint challenge?

Posterior/ Lateral/ Superior

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SC Supine- Same and Opposite side

SCP- Medial aspect of SC joint
CP- Soft pisiform (of inside or outside hand)
SH- Lateral side of head of humerus, gently tractioning P-I
LOC- M-L (95%), A-P along line of clavicle (usually I-S)

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SC modified side laying

SCP- Medial side of SC joint
CP- Soft Pisiform of inferior hand
SH- Support pt. head (C-spine) AND inferior knee behind scapula
LOC- M-L (95%), A-P along line of clavicle (usually I-S)

On female- use hand opposite side of joint (side) being adjusted to cover ( o )( o ). Dr. can place the forearm of the CP hand over pt’s. hand to achieve LOC

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Muscle test for AC joint

Corcobrachialis

-Dr. at head of table facing down. Pt. supine with humeral flexion to 30 degrees. Push arm towards ipsilateral ASIS.

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M/C misalignment of A/C joint

Superior

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A/C joint Supine Adjustment

SCP- 12-1” medical to AC joint (distal 1/3 of clavicle)
CP- End of thumb and 2nd digit middle phalanx
SH- supporting elbow
LOC- S-I

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A/C joint Seated web contact

SCP- 1/2-1” medial to AC joint
CP- Web of hand or 2nd MCP joint
SH- Outside hand grasping the flexed elbow jt. keeping the shoulder in same position as others. Varies from pt. to pt.
LOC- S-I

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AC seated Chiro-Chiro

SCP- 1/2-1” medial to AC joint
CP- dominant chiro index finger overlaps the other chiro index finger
SH- Supine with arm abducted, motion joint to find where it closes and bring the arm down 5-10 degrees this is the position for stabilization. Place pt’s elbow on doc’s shoulder
LOC- S-I

*Arms flared out!

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A/I Humerus relative muscle test

Anterior Deltoid and Teres Major

*Test both before considering adjusting either one

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A/I humerus Same Side/ opposite side

SCP- Olecranon of involved side and lateral GH joint
CP- Palms of the hands
SH- Bring GH joint back into nutral position
LOC- I-S, A-P, M-L

*Pt. elbow pressed against the chest to bring GH joint to tension. Take to the midline over Xiphoid process to clear labrum

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A/I Humerus seated adjustment

SCP- Olecranon of involved side
CP- Palms of hands with fingers interlocked (same side)
SH- Doc’s strenum against spine of scapula
LOC- M-l, A-P, I-S

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Posterior Humerus Web Contact (and knife edge)

SCP- Posterior Proximal aspect of humerus (distal to Gh joint)
CP- Web of inside hand
SH- Outside hand grasping the humerus above flexed elbow joint with humerus slightly abducted (no more than 30 degrees) and extended- DO NOT WING- Outside hand also applies slight long axis traction
LOC- P-A, I-S, M-L (Slightly- bend elbow to demonstrate slight M-L)

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Elbow Rules

Medial elbow listings where is the Doctor’s position?

Dr. stands medial to the patient’s arm

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Elbow Rules

Lateral elbow listings where is the Doctor’s position?

Dr. stands lateral to the patient’s arm

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Elbow Rules

For all ULNA listings what is the position of the patient’s forearm

For all RADIAL listings what is the position of the patient’s forearm

ULNA–> supinated

RADIAL –> pronated

Note for a PL or PM elbow listing, ALWAYS test ULNA first, therefore, wrist flexion is your set up. Also, before adjusting PL, try adjusting PM 2x with appropriate re-muscle testing.

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MC subluxation of the elbow

Posterior medial ulna

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Posterior Medial Ulna
(web contact or End of Thumb and 2nd Digit)

Proximal medial ulna approximately 1 inch distal to the medial epicondyle

Web of medial hand or end of thumb and 2nd digit DIP joint

Outside hand on lateral humerus

M-L, P-A, I-S

*** Must state, I would do this adjustment twice

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Posterior Lateral Ulna - 4 Finger contact

Proximal lateral ulna, approximately 1 inch distal to olecranon

Four finger tips of the lateral hand or end of thumb

Medial hand grabbing the medial arm, ensuring patient elbow is firmly stabilized against doctor forearm

L to M, P to A, I to S

*** Must state, I would do the PM adjustment twice before adjusting the PL Ulna

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Elbow -Radius-RMT

______ muscle test with wrist in ______

Triceps

Extension

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To differentiate between a posterior lateral (PL) and anterior medial (AM) radius, what RMT would your perform?

Brachioradialis

“Coffee drinking muscle”

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If Brachioradialis muscle test is strong, the listing will be ____

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If Brachioradialis muscle test is weak, the listing is

“Too early in the am, not enough coffee)

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PL- Radius - SCP - CP - SH - LOC

Proximal lateral radius , approx. 1/4 inch distal to radial head End of thumb against the proximal lateral radial head Medial hand grabbing the medial arm, assuring the patient's medial elbow is firmly stabilized against doctor's forearm. L to M, P to A, I to S

MC radius subluxation is _____

PL-Radius

For an AM-Radius listing the doctor will stand ________ to the patient arm and place CP in to the ____ ______ and _____ the patient hand during the set up.

Medial cubital fossa pronate

AM-Radius - SCP - CP - SH - LOC

Proximal anterior medial radial head End of thumb against the anterior medial radial head in the cubital fossa Outside hand grasping the lateral arm, ensuring the lateral elbow is firmly stabilized against the doctor's forearm M to L, A to P (elbow high, no tea pot) , I to S

What is the theory states that a muscle functioning across a misaligned joint will be inhibited by a reflex signal originating from mechanoreceptors surrounding that joint.

Mechanoreceptor Theory

Normally the G/H capsule contains .5-1.5 cc of fluid. How much fluid can the G/H capsule contain before seeing it?

30 cc

Trauma, if acute check for patient ______, joint ________, then _________.

patient safety joint stability subluxation/misalignment

_________ is probably responsible for most of the proprioception information for the upper extremity

Sternoclavicular joint

The elbow in closed packed position is in full ________

extension

Medial epicondylitis = golfers elbow typically from _____ ulna

Tennis elbow typically from a _____ Ulna

PL Ulna

List the dynamic stabilizers

Levator Scap (medial superior border) Pectoralis Minor (anterior border) Rhomboids (Major and Minor- medial border) Serratus Anterior (Lateral border) Trapezius (middle and lower mainly- superior medial border)

The compensatory stabilizers are

BICEPS and SUPRASPINATUS

Describe the shoulder sulcus sign?

inferior and anterior instability of GH joint.

Lack of joint play will cause dysfunction and _____

PAIN

After clearing the SC joint, AC joint, G/H joint, and biceps, next check ____________?

Scapulothoracic Articulation

The most common reason for re-injury is a

Failure to properly condition the healed tissues

The concept of extraspinal management within the Chiropractic paradigm must include integration of extraspinal areas to the spine. First one must consider the ___________ connection, then the _____________.

Neurological, muscles

If multiple extremities are subluxated, how do you determine which one to adjust?

Use the pain scale (adjust the extremity w/highest pain level)

What are benefits of bracing vs. using tape?

Brace can be washed No dermatitis from the brace (tape can cause contact dermatitis)

Forces of injury, position of joint, and time of episode fall under which category?

Safety Note that during the safety mgmt criteria, we must consider closely the MOI

A sprain with no separation is considered grade ____

The end of travel in a joint whereby the surfaces are at maximal congruency, the ligaments are taut, and no further movement in that direction of travel may result in

Dislocation/fracture

The most common subluxation for the SC joint is and what is the LOC

Inferior, anterior and medial LOC is Superior, Posterior and Lateral

Ligamentous disruption of _________ mm is a SC separation and the direction it most commonly separates is ______________ and _________________.

5, Anterior and Superior

AC Joint separation between Coracoid and Clavicle >1.3cm =

coracoclavicular ligament disruption

What can mimic carpal tunnel syndrome. Patient is tested by pronation against resistance; symptoms follow a median nerve distribution

Pronator teres syndrome

TMJ intra-articular involvement = synovitis and capsulitis with the focus on the disc which is considered displaced or degenerated. Studies show that ___to____% of all individuals will show some TMJ related symptom in their lifetime

85-90%

Based off Ameripress (BOAP) what is the innervation to musculature that suspends the scapulae?

Lower cervicals

BOAP: Trigger point pain between the scapula and upper trap/levator scap is evidence of ____ and symptomatic referred pain

dysfunction

BOAP TRUE or FALSE Scapular efficiency determines GHJ efficiency

true

BOAP The dynamic stabilizers of the shoulder are mostly _____ in contrast to the compensatory stabilizers, which are mostly _______

underused overused

BOAP Of the following two, which is a biomechanical responder and which serves as an intersection of forces with little force dissipation options Wrist Elbow

Wrist --> biomechanical responder Elbow --> intersection of forces with little force dissipation options

BOAP In the managment of an upper extremity (UE) DIRECT injury, for instance a contusion, what is the preferred modality?

Icing

BOAP Orthopedic tests provide ______ information for teh examining doctor

stability

BOAP Sulcus sign displays inferior and _____ instability of GH joint

BOAP The ______ tests of the shoulder are

Neer or Hawkins-Kennedy test

BOAP Crank test or empty can test are great indicators for ______ ______ tears

Rotator cuff

BOAP O'Brien sign or anterior slide test indicate _____ or ______ joint instability

Labrum or AC joint

BOAP Frozen shoulder----> Adhesive _______

Capsulitis

BOAP Postural Signs/Upper Cross Syndrome (UCS) Rounded Shoulders ='s

Shortened Pectoralis Critical thought: What would you do to lengthen the muscle?

BOAP Postural Signs/Upper Cross Syndrome (UCS) Forward head weight--> anterior head carriage ='s

A kyphotic upper thoracic spine

BOAP Postural Signs/Upper Cross Syndrome (UCS) Elevated Shoulders ='s (Shortened and Weak)

Shortened upper trap/levator scap | Weak lower and middle trap

BOAP Postural Signs/Upper Cross Syndrome (UCS) Winging of the scapulae indicates a ________ and what could you do to help correct this ?

Weak Serratus Anterior Use wall pushup, squeezing shoulder blades together, thus opening up the chest and diaphragm

BOAP When managing the UE, the soft tissue involvement should be categorized into _____ or ______

Acute or Chronic

BOAP What are the 3 S's for Chiropractic Extremity Management

Safety Stability Subluxation

BOAP As it pertains to Safety what must we consider in management criteria "FD-PUP"

``` fracture dislocation pathology underlying condition pain tolerance ```

BOAP Safety mechanism of injury (MOI) 3 considerations _______ involved, _______ of joint, and time of episode

Forces involved Position of joint Time of episode ( was it quick/slow/insidious/or gradual, or occurred over a long period of time)

BOAP Mgmt criteria for Stability Perform____ evaluation of injured area or area of pain Do we adjust sprains and strains? Do we adjsut grade III injuries? Why?

Orthopedic Yes No, bc tissue no longer is attached

BOAP Sensations transmitted from joints include ___ and _____

Pain and position

T or F Joints and muscles acting on joints have same nerve supply ? And this is based off what law?

True Hilton's Law The principle that the nerve supplying a joint also supplies both the muscles that move the joint and the skin covering the articular insertion of those muscles.

LAB Rules of Thumb _____ spine first Establish criteria for adjustment utilizing the _______

Clear 3 S's (safety, stabilization, subluxation/misalignment)

BOAP Regarding the safety criteria for UE adjusting, neurological involvement means there is _______ dysfunction

sensory

BOAP Regarding the stability criteria for UE adjusting, what two methods of evaluation can be used ?

ROM | Orthopedic tests

BOAP Regarding the subkuxation criteria for UE adjusting, we always start ______ and go _______

Proximal Distal

SC joint most common subluxation

AIM

During SC RMT, the arm is ______ rotated with the palm facing ____.

Internally rotated

During RMT in general you want to always ask the patient?

Do they have any problems in the respective area you are evaluating?

During the SC muscle test, the arm is extended forward and how many degrees with the table How many degrees is the arm brought down during the aforementioned RMT?

90 45

During RMT we are looking for joint lock, ________ or ________

compensation or recruitment

After completing a challenge what is the next step?

Redo RMT

When adjusting a SC joint what direction is the traction of the humerus during stabilization

Posterior and inferior

BOAP RMT for AC joint? How many degrees does this muscle flex the shoulder

Coracobrachialis 15-30 degrees

MC subluxation for Ac joint

Superior

As with the SC jint, the AC joint RMT has the arm extended forward with the _____ bent and the forearm is kept parallel to the chest. SH point is the _______

elbow Olecranon fossa

The challenge set up for an AC joint is similar to what Orthopedic test set up?

Dugas | involved side hand is rested on opposite shoulder, with elbow firmly against the chest

LOC for Ac joint and SCP

S to I | 1/2 inch or 1 medial to the AC joint (aka distal 1/3 of clavicle)

BOAP What are the various methods to evaluate for joint play? (5)

``` Motion (tests fo joint proper motion) Muscle testing (based on mechanoreceptor theory) MOI Symptoms X-rays ```

3 ways to adjust extraspinal area(s)

hands instrument (i.e. activator) mechanically assisted "drop"

What three ways does a SC compensate (Lab tidbit) What way does AC joint compensate?

SC: protraction, shoulder shrug, body roll AC: humeral abduction

When setting up for AC joint adjustment, how many degrees is attained for stabilization before impulse/thrust is delivered?

5-10 degrees

hydrodynamics are essential for Proper ______ Transport of _________ Removal of waste material form ______ surfaces

Lubrication Nutrients articular surfaces

BOAP AI Humerus Arm is extended 40-__ degrees to the table, per lab it is and is MC 95% of the time RMT is and if weak what RMT do we do next?

40-60 degrees, per lab its 45 degrees Anterior deltoid Teres MAJOR

What type of subluxation is the biceps tendon? and what direction is the sub-x in?

Soft tissue sub-x Lateral * Ask patient if they have any problems with shoulder or elbow*

BOAP ST Articulation Criteria __ of ___ must be met 1. 2. 3.

2 of 3 Apleys Inferior 1inch to 1.5 inch lower is + the lower side is the fixated side Scaption Less movement +, and the less moveable scapulae is the fixated one Internal rotation 70 degrees is normal the higher side of the two is the fixated side!

What does compensation look like while RMT Elbow baseline

Clenching of fist | Wrist rotates

If during examination, you are thinking the trauma is chronic yo must 1. Check for ____ joint______ 2. Then ______

1. Residual joint instability | 2. Then subluxation

A forgotten acute injury to extraspinal areas by patients lead to altered joint mechanics 1. 2.

1. Fixations | 2. Hypermobility

3 Reasons the body compoensates for injury

Abnormal stress upon normal structure i.e. pregnancy Normal stress upon abnormal structure i.e. spondylolisthesis, hemivertebra, scoliosis Normal stress upon normal structure that is NOT prepared t receive stress i.e. stepping off curb and twisting ankle

FYI: Five questions must be answered prior to extrasinal adjusting

1. is this chronic or acute 2. What tissues are damaged 3. What is severity of damage 4. Is there instability or restiction of motion 5. Is this pre or post surgical area

Ligaments _______ | Muscles ______

Sprain Strain

Grade 1 7- __ days NO _____ laxity NO residual ______

7 to 10 days No residual laxity No residual weakness

Grade 2 ______ deformation residual laxity ______ muscle tear

Plastic residual laxity present Partial muscle tear

Grade 3 | Complete ______ of structure --> complete tear

rupture

MC grade injuries seen in DCs office

grade 1 or MILD grade 2 Remember serious grade 2 and grade 3 legally require a referral OUT

Grade 3 injuries will heal without ____ and almost will never return to normal Stability and/or function

reconstruction

``` In CPP (closed pack position) End of travel in a joint Surface is at maximum______ Ligaments are ______ and ``` Further direction of travel in CPP leads to

congruency taut Fracture or dislocation

Loose or Open packed position (OPP) Position of travel of joint away from CPP Capsule and ligaments are _____ _______ Extreme movement in that direction of OPP leads to

NOT TAUT strain/sprain

Degenerative changes in joint (loss of normal joint mechanics) Produces _______, leading to fibrotic response aka _____ tissue Ultimately degenerative changes promote altered ______ ______

inflammation scar tissue joint mechanics

Initial healing 3 - __ days Regeneration 6 - __ weeks Remodeling __ months to ____ Years

3 to 10 6 to 8 weeks 6 months to 2+ years

Proper hydrodynamics occur during 1. 2. Intermittent ______ activity 3. Full ROM of ______ and capsule

Weight bearing Intermittent muscle activity Full ROM of joint and capsule "running is a good example"

How many degrees is the elbow bent for elbow baseline muscle test?

70 degrees

The GH joint capsule may contain up to 3o cc of lfuid, which is equivalent o about ____ oz

1 Note, you can not always see edema on average you the space contains 0.5 to 1.5 cc ( 0.02 to 0.05 ounces)

What is the osseous link to the GH joint?

SC joint elevation 4 to ____ degrees depression 5 ____ degrees Protraction and Retraction _____ degrees Rotation ____ to ___ degrees Adjusting SC-joint helps what 4 lung pathologies

60 15 15 30-50 Asthmatics, COPD, Emphysema, Bronchitis

Sc joint seperation in 3 directions 1. 2. 3. It does not move posterior due to _____, if it does you nede to call 911 as this could occlude ___ or ______ arteries, veins, or lung tissue MC seperation

superior, inferior, and anterior 1st and 2nd ribs are behind it carotid or jugular arteries Anterior and Superior Note, upon care if x-rayed, the post should be less than 5mm in height difference. If not better by 6 weeks REFER OUT

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