Lecture 3 - Rule outs

Question 1

list some general rule outs

Answer 1

• joint A/B
• fracture - tap, tuning, squeeze
• arthrological scan axam
• neurological scan exam - during myotomes / dermatomes
• circulation problems- BP etc.
• spinal problems - aching, burning sensation down limbs etc.
• visceral pathology

Question 2

examples of rule outs: IOS - IVD pathology

Answer 2

Rule out via forward flexion, rotation, side bending, straight leg raise
Refer to physician if you are unsure

Question 3

explain the james cyriax technique for functional testing

Answer 3

designed to test the joint motions

designed to tell you if contractile or inert structures are involved

Question 4

Pain at the extremes of movement indicate:

Answer 4

Painful structure is stretched

Painful structure is being compressed

Question 5

Painful arc indicates:

Answer 5

Impingement

Typically around 60-90 degrees

Question 6

functional testing general guidelines:

Answer 6

Test bilaterally

Uninjured side first

Most painful test last
Patient comfort
A, P, R vs. A, R, P

Testing influenced by history and observations

Support the injured site well during testing

Document referred pain as you test

Document radiating pain as you test

Ask location of pain throughout testing

Question 7

Referral of pain is a common occurrence in problems associated with the __ system

Answer 7

MSK

Question 8

The reference of pain is an indicator of the segment which is _____

Answer 8

dysfunctional - Don’t focus on just the areas of pain recognize the source of pain is likely a disfunction somewhere else

Question 9

example of functional testing: Pain in the C5 dermatome could arise from:

Answer 9

irritation around C5 nerve root

disc or facet involvement of C4,5

any muscle supplied by the C5 nerve root

any visceral structure having C5 connections

the shoulder joint – something could be impinging the nerve

Question 10

functional testing for contractile tissue refers to what components of a muscle?

Answer 10

Muscle belly

Tendon

Tendoperiosteal junction

Question 11

how can tension be applied to contractile structures?

Answer 11

A/P/R

Question 12

functional testing - inert tissue includes:

Answer 12

Joint capsules

Blood vessels

Skin

Fascia*

Ligaments

Meniscus

Dura mater

Nerve

Cartilage

Bursa

Question 13

how can tension be applied to inert structures?

Answer 13

Actively moving the joint

Stretching during passive movement

Sometimes tenderness may be elicited by pinching these structures

• fat pad
• anterior capsule of shoulder joint

Question 14

describe functional testing for active movements

Answer 14

Ask athlete to move the joint through as much ROM as possible

Compare ROM bilaterally

Each physiological movement for the joint is tested

Question 15

would are the possible results for active “free” movements?

Answer 15

Normal

Limited (hypomobile)

Excessive (hypermobile)

Question 16

what can active movements tell the therapist?

Answer 16

Active movements tell the therapist;

Athlete’s willingness to move the joint

Athlete’s active joint range

That the muscular strength can move the joint and body part

Painful or not

Trick motions

Joint surface degeneration

Question 17

what is the method for relaxed passive movements

Answer 17

The therapist lifts the limb through the full possible ROM

Measure or approximate the degrees of motion

Compare the range bilaterally

Each anatomical range of the joint is tested

The athlete must be relaxed

Be gentle

Do not force the joint when there is pain or spasm

Question 18

what should you record for passive movements

Answer 18

Record:

The range of motion in degrees

If there is pain during any part of the range

Describe the pain and it’s location during the movement

End feel

Question 19

what are the possible ranges for passive movement?

Answer 19

The range may be;

Normal

Limited (Hypomobile)

Excessive (Hypermobile)

Question 20

What two patterns of restriction can be present with passive movement?

Answer 20

Restriction can be in;

A capsular pattern

A non-capsular pattern

Question 21

what does end feel mean?

Answer 21

END-FEEL is the term used to describe the sensation imparted to the therapist’s hand at the extreme of the possible range

Question 22

what is the end-range sensation for soft tissue approximation?

Answer 22

The limiting factor of joint movement feels “soft” and pressure at the initial end of range of motion easily yields more range.

Question 23

what are the treatment guidelines for soft tissue approximation with regard to end-feel

Answer 23

Probably easily rehabilitated and full movement restoration will be rapid.

Question 24

what is the end-range sensation for capsular?

Answer 24

The initial end range of motion can be increased, but resistance is greater and the amount of range increase is smaller.

Question 25

what are the treatment guidelines for capsular end-feel?

Answer 25

The capsule can be stretched over a period of time, dependant on how firm the capsular end-feel is and the chronicity of symptoms.

Question 26

what is the end-range sensation for bone on bone

Answer 26

An abrupt end-feel occurs that does not yield more range from the initial end range when pressure is applied.

Question 27

what are the treatment guidelines for bone on bone end feel?

Answer 27

Small chance of increasing the present range of motion. Manipulation under anesthesia or surgical intervention most likely needed.

Question 28

what is the end-range sensation for a springy block?

Answer 28

When end range is reached, there is a rebound felt. Intra-articular meniscal displacement is usual cause.

Question 29

what are the treatment guidelines for a springy-block end feel?

Answer 29

Traction is the only alternative to allow the intra-articular block to move out of the path of movement.

Question 30

what is the end-range sensation for muscle spasm?

Answer 30

A rapid abrupt stop of movement with muscle tension is apparent. Spasm end-feel varies many times with range. Avoidable with increases in speed of movement.

Question 31

what are the treatment guidelines for muscle spasm end feel?

Answer 31

Spasm is secondary to irritation. Check muscle and joint structures. Treat for inflammation.

Question 32

what is the end-range sensation for an empty end-feel?

Answer 32

When moving through the range of motion, no resistance is felt regarding the joint surfaces, but at a point in the range the client will voluntarily contract the muscles and stop further movement. An abrupt unexpected stop of movement.

Question 33

what are the treatment guidelines for an empty end-feel?

Answer 33

This end-feel can indicate major problems in tissue around and serving the joint. It can also be of psychological origin. Usually the end range does not vary with speed of movement as it does with a spasm end-feel.

Question 34

what are some normal end feels?

Answer 34

Bone on Bone Soft Tissue Approximation Capsular – feeling a capsular end feel is normal depending on joint Soft Tissue Stretch

Question 35

what are some abnormal end-feels?

Answer 35

Bone on Bone Muscle Spasm Capsular Springy Block Empty Soft Tissue Approximation

Question 36

what are some key guidelines for resisted isometric contractions?

Answer 36

Isometric Only the muscle working build contraction gradually Be sure to adjust the therapist position so you can resist the athlete when they are working as hard as possible When positive each contraction should be done in inner, middle and outer ranges

Question 37

what is the method for resisted isometric contractions?

Answer 37

Ask the athlete to attempt a joint movement while the remainder of the limb or body is stabilized Stabilization is needed to minimize substitution and minimize joint movement Muscle groups are tested and if a weakness is found individual muscles should be tested Therapist and athlete build to a maximal contraction gradually disallowing any joint movement Each muscle and tendon are tested in a position that best isolates them They are at optimal length for a maximal contraction The amount of therapist pressure depends on the part being tested, the leverage and the strength of the athlete Instruct the athlete when the resistance will start and coach them on the length of contraction with a slow cessation of pressure Muscles other than those being tested must not be included (i.e. Elbow resistance at hand vs. above wrist) Athlete must be encouraged to try their hardest (NB cannot resist plantar flexors manually)

Question 38

what should the therapist record for resisted isometric contractions?

Answer 38

The degree of strength on a scale from 0-5: Gone 0 – no contraction left Trace 1 – muscle can be felt to tighten, but cannot produce movement Poor 2 – produces movement with gravity eliminated, but cannot function against gravity Fair 3 – can raise part against gravity Good 4 – can raise part against outside resistance as well as against gravity Normal 5 – can overcome a greater amount of resistance than a good muscle Whether the test is painful or pain free record where there is pain during the contraction record when there is pain during the contraction Ex. Did the pain come immediately or at the end

Question 39

what can the results of resisted isometric contractions show?

Answer 39

weakness can be due to a neurological deficit or actual loss of strength of the muscle or tendon appropriate neurological testing can rule this out It is important to determine true weakness from apparent weakness due to pain or an unwillingness of the athlete to exert the muscle

Question 40

For resisted isometric contractions - Possible combinations of other strength and pain factors include:

Answer 40

Strong and Painless Strong and Painful Weak and Painless Weak and Painful

Question 41

what is the significance of resisted isometric contractions?

Answer 41

These movements test the state of the contractile structures and their nerve supply

Question 42

how do you determine "normal" in relation to muscle testing?

Answer 42

Bilateral on each patient Build a basis for comparison of test results through experience in muscle testing Test a series of individuals of various ages and activity levels both male and female Test persons with faulty posture as well as those with good posture The grade strength (0-5) of the muscle will indicate how to plan a program for muscle re-education This will be used as a sign for continual reassessment

Question 43

What conditions could you have if you have pain and limitation in every direction with passive movement when the whole joint is affected.

Answer 43

Pain and limitation in every direction when the whole joint is affected is arthritis or capsulitis

Question 44

T/F Each joint has its own “capsular” pattern with different limitations in each direction

Answer 44

True