MSK Flashcards
Special test for TOS
These 5 involve palpating radiual pulse and if pulse decreases then positive for arrterial TOS
Adson maneuver Costoclavicular syndrome (Militarry brace) test Halstead maneuver Wright test Allen test
Roos test (Elevated arm stress test): Arterial TOS, open close hands 3 mins and fatigue
Shoulder girdle passive elevation (Cyriax release test): Cross arms on shoulders, physio lifts arms up, looking for reduction of symptoms
Possible complications of a shoulder dislocation
Axillary nerve damage
Axillary artery
brachial plexus (most common the posterior cord)
bankart lesion (damage to the anteroinferior glenoid labrum)
Hill sachs lesion (fracture to the posterolateral humeral head secondary to forceful impact on the anteroinferior labrum)
Spectrum of instability
AMBRI (born loose)
Atraumatic etiology, multidirectional with bilateral shoulder findings, rehab for treatment, and rarely inferior capsule shift surgery if required
TUBS Torn loose
Traumatic etiology, unilateral aterior with a bankart lesion responding to surgery (surgery will lead to reductions in ER)
Special tests for shoulder dislocation
Anterior instability
- Apprehension test and relocation test
- Apprehension release (surprise test)
- Load and shift test
Posterior instability
- Jerk test
- load and shift test\
- posterior apprehension test
Inferior instability
-Sulcus sign
-feagin test (Examiner position: The clinician holds the patient’s upper extremity at 90
degrees of abduction, with the patient’s forearm over the clinician’s shoulder
and elbow extended.
Technique: The clinician uses one hand to apply an inferiorly and slightly
anteriorly directed force while the other hand palpates the edge of the
acromion and the humeral head to feel for displacement anteriorly and
inferiorly.
Special tests for SLAP lesions
Compression test of obrian (best test to use) ( positive with resistance to arm in 90 degree flex and internally rotated, and symptoms resolved when repeated with ER)
Biceps load test (Kim test II)
Clunk test
Bankaert lesion
Injury of labrum at 3 to 7 o clock
common in overhead athletes and with anterior GH dislocations
presents with clicking or popping
worse with HBB
Adhesive capulitis
Idiopathic condition characterized by shoulder pain followed by progressive loss of GH ROM following the capsular pattern (ER>ABD>IR) d/t dense adhesions and capsular thickening
Primrary adhesive capsulitis is idiopathic
Secondary is due to other conditions ex trauma, immobilization, surgery, post stroke, etc.
Has a high correlation with psychosocial issues
Stages of adhesive capsulitis
Stage 1
- Gradual onset of pain
- Increase with movement and at night
- Loss of ER ROM with intact RC strength
- Duration: <3 months
Stage 2: “freezing”
- Persistent and more intense pain, even at rest (dull and achy)
- Restricted ROM in all directions
- Duration: 3-6 months
Stage 3 “frozen”
- Pain only with movement, less night pain
- Signiicant adhesions. Hard capsular end-feel in most directions
- Restricted ROM in all directionswith increased scapular compensations
- May present with atropy of deltoid, RC, biceps and triceps d/t disuse
- Duration 9-15 months
Stage 4: " thawing" -Minimal pain -Significant capsular restrictions initially, bit get a gradual return of ROM -Some patients may never regain full ROM _Duration 15-24 months or longer
Special tests for subacromial impingement syndrome
Hawkins kennedy test
Neers impingement test
scapular assistance test
Hallmark sign of Subacromial impingement syndrome
Painful arc (60-120 degrees)
Special tests for tendinopathy of Biceps and RC muscles
Biceps
- Yergasons
- Speeds
Subscapularis
- Lift off test
- belly press test
- internal rotation lag sign
Infranspinatus
-External rotation lag sign
Teres minor
-Hornblowers sign
supraspinatus
- Empty can
- drop arm test
Causes of dynamic scapular winging
Sprcial tests for scapular winging
Serratus anterior weakness, long thoracic nerve damage affecting serratus anterior, spinal accessory nerve (trapezius), C3,C4 trapezius, C5 rhomboids, C7 serratus anterior and rhomboids
Wall push off test
punch out test
scapular load test (manual resistance at 45 degrees abduction and observe scapula for winging)
Lateral epicondylosis
Special tests for lateral epicondylosis
Management
Commonly involves the extensor carpii radialis brevis tendon
Commonly known as tennis elbow
Cozens test (Resisted wrist extension) Mills test ( Passive wrist extension) Maudsleys test (resisted extension of 3rd MCP)
- Counterforce brace
- Eccentric exercise
- activity modification
- Stretching
Medial epicondylosis
Management
Degeneration due to overuse of flexor trndon at the medial epicondykle
Commonly involves the pronator teres, and the flexor carpi redialis tendon
Known as golfers eelbow
Pain with resisted wrist flexion, resisted forarm pronation and passive wrist extension
Eccenteric exercise
Bracing
Stretching
activity mofication
Median nerve (C6, C7, C8, and T1) Peripheral nerve injuries
humerus supracondylar process syndrome
-median nerve entrapped under the ligament of struthers ( on the distal humerus)
pronator syndrome
-Median nerve entrapped between the two heads of the pronator teres muscle
Anterior interosous nerve syndrome
-the anterior interousous nerve, which is a branch of the median nerve is entrapped between the two heads of the pronator teres muscle and characterized as a pinch deformity
Ulnar nerve (C7, C8 and T1)
cubbital tunnel syndrome
-Ulnar nerve entrapped between the cubittal tunnel or the two heads of the flexor carpi ulnaris muscle
Special tests
- Tinnels test at the elbow
- cubital tunnel compression test
- Elbow flexion test
Radial nerve (C5, C6, C7, C8, and T1)
radial tunnel syndrome
- Entrspment of the posterior interousous nerve (branch of rsadial nerve) in:
1) Between the 2 heads of the supinator in the arcade of froshe
2) At the entrance of the radial tunnel anterior to the radial head
3) Nerve the brachioradialis and the ECRL
4) Between ulnar half of ECRB tendon and fascia
5) Distal border of the supinator
Complex regional pain syndrome (CRPS)
S & S
Clinical course
Type I: Occurs after injury to tissue, previously known as regional sympathetic dystrophy
Type II: Occurs after injury to a nerve, previously known as causalgia
S & S:
- Severe pain (burning)
- Allodynia/hyperalgesia
- Abnormal blood flow (vasomotor changes)
- Abnormal sweating ( sudomotor changes)
- Abnormal motor function
- Trophic changes (Colour changes, temperature changes, edema, shiny taut skin, abnormal hair and nail growth)
Stage 1: Acute/reversible stage
- typically begins several days after the injury or insidious over several weeks
- characteristics: pain, hyperhidrosis, warmth, erythema, rapid nail growth, edema in distal extremities
Stage 2: dystrophic. or vasoconstriction (Ischemic) stage
- Typically begins 3 months after the injury and lasts 3-6 months
- characteristics: Burning pain, sympathetic hyperactivity, hyperesthesia exacerbated by cold weather, mottling and coldness, brittle nails, osteoporosis
Stage 3: Atrophic stage
- Typically begins 6 months to 1 year after the injury and can last months or years
- characteristics: Pain either decreasing or becoming worse, severe osteoporosis, muscle wasting, and contracturees.
-
Most fractured carpal bone and the complications
Scaphoid
- Avascular necrosis
- Non-union of fracture and srtyhritis.
Muscle innervation
Radial nerve
Brachioradialis
extensors
supinator
triceps and anconeus
Muscle innervation
median nerve
lumbricals 1 and 2
opponens pollicis
abductor pollis brevis
Flexor pollicis brevis
Muscle innervation
ulnar nerve
adductor pollicis*** lumbricals 3 and 4 hypothenar muscles -flexor digiti minimi -abductor digiti minimi -opponens digit minimi -palmaris brevis
interossi (PAD and DABS)
Ape hand
Median nerve
- Inability to abdut or oppose the thumb
- Stuck in the same plane as D2-5
- Seen with a low level lesion
Hand of benediction
Median nerve
- Inability to flex D1-D3
- D1-D3 remain in extension when trying to actively make a fist
- A higher level lesion
Claw hand
Ulnar nerve
-D4 and D5 extend at the MCP, flex at the PIP and DIP when actively trying to make a fist
Wrist Drop
Radial nerve
-Inability to extend the wrist or the hand
Carpal tunnel syndrome
Compression of the median nerve in the carpal tunnel
- The floor is made up of carpal bones, and the roof is the flexor retinaculum
- Components are the 4 tendons of the flexor digitorum profundus
- r4 tendons of the flexor digitorum superficialis
- Median nerve
- tendon of the flexor pollicis longus
-D/t repetitive hand movements Associated conditions: -RA and other inflammatory disease -Colles fracture (d-t inflammation) -Lunate subluxation (Anterior sublux takes up space) -Hypothyroidism (Excess fluid retention) -Pregnancy (2nd trimester) -DM
S & S
- Paresthesia of median nerve distribution
- Worse with repetitive and sustained wrist movements
- nocturnal numbness and pain
- relieved by “flicking” the wrist
- weakness and clumsiness in hand (Decrease grip strength and drop objects)
Special tests
- Tinnels test at the wrist
- Phalens test
- Reverse phalens test
- Carpal tunnel compression test
- Resisted APB
- ULTT median nerve bias
Intervention
- Activity modification
- Wrist splint/brace in neutral
- Mobility techniques (nerve mobs, tendon-gliding exercises, jt mobs)
Carpal tunnel release surgery
- Immobolized for 7-10 days with wrist in slight extension and fingers free to move
- During first 10 days post-op avoid wrist flexion past neutral, and finger flexion with wrist flexed.
In max protection phase do finger and thumb AROM
- Wrist extension
- Ulnar and radial deviation with wrist in slight extension
- forearm pronation and supimnation
- All elbow and shoulder movements
- Begin isometrics 4 weeks post-op
- Grip and pinch exercises 6 weeks post-op
- Sensory reduction, desensitization
In severe case of ulnar tunnel syndrome what can happen
Special tests for ulnar tunnel syndrome
Claw hand and/or hypothenar muscle atrophy
Special tests:
- Froments sign: paper between thumb and index finger and uses adductor pollicis to grip paper (ulnar nerve innervation)
- Guyon canal compression test
- tinnels test
- ULTT for ulnar nerve
Interventions
- Cock-up splint
- padded handlebars and gloves, ergonomic aids and equipment
- change of hand positions
- nerve mobs
Finger deformities
Duputryens contracture
- Contracture of the palmar fascia
- fixed flexion deformity of the MCP and PIP joints
- D4 and D5
- skin often adherent to the fascia
trigger finger
- thickening of the tendon sheath (Notta’s nodule)
- results in tendon sticking catching, or locking when attemopt to flex finger
- Commonly affects D3 and D4
- Often associated with RA
mallet finger
- DIP stuck in flexion due to rupture of the extensor tendon
- Treeated by splinting DIP straight for 6-8 weeks
bouchards nodes
-OA enlargement of the dorsal surface of the PIP
heberdens nodes
–OA enlargement of the dorsal surface of the DIP
swan neck deformity
-flexion of the MCP, hyperextension of the PIP, and flexion of the DIP
boutinierres deformity
-Hyperextenion of the MCP, and flexion of the PIP, DIP extension
ulnar drift
With Hip OA is OKC or CKC exercises preferred in acute phase?
OKC, then progress to functional CKC exercises as tolerated
Hip OA complications
Intra-op
Early post-op
Late post op
Intra op
- malpositioning of prosthesis
- femoral fracture
- nerve injury
- LLD
Early post op
- Infection
- DVT
- wound healing problems
- pneumomnia
- dislocation of the prosthetic joint
Late post-op
- mechanical loosening of components
- atraumatic wearing out of the components
Post op THA precautions
Posterior/posterolateral
Anterior/anterolateral and direct lateral
Posterior/posterolateral
- No hip flexion >90
- No adduction past neutral
- No Ir past neutral
Anterior/anterolateral and direct lateral
- No hip flexion >90
- No ER beyond neutral
- No hip adduction beyond neutral
- No FABER movements
- If glute med incised, no resisted or antigravity hip abduction for 6-8 weeks.
Hip neuropathies
Sciatic nerve
Obturator nerve
Femoral nerve
Sciatic nerve
-Entrapment as the nerve passes under the piriformius muscle
Obturoator nerve
-d/t uterine pressure and damage during labor
Femoral nerve
-D/t features of upper femur or pelvis, reduction of congenital dislocation of the hip,, or pressure during a forceps delivery.
Special tests for meniscus trears
Mcmurrays test (Most important)
Thessalys test
Bounce home test
Apley’s test
Special tests for ACL tear
Lachmans test
Anterior drawer test
pivot shift test
Special tests for PCL tear
Posterior drawer test
Gofrey (gravity) test
Posterior ag sign
Infrapatellar fat pad syndrome etiologies
Common sign
Patella alta inferior patellar tilt anterior pelvic tilt genu recurvatum Hyperextensio n injury
camel sign
plica syndrome common sign
& special tests
Pseudo locking
Hughtons plica test
mediopatellar plica test
patellar bowstring test
Patellar subluxation/dislocation structural abnormalities
Interventions
Shallow patellofemoral groove
Patella alta
Increased Q angle
foot pronation
PT management
Early
immobilization (zimmer splint) for 3-6 weeks
crutches until full extension obtained
Normalize gait
Isometric and ROM (OKC and progress to CKC)
Later
Progreess to CKC with emphasis on VMO and glute med
patellar bracing
Contraindications fo myositis ossificans
Passive stetching, massage, and resistive exercises
Only thing that is indicated is AROM
Special tests for lateral ankle sprain
Anterior drawer test talar tilt (Inversion stress test)
Also can do: Ankle lunge test (knee to wall test) Proprioceeption testing(single leg balance) Strength testing (heel raise)
Special tests for medial ankle sprains
Anterior drawer test
Talar tilt test (eversion)
External rotation stress test (kleiger)
Special tests for high ankle sprain
External rotation stress test (Kleigers test)
Squeeze test
Ottawa ankle rules
1) Bony tenderness along distal 6cm of posterior edge of fibula or tip of lateral malleolus
2) Bony tenderness along distal 6cm of posterior edge of tibia/ tip of medial malleolus
3) Bony tenderness at base of 5th ,metatarsal
4) Bony tenderness at the navicular
5) Inability to bear weight both immediately after injury and for 4 steps during initial evsluation
3 classes/ causes of shin splints
Periostitis (inflamation of the periosteum of the bone)
Compartment syndrome (to much pressure in the fascia
stress fractures
Plantar fasciitis
overuse of plantar fascia, assess using the windlass mechanism
Treat with soft tissue mobs of plantar fascia and calf
stretching, and strengthening intrinsic foot muscles
Mortons neuroma
Thickening of the fibrous tissue leading to entrapment of the digital nerve of the foot
Usually digital nerve of 3rd and 4th toes
Assess using mortons test (essentially lateral compression of transverse MTP arch)
