MSK Flashcards
Ulnar Collateral Ligament (medial) tear elbow
restricts valgus stress
MOI: excessive valgus force
s/s: pain, TOP, effusion, < ROM, instability, “pop”
special test: valgus stress test
intervention: reduce pain/swelling, bracing, strengthen forearm flexors/pronators, restore ROM
Nursemaids elbow
subluxation of radial head children 1-4, annular ligament tear
MOI: longitudinal traction with wrist pronation
s/s: refusal to move arm, held against body in slight flexion
Olecranon bursitis
inflammation of bursa
MOI: trauma, pressure, infection
s/s: swelling, redness
interventions: ice, compression, NSAIDS, cortisone injection, aspiration, antibiotics, bursectomy
lateral epicondylitis (tennis elbow)
degenerative changes/inflammation commonly at ECRB tendon of lateral epicondyle (common extensor tendon)
MOI: repetitive use, heavy ball/racquet, load > capacity for recovery
s/s: aching pain lateral epicondyle to proximal forearm extensor muscle mass, insidious, TOP, pain resisted wrist extn/gripping, pain wrist extn stretch
special tests:
cozens - resisted wrist extn with pronation + radial deviation
mills - passive wrist flexion + pronation with elbow extension
maudsleys - 3rd finger extn
interventions: eccentric wrist extn strengthening, stretching, counterforce brace, cross-frictions, mobilizations, pain modalities, reduce inflammation (cortisone, NSAIDS)
medial epicondylitis (golfers elbow)
degenerative/inflammation to wrist flexor tendons at medial epicondyle (common flexor tendon), PRONATOR TERES, FCR tendon
MOI: repetition, load > capacity
s/s: aching pain medial epicondyle to proximal forearm flexor muscle mass, insidious, TOP, pain resisted wrist flexion/forearm pronation/gripping, flexion stretching
special tests:
med epic. (reverse mills): passive wrist extension stretch, resisted pronation/flexion at wrist
interventions: eccentric wrist flexion strength, stretching, counterforce brace, cross-frictions, mobilizations, pain modalities, reduce inflammation (cortisone, NSAIDS)
anterior interosseous nerve syndrome
median nerve branch entrapment between two heads of pronator teres muscle
MOI: forearm fracture
s/s: pinch deformity (motor nerve injury)
interventions: nerve mobilizations, NSAIDS, cortisone
cubital tunnel syndrome (elbow)
entrapment of ulnar nerve at cubital tunnel between two heads of the flexor carpi ulnaris
special tests:
cubital tunnel compression test, tinnels tap at elbow (cubital tunnel), elbow flexion test (90/90 at elbow + hold like ULTT)
interventions: nerve mobilizations, NSAIDS, cortisone
radial tunnel syndrome
entrapment of posterior interosseous nerve
interventions: nerve mobilizations, NSAIDS, cortisone
Colles fracture
distal radial fracture with dorsal displacement
complications: median nerve compression, CRPS, arthritis
MOI: FOOSH injury, osteoporotic women
s/s: dinner fork deformity
interventions: spica brace, mobilization above/below, strengthening
**no pronation/supination ROM
CRPS
chronic pain disorder by SNS malfunction pain>stimulus
s/s: allodynia, hyperalgesia, burning pain, abnormal blood flow, abnormal sweating, stiffness (hallmark sign), edema, mottled skin, nail/hair growth, shiny tight skin, osteoporosis
days/weeks after injury
pain, hyperhydrosis, warmth, erythemia, rapid nail growth, edema distal extremity
stage 1 (acute/reversible)
3 to 6 months after injury
burning pain, sympathetic hyperactivity, hyperesthesia to cold weather, mottling and coldness, brittle nails, osteoporosis
stage 2 (dystrophic or vasoconstriction (ischemic) stage)
6 months to 1 year after injury
pain decreasing or increasing, severe osteoporosis, muscle wasting, contractures
stage 3 (atrophic stage)
CRPS interventions
education, TENS, mobility, ADL encouragement, desensitization. RICE, mirror therapy, avoid passive treatments
de quervains tenosynovitis
painful inflammation of sheath around tendons of thumb (abductor pollicis longus + extensor pollicis brevis)
MOI: chronic overuse, repetitive use wrist/thumb movements - golfing, carpentry, gripping, pinching
s/s: radial sided wrist pain, tenderness, swelling, pain stretching/contraction of EPB+APL
special tests: finkelstein test
interventions: activity modification, cryotherapy, thumb spica, gradual stretching/strengthening, NSAIDS, cortisone
Muscle innervation of median nerve
Lumbricals 1 + 2
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Radial nerve muscle innervation
Brachioradialis
Extensors of wrist
Supinators
Triceps (anconeus)
Ulnar nerve muscle innervation
Adductor pollicis
lumbricals 3 + 4
hypothenar muscles - flexor digiti minimi, opponens digiti minimi, palmaris brevis
interossei muscles - PAD (palmar adductors), DAB (dorsal abductors)
median nerve palsies
APE hand (low level lesion - carpal tunnel)
inability to abduct thumb - opposed muscles
HAND OF BENEDICTION (high level lesion)
inability to flex D1-D3 - will remain in extn when making a fist
ulnar nerve palsy
CLAW HAND
hyperextension of MCP and flexion of IP joints D4-5
unopposed muscles
radial nerve palsy
WRIST DROP
inability to extend the wrist or MCP joints
muscles are unopposed (BEST)
what makes up the carpal tunnel
carpal bones (floor)
flexor retinaculum (roof)
*9 tendons: flexor pollicis longus, 4 tendons of the flexor digitorum profundus, 4 tendons of flexor digitorum superficialis
median nerve
carpal tunnel risk factors/populations
insidious onset, repetitive stress, associated conditions (RA + inflammatory conditions), colles #, lunate subluxation, pregnancy, hypothyroidism, DM, obesity
carpal tunnel s/s
paresthesia median nerve distribution (palmar - 1, 2, 3, half ring finger)
increasing pain with repetitive hand movements, nocturnal pain/numbness, relieved by “flicking wrist”, weakness in grip strength, severe = atrophy of thenar eminence + 1/2 lumbicals
carpal tunnel special tests
tinels tap @ carpal tunnel (@ the wrist) *not guyons canal
phalens test (fingers down)
reverse phalens test (prayer test)
carpal compression test
resisted APB -only muscle exclusively innervated median nerve
ULTT median nerve
nerve conduction velocity test
carpal tunnel interventions
activity modification, splinting in neutral, nerve mobilizations, tendon gliding, joint mobilization, isometrics, resistance + endurance exercise progression, fine-finger dexterity, NSAIDS, cortisone, carpal tunnel release
double crush syndrome
nerve compression at more than one site along same nerve
eg. compression median nerve at carpal tunnel + cubital tunnel
ulnar nerve at guyons canal + cubital tunnel at elbow
ulnar tunnel syndrome (location, MOI, s/s), interventions
compression as it passes through guyons canal (between pisiform and hook of hamate)
MOI: FOOSH, chronic pressure (cycling*), ganglion cyst, extended use of crutches, baseball catchers, jackhammers
s/s: paresthesia ulnar nerve (half ring + pinky finger), motor weakness, claw hand, atophy hypothenar eminence
interventions: activity modification, cock-up splint, padded equipment, change handle bar positioning, nerve mobilizations, NSAID, cortisone
ulnar tunnel special tests
froments sign (paper between thumb and pointer finger + thumb flexes) tests adductor pollicis innervated by ulnar
guyons canal compression test
guyons canal tinel tap
ULTT ulnar nerve
Gamekeepers thumb
sprain of ulnar collateral ligament of thumb (thumb jam)
MOI: valgus force to MCP of thumb - skiers, volleyball players, gamekeepers
s/s: tenderness/pain base of thumb, pain with movement + stretch, reduced pinch/grip strength, swelling/bruising
special tests: thumb UCL laxity or instability
interventions: activity modification, splint MCP in slight flexion, gentle ROM, strengthening - theraputty
thumb carpometacarpal OA (CMC)
pain base of thumb at CMC, worse at night with weather or overuse, decreased pinch/grip, muscle wasting at thenar eminence, possible instability due to joint space narrowing
special test: grind test
interventions: activity modification, splinting, larger grip handles, AROM within tolerance, strengthening, paraffin wax, NSAID, cortisone
dupuytrens contracture
contraction of the palmar fascia not flexor tendons
fixed flexion of MCP/PIP joint
usually D3/D4
skin adheres to fascia
trigger finger
thickening flexor tendon sheath
nodule formation, tendon sticks, catching, locking when attempting to flex the finger
usually D3/D4
mallet finger
flexion of the DIP at rest
due to rupture/avulsion of extensor tendon resulting in flexors unopposed + pulls into flexion due to hyperextension injury
splint 6-8 weeks with DIP straight
bouchard node
OA enlargement at the PIP on dorsal side *not RA
heberdens node
OA enlargement at the DIP on dorsal side *not RA
hip anteversion
neck faces forward and inwards, internal rotation of the hip causes intoeing. “W sitting”
hip retroversion
neck is pointed back and goes outwards, external rotation of the hip and out-toeing
Hip OA signs/symptoms
pain in the groin, hip, buttock, thigh, knee
pain with weightbearing
reduced pain in loose packed (30 degrees flexion, 30 abduction, slight ER)
limited ROM with firm capsular end-feel
capsular pattern (FAM)
difficulty with sit to stand, ADLs
HIP OA special tests
scour test
Patricks (FABER) test
flexion-adduction (hip quadrant) test
HIP OA interventions
Education (safe ambulation)
Decrease pain - grade 1/2 with hip resting position, cane in contralateral side, shoe lift for LLD, modalities TENS, heat, reduce deep squat
Increase ROM - within tolerable limits, grade 3/4 mobs stretch capsule, stretching
Strengthening - as tolerated, begin OKC than CKC functional
Hip total arthroplasty posterior approach
soft tissues: glute max, short ERs and piriformis released and repaired - no high impact running
Hip post-op precautions (posterior approach)
no flexion >90, no hip IR > neutral, no hip adduction > neutral
wedge between legs when rolling
roll towards good side
exit same side as surgical side
stand up straight/tall from bed
highest risk subluxation/dislocation
Hip post-op precautions (anterior/direct approach)
no hip flexion >90, no hip extension, no hip adduction > neutral, no combined hip mvmts (FABER)
if glute med cut through - no anti-gravity hip abd 6-8 weeks
direct approach walking same day as surgery
Hip post-op maximum protection phase
4-6 weeks
ankle pumps, deep breathing, secretion clearance, strengthen quads, glut max, hamstrings, hip abds (if not lat. approach), AROM/AAROM within protected ranges
CKC weight-shifting, balance, heel raises, mini squats
assistive devices:
WALKER (older pop, reduced balance)
CRUTCHES (young, good balance, upper body strength)
loose packed position of hip
30 degrees flexion, 30 abduction, slight ER
hip fractures
fracture of proximal femur
generally 75 years + F>M, osteoporotic fractures
risk factors: falls, sudden twist of lower extremity, sarcopenia
hip fracture signs/symptoms
pain in groin or hip region
pain with AROM/PROM hip
pain with weight bearing
leg length discrepancy
leg held in ABDUCTION + EXTERNAL ROTATION
signs/symptoms hip internal fixture failure post-op
severe, persistent groin, thigh, knee pain that increases with weight bearing or hip movements
shortening of that limb that was not present after surgery
positive trendelenberg sign even after strengthening – could be due to damage to superior gluteal nerve (alt. hip drop)
persistent ER at operated hip
developmental/congenital dysplasia of the hip
babies! instability of the hip joint, resulting in increased risk of hip dislocation
signs/symptoms: gluteal fold asymmetry, LLD, hip abduction limitations, hip clicking
hip dysplasia baby tests
barlow maneuver (dislocation): babies hip adducted with AP force resulting in palpation subluxation/dislocation
ortolani maneuver (relocation): hip and knees flexed to 90 degrees + gently abducted with PA force to proximal femur resulting in palpable + audible clunk as the hip reduces
hip dysplasia interventions
ultrasound gold standard for diagnosis
pavlik harness - maintains hip in flexion/abduction
hip spica cast 6-24 months used if pavlik harness fails
legg-calve perthes disease
children 2-15 years old (common 4-8)
avascular necrosis of the femoral head resulting in interruption of blood supply to neck of femur
legg-calve perthes disease s/s
limp of insidious onset
+ve trendelenberg sign
pain aggravated by activity + relieved by rest
referral pain to anteromedial thigh/knee
reduced ROM ABD/IR++
legg-calve perthes disease interventions
petrie cast or abduction wedge (bar between legs)
low impact exercises, strengthening, ROM
reduction of WB if pain severe - crutches/wheelchair
slipped capital femoral epiphysis
ADOLESCENTS
fracture through the growth plate (physis) causing anterior slipping of the end of the femur (metaphysis), head of femur will sit posterior to slippage
OBESITY
slipped capital epiphysis signs/symptoms
pain in hip/anterior thigh
pain with activity
ROM reduced in flexion/abduction/internal rotation (FABDIR)
intervention = surgery
round back
increased posterior pelvic tilt ~20 degrees with increased thoracolumbar or thoracic kyphosis, rounded shoulders, head forward posture
scheuermanns disease
congenital and/or degenerative weakening of vertebral end plates in adolescents
uneven growth in sagittal (AP) direction with excess wedging
more rounded kyphotic structure T10-L2
flat back
loss of kyphosis, increased posterior pelvic tilt ~20 degrees and decreased curve in thoracic spine
dowagers hump
anterior wedge fractures in upper to middle thoracic spine causing increased kyphosis in older/post menopausal women
osteoporosis leading cause
interventions of thoracic kyphotic deformities
posture education, extension approach for hyperkyphosis in PRONE unless cardiopulmonary conditions
stretching tight structures
mobilizations unless low bone density (scheuermanns disease and dowagers hump)
spine compression fractures contraindications
trunk flexion, mobilizations if due to low bone density or steroid use
scoliosis
lateral curvature in the spine
labeled in direction of CONVEX at level of APEX
cobb angle >10 degrees = scoliosis
non-structural scoliosis
postural/functional scoliosis
curve disappears with forward flexion (Adams test)
due to poor posture, muscle guarding/spasm, nerve root irritation, inflammation, LLD (thoracic scoliosis towards longer leg side)
structural scoliosis
changes to the bones, typically congenital (does not disappear with forward flexion) Adams test
severe = cobb angle > 60 degrees = cardiorespiratory system compromised
RESTRICTIVE DISEASE
irreversible curvature with fixed rotation of vertebrae
vertebral bodies rotate to side of CONVEXITY
rub hump more prominent posteriorly
shingles
painful skin rash following dermatomal pattern
visceral pain referral to right neck and shoulder, right upper quadrant
liver and gallbladder
visceral pain referral to left neck and shoulder
lung and diaphragm
visceral pain referral left chest and arm, bwtn shoulder blades
heart
visceral pain referral left upper quadrant
pancreas
visceral pain referral to right lower quadrant
appendix
interventions scoliosis
posture education - mirror
stretch side of CONCAVITY - shortened erector spinae on concave side, side bending to shortening side
strengthen side of CONVEXITY (lengthened side)with rotation to opposite side of scolosis
scapular stabilization exercises
nerve roots exit ABOVE corresponding vetebrae
cervical spine C1-C8
cervical radiculopathy definition/causes
signs/symptoms of nerve root compression or irritation
disc herniation
stenosis:
spondylosis
ligamentum flavum thickening - central stenosis UMN signs
inflammation/swelling
hand dermatomes (radial to ulnar aspect)
star trek fingers (test PROXIMAL TO DISTAL)
C5 -radial head
C6 - thumb
C7 - middle + pointer fingers
C8 - ring + pinky fingers
T1 - ulnar head
Myotomes C1-T1
C1-C2: neck flexion
C3: neck lateral flexion
C4: shrug
C5: shoulder abduction
C6: elbow flexion, wrist extension
C7: elbow extension, wrist flexion
C8: thumb extension, ulnar deviation
T1: finger abduction/adduction
LMN reflexes (upper body)
Jendrassik maneuver
C5 - Deltoid
C6 - Biceps/Brachioradialis
C7 - Triceps
C8 - Pronator Quadratus
T1 - Abductor Digiti Minimi
UMN reflexes
Clonus - dorsiflex ankle quickly + forcefully and hold in DF
positive - sustained clonus of 5 beats or more
Babinski - scrape bottom of foot lateral to medial from heel and across ball of foot
positive - splaying of toes and/or extension of big toe
order of upper limb tensioning for testing
shoulder > forearm > wrist > fingers > elbow
ULTT1
MEDIAN NERVE, ant. interosseous nerve, C5, C6, C7
1. shoulder depression + abduction to 110’
2. forearm supination
3. wrist extension
4. finger + thumb extension
5. elbow extension
ULTT2
MEDIAN NERVE, musculocutaneous nerve, axillary nerve
1. shoulder depression + abduction to 10’
2. forearm supination
3. wrist extension
4. finger + thumb extension
5. elbow extension
ULTT3
RADIAL NERVE
1.shoulder depression + abduction to 10’
2. forearm pronation
3. wrist flexion + ulnar deviation
4. finger + thumb flexion
5. elbow extension
ULTT4
ULNAR NERVE, C8, T1 nerve roots
1. shoulder depression + abduction to 10’
2. forearm pronation
3. wrist extension + radial deviation
4. finger + thumb extension
5. elbow flexion
Erb-Duchenne Paralysis
WAITERS TIP
injury to nerve roots C5-C6 (upper brachial plexus)
paralysis of shoulder and elbow (arm) not hand
commonly due to shoulder dystocia during birth
arm hangs by side, shoulder IR, elbow extension, forearm pronated
Klumpke’s Paralysis
injury to lower nerve roots C8, T1
weakness in the triceps, forearm and hand
may present with Horner’s Syndrome (T1) drooped eyelid, excessive pupil constriction
reduced sensation ulnar forearm/hand
due to traction on abducted arm during birth
elbow flexion, forearm supination, wrist + MCP extension, PIP + DIP flexion»_space; claw hand
facet syndrome
pain with compression of facet joints in c-spine
referral to scapula/neck
side bending/rotation occur towards SAME SIDE
add extension to coupled movements above to rule out facet
non-coupled movements (side bend + rotation in OPPOSITE DIRECTIONS - most provocative
VBI symptoms (5D’s + 3 N’s)
dizziness
diplopia
drop attacks
dysarthria
dysphagia
nystagmus
nausea
neurological symptoms
VBI definition
compression of vertebral artery causing reduced blood flow to the brain stem
pons, medulla, cerebellum
torticollis
congenital or acquired unilateral shortened SCM muscle
ipsilateral side flexion + contralateral rotation of c-spine
interventions: stretch side of affected SCM, strengthen weakness to improve muscle balance
positioning/handling to more neutral
upper cross syndrome tight + weak muscles
tight: pecs, upper traps, levator scapulae
weak: deep neck flexors, serratus ant., lower traps, rhomboids
interventions upper crossed syndrome
postural correction*
strengthen weak + elongated structures (chin tucks, serratus)
stretch tight structures (pecs, upper traps, lev scap)
cervical instability
excessive motion between 2 vertebrae
causes: ligament/joint damage, fracture, dislocation, weak muscles, trauma, long-term steroid use, RA, osteoporosis, down syndrome
mobilizations/manipulations contraindicated**
cervical instability signs/symptoms
dizziness
facial numbness
lump in throat*
nausea/vomiting
nystagmus
hesitancy to move neck - flexion most
pupil changes
severe headache
soft end-feel*
severe muscle spasm
spinal cord signs - cord compression signs UMN
nerve roots exit BELOW the corresponding vertebrae
lumbar spine
lumbar spine dermatome L4
across the patella, big toe
dermatome L5
toes on the dorsum + plantar surface, lateral heel
dermatome S1
posterior thigh, pinky toe
dermatome S2
medial calf, medial heel
myotome L1-L2
hip flexion
myotome L3
knee extension
myotome L4
ankle dorsiflexion
myotome L5
big toe extension
myotome S1
ankle plantar flexion, ankle eversion, hip extension
myotome S2
knee flexion, hip extension, ankle plantar flexion
deep tendon reflexes L3-S2 LMN
L3-L4 patellar
L5-S1 medial hamstring
S1-S2 achilles
how to stress sural nerve
SID - inversion + dorsiflexion
how to stress tibial nerve
TED - eversion + dorsiflexion
how stress peroneal nerve
PIP - inversion + plantar flexion
spinal stenosis
narrowing of central canal or intervertebral foramen
age of onset >60 y/o, insidious onset
cause: osteophytes, spondylosis, or ligament thickening
may cause neurogenic claudication
spinal stenosis aggs/eases
aggs: extension.. standing, walking, especially downhill
eases: flexion.. sitting, leaning forward - opens up intervertebral foramen
shopping cart sign, foot on stool, fetal position
interventions: flexion based exercises
laminectomy
intermittent claudication
pain/cramping in the buttocks/legs (calves) as a result of poor circulation to the affected area
cause: peripheral artery disease (PAD)
increased pain during activity
reduced pain at rest
DISTAL to PROXIMAL
UNILATERAL
neurogenic claudication
nerve root compression due to lateral stenosis
immediate onset
burning, tingling
worse in spine extension, walking downhill
eases with flexion
PROXIMAL to DISTAL
usually BILATERAL
disc herniation
migration of nucleus polposus through annulus fibrosus
posterio-lateral herniation = flexion mechanism injury
acute onset 30-50 years old
aggs: flexion, sitting, lifting from floor, worse is AM, coughing, sneezing, lateral shift away (listing) if herniated to side
eases: extension, walking, prone lying
4 stages of disc herniation
- protrusion - bulges posteriorly with no rupture
- prolapse - covered by thin layer of annulus fibrosis
- extrusion - disc material moves into epidural space
- sequestration - disc segments form outside disc
disc herniation interventions
McKenzie approach with directional preference
extension protocol 10x each waking hour
lumbar roll in sitting to promote extension
green, yellow, red light system
prone lying > prone on elbows > extensions in lying > extension in lying with OP > extensions in standing
lateral bulge - side glides towards direction of bulge
anterior bulge - flexion based exercises (knees to chest)
lower crossed syndrome
increased lumbar lordosis
overactive hip flexors compensate for weak abdominals causing ant. pelvic tilt
overactive hamstrings and erectors compensate for weak glutes to assist with hip extension
ASIS low, PSIS high
tight: erectors (multifidus + rotatores), hip flexors, hamstrings
weak and lengthened: abdominals, glutes
spondylosis
degenerative changes in vertebral body and disc
age > 50, insidious onset
DDD, fibrosis in disc, osteophyte formation
loss of lordosis
increased stiffness, back aching, potential muscle spasms
worse with prolonged positions: sitting, standing, flexion, extn
better with unloaded positions: lying supine, side lying, position changes
facet syndrome
pain worst with compression on facets
referral to low back, glutes, hips, groin, or thighs (not below the knee*)
tested using coupled or combined movements
interventions: flexion based exercises and positioning, avoid aggravating movements
physiological coupled movements (lumbar spine)
rotation + side flexion to the same side with flexion
» flexion + right side flexion + right rotation
rotation + side flexion to the opposite side with neutral/extn
» extn + right side flexion + left rotation
spondylolysis
defect in the pars interarticularis
PARS # with no slippage
spondylolisthesis
forward displacement of one vertebrae over another
bilateral pars #
retrolisthesis
backwards displacement of one vertebrae over another
isthmic spondylolisthesis
due to repetitive micro-trauma causing a fracture of the pars interarticularis
most common at L5/S1
athletes in sports involving hyperextension (gymnasts)
pathological spondylolithesis
secondary to another disease/pathology
» osteoporosis, pageants bone disease, brittle bones, steroids
grades of spondylolisthesis
grade 1: < 25% slippage
grade 2: 25-50% slippage
grade 3: 50-75% slippage
grade 4: >75% slippage
grade 5: 100% slippage (spondyoptosis)
Core stabilization exercises grade 1-3
fixation (spinal fusion) required grade 4/5
signs/symptoms spondylolisthesis
pain with hyperextension
hyperlordotic posture
tight hamstrings
“scotty dog with collar” sign or “scotty dog with decapitation”
+/- step deformity
+/- s/s of lateral or central stenosis
maximum protection phase (laminectomy/fusion)
6 weeks to 3 months
no heavy lifting >10lbs up to 3 months
signs of inflammation/infection
avoid wetting incision up to 2 weeks
rotation contraindicated 1st week, avoid excessive flex/extn
extension contraindicated laminectomy
bed mobility, exercises in supine, walking
moderate/minimum protection phase (laminectomy/fusion)
4-6 weeks+ after maximum protection
scar tissue mobilization
progressive stretching + joint mobilizations on restricted tissue
grade 1/2 mobs on adjacent segments for pain
walking, strengthening segmental to global
joint mobs at levels of fusion CONTRAINDICATED
extension exercises for laminectomy CONTRAINDICATED
cauda equina syndrome
damage to long nerve roots below L1
flaccid paralysis LMN lesion - areflexive bowel/bladder
saddle anesthesia (detrusor muscle not working, trickles out)
send to ER immediately
malignancy
spinal pain common in patients with spinal metastasis
age >50
previous history cancer
unexplained weight loss
constant, unrelenting pain, unrelieved with rest
night pain
failure to improve with consecutive therapy (within 1 month)
medial meniscus
lateral 1/3 vascular, medial 2/3 avascular
medial meniscus: C shaped, thicker posteriorly/anteriorly
attached to MCL, ACL, PCL, semimembranosus muscle
terrible triad - valgus force to knee (MCL, ACL, med. meniscus)
lateral meniscus
O shaped, moves more posteriorly during flexion: less risk tear
attached to: PCL, tendon of popliteus muscle
function of menisci
aid in lubrication
shock absorbers
increase congruency of joint surfaces
improve weight distribution
reduce friction during movement
aid the ligaments + capsule in preventing hyperextension
meniscus tear mechanisms
loaded shearing/ twsiting forces in tibiofemoral joint
WB + compression with hyper flexion >90’ (deep flex + twist)
early flexion = anterior meniscus
deep flexion = posterior meniscus
TIBIAL ER = medial meniscus
TIBIAL IR = lateral meniscus
meniscus signs/symptoms
joint line tenderness
joint effusion
“locking” bucket handle tear
clicking noise
knee “giving away”
reduced ROM
“springy block” end feel
meniscus interventions
decrease inflammation
pain-free ROM
strengthening
partial/total meniscectomy - WB as tolerated, caution > 90’ flexion 1st six weeks, no deep squatting or cutting sports 3-4 months
ACL
medial tibial plateau, superior posterior-lateral to lateral femoral condyle (BUL = BACK, UP and LATERAL)
restrains anterior tibial translation, medial tibial rotation, tibial varus/valgus
ACL MOI
excessive anterior translation
contact - valgus stress on lateral knee (terrible triad)
non-contact - pivot/cutting mvmts tibia ER or tibia IR on fixed femur planted foot
rapid deceleration
forceful hyperextension - skiiiers jump
ACL signs/symptoms
audible “pop” or “snap”
pain - constant throbbing, aching, increased WB
hemarthrosis
joint effusion
knee “giving out” or instability
reduced ROM
ACL interventions
decrease pain
decrease swelling - ultrasound, ice
bracing
crutches
strengthening - CKC to OKC - quarter squats
proprioception training
increase ROM
surgery - ACL reconstruction (no blood supply)
PCL
attaches from lateral tibial plateau, runs superior-anterior-medial to the medial femoral condyle
restrains excessive posterior tibial translation, medial tibial rotation, tibial valgus/varus
stronger + thicker than ACL - less likely to tear
PCL MOI
deep flexion
dashboard knee
falling on flexed knee - ice skater falling on knees
sudden forceful hyperflexion/hyperextension
PCL signs/symptoms
pain - constant, throbbing, with mvmt, kneeling, stairs
hemarthrosis after injury
joint effusion
limited ROM acutely
increased passive extension ROM, or in standing
PCL interventions
decrease pain, swelling
bracing
strengthening
proprioception
restore ROM
MCL
restrains valgus, lateral tibial rotation (ER), anterior/posterior translation
all fibers taut in full extension
MCL MOI
valgus force with tibial ER ++
MCL signs/symptoms
pain - constant, throbbing, WB, mvmt
joint effusion
knee “giving out” or instability
limited ROM
MCL interventions
same as ACL, PCL
conservative management - blood supply can heal on its own
LCL
runs from lateral epicondyle of femur to fibular head
restrains varus, lateral tibial rotation, ant/post tib. translation
taut in extension, loosing at > 30’ flexion
knee OA non-modifiable risk factors
age
gender (F>M)
heredity
congenital malformations
knee OA modifiable risk factors
OBESITY*
high impact activities
inactivity
muscle weakness
trauma
decreased proprioception
joint mechanics
knee OA s/s
insidious onset
morning stiffness <30 minutes
pain increased WB, squatting, stairs, static postures, rising from prolonged sitting, walking, fall in barometric pressure
joint line tenderness
reduced ROM, strength, ADL
bony enlargement
crepitus
swelling with no erythema
instability
genu varus/valgus
knee OA interventions
strengthening
low impact exercise - swimming, cycling, elliptical
reduce swelling, pain
increase ROM
walking aid - cane to unload knee
bracing if needed
weight loss
total knee replacement - 90’ required by 6 weeks or MUA
varus knee deformity (effect on knee + correction)
gapping at lateral knee joint with increased compression at medial joint line which can cause degeneration. Lateral wedge orthosis will reduce impact on lateral foot and level out foot position to reduce load on medial knee.
Patellofemoral Pain Syndrome
diffuse pain around kneecap from abnormal patellar tracking
chondromalacia patellae - if degeneration of articular cartilage
common in runners, adolescents, F>M
PFPS risk factors
extrinsic: increased FITT drastically + suddenly
increased distance, surface, footwear, distance
intrinsic: abnormal patella tracking, inceased q angle, muscle and fascial tightness, hip muscle weakness, VMO insufficiency, lax medial retinaculum
Q angle
from the ASIS to the midpoint of the patella
other line tibial tubercle to midpoint of the patella
PFPS s/s
insidious onset
anterior knee pain
pain with kneeling, squatting, stairs, prolonged knee flexion (movie theater sign), knee “buckling” or “giving way”, crepitus, patellofemoral joint pain, swelling and tenderness
PFPS interventions
reduce activity involving high loads/prolonged loads
bracing/taping to reduce lateral pull
lateral retinaculum stretch
VMO strengthening
glute med strengthening
orthotics
patellar subluxation/dislocation interventions
early:
immobilization (3-6 weeks)
decrease inflammation
crutches until full extn achieved
normalize gait
isometrics and ROM exercises
later:
CKC - emphasis on VMO/glute med
patellar bracing
patellar tendinitis (jumpers knee)
degeneration to the patellar tendon causing pain in the infrapatellar region
MOI: jumping sports, repetitive quad overloading
eccentric quads contraction - rapid deceleration, cutting, landing from jump
jumpers knee s/s
pain with quads contraction - jumping, squatting, resisted knee extension
TOP
localized swelling
quads weakness
jumpers knee interventions
patellar tendon strap
avoid overloading
progressive loading - eccentric quads (decline squat)
osgood-schlatter disease
traction apophisitis of the tibial tuberosity
common overuse injury in adolescents (growth spurts)
repeated tension of growth plate of upper tibia
increased FITT in sports involving running/jumping
bakers cyst
excess fluid collection
intra-articular knee pathologies (OA, RA, meniscus tear)
swelling in popliteal fossa, joint stiffness, decreased ROM, warmth, pain - mvmt, knee extn, standing
interventions - manage inflammation, compression sleeve, self-limiting (will resolve on its own)
osteochondritis dissecans
cracks from the articular cartilage and subchondral bone due to avascular necrosis
causes pain, crepitus, swelling
catching/locking if loose body in joint
increased pain with squatting, walking, going down stairs
myositis dissecans
formation of bone inside muscle-tendon unit, capsule or ligamentous structures
calcification after injury typically in quads following contusion, strain, or other traumatic injury to the muscle
contraindications: MASSAGE, PASSIVE STRETCHING, RESISTED EXERCISES**
TMJ max opening / functional opening
max = 50mm/5cm/3 flexed proximal interphalangeal joint
functional = 40mm/4cm/2 flexed proximal interphalangeal joints
TMJ hypomobility
pain is on same side as deviation (ipsilateral)
wheechair locked - R side = left will pull towards right
TMJ hypermobility
pain on opposite side on deviation
deviation towards unaffected side
TMJ lateral deviation muscles
iplsilateral temporalis
contralateral masseter, medial pterygoid, lateral pterygoid
nerves of the TMJ
trigeminal nerve (CN 5) - difficulty with shaving for men
TOS - costoclavicular syndrome
costoclavicular space - between clavicle and 1st rib (subclavicular)
TOS - anterior scalene syndrome
interscalene triangle
between scalenus anterior and medius (supraclavicular) and the rib at the base
resting position of shoulder
40-55’ abd, with slight (30’) horizontal add, ER
hyperabduction syndrome TOS
axillary interval - under coracoid process and behind pec minor (infraclavicular)
neurogenic “true” TOS
nonspecific “symptomatic” neurogenic TOS
anatomical anomaly compressing brachial plexus - cervical rib
similar signs/symptoms with no evidence of anatomical anomaly, muscle atrophy of EMG findings.»_space; maladaptive posture = shortening of scalene muscles and pec minor (hypertrophy scalenes)
athletes with overhead sports abd + ext rotation
pressure of bra strap, backpack
paresthesia
numbness
weak grip strength
loss of manual deterity/fine motor mvmts in hands
special tests - relief of symptoms
roo’s test (90/90 hold open close fists), shoulder girdle passive elevation (cyriax release test)
vascular arterial TOS
compression of subclavian artery due to cervical rib or thrombus
aggravated by arm motion, overhead activity. Pancoast tumor
cool skin
pale colour extremities
reduced/absent pulse
rapid fatigue/heaviness of limb
lower BP on affected side
special tests - radial pulse disappears
> Adson’s, military brace, Halstead, wright, Allen
Vascular Venous TOS
compression of subclavian vein does not cause complaint, tyically due to thrombus or another cause. Pancoast tumor
painful swelling in arm
mottled, bluish discoloration
special tests - radial pulse disappears
> Adson’s, military brace, Halstead, wright, Allen
shoulder separation (AC)
step deformity -distal end sticking up
grade 3 sprain - both acromioclavicular and coracoclavicular ligaments torn. deltoid + traps muscles may be torn from distal clavicle
cross body/horizontal adduction test
frozen shoulder
progressive loss GHJ ROM in capsular pattern (LAM) due to development of dense adhesions and capsular thickening
F>M 40-60 years
primary: idiopathic
secondary: other conditions with shoulder pain/restricted ROM (stroke, trauma, immobilization, surgery, MI, DM, OA, RA)
frozen shoulder s/s
loss ROM ++ HBB, HBH, overhead activities
capsular pattern
reverse scapulohumeral rhythm 1:2 GHJ:scapula (normal=2:1)
trick mvmts - shoulder hiking, side bending
general muscle weakness with low endurance
frozen shoulder stages
1 = (< 3 months) gradual onset pain, increasing with mvmt/at night, loss ER
2 = “freezing” (3-9 months) persistent increased pain even at rest (dull and achy), restricted ROM all directions capsular
3 = “frozen” (9-15 months) pain only with mvmt, significant adhesions, hard capsular end feel, restricted ROM with scapula compensations, muscle atrophy deltoid, rotator cuff, biceps, triceps
4 = “thawing” (15-24+ months) minimal pain, significant capsular restrictions with gradual return ROM, may never recover ROM
ultrasound = deep and thermal settings
subacromial impingement
impingement of the structures (subacromial bursa, supraspinatus tendon, LHB, coracoacromial ligament, joint capsule) from increased pressure on a narrowed space
due to structural, functional, or calcific tendinitis (supraspinatus tendon)
subacromial impingement s/s
painful arc 60-120 degrees
pain with overhead activities, side lying in anterior/lateral shoulder
no radiation below elbow*
no pain at rest
reversed scapulohumeral rhythm, HBB, HBH
pain/weakness resisted abduction and ER
palpation shoulder structures
supraspinatus tendon - HBB
subacromial bursa - passive shoulder extension
