Quiz 1 Flashcards
Obriens test is for what? Explain the test
labral tear
fully supinate then res, fully pronate then res.
if px is worse or only with pronation it’s pos
Drop arm test is for
supraspinatus tear
full or empty can test is for
supra. tendonitis
cross over test is for
AC joint
Speeds test is for
Biceps lesion
Yergason’s test is for
tear of Transverse humeral lig
2 main impingement tests
Hawkins Kennedy
Neers
the TOS test for pec minor being the issue
Allens
The TOS tests for scalenes being the issue
Halsteads
Addsons
Lift off test is for
subscap tear
what does Fromonts sign test for
Adductor pollicis weakness
Ulnar nerve
Murphys sign
(looking for depressed 3rd MC)
lunate fx test
tendons that are tested by Finklestein’s test
abd. poll. longus
Ext. poll brevis
how much mobility is needed for Reaching overhead
Flexion/abduction functionally
148 degrees
what are the functional degrees needed to comb your hair
Abduction: 112°
Horizontal add: 104°
ER: 54°
2 gross assessments that are good to check for overall functional movement of UE
big circle with arm
arrest position
functional degrees needed for arrest position
Horiz abd: 69°;
IR: 60°
Extension: 56°
2 main components of GIRD
loss of IR 15-25 degrees compared to non dom side
AND total loss of ROM
pec minor actions
protracts, depresses, & downwardly rotates scapula (PDDR) (minor is all scap)
levator scap actions
elevates scap
DR scap
serratus ant does what to scap
UR
If shoulder IR are limited, what part of the capsule is tight
post
if these are tight, ER can be limited
IR: subscap, teres major, lats, pec major
If shoulder ER is limited, what part of the capsule is tight
ant
good post capsule stretch for GIRD
cross over rated better than sleeper stretch
adhesive capsulitis, what motions are really limited
Limited in ER, Abd, Flexion, IR
how to differentiate between a true capsular issue vs muscular or soft tissue issue with the shoulder
if motion is limited in more than 2 planes its the capsule
greatest ROM loss with adhesive capsulitis occurs in what stage
Stiffness/Frozen
stages of adhesive capsulitis
Painful/Freezing - usually reversible here
Stiffness/Frozen (loss of ROM here),
Recovery/Thawing
instead of the freezing stages of adhesive capsulitis, what is a better way to classify pts
Irritability
High =Pain > 7, consistent, ↑disability, pn limits ROM
Moderate Irritability= 4-6/10, intermittent, mod disability, pn at end of range
Low Irritability=
explain how to tx high irritability pts with adhesive capsulitis, what are your limits to tx
ROM: short duration (1-5 sec holds), pn-free range or px less than 3
best way to do shoulder flexion with a pulley
bend elbow slightly -it shortens the lever arm
tx for mod irritability ad. capsulitis
ROM: (5 – 15 sec holds at end range)
AAROM – AROM
Manual Techniques: Low-high grades (grade 3 – high amplitude motion)
Functional Activities
what glide is best to regain ER for adhesive capsulitis (not the norm glide for ER)
ER is usually most limited
This study found that a post glide was more effective in improving ER
treatment for low irritability of adhesive capsulitis
ROM: We are going to end-range, OP, longer duration
Manual technique: higher grades (grade 4)
Strengthen: Low- high resistance at end ranges
Functional activities: increase demand
MOBS: take to end range and then mob
If Pec Minor is tight you see what with the scapula
Anterior tilt of scap
if levator scap is tight, you might see with what with scapula
elevation and DR
if rhomboids are tight, the scap appears how
adducted or retracted
muscles prone to weakness that can alter glenoid position and scapular position
Lower trap
Serratus Anterior
Rotator Cuff
Which are typically weaker, IR or ER of shoulder
ER
what must occur in order to clear acromion in humeral elevation
upwardly rotate scap
posteriorly tilt scap
externally rotate scap
what role does serr ant play in humeral elevation (being able to clear and actually elevate shoulder)
UR, post tilt and ER scap
stabalizes medial brdr and inf angle of scap to prevent winging
explain the force couple of serratus and low trap
Serratus and low trap work together to force couple UR and returning the scap from elevation
If the pt has scap DR syndrome this cannot occur - typically bc the low trap is weak
how does the lower trap help with PICR
Maintains PICR of scapula during arm elevation by eccentric control of protraction and elevation
the low trap prevents ____ from occuring during lowering of the arm
winging
so if winging is occuring during lowering-think low trap
the RC stabalizes the humerus where
ant and superiorly
scapular wall clocks are good for what muscles
low/mid trap
wall washes are for what muscles
low trap and serratus
if winging is occuring with raising of arm, think what muscle
serratus ant
3 main components of pathoanatomic classification of dx
pts with that patho dx look similar and should be treated similar
Must fix pathologic anatomy for pain and function to improve
strong relationship btwn tissue pathology and pt complaint
Scap DR syndrome: if pt sx decrease if you assist their scapula in UR, what might you infer
that they are pos for DR syndrome
explain scapula DR syndrome
they are stuck in DR, When you abd shoulder the scap should UR. However, with scap DR syndrome it doesn’t UR
Rhomboids and levator are dominating
px probs assct w scap DR syndrome (pathos)
GH impingement
rotator cuff tear
humeral subluxation
thoracic outlet
explain scap depression syndrome
low trap is dominating
scap elevators are stretched
passive elevation decreases their sx
what px or pathos are assct with scap depression syndrome
neck px
impingement
scap depressors
lats, pecs
explain scap abd syndrome
stuck in abd and won’t return to add (excessive abd)
abd are tight, add are stretched
Dominance of serr ant., dominance of both pecs
Short: pecs
long/weak: scap adductors
pathos/px assosiciated with scap abd syndrome
TOS
subluxation
impingement
scap tilt syndrome
Dominance of pec minor, dec activity of serratus and low trap
Short: p. minor
long/weak: serratus
pathos/px associated with scap tilt
tos
impingement
scap winging syndrome (explain)
Dominance of pec minor
dec activity serratus
timing problem of low trap
pathos assct with winging
GH impingement
thoracic outlet
GH subluxation
scap elevation syndrome (explain)
stuck in elevation
dominant scap elevators
causes cervical/neck px
if pec minor is shortened, it can cause ____ of scap
ant tilt
stages of intervention
Stage I: Relieve Primary Impairment
Stage II: Relieve Movement Issues at Adjacent Body Segments
Stage III: Address Global Issues
why is Tspine important with humeral/shoulder motion
Upper segments must extend with humeral elevation
this is why we need to stretch tspine for shoulder limitation pathos
Also, you should palpate upper Tspine during shoulder elevation - if Tspine has no mvmt do PAs
explain prone low trap therex we did in class
prone
scaption
thumb up, raise arm
explain prone mid trap there
prone
arms in t out to side and raise arms
thumbs up
explain a simple therex used early on in order to strengthen serratus anterior
wall slides Above 90 degrees SCAPULAR PLANE Early in rehab Watch excessive upper trap activation prevent winging
explain 3 serratus ant therexs that would be good to progress to after wall slides
Scaption above 120 deg. with hand weight
Important to work above 90 deg to fire serr. Ant
or upper cuts that go above 90
or dynamic hugs
wall washes are a good closed chain therex for what 2 muscles
serr ant
low trap- coming down
scapular clocks are good closed chain therex for what 2 muscles
low and mid trap
with the prone therex for mid traps vs rhomboids (arm out to side not in scaption), how would you isolate one vs the other
mid traps is thumb up, rhomboids is thumb down
why might serr. punches not be the best therex choice
bc pec major dominates
what might we need to consider with isometric therex
their force used
we need to monitor it (bladder) bc if they over do they can cause ischemia
best supraspinatus therex for impingement pts
Open can is best (thumb up) bc it doesn’t cause sx with impingement pts
how to isolate/exercise teres minor
prone 90/90 ER with light wt
elbow on pillow
best way to progress (in general) therex
Do Scapular stability before rotator cuff!
Closed chain before open chain
why do closed chain ex first
Promotes co-activation (R Cuff) Increases scapular activity Decreases tensile stress Improves proprioception Start with scapular stabilization
list the progression of therex if you are working on scap stabiilty
static postures - set scap and hold
isolated GH motion- stabalize scap and do shoulder IR/ER
Large shoulder ROM under controlled situations (proper timing of mm) - bands or pulley through entire range
Loaded mobility upon stability - side plank with pnf
explain how to dose RC therex
Rotator cuff mm are endurance-type mm
Increasing load too quickly causes compensatory movement
Do high reps low load
explain (in general) the progression of how to increase dosing of therex
Increase load Increase speed increase Power Multiplane Sport-specific
explain the considerations for hypo/hypermobile joints with dosing therex
Hypomobile joints – exercise through entire range
Hypermobile joints – stay mid to shortened range
** may need to gradually introduce normal end-range motion
with shoulder rehab, educate pts to avoid/modify what lifts during workouts
bench press (limit range, grip) military press pull downs
is pull or push better for the shoulder/scap
pull
easy way to special test either epicondylitis
palpate the origin of the muscle and do resisted testing
lat epi = resist ext
medial epi=resist flexion
what is the lat epicondylitis test where you resist 3rd digit ext
Maudsleys
tendons effected by DeQuarvains
abd Polli longus
Extensor polli brevis
explain bunnel littner test
you passively measure PIP without MCP flexion then flex the MCP and measure the flexion of the PIP) if they are different there is imbalance
the PIP has more flexion with the MCP flexed then with it is tight intrinsic muscles
If PIP does not move further and does not reach full ROM, consider capsular tightness.
froment tests what nerve and what muscle is isolated
ulnar
adductor pollicus
normal sternal rib angle
90 deg
narrow sternal rib angle would indicate
tight ext obliques
wide sternal rib angle indicates
tight internal obliques
tight ext obliques can do what to pelvis/lumbar
: shortness or stiffness contributes to excessive posterior pelvic tilt and lumbar flexion.
ext oblique prevents/controls ____ pelvic tilt
ant
low lying AC joint might indicate lengthened __
upper traps (ant tight lower traps)
Palpate under sternal notch as pt drops chin to chest then chin to ceiling (flex neck)
This describes what test, and what is it for
spinal activated manubrium test
if you get rotation on one side where you are palpating then there is tightness in the spine somewhere (you should feel same thing on both sides of your thumbs/fingers
sup angle of scap is approx at T __
T2
spine of scap is approx at T __
T3
when you are doing the palpation technique where you push the sternum post and palpate the transverse processes, what stays stable and what moves
C7 stays stable with ext
T1 will move post as you push on sternum
Jim says to teach what breathing techniques for any acute Cspine pts
diaphragmatic
during diaphragmatic breathing, if there is increased px with exhalation vs inhalation what might this indicate
exhale -disc
inhale -rib
in scap elevation syndrome, if the superior angle of the scapula is high, but the acromion is normal, it suggests tighness of what muscle
short levator scapula.
in scap elevation syndrome, if the entire scapula AND the acromion are high it suggests tighness of
upper trap
differentiate stretching upper trap vs levator scap
upper trap is sb away rot toward
levator scap is sb away rotate away
differentiating btwn look of ant tilt or winged scap
ant tilt= about the inf angle, it comes off ribs
winged = is about the vert border, it all comes post
in general, if the issue is impingement, what should you work on
work on ER of RC to bring the humeral head down
a dominant delt would do what to the humerus
sup glide
if ER is restricted, how to tell if it is tight IR or capsule issue
If there is decreased glenohumeral ER with the arm abducted to 45º, consider a short subscapularis; if there is decreased ER with the arm abducted to 90º, suspect a tight capsule.
humeral head depressors, why are they significant
Infraspinatus
Teres minor
Subscap
During impingement (or shortened delts), working on the depressors can help to add more space and pull the humerus down
normal resting position clavicle
normal is slight upward to acromion
normal rib cage resting angle
Normal is 90
normal resting position humerus
Normal = less than ⅓ of the humeral head should protrude in front of the acromion, antecubital crease should face forward and olecranon should face posterior
axns of SCM
CRIS
contra rotation ipsi SB and neck flexion
treatment for moderate stage of ad. capsulitis
● Treat with: 5-15 s AAROM, AROM, grade II-III posterior mobs AP technique, begin functional activity. Work on ER
explain sx of moderate stage adhesive capsulitis
their Pain 4-6/10, it’s intermittent, moderate disability, pain at end range
explain fibromyalgia
a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.
AMPLIFIES painful sensations by affecting the way your brain processes pain signals.
● Causes: physical trauma, surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event.
● Many people who have fibromyalgia also have tension headaches, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, anxiety and depression.
● Things that can ease symptoms include:
○ exercise
○ relaxation
○ stress-reduction
what is myofascial syndrome
Myofascial pain syndrome is a chronic pain disorder. Pressure on sensitive points in your muscles (trigger points) causes pain in unrelated parts of your body.
Inf shoulder mobs help improve
abduction
flexion
post shoulder mobs help improve
IR
flexion
hor add
Ant shoulder mobs help improve
ext
ER
hor abd
○ Form of massage using circular strokes with palm of hand
effluerage (stroke)
kneading massage is aka
pettriassage
contraindications to massage
- Obstructive Edema: (note that massage is indicated for non-obstructive edema.)
- Active malignancy: might spread the malignant cells 3: although massage during end-stage disease is most probably okay.
- Thrombophlebitis: might throw an embolus.
- Hematoma
- fractures
- In post-operative areas (e.g. around sutures, grafts, etc.)
- Around lacerations
- Active communicable diseases (via routine contact, open lesions, etc.)
- Mental disturbances: if you think there might be a chance that your touch could be misunderstood, don’t do it.
Indications for massage
- Amputations: increases circulation
- Arthritis: decreases edema
- Burns: stretches skin to lessen scar formation, increases circulation
- Bursitis: decreases edema
- Myositis: increases comfort
- Facial paralysis (e.g. Bell’s palsy): stimulates circulation around the nerve site.
- Inflammation (can decrease residual edema)
- Insomnia: increases relaxation
- Pain
- Postural dysfunction: stretches muscle
- Prolonged bedrest: stimulates circulation to pressure areas.
- Scar tissue/contracture: softens collagen
- Edema (non-obstructive)
type of effluerage For this stroking technique, both hands are used and typically sweep toward and away from each other
fulling
type of effleurage that is used for deep pressure, heavy form of stroke - use fist
knuckling
effleurage improves
circ flow (main feature)
things we focus on in stage 1 of intervention
● Relieve Primary Impairment - mobs and positioning
■ Educate the patient, discuss goals, ○ Immobility/Modified Activity ○ Mobility - how can we improve it? ○ Fear avoidance behavior ○ Educate on positioning ○ Exercise and conditioning - how can we progress it? ● Start with the concordant signs/sx
and mobility needed for function
things we focus on in stage 2 of intervention
Relieve movement issues at adjacent body segments
● Treat regional movement impairments;
● PROXIMAL STABILITY BEFORE DISTAL MOBILITY
● ex:
○ First Rib: if elevated could interfere w/ clavicle inf glide needed with humeral elevation
○ T-Spine: upper segments must extend with humeral elevation
HU medial glide is for
flexion and add
HU lateral glide is for
ext and abd
medial and lateral gap glides are for
flex, ext, pronation
HR dorsal/post glide is for
ext
HR volar/ant glide is for
flexion
prox RU post
pro
prox UR ant glide is for
sup
dist RU post glide is for
sup
dist RU ant glide is for
pro
post/dorsal wrist glide improves
flexion
ant/ventral wrist glide improves
wrist ext
radial wrist glide improves
ulnar deviation
ulnar wrist glide improves
radial deviation
joint mob grade progression for stages of adh. capsulitis
irritable -grade 1
moderate-grade 3
low irritable-grade4
what muscles are dominating in scapular DR syndrome
rhomboids
levator
RC tear is assct with what syndrome
DR syndrome
proximal ____ before distal _____
stability before mobility
diff btwn a neural slider and tensionor
tensioner you are lengthening at both ends
slider you lengthen 1 end only
maitland = \_\_\_\_ standard ULNT (1) test = \_\_\_\_ ULNT 2 and 3 = \_\_\_\_
maitland = slump
standard = elvey
2 and 3 = butler
2 main tension points in body
ant elbow
post knee
pulling like a tight string, catches of pain and tightness is ____ neural
extraneural px
symptoms such as bizarre clumps of pain, crawling, antlike, dry, woody, and dragging and report sensations of swelling, burning or electricity are ___ neural
intraneural
ULNT 1 stresses what
brachial plexus and the median nerve.
ULNT 2a (Mb) stresses what
brachial plexus and the median nerve.
steps to ULNT 2a
Shoulder girdle depression Elbow extension GH lateral rotation Wrist and finger extension GH abduction
steps to ULNT 2b
Shoulder girdle depression Elbow extension Forearm pronation and shoulder medial rotation Wrist flexion Thumb flexion and ulnar deviation
ULNT 2 b stresses
brachial plexus and radial N
ULNT 3 stresses
ulnar nerve
steps to ULNT3
Shoulder girdle stabilization Full elbow flexion Wrist extension Forearm pronation Shoulder lateral rotation
great way to stretch Tspine
lay on vertical bolster or towel
ball overhead and hold stretch at end range
what is a key component to strengthening serr ant (position wise)
do above 90 deg
which elbow glides are “backwards” from your thought process
HR
proximal RU
distal RU make sense
tx for high irritability adhesive capsulitis
ROM: short duration (1-5 sec holds), pn-free range or px less than 3, PROM, AAROM
explain how traps can be weak in scap DR sydrome
it’s lower traps
Serratus and trap force couple for UR, so if these are weak then UR is an issue and the scap is stuck in DR
what muscle is weak in scap DR syndrome
lower traps
steps to ULNT1
○ GH abduction ○ GH external rotation ○ Forearm supination ○ Wrist and finger extension ○ Elbow Extension
adhesive capsulitis is restricted in both ___ and ___ movements
active and passive
the 2 shoulder pathologies with clicking/popping
labral tears/instability
impingement
with a RC tear, is PROM usually an issue
no
which flexor is most common for medial epicondylitis
FCR
what N is cubital tunnel involved
ulnar
diff btwn radial tunnel syndrome and post int syndrome
radial tunnel is sensory loss and px at lat elbow
post int is motor loss of finger/thumb ext
loose bodies
ant LAT elbow px
necrosis
osteochonritis dissecans
panners disease
lateral elbow px
young pts
necrosis of bone
Little leagers elbow
young
medial elbow sx/px
