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Musculoskeletal Lecture > Tendinopathies of UE > Flashcards

Tendinopathies of UE Flashcards

1
Q

Tendons

A

Connect Mm to bone

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2
Q

Tendinopathies often fall in the category of

A

Cumulative Trauma (CTI) or Repetitive Strain Injuries (RSIs)
* Common work related injuries
* Can occur in anyone
* Can affect tendons and or Nn (nerve issues usually
due to the inflammation and swelling

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3
Q

Other causes of Tendinopathy

A

Falling on an area
Trauma induced tendinopathy
Poor blood flow
Poor posture and mechanics
Poor proximal stability and core strength decreased ability to maintain a good safe posture leading to added stress on the tendons
* Tendonitis or nerve issue = always correct posture

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4
Q

Tendon pain

A

“itis” (inflammation)

“osis” (scar tissues) - fibrosis of the tendon that has been injured more than once and laid down scar tissue (tendinosis)

“algia” (nerve irritation)

Could have a combination of all the above, which makes it hard to treat

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5
Q

Tendonitis

A

Inflammation process. Inflammatory cells found in tissue.

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6
Q

Tendinosis

A

Degenerative process with fibrosis, decreased circulation. Fibrosis found in the tissue.

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7
Q

Tendonalgia

A

“Pain” neurogenic in nature. Free nerve ending are irritated and signaling “pain” to the brain. Neurotransmitters and inflammatory markers are present (immune system signals and sends those out)

*Doctors often call it tendonitis but does not mean you 
 take that at face value, so you must ask ?'s to figure out 
 if it is "itis"  "osis"  "algia".
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8
Q

Tenosynovitis

A

The synovial sheath the tendon runs through is also inflamed

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9
Q

Combination

A

Various processes occurring simultaneously

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10
Q

Tendinopathy Secondary to an RSI

A
  • Repetitive use especially against resistance
  • Repetitive sheering of tissue across a bone
  • Extreme postures for prolonged period of time
    Pulls on the origin and insertion sites
  • Carrying resistance when Mm are stretched
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11
Q

Lateral Epicondylitis (Tennis Elbow)

A

Very common

Very challenging diagnosis (is it inflammation = acute or scar tissue = chronic????

Originally is an “itis”

Starts as inflammation of the tendon fibers that attach the forearm extensor Mm to the lateral epicondyle

Routine use of the arm causing shearing of the ECRB over the radial head especially with the elbow extended or an injury to this area may stress or damage the muscle attachment

During healing the tendons often get stuck in fibroplasia (the process of forming fibrosis tissue)
The tissue has a failure to thrive.
Calcification, rupture and additional fibrosis follows.

Shearing over radial head and stress to muscle attachments

First stage wants to lay down collagen = fibrosis

Usually caught after the inflammatory stage

Difficult to alleviate symptoms if the condition is chronic

Treatment is different for acute vs chronic

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12
Q

Over 23 ailments that can cause lateral elbow pain

A

Cervical Radiculopathy =
(C5/C6) narrowing of foramen (compression)

Proximal Neurovascular entrapment of lateral ante brachial cutaneous nerve

Arthritis

Tumors

Radial Tunnel/PIN entrapment = big one that mimics or coexists with tennis elbow (Posterior Interosseus Nerve entrapment)

Distal biceps insertion at radial tuberosity

Triceps insertion at olecranon

Shoulder tendonitis

Carpal Tunnel Syndrom

Trigger points

Loose Bodies (bone fragments (often see with falls, do X-ray

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13
Q

Anatomy

A

Common Extensor Origin:
* ECRB = biggest, primary structure involved in LE and
has a poor blood supply at origin
* EDC = next biggest, the EDC of long finger combines with
the ECRB tendon to insert at the lat epicondyle
poor posture and body mechanics while typing
and playing piano. Excessive use of EDC instead
of floating digits can lead to LE
* ECRL
* ECU

  • ECRB = origin: lat epicondyle of humerus
    ins: base of MC 3
    actions: ext and radial deviation of carpus
    nerve: deep radial N
    * active during sup and pro
  • EDC = origin: lat epicondyle of humerus
    ins: extensor expansions of dig 2-4 and distal
    tendon of extensor digits minimize
    actions: extends carpus and dig 2-5
    nerve: deep radial N
  • ECRL = origin: lat supracondylar ridge of humerus
    ins: base of MC 2
    actions: ext and radial deviation of carpus
    nerve: radial N
  • ECU = origin: lat epicondyle of humerus and post
    border of ulna
    ins: base of MC 5
    actions: ext and ulnar deviation of carpus

When pt have been casted, after cast is removed they have a tendency to want to use the EDC to extend the wrist = put a pen or pencil in their hand and then have them extend the wrist this will force them to use their ECRB and ECRL

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14
Q

Lateral Epicondylitis

A

NOT usually an inflammatory conditions
Tissue death due to:
* Microscopic tears of ECRB and EDC
* Calcifications = muscle started hardening and turning
into bone
* Excessive granulation = lots of scar tissue
* Alteration in neuropeptides = things that are not
supposed to be there
* Avascular areas = scar tissue
* Adhesions = things are stuck
* Mucoid Degeneration

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15
Q

Immuno-reactive neurogenic component to lateral epicondylitis

A

Presence of Neuropeptides/Neurokinin 1-receptors, Substance P (SP) and calcitonin gene related peptide (CGRP)

Glutamate = good when it is supposed to be there but toxic if not supposed to be there. Toxic to nerve tissue and eats away at it, therefore free nerve endings increase sensitivity and pain.

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16
Q

Evaluation Components

A
  • History how long and how many times have they had LE
    (<12 weeks = acute) (>12 weeks = chronic)
  • Cervical screening- Dermatomes and Myotomes
  • Visual Analog scale (unidementional measurement of
    pain intensity
  • Grip strength (elbow flex and ext if not in a lot of pain)
  • Pinch strength
  • Palpate for tenderness:
    radial head
    lateral epicondyle
    radial tunnel-crepitus, 2-5cm distal and ant to
    LE. Radial tunnel 4
    finger widths and dorsal
    over supinator
  • Arcade of Frohse = where radial nerve bifurcates
    (dives deep) and can get
    trapped
  • If posterior interoseus nerve gets pinned, it can look like
    LE
  • Can have both radial tunnel and lateral epicondylitis
    (LE = tennis elbow and arcade of frohse = radial tunnel)
  • If long finger extension test causes pain = ask where
    the pain is, LE = TE and arcade = RT
  • Resisted wrist extension, supination (Cozen’s Test)
    pain = ask where and if pain at rest is greater than
    5 do not do resistance training
  • ROM/Muscle tension with composite stretch
    progressively check positional progress and can use as a
    treatment tech, always stretch if non-painful
  • Patient Rated Functional Assessment: PREE, DASH
  • Muscle strength if not in a great deal of pain
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17
Q

Grip Strength Tension Test

Indiana Hand Center

A

Should be seated
1) Elbow flexed
2) Elbow extended, wrist neutral and full pronation
Places tension on the origin (stretching and grip)
Positive = decrease in strength, probably TE
Negative = no decrease in strength, not TE
3) More challenging is extend arm horizontal to floor

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18
Q

Treatment Interventions

A
  • Always proximal to distal, correct posture (rhomboids,
    post delt) and strengthen coreForward shoulder and int rotation puts tension on
    lateral elbowExt rotation = puts force on medial elbow (Tommy
    Johns surgery)
  • Determine whether condition is inflammatory or chronic
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19
Q

Inflammatory Tendonitis

A
  • Rest
  • Ice massage or cold packs
  • Cortisone injections
  • Iontophoresis using Dexamethasone ( do not do
    if they have had a cortisone shot)
  • Stretching exercises = as long as it is done progressively
    it should be pain free
    full stretch for ECRB = arm extended, hand in fist with
    ulnar deviation
  • Wrist support = only decreases firing of extensors
    7%
  • Tennis elbow strap = only works with power gripping
    wear 2 inches below LE, if worn wrong could compress
    radial nerve, good for placebo effect
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20
Q

Chronic Tennis Elbow

A
  • Most of what we see
  • Scar tissue needs blood flow and remodeling (use heat)
  • Exercise (graded eccentric exercises (help with
    concentric and let them do eccentric, want to remodel
    and elongate scar tissue, more reps less weight
  • Best way to warm up tissue is active exercise, arm bike
    focused on extension
  • Progressive stretching
  • Joint mobilization (loosen up capsule)
  • Modalities-Heat focus (hot packs)
  • Strengthen core and correct posture
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21
Q

Acute or Chronic Interventions

A

Long arm elbow splint for night wear, placing arm at 35 - 40 degrees of flexion to prevent extreme flexion which also places stress on the extensor origin

About 6 weeks if tolerated

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22
Q

Physical Agents Modalities (PAMS)

A
  • Ultrasound/Phonophoresis
    used to administer meds (dexamethasone)
    transcutaneously but now docs do cortisone
    injections (with cortisone may raise blood sugar
    if they have diabetes be aware)
  • Cryotherapy
  • Heat
  • High volt Iastem
  • TENS
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23
Q

Exercise

A

Controlled and close to body, working toward farther away

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24
Q

Instrument Assisted Soft Tissue Mobilization

A

Scar tissue massage through skin

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25
Q

Kinesiotape

A

Opening over the arcade of frohse = decompress radial nerve, relaxing extensors

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26
Q

Alternative Modalities

A

Acupuncture = Short term pain relief (24 hrs)

Extracorporeal Shock Wave therapy: very expensive, cortisone found to be more effective

Low Level Laser Therapy = no evidence except when used in combination with PT

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27
Q

Cortisone injection

A

Occasionally work
Dependent on timing of injection
May have an effect on the sensory nerve response
Cortisone injection can lead to cell death and atrophy and inhibits collagen synthesis

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28
Q

Autologous Blood Injections/Protein Rich Plasma (PRP)

A

Induce healing by providing cellular mediators

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29
Q

Botox Injections

A

Decreased muscle activity by blocking actylcholine gates

30
Q

Surgical Intervention

A

Open/Incision
Arthroscopic
Fasciotomy = fascia cut to relieve tension
Debridement = clean up
Percutaneous release = needle used to break up constricted tissue around tendon sheath
Split procedure = lengthen ECRB

70-80% success rate
Eventually resolves on its own in 2 yrs

31
Q

Exercise:

Selecting the most beneficial exercises based on tissue healing

A

Timing of exercise within the healing process needs to be adjusted for each patient

Pain should be resolved or minimal when beginning resistance training

Exercise should be performed without pain

32
Q

Progressive Stretching

Indiana Protocol stretches

A

An example of using the concept of non-composite (close to the body) and working toward composite movement (further away from the body)

The next progression would include overpressure in non-composite and working toward composite with overpressure

The patient is advanced when the stretch can be performed without pain or discomfort

33
Q

Progressive Stretching with Over Pressure

Mills Stretches

A

Be Careful!!!

Aggressive stretching can cause damage to tendon

All wounds result in scars and all scars contract

Flexors and extensors should be stretched

Start with elbow bent and passively use the other arm to apply over pressure

34
Q

Resistance Training

A

Stretch and controlled eccentric strengthening were found to have significant effects on decreasing pain and improving grip in the long-term

Always start when pain level has decreased and non-composite first working toward composite

35
Q

Controlled Strengthening

A

Strengthening may begin once pain becomes minimal as long as it can be performed without increasing pain

A general warm up on the UBE (forward motion) may be performed to increase blood flow.

Exercised should be initiated in a non-composite (elbow flexed) position.

Motions should be slow and controlled

Could vary speed of motions between sets

Eccentric exercises more effective (therotube = great for constant eccentric pull)

36
Q

Pronation/Supination

A

The ECRB is active during supination and pronation

All forearm and wrist muscles should be strengthened as well as the rest of the kinetic chain including shoulder and elbow

37
Q

Wrist Flexion
Biceps and Triceps
Scapular Stabilizer
Rotator Cuff and Scapular Stabilization

A

Perform all exercises slow and controlled

May choose to start without resistance and advance

Once patient can perform 3 sets of 10 the resistance can be increased

Scapular Stabilizer = Prone extension
Prone scaption
Prone horizontal abduction

Rotator Cuff and Scapular Stabilization = rhomboids and
middle trap

38
Q

Speed, Accuracy, Neuromuscular Reducation

A

Advanced rehabilitation should focus on motor performance including speed of motion and reaction time

Athletes

Rhythmic Stabilization

Specific Sports Training
Work Hardening

Ex: wad up newspaper into small ball and throw into trash

39
Q

Other beneficial exercises

A

Radial Nerve Glides ( not full extension)

EDC exercises = rubber bands around fingers, putty (start close and work towards far away

Clam shells (glut med) important to maintain neutral alignment of pelvis

Neutral pelvis with isometric contractions of the transverse abdom

Diaphragmatic breathing = keep tilt of pelvis neutral by tightening the transverse abdomen

40
Q

Activity Modification

A

Avoid repetitive wrist movements

Avoid excessive finger extension (keyboarding)

Avoid lifting (especially with arm in pronation) and pulling resistance-car door, refrigerator, brief case, coffee pot, skillet, jug of mild etc

When using the effected extremity try to lift with the flexors with the forearm supinated and close to the body

Maintain good posture = a forward internally rotated shoulder increases forces on the lateral epicondyle origin

41
Q

Sports Modification

A

Technique

Interval Training

Proper equipment = light racket made of graphite
string tension 52-55lbs

42
Q

Medial Epicondylitis

A

Golfers Elbow

Results from repetitive wrist and finger flexion or repetitive motion against resistance

Involves the common origin of the wrist and finger flexors

Ulnar nerve can get inflamed resulting in pain, tingling, and numbness in the ulnar nerve distribution of the hand

Avoid lifting with forearm supinated and elbow extended

43
Q

Medial Epicondylitis Assessment

A

Palpation of the medial epicondyle

Clear sensory and motor ulnar nerve at the cubital tunnel

Do they have tingling?

44
Q

Trigger Finger - A1 Pulley Tenosynovitis

A

Tendon has to go through pulley system

Can happen in multiple fingers

Flexor Retinacular Pulley System: 5 annular pulleys
3 cruciate pulleys

  • A2 and A4 are necessary for finger mechanics. Prevent bowstringing
A1 - metacarpal head
A2 - proximal phalanx
A3 - PIP
A4 - middle phalanx
A5 - DIP

FDS and FDP run through the pulley system

Pulley system keeps tendons up close to the phalanges and allows us to flex jt by jt by jt

3 cruciates usually at joints

45
Q

Dupuytren’s

A

A fascial contracture = disease in the fascia (enzyme, hereditary). The fascia in the palm contracts, has pitting and thickening of fascia

46
Q

Trigger Finger

A

Swollen tendon creates a nodule that gets pulled under the bridge, can’t get back out when trying to extend

In early stage it can be manually released

Common in the thumb

47
Q

Risk factors for trigger finger

A 
RA
OA 
DM
Other inflammatory conditions
Repetitive gripping
Sustained pinching (thumb)
48
Q

Patient symptoms for Trigger finger

A

Tenderness at the level of the A1 pulley
May c/o pain volubly over A1 pulley or with active flexion

There might be a presence of a nodule or thickening
Thickened flexor sheath can be palpated

  • Palpate for tenderness and thickness on palmar surface of A1 head (MC head)

Don’t confuse with Dupuytren’s Disease

Finger clicks when trying to straighten

Finger gets stuck

49
Q

Green Classification of Staging for Trigger Finger

A

Grade 1 = Pain and tenderness at A1 pulley
Grade 2 = Catching of digit
Grade 3 = Locking of digit which is passively correctable
Grade 4 = Fixed locked digit, joint contracture

50
Q

Trigger Finger Treatment

A

Conservative management through therapy
Splinting: hand based flexion block fitted with MCP
being the only jt immobilized in neutral
extension (try to block MP flexion, allow
PIP/DIP flexion, splint on one finger)

                   include only involved digit or adjacent
                   digit for comfort

                   wear up to 6 weeks, usually 3-4 weeks

   Patient education: important with respect to modifying
                                   provocative activities, avoid or 
                                   minimize activities that require 
                                   repetitive gripping or demand a 
                                   sustained pinch

    Digit is immobilized from making a full fist for up to 6 
    weeks (hook fist allowed in splint or intrinsic plus 
    grasp is used).  PROM can be performed to MP with
    IP extended at 3 weeks if MP flexion block is used

    At 4 weeks PROM to a full fist flexion, 5 times holding
    10 seconds

    Progress  re-evaluated after 6 weeks by assessing
    comfort during AROM

    If all that does not work:

    Medical Management:
    corticosteroid injection into tendon sheath

    Surgical Intervention:
    very easy snip
    the A1 pulley is released leaving the A2 pulley intact

    in patients w/ RA the A1 pulley is not released b/c
    this would enhance the biomechanical forces that are
    in part responsible for ulnar drift at the MP joint

    open procedure = 1cm horizontal incision 

    Post surgical management:
    2-3 days post op AROM 6x/day x 10min each
    isolated tendon glides, differential tendon glides,
    MP ext/flex with IP joints flexed - moving into 
    extension as incision heals (2-3 wks)

    splinting is usually not necessary s/p release
    exception = limited MP or IP joint extension; wear at
    or if quite painful

    10-14 days: scar management and desensitization 
                       techniques (silicone, heat, US, fluido, 
                       textures)

    3-4 weeks: gently strengthening if wound has healed
                       (putty, hand exerciser, HEP)

     * because they did not repair anything you don't have 
        to wait 8 weeks, same with CTR
51
Q

Tigger Finger Exercises

A

Avoid full active flexion of the digit, but passively stretch to not get too tight

Maintain PROM of each joint

Perform individual joint blocking exercises (DIP, PIP, MCP)

Perform finger extension exercises

In severe cases = PIP blocking but it is better to block MCP b/c that is where A1 pulley is

52
Q

DeQuervain’s Tenosynovitis

A

Inflammation or tendonosis of the sheath (retinaculum) of the tendons in the first extensor compartment

Starts as an “itis” and turns into an “osis”

53
Q

S/S of DeQuervain’s

A

Pain on the radial side of the thumb when pinching or grasping objects (radial styloid pain)

Sometimes can see swelling

Rule out CMC arthritis of the 1st Metacarpal joint
by doing test (called differential diagnosis, always paint the picture for the doctor)

Superficial branch of the Radial Nerve runs along the same path as tendons involved with this and it responds to tension and stress along with muscles when forces are applied

54
Q

The Extensor Compartments

A

6 Dorsal Extensor Compartments starting from radial side and working over to ulnar side

221211 = how many tendons are in each compartment
longus, brevis, longus, brevis across

First Dorsal Extensor Compartment:
APL (abductor pollicis longus)
EPB (extensor pollicis brevis)
These pull the thumbs away from the palm

Second Dorsal Extensor Compartment:
ECRL (extensor carpi radialis longus)
ECRB (extensor carpi radialis brevis)
These extend and abduct carpus

Third Dorsal Extensor Compartment:
EPL (extensor pollicis longus)
extends pollex and carpus

Fourth Dorsal Extensor Compartment:
EDC (extensor digitorum communis)
EIP (extensor indicis propreous)
extends carpus and digits 2-5

Fifth Dorsal Extensor Compartment:
EDM (extensor digiti minimi)
extends carpus and digit 5

Sixth Dorsal Extensor Compartment:
ECU (extensor carpi ulnaris)
extends and adducts carpus

  • If surgeon releases but does not release the sheath, it will not get better
55
Q

Intersection syndrome

A

ECRB and ECRL but as it crosses over APL and APB

Pain is higher up

56
Q

DeQuervain’s Tenosynovitis Diagnosis

A

Blackberry thumb
Game keeper thumb = not DeQuervain’s but ulnar collateral ligament

  • If you can visualize swelling, must measure edema and compare to the other side

Positive Finkelstein’s test
(Eichhoff’s test = active contraction with active stretch will cause tension, do not do this test)

Pain along first dorsal compartment

Decreased pinch and grip = lets us know how it is affecting function

A nodule or thickening of the extensor retinaculum

57
Q

Eichhoff’s test

A

This test aggravates the radial superficial nerve and can cause a false postitive

Not specific or sensitive enough to test for DeQuervain’s

58
Q

Finkelstein’s test

A

Progressive tension testing =

  • ulnarlly deviate (forearm in neutral) no thumb
  • passively ulnar deviate (no thumb)
  • still ulnar deviation and then passively flex thumb

positive if pain over the dorsal compartment is present when the wrist is ulnarly deviated while the thumb is held in flexion

unlikely to have pain in the first 2 stages if chronic

59
Q

DeQuervain’s Etiology

A

Frequently results from repetitive motion

Could also result from blunt trauma to the styloid process

Overuse and improper mechanics of gripping and wringing

Pregnancy = Prolactin

60
Q

DeQuervain’s S/S

A

Pain with grasp/release activities near base of thumb

Edema near base of thumb

Decreased range of motion: specifically in thumb

Limited in flexion (stretch) and full extension (doing job)

61
Q

DeQervain’s Tenosynovitis Treatment

A

Conservative management non-surgical (therapy and docs) could include medications

All should get a thumb spica splint, most cross hand and immobilize ulnar deviation

Must rest

Splint: Thumb Spica
Wrist 15 degree extension
MP 10 degree flexion, thumb MCP midway
between palmar and radial abduction
2/3 up forearm

        * splint doff qd (once a day) to perform isolated 
          wrist/thumb AROM - progress to PROM

        * remove 4x/day for A/PROM to thumb and wrist 
          separately

        * must be able to oppose to digits 2 and 3

Medical Management: NSAIDS
Corticosteroid injections
Surgical intervention

Surgical intervention: decompression of first dorsal compt
cut retinaculum 1cm incision vertical

Post surgical therapy: initiate therapy within first 10 days
(scar mobilization once sutures out)

                                 manual desensitization along super-
                                 ficial branch of radial nerve

                                 gently edema mgmt

                                 light compressive dressing

                                 gentle AROM / AAROM / PROM
                                        4-6x daily x 10 mins

                                 3-4 wks initiate wrist and thumb
                                 strengthening exercises as well as
                                 fx use of hand
62
Q

Intersection Syndrome

A
  • Not as common as DeQuervain’s but can be misdiagnosed = pain may be higher up and on dorsal side more than radial

Tenosynovitis of second dorsal compartment crosses at the radial dorsal forearm (3 to 6cm proximal to the location of DeQuervain’s or radial styloid)

APL, EPB cross the ECRL and ECRB

Repetitive motion or direct trauma

Pain, crepitus (fascia has fluid bound up in it, soft tissue work is helpful), edema, point tenderness

63
Q

Intersection Treatment

A

Thumb spica splint with wrist in 15 to 20 degrees of extension

Pt education: Avoid repetitive wrist flexion and extension with combined power grip

Surgical: second dorsal compartment release

64
Q

Flexor Carpi Radialis and Flexor Carpi Ulnaris Tendonitis

A
  • Any tendon can become fibroses or get “itis”
  • On computer typing all day and musicians
    float fingers while typing and don’t type while
    resting on wrist pillows
65
Q

Extensor Carpi Ulnaris and Extensor Digitorum Communis

A

ECU = supination/pronation
b/c in ECU sheath and if sheath not keeping
it in place

After casting = when cast removed our natural wiring
EDC thinks it can move the wrist and if not
corrected will get tendonitis

                     * to correct put pen in hand and extend 
                     wrist to force them to use the ECRL and 
                     ECRB
66
Q

Impingement

A

Forward shoulder

Scapular Dyskinesia

Tight pectoralis minor

Weak serrates anterior

Sleeping posture

Long head of the bicep gets inflamed from repetitive reaching or being “pinched” under acromion process

Supraspinatus of the rotator cuff can also be impinged

67
Q

Proximal Bicep Tendonitis

A

Head of humerus

Inflammation occurs where bicep tendon passes through the bicipital groove and over the head of the humerus, just like a rope through a pulley.

Lots of overhead reaching or forward rounded upper back can be the cause

68
Q

Supraspinatus

A

Always strengthen rotator cuff

Cross friction massage = always ext/int rotation to access supraspinatus

69
Q

Cross Friction Massage

A

Dr. James Cyriax

Transverse friction massage (aka cross-friction and cross fiber massage) is a tech that promotes optimal collagen healing by increasing circulation and decreasing collagen cross-linking, thus decreasing the formation of adhesions and scar tissue

Want to create a little inflammation to produce traumatic hyperemia and a histamine response to help flush the area of substance P

70
Q

IASTM (Instrument Assisted Soft Tissue Mobilization)

A 
Graston
ASTM
Rockblades
Baby spoons
Jar lids
Bones
Rocks
71
Q

Impingement Treatment

A

Posture and Activity Modification

  • Must address Posture (static and dynamic)
  • Strengthen scapular stabilizers
  • Soft tissue work on the Pec Major, Minor or scalenes
    (tight)
  • Soft tissue work on the Upper trap and Levator Scapulae
    (tight)
  • Strengthen lower trap and rhomboid
  • Work on restoring the neuromuscular timing and control
    to correct the motor timing issue
    (Shirley Jarmen PT at Wash U, neuro-orthepedic
    approach)

Musculoskeletal Lecture (14 decks)

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