Test 2 Flashcards
A person with GH instability has an excessive anterior humeral translation on the glenoid. Describe an isometric resistance exercise that directly emphasizes the muscle responsible for reversing this translation
To limit anterior translation target the GH internal rotator, subscapularis.
An exercise emphasizing the subscapularis would be an isometric GH internal rotation with 0 degrees of shoulder abduction to maximize stability of the GH joint during contraction. Resistance can be provided using the other arm or by someone else.
Thoracic spine motion is coupled/partnered with shoulder motion. For each of the following shoulder motions, state the thoracic spine and a scapular motion that pairs with it—flexion, extension, rotation and abduction. For two of these, provide a thoracic mobility exercise to increase that motion.
Flexion: thoracic extension and posterior tilt and superior rotation of scapula; improve thoracic extension using low cobra pose
Extension: thoracic flexion and anterior scapular tilt; improve thoracic flexion using cat pose
Rotation: thoracic rotation and scapular retraction for external rotation, scapular protraction for internal rotation
Abduction: thoracic lateral flexion and scapular superior rotation
For each of the following scapular positions, indicate which specific muscle(s) need to be lengthened and which need to be strengthened, to help reverse the position.
1. Anterior scapular tilt
2. Inferiorly rotated scapula
3. Protracted scapula
- Anterior tilt: lengthen pectoralis minor, strengthen serratus anterior and lower fibres trapezius
- Inferior rotation: lengthen levator scapulae and rhomboid, strengthen serratus anterior and lower traps
- protraction: lengthen serratus anterior and pec minor, strengthen rhomboid and middle trapezius
Explain the difference between scapular winging and excessive anterior tilt and include what would this would look like on a patient. Which muscles are responsible for reversing a winging scapula? For each one, list two different resistance exercises you could prescribe (four exercises in total).
winging is when stabilizing muscles of the scapula lack control and the scapula lifts off the ribcage excessively, which is shown as a prominent protrusion of the scapula, especially the medial border, on a client. Excessive anterior tilt is when the bottom of the scapula lifts off the ribcage but not the top, which is shown as a prominent protrusion of the inferior angle of the scapula on the client.
The muscles responsible for reversing a winging scapula are serratus anterior and rhomboids.
Exercises for serratus anterior for anti-winging and limiting anterior tilt: Y postition, forearm wall slides. Exercises for rhomboids for anti-winging: T position, W position.
Describe how you would perform the hold-relax technique to increase medial rotation of the GH joint. Which shoulder injury or condition is this most likely to be associated with? If this approach was not effective, what static stretches would you try and how could you use SMR instead?
To increase medial rotation, there needs to be a decrease in muscular tone of the external rotators (infraspinatus and teres minor). First, I would hold the arm in an 45 degree GH abducted position (more ROM than 0 degrees but less vunberable to GH instability than 90 degress) with one hand (with consent to touch the client) with the elbow flexed 90 degrees and rotate the GH joint internally in a modified sleeper stretch until a stretch is felt in the posterior shoulder. Then I would ask the client to externally rotate their GH joint isometrically at 10-30 1RM for 5-10 seconds against my other hand then relax. I would then passively move their shoulder into internal rotation.
The shoulder condition most likely associated with this is posterior internal impingement. If this approach is not effective, I would perform a modified sleeper stretch or a modified crossbody stretch to open up the posterior capsule. I can also use SMR with a lacrosse ball on the wall to open up the infraspinatus and teres minor which can be done on its own or with a modified crossbody stretch.
A person with long head of bicep tendinopathy needs a static stretch and a resistance exercise to emphasize the biceps. Briefly describe two static stretches you would consider, and two resistance exercises (with different levels of difficulty).
Two static stretches I would consider are a wall/corner stretch with the elbow extended and forearm pronated and a scootch stretch sitting with arms propped behind, slide hips along ground to lengthen biceps.
Two resistance exercises I would prescribe are an isometric flexion with the shoulder in an extended position which is easier since the joint does not move and target the tendon through a lengthen bicep position. A harder exercise is lowering from a front raise the eccentric motion will challenge the biceps more.
Describe how you would perform the hold-relax technique to reduce excessive shoulder girdle elevation. Why would a patient adopt this pattern (what are they compensating for)? Briefly describe two different resistance exercises you could use to address this.
To reduce elevation of the shoulder girdle I would target the upper trapezius. I would ask the client to depress their shoulders until they feel a stretch then isometrically shrug their shoulders at 10-30 1RM for 5-10 seconds against my hands (with consent to touch them) which will exert downward pressure on their shoulders. Then I will ask them to relax their shoulders as I move them into a new range of shoulder girdle depression.
A patient may adopt this pattern to have greater overhead reach when they have limited superior rotation. I would address this using wall angels (abduction based superior rotation) or a forearm wall slide (flexion based superior rotation).
List four different GH ROM exercises you could prescribe for a patient one-week post shoulder surgery—in addition to general mobility, the surgeon has asked you to include work on shoulder flexion.
Since they are early in their rehab program I would prescribe cyclic motion exercises to move through the ROM they currently have. I would use codman’s pendulum (flexion, extension, abduction), rock the baby with a forward lean (flexion, extension, abduction), table towels slides forward (for flexion) and sideways (for abduction), and dowel assisted movement (flexion, extension, abduction, external rotation) and therapist or self assisted internal rotations.
To improve shoulder flexion ROM, I would stretch the shoulder extensors such as the lats in a wall lat stretch.
Briefly describe four exercises you could prescribe, to help a patient improve their mobility into abduction and lateral rotation—use static stretch and SMR only (two each). Which two muscles are you targeting with these exercises?
To improve abduction and lateral rotation I would target the adductors and the internal rotators. Pectoralis major and latissimus dorsi are both adductors and internal rotators.
Latissimus dorsi: SS lats: wall lat stretch, hands overhead on the wall, with thumbs pointing backwards; SMR lats: foam rolling lats, side lying with arm over head, foam roller under side of body and thumb up, slide foam roller up and down the lat.
Pectoralis major: SS pec major: doorway stretch, standing in doorway hands on the frame, lean forward to lengthen the pec; SMR pec major: foam rolling pec, place foam roller 45 degrees to midline on the gorund, lower chest to foam roller and slide foam roller up and down chest
Explain the cueing strategies you can use to help address base position for a patient with ashoulder injury. Provide three specific examples.
To provide a visual cue demonstrate the exercise and have the client mirror the action. For example, I would demonstrate scapular protraction to the patient and ask them to copy me.
To provide a verbal cue use instructions and imagery. E.g. I would tell a patient to push their shoulders away from their ears to decrease shoulder girdle elevation.
To provide a physical cue use your hands to move the patient into position (with consent) or tell the patient what they should feel. E.g. telling the client to feel their shoulder blades squeeze together.
Describe the pathological tissue changes associated with osteoarthritis. Include clear connections to the structure and function of articular cartilage, and a specific sign you might find on x-ray.
hyaline cartilage has 4 layers. Pathological changes to cartilage are: deepest subcondral bone layer begins to calcify, decreasing ability to absorb force and misshapens to be thicker, causing bony outgrowths in some places as seen in X-rays. second deepest layer is firm collagen that anchors cartilage to bone. second outermost layer mostly fluid with some collagen fibres, loses fluid, and thins, decreasing ability to absorb compressive forces. outermost thick cartilagenous shell made of collagen begins to thin, decreasing ability to withstand compressive and shear foces.
Other pathological changes are synovial membrane also misshapens and thins. synovial fluid loses viscosity, decreasing ability to reduce friction, and menisici will also thin out, decreasing ability to absorb compressive forces.
these changes together increase chronic inflammation, pain, and joint stiffness.
Full knee extension can be challenging to recover in rehabilitation—describe the complex of motions that combine to allow full knee extension to happen. Outline a progression of three resistance exercises to help a patient strengthen near full extension—briefly describe each one.
To fully extend the knee, the tibia must rotate externally and the patella must translate inferiorly.
To progress knee extension, a quad set can be performed as a non-weight bearing resistance exercise in early rehabilitation by placing a towel under the knee and pressing into it to extend the knee. Next, body weight squat for weight bearing, standing with feet shoulder width apart and bending at the knees to lower the body to ground. Then progress to a loaded split squat weight bearing focus on eccentric phase and address asymmetries with greater unilateral focus on front leg and challenging the hip abductors, in split stance, feet shoulder widith apart, holding weight, lower into a lunge position then stand up straight.
Full knee extension can be challenging to recover in knee rehabilitation—describe the complex of motions that combine to make full knee extension ROM happen. List three different mobility/ROM exercises you can use to increase this end range—one for early rehab, and two for later stages. For the two later stages, use different ROM strategies.
To fully extend the knee, the tibia must rotate externally and the patella must translate inferiorly.
In early rehab, a heel prop with overpressure uses gravity to passively increase knee extension. In later stage rehab, use a static hamstring stretch using a pyramid stance or SMR foam rolling the hamstrings.
Explain the three biomechanical sources of patellofemoral joint stress, that can result in overload—include the specific anatomic tissues/structures involved.
Tightness of quadriceps will exert excessive superior force on the patella and increase compression of the patella against the femur, especially in deep knee flexion.
Excessive internal rotation of the hip due to weak deep gluteals will cause the lateral femoral condyle to exert a medial direction force against the lateral side of the patella increasing stress.
Excessive valgus from excessive hip adduction due to weak hip abductors (gluteus medius and tensor fascia latae) increases a lateral direction pull on the patella, increasing stress.
What you need to be cautious of (or minimize) when choosing exercises for each of the following knee injuries/conditions: osteoarthritis of the lateral compartment of the tibiofemoral joint, PCL sprains, ACL sprains
Osteoarthritis: movement that increase valgus since it will cause greater weight bearing load and compression on the lateral side, which may irritate the joint as it already has a diminished ability to withstand compressive forces.
PCL sprains: depth of knee flexion since client should work through a pain free range and open chain knee flexion exercises since the proximal end of tibia will experience a high degree of posterior translation due to the load pushing distal end anteriorly, stressing the PCL.
ACL sprains: open chain knee extension exercises since the proximal end of tibia will experience a high degree of anterior translation since the load will push the distal end posteriorly, especially in the full extension to 45 degrees before full extension range.
What non-knee muscle groups are particularly important partners to consider strengthening, in a program for patellar tendinopathy? For this condition, briefly explain two knee resistance exercises that will help you focus on the target knee in a way that will optimize tendon healing.
Strengthen hip abductors to limit knee valgus (valgus puts lateral stress on the patella) by decreasing adduction. Hip external rotators to limit pressure stress of lateral femural condyle on patella due to internal rotation.
A knee resistance exercise is a spanish squat which the patient squats with a band pulling anteriorly on their knees. The band offsets patellofemoral joint pain and allow the patient to squat in a more upright trunk and tibia position, decreasing stress on the quadriceps. Another knee resistance exercise is step down in which is an unilateral exercise where the patient on a step will squat with their target leg and lower the heel of the non-target knee to the ground. This will target the knee extensors and activate the abductors at the same time with an eccentric focus.
Which muscle group is particularly important to train following ACL injury, and why? Briefly describe three resistance exercises that target this group—one for early rehabilitation for a patient who is non-weight-bearing, one for middle rehabilitation that includes an emphasis on the hip, and one for the latest stages of rehab with an emphasis on eccentric control.
The hamstring should be trained following an ACL injury since they co-contract to control knee extension which stresses the ACL.
A non-bearing resistance exercise for early rehab is an isometric heel dig where the patient will lie on the ground with their feet on a chair and dig their heels into the chair.
A middle rehab resistance exercise with an emphasis on the hip is an glute bridge where the client will lie supine with the ankles stacked under the knees and lift their hips up until their body is a straight line with their shoulders and knees.
A late stage rehab exercise with eccentric emphasis is a nordic hamstring curl where the client will kneel on the ground with the ankles anchored to the ground using assitance, they will then lower their body to the ground while maintaining a straight line through their head to their knees.
Hip abductor and lateral rotator strengthening may be essential in a knee rehabilitative program. Explain why and include a specific injury/condition to support your answer. Briefly describe two resistance exercises that will emphasize these muscle groups—one in weight-bearing position, one in non-weight-bearing.
Hip abductors (gluteus medius and TFL) and lateral rotators (deep gluteals) stabilize the pelvis and the femur during knee movement and are especially relevant for anterior knee pain. The hip abductors limit adduction to decrease lateral direction pull stress on the patella from valgus. The lateral rotators limit internal rotation of the femur which decreases the medial direction force exerted on the lateral side of the patella by the lateral femoral condyle.
Non-weight bearing exercise such as clamshells (side lying, knees and ankles stacked, open the knees by pivoting off the ankle) and side lying abduction (side lying, knees fully extended, lift top leg up in abduction) emphasize the lateral rotators and hip abductors, respectively. Monster walk (walk forward in slight squat with band around ankles) is a weight bearing exercise that will emphasize both muscle groups.
Explain the specific benefits of isometric resistance exercise in a rehabilitation program—include the specific parameters you need to include in your prescription
Isometric exercises facilitate muscular activation without potentially harmful ROM, are useful when prioritizing joint stability, and have joint angle-specific adaptation. Isometric exercises should be done for 3-30 seconds at 70-75% MVC with a set being 80-150 seconds.
Be the professor. Create a question you think should be on this test (and isn’t in the prep list already)
Q: What are 2 resistance exercises you would prescribe for a patient with an anteriorly tilted scapula? What are 2 kinds of cues could you give them to address this problem? Use specific examples.
A: Forearm wall slide and Ys. Cue posterior tilt by providing visual cues with a demonstration or physical cues by moving their scapula into a posterior tilt motion with your hands.
