upper body Flashcards
O/I/A/N
differences between right and left bronchus
R is angle more vertically and is wider compared to L
Right lung: lobes, fissures, segments
3 lobes: upper middle lower
2 fissures: tansverse seperateing upper and middle, oblique seperated middle and lower
10 segments: upper (apical, posterior, anterior). middle (lateral and medial). lower (superior, lateral basal, posterior basal, anterior basal and medial basal)
Left lung: lobes fissures segments
2 lobes: upper and lower
1 fissure: oblique seperating upper and lower
8 segments: upper (apical posterior, anterior, superior and inferior lingula). lower ( superior, posterior basal, lateral basal, anteriormedial basal)
muscles of mastication
+ muscles that attach to the mandible
1)temporalis. origin: temporal fossa. runs deep to the zygomatic arch. insertion: coronoid process of mandible.
2) masseter: origin: zygomatic arch. insertion angle of the mandible.
3)lateral pterygoid: 2 horizontal heads, origin: sphenoid. insertion: disc (superior) and condylor process of mandible (inferior).
4)medial pterygoid: orgin: sphenoid. insertion inner angle of mandible. forms sling around mandible with masseter.
opening: laeral pterygoid
closing: masseter, temporalis, medial pterygoid
protrusion: lateral and medial pterygoid
retrusion: temporalis
lateral deviation: contraleral medial/lateral pterygoids, masseter—ipsi temporalis
I: mandibular branch of trigeminal nerve
maxillary artery
brachial plexus
which roots?
pneumonics?
C5/C6/C7/C8/T1
“remeber to drink cold beer”:
roots, trunks, divisions, cords, branches
“marmu”: musculocutaneous, axillary, radial, median, ulnar
rhomboids major and minor
O: -. nuchal lig, C7-T1
+,T2-T5
I: -. root of spine of scapular
+, medial border of scapula
A: retraction of scapula, supports scapular positioning
N: dorsal scapular
levator scapular
O: C1-C4
I: superior angle of scapula
A: elevate scapular, ipis neck skide flexion, b/l nexk extension
N: dorsal scapular (C5)
serratus anterior
O: ribs 1-7/9 intecostal fascia
I:anterior surface of superior angle, medial border of scapula
A: anterior lateral scapular movement, facilitate scapular rotation, accesroy inspiratory
N: long thoracic “SALT”-serratus anterior long thoracic
supraspinatus
O:suprspinous fossa of scapula
I: greater tubercle of humerus
A:abduction of shoudler, stabilize GH head
N: suprascapular
infraspinatus
O: infraspinatus fossa of scap
I: greter tubercle of humerus
A: ER of shoudler
N: suprascapular
subclavis
O: 1st rib
I: clavicle
A: depress clavicle
N: nerve to subclavis
Pec +
O: clavlicle, sternum, costal cartilages, rectus ab sheath
I: greater tubercle of humerus
A: felxion, IR and adduction of shoulder
N: Lateral and medial pectoral n.
subscapularis
O: subscpular fossa of scap
I: lesser tubercle of humerus
A: IR of scapular/shoulder
N: upper and lower subscapularis
lat dorsi
O: T7-T12, thoracilumbar fascia, crest of lillium ribs 9-12, inferior angle of scap
I:intertubercular sulcus of humerus
“lady betweey 2 majors” between pec and teres +
A: extend/adduct shoudler, MR shoulder
N: thoracodorsal or middle subscap
teres major
O: inferior angle and lateral scapula
I: interubercular sulcus medial
A: adduction/extension, IR of shoudler
N: lower subscapular
pec -
O: ribs 3-5
I: coronoid process of scapula
A: protraction (anterioinferior) of scapular
N: medial pectoral
medial brachial cutaneous
posterior surface of upper arm
branch off of the medial cord of the brachial plexus
medal antebrachial cutaneous
medial surface of upper arm into forearm
branch of the medial cord of the brachial plexus
describe the path of the musculcutaneous nerve
peirces coracobrachialis, travels above brachialis but beneath biceps,
gives rise to the lateral cutaneous nerve of the forarm
coracobrachilais
O: coracoid process of the scapula
I:anterior medial surface of humeral shaft
A: adduction and flexion of the arm at the shoudler joint
N: musculocutaneous
brachilas
O: distal half of anterior humerus
I: cornoid process of ulna
A: elbow flexor
N: musculocutaneous
deep to biceps
biceps
O: short head-apex of cornoid process, long head: supraglenoid tubercle of GHJ,
I: radial tuberioisty, deep fascia of forarm
A: elbow flexor, supinator when elbow is flexed
N: musculocutaneous
cutaneous innervation of muculocutaneous n
lateral forarm
describe the path of the axillary nerve
through the quadrangular spacr
quadrangular space
on posterior shoulder
lateral border: huumerus
inferior border: teres major
superior border: teres minor
medial border: long head of triceps
cutaneous innervation of the axillary nerve
superior lateral shoulder
deltoid
O: lateral 1/3 of clavicle, acromion, spine of scap (delotoid helps you carry sacs
I: deltoid tuberoisity of humerus ( lateral)
A: shoudler abduction, felxion, extension
N: axillary
teres minor
O: lateral border of the scapula
I: inferior facet of greater tubercle
A: ER and adduction of arm
N: axilary
cutaneous innervation of radial nerve
1) inferior lateral cutaneous nerve of the arm-inferior lateral upper arm
2) posterior cutaneous nerve of the arm- inferio posterior upper arm
3) posterior cutaneous nerve of the forarm-posterior forarm
4) superficial branch-drosal surface of digits 3.5 excluding the tips
motor innervation of radial nerve pneumonic
BEST nerve
brachilradialis
extensors
supinator
tricpes and acconeus
describe the path of the radial nerve
C5- T1
though triangular interval
radial groove on humerus
wraps around humerus anteriorly
cubital fossa ( lateral)
divides into two branches
deep branch PIN: passes through the two heads of the supinator (motor for deep extensors of forarm)
superfiscal branch is sensory: dorsal durface of lateral 3.5 digits.
triangular interval
medial to quandrangular space
triceps (lateral)
teres major (inferior)
teres minor (superior)
triceps
aconeus
triceps
O: long head-infragelnoid tubercle, medial head-posterio humerus inferior to radial groove, lateral head- posterio humerus superio to raidal groove
I: olecronon of the ulna and fascia of the forarm
A: elbow extension, extesnsion and adduction of the arm
N:radial nerve
Aconeus
O:lateral epicondyle of the humerus
I: lateral surface of the olecranon
A: elbow extesnion accesory, stabilize elbow joint
n: radial nerve
bracioradialis
O: lateral supraxondylar ridge of humerus
I: styloid process of radius
A: forarm flexion with arm in neutral pronation
N: radial nerve
extensor carpi radiais brevis
extensor carpi radialis longus
ECRB
O: lateral epicondyle of the humerus (CET)
I: D3
A: wrist extension and radial deviation
N: radial nerve–> posterior innterosseus nerve
ECRL
O: lateral supracondylar ridge of humerus/lateral intramuscucular septum
I: posterio of base of metacarpal 2
A: wrist extension and radial deviation
N: radial nerve
extensor digitorum
O: lateral epicondyle of the humerus (CET)
I: extensor expansion of D2-5
A: finger extension
N: radial nerve–> posterior interoosseus nerve
extensor indices
O: posterior 1/3 of the of the ulna and interosseus memebrane
I: extesnor expansion of the index finger
A: extesnsion of D2
N: radial nerve–> posterio interosseus nerve
extensor digiti minimi
O: lateral epicondyle of the humerus (CET)
I: extesno expansion of digit 5
A: D 5 extension
N: radial nerve–> posterio interosseus nerve
extensor carpi ulnaris
O: lateral epicondyle of humerus, posterior border of ulna
I: base of metacarpal bone 5
A: hand extension and adduction/ulnar deviation
N: radial nerve–>posterior interoseaus nerve
supinaotor
O: crest of ulna, lateral epicondyle of humerus, radial collatoral l., annular lig
I: proximal thrid of the radius anteriolateral and posterior surface
A: Supination
N: radial nerce
which splits into deep and superfiscal branches here-> after passing underneat the supinator becomes the posterior interosseus nerve
arcade of FROSHE
common site of impingment of the PIN- branch of radial nerve.
supinator muscle. results in motor deficits: innervates the supinnator, extensor carpi radialis breviw, extensor digitorium communis, extesnor digiti minimi, extesnor carpi ulnaris, abductor pollices, extensor polices brevis, extensor pollices longus, extensor indices
extenor policis brevis
extensor policies longus
EPB
O: posterior distal radius and interousseus membrane
I: posterior base of proximal phalanx of the thumb
A: thumb extension
N: radial nerve–> posterio interosseus nerve
EPL
O: posterior ulna and interousseus mmebrane
I: distal phalanx of the thumb
A: excommontension of the thumb
N: radial –> posterior interosseus
abductor pollicis longus
O: posterior proximal raridus/ ulnar; interosseous memebrane
I base of metacarpal of the thumb
A: abduct/ extend the thumb, wrist extension
N: radial–> posterior interossueous nerve
decribe the course of the median nerve
courses into the forarm via th cubital fosssa (Medial elbow)
beneath the liganment of struthers
travels between the 2 heads of the pronator teres!!
decends between flexor digitorum profundus and superficialis
2 forarm branches
1) anterior interrossesus nerve
2) palamar cutaneous nerve/digtal cutaneous
eneters the hand through the carpal tunnel
median nerve pneumonic
2 LOAF
1st 2 lumbricals 1 and 2
opponens policis
adductor pollicies brevis
flexor pollicis brevis
cutaneous innervation of the median nerve
palamer D1-3.5 and dorasal tips
lateral/ventral palm
ligment of struthers
band of connective tissue on the media humerus
median nerve runs beneath
not a common site of intrapment-increases after a humeral fracture
pronator teres
O: medial supracondylar ridge, coronoid process of ulna
I: laterl surface of radius
A: pronation of forarm, flexion of forarm at elbow
N:median nerve+
pronator teres syndrome
compression neruopathy of the median nerve ( and the anterior interosseus nerve) at the elbow
pain over pronator teres and with resisted pronation, numbness and tinigling in the palm of the hand
MOI repeitive forarm pronation especialiy with added finger felxion (tool use) leads to increased muscle bulk in pronator teres
rest, ice for pain and swelling
anterior interosseus nerve
small branch of median nerve that arises between the two heads of pronator teres
I: Flexor pollicis longus muscle, flexor digitorum profundus, pronator quadratus muscle
pronator quadratus
O: distal anterior ulna
I: distal anteriorradius
A:forarm pronation
N: median nerve–> anterior interosseus nerve
palmaris longus
O: medial epicondyle of the humerus
I: felxor retinaculum and palmaris aponeurosis
A: wrist flexion, tenses aponeurosis
N; median nerve
felxor carpi radilis
O: medial epicondyle of humerus
I : bases of metacarpals 2 and 3
A: flexion at wrist , radial deviation
N: median nerve
flexor digitorum superfiscal and flexor digitorum profondus
FDS
O: Humeroulnar head: Medial epicondyle of humerus, coronoid process of ulna
Radial head: Proximal half of anterior border of radius
I: tendon splits (FDP passess through split) and attaches to sides of middle phalanges of 2-5
A: MCP and PIP flexion
N:median
FDP
O: proximal half of anterior ulna and interosseus memebrane
I: palmer surface of distal phalanges
A: finger flexion (DIP), erist felxion
N: D2&3 median nerve–> anterior interouseus nerve
D 4 and 4 ulnar nerve
carpal tunnel
site of compression of the median nerve as it travels through , most common nueropathy
numbness tingling in plamaer D1-3.5- no senesation changes in the palm ( palmer cutaneous branch tavels above the tunnel)
sevrer–> weakness and atrophy of thenars
floor is the carpal bones, roof is the felxor retinaculum- attaches to pisoform/hook of hamate and scaphoid and trapezium
contents: median nerve, flexor pollices longus, FDs adn FDP tendons,
hand of bendiction
occurs as the result of prolonged compression of th emedian nerve
damage to the nerve leads to inability to flex D1-D3 when trying to make a fist
ape hand
thumb permenatly rotated and adducted
damage to distal median nerve that supplies the muscles that control the thumb
imparied opposition and abduction
thenar eminence
opponens pollices
o: carpal bones
I: lateral aspect of first metacarpal
A: opposition of the thumb
N: median
flexor pollices brevis
O: carpal bones
I: superfiscal and deep head that attach to proxial phalanx of the thumb
A: thumb flexion
N: superfiscal head-median and
deep head innervated by ulnar nerve
abductor pollices brevis
O: carpal bones
I: lateral side of proximal pahalanx of the thumb
A; thumb abduction
N: median nerve
lumbricals
4 short muscles in the hand between the metacarpals
O: tendons of FDP
I: extesnor expansion of hand
A: flex the fingers at the MCP joints and extend at the IP’s
N: lateral 2 lumbricals median, medial to lumbricals ulnar
ulnar nerve course
C8- T1
descends down the medial arm pases to posterior compartment, passes beneath ligament of struthers
between medial epicondyle and olecronanon (cubital tunnel)
2 muscular brnaches in proximsl forarm ( medal FDP, FCU)
decends in the medial forram above the FDP
distal forarm doral and plamer cutaneous branches to medial hand
motor innervation of the hand ( interossi, medial 2 lumbricals, hyothenars, deep head of aductor pollices brevis, and adductor pollices
enter the hand just lateral to pisform through guyons cannal (pisform to hook of hamate)
cutaneous innervation of the ulnar nerve
medial hand and 1. 5 digiits
ulnar nerve motor innervation
lumbricles 3 and 4
hypothernars ( dlexor digiti minim, abductor digit minimi, opponesns difiti minimi, plamaris brevis)
interossei
adductor pollicis!! (thenar mucles)
adductor pollices brevis
O: carapl bones/ metacarpals
I: medial proximal phalanx
A: thumb adduction, assists in late opposistion
N: ulnar
flexor digitorum profundus
O: proximal half of anterior ulna and interosseus memebrane
I: palmer surface of distal phalanges
A: finger flexion (DIP), erist felxion
N: D2&3 median nerve–> anterior interouseus nerve
D 4 and 4 ulnar nerve
hypothernars
Abductor digiti minmi
O: carpalsI: ulnar base of prximal phalanx
A; abduction of D5
N: ulnar
flexor digit minimi
O: carpals
I: medial base of proximal phalanx
A: flexion of D5 at MCP
N; ulnar
opponens digit minimi
O: carpals
I: ulanr base of MCP
A: opposition of D5, felxion of D5
N: ulnar
cardinal signs of TMD
orofascail pain
crepitus
restricted jaw movment
TMD osteoarthritis
degernative changes
highly used joint-thats why there is a disc for extra protection
diffuse pain that increases when bitting firm foods
decreased ROM, stiffness
morning pain that decreases as day goes on
weakness and atrophy of muscles of masticaption
CREPTIUS is halmark for OA
grinding/clenching increases wear
goals decrease inflammation and pain, preserve and prevent further degeneration
strengthen supporting muscles, massage to increase bloodflow and healing
night guard if grinding
TMD: disc displacement with reduction
anterior disc displacement is the most common
instability in ligaments supporting disc
inflamamtion in the joint space
click when opening= reduction
click when closeing=displacment
CLICKING
TMD closed lock
open lock
closed lock can not fully open the jaw, it is locked due to anterior displacment of the disc
Tx j stroke: caudal distraction to reposition the disc, followed by a caudal anterior glide
open lock
can not close jaw due to posterior displacment of the disc
much less common
will often present to emergency soon after locked, more uncomrftable
cuadal distraction, posterior cuadal glide
TMD hypomobility syndrome
decreased ROM, localized pain at end range, signs of contracture, Hx of truama, deviation towards affected side, may have secondary myofascial syndrom
manual therapy: streching, soft tissue techniques, mobilizations, strengthening,
TMD hypermobility syndrome
excessive anterior translation, increased ROm > 50mm of opening
generalized laxity, pain with opening, deviation towards unaffected side
ay have joint nose at end range
TMD myofascial syndrome
pain that increases with opening, no joint noise, traumatic or insidious, tirgger points may result in referred pain to other ares
may result in decreased ROM due to spasm and pain
trigger point release
streching
coordiation
ROM of jaw
funtional opening 4omm, 2 flexed knuckles
maximal opening 50 mm
lateral deviation 9 mm
protrusion 9 mm
retrusion 1-2 mm
4 joints of the shoulder complex
1) glenoid humeral
2) Acromioclavicular
3) sternoclavicular
3) scapular throacic
capsular pattern of the glenohumeral joint
ER> abduction> IR
resting postion of the glenohumeral joint
40-55 degrees of abduction, 30 degrees of horizonal adduction
thoracic outlet borders and contents
borders
anterior: clavicle/corocoid process, pec minor
posterior: UFT/scapula
medial: scalene muscles and first rib
lateral axialla
contains: brachial plexus,subclavian artery, sublcavian vien
neurogenic TOS
true TOS
patient presents with an anatomic anomoly compresing the brachial plexus (cercial rib, elongated C7 TP
rare
paresthesia/numbness/weak grip/loss of manual dexterity and precision movments in hands
nonspecific symtpomatic neurogenic TOS
no evidence of antomical anomolyies
Dx based on signs and symptoms
maladapive postures, shortening of scalenes and pec-
most
paresthesia/numbness/weak grip/loss of manual dexterity and precision movments in hands
vascular arterial TOS
compression of subclavian artery
typically agravated by arm motions
cool skin, pale extremity, diminished or absent pulse, raipid fatuge of limb, lower BP on the affected side
vascular venouse TOS
compression of subclavian vien
painful swelling n arm
mottled blusih discoloration
thrombus
etiology of TOS
contenital anatomical anomaly
muscle hypertrophy (scalene, subclavis, pec minor)
inflammation/scar tissue in strucutures surrounding the plexus
truamatic (fracture/WAD-scalene spasm)
posture- maladaptive posturing shoretning of scalenes and pec -
excessive overhead acivities
thrmnbus-venous TOS
pancoast tumor
scalenus anterior syndrome TOS
site of compression: interscalene triangle between scalen anterior and scalenus medius supracalvidulary
costocalvicular syndrom TOS
site of compression constoclavicular space between the clavicle and first rib
hyperabduction syndrom TOS
site of compression axillary interval under the coracoid process and behind the pec minor-infraclavicular
Pancoast Tumor
type of lung cancer location =top of R or L lung
can compress brachial prelxus and sympathetic ganglia
horners syndrome: miosis (constricted pupil), partial ptosis ( weak droopy eyelid), aparent anhydrosis (decreaed sweating), enopatholmos (inset eyebal)
adsons manevar
The arm patient is abducted 30 degrees at the shoulder and maximally extended.
The radial pulse is palpated and the examiner grasps the patient’s wrist.
The patient then extends the neck and turns the head toward the symptomatic shoulder and is asked to take a deep breath and hold it.
The quality of the radial pulse is evaluated in comparison to the pulse taken while the arm is resting at the patient’s side
The test is positive if there is a marked decrease, or disappearance, of the radial pulse. It is important to check the patient’s radial pulse on the other arm to recognize the patient’s normal pulse.
A positive test should be compared with the non-symptomatic side.
costoclavicular syndrom (military brace) test
halstead maneuvar
allen test
tests for TOS-arterial
positive tests have a disperance of radial pulse
Roos test (elvatede arm stress test)
test for TOS
anducted to 90 degreess, open and close fists for 3 min
+ test is reproductino of symptoms
minor fatigue is normal
shoudler girdle passive elevation (Cyaraix release test)
sitting position. The therapist stands behind the patient and grasps under the forearms holding the elbows at approximately 80-90°, while maintaining the forearms, wrists, and hands in neutral. The therapist then leans the patient’s trunk posteriorly, approximately 15° from vertical, and elevates the patient’s shoulder girdle close to end range. This passive shoulder girdle elevation position of both shoulder girdles is held for up to three minutes.
This test is considered positive if either a release phenomenon occurs or the patient’s familiar symptoms are reproduced.
shoudler seperation
what?
MOI?
S/s?
sepecial tests?
radiology?
trauma to the ligaments holding the acromion and clavicle together cuaseing seperation betweent the two
MOI: downward force on the acromion, directly falling and hitting the acrominon, fallinf on outstreached hand, falling on elbow
S/S: step deformity ( distal end of calvicle is sticking up), grade 3 sprain (both acromiocalvicular and coracoclavicular ligament shance been torn, deltoid and traps may be torn from end of calvicle.
tenderness and swlling over the AC joint
pain with shoudler horixontal adduction, elevation and Hand behaind back
pain between 160-180 degrees of abudctino due to lack of calvicle rotation
cross body horizontal adduction test ( + reproduces symptoms)
stress view x ray- xray of ac while holding weight in arm so seperation is apperent.
rockwood classification Ac joint seperation
type 1: sprain, capsule is intact, no speration or excessive spacing is seen, all strucutres are intact
type2:subluxation, increased AC joint spacing, AC lig ruptured CC is sprained, capsule is ruptured, minimal damage to traps and deltoid
type 3: dislocation, increased Ac joing and coracoclavicular space, joint surfaces are not in contact with each, AC and CC ruptured, capsule ruptured, deltoid and traps detached
glenohumeral joint instability
how to describe
who
what direction, degree-subuxation/dislocation, truamatic/atruamatic, acute/reoccurent
males, younger then 30 years
shoudler dislocation
anterior dislocation
seperation of the humerus from the scapula-most common in the body
anterior dislocation is the most common
anterior dislocation occurs in ER and abduction, stability hear is provided by long head biceps and subscap. anterior dislocation may damage subscapularis, long head of bicepsm GH ligaments, anterior capsule and andterior glenoid labrum
shoudler subluxation
incomplete dislocation
MOI for GH instability
truamatic: direct truama to humeral head, inderect trauma, most common when in abduction and ER
atruamatic: general laxity of the shoudler cuases it to become unstable. hypermobile
s/s of gh instability
feeling slipage with pain
feeling insecuirty with specific activities
paossible pain and apprehension when appraching extremes ROM
decrease ROm during acute pashe due apprehension
increased Rom in chronic phase due to instability
may apperar normal on clinical examination-may be apperent after repeated activity when fatigue sets in
possible atrophy due to disuse-chronic
sulcus sign may be present
sulcus sign
inferior traction of the humerus
feeling dislocation
dip benath the acromion
potenial complications of GH instability
1) axillary nerve injury- must check before relocating-innervates teres minor and deltoids
2) axillary artery- may be damaged with injury and reduction
3) brachial plexus- les commonly damaged. posterior cord most common
4) bankart leision- most anterior dislcations damage the labrum resulting in chronic instability and may require sx repair
5) hillsachs leision- poseterolatera humeral head compression (indentation) fracture, may occur secondary to anterior dislocationdue to forcefull inpect of the humeral head against the anterioinferior glenoid rim
describe spetrum of instability of GH
AMBRI “ born loose”
-Atruamatic etiology, multidirectional with bilateral shoudler findings with reahbhilatation as a tratment choice and rarely inferior capsule shift surgery if required
-hypermobile (beightons scale)
TUBS “torn loose”
truamatic onset unideirectional anterior with a bankart leision responding to surgery
-sx to tighten anterio capsule and subscaoularis to prevent relocation anteriorly
special tests for anterior instability
1) crank (Apprehension and relocation test-passive ER in abduction, will be apprehesive to movent, apply posterior glide to relocate
2) apprehension release (suprise test)-release posterior glide- will cuase pain =+ test
3) load shit test- stabilize scapula glide humerus anterior to assess laxity/stabiliyt
SLAP leison
superior labrum anterior to posterior ( 10 -2 oc clock)
-a forceful pull by long head of biceps if it becomes detached shoudler will be unstable
MOI rep overuse like baseball injury, thorwing, deacceleration while throwing, direct truama, FOOSH, traction injury to biceps
sensation of clicking and or popping with mocment, pain with overhead activity and lying on affected side, GH IR deficit, loss of strength and endurance of rotator cuff and scapular stabilizers, dead arm syndrome in pitchers-decreased velocity and pain
clunk test- abduction and ER with anterio shoudler glide +clunk/grinding/pain
active compression test of obrien-flex to 90, IR adduct 10 degrees ressist downward motion
bicep load test- iin aprrehsion test position- resisted elbow flexion + if apprehsion doesnt change or if increaed pain
posterio instability special tests
Jerk test- horizontall adduction then abduct with force on humeral head- clunk indicates instability
load shift test- stabilize scapula and shift humeral head posteriorl to assess for instability
posterior apprehension test- flex humerus to 90bend elebow, apply posterior force to humerus in suppine with hand underneath
special tests for inferior and multidirectional instability
suclus sign- inferior force to humerial shaft will see spacing beneath acromion
feagin test- same as above but with arm abducted to 90
bankart leision
anteior inferior tear of the labrum (3-7 oclock))
commonly occurs with anterior dislocation of the GH
common in overhead sports/occupations ( in abduction and ER over head)
snensation of clicking/poopping. diffuse pain, worse with hand behind head, feeling weakness and instability
adhesive capsulitis
idopathic conditon charctirized by shoulder pain followed by progressive loss of GH ROM following a capsular pattern due to the development of dense adhesions/capsular thicking surrounding the GH
idopathic or secondary to other conditions involving pain/decreased ROM
highly correlated with psychosocial issues
capsular pattern ER abd IR hallmark sign, difficultu with shoulder mvts leading to activity and functional limitations, reverse scapular humeral rhythm present (more scap mvt then GH, trick mvts, muscle weakness poor endurance
describe the four stages of adhesive capsuliitsis
1) gradual onset of pain that increase with mvt and at night , loss of ER ROM with intact strength in rotator cuff , 3months duration
2) freezing- persistent and more intense pain even at rest (dull and achy), restricted ROM in all diretions ER Abd IR, 3-9 months
3) Frozen- pain only with movment, night pain decreases, sig adhesions, hard capsular end feel, restricted ROmin all directions, increase in scapular compensatino mvtsm atrophy of deptoid rotoatr cugg biceps tirceps, 9 -15 months, disuse,
4) thawing- minimal pain, sig restrections at start but gradual return of ROMm some patients never regain full, 15-24 months
** most benefit from PT
eraly frequent ROM
subacromial impingment syndrome
signs and symptoms from increased pressue on the sturcutres running under a narrowed sub acrominal space.
subacromial bursa, supraspinatus tendomn, long head biceps tendon, coracoacromial lig, joint capsule
primaey impingment: result of congenital abnormailities or degneerative changees to acromion process, corocoid process, greater tuberosity, rotator cuff, or anterior tissues due to stress overload cusing impingment
Secondary: functional impingment, result of abnoraml force couping action leading to muscle imba,aaces and abnormal movment pattersn, may result after instability, kyphotic posturing, tight pec minor pulls scap foward narrows space, LFT not pulling scap down and back narrows space, winging-weak SA decreased space
calcific tendonitis: calcific depostis within a tendon (supraspiniatus) deposts produce bulge in tendon which increases likelyhood of impingment
S/S: painful arc 60-120, pain anterior lateral shoudler worse with overhead activities, does not radiate below elbow, no pain at rest, tendernoss to strucutres passing below arch, reversed scap humeral rhythm, decreaesd HBB and HBH, anterior supeerio humeral head at rest, may present with decreaseed posterio inferio gilde
tests: hawkin kennedy impingment , neers impingment (passice arm elevation, scapular assist test (humerus mvt with assisted scap movt will decrease paiin
tenditnitis
inflammation of a tendon
tenosynovitis
inflammation of the synoviu,-the fluid filled sheath surrounding the tendon
tendinosis
degenerative changes within a tendon without inflammation, though to be asa result of overuse and repetive stress on the tendon cuasing degnerative microdamage, typically takes loniger to heal then tendinitis
tendon ruputre
tear of a tendon, occurs when the forces placed on the tendon are greater than the tensile strength and capcity of the tendon, may be partial or complete
tendonopathy
pain and dysfuntion in tendon due to impaired healing( tendititis, tnensynovitis tendinosis)
s/s: pain with contraction, tenderness at origin and insertion, pain with passive stretch
biceps tnedonopathy special tests
speeds test- resisted shoudler flxion palm up
yergasons teset- resisted supination with palaptino of biceps insertion
supraspinatus tendonopathy special tests
drop arm test- slow controlled lower of abducted arm, can add min resitance look for strength deficiets, and inability to controll the decent
empty can test in scaptionu
subscapularis tendonopathy speacial test
belly press test-resisted IR
lift off sign - HBBm lift, resist
infraspinatus tendonpathy special test
infraspinatus test -resisted ER open door, weakness
lateral rotation lag sign- elbow bend arm in 30 degreess abduction in ER asked to hold position. if they drop, move =lag
teres minor special tests
hornblower sign - 90 abduction, ER with elbow bent, hold position if drops +
scapular dyskinesia
an alteratio in the noraml position or movment of the scapula
scapular winging
static- winging at rest, typically as a rsly of structureal defromity of the scapula, clivicle ribs or spine
dynamic winging- winging with movement, may be due to the lesion of the long thorisc nerve (serratus), spinal accesroy nerve (traps), C3 4 traps, C5 rhomoboids, C7 serratus anteior/rhomboids, SA weakness, rhomboid weakness, or mulitidirectioni instability
wall push up test, scapular lod test, punch out test ( SA weakness)
GH joint: loose packed, closed pack, capsular pattern
loose packed: 40-55 abduction, 30 horizontal adduction
closed packed: max abduction and ER
capsular pattern ER, abd IR
elbow complex joints
ulnahumeral joint- ulnar and radial collateral ligs
radiohumeral joint- ulnar and radial collateral lig
procimal radioulanr joint-annular ligament
elbow carrying angle
normal 5-15 ( women greater angle in women)
excessive cubitus valgus- greater then 30
cubitos varus- less then 5
describe grade 1 2 3 lig sprains
Grade 1 minimal swelling and pain , no lig laxity, microtear
Grade 2 moderate swelling, eccymosis and pain, increased lig laxity but with frim end feel, partial tear
Grade 3 sig swelling, eccymosis, pain, gross laxity present, no end feel, complete tear
ulnar collateral ligament tear
fan shaped lig ament that has anterior posterio and transvers portions, restrains valgus
tear in UCL
MOI valgus stress-acute or chronic
s/s pain, localized tenderness, joint effusion, instability with valgus stres test, limited ROM, may have heard an audible pop
Tx activty modification-avoid mvts that stress ligs
correcting fualty technique- elbow may be compensating for lack of mvt elsewhere-eg shoudler rotation
decrease pain- modalitites
decrease swelling- pulsed ultrasound, ice, compression, elevation
braching- medial strapping of the elbow, external support
strengthing of foramflexors/pronators tp stabilize area
restore ROM after immbilization period
Sx lig reconstruction from tendon, peroid of immobilization
posterior elbow dislocation
the most common, disocation of the olecranon posteriorly, often invovles disruption of UCL/RCL
often invovles a fracture of the coronoid porcess or radial head ( top of distal foram segment)
major complications can occur including impairment of vascular supply to forearm-check distal pulse
nursemaids elbow
subluxation of the radial head-partial dislocation, disruption of the anular ligament, commonin young children 1- 4 years (older children have a mature annular lig),
s/s child reufses to move ar,m arm is common ly held at the side in slight flexion
Tx reduction
olecranon bursitis
inflammation of the olecranon bursa
turma, pressure, infection
s/s swelling , redness, tender on palpation,
Tx activity modification- decreased comprsesion and painful mvts
ice for selling
compression sleeve for swelling
NASAIDS, coroticosteriod injections, aspiration-draininage, antibiotic if infected, bursectomy- Sx removal
lateral epicondylosis
itis= inflamation, losis is dengeneration
one of the most common ortho conditions
degernerative changes to wrist extensor tendons inserteing into the lateral epiconcdyle ot the humerus
most commonly invovles ECRB,
AKA tennis elbow
>35 yers
repetitive use, poor technique, heave racquet, heave ball samll grip
load» capacity to recover=degeneration
poor blood supply impairs recovery
s/s aching pain, insidious onset, tender palapation at insertion, pain with stretching of wrist extensors. decreased wrist extension and grip strength
COzens test, maudsleys test, mills test
Tx activity modification decrease loading
coutnerforce brace
stretch
strengthen eccentric
mobilizations
cross friction massate
pain modialities- US, ice, compression, elvation.
NSAIDS, corticosteriods
medial epicondylosis
degenerative changes the wrist flexor tendons inserting into the medial epicondyle of the humerus
commonly invovles pronator teres and flexor carpi radialis tendon
golfers elbow
> 35 years
repetive use
s/s aching pain, tender on palpation at medial epicondyle, pain with resisted wrist flexion/resisted pronation and gripping, pain with stretch on wrist flexors, decreased wrist flexion, pronation and grip strenght
reverse mills
Tx: activity modifiction, stretching, eccentric strength, mobilization, cross friction massage, pain modialities
nsaids and cortiocosterof injections
which 3 nerves can be injured at the elbow
radial
medial
ulna
median nerve entrapments at elbow
humerus supracondylar process syndrome- underneath of the ligment of struthers, medial humerus, rare
pronator syndrome- between to heads
anterior interosseioua nerve syndrome- branch of median nerve, between two heads of pronator teres, , may oaccur with forarm fracture, pinch deofrmity- cant tip to tip but pulp to pulp
ulnar nerve entrapments at elbow
cubitol tunnel syndrome lateral or between two heads of flexor carpiulnaris muscle
nerve mobilizations
nasaids, cortiocosteriods, ulnar nerve transposition sx
radial nerve entrapments at the elbow
radial humeral groove- disrputed often with humeral fractures
entropment of PIN betweem 2 heads of supinatory in the arcade of Froshe, radial tunnel, may mimi tennis elbow
superfiscal brach -traped under the tendon of the brachioradilais
nerve mobilizations
NSAIDS, Corticosteriods, radial tunnelrelease sx
describe the wrist joint
radiocarpal joint, the ulna does not articulate with the carpal bones, the ulna articulates with the TFCC
Colles fracture
distal radail fracture resulting in dorsal displacment of the distal fragment
complication include compresion neruopathy from swelling (median), CRPS and arthritis
-FOOSH
-common in osteoporitic women
-dinner fork deformity, dorsal wrist pain and tenderness, swelling, may present with bruising, may present paresthesia, difficulty lifting and grasping
Tx immobilization ( move everything above and below- no pro/sup, if stable in a closed reduction and thumb spica, unstable and displaced will require ORIF
at least 2 weeks immboization, begin AROM/PROM, progressive loading ( will be atrophy due to immobilization)
Smiths fracture
distal segment moves palmer
foosh with wrist in flexion
complex regional pain syndrome
what ?
symptoms?
a chronic pain disorder cuased by sympoathetic nervous system malfunction and is characterized by pain that is out of proportion to the original insult or injury
CRPS type1 occurs after injury to tissue/regional sympathetic dytrophy
CRPS type 2 occurs after injury to nerve, formaly know as cuasaligia
unkwon cuase, symptoms developin association with an injury to th affected area
s/s: severe pain (burning),, sesnory abdnormalities ( allodynia, hyperalgisia), abnormal blood flowm abnormal sweating, abnormal motor function -weak/stiff/poor cordination, ,trophic changes (colour changes, temp changes, edema, shiny tight skin, abnormal hair and nail growth
clinical course (stages ) of CRPS
Stage 1: several days after an injury or insidous over weaks, pain/ hypehidrosis/ warmth/ erythema/rapid nail growth, edema in distal extermeity
stage 2: dystrophic/vasoconstriction, 3 months after intial injury and lasts 3-6 months, burning pain/ sympythetic hyperactivity, hyperestheisa exacerbated by cold wather, mottling and coldness, brittle nails and osteoporisis
stage 3: atrophic stage. typically begins 6 months- 1year, can last for months or years, pain either decreaseing or becoming wrose, sever osteoporisis, muscle wasting, contactures
CRPS interventions
education, mobility (early AROM, tendon gliding, nerve mobilization), encourage ADLS, compreseive loading, dsitraction, dessenitization, edema control (elvate, compression, retrograde massage), modalities (TENS, US, Ice), mirron therapy, areriobic activity (PA benef its)
ACTIVE appraoach, use hand as much as tolerated
immobilization
-warning signs
-dos and donts
warning signs: increased pain, cast tightness, cast loosesness, changes in surrounding skin colour/sensation, increased swelling,
Do! maintain ROM of joints above and below, check skin integrity above and below, check capillary refill, education on how to reduce selling, educate on warning signs/precuations, remove any tight jewlery
DONT! stick things inside a cast, get cast wet
Scaphoid fracure
fracrue of scaphoid bone, most commonly fractured carpal bone,
requires MRI BONE scane- not seen on reg x ray
FOOSH -in younger indifivivduals, old osteoporitic will get colles fracture, MVA
complicatinos include avascular necorsis ( damage to radial artiery- can be grafted), non union of fracture and arthritis
s/s: radial side wrist pain, tnderness in anatomical snuff box, may have swelling in anatomical snufff box, pain with longitudinal compression of thumb
sstable: cast thumb spica, unstable: ORIF
+ 2 weeks of imobility adn rexray tto see if there is healing
mobilization, strengthening
de quwevains tenosynovitis
painful inflammation of the sheath (synovium) surrounding the tendons of the 1st dorsal compartment ( abducror pollicies and extensor pollicies brevis ( most radial boundary of snuff box)
chornic overuse, direct trauma
s/s radial sided wrist pain extending porximal or distal tendons, tenderness, swelling, worse with wrist and thumb movments, may have crepitus
finklesteint test- thumb enclosed in fist + ulnar deviation
activitiy modification (avoid aggrvation), cyrotherapy, splomting- may decrease irritation, gradual stretch and strenght
nsaids, coroticosterioids!!!, surgical release
TFCC Tear
triangular fibrocartilage complex
stablizes/transmitts loads to ulna
a tear in th eligamentous and cartilaginous strucutres of the TFCC resulting in ulnar sided wrist pain
compressive loads to wrist especially with ulnar deviation
can be degernative or traumatic
distal radial ulnar fracture
s/s ulnar sided wrist pain, may have tenderness and selling oer dorsal aspect of wrist, may have clicks with wrist mvt, pain with wrist extensino and ulnar deviation, pain with resisited extension and ulnar deviation
activity modifications, bracing, ice, progreesive strength and mobility
NSAIDS, cortiocosteriods, Sx
TFCC load test (compressive load with ulnar deviation), press test (tricep dip, pushing chiar)
interossei
PAD-palmer adduct
DAB- dorsal abduct
innervated by ulnar nerve
ape hand
inability to abduct or oppose the thumb, thumb is held in the same doesal ventral plane as D2-5
median nerve leison
hand of bendiction
inability to flex D1-3, remain in extension when atempting to make a fist, only seen during active flexion,
median nerve leision
claw hand
hyper extension od MCP and flexion of IP joints of D4/5 , ulnar nerve lesion
radial nerve leison in the wrist and hand
wrist dropp, inabitliy to extend wrist or MCP joints of hands
Carpal tunnel
a compression of the median nerve as it passes through the carpal tunnel
a narrow passageway for tendons and the median nerve on the volar side of the hand created by th carpal bones (floor and the flexor reteinaculum)
contents ( FDS and FDP tendons, flexor pollices longus, median nerve)
carpal tunnel syndrom risk factors and s/s
insidous onset typically, repetitve hand mvts, vibration, ass with ( RA other inflammatory conditions, colles fracture, lunate subluxation, hypothyroidism, pregnancy DM, obestiy), femaile
paresthesia and pain in median nerve distribution of hand, worse with sustained or repetitive wrist mvts, nocturnal numbness and pain, relived by “flicking the wrist”, weakness and clumsiness in hand, decreased grip strength, frequent dropping of objects, severe: attrophy of thenar and first 2 lumbricals,
specail test for carpal tunnel
tinel’s test (Tappig)-elicits pins and needles in distribution distal also indicates nerve regeneration
pahlens test-press dorsal hands together for 30-60 sec, will increase compression and elecit symptoms
reveres phalens - praryer pose will 30- 60 sec will also elicit symptoms
carpal compression- applie compression 30- 60 sec will elicit symptoms
resisted APB- deed head is ulnar nerve
ULTT with median nerve bias-shoulder depression, abduction to 110, ER with elbow bent, finger and wrist extension, ebow extensino
nerve conduction velocity test
EMG
carapal tunnel PT tx
activity modification- decrease aggrvating acitiviities
splinting wrist in neutral
mobilty- nerve mobilization, tendon gliding, joint movilization if restricted
gentle multi angle muscle setting, progeress to resitance and endurance, fine finger dexterity
NSAIDS, corotocosterioids, carpal tunnel release sx- to increase space, not always efective
postoperative managment for carpal tunnel release
wrist immobilization 7 - 10 days (slight extension with the fingers free to move), possibly splint may be removed for therapy
Carpal Tunnel maximum protection phase
patient education
wound managment
control of edema
control of pain
active tendon gliding exercises
nerve gliding exercises
active finger and thumb ROM
active wrist extesnion, radial and ulnar deviation with wrist in extension
pronation supination of the forearm
all elbow and shoulder movments
Carpal tunnel moderate and minimus protection phases
sutures are usually removed around post op day 10-12
return to full activity by 6 -12 weeks
residual impariemtns may include weakness/sensory dificits, persistent edema, limited ROM, hypersensitivity and pain
scar tisssue mobilization
progressive streching and joint mobilizations
progressive strengthening-isometrics at 4 weeks, grip and pinch 6 weeks, dexterity
sensory reducation
double crush syndrom
nerve compression at more than one site along th same nerve, procimal compression or pathology of a nerve is usggested to increase vulnerability of a nerve at a distal point
ulnar tunnel syndome
a condition cuased by localized compression of the ulnar nerve as it passes through guyons cannal
a semi rigid cannal created by the connections between the pisiform bone and the hook of hamate
risks: trauma (FOOSH with or with out hook a of hamate fracture), chronic pressure (cycling), space occupying leision (ganglion cyst), extended use of crutches, anything that increases perssure or repetitive compression
s/s: presthesia and pain in nerve distribution (palmer lateral d4 and 5) , decreased grip strength, fatigue with repetive activities, clap hand and atrophy of hypthenars in severe cases
forments sign-tests strength of adductor polices, + will felx DIP
guyons canal compression reproduce symptoms
tinnels- tingling, symptoms in ulnar distribution
ULTT- likley postive
nerve conduction velocity test
Tx: activity modification, cock up splint, padded equiptment/tools, frequent hand position changes, nerve mobilization
nsaids, corticostreriods, guyins cannal release sx
game keepers thumb
sprain of UCL of thumb
moi: valgus force to thumb-skiers, volleyball
test for for lig laxity with valgus stress
s/s: pain and tenderness at base of thumb on ulnar side of MCP joint, pain with mvt-wrose with abduction/extension, decreaed pinch/grip, swelling discolouration at base of thumb
Tx: activity modification, splint MCP in slight flexion, gentle ROM as tolerated, strenghting (theraputty)
Sx repair if tear is repair or complete avulsion fracture
CMC OA
osteoarthritis of the CMC joint
most common OA in the hand
repetitve mvt, joint injury, F>M, advanced age
s/s: pain at base of thumb, worse at night/changes in weather/overuse, tenderness at CMC, decreased pinch /grip, muscle wasting in thenars due to disuse, possible instability joint space narrowing increases lig laxity
GRIND test
Tx: activity modification, splinting, larger grip handles, AROM within tolerable limits, strengthening
Nsaids, coroticosteriod, 1st CMC athoplsty ( remove trapezium), 1st CMC arthrodesis( fuse- dcreased rom but decreased pain)
duputren’s contracture
contracture of palmer fascia, fixed flexion deofermity of the MCP and PIP joints, usually seen in D4 and 5 sin gis often adherent to the fascia
trigger finger
thickening of the flexor tendon sheath
results in the tendon sticking, catching or locking when atempting to flex the affected finger, more common in D3-D4, often assicated with RA
mallet fingerq
flexion of the DIP at rest, due to rupture or alvulsion of the extensor tendon at its insertion in the distal phalanx from hyper flexion injury,
tx splint the DIP strait for 6- 8 weeksb
bouchard nodes
OA enlargment of the PIP on dorsal surfacehe
heberden nodes
OA enlargement of the DIP on the dorsal surface
how many cervical nerve roots and where do they exit ?
there are 7 cervical vertebra, 8 cervical nere roots that exit above the coressponding nerve root. C8 exits below C7vertebrae ( the rest of the spine, nerve roots exit below the corresponding vertebrae)
cervical radiculopathy
a condition decribing a group of signs and symptoms related to compressed or irritated nerve
imaging does not always correlate with pathology
closing down of the IVF will cuase symptoms
cuases: constant flexion or flexion under load, disc herniation, lateral stenosis (narrowing) osteophytes, ligament thicking, swelling/inflammation
1. dermatomes- a area of skin mostly innervated by a single nerve root
2. myotomes- a muscle or group of muscles supplied by a single nerve roots
3. refelxes- an involuntary and almost instant response to a stimuli
4. special tesets
spondylosis
degeneration in the spine, OA
dermatome procedure
comfrotably positionined with tested areas exposed, confirm understanding, test on in tact skin, as patient to close eyes, test dermatome proximal to distal bilaterally, start with light touch- if impaired can do crude touch (sharp/dull) and temperature.
myotome procedure
patient is positioned in an appropriate position to test
joint to be tested is placed in neutral position
therapist instructs ( hold and dont let me move you)
manual resisitance for 5-8 sec
test bilateral when possible
C1-2 flexion of the neck
C3 lateral felxion of the neck
C4 elevation of the shoulder
C5 shoudler abduction and ER
C6 biceps elvow flexion, wrist extension
C7 elbow extension, wrist flexion
C8 themb extension ulnar deviation
T1 finger abduction adduction
deep tendon reflexes
patient needs to be completely relaxed
place tendon under slight strech and sttiem with hammer
use distractions to increase refllex response
C5 deltoid
C6 biceps/brachioradialis
C7triceps
C8pro quad
T1adductordigit mini
0 no response
1+ decreased response
2+ normal response
3+ exagerated
4+ clonus very brisk
Clonus
quick and forcefully dorsi fleci and ankle and hold in position, abnormal response
indicatespossible lesion of spinal cord, brainstem or brain
Babinski
run a pointed object along the lateral aspect of the foot from heel across the ball to big toe base
abnormal response: splaying toes and or extension of big toe
indicates a possible leison of the spinal cord, brainstem or brain
cervical distraction test
when a patient is currently experincing radicular symptoms, traction to cervical spine
postive will lead to symptom decreased/abolished
spurlings test
foraminal compression test- applies axial loadby pressing straigh down on patients head, if no symptoms in neutral progress to extension and rotation to unaffected side then extesnion and rotation to affected side, side flecion to affected side
postive= symptoms towards side of side flexion
ULTT1
Median nerve /AIN
shoulder depression/abducton 110
forarm supination
wrist extension
finger and thumb extensino
elbow extension
ULTT2
median nerve 2
shoulder depression abduction to 10
forearm supination
wrist extension
finger and thumb extension
elbow extesnion
ULTT3
radial nerve
shoudler depression and abduction 10
pronation
wrist felxion and ulnar deviation
finger flexion, thumb flxion
elbow exension
ULTT4
ulnar nerve
shoulder depression and abduction 110
forarm supination
wrist extension, radial deviation
finger and thumb extension
elbow flexion
erb duchenne parpalysis
C5/C6 upper brachial plexus injury
paralysis of arm, hand is not affected
waiters position: arm handging besi8de shoudler IR, elbow extesnsion and forearm pronation
sesnsatino of deltoid area and radial surface of the forarm affected
lateral traction of neck
affects axillary, muscultaneous, supracalvicular nerves
klumpkes paralysis
injury to lower neve roots C8 and T1
weakness in the muscles of forearm hand and tricpeps
horners syndrome * ptosis, miosis, ( dropping eyelid and pupil constriction)
elbow felxion, forearm supination, wrist and MCP extension PIP and DIP felxion
claw hand
sensation on ulnar side of foram and hand affected
traction and abducted arm
Facet syndrome
cuased by facet joints
pain aggravated by compression stress on joints, pain may refer to neck of scapula region
etiology:
spondylosis (degeneration, OA), secondaary to trauma, secondary to other conditons RA/anklosising spondolytis, spondylolisthesis ( subluxation)
physiological movemnts into extension can be used to rule out
uncoupled non physiological mvts can be symptoms provocative
normal arthokinematics of the cervical spine
side flexion and rotation to the same side
VBI
vertebrabasiler insuffienciey!! RED FLAG qeustions!! screen before treating the C/S, manual therapy is contraindicated if present, refer to physican to rule out VBI
compression of the vertebral artery can lead to decreased bllodd flow to areas of the brain ( posterior: stem, cerbellum)
5d”s: drop attacks, dysphagia, dysarthria, diploplia, dizziness
3n’s: nyatagmus, nausea/vomiting, nerological symptoms
cranial nerve pnumonic
OH OH OH to touvh and feel very good velvelt ah heavenly
1olfactiry
2optic SMEL
3oculomotor
4trochlear
5trugeminal FACIAL SENSATION, JAW MUSCLES RIM
6abducens
7facial-MUSCLES OF FASCIAL EXPRESSION
8vestibocular _HEARING
9glossopharngeal- SWALLOW
10vagus-AH UVUAL DEVIATION
11accesory-TRAPS MMT
12hypoflossal- TOUGNE STENGTH
346 H Eye tracking
vertabral artery (cervical quadrant) test
supine
pt neck extended and side flexed held for 10- 30 sec
symptoms of dizziness or nystagmus indicate contralateral side vertibra arteriy is being compressed
if no symptoms ipsi rotation is added and held for same
torticolois
unilateral shortening of sternocleido mastoid mmuscle
contralateal rotation and ipsilateal side bend
arom prom: side flex away and rotate towards affected side
strech SCM and strengthen opposing SCm
postioning and handling to stimulate sympetry and prevent plagiocephaly
baby helment if plogiocephaly is severe
upper crossed syndrome
a result of forward head psoture
tight pectorails and upft lev scap, occipitals
weak deep neck flexorsm LFT, rhomboids, SA
ideal seated work posture
top of screen at eye level
monitor arms length away
head in neutral with chin paraleel to ground
back rest comforably agains the backrest of the chair
elbows bent at 90 and cloe to the body
lower or remove arm rests
fingers relxed with wrists straight
hips and knees at 90
feet flat on ground or on foot rest
Cervical instability
excessive motion between two adjacent vertebrae
due to ligament damage, fracture, dislocation, joint damage or weak muscle
mobilizations and manipulations are contraindicated
s/s: dizziness, lip or facial parathesia, lump in throat, nausea vomiting, nystagmuss, hesitatnt to move neck, pupil, severe headache, severe muscle spasm, soft end feel
Specail Test: anterior shear/sagital, lateral lfexion alar lig, lateral/transverse shear test, sharp purser, cervical felxion rotatino
anterior shear or sagital stress test
patient in supine, stabilize with basak segmetn anterior to TPS with thumbs, superior segment is translated anteriorly with other digits
+ symptoms, excessive motions
lateral flexion alar ligment stress test
tests the integretiy of the alar ligs
sstabilize C2 in supine
side flex occiput and C1
+ symptoms, excessive side flexion
intact lig should have strong capsular end feel
lateral (transverse) shear test
tests the integreuty of the lateral lifs and capsualr tissues
supine
radial aspect of second MCP on inferior vertibrae
radial aspect of second MCP on superior vertbrae
apply shear force
+ symptoms or excessive motion
should have minimal motion and ot sumptoms
shar-purser test
performed with extreme cuatioon
test to determine subluzation of C1 and C2 , transverse lig maintains the position of the dens
seated, thumb stabilizes C2 posteriorly at SP
patient asked to slowly flex head while PT applies pressure to forehead
+ PT feels head slide backwards during movment which indicates relactation of subluzed atlas may be accompinaed by a clunk
cervical flexion rotation test
supine, flex c spine chin to chest to lock lower C Spine
rotation of upper C spine, increased or decreased c spine rotation indicates C1/2 dysfunctionor reprorduction o headache
Cspine rule
- high risk factor that mandates x ray
-> 65
-paresthesia in extremities
-danagerous mechanism ( fall from > 3 ft, axial compresion, MVC > 100 km, rollover, ejection, rec vehicles biclcyes)
=x ray - presence of low risk factors that allows safe ax of neck ROM
-simple rear end
sitting position
ambulatory
delayed onset pain
absense mid c spine tenderness
=no xray
3.able to rotate 45 L and R
=no x ray
segmental instability in the C/S
inner unit musccular control
attach segmentally, fucntion as stabilizers/not prime movers
includes deep neck flexorm deep neck extensors, suboccipitals
dysfunction can lead to segmental/clnical instability leading to abnormal movement between segments, may lead to recruitment of global muscles which can lead to over use
Craniocervical flexion test: supine eithinflatable cuff beneath upper c spine. base pressure to 20 mmHg hold for 10 sec, increase by 2 sec intervals with 10 sec holds and each,
+ test unable to increase pressure to at least 26 mm Hg and hold 10 sec, inability to raise by incremnets
compensatory patterns-use of superfiscal neck muscles like SCM, extention of the heads
Tx: deep neck flexor training, coordiation and timing/not strength- unload global muscles
ideal alignmnet in standing (lateral)
line through external auditory meatus of the ear, acromion process of scapula, greater trochanter of the femor, posterior to the patella, anterior to lateral malleolus
scheuermann’s DIsease
rare congential and/or dengenerative weaking of vertebral end plate
most common structural kyphosis in adolecents, second decade
uneven growth ot the growth of vertebrae in the sagittal plane resulting in excessive wedge shape leading to increase kyphosis, T10–L2
anterior wedgeing> 5 degress on three or more adjacent vertbrae, hyperkyphosis, adolescents,
rigid deformity
severe can cause heart and lung compromise
irrgueular endplates, schmorl nodes
Physio can help to impede progression, bracing, strecht strengthen into extension, pain managment
Dowagers Hump
increased kyphosis seen in older women with postmenopasual osteoporosis, anterior wedge fractures occuring at several vertebrae, typically results of trunk flexion, upper to middle thoracic spine, decreased hieght,
kyphosis tx
posture education, extension approach, stabilization exercises, stretching as needed, mobization as needed
joint manips and aggresive moiblizations are contraindicated
compression fracture
typically secondary to osteoporosis, 6-7th decade of life, Females, typicaly in anterior vertebral body,
cuased by falls/truamas/ trunk flexion,
tx posture education, extension appraoch, stabilization exercises, wb’ing activities and exrecises, light mobilixation as needed
no trunk flexion, aggressive mobilization, joint manips
Scoliosis
lateral curvature of the spine,
curves are labled in the direction on the convexity and level of apex
the lareger curve is labled major and smaller in the minor
cobb angle > 10 degreees= scolosis
non structural scoliosis
due to cuases outside the spine
curve disapears with forward flexion
relatively easy to correct once cause is found
poor posture, muscle guarding/spasm, nerve root irritation,inflammation, leg lenght discrepency
stretch and strength
leg length-long leg side, hip adduction, hip hike, side of convexity
short side: hip drop, leg abduction, side of concavity
structural scoliosis
structural changes in bone
congenital or aquired, does not disapear with forward bend
cobb angle >60 will compromise cardioresp system
irreversible with fixed rotation
vb bodies rotaate tto side of convexity-posterior rib hump on side if convexity more easily visible un forward flexion
scolosis interventions Tx
posture education
stretch side of concavity
strengthen side of convexity
rotatation to side of concavity
stabilization exercises
scap stailizer exercises
mobilzation as needed
bracing as needed
sx in severe cases
we can fix non structural by addressing cuase
we can prevent non structural influences on top of structual
herepes zoster
viral infection of a nerve cuasuing a painfuls kin rash following a dermatome patterns,
in thoracic spine presnets in a stripe
may be accompained by fever
