W2 Flashcards
Rotator Cuff Tear Cluster
- Age >65
- Night pain
- Weakness in ER
Rotator Cuff Full Thickness Tear Cluster
- drop arm test
- painful arc test
- Infraspinatus test
- Age >60
Impingement Cluster
+ Hawkins Kennedy
+ Painful arc
+ Infraspinatus weakness MMT
Anterior Instability Test Cluster
+ Apprehension
+ Relocation
Labral Tear Cluster
+ Relocation test
+ O’Brien’s/ active compression test
Acromioclavicular Joint Pathology Cluster
+ Crossbody Adduction Test
+ AC resisted extension test
+ O’Brien’s
What are all the tests for : Subacromial Impingement/Pain Syndrome
- Hawkins Kennedy–> (+) pain or motion limitation
- Painful Arc –> (+) Pain or compensation : 60-120 degrees: pain at end range is ACJ
- Neer’s–> (+) pain or limitation in motion
What are the Special Tests for: Scapula
- Scapular Assistance–> (alleviating) (+) relief of symptoms
- Scapular Repositioning–> (+) if patient no longer exhibits pain or weakness after repositioning
What are the Special Tests for: Muscle/Tendon Dysfunction
- Full/Empty Can Test ( Supraspinatus)–> (+) if the patient can’t hold position or pain
- Drop Arm Test (Supraspinatus: especially good for tears)–> (+) If patient isn’t able to slowly lower arm down
- IR Liftoff/ IR Lag Sign (Subscapularis)–> (+) if patient isn’t able to hold and slowly bring hand off of back
- ER Lag Sign ( Infraspinatus shoulder is abducted 20 degrees and elbow 90)/Horn blowers (Teres minor and shoulder is 90 and so is elbow in 90 )–> (+) if patient isn’t able to hold position
- Speeds Test (Tendinitis/ Labral Tear)–> (+) deep pain in bicipital groove = biceps / Deep pain in the shoulder = labrum
What are the special tests for: Shoulder (GH) Instability and Posterior Impingement
- Apprehension Sign/ Jobe Relocation –> (+) apprehension test = apprehension/ (+) relocation test= reduction of pain or an increase in ROM
- Jerk Test ( Posterior-inferior instability/Labral) –> (+) pain with possible click or clunk
- Load Shift Test–> (+) depends on where the hypermobility is either anterior or posterior and you compare sides
- Posterior Shoulder Impingement/ Modified and Relocation Test
What are the special tests for: Labral Lesions
- Active Compression/Obrien’s Test (Labral/AC)–> (+) pain at the shoulder = Labral / Pain at the AC = ACJ issues
- Biceps Load 1 ( Labral/SLAP/ shoulder is at 90 degrees abduction)–> (+) deep pain in shoulder
- Biceps Load 2 (Labral/SLAP/ shoulder is at 120 degrees of shoulder abduction) –> (+) deep shoulder pain
- Anterior Slide Test (SLAP) –> (+) Pain localized to anterosuperior aspect of the shoulder, pop, click, clunk in the anterosuperior region, or reproduction of symptoms
- Crank Test (Labrum) –> (+) deep pain in shoulder, click, clunk, and reproduction of symptoms
- Speeds Test ( Biceps Tendonitis/ Labral)–> (+) deep pain
What are the special tests for : AC joint Pathology
- Crossbody Adduction Test ( can help with subacromial impingement diagnosis)–> (+) pain depending on location
- AC Resisted Extension –> (+) pain in the AC joint
- Active Compression/O’Brien’s Test –> (+) Pain at the AC joint
What Muscles of the shoulder do Flexion
- Anterior Delts
- Pec Major
- Coracobrachialis
- biceps
What muscles of the shoulder do Extension
- Posterior delt
- Teres Major
- Teres Minor
- Lats
- Pec Major
What muscles of the shoulder do Horizontal Adduction
- pec Major
- Deltoid
What muscles of the shoulder do Horizontal Abduction
- Posterior Delt
- Teres major
- Teres Minor
- Infraspinatus
What muscles of the shoulder do Abduction
- Middle Delt
- Supraspinatus
- Infraspinatus
- Subscapularis
- Teres Minor
What muscles of the shoulder do Adduction
- Pec major
- Lats
- Teres Major
- Subscapularis
- Coracobrachialis
What muscles of the shoulder do IR
- Pec Major
- Subscapularis
- Lats
- teres Major
- Anterior Delt
What muscles of the shoulder do ER
- Infraspinatus
- Teres minor
- Posterior Delt
What muscles do scapular elevation?
- Upper traps
- Levator Scapulae
- Rhomboids maj/min
What muscles do scapular depression
- Lats
- Lower traps
- Pec Major/Minor
- Serratus Anterior
What muscles do scapular protraction
- Serratus anterior
- Pec major/minor
- Lats
What muscles do scapular retraction
- Traps
- Rhomboids Major/Minor
What muscles do scapular Upward Rotation
- Traps
- Serratus Anterior
What muscles do scapular downward Rotation
- Levator Scapulae
- Rhomboid Major/Minor
- Pec Minor
Axillary Nerve:
C5-C6
Innervates –> Delts/Teres minor
If you have a lesion of the axillary nerves what might you see?
Teres Minor and Delts would be affected:
Potentially see:
- could see delt and teres minor atrophy
- patients inability to raise arm correctly
- Weak to little ER/abduction
Long Thoracic Nerve
C5-C7
Innervates Serratus Anterior
If there was a lesion at the Long thoracic nerve what might you see?
- Scapular movement issues including lack of upward rotation/protraction/depression
Suprascapular Nerve
C5-C6
Innervates Supraspinatus and infraspinatus
Supraclavicular Nerve
C3-C4
Musculocutaneous Nerve
C5-C7
Innervates Brachialis, biceps, coracobrachialis
Radial Nerve
C5-T1
Innervates Extensors of wrist, fingers, brachioradialis, supinator
Median Nerve
C5-T1
Innervates Pronator teres, Flexors of the forearm, wrist and hand
Ulnar Nerve
C8-T1
Innervates flexor carpi ulnaris, adductor pollicis, flexor digitit minimi brevis, hypothenar
Joint Mobs: Shoulder Flexion
Humeral Head spins anterior
Posterior glide
Joint mobs: Shoulder abduction
Humerus rolls superior and slides inferior
Inferior Glide
Joint Mobs: Shoulder Extension
Humeral head spins posterior
Anterior Glide
Joint mobs: Shoulder ER
Posterior roll and anterior slide
Anterior Glide
Joint mobs: Shoulder IR
Anterior roll and posterior slide
Posterior glide
Joint Mobs: Scapular Thoracic Elevation
Superior glide
Joint Mobs: Scapular Thoracic Depression
Inferior Glide
Joint Mobs: Scapular Thoracic Flexion
Upward rotation
Joint Mobs: Scapular Thoracic Adduction
Medial Glide
Joint Mobs: Scapular Thoracic Abduction
Lateral Glide
Thoracic Mobility:
Exam Findings
Proposed Interventions
Exam Findings:
- Restricted AROM
- Restricted PIVM thoracic spine and robs
- No UE radicular symptoms
- Postural deviations
- Muscle imbalances
Proposed Interventions:
- Mobility exercises
- Thoracic spine and rib mobs/manips.
- Self mobilization techn.
- Postural Exercises
Thoracic Hypomobility with UE Referred Pain
Exam Findings:
Proposed Interventions:
Exam Findings:
- Restricted AROM
-Restricted PIVM upper thoracic spine and robs
- UE symptoms
- Positive ULTT
- Muscle Imbalances
- Postural Deviations
Proposed Interventions:
- Mobility exercises
- Thoracic spine and rib mobs/manips.
- UE neural mobs/exercises
- Self mobs
- Postural Exercises
Thoracic Hypomobility with Neck Pain
Exam Findings:
Proposed Interventions:
Exam Findings:
- Symptoms <30 days
- No symptoms distal to shoulder
- No aggravation of symptoms w/looking up
- FABQPA score <12
- Decreased up thoracic visual
- Cervical extension ROM <30 degrees
Proposed Interventions:
- Thoracic spine and rib mobs/manip
- Mobility exercises
- Self mobs
- Postural exercises
- treatment of cervical impairments
Thoracic Hypomobility with Shoulder Impairments
Exam Findings:
Proposed Interventions:
Exam Findings:
- Stiff thoracic spine with shoulder AROM
- Restricted PIVM upper thoracic spine and ribs
- Shoulder impingement/rotator cuff signs
- Muscles imbalances
- Postural deviation
Proposed Interventions
- Mobility exercises
- thoracic spine and rib mobs/manip.
- Self mobs
- Postural exercises
- Rotator cuff exercises
Thoracic Hypomobility with LBP
Exam Findings
Proposed Interventions
Exam Findings:
- Stiff thoracic spine with thoracolumbar AROM
- Restricted PIVM testing
- Lumbar Impairment
- Muscle imbalances
- Postural deviations
Proposed Interventions:
- Mobility exercises
- Thoracic spine and rib mobs/manips.
- Lumbar rehab
- Self mobs
- Postural Exercises
Thoracic Clinical Instability
Exam Findings:
Proposed Interventions:
Exam Findings:
- History of trauma or thoracic surgery
- Provocation with sustained WB posture
- Relief with sustained WB posture
- relief with NWB posture
- Hypermobility with loose end feel with PIVM
- Poor strength (2/5) of thoracic multifidi’s, erector spinae, and parascapular muscles
- Aberrant movement (shaking/poor control) with thoracic AROM
Subacromial Debridement
- Arthroscopic–> clean up shave down and remove part of the acromion potentially
- NO PRECAUTIONS AS TOLERATED
- Control pain edema, preserve ROM
- Stretching and neuromuscular control
- Optimize posture
- Strengthening
RTC Repair General Post Op Guidelines**
- 4-6 weeks continuous use of brace
- 4-6 weeks NO AROM
- 4-6 weeks NO UE WB
- 2-4 weeks NO PROM
What is the RTC Protocol for Immediate Phase of 2-4 weeks
- Scapular, cervical ROM and isometrics
- Elbow, wrist, hand AROM and resisted exercise
- GH PROM- manual pendulums
What is the RTC Protocol for Protective Phase 4-10 weeks
- Ween brace
- pain free PROM–> AAROM
- Joint Mobs
- RTC isometrics
- GH AROM
What is the RTC protocol for Intermediate phase 10-14 weeks
- Dynamic stabilization
- strengthening
RTC Protocol days 1-6
- Abduction brace/sling
- sleep in brace/sling
- begin scapula musculature isometrics/ cervical ROM
- Patient education, posture, joint protection, positioning, hygiene
- cryotherapy for pain and inflammation
days 1-2 as much as possible / days 3-6 post activity or for pain
What are the Precautions for Immediate Post Op surgical phase of RTC tear weeks 1-4
- NO ACTIVE RANGE OF MOTION OF SHOULDER
- Maintain arm in sling, remove only for exercise
- No lifting objects
- No shoulder motion behind the back
- No excessive stretching or sudden movements
- No supporting body weight with hands
- Keep incision clean and dry
What is the protocol for Post- surgical rehab of a SLAP repair weeks 1-2
- Limited ER/IR motion
- No biceps activation (elbow flexion, supination)
- AROM scapula, cervical, elbow, hand, wrist
- Submax isometrics to GH, periscapular musculature
- THEY DONT WANT IR/ER MOTION BECAUSE THE BICEPS TENDON RUNS THROUGH THE BICIPITAL GROOVE IN THAT LITTLE TUNNEL AND WHEN YOU DO THOSE MOTIONS IT ADDS TENSION TO THE BICEPS TNEDON AND THE BICEPS TENDON ATTACHES TO THE LABRUM
What is the protocol for Post- surgical rehab of a SLAP repair weeks 3-4
- Rhythmic stabilization
- Proprioceptive training
- Progressive isometrics
What is the protocol for Post- surgical rehab of a SLAP repair weeks 5-8
- Progress preriscap strengthening
- Manual resistance PNF
- Shoulder AROM
-Progress to full PROM
TSA/Hemi-TSA
- joint degeneration with INTACT ROTATOR CUFF and deltoid, adequate bone quality, stable joint
- Gentle progression of ROM
- NO EXTENSION > neutral (patient always has to be able to see their own elbow)
- NO IR + ADD (shift tuck/hygiene)
- NO WB
rTSA
- Arthritis with inoperable RC tear, complex fractures, or revision of failed TSA
- Joint protection ( higher dislocation risk/ Ext, IR + Add x 10-12 weeks )
- Dependents on deltoid and periscapular muscles
What is the best exercise for lower trap to achieve max recruitment with the least amount of upper trap recruitment?
Modified cobra
- retracts, depresses and extends
- if patient cant do this yet they may want to do seated depressions
T/F thumb up prone T’s are not safe for patients with anterior instability
True - not safe
What are some good Serratus Anterior exercises with the best activation and not a lot of UT activation?
- Supine punches 50-80% MVIC of the SA and only 7% UT activation
- Push up Plus 73-80% MVIC SA and only 8-19% UT MVIC
Advanced exercises are standing upper cut with a 100% MVIC SA but a 66% MVIC of UT
or
Scaption of 120 degrees w/96% MVIC but a 79% MVIC of UT
Resistance training Dosage for
1. Power
2. Strength
3. Hypertrophy
4. Endurance
- Power
Intensity= 75-90 1RM
Sets= 3-5
Reps= 1-5
Rest 2-5 minutes - Strength
Intensity= >85% 1RM
Sets= 2-6
Reps= <6
Rest 2-5 minutes - Hypertrophy
Intensity = 67-85% 1RM
Sets = 3-6 sets
Reps = 6-12
Rest= 30-90 seconds - Endurance
Intensity= <67% 1RM
Sets= 2-3
Reps= >12
Rest = 30 seconds
What are some Subscapularis EMG Common Exercises for rehab
- Push Up plus 122+
- Flexion above 90 degrees with 120 degrees of ER 99+
- Standing extension from 90-0
- D2 extension
- Standing row at 90 degrees
- Standing IR at 0
- Standing IR at 90 degrees
Based off of EMG what is the best Serratus Anterior scapular stabilization prescription?
Wall slide
Based off of EMG what is the best Middle trap scapular stabilization prescription exercises?
- prone row
- prone horizontal abduction with ER
Based off of EMG what is the best Lower trap scapular stabilization prescription exercises?
- Prone full can scaption (Y’s)
- Bilateral ER in neutral (W’s)
Based off of EMG what is the best Rhomboids scapular stabilization prescription exercises?
- Prone row
- Prone extension with ER
What is the UE kinesthetic Awarness Progression
- Static kinesthetic awareness
- Dynamic Stability
- Reactive stabilization
- Plyometric progression
What is the critical zone of the spinal canal?
T4-T9 is where the spinal cord narrow
- T6 is the spinal cord tension point
- mobility in these regions may be associated with altered neural dynamics
T4 SYNDROME
Pes Carinatum
- Pigeon Chest
- Sternum projects forward and downward
- Congenital deformity
Pes Excavatum
- Sternum pushed posteriorly into the thoracic cavity by overgrowth of ribs
- Shrinks AP diameter
- Decreases the space and can even displace the heart
What are the neurovascular special tests for the thoracic
- Slump test
- First thoracic nerve root stretch
- Roos test
- Provocation elevation test
- Wrights Test (Allens)
- Shoulder girdle passive elevation test
- Adson test
C7-T1 and T1-T2 hypomobility is a predictor of
Neck and shoulder pain and hand weakness
C7-T1 and T3-T4 hypomobility predicts
Headache
TOS Scalene Syndrome
- Compression (arterial (subclavian) and or neural) between ANTERIOR and MIDDLE scalene
- NOT VENOUS
Etiology= - Scalene tightness
- fibrous bands - congenital or scar
- Accessory Scalene Muscle
- Enlarged C7 TP
- Cervical rib syndrome (extra bone?)
TOS: Costoclavicular Syndrome
- Compression of neurovascular bundle between 1st rib and clavicle
- Possible vein, artery, nerve
- results from elevated first rib, clavicle fracture/callus, subclavius muscle disorder or morphological abnormality
TOS: Hyperabduction Syndrome
- Compression of neurovascular bundle underneath pec minor
- Possible vein, artery, nerve
- Results from tight pec minor, expansion of fascia, prolonged arm elevation
What are good Special tests for TOS
Costoclavicular
Hyperabduction test
Adson test
Red Flags for Thrust Techniques
- Myelopathy
- cancer
- upper cervical ligamentous instability
- vertebral artery insufficiency
- Inflammation or systemic disease
What test is good to perform to show serratus anterior weakness and / long thoracic nerve weakness?
Wall push up test
Biceps Tests
- Yergasons
-Bicipital tendonitis
What must be present for it to be considered a tendinopathy?
- Tendon pathology
- Pain system changes
- Motor system impairments
What are the Subscapularis Tests ??? ( These are from the notes)
- Belly press test
- Lift off test
- Bear hug test
- if its + belly press and bear hug = 30% torn
- if its + lift off: its 75 % torn ( this test will be negative until its at least 75% torn)
What is the different types of SLAP tears
Type 1= labrum and biceps strain, anchor still intact
Type 2= Labral strain with a detached biceps anchor
Type 3= bucket handle tear intact biceps anchor
Type 4= bucket handle tear with a detached biceps anchor
Bankhart tear isssss
Avulsion of the anterior inferior labrum from the glenoid rim
Hill-Sachs Lesion issss
Compression fracture of the posterior humeral head at the site where the humeral head impacted the inferior glenoid rim
