Download MS 1 final - KUPT2013comps

Hip Glides & Special Tests:
 Inferior glide
 Lateral traction
 Posterior glide- for Flexion and IR
 Compression- if have cartilage prob. might have sx
 Anterior glide- Extension and ER
 Hip Manipulation- (for decr mobility) pt supine, grasp ankle; hip flex, abd, ER, knee extended
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Thomas Test (Hip flexor length- rectus femoris, IT band, Iliopsoas)
Modified Ober test ( IT band length)
Quadrant test (putting in close packed position- hip flexion and add)
Hamstring length (watch pelvis for posterior tilt)
Ely’s Test (rectus femoris length)
Faber test (SI joint pain: more posterior; Hip joint pain: more anterior)
Craig test (hip anteversion: >15; hip retroversion: <8)
Leg roll test (for hip impingement; CAM or Pincer)
Leg length test (ASIS to medial malleolus)
Gluteus medius strength test (bias the posterior fibers; bring into S/L extension)
Piriformis test
Hip Pathologies:
 Developmental hip dysplasia
o Hip weakness; balance prob; short limb; xray; Barlow or Ortolani test
o Seen in newborn or older; treat with splinting (flex, abd), hip spicae, or surgery
 Legg-Calve Perthes (LCP)
o Groin, ant thigh, or med knee pain; limp, loss of IR, abd; can be bilateral (12%)
o Osteonecrosis of the epophyseal center of prox femur; more in males 3-10 y/o
o 3 stages: 1=bone death, normal xray; 2=necrosis, revascularization, xray shows increased
density; 3=distortion/remodeling, xray shows widening of jt and flat ossification center
o Tx: petrie splint- 30 abd, IR; surgery= varus osteoptomy
 Slipped Capital Femoral Epiphysis (SCFE): post, inf slippage
o More common in M; when in F they are younger; can be bilateral (30%)
o Transphyseal Salter I fracture
o Grade 1: <1/3 head; Grade 2: 1/3 to ½ head; Grade 3: > ½ head
o Hip pain/tenderness, ant thigh pain; walks with ER and flex of hip
o Loss of IR and abd weakness
 Avascular Necrosis: nothing we can do, just be aware of it
 Pelvic Apophysitis- can occur wherever a tendon attaches
 Femoral Ant Glide: Ant capsule pain; HS dominance, gluts should fire first to stabilize pelvis
o With SLR femur glides anteriorly instead of posteriorly
 Hip Add Syndrome: lat thigh/butt pain; weak hip abd; see add in stance; trendelenburg
 Lat glide Syndrome: deep hip pain, active subluxation and snapping; hypermobile joint
o IR of femur; Weak hip abd, and ER; IT band might be problem
 Piriformis Syndrome: from ant sacrum to greater trochanter
o Sciatic nerve may pierce piriformis (15% of ppl- more prone to syndrome)
o IR, flexion, or adduction puts more strain on mm
o Complain of posterior butt pain; down post leg; worse when sitting
o More common in F; trauma to SI or glut; Check lumbar and SI
o Walk in ER; flat back; SLR (+); N/T; Piriformis test positive (Flex,IR, Add)
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o Do HS stretch, passive knee to chest, rock backs (quadriped onto heels), core
o Could be a hypomobile L spine; do soft tissue massage and L-spine mobs
Hip Labral Tear
o Seen in all ages, more common in Females, and an active lifestyle
o MOI: hyperabduction, twisting /cutting, falling, running, MVA, repeted mvmt, direct blow
o S/S: ant hip, groin pain; clicking, pain w/ walking, stairs; limping, giving way, night pain
o Avoid hyperext; posture, hip strength, flexibility, core strength
o Precautions: 90 flexion, 25 abd, 10 extension (for 10-14 days)
Snapping Hip
o Internal: iliopsoas tendon snapping over iliopectineal eminence, capsule, or lesser troch.
 When hip extended from flexed, abd, ER position
o External: IT band snapping over greater trochanter (glut max is rare)
 With sudden loading, leg length diff, tight IT, weak hip abd and ERs, foot
overpronation (femoral IR)
o Could also be a labral tear or debris in hip
o MOI: acute (bursitis/tendonitis); repetitive (ext: dwnside leg on sloped road; int: ballet)
o S/S: pain/snapping lat or ant hip, or deep in groin; feel like hip is dislocating if ITB involved
o Palpate for tenderness, AROM of IR/ER, F/E; Ober test
Trochanteric Bursitis
o Painful inflamm of bursa; greater trochanteric pain syndrome (GTPS)
o MOI: impact, friction, posture, leg length diff, calcium deposits
o S/S: lat hip pain, inc when get up from chair/ascending stairs; N/T (non-dermatomal)
o Tx: strengthen hip mm (abd, ext, flex); soft tissue mobs; stretching, ice, US
Femoral Neck Stress Fx
o Most common on tensile side (superior) or compression side (inferior)
o S/S: ant/lat hip pain, front of groin pain post activity; pain walking, SLS, IR/ER,
o May have an non-CPR: IR, flexion, some abd
o Risk factors: coxa vara (neck and shaft <120); decreased bone density; female athlete triad
o Tx: PROM, massage, mild joint mob as WBin allows
Hamstring Strain
o Grade 1: <25% torn; Grade 2: 25-75% torn; Grade 3: >75% torn
o MOI: high speed running (biceps femoris); dancing/kicking (semimembi)
o Tx: Acute (AROM knee flex/ext; RICE); Subacute (ROM, stretching, strengthening);
OA of the Hip
o Wear and tear, repeted mvmt, obesity, age, congenital
o S/S: pain (butt, groin, thigh, knee) and stiffness (after activity); difficulty walking, stairs
o Restriction of IR and abd or flexion; mechanical disadv of mm (lose ligaments)
o Ant hip capsule tenderness, PROM causes pain, Stinchfield’s test (supine and resisted SLR)
o Tx: education, joint mobs, passive stretching (flex, abd, ER), traction, ROM, strength
o Surgical intervention, intraarticular injection of synovial fluid, glucocorticoids (anti-inflam)
Knee Glides & Special Tests:
 AP glide at 90 of tib fem jt- for flexion
 PA glide at 90 of tib fem jt- for extention
 AP/PA glide for sup tib fib jt- AP (flexion); PA (ext)
 Sup/inf patellofem glide; Med/Lat patellofem glide
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Lachman’s Test (+ for ACL problem if excessive motion compared to other side)
Anterior Drawer (for ACL)
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Posterior Sag (for PCL)
Posterior Drawer (also for PCL problems)
Varus Stress Test (for LCL)
Valgus Stress Test (for MCL)
Apley’s Compression/rotation (for meniscus)
Apley’s Distraction/rotation (for collateral ligaments)
Apprehension Test (for lat patellar movement)
Critical Test – knee to diff position (90. 60. 30. 0) and doing isometric contraction
Patellar tap test- looking for swelling in jt.; effusion
Knee Pathologies:
 Femoral Condyle Injury
o Articular cartilage defect- OCD (osteochondritis dissecans) lesion; or Sports trauma
o Pain, swelling, catching; pain with palpation
o Problems with ROM, quads, WB exercises
o Surgical: Carticel transplant- cartilage from NWB part of fem condyle; grow in petri dish;
then replant and cover with periosteal flap from tibia
 Bursitis
o Trauma (direct blow to front of knee); or overuse
o Limited ROM; Quad will get weak; obvious inflamm/edema
 Fat Pad irritation (under patellar tendon)
o Malalignment of patella: if sup patella is tilted anteriorly, can pinch fat pad inferiorly
o Pain and swelling; from trauma, hyperextension injury, or chronic irritation
o Anterior knee pain: differentiate b/t patellar tendonitis
o Acute: avoid quad ex.; use modalities, NSAIDS, and tape inferior pole
o Subacute/Chronic: restore ROM and mm length, avoid hyperext, quad ex., taping
 Osgood-Schlatter’s Disease
o Irritation of tibial plateau (epiphysitis); problem with growing boys; overuse injury
o Knee pain, swelling, tenderness below knee cap; pain at rest if severe
o Avoid activities, surgical if causes avulsion (attachment of tendon to bone irritated)
 Baker’s Cyst
o Secondary problem; build up of fluid pushed into posterior capsule
o Swelling, pain, limited ROM; flexion painful and last degrees of extension
o Aim tx at primary problem (arthritis or knee injury causing swelling) ROM exercises
 Plica Syndrome
o Normal extension of synovial capsule, thru oversuse causes it to thicken (medial side)
o Anterior or medial knee pain; feeling of catching; when flex and ext knee gets caught
o Secondary problem; above joint line; can palpate when irritated and thickened
o Tx: rest, antiinflamm meds, surgical resection
 Spine Referral
o Location of sx- medial knee (L3), lateral knee (L4); behind knee (L5/S1)
 Knee Instability
o Laxity of joint due to ligamentous tear (ACL, PCL, MCL, LCL)
o Ache deep in joint, knee unstable, stairs painful, swelling, pain with pivoting and WBing
o HS /gastroc stretch, ankle pumps, quad sets, manip/mob of knee cap; avoid extension
 Patellar Tendinosis
o Degeneration w/out inflamm; due to aging, vascular irregularites, repeted microtrauma
o MOI: impaired healing and repair response; weak quads to control deceleration motion
o Ant knee pain, pain at end range F/E; poor lumbo pelvic control; abnomal mm-tendon fxn
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o Tx: max tissue strength; allow adequate healing; ecc control LE; load tendon w/out pain
Meniscal Injury
o MOI: compression, rotation (flexed and ER), deterioration
o Longitudinal, radial, horizontal tears
o S/S: pain, weakness, locking during ext, swelling, stiffness, decreased ROM
o Joint line tenderness, McMurray’s test
o Acute: ankle pumps, quad set, HS raise, SLR, SAQ, wt shifting, prone leg hang, stretching
OA of the Knee
o Men> women until age of 50; most common form of OA
o Secondary causes: trauma, disease, job, sports, age, obesity
o S/S: progressive pain; limited ROM w/ inflamm; Xray- osteophytes, jt narrowing
o Tx: sx relief, inc. ROM, inc strength/proprioception; combo of manual and resistive ex.
Patellofemoral Pain Syndrome
o Overuse, malalignment, pronation, mm imbalance, genu valgum, tight quads/HS/gastroc
o S/S: pain around/behind patella; pain with stairs, prolonged sitting, squats, running (hills)
o Consider hip rotation, knee tracking, foot overpronation
o Patellar mobs, taping/bracing, quad stretch/strengthening, ITB stretch, glut med and hip
abd. Strength, HS/gastroc/soleus stretch
Iliotibial Band Syndrome
o Repetitive stress injury from sliding over lat fem condyle; or compression of deep CT
o Common in runners (weak hip abd), cyclists; inc valgus at knee
o Lat pain over fem condyle; noble compression test, creak test
o Pain control, stretching, manual, strengthening hip abd, surgery
Ankle Glides & Special Tests:
 TCJ Distraction
 TCJ Posterior glide- DF
 TCJ Anterior glide – PF
 STJ Distraction
 STJ medial glide- inversion
 STJ lateral glide- eversion
 STJ neutral- forefoot and rearfoot relationship
 Cuboid manipulation- (for PF cuboid, decr mobility-calcaneocuboid jt) pt prone, ext. knee and PF
 Ankle manipulation- (for decr mobility of talocrural jt) pt supine, wrap around foot and DF
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Thompson’s Test: see if intact Achilles tendon (also can’t do heel raise)
Homan’s Sign: DF foot, if pain, positive for DVT
Anterior Drawer sign: excessive mvmt indicates ant talofib lig tear or ant tibfib lig
Talar Tilt: inversion stress test; testing calcaneofib ligament and ant talofib
Navicular drop test: >10 mm positive for excessive pronation
Squeeze test- squeeze over MTs for Morton’s Neuroma (b/t 3rd and 4th) v. Stress Fx (over MTs)
Ankle Pathologies:
 Retrocalcaneal bursitis
o Friction, overuse, or blunt trauma
o Palpate for inflamm toward heel; AROM and PROM in both directions could bother bursa
o If Achilles-pain higher up; Passive PF shouldn’t bother Achilles
 Shin Splints
o Could be Med Tibial Stress Syndrome, Stress Fx, or Chronic Compartment Syndrome
 Stress Fracture
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o Pin-point tenderness; bone scan to confirm; due to female triad; abnormal bone dev’t
Compartment Syndrome
o Acute (due to trauma) or chronic; involves neurovascular system
o See N/T; Vascular changes (check distal pulse); compartmental pressure increased
o High if: >15 mmHg before exercise; OR >30 after 1 min of exercise
Nerve Entrapment
o Sural, saphenous superficial peroneal
Spine Referral
Hypomobile Ankle
o Post immobilization; adhesions in synovium; atrophy; fiber disorganization
o Affects talocrural (DF, PG); and Subtalar (Inv, Ever)
o Decreased ROM, deep ache, sharp pain at end range, stiffness in morning, walk w/ abd foot
o Stretches, glides, WBing, TB; stimulus for lig (tension), cartilage (comp/decomp w/ glides)
Medial Tibial Stress Syndrome
o Periosteal irritation along tibia; or soleal microtrauma; mm too tight, not strong enough
o Overuse/weakness of ant tib, EDL, EDB; common in activities w/ starts and stops
o Biomechanical- flat feet, fwd/bwd lean, toes out (women more likely to have these probs)
o S/S: pain/soreness on middle/distal postmed tibia (4-6 cm); mild swelling (not pinpoint)
o Tx: heel/toe raises/walks; calf stretch, sit-back stretch (ant. tib)
Ankle Sprains
o S/S: swelling, bruising, pain, loss of fxn, joint laxity, decreased ROM, point tenderness
o Lat ankle sprain MOI: inv/PF; Grade 1: ATFL; Grade 2: ATFL, CFL; Grade 3: ATFL, CFL, PTFL
o Med sprain MOI: Eversion/ER; deltoid lig stronger than lateral lig
o High ankle= sprain to syndesmosis b/t tibia and fibula; MOI: DF and ER
o Tx: massage, jt mobs; balance training; agility
Plantar Fasciitis
o MOI: running, jumping, dancing, step on hard object, tight Achilles, fat, high arch, flat foot
o S/S: heel pain w/ WBing, swelling, redness, point tenderness on plantar surface calcaneus
o Tx: stretch (passive/active) & strengthening (plantar fascia, gastroc, soleus, intrinsic mm)
o Massage to reduce tension in fascia (top of foot, sole of foot, cross friction heel massage)
Achilles Tendinopathy
o Insertional and non-insertional (2-6 cm prox to insertion)
o Types of non-insertional: peritendonitis, peritendonitis w/ tendinosis, and pure tendinosis
o Prone to degenerative changes due to lack of blood supply (tendinosis)
o S/S: post swelling, pain, decr. strength and ROM (more DF), stiffness, tendon thickening
o Tx: soleus/gastroc stretch, BAPS, ecc calf exercises, low impact aerobic, balance ex.
o No massage on tendinitis; no steroid injection b/c weaken the tendon
Ottwa Rules for Imaging
 Pain on Palpation:
o Distal 6 cm of fibula (post, midline)
o Distal 6 cm of tibia (post, midline)
o Base of 5th metatarsal
o Navicular Tubercle (medial aspect)
 Unable to bear weight immediately after injury
 Over age of 18 and below age of 55
Ankle Joint: Subtalar joint 4 points of Normalcy:
1. Tibia is vertical
2. Calcaneus in line with tibia
3. MTs in same plane
4. MT plane perpendicular to calcaneus
Laterally: ant talofib, calcaneofib, post talofib, peroneals, lat malleolus
Medially: deltoid, post tib, FDL, FHL, tibia
Anteriorly: ant tib
Posteriorly: Achilles, calcaneous, bursa
Deep: joint itself
Plantar: arch ligaments, plantar fascia
Shoewear:
Last of the shoe is the shape: Straight to Curved- no forefoot adduction to significant add.
Straight last - pes planus foot (need stability and motion control to control rf pronation);
Curved last for pes cavus foot (need shock absorbing)
Last construction: full board (cardboard on bottom), combo (½ board ½ slip), California
(peripheral slip), Banana (central slip, most mobile)
Outsole: Blown rubber (lighter); Carbon rubber (in rearfoot)
Midsole: Ethyl Vinyl Acetate (light, compressible); Polyurethane (dense, heavy, durable)
Looking at shoe wear won’t tell foot motion, can tell leg length diff (more worn on shorter limb)
Heel Counter- back of shoe, should be rigid to hold calcaneus in place
Torsional rigidity- need to have especially if overpronates a lot
Shoe should ben at MT area
Post to deformity (50%); ex: if have a 10 degree deformity would fix 5 degrees of it (5mm)
PNFs:
Hold-Relax: Antagonist mm inhibits agonist allowing it to relax more; reciprocal inhibition
Muscle spindle; deep tendon reflex; as mm contracts it is inhibitory to other mm group
Contract-Relax: contracting the agonist
Golgi tendon organ; autogenic inhibition; goes to spinal cord and inhibits itself
Aquatic PT:
Optimal temp: 88-92 degrees F – normally
92-98 degrees F- for less active ppl; or high spasticity or tone
82-88 degrees F- for MS or active pts
Safety:
Non skid ramp and/or hydraulic lift
Depth clearly marked
Lifeguard (can be therapist)
Therapist should not be in water >4 continuous hours/day
Reimbursement:
97113; may not be able to bill aquatic and land therapy on same day
Buoyancy: Archimedes principal: buoyant force = to weight of water displaced
Specific Gravity: ratio of body weight to weight of water it displaces
>1.0 (sinks- bone;mm); <1.0 (floats-fat)
Center of Buoyancy: usually located at mid thoracic (due to lungs); this isn’t the COM
Resistance: Viscosity: water is thicker than air
Drag Force: depends on Velocity and SA; as move faster & increase SA, it gets harder
Turbulence: Movement of water creates drag and increase resistance
Hydrostatic Pressure: force per unit area; increases as depth increases (at 48”=88.9 mmHg)
Can aid in venous return, used to decrease edema and control inflammation
Indications:
Cardiopulmonary: CO inc. with inc water temp; inc cardiac stroke volume
Musculoskeletal: improved O2 delivery and waste removal; decreased DOMS
Neurological: decreased pain and sensitivity, improve relaxation
Renal: inc blood flow to kidneys- diuretic effect
Contraindications:
Infections, open wounds, fever, contagious skin rash, seizure, cardiopulm problems, mental
disorders, fear of water, uncorked tracheotomy
Precautions:
Tubes and catheters, visual/hearing problems, hypertension, pregnancy, diabetes,
autonomic dysreflexia, hyper/hypotension, MS, tracheotomy, impaired cough reflex
Weight-Bearing Percentages:
85% WB – Mid Shin
65% WB – Mid Thigh
50% WB – Mid Pelvis
25% WB – Nipple line
10% WB – Level of C7
Shoulder Glides & Special Tests:
 Ant shoulder glide- for ext, ER, horiz ABD
 Posterior glide in Abd- for flexion, IR, horiz ADD
 Posterior glide in horiz Add- more aggressive
 Inferior glide (arm by side)- for ABD and flexion
 Inferior glide in Abd- more aggressive than by side
 Inferior glide in full flexion- even more aggressive
 Lateral glide
 Superior/inferior SC glide- sup (ext, depression); inf (flex, elevation)
 Ant/Post SC glide- post for retraction; ant for protraction
 Sup/Inf ST glide
 Lat/Med ST glide
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OP: Flexion, Abduction, ER, HBB (Ext,add,IR), HAC (horiz add), HBH (scaption/ER)
Sulcus Sign- (for instability)
Hawkins-Kennedy Impingement test
Neer’s test- (for impingement)
Speed’s test -For biceps tendonitis or labral tear
Supraspinatus tendonitis test
Drop arm test- RC tear
Load and shift test- ant/post instability
Crank test/ Clunk test- labral tears, clunk not as specific as crank
Apprehension test- ant dislocation/instability
Relocation test
Shoulder Pathologies:
 Dislocation
 mostly Ant/Inf; pain in ant/post direction; weakness in deltoid if axillary N affected
 MOI: trauma, sports, arm ABD/ER; blunt force in PA direction; Pt holds arm flexed and IR
 Do apprehension test, load/shift test; Can use sling and avoid ER/Horiz ABD
 Isometric ex, AROM, strengthening
 Subacromial Bursitis
 Overhead use; do palpation, ROM, MMT, and impingement tests- positive
 If get bone spur can tear supraspinatus tendon or push against bursa
 Shoulder Instability
ant most common then post and inf dislocation; trauma or overuse; can be congenital laxity
MOI for ant: Abd and ER; arm held slightly abd and ER
MOI for post: FOOSH, follow thru in throwing (powerful contraction IR mm); arm add and IR
MOI for inf: axial F to arm overhead, hyper-abd arm; will have elbow flex, pron, hyper-abd
Post/Ant glides; improve stabilizers of GH jt, AROM (flex, IR/ER-90, Abd-90, ext); scap
pinch, shrugs, quadriped rocking, bodyblad, PNF, modified push-up
Adhesive Capsulitis
 Painful gradual loss of AROM/PROM; progressive fibrosis/contracture of GH jt; elderly F
 Primary (idiopathic)= global capsular inflamm and fibrosis in absence of lesions/injury
 Secondary= due to trauma or immobilization
 Arthroscopic look= synovial inflam, Xmas tree synovitis, no axillary fold, capsular adhesions
 Painful stage(<3mo)-inc pn deltoid insert, achy at rest, sharp w/ mvmt; night & capsular pn
 Freezing/trans(4-12mo)-pn@end range; mm disuse; CPR limit ER/IR, flex; plateau w/ no pn
 Frozen/maturation(9-15mo)-complaint=stiffness; pn may be there; PROM show mech block
 Thawing/chronic (<42mos)-gradual return of motion; min pn; decr intracapsular volume
 Tx: NSAIDS, corticostd, manip, release, low grade mobs, pendulums, P/AAROM(ER/IR, Flex)
AC Joint Separation
 AC lig=horiz stability; CC lig=vertical stability (conoid and trapezoid lig); mvmt in 3 planes
 Type1= incomplete AC tear; Type2= AC tear and partial CC tear; Type 3= AC and CC torn
 MOI: fall on tip of shoulder, force to acromion with arm add, FOOSH, athletes at risk
 S/S: pain, pt tenderness, inflam, bruising, decr. ROM, instability, step deformity, pop felt
 Tests: cross-body Add test, O’Brien test, HBB elicits pain
 TherEx: pendulums, scap squeeze, wall crawl, shrugs, RC mm (Abd, IR, ER)
Shoulder Impingement
 Compression w/in subacromial space of supraspinatus tendon, long head of biceps, sup GH
capsule, and sub-acromion bursa- inflamm  deterioration  rupture
 Compression= arm ABD at 60-120 degrees; abnormal GH and ST arthrokin; poor posture
 Also: lig instab, mm wknes, adhesive capsulitis, tightness, abnorm arch, swelling, osteophyte
 S/S: pain in ant shoulder, lying on side, w/ lifting, overhead and arm abd.
 Primary=older(>35); neg stability, pos impingement, painful ABD 60-120; little IR/ER/ABD
 Secondary= younger, non-athlete; pos impingement and stability; incr ER; wk scapular mm
 Tx: horiz add and corner stretch; PROM/AAROM; isometric ER,IR,biceps,deltoid
Rotator Cuff Pathology
 Deterioration of tendons due to trauma, overuse, impingement; tendinitis/-osis or tear
 Pain with overhead mvmt; weakness of RC; disruption of arthrokinematics; limited ROM
 Do drop arm test or impingement test; progressive strengthening -focus on IR/ER and Abd.
Shoulder Labral Tear
 It is a soft fibrous tissue, surrounds fossa, deepens it and GH lig and biceps tendon attach
 MOI: FOOSH, sudden pull, overhead reach, direct blow; repetitive overhead motion
 3 types: SLAP (above); Bankart (below); tear of glenoid rim (from dislocations)
 Do crank/clunk test; See pain, catching, locking, popping, instability, decr ROM/strength
 Tx: anti-inflamm; strengthen RC; post surgery gentle PROM; isometric ER/IR; pendulums
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Elbow Glides & Special Tests:
 H-R distraction
 Proximal R-U anterior (volar) glide- for supination
 Proximal R-U posterior (dorsal) glide- for pronation
 Distal R-U anterior (volar) glide – for pronation
 Distal R-U posterior (dorsal) glide- for supination
 H-U medial glide- for extension
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H-U distraction
H-U lateral glide- for flexion; can vary elbow flexion (she did at 10 deg)
H-R volar glide- for flexion
H-R dorsal glide- for extension
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Resisted wrist extension- lat epicondylitis
Resisted 3rd finger extension- more specific to lat epicondylitis
Passive Stretch Test (Mill’s test)- lat epicondylits- elbow extended, wrist flexed, ulnarly deviated
Resisted wrist flexion- med epicondylitis
Passive stretch test- med epicondylitis – bring to sup, finger/wrist ext, elbow ext
Tinel’s test- ulnar nerve- tap nerve in groove to see if brings on sx
Elbow flexion test- ulnar nerve; hold for 3-5 min to see if get sx
Median nerve nerve test- have pt pronate and extend arm; resist pronation (pn over Pron Teres)
Varus stress test- at 5 degrees; look for instability and reprod. of sx
Valgus stress test- at 20 degrees elbow flexion; make sure not rotating arm
Elbow Pathologies:
 Little Leaguer’s Elbow
 Overuse injury in young baseball players (valgus F); epiphysitis of med epi; avulsions poss.
 S/S: gradual pn; med elbow; dec elbow ext, pron/sup; triceps wkness; lock/catch; 10-16 y/o
 TherEx: ROM, strength, jt stab.; core, balance, scap stab.; decr pitches/game and per week
 Panner’s Disease
 Rare bone dev’t condition affecting growth plate of elbow; athletic boys age 5-10 in dom arm
 MOI: loss of blood to capitellum; AVN; resolves itself in 2 yrs; overuse-lat compr F on elbow
 Agg= mvmt; ease=rest; dull ache at lat elbow; stiff, swelling, clicking; cant extend, pron/sup
 Tx: rest, anti-inflamm, NO aspirin, splint/cast for 3-4 wks; PT focus on flexibility, strength,
mm balance (ROM, stretching, open/closed chain, fxnl)
 Ulnar Nerve Transposition
 Surgery to correct ulnar N compression (parathesia to 4th and 5th digits)
 MOI: direct trauma; Entrapment (Zone1-prox to med epi; Z2-med epi; Z3-distal to med epi)
 S/S: weak pinch/grasp, claw, pn/parasthesis; dec sensation; Forment’s sign (+); Tinel’s (+)
 TherEx: P/AAROM; gripping, stretching, isometric, progress to eccentric
 Medial Epicondylitis
 Golfer’s elbow; need to address shoulder/scapular stabilization
 Pathologic chg to flexor-pronator musculotendinous bundle
 Inflamm, microtrauma; 4 stages (inflamm, tissue alt; structure failure; fibrosis/calcification
 S/S: pn, tenderness, stiffness, weakness, N/T in ring or little finger (ulnar nerve)
 Pain with resisted pronation and wrist flexion
 R/o: ulnar coll lig (valgus stress test), ulnar neuritis, flexor-pron mm belly, little league (age)
 TherEx: wrist flex/ext; finger ext; ball squeeze; pron/sup
 Radial Head Fx
 30-40y/o F; risk w/ OP, OA, postmenopausal; MOI: FOOSH (abd arm, elbow flex); direct blow
 Type1=fissue w/out displacemt; Type2=fx w/ displcmt; Type3=comminuted fx of whole
head; Type4= comminuted fx w/ dislocation, lig injury, coronoid fx, or Monteggia lesion
 S/S: dec ROM, stiffness, swelling, tenderness, lig, wkness, deformity, N/T, fat pad (sail) sign
 Tx: protect fx site; control pn/edema; prevent contracture; maintain ROM; progress strength
 TherEx: wrist AROM- flex/ext, sup/pron; AROM elbow flex/ext.
 Lateral Epicondylitis
 Repeated stress; damage, inflamm, pain, tenderness; flex moment absorbed by extensor mm
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 Find out if truly an inflamm problem or a biomech problem- need to correct biomech.
 ECRB often involved; See pain/burning, weak grip; rule out-arthritis, Cspine, N compression
 Tx: bracing, NSAIDS, wrist extensor stretch, ext w/ weight, sup/pron, finger extension
Osteochondrosis Dissecans
 Ant or LAT elbow pain; MOI: throwing, gymnastics, wrestling;
 Repetitive trauma or radial head compression; gradual onset (1-2 yrs)
 See pain/swelling, limited ROM, clicking/locking; Mostly in 15-20 y/o Boys
 Need rest, exercise or surgery if have chondral damage
Olecranon Bursitis
 Inflamm; swelling on posterior elbow; MOI: acute trauma, cont. pressure
 See limited ROM, pain with palpation; Intervention: protection/padding, ionto, ice
Myositis Ossificans
 Mm calcification; MOI: direct trauma; Decr. ROM, palpate mass; bone scan
 Intervention: Rest, immob., anti-inflamm, gentle ROM, or surgery (if had for > 6 mos)
CRPS
 Sympathetic response; severe pain (hypersensitivity); hypovascularity
 MOI: trauma, immobilization; gradual onset, pt reluctant to move arm
 Sensitive to touch, pitting edema, color changes (blue, mottled, shiny); decr. ROM
 Intervention: desensitization, meds, sympathetic nerve blocks, ROM as able
Volkmann’s Ischemic Contracture
 Compartment syndrom; following fx or dislocation of elbow
 Have decreased circulation; nerve disturbance; arterial ischemia; Do fasciotomy
 Have severe forearm mm pain; look purple in hand; lose radial pulse; clawed fingers
Pulled Elbow – radial head slippage (2-3 y/o); traction injury with arm extended/pronated
 Have limited extension, guarding; Do joint manipulation
Biceps Muscle Rupture – disruption of biceps from distal attachment (can be prox)
 MOI: quick, forceful bicep contraction; Deformity= discontinuation of mm; decr. elbow flex.
 Can opt for surgery; but sometimes other mm can make up for lack of biceps flex in elderly
C-Spine Referral – differentiate local elbow dysfxn from referral; and peripheral nerve dysfxn
Wrist Glides & Special Tests:
 Distal R-U Volar glide= for pronation (do in end range of motion)
 Dista R-U Dorsal glide= for supination
 R-C distraction
 R-C Volar glide= for extension
 R-C Dorsal glide= for flexion
 R-C Ulnar glide= for radial deviation
 R-C Radial glide= for ulnar deviaion
 MCP Volar glide= for flexion
 MCP Dorsal glide= for extension
 IP Volar glide= for flexion
 IP Dorsal glide= for extension
 CMC Ulnar glide= for flexion; slightly volar
1st MC is concave in frontal plane and convex in sagittal plane
 CMC Radial glide= for extension; slightly dorsal
 CMC Volar glide= for ADDuction
 CMC Dorsal glide= for ABDuction
 Capitate thrust= for subluxed capitate or stuck dorsally; have wrist flexed, bring to neutral
 MCP thrust- (for decr mobility); bring skin together and dorsally or volarly thrust
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Allen Test= to check blood supply
Finkelstein’s Test= for DeQuervain’s or irritation of Abd Poll Longus or Ext Poll Brevis
Froment’s Sign= testing strength of Add Poll (for prob with Ulnar N)
Phalen’s Test= for compression of median n
Reverse Phalen’s= stretches median n
Tinel’s Sign= tap on distal crease on radial side of wrist- Median N
Wrist Pathologies:
 Carpal Tunnel Syndrome
 9 flexor tendons and 1 nerve: median N, flex digit prof, flex digit superfic, flex poll longus
 median nerve entrapment- gradual, burning, itching, N/T, at night, decr grip, pain
 women more likely, assembly line workers, computer workers, diabetes, metabolic disorders
 Tinel’s (+) for median N; Phalen’s test (+) compressing nerve; reverse phalen’s- stretching N
 A/PROM- wrist flex/ext, RD, UD, finger/thumb flex/ext, thumb abd/add, grip strength
 Nerve glides, wrist splint; Consider ergonomics, address posture with all wrist pathologies
 Ulnar Neuropathy
 Guyon canal syndrome; inflamm of ulnar nerve; due to compr at elbow or wrist
 Risk factors: prior fx, bone spur, biking, cysts, overuse injury, constant pressure on palm
 S/S: N/T in 4th and 5th digits (early morn); progress to burning; decr sensation; weakness
 Weak grip, claw hand, Froment’s (+); Tinel’s (+); decr abd of fingers
 Do neck/wrist stretching and strengthening, nerve/tendon glides; avoid compr positions
 High rep, low wt: neck rot, lat, flex/ext, scapular AROM; elbow flex/ext, finger flex,, grip
 DeQuervain’s Syndrome
 Inflamm of sheat around abd poll longus and ext poll brevis; swelling/irritation of tendons
 Overuse, freq repetitive abduction and UD at wrist; common in middle age F; racquet sports
 Radiating pn; numb-dorsal thumb/index finger; diff moving thumb/wrist; Finklestein test
 MWM- mob w/ mvmt; Do eccentric ex, b/c it is an itis prob; keep wrist neutral; chg work pos.
 Complex Regional Pain Syndrome (CRPS)
 Chronic pain, continuous, intense, more common in extremities and F age 30-60
 CRPS 1= RSD- NOT assoc with nerve damage, sympathetically maintained pain
 CRPS 2= causalgia- assoc with nerve damage; neuropathic pain
 S/S: pain; allodynia (nonpainful stim); hyperalgesia; edema; stiffness; skin temp chg;
abnormal sweating; jt prob; mm prob; hair/nail chg
 R/O: RA, septic arthritis, gout, herniation; peripheral neuropathy, entrapment, vasc disease
 Acute inflam phase (10 d -2 to3 mos); Vasomotor instab (3-6mos); cold end phase (2-3yrs)
 Tx: Mirror therapy- prov sensory input to brain; gen strengthening; stretching; fluidotherapy
 Colles Fx
 Fx of distal radius-dorsal displacement of radius; dinner fork deformity; extra/intra-articular
 MOI: contact sport; F>50 (OP); MVA; FOOSH (pron, wrist ext 40-90); compression injury
 S/S: pain, tenderness, swelling, bruising, dec ROM (exp wrist ext/sup); decr grip; deformity
 Tx: after 4 wks immob- protect, control pain/edema, inc. ROM & strength- flex/ext, sup/pron
 Triangular Fibrocartilage Complex Injury
 AKA radioulnar disc or wrist meniscus, absorbs shock/ provides smooth mvmt for wrist
 Disc and supporting lig=TFCC= ulnolunate +ulnotriquetral (wrist MCL), palmar/dorsal R-U
 Type1-traumatic FOOSH, overload/twisting mvmt; Type2=degenerative thinning of disc
 Grading: A-horiz tear adj to radius; B-detach from ulna; C-ulnocarpal lig tear; D-avulsion
 S/S: pn over ulnar styloid; tenderness, decr grip; clicking, 50% assoc w/ wrist fx/dislocation
 TherEx: PROMAAROMAROMstrength/grip; PAMs (dorsal, palmar, lateral)
 Raynaud’s
 Constriction of small blood vessels of hands/toes (vasospasm); have diffuse pain, cold, N/T
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 Idiopathic, trauma, cold, emotional stress, smoking habits (can all trigger episodic events)
 Has positive Allen’s test, white fingers, nail beds can change, skin changes
Dupuytren’s Contracture
 Abnormal thickening of tissue in palm/fingers; seen in 50-70 y/o Males; 4th & 5th MCP & PIP
 Idiopathic, Have palpable nodules, limited AROM/PROM; Do stretching or surgical release
Smith’s Fx
 Fx of distal radius with Volar displacement; MOI: Flexion and compression; edema, decr ROM
 Last few degrees really hard to get back, keep hand moving to decrease swelling
Scaphoid-Lunate Disassociation
 See increased space because of injury to lig that holds lunate and scaphoid together
 MOI: fall/trauma; Do Watson’s test, Xray, has limited wrist motion, and increased glide
 Need to immobilize til fully healed before work on mobility
 Watson’s test- thumb on volar side of scaphoid, when RD scaphoid should glide volarly, if you
can push it dorsally then it is a positive test (may have pain or clunk)
Lunate Dislocation
 Can have volar or dorsal dislocation; occurs with trauma (FOOSH)
 Have pain, limited wrist motion, may have median nerve compression
 Surgically reduce; immobilize for 3-4 wks; no wrist extension for 2 mos
Bennett’s Fx
 Fracture of 1st MC (obliquely), from trauma or force from punch
 See local pain, swelling, deformity, decr gripping, thumb mvmt impaired
Boxer’s Fx
 Fracture of neck of 5th MC (can also be seen in 3rd or 4th MC)
Mallet Finger
 Avulsion of extensor tendon from DIP (may just be tendon, or also a piece of bone)
 MOI: direct flexion force on extended finger
 Put in volar splint to passively extend finger
Kienbock’s Disease
 Osteonecrosis/AVN of lunate after fx; Hx: FOOSH or compression fx; can be any carpal
 See tenderness, swelling, limited wrist motion, pain with gripping
 If still have pain 6 mos after initial injury, then concerned about AVN
 Tx: goal to increase circulation; thermal modality, ROM/glide
Scaphoid Fx
 Distal pole is vascularized; as get to proximal pole it becomes less vascularized
 Hx of FOOSH; pain in snuffbox, limited/painful wrist mvmt, pain with compression
 Need to make sure it is healed, can be in splint up to 4 mos.
 4 tests: squeeze snuffbox; compress 1st MC; palpate tuberosity on volar side; resisted pron
Skier’s Thumb
 Sprain of ulnar collateral lig of 1st MCP joint; can be partial or complete tear
 MOI: from fall, trauma, or repetitive mvmt
 May see laxity/deformity; Can do taping, spica brace to reduce mobility of thumb, or surgery