Download 1 – OMM Landmarks

1 – OMM Landmarks
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Pivot – Atlanto-Axial joint
Ball and Socket – Hip Joint
Plane – acromioclavicular joint
Hinge – Elbow joint
Saddle – first metacarpal joint (thumb)
Condyloid – metacarpophalangeal joints
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Functional Landmarks
o Suprasternal Notch = T2
o Angle of Louis = T4
o Xiphoid Process = T9
o Ubmilicus = L3-L4
o Spine of Scapula = T3
o Inferior Angle of Scapula = SP of T&, TP of T8
o Spinous Process of C7 = longest spinous process of cervical vertebrae – C7
moves, but T1 does not.
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Active Motion  Physiologic Barrier
o Passive Motion  Anatomic Barrier
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Labeling Somatic Dysfunction of Vertebral Unit
o Somatic dysfunction of C4  describes motion of C4 on C5
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Fryette’s Principles of Physiologic Motion
o 1st Principle (only applies to T and L spine) – When sidebending is attempted
from neutral (anatomical position) rotation of vertebral bodies follows to the
OPPOSITE direction.
 Sidebending occurs 1st with rotation 2nd in opposite direction
 N(neutral)SxRy
o 2nd Principle (only applies to T and L spine) – When sidebending is attempted
from non-neutral (hyperflexed or hyperextended) position, rotation must
precede sidebending to the SAME SIDE.
 Rotations occurs 1st with sidebending following in the SAME
direction
 E(extension)RxSx
o 3rd Principle – Motion introduced in on plane limits and modifies motion in
the other planes
2 – Palpation and ROM of Cervical Spine
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Dx Approach – History
o O - Onset
o L - Location
o D - Duration
o C - Characteristics
o A - Aggravating
o R - Reliveing
o T - Treatment/Timing
o S - Severity
Neck Pain
o 2nd to lower back pain as a musculoskeletal complaint seeking manual
therapy
o Females>Males
o Stress related
o Most common reported Somatic Dysfunction amongst NMM/OMM
specialists
C Spine
o Two Divisions
 Superior (atypical – C1-C2)
 Occipito-atlantal (OA)
 Atlantoaxial (AA)
o C2 – prominent SP
 Inferior (typical – C2 – C7 - joints)
 C2 = motion of C2 on C3
 C7 = Motion of C7 on T1
o C7 prominent SP
o ATLAS – supports head, forms OA
 Transverse Foramen
 Vertebral a, v and sympathetics
 Superior Articular Facet
 Peanut shaped, converge anteriorly, hyaline
 Inferior Articular Process
 Pear shaped, concave, hyaline
o AXIS
 Dens – extends from body and articulates with Atlas – AA joint
 1st SP
 Convex Superior Facet
 4 Joints
 Anterior articular facet with post portion of Anterior tubercle
 Posterior articular facet with transverse ligament of Atlas
 Superior articular facets articulate with inferior articular facets
of atlas
 Inferior articular facets articulate with superior articular facets
of C3
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Ligaments
o Longitudinal
 Anterior, Posterior – Support, esp. to Inter-vertebral Discs
o Ligamentum Nuchae
o Tectorial Membrane – termination of posterior Longitudinal Ligament
o Cruciform Ligaments
 Superior and inferior limbs
 Transverse ligament of atlas
 Part of cruciform ligament
 Has synovium like a joint
 Spinal cord is posterior this
o Alar Ligmanets
 Oblique orientation – odontoid process to medial aspect of occipital
condyles
o Suspensory Ligament
 Superior orientation (tip of odontoid process) to base of occiput
Joints of Luschka
o Articulations between superior and inferior surfaces of Typical Cervical
Spine
Characteristics of Cervical Spine
o Do NOT follow Fryette’s 1st Principle
 Rotate and sidebend to the SAME side (except AA and OA joints)
 Majority of sidebending in inferior division
Intervertebral Discs – thicker anteriorly
o Annulus fibrosus
o Nucleus pulposus
 Thickest in Lumbar, 2nd thickest in C-spine
o Flexion
 IVD moves posteriorly
o Extension
 IVD moves anteriorly
Muscles
o Posterior Group
 Superficial
 Trapezius
o Stabilizes and elevates scapula, extends head
 Levator Scapulae
o Elevates medial scapula and rotates it medially
 Intermediate
 Splenius Capitus
 Splenius Cervicis
o Extension of head and neck
 Deep
 Erector Spinae
o Illiocostalis
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Longissiumus cervicis
Spinalis Cervicis
Mulifidus
Rotatores
o Anterior Group
 Anterior Scalene
 Middle and Posterior Scalene
 Playsma
 SCM
 Hyoid
 Scalenes
 Longus Coli
 Longus Capitis
Nerves
o Cervical Nerves exit Above the vertebrae – C1 – C7; C8 exits above T1
Level
Major Motion
Minor Motion
Diagnosis
OA
FB/BB
(Flexion/Extension)
Side-slipping/
Rotation
FB (F) or
BB (E) SxRy
AA
Rotation only
Wobble
RL or RR
Sidebending/Rotation
and
FB/BB
(Flexion/Extension)
Slight
Translation
FB (F) or
BB (E)
RxSx
C2-C7
Spurling’s Test
Sidebend and backward bend head; add compression, positive if pain radiates to
ipsilateral arm.
Adson’s Test
Radial Pulse of arm; move arm into abduction and external rotation; patients takes
deep breath and turns head – marked diminution or loss of pulse = positive test.
Indications subclavian artery compression by cervical rib and/or scalene muscles.
Thoracic Outlet Syndrome
3 – Medical Hx and Differential Diagnosis of Cervical Pain
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Diseases can weaken transverse ligament – RA, patients with Downs are susceptible
to weakened transverse ligaments. AA articulations.
STRAP muscles – Sternothyroid, Sternohyoid, Thyrothyroid, Omohyoid –
Intermedaite anterior cervical muscles
Lateral Neck Muscles – Sternocleidomastoid, Scalene, Trapezius.
Chronic Pain in the upper neck, back of head and behind eyes – areas correspond to
locations of the lesser and greater occipital nerves.
SOAP Note Subjective Data
o PMHx
o PSHx
o FamHx
o SHx
o Meds, Allergies
o ROS
Physical Evaluation
o Observation
o Palpation
o Gross Motion Testing
o DTR’s deep tendon reflex
o Muscle Strenght Testing
o Special Tests
 Spurlings Test
 Good for ruling out, but not confirming cervical radiculopathy
 Anterior and middle scalenes may be impacting brachial
plexus
 Lhermitte’s Sign – Barber’s Chair phenomenon
 Pt sitting, flexion of cervical spine – electric shock or
lightening like paresthesias or dysthesias in the hands or legs
upon cervical flexions = positive test = Multiple sclerosis or
large disc herniation
 Valsalva Test
 Increases intrathecal pressure (pressure of cerebrospinal fluid)
Radiculopathy
o Any pathologic condition of a nerve root
Spondylosis
o Any of various degenerative diseases of the spine
 Decreased ROM, pain, pain with upward gaze or rotation of neck,
pain with extension of neck.
 Anykylosis of adjacent vertebral bodies
 Degeneration of the intervertebral disc
Torticollis
o Contracture of neck…usually SCM, causes head to SB to side of spasm and
rotate opposite with flexion “twisted neck” “wry neck”
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Whiplash
o Musculoligamental sprain or strain from forced hyperflexion/hyperextension
injury to the neck
Hangman’s Fracture
o C2 SP fracture
Odontoid Fracture
o 15% of all c-spine fractures – pain and inability to actively move the neck,
most patients complain of a sensation of instability, feeling of head being
unstable on spine, present holding head with hands to prevent motion. –
quadriplegia tto respiratory center involvement
Major Rule Outs for Non-traumatic Neck pain
o Carotid Aneurysm dissection
o Myocardial Infarction
o Meningitis
o Spinal cord Injury
o Vertebral Artery dissection
Cervical Radiculopathy
o Arm pain/ clumsiness
o Pain in trapezius/paraspinal/interscapular
o Dermatomal paresthesias
Cervical Spondylosis
o Common degenerative condition
o Spasm of cervical muscle
o Knotty or fibrous (ropey) texture due to chronic spasm
C7 – Triceps
C6 – Brachioradialis
C5 – Biceps
Cervical Pearls
o If Head automatically SB’s and R’s in opposite directions – OA or SCM
o Restriction in Flexion – Trapezius
o Restriction in Extension – SCM and STRAP muscles
o Difficulty Swallowing – STRAP muscles
o Radiation of pain to upper extremities – entrapment
o Radiation of pain to occiput – many muscles, occipital nerves
o HA w/ pressure and tight headband sensation – suboccipital and occipitalis
muscles and greater and lesser cranial nerves
o Any symptom – somatic dysfunction
o Dizziness or syncope, especially on turning with extension – compromise of
carotids and/or vertebral arteries
o Respiratory Disease – scalenes and SCM and C3,4,5 and Rib 1 attachement
of scalenes and origin of phrenic nerves.
o Radiation of pain to ear or jaw – SCM, stylohyoid, TMJ and angina
4 – Intro to Direct Methods of Tx of Cervical Spine
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Somatic Dysfunction
o Impaired or altered function of related components of the somatic
system: skeletal, arthrodial, and myofascial structures and related
vascular, lymphatic and neural elements. SAMVLNE
Two major factors determine technique
o Ability of patient to respond to the Treatment
o Ability of the physician to perform the technique
Direct Technique
o Positioning in the direction of the restrictive barrier
o Activating force is applied
o Movement through restrictive barrier
o Examples:
 Soft tissue
 Myofascial
 Articulatory
 Muscle Energy
 Thrust
 HVLA-high velocity, low amplitude
 Inhibition
Indirect Technique
o Positioning away from restrictive barrier
o Move tissues in a direction that is freer
o Release by inherent forces
o Examples:
 Myofascial release
 Counterstrain
 Facilitated positional release
 Functional technique
 Ligamentous release
 Balanced ligamentous release
 Ligamentous artircular strain
 Cranial
5 Models
o Structural
 Biomechanical adjustment and mobilization of joints. Seeks also to
remove restrictions and limitations of motion in soft tissue as well as
myofascial structure to enhance freedom of motion.
o Respiratory Circulatory
 Improve diaphragm restrictions in the body.
o Metabolic
 Enhance self healing and self regulatory mechanisms, enhance energy
expenditure and exchange, enhance immune function.
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o Neurologic
 Attain autonomic balance and address neural reflex activity, remove
facilitated segments, decrease afferent nerve signals and to decrease
pain.
o Behavioral
 Improve biopsychosocial aspects of the health spectrum including
emotional balancing as well as compensatory mechanisms.
Barriers
o Anatomical Barrier – point at which further motion would result in injury
o Physiological Barrier – point at which active motion stops
o Clinical Barrier/Restrictive Barrier – point before physiologic barrier
HVLA
o When NOT to use:
 Fracture at site of manipulation
 Severe RA/Down’s
 Primary or metastatic cancer to the region
o Relative
 Osteoporosis
 Medicolegal situations
 RA
 Neurologic symptom exacerbation during localization or testing
Dangers of Manipulation
o Highest complications with:
 Manipulations under anesthesia
 Thrust techniques with extension and rotation
o NSAIDS more dangerous
o Wararin more dangerous
o Injections more dangerous
Myofascial Release
o Position tissue against a barrier
o Hold the position
o Wait for a change to take place
 Softening
 Barier relocation
o Breakdown of micro-adhesions
Respiratory Cooperation
o Force used to increase the effectiveness of a treatment
Muscle Energy
o OMT where patient’s muscles are actively used, form a precise position, in a
specific direction and against a purposeful counterforce – Direct Technique.
 Developed by Fred Mitchell – 1958
o Goals
 Reduce restraint of movement
 Strengthen weaker side of an asymmetry
 Stretch tight muscles and fascia
 Alter related respiratory and circulatory function
 Balance neuromuscular relationships to alter muscle tone and function
o Treatment Approach
 Set to barrier
 Ask Patient to engage
 Apply counterforce 3-5 seconds
 Ask patient to relax
 Pause
 Engage new barrier and repeat 2-4 times.
o Muscle Contractions
 Isometric
 Distance between proximal and distal attachments of muscle =
SAME - NO WINNER
 Physicians forces = patient’s contraction
 Isotonic
 Distance between proximal and distal attachments
DECREASES – PATIENT WINS
 Physician force < patient contraction
 Isolytic
 Distance between proximal and distal attachments
INCREASES – DOCTOR WINS
 Physician Force OVERCOMES patient’s contraction through
a sudden increase in applied force
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INDIRECT RX MUSCLE
ENERGY RX
DIRECT RX
Reduce edema
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+/-
Reduce spasm
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Reduce fibrosis +/-
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Side effects
Minimal
Few
Potential
Quickness
+/-
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5 – Intro to Indirect Methods of Tx of Cervical Spine
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Indirect Method – work through reducing afferent tone to spinal cord
o Technique where the restrictive barrier is DISENGAGED
o Dysfunctional body part is moved AWAY from restrictive barrier until tissue
tension is EQUAL in one or all planes and directions
o All planes of motion are balanced and there is relaxation of all the factors that
are maintaining the barrier (mechanically or neurologically)
o Release is by INHERENT FORCES rather than physician forces
 Body is self healing, self regulating
 Allow health to move back into the area
Exaggeration of Lesion
o Follow path of injury or lesion – that is to say away from the restrictive
barrier
o Find the point at which the restriction or tension in the body part seems to
disappear
 All tensions are apparently equal under or within the physician’s
hands – give the body a second chance to restore appropriate structure
to the lesioned area.
Indications
o Acute Painful situations
o Hospitalized patients
o Metastatic cancer
o Arthritis
o Osteoporosis
o Limitations of patient positioning for other techniques
Contraindications
o Inability to position patient appropriately
Thoracic Respiration
o Inhalation  external rotation, spinal curves tend to flatten
o Exhalation  internal rotation, spinal curves tend to increase
o Muscles tend to tighten with inhalation and relax with exhalation
Fascia and Myofascial Release
o Nerves, lymphatics and vasculature all course through the fascia
o Restrictions in fascia can reduce flow in any of these structures
o Stacking and respiratory cooperation involved
o Goals
 Reduce restraint of movement
 Alter related respiratory and circulatory function
 Balance neuromuscular relationships to alter muscle tone and
function; to alter visceral function
o Mechanism of action
 Plasticity, elasticity, hysteresis
 Neuroreflexive alterations via mechanoreceptors
 Energy alterations
 Facilitation, “helper”, “catalyst” through application of external forces
on the fascia
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Tensegrity – principles of a balance in compression and suspension
and how a change in one area will have an impact throughout the
whole system.
Treatment Approach
o Set to position of freedom or direction of ease
o Stack various planes of preferred motion on top of one another.
o Use respiratory cooperation to augment treatment – ask the patient to take a
deep breath and then exhale fully while assessing which respiratory phase
puts the tissues in MORE EASE/MORE FREEDOM
o Hold the tissues in the position of > freedom until they begin to change or
“unwind”
Jones Strain/Counterstrain
o Counter the strain by reintroducing the original strain, which IS the position
of ease
o Counterstrain is based on identifying tender points and positioning the patient
to eliminate the tenderness
Chapman’s Reflexes
o A system of reflex points
o Myofascial Clues
o Palpable, predictable anterior and posterior fascial tissue texture
abnormalities assumed to be reflections of visceral disease
o Gangliform congestion – increased sympathetic tone
o A painful nodule that has been described as:
 Small, smooth, firm, discreetly palpable
 Approximately 2-3mm in diameter
o Diagnosis importance due to predictability
 Appendix – tip of 12th rib on the right
 Colon – iliotibial band
o Treatment
 Rub in a firm, circular direction for about 10-30 seconds
o Reflexes for the colon
 Found on the lateral thigh
 Useful for diagnosis as well as treatment
 Look for these on your patients
 Tx
 10-30 seconds of vigorous clockwise rotatory pressure
 Points
 Right
o Illiocecal area
o Ascending Colon
o Hepatic Flexure
 Left
o Sigmoid colon
o Descending colon
o Splenic flexure
6 – Hx and Differential Dx of Thoracic Spine Pain
7 – Palpation and ROM of Thoracic Spine
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Characteristics of Thoracic Vertebrae
o Medium sized body
o Superior and inferior articular processes
o Facet joint on transverse process to articulate with rib
o Facets on body to articulate with ribs
o Sloping spinous process
Somatic Dysfuntion in Ribs is often the result of SD in the thoracic spine; spine
should be treated first
Common Viscero Somatic reflex patterns in paraspinal mm
o T2-T4 – Bronchus
o T2-T5 – Lung
o T1 – T11 – Pleura of Lung
o T2-T5, Left – Heart
o T5-T9, Left – Stomach
o T6-T9, both – Pancreas
o T7-T10, right – Pancreas
o T7-T10, right – duodenum
o T9, right – Gallbladder
o T5-T9, right – Liver
o T10-12 – kidney, ureters
o T10-11 – adrenals
o T11-12, ribs right – appendix
o T11-12, L1 – fallopian tubes
Rule of Threes – approximates positions of Thoracic Spinous processes in relation to
the transverse processes
o T1-3  equal
o T4-6  ½ level up
o T7-9  1 level up
o Reverse each level from T10-12
Scoliotic curves
o Named for the side of the convexity
Scapular Anatomy
o Elevation – Levator Scapula, Trapezius
o Depression – Lower Trapezius and Rhomboids
o Protraction (lateral) – Serratus Anterior
o Retraction (medial) – Rhomboids, Trapezius
o Rotatory (clockwise or counterclockwise) – combination of these muscles
o Chapter 43 of Foundations
Erb’s Palsey
o Long Thoracic Nerve – typically described as transient – childbirth, pulling
on the arm
Spine of Scapula – T3
Tip of Scapula – T7
TART
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o Tissue Texture Changes
o Asymmetry
o ROM
o Tenderness
Thoracic Examination
o Observe
 Posture
 Breathing
o Palpation
 Global Screen
 Directed soft tissue screen
 Run fingers along paraspinal mm, paplate along sp’s
 Paraspinal red reflex
 Paraspinal hypertonic changes
 Segmental screen
 Compress the R transverse process (inducing L rotation), then
do same for the Left
o Repeat test with flexion, then extension and compare to
neutral
 Springing
Notation
o TP – transverse process
o PROM – passive range of motion
o Sb – sidebent
o Rot – rotated
o Name Somatic Dysfunction by MOTION PREFERENCE
Trigger Point vs Tenderpoint
o Triggerpoint
 Characteristic pain pattern
 Located in muscle
 Locally tender
 Elicits jump sign when pressed
 Elicits a radiating pain pattern when pressed
 Present within a taut band of tissue
 Elicits twitch response withsnapping palpation
 Dermagraphia of skin over point
o Tenderpoint
 Typically no characteristic pain pattern
 Located in muscle, tendons, ligaments
 Locally tender
 Elicits jump sign when pressed
 No radiating pattern when pressed
 Taut band not present
 Twitch response not present
 Dermographia Not present
8 – Hx, Differential Dx, and Exam of Shoulder
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Questions for a thorough Hx
o Mechanism of Injury?
o Symptoms of Instability?
o Location and Character of Pain?
o Aggravating and alleviating factors?
o Where does pain initiate? Radiate to?
o Mechanical symptoms – locking or popping?
o Relationship of Pain to ROM?
Shoulder Pain Patterns
o Anterior Pain
 Biceps Tendinitis
o Lateral Deltoid Pain
 Referred
o Pain with clicking
 Labral, bursa
o Superior Pain
 AC Joint/scapula/neck
o Radicular
 Lightning/parasthesia
 Cervical spine or shoulder dislocation
Overview of examination
o General Appearance
o Inspection/Palpation
 Sulcus – sign between acromion and humeral head indicates
multidirectional instability.
o ROM (active/passive)
o Strength
o Stability
o Special Testing
o Biomechanics
o Neurovascular Status
o ALSO examine the neck/elbow
Spurling’s Test
o Examiner passively hyperextends and laterally flexes the patient’s neck
toward the involved side. Test is positive if axial loading by the examiner’s
hands reproduces symptoms – indicates a cervical nerve root disorder.
SITS – Rotator cuff – DYNAMIC STABILIZERS
o Supraspinatus – AB-ducts humerus
o Infraspinatus – EX-ternally rotates humerus
o Teres Minor – EX-ternally rotates humerus
o Subscapularis – IN-ternally rotates humerus
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Glenohumeral Joint
o Motion
 Rotation
 Translation (gliding)
 Rolling (combination of rotation and translation)
o Labrum ring of fibroid cartilage that surrounds and deepens the glenoid fossa
 Increases surface area by 70%
o ROM ratio Glenohumeral to scapulothoracic is 2:1
o AC joint allows scapula to move in 3 dimensions – following curved contours
of ribcage
 AC Joint – between clavicle and acromion
 Synovial joint
 Small cartilage plate (meniscus) between acromion and
clavicle
o Gliding during protraction and retraction of scapula
o SC Joint – synovial joint w/ meniscus – Attaches extremities to Thoracic
Cage
 Strong ligaments stabilize joint
 Costoclavicular and sternoclavicular ligaments
 Glides down with overhead
 Glides inward with push-up motion
 Elevation/depression
 Protraction/retraction
 Rotation
 Total motion = 40degrees during arm elevation
 Motion is reciprocal with AC motion.
Shoulder ROM
o Movement Sequence
 Supraspinatus 0-90
 Deltoid 0-90
 Trapezius 90-150
 Erector spinae 150-180
Apley Scratch Test
o Positive result = loss of ROM: rotator cuff/tight capsule problem
o Internal rotation measured by vertebral levels; compare sides; dominant side
NORMALLY has less ROM and lower by 2 vertebral levels
Impingement Syndrome
o Tendons of RC muscles become irritated – painful arc sign – patient abducts
arms –
 70-120 – impingement
 17-180 – acj
Strength Testing of Rotator Cuff – 0-5 Scale-test BOTH sides
o 0 – no muscle contraction detected
o 1 – barely detectable trace of contraction
o 2 – Active movement w/out gravity
o 3 – Active movement against gravity
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o 4 – Active movement against gravity and some resistance
o 5 – Active movement against full resistant – 5/5 is NORMAL
Supraspinatus Strength testing – Beer Cans
Infraspinatus and Teres minor-ext rotation – stabilize arm at elbow to prevent
abduction
o Patient externally rotates
o Doctor internally rotates
 Pain or weakness = positive test
Subscapularis – allows internal rot
o Lift off test
 Internal rotate hand behind back
 Patient tries to lift, doctor resists, difficult for patients w/
impingement
o Test against belly
 Less precise than “lift off”
 Patient holds arm against abdomen
Stability Testing
o Glenohumeral joint
 Glenoid
 Convex
 Humeral Head >3x larger
 Labrum
 Deepens fossa
 Like “chop-block”
 Superior portion
o Relatively mobile
 Inferior Portion
o Relatively immobile
 Capsule
 Airtight
 Joint cohesion – limited fluid
 Negative intra-articular pressure
 Ligaments – thickenings of capsule aid in restraint
 Superior glenohumeral
 Middle glenohumeral
 Inferior glenohumeral – most important stabilizer when
shoulder is Abducted and externally rotated
o SITS + Long Head of Biceps – DYNAMIC STABILIZERS
 Compress the humeral head into glenoid
o Scapulothoracic Dynamic Stabilizers
 Scapular retractors  rhomboids + trapezius (middle fibers)
 Scapular protractors  serratus anterior + pectoralis minor
 Scapular rotators  trapezius (upper, lower fibers) + serratus anterior
(lower fibers)
o Abnormal Scapulothoracic Motion
 Winging – Long Thoracic Nerve Injury – serratus anterior
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Instability Testing
o Anterior apprehension – vast majority
 Doctor applies anterior pressure to humerus and externally rotates arm
 Positive = apprehension of patient i.e. “hey, wtf, you’re gonna
dislocate my shoulder!”
o Posterior apprehension
 Apply posterior force to anterior shoulder
 Positive = instability, same as above.
o Anterior Release Test
 Relocation test – anterior to posterior pressure is placed by the
examiners R hand to “relocate” shoulder – if symptoms are relieved
test is positive - indicating anterior instability.
- Best Instability tests
Test
Sensitivity Specificity LR (+) LR(-)
Apprehension
0.88
0.50
1.8
0.23
Relocation
0.85
0.87
6.5
0.18
Anterior Release 0.92
0.89
8.3
0.09
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AC Joints test
o Crossed arm adduction test – pain = positive
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AC Joints test
o Chuck Norris Test – patient forcefully Abducts against examiner
o Pain = positive test
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Drop arm test – RC tear
o Physician passively abducts shoulder the observes patient slowly lower arm
 Arm will drop post 90 degrees (or sooner) if the patient has a RC tear
or supraspinnatus dysfunction
SLAP lesions – Superior Label Tear in Ant Post Plane
o Tears are often associated w/ biceps tendinosis/tendinitis
 Many types
Obrien’s Test
o Shoulder forward flexed 90 degrees w/ 15 degrees adduction – initially thumb
down (internal rotation)
o Resist with palm up – possible labral tear with pain
Biceps Load Test
o Loads the superior labrum via stress on the biceps tendon during resisted
extension force
Yergason’s resistance of supination while palpating biceps tendons
Speeds – a straight arm resisting shoulder extension
Neuro Evaluation
o Axillary Nerve
 Can be damaged with anterior dislocations
 Test of intact sensation over lateral deltoid
o Reflexes
 Biceps, triceps, brachioradialis
Key Findings in Hx
o Scapular Winging – serratus anterior problems
o Seizure cannot ext. rotate – posterior should dysfunction (rare)
o Pain radiating below elbow, decreased cervical ROM – cervical disc disease
o Pain or clunking sound w/ overhead motion – Labral disorder
o Nighttime shoulder pain – impingement
9 – Somatic Dysfunction Associated with Brachial Plexus and
Shoulder
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Bursitis – inflammation of bursa – bursa – fluid sac between acromion and head of
humersu, overlying supraspinatus tendon – small subacromion space + bursitis =
impingement
o Pain in shoulder, top, posterior or radiating to lateral deltoid area
o Worse after overload activity
o Onset after repetitive activity
o Can’t fasten bra
o Wakes if rolls over on it
o Findings
 No atropy
 Joint is stable
o Plan
 Rest, Ice, NSAIDS
 Severe – sling, steroid injection
 OMT – to shoulder complex, upper thoracic and ribs
 X-rays – probably not
Adhesive Capsulitis
o Patients > 40
o 15% bilateral
o May follow trauma
 Vague pain in shoulder
 Inability to retrieve wallet/undo bra straps (on self : )
o Symptoms
 Progressive stiffnes
 Pain if rolling over on joint
Osteoarthritis
o Can affect any joint
o Chronic wear and tear
o AKA – DJD – degenerative joint disease
o Tx – injection, acetominophin, PT
o Joint replacement
o OMT – work on ROM and strength
Biceps Tendinitis
o Inflammation of tendon and sheath along LONG head of biceps
o Overuse  adhesions bind tendon to bicipital groove
o Pain over bicipital groove, aggravated by resisted flexion of forearm
o Tx – rest, ice, NSAIDS
o OMT – freeing restriction in glenohumeral area an myofascial release
Biceps Tendon Rupture
o Popeye
o Anterior Pain, usually a painless “pop”
o 96% involve Long Head
o Pain at bicipital groove
o Tx – repair for younger patients; education and rehabilitation for older
Review of Shoulder Lab
- Inspection, palpation, ROM
- Strength testing – SITS
- Spurling’s
- Instability Testing – Anterior Apprehension, Relocation Test, Anterior Release
- Impingement Testing – Hawkins, Neers
o Neers
 Arm is placed thumb down, examiner stabilizes scapula border to
prevent rotation, arm is raised in forward flexion – pain = positive.
o Hawkins
 Examiner exerts internal rotation of Humerus with 90degress of
forward flexion and 90 degrees of elbow flexion – positive test = pain
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Techniques
o Spencer
 Indications
 Adhesive capsulitis
 Post-op patients
 Elderly patients w/ shoulder pain
 Shoulder strain
 Contraindications
 Fracture, severe OA, metastatic CA
 Steps – Elephants flatuate constantly to annoy intelligent people
 Extension
 Flexion
 Circumduction w/ compression
 Traction w/ circumduction
 Abduction
 Internal Rotation
 Pump
10 – Exam of Elbow, Radius and Ulna
11 – Examination of Wrist and Hand
12 – OMT for Non-Surgical Forearm, Wrist and Hand Somatic Dysfunctions