Download Exam 2

Shoulder
Classification impairments at Shoulder, Elbow, Wrist, and Hand
1. Pain (ex-Systemic sources: Cervical spine, dermatomes, diaphragm, heart, gallbladder, myofascial trigger
points or non-systemic/localized pain)
2. Postural (muscle imbalances)
3. Mobility (hypo and hyper)
4. Muscle (neurological, misuse, strain)
Adhesive Capsulitis
o Joint capsule becomes inflamed, fibrotic, shrunken
o Adhesions form
o RC and biceps tendon shorten/change
PROM
o Decreased classical PROM in the capsular pattern: (ER>ABD>FLEX>IR)
o Decreased accessory PROM in the capsular pattern: (P/A>inf> A/P)
Muscle Length
o Tight muscles may include: Pec minor and major, teres major, lats, subscap (Interal Rotators/Adductors)
GH joint precautions
o Acutely, oscillations may irritate patient
 Use only to decrease pain
o Do not perform grade III, IV manips until inflammation is gone
o Careful of pt dizziness after Codman’s
o Watch for scapular substitutions during ROM and exercises
Acute stage – focus to decrease pain and inflammation
 Modalities
 Grade I manips
 Codman’s
 Sub-max isometrics (to decrease swelling not strengthen)
Subacute
 Restore PROM  AAROM
 Grade II & III mobs
Settled/chronic
 Focus on AROM (PROM & jt mobility should be restored)
Impairment
Treatment during ACUTE stage
Postural
May/may not be able to improve w/exercise…depends on age
Don’t sleep on involved arm
Rest in loose pack position
Mobility
AROM – pain/limited – reduce inflammation
PROM – capsular pattern, perform in painfree range
Codman’s
Grade I mobs
MLT – defer
Muscle- Strength
Sub-max isometrics (to decrease swelling not strengthen)
Impairment
Postural
Mobility
Muscle- Strength
Treatment during SUBACUTE stage
Postural exercises to decrease forward head, rounded
shoulders
Look at LB positioning (lumbar roll)
ROM – restore PROM 1st, then work on AROM in new range
Progress to AAROM to AROM (include wand exercises)
Start ER early!
Muscle length – as ROM improves, begin gentle manual stretching
As PROM improves, work on AROM
Sub-max isometrics  isotonics (as tolerated)
Emphasize good mechanics, no substitutions
Impairment
Postural
Mobility
Strength
Treatment during SETTLED/CHRONIC stage
Progress postural exercises
Grade III/IV mobs, grade III distractions
AROM progresses as PROM improves
Progress stretching to end-range w/overpressure
May need to strengthen to improve scap mech to enhance
alignment & proper functioning & improved posture
AC (acromioclavicular) Injury: MOI- Direct blow to area
Injury Type
AC ligament
CC ligament
Delt-trap fascia
Grade I
Sprain
Intact
Intact
Grade II
Complete
Sprain
Intact
Grade III
Grade VI
Grade V
Grade VI
AC osteoarthritis
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Injury
Detached
Detached
Detached
Direction
Non-displaced
<25% superior
25-100% sup.
Post trap
1-3x superior
Result of repetitive minor stresses, grade I, II separations, clavicular fractures
Symptoms
o Minor ache with throw or resisted exercise to pain with all activities
o Pain with lying on side
o Painful or painless crepitus
o Horizontal flexion test positive
Tendonitis (supraspinatus and biceps common)
Impairment
Treatment during ACUTE stage
Postural
Educate on proper sitting/standing posture
Mobility
AROM defer
PROM in pain free range; Codman’s
Grade I & II mobs
MLT – defer
Strength
Decrease inflammation
-
Inferior to
acromion
Treatment
ROM
Protect, no
activities until
painfree
Surgery, sling
Functional limits
Impairment
Postural
Mobility
Strength
Functional limits
Impairment
Postural
Mobility
Strength
Strengthening deferred
Avoid sleeping on involved side
Rest arm in ABD position to improve vascularity
Treatment during SUBACUTE stage
Stretch tight anterior structures
PROM – Codman’s
AAROM to AROM in painfree range
Grade II & III mobs (inferior glide)
ML – use AC or gentle stretching of mm that cross GH joint
TFM w/ tendon in short position  to lengthened position
Gentle strength to RC muscles
Light MRE IR/ER w/slight distraction to decrease joint
compression
Teach pt. to function in proper plane
ICE after treatment
Treatment during SETTLED/CHRONIC stage
Further stretch anterior
Strengthen scap mm to maintain position (include SA)
AROM  resisted ROM (as tolerated)
Grade III & IV jt. mobs, stabilize hypermobility
ML – passive stretch or active inhibition (pecs, IR, ER, Lats,
teres maj, rhomboids)
MSTT – increase load as pain decreases
TFM
Begin strength 0-90 to avoid impingement  to full ROM
Bursitis
-
-
Subacromial and subdeltoid are the most common
Acute
o Spontaneous, rapid onset
o Severe debilitating pain
o Resolves rapidly
o Exam
 All motions limited
 Empty end-feel
 Tender over bursa
Chronic
o Associated with impingement
o Exam
 Impingement signs
 Painless restricted motions
 May have mild capsular restrictions due to disuse
Categorizing shoulder pathology
>35 – degenerative aging process
 Factors include
o Overuse
o Posture
o Acromion shape; ACJ, DJD
o Post &/or inf capsule tightness
o RC/biceps weakness or fatigue
o SH rhythm
<35 – microtrauma to muscle, tendon, capsule & ligamentous tissue (often due to laxity)
Shoulder instability/laxity – dislocations
Contraindications with Shoulder Instability:
• Anything that increases mobility of GH jt
– Contraindicated therapeutic interventions:
• Joint manipulation (for mechanical effects)
• Manual passive stretching
• End range of motion activities
Classification of impingement groups (for impingement syndrome)
Group 1
Pure impingement
(Greater than age >35)
No instability










Group 2
(Less than age <35microtrauma due to
laxity)
Group 3
(AMBRI- Atraumatic,
Multidirectional,
Bilateral,
Rehabilitation- Inferior
capsule shift
recommended)
Group 4
(TUBS- Traumatic
Unidirectional, Bankart,
Surgery recommended)
-Due to: overuse, posture, acromion shape, posterior and/or inferior
capsule tightness, RC or biceps weakness, SH rhythm
-Impingement Syndrome
-Impingement of the RC, bursa, or biceps tendon under the CA arch
(anterior portion)
-Often in the area of hypovascularity of the Supraspinatus and biceps
tendon
Exam:
-ROM: lack IR, ER, HADD
-RC imbalance: dominant Supraspinatus
-Radiology: hooked acromion, AC DJD
Primary instability due to microtrauma with impingement
 IIA – internal impingement
 IIB – subacromial impingement
Exam:
-Laxity tests
-Relocation test most sensitive
-ROM: increased with external rotation
Primary instability due to hyperelasticity with impingement
 IIIA – internal impingement
 IIIB – subacromial impingement
Multidirectional Laxity: AMBRI Patients
Pure instability (traumatic)
No impingement
-Can occur at any age but usually in younger people
-Unidirectional laxity : TUBS Patients
Neer’s classification for impingement syndrome
Stage I
Edema & inflammation
 <25 yrs old
 painful arc btw 60-120 deg
 +/- decreased ROM
 significant subacromial inflamm
 reversible
Stage II
Stage III
RC tears & repairs
Stage
ACUTE
MAX protection
0-6 weeks post-op
ACUTE
MAX protection
0-6 weeks post-op
ACUTE
MAX protection
0-6 weeks post-op
ACUTE
MAX protection
0-6 weeks post-op
 treatment – conservative
Fibrosis & tendinitis
 25-40 yrs old
 crepitus due to subacromial scarring
 catching sensation
 limitation of AROM & PROM
 not reversible w/activity mods
 may need bursectomy or CA lig resection
Bone spurs & tendon ruptures
 >40 yrs old
 decreased ROM; AROM worse than PROM
 atrophy
 weakness of ABD/ER
 Biceps tendon involved
 Not reversible (prog disability)
 Treatment – acromioplasty or RC repair
Impairment
Surgical healing
Swelling
Treatment
Ice, E-stim
Possibly gentle massage
Mobility
ROM – decreased & painful
Codman’s & PROM (painfree range)
Grade I & II mobs
Deferred
Strength
Functional
limitation
Educate about resting in ABD position
Educate about precautions based on
protocol ROM limitations
Stage
SUBACUTE
Mod Protection
6-12 weeks post-op
SUBACUTE
Mod Protection
6-12 weeks post-op
SUBACUTE
Mod Protection
6-12 weeks post-op
Impairment
Mobility
Treatment
AAROM, begin AROM when MD ok’ed
Grade II & III mobs, as needed
Stage
SETTLED/CHRONIC
Min protection
12wks – 1 yr post-op
SETTLED/CHRONIC
Min protection
12wks – 1 yr post-op
Impairment
Mobility
Strength
AAROM to AROM
Light isometrics
MRE ~8 weeks, if ok w/MD
Functional limits Out of sling
Educate to avoid/reaching overhead
Strength
Treatment
Begin passive stretching to end-range
where limited
Grade III & IV mobs
Strengthen IR/ER 1st specific
deltoid & RC exercises
Be cautious w/eccentrics
SETTLED/CHRONIC
Min protection
12wks – 1 yr post-op
Functional limits Progress back to functional activity
Thoracic outlet syndrome
Signs
 Forward head, rounded shoulders
 Hypertrophied scalenes
 Upper respiratory breather
 Raised/limited 1st rib
 Restricted upper thoracic mobility
 Tight pec minor/major
 Hypertrophied pec minor
Peripheral nerve injuries
 Long thoracic N.
Exam step
Structural inspection
AROM
Finding/impairment
Scapular winging
Scap winging w/FLEX, ABD, SCAP (20-30 deg limited)
Decreased AROM bc weak SA
May/may not = hyper/hypomobile
May have impingement bc lack of scap movement
SA = 0/5
Shoulder Flex = 4/5
Other mm = WNL w/scap manually stabilize
Negative or possible tender subacromion area
PROM
Muscle strength
P for T
 Suprascapular N.
Exam step
Pain assessment
Structural inspection
AROM
PROM
Muscle strength
Symptoms
 Deep aching, not well defined
 Raynaud’s
 Pallor, coldness, claudication
 Intermittent edema, venous
engorgement
 Cyanoses
 Dorsal scapular pain
 Parasthesias into the hand
Finding/impairment
Pain at posterior, lateral shoulder
May see atrophy of innervated mm
Possible decreased ABD & ER
Examine for hyper/hypomobility
Weak ER & ABD
Pain if impingement developed
Axillary N. ****same as above****
Elbow
Capsular pattern for the elbow  flexion > extension, pronation= supination
Nerve disorders at the elbow
-
-
Ulnar Nerve
o Cubital tunnel syndrome
 Referred to: Ulnar side of the hand and 4th and 5th phalanx
Radial Nerve (Motor Only)
o Deep radial compressed by ECRB or supinator
Superficial radial caused by direct trauma to lateral radius
 Referred to: dorsum of the radial palm to PIP of 1st thru 4th phalanx
Medial Nerve
o Pronator syndrome- compressed at the pronator teres
 Referred to: radial palm and 1st thru 4th phalanx
o
-
Joint hypomobility (non-op)
ACUTE
PROTECTION
Common
impairments
 Jt. effusion
 Mm guarding
 Pain (@ rest)
Myositis ossificans
Exam step
Palpate for Cond.
AROM/PROM
MSTT/MMT
Palpate for Tender.
Educate pt.
Decrease inflamm
Gr I/II distraction
Maintain ROM
Maintain function
SUBACUTE/CHRONIC CONTROLLED
MOTION
Common
Increase soft tissue
impairments
& joint mob
 Cap. Pattern
 HEP
 Firm end-feel
 Gd III/IV mob
 Decreased
 Manual & self
joint play
stretching
Increase strength &
 Pro/sup
restricted(OA) function
Finding/impairment
Increased warmth/firmness of brachialis region
Elbow ext > flex (and painful)
End range elbow flex is painful due to muscle being compressed
Resisted elbow flexion causes increased pain
Palpation of the brachialis mm is painful
Tendonitis of the elbow- Treatment
ACUTE
SUBACUTE
Ice/splint
Keep icing
No AROM
AAROM – AROM in pain
PROM in pain free range
free range
Grade I mobs
Gently stretch 1 joint at a
Stop the aggravating activity time
Only non-stressful activities TFM as tolerated
Light MRE
****find the cause****
CHRONIC/SETTLED
Ice pre/post exercise
Add resistance to AROM
Increase intensity of
passive stretching,
inhibition tech, be specific
to the mm
Grade III/IV mobs
Deeper TFM
Progress weights/T-bands
Work on endurance!
Cubital tunnel syndrome(Ulnar Nerve Compression)-Treatment
ACUTE
SUBACUTE
CHRONIC/SETTLED
Treat any swelling/warmth
AAROM  AROM to elbow
AROM  active RE to UE
w/modalities
Gentle PROM  mild
PROM, passive stretching to
No AROM @ elbow
discomfort
elbow & wrist, especially
AROM of neighboring joints Grade II/III joint mobs
intrinsics
PROM in pain free range
Continue w/modalities +
Grade III/IV joint mobs
Grade I mobs
massage to FCU
Strengthen wrist flexors &
Stretch to prevent contract.
Light manual/mechanical RE intinsics (ulnar n.)
Defer strengthening
to bis/tris & ulnar n. mm
Gripping/fine motor therapy
Treat the cause of compress. Continue treating the cause
Increase intensity of
Consider bracing at night
Neuromobilizations
neuromobilizations
Overuse syndromes
-
-
Lateral Epicondylitis (Tennis Elbow)
o Tendonitis of the wrist extensors
o Common Extensor Tendon- ECRB most common
Medial Epicondylitis (Golfers Elbow)
o Tendonitis of the wrist flexors
o Common Flexor Tendon- FCR and pronator teres most common
Triceps tendonitis: Distal triceps
Antecubital tendonitis: Distal biceps
WRIST AND HAND
Capsular patterns
Wrist  Flexion = Extension
IP of digits 2-5  flexion(more limited)> extension
MCP digits 2-5
 Open pack
o Slight flexion
 Closed pack
o Full flexion
Length-tension relationship
 Wrist position controls length of extrinsic muscles
o Wrist extension for grip
o Wrist flexion stability for finger extension
Hand function
 Extensor hood
o Made up of:
 Extensor digitorum
 Dorsal and palmar interossei
 Lumbricals
o Reciprocal motion of MCP flexion and IP extension  interossei
o Lumbricals remove tension from FDP and assists IP extension
o Isolated contraction of Extensor Digitorum causes clawing motion
Hand Grips
 Power grip(Primarily isometric function)
o Cylindrical grip
o Spherical grip
o Hook grip
o Lateral prehension
o Major gripping force  extrinsic finger flexors
o Compressive force  ED which also increase stability
 Precision patterns(Object does not come in contact with palm)
o Between thumb and fingers
o Compressive force  extrinsic muscles
o Object manipulation
 Interossei abduct and adduct
 Thenar muscles control thumb
 Lumbricals help move object away from palm
o Tip to tip
o Pad to pad
o Pad to side prehension

Combined grips
o Digits 1 & 2  precision
o Digits 3-5  power
o Pinch
Nerve disorders
 Median nerve
o Carpal tunnel most common
 Ulnar nerve
o Guyon’s canal most common
Rheumetoid Arthritis- RA
Stage
Acute
PFC
Massage/Modalities
AROM
Painfree AROM/PROM
Remission
Massage/Modalities
AAROM w/progression to active exercise
PROM Classical
Painfree AROM/PROM- DON’T STRETCH!
Gentle stretching
PROM Accessory
Grade I & II manips
MLT
MMT
Painfree AROM/PROM
Gentle muscle setting
Grade I & II manips
Possibly Grade III
Gentle stretching (intrinsics)
Light-moderate resistance exercise
o Active



o Remission
Pt. education
Joint protection- NO STRETCHING
Active exercise if possible
Improve function
 Flexibility
 Muscle performance
 CV endurance
 Nonimpact or low impact conditioning
 Swimming
 Bike
 Water aerobics
o RA and other Hand Deformities
 Swan neck
 Boutonniere deformity
 Ulnar drift
 Volar sublux of triquetrium
 Ulnar sublux or carpals
 Z deformity of thumb

Osteoarthritis- OA
o Acute stage
 Achiness and stiffness  lessen w/movement
 Inflammation
 Affects prehension and ADLs
o Advanced stages
 Capsular laxity  hypermobility/instability
Contractures develop as it progresses
 Limits in flexion and extension  firm capsular end feel
 Muscle weakness
o Weak grip strength
o Poor muscle endurance
o Protection phase
 Control pain
 Grade I & II manips
 Splinting
 Modify activities
 Educate pt.
 Maintain joint & tendon mobility
 PROM/AAROM/AROM
 Heat
 Aquatics
 Muscle setting (multiple angle)
o Controlled motion and Return to function phase
 Increase joint play and accessory motion
 Grade III and IV manips
 Improve joint tracking
 Mulligan
 Mobility w/movement
 Lateral glide of wrist while pt. actively moves
 Other hand passively stretches at end range
 Improve mobility, strength & function

Tenosynovitis/Tendonitis
o Protection phase
 Splint
 Cross fiber friction in elongated position
 Tendon gliding exercises to prevent adhesions
 Multiangle muscle setting
 Painfree ROM
o Controlled motion and return to function phase
 Progress intensity of massage, exercise, and stretching
 Dynamic exercises
 Be careful of eccentric exercises- May provoke symptoms
Traumatic Lesions
 Sprain
o Possible impairments
 Hypermobility
 Torn ligaments
 Pain
o Management
 Maintain mobility
 Minimize stress to healing tissue
 Laceration of tendons
o Flexor tendon zones
 Zone 1
 FDP insert  insert of
FDS
 FDP, A4 & A5 pulleys
 Unable to fully make fist
 Zone 2
 FDS insert  palmar
crease (prox to neck of
MCP)
 FDS, FDP tendons,
annular pulleys
 Unable to flex PIP & DIP
if both severed
 No mans land
 Zone 3
 Neck of MCP  distal carpal tunnel
 FDP, FDS, lumbricals
 MCP flexion affected
 Zone 4
 Carpal tunnel
 FDP, FDS, FPL
 Nerve injury
 Zone 5
 Proximal to wrist
 Flexor tendons of digits and wrist
o Loss of finger & wrist flexion
o Damage to median & ulnar nerves possible
o Extensor Tendon Zones
 Zone 1
 DIP region
 No active DIP extension
 Flexion contracture
 Swan neck deformity
 Zone 2
 Middle phalanx
 Same as Zone 1
 Zone 3
 PIP region
 Central slip damaged
 Possibly lateral bands
 Cannot extend PIP from 90°
 Boutonniere deformity
 Prone to adhesion forming
o Multiple soft tissue attachments
o Broad bone-tendon interface
 Volar splints
o Wrist in 30° active flexion
o MCP in neutral




o Splint limits PIP flexion (30°) and DIP flexion (20-25°)
Zone 4
 Proximal phalanx
 Same as Zone 3
Zone 5
 Apex MCP joint
 EDC, EIP, EDM damaged
 Unable to extend MCP
Zone 6
 Dorsum of hand
 Retinaculum and multiple tendons damaged
 Bowstring effect of tendons
 Loss of wrist and digit extension
Zone 7
 Wrist
 Same as Zone 6
o Repairs
 Balance between protection & movement
 Excess movement  tendon rupture
 Early ROM important to prevent contractures
1. Immediate primary repair: Done within 24 hours of injury
2. Delayed primary repair: Done within 10 days
3. Secondary repair: Done 10 days to 3 weeks post injury
4. Late reconstruction: Done well beyond 3-4 weeks post injury
o Direct repair no longer possible, Tendon graft necessary
o Treatment
 Immobilization
 PIP extensor joint: 4-6 weeks
 DIP extensor joint: 6-8 weeks
 Flexor tendons
o Early movement important
 Decreases edema
 Maintains tendon gliding
 Decreases adhesion forming
 Increases synovial fluid production
 Increases tensile strength of tendon
o Position of immobilization
 Zones 1-3
 Wrist & MCP flexion, PIP & DIP extension
 Zone 4
 MCP flexion 70°, neutral wrist
Timing
Splinting
Management for flexor tendon laceration
Moderate
Max Protection Phase
Protection phase
1-3 days postop to 5 weeks
4-8 weeks
-Static blocking
Splint (dorsal blocking splint
splint (day)
w/dynamic traction)
-Night splint for
Minimum Protection
Phase/return to function
8 weeks postop
Splinting discontinued
Exercise
-Very low controlled stresses
-Passive & active exercises
-Place & hold
Goals
-Control pain & edema
-Wound management
-Prevent adhesions
protection
Tendon gliding &
blocking
-Place & hold
-AROM
-Safely increase
stresses
-Full AROM
Gradual progressive resistance
exercises
Full activity by 12 weeks
Colles Fracture
o FOOSH
o Distal radius
o Complications
 Capsule tightness
 UCL sprain
 Avulsion fx
 CRPS complications
 Malalignment
 Carpal tunnel syndrome
 Volar sublux of lunate
 Rupture of EPL
 Malalignment of Lister’s tubercle
Posture
Acute
Not likely to see
in acute phase.
-Avoid exercise
-Educate pt.
about posture
Colle’s Fracture
Sub-acute
Chronic
- Holds arm to side Educate pt. to use normal
swing motion
-Codmans
Palpation for
Condition
Swelling RICE
AROM
Limited in all directions  AAROM & AROM as
tolerated. Maintain ROM of Shoulder/elbow/fingers
PROM
Classical
Capsular pattern  progress to endrange stretches
PROM
Accessory
Hypomobile  Grade II & III manips, soft tissue
work
MMT
Generally weak UE  light MRE progressing to
weights, t-band
Skier’s thumb
o Sprain of UCL of 1st MCP joint
o Hyperabduction force to thumb
o Signs & symptoms
 Tender to palpation and swelling over UCL
Progress to full
end range
Progress as
tolerated
-passive
stretching in
HEP
Grade III & IV
manips
Progress MRE &
isotonics
-use functional
activities
 Pain w/pinching
 + adduction stress testing
Scaphoid fracture
o FOOSH
o Signs & symptoms
 Tender over snuffbox
 Especially palmar side
 Possible swelling
 Decreased ROM
 X-rays  4 views
 If negative, treat as fx and reorder films in 2 weeks
TFCC Tear- Triangular Fibrocartilage Complex
 Loading wrist in pronation
 Usually 2° to ulnar impaction
 Signs & symptoms
 Pain on ulnar side or wrist
 Swelling
 Decrease grip strength
 Tender distal to ulnar Styloid process
 Click w/ulnar deviation
CRPS(RSD)- Complex Regional Pain Sydrome (Reflex Sympathetic Dystrophy)
o Type I
 Triad of symptoms
 Sensory
 Autonomic
 Motor
 Stages
 Stage 1
o Acute
o Persistent pain
o Edema
o Warm skin
 Stage 2
o Dystrophic
o Same as Stage 1
o Deteriorating changes to tissues & nails
o Hair loss
o 3 weeks – 3 months post
 Stage 3
o Atrophic
o Same as Stage 2
o Add cold skin
o Atrophy of skin, soft tissue, muscle & bone
o 6-9 months post
o Type II(Causalgia)- Specific Nerve Associated with CRPS
 Precedes w/partial injury of peripheral nerve or major branches
 Symptoms same as Type I
 Only in region of specific nerve
 Symptoms unique to Type II
 Electrical shooting sensation of pain
 Hyperalgesia in nerve distribution
 Swelling & trophic changes very discrete
 Usually NO CHANGE in bone metabolism
 Treatment
 Decrease pain
o Gradual desensitization
 TENS
 Fluidotherapy
 Contrast baths
o Elevated massage
 Maintain or increase ROM
o Small, gentle active and passive therapies
o Dynamic & static splinting
 Increase strength
o Posture correction
 Reduce edema
o Elevation & compression
o Massage distal  proximal
Carpal Tunnel Syndrome
o Signs & symptoms
 Night pain
 Tingling, numbness, pain
 Usually insidious unless following trauma
 Decreased strength/sensation in median nerve distribution
 Pain referred proximally
 + Tinels, Phalens, Reverse Phalens
Inspection
Carpal Tunnel Syndrome
Acute
Subacute
Wean from splint
Atrophy of thenar muscles  Reduce
-Continue to
inflammation, night splint
decrease
inflammation
AROM/PROM
Classical
Decreased w/pain in carpal tunnel 
decrease inflammation
PROM Accessory
Possible limited pisiform and/or lunate
 Grade I manip
MMT
Special Tests
Movement
Analysis
Neurovascular
decreased strength in median nerve
distribution  defer
Decreased grip strength  rest, decrease
inflammation
Clumsiness  avoid extreme wrist
flex/ext
Decreased strength/sensation in median
AAROM/AROM to
UE
-Begin light passive
stretching
Settled
Increase vigorousness
of passive stretch
-Progress AROM
w/hand weights as
tolerated
Grade II & III manips Grades III & IV manips
Isometrics to elbow
& wrist
-Light MRE to thumb
& intrinsics
-Pinching activities
-Open/close fingers
Grip strengthening
-HEP  rubberbands
-Fingertip pushups
-Functional tasks
Look at ergonomics
Neural mobs as
nerve distribution  rest, splint, remove
causative factors
Modes of exercise
Muscle
setting  MRE  Isometrics
Test grades
0
1 (Trace)
2-/2 (Poor)
2+/3 (P+/
Fair)
3+/5 (Fair)
Isotonics 
Isokinetics

indicated
Eccentrics

Plyometric

Exercises
PROM
AAROM
AAROM/AROM in GL
AAROM against gravity
AAROM/AROM against gravity
Resistive in GL
Resistive against gravity
Intervention progression
Injury  pain management  flexibility  strength  proprioception  endurance  power 
skilled activity  full activity
Include  tissue healing, pain free functional activity & pt. education