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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 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) 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 Lachman’s Test (+ for ACL problem if excessive motion compared to other side) Anterior Drawer (for ACL) 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 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 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 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 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 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 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 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 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 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: PROMAAROMAROMstrength/grip; PAMs (dorsal, palmar, lateral) Raynaud’s Constriction of small blood vessels of hands/toes (vasospasm); have diffuse pain, cold, N/T 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