WEEK 3: 3.3 BIOMECHANICS Shoulder Mobility ● Osseous components of functional shoulder: ​ ○ AC : articular surface of is convex in all planes of motion ​ planejoint ○ SC joint: clavicle is convex frontal and concave sagittal plane ​ saddle ■ Very strong, stable joint joint ● Shoulder characteristics that benefit mobility: ​ ○ Healthy articular surface ○ Supple capsuloligamentous restraints ○ is flat ■ Helped by labrum ○ ⅓ to ¼ articulation with humeral head ■ Not a lot of joint congruency ○ Inferior capsule is lax ○ Recess in inferior capsule allows for more mobility ○ muscles Non-Contractile Stability Dynamic Stability

Joint capsule Muscles of rotator cuff Ligamentous Muscle force couples Je Integrity of osseous articular structures

Labrum ● Motions with significantly reduced contact between and labrum: ​ ○ Max flexion, adduction, and IR ○ Max abduction and flexion ○ Adducted at the side, with the rotated downward ○ *least amount of joint congruency Shoulder Osteology ● Scapular Structure: ​ ○ Scapula wide and thin structure ■ Easy gliding on thoracic wall ■ Multiple sites for muscle attachments ○ Overhanging and coracoacromial ■ Provides improved mechanical advantage of deltoid ○ Scaption plane: loose pack position → less impingement and stress ● Acromion types: ​ Mohehooked morechange forimpingement RTCtear

○ ○ Acromion type is a strong predictor of rotator cuff impingement OPEN ■ Type I: 3% incidence of rotator cuff tears ■ Type III: 70% incidence of rotator cuff tears ● : O ​ ○ Long lever → allows pec minor to provide scapular stability to ○ Site of attachment for coracobrachialis and short head of biceps ● Close/Open Packed Position: ​ ○ Close Pack: full abduction and ER I'll ○ Open Pack: 39 degrees of abduction in the scapular plane Ch08ED_ Shoulder Ligaments µ

● ● Glenohumeral ligaments: ​ ○ Distinct thickenings in the anterior capsule ○ Superior GH ligament: ​ ADD 1 guides ■ Torn SGHL allows inferior suIAPbluxation of humerus ■ Contracture limits ER and flexion ■ Taut: adduction, inferior and AP translations of humeral head ○ Middle GH ligament: ​ A ■ Blends with the subscapularis tendon ■ Taut: anterior translation of the humeral head, esp in ~45-60 degrees of abduction, ER ○ Inferior GH ligament: ​ 900Abd ■ Most important ligament for GH stability ■ Divided into anterior and posterior band with a axillary pouch in between that acts like a hammock to support the humerus during abduction and ER ■ Primary static stabilizer when the is abducted from 45-90 degrees S ■ Taut: M AB PB AP ● Anterior band: 90 degrees abduction and full ER, anterior a translation of humeral head ● Posterior band: 90 degrees abduction and full IR ● Axillary pouch: 90 degrees abduction, combined with AP and inferior translations ○ ● Coraco-humeral ligament: translation ​ AP ○ Has a similar restraMadd.intint to GH motion as the superior gleno-humeral ligament ○ Coraco-humeral ligament is taut with adduction providing significant restraint to inferior translation and ER of the humeral head ● Capsular Patterns: ​ ○ Adhesive capsulitis: ER limited > Abd > IR > Flex ○ Selected capsular hypomobility: IR > Abd > ER Coracoacromial Arch ● Structures under the arch: ○ Long head biceps ○ Superior JC odd ○ Supraspinatus, infraspinatus, subscapularis ○ Subdeltoid, subacromial bursa Subacromial Space ● Arm adducted suprahumeral space 10-11mm ● 60-120 degrees of scaption space is at its narrowest ● With overhead motion, supraspinatus tendon passes under the coracoacromial arch ○ With the addition of IR, the supraspinatus tendon passes under the igngaggann coracoacromial ligament ○ With the addition of ER, the supraspinatus tendon passes under the acromion ER acromion● Weak/injured RTC allows increased humeral head translation ○ Increased wear labrum ○ Overuse of static restraints ○ Overuse of dynamic restraints Muscle Functional Classification ● Scapular Pivoters: ​ movessoap ○ Traps, serratus anterior, levator scap, rhomboids major and minor ○ Functions at the scapulothoracic articulation ○ Serratus anterior: protracts, upwardly rotates scapula, and maintains scapula on thorax ■ Works in synergy with traps (force couple) ■ Active with all shoulder movements, esp flex and abd ■ Lower fibers draw inferior angle of the scapula forward upwardly rotating scapula ● Humeral Propellers: ​ moveshumerus ○ Lats, teres major, pec major, pec minor ○ IRs have larger mass than external rotators ● Humeral Positioners: ​ stabilizeshumerus ○ Deltoid: anterior, lateral, posterior ● Shoulder Protectors: ​ shoulderstability ○ Rotator cuff ■ Actively move and fine tune humeral head positioning during arm elevation ■ During abd, the greater tuberosity must pass under the coracoacromial arch ● Humerus must ER (infraspinatus, teres minor) ● Acromion must elevate ■ Contractile ligaments ■ Reinforces coracohumeral and glenohumeral ligaments ■ Controls GH arthrokinematics ● Horizontally oriented supraspinatus produces a compressive force into the glenoid fossa ● Holds humeral head in glenoid fossa during superior roll ● Provides: ○ Stability ○ Efficient fulcrum ○ Balances vertical force of deltoid avoiding impingement ○ In mid range arm elevation, passive restraints are lax ● Force Couples: ​ ○ Subscap co-contracts with infra and teres minor to depress and compress the Subscap infrag humeral head during overhead movements 1Min ○ Deltoid co-contracts with interior RTC muscles ■ Creates a compressive force and downward rotation force to Deltoid inf RTC counterbalance the deltoid ■ injury/weakness of the RTC allows deltoid to elevate humerus causing impingement of the RTC on the anterior acromion

WEEK 5: SHOULDER PT. 2

Supraspinatus Tendonitis vs. Calcific Supraspinatus Tendonitis ● Supraspinatus tendon is susceptible to tendinous pathology: ​ ○ With the arm along the side of the body, the tendon is pulled down and over the greater tuberosity of the humerus → compressive force of the tendon into the tuberosity and creates a zone of avascularity ■ Decreased blood to tendon → pathology ■ Tensile stress + compressive force = flushes out blood and fluid = avascular ○ Shoulder tendinopathy: ​ ■ Reactive or degenerative: ABRALPATHOLOGY ​ immobilize ● Reactive: acute, just occurred youngerpeople ● Degenerative: chronic, takes time to happen/usually later in life controlparinginflammation olderpeopl ■ Etiology: activitymod ​ canbeunaccustomed dynamicstabilization ● Traumatic closedlopenchainax ● Overuse/repetitive (unaccustomed activity for that individual) ○ Is their body ready to handle the stresses? canhavesurgery ● Insidious debridement gradual ■ Presentation: ​ ANKARTISMPHUSAUTS ● Acute/subacute: signs of inflammation Bantam ● Pain with contraction/activity avulsion anteriorinferior ● Pain with passive stretch depending on tissue reactivity labrum ● Tenderness over tendon trauma ■ Treatment: ​ baidu.org laxity1spea'aliens ● PT surgery ● Reactive/Early Stage of Condition (acute/subacute) http ○ protect/reduce aggressive loading (frequency/duration) superiorlaterallesion ○ Encourage healing - STM, modalities anteriorposterior ● Degenerative/Late Stage of Condition (Chronic Condition) traumalmicrotrowma ○ Normalize load baidu.org laxity1spea'aliens ○ Transverse/Cross friction massage HillSachs ○ Exercise with heavy loading trauma dislocatesantlinf ○ Modalities ● Supraspinatus can be traditional tendonitis or calcific tendonitis: compression ​ fracture ○ But have same patient complaints and presentation ■ Difference: calcific tendonitis needs radiography to identify it Numeralhead ○ Calcific tendonitis: from local areas of necrosis within the tendon ​ onglenoid ■ Necrosis causes calcium to be deposited within the tendon ● But not as → has a toothpaste consistency ● Can be slow or fast ○ Fast → acute ○ Slow → chronic ■ Men > women menanestubborn ■ Same symptoms as non-calcific tendonitis ■ Radiograph to diagnose it toseecalcifiedpans ■ Positive exam findings: ​ ● Step 7: PFC → warmth and swelling over the supraspinatus MSTT ERAbd tendon inflammation to ● Step 8: AROM → painful arc 11 MLT IR Add ● Step 9: PROM → painful in IR and adfoppositeduction ISPET Wpmsp ● Step 10: MSTT → strong and painful with ER and abduction 17Imaging opaque ○ Good for diagnosing tendinopathy ○ Don’t move onto MMT because pain ● Step 11: MLT → decreased length and painful with IR and adduction st ● Step 15: PFT → painful over the supraspinatus tendon ● Step 17: Imaging → brightness (opaque area) noted within the supraspinatus tendon location ■ Treatment: ​ NO TREATMENT ● Anti-inflammPTatories or aspirate calcium deposit ● Maybe surgery if severe enough ○ Osteophytes forming on the underside of the acromion - tendon is squeezed every time patient raises arm ○ Keep GH joint slightly abducted after surgery ■ Increase blood supply and promote healing ● Lifestyle modification gina ○ Supraspinatus Tendonitis: arm at side of body causes a downward pull on ​ supraspinatus tendon over the ■ Compressive force causes zone of avascularity STEPS10111,15 ● Tensile stress + compressive force = flushes out blood/fluid → avascular ■ Examination: ​ www.ascakiticbrtw ogepn Tendinitislosis ● Step 7: PFC supraspinatus tendon → warmth and swelling ● Step 8: AROM: Painful arc → pain in mid range stronglypainful ● Step 9: PROM IR, Add = pain → lengthening tissues causes pain ● Step 10: MSTT ER and Abd = strong and painful → don’t do MMT ● Step 11: MLT IR and Add = Decreased length and painful ifeng.agai.hr ● Step 15: PFT supraspinatus tendon → pain ■ Treatment: ​ ● MD: inflammatories, lifestyle modification weak painless ● PT: maroon q ○ Exercises in slight abduction to avoid wringing out of tendon Erinthid9ftsie ○ Put into areas of vascularity (ex. Scaption plane, loose Ofstraign pack) darn Adhesive Capsulitis 390abq STEPS 849 capsule ARON PROM ● Adhesive Capsulitis: the capsule becomes inflamed and adheres to the humeral head → ​ fibrotic ○ Idiopathic don'tknowcause ○ AKA frozen shoulder ○ Will go through the stages of condition and will often result in chronic condition ○ ROM decreases over time ○ Self limiting condition heal itself PTdoesn'tspeeduphearingprocess ○ Entire capsule is involved by ○ Predisposing factors: ​ ■ Women who are perimenopausal are most often affected hormones ■ No known cause but could be hormonal ■ Diabetes ■ Thyroid disease ■ Shoulder pathology ■ immobilization ○ Clinical Features: ​ ■ Onset is gradual and insidious ● Could be because of immobilization or pathology ■ Could resolve on its own - could take up to 24 months ■ Entire capsule is involved ■ Primary findings: decreased ROM → capsular pattern ● Shoulder capsular pattern: ER>ABD>IR ■ Self-limiting condition ○ Exam findings resulting in capsular pattern: ​ ■ Step 8: AROM - decreased ER>ABD>IR capsular ■ Step 9: PROM pattern ● PROM Classical Quantity - decreased with limitations of ER>ABD>IR ● PROM Classical Quality - tight capsule end-feel all directions ● PROM Accessory Quantity - decreased P/A>inferior>A/P ● PROM Accessory Quality - tight capsule gend-feel all Osponenfwaedirections ○ Treatment: ​ guida ■ Medical tx: surgical manipulation, rest, paTain me nds, t or NSAIDs ■ PT tx: increase ROM by oscillations antiinflammatories Fractures ● Humeral Neck Fractures: ​ ○ Can be extracapsular or intracapsular ■ Extracapsular fracture: fracture outside the joint capsule Outside ● With edema see ■ Intracapsular fCracture: fracture inside the joint capsule swervingoutside ● May be bleeding in the actual joint - hemarthrosis ○ Can lead to malalignment nospace move f ● With effusion to insidego C swellinginside ○ Predisposing factors: ​ ■ Most occur secondary to a minor fall and related to a FOOSH injury ● FOOSH injury: Fall On an Out Stretched ​ ■ Elderly women > men Women fall osteoporosis ■ Can sustain humeral head trauma from c91Aompressive forces into glenoid ○ Treatment: ​ ■ MD: ● usually immobilization in a sling ■ PT: ● Early PROM a discolorationbobmising ● Decrease swelling and ecchymosis ● Humeral Shaft Fractures: ​ Fo0ht ○ Usuaally because of direct trauma to the arm neqme ○ ex) direct blow to the arm in a car accident or falling without an outstretched arm porte and landing on a hard, elevated object ○ Tend to heal well due to good blood supply shaft surgery○ Treatment: ​ preset neck cast ■ Depending on severity, can be treated with a closed reduction or an open reduction internal fixation (ORIF) ● Closed: cast or splinoting ○ Used when are still aligned with each other ● ORIF: used when bones are malaligned to some degree to setproperly ● Clavicular Fractures: ​ ○ Predisposing factors: ​ ■ More common in kids fall 9lot ■ FOOSH ■ Person falls directly onto the outside of their shoulder - direct trauma ○ Presentation: ​ m ■ Most common location: middle ⅓ i ■ Most lateral aspect is usually pulled inferomedially due to the weight of the UE ■ Not considered a serious injury as long as the fracture is allowed to heal ○ : when the bone does not break all the way ​ ■ Apply a load that creates a concavity on one side and a convexity on the other side ■ Only one cortex disrupted ■ Convex side will break but the concave side does not ■ Intervention: figure 8 brace ● Attempts to allow the bone ends to align Sprengel’s Deformity ● Not a fracture RARE ● Predisposing factors: ​ ○ Congenital onlyI usually ■ Scap did not descend appropriately during embryonic development and sits too high on the thorax ● Presentation: ​ ○ Is a “high scapula” ■ Too high on the thorax ■ Scapula elevated and rotated inferiorly → can cause lots of biomechanical problems w○ Scap tends to be smaller than the contralateral side ○ Can cause abnormalities of the cervical spine and the ossification of ligamentous I connections I ■ Can also have brachial plexus and muscular imbalance dysfunctions ○ Overhead function limited Codman’s Exercises ● AKA pendulum exercises NOTION Af ● Purpose: used to assist people in the performance of ADL’s for shoulder injury 1in ● Patient bends forward at the waist allowing the trunk to be positioned in front of the legs ADL's ○ Allows the UE to hang towards the ground grade1911distractions ■ Positions the shoulder into some amount of flexion and slight abduction toinpain ○ Then patient flexes their without having to lift their shoulder ○ Perform ADLs in this position avoiding having to elevate arm NDUHMEXERASE ■ Can simply flex elbow without lifting shoulder armshangwhenMMK ■ Loose pack position so less stress on shoulder bentforward ● Creates less pain and requires minimal muscular effort dpain d ● As an exercise, use trunk to perform UE circles, forward/backward and lateral muscleeffort movements ● Allows joint separation and repetitive movement gaits pain → neurophysiological effect ● Used as therex AC Joint Sprain ● Predisposing factors: ​ ○ MOI: FOOSH ○ Force: clavicle against cage ■ Acromion down, back, and in ● Types: ​ ○ Type I: sprain of the AC ligament ​ ○ Type II: rupture of the AC ligament ​ asprain ○ Type III: AC joint disrupted (clavicle elevated above acromion) and ​ coracoclavicular ligament ruptured ● Rockwood Classification: ​ ○ Grade I: Clavicle not elevated ​ ■ AC ligament: mild sprain ○ Grade II: Clavicle elevated but not above superior border of acromion ​ ■ AC ligament: ruptured ■ CC ligament: sparin sprain ■ Joint capsule: ruptured ■ Deltoid: minimally detached ■ Trapezius: minimally detached ○ Grade III: Clavicle elevated above superior border of acromion ​ ■ AC ligament: ruptured ■ CC ligament: rupture ■ Joint capsule: ruptured ■ Deltoid: detached ■ Trapezius: detached ○ Grade IV-VI: essentially different variations of Grade III ● Subjective: ​ ○ Localized pain ● Examination: ​ ○ Step 7: PFC → acute condition and those with deformity ○ Step 8 and 9 → pain with A/PROM ○ Step 15: PFT Fender ● Assessment: ​ ○ Piano key sign push back ○ Imaging: X-ray 9springs up ● Treatment: ​ ○ MD: ■ Grade I and II conservative: immobilization ■ Grade >3: surgical candidate ○ PT: Gear ■ Acute: fit with sling, ice, and compression 24-48 hours ​ ■ Subacute: ROM after sling is removed, pendulum, pulley, L-bar exercises, ​ wall climb ■ Settled: ​ ● Strength: GH cardinal planes, biceps/triceps, scapular stabilization (superman’s seated push-ups) ● Advanced strength: endurance, high speed, eccentrics, PNF diagonals, bird dog rhythmical stabilization, return to sport SC Joint Injury ● Anterior dislocations more common ● Posterior dislocations rare ○ Difficult to diagnose ○ May be life-threatening due to pressure placed on vital structures between sternum and cervical spine ● Biomechanically proper alignment is essential for normal UE movement ● Presentation: meniscus type symptoms of clicking, popping, and/or locking ● Grades: ​ ○ Type I: sprain of SC ligament ​ ○ Type II: subluxation, partial tear of capsular ligaments, disk, or costoclavicular ​ ligaments ■ Type IIA: anterior subluxation (most common) ■ Type IIB: posterior subluxation ○ Type III: dislocation ​ ■ Typee IIIA: anterior dislocation ■ Type IIIB: posterior dislocation ○ Type IV: habitual dislocation - rare ​ dislocatesoften Bursitis Bma STEPS ● Types: subacromial, subdeltoid, subscapular ● Presentation: 7gq ​ ○ Inflamed and irritated ○ Pain lateral brachial region ○ Gradual onset with previous history of tendonitis/osis ○ Patient support arm in loose pack position scaptionplane ● Examination: ​ ○ Step 7: PFC → warmth and swelling over bursa location mitis ○ Step 8: AROM → pain with any motion that compresses bursa palpation ○ Step 9: PROM → pain with any motion that lengthens the muscle over the bursa or compresses the bursa ○ Step 15: PFT → painful with direct palpation of bursa ● Treatment: ​ ○ MD: ■ anti-inflammatory/anesthetic - oral or injection ■ Excision ○ PT: ■ Acute: modalities to decrease swelling, lifestyle modification ■ Subacute: massage to mobilize fluid ■ Settled: retrain functional movements Rotator Cuff Pathology ● Etiology: ​ ○ Most often supraspinatus ○ Least often subscapularis ○ Young = traumatic etiology shoulder tendinopathy ○ Old = degenerative with insidious/gradual onset Juke ● Presentation: ​ ○ Pain at rest and at night ○ Worse with volitional movement ○ Weakness and loss of ROM ○ Painful arc ● Examination: ​ ○ Step 7: PFC → warmth and swelling ○ Step 8: AROM → painful in direction muscle contracts ○ Step 9: PROM → painful when muscle lengthens, opposite direction of contraction ○ Step 10: MSTT → findings depend on severity of injury ■ Strong and painful = strain/degeneration/inflammation Iitistosis ■ Weak and painful = partial tear ■ Weak and painless = complete tear ○ Step 11: MLT → painful with len0gthening of involved muscle (if not deferred due to MSTT findings) ○ Step 12: MMT → weakness of involved muscle (if not deferred due to MSTT findings) ○ Step 13: Special tests → multiple test, combination of painful arc, drop arm sign, Noneurovascular and test had high probability of full thickness tear step14 ○ Step 15: PFT → painful with direct palpation of injury ● Treatment: ​ ○ MD: acute with large significant tears → surgical candidate severeacute ○ PT: ■ Chronic degenerative and/or small tears: conservative care surgery ■ Stage I: pain/inflammation reduction: ​ ● Decrease pain and inflammation: modalities, activity modification, chronic mildacute 1 NSAIDS PT ● Improve depressor effect on humeral head → strengthen RTC (IR/ER isometrics) and scapula pivoters ○ Inhibit delotoid ● Avoid positions that may exacerbate supraspinatus impingement ● Manual techniques to improve capsule mobility ■ Stage II: ROM restoration: ​ ● Restore ROM → stretching/self mobilization ● Strengthening → free weights, concentrics RC, push up + ● Neuromuscular training → quadruped rocking, fitter board ● Plyometrics → medicine ball, push up with a clap ● Manual neuromuscular techniques PNF → quick reversals ■ Stage III: Strengthening: ​ ● PNF diagonal patterns, eccentrics RC, military press, reverse flys, push ups ■ Stage IV: Return to normal activity: ​ Returnfunctionality ● Advanced plyometric training, sport specific training Shoulder Impingement ● External vs. Internal: ​ ○ External impingement: acromial side of RTC ​ lateral ■ RTC with coracoacromial ligament or acromion ■ Type III acromion hook shaped ■ Older non-athletic population ■ Superior surface of RTC fraying, abrasion, inflammation ■ Degenerative changes: fibrosis, decrease in joint space, spurring ■ Decreased vascularity ■ Arthrokinematics: too much roll without enough inferior glide ■ Infraspinatus (ER) training at 90 degrees abduction will be the most effective muscle to train ○ Internal impingement: glenoid side of RTC ​ ■ Young overhead athlete ■ Extreme ranges of abduction and ER ■ Weak scapula retractors causes decreased force couple of RTC and stretching of capsular ligaments ■ Greater tubercle impinges the glenoid side RTC against the posterior/superior glenoid labrum ■ Biomechanical problem ● Importance of Scapular Upward/Rotation: ​ ○ Patients with internal impingement had decreased scapular upward rotation with shoulder abd ■ Puts the underside of the RTC in danger of being impinged between the greater tubercle and the glenoid rim ■ Leads to inflammation of underside of RTC tendon, labrum posterior superior tears, humeral head posterior defect ● Assessment: ​ ○ Predisposing factors: ​ ■ Scapula dyskinesia ■ Osteophytes (more likely with age) ■ RTC thickening ■ Labral injury ■ Multidirectional instability ■ Biceps tendinopathy ■ Type II or III acromion ○ External Impingement: ​ ■ Primary: Type III acromion, bone spurs, calcified coracoacromial ligament ■ Secondary: superior migration of humerus due to RTC weakness/tear, instability, anterior/posterior capsule contracture (adhesive capsulitis), reduced upward rotation of scapula, posture, T-spine hypomobility, poor form, stiff/short lats, inefficient breathing ○ Internal Impingement: ​ ■ Extreme ER and abd ○ Subjective: ​ ■ Reaching behind back, overhead, and night pain ■ External Impingement: pain ant/lat with overhead activity (ex. throwing, swimming) ■ Internal Impingement: pain post/lat with max abd and ER ○ Assessment: ​ guppespinatus

■ Painful arc, yocum, empyty can, neer’s, hawkins-kennedy ■ Imaging: X-ray, MRI seeimpingement ● Stages: ​ seecalcification acromionshape ○ Stage 1: BY 4 ​ revered ■ Age <25 y/o ■ Localized hemorrhage and edema with tenderness at supraspinatus insertion and anterior acromion ■ Painful arc 60-120 degrees (increased with resistance at 90 degrees) txt p19 ■ Weakness secondary to pain rest ■ + Neers, Hawkins-Kennedy ■ - Radiography notexternal wouldsee calcification ■ Reversible with rest, activity modification, and rehab ○ Stage 2: ​ NOTREVERSIBLEBUTMANAGEABLE ■ 25-40 y/o with repetitive overhead activity ■ Same clinical findOings as Stage 1 ■ Symptom severity increased to pain with activity and at night longterm ■ Soft tissue crepitus or catching at 100 degrees txt ■ Fibrosis restricts PROM PT ■ + radiograph may show osteophytes under acromion, degenerative AC changes ■ No longer reversible with rest, possibly helped by a long-term rehab program ○ Stage 3: ​ NOTREVERSIBLE NEED ■ Age >40 y/o MAY SURGERY ■ Same clinical findings as stage 2 ■ Tear in RTC usually less than 1 cm 8MW ■ Increased limitations in oA/PROM txt ■ Prominent capsular laxity with multidirectional instability seen on radiograph ■ Atrophy of infraspinatus and supraspinatus ■ Surgery following a failed conservative approach ● Treatment: E ​ ○ Goal: ■ Inhibit middle deltoid ■ Facilitate ER: infraspinatus, teres minor, supraspinatus, subscapularis to depress and compress GH joint ■ Stretch posterior and inferior joint capsule guides ■ Protect anterior joint capsule ■ Strengthen muscles that abduct, elevate, and upwardly rotate scapula: ● SA, upper trap, lev scap ■ Eccentrically strengthen middle trap and rhomboids to help decelerate arm with throwing ■ Strengthen lower trap tp balance forcnae couple with upper trap ■ Mobilize SC and AC in any planes that are limited ■ Strengthen LE and core to decrease stress on ○ Neuromuscular Control Phase: ■ PNF diagonals, bird dog rhythmic stabilization ○ Return to sport ■ Consistency with program important to avoid recurrence ○ External Impingement: ■ Focus on scapula position → improve upward rotation ■ Work on shoulder instabilities ● Rhythmic stabilization GH Joint Multidirectional Instability ● Assessment: ​ ○ Predisposing factors: ​ ■ Atraumatic: congenital laxity, stabilizing muscles unable to control laxity especially during deceleration throwing ● Humeral head translates anteriorly and inferiorly stretching capsuloligamentous structures ● Proprioceptive deficits ■ Traumatic ○ Subjective: pain and clicking ​ ○ Assessment: load and shift, sulcus sign, crank test ​ ● Treatment: ​ ○ Early phase: improve muscle tone and scapulothoracic posture ■ Provides steady base with proper length tension relationship of ant/post muscles ○ Strength phase: RTC begins at 0 degrees of elevation ○ Neuromuscular control phase: PNF diagonals, bird dog rhythmical stabilization ○ Return to sport: consistency with program important to avoid recurrence

WEEK 6: ELBOW Elbow Tendinopathy ● Tendinopathy/itis/osis: ​ ○ Tendinopathy: pathology of tendon ​ ○ Tendonitis: inflammatory process occurring within the tendon ​ ○ Tendonosis: tendon degeneration ​ ● Predisposing factors: ​ ○ Joint restriction or hypermobility → alters length tension relationship → increases stress on tendon ○ Muscle imbalance → increases stress on tendon ○ Faulty ergonomics (sport/ADL) increases stress on tendon ○ Unaccustomed stress (joint dysfunction, insufficient strength, tight muscles, wrong racket, holding racket wrong ● Locations: ​ oppositutrARomy ○ Lateral tendinopathy → lateral epicondyle painw PROMwristflex ○ Medial tendinopathy → medial epicondyle painwpromwristext ○ Posterior tendinopathy → posterior elbow (triceps tendon) painw promensowflex tripoaepesn.cm ○ Bicipital tendinopathy → anterior elbow (biceps tendon) painwpromeuronext ● Examination: elbow ​ biceps inbicipital ○ Step 2: initial observation → may note some swelling ​ ○ Step 3: history → gradual onset, repetitive use ​ ■ Lateral/medial: middle age tenniselbow ■ Biceps/triceps: younger ○ Step 6: structural inspection → muscle atrophy/hypertrophy ​ ○ Step 7: PFC → warmth and swelling ​ ○ Step 8: AROM → painful with muscle contraction ​ ○ Step 9: PROM → painful with lengthening tissue ​ ○ Step 10: MSTT → ​ Todetermineextentofinjury ■ Strong painful: tendonitis/osis or muscle strain (don’t do MMT) ■ Weak painful: partial tear (do not do MLT/MMT) ■ Weak painknessful: complete tear ○ Step 11: MLT → pain with lengthening tendon and may have decreased length ​ ○ Step 12: MMT → pain with contraction ​ don'tdoif MSTTispainful ○ Step 13: special tests ​ ○ Step 15: palpation for tenderness → pain with palpation of involved tendon ​ ○ Step 16: movement analysis → recreate functional task that reproduces ​ symptoms ○ Step 17: imaging → MRI or CT scan may be useful in narrowing down involved ​ tendon ● Treatment: ​ ○ Acute: prevent condition from worsening, decrease inflammation ​ ■ PRICE ■ Gentle PROM in pain free range = top preserve ROM ■ 50% 1RM exercise (31+ reps without fatigue) for vascularity/pain ■ Look at above and below ○ Subacute: maintain range and begin to reintroduce tendon stress ​ ■ Progress to AAROM and then to AROM as tolerated to preserve ROM and being to reintroduce stress to tendon ■ Manipulations to address any joint restrictions ■ Gentle PRE (progressive resistance exercises) at end of subacute 60% 1RM (25-30 reps) for coordination ■ Eccentrics for tendon healing - low grade muscle contraction attheend ○ Settled: progress strengthening ​ ■ To more aggressive forms ■ 80% 1RM (8-12 reps) for strengthening ■ Stretch tight muscles ■ Progress ○ Additional Elbow Treatments: ​ ■ Bracing/splinting for lateral tendinopathies → changes origin ■ Eccentrics for degenerative tendinopathies ■ Surgery if conservative management not successful ● Goal is to stimulate improved vascularization to create a new healthy scare ● Post op therapy important to promote proper healing and scar formation Elbow Capsular Pattern ● Entire joint capsule is restricted (hypomobile) ● All directions that the joint move are hypomobile with a tight capsule end feel ● Elbow Capsular Pattern: Flex/ext ​ ○ Decreased AROM with flex, more limited than ext flex feel ○ Decreased PROM classical flex more limited than ext extend PIA AIP tightcapsule ○ Tight capsule end feel with PROM classical ○ Decreased PROM accessory: P/A glide radial head more limited than A/P glide of radial head o o ○ Tight capsule end feel with PROM accessory Medial Collateral Ligament Sprain ● Predisposing factors: ​ ○ Overhead athlete → throwing, tennis serve ○ Trauma → direct trauma to medial elbow ● Examination: ​ ○ Step 3: history → pain medial elbow ​ ○ Step 7: PFC → warmth and swelling psthetchesligament ​ inflammation ○ Step 13: special tests → pain and increased mobility with valgus stress test ​ ○ Step 15: PFT → pain in MCL ​ ● Treatment: ​ ○ MD: ■ Surgery for competitive throwing athletes ■ Us0e of palmaris longus, plantaris, or toe extensor tendons forreplacement ○ PT: ■ PRICE, modify activities ■ Increase ROM and strength ■ Strengthen/stabilize above and below ■ Supervised throwing progression Bursitis ● Predisposing factors: ​ ○ Direct trauma ○ Repetitive weight bearing ● Examination: ​ ○ Step 7: PFC → warmth and swelling posterior elbow ​ painintriceps b c ○ Step 8: AROM → Pain with AROM ext (triceps) ​ itgoesoverolecranon ○ Step 9: PROM → pain with PROM flex (triceps) ​ ○ Step 11: MLT → pain with lengthening triceps ​ ○ Step 15: PFT → pain over olecranon bursa ​ ● Differential diagnosis: ​ ○ Infection within joint ○ RA ○ Gout crystalsthatformbetween ajoint excessuricacid ○ Fracture ● Treatment: ​ ○ MD: ■ Aspiration, cortisone injection, antibiotics ■ Sling ○ PT: ■ Modalities to decrease inflammation and pain ■ Education for repetitive stress ■ stretch/strengthen as indicated by clinical exam Heterotopic Ossification and Myositis Ossificans ● Heterotopic ossification: bone formation in location other than bone ​ ● Myositis ossificans: bone formation in inflamed muscle ​ ○ Predisposing factors: ​ ■ Trauma ■ Burns ■ Genetic disorders ○ Examination: ​ ■ Step 8: AROM → limited in flex and ext ​ ■ Step 9: PROM → classical limited in flex and ext ​ ■ Step 10: MSTT → weak ​ ■ Step 11: MLT → decreased length ​ ■ Step 12: MMT → Weak ​ ■ Step 17: imaging → as early as 2 weeks post injury may see bone ​ formation in muscle ○ Treatment: ​ ■ PT: ● Maintain ROM ● Don’t be too aggressive - don’t want to reinjure ○ Avoid bleeding into muscle Nerve Entrapments ● Predisposing factors: ​ ○ Trauma ○ Tight muscles ○ Soft tissue restrictions ○ Joint mobility restrictions ○ Swelling ○ Bony changes ○ Ergonomics ● Examination: ​ ○ Motor and sensory changes distal to the site of entrapment ○ Stress the site of entrapment to confirm location ● Treatment: ​ ○ Address pressure that is on the nerve ■ Soft tissue: soft tissue manipulation ■ Tight muscle: stretch muscle ■ Joint mobility: joint manipulation ■ Ergonomics ○ Cannot strengthen muscles until pressure relieved off the nerve ● Median Nerve Elbow Entrapment Sites: ​ ○ Ligament of Struthers → becomes irritated between ligament and humerus ○ Bicipital aponeurosis: ​ ■ Fascia where the biceps tendon attaches to ■ Median nerve becomes adhered to fascia ○ 2 heads of pronator teres: ​ LX ■ Runs between the 2 heads ■ Compressed due to tightness, hypertrophy, swelling of pronator teres ■ Anterior interosseous nerve is a branch of the median nerve that can be entrapped at pronator teres ● Only motor so use that to differentiate median nerve from AIN entrapment ○ Median nerve muscle innervations: ​ ■ Pronator teres, FCR, PL, FDS, lumbricals, sensory - volar of digits 1,2,3,½ 4 ■ Anterior interosseous: FDP, FPL, pronator quadratus ■ Recurrent branch: OP, APB, FPB ● Ulnar Nerve Elbow Entrapment Sites: ​ ○ Cubital Tunnel behind the medial epicondyle: ​ ■ Sharp turn behind the medial epicondyle can aggravate the nerve ■ Large carrying angle increases susceptibility to nerve irritation ■ flexor mass may become hypertrophied or tight causing compression on nerve ○ Ulnar Nerve Muscle Innervations: ​ ■ FCU, FDP, Sensory ½ 4, 5, FPB (deep head), AP, Interossei, lumbricals 3 and 4, ODM, ADM, FDM ■ Superficial ulnar: palmaris brevis ● Radial Nerve Deep and Superficial Branch Elbow Entrapment Sites: ​ ○ Direct trauma to the area or radial head or neck fracture can damage the nerve ○ Deep branch within muscle belly of supinator due to muscle hypertrophy or tightness ○ Superficial branch fibrous angle of ECRB ■ Main complaint is pain over dorsal aspect of 1st CMC joint ○ Radial Nerve Muscle Innervations: ​ ■ Brachioradialis, ECRL, anconeus, triceps, sensory to dorsum of digits 1,2,3,½ 4, supinator, ECRB, ED, EDM, ECU, APL, EPB, EPL, EI Elbow Fractures ● Supracondylar Fracture: ​ ○ Fracture through the epicondyles of the humerus ○ Can be intra or extra-articular depending on location ○ Predisposing factors: ​ ■ Children ■ Hyperextension or fall on flexed elbow ■ Severe comminuted fractur0e possible ● Jagged ends can be driven into anterior periosteal tissue and the brachialis ● Bone fragments may damage the median nerve or brachial artery ○ Treatment: ​ ■ MD: ● Based on the amount of displacement and nerve/arterial damage Nodisplacement sling ○ If no displacement or neurovascular damage than the displacement closedreduction fracture is immobilized with the elbow flexed ○ If displacement, a closed reduction can be done Neurovascular ○ But if neurovascular damage → ORIF needed ■ PT: treat secondary complications from the fracture, surgery, immobilization ● Radial Head Fracture: ​ ○ Compression of radial head in capitellum due to FOOSH ○ Can be comminuted or non-comminuted ○ In this area, malunion is highly likely ○ Treatment: ​ ■ MD: ● Closed reduction and casting ○ Often associated with high rates of stiffness ● Closed reduction and early motion ○ May have bony malunion and malunion especially with comminuted and unstable fractures ● ORIF or replacement or excision depending on fracture 0 ○ Improved long term functional outcomes ■ PT: ● Treat secondary complications due to the fracture, surgery, immobilization ● of Olecranon: ​ Friday T'T IF FEET ○ Sudden passive flexion with a powerful contraction of the triceps or a fall backwards onto elbow ○ This causes the triceps to avulse the olecranon procress ○ Immediately post injury will have decreased elbow extension ○ Complications: ​ ■ Non-union ■ Post traumatic DJD ○ Treatment: ​ ■ MD: ● If non-displaced or minimally displaced → immobilization with elbow flexed 90 degrees likeelbowfracture ● For any other fracture → ORIF followed by immobilization ■ PT: ● Will treat any secondary impairments from surgery and immobilization ● Fracture Complications: ​ ○ Post traumatic DJD: articular cartilage damaged ​ ■ Associated with: ● Intra-articular fractures ● Dislocations ● Malunion ○ Nonunion: Fails to heal with bone ​ ■ Fibrous non union: healed by fibrous tissue but not bone ○ Pseudoarthrosis: Nonunion with continual motion at fracture site ​ ■ Causes formation of false joint ○ Malunion: fracture has healed but incorrectly ​ ■ Significant deformity ○ Delayed union: healing but at a slow rate ​ ○ Greenstick fracture: failure on convex side (break of cortical surface) with only ​ bending on concave surface ● Possible End Feels after Immobilization: ​ ○ PROM classical → tight muscle, tight capsule, edema, bony block ○ PROM accessory → tight capsule, effusion, bony block Dislocation ● Severe hyperextension or a fall on the hand with the elbow slightly flexed ● and radius move posteriorly in relation to humerus which is now more anterior ● 20-25% of the time a posterior dislocation is associated with a fracture ● Complications: ○ Capsular damage ○ Injury to brachialis muscle ○ Damage to the collateral ligaments ○ Median nerve injury ○ Brachial artery damage ○ Fractures ○ Myositis ossificans ○ Post traumatic DJD ○ Tight muscles/capsule

WEEK 7: AND HAND

Fractures and Deformities ● Mallet Finger: ​ ○ Rupture of extensor tendon (central slip) that attaches to base of distal phalanx or avulsion of attachment site ○ MOI: fingers actively extending while ball hits tip of finger hyperflexing DIP (bent q ​ down) ■ Finger jam during eccentric loading ○ Presentation: loses ability to actively extend → intact flexor musculature pulls DIP ​ into flexion ● Bennett’s Fracture: ​ ○ Fracture at base of 1st MC ○ Common in boxers, football players ○ MOI: ​ ■ Axial load to tip of 1st digit while it is in slight flexion ■ Drives MC into causing fracture on ulnar side ■ Often associated with dislocation of 1st CMC joiDamont with MC moving in 0 radial direction ■ Strong interosseous ligament holds fragment in place against 2nd MC while 1st MC displaced laterally ○ Treatment: ​ ■ MD: ● Closed reduction and casting ● Percutaneous pinning Mp PT ● If significant → open reduction with K wire or screws ■ PT: ● Often see them after surgery or immobilized ● May present with CMC laxity or hypomobility ○ Treat what you find ○ Joint capsule stiffness, muscle atrophy ● Boxer’s “Street Fighter’s” Fracture: ​ ○ Fracture at neck of 5th MC ○ Unskilled in fighting ○ MOI: ​ ■ Poor technique striking force through ulnar side of fist vs. radial side ■ MC 4 and 5 are mobile whereas 2 and 3 are more rigid ● Because adductors are on the 2nd and 3rd so more rigid ■ Ulnar nerve can be damaged - weakness in adduction ○ Treatment: ​ ■ MD: ● Close reduction ● ORIF with plating ● : ​ ○ MOI: ​ ■ FOOSH with wrist in ext and slight radial deviation ■ Causes scaphoid and lunate to approximate with radius ○ Subjective: pain in anatomical snuff box ​ ○ Radiography: acute injuries are often missed on radiographs ​ ○ Complications: ​ EX ■ Avascular necrosis Win ■ Delayed healing and non-unions ○ Treatment: ​ ■ MD: ● Medical treatmejaimooua.amnt mandatory ● Casting, surgery, bone stimulators ■ PT: after immobilization ● Hyper/hypomobilities ● Swelling ● Tight extrinsics ● Colles Fracture: ​ s ○ Transverse with dorsal displacement ○ Predisposing factors: ​ ■ Age > 50 ■ Females > Males ○ MOI: ​ ■ FOOSH with wrist in extension (often supinated) ● Force travels dorsally though the distal radius ○ Presentation: ​ ■ Distal segment will have a dorsal displacement ■ “Dinner fork deformity” ● ○ Complications: ​ ■ Median and ulnar nerve injury ■ Malunion “dinner fork deformity” ■ Post-traumatic arthritis ■ Soft tissue adhesions ■ Complex regional pain syndrome ■ Shortening or lengthening of radius due to poor alignment ● Smith’s Fracture: ​ ○ Transverse distal radius fracture with palmar displacement volarly ○ MOI: ​ ■ FOOSH with wrist in ext (often pronated) ■ FOOSH with wrist flexed ● Force travel8s palmarly through the distal radius ○ Presentation: ​ ■ Distal segment will have a volar displacement ■ Muscle atrophy ■ Joint laxity ● : ​ GO ○ Fracture of distal radius with dislocation of distal radio-ulnar joint ○ : bone through skin ○ Can have non-union ○ Treatment: ​ ■ MD: ● Best results with ORIF of radius and distal radioulnar joint ● : ​ M ○ Fracture of proximal ulna with dislocation of distal radio-ulnar joint when mount ○ Treatment: penal you ​ someone you ■ MD: goontop proximal ● Closed reduction: realign by traction/cast ● Dupuytren’s Contracture: ​ ○ Contracture of palmar fascia of hand ○ Cellular level formation of nodules on palmar fascia ■ Thickens and shortens palmar fascia pulling MCP and PIP joints into flexion ○ Digits 4 and 5 most common ○ Predisposing factors: ​ ■ European Caucasian males congenital ○ Treatment: ​ ■ MD: ● Resting hand splint ● Excise tissue with Z incision ● Tenolysis - make room for tendon ■ PT: ● Scar management ● ROM ● Kienbock’s Disease: ​ ○ Osteochondrosis of lunate bone ○ Predisposing factors: ​ ■ Trauma from FOOSH or laxity of lunate bone ● Causes avascular necrosis ● Bouchard’s and Heberden’s Nodes: ​ ○ Fibrous part of capsule thickens laying down ossification forming bony node ○ Bouchard’s = at the PIP joint ■ May be associated with RA ○ Heberden’s = at the DIP joint if ○ Presentation: ​ 8 ■ Decreased joint space ■ Sclerosis of subchondral bone ■ Osteophytes at articular margins ■ Joint deformities ● Swan Neck and Boutonniere Deformity: ​ ○ Displacement of the lateral bands of the extensor mechanism at the PIP joints ○ Swan Neck: lateral bands displaced dorsally ​ ■ PIP pulled into hyperextension ■ MCP and PIP pulled into flexion ○ Boutonniere: lateral bands displaced volarly ​ ■ PIP flexed I ■ MCP and DIP extended ● Digital Tendovaginitis Stenosans “Trigger Finger”: ​ ○ Thickening of flexor tendon sheath causing finger to be stuck in flexion and unable to extend ○ With active flexion, tendon becomes stuck proximal to A1 pulley ○ Individual must passively extend finger to pass tendon through pulley ○ Predisposing factors: ​ ■ Swelling around the flexor tendons ■ Nodule within flexor tendons ■ Thickening of fibrous sheath of flexor tendons ● Z Deformity: ​ ○ 1st digit ■ CMC flexed ■ MMeCP hyperextended ip ■ AIP flexedmop ○ Predisposing factor: ​ ■ Laxities from RA ● Opera Glove Anesthesia: ​ ○ Loss of sensation from wrist down to fingertips ○ Is not correlated with any neurologic cause ○ Predisposing factors: ​ ■ Hysteria ■ Leprosy ■ Diabetes ■ CRPS sensoryactivemedian ● Benediction Sign and Bishop’s Deformity: spray ​ e passiveulnardeformity ○ 4th and 5th digits are flexed while rest of hand is extended ○ Benediction Sign: ask patient to make a fist and only able to flex 4th and 5th ​ digits ■ Indicates loss of median nerve and therefore ability to flex 2nd and 3rd iq digits C f ○ Bishop’s Deformity: patient holds their hand with the 4th and 5th digit flexed due ​ to loss of ulnar nerve and medial two lumbricals that assist with PIP extension ■ Patient unable to extend digits fully Pathologies ● Complex Regional Pain Syndrome: ​ ○ Regional pain and hypersensitivity disproportionate to any specific event ○ Theories on Etiology: ​ ■ Direct trauma to sympathetic nerves ■ Direct trauma to peripheral nerve ■ ImmobEilization ■ Immobilization in the presence of edema ■ Psychological predisposition ○ Miscommunication between ANS and CNS: ​ ■ S&S associated with miscommunication between ANS and brain ● Atrophy of hair, nails, and other soft tissue ● Alterations of hair growth Hair ● Glassy or shiny skin, red blotchy skin skin ● Loss of joint mobility joiningbaes ● Impaired motor function (weakness, tremor) ● Osteopenia pain sweat red temp ● Sympathetically maintained pain ● Pain described as burning, throbbing, shooting, or aching ● Hyperalgesia ● Aloodynia: perception of pain with normally innoculous stimuli (sympathetic mediated pain) ● Abnormal sweating or Anhidrosis (inability to sweat) ● Redness or bluish discoloration ● Heat or cold sensitivity ■ Brain responds with edema, attempts to heal and heightened sensations to protect individual from doing further harm ■ Sympathetic system responds to injury by enlarging blood vessels, onset of swelling, pain, and redness ● Sympathetic system is trying to fight ○ Treatment: ​ ■ MD: ● Pharmacology, sympathetic blocks and psychotherapy ● This should be integrated with rehab program ● Surgical intervention: spinal cord stimulator, intrathecal infusion, baclofen pump, morphine pump, sympathectomy, and radiofrequency ablation ■ PT: ● Sensory training: tactile habituation (fluidotherapy) ● Massage and muscle pumping for edema ● Maintain mobility and muscular functioning ● Pain science education ○ Prognosis: ​ ■ 80% have complete spontaneous relief of signed and symptoms in 18 months ■ 50-80% have disability secondary to pain and or limited ROM ■ Poor outcomes associated with long duration of symptoms, presence of trophic changes, presence of cold RSD ● Volkman’s Ischemic Contracture: ​ ○ Compartment syndrome specific to the forearm ○ Predisposing factors: ​ ■ Direct trauma to area causing edema ■ Forearm cast ○ Etiology: ​ ■ Increased build up of pressure leads to compression of neurovascular components ■ Causes decreased sensation and decreased blood flow → ischemia ■ Ischemic muscles and soft tissue become necrotic and fibrotic ■ Leads to contractures of muscle or soft tissue including nerves ○ S&S: ​ ■ Swelling and ℅ tightness ■ Diminished radial or ulnar pulses and capillary refill ■ Significant motor weakness and paralysis ■ Measurement of pressure remains controversial ○ Treatment: ​ ■ MD: ● Emergent condition ● Fasciotomy to restore compartment pressure to normal ● Remove cast ● If pressure not released in time will require further surgical interventions ● Injury to “No-Man’s Land”: ​ ○ Flexor Zone 2 of the hand → distal palmar crease to mid portion of middle phalanx ○ FDP and FDS pass through their fibrous tunnels ○ Laceration in this zone has poor prognosis 417 ■ Poor blood supply and tendons are prone to adhesion formation ■ Will require surgery ● Dequervain’s Tenosynovitis: E ​ ○ Inflammation of APL and EPB tendons and sheath (1st extensor tunnel) ○ Predisposing factors: ​ ■ Repeated action that causes friction where the tendons glide → inflammation ○ Examination: ​ ■ Step 3: history → pain radial side of wrist over 1st extensor tunnel ​ ● Worse with thumb active abduction and extension and wrist ulnar deviation ● Female > male ■ Step 7: PFC → warmth, swelling, and thickening over the APL and EPB ​ ■ Step 8: AROM → pain with thumb abduction and extension ​ ■ Step 9: PROM → pain with thumb adduction and flexion to ​ ■ Step 10: MSTT → Abd and ext of thumb: strong and painful ​ ■ Step 11: MLT → pain in thumb abductors and extensors ​ ■ Step 13: Special tests → Finkelstein ​ ○ Treatment: ​ ■ PT: ● Activity modification ● Decrease inflammation ● Splint to decrease stress and strain on tendons ● Treat impairments that are causing tendon irritation ○ Hypo/hypermobilities ○ Stretching tight muscles ○ Strengthening weak muscles Peripheral Nervous System Pathologies ● Syndrome: ​ ○ Median nerve entrapment in carpal tunnel ○ Mixed efferent and afferent nerve ○ Predisposing factors: ■ Pressure on wrist from work or bicycle riding ■ Trauma: fracture/fall on area ■ Disease: diabetes or other metabolic disorders ■ Space occupying lesion: ganglion cyst ■ Tight wrist flexors: prevent neural gliding in carpal tunnel ■ Displaced lunate: more in volar direction ● Hypomobile: lunate on scaphoid restricted in dorsal direction ● Hypermobility: is lax ○ Lunate moves in volar direction ■ Retinaculum tightness: causes compression ■ Edema: interstitial fluid ■ Effusion: between carpals ■ Pronator Teres Syndrome: any median nerve entrapment at elbow ■ C5-T1 nerve root pathology ○ Examination: ​ ■ Step 3: history → paresthesias in the median nerve distribution, night pain, hand weakness ■ Step 9: PROM accessory → lunate mobility ■ Step 10: MSTT → weak and painful soNOMMT ■ Step 11: MLT → tight wrist fIlexors ■ Step 13: special tests → Phalen’s, Tinnel’s ○ Treatment: ​ ■ MD: ● Endoscopic release ● Open release ■ PT: ● Depends on impairments and lifestyle that caused it ● Education in lifestyle modifications/ergonomics ● Night splint to keep patient out of flexed postures ○ Only use when acute or highly reactive ● Stretch wrist flexors ● Decrease fluid with manual techniques and modalities ○ Nerve Injuries: ​ ■ Neuropraxia: ​ ● Slight damage to the nerve with transient loss of conductivity ● Corresponds to a 1st degree injury to a nerve ● Demyelination with restoration in weeks ● Complete recovery is expected in approximately 12 weeks ● S&S: ​ ○ Pain ○ None or minimal muscle wasting ○ Some muscle weakness ○ Numbness ○ Loss of proprioception ■ Axontmesis: ​ ● Injury damages the axons but not the body of the nerve ● Axons, myeling, and internal structures are all disrupted ● Corresponds with 2nd, 3rd, and 4th degree injury to a nerve ● Axons are disrupted and must regenerate while the epineurium is intact ● Typically occurs with traction type injuries ● Regeneration occurs in the intact neural tubes but slowly (1mm/day) ● S&S: ​ ○ Pain ○ Evident muscle atrophy ○ Diminished motor, sensory, and sympathetic function ○ Recovery sensations return before motor function ■ Neurotmesis: ​ ● The internal structural framework and the enclosed axons are destroyed ● Corresponds to a 5th degree injury to a nerve ● An injury that results from disruption in the continuity of both axons and all supporting structures, including epineurium ● Losing the neural tubes negates the potential for normal regeneration ● Neurofibrils can grow out from the divided ends to produce a neuroma ● S&S: ​ ○ No pain ○ Muscle wasting ○ Complete motor, sensory, and sympathetic function loss

WEEK 8: CERVICAL/THORACIC Anatomy ●

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● ● armrest Arthrokinematics ● Functional Anatomy: ​ ○ Cervical Thoracic: occiput → T4 f.ma ○ Upper Cervical: C0 → C2 msn.fi ○ Mid-Lower Cervical: C2 → T4 ● Sub-cranial: ​ ○ Flexion: ​ ■ C0 on C1 → anterior roll/posterior glide (convex on concave) ■ C1 on C2 → anterior roll/anterior glide (convex on convex) ○ Extension: ​ ■ C0 on C1 → posterior roll/anterior glide (convex on concave) ■ C1 on C2 → posterior roll/posterior glide (convex on convex) ○ R Rotation: ​ ■ C0 on C1 → 1-3 degrees R posterior roll/anterior glide (convex on convave) ■ C1 on C2 → R posterior roll/posterior glide (convex on convex) ● 30 degrees ○ R Sidebending (Lat Flex): ​ ■ C0 on C1 → R roll/L glide (convex on concave) ● C1 will side glide to R ● C1 always moves with skull ■ C1 on C2 → no sidebending occurs (convex on convex) ○ *roll will go to the same side the bone is moving ■ ex) flex arm → arm goes up → roll goes up ● Mid Cervical/Upper Thoracic: ​ ○ Flexion: Superior/Anterior ​ ■ Up/forward ○ Extension: Inferior/Posterior ​ ■ Down/back ○ Sidebending/Rotation: Ipsilateral Inferior/Posterior, Contralateral ​ Superior/Anterior Collagen ● Type 1 Collagen: Stretch ​ ○ Muscles, tendons, ligaments, capsule, annulus of disc ● Type 2 Collagen: Compression ​ ○ Facet cartilage/nucleus of disc ○ Responds well to compression and cyclical loading Myofascial Tightness and Posture ● Myofascial tightness: ​ ○ Differential diagnosis: cervical SB with unsupported and supported ■ Decreased range with unsupported → tight muscle or facet ■ Decreased range with supported → tight facet ● Posture Related Neck Pain: aka Val syndrome ​ ○ Pain in neck, upper trapezius, interscapular, suboccipital ○ Cervicogenic headaches ○ No complaint of paresthesias or neurological symptoms since source of pain is typically facet (cartilage, capsule, or both) ○ Forward head posture: ​ ■ Excessive upper thoracic flexion ■ Excessive mid and upper cervical extension ○ Impairments: ​ ■ Forward head and rounded ■ Decreased cervical AROM ■ Tight upper trapezius, levator scapula, suboccipital muscles, pec major, pec minor ■ Weak middle lower trapezius and deep neck flexors ■ Increased tenderness and tone in cervical/thoracic paraspinals, suboccipital muscles, SCM, upper trap, levator scap, and interscapular muscles ■ Poor posture awareness and ergonomics set up ○ Treatment: ​ ■ Identify tissue specific impairments ■ Reduce pain and muscle guarding ● Soft tissue mobilization ● Joint manip ● Light exercise (50% 1RM) ● Physical agents (thermal, electrical) only if patient can tolerate manual treatment ■ Focus on TSI ■ Postural education and ergonomic set up ■ Ex) ● Stretching mid-upper thoracic spine into extension ● Actively stretching tight pec muscles while strengthening middle traps (cable rows) Sprain/Strain/Synovitis and Painful Entrapment ● Sprain/Strain/Synovitis: ​ ○ Ligament-Capsule Sprain on Right: ​ ■ Painful movement pattern: 0 ​ ● In end range with all motions ● Worse with L SB/flex → gapping of facet joint ligament ● Unilateral pain ■ Worse with up glides ext Hex ■ Better with down glides ■ Ex) Tear in capsule C3-C4 contrarot ipsirot ● Cervical flex → bad ipsisB contraSB ○ Tension in capsule ● R rotation → bad ○ Creates up glide ○ Tensions capsule capsules ● R SB → good flex ext ○ Bunches up capsule contralateral ● Cervical ext → good ligament contrarotfSB ipsimHB ○ Puts capsule on slack bad ○ Capsular Entrapment: ​ ■ Painful movement pattern: ​ capsuarsipsicateralSB ● End range with all motions bad ● Worse with compression → ext, ipsilateral SB/rotation ● Unilateral pain ■ Treatment: ​ ● Isometric multifidi contraction to pull capsule out of joint space ○ Keeps capsule from folding in and getting pinched ○ An unexpected perturbation can irritate multifidi ● R sided problem → PT stands on L ○ Facet Cartilage on Right: ​ ■ Painful movement pattern: ​ ● Ext ● Ipsilateral SB/rot ● Unilateral pain in R ■ Pain relieved with: ​ ● Flexion ● Contralateral SB/rot ○ Posterior Annular Tear: ​ ■ Painful Movement Pattern: ​ ● + flexion Annular ● B rotation ● Possible ext ● uni/bilateral pain Cervical Radiculopathy & Myelopathy ● Cervical Radiculopathy: ​ ○ Pressure on a cervical nerve causing pain, numbness, tingling, or weakness ○ Etiology: ​ ■ Uncovertebral (“U” oI r “Von Lushka”) joint spondolytic changes ■ Inflammation from annular tear ■ Inflammation from facet joint ○ Painful Movement Pattern: ​ ■ Decreased ipsilateral SB and BB with UE symptoms ○ Neurologic findings: ​ ■ Dermatome/myotome (muscle weakness) ● Changes movement distally ■ Distraction decreases symptoms d ■ Compression increases symptoms (numpressingbness) Mfffssine onnumb ■ Tenderness on side of involvement ○ Impairments: ​ ■ Forward head and shoulders posture ■ Limited and painful BB and ipsilateral SB with pain radiating into UE ■ Neurologic signs in corresponding dermatome/myotome ■ Distraction decreases symptoms ■ Compression/Spurlings and Quadrant test all increase symptoms in the UE ■ Tenderness on side of involvement in the upper trap/levator/paraspinals/interscapular muscles ○ Clinical Prediction Rule: ​ ■ + ULTT1 ■ Cervical rotation < 60 degrees ■ Distraction decreases symptoms ■ + Spurling’s Test ● Central Spine Stenosis and Myelopathy: ​ ○ Damage to cervical spinal cord due to degeneration of cervical spine ○ Etiology: ​ ■ Osteophytes on posterior aspect of vertebral body ■ Disc and ligamentum flavum protrusion ■ DJD and DDD in the c spine ○ Presentation: ​ ■ Aching in neck and shoulders with occasional radiation into arms ■ Paresthesias in /feet, weakness in legs and imbalance ○ Impairments: ​ ■ Forward head posture with thoracic kyphosis ■ Limited AROM ■ Permanent or transient neurologic signs/+ Babinski and Clonus ■ General weakness of extremities ■ Muscle tightness/weakness associated with posture ■ Tenderness and increased tone in the upper traps, cervical region ○ Treatment: ​ ■ Notify MD ■ If cleared for therapy: ● Work on tightness/weakness associated with posture ● Strengthen the extremities ● Work on balance ● Local treatment for muscle soreness ● Chin tucks with head on 2 pillows

*Read these if you have time LOL - not much will be on test WEEK 4: MS PATHOLOGY

Musculoskeletal Pathology Part 1 ● Metabolic Diseases: ​ ○ Osteoporosis: porous bone ​ ■ Metabolic disorder ■ Bone reabsorption > bone formation ■ Osteoclast activity > osteoblast activity ■ Areas most susceptible: ​ ● Areas rich in blood supply and trabecular: vertebrae, calcaneus, and metaphyseal area of long bones ■ Risk factors: ​ ● Menopause ● Men 4x > women after 40 y/o ● Aging ● Heredity ● Ethnicity ● Inactivity ● Tobacco ● Alcohol ● Corticosteroid use ● Nutrition ● Depression ■ Signs and symptoms: ​ ● Loss of height ○ Thoracic kyphosis ○ Vertebral fracture ● Postural changes ○ Protruding abdomen ○ Increased thoracic kyphosis ○ Dowager’s hump ○ Loss of lumbar lordosis ○ Forward head, internally rotated shoulders, backward facing palms ○ Posterior pelvic tilt ○ Knee hyperextension ○ Back pain ■ Fracture site ■ Muscle imbalance ■ Paravertebral spasm ○ Fracture ■ Spontaneous fracture ● Vertebral bodies ● Femoral neck/acetabulum ● Rib ● Radius ● Shaft of femur ● Metatarsal ■ Determined by bone mineral density: ​ ● *Radiological definition: low bone density regardless of cause (osteoporotic or not) ● Normal: bone density within 1 SD of the young adult mean (+1 or ​ -1) ● Osteopenia: bone density is 1.0-2.5 SD below the young adult ​ mean (-1 to -2.5 SD) ● Osteoporosis: bone density is 2.4 SD or more below the young ​ adult mean (> -2.5 SD) ■ Radiological features of common osteoporosis: ​ ● Cortical bone thinning (long bones) and periarticular areas ○ First areas to lose density or show loss ● Osteopenia: hallmark of osteoporosis ○ Radiolucency areas in bone ● Trabecular changes ○ Thin, sparse, and delicate ○ Easily seen in proximal femur ● Fractures ○ Vertebral bodies, proximal femur + humerus, and distal radius

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● ■ Treatment: ​ ● Stop bone loss ○ Estrogen replacement therapy: selective estrogen receptor modulator (SERM) ○ Supplements: calcium, vitamin D ○ Pharmacology: calcitonin, bisphosphonates (actonel, boniva, fosamax) ● Fracture management ○ Vertebroplasty ○ Kyphoplasty ○ ORIF ○ THA ● Proper nutrition: keep BMI above 22 ● Load bearing exercise ○ Walking, jogging ■ Prevention: ​ ● Bone density screening ● Calcium and vitamin D supplements ● Adequate nutritional intake ● Weight bearing activity ● Fall prevention ● Smoking cessation ○ Osteomalacia (soft bone): ​ ■ Bone is built incorrectly ● It is built too soft ■ The cause may be poor nutrition, person may not be able to absorb calcium or phosphate (GI disorder), or has a metabolic deficiency excreting too much calcium or phosphate (kidney related) ■ Similar to Rickets disease in children (poor nutrition and lack of vitamin D) ● Don’t confuse with osteogenesis imperfecta (brittle bones) ■ Risk factors: ​ ● SLE due to photo sensitivity ● People from northern China, India, and Japan ● Long term antacid use-usually at high doses (aluminum hydroxide)-aluminum hydroxide causes hypophosphatemia and subsequent stealing of phosphate from bones ● Sedentary and institutionalized individuals ○ Osteitis Deformans: ​ ■ Bone inflammation causing deformity ■ AKA Paget’s disease ■ Progressive metabolic bone disease: ​ ● 2nd most common metabolic bone disease ● Origin may be genetic and/or virotic ■ Pathology: ​ ● Greatly accelerated bone remodeling activity → presence of giant osteoclasts that are actively resorbing bone ● Rebuilding process is at a loss to catch up ○ But when it does, it’s bad ● Abnormal bone turnover may cause unwanted bone growth compressing nerves, spinal cord, and brain leading to headaches, cognition deficits, and hearing problems ● Increased bone turnover require increased blood circulation and overtime may cause heart related problems ■ Incidence: ​ ● British isles and british immigrants ● Age > 50, more common in males ■ Pelvis (75%) most commonly affected ■ Bowing of the femur and tibia ■ Enlarged skill (29% to 65%) ○ Osteopetrosis: ​ ■ Stone bone ■ Increased bone density ■ Pathology: ​ ● Very rare disorder where osteoclasts fail to resorb bone → impaired bone modeling and remodeling ● Defect in bone turnover → skeletal fragility despite increased bone mass ○ Key points to remember about metabolic bone disorders: ​ ■ Osteoporosis: normal bone losses density, common in caucasian ​ post-menopausal women ■ Osteomalacia: bone is built too soft, lack of minerals often from nutritional ​ intake deficit or GI disorder ■ Paget’s disease: bone turnover too high → can cause neurological ​ (compression) and cardiovascular (excessive blood demand) problems ■ Osteopetrosis: bone too dense → rare, weak structure ​ Musculoskeletal Pathology Part 2 ● Fractures: ​ ○ Definition: defect in the continuity of a bone or cartilage ranging from a crack to a break with multiple segments ○ Classification: ​ ■ Traumatic (impact): acute bone failure often caused by a single ​ application of high magnitude stress ■ Stress: insidious bone failure usually caused by repetitive application of ​ stress of small magnitude over time (extremely rare in sedentary people) ■ Pathologic: bone failure is caused by a pathologically fragile bone ​ structure caused by neoplasm or infection ■ Insufficient: bone failure caused by normal application of stress in fragile ​ bone weakened by metabolic bone disease or abnormal calcium metabolism ○ Types: ​ ■ Displaced (no contact between pieces) or non-displaced ■ Open/compound (skin-breached) or closed ■ Complete (transverse, bone loss, oblique, spiral, comminuted, segmental and butterfly) or incomplete (stress, green-stick, torus, or hairline) ■ Intraarticular (involving the articulating synovial cartilage) or extraarticular ■ ○ Special features: ​ ■ Impacted fx: when a bone piece, generally cortical, is impacted into trabecular bone ● Common in long bones ● Traction required for reduction ■ Compression fx: when trabecular bone collapses into itself ● Common in the spine ■ Avulsion in locations where tendons or ligaments tear pieces from the bone ○ Mechanism of Traumatic Fractures: ​ ■ Shearing loads: ● Transverse ■ Torsional loads ● Oblique ● Spiral ■ Combined loads ● Comminuted ● Segmental ● Butterfly ● ○ Risk Factors for Fractures: ​ ■ All fractures: ● Trauma ● Age >50 yr ● Low BMI ● History of falls ● Vitamin D deficiency ● Low physical function ● Medications that interfere with calcium absorption ● Poor nutrition ● Metabolic bone disease ● Malignancy ● Infection ● Poor calcium metabolism ● Radiation treatment ● Postmenopausal women ● Long term care facilities ■ Stress fractures: ● Armed force soldiers ● High caliber athletes ● Too much physical activity without a period for adaptation, increased training (esp in females > 40 yr because of hormonal changes) ● Leg length discrepancy ● Low muscle mass - bones have to take more of the force ● Rare in sedentary people ○ Fractures in Children: ​ ■ Greenstick: incomplete long ​ ● One side of the bone is fractured, whereas a portion of the bone and periosteum remains intact ■ Epiphyseal: cartilage on growth plate affected ​ ● Growth abnormality may occur ○ Signs and Symptoms: ​ ■ Traumatic: bone deformity and swelling, unable to weight bear, extreme pain, difficulty to move, grossly restricted ROM, gross weakness ■ Stress: point tenderness or pain upon palpation over fracture site, pain with repetitive weight bearing ■ Insufficient/pathologic: either one above ○ Fracture Management: ​ ■ Non-surgical: immobilization and closed reduction ■ Surgical: open reduction and internal fixation ○ Complications: ​ ■ Malunion, delayed union, or non-union ■ Pseudoarthrosis (non-osseous union of bone) ■ Joint instability, osteoarthritis because of abnormal joint mechanics, esp intra-articular ■ Shortened limb, postural deformities ● Osteomyelitis: inflammation of bone marrow ​ ○ Commonly caused by bacteria ■ Can be caused by virus, fungi, and parasites ○ Incidence: ​ ■ Acute is rare: children, male>female ■ Chronic is more common in adults - immunosuppressed patients, elderly ○ Etiology/Pathogenesis: ​ ■ Bacteria spreads easier on trabecular bone rich on blood supply ○ Risk factors: ​ ■ Surgery - prosthesis ■ Open fractures/wounds ■ GI, GU, and respiratory tract infection ■ Diabetes ■ SCI ■ Malignancy ■ Chronic disease (renal, liver) ■ IV drug use ■ HIV ■ Prolonged use of oral coricosteroids ○ Diagnosis is difficult: ​ ■ May be painless without fever ■ Sleep disturbances ○ Management: ​ ■ IV antibiotics ■ Surgical resection of infected bone ○ Serious Complications: ​ ■ Septicemia ■ Bone necrosis (possible amputation) ■ Impaired bone growth ■ Septic arthritis ■ Prosthetics infection (surgical revision) ■ *all require immediate care ○ Septic Arthritis vs. Osteomyelitis: ​ ■ Septic Arthritis Osteomylitis

Acute onset of limp/non-weight Subacute onset of ​ ​ bearing/refusal to use limb limp/non-weight bearing/refusal to use limb

Pain on movement and at rest Localized pain and pain on ​ ​ movement

Limited range/loss of movement Tenderness

Soft tissue redness/swelling often Soft tissue redness/swelling may ​ ​ present not be present and may appear ​ late

Fever +/- Fever (acute might present ​ fever, chronic might not) ● Osteonecrosis: bone death as a result of blood insufficiency in absence of infection ​ ○ AKA Avascular or aseptic necrosis ○ Risk factors: ​ ■ Fractures ■ Alcoholism ■ Pancreatitis ■ Obesity, diabetes, hyperglycemia ■ HIV ■ Systemic lupus ■ Prolonged use of corticosteroids, intravenous bisphosphonates (jaw), or contraceptives ■ Sickle cell disease ○ Pathogenesis: ​ ■ Development of fat emboli in vessels of the bone ■ Interruption of blood supply after fractures ■ Osteoclasts inhibition: necrosis stays in bone and bisphosphonates aren’t removed ○ Incidence: ​ ■ Femoral head (most common) ■ Humeral head ■ Tibial plateau ■ Small bones of hand and feet (lunate, scaphoid, talus), jaw ○ Signs and Symptoms: ​ ■ Pain, especially on WB, antalgic gait pattern (hip, ) ■ Restricted ROM or fracture (late stages) ■ Numbness or heaviness of the jaw ○ Treatment: ​ ■ Core decompression to remove dead bone (bone graft may be added) ■ Prosthesis (THR, TSR) ○ Legg-Calve’-Perthes Disease: ​ ■ Femoral head necrosis in children (males 3-10 y/o) ■ May have spontaneous healing, unlike adult osteonecrosis ■ Cause: unknown, possibly second hand smoke exposure in utero and in childhood ○ Slipped Femoral Capital Epiphysis: ​ ■ Fracture (often insidious) of the proximal epiphyseal plate of the femur (NOT osteonecrosis) ■ Affects mostly obese African-American male teens (8-13 year old) ■ It is believed to be associated with an inherited weakness of the epiphyseal plate ● Key Points to remember: ​ ○ Fractures: ​ ■ Classification: traumatic, stress, pathologic, insufficient ■ Types and features: incomplete, displaced, avulsion, compression, epiphyseal, intra-articular ■ Complications: non-union, mal-union, OA, joint instability ○ Osteonecrosis: ​ ■ Caused by emboli or poor circulation ■ Complication of injuries, systemic, unknown ■ Initially affects the bone without changing the joint surface ○ Osteomyelitis: ​ ■ Infection has preference for trabecular bone ■ Difficult diagnosis ■ Complication of surgery and open wound

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