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CHAPTER I MUSCULOSKELETAL PHYSICALTHERAPY Robert Rowe I. Anatomy and Biomechanics of the (I) Roll consists of one joint surface rolling on Musculoskeletal System another such as a tire rolling on the road. An example of this would be movement A. General Principles of Biomechanics between the femoral and tibial articular 1. Levers are defined as rotations of a rigid surface surfaces of knee. about an axis. There are three types of levers. a. First class lever occurs when two forces are (2) Glide consists of a pure translatory motion appljed on either side of an axis. of one surface gliding on another as when a (1) The effort force artempts to cause movement. braked wheel skids. An example of this (2) The resistance is the force that opposes type of motion in the human body would be movement of the joint surface of proximal movement. phalanx at head of metacarpal bone of (3) Example in human body is the contraction hand. of triceps at elbow joinr. (3) Spin consists of a rotation of the movable b. Second class lever occurs when two forces are component of the joint. An example of this type of motion is movement between joint applied on one side of the axis. surfaces of radial head with humerus. (I) Resistance lies between the effort force and (4) Combinations of all three motions can axis of rotation. occur at joints. Example is movement (2) Few examples in human body (toe raises). between joint surfaces of humerus and c. Third class lever occurs when two forces are scapula of shoulder. applied on one side of the axis. (1) The effort force lies closer to the axis than c. Osteokinemalics is defined as movement between two bones. the resistance force. (2) Most muscles in the human body are third d. Convex-concaye rule describes relationship between arthrokinematics and osteokinematics. class levers (elbow flexion). (I) When a convex surface is moving on a 2. Selected kinematics. fixed concave surface, the convex surface moves in a direction opposite to the direc- a. Arthrokinematics is defined as the movement tion of the shaft of the bony lever. between joint surfaces. b. There are three motions that describe move- ment of one joint surface on another.
2 (2) When concave surface moves on a fixed (2) Maximal contact between joint surfaces. convex surface. the concave articulating (3) Joint play and mobilization cannot be prop- surface moves in same direction as bony lever. (Table I-I). erly performed in this position. c. Selected capsular patterns. (Table 1-4). (3) For spine, convex rule applies at at1anto- d. End feels. occipital joint. Below second vertebra, con- cave rule applies. (I) Normal physiological end-feel. (a) Soft: occurs with soft tissue approxi- 3. Capsular positions. mation. a. Resting or loose-packed position. (Table 1-2). (b) Firm: capsular and ligamentous (I) Joint position where capsule and other soft stretching. tissues are in most relaxed position. (c) Hard: when bone andlor cartilage (2) Minimal joint surface contact. meet. (3) May perform joint play and mobilization techniques in this joint position. (2) Pathological end-feel. b. Close-packed position. (Table 1.3). (a) Boggy: edema, joint swelling. (I) Joint position where capsule and other soft (b) Firm with decreased elasticity: fibrosis tissues are maximally tensed. of soft tissues. (c) Rubbery: muscle spasm. TABLE I-I - CONCAVE - CONVEX RULE APPLICATION (d) Empty: loose then very hard; associat- ed with muscle guarding or patient JOINT FUNCTION DISTAL MOVING SHAPE protecting from going into painful part PART concave of range. Fingers flexion/extension (e) Hypermobility: end feel at a later time Metacarpat- distal phalanx than opposite side. phalangeal abduction/adduction Wrist flexion/extension proximal phalanx concave e. Grading of accessory joi nt movement. (1) Accessory joint movement or joint play is capitate, scaphoid, convex graded to assess arthrokinematic motion of lunate, triquetrum concave the joint and/or when it is impractical or trapezoid impossible to measure joint motion with a goniometer (Table 1-5). Radio-ulnar pronation/supination radius concave (2) Although interrater reliability is poor, Distal pronation/supination radius convex intrarater reliability has been found to be Proximal radius acceptable. ulna concave (3) Data gleaned provides clinician with more Humeroradial flexion/extension humerus specific data as to source of patient's problem. clavicle concave Humeroulnar flexion/extension clavicle 4. Muscle substitutions. scapula convex a. Occur as result of muscles that have become Glenohumeral all movements distal phelanx shortenecVlengthened, have become weakened, COf1vex have lost endurance, developed impaired coor- Stemoclavicular elevation/depression coocave dination, or have become paralyzed. protraction/retraction b. Stronger muscles compensate for loss of coocave motion. Acromioclavicular all movements coocave c. Common muscle substitutions: (I) Use of scapular stabilizers to initiate shoul- Toes flexion/extension der motion when shoulder abductors are weakened. Metatarsal- alxluetiolv'adduction proximal phalanx coocave (2) Use of lateral trunk muscles, or tensor fascia phalengeal latae (TFL) when hip abductors are weak. (3) Use of passive finger flexion by contraction Ankle/Foot all movements navicular, cuneiform concave of wrist extensors when finger flexors are Subtalar inversionfeversion cuboid, calcaneus coovex weak (tenodesis). talus coovex Talocrural dorsaVplantar flexion fibular head coocave Trbio-fibular all movements tibia coocave femur coovex Knee all movements mandible COf1vex Hip all movements TMJ all movements (From Kaltenbom. FM Manual Mobilization of the Extremity Joints, 4 ed., 1989 FM Kaltenbom, Oslo, with permission)
Musculoskeletal Physical Therapy 3 (4) Use of long head of hiceps, coraco- B. Functional Anatomy and Biomechanics brachiaJis, and anterior deltoid when pec- I. Shoulder region. lOralis major is weak. a. Osteology (humerus, scapula, and clavicle). (5) Use of lower hack extensors, adductor (I) Humerus. magnus, and quadratus lumborum when (a) Proximal end of humerus is approxi- hip extensors are weak. mately half a spheroid. (b) Articular surface is covered by hyaline (6) Use of lower ahdominal, lower obliques, canilage. hip adductors and latissimus dorsi when (c) Head is retroverted 20°_30°. hip flexors are weak. (d) Longitudinal axis of head is 135° from axis of neck. TABLE 1-2 - JOINT LOOSE-PACKED POSITIONS TABLE 1-3 - JOINT CLOSE-PACKED POSITIONS JOINT(S) POSITION JOINT(S) POSITION Mict·....ay between Oexion and extension Maximal extension ~avicular Jaw slightly open (fieeway space) Vertebral maximal retrusion (mouth closed with teeth denched) Arm resting by side TemporomandJbular or maximal anterior positioo (mouth maximally opened) :e-.:tMJrneral Arm resting by side Arm maximally elevated 55-70° abduction; 30° horizontal adduction; neutral (otation Sternoclavicular Arm abducted 90\" Acromioclavicular Maximum abduction and external rotation _lnar 7CJ' flexion and 10° supination Glenohumeral tuneroradOl Full extension and supilation Elbow Ful extension and ~tion 'narm 9Cf flexion and 5° supination Proximal radioulnar 7fr lIexion and 35\" ~ination H1.ITl€roolnar Distal radioulnar 10\" supination HumerOfadial 5\" supination and full extension -::ailiulnocarpal Forearm 5\" supination Neutral with slight ulnar deviation Proximal radioulnar Full extension with radial deviation -,nj Distal radioulnar Neutral with slight Oexion and ulnar deviation Radiocarpal Full extension \\IodcaJpa1 Midway between fIexioo'extension, mid flexion, Hand Full opposition CaJpometacaq>aJ and rOO extension MidcarpaJ FuR oppostition Midway betweeen flexion/extension and between CarpomelacarpaJ (2 lhroog, 5) abductiorVadduction TraperonelacarpaJ First MC? joint: tun extension - raperonelacarpaJ RiSI MCP joint: sli{;ttt flexion MCP joints 2-5: fun lIexion MCP joints 2-5: slight flexion with ulnar deviation Metacarpopha~al l,Ietaearpopl1alange~ ProximallP joints: 10' flexion Full extension DistallP joints: 30° flexion (Me?) ligamenious: full extension, abduction, and internal (MCP) 30\" flexion, 30° abduction, and slight lateral rotation Interphalangeal rotation If1terphalangeal (IP) Hip Bony: 90\" flexion, slight abduction. and slight extema! 25° nexion rotation ..... Knee Full extension and extemal rotaOOo -arsomelatarsal Mid rwersm'eversion and lrt' piarltar flexion ArlkleJFoot Full dorsiflexion TaIocnJraJ Full inversion Midway behveen extremes 01 range of motion with Subtalar Full supination 10\" plantar flexion Mid-tarsal Full supination Midway behveen supination and pronation Tarsometatarsal Fun extension Neutral (extension 10°) Toes Ful extension Sl~~ f1exioo MetatarsophaJangeal Interphalangeal -=rom HertJing, DH; Kessler, RM. Management of Common (From Herding. DH; Kessler, RM. Management of Common usculoskeletal Disorders: Physical Therapy Principles and Musculoskeletal Disorders; Physical Therapy Principles and Methods, 3 ed, Lippincott. Philadelphia, 1996, with permission) Methods, 3 ed, Lippincott. Philadelphia, 1996, with permission)
4 TABLE 1-4 - CAPSULAR PATTERNS (2) Scapula. (a) Large flat triangular bone that sits over JOINT(S) PROPORTIONAL LIMITATIONS 2nd to 7th ribs. (b) Costal surface and a dorsal surface. Temporomandibular Limitation of mouth opening (e) Three angles- medial, superior, and lat- eral. Upper cervical spine For.vard bending more limited than backward bending (d) Lateral angle bears glenoid fossa, (occiput - C2) RestMction with rotation which faces anterior, laterally and Occipiloatlanlal joint superiorly. Atlantoaxial joint Pear-shape of fossa allows for freer ROM in abduction and flexion. Lower cervical spine Umilalion of all motions except flexion (sidebending = Concave shape receives convex (C3· T21 rotation> backward bending) humeral head. • Orientation of the glenoid fossa Sternoclavicular Full elevation limited; pain at extreme range of motion places true abduction at 30° anterior to frontal plane. Acromioclavicular Full elevation Iimrted; pain at extreme range of motion (3) Clavicle. Glenohumeral Greater limitation of external rotation, followed by abduction and internal rolation (a) Extends laterally and links manubrium to acromion. Humeroulnar Loss of flexion> extension (b) Connects shoulder complex to axial Humeroradial Loss of flexion> extension skeleton. Forearm Equally restricted in pronation and supination in presence b. Arthrology (glenohumeral, sternoclavicular, of elbow restriction acromioclavicular, and scapulothoracic). (I) Glenohumeral joint Proximal radioulnar Limitation: pronation = supination (a) Convex humeral head articulates with concave glenoid fossa. Distal radioulnar Limitation: pronation = supination (b) Glenoid fossa very shallow. (2) Sternoclavicular joint Wrist Limitation: flexion = extension (a) Convex (superior/inferior) and concave (anterior/posterior) articulates with Midcarpal Limitation: equal all directions reciprocal shape of sternum. (b) Both articulations covered with fibro- Trapeziometacarpal Limitation: abduction> extension cartilage. Carpometacarpals II - V Equally restricted all directions Upper extremity digits Limitation: flexion:> extension Thoracic spine Limitation of sidebending and rotation> loss of extension > flexion Lumbar spine Marked and equal limitation of sidebending and rotation; loss of extension:> flexion Sacroiliac, symphysis Pain when joints are stressed pubis, sacrococcygeal Limited flexionlintemal rotation; some limitation of Hip abduction; no or little limitation 01 adduction and extemal rotation TABLE 1-5 - MANUAL GRADING Tibiofemoral (knee) Flexion grossly limited: slight limitation of extension OF ACCESSORY JOINT MOTION Tibiofibular Pain when joint is stressed Talocrural (ankle) Loss 01 plantarllexion >dorsdlexion GRADE JOINT STATUS Talocalcaneal (subtalar) Increasing limitations 01 varus: joint fixed in valgus o Ankylosed (inversion:> eversion) Considerable hypomobility 2 Slight hypomobility Midtarsal Supination:> pronation (limited dorsiflexion, plantar 3 Normal flexion, adduction, and medial rotation) 4 Slight hypermobility 5 Considerable hypermobility First metatarsophalangeal Marked limitation of extension; slight limitation of flexion 6 Unstable Metatarsophalangeal (II . V) Variable; tend toward flexion restrictions Interphalangeal Tend toward extension restrictions (From Hertling, DH; Kessler, RM. Management of Common (From Grieve, GP. Mobilization of the Spine;A Primary Musculoskeletal Disorders; Physical Therapy Principles and Handbook of Clinical Method, ed 5, Churchill Livingstone, Methods, 3 ed, Lippincott, Philadelphia. 1996, with permission) NY, 1991 with permission)
(3) Acromioclavicular joint. Musculoskeletal Physical Therapy 5 (a) A plane joint with relatively flat sur- faces. (b) Attached to capsule superiorly and inferiorly as well as to the long head of (4) Scapulothoracic joint. the biceps tendon superiorly. (a) A \"clinical\" articulation. (c) Internal surface covered with articular c. Muscles (depressors, elevators, protractors, cartilage which is thicker peripherally retractors, internal rotators, external rotators, and thinner centrally. flexors, abductors, adductors, and extensors) (Table 1.6A). (d) Aids in lubrication like meniscus of knee and serves to protect the bone. d. Noncontractile slruClUres (acromioclavicular. trapezoid, conoid, and sternoclavicular liga- (4) Bursae. ment, subacromial bursa, shoulder capsule, gle- (a) Multiple bursae found within this noid labrum and associated nerves and vessels). region. (I) Capsule. (b) Primary bursa involved with pathology (a) Attaches medially to glenoid margin, is subacromial bursa between deltoid glenoid labrum, coracoid process. and capsule. It also runs under (b) Attaches laterally to humeral anatomical acromion and coracoacromial ligament neck and descends approximately I em and between the supraspinatus tendon. on the shaft. (c) Supported by tendons of supraspinatus, e. Shoulder biomechanics. infraspinatus. teres minor, subscapu- (I) Glenohumeral joint arthrokinematicsl laris and long head of triceps below. osteokinematics. (d) Inferiorly capsule is least supported (a) Occurs in opposite directions. With and most lax. elevation of humerus, head of humerus (2) Ligaments. moves in an inferior direction because (a) Coracohumeral ligament. of convex moving on concave. Base of coracoid process to greater (b) A rolling-glidjng exists during elevation and lesser tubercle of humerus. of the humerus. such that the instanta- Primary functjon to reinforce biceps neous centers of rotation will vary con- tendon, reinforce superior capsule. siderably during the complete range. and prevents caudal dislocation of (c) At approximately 75° of elevation, humerus. Taut with external rotation. external rotation (conjunct rotation) (b) Coracoacromial hgament. occurs which prevents compression of Strong triangular ligament runs from greater tubercle against the acromion. coracoid to acromion. (2) Scapulothoracic and glenohumeral rhythm Not a \"true\" ligament; connects two (scapulohumeral rhythm) is the ratio of points of same bone. movement of (he glenohumeral with the (c) Glenohumeral ligaments. scapulothoracic joint. 3 bands (superior, middle. and infe- (a) With 180 degrees of abduction there is rior) located on anterior gleno- a 2: I ratio of movement between the humeral joint. two joints. Reinforce anterior glenohumeral (b) First 30° to 60° of elevation occurs capsule. mainly in the glenohumeral joint. (d) Transverse humeral ligament. (c) 1200 of movement occurs at gleno- Broad band passing over top of humeral joint. bicipital groove. (d) 60° of movement occurs at scapulotho- It acts as a retinaculum for long racie joint. biceps tendon. (3) Requirements of full elevation. (3) Labrum. (a) Scapular stabilization. (a) Glenoid labrum is a fibrocartilaginous (b) Inferior glide of humerus. ring that deepens glenoid fossa. (c) External rotation of humerus. (d) Rotation of the clavicle at sternoclavic- ular joint.
6 TABLE 1-6A - SHOULDER GIRDLE AND UPPER EXTREMITY MUSCULAR & NEUROLOGICAL SCREENING ACTJONTO DETESTED MUSCLES MYOTOMES REFLEXES CORD SEGMENT NERVES C1-e4 cervical spinal neck flexion sternocleidomastoid, accesso'Y neck extension trapezius, other deep neck rotation neck muscles neck lateral bending shoulder shrug, scapular upper trapeZius C4 Cl-C4 spinal accessory upward rotation shoulder horiz. adduction peel. major/minor C5-C8 mediall1aleral Tl pectoral scapular downward rotation pectoralis minor medial pectoral shoulder protraction, serratus anterior C8-Tl long thoracic scapUlar upward rolation C5-C7 scapular elevation, levator scapula dorsal scapular downward rolation C5 scapular adduction, elevation. rhomboids dorsal scapular downward rolation C4-C5 shoulder abduction supraspinatus CS suprascapular shoulder lateral rotation infraspinatus C4-C6 suprascapular shoulder medial rotation, latissimus dorsi, teres C4-C6 subscapular adduction major and subscapularis C5-C8 thoracodorsal shoulder atxluction, flexion, deltoid axillary extension C5-C6 shoulder lateral rotation teres minor C6 C5 axillary elbow flexion, forearm supination biceps brachii C7 C4-C5 musculocutaneous shoulder flexion, adduction coracobrachialis T1 C6 CS-C6 musculocutaneous elbow flexion brachialis C7 C6-C7 musculocutaneous 4th & 5th digit DIP flexion flexor digitorum profundus C5-C6 ulnar (ulnar part) C7-T1 wrist ulnar flexion flexor carpi ulnaris ulnar thumb adduction adductor pollicis C7·T1 ulnar 5th digit abduction abductor digiti quinti C8-T1 ulnar 5th digit opposition opponens digiti quinti C8-T1 ulnar 5th digit MCP flexion flexor digiti guinti brevis C7·T1 ulnar 2nd-5th digit MCP flexion, interossei C7-T1 ulnar adduction, abduction C8-Tl forearm pronation pronator teres, pronator median quadratus C6-C7 wrist radial flexion flexor carpi radialis median wrist flexion palmaris longus C6-C7 median 2nd-5th digit PIP flexion flexor digitorum sublimis C7-T1 median thumb IP flexion flexor pollicis longus C7-T1 median 2nd-3rd digit DIP flexion flexor digitorum profundus C7-T1 median (radial part) C7-T1 thumb atxluction abductor pollicis brevis median thumb MCP flexion flexor pollicis brevis C6-T1 median/ulnar thumb opposition opponens pollicis C6-T1 median 2nd-5th digit MC? flexion, lumbricals C8-T1 median/ulnar IP extension C8-T1 elbow flexion brachioradialis C8 radial elbow extension triceps brachii, anconeus C5-C6 radial wrist radial extension extensor carpi radialis C6-C8 radial 2nd-5th digit MCP, IP extensor digitorum communis C6-C8 radial extension extensor digiti quinti proprius C6-C8 wrist ulnar extension extensor carpi ulnaris radial forearm supination supinator C6-C8 radial thumb MCP abduction abductor pollicis longus C5-C6 radial thumb extension extensor pollicis longus/brevis C7-G8 radial 2nd digit extension extensor indicis proprius C6-G8 radial CS-G8 (Adapted from Chusid JG: Correlative Neuroanatomy and Functional Neurology, Lange Medical publications, Los Altos, CA, 1970 and Kendall, FP; McCreary, EK, and Provance, PG. Muscles Testing and Function 4 ed,Williams and Wilkins, Baltimore, 1993).
(e) Scapular abduction and lateral rotation Musculoskeletal Physical Therapy 7 of acromioclavicular joint. An osteofibrous ring attached to (I) Straightening of thoracic kyphosis. medial ulna and encircles radial 2. Elbow region. head. Cone-shaped and inner surface is a. Osteology and arthrology (ulnohumeral, radio- lined with fibrocartilage. humeral, superior and inferior radioulnar). Protects radial head, especially In (I) Humeroulnar joint. semiflexion where it is very unsta- (a) Distal end humerus (trochlea) articu- ble. Taut in extremes of pronation lates with proximal end of ulna. and supination. (b) Trochlea and trochlear notch face anteri- (d) Quadrate. orly at an angle of 45° allowing space Extends from radial notch (ulna) to between ulna and humerus during flexion. the neck of radius. (2) Humeroradial joint. Reinforces inferior joint capsule, (a) Distal end humerus (capitulum) articu- maintains radial head in opposition lates with concave oval facet of proxi- to ulna, limits amount of spin in mal radius. supination and pronation. (3) Proximal radioulnar joint. (e) Distal radioulnar. (a) Radial head is ovoid and cone-shaped. Anterior radioulnar ligament: pfl- (b) Medial radius articulates with radial marily strengthens capsule. notch (of ulna). Posterior radioulnar ligament: pri- (4) Distal radioulnar joint. marily strengthens capsule. (a) Convex ulna articulates with concave (3) Bursa. radius (opposite to proximal articula- (a) Olecranon bursa located on posterior tion of lhese two bones). aspect of elbow over olecranon process. b. Muscles (flexors, extensors, supinators, and (4) Blood supply. pronators) (Table 1-6A). (a) Elbow joint receives blood supply from brachial artery, anterior ulnar c. Noncontractile structures (medial collateral recurrent artery, posterior ulnar recur- ligament, radial collateral ligament, annular rent artery, radial recurrent artery, and Iigament, elbow capsule, associated bursae, middle collateral branch of arteria pro- nerves, and vessels). funda brachii. (I) Capsule. (5) Elbow joint stability. (a) The capsule encloses entire elbow joint (a) Elbow joint complex possesses signifi- complex. It is thin both anteriorly and cant inherent stability. posteriorly. It is continuous medially (b) Main contributor to bony stabilit)' is with ulnar collateral ligament and lat- articulation between the trochlea erally with radial collateral ligament. (humerus) and trochlear fossa (ulna). (2) Ligaments. (c) Medial collateral ligament provides (a) Ulnar collateral. strong resistance to valgus forces. Ligament is triangular shaped con- (d) Lateral collateral ligament resistance sisting of three parts. to varus forces minimal due to its Reinforces humeroulnar joint medi- attachment to another soft tissue struc- ally. ture (annular ligament). (b) Radial collateral. (e) Functionally this relationship is benefi- Ligament is fan shaped and runs cial since functional activities place from lateral epicondyle of humerus tensile forces medially and compres- to annular ligament. sive forces laterally, so the lateral liga- Reinforces humeroradial joint later- ment would not have to be as srrong as ally and is stronger (histologically) medial ligament. than ulnar collateral ligament. (c) Annular.
8 tion with trapezium being convex in medial/lateral direction and concave in d. Elbow biomechanics. anterior/posterior direction. (I) Conjunct rotations. (b) First metacarpal is opposite in shape to (a) Ulna pronates slightly with extension. trapezium. Ulna supinates slightly with flexion. (c) 2nd-5th CMC are essentially Ilat (b) Proximal ulna glides medially during between bases of metacarpals and dis- extension and laterally during flexion. tal row of carpals. (c) Flexion/extension of elbow is accom- (4) Metacarpalphalangeal (MCP) joints consist panied by a screw-home mechanism of convex metacarpals with concave proxi- with conjunct rotation of ulna. Ulna mal phalanges. externally rotates (or supinates) during (5) Proximal interphalangeal (PIP) joints con- elbow flexion and internally rotates (or sist of convex distal aspects proximal pha- prenares) during elbow extension. langes with concave proximal aspect of middle phalanges. Same orientation exists 3. Wrist and hand region. at distal interphalangeal (DIP) joints. a. Osteology (radius, ulna, carpals. metacarpals. c. Muscles (wrist flexors, wrist extensors, radial and phalanges). devialOrs, ulnar deviators. extrinsic finger flex· (I) Radius is biconcave relative to carpals. ors, extrinsic finger extensors, and intrinsic fin- (2) Ulna is convex at its distal end relative to ger muscles) (Table 1-6A). the triquetrum. d. Noncontractile structures (volar carpal, radio- (3) Proximal aspect of proximal row is bicon- carpal, collateral, and palmar ligaments; exten- vex. Distal aspect of proximal row is con- sor hood; associated capsules; volar plate; cave at lunate/capitate and triquetrum/ nerves; and vessels). hamate articulations. Scaphoid is convex (I) Ligaments. anterior/posterior and concave medial/later- (a) Fingers. al relative to trapeziUm/trapezoid. Capitate is convex and articulates with concavities of Collateral: run from lateral condyle to scaphoid, hamate and trapezoid. distal phalanx and lateral volar plate. (4) Metacarpal heads are biconvex and bases All fibers tighten with tlexion and are generally flat relative to dislal row of volar fibers tighten with extension. carpals. Accessory: run from condylar head (5) Phalanges proximal ends are mostly bicon- to volar plate. cave with a ridge running down center Transverse: present at MCP joints. dividing into two surfaces. Distal end is Provide stability linking MCP joints pulley shaped being mostly biconvex with a and providing reinforcement to ante- groove running through center. rior capsule. b. Arthrology (radiocarpal, midcarpal, car- (b) Wrist. pometacarpal, MCP, and !P). Radial collateral: limits ulnar devia- (I) Radiocarpal joint. tion. (a) Convex scaphoid and lunate articulate Ulnar collateral: limits radial devia- with concave radius. tion. (2) Midcarpal joint. Palmar ulnocarpal: limits extension (a) Articulation between four proximal and supination. and four distal carpal bones is known Palmar radiocarpal: limits extension as midcarpal joint. and supination. (b) Functional rather then anatomjcal joint. Dorsal radiocarpal: limits flexion, (c) Can be divided into middle pillar pronation, and possibly radial devia- (lunate and triquetrum with capitate tion. and hamate) and lateral pillar (scaphoid Radiate: stabilizes hand for any with trapezoid and trapezium). impact through knuckJes. (3) Carpometacarpal (CMC) joint. (a) First CMC (thumb) is a saddle anicula-
(2) Extensor hood. Musculoskeletal Physical Therapy 9 (a) Fibrous mechanism on the dorsum of each finger that is a fibrous expansion other carpals) plane of flexion! of the extensor digitorum tendon. extension is perpendicular to other (b) Its purpose is to assist with extension digits. of the PIP and DIP joints. During flexion/extension it is con- cave moving on convex. (3) Capsule. • During abduction/adduction it is (a) Fingers. convex moving on concave. MCP, PIP, and DIP joints all have During flexion and abduction the 1st fibrous capsules that are strong but metacarpal rotates ulnarly. lax and supported by ligaments. During extension and adduction the (b) Wrist. Ist metacarpal rotates radially. • Radiocarpal joint shares fibrous cap- (2) Wrist. sule (which is thicker palmarly and (a) Flexion. dorsally) with midcarpal joint, but usu- • Proximal aspect of scaphoid/lunate ally has it<; own synovial membrane. glide dorsally relative to radius. (b) Extension. (4) Volar plate. • Proximal aspect of scaphoid/lunate (a) Present on palmar aspect of the MCP, glide ventrally relative to radius. PIP and DIP joints. Thickening of cap- (c) Radial deviation. Proximal row glides ulnarly. sule. Functions to increase articular Proximal surface of scaphoid rotates surface during extension and protect palmady. (d) Ulnar deviation. joint valarly. Volar plate more mobile • Proximal row glides radially as a unit. 4. Hip region. at MCP than at IPs. a. Osteology (femur and acetabulum of pelvis). (5) Nerves. (I) Femur. (a) Head is 2/3 of a sphere with a depres- (a) Ulnar innervates hypothenar region sion at its center called the fovea capi- (palmarly and dorsally), 5th digit, and tis femoris. medial half of 4th digit. (b) Head is oriented superiorly. anteriorly, and medially. (b) Median nerve innervates remainder of (c) Articular cartilage covers entire head except for fovea capitis. palmer surface not innervated by ulnar (d) Angle of inclinarion- normally 115° to nerve and dorsal portions of 2nd, 3rd. 125°. and lateral half of 4th digit from DIP • Coxa valga is angle> 125° . joint to tip of finger. • Coxa vara is angle < 115° . (c) Radial nerve innervates remainder of (e) Femoral neck angles anteriorly 100 _ dorsum of hand not innervated by ulnar 25° from frontal plane to form anterior anletorsion angle. or median nerves. / \\ Anteversion- anterior antetorsion angle> 25°. (6) Blood supply from ulna and radial arteries. Retroversion- anterior anterorsion Merge to fonn palmar arch and then send angle < 10°. digital branches that run up medial and lat- (2) Acetabulum. eral aspects of each digit. (a) Acetabulum faces laterally, inferiorly, and anteriorly. e. Hand and wrist biomechan.ics. (b) Made of union between ischium. ilium, (I) Hand. and pubis bones. (a) PIPs and DIPs. • During flexion digits rotate radially to enhance grasp and opposition. (b) MCPs. • During flexion digits rotate radially to enhance grasp and opposition. (c) First CMC. • Due to position of trapezium (anteri- orly and medially rotated relative to
Acetabular fossa- center of acetabulum, iliofemoral ligament. whicb is non-articulating and filled Taut with extension, external rota- with fat pad for shock absorption. tion, and abduction. (d) Acetabulum is not completely covered (c) Ischiofemoral ligament. with cartilage. Lined with a horseshoe Runs from ischium and posterior acetabulum superiorly and laterally shaped articular cartilage with inter- blending with zona articularis and ruption inferiorly forming acetabular attaching to greater trochanter. Taut with medial rotation, abduc- notch. tion, and extension. (d) Zona orbicularis. b. Arthrology (coxofemoral). Runs in a circular pattern around (I) Synovial joint. femoral neck. (2) Convex femoral head articulates with con- Has no bony attachments, but helps to hold head of femur in acetabulum. cave acetabulum. (e) Inguinal ligament. 12-14 em long running from ASIS (3) Very stable joint due to bony anatomy as medially and inferiorly attaching to well as strength of ligaments and capsule. pubic tubercle. Fonus tunnel for muscles, arteries, c. Muscles (flexors, extensors, adductors, abduc- veins, and nerves. tors, IRs, and ERs) (Table 1-6B). (4) Bursae. (a) Subtendinous iliac located between hip d. Noncontractile structures (capsule, labrum, and os pubis. bursae, iliofemoral ligament, ischiofemorallig- (b) Iliopectineal between tendons of psoas ament, pubofemoral ligament, and associated major, iliacus and capsule. Lies close nerves and vessels). to femoral nerve. (I) Capsule is strong, dense, and encloses the (c) Ischiofemoral between ischial tuberos- entire joint. ity and gluteus maximus muscle. May (2) Labrum. cause pain in sciatic distribution. (a) Triangular shape and is made up of a (d) Deep trochanteric between gluteus fibrocartilaginous ring thickest superi- maximus and posterior lateral greater orly. trochanter. May cause pain with hip (b) Attaches to bony rim of acetabulum, flexion and internal rotation due to bridging acetabular notch. compression of gluteus maximus. (c) Serves to deepen acetabulum. (e) Superficial trochanteric located over (d) Inner surface is lined with articular car- greater trochanter. tilage and outer surface connects to (5) Innervation of hip joint comes from joint capsule. femoral, obturator, sciatic, and superior (3) Ligaments. gluteal nerves. (a) IJiofemoralligament (\"Y\" or Ligament (6) Blood supply. of Bigelow). (a) Medial and lateral femoral circumflex Two bands both starting from anteri- supplies proximal femur. or inferior iliac spine (AIlS). Medial (b) Femoral head is supplied by a small running to distal intertrochanteric branch off obturator artery. line. Latera] running to proximal (c) Acetabulum is supplied by branches aspect of intertrochanteric line. from superior and inferior gluteal Very strong. arteries. • Both bands taut with extension and (7) Hip biomechanics. external rotation. Lateral band taut (a) Coxofemoral joint arthrokinematicsl with abduction. (b) Pubofemoral ligament. Runs from iliopectineal eminence, superior rami of pubis, obturator crest, and obturator membrane later- ally blending witb capsule and insens into same point as medial
Musculoskeletal f'Io,\"*IU:.....-.o! osteokinematics occur in opposite or/posterior and con 3\\e \",,>ila:'Is~ directions due to relationship of con- aL Smaller surface area. ~ ... -... vex femoral head moving within con- and less stable, therefore moce m<tt... cave acetabulum. (c) Both tibial surfaces are rabed 5. Knee region. they border intercondylar are:L a. Osteology (femur, tibia, fibula, and patella). (3) Patella. (I) Femur. (a) There is a vertical ridge which din~ (a) Femoral condyles are convex in anteri- patella into a larger and smaller medi31 or/posterior and medial/lateral planes. part. Patella can further be divided b~ Both femoral condyles are spiral- two faim horizontal ridges which shaped but lateral one has a longer sur- divide it into its facets. face area and medial one descends fur- b. Arthrology (tibiofemoral, patellofemoral. and ther inferiorly. proximal tibiofibular). (2) Tibia. (I) Proximal tibiofibular joint. (a) Medial tibial condyle is bi-concave and (a) Oval tibial facet is flat or slightly con- has a larger surface area and is more vex. Fibular head has an oval, slight!} stable, therefore less mobile. concave to flat surface. (b) Lateral tibial condyle is convex anteri- (2) Tibiofemoral joint. TABLE 1-6B - PELVIC GIRDLE AND LOWER EXTREMITY MUSCULAR & NEUROLOGICAL SCREENING ACTION TO BETESTED MUSCLES MYOTOMES REFLEXES CORD SEGMENT NERVES L2 L4 flexion iliopsoas L2 L1-L3 femoral flexion, abduction, lat. rotation sartorius L3 l2-L3 femoral talee extension quadriceps femoris L2-L4 femoral \"lip adduction pectineus, adductor L5 l2-L3 obturator longus adduction adductor brevis l2-L4 obturator gracilis L2-L4 obturator --9 adduction gluteus medius, minimus L4·51 sup. gluteal abduction, flexion, -edial rotation tensor fascia lata L4·L5 sup. gluteal -.o1P flexion, abduction, ~ial rotation piriformis L5-51 sup. gluteal -tp lateral rotation gluteus maximus L4-52 info gluteal obturator internus L5-51 sacral plexus extension, lateral rot. gemelli, quadratus femoris L4-51 sacral plexus lateral rotation biceps femoris L5-52 sciatic Lateral rotation extension, knee flexion, semitendinosus L5 L5-52 sciatic eg Lateral rotation semimembranosus extension, knee flexion, tibialis anterior L5·52 sciatic eq medial rotation extensor digitorum longus extensor hallucis longus L4 L4-L5 deep peroneal r e dorsiflexion peroneus longuslbrevis popliteus L5 L4-51 deep peroneal 2nd-5th digit MTP extension tibialis posterior 51 7f!8t toe MTP extension gastrocnemius/soleus L4-51 deep peroneal flexor digitorum longus 51 ~eversion flexor hallucis longus L5-51 sup. peroneal flexor digitorum brevis eg medial rotation flexor hallucis brevis L4-51 tibial inversion dorsaVplantar interossei perineals and sphincters 51 L5-52 tibial or e plantar flexion 51 L5-52 tibial 2:xj·5th digit DIP flexion ~t toe IP flexion L5-52 tibial ~5th digit PIP flexion L5·52 tibial toe MTP flexion adduction/abduction L5-51 medial planlar floor control L5-52 medial pIamar 51-52 lateral j:lIa\"'1aJ 52-54 pudenda. ~ted from Chusid JG: Correlative Neuroanatomy and Functional Neurology, lange Medical publications, Los Altos.. CA ... rd Kendall, FP; McCreary. EK, and Provance, PG. Muscles Testing and Function 4 ed, Williams and Wilkins, Baltimor-e. 993
12 in extension and slackened in flexion. Prevents external rotation and provides (a) Synovial hinge joint with two degrees stability against varus forces. of freedom. Minimal bony stability Anterior cruciate ligament (ACL): thus relies on capsule. ligaments, and attached to anterior intercondylar muscles. fossa of tibia and to femur at medial aspect of lateral condyle. Runs (3) Patellofemoral joint. oblique superiorly and laterally. (a) Patella articular surface is adapted to Extracapsular, but more correctly a patellar surface of femur. An oblique thickening of the capsule. Checks groove runs inferiorly and laterally is forward gliding of tibia on femur the guiding mechanism on femur for and limits internal rotation of tibia patellar tracking. Patellar surface of during flexion as it twists around femuf is concave transversely and con- posterior cruciate ligament. vex sagittally thus its saddle (sellar) Posterior cruciate ligament (PCL): shape. attaches to posterior intercondylar fossa of tibia and on lateml surface c. Muscles (flexors, tibial rotators, and extensors) of femoral medial condyle. Runs (Table 1-6B). oblique medially and anteriorly- superiorly. Checks posterior dis- d. Noncontractile structures (medial collateral placement of tibia on femur. ligament, lateral collateral ligament, anterior Meniscofemoralligament: runs with cruciate ligament, posterior cruciate ligament, PCL. Attaches below posterior horn menisci, capsule, bursae and associated nerves of lateral meniscus. Has common and vessels). insertion into lateral aspect of medi- (I) Capsule. al condyle. Occasionally a similar (a) Tibiofemoral capsule is a fibrous ligament exists medially. sleeve, which attaches to distal femuf • Oblique popliteal ligament: inserts and proximal tibia. Inner wall is cov- into expansion from tendon of semi- ered by a synovium. Shaped as a cylin- membranosus. It partially blends der with a posterior invagination, which with capsule. Forms floor of posteriorly divides cavity into medial popliteal fossa and is in contact with and lateral halves. Anterior surface has popliteal anterior artery. Strengthens a window cut out for patella. posteromedial capsule. (b) Proximal tibiofibular joint has a Arcuate popliteal ligament: Y- fibrous capsule, which is continuous shaped and commonly described as with knee joint capsule 10% of time. having two bands (medial and later- (2) Ligaments. al). Stem attaches to fibular head. (a) Tibiofemoral and patellofemoral joints Medial band attaches to posterior (knee joint proper). border of intercondylar area of tibia. Medial collateral ligament (MCL): Lateral band extends to lateral epi- runs from medial aspect of medial condyle of femul. Strengthens pos- femoral condyle to upper end of tibia. terolateral capsule. Posterior fibers blend with capsule. • Transverse ligament connects lateral Runs oblique anteriorly and inferior- and medial meniscus anteriorly. ly. Taut in extension and slackened in Meniscopatellar ligament: runs from flexion. Prevents external rotation infero-Iateral edges of patella to lat- and provides stability against valgus eral borders of each meniscus. Pulls forces. Runs in same direction as menisci forward with extension. ACL. Alar folds: runs from lateral borders Lateral collateral ligament (LCL): runs from lateral femoml condyle to head of fibula. Free of any capsular attach- ment. Runs oblique inferiorly and pos- teliorly in same direction as PCL. Taut
of patella to medial and lateral Musculoskeletal Ph)sicaJ ~ U aspects of femoral condyles. Keeps patella in contact with femur. With isolated tibial rotation (b) Infrapatellar fold: is formed by attach- menisci move opposite e.g.. v.iili -1-\\. ments of patella fat pad and tendons ial IR medial meniscus moves anteri- via a fibro-adipose band lying in inter- orly and lateral meniscus moves p<b- condylar notch. Acts as stop gap as it is teriorly. compressed by patella tendon in full Meniscal motion is also influenced flexion. by soft tissue structures. Medial (c) Proximal tibiofibular joint ligaments. meniscus is pulled posteriorly (fle.'- Anterior tibiofibular ligament: locat- ion) by semimembranosus muscle ed on anterior aspect of joint. and ACL. Pulled anteriorly (exten- sion) by medial meniscopatellar lig- Reinforces capsule anteriorly. ament. Held firm by attachment to MCL and fibrous capsule. Posterior tibiofibular ligament: Lateral meniscus pulled posteriorly located on posterior aspect of joint. (flexion) by popliteus muscle and Reinforces capsule posteriorly. anteriorly (extension) by lateral (3) Menisci. meniscopatellar ligament and menis- (a) Medial meniscus. cofemoral ligament. (4) Bursae. Medial menjscus is large and \"e\" (a) Prepatellar, between skin and anterior distal patella. shaped and fairly stable. Laterally, it (b) SuperficiaJ infrapatellar, anterior to lig- is firmly attached to MCL and amentum patella. fibrous capsule. Other structures that (c) Deep infrapatellar, between posterior attach to the medial meniscus are ligamentum patella and anterior tibial semimembranosus muscle and medi- tuberosity. (d) Suprapatellar, between patella and al meniscopatellar ligament. tibia femoral joint. (b) Lateral meniscus. (e) Popliteal, posterior knee often con- nected to synovial cavity. Smaller than medial meniscus and (f) Semimembranosus, between muscle more circular shaped. Structures that and femoral condyle. attach to lateral meniscus include (g) Gastrocnemius, one for each bead. popliteus muscle, lateral menisco- Medial bursa usually communicates patellar ligament, and men is- with semimembranosus bursa. cofemoral ligament. Lateral meniscus (h) Pes anserine bursa, between pes anser- is separated from LCL and lateral ine and MCL. capsuJe by popliteus muscle tendon. (5) Blood supply comes from descending (c) Function of menisci. branch from lateral circumflex femoral Deepens fossa of tibia. branch of arteria profunda femoris. Increase congruency of tibia and Genicular branches of popliteal anery and femur. recurrent branches of anterior tibial ane~. Provides stability to tibiofemoral (6) Articular innervation is provided by obtur.>- joint. tor, femoral, tibial, and common fi Provides shock absorption and lubri- nerves. cation to knee. e. Biomechanics knee joint proper. Reduces friction during movement. (J) Arthrokinematics/osteokinemati<_. Improves weight distribution. (a) Movements of femoral COI\"'-\"~ (d) Movement of menisci. iog flexion and extensi Menisci follow tibia with flexion! extension and femoral condyles with • Condyles roll and ghj< =s;:l:mo.- internal/external rotation. Medial meniscus moves a total of 6mm while lateral moves 120101.
ously (only way that posterior dislo- Lateral femoral condyle glides more cation of femoral condyle can be freely on lateral convex (anterior- avoided). Initially, movement is pure posterior) facet of tibia. Causes rolling and ends in pure gliding. For greater tibial motion in posterior medial condyle, pure rolling occurs direction on lateral side. during first 10°- I5° of flexion. For Lateral femoral condyle has a longer lateral condyle, rolling continues articular surface than medial until 20° of flexion. condyle. During femoral rolling, During flexion, femoral condyles more motion occurs on lateral side roll posteriorly, ACL becomes taut (20°) than on medial side (10°-15°). causing condyles to glide anteriorly. Medial meniscus is attached to MCL • During extension, femoral condyles which tightens during extension. roll anteriorly, PCL becomes taut Medial meniscus stops gliding while causing condyles to glide posteriorly. lateral meniscus continues to glide (b) During walking, normal range of knee forward. Creates internal rotation of flexion is approximately 15°. We are femur, which is same as external essentially using pure rolling of femur rotation of tibia. on tibia. Twisted cruciate ligaments create (2) Conjunct rotations. external rotation force on tibia while (a) During flexion at 10°_15° ACL tight- preventing an internal rotation. ens causing femuf to glide anteriorly, Lateral angle of pull of quadriceps then 5° further, rolling occurs on later- muscle creates external rotation of al condyle causing a conjunct medial tibia. rotation of tibia. f. Biomechanics proximallibiofemoral joint. (b) During extension, PCL causes femur to (I) Dorsiflexion of talocrural joint. glide posteriorly while condyles roll (a) Fibular head glides superiorly and pos- anteriorly 10°_15°. Then a further 5° of teriorly. Fibular shaft rotates externally. rolling occurs anteriorly on lateral side (2) Plantarflexion of talocrural joint. causing a medial femoral rotation or a (a) Fibular bead glides inferiorly and ante- lateral rotation of tibia as a conjunct riorly. Fibular shaft rotates internally. rotation with extension. 6. Foot and ankle region. (c) \"Screw home\" mechanism describes a. Osteology and arthrology (taJocrural, subtalar, the 5° of tibial external rotation, which talocalcaneonavicular, calcaneocuboid, trans- occurs during terminal knee extension. verse tarsal, tarsometatarsal, metatarsopha- langeal, and interphalangeal). Occurs as closed-chain internal (I) Talocrural joint. femoral rotation during weightbear- (a) Ankle mortise formed by distal end of ing to provide increased stability of tibia and its medial malleolus, with lat- knee joint during weightbearing eral malleolus of fibula and inferior activities. Can also occur as open- transverse tibiofibular ligament; and chain external tibial rotation. trochlear surface of talus. Lateral or external rotation of tibia (b) Three articulations involved in the occurs as knee moves towards termi- talocrural joint: (I) tibiofibular (2) nal extension due to anatomical rela- tibiotalar (3) fibulotalar. tionship of surfaces of tibia and (c) Transversely (medial/lateral), trochlear femur. surface is gently concave. Trochlear • Unlocking occurs through action of surface is wedge shaped, wider anteri- popliteus. Open-chain unlocking orly than posteriorly. occurs primarily with popliteal action. (d) Laterally, talus is triangular shaped and (d) Causes for screw home mechanism.
concave in superior/inferior direction Musculoskeletal Physical ~ 15 and convex in anterior/posterior direc- tion. Articulates with reciprocally longest. Third MT articulates pn~ curved fibula. Medial part of trochlear with the third cuneiform. Founh and surface is comparatively flat and artic- fifth MT articulate with cuboid. ulates with distal end of tibia, which is (6) Cuneonavicular joint. also flat. (a) Biconvex anterior surface of na\\icular (2) Subtalar joint. has three facets to articulate with con- (a) Two separate articulations; anterior cave posterior surfaces of three and posterior talocalcaneal. cuneifonn bones. (7) Metatarsalphalangeal joint. Posterior talocalcaneal articulation (a) Metatarsal heads are convex and prox- (subtalar joint proper): posterior imal phalanges are concave. superior articulation is convex in (8) Interphalangeal joints. anterior/posterior direction and con- (a) Same as fingers of hand (section cave in mediaViateral direction. This l.B.3.a.). articulates with reciprocally curved b. Muscles (ankle plantarflexors, ankle dorsiflex- posterior part of inferior surface of ors, everters, inverters, and intrinsics) (Table 1- talus. 6B). Anterior talocalcaneal articulation c. Noncontractile structures (deltoid ligament, consists of obliquely oriented sur- anterior talofibular, posterior talofibular, calca- faces of biconvex inferior surface of neofibular, calcaneonavicular [spring liga- neck and head of talus resting on the ment], interosseous, bifurcate ligament, plantar biconcave anterior surface of calca- aponeurosis, long plantar ligament, and short neus. Anterior talocalcaneal articu- plantar ligament, capsule, bursae, fascia, lation, when described functionally, nerves and vessels). also includes posterior surface of (I) Capsule. navicular bone which articulates (a) Talocrural joint. with head of talus. Joint is properly referred to as talocalcaneonavicular Fibrous capsule lined with synovial joint. membrane strengthened by collater- (3) Talonavicular joint. al, anterior, and posterior ligaments. (a) Biconvex head of talus articulates with Thin anteriorly and posteriorly and biconcavity formed by posterior navic- thickened laterally. ular surfaces and upper edge of plantar (b) Subtalar joint. calcaneonavicular ligament. Posterior articulation has an inde- (4) Calcaneocuboid joint. pendent capsule with synovial mem- (a) Anterior calcaneus is concave brane. Anterior articulation has cap- medial/lateral and convex superior/ sule with synovial membrane that inferior. Posterior cuboid is concave includes talonavicular joint. superior/inferior and convex mediaV (c) Talonavicular joint. lateral. Bony prominence on inferi- • Fibrous capsule with synovial lining or/medial surface of cuboid articulates is shared with anterior subtalar joint. with inferior surface of calcaneus mak- (d) Calcaneocuboid. ing saddle shape deeper. Cuboid is key Independent fibrous capsule with to lateral arch. synovial membrane independent (5) Tarsometatarsal joints. from other tarsal articulation _ (a) Proximally three cuneiforms medially (e) Tarsometatarsal (three capsular ca\\;tie-> and cuboid laterally. Distally bases of 1st MT with medial cuneifonn. five metatarsals. First metatarsal (MT) 2nd and 3rd cuneiform C3jNO.~ is largest and strongest, second MT is continuous with intercune' cuneonavicular joint C3\\ I . 3rd cuneiform \\\\ith
I capsule encloses 4th MT with straight fibers from middle cuboid and 3rd cuneiform. cuneiform to second MT, lateral (f) Cuneonavicular. cuneiform to third MT, cruciate fibers Continuous with tbose of inter- from lateral cuneiform to 2nd MT, cuneiform and cuneocuboid joints as and middle cuneiform to 3rd MT. is its synovial cavity. Capsule is con- (I) Cuneonavicular joint. nected to second and third • 3 dorsal cuneonavicular ligaments, cuneometatarsal joints between 2nd- one attached to each cuneiform. 4th metatarsal bones. Plantar ligaments have similar (g) Metatarsalphalangeal joint. attachments and receive slips from • Fibrous capsule present for each tendons of posterior tibialis muscle. articulation. (g) Metatarsalphalangeal joint. (h) Interphalangeal joints. • Plantar ligaments and collateral lig- • Fibrous capsule present for each aments present. articulation. (h) Interphalangeal joints. (2) Ligaments. • Plantar ligaments and collateral lig- (a) Talocrural joint. aments present. Medial collateral ligament (deep (3) Plantar fascia. fibers): anterior talotibial ligamem (a) Also known as plantar aponeurosis. and posterior talotibial ligament. (b) A broad, dense band of longitudinally Medial collateral ligament (superfi- arranged collagen fibers that can be cial fibers): deltoid ligament. divided into three components running Lateral collateral ligament: anterior from medial calcaneus to phalanges. talotibular ligament, calcaneofibular (c) Fascia tightens with dorsiflexion of ligament, posterior talofibular liga- MTP joints as occurs during push off. Known as \"windlass effect\". Tightening ment. of this fascia causes supination of cal- caneus and inversion of subtalar joint (b) Subtalar joint. creating a rigid lever for push off. Interosseous talocalcaneal ligament: (4) Bursa. two fibrous bands taut with eversion. (a) Posterior calcaneal bursa. Lateral talocalcaneal ligament. (b) Retrocalcaneal bursa. Posterior talocalcaneal ligament. (5) Blood supply comes from malleolar rami Medial talocalcaneal ligament. of anterior tibial and fibular arteries. (6) Articular innervation comes from deep (c) Talonavicular joint. fibular and tibial nerves. Plantar caJcaneonavicular Iigamem d. Ankle and foot biomechanics. (spring ligament). (I) Talocrural joint. Dorsal talonavicular ligament. (a) Conjunct rotations. Talus rotates medially 30° from dor- (d) Calcaneocuboid joint. siflexion to plantarflexion. Also Medial band of the bifurcate liga- slight side to side gliding, rotation, ment (lateral calcaneonavicular liga- and abduction/adduction are permit- ment). ted when foot is plantarflexed. Medial calcaneocuboid (lateral band (b) Arthrokinematics/osteokinematics. of the bifurcated ligament). Open chain: during plantarflexion Long plantar ligament (superficial talus describes anterior glide on plantar calcaneocuboid). mortise with slight medial rotation Plantar calcaneocuboid (short plan- or adduction. Dorsiflexion occurs as tar). reciprocally opposite motion. (e) Tarsometatarsal joint. Medially, dorsal ligament runs from medial cuneiform to base of 2nd MT. Laterally, dorsal ligaments with
Closed chain: during plantarflexion Musculoskeletal Physical Tbe~ 1- tibia glides posteriorly on talus with slight latera] rotation. Dorsiflexion mobilizing navicular on a fn. occurs as a reciprocally opposite talus. Rotational movements of mid- motion. tarsal joint allow forefoot to twist OIl (2) Subtalar joint. rearfoot. Talus and navicular rotate (a) Joint axes. in opposite directions. • Oblique axis extends from posterior, Open chain: during inversion navicu- plantar and lateral to anterior, dorsal lar plantarflexes, adducts and exter- and medial. Joint is oriented obliquely nally rotates on talus. Eversion occurs with the average at 42° from the hori- as a reciprocally opposite motion. zontal and 16° from midline of foot. • Closed chain: during inversion nav- Variances in joint axis are fairly icular plantarflexes (talus glides dor- common. sally on navicular), adducts (talus With a high inclination of axis, move- abducts), and internally rotates. ment at subtalar joint is increased in Eversion occurs as a reciprocally transverse plane and decreased in opposite motion. frontal plane. (4) MTPs and PIPs sarne as fingers (Section With a low inclination of axis joint I.B.3.e). will be more frontal plane dominant 7. Spine. leading to greater calcaneal prona- a. General function of the vertebral column. tion/supination. (I) Support for head and internal organs. (b) Conjunct rotation. (2) Stable attachment for all soft tissues, Calcaneus can move in many direc- extremities, rib cage, and pelvis. tions due to its multiple articulations. (3) Protection of internal organs and spinal cord. Like a ship in the waves- rotation (4) Attenuates forces from above and below. around a vertical axis; tilts medially b. Components of the vertebral column. and laterally; glides anteriorly and (I) Consists of 24 freely movable and 9 fused posteriorly. bones. (c) Arthrokinematics/osteokinematics. (2) Divided into 5 distinct regions (cervical, • Occurs in same direction when mobi- thoracic, lumbar, sacral, and coccygeal). lizing calcaneus on a fixed talus. c. Osteology. Subtalar joint represents the purest (I) Typical vertebra (vertebral body, pedicles, triplanar movement. lamina which includes superior and inferi- Open chain: during inversion calca- or articular processes or facets, transverse neus moves into adduction, supina- processes. and the spinous process). tion and plamarflexion on fixed talus. (2) Regional variations. Eversion occurs as a reciprocally (a) Cervical: two atypical (atlas and axis opposite motion. which allow for increase AROM in Closed chain: during inversion supina- rotation without compressing the tion of calcaneus (talus guides lateral- spinal cord), uncinate processes and ly) with abduction and dorsiflexion of transverse foramen. talus. Produces extel1lal rotation of Vertebral body IS rectangular tibia. Eversion occurs as a reciprocal- shaped. ly opposite motion. Produces internal Uncinate joints Uoints of von rotation of tibia. Luschka) found at Cr C7 limit later- (3) Talonavicular joint. al cervical motion. (a) Arthrokinematics/osteokinematics. (b) Thoracic: demifacets for articulation Artbokinematics and osteokinemat- with the ribs. Vertebral bod} is he:J;- ics occur in same direction when shaped. Prominent spinous p~ are angled following ··Rule f T • Rules of 3: spinou Jl'OC'\" T
18 combination. [)ial articulation is primarily convex and covered with a thin layer of even with transverse process of same fibrocartilage. Sacral articulation is prima- level vertebra; T4-6 spinous process- rily concave and covered with hyaline car- es are found I~ level below transverse tilage. SI joints anenuate forces from trunk processes of same level; T7-9 spinous and lower extremities. processes are one full level below e. Fibroadipose meniscoid. transverse process of same level; T 10 (1) Structure composed of dense connective is full level below; T II is '~ level tissue and adipose tissue. below; and T 12 is level. (2) Found at superior and inferior aspects of (c) Lumbar: veltebra larger than other facet joints. regions and body is kidney shaped. (3) Protects cartilage of facet surface during Very prominent spinous processes. extremes in motion. (d) Sacrum is wedge shaped both anterior- f. Muscles (Table 1-6C). ly/posteriorly and inferiorly/superiorly. g. Intervertebral disc/endplate. Made of 5 fused vertebrae. (I) Anoulus fibrosislfibrosus. (e) [limn is made up of three fused bones (a) Concentric layers or lamellae com- (ischium, ilium, and pubis). Shape varies widely among people and significant posed of collagen (Type II) and fibro- difference in shape between men and cartilage. 65% water. (b) Outer JI.l of annulus is innervated by women. branches from sinovertebral nerve. (c) Functions to sustain compressive. tor- d. Arthrology. sional, shearing. and distraction loads. (I) Atypical joints. (2) Nucleus pulposislpulposus. (a) Atlanta-occipital joint: synovial articu- (a) Gel with imbibing capabilities com- lation between occiput and Ct. Also posed of water and proteoglycans with known as \"yes\" joint since much of a minimal amount of collagen (Type I). head nodding motion comes from this 70%-90% water. articulation. (b) Avascular and aneural structure. (b) Atlanta-axial joint: non-synovial artic- (c) Makes up 20% to 33% height of verte- ulation between dens of C2 and anteri- bral column. or arch of C 1_ Known as \"no\" joint (d) Functions (0 sustain compressive, tor- sional. shearing, and distraction loads. since much of head rotation comes (3) Vertebral endplate. (a) Structure cominuous with annulus and from this articulation. nucleus. Sits inside ring apophysis of (c) Costotransverse and costovertebral: venebraJ body. (b) Composed of proteoglycans, COllagen, articulations between rib and trans- and water as well as both fibrocaJtilage verse process and vertebral body (on side closest to disc) and hyaline car- respectively. tilage (on side closest to vertebral (2) Apophyseal or facet joints which guide body). movement of spine. SynoviaVdiarthrodial (c) Functions to provide passive diffusion joints with capsule and synovial mem- of nutrients. brane. Composed of superior and inferior h. Other noncontractile soft tissues. articulatory processes of adjacent verte- (I) Ligaments. brae. In lumbar region facet sulfaces may (a) Alar ligament. be flat or cwved. In cervical and thoracic, (b) Tectorial membrane. surfaces are generally flat. (c) Anterior longitudinal ligament. (3) Intervertebral joints between intervertebral (d) Posterior longitudinal ligament. disc and adjacent superior and inferior ver- (e) Ligamentum flavum. tebral bodies. Allow movement between vertebral bodies and transmit loads from one vertebral segment to another. (4) Sacroiliac (SI) joint: composed of auricular shaped joint surfaces of sacrum and ilium. Diarthrosis/synarthrosis (syndesmosis)
Musculoskeletal Physical Therapy 19 (f) Interspinous ligament. spinal cord by a dorsal and ventral root, (g) Supraspinous ligament. (h) Transforaminal ligaments. which join to become the spinal nerve in (i) Costotransverse ligament (superior, the intervertebral foramen. Spinal nerve posterior, and lateral). (j) Iliolumbar ligament. divides into dorsal and ventral rarni. (k) Posterior sacroiliac ligaments (short, (a) Dorsal rami innervate structures on transverse, and long). (I) Anterior sacroiliac ligament. posterior trunk. (m) Sacrotuberous ligament. (n) Posterior interosseous ligament (SlJ). (b) Ventral rami. (2) Capsules. (a) Facet joint: assist ligaments in provid- Cervical ventral rami form cervical ing limitation of motion and stability and brachial plexuses. of spine. Strongest in the thoracolum- bar and cervicothoracic regions. Thoracic ventral rami innervate (b) Sacroiliac joints: synovial capsule pres- ent surrounding joint which is very anterior structures of trunk within prominent anteriorly; posteriorly it is lost within posterior interosseous ligament. thoracic region. (3) Thoracolumbar fascia. (a) Provides stability of vertebral column Lumbar ventral rami form lumbar when a force is applied. (b) Acts as a corset when tension is creat- and lumbosacral plexuses. ed by contraction of the abdominals, gluteals, and lumbar muscles. (3) Spinal nerves in various sections of spine. I. Nerves. (I) Dorsal roots transmit sensory fibers to spinal (a) Cervical: spinal nerves come out at the cord and ventral roots mainly transmit motor fibers from spinal cord to spinal nerve. level above its associated vertebra. (2) Spinal nerves are connected centrally to (b) Thoracic/lumbar: spinal nerves come out at level below its associated verte- bra. (4) Spinal cord terminates approximately at level of L t_2 disc. J. Spinal biomechanics. (l) Arthrokinematics. (a) Flexion: upper facets glide anteroprox- imally and tilt forwards. roo,..,(b) Extension: upper facets doonward, slightly posterior, and tilt backwards. (c) Side bending: when side bending right, upper facet moves do\\\\n and lightly anterior. Left facet moves upward and TABLE 1-6C - TRUNK AND RIBCAGE MUSCULAR & NEUROLOGICAL SCREENING ACTION TO RETESTED MUSCLES CORD SEGMENT NERVES nspiration C3-C5 phremc diaphragm Tl-T12 intercostal n-ced expiration levator costarum, external intercostals, anterior intemal intercostals T7-L1 Intercostal spine extension internal obliques,transverse abdominis, T7-T12 intercostal extemal obliques, T1-T12 intercostal spine flexion posterior internal inlercostals, T7-T12 intercostal rectus abdominis T1-T12, Ll-L5, 81-83 spine lateral flexion (hip erector spinae, transversospinafis, intercostal hiking in reverse) interspinales, rotatores T7-T12 intercostal spine rotation intertransversarii T7-Ll lumbar plexus rectus abdominislexternal obliques, lumbar plexus internal obliques, 11 psoas minor quadratus lumborum T12-L3 rotators, internaVextemal obliques, as above intertransversarii, transversospinalis Adapted from Chusid JG: Correlative Neuroanatomy and Functional Neurology. Lange Medical publications. Los Altos, CA, 1970 CA, 1970 and Kendall. FP; McCreary, EK, and Provance, PG. Muscles Testing and Function 4 ed.Williams and Wilkins. Baltimore, 1993).
20 slightly posterior. Both facets move to (b) Nutation and counternutation: cou- the left. pling movement that occurs between (d) Rotation. sacrum and ilium during gait. (e) Cervical: rotation right rotation causes Nutation: describes a movement that facets on right to glide down and back involves flexion of sacrum and pos- causing approximation of facet joints terior rotation of ilium. on right. Countemutation: describes a move- (f) Lumbar/thoracic: very lillie, but clini- ment that involves extension of sacrum cally important because this motion and anterior rotation of ilium. causes separation and approximation of 8. Temporomandibular joint (TMJ). the facet joints e.g., if L:3 rotates right 3. Functional anatomy. A bilateral articulation between mandible and cranium (cranioman- there is separation at right L3-4 joint dibular joint). b. Arthrology. and approximation at left L:J-4 joint. (1) Synovial joint with articular surfaces cov- ered by dense fibrous connective tissue (2) Coupled motions. rather than hyaline cartilage. (a) Cervical. (2) Articular disc composed of dense fibrous Side bending and rotation occur in connective tissue without blood vessels or nerves in pressure bearing areas. same direction from Y-7 regardless (3) Discal ligaments function to restrict move- if spine is in neutral/extension or ment in sagiual plane. flexion. When occiput side bends C 1 (4) Superior retrodisca! lamina (superior stra- rotates in opposite direction. tum) composed of elastic connective tissue; (b) Lumbar/thoracic. counteracts forward pull of superior lateral Neutral/extension: lumbar segments pterygoid muscle on articular disc. will side bend and rotate in opposite (5) Retrodisca! pad consists of loose neurovas- directions e.g., side bend right results cular connective tissue. in segment rotating left. c. Joint movement. • Flexion: lumbar segments will side (1) Combination of hinge axis rotation in disc bend and rotate in the same direction. condyle complex and sliding movement of This coupling described above is a the upper joint. very basic interpretation. In reality (2) Functional range of opening is 40 mm with there are significant variations 25 rom of rotation and 15 mm of translatory regarding coupling motions between glide. individuals. Coupling motion may be dependent on whether you side bend II. Physical Therapy Examination rust or rotate first. Direction of spinal segmenLal coupling should always be A. Patient/Client History (or Interview), Systems checked with each patient prior to Review, and Tests and Measures performing a manual technique. I. Patient/client history. (3) Lumbopelvic rhythm. a. Gather information in order to develop a hypo- (a) During flexion, spine (primarily lum- thetical diagnosis. which will dictate flow of bar spine) goes through 60°_70° of examination. Will also help to delineate any precautions and/or contraindicarions when per- motion and then pelvis will rotate ante- forming components of examination (Table 1-7). riorly to allow more movement eventu- b. Components of history. ally followed by flexion of hips. (1) Demographics: age, gender, diagnosis and (b) During extension (coming from flexed referral (if appropriate), hand dominance, position) hips extend, pelvis rotates etc. posteriorly, and then spine begins to (2) Social and family history. extend. (4) Sacroiliac joint osteokinematics. (a) Motion limited, but during gait move- ments take place in multiple planes.
(3) Current condition(s)/chief complaint. Musculoskeletal Physical Therap~ .= I (4) General health status. (5) Social health. (l7)Special tests (see specifics for e (6) Employment/work. joint/region). (7) Growth and development. (8) Living environment. 4. Diagnostic testing. (9) Functional status and activity level. 3. Diagnostic tests are utilized for correlation (I0)Medicallsurgical history including previous with history and tests and measures to deter- mine patient's primary physical therapy diag- treatment and review of systems. nosis as well as identify any medical conditions 2. Systems review. that may be a contributing factor or comorbidity. b. If determined that further diagnostic tests a. Components of system review. (Table 1-8) would be warranted and/or beneficial, make (I) Musculoskeletal. appropriate referral or recommendation. (2) Neuromuscular. c. Most common types of diagnostic testing for (3) Cardiopulmonary. musculoskeletal dysfunctions include imaging, (4) Integumentary systems. laboratory tests, and electrodiagnostic testing. d. Imaging. b. Make deterrrtination if identified condition(s) (I) Plain film radiograph (x-rays). are comorbidity(s) and/or complicating factor{s). (a) X-rays are used to demonstrate bony tissues. Bearns pass through the tissues c. Determine if a referral to an additional health- resulting in varying shades of gray on care provider is appropriate and if so, make the film depending on density of tissue it passed through. The more dense the referral. structure (bone) the mote white the 3. Tests and measures. structure will appear on the film. (b) Readily available, relatively inexpen- a. Gather specific data regarding patient/client. sive, and shows bony anatomy very Choosing specific components as well as order well. of exam will be dictated by history. (c) Negative is patient exposure to radiation. (d) Requires two different projections b. Components that may be a part of tests and since structures may be superimposed measures include: on each other making it difficult to (I) Anthropometric characteristics. identify pathology with one view. (2) Postural alignment and position (Table 1-9, Typical views are anterior-posterior Figure I-I). and lateral, although other views may (a) Dynamic. be used. (b) Static. (e) Used for viewing dysfunction and/or (3) Range of motion. (Table I-lOA and B) disease of bones. Do not demonstrate (a) AROM. soft tissues well or at alL (b) PROM. (2) Computed tomography (CT scan). (c) Flexibility testing. (a) Uses plain film x-ray slices that are (4) Muscle performance: resisted tests, manual enhanced by a computer to improve muscle testing, muscle tension (Table I-I I). resolution. It is multi planar so can (5) Motor function. image in any plane, therefore tissue can (6) Cranial and peripheral nerve integrity be viewed from multiple directions. (Tables 1-6 A-C, Figure 1-2). (b) Typically used to assess complex frac- (7) Reflex integrity. tures as well as facet dysfunction, disc (8) Sensory integrity. disease, or stenosis of the spinal canal (9) Joint integrity and mobility. (IO)Pain. or intervertebral foramen. cr demon- (Il)Assistive and adaptive devices. (12)Orthotic, protective, and supportive devices. strates better quality and better ,isUJ.li- (13)Ergonomics and body mechanics. zation of bony structures than (I 4) Self-care and home management. films. CT is also able to demollSlJ:'3>e (I5)Gait, locomotion, and balance. soft tissue structures altholl_ (16) Work, community, and leisure integration or reintegration.
22 well as MR!. inserted into the disc with the assis- (c) Fairly expensive and patient is exposed tance of radiography (fluoroscopy). (b) Not commonly used. Requires a high to radiation. level of skill and proper equipment to (3) Discography. perform. Fairly specific technique to identify internal disc disruptions of the (a) Radiopaque dye is injected into the disc nucleus and/or annulus. to identify abnonnalities within the disc (c) Expensive, may be painful, and since it (annulus or nucleus). The needle is is invasive there is a risk of infection. (4) Magnetic resonance imaging (MRI). TABLE 1-7 - QUESTIONS RELATED TO (a) Uses magnetic fields rather than radia- SPECIFIC AREAS OF DYSFUNCTION tion. AREA OF DYSFUNCTION RELATED QUESTIONS Shoulder Do you have pain raising your arm up and ~ so, what part TABLE 1-8 - SUMMARY OF SYMPTOMS of the range does thai occur? OBSERVED IN COMMON Have you ever dislocated your shouk:ler? AND UNCOMMON DYSFUNCTIONS Do you have pain s\\eepi1g on your shoulder at night? Elbow Have you recently changed your activities? DYSFUNCTtON SYMPTOMS OBSERVED Have yoo recefltIy change<l1he type 01 tools yoo use at OJDlOsteoarthritis Pain and stiffness upon rising Pain eases through the morning (4 to 5 hours) worX or the instruments you use for recreational activities? Pain increases with repetitive bending activities Constant awareness of discomfort with episodes of Hand Have you been doing roore or different work with your hands exacerbation than the usual such as typilg, sewing, gardening, etc? Describes pain as more soreness and nagging Cervical Do you have dizziness when looking overhead? Arrt previous ITKllor vehicle accidents with resulting neck injury? Facet Joint Dysfunction Stiff upon rising. Pain eases within an hour loss of motion accompanied by pain How many pillOWS do you use at night? Patient will describe pain as sharp with certain movements Movement in painfree range usually reduces symptoms TMJ Do you have any popping or clicking in the TMJ? Stationary positions increase symptoms Do you have pain IlYing to eat specific foods? Does your jaw ever gel stuck open Of closed? Thoracic Do you have pain with breathing? Discal with nerve root No pain in reclined or semireclined position Have you had a recent upper respiratory infection? compromise Pain increases with increasing weightbearing activities Lumbar Have you had any changes in your ability to urinate or Describes pain as shooting, burning, or stabbing have a bowel movement? Patient may describe altered strength or ability 10 performADLs Do yoo have any ~Ioms such as pain, tingling, \"\"ming, etc WI either of your legs? Spinal Stenosis Pain is related 10 position Rexed positions decrease pain, and extended positions Sacroiliac Did you fall onto your buttocks? increase pain Did you step oN a curb and experience pain? Do you have pain with walking aodlor sustained postures? _ syTrjlloms as a I>JITIiness, tqltness, or crarrpng Hip Do you have pain in your groin? Walking for any distance brings on symploms Pain may persist for hours after assuming a resting position Do you have stiffness in the morning thalleels better with movement? Vascular Claudication Pain is consistent in all spinal positions Pain is brought on by physical exertion Knee Does your knee .pop\"? Pain is relieved promptly with rest (1 to 5 minutes) Pain is described as a numbness Does your knee ever give way and/or lock? Patient usually has decreased or absent pulses Did your knee swell as soon as you were injured Ot did the Neoplastic Disease Patient will describe pain as gnawing, intense, or penetrating swelling come later? Pain is not resolved by changes in position, time of day, AnklelFoot Have you ever sprained your ankle in the past and if yes or activity level how many times? Do you have pain in your foot when you first try to step out Pain will wake the patient of bed in !he morning?
(b) Offers excellent visualization of tissue Musculoskeletal Physical Therapy ::J. anatomy. Utilizes two types of images known as TI and 1'2. Tldemonstrates rounds tissues demonstrating the fat within the tissues and is typically my by where fluid moves within joinL used to assess bony anatomy while 1'2 (b) Typically used to identify abnormali- suppresses fat and demonstrates tissues ties within joints such as tendon rup- with high water content. T2 is used to tures. assess soft tissue structures. (c) Expensive procedure and carries risks since it is invasive. (c) Fairly expensive and patients with (6) Bone scans (osteoscintigraphy). claustrophobia do not tolerate this test (a) Chemicals laced with radioactive trac- well. There is an open MRI, but quali- ers are injected. ty is inferior to closed. May not be able (b) Isotope settles in areas where there is a to use with patients who have metallic high metabolic activity of bone. implants. (c) Radiograph is taken which demon- strates any \"hot spots\" of increased (5) Arthrography. metabolic activity. (a) Invasive technique injects water soluble (d) Patients with dysfunctions such as dye into area and is observed with a rheumatoid arthritis, possible stress radiograph. Dye is observed as it sur- fractures. bone cancer, infection within bone, will often receive a bone scan TABLE 1-9 - EFFECTS OF FORWARD HEAD since these dysfunctions are known to POSTURE ONTHE SPINE,TMJAND have an increase in metabolic activity of bone in affected region. ASSOCIATED SOFT TISSUE STRUCTURES (7) Diagnostic ultrasound. (a) Utilizes transmission of high frequen- STRUCTURE POSTURE CHANGES cy sound waves, similar to therapeutic ultrasound. Cranium Extended on upper cervical spine (b) Limited by contrast resolution, small viewing field, how deep it penetrates, 2. Mandible Elevaled and retruded and poor penetration of bone. Interpre- tation of data is subjective, so results are : TMJ Posterior close-packed position dependent on skill of operator. (c) Provides real time dynamic images and Maxiliomandibular Increased freeway space with significant able to assess soft tissue dysfunctions. relationship peslerior intercuspation (d) No known harmful effects are known at this time. \"/Oid Elevated (suprahyoids shorten, infrahyoids lengthen) (8) Myelography. (a) fnvasive technique using water soluble -rogue Drops to the floor of mouth dye. Dye is visualized as it passes through vertebral canal to observe -Wer celVical spine Extended (can compress neurovascular structures) anatomy within region. (b) Seldom used because of many side l6:tIe and lower lordosis decreased (flexed positioning) effects versus MRl or CT scan, which ::e-t'ICaI spine Elevated provide as good if not better infonna- tion. Very expensive since it often = and second ribs involves a hospital stay overnight. (c) Traditionally had been used for diag- Xaenes, Suboccipnal, Shorten nostic assessment of the disc and Shorten creating rounded shoulder position stenosis. May still be beneficial 10 ~eidomastoids, identify stenosis. e. Laboratory tests. .....:rgus colli, Upper (I) Laboratory tests are typi all. \"\"3:leZlJs, levator >:I'U\" ~Iis major and il::a:t.iar stabilizers Stretched capitis anterior cap;tis Stretched suboccipital region, shorten C2·C6 from Darnell. M.A proposed chronology of events 'orward head posture. The Journal of :'7\" mandibular Practice. 1983. I (4): SO-54.
24 screen patients, assist with making a diag- musculoskeletal conditions. nosis, or for monitoring. B. Special Tests of the Upper Extremity (2) Since many patients with musculoskeletal dysfunction present with other medical I. Shoulder special tests. pathology, it is imponam to monitor clini- a. Yergason's test. cal laboratory findings (I) Tests for integrity of transverse ligament (3) Multiple tests available that fall into tbe and may also identify bicipital tendonitis. following categories. (2) Patient sitting with shoulder in neutral sta- (a) Blood tests. bilized against trunk, elbow at 90°, and (b) Serum chemistries. forearm pronated. Resist supination of (c) Immunologic tests. forearm and external rotation of shoulder. (d) Pulmonary function tests. (3) Will note that tendon of biceps long head (e) Arterial blood gases. will \"pop out\" of groove. May also repro- (f) Fluid analysis. duce pain in long head of biceps tendon. f. Electrodiagnostic testing. (also refer to b. Speed's test (Biceps straight arm). Neuromuscular Physical Tberapy chapter) (I) Identifies bicipital tendonitis or tendonosis. (I) EIectroneuromyography (ENMG) and (2) Patient sitting or standing with upper limb nerve conduction velocity (NCV) tests are in full extension and forearm supinated. commonly used to assess and/or monitor Resist shoulder flexion. May also place shoulder in 90° flexion and push upper TABLE I-lOA· EXTREMITY RANGE OF MOTION JOINT FLEXIONI ABDUCTIONI EXTERNAU HORIZONTAL SUPINATIONI RADIAUULNAR PLANTARFLEXIONI EXTENSION ADDUCTION INTERNAL ADDUCTION PRONATION DEVIATION DORSIFLEXION ROTATION Shoulder 160-180/50-60 170-180/50-75 80-90/60-100 130/45 Elbow 140-15010-10 90/80-90 Wrist 80-90170-90 15/30-45 MCP 85-90/30-45 PIP 100-115/0 DIP 80-90/20 1\"CMC 45-50 60-70/30 1\" MCP 50-5510 l·IP 85-90/0-5 HiD 110-120110-15 30-50130 40-60/30-40 Knee 13510-15 30-40120-30 Ankle 45-60115-30 50/20 2\"\"·5'\" MTP 40/40 1· MTP 45170 lOll? 90/0 2'\"'-5'\" PIP 3510 2\"\"-5'\" DIP 60/30 TABLE I-lOB· SPINE RANGE OF MOTION REGION FLEXIONI SIDEBENDING ROTATION OPENING PROTRUSIONI LATERAL EXTENSION RETRUSION DEVIATION Cervical 20-45 70-90 Thoracic 80-90170 20-40 35-50 10-15mm Lumbar 15-20 3-18 TMJ 20-45/25-45 40-60120-35 35-50mm 3-6mml3-4mm
limb into extension causing an eccentric Musculoskeletal Physical Therapy 25 contraction of the biceps. (3) Will reproduce symptoms (pain) in long position. head of biceps tendon. e. Drop arm test. c. Neer impingement test. (1) For impingement of soft tissue structures of (1) Identifies tear and/or full rupture of rotator shoulder complex (long head of biceps and cuff. supraspinatus tendon). (2) Patient silting and shoulder is passively (2) Patient silting with shoulder passively internally rotated then fully abducted. abducted to 120°. Patient instructed to slow- (3) Will reproduce symptoms of pain within ly bring arm down to side. Guard patient's shoulder region. arm from falling in case it gives way. d. Supraspinatus (empty can) test. (1) Identifies tear and/or impingement of (3) Patient unable to lower arm back down to supraspinatus tendon or possible supras- side. capular nerve neuropathy. (2) Patient sitting with shoulder at 900 and no f. Posterior internal impingement test. rotation. Resist shoulder abduction. Then (1) Identifies an impingement between rotator place shoulder in \"empty can\" position, cuff and greater tuberosity or posterior gle- which is internal rotation and 30° forward noid and labrum. (horizontal adduction) and resist abduction. (2) Patient supine and move shoulder into 90° Differentiate if pain present between two abduction, maximum external rotation, and positions. 15°_20° horizontal adduction. (3) Reproduces pain in supraspinatus tendon (3) Reproduction of pain in posterior shoulder and/or weakness while in \"empty can\" during test. TABLE I-II - MUSCLE GRADING g. Clunk test. (1) Identifies a glenoid labrum tear. Normal N 5/5 Utt or hold against gravity wnh maximal resistar.ce (2) Patient supine with shoulder in full abduc- tion. Push humeral head anterior while Good + G+ 4+15 Good grades include lifting or holding against rotating humerus externally. (3) Audible \"clunk\" is heard while performing gravity with moderate to minimal resistance test. Good G 4/5 h. Anterior apprehension sign. (I) Identifies past history of anterior shoulder Good- G- 4-15 dislocation. (2) Patient supine with shoulder in 90° abduc- Fairt F+ 3+/5 Fair grades include lifting or holding against gravity tion. Slowly take shoulder into external rotation. without resistance (3) Patient does not allow and/or does not like shoulder to move in direction to simulate Fair F 3/5 anterior dislocation. Fair F·- 3-/5 Some assistance may be required to complete the 1. Posterior apprehension sign. (1) Identifies past history of posterior shoulder motion in the minus category dislocation. (2) Patient supine with shoulder abducted Poort P+ 2+/5 Poor grades include movement with gravity 900 (in plane of scapula) with scapula stabi- lized by table. Place a posterior force eliminated through shoulder via force on patient's elbow while simultaneously moving shoul- Poor P 2/5 der into medial rotation and horizontal adduction. Poor- P- 2-15 Some assistance may be required to complete the (3) Patient does not allow and/or does not like shoulder to move in direction to simulate motion in the minus category posterior dislocation. Trace T 1/5 Muscle contraction can be se€n or fen J. Acromioclavicular shear test. No movement is produced (I) Identifies dysfunction of AC joint (such as Zero 0 0/5 No contraction is seen or felt (Adapted from Kendall, FP, McCreary, EK; Provance, PG, Muscles Testing and Function, 4 ed, Williams and Wilkins, Baltimore, 1993)
26 (I) Evaluation of peripheral nerve compression. (2) eurologic symptoms will be reproduced arthritis, separation, etc). (2) Patient sitting with arm resting at side. in upper extremity. 2. Elbow special tests. Examiner clasps hands and places heel of one hand on spine of scapula and heel of a. Ligament instability tests (medial and lateral other hand on clavicle. Squeeze hands stability). together causing compression of AC joint. (I) Identifies ligament laxity or restriction. (3) Reproduces pain in AC joint. (2) Patient is sitting or supine. Entire upper k. Adson's test. limb is supported and stabilized and elbow (I) Identifies pathology of structures that pass placed in 20°_30° of flexion. Valgus force through thoracic inlet. placed through elbow tests ulnar collateral (2) Patient sitting and find radial pulse of ligament. Varus force placed through elbow extremity being tested. Rotate head tests radial collateral ligament. towards extremity being tested then extend (3) Primary finding is laxity, but pain may be and externally rotate the shoulder while noted as well. extending head. (3) Neurologic and/or vascular symptoms (dis- b. Lateral epicondylitis (\"tennis elbow\") test. appearance of pulse) will be reproduced in (I) Identifies lateral epicondylitis. upper extremity. (2) Patient sitting with elbow in 90° flexion I. Costoclavicular syndrome (military brace) test. and supported/stabilized. Resist wrist (1) Identifies pathology of structures that pass extension. wrist radial deviation. and fore- through thoracic inlet. arm pronation with fingers fully flexed (2) Patient sitting and find radial pulse of the (fist) simultaneously. extremity being tested. Move involved (3) Reproduces pain at lateral epicondyle. shoulder down and back. (3) Neurologic and/or vascular symptoms (dis- c. Medial epicondylitis (\"golfer's elbow\") test. appearance of pulse) will be reproduced in (I) Identifies medial epicondylitis. upper extremity. (2) Patient sitting with elbow in 90° flex.ion m. Wright (hyperabduction) test. and supported/stabilized. Passively supinate (1) Identifies pathology of structures that pass forearm, extend elbow, and extend wrist. through thoracic inlet. (3) Reproduces pain at medial epicondyle. (2) Patient sitting and find radial pulse of extremity being tested. Move shoulder into d. Tinel's sign. maximal abduction and external rotation. (I) Identifies dysfunction of ulnar nerve at ole- Taking deep breath and rotating head oppo- cranon. site to side being tested may accentuate (2) Tap region where the ulnar nerve passes symptoms. through cubital tunnel. (3) Neurologic and/or vascular symptoms (dis- (3) Reproduces a tingling sensation in ulnar appearance of pulse) will be reproduced in distribution. upper extremity. Il. RODS elevated ann test. e. Pronator teres syndrome test. (I) Identifies pathology of structures that pass (I) Identifies a median nerve entrapment with- through thoracic inlet. in pronator teres. (2) Patient standing with shoulders fully exter- nally rotated, 90' abducted, and slightly (2) Patient sitting with elbow in 90° flexion horizontally abducted. Elbows flexed to and supported/stabilized. Resist forearm 90' and patient opens/closes hands for three minutes slowly. pronation and elbow extension simultane- (3) Neurologic and/or vascular symptoms (dis- ously. appearance of pulse) will be reproduced in (3) Reproduces a tingling or paresthesia within upper extremity. median nerve distribution. o. Upper limb tension tests (Table 1-12). 3. Wrist and hand special tests. a. Finkelstein test. (I) Identifies deQuervain's tenosynovlus (paratendonitis of the abductor pollicis longus and/or extensor pollicis brevis). (2) Patient makes fist with thumb within con-
fines of fingers. Passively move wrist into Musculoskeletal Physical Therapy 27 ulnar deviation. (3) Reproduces pain in wrist. Often painful tight intrinsic muscles. If flexion is limited with no pathology, so compare to unin- in both cases capsule is tight. If more PIP volved side. flexion with Mep flexion then intrinsic b. Bunnel-Littler test. muscles are tight. (1) Identifies tightness in structures surround- c. Tight retinacular test. ing the MCP joints. (1) Identifies tightness around proximal inter- (2) Mep joint is stabilized in slight extension phalangeal joint. while PIP joint is flexed. Then MCP joint is (2) PIP is stabilized in neutral while DIP is flexed and PIP joint is flexed. flexed. Then PIP is flexed and DIP is (3) Differentiates between a tight capsule and flexed. (3) Differentiates between a tight capsule and re 1·1 Vertical Line of Gravity tight retinacular ligaments. If flexion is limited in both cases capsule i tight. If d from Kendall, FP, McCreary, EK; Provance, PG, more DIP flexion with PlP flexion then es Testing and Function, 4 ed, Williams and Wilkins, retinacular ligaments are tight. -~~.1993) d. Ligamentous instability tests (medial and later- al stability). (l) Identifies ligament laxity or restriction. (2) Fingers are supported and tabilized. Valgus and varus forces applied to PIP joints all digits. Repeated at DIP joints. (3) Primary finding is laxity. but pain may be noted as weU. e. Froment's sign. (I) Identifies ulnar nerve dysfunction. (2) Patient grasps paper between Ist and 2nd digits of hand. Pull paper out and look for IP flexion of thumb, which is compensation due to weakness of adductor pollici . (3) Patient unable to perform test withoot compen- sating may indicate ulnar nerve dysfunction. f. Tinel's sign. (I) Identifies carpal tunnel compression of median nerve. (2) Tap region where median nerve passes through carpal tunnel. (3) Reproduces tingling and/or paresthesia into hand following median nerve distribution. g. Phalen's test. (1) Identifies carpal tunnel compression of median nerve. (2) Patient maximally flexes both wrists hold- ing them against each other for one minute. (3) Reproduces tingling and/or paresthesia into hand following median nerve distribution. h. Two point discrimination test. (I) Identifies level of sensory innervation within hand which correlates with functional ability to perform certain tasks involving grasp. (2) Patient sitting with hand stabilized. Using a caliper, two point discriminator, or paper
28 clip apply device to palmar aspect of fin- and externally rotate test leg so that foot is gers to assess patients ability to distinguish resting just above knee on opposite leg. between two points of testing device. Slowly lower testing leg down towards Record smallest difference that patient can table surface. sense two separate points. (3) Positive test when involved knee is unable (3) Normal amount that can be discriminated is to assume relaxed position and/or repro- generally less than six mm. duction of painful symptoms. 1. Allen test. b. Grind (Scouring) test. (I) Identifies vascular compromise. (I) Identifies DJD of hip joint. (2) Identify radial and ulnar arteries at wrist. (2) Patient supine with hip in 900 flexion and Have patient open/close fingers quickly knee maximalJy flexed. Place compressive several times and then make a closed fist. load into femur via knee joint therefore Using your thumb, occlude the ulnar artery loading hip joint. and have patient open hand. Observe palm (3) May reproduce pain within hip joint. of hand and then release the compression c. Trendelenburg's sign. on artery and observe for vascular filling. (I) Identifies weakness of gluteus medius or Perform same procedure with radial artery. unstable hip. (3) Positive finding will present by abnormal (2) Patient standing and asked to stand on one filling of blood within hand during test. leg (flex opposite knee). Observe pelvis of Under normal circumstances there is a stance leg. change in color from white to normal (3) Positive when ipsilateral pelvis drops when appearance on palm of hand. lower limb support is removed while standing. C. Special Tests of the Lower Extremity d. Thomas test. I. Hip special tests. (I) Identifies tightness of hip flexors. a. Patrick (FABER) test. (2) Patient supine and one hip and knee are (I) Identifies dysfunction of hip such as mobil- maximally flexed to chest and held there. ity restriction. Opposite limb is kept straight 011 table. (2) Patient lies supine. Passively flex, abduct, Observe if hip flexion occurs on straight TABLE 1-12 UPPER LIMB TENSION TESTS SHOWING ORDER OF JOINT POSITIONING AND NERVE BIAS Shoulder ULTTt ULTT2 ULTT3 ULTT4 Depression and Depression and Depression and Depression and abduction (110°) abduction (1 DO) abduction (1 DO) abduction (10° to 90°) hand to ear Etbow Extension Extension Extension Flexion Forearm Supination Supination Pronation Supination Wrist Extension Extension Flexion and Extension and radial deviation ulnar deviation Fingers and thumb Extension Extension Flexion Extension Shoulder Lateral rotation Medial rotation Lateral rotation Cervical spine Contralateral side Contralateral side Contralateral side Contralateral side flexion flexion flexion flexion Nerve bias Median nerve, anterior Median nerve Radial nerve Ulnar nerve, C8 and T1 interosseous nerve, musculocutaneous nerve roots C5, C6, C7 nerve, axillary nerve (From Magee 0: Orthopedic Physical Assessment. 4th ed. WB. Saunders Co., Philadelphia, 2002. p. XXX. with permission).
leg as opposite limb is flexed. Musculoskeletal Physical Therap~ ~ (3) Weakness of test is that it does not differ- come to rest on table. entiate between tightness in iliacus versus psoas major. f. Ely test. (4) Positive if straight limb's hip flexes and/or (I) Identifies tightness of rectus femoris. unable to remain flat on table when oppo- (2) Patient prone and knee of testing limb site limb is flexed. flexed. Observe hip of testing limb. e. Ober's test. (3) Positive if hip of testing limb flexes. (I) Identifies tightness of tensor fascia latae and/or iliotibial band. g. 90-90 Hamstring test. (2) Patient lying on their side with lower limb (I) Identifies tightness of hamstrings. flexed at hip and knee. Passively extend (2) Patient supine and hip and knee of testing and abduct testing hip with knee flexed to limb is supported in 90° flexion. Passively 90°. Slowly lower uppermost limb and extend knee aftesting limb until a barrier in observe if it reaches table. (3) Positive if uppermost limb is unable to encountered. (3) Positive if knee is unable to reach 10° from neutral position (lacking 10° of extension). h. Piriformis test. (I) Identifies piriformis syndrome. Poslculan. (radial) Postcutan.- Radial { Dorsal cutan\" Musculocutan. Med. cutan. AadlaJ_ Median Median _ Post eutan. Ant cutan.} Femoral &>pOe\"\"\", l5 Peroneal 51 Lal cutan. } Common peroneal Sdatic { Tom. { Su<ai- Sup. peroneal Sural-- Tom. Plan\"\" { Lal l5 Deep peroneal Me<!. 1·2: Segmental and peripheral nerve distribution Hertling, DH; Kessler, RM. Management of Common Musculoskeletal Disorders; Physical Therapy Principles and Methocs. J ~ ~ppincott. Philadelphia. 1996, with permission)
30 J. Craig's test. (I) Identifies abnormal femoral antetorsion (2) Patient supine and foot of test leg is pas- angle. sively placed lateral to opposite limb's (2) Patient prone with knee flexed to 90°. knee. Testing hip is adducled. Observe Palpate greater trochanter and slowly move position of testing knee relative to opposite hip through internal/external rotation. knee. When greater trochanter feels most lateral, stop and measure the angle of leg relative (3) Positive if testing knee is unable to pass to a line perpendicular with table surface. over resting knee andlor reproduction of (3) Based on findings patient may have an pain in buttock and/or along sciatic nerve anteverted or retroverted hip. Normal angle distribution. is betweeIl8°~15° hip internal rotation. Less than 8° indicates a retroverted hip and I. Leg length test. greater than 15° indicates an anteverted hip. (I) ldentifies true leg length discrepancy. (2) Patient supine and pelvis is balanced! 2. Knee special tests. aligned with lower limbs and trunk. Measure a. Collateral ligament instability tests (medial and distance from ASlS to lateral malleolus on lateral stability). each limb several times for consistency and (I) Identifies ligament laxity or restriction. compare results. (2) Patient is supine. Entire lower limb is sup- (3) A difference in lengths between two limbs ported and stabilized and knee placed in is noted identifying a true leg length dis- 20°_30° of flexion. Valgus force placed crepancy. This test will determine if the through knee tests medial collateral liga- limb djscrepancy is true or functional. True menl. Varus force placed through knee tests discrepancy is caused by an anatomical dif- lateral collateral ligament. ference in bone lengths (either tibia or (3) Primary finding is laxity, but pain may be femur). Functional discrepancies are not noted as well. anatomical in origin and are the result of a b. Lachman stress test. compensation due to abnormal position or (1) Indicates integrity of anterior cruciate liga- posture such as pronation of a foot or ment. pelvic obliquity. (2) Patient supine with testing knee flexed 20°_ 30°. Stabilize femur and passively try to TABLE 1-13 - POSITIONS/ACTIVITIES glide tibia anterior. THAT PRECIPITATE SI DYSFUNCTION (3) Positive finding is excessive anterior glide of tibia. TYPE OF ACTIVtTIES THAT c. Pivot shift (anterolateral rotary instability). DYSFUNCTION PRECIPITATE DYSFUNCTION (I) Indicates anterior cruciate ligament integrity. (2) Patient supine with testing knee in exten- Anterior Torsion of IMOlllinale Squalti~ering sion, hip flexed and abducted 30° with slight internal rotation. Hold knee with one Pregnancy hand and foot with other hand. Place valgus Hip al 90 degrees with axial loading force through knee and flex knee. Golfingibattingltennis (3) Positive finding is ligament laxity as indi- cated by tibia relocating during the test. As Posterior Torsion of Innominate Verticallhrusl onlo extended lE knee is being flexed, the tibia clunks back- Sprint starting position ward at approximately 30°_40°. The tibia at beginning of test was subluxed and then Fall onlo ischial tuberosity was reduced by pull of iliotibial band as Unilateral standing knee was being flexed. d. Posterior sag test. Sacral Dysfunction long term postural abnormalities (I) Indicates integrity of posterior cruciate lig- Fall onlo sacrun'Vcoccyx ament. Carrying a load during ambulalion Trauma during childbirth Loss of balance during ambulalion Sitting combined with rotation and lifting
(2) Patient supine and testing hip flexed to 45° Musculoskeletal Physical Therapy 31 and knee flexed to 90°. Observe to see if tibia \"sags\" posteriorly while in this position. as you passively flex and extend the knee (3) Positive finding is pain and/or ·'popping\" (3) Positive finding is sag of tibia relative to noted during the test. femur. J. Patellar apprehension test. e. Posterior drawer test. (I) Indicates past history of patella dislocation. (2) Patient supine and patella is passively glid- eI) Indicates integrity of posterior cruciate lig- ed laterally. ament. (3) Patient does not allow and/or does not like (2) Patient supine and testing hip flexed to 45° patella to move in lateral direction to simu- and knee flexed to 90°. Passively glide tibia late subluxation/dislocation. posteriorly following the joint plane. k. Clarke's sign. (I) Indicates patellofemoral dysfunction. (3) Positive finding is excessive posterior (2) Patient supine with knee in extension rest- glide. ing on table. Push posterior on superior pole of patella then ask patient to perform an f. Reverse Lachman. active contraction of the quadriceps muscle. (1) Indicates integrity of posterior cruciate lig- (3) Pain is produced in knee as a result of the test. ament. 1. Ballotable patella (Patellar tap test). (I) Indicates infrapatellar effusion. (2) Patient prone with knees flexed to 30°. (2) Patient supine with knee in extension rest- Stabilize femur and passively try to glide ing on table. Apply a soft tap over the cen- tibia posterior. tral patella. (3) Positive finding is perception of the patella (3) Positive finding is ligament laxity. floating (\"dancing patella\" sign). g. McMurray test. m. Fluctuation test. (1) Indicates knee joint effusion. (1) Identifies meniscal tears. (2) Patient supine with knee in extension rest- (2) Patient supine with testing knee in maximal ing on table. Place one hand over suprap- atellar pouch and other over anterior aspect flexion. Passively internally rotate and of knee joint. Alternate pushing down with extend the knee. This tests lateral meniscus. one hand at a time. Test medial meniscus with same procedure (3) Positive finding is fluctuation (movement) except rotate tibia into lateral rotation. of fluid noted during the test. (3) Positive finding is reproduction of click n. Q-angle measurement. and/or pain in knee joint. (1) Measurement of angle between the quadri- h. Apley test. ceps muscle and the patellar tendon. (1) Helps to differentiate between meniscal (2) Normal is 13° for men and 18° for women. tears and ligamentous lesions. (3) Angles < or > normal may be indicative of (2) Patient prone with testing knee flexed to knee dysfunction and/or biomechanical 90°. Stabilize patient's thigh to table with dysfunctions within the lower limb. your knee. Passively distract the knee joint o. Noble compression test. then slowly rotate tibia internally and exter- (I) Identifies if distal IT band friction syn- nally. Next step is to apply a compressive drome is present. load to knee joint and once again slowly (2) Patient supine with hip flexed to 45° and rotate tibia internally and externally. knee flexed to 90°. Apply pressure to later- (3) Pain or decreased motion during compres- al femoral epicondyle then extend knee. sion indicates a meniscal dysfunction. If (3) Reproduces same pain over lateral femOf\"a1 pain or decreased motion occurs during the condyle. Patient will complain of pain O\\n'\" distraction then it is most likely a ligamen- lateral femoral epicondyle at approximaIe ~ tous dysfunction. 1. Hughston's plica test. (I) Identifies dysfunction of the plica. (2) Patient is supine and testing knee is flexed with tibia internally rotated. Passively glide the patella medially while palpating the medial femoral condyle. Feel for popping
32 deep fibular nerve anterior to talocrural joint. 30' flexion. (2) Patient supine with foot supported on the p. Tillel's sign. table. Tap over region of posterior tibial nerve as it passes posterior to medial malle- (I) Identifies dysfunction of common fibular olus. Tap over region of deep fibular nerve nerve posterior to fibula head. as it passes under dorsal retinaculum (ante- rior to ankle joint). (2) Tap region where common fibular nerve (3) Reproduces tingling and/or paresthesia into passes through posterior to fibula head. the respective nerve distributions. f. Morton's test. (3) Reproduces tingling and/or paresthesia into (l) Identifies stress fracture or neuroma in leg following common fibular nerve distri- forefoot. bution. (2) Patient supine with foot supported on table. Grasp around metatarsal heads and 3. Ankle and foot special tests. squeeze. a. Neutral subtalar positioning. (3) Positive finding is pain in forefoot. (1) Examination lO determine if abnonnal rear- D. Special Tests of the Spine, Pelvis, and fOOL to forefoot positioning exists. Temporomandibular Joint (2) Patient prone with fOOl over edge of table. I. Cervical special tests. Palpate dorsal aspect of talus on both sides a. Vertebral artery test. with one hand and grasp lateral fore fOOl (I) Assesses the integrity of the vertebrobasilar with other hand. Gently dorsiflex foot until vascular system. resistance is felt then gently move foot (2) Patient supine with head supported on table through arc of supination and pronation. and follow the progression. (3) Neutral position is point at which you feel (a) Extend head and neck for 30 seconds. foot fall off easier to one side or other. At this point compare rearfoDt to forefoot and If no change in symptoms progress to rearfool to leg. next step. b. Anterior drawer test. (b) Extend head and neck with rotation left (I) Identifies ligamentous instability (particu- then right for 30 seconds. If no change larly anterior talofibular ligament). in symptoms progress to next step. (2) Patient supine with heel just off edge of (c) With head being cradled off table table in 20° plantarflexion. Stabilize lower extend head and neck for 30 seconds. leg and grasp foot. Pull talus anterior. If no change in symptoms progress to (3) Positive finding if talus has excessive ante- next step. rior glide and/or pain is noted. (d) With head being cradled off table c. Talar tilt. extend head and neck with rotation left (1) Identifies ligamentous instability (particu- for 30 seconds. Repeat same procedure larly calcaneotibular ligament). with rotation to the right (2) Patient sidelying with knee slightly flexed (3) Patient should be continuously monitored and ankle in neutral. Move foot into adduc- for any change in symptoms during entire tion testing caJcaneofibular ligament and test. Caution should be used with this test, into abduction testing deltoid ligament. since there is an inherent danger in test (3) Positive finding if excessive adduction or itself, therefore progressive flow should be abduction occurs and/or pain is noted. followed. d. Thompson test. (4) Performing mobilization/manipulation (I) Evaluates the integrity of the Achilles ten- within cervical region without prior per- don. fonning this test would be considered by (2) Patient prone with foot off edge of table. most to be a breach in standard of care. Squeeze calf muscles. (5) Positive finding is dizziness, visual distur- (3) No movement of foot while squeezing calf indicates positive finding. e. Tinel's sign. (I) Identifies dysfunction of posterior tibial nerve posterior to the medial malleolus or
bances, disorientation, blurred speech, nau- Musculoskeletal Ph~'sicaJ Therapy 33 sea/vomiting, etc. b. Hautant's test. side bending and rotation towards DOD.- (1) Differentiates vascular versus vestibular painful side followed by extension. Repe31 causes of dizziness/vertigo. this towards painful side. (2) Two steps to this test. (3) Be careful since this is very similar to ver- (a) Patient sitting with shoulders at 90° tebral artery test. (4) Positive finding is pain and/or paresthesia and palms up. Have patient close their in dermatomal pattern for involved nerve eyes and remain in this position for 30 root or localized pain in neck if facet dys- seconds. If arms lose their position function. there may be a vestibular condition. g. Distraction test. (b) Patient sitting with shoulders at 90° (I) Indicates compression of neural structures and palms up. Have patient close their at the intervertebral foramen or facet joint eyes and cue patient into head and neck dysfunction. extension with rotation right then left, (2) Patient sitting and head is passively dis- remaining in each position for 30 sec- tracted onds. If arms lose there position the (3) Positive finding is a decrease in symptoms condition may be vascular in nature. in neck (facet condition) or a decrease in (3) Position/movement of arms determines upper limb pain (neurologic condition). positive finding. h. Shoulder abduction test. Transverse ligament stress test. (1) Indicates compression of neural structures (I) Tests integriLy of transverse ligament. within intervertebral foramen. (2) Patient supine with head supported on table. (2) Patient sitting and asked to place one hand Glide C I anterior. Should be firm end feel. on top of their head. Repeat with opposite (3) Positive finding is soft end feel, dizziness, hand. nystagmus, a lump sen·sation in throat, nau- (3) Positive finding is a decrease in symptoms sea, etc. into upper limb. d. Anterior shear test. I. Lhermitte's sign. (1) Assesses integrity of upper cervical splne (I) Identifies dysfunction of spinal cord and/or ligamems and capsules. an upper motor neuron lesion. (2) Patient supine with head supported on table. Glide C2-7 anterior. Should be firm (2) Patient in long sitting on table. Passively end feel. flex patient's head and one hip while keep- (3) Laxity of ligaments is positive finding as ing knee in extension. Repeat with other well as dizziness, nystagmus, a lump sensa- hip. tion in the throat, nausea, etc. e. Foraminal compression (Spurling's) test. (3) Positive finding is pain down the spine and (I) Identifies dysfunction (typically compres- into the upper or lower limbs. sion) of cervical nerve root. 2) Patient sitting with head side bent towards J. Romberg's test. uninvolved side. Apply pressure through (1) Identifies upper motor neuron lesion. head straight down. Repeat with head side (2) Patient standing and closes eyes for 30 sec- bent towards involved side. onds. 3 Positive finding is pain and/or paresthesia (3) Excessive swaying during test indicates in dennatomal pattern for involved nerve positive finding. root. ta.timum cervical compression test. k. Thoracic outlet syndrome (TOS) tests (see Identifies compression of neural structures shoulder special tests). at intervertebral foramen and/or facet dys- function. I. Upper limb tension tests (see shoulder special 2) Patient sitting. Passively move head into tests). 2. Thoracic special tests. a. Rib springing. (I) Evaluates rib mobility. (2) Patient prone. Begin at upper ribs applying a posterior/anterior force through each ri
34 c. Femoral nerve traction test. (1) Identifies compression of femoral nerve progressively working through entire rib anywhere along its course. cage. Following prone test, position patient (2) Patient lies on non-painful side with trunk sidelying and repeat. Be careful with in neutral, head flexed slightly, and lower springing the 11 th and 12th ribs since they limb's hip and knee flexed. Passively have no anterior attachments and therefore extend hip while knee of painful limb is in less stable. extension. If no reproduction of symptoms (3) Positive finding is pain, excessive motion flex knee of painful leg. of rib, or restriction of rib. (3) Positive finding is neurologic pain in ante~ b. Thoracic springing. rior thigh. (1) Evaluates intervertebral joint mobility in thoracic spine. d. Valsava maneuver. (2) Patient prone. Apply posterior/anterior (I) Identifies a space occupying lesion. glides/springs to transverse processes of (2) Patient sitting. Instruct patient to take a deep thoracic vertebra. Remember that the spin- breath and hold while they \"bare down\" as if ous process and transverse process of the having a bowel movement. same vertebra may not be at the same level (3) Positive finding is increased low back pain or in the thoracic region (refer to I.B.7.c.2.b). neurologic symptoms into lower extremity. (3) Positive finding is pain, excessive move- ment, andlor restricted movement. e. Babinski test. c. Slump test. (I) Identifies upper motor neuron lesion. (1) Identifies dysfunction of neurologic struc- (2) Patient supine or sitting. Glide bottom end tures supplying the lower limb. of a standard reflex hammer along plantar (2) Patient sitting on edge of table with knees surface of patient's foot. flexed. Patient slump sits while maintain- (3) Positive finding is extension of big toe and ing neutral position of head and neck. The splaying (abduction) of other toes. following progression is then followed. (a) Passively flex patient's bead and neck. f. Quadrant test. (1) Identifies compression of neural structures If no reproduction of symptoms move at the intervertebral foramen and facet dys- on to next step. function. (b) Passively extend one of patient's knees. (2) Patient standing. If no reproduction of symptoms move (a) Intervertebral foramen: cue patient into on to next step. side bending left, rotation left, and (c) Passively dorsiflex ankle of limb with extension to maximally close interver- extended knee. tebral foramen on Lhe left. Repeat to (d) Repeat flow with opposite leg. other side. (3) Positive finding is reproduction of patho- (b) Facet dysfunction: cue patient into side logic neurologic symptoms. bending left, rotation right, and exten+ 3. Lumbar special tests. sian to maximally compress facet joint a. Slump test (see thoracic special tests). on left. Repeat to other side. b. Lasegue's (straight leg raising) test. (3) Positive finding is pain and/or paresthesia i.n the dermatomal pattern for the involved e1) Identifies dysfunction of neurologic struc- nerve root or localized pain if facet dys- function. tures that supply lower limb. (2) Patient supine with legs resting on table. g. Stork standing test. (I) Identifies spondylolisthesis. Passively flex hip of one leg with knee (2) Patient standing on one leg. Cue patient extended until patient complains of shooting into trunk extension. Repeat with opposite pain into lower limb. Slowly lower limb until leg on ground. pain subsides then passively dorsiflex foot. (3) Positive finding is pain in low back with (3) Positive finding is reproduction of patho- ipsilateral leg on ground. logic neurologic symptoms when foot is dorsiflexed.
h. McKenzie's side glide test. Musculoskeletal Physica1 Therap~ .3.5 (l) Differentiates between scoliotic curvature versus neurologic dysfunction causing hip of limb being tested. Assess movemen abnormal curvature (lateral shift) of trunk. of PSIS via comparison of positions of (2) Test is performed if \"lateral shift\" of trunk is your thumbs. Make sure your eyes are level noted. Patient standing. Stand on side of with your thumbs. PSIS should move in a patient that upper trunk is shifted towards. superior direction. Place your shoulders into patient's upper (3) Positive finding is no identified movement trunk and wrap your arms around patient's of PSIS as compared to sacrum. pelvis. Stabitize upper trunk and pull pelvis to c. Gaenslen's test. bring pelvis and trunk into proper aligrunent. (I) Identifies sacroiliac joinl dysfunction. (3) Positive test is reproduction of neurologic (2) Patient sidelying at edge of table while symptoms as alignment of trunk is corrected. holding bottom leg in maximal hip and knee flexion (knee to chest). Standing I. Bicycle (van Gelderen) tesl. behind patient passively extend hip of (I) Differentiates between intermittent claudi- uppermost limb. This places stress on SIJ cation and spinal stenosis. associated with uppermost limb. (2) Patient seated on stationary bicycle. Patient (3) Positive finding is pain in SU. rides bike while sitting erect and time how d. Long sitting (supine to sit) test. long they can ride at a set pace/speed. After (I) Identifies dysfunction of SU Ihat may be a sufficient rest period have patient ride bike cause of functional leg length discrepancy. at same speed while in a slumped position. (2) Patient supine with correct alignment of (3) Determination is based on length of time trunk, pelvis and lower limbs. You stand at patient can ride bike in sitting upright ver- edge of table by patient's feet palpating the sus sitting slumped. If pain related to spinal medial malJeoli to assess symmetry (one stenosis, should be able to ride bike longer longer than other). Have patient come into while slumped. long sitting position and once again assess their leg length making a comparison j. Leg length lest (refer to Le.I.i). between supine and long sitting. 4. Sacroiliac joint (SIJ) special tests. (3) Abnormal finding is reversal in limb lengths between supine as compared to a. Gillet's tesl. long sit. (l) Assessing posterior movement of the ilium e. Goldthwait's test. relative to the sacrum. (I) Differentiates between dysfunction in lum- (2) Patient standing. Place thumb of your hand bar spine versus SIJ. under PSIS of limb to be tesled and place (2) Patient supine with your fingers in between your other thumb on center of sacrum at spinous processes of lumbar spine. With same level as thumb under PSIS. Ask your other hand passively perform a patient to flex hip and knee of limb being straight leg raise. tested as if bringing their knee to chesl. (3) If pain presents prior to palpation of move- Assess movement of PSIS via comparison ment in lumbar segments, dysfunction is of positions of your thumbs. Make sure related to SU. your eyes are level with your thumbs. PSIS 5. TMJ special tests. should move in an inferior direction. 3. TMJ compression. (3) Positive finding is no identified movement (I) Evaluates for pain with compression of the of PSIS as compared to sacrum. retrodiscal tissues. (2) Patient sitting or supine. SupportlstabiJize b. Ipsilateral anterior rotation test. patients head with one hand and with other (I) Assessing anterior movement of ilium rela- hand push mandible superior causing a tive to sacrum. compressive load to the TMJ. (2) Place thumb of your hand under PSIS of (3) Positive finding is pain in TMJ. limb to be tested and place your other thumb on center of sacrum at same level as thumb under PSIS. Ask patient to extend
m. Musculoskeletal Conditions (7) Medications: NSAlDs such as aspirin are used to reduce inflammation and pain asso- A. Arthritic Conditions ciated with condition. Corticosteroid thera- py or medications to suppress immune sys- I. Degenerative joint disease (D1D; degenerative tem may be used to control various symp- toms. Cytotoxic drugs (drugs that block osteoarthritis/osteoarthrosis[OA]) (Table 1.8). cell growth) may be used in people who do not respond well to corticosteroids or who a. A degenerative process of varied etiology are dependent on high doses of corticos- teroids. Tumor necrosis factor (TNF) which includes mechanical changes. diseases inhibitors have been shown to improve some symptoms of ankylosing spondylitis. and/or joint trauma. (8) Diagnostic tests utilized: HLA-B27 antigen b. Characterized by degeneration of articular car- may be helpful, but not diagnostic by itself. tilage with hypertrophy of subchondral bone (9) Clinical examination will assisl in confirm- ing diagnosis. and joint capsule of weight bearing joints. (I0)Physical therapy goals. outcomes, and c. Many different medications are used to conlrol interventions. pain, including cOl1icosteroids and NSAIDs. Glucocorticoids injected into joints that are inflamed and n01 responsive to NSAlDS. For mild pain without inflammation, acetamino- phen may be used. d. Diagnostic tests utilized: plain film imaoain o 0 demonstrates characteristic findings of OA (diminished joint space. decreased height of articular cartilage, presence of osteophytes) PREFERRED PRACTICE PATTERNS MUSCULOSKELETAL and lab tests help to rule out other disorders such as rheumatoid arthritis (RA). e. Clinical examination will assist in confirming diagnosis. Pattern A: Primary Prevention/Risk Reduction for Skeletal Demineralization f. Physical therapy goals, outcomes, and inter- ventions. Pattern B: Impaired Posture (I) Joint protection strategies. Pattern C: Impaired Muscle Performance (2) Maintain/improve joint mechanics and Pattern D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue connective tissue functions. Dysfunction (3) Implementation of aerobic capacity/ endurance conditioninoa or reconditionin a Pattern E: Impaired Joint MobUity, Motor Function, Muscle Performance, and Range of Motion Associated with Localized 0 Inflammation such as aquatic programs. 2. Rheumatoid conditions. a. Ankylosing spondylitis (Marie-Strtimpell. Bechterew, rheumatoid spondylitis). Pattern F: Impaired Joint Mobility, Molor Function, Muscle Perfonnance, Range of Motion, and Reflex Integrity Associated with (I) Progressive inflammatory disorder of Spinal Disorders unknown etiology that initially affects axial skeleton. Pattern G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture (2) Initial onset (usually mid and low back pain for 3 months or greater) before fourth Pattern H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty decade of life. (3) First symptoms include mid and low back Pattern I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soil Tissue pain, morning stiffness and sacroiliitis. Surgery (4) Results in kyphosis deformity of the cervi- cal and thoracic spine and a decrease in Pattern J: Impaired Motor Function, Muscle Performance, Range of Motion, Gait, locomotion, and Balance Associated with lumbar lordosis. Amputatioo (5) Degeneration of peripheral and costoverte- bral joints may be observed in advanced stages. From Guide for Physical Therapist Practice. 2nd ed. Phys Ther 81:9.2001 (6) Affects men three times more often than women.
Musculoskeletal Physical Therapy r TABLE 1-14 - DIFFERENTIAL DIAGNOSIS OF CERVICAL FACET SYNDROME, CERVICAL NERVE ROOT LESION,ANDTHORACIC OUTLET SYNDROME S AND SYMPTOMS FACET SYNDROME CERVICAL NERVE ROOT THORACIC OUTLET SYNDROME --eferral Possible Yes Possible on hyperextension and Yes (often without increased Yes with increased symptoms \"\"\"lIOn No referral of symptoms) Possible stiffness Yes Yes Possible sia May be affected Possible No Yes May be affected spasm Positive Yes tests Not affected May be positive Yes No Possible weakness Mayor may not be positive Not early (later smaller muscles) fatigue and cramps Possible Possible No No No No Magee D: Orthopedic Physical Assessment, 3rd ed. WB. Saunders Co., Philadelphia, 1997. p. 148, with permission). TABLE 1-15 - DIFFERENTIAL DIAGNOSIS OF CERVICAL SPONDYLOSIS AND TEMPOROMANDIBULAR JOINT (TMJ) DYSFUNCTION i CERVICAL SPONDYLOSIS TMI DYSFUNCTION Insidious onset Insidious onset o<l1lOn May complain of referred pain into arm or head May be related to biting something hard Stiff neck Pain may be referred to neck or head o'E- 'TlOvements Muscle guarding of neck muscles Minimal or no muscle guarding Cervical spine movement limited Cervical movements may be limited if they TMJ movements normal compress or stress TMJ TMJ movements mayor may not be painful but _ movements Restricted May have altered end feel: muscle spasm or range of motion is altered isometric movements Restricted tests bone-to-bone Normal and cutaneous distribution Relatively normal Myotomes may be affected None Spurling's test may be positive No effect Distraction test may be positive See history for referred pain Deep tendon reflexes may be hyporeflexic See history for referred pain \"1agee D: Orthopedic Physical Assessment, 3rd ed. WB. Saunders Co. Philadelphia. 1997, p. 173, with permission).
38 TABLE 1-16 - DIFFERENTIAL DIAGNOSIS OF ANKYLOSING SPONDYLITIS AND THORACIC SPINAL STENOSIS History ANKYLOSING SPONDYLITIS THORACIC SPINAL STENOSIS Active movements Morning stiffness Intermittent aching pain Passive movements Male predominance Pain may refer to both legs with walking Resisted isometric movements Sharp pain --. ache Special tests Bilateral sacroiliac pain may refer to posterior thigh (neurogenic intermittent claudication) Restricted Reflexes Restricted May be normal Sensory deficit Normal May be normal Diagnostic imaging None Normal Bicycle test of van Gelderen may be positive Normal Stoop test may be positive None May be affected in long-standing cases Plain films are diagnostic Usually temporary Computed tomography scans are diagnostic (From Magee D: Orthopedic Physical Assessment, 3rd ed.W.B. Saunders Co, Philadelphia. 1997, p. 359, with permission). TABLE 1-17 - DIFFERENTIAL DIAGNOSIS OF LUMBAR STRAIN AND POSTEROLATERAL LUMBAR DISC HERNIATION AT LS-S I LUMBAR STRAIN LUMBAR DISC (LS-S I) History Mechanism of injury: flexion, side flexion and/or Quick movement into flexion. rotation. side Pain rotation under load or without control flexion. or extension (mayor may not be load) Observation In lumbar spine, may be referred into buttocks In lumbar spine with referral into posterior foot Active movements May increase with extension (muscle contraction) (radicular pain) Resisted isometric movements or flexion (stretch) Increases with extension Special tests Scoliosis may be present Scoliosis may be present Sensation Muscle spasm Muscle guarding Reflexes Pain especially on stretch (flexion, side flexion, and Pain especially on extension and flexion Joint play Side flexion and rotation may be affected rotation) Limited range of motion Pain on unguarded movement Limited range of motion Minimal pain unless large protrusion Pain on muscle contraction (often minimal pain) L5·S1 myotomes may be affected Myotomes normal Straight leg raising and slump test often positive Neurological tests negative L5·S1 dermatomes may be affected Normal L5·S1 reflexes may be affected Normal Muscle guarding Muscle guarding (From Magee D: Orthopedic Physical Assessment, 3rd ed.WB. Saunders Co. Philadelphia, 1997, p. 428, with permission). (a) Implementation of flexibility exercises Breathing strategies to maintain/ for trunk to maintain/improve normal improve vital capacity. joint motion and length of muscles in b. Gout. aU directions, especially extension. (I) Genetic disorder of purine metabolism characterized by elevated serum uric acid (b) Implementation of aerobic capacity/ (hyperuricemia). Uric acid changes into endurance conditioning or recondition- crystals and deposits into peripheral joints ing such as aquatic programs. and other tissues (e.g., kidneys). (2) Most frequently observed at knee and great (c) Implementation of relaxation activities toe of foot. to maintain/improve respiratory func- tion.
(3) Medications: NSAIDS (specifically indo- Musculoskeletal Physical Therapy 39 methacin), cox-2 inhibitor.; (cardiac side effects may limit use), colchicine, corticosteroids, interphalangeal (pIP) joints are usually adrenocorticotropic bonnone (ACTH), allop- affected with characteristic pannus forma- urinol, probenecid, and sulJinpyrazone. tion (inflammatory granulation tissue that cover.; joint surface). ulnar drift and volar (4) Diagnostic tests utilized: lab tests identify subluxation of MCP joints; ulnar drift observed at PIPs in severe forms. Distal monosodium urate crystals in synovial interphalangeal (DW) joints are usually fluid and/or connective tissue samples. spared. Other deformities include swan- neck and boutonniere deformities and (5) Clinical examination will assist in confirrrung Bouchard's nodes (excessive bone forma- diagnosis. tion on dor.;al aspect of PIP joints). (3) Women have two to three times greater (6) Physical therapy goals, outcomes, and incidence than men. interventions. (4) Juvenile rheumatoid arthritis (JRA) onset (a) Patient/client education for injury pre- prior to age sixteen with complete remis- vention and reduction of involved sion in 75% of children. joint(s). (5) Pharmacological management varies with (b) Early identification of condition with disease progression and may include gold fast implementation of intervention is compounds and antirheumatic drugs very important. (DMARDs) (e.g., hydroxychloroquine and methotrexate) early. Nonsteroidal anti- c. Psoriatic arthritis. inflammatory drugs (e.g.. ibuprofen). (I) Chronic, erosive inflammatory disorder of immunosuppressive agents (e.g .. cyclo- unknown etiology associated with psoriasis. sporine, azathioprine, and mycophenolate) (2) Erosive degeneration usually occurs in or corticosteroids are commonly prescribed joints of digits as well as axial skeleton. for long-term management. (3) Both sexes are affected equally. (6) Diagnostic tests utilized: plain film imag- (4) Medications: acetaminophen for pain, ing demonstrating symmetrical involve- NSAIDs, corticosteroids, disease-modify- ment within joints as well as laboratory ing antirheumatic drugs (DMARDs) can testing. Positive test findings include an slow the progression of psoriatic arthritis, increased white blood cell count and ery- and biologic response modifiers (BRMs) throcyte sedimentation rate. Hemoglobin such as Enbrel are a newly developed class and hematocrit tests will show anemia and of medicines. rheumatoid factor will be ele,·ated. (5) Diagnostic tests utilized: lab tests are not (7) Clinical examination will assist in continn- useful except to rule out rheumatoid anhritis. ing diagnosis. (6) Clinical examination will assist in confinn- (8) Physical therapy goals. outcomes. and ing diagnosis. interventions. (7) Physical therapy goals, outcomes, and (a) Joint protection strategies. (b) Maintain/improve joint mechanics and interventions. (a) Joint protection strategies. connective tissue functions. (b) Maintain/improve joint mechanics and (c) Implementation of aerobic capacity connective tissue functions. lendurance conditioning or recondi- (c) Implementation of aerobic capacity! tioning such as aquatic programs. B. Skeletal and Soft Tissue Conditions endurance conditioning or recondition- 1. Osteoporosis. ing such as aquatic programs. a. A metabolic disease which depletes bone min- d. Rheumatoid arthritis (RA). erai density/mass, predisposing individual to (I) Chronic systemic disorder of unknown etiol- fracture. ogy that usualJy involves a symmetric pat- b. Affects women ten times more frequently than men. tern of dysfunction in synovial tissues and articular cartilage of joints of hands, wrists, elbows, shoulders, knees, ankles and feel. (2) Metacarpophalangeal (MCP) and proximal
40 pressed adults than healthy adults and more common in males than females. c. Common sites of fracrure include thoracic and d. Medical treatment consists of antibiotics. lumbar spine. femoral neck, proxima] humerus, Proper nutrition is important as well. Surgery proximal tibia, pelvis. and distal radius. may be indicated if infection spreads to joints e. Diagnostic tests utilized: lab tests for infection d. Primary or postmenopausal osteoporosis is and possibly a bone biopsy. directly related to a decrease in the production f. Clinical examination will assist in confirming of estrogen. diagnosis. g. Physical therapy goals. outcomes, and inter- e. Senile osteoporosis occurs due to a decrease in ventions. bone cell activity secondary to genetics or (I) 10intlbone protection strategies as well as acquired abnormalities. cast care. f. Medications: calcium, vitamin D. estrogen, (2) Maintain/improve joint mechanics and calcitonin, and biophosphonares. connective tissue functions. g. Diagnostic tests utilized: CT scan to assess 4. Arthrogryposis multiplex congenita. bony density. Single and dual photon absorp- tiometry are aJso used, but very expensive. a. Congenital deformity of skeleton and soft tis- sues which is characterized by limitation in h. Clinical examination will assist in confirmjng joint motion and a \"sausage-like\" appearance diagnosis. of limbs. i. Physical therapy goals, outcomes, and inter- b. Intelligence develops normally. ventions. c. Ongoing communication with family and (l) Joinr/bone protection strategies. (2) Maintainlimprove joint mechanics and school is important in therapeutic management. connective tissue functions. d. Diagnostic tests utilized: plain films. (3) Implementation of aerobic capacity/ e. Clinical examination will assist in confirming endurance conditioning or reconditioning such as aquatic programs. diagnosis. f. Physical therapy goals. olilcomes, and inter- 2. Osteomalacia. a. Characterized by decalcification of bones as ventions. result of a vitamin D deficiency. (1) Joint/bone protection strategies. b. Symptoms include: severe pain, fractures, (2) Maintainlimprove joint mechanics and weakness and deformities. c. Medications: calcium, vitamin D, and vitamin D connective tissue functions. injection in the form of calciferol (vitamjn D2). (3) Implemel1lation of aerobic capacityl d. Diagnostic tests utilized: plain t1lms, lab tests (urinalysis and blood work), bone scan. and endurance conditioning or reconditioning potentially a bone biopsy. such as aquatic programs. e. Clinical examination will assist in confirming (4) Application of and patient education diagnosis. regarding adaptive devices, assistive f. Physical therapy goals, outcomes. and inter- devices. orthotic devices, and supportive ventions. devices. (I) 10intlbone protection strategies. (5) Implementation of flexibility exercises lo (2) Maintain/improve joint mechanics and maintain/improve normal joint motion and connective tissue functions. length of muscles. (3) Implementation of aerobic capacity/ 5. Osteogenesis imperfecta. endurance conditioning or reconditioning a. Inherited disorder transmitted by an autosomal such as aquatic programs. dominant gene. b. Characterized by abnormal col1agen synthesis 3. Osteomyelitis which leads to an imbalance between bone a. An inflammatory response within bone caused deposition and reabsorption. by an infection. c. Cortical and cancellous bone become very thin b. Usually caused by staphylococcus aureus, but leading to fractures and deformity of weight could be other organism. bearing bones. c. More common in children and immunosup-
d. Medications: calcium, vitamin D, estrogen, Musculoskeletal Physical Therapy 41 calcitonin, and biophosphonates. can be converted into an active trigger point. e. Diagnostic tests utilized: bone scan and plain c. Onset is hypothesized to sudden overload, films will demonstrate old fractures and defor- mities. Serologic testing is also indicated. overstretching. and/or repetitive/sustained muscle activities. f Clinical examination will assist in confirming d. Medical intervelllion may include dry needling diagnosis. and/or injection of analgesic possibly com- bined with a corticosteroid. g. Physical therapy goals, outcomes, and inter- e. Diagnosis is made by clinical assessment with ventions. no diagnostic tests available. (I) Joint/bone protection strategies. f. Clinical examination will assist in confirming (2) Maintain/improve joint mechanics and diagnosis. connective tissue functions. g. Physical therapy goals, outcomes, and inter- (3) Implementation of aerobic capacityl ventions. endurance conditioning or reconditioning (l) Implementation of flexibility exercises to such as aquatic programs. maintainlimprove normal joint motion and 6. Osteochondritis dissecans. length of muscles. a. A separation of articular cartilage from under- (2) Implementation of manual therapy for lying bone (osteochondral fracture) lIsually maintenance of normal joint mechanics. involving medial femoral condyle near inter- (a) Soft tissue/massage techniques and condylar notch and observed less frequently at femoral head and talar dome. Also affects the joint oscillations to reduce pain and/or humeral capitellum. muscle guarding. b. Surgical intervention is indicated if fracture is (b) Biomechanical faults caused by joint displaced. restrictions should be corrected with c. Diagnostic tests utilized: plain film or CT scan joint mobilization to the specific imaging to identify defect. restrictions identified during the exam- d. Clinical examination will assist in confirming inmion. diagnosis. (c) Use of \"spray and stretch\" technique. e. Physical therapy goals, outcomes, and inter- (d) Cryotherapy. thermotherapy, hydrother- ventions. apy. sound agents. and TENS for (l) 10intlbone protection strategies. symptomatic relief of pain. (2) Implementation of flexibility exercises to (e) Desensitization of trigger point with maintain/improve normal joint motion and manual pressure. length of muscles. (3) Implemenration of strength, power, and (3) Implementation of aerobic capacityl endurance exercises. endurance conditioning or reconditioning (a) Active assistive. active. and resistive such as aquatic programs. exercises. (4) Implementation of strength, power, and (b) Task specific performance training. endurance exercises. 8. Tendonitis. a. An inflammation of tendon as result of micro- 7. Myofascial pain syndrome. trauma from overuse, direct blows and/or a. Characterized by clinical entity known as a excessive tensile forces. \"trigger point\" which is a focal point of irri- b. Medications: acetaminophen, NSAIDS, and/or tability found within a muscle. Trigger point steroid injection. can be identified as a taut palpable band within c. Diagnostic tests utilized: possibly MRJ. the muscle. d. Clinical examination will assist in confirming b. Trigger points may be active or latent. Active diagnosis. Specific special tests are available to trigger points are tender to palpation and have assist with making diagnosis within each a characteristic referral pattern of pain when region/joint. provoked. Latent trigger points are palpable e. Physical therapy goals. outcomes, and inter- taut bands that are not tender to palpation, but ventions.
42 (2) Implementation of manual therapy for maintenance of normal joint mechanics. (I) Implementation of flexibility exercises to (a) Soft tissue/massage techniques and maintain/improve normal joint motion and joint oscillations to reduce pain and/or length of muscles. muscle guarding. (b) Biomechanical faults caused by joint (2) Implementation of manual therapy for restrictions should be corrected with maintenance of norma] joint mechanics. joint mobilization to the specific (a) Soft tissue/massage techniques and restrictions identified during the exam- joint oscillations to reduce pain and/or ination. muscle guarding. (b) Biomechanical faults caused by joint (3) Implementation of aerobic capacity/ restrictions should be corrected with endurance conditioning or reconditioning. joint mobilization to the specific restrictions identified during the exam- (4) Application of thermal agents for pain ination. reduction, edema reduction, and muscle perfonnance. (3) Implementation of aerobic capacity/ (a) Cryotherapy, thermotherapy, hydrother- endurance conditioning or reconditioning. apy, and sound agents. (4) Application of thermal agents for pain (S) Patient/client education and training/ reduction, edema reduction, and muscle retraining for instrumental activities of performance. daily living (lADL). (a) Cryotherapy. thermotherapy. hydrother- (a) Household chores, yard work, shop- apy, and sound agents. ping, caring for dependents, and home maintenance. (5) Patient/client education and training/ retraining for instrumental activities of 10. Bursitis. daily living (IADL). a. Bursitis is an inflammation of bursa secondary (a) Household chores. yard work. shop- to overuse, trauma, gout or infection. ping. caring for dependents. and home b. Signs and symptoms of bursitis. maintenance. (I) Pain with rest. (2) PROM and AROM are limited due to pain 9. Tendonosis. but not in a capsular pattern. a. Common chronic tendon dysfunction whose c. Medications: acetaminophen, NSAlDS, and/or cause and pathogenesis are poorly understood. steroid injection. Often referred to as chronic tendonitis. howev- d. Clinical examination will assist in confirming er, there is no inflammatory response noted. diagnosis. b. Common in many tendons throughout body e. Physical therapy goals. outcomes. and inter- (supraspinatus, common extensor tendon of ventions. elbow, patella. achilles). (I) Implementation of flexibility exercises to c. Histological characteristics include hypercellu- maintain/improve normal joint motion and larity, hypervascularity. no indication of length of muscles. inflammatory infiltrates, and poor organization (2) Implementation of manual therapy for and loosening of collagen fibrils. maintenance of normal joint mechanics. d. Medications: acetaminophen. SAIDS. and/or (a) Sof[ tissue/massage techniques and steroid injection. joint oscillations to reduce pain and/or e. Diagnostic tests utilized: possibly MRI. muscle guarding. f. Clinical examination will assist in confrrming (b) Biomechanical faults caused by joint diagnosis. Specific special tests are available to restrictions should be corrected with assist with making diagnosis within each joint mobilization to the specific restric- region/joint. tions identified during the examination. g. Physical therapy goals, outcomes, and inter- (3) Implementation of aerobic capacity/ ventions. endurance conditioning or reconditioning. (I) Implementation of flexibility exercises to maintain/improve normal joint motion and length of muscles.
(4) Application of thermal agents for pain MuscuJoskeletal Ph)'sical Therapy 43 reduction, edema reduction, and muscle pelfofmance. 12. Myositis ossificans. (a) Cryotherapy. thennotherapy, hydrother- a. Painful condition of abnormal calcification apy. and sound agents. within a muscle belly. b. Usually precipitated by direct trauma which (5) Patient/client education and training! results in hematoma and calcification of the retraining for instrumental activities of muscle. daily living (IADL). c. Can also be induced by early mobilization and (a) Household chores, yard work, shop- stretching with aggressive physical therapy fol- ping, caring for dependents. and home lowing trauma to muscle. maintenance. d. Most frequent locations are quadriceps, brachialis. and biceps brachii muscles. 11. Muscle strains. e. Medications: acetaminophen and/or NSAIDS. a. Characterized by an inflammatory response f. Surgical care is warranted only in patients with within a muscle following a traumatic event nonhereditary myositis ossificans and only that caused microtearing of the musculotendi- after maturation of the lesion (6-24 mo). nous fibers. Surgery is indicared when lesions mechanical- b. Pain and tenderness within that muscle. ly interfere with joint movement or impinge on c. Seen within muscles throughout the body. nerves. d. Medications: acetaminophen and/or NSAIDS. g. Diagnostic tests utilized: imaging (plain films, e. Diagnostic tests utilized: MRl if necessary. CT scan. and/or MRI). f. Clinical examination will assist in confirming h. Clinical examination will assist in confirming diagnosis. diagnosis. g. Physical therapy goals. outcomes. and inter- 1. Physical therapy goals. outcomes. and inter- ventions. \\·entions. (I) Implementation of flexibility exercises to (I) Implementation of flexibility exercises to maintain/improve normal joim motion and maintain/improve normal joint motion and length of muscles. length of muscles. Must avoid being overly (2) Implementation of manual therapy for aggressive with muscle Oexibility exercis- main~enance of nonnal joint mechanics. es. which may worsen condition. (a) Soft tissue/massage techniques and (2) Implementation of manual therapy for joim oscillations to reduce pain and/or maintenance of nonnal joint mechanics. muscle guarding. (a) Soft tissue/massage techniques and (b) Biomechanical faults caused by joint joim oscillations to reduce pain and/or restrictions should be cOl'rected with muscle guarding. Avoid aggressive soft joint mobilization to the specific tissue/massage techniques. which may restrictions identified during the exam- worsen condition. ination. (b) Biomechanical faults caused by joint (3) Implementation of aerobic capacity/ restrictions should be corrected with endurance conditioning or reconditioning. joint mobilization to the specific (4) Application of thermal agents for pain restrictions identified during the exam- reduction. edema reduction. and muscle ination. performance. (3) Implementation of aerobic capacity/ (a) Cryotherapy. thennotherapy. hydrother- endurance conditioning or reconditioning apy. and sound agents. such as aquatic programs. (5) Patient/client education and training/ retraining for instrumental activities of 13. Complex regional pain syndrome (CRPS). daily living (IADL). a. Formerly referred to as reflex sympathetic dys- (a) Household chores. yard work. shop- trophy (RSD). ping. caring for dependents, and home b. Etiology largely unknown but thought to be relat- maintenance. ed [Q trauma. Can affect the upper extremity, lower extremity, trunk. head and neck.
44 e. Diagnostic tests utilized: plain film imaging ident.ifies bony changes. Lab tests look for c. Results in dysfunction of sympathetic nervous increascd levels of serum alkaline phosphatase system to include pain. circulation. and vaso- and urinary hydroxyproline. motor disturbances. f. Clinical examination will assist in confirming d. Two types of CRPS. diagnosis. (I) CRPS I is frequeI1lly triggered by tissue injury: term describes all patients with the g. Physical therapy goals, outcomes, and inter- above symptoms but with no underlying ventions. nerve injury. (I) !ointfbone protection strategies should be (2) Patients with CRPS II experience same taught to patient. symptoms but their cases are clearly asso- (2) Maintain/improve joint mechanics and ciated with a nerve injury. connective tissue functions. (3) Implementation of aerobic capacity! e. Medical intervention may include symparhetic endurance conditioning or reconditioning nerve block. surgical sympathectomy. spinal such as aquatic programs. cord sti mulation, intrathecal drug pumps. IS.ldiopathic scoliosis. f. Medications: multiple forms of medications a. Two types: structural and nonstructural both of are used to treat eRPS, including topical anal- unknown etiology. gesic drugs that act locally on painful nerves, b. Structural scoEosis is an irreversible lateral skin. and muscles: antiseizure drugs: antide- curvature of spine with a rotational component. pressants. corticosteroids. and opioids. c. Nonstructural scoliosis is a reversible lareral curvature of spine without a rotational compo- g. Long term changes include muscle wasting. nent and straightening as individual flexes trophic skin changes. decreased bone density, spllle. decreased proprioception. loss of muscle d. [ntervention for structural scoliosis includes strength from disuse. and joint contractures. bracing and possible surgery with placemcnt of Harrington rod instrumentation. Rule of thumb is h. Diagnostic tests utilized: none. less than 25° do conservative physical therapy I. Clinical examination will assist in confirming (see below). between 25°_45° use spinal orthoses. and surgery for curves greater than 45°. diagnosis. e. Diagnostic tests utilized: plain film imaging j. Physical therapy goals. outcomes, and inter- using full length Cobb method. CT scan and/or MRI may be used to rule out associated condi- ventions. tions. (1) Patient/client educarion for injury preven- f. Clinical examination will assist in confirming diagnosis. tion and reduction. g. Physical therapy goals, outcomes, and inter- (2) Desensitization activities that focus on ventions. (I) Implementation of flexibility exercises to return to worklschoollhome activities. maintain/improve norma] joint motion and (3) Implementation of flexibility exercises to length of muscles throughout trunk and pelvis. maintain/improve normal joint motion and (2) Implementation of strength, power. and length of muscles. endurance exercises. (4) Electrical stimulation (TENS) for pain (3) Electrical stimulation to improve muscle relief. performance. 14. Pager's disease (osteitis deformans). (4) Application and patient education regard- a. Etiology is largely unknown but thought to be ing spinal orthoses. linked to a type of viral infection along with environmental factors. 16. Torticollis. b. Considered to be a metabolic bone disease a. Spasm and/or tightness of sternocleidomastoid involving abnom1aI osteoclastic and osteoblas- tic activity. c. Results in spinal stenosis. facet arthropathy, and possible spinal fracture. d. Primary medical intervention is drug therapy such as acetaminophen for pain control. Drugs such as calcitonin and elidronate disodium may be beneficial since they limit osteoclast activity.
(SCM) muscle with varied etiology. Musculoskeletal Physical Therapy 45 b. Dysfunction observed is sidebending towards externaJ rotarjon to 80 degrees). and rotation away from the affected SCM. (7) Diagnostic tests utilized: plain film imag- c. Medications: acetaminophen, muscle relax- ing. CT scan. and/or MRI. ants. and/or NSALDS. (8) Diagnosis made by clinical examination. d. Diagnostic tests utilized: none. e. Physical therapy goals. outcomes. and inter- Apprehension tests will be positive. (9) Medications. ventions. (I) Implementation of flexibility exercises to (a) Acetaminophen for pain. (b) SALDS for pain and/or inflammation. maintain/improve normal joint motion and (IO)Physical therapy goals. outcomes. and length of muscles. interventions. (2) Implementation of manual therapy for (a) Physical therapy intervention is varied maintenance of normal joint mechanics. (a) Soft tissue/massage techniques and dependent upon the specific patient problems and whether surgery is per- joint oscillations to reduce pain and/or formed. muscle guarding. (b) Biomechanical faults caused by joint (b) Biomechanical faults caused by joint restrictions should be corrected with restrictions should be corrected with joint mobilization to the specitic restric- joint mobilization to the specific tions identified during the examination. restrictions identified during the exam- (c) Restoration of normal shoulder mechanics ination. via strengthening/endurance/coordination • Cpper Extremity Disorders exercises that focus all regaining dynam· L Shoulder conditions. ic scapulothoracic and glenohumeral a. Glenohumeral subluxation and dislocation. stabilization and muscular reeducation. (I) Most dislocations (95%) occur in anterior- b. Thoracic outlet syndrome (TOS). inferior direction. (I) Compression of neurovascular bundle (2) Anterior-inferior dislocation occurs when (brachial plexus. subclavian artery and vein, abducted upper extremity is forcefully vagus and phrenic nerves, and the sympa~ externally rotated causing tearing of inferi- thetic tmnk) in thoracic ourlet between or glenohumeral ligament. anterior capsule bony and soft tissue structures. and occasionally glenoid labrum. (2) Compression occurs when size or shape of (3) Posterior dislocations are rare and occur thoracic ourlet is altered. with multidirectional laxity of glenohumer- (3) Common areas of compression are: al joint. (al Superior thoracic outlet. (4) Posterior dislocation occurs with horizontal (b) Scalene triangle. adduction and internal rotation of gleno- (c) Bet\\\\'een c1a\\·icle and 1st rib. humeral joint. (d) Between pectoralis minor and thoracic (5) Complications may include compression waU. fracture of posterior humeral head (Hill- (.+) Surgery may be performed to remove a cer- Sachs lesion). tcaring of superior glenoid vical rib or a release of anterior and/or mid· labrum from posterior to anrerior (SLAP dIe scalene muscle. lesion), an avulsion of anteroinferior cap- (5) Diagnostic tests utilized: plain tilm imag- sule and ligaments associated with glenoid ing to identify abnormal bony anatomy and rim (Bankart lesion) and bruising of axil- MRf to identify abnormal soft tissue anato- lary nerve. my. Electrodiagnoslic test to assess nerve (6) Following surgical repaIr for dysfunction. dislocarion/chronic subluxation. patients (6) Clinical examination including the follow- should avoid apprehension position (flex- ing special tests will be useful to make ion to 90 degrees or greater. horizomal diagnosis. abduction to 90 degrees or greater. and <aJ Adson test. (b) Roos test.
46 pain. (b) Functional training and restoration of (c) Wright test. (d) Costoclavicular test. muscle imbalances using exercise to (7) Medications. (a) Acetaminophen for pain. normalize strength, endurance, coordi- (b) SAlDS for pain andlor inflammation. (8) Physical therapy goals. outcomes. and nation. and flexibility. interventions. (c) Manual therapy techniques to AC and (a) Physical therapy intervention will vary SC joints and surrounding connective depending on the exact cause. tissues such as soft tissue/massage. (b) includes poslllral reeducation. joint oscillations, and mobilizations to (c) Functional training and restoration of normalize soft tissue and joint biome- chanics. muscle imbalances using exercise to d. Subacromiallsubdeltoid bursitis. (I) Subacromial and subdeltoid bursae (which normalize strength. endurance, coordi- may be continuous) have a close relation- ship to rotator cuff tendons which makes nation. and flexibility. them susceptible to overuse. (d) Biomechanical faults caused by joint (2) They can also become impinged beneath the acromial arch. restrictions should be corrected with (3) Diagnosis made by clinical examination. joint mobilization to the specific restric- Differentiate from contractile condition by tions identified during the examination. comparing results of AROM, PROM. and (e) Manipulations (typically 1st rib articu- resistive tests. lation) to diminish pain and soft tissue (4) Medications. guarding. (a) Acetaminophen for pain. (b) SAfDS for pain andlor inflammation. c. Acromioclavicular and sternoclavicular joint (5) Physical therapy goals. outcomes, and disorders. interventions. (I) Mechanism of injury is a fall onto shoulder (a) Refer to intervention for general bursi- with upper extremity adducted or a collision tisltendonitisltendonosis (III. 8.9-11). with another individual during a sporting e. Rotator cuff tendonitis. (I) Tendons of rotator cuff are susceptible 10 event. tendonitis due to relatively poor blood sup- ply near insertion of muscles. (2) Traditionally degree of injury is graded (2) Results from mechanical impingement of from tirs! to third degree. Rockwood classi- the distal attachment of the rotator cuff on fication scale uses grades from I-IV with the anterior acromion, and/or coracoacro- mial ligament with repetitive overhead grades JV- VI variations of the traditional activities. (3) Diagnostic tests utilized: MRI may be used, grade III. but sometimes not sensitive enough for (3) Upper extremity is positioned in neutral accurate assessment. (4) Clinical examination including the follow- with use of sling in acute phase. Avoid ing special tests will be useful to make shoulder elevation during the acute phase diagnosis. of healing. (a) Supraspinatus test. (4) Diagnostic tests utilized: plain film imaging. (b) Neer impingement test. (5) Clinical examination including the follow- (5) Medications. ing special tests will be useful to make (a) Acetaminophen for pain. diagnosis. (b) NSAIDS for pain andlor inflammation. (a) Shear tesl. (6) Physical therapy goals, outcomes, and (6) Surgical repair is rare due to tendency of acromioclavicular joint degeneration fol- lowing the repair. (7) Medications. (a) Acetaminophen for pain. (b) SAIDS for pain andlor inflammation. (8) Physical therapy goals. outcomes. and interventions. (a) Emphasize return of function without
interventions. Musculoskeletal Physical Therapy 47 (a) Refer to intervention for general bursi- interventions. tis/tendonitis/tendonosis (m.B .9-11). (a) Correction of muscle imbalances and f. Impingement syndrome. biomechanical faults using strengthen- (1) Characterized by soft tissue inflammation ing, endurance, coordination, and flex- of the shoulder from impingement against ibility exercises to gain restoration of the acromion with repetitive overhead normal function. AROM. (b) Biomechanical faults caused by joint restrictions should be corrected with (2) Diagnostic te ts utilized: arthrogram or joint mobilization to the pecific MRI may be used. restrictions identified during the exam- ination. (3) Clinical examination including the follow- h. Bicipital tendonitis. ing special tests will be useful to make (1) Most commonly an inflammation of the diagnosis. long head of the bicep . (a) Neer impingement test. (2) Results from mechanical impingement of (b) Supraspinatus test. the proximal tendon between the anterior (c) Drop arm test. acromion and the bicipital groove of the humerus. (4) Surgical repair of shoulder impingement. (3) Diagnostic tests utilized: MRI may be u ed, The patient should avoid shoulder elevation but sometimes not sensitive enough for greater than 90 degrees. accurate assessment. (4) Clinical examination including the follow- (5) Medications. ing special tests will be useful to make (a) Acetaminophen for pain. diagnosis. (b) NSAIDS for pain and/or inflammation. (a) Speed's test. (5) Medications. (6) Physical therapy goals, outcomes, and (a) Acetaminophen for pain. interventions. (b) NSAIDS for pain and/or inflammation. (a) Restoration of posture. (6) Physical therapy goals, outcomes, and (b) Correction of muscle imbalances and interventions. biomechanical faults using strengthen- (a) Refer to intervention for general bursi- ing, endurance, coordination, and flex- tis/tendonitis/tendonosis (III.B.9-11). ibility exercises to gain restoration of i. Proximal humeral fractures. normal function. (1) Humeral neck fractures frequently occur (c) Biomechanical faults caused by joint with a fall onto an outstretched upper restrictions should be corrected with extremity among older osteoporotic joint mobilization to the specific women. Generally does not require immo- restriction identified during the exam- bilization or surgical repair since it is a fair- ination. ly stable fracture. (2) Greater tuberosity fractures are more com- g. Internal (posterior) impingement. mon in middle aged and elder adults. This (1) Characterized by an irritation between the is also usually related to a fall onto the rotator cuff and greater tuberosity or poste- shoulder and does not require immobiliza- rior glenoid and labrum. tion for healing. (2) Often seen in athletes performing overhead (3) Diagnostic tests utilized: plain film imaging. activities. Pain commonly noted in posteri- (4) Medications. or houlder. (a) Acetaminophen for pain. (3) Diagnostic tests utilized: None (b) NSAIDS for pain and/or inflammation. (4) Clinical examination including posterior (5) Physical therapy goals, outcomes, and internal impingement test helps to identify interventions. this condition. (5) Medications. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (6) Physical therapy goals, outcomes, and
48 mentous sprain, and/or complex regional pain syndrome. (a) Physical therapy intervention empha- (3) Diagnosis made by clinical examination by sizes return of function without pain. comparing results of AROM, PROM, resis- tive tests, and palpation. (b) Functional training and restoration of (4) Medications. muscle imbalances using exercise to (a) Acetaminophen for pain. normalize strength, endurance, coordi- (b) NSAIDS for pain and/or inflammation. nation, and flexibility. (5) Physical therapy goals, outcomes, and interventions. (c) Biomechanical faults caused by joint (a) Biomechanical fault caused by joint restrictions hould be corrected with joint mobilization to the specific restrictions should be corrected with restrictions identified during the exam- joint mobilization to the specific ination. restrictions identified during the exam- ination. (d) Early PROM is important in preventing (b) Soft tissue/massage techniques, modal- capsular adhesions. ities, flexibility exerci es, and function- al exercise including strengthening, j. Adhesive capsulitis (frozen shoulder). endurance, and coordination. (1) Characterized by a restriction in shoulder (c) Splinting may be an effective adjunct motion as a result of inflammation and to physical therapy management in fibrosis of the shoulder capsule usually due regaining 10 s of motion for capsular to disuse following injury or repetitive restrictions. microtrauma. b. Lateral epicondylitis (\"tennis elbow\"). (2) Restriction follows a capsular pattern of (1) Most often a chronic inflammation of the limitation: extensor carpi radiali brevis tendon (a) Greatest limitation in external rotation, (ECRB) at its proximal attachment to the followed by abduction and flexion, and lateral epicondyle of the humerus. least restricted in internal rotation. (2) Onset is gradual, usually the result of sports (3) Commonly seen in association with dia- activities or occupations that require repet- betes mellitus. itive wrist extension or strong grip with the (4) Diagnosis made by clinical examination by wrist extended, resulting in overloading the comparing results of AROM, PROM, resis- ECRB. tive tests, and palpation. (3) Must rule out involvement or relationship (5) Medications. to cervical spine condition. (a) Acetaminophen for pain. (4) Clinical examination including lateral epi- (b) NSAIDS for pain and/or inflammation. condylitis test helps to identify this condi- (6) Physical therapy goals, outcomes, and tion. interventions. (5) Medications. (a) Physical therapy intervention empha- (a) Acetaminophen for pain. sizes return of function without pain. (b) NSAIDS for pain and/or inflammation. (b) Functional training and restoration of (6) Physical therapy goals, outcomes, and muscle imbalances using exercise to interventions. normalize strength, endurance, coordi- (a) Correction of muscle imbalances and nation, and flexibility. biomechanical faults u ing strengthen- (c) Biomechanical faults caused by joint ing, endurance, coordination, and flex- restrictions should be corrected with ibility exercises to gain restoration of joint mobilization to the specific restric- normal function. tions identified during the examination. (b) Biomechanical faults caused by joint restrictions should be corrected with 2. Elbow conditions. a. Elbow contractures. (1) Loss of motion in capsular pattern (loss of flexion greater than extension). (2) Lo s of motion in noncapsular pattern as the result of a loose body in the joint, liga-
joint mobilization to the specific Musculoskeletal Physical Therapy 49 restrictions identified during the exam- ination. (a) Physical therapy intervention includes (c) Education regarding prevention. pain reduction and limiting the inflam- (d) Cryotherapy, thermotherapy, hydrother- matory response following trauma apy, sound agents, and TENS for and/or surgery. symptomatic relief of pain. (e) Counterforce bracing is frequently (b) Improving flexibility of shortened used to reduce forces along the ECRB. structures, strengthening, and training c. Medial epicondylitis (golfer's elbow). to restore functional use of DE. (1) Usually an inflammation of the pronator teres and flexor carpi radialis tendons at e. Osteochondrosis of humeral capitellum. their attachment to the medial epicondyle (I) Osteochondritis dissecans affects central of the humerus. and/or lateral aspect of capitellum or radial (2) Occurs as the result of chronic overuse in head. An osteochondral bone fragment sports such as baseball pitching, driving becomes detached from articular surface, golf swings, swimming, or occupations that forming a loose body in joint. Caused by require a strong hand grip and excessive repetitive compressive forces between radi- pronation of the forearm. al head and humeral capitellum. Occurs in (3) Diagnostic tests utilized: none. adolescents between 12 and 15 years of age. (4) Clinical examination including medial epi- (2) Panner's disease is a localized avascular condylitis test helps to identify this condi- necrosis of capitellum leading to loss of tion. subchondral bone with fissuring and soft- (5) Physical therapy goals, outcomes, and ening of articular surfaces of radiocapitel- interventions. lar joint. Etiology is unknown but occurs in (a) Intervention is similar to lateral epi- children age 10 or younger. condylitis. (3) Diagnostic tests utilized: plain film imaging. d. Distal humeral fractures. (4) Medications. (1) Complications can include loss of motion, (a) Acetaminophen for pain. myositis ossificans, malalignment, neu- (b) NSAIDS for pain and/or inflammation. rovascular compromise, ligamentous injury (5) Physical therapy goals, outcomes, and and CRPS. interventions. (2) Supracondylar fractures must be examined (a) Physical therapy intervention includes quickly for neurovascular status due to high rest with avoidance of any throwing or number of neurologic (typically radial upper extremity loading activities (e.g., nerve involvement) and vascular structures gymnastics). that pass through this region (may lead to (b) When patient is pain free initiate flexi- Volkmann's ischemia). In youth it is impor- bility and strengthening/endurance/ tant to assess growth plate as well. These coordination exercises. fractures have high incidence of malunion. (c) During late phases of rehabilitation, a (3) Lateral epicondyle fractures are fairly com- program to slowly increase load on mon in young people and typically require joint is initiated. If symptoms persist, an open reduction internal fixation (ORIP) surgical intervention is necessary. to insure absolute alignment. (d) After surgery, initial focus of rehabilita- (4) Diagnostic tests utilized: plain film imaging. tion is to minimize pain and swelling (5) Medications. using modalities. flexibility exercises are (a) Acetaminophen for pain. begun immediately following surgery. (b) NSAIDS for pain and/or inflammation. (e) Thereafter, a progressive strengthening (6) Physical therapy goals, outcomes, and program is initiated. interventions. (f) Biomechanical faults caused by joint restrictions should be corrected with joint mobilization to the specific restrictions identified during the exam- ination.
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