1.
MPS
Ax
I. Physical exam
II. Diagnostic procedures: lab
test, imaging (spinal
radiography – minimal, CT,
MRI) ->
anatomic/structural
disorders (low percentage
of fxl abnormalities), CT,
myelography, MRI -> well
established in dx of disc
herniation & provide
significant false-positive
results
III. Psychological evaluation –
important part if any pain
mx program (VAS,
torniquet test, cold pressor
test, McGill Pain
Questionnaire (130), MMPI
or Minnesota Multiphasic
Personality Inventory
(MMPI-2)
IV. Electrodiagnosis – EMG
and evoked potential
studies
V. Anesthetic procedures
Tx
I. Primary goals: alleviating
pain, enhancing QOL and
functional capabilities
II. Multidisciplinary approach
III. Pain treatment centers
IV. Physical modalities –
therapeutic heat &
cryotherapy* time-honored
interventions; TENS,
acupuncture, cold laser –
questioned methods in
alleviating discomfort
Heat and cold applications
are primarily directed at
reducing spasmodic
muscle shortening. The
shortened muscle may be
a result of direct muscular
trauma or underlying
primary neurologic or
skeletal disease.
cryotherapy 4 distinct
applications in medicine:
stop
or slow bleeding, induce
hypothermia, decrease
spasticity, and relieve pain
heat therapy best
tolerated in the subacute
and chronic phases of a
disease process.
➢ Musculoskeletal
contractures respond
well to deep heat used
in
association with prolonged
stretch. Joint stiffness
associated
with chronic inflammatory
diseases, particularly
those affecting
the limbs, responds to
superficial heating with
decreased pain and
increased range of motion
and function. Subacute
and chronic
bursitis, tenosynovitis,
and epicondylitis also
may respond to
heat with decreased pain
and symptom resolution
TENS
Therapeutic ex
V. Behavioral treatment
modalities
VI. Pharmacological
intervention
De lisa pg 1317 – MPS pg 1325
Pain
O’sulli
Myofascial pain syndromes
demonstrate generalized aching
and at least three trigger points,
which have lasted for at least 3
months with no history of trauma
Medical Background (Kisner, De
Lisa)
Myofascial pain syndrome (MPS)
is defined as a chronic,
regional pain syndrome.
The hallmark classification of
MPS comprises the myofascial
trigger points (MTrPs) in a muscle
that have a specific referred
pattern of pain, along with
sensory, motor, and autonomic
symptoms.
The trigger point is defined as a
hyperirritable area in a tight band
of muscle. The pain from these
points is described as dull,
aching, and deep.
Possible Causes of Trigger
Points
Although the etiology of trigger
points is not completely
understood, some potential
causes are:
■ Chronic overload of the muscle
that occurs with repetitive
activities or that maintain the
muscle in a shortened position.
■ Acute overload of muscle, such
as slipping and catching
oneself, picking up an object that
has an unexpected
weight, or following trauma such
as in a motor vehicle accident.
■ Poorly conditioned muscles
compared to muscles that are
exercised on a regular basis.
■ Postural stresses such as
sitting for prolonged periods of
time, especially if the workstation
is not ergonomically
correct, and leg length
differences.
■ Poor body mechanics with
lifting and other activities
Principles of Management:
Myofascial Pain Syndrome

Pain from trigger points is
described as dull, aching, and
deep.
Additional impairments from the
trigger points include decreased
ROM when the muscle is being
stretched, decreased strength in
the muscle, and increased pain
with muscle stretching. The
trigger points may be active
(producing a classic pain pattern)
or latent (asymptomatic unless
palpated).
Treatment consists of three main
components:
■ Correct chronic overload.
Correct contributing factors that
cause chronic overload of the
muscle, such as faulty posture,
repetitive activity, or poor lifting
techniques. The correction is
often done with education
including stressing the
importance of taking intermittent
mini-breaks. If indicated, an
ergonomic assessment of the
work environment is performed.
■ Eliminate the trigger point.
Several techniques are used to
eliminate trigger points
■ Contract-relax-passive
stretch done repeatedly until the
muscle lengthens
■ Contract-relax-active
stretch also done in
repetition
■ Trigger point release
■ Spray and stretch
■ Modalities
■ Dry needling or injection
■ Strengthen muscle. Exercise
prescription, using a muscle
endurance protocol, is typically
indicated for core and
➢ Dry needling (DN) has
been shown to be a
low-risk intervention
that can decrease pain
severity and pain
pressure threshold as
well as improve
functional outcomes in
people with MTrPs
(upper trapezius,
cervicothoracic region)
➢ If the cause of the
trigger point in
myofascial pain
syndrome
is a chronic overload of
the muscle, eliminate
the contributing
factor prior to
addressing the trigger
point. Initiate muscle
strengthening when
ROM is restored and
the trigger point has
been addressed.

- Myofascial pain syndromes are
commonly seen when evaluating
and treating patients for chronic
pain.
- Trigger points are characterized
by pain originating from small
circumscribed areas of local
hyperirritability and myofascial
structures, resulting in local and
referred pain
- The pain is aggravated by
stretching the affected area,
cooling, and compression, often
giving rise to a characteristic
pattern of referred pain
- Although the exact
pathophysiology of the trigger
point phenomenon has not been
identified, myofascial pain
syndromes appear to be initiated
by trauma, tension, inflammation,
and other unidentified factors.
- The trigger point acts as a source
of chronic nociception. The
resultant muscle dysfunction and
altered mechanics lead to the
referred pain and associated
phenomenon.
- Trigger points may occur in any
muscle or muscle group of the
body. They are commonly found
in muscle groups that are
routinely overstressed or those
that do not undergo full
contraction and relaxation cycles.
In the upper body, the groups of
muscles involved commonly
include the trapezius, levator
scapulae, and infraspinatus. In
the lower body, they include the
gluteal, tensor fasciae latae,
quadratus lumborum, and
gastrocnemius muscles
- Trigger points are best located by
deep palpation of the affected
muscle so as to reproduce the
patient’s pain symptom both
locally and in a referred zone.
When they are present, passive
or active, stretching of the
affected muscle routinely
increases the pain. The muscle in
the immediate vicinity of the
trigger point is often described as
ropy, tense, or having a palpable
band. Compared with equivalent
pressure in palpation to normal
muscle, the trigger point region
displays isolated bands,
increased tenderness, and
referred pain
- The most reliable method of
treating trigger points consists of
routine, regular stretching to
restore the normal resting length
of the muscle. Methods to
interrupt the pain cycle:
a. injection or needle stimulation
of the hypersensitive trigger
points
b. coolant sprays
c. relaxation therapy
d. pressure techniques
e. botulinum toxin injection
(provide pain relief for weeks
to months by selectively
weakening the painful
muscles)
- After interrupting the pain cycle,
the treatment is directed at
restoring the normal resting
muscle length with a regular
routine stretching program of the
involved muscle groups. This
 may be accomplished with ↑ ROM (Stretching +
physical modalities: Ultrasound, AROMS)
a. Heat and electrical ↑ Strength
stimulation, ADL Centered Approach
b. Cold Sensory Resensitization
c. correction of poor body
mechanics IV. Prevention of further
- Psychological intervention may complications
be necessary if long-standing PROPER POSITIONING:
stress and tension are the to minimize edema,
underlying cause of the problem. prevent tissue destruction,
- A long-term home modality and maintain soft tissues in
stretching program is essential in elongated state and to
the management of patients with preserve function
myofascial pain. ➢ THERAPEUTIC
- Attention to body mechanics, POSITIONING
stress, and
- daily routines may significantly
alter their functional capabilities.

2. BURN
Ax

Tx
I. Acute Compartment
Syndrome Management
FASCIOTOMY SPLINTING
II. Burn Wound Surgical Basic rule of splinting → to
Management splint the body part in a
PRIMARY EXCISION position OPPOSITE of the
SKIN GRAFTING expected deformity
➢ Autograft
➢ Allograft (or homograft) Factors to consider when
➢ Xenograft (heterograft) prescribing a splint
SKIN SUBSTITUTES ● burn size
● burn location,
III. Primary Care and ● burn type
Prevention ● functional goals
BREATHING EXERCISES ● patient activity level
↓ Pain & Pruritus
(Debridement, Ointment, Serial Casting Use in Burn
Scar massage, Injury
Thermotherapy)
 1. Long duration of stretch
with minimal force.
2. Protection of exposed
tendons
3. Mechanical forces to
remodel scar
4. Cost-effective
5. Treatment useful in
children and noncompliant
patients
6. Treatment option when
an open wound is
Present
V. EXERCISE
● Obtunded or comatose
patient → passive
ROM exercises
emphasizing the end ROM
● Alert and cooperative
patients can participate
in active and active-
assisted exercise
● Children →
developmentally
appropriate
exercise and play activities
● A structured exercise
program composed of
aerobic and resistance
training leads to
○ ↑ function as measured
by ↑ muscle
mass, strength, and
cardiovascular
endurance
● Anabolic agents, such as
oxandrolone and
HGH, reduce the effects of
hypermetabolism
while also increasing
muscle mass and strength
and decreasing resting
energy
expenditure
VI. SURGICAL ANESTHESIA
VII. STRETCHING
EXERCISES
● prescribed when ROM is
abnormal
● skin and muscle are
stretched differently
● injured skin or scar
tissue → slow sustained
mechanical stretch to
enhance elongation of
collagen and underlying
fibers
● When a prolonged
stretch is performed, the
stretch is maintained until
the tissue blanches
VIII. BLANCHING
IX. GAIT
X. GRAFTING
XI. SURGICAL
RECONSTRUCTION
XII. SIMPLE EXCISION
XIII. Z-PLASTY
XIV. LOCAL FLAPS
Medical Background
3. IMMOBILIZATION
Ax
Tx
Medical Background
4. LATERAL EPICONDYLITIS
Ax
Tx
Medical Background (Kisner)
 Lateral Elbow Tendinopathy
(Tennis Elbow)
- Tennis elbow is commonly
referred to as lateral epicondylitis
(despite current literature), lateral
epicondylalgia, lateral
epicondylosis, or lateral elbow
tendinopathy.

- Symptoms include pain over the

lateral epicondyle of
the humerus, primarily with
gripping activities.

- Activities requiring firm wrist

stability, such as the backhand
stroke in tennis, or repetitive work
tasks that require repeated wrist
extension, such as computer
work or pulling weeds in a
garden, can stress the
musculotendinous unit and cause
symptoms.
- The primary structure involved is
the origin of the extensor carpi
radialis brevis muscle (ECRB)
although the extensor digitorum
(ED) is also involved in
approximately 50% of patients.
- Positive tests of provocation
include palpation tenderness on
or near the lateral epicondyle,
pain with resisted wrist extension
performed with the elbow
extended, pain with resisted
middle finger extension, and pain
with passive wrist flexion with the
elbow extended and forearm
pronated.
De Lisa
5. DQT
Ax
Tx
Medical Background
6. FROZEN SHOULDER
Ax
Tx
Medical Background (De Lisa)
- The pathophysiology of the
frozen shoulder can be either
idiopathic or associated with
internal derangement such as
trauma, tendonitis, and tears.
- Prolonged immobilization
following one of these injuries is a
significant risk factor.
- However, a frozen shoulder can
occur in the absence of these
diagnoses. Middleage women
and diabetic patients appear to
be at a higher risk
for spontaneous idiopathic
adhesive capsulitis.
- The loss of range is multiplanar,
with external rotation and
abduction
being the most affected.
- Clinically, the diagnosis should be
suspected with progressive loss
of range and diffuse pain despite
conservative treatment
measures.
- The syndrome is typically painful
to treat and has a natural
recovery that can be prolonged
lasting up to 2 years. Early
intervention may help with
range in the pain-free zone
(Codman’s or pendulum
exercises),
joint mobilization with or without
ultrasound, and a nonsteroidal
anti-inflammatory drug (NSAID)
trial.
- An intra-articular or subacromial
injection of anesthetic and
steroid may help.
- In addition, oral steroids may play
a role in the acute management
of adhesive capsulitis. According
to Buchbinder and the Cochrane
reviews, oral steroids provide
significant short-term benefits in
pain, range of movement of
the shoulder, and function in
adhesive capsulitis but the effect
may not be maintained beyond 6
weeks.
- Distention of the capsule can be
attempted but requires larger
volumes to
be injected (25 to 35 mL is the
typical joint capacity). Initial
infusion of lidocaine (3 to 5 mL)
may make distention easier
7. ROTATOR CUFF TENDINITIS
Ax
Tx
Medical Background (De Lisa)
Rotator Cuff Tendonitis and
Tears
- The two main categories of
rotator cuff tears are related to
their mechanism of injury:
traumatic and degenerative tears.
- Traumatic tears can happen at
any age, but older people are
more susceptible because of
underlying degeneration. McNab
has defined an area in the cuff
that is noted to have less
vascularization, which may
contribute to some of the
changes
noted. As we age, the cuff thins
and becomes frayed. There is a
54% incidence of tears within the
cuff in asymptomatic individuals
older than 60 years.
- Calcific tendonitis is also a risk
factor for cuff tears and frozen
shoulder. This occurs more
commonly in diabetic patients.
- The cuff can be evaluated with
diagnostic ultrasound,
arthrography, and MRI.
- Ultrasound is the least sensitive
and can miss incomplete tears.
- MRI with T2-weighted images is
highly specific for a full-thickness
tear,
whereas its sensitivity is less for
partial-thickness tears.
The use of arthrography can
sometimes demonstrate
extravasations of
 contrast in a partial-thickness 12. DOCUMENTATION
tear, often missed with other
imaging techniques.
- Symptoms frequently associated
with rotator cuff tendonitis and
tears are pain at the site along
the tuberosity, night pain,
exacerbation of the symptoms
with
lying on that shoulder at night,
pain along the lateral aspect
of the arm toward the insertion of
the deltoid, and pain with
overhead activities.
- A painful arc is present, and
sometimes a drop arm test (pain
on lowering the arm causing the
individual to drop the arm rapidly)
is noted.
- Manual strength testing can be
done to isolate the supraspinatus,
performed along the plane of the
scapula (about 30% anterior to
the frontal
plane) with the arm internally
rotated.
- Significant weakness will be
noted if there is a full-thickness
tear, and mild or no
weakness is noted with partial
tears, secondary to muscular
compensation.

8. WRIST
Anatomy
Kinesiology
9. SHOULDER
Anatomy
Kinesiology
10. ELBOW
Anatomy
Kinesiology
11. EBP