2 Musculoskeletal Physical Therapy MICHAEL S. CROWELL, BRADLEY S. TRAGORD, AND + Study Tactics, 27 » Anatomy and Biomechanics of the Musculoskeletal System, 28 General Principles of Biomechanics, 28 netional Anatomy and Biomechanics, 31 al Therapy Examination, 50 atientClient History (or Interview), Systems Review, nd Measures, 50 Special Tests of the Upper Extremity, 55 cial Tests of the Lower Extremity, 60 ecial Tests ofthe Spine, Pelvis, andTemporomandibular Joint, 71 + Geit, 78 » Evaluation, Differential Diagnosis, Prognosis, and Plan of Care of Musculoskeletal Conditions, 79 * Evaluation and Clinical Reasoning, 79 * Prognosis, 79 + Plan of Care, 79 + Arthvitic Conditions, 79 + Skeletal and Soft Tissue Conditions, 82 + Upper Extremity Disorders, 85 + Lower Extremity Conditions, 97 * Spinal Conditions (See Boxes 2-14 and 2-15), 112 * Pediatrie Orthopedic Conditions, 121 * Orthopedie Surgical Procedures, 126 Interventions for Patients/Clients with Musculoskeletal Conditions, 129 + Interventions for Patients/Clionts wi + Interventions for PatientsClie + Specific Interventions, 130 + Relevant Pharmacology, 133 + Psychosocial Consideratior2A; Selected Musculoskeletal Outcom, e + Appendix Measures, 135 « Appendix 2B: ‘Musculoskeletal Imaging, 138 7. Review Questions and Case Studi ies « AppendixQuestions About the Musculoskeletal System Comprise 28% of the NPTE, or a Total of 51-60 Question: ‘The Number of Questions by Category Are: © Exan ination of the Patient/Client: 18-21 + Evaluation, Differential Diagnosis, Prognosis: 17-20 «Interventions: 16-19 Examination of the Patient/Client. Focus on: ‘+ Orthopedic tests and measures, including knowledge and interpretation of special tests for a given pathol- ogy or impairment ‘+ Movement analysis to include range of motion assess- ‘ment, mobilizations, and resisted motion testing ‘= Phases of the gait cycle, gait analysis, and common. gait deviations « Joint biomechanics and arthrokinematics, including, aberrant movements and responses to examination techniques such as joint mobilizations or special tests (Lachman’s, Sharp-Purser, ete.) ‘* Clinical practice guidelines and clinical prediction rules that help guide the examination process Evaluation, Differential Diagnosis, and Prognosis. Focus on: « The clinical features (signs and symptoms) and differ- ential diagnosis of prevalent musculoskeletal condi- tions across the lifespan StudyTactics 27 ‘Connective tissue disorders to include lupus, osteo- genesis imperfecta, Marfan syndrome, and Ehlers- Danlos syndrome # Development of a plan of care to include prognosis for common musculoskeletal disorders ‘Imaging techniques such as plain x-rays, MRI, CT, bone scans, and ultrasound, and the indications for the use of each technique * Actions and side effects of pharmacological manage- iment of musculoskeletal problems Interventions. Focus on: ‘= Physical therapy interventions and their applications for rehabilitation, health promotion, and perfor- ‘mance according to current best evidence ‘Principles that guide intervention strategies such as the centralization phenomenon, . Close packed position (see Table 2-2). Close Pacts where capsule and other sf ti are maximally tensed. b, Maximal contact between joint surfaces. C Joint play and mobilization cannot be pr performed in this position 3, Selected capsular patterns (see Table 23). End-feels, 11! Norma physiological end-eel Soft: occurs with soft tissue approximation « Fim: capsular and ligamentous stretching ‘Hard: when bone andor cartilage meet b. Pathological end-feel * Boggy: edema, joint swelling + Firm with decreased elasticity: fibrosis of softs * Rubbery: muscle spasm. :mpty: loose, then very hard associated with muse ‘guarding or patient avoiding painful part of rns + Hypermobility: end-feel at a later time than 0 opposite side. 5. Grading of accessory joint movement. a. Accessory joint movement or joint play is gr! {0 assess arthrokinematic motion of the joint 2" ot when itis impractical or impossible to mess joint motion with a goniometer. * Movement is assessed in comparison to the us volved extremity or adjacent vertebral joints * Graded normal, hypomobile, or hypermobile. b-Although interrater reliability is poor, intare reliability is acceptable. © Data gleaned provides clinician with more specif data on source of patient's problem, Muscle Substitutions 1. Occur wi Gecut when muscles have become shortened/lent" ened, weakened, lost end paired 00: ere gt ancy ceveioped im 2. Stton BEF muscles compensate for loss of motion.a Anatomy and Biomechanics of the Musculoskeletal System 29 § ey ame showno coupon oF Fagen Flexion/extension Dil phélant. Se eee ost ae on oa Ce aaa ee oo sane miesean roa cca sea ee oe aaa Protraction/retraction Clavicle Concave moving on Comex ae Sees ae ees 3 ee epee Ceres Metotarakphalangeal Bete feetert resimal phalors Concave moving on Convex re a pees Ce PIE a lnversion/eversion Cuboid, calcaneus: ‘Convex moving on Conesve Talocrural Dorsal/plantar flexion Talus, ‘Convex moving on Concove Tibiofibulor All movements, Fibulor head ‘Concave maving on Convex Knee ‘All movements Tibie Concave moving on Convex Hip ‘All movements Femor ‘Convex moving on Coneawe, ee abe ase ee Coeceegen oa "jad rom Kaheborn F Manual Maizon ofthe ons, Val The Exons, fh od, 204 Joint Positions. | ARMCULATIONS RESTING POSTION LOSE PACKED POSITION. i Verebral ‘Midway between flexion ond exesion Maximal nenion Pompormendilr Sew sigh open (reway p28) Mata orson (nuh closed wih eh dered See See mga pninc en Ssemeclavader om esting by sido ‘Ammannay eid ee fm esting by side fam doce 90" Glonchmere Ae ee * hizoncl auction Maxim dadcion ond ER | (seapuer plone) how Fomerohor 70 xin and 10 pation ful extension cod npiatin Horeroradl Filesenon and pinion 0" exon ond 5" opinion | en Pronialodiuhor 70 sion and 35° wpition Sprain Dal eddhor {0° spinon ‘win teri /snocarpel evel wth sight ar devon Fulttaomin wi od deviation | Hand Miccorpl Nel or sigh exon wih unr devon Brion wih par dicen | Carpometocarpal (2-5) ‘Metacarpophalangeal (MCP) _inepolngel ania Midway between abduction adducon ond oxto-enension (hub); midway between Flexion ond exension (fingers) slight lexion| Full opposition thumb); full exon (fingers) | Fall opposition (thumb; fll lexion (fingers) | Faletension oes \ (Continued)Cake TwenanEo + Musculoskeletal Physic! TTaPY 5 Table 22 on) trues ee rotation : mee ipbetion internal — esTNG POSTION, pul enerson ar acon, ord ooh! son, slight abduction, ond sigh ER, Ne 20" sion, 30" beh say 90 tein : bee ful exosion 25 axon flexion owe full dv fexion Pilaf! reson oe 10" loi Fulinversion pres id invenion/errnen rel ange oh HCS Fl pion Reset Miwa batwemn enreref range of mR" pinion a ‘ 4 eae Tiscloropholongesl ‘New extension 107) fille Inepholrgedl Sight exon Trop Fon Mage Orbe ysl Aves Oh 2014 : Es) Capsular Paterns ARTICUATONS RELATVE LINTATIONS OF MOVEMENT Tenporemendiblor Ui moh paring Upper eee pie foc C2] SSiccel one | Fervor Ren lid gra hn eterson ‘lonootara font Uimton wth rson lower cervical spine (C3-T2) Homersradil Frotimalrodioulnar Dist redioulnar wit Tropeziometocarpa Carpomelocarpae ILV Upper exremity digits Tic (proximal & ds) | dora “elocaleanea (blr) Midora Liman oll mon excep Reson (ide bending and rotation equclly limited and both greater than exer) Greate littion of ER, flowed by abduction and internal rotation Ful twain ited; pain ot extreme range of motion Full tevation imited; pain at extreme range of mation os flexion moreso than extension oi fflexon moreso than extension Limitation: pronation = spination Limitation: pronation = supination Limittion: Resin = extension Limittion: equal all directions imitaon: abduction mere so than exensic fcpolyrsiced ol dreiens Limition: Resin > extension rn arborea» oe eaonSRasn Marked ard equal limon of sde- bend aura 9 ond rttion oss of extension > flexion Limited flexion/internal rotation; some ; ‘aon; sm aon evn gy Ini linia cheamren Poin when oi is stressed ‘extension ¥ n© or litle limitation of adduction ond &Anatomy and Biomechanics of the Musculoskeletal System 31 3. Common muscle substitutions: a, Use of scapular stabilizers to initiate shoulder ©, Acromiodlavicular joint * Applane joint with relatively flat surfaces. motion when shoulder abductors are weakened —__d. Seapulothoracic joint (reverse scapulothoracic rhythm), © A “clinical” articulatio b Use of lateral rune or tensor fi Tatas, Mile (depressor armas prtacon eect py Sy eval ee Increase aoe Nes ase ce finger flexion by contraction of wrist _adductors, and extensors) (see Table 2-4 ccna when ge era gel Ee mee oe Use of long head of biceps, coracobrachialis, and a, Glenohumeral joint capsul anterior deltoid when pectoralis major is weak Attaches medially 49 gl is weak @ Attaches medially 10 glenoid margin, glenoid ¢ Use of lower back extensors, adductor magnus, and labrum, coracoid process aa quadratus lumborum when hip extensors are weak. Attaches lat Fe we # Auaches laterally to humeral anatomical neck £, Use of lower abdominal, lower obliques, hip adduc and descends approximately 1 cm on the shaft. tors, and latissimus dorsi when hip flexors are weak, «© Supported by tendons of supraspinatus, infraspi natus, teres minor, subscapularis, and long head Functionallalm of triceps below. - « Inferiorly capsule is least supported and most lax. Biomechanics iiteiniesit Coracohumeral ligament. Base of coracoid process to greater and lesser tubercle of humerus Primary function to reinforce biceps tendon, See Figures 2-1, 2-2, 2-3, and 2-4. Shoulder Region 1, Osteology reinforce superior capsule, and prevent cau- a. Humerus (see Figure 2-5). dal dislocation of humerus. Taut with external «Proximal end of humerus is approximately half rotation (ER) a spheroid. * Coracoacromial ligament. + Articular surface is covered by hyaline cartilage. © Strong triangular ligament runs from coracoid # Head is retroverted 20°-30° to acromion. ‘ Longitudinal axis of head is 135° from axis of neck. © Not a “true” ligament; connects two points of b. Scapula, same bone. « Large, flat triangular bone that sits over second to © Glenohumeral ligaments seventh ribs. ¢ Reinforce the glenohumeral joint capsule antes + Costal surface and a dorsal surface. rly and inferiorly. Three angles: medial, superior, and lateral © Superior glenohumeral ligament: limits ER and. «Lateral angle bears glenoid fossa, which faces inferior translation, anteriorly laterally, and superiorly. © Middle glenohumeral ligament: limits ER and © Pear shape of fossa allows for freer range of anterior translation, motion (ROM) in abduction and flexion. « Inferior glenohumeral ligament. © Concave shape receives convex humeral head. ~ Anterior band: limits ER, anterior, and supe- © Orientation of the glenoid fossa places true rior translation, abduction at 30° anterior to frontal plane. ~ Posterior band: limits IR and anterior transla- tion. ¢ Clavicle. © Extends laterally and links manubrium to acro- «Transverse humeral ligament. mion. © Broad band passing over top of bicipital groove # Connects shoulder complex to axial skeleton. o Acts as a retinaculum for long biceps tendon. 2. Arthrology. . Labrum. © Glenoid labrum is a fibrocartilaginous ring that deepens glenoid fossa. # Attached to capsule superiorly and inferiorly as well as to the long head of the biceps tendon superiorly. «Internal surface covered with articular cartilage, which is thicker peripherally and thinner centrally. « Aids in lubrication, as in meniscus of knee, and. serves to protect the bone. a. Glenohumeral joint. © Convex humeral head articulates with concave glenoid fossa, ‘© Glenoid fossa very shallow. Sternoclavicular joint. ‘© Convex (superios/inferior) and concave (anterior) posterior) articulates with reciprocal shape of sternum. « Both articulations covered with fibrocartlage b.Cae 1 Therapy skeletal Physical [Bow ston [Brvoeraar stron GEMEDD Wescriersyatemmancenares ‘Stemocieidomastot Voss ata Adductr Magnus Gracia astrocnemus| (edi eas)Anatomy and Biomechanics of the Musculoskeletal System — 33 —Subacromial bursa | Acromion Deltoid Supraspinatus ¢— Tendon of long head of biceps brachii axillary nerve Quadrangular space Teres major ‘Triceps brachii (long head) GEEEEED Coronal section of shoulder. cr Girdle and Upper Extremity Muscles and Innervation = z \TION TO BE TESTED muscles MYOTOMES REFLEXES CORD SEGMENT _ NERVES exon Sernocetdomestid cca (C34 posterior ri i extension Tropezis, other deep CNN biel i rotton eck muscles oxcenory) I otra bending Ider shrug, seapular Upper tropezivs a cree CN loping oxcesory] ward rotation der horizontal Pec. majr/ minor c5-ca,T. Medi /leterl pecorl odducion soular downward rotation Pectrals minor cen Medial pectoral houldeeprotraion, scapular Serra anterior oo ong theraie Arthrology’ (fadiocarpal, midearpal, carpometacarpal, # Convex scaphoid and lunate articulate with con b. Mideatpal joint. «+ Articulation between four proximal and four dis: tal carpal bones is known as midcarpal joint _ cea ae Ea * Can be divided into mid pillar hnate and quetram with capitate and hamate) and lateral c, Carpometacarpal (CMC) joint. « First CMC (thumb) is a saddle articulation with trapezium being convex in medial/lateral direc tion and concave in anterior/ posterior direction. « First metacarpal is opposite in shape to trapezium. © The second through fifth CMC joints are essen tially flat between bases of metacarpal and distal row of catpals 4: Metacarpalphalangeal (MCP) joints consist of con- vex metacarpals with concave proximal phalanges ¢ Proximal interphalangeal (PIP) joints consist of convex distal aspects proximal phalanges with con- ‘ave proximal aspect of middle phalanges. Same or- ntation exists at distal interphalangeal (DIP) joints. 3, Muscles (wrist flexors, wrist extensors, radial deviators, Ulnar deviators, extrinsic finger flexors, extrinsic finger xensors and intrinsic finger muscles) (see Table 2-4); 4.Noncontractile structures (volar carpal, radiocarpal, Collateral, and palmar ligaments; extensor hood: sesociated capsules; volar plate; nerves; and vessels) | a. Ligaments. ; « Fingers (see Figure 2-8) > Collaterals: run separately from lateral condyle to distal phalanx and lateral volar plate at each MP, PIP, and DIP joint. All fibers tighten with flexion and volar fibers tighten with extension « Accessory run from condylar head to volar plate ¢ Transverse: present at MCP joints. Provide sta bility linking MCP joints and providing rein: forcement to anterior capsule. © Wrist. w Dorsal radiocarpal: limits flexion, pronation, and possibly radial deviation. «o Radiate: stabilizes hand for any impact (GEIEED Dissection of the third digit. Radial collateral: limits ulnar deviation. 6 Ulnar collateral: limits radial deviation © Palmar ulnocarpal: limits extension and supi © Palmar radiocarpal: limits extension and supi nation through knuckles. b. Extensor hood. « Fibrous mechanism on the dorsum of each finger that isa fibrous expansion of the extensor digito rum tendon. «Its purpose is to assist with extension of the PIP and DIP joints. ¢. Capsule. « Fingers. © MCP, PIP, and DIP joints all have fibrous 125°, © Goxa vara is angle <115°, «© Femoral neck angles anteriorly 10°-y5» frontal plane to form anterior. eos fon © Anteversion: considered excessive if se ‘antetorsion angle >25°-30°. anterior «o Retroversion: considered antetorsion angle <10” ve if anterior GED HP doint osteolog b. Acetabulum. aecatabulum faces laterally, inferiorly, and ante orly. Made of union between ischium, ilium, ani pubis bones. * Acetabular fossa: center of acetabulum, which nonarticulating and filled with fat pad for shos absorption. © Acetabulum is not completely covered with « tilage. Lined with a horseshoe-shaped articu! cartilage with interruption inferiorly formiee acetabular notch, i 2. Anthrology (coxofemoral). a. Synovial joint. b.Cor ‘ aa head articulates with concave «Ve loi {table oint due to bony anatomy as A Zone of wens and capsule. beculac are relativet the femoral neck in where , eaaatively thin and do not cross each intemal rotators [Ine on™ atductors, abdc URS}, and external rotators |!Anatomy and Biomechanics of the Musculoskeletal System 39 Pelvic Girdle and Lower Extremity Muscles and Innervation [ACTION TO Be TESTED muscurs MYOTOMES REFLEXES CORD.—_NERVES | a en : eon ee te aiden: bare @ fom Kee extension Quodricops femoris 6 u 14 Femoral Hip oddoction| Pecineus, adductor longus 1243 Obarater Hip oddoction| ‘Adductr brevis (24 Obewater odduction Gross (244 Obhrater tip abduction, flexion, meal rotation Gltevs medivs, minimus 15 US| Superior ghteal Hip exion, abduction, medial rotation Tenor fascia lata ets Superior ght Hip lateral rotation Piiormis 151 Socral plows Hip extension, lateral rotation Ghtous maximus US2 Inferior gluteal Hip ltera rotation brat internus 551 Scr plows Hip lateral rotation Gemelli, quadrats femoris iss Socral plexus "i ems om eon, gel Bp mas 15-52 Tibia, common fibular Hip extension, knee flexion Semitendinoses b 1582 Tibioh log medial rotation Somimembronosus 682 Thiol Ankle dorsifexion Tibialis anterior u wuts Deep fibular 2nd digit MIP extension Extensor digiorum longus ust Deep fibular Great foe MTP extension Extensor halls longus 5 Lest Deep fibular Foot everson Fibulocis longus/brevis SI 1552 Superfciol fibular leg medio rotation Poplitous ust Tibi Foot inversion Tibial posterior si 682 Thiel Alle plartor flexion Gostrocnemis/soleus SI 1582 Tibial 2nd-Sth digit IP flexion 1582 Thiel Great oe IP flexion Flexor halls longus 1582 Tiel 2nd-Sth digit PP flexion Flexor digitorum brevis 5s1 Medial plontor Great oe MIP flexion Flexor hallucis brevis 1552 Medial plontor ‘Toe adduction abduction Dorsel/ planta introsel 51-82 Lateral plontor Pei oor contr Perineals ond sphincters soa Socral plows ‘doped ron Kendal, or Made: esing ond Funcion, wi Poskre ond Pan, Sh ed. 2005. * Serves to deepen acetabulum. + Pubofemoral ligament. ‘Inner surface is lined with articular cartilage, and © Runs from iliopectineal eminence, superior outer surface connects to joint capsule. rami of pubis, obturator crest, and obturator ¢ Ligaments. membrane, laterally blending with capsule; * liofemoral ligament (*Y" or ligament of Bigelow). inserts into same point as medial iliofemoral © Two bands, both starting from anterior infe~ ligament, rior iliac spine (AHS). Medial running to distal © Taut with extension, ER, and abduction. intertrochanteric line, Lateral running to proxi « Ischiofemoral ligament. ‘mal aspect of intertrochanteric line. © Runs from ischium and posterior acetabulum, o Very strong, superiorly and laterally, blending with zona © Both bands taut with extension and ER. Supe- articularis, and attaching to greater trochanter. rior band taut with adduction. Inferior band © Taut with medial rotation, abduction, and taut with abduction. extension,40 Theman GEEZER Hip joint: igament and muscular attachments. * Zona orbicularis, Runs in a circular pattern around femoral neck Has no bony attachments, but helps to hold head of femur in acetabulum, © Inguinal ligament 12-14 cm long, running from anterior supe rior iliac spine (ASIS) medially and inferiorly, attaching to pubic tubercle, Forms tunnel for muscles, arteries, veins, and rior and inferior gluteal arteries. - femoral head_mo f convex fi ig Ee ve acetabulum. R gait on level BF e. « Normal sa Mijint ranges of motion: 30* gq’ eile 5° abduction/adduction, » ¢ Walking on uneven hair OF SittiNg CrOSS-lepp Ma A tding in 2 a rane i i tange of motion requirements Nii ts, such as forward bendin, «Many movement involve combined vis, and lumbar SP titing to the relativ J movements of the fernur, pine, with many factors con ye contributions, Knee Region Meeology (femur, tibia, fibula, and patella) Figures 2-11 and 2-12). a, Femur eSfemoral condyles are convex in anterior/p rior and medial/lateral planes. +s Both femoral condyles are spiral, but lateral has longer surface area and medial one desce further inferiorly Go rates = eos oer of pte Nenana ‘Qusorcep ed; : Anatomy and Biomechanics of the Musculoskeletal System = 47 b.Tibia + Medial tibial condyle is biconcave, has a larger surface area and is more stable, and therefore less mobile. « Lateral tibial condyle is convex anterior/posterior and concave medial lateral, Small more circular, and less stable, therefore more mobile # Both tibial surfaces are raised where they border intercondylar area c. Patella, A vertical ridge divides patella into a larger and smaller medial part. «+ Patella can further be divided by two faint hori zontal ridges that divide it into its facets. > Arthrology (tibiofemoral, patellofemoral, and proxi- ‘mal tibiofibular) a. Proximal tibiofibular joint. # Oval tibial facet is flat or slightly convex. « Fibular head has an oval, slightly concave to flat surface b. Tibiofemoral joint « Synovial hinge joint with two degrees of freedom. + Minimal bony stability thus relies on capsule, ligaments, and muscles. ¢ Patellofemoral joint. « Patella articular surface is adapted to patellar sur- face of femur. «An oblique groove running inferiorly and later- ally isthe guiding mechanism on femur for patel- jar tracking, Patellar surface of femur is concave transversely and convex sagittally, creating its sad dle (sellar) shape. 3, Muscles (flexors, tibial rotators, and extensors) (see Table 2-5) 4, Noncontractile str lateral collateral ligament, anterior posterior cruciate ligament, menisci, and associated nerves and vessels). a. Capsule. * Tibiofemoral capsule is a fibrous sleeve attached to distal feruur and proximal tibia, Inner wall is covered by a synovium. Shaped as a cylinder ‘with a posterior invagination, which posteriorly Uivides cavity into medial and lateral halves. ‘Anterior surface has a window cut out for patella « Proximal tibiofibular joint has a fibrous capsule, which is continuous with knee joint capsule 10% of time. b. Ligaments (see Figure 2-12). e Tibiofemoral and patellofemoral joints (knee joint proper). sy Metial collateral ligament (MCL): runs from medial aspect of medial femoral condyle to uPPry int} of tibia, Posterior fibers blend with capsule, Runs oblique anteriorly and inferiorly. Taut 10 ertension and slackened in flexion. Prevents ER .ctures (medial collateral ligament, cruciate ligament, capsule, bursae and provides stability against valgus forces. Runs in same direction as anterior cruciate ligament. Lateral collateral ligament (LCL): runs from lat- eral femoral condyle to head of fibula. Free of any capsular attachment, Runs oblique inferi- orly and posteriorly in same direction as pos. terior cruciate ligament, aut in extension and slackened in flexion, Prevents ER and provides stability against varus forces Anterior cruciate ligament (ACL): attaches to anterior intercondylar fossa of tibia and to femur at medial aspect of lateral condyle. Runs oblique superiorly and laterally. Extracapsular, but more correctly a thickening of the capsule. Limits anterior translation of the tibia on the femur and provides rotational stability. Posterior cruciate ligament (PCL): attaches to posterior intercondylar fossa of tibia and on lateral surface of ferioral medial condyle. Runs oblique medially and _anteriorly-superiorly Checks posterior displacement of tibia on femur. Meniscofemoral ligament runs with PCL: attaches below posterior horn of lateral menis- ‘aus. Has common insertion into lateral aspect of medial condyle. Occasionally a similar liga- ‘ment exists medially. ‘Oblique popliteal ligament: inserts into expan- sion from tendon of semimembranosus. It partially blends with capsule. Forms floor of pop- Titeal fossa and is in contact with popliteal ante: rior artery. Strengthens posteromedial capsule. © Arcuate popliteal ligament: Y-shaped and com- monly described as having two bands (medial and lateral). Stem attaches to fibular head. Medial band attaches to posterior border of intercondylar area of tibia. Lateral band extends to lateral epicondyle of fernur. Strengthens pos terolateral capsule. ‘Transverse ligament: connects lateral and medial meniscus anteriorly. © Meniscopatellar ligament: runs from inferolat eral edges of patella to lateral borders of each meniscus. Pulls menisci forward with extension, ‘Alar fold: runs from lateral borders of patella to medial and lateral aspects of femoral condyles. Keeps patella in contact with femut « Infrapatellar fold: formed by attachments of patella fat pad and tendons via a fibroadipose and lying in intercondylar notch. Acts as stop gap as it is compressed by patella tendon in full flexion «« Proximal tibiofibular joint ligaments. © Anterior tibiofibular ligament: located on ante- rior aspect of joint. Reinforces capsule anteriorly. «> Posterior tibiofibular ligament: located on pos terior aspect of joint. Reinforces capsule poste- riorly. eeChapter 2 MS 42 TuenarvEo « "*4vEo + Musculoskeletal Physical Therapy © Menisei, * Medial meniscus, Medial meni e, C-shaped, and faitly iscus is large, C-shaped, and stable. Laterally and fibro IS caps medial i firmly attached to MCL Other structures that attach Smale and medial meniscopatellar ligament. than medial meniscus and more cit Structures that attach to lateral meniscus nclude popliteus muscle, lateral meniscopatel: ar ligament and meniscofemoral ligament Lateral meniscus is separated from LCL and lat eral capsule by popliteus muscle tendon. Deepens fossa of tibia. Increase: ongruency of tibia and femur. Provides stability to tibiofemoral joint. Provides shock absorption and lubrication to knee. Reduces friction during movement. Improves weight distribution. ‘+ Movement of menisci Menisci follow tibia with flexion/extension and femoral condyles with intemal/extemal rotation. Medial meniscus moves a total of 6 mm while lateral moves 12 mm. With isolated tibial rota tion, the menisci move opposite; eg, with tibial IR, the medial meniscus moves anteriorly and the lateral meniscus moves posteriorly. © Meniscal motion is also influenced by soft tissue structures. Medial meniscus is pulled poster: orly (flexion) by semimembranosus muscle and. ACL. Pulled anteriorly (extension) by medial meniscopatellar ligament. Held firm by attach- ‘ment to MCL and fibrous capsule. > Lateral meniscus pulled posteriorly (flexion) by popliteus muscle and anteriorly (exten- sion) by lateral meniscopatellar ligament and ‘meniscofemoral ligament. 4. Bursae. + Prepatellar, between skin and anterior distal patella, ‘* Superficial infrapatellar, anterior to ligamentum, patella + Deep infrapatellar, between posterior ligamen- tum patella and anterior tibial tuberosity ‘* Suprapatellar, between patella and tibia femoral joint. « Popliteal, posterior knee often connected to syn. ovial cavity. ‘# Semimembranosus, between muscle and femoral condyle. # Gastrocnemius, one for each head, Medial bursa usually communicates with semimembranosus bursa. ‘ «e Des anserine bursa, between pes anserine and MCI, echanic 5, Biomec m descending branch frp, Femoral branch of the deep fem a Tee OF popliteal aar> oral artery, Cen of anterior tbial artery nner Aibular nerves « knee joint Proper viveajosteoKinematics al condyles during flexion ‘mes fro «¢. Blood supply 4 f, Anticular i oral, tibial Prokineratics/osteok a Movements of fe™ pnd extension ‘condyles roll sway that poster and glide simultaneously (op), ior Gislocation of femoral con, ; avoided). Initially, movement is pure Riel .ds in pure gliding. For medial co, rlingand occurs during ist 10 ted for lateral condyle, 20° of flexion, « During flexion, femoral condyles roll poster * oily; ACL becomes taut, causing condyles i aie Du ereeomes taut, causing condyle . eee earl range of knee flexion is approximately 15°. We are essentially using pure rolling of femur on tibia. © During flexion at 10°-15°, ACL tightens, causing femur to glide anteriorly, then 5° further, rol! ing occurs on lateral condyle, causing a conjunc: ‘medial rotation of tibia. During extension, PCL causes femur to glide pos teriorly, while condyles roll anteriorly 10°-15 ‘Then a further 5° of rolling occurs anteriorly on lateral side, tore inlerronsvesoi i ‘ic ini sal obliques, internal obliques, WN? Spine flexion Ins crise obi tin, Ff nero ee u Lumbar planus | Spin era lesion hip hiking in overse) vost born m3 mb Spe rotation Faason, inernal/externa obliques, ineranerir, a8 Be ‘transversospinalis Functional Newrology- ‘Lange Medical Publications, 1970; Kendal FF, McCreary EK, Provonce PG: Muscleshr" nr aa 48 TrerarvEo « Musculoskeletal Physica! TheraPY * Ligamentum flavum, Courses €2 10 the senith connecting lamina of one verteba to the lami above it, Limits flexion, particularly in the 1am bar region * Interspinous ligament, Courses between spinous processes and limits flexion and rotation: i Supraspinous ligaments, Pound in thoracie ane lumbar region, Limit flexion Costotransverse ligament (superior posterior and lateral). Support costotransverse joint capsule Hiolumbar ligaments. Extends from posterior aspect of the ilium t0 the transverse process of the LS vertebra. Very strong and functions to limit motion between L5 and SI Posterior sacroiliac ligaments (short, transverse, and long), # Anterior sacroiliac ligament, Courses the anterior aspect of the ilium to the anterior sacrum. Thick ening of the joint capsule Sacrotuberous ligament. Limits sacral anterior rotation and superior translation of the sacrum. Posterior interosseous ligament. Courses the pos: terior superior iliac spine to the 3rd and 4th sacral segments. Limits sacral motion in all directions. b. Capsules. © Facet joint: assist ligaments in providing limita: tion of motion and stability of spine. Strongest in the thoracolumbar and cervicothoracic regions. Sacroiliac joints: synovial capsule present in sur- rounding joint, which is very prominent ante riorly; posteriorly, it is lost within posterior interosseous ligament. ¢. Thoracolumbat fascia. « Provides stability of vertebral column when a force is applied. «# Acts asa corset when tension is created by contrac. ‘ion of abdominals, gluteals, and lumbar muscles 9. Nerves. a Dorsal roots transmit sensory fibers to spinal cord and ventral roots; mainly transmit motor fibers from spinal cord to spinal nerve, bb Spinal nerves are connected centrally to spinal cord by a dorsal and ventral root, which join to become the spinal nerve in the intervertebral foramen. pi. nal nerve divides into dorsal and ventral rami * Dorsal rami innervate structures on posterior trunk Ventral rami © Cervical ventral rami form cervical and brachial plexuses (see Figures 2-17 and 2-18), ‘9 Mhoracic ventral rami innervate anterior ste tures of trunk within thoracic region, 4 Lumbar ventral rami form tumbar and tym, Dosacral plexuses (see Fig6res 2-19 and 2.99)" Dorsal Ram FB roxts verte aan & En« 68 BB arteror dv Posterior Dvson oper Trunk (5.08) \ Posterior Cord (cs.c8) 4 ere (3, C8 dale Trunk re) Ler Trunk (3,71) Medial Cora Aaltory Artery Nene esceay, 8.T1) Brachial plexus, © Spinal ng i Sbinal ae ANOUS sections of spine. ae come out at the lev! vertebra, ciated at BetVes come out at lee! ee: mas ne APproximately at lev! medullaris).Anatomy and Biomechanics of the Musculoskeletal System 49 | ord Lumbar | Bl roxeroe owsion stn Lumbar L "wore Lumbar plexus 10. Spinal biomechanics. a, Arthrokinematics. « Flexion: upper facets glide anteroproximally and tilt forward « Extension: upper facets move downward, slightly posterior, and tilt backward. « Side-bending: when side-bending right, upper facet moves down and slightly anterior. Left facet moves upward and slightly posterior. Both facets move to the left. «# Cervical rotation: right rotation causes facets on right to glide down and back, causing approx! mation of facet joints on right. «© Lumbar rotation: very litte, but clinically impor, tant because this motion causes separation and approximation of the facet joints: eg, if13 rotates right, there is separation at right 13-14 joint and approximation at left 13-14 joint b. Coupled motions # Cervical © Side-bending and rotation occur in same direction from C2-C7, regardless of whether Gm ROAR eH] Pens ecru rene Ley a Some Nene eee Dh rostenor onision et Saat | [Bi menor onion sn EN Sacral plexus. spine is in neutral/extension or flexion. When occiput side bends, C1 rotates in opposite direction # Lumbar/thoracic © Neutraljextension: lumbar segments will side bend and rotate in opposite directions; e: side bend right results in segment rotating left. © Flexion: lumbar segments will side bend and rotate in the same direction. © This coupling described above is a very basic interpretation. In reality, there are significant variations in coupling motions between indi- viduals. Coupling motion may depend on whether a side bend or rotation is done first. Direction of spinal segmental coupling should always be checked with each patient prior to performing a manual technique. ¢ Lumbopelvic rhythm. « During flexion, spine (primarily lumbar spine) goes through 60°-70° of motion and then pel- vis will rotate anteriorly to allow more move- ‘ment, eventually followed by flexion of hips.Aca) Tuenarv€o « Musculoskeletal Physical Ther@Py ition) * During extension (coming from flexed pos 8 aa then hips extend, pelvis rotates posteriorly, an spine begins to extend Sactoiliac joint osteokinematics ements * Motion limited, but during gait mov akes place in multiple plane Nutation and counternutation; coupling move ( itiuim ment that occurs between sacrum arid during gait Notation: describes a movement that involves flexion of sacrum and posterior rotation | itium that involves extension of sacrum and anterior Temporomandibular Joint (TMJ) 1. Functional anatomy. A bilateral articulation between mandible and cranium (craniomandibular joint) Patient/Client Histor Interview), System: and Tests and Meas Patient/Client History 1. Gather information to develop a hypothetical diagno- sis, which dictates flow of examination. Delineate any precautions and/or contraindications when perform. ing components of examination (see Table 2-7), 2. Components of history. a, Demographics: age, gender, diagnosis and referral (if appropriate), hand dominance, etc Social and family history ©. Current condition(s)/chief complaint General health status. Social health. f, Employment/work Growth and development. h. Living environment i, Functional status and activity level, j. Medical/surgical history, including previous trea, ment and review of systems, ‘Systems Review 1. Components of system review (see Table 2-8) a, Musculoskeletal b, Neuromuscular. P Physical Therapy Examination ‘cular surfaces covered j, artic gue rather than hyaline 2 a Joi vest prous COF dense ued of dense ADTOUS Conn ti cataar disc od vyessels OF NETVES in pre , ‘without! tive Searing area strict movement ig sure id function to Fest Mt is « Diseal lig al pane Sup eed of elastic conte compen pull of superior an tiueal pad consist 1 ombination al lamina (superior stratum nective tissue; Counteracy, lateral pterygoid mus, s of loose neurovasculac ‘of hinge axis rotation in disc condyje mmplex and sliding movement of the upper join is 40 mm, with 25 mn tional range of opening: Ota 15 mm of tanslatoy glide «. Cardiopulmonary. Integumentary. €. Gastrointestinal/Genitourinary systems. 2.Determine whether identified condition(s) are comorbidity(ies) and/or complicating factor(s) 3.Determine whether a referral to an additional health-care provider i i ise is appropriate, and if so, make ponent mf include: “M4 May bea part of tests and measurs My testing muscle ae: Fesisted © Motor: tensioy tests, manual muscle £ Granggitetion, "(Table a 19). Neve integrityYee ys Pinpw Voting treo 90 Aah pos wttaed ove pon vcry tae oe yn bods yb i 7 wate te py os tr bahen h ‘Were yo bona Achoeg te 31 Aihaaeh eats wits yore Vile tome tom urd, wh 8 spiny, meter, prin (Do you hove sinew whan lashing metas ep bene gee wl home you bad 0 recens upp voupeihiny hocsiod Wom yb ny wees yt ey tn oboe ren (oyu home yogi «rir ears ell arena Od yon bh orks yom bom Od yom ty 0 chs 00h engararen proc De yons home gn hs airy hn wrdesenes yrrbse bones. Does not demonstrate soft tissucs wo atall. ‘b. Computed tomography (CT) scan. ‘¢ Uses plain film x-ray slices that are enhanced by 2 ‘computer to improve resolution. It is mul=:p 272 so can image in any plane: therefore. soe 27 bbe viewed from multiple directions.Chapter 2 MS onal gee Sy aan ‘ros ono Degeneres ont dues css aT 0 Sha Pa ove hugh He mer ending OCNg sation Pm ep eh pn renee el re Deseo pn cue wi on OM ; Sige i rl oP yin ene i Chan a Oo ae ns increase symprorns ‘No pin in rec tere arth acwang wed sin Sin prom AH Describes poin 2: Potent may describe cere Pain isle to poston Fs darn pain ond oe ng Pome a aoma os csnbnen NOES I Wraine fr ony cstoce brings on MPO za Pere i br hows oer assuming 2 resting Pos Pains consent in al inal positions Pain is brought on by Pain i rebeved ih et (1-5 minutes) Fain desebed oa merbess Fate sel hos dacresed ox absent ples Peri ninco ay vats nt resched by changes in pion, Hime f dy, or ov a a ions increase Pon Sao Ferma HGS Po 0 SoHo cra ee “Cranium : Extended on fe ble pe vical a . Elevated and retruded sa Posterior ‘Mexillomandibularreltionshif close: pocked posit a ss Increaed Freeway space with signi Tongue Roce ench a fo position Upper cervical spine Drops foo ohh engten idle ond lower ceva pine Exended lean First and second ribs Leds dee ney ocular sutras) Scolenes, uboccigitl, sernoddomasecs,ongu cli, Elevoted Pedtioning) “ius, levator scapuloe \ YP" rope Shore saree Pecoralis moor ond minor ines Shore, Scopulersbilize, 620s cop ntrir SeedPhysicalTherapy Examination 53 Ily used to assess complex fractures as well as facet dysfunction, disc disease, or stenosis of the spinal canal or intervertebral foramen. CI demonstrates better quality and better visualiza- tion of bony structures than plain films. CT also demon structures, although not as well as MRI ly expensive, and patient is exposed to radia tion, . Discography. « Radiopaque dye is injected into the disc to iden tify abnormalities within the disc (annulus or nucleus). The needle is inserted into the disc with the assistance of radiography (fluoroscopy). © Not commonly used. Requires a high level of skill and proper equipment to perform. Fairly specific technique to identify internal disc disruptions of the nucleus and/or annulus. « Expensive, may be painful, and since it is inva sive, there is a risk of infection dd. Magnetic resonance imaging (MRI) + Uses magnetic fields rather than radiation. © Offers excellent visualization of tissue anatomy. Utilizes two types of images: Tl demonstrates fat within the tissues and is typically used to assess *Typi Les soft tiss bony anatomy, while T2 suppresses fat and dem- onstrates tissues with high water content. T2 is used to assess soft tissue structures. Ferrari) arasel stots mnnannan aS Z a LEXTERNAL/_ -RADIAL/ ‘PLANTAR JOINT ‘EXTENSION: /ADDUCTION ROTATION |ADDUCTION PRONATION DEVIATION DORSIFLEXION ‘Shoulder 160-180/50-60 170-180/50-75 80-90/60-100, 190/45 Elbow 140-150/0-10 90/80-90 Wis ‘80-90/70-90 aa MCP 85-90/30-45 PIP 100-115/0 DIP 80-90/20 1sCMC 45-50 60-70/30 Ast MCP 50-55/0 Ast iP 85-90/0-5 Hip: 110-120/10-15 3050/30 40-60/30-40 Knee 135/015 30-40/20-30 | ‘Ankle 45-40/15-30 50/20 | 2nd-Sih MTP 40/40 | 1stMIP 45/70 | lap 90/0 | 2nd-Sih PP 35/0 |2nd-Sih DP 60/30. =84 THERAPYED « Musculoskeletal hysical Therapy up Spine Range oi as PROTRUSION! sTERAL DEVIATION, REGION ‘ROTATION ———— —— | RexoN/oxTtNsioN soERENONG —_ROIATON _O Cervea! 80-90/70 20-45 70-90 Thorac 20-45/25-4 20-40 35-50 Lumbar 40-60/20-35, 15-20 +8 3-6 mm/3-A mm 10-15 mm ™ 35-50 mm Gap Muscle Grading ial resistances. _— Ne nt gravity with moderate '0 minimal resistance Good + G+ 44/5 Good odes inde iting holding asia Good sas Good ~ oS 4/5 ‘ Foics Fe 34/5 Foirgrodes indudeliting or holding against gravy without resistance. Foi Fas Foir= F315 Some osistane may be required to complete the motion in the minus category. Poors Ps 2+/5 Poor grado include moverent wih groviyeiminaed, Poor ruRReyS Poor — P __2°15 Some cnsnce maybe reqiedo compete he mein inthe minus category. Troce T 1/5 ‘Muscle conkacton canbe seen o eh No moveren is produced Zero 00/5 _ No contraction i seen o fh, “doped Fam Kendall Fo a Mess Tsing ord Frc, wih Poses od Pan, Shad OOS + Fairly expensive, and patients with claustropho- MRIs Inferios to dove. May notbe able 0 use ivan A increase metabolic acti ppt a hage sical plans 8 Diaghostic tmnt Fegions, . Arthrography. ae : * Invasive technique that injects water-soluble dye ec’ tansmission of high-fi juency sound into area and is observed with a radiograph. Dye waves, simil: Soetency is observed as it surrounds tissues, d fe a to therapeutic ultras: Itrasound. lemonstrat Limited by contrast resolut ewing field, hi Hast resolution, small viewin’ ing the anatomy where fluid moves within joing | how deep it * Typically used to identify abnormalities wiinin ton of bone. Inerprensaste® and poor penet® joints such as tendon ruptures 0 results retation of data is subject: iss ‘ end onan + Expensive and caries risks since itis invasive Peace skill of operator £, Bone scans (osteoscintigraphy), “ynamic images and can assess * Chemicals laced with radioactive tracery aye one anes aati ete phy, effects at this time les in areas where there i ahi cy croc arta Ene ng F. lic activity of bone. aa é Bee + Radiograph is taken to demonstate any “hop 10 obser 38 it water-soluble dys spots” of increased metabolic activity «© Patients with dysfunctions, such as 1 * Sel anator through vertebral can! ldom sen Y Within eush vertebra arthritis, possible stress frac ay in me ‘iheumatoid Scan, whieh Sue to side on eo a hospital SY &xpengic 8°04. if not better, in!" ey Ovemighn’ SINCE it often involves ** Tradit onally used for diagnostic asses the discs and stenosis, May still be beneficial to identify stenosis, 5. Laboratory tests. a. Laboratory tests are typically used to sereen patients, assist with makin b.Since many patients with musculoskeletal dys function present with other medical pathology it is important to monitor clinical laboratory findings Multiple tests available that fall into the following categories. « Blood tests. Serum chemistries. Immunological tes Pulmonary function tests. Arterial blood gases. Fluid analys 6.Flectrodiagnostic testing (also refer to Chapter 3: Neuromuscular Physical Therapy). a. Electroneuromyography (ENMG) and nerve conduction velocity (NCV) tests are commonly used to assess and/or monitor musculoskeletal conditions, Special Tests Extremity Shoulder Special Tests (See Table 2-13) 1,Glenohumeral joint anterior instability a. Apprehension test. Patient is supine, with shoulder in 90° abduc- tion; slowly take shoulder into full ER. + Positive if the patient looks or feels apprehensive/ alarmed and resists further motion (apprehen- sion > pain). b. Relocation test. * With a positive apprehension test, a posterior translation stress is applied to the humeral head. * Positive if the patient loses apprehension or pain decreases. ‘Relocation test does not typically change pain with primary impingement. 2.Glenohumeral joint posterior and inferior instability a. Jerk test (posterior). + Patient seated; shoulder flexed to 90° and inter- nally rotated. ‘* Axially load humerus and horizontally adduct arm. '* Positive test is production of a sudden jerk or lunk as humeral head subluxes off the back of the glenoid. b. Sulcus sign. ‘ Patient stands relaxed with arm at side; arm is pulled distally. \osis, or for monitoring, Physical Therapy Examination — 85 © Positive test is the presence of a sulcus inferior to the acromion combined with reproduction of symptoms. 3, Subacromial impingement 4. Hawkins-Kennedy test ‘© Patient is seated or standing, shoulder is passively flexed to 90° and then internally rotated maxt- mally. © May be performed in various degrees of forward flexion and horizontal adduction «© Positive if reproduces pain within shoulder region, b. Neer test (see Figure 2-22) © Patient is seated; shoulder is passively internally rotated, then fully abducted. «© Positive if reproduces pain within shoulder region. . Painful arc « Patient actively abducts the shoulder and reports the start/stop range of any pain. « Positive if pain is reported between 60° and 120° of abduction 100 021 Medial instability Pain with valgus stress ot 30° of knee flexion o78 067 23 030 Lauiy with vlgus sess ot 30° of knee flexion 091 049 18 07 eral otory insobily Pro shi test (0/0 anesthesia) 0.28 oat 15 ow Fr shift est (4/anesthesia) 073 098 65 07 McMurray test 051 078 23 063 hessaly test 031-092 0467-095 18-393 009-073 032 0.86 23 07 row knee roles “Adols 099 oag 19 00s Children 09 0.46 19 007 Combination of et or meniscus ears Combined history and physical examination 0.86 0.83 51 017 {jin effusion, jin line Yenderness, McMurray ts hypedxion tx, squat ts) Jet ine tenderness plus (+) McMurray test 075-091 091-099 101-750 010-025 ‘ein line tenderness pls (+) Thessaly est 078-093 092.099 11.6780 0.08-0.22 pnd om: Noes D:Ortoped Piel Asmat, Gd 2014; ld 1, Kopein 5,S:Nete/sOrhepodi Ciel Emin ded. 2016 4. Anterolateral instability: pivot shift test 2. Tests integrity of the anterior cruciate ligament. b.Patient supine; knee in extension, hip flexed/ abducted to 30° with slight internal rotation. Hold knee with one hand and foot with other hand; place valgus force through knee and flex knee. 4. Positive test is indicated by tibia relocating during the test; as the knee is flexed, the tibia clunks back ‘ward at approximately 30° t0 40°. e Tibia was subluxed at the beginning of the test’ reduced by pull of the iliotibial band as the knee was flexed. 5, Meniscus tear. a, McMurray test (see Figure 2-39). « Patient supine; tested knee in maximal flexion. « Passively, internally rotate and extend the knee (tests lateral meniscus) « Passively, externally rotate and extend the knee (tests medial meniscus). « Positive finding is reproduction of click and/or pain in knee joint. b. Thessaly test. « Patient standing on the symptomatic leg, holding the examiner's hands. « Patient rotates the body and leg internally and externally with the knee flexed 5° and then 20° « Positive finding is reproduction of click and/or pain in knee joint. 6, Patellofemoral instability: patellar apprehension test a. Patient supine; knee flexed to 30°, quadriceps relaxed. b, Passively translate the patella laterally Positive if the patient expresses apprehension or conttacts the quadriceps to prevent patella from locating, 7. Patellar tilt test a. Patient is supine with the knee extended. b-Lift the lateral edge of the patella from the lateral femoral condyle. « Positive test if the patella is not able to be lifted to at least a neutral angle with respect to the horizon- tal plane. .Snand Sp not available. swGrind (Scouring) test. Patrick's (FABER) test. ® PS a A a 5 Fr °FIESEID Thomas test; negative. GEMEZEED Ws test: negative GOED Wyss test: positive(NEEZLED Novle compression test; hip and knee flexion. GEMREZILD Noble compression test; knee ‘extension and pressure GEEEID Thompson's test. 8 .lliotibial band friction syndrome: noble compression test (see Figure 2-40) a. Patient supine; knee flexed to 90° with hip flexion b. Pressure applied 1 to 2.cm proximal to lateral femo- ral epicondyle; with pressure maintained, patient's knee is passively extended. . Positive if patient experiences pain over the lateral femoral condyle. 9, Swelling: brush (stroke) test. a. Patient is supine, knee in full extension b.Starting at the medial tibiofemoral joint, stroke upward two to three times toward the suprapatel- lar pouch. Then stroke downward on the distal lateral thigh, just superior to the suprapatellar pouch, toward the Tateral joint line. «Positive if fluid is observed on the medial knee. ¢. Quantified with a 5-point scale: 0 = no wave produced on down stroke; trace = small wave; 1+ = larger bulge; 2+ = spontaneous return after upstroke; 3+ = unable to move effusion out of medial knee. £, Substantial reliability (Kappa = 0.61) 10, Fractures: Ottawa Knee Rules (see Box 2-9) a. SN 0.99; SP 0.49; +LR 1.9; =LR 0.05 RED FLAG: Fractures of the tibia, fibula, or patella may occur with traumatic injuries of the knee. Physi- cal therapists must be able to recognize the signs and. symptoms of a possible undiagnosed fracture in their patient. The Ottawa Knee Rules (Box 2-9) provide the therapist with guidelines to determine if a referral for an xray is indicatedya b. Weight-bearing test «+ Patient standing on step with toes positioned over. SPeCial Tes the edge of the step and equal weight bearing, and Temp + Passively extend the patient’ first MTP joint c. Non-weight-bearing test. Cervical Spine Special Tests 1, Vertebral artery test (see Table 2-20) # The patient seated in non-weight-t a, Assesses the integrity of the vertebrobasilar vascular tion with the knee flexed to 90° # Stabilize the ankle and passively extend the system. patient's first MTP joint b. Patient supine, with head supported over end of 4A positive test is the reproduction of plantar sur table, eyes open. face symptoms. (In a non-weight-bearing test, the * Passively extend head and neck, hold for 30 sec symptoms occur at the end of range of motion.) ‘onds. If no symptoms, progress to passive rota s. Fracture: Ottawa Ankle and Foot Rules (see Box 2-11). tion and side-bending with extension in both a, SN 0.98; SP 0.20; +LR 1.2; -LR 0.10. directions. Hold each position for 30 seconds. © Causes reduction of the lumen of the vertebral artery (VA), resulting in decreased blood flow of the intracranial VA of the contralateral side. ‘Symptoms include drop attacks, dizziness, dys- phasia, dysarthria, diplopia, ataxic gait, numb- hess, nausea, or nystagmus. . Patient should be continuously monitored for any change in symptoms during entire test. Test is not progressed beyond that point if symptoms appear. RED FLAG: Fractures of the medial and lateral malleo- lus and foot bones may occur with traumatic injuries of the ankle and foot. Physical therapists must be able to recognize the signs and symptoms of a possible undi- agnosed fracture in their patient. The Ottawa Ankle and Foot Rules (Box 2-11) provide the therapist with guide- lines to determine if a referral for an x-ray is indicated Diagnostic Accuracy of Cervical Spine Special Tests | SUSPECTED PATHOLOGY TESTS SN ° +R aR Cervical Instability ~ Sharp-Purser 069 096 1725 032 Neurological ~ Diskaction Test 0.26-0.43 1.00 a ee Focominal compression (Spurting) 0.28-0.95 0.74-1.00 19-186 005-075 Shoulder Abduction Test 031-043 0.80-1,00 196-36 064-077 ~ Upper limb Tension A 097 022 13 oz Upper Limb Tension B o72 0.33 n 08s Cervical myelopathy Hoffmann sign 0.44 075 18 070 |= Rel Testing 0.48 o71 15 0.80 (> Inverted 061 0.78 28 0.50 + Babinski sign 0.33 092 40 070 > Clonus on 096 27 oso Vertaal artery test Hold planned mobilization position for at least N/A | 30 seconds watching for vertebra basilar signs | «nd symptoms First ib mobility Intaexaminer x = 0.35 | Cervical Muscle Strength (Deep Neck Flexors) | ~ Craniocervical flexion test Inttaexaminer x = 0.72 | ical ili _ raion est Inroexaminer x = 0.50, “doped om Magee, Onopedi hyicl Asner! 6h Edn; Cleland, pont Cincl Exninaion, rd Eon, Us72 Twenam€o + Musculoskeletal Physical Ter™PY 4. Performing mobitization/manipulaion vite vical region without performing this 1t HEE, hand w considered, by most t0 be a Bren stand of care even if current evidence demon trates statistical imitations ofthis test RED FLAG: Life-threatening consequences have Deel associated with vertebrabbasilar artery and cervice arterial dysfunction. Factors associated may include hypermobility, ligamentous instability, oF predisPo% thas anterosclerosis or spondylosis. It ie signs or symptoms ral-basilat is critical to monitor for hallmar secondary to injury or damage to the verte ]Vertebral-basilar artery dysfunction signs | symptoms (adapted from Magee, Orthopedic Physi cal Assessment, 6th Edition): and. Dizziness/vertigo Dysphagia (difficulty swallowing) Dysarthria (difficulty with speech). Diplopia (double vision) Drop attacks Ataxia (incoordination) + Numbness (sensory changes in face or body) + Nausea + Nystagmus + Severe headaches 5 Unconsciousness, disorientation lightheadedness + Hearing difficulties « Facial paralysis 2. Flexion rotation test 2. Provocative test for atlantoaxial dysfunction andjor cervicogenic headache. b-Patient supine, passively perform maximal flexion of the cervical spine then fully rotate the head in each direction Positive finding is reproduction of headache symp. toms or a loss of 10° range of motion fi side compared to other. lone 4.SN 8696; SP 20%. 3, Foraminal compression/Spusling’s est (see Table 2 A denies desfinction’ (pial eemnece any cervical nerve root. ) of b. Patient sitting, with head side bent toward im le Apply poaneeaoaihen Mer «Positive finding is pain andjor paresthesia in’ matomal patter for involved nerve rooy, 1 SN 50%; SP 86%. 5 4, Maximum cervical compression test identifies compression of ‘neural Srveebral (oramen and/or face dyogiennes, b. Patient sitting, Passively move head intosuie ra a ered eee ea by extension. Repeat this toward painful sige 4 «very similar t0 vere, 2 tnis is Ve al 1, and/or paresthesia in de red NeTVe FOOL, OF loca, irfacet dysfunction. ilable ne table 2-20) Pe ae ‘of neural Structures at th, compression & facet joint dysfunction assively distracted test ‘ finding 6 Pa ov patvern fori” | forame head pa ‘ng with siting is a decrease finding is @ 4 finttion) or a dectease ondition) mn test (see Table 2-20) ion of neural structures wit in symptoms in ne in upper limb pa (neuro! fer abductio! .s compressi ppral foramen. ‘d asked to place one hand on eat with opposite hand. ¢ in symptoms should a. Indicates intervertel b Patient sitting a” of their head. Reps Positive finding is a decreas upper limb. 7. Lhermitte’s sign (see Figur a. Identifies dysfunction of ‘upper motor neuron lesion. » Patient longsitting on table. Passively flex patien head and one hip, while keeping knee in exe sion, Repeat with other hip. . Positive finding is “electrical” pain down the spine and into the upper or lower limbs. A.SN 39%; SP 80%. 8. Alar ligament test. @. Determines integi 6 ire 2-42). f spinal cord and/or » of the alar ligament Patient seated, passively, slightly flex the unre & oa spine and apply a firm pincer grip (0 ing path Process. Palpate movement at C2 Tap asSNe upper cervical side-bending and) © Positive finding i it oo a See Saati to palpate C2 mo SN and i 9. Modified sheet vailable ent seated, passi . Cervical spine ah we) slightly flex the vPr ©2 spinous prone PPLY a firm pincer grip 10 and extension fans, APPLY a posterior transla" ASSeSSing for excenee OUR the forehead whi! peua of my nestive. linear tanslation or rep” esitive findings pattie symptoms, i Upper cervical ese MYelopathic symp'o!™ Sie ora decrease in sy" lation during the poste!” Should tension teqq petal tests), 8 (See Table 2-14).RED FLAG: Clinical instability of the cervical spine may exist when physiological loads overcome sta bilizing tissues. Patients with neck pain, headache torticollis, or neurological signs should be screened carefully for upper cervical spine instability, prior to conducting interventions. Ligamentous testing is usefill after trauma or in special populations (eg, rheumatoid arthritis) where degradation of ligamen tous tissues may exist, Itis critical for the clinician to monitor for hallmark signs and symptoms through a careful subjective history and physical examination, Cervical instability signs and symptoms «# Severe muscle spasm « Patient does not want to move head (especial into flexion) ne + Lump in throat « Lip or facial paresthesia Severe headache « Dizziness # Nausea * Vomiting, + Softend feel ystagmus « Pupil changes Thoracic Spine Special Tests 1. Rib springing, a. Evaluates rib mobility. b. Patient prone. Begin at upper ribs applying a pos- terior/anterior force through each rib progressively ‘working through entire rib cage. Following prone test, position patient side-lying and repeat. Be care- ful with springing the eleventh and twelfth ribs, since they have no anterior attachments and there- fore are less stable. Positive finding is pain, excessive motion of rib, or restriction of rib. 4.SN and SP not available. 2. Thoracic springing, a. Evaluates intervertebral joint mobility in thoracic spine. b. Patient prone. Apply posterior/anterior glides/springs to transverse processes of thoracic vertebra, Remem- ber that the spinous process and transverse process of the same vertebra may not be at the same level in the thoracic region. ¢ Positive finding is pain, excessive movement, and/ or restricted movement. d.SN and SP not available. Lumbar Spine Special Tests 1. Slump test (see Figure 2-44 and Table 2-21), 4a Identifies dysfunction of neurological structures supplying the lower limb. Physical Therapy Examination 73 ' Patient sitting on edge of table with knees flexed, Patient slump:sits, while maintaining neutral posi- tion of head and neck. The following progression is then followed «© Passively flex pa tient’s head and neck. If no repro duction of symptoms, move on to next step assively extend one of patient’s knees. If no reproduction of symptoms, move on to next step. ‘Passively dorsiflex ankle of limb with extended knee + Repeat flow with opposite leg Positive finding is reproduction of pathological neurological symptoms 2.Straight leg raise (Lasegue's test) (see Tables 2-21 and 2-22) a. Identifies dysfunction of neurological structures that supply lower limb, b, Patient supine, with legs resting on table. Passively flex hip of one leg with knee extended until patient complains of symptoms into lower limb. Slowly lower limb until symptoms subside, then passively dorsiflex foot c. Positive finding is reproduction of pathological neurological symptoms when foot is dorsiflexed. 3. Femoral nerve traction test (see Table 2-21) a. Identifies compression of femoral nerve anywhere along its course. b. Patient lies on nonpainful side with trunk in neu- tral, head flexed slightly, and lower limb’s hip and knee flexed. Passively extend hip while knee of painful limb is in extension. If no reproduction of symptoms flex knee of painful leg c. Positive finding is neurological pain in anterior thigh 4. Valsalva’s maneuver. a Patient sitting, Instruct patient to take a deep breath and hold while they “bear down” as if hav- ing a bowel movement. b. Increases pressure in middle ear and in the chest. Used when bracing to lift heavy objects Can be used to identify a space-occupying lesion. Positive finding is increased low back pain or neu- rological symptoms into lower extremity. SN 2296; SP 94%. 5, Prone instability test (see Table 2-21). Tests instability of the lumbar spine, b. Patient prone with torso resting on the plinth and Jegs off the edge with feet supported on the ground. Apply PA springing throughout the lumbar spine tuntil a painful segment(s) is identified. « Instruct the patient to lift their legs a few inches off the ground then perform spring testing again on the painful segment(s). «Positive finding is decreased pain during PA spring- ing with the legs raised compared to when the feet ‘were supported on the ground.(i Aaa) Daye RAPED Musculoskeletal Physical TheraPY ak Diagnostic Accuracy of Lumt a ial Toots % aR SUSPECTED PATHOLOGY TESTS. a “ps 019 Ne 063 3 029 | oe 028 28 080 092 0.90. E : 028 fa e 0.84 69 0.63 oe 0.94 5 mm oe ere 2 0.70 exo airs 0.29 oe 17 0.48 one ty te 072 ® Aber n fexion, ns Intraexominer x = 0.60 painful rom Rexior bility catch, 078 ay 0.54-0.66 051-062 sai 28 o7t 050-053 071-077 1.84-2.21 0.60 0.69 22 0.23-0.60 0.81 1.24-3.20 063 075 049 ‘Combined tests (thigh thrust, Goenslen, compression, 085 0.76 3.54 “apd an Hoge, Otopd yc Ane Gh Er Cloud Oropani al xine, Sed Elion Hicks GE, Fiz M, Dalit A SP ese pana org hhh ee an lord een se om Lower Extremity Neurotension Tests VERSION OF ar sig POSTION OF HP KNEE POSTION OF a Flexion and abduction Extension Deaths sua Flexion Extension Dersifexion version sues Flexion rae, er = sins Flexion and internal Extension nesta Inversion SE Tibial nerve rottion lanarfeson —laveren NY ae ji a Zommen fibulo suns Fexion es soso sere wae NA pene ‘doped rm Magee O: Oped Physical Assan), hed N/A Bihar! 6. Quadrant test. o identfies compression of neural strictures a intervertebral foramen and facet dysfunction | b. Patient standing «intervertebral foramen: cue patient into pending left rotation left and extension to meee nally close intervertebral foramen on the i Repeat on other side le ic @ * Facet dytuneto f. rotatio, compress side, Positive fy de nding j, m Toate ene atdlor parts SN 709, Cail if faceg qyen® Involved nerve 100" SP hot available tion. n: cus n right, a i f 8 facet joint €xtension to maxi! nt on lefi. Repeat on ot” © Patient into side-benti"® ee LLLAberrant movement testing (see Table 2-21). the patient displays any of the five possible movement patterns they are considered positive for aberrant movement b. Instability catch, pai ful arc in flexion, painful are from flexion, Gower's sign (thigh climb. 1g), reversal of lumbopelvie rhythm, 8. Bicycle (van Gelderen’s test) a. Differe es between intermittent claudication and spinal stenosis, b, Patient seated on stationary bicycle. Patient rides bike while sitting erect, Time how long the patient can ride at a set pace/speed. After a sufficient rest period, have patient ride bike at same speed while ina slumped position, ¢. Determination is based on length of time patient can ride bike in sitting upright versus. sitting slumped. Ifpain is related to spinal stenosis, patient should be able to ride bike longer while slumped, 4.SN and SP not available. 9. Crossed straight leg raise (see Table 2-21) a. Identifies herniated nucleus pulposis or neural tension/radiculopathy. b. Patient supine with head, neck, and torso in new: ural, maintain knee extension and neutral dorsi- flexion and lift the leg to the point of symptom provocation. Perform on the contralateral, non extremity. 4. Positi involved lower finding is reproduction of low back pain during the straight leg raise of the non-involved lower extremity 10. Schober test a. Measures the mobility of the lumbar spine. b.Patient standing. Examiner marks a point 5 cm below and 10 cm above $2. This distance is measured Positions/Activties That Precipitate SI Dysfunction _TYPE OF DYSFUNCTION | Aotetir torsion of innominate Posterior torsion of innominate Sacral dysfunction PhysicalTherapy Examination 75 in the upright position and then in full flexion. The difference between the two meastirements is calcu lated and recorded to the nearest centimeter. ©. SN 30%; SP 8696 in patie dylitis, is with ankylosing spon: Sacroiliac Joint (SIJ) Special Tests (See Table 2-23) 1. Gillet’s test (see Figure 2-44), a. Assessing ;ostetior movement of the ilium relative to the sacrum. bs. Patient standing. Place thumb of the hand under pos ior superior iliac spine (PSIS) of limb to be tested and place the other thumb on center of sacrum at same level as thumb under PSIS. Ask patient to flex hip and knee of limb being tested as if bringing the knee to the chest. Assess movement of PSIS via com. parison of positions of the thumbs. Make sure eyes are level with thumbs. PSIS should move in an infe rior direction, . Positive finding is no identified movement of PSIS as compared to sacrum, 4.SN 4396; SP 680%. 2. Thigh thrust (see Table 2-21). a. Pain provocation test b. Patient supine with hip passively flexed to 90° on the test side. Use one hand to palpate Si) while thrusting downward through knee and hip. 3, Gaenslen’s test (see Table 2-21) a. Identifies SI} dysfunction, b, Patient side-lying at edge of table while hold- ing bottom leg in maximal hip and knee flexion {knee to chest). Standing behind patient, passively extend hip of uppermost limb. This places stress on SU) associated with uppermost limb, ©. Positive finding is pain in SI} ACTIVES THAT PRECIPTATE DYSFUNCTION, | Sevating/iing/loverng regnaney Hip ot 90" with axial loading Goling/boting/ennis Vertical thst onto estonded UE int skating positon Fake ed ube Uniltealsonding Long-term postural abnormalities, Fallon rosum/socoe Corryng load during ambulation Tram ving dh tos of balance during ambulation Siting combined wit rotation and itingToe Gillet’s test: hand positionPhysical Therapy Examination — 77 Long sitting (supine to sit) test. initial hand position. GEEEZED 10n9 sitting (supine to si) test | ———— GEMEEZEED Long sitting (supine to sit) test. CEED cotarnwair’s toseCrean) patient’ feet, palpating the medial malleol oem syria than other). Have again assess leg length, making a comparison bnormal finding is reversal in limb lengths bar segments, dysfunction is related to SU SN and SP not available npression test (see Table 2-21), Identifies SI} dysfunction b, Patient lies in side-lying position with painful side ‘up and baseline symptoms are gathered. Examiner Places hands on the iliac crest and applies force through the ilium in the downward direction, The examiner may hold the position for 30 seconds and apply continued force © A positive test reproduces the Patient's chief com. plaint jiPical Coupling Patterns Throughout the Lower Komal Coa, oer hh ik pet ena iy ‘coupled with ili | Oty nied ere inn et be onan ah tii: lp Ba belrerma diene TOE hoopla ‘sn a et it ‘Supination of the foot is, oped with cr L ‘i and anerior ge of heii ti g test (see Table 2.2 ing ). pi en SI) Ayton and baseline syn a. Identifies pine crosses arms it les i xamine a TOE REISE toe medial aspec of 5 P15 costerior and lay Coen i eT tne positon | he examiner MY force .d force omtinue ply <0 seconds an re reproduction of patient Positive finding. is © complaint. rms Special Tests 2 erates for Pa See adbemipine! Sopport/stabilize patie b Pater h one hand. With other hand, pus Mole superior causing a compressive load TMI « Poste findings pain in TMI dsN and SP not available Gait az ‘See Chapter 12, Figure 12-1 for Phases of Gait n with compression of Typical Coupling Pattern: the Lower Kinematic Ch; Presented in Table 2-24 cematic Chain Compensations ented in Table 2.25 is Throughout ain Are Are Pres Tt the compensars nal compensations desi! yen ad oh een pmEvaluation, Differential Diagnosis, Prognosis, and Pan of Care of Musculoskeletal Conditions 79 > Evaluation ant Reasoning 1. Process of ongoing cognitive skill used to process information and inform clinical decisions, 2.Synthesize examination findings in relation to the Intemational Classification. of Function, Disability and Health (ICF) (see discussion in Chapter 14 and Box 14-1). a. Consider all body functions and structures, activi ties, and participation, b.Use evidence-based decision making based on examination findings. . Consider altemative hypotheses based on exami: nation findings, 4. Document the evidence to support clinical deci- sion making, 3. Integrate relevant evidence to support clinical decision. making process. Pra 1. Anticipated level of optimal functioning and the amount of time required to achieve that level. 2. Barriers to achieving optimal function may include age, medication use, socioeconomic status, co-morbidities, cognitive status, nutrition, social support, and/or envi- ronment, | 1.Goal setting. 2. Coordination of care. 3. Progression of care. 4. Discharge Arete Condition NN Degenerative Joint Disease (DJD); Degenerative Osteoarthritis (OA)/ Osteoarthrosis (See Box 2-1) 1.A degenerative process of varied etiology, which includes mechanical changes, diseases, and/or joint trauma primarily confined to one or more synovial joints and its surrounding soft tissues. elle ECE emer nen LeU Rae imern niin 2. Characterized by degeneration of articular cartilage, with hypertrophy of subchondral bone and joint cap sule of weight-bearing joint, 3. Most common form of arthritis, affecting men more than women before age 50 and then mote women than men after age 50. Differentiated in two ways primary (idiopathic) and secondary disease (ie, uma) 4, Slowly progressive condition with pain initially epi sodic and triggered activity. Eventually, pain and stff- ness become chronic. DID/OA is a progressive and chronic condition. Knee OA is considered the leading cause of disability in the elderly. 5. Clinical examination assists in confirming diagnosis, Signs and symptoms include pain, swelling, loss of ROM, and bony deformity. Finger DIP and PIP joints and CMC of the thumb are commonly involved. The cervical and lumbar spine, hips, knees, and MTP of the great toe are also ofien involved. 6. Diagnostic tests utilized: plain film imaging demon- strates characteristic findings of OA (diminished joint space, decreased height of articular cartilage, pres- ence of osteophytes, subchondral cysts) and lab tests help to rule out other disorders such as rheumatoid arthritis (RA), 7. Oral analgesics, NSAIDs, and corticosteroid. injec- tions are the primary medications used in medical ‘management. Viscosupplementation (e.g., Synvisc) or intra-articular injections of the knee with a form of hyaluronic acid (HA) can be used 8, Physical therapy goals, outcomes, and interventions. a, Maintain joint and soft tissue mobility b, Physical therapy is most valuable during exacerba- tion; however, some cases may result in joint sur- gery including arthrodesis or arthroplasty to help the patient regain function. «Flexibility and general strengthening, Implementa- tion of aerobic capacity/endurance conditioning or reconditioning, such as aquatic programs. Rheumatoid Conditions 1. Ankylosing spondylitis (Marie-Strtimpell disease, Bechterew’s disease, rheumatoid spondylitis) (see ‘Table 2-26). a, Progressive inflammatory disorder of unknown eti- ‘ology that initially affects axial skeleton. b. Initial onset (usually mid- and low back pain for 3 months or greater) before fourth decade of life.(TR) q herapy TwerarvEo « Musculoskeletal Physic '» clinical F' diminishing Pain/Hip Osteoarthritis fe not mptomns at cation of SYT™™ Diagnosis ssi « Revise diag snestont wih he sores volt smmendation, U re walk prysical Per res strong re uch 23 6mninu! aceite s Me vance measures SU iaruchanutaha ecieots of Or id physical perf" Physical Impairment (A-strong recommendation, Level I ip pain or osteoarthritis + Document passive ROM, hip muscle strength sewn over opcode of care wan PPS careers Mecence,Activiy Lrneton ston recounts na Naina Ostecaaiieed ier (WOMAC) anc 4 outcome measures such as Westem ontario and MMos Univ as a visual analog scale (VAS) © Use v Diagnosis/Classtication (A-strong recommendation, Level) ilexion 15° ess ‘ Hip internal rotation ess than 24” or internal rotation! than nonpainful side + Passive internal rotation increases pain ip stiffness after awakening ‘= Morning hi ‘= Moderate anterior of lateral hip pain when weight beating Interventions Flexibility, Strengthening, and Endurance (A:strong recommendation, Level snes to address impairments (dosage 1-5 times per week for 6-12 weeks with mild to moderate hip « Individualized exerci osteoarthritis) Manual Therapy (A-strong recommendation, Level «Manual therapy for mild to moderate hip osteoarthritis that may include soft tissue mobi OF 123 times per week over 6-12 weeks) eee cerns? (50000? Patient Education (B-moderate recommendation, Level I «Provide patient education consisting of general exercise, weight reduction painful joint, and activity modification {for the overweight, methods of unloading the Functional, Gait, and Balance Training (C-weak recommendation, Level Il » mpaimentbased functional, gait andbalance traning including use of amb latory a . Modalities (@-moderate recommendation, Level) tory aids, and activity limitations ‘se not packs for pin short-term and wltasound = May us -in and Mobility Deficits-Hip Osteoart Adapted trom eee a7. 2, 2017 hoped Section, APTA, Summary of R z cos Table 16-4 in Chater 16 for Levels of Evidence and Grades of Recommend ieiuiencstons JOS? ations. ¢ First symptoms include mid- and low back pain, therapy or medi roming stiffness, and sactoilit ee tions to suppress immune sss" 4. fesults in kyphotic deformity of the cervical may be used thoraispne anda detain lumbar lordosis toxic drugs td ontol various symptoms. 0" e Degeneration of peripheral and costovert Used ir at block w Denon be obseed in avanced sagen cone ee ho do not ole ions: NSAIDs, such as aspir i cation aspirin, are used itors have been Recrosis factor (INF) ith” Medi ‘0 improve some sympt0™ ¢ Affects men three times more often than w " 0 f, Affects met an women, Corticosteroids.) mg ePendent on high doses” to reduce infl shown lammation and ps Coniconerod ——_284Voxing op aDifferential Diagnosis of Ankylosing Spondylitis and Spinal ANKYLOSING SPONOYUIS Morning sfness Male predominance Sharp pain» ache History Biter socrolioc pain may refer posterior high Active moveren’s Restricted Passive movements Restricted Rrsisted isometric movements Normal in beginning of disorder) Pose Flexed posture of entire spine Special tes Schober test (mobility less than 4 em) payee Normal in beginning of disorder) Sensory deficit None (in beginning of disorder) Diagnostic imaging Plain films ore diagnostic uation, Differential Diagnosis, P it Diagnosis, Prognosis, and Plan of Care of Musculosh Stenosis SPINAL STENOSIS Interment aching pa Poin may refer o bo lage with walking (neurogenic intemitert coudicion) May be normal May be normal Normal Flered posure of lumbar spine Bicyla test of van Gelderen may be posi five; Stoop tes! may be postive May be oected in long standing coves sully temporary Computed omearaphy cons oe Gognosic ‘Adepied fon Magee D: Orhopedi Phycol Aseamant, dh ed. 2074. Cand JA, Kapperhower SS} Nee’s Orhopandi incl Examination, rdw 2016, bh. Diagnostic tests utilized: HLA-B27 antigen may be helpful, but not diagnostic by itself i. Clinical examination will assist in confirming diag. j. Physical therapy goals, outcomes, and interventions. + Implementation of flexibility exercises for trunk to maintain/improve normal joint motion and length of muscles in all directions, especially extension, * Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programs, + Implementation of relaxation activities to main- tain/improve respiratory function. © Breathing strategies to maintain/improve vital capacity 2.Gout a. Genetic disorder of purine metabolism, character- ized by elevated serum uric acid (hyperuricemia). Uric acid changes into crystals and deposits into Peripheral joints and other tissues (eg, kidneys). b. Mast frequently observed at knee and great te of foot Medications: NSAIDS (specifically indomethacin), COX-2 inhibitors (cardiac side effects may limit use), colchicine, corticosteroids, adrenocortico- tropic hormone (ACTH), allopurinol, probenecid, and sulfinpyrazone. 4. Diagnostic tests utilized: lab tests identify monoso- dium urate crystals in synovial fluid and/or connec- tive tissue samples. €. Clinical examination assists in confirming diag: I therapy goals, outcomes, and interven- * Patient/client education for injury and reduction of involved joint(s) « Patient/client education on dietary effects on the disease. « Early identification of condition, with fast imple- ‘mentation of intervention, is very important. Psoriatic arthrit a. Chronic, erosive inflammatory disorder of unknown etiology, associated with psoriasis. b. Erosive degeneration usually occurs in joints of digits as well as axial skeleton . Both sexes are affected equally. d, Medications: acetaminophen for pain, NSAIDs, corticosteroids, disease-modifying antirheumatic drugs (DMARDs) can slow the progression of pso- riatic arthritis, and biological response modifiers (BRMs) such as Enbrel (etanercept) are a newly developed class of medicines. . Diagnostic tests utilized: lab tests are not useful except to rule out rheumatoid arthritis. £. Clinical examination assists in confirming diag- nosi 8g, Physical therapy goals, outcomes, and interventions. * Joint protection strategies. ‘* Maintain/improve joint mechanics and connec- tive tissue functions. prevention82 THEMED - Musculoskeletal Physical Therapy “Implementation of aerobic capacity/endurance Conditioning or reconditioning, such as aquatic Programs, 4- Rheumatoid arthritis (RA) * Chronic systemic autoimmune disorder of unknown ‘ology thought to have a genetic basis. pain. © Associated injuries. ‘© Hill-Sachs lesion: compression fracture of the posterior humeral head. © Superior labrum, anterior-to-posterior (SLAP) tear © Bankart lesion: avulsion of the anterior-inferior capsule and glenoid labrum. © Axillary nerve injury: exam will demonstrate numbness and tingling in the lateral deltoid and weakness in shoulder abduction. sternocleidomastoidEvaluation, Diff itferential Diagnosis, yanosis, Prognosis, and Plan of Care of Musculoskeletal Conditions nosis of Common Shoulder Diso a ers “Anrolaterl shoulder poin with overhead activities and/or poi ity /aprtanon ihc with pi] wih, oy ly shoulder is abducted and externally rotted Decreased ronge of motion and pain with muscle contraction ‘age >60 wih poin, shoulder weakness, ond night pain poody localized shoulder poin ond snes; typical age ver 45, Fallon odducted shoulder Upper exremiy paresthesia wih prolonged postr or sdehing Taped Fon Clond JA, Koppenhaver S, Su Net's Orhopontc Clinical Exonina Signs and Symptoms of Possible Peripheral Nerve Involvement in Shoulder Region Syetecesery neve nobly to obdct om beyond 90° Poin in shoulder on cbducion ump threicnerve Poin on xing fly exended orm Inobility to Hex fly extended orm Winging sors o 90° forward exon Sqroupdarzee | Inroosed poinon forward saul Hoven ‘Shoulder weokness (poral lss of humeral contr) Poin increases wih scapular abduction increases with cervical reotion 10 ‘opposite side sry rm) relly occ crm wih ron of the socket that may also involve the biceps te" Sean sect of the im below the middle of the gle Sn a ciet is called a Bankar’s lesion and also ro pos the inferior glenohumeral ligament. Tes of the glenoid labrum may often occur with other Shoulder injuries, such asa dislocated shoulder b. Characterized by the following signs and symptoms. ® Shoulder pain that cannot be localized to 4 $P® cific point. * Pain is made worse by ‘overhead activities oF ‘ehen the arm is held behind the back. ‘© Weakness. « Instability in the shoulder. Shain on resisted flexion of the biceps (bending the elbow against resistance). « Tenderness over the front of the shoulder. ¢ Diagnosis made by clinical examination, through comparing results of AROM: PROM, resistive tests a bawenid hued beni ait] Rosco cll erdinopathy Subrcromiol bursitis Glenchumera inataity Glercid label oar Rotator cl endinapethy Bciitaltendinopathy Rotator cl oor Frozen shoulder ‘Acromiocivicular joint specin Thoracie outlet syndrome Cervical radiculopethy Qrded 2016. and palpation. MRI arthrograms are very effective in identifying labral tears. The “gold” standard for identifying a labral tear is through arthroscopic sur gery of the shoulder. d. Medications. ‘* Acetaminophen for pain. @ NSAIDS for pain and/or inflammation. ¢: Physical therapy goals, outcomes, and interventions « Physical therapy intervention emphasizes return of function without pain. «» Functional training and resistance training exer ses to improve strength, endurance, ProprioceP- tion, coordination, and flexibility «s Anyunderlying causes that contributed to the injury such as shoulder instability should be addressed. « Joint movement restrictions should be addressed by exercises and/or manual therapy tailored to impairments identified during the examination, ‘Avoid apprehension position (90/90° abduc tionyexternal rotation) for 12 weeks after surgical repairs of the glenoid labrum. « Following surgery, the shoulder is usually kept in ling for 3-4 weeks. Afier 6 weeks, more sPOns Specific training can be done, although full fitness may take 3-4 months. Thoracic outlet syndrome (TOS) (see Table 230). segompression of neurovascular bundle (brachial plemus, subclavian artery and yeine Wage! and phrenic nerves, and the sympathetis trunk) in tho- ve outlet between bony and soft tissue structure b, Compression occurs when size or shape of thoracic outlet is altered. ¢ Common areas of compression: «© Superior thoracic outlet «# Scalene triangle,ott Stade venArvEa » Musculonketoal Physio THOR aaiet Syndrome oracle amp poRacic OUTIET SYNDROME erential Dag oxic ‘SIGNS AND SYMPTOMS i No ed 90 Referred po soe Seen ible rypicly ore cer Posecompored 10 joint iff, Spine stiffness. Possible a! Possible sible Poresthesio Ye Nat key but pos May be affected ia en aed e Muscle guarding Yes Ye May be positive Tension tests Peano Typically not posive Possible—primarily in hor x Ne Not eaty later smaller murde Possible: e Possible usd Ne Tegal © Between clavicle and first rib. b. Traditionally, degree of injury is graded from fi ‘© Between pectoralis minor and thoracic wall. 4. Surgery may be performed to remove a cervical rib or a release of anterior and/or middle scalene muscle. Diagnostic tests utilized: plain film imaging to identify abnormal bony anatomy and MRI to iden tify abnormal soft tissue anatomy. Electrodiagnos- tic test to assess nerve dysfunction. £ Clinical examination including the following spe- cal tests will be useful to make diagnosis. # Adson's test. # Roos test «© Wright test. © Costoclavicular test Medications. ‘Acetaminophen for pain. ‘© NSAIDs for pain and/or inflammation, hh Physical therapy goals, outcomes, and interventions ‘ Physical therapy intervention varies, depending fon the exact cause, ‘Includes postural reeducation. Functional training and resistance training exer. cises to improve strength, endurance, propriocep- tion, coordination, and flexibility. « Joint movement restrictions should be addressed by exercises and/or manual therapy tailored to impairments identified during the examination ‘© Manipulations (typically ts ib articulation) to diminish pain and soft tissue guarding 4, Acomioclavicular and stemoclavicular joint disorders, a Mechanism of injury is a fall onto shoulder with upper extremity adducted, oF a collision yi nother individual during a sporting event. to third degree. Rockwood classification scale us grades from I to IV, with grades IV-V1 as variat of the traditional grade IIL Upper extremity is positioned in neutral wit of sling in acute phase. Avoid shoulder elevation during the acute phase of healing Diagnostic tests utilized: plain film imaging. Glinical examination, including the horizon adduction test and Paxinos test, will be usefu order to make diagnosis. Surgical repair is rare, due to tendency of actom clavicular joint d : Meter, int degeneration following the rps 4 re for pain, h Physical te Pa? and/or inflammation, Pm pnt3PY 80als, outcomes, and intervent f connective ti sof SABE, joing te tissues, such 35 s tions to no} eee Oscillations, and mobiliz# Soft tissue and joint biom? toia bursitis subdeltoi reed bursae (which makin felationship to 10" MB them susceptible "° inged beneath the 4“