Musculoskeletal Physical Therapy Overview

Musculoskeletal Physical Therapy Overview

• Focus on assessing and treating musculoskeletal conditions through various physical therapy techniques.

Upper Quarter Screen

• Peripheral Joint Scan includes assessments for cervical flexion, extension (no overpressure), rotation, side bending, and shoulder abduction as well as functional external/internal rotation.

Myotomes

• Key muscle functions associated with cervical spinal levels:
  • C1-C3: Cervical rotation
  • C4: Scapular elevation
  • C5: Shoulder abduction, internal rotation, external rotation
  • C6: Elbow flexion, wrist extension
  • C7: Elbow extension, wrist flexion
  • C8: Thumb extension
  • T1: Finger abduction

Dermatomes

• Sensory distributions for cervical spinal levels:
  • C3: Side of neck
  • C4: Supraclavicular region
  • C5: Lateral aspect of the arm
  • C6: Thumb
  • C7: Digits 2 and 3
  • C8: Ulnar border of the hand
  • T1: Medial aspect of the arm

Muscle Stretch Reflexes (MSRs)

• Key reflexes tested at cervical levels:
  • C5: Biceps reflex
  • C6: Brachioradialis reflex
  • C7: Triceps reflex

Key Muscles and Their Details

• Deep Neck Flexors

  • Origin: Vertebral bodies
  • Insertion: Transverse processes (TPs, anterior)
  • Innervation: Cervical primary rami
  • Relevance: Weakness associated with forward head posture; assessed using pressure biofeedback method.

• Suboccipitals

  • Origin: Spinous processes (SPs) and TPs of C1/C2
  • Insertion: Occiput
  • Innervation: C1 dorsal rami
  • Relevance: Restricts occipital-atlantal flexion; relevant for cervicogenic headaches.

• Levator Scapulae

  • Origin: TPs C1-C4
  • Insertion: Superior/medial scapula
  • Innervation: Dorsal scapular nerve (C5)
  • Relevance: Attention for contralateral scapular assistance and C1-C4 dysfunction.

• Trapezius

  • Origin: Medial ⅓ superior nuchal line, nuchal ligament, SPs T1-T7
  • Insertion: Acromion, spine of scapula, lateral ⅓ clavicle
  • Innervation: CN XI and cervical nerves C3, C4
  • Relevant tests include MMT for upper, middle, and lower trapezius with specified body positions and actions.

• Sternocleidomastoid (SCM)

  • Origin: Sternum, medial ⅓ clavicle
  • Insertion: Mastoid process
  • Innervation: CN XI, C2, C3
  • Relevance: Important for assessing occipital-atlantal (OA) flexion; techniques include chin tucks and contralateral side bends.

• Scalenes

  • Origin: TPs C3-C7
  • Insertion: 1st rib
  • Innervation: Spinal nerves C3-C8
  • Relevance: Stuck open positioning; vital to assess for thoracic outlet syndrome.

• Latissimus Dorsi

  • Origin: Inferior 3-4 ribs, SPs T6-T12, posterior iliac crest, thoracolumbar fascia
  • Insertion: Floor of intertubercular groove
  • Innervation: Thoracodorsal nerve (C6-C8)
  • Relevance: Key for thoracic spine assessment; MMT performed prone with arms at the side.

Muscles and Their Attachments

• Latissimus Dorsi: Originates from the inferior 3-4 ribs, SPs T6-T12, posterior iliac crest, TL fascia, and inferior angle of scapula. Innervated by thoracodorsal nerve (C6-C8).
• Serratus Anterior: Attaches to lateral ribs 1-8, inserting on the medial scapula. Innervated by long thoracic nerve (C5-C7). Associated with muscle imbalance and restriction in flexion.
• Multifidus: Originates from superior SPs and inserts on inferior TPS. Innervated by dorsal rami, involved in contralateral rotation and flexion.
• Rhomboids (Major/Minor): Attachments from SPs C7-T5 to the medial scapula, controlled by dorsal scapular nerve (C5).
• Teres Major & Minor: Major attaches to lateral scapula and intertubercular groove (C5-C6). Minor attaches near the greater tubercle; both have no specific muscle testing.
• Pectoralis Minor: Arises from ribs 3-5 to coracoid process; tightness linked with TOS and forward head posture.
• Pectoralis Major: Has two heads (sternal/costal and clavicular) with different points of insertion and tightness issues related to TOS.
• Supraspinatus: Originates from the supraspinous fossa, inserts on the superior facet of the greater tubercle (C5-C6).
• Infraspinatus: Located in the infraspinous fossa, inserts on the middle facet of the greater tubercle (C5-C6).
• Deltoid: Divided into anterior, middle, and posterior sections with attachments to the acromion and clavicle, innervated by the axillary nerve (C5-C6).

Muscles Responsible for Arm Movements

• Subscapularis: Originates from the subscapular fossa and inserts on the lesser tubercle, innervated by upper and lower subscapular nerves (C5-C6).
• Biceps Brachii: Includes long (supraglenoid tubercle) and short head (coracoid process) elements, innervated by musculo-cutaneous nerve (C5-C6). Used in elbow flexion with supination.
• Brachialis: Sources from the distal anterior humerus to the coronoid process, also innervated by musculo-cutaneous nerve (C5-C6).
• Brachioradialis: Runs from the lateral supracondylar line to the radial styloid process, involved in neutral elbow flexion (C5-C7).
• Triceps Brachii: Comprised of three heads (long, lateral, medial) with specific origins; crucial for elbow extension.

Forearm Muscles

• Pronator Teres: Located on the medial supracondylar line, assisting in forearm pronation (Median, C6-C7).
• Supinator: Connects lateral epicondyle with the proximal third of the radius, countering forearm pronation (Deep radial, C7-C8).
• Pronator Quadratus: Attached to the distal ulna and radius, facilitates forearm pronation (AIN, C8-T1).

Range of Motion (ROM) Values

• Cervical Spine: Flexion at 45 degrees, extension 45 degrees, lateral flexion 45 degrees, rotation 60 degrees.
• Thoracic Spine: Flexion 60 degrees, extension 10 degrees.
• Shoulder: Flexion 180 degrees, extension 60 degrees, abduction 180 degrees, IR 70 degrees, ER 90 degrees.
• Elbow: Full flexion at 150 degrees, with a slight hyperextension range 0-10 degrees.

Mobilization Techniques

• Mobilization Direction: Should be towards the direction of restriction.
• Grades of Mobilization: Ranges from I (small amplitude) to V (high velocity), commonly used for pain and ROM improvement.
• The Mulligan Technique: Involves pain-free, weight-bearing movements with specific blocking or SNAG protocols.

Exercise Guidelines

• Strength Training: Target intensity over 84% 1RM, performing 2-6 sets of 1-1 reps with short rests.
• General Fitness: Utilize 65-80% 1RM for 2 sets of 8-15 reps.

TMJ Biomechanics

• Articulation: TMJ comprises a synovial, bilateral moving hinge joint between the mandibular condyle and temporal bone, divided by a fibrocartilaginous disc.
• Mandibular Movements: Includes depression, elevation, protrusion, and lateral deviation. Normal ROM for opening is 35-55 mm.

Assessment and Treatment of TMJ Conditions

• Hypomobility: Characterized by reduced opening (< 35 mm) and C curve toward the affected side, often due to disc displacement or degeneration.
• Hypermobility: Identified by excessive motion (> 50 mm) typically caused by habitual behaviors.
• Management of Inflammation: Utilizing modalities, protected motion, and soft foods.
• Joint Hypomobility Treatment: Includes mobilization, active ROM exercises, and strengthening.

Cervical Spine Safety Tests

• Stability Tests: Assess for cervical instability and ligament integrity through tests like the Anterior Shear or Alar Ligament tests.
• Imaging Techniques: CT for bone assessment, MRI for soft tissue analysis, and measuring spinal curvature via Cobb or Pedicle methods for scoliosis evaluations.### Dysfunction and Pain
• Dysfunction can cause pain when deep breathing, rotating, sneezing, or coughing.
• Structural dysfunction often involves subluxations from force.
• Torsional dysfunction is characterized by retention in internal or external rotation.
• Respiratory dysfunction is frequently linked to poor posture.

Common Chest Deformities

• Pigeon Chest: Abnormal protrusion of the sternum.
• Funnel Chest: Indentation of the chest wall, also known as pectus excavatum.
• Barrel Chest: Increased anteroposterior diameter of the chest, often associated with respiratory conditions.

Assessment Methods

Respiration Screening

• Observation: Look for rib flare, lateral mobility of the rib cage, and prominent accessory muscles like SCM and scalenes.
• Breath Hold Test:
  • Measure functional residual capacity post-normal exhale (normal > 25 seconds).
  • Measure total lung capacity post-full inhale (normal > 35 seconds).
• Hi-Lo Test: Assess movement of the sternum and upper abdomen during breathing, checking for paradoxical breathing.
• MARM Assessment: Palpation from behind to evaluate lower rib cage and abdomen with breathing.
• Costovertebral Expansion: Measure expansion with an inhale after a full exhale, normal expansion is 3-7 cm at T4, Axilla, T8, and T10.

Biomechanical Assessment

• Palpation can occur posteriorly, anteriorly, and laterally to assess intercostal spacings and depth.
• Note tenderness in intercostal muscles or iliocostalis.
• Rib Motion and Thoracic Excursion: Evaluate motion between transverse processes and rib during flexion/extension.
• Rib Spring Test: Apply posterior-anterior pressure with the thumb over the rib, assessing for pain which indicates rib dysfunction.
• If no pain is present during rib springing, it may indicate a facet joint issue.
• Rib Maneuver for Costal Sprain:
  • Laterally flex away from the painful side.
  • Raise the arm of the painful side overhead.
  • Perform caudal and cranial glides on the involved rib:
    • Pain increases with stretching and decreases with compression indicates a costal strain.

Manual Therapy

• Rib Elevation (Inhalation) Mobilization: Targeting ribs that are stuck in a depressed position through accessory motion techniques.