Myotomes: Cervical, Lumbar, Pain Types

• Cervical and lumbar myotomes correlate spinal nerve roots to specific muscle actions.

Cervical Myotomes

• C1-C2: Neck flexion.
• C3: Neck side flexion.
• C4: Shoulder elevation.
• C5: Shoulder abduction.
• C6: Elbow flexion and wrist extension.
• C7: Elbow extension and wrist flexion.
• C8: Thumb extension and ulnar deviation.
• T1: Hand intrinsics.

Lumbar Myotomes

• L1-L2: Hip flexion.
• L3: Knee extension.
• L4: Foot dorsiflexion.
• L5: Extension of the big toe.
• S1: Ankle plantar flexion and eversion.
• S2: Hip extension.
• S3: Knee flexion.

Types of Pain

• Nerve pain is sharp, bright, and burning along specific nerve distributions.
• Bone pain is deep, boring, and localized.
• Vascular pain is diffuse, aching, poorly localized, and can refer to other areas.
• Muscle pain is hard to localize, dull, aching, aggravated by injury, and can refer.

Contractile vs Inert Tissue Pain

• Contractile tissue pain occurs with RROM (Resisted Range of Motion) and OP (Overpressure), indicating muscle involvement.
• Inert tissue pain occurs with joint play and OP, indicating joint involvement.

Capsular Patterns

• Capsular patterns indicate joint-specific limitations in range of motion, with a typical order of restriction.
• Cervical: Bilateral side flexion and rotation are equally limited, followed by extension.
• Thoracic/Lumbar: Rotation and side flexion are equally limited, followed by extension.
• Shoulder: Lateral rotation followed by abduction and then medial rotation.
• Elbow: Flexion and extension are equally limited.
• Wrist: Flexion and extension are equally limited.
• SI joint: Pain when stressed.
• Hip: Flexion, abduction, medial rotation.
• Knee: Flexion, followed by extension.
• Ankle: Plantar flexion and dorsiflexion.

Closed Packed Positions

• Closed-packed positions are joint positions where the ligaments are maximally taut, and joint surfaces have maximal contact.
• Cervical Spine: Full extension.
• Thoracic/Lumbar Spine: Extension.
• Shoulder: Abduction and external rotation.
• Elbow: Full extension, supination.
• Wrist: Extension, radial deviation.
• SI Joint: Counter-nutation.
• Hip: Extension, internal rotation, abduction.
• Knee: Extension.
• Ankle: Dorsiflexion.

Joint Mobilizations

• Specific joint mobilizations can improve range of motion by addressing joint restrictions.
• C Spine:
  • Flexion: Posterior/Anterior glide on SPs (Spinous Processes).
  • Extension: Anterior/Posterior glide on SPs.
  • Side Flexion: Lateral glides on SP of the affected side.
  • Rotation: Unilateral PA glide on TvPs (Transverse Processes).
• GH (Glenohumeral) Joint:
  • Flexion: Posterior glide.
  • Extension: Anterior glide.
  • Abduction: Inferior glide.
  • External Rotation: Anterior glide.
  • Internal Rotation: Posterior glide.
• Elbow Joint:
  • Flexion: (glide direction not specified)
  • Extension: (glide direction not specified)
• Wrist Joint:
  • Flexion: Posterior glide.
  • Extension: Anterior Glide.
  • Radial Deviation: Medial glide.
  • Ulnar Deviation: Lateral glide.
• Hip:
  • Flexion: Posterior glide and inferior glide.
  • Extension: Anterior glide.
  • Abduction: Distraction.
  • Horizontal Adduction: Posterior glide.
  • Internal Rotation: Posterior glide.
• Knee:
  • Flexion: Posterior glide.
  • Extension: Anterior glide.
• Ankle (Talo-crural):
  • Dorsiflexion: Posterior glide.
  • Plantar flexion: Anterior glide.
  • Eversion: Lateral glide.
  • Inversion: Medial glide.

Elbow, Wrist, and Hand Pathologies

• Common conditions affecting the elbow, wrist, and hand include Dupuytren’s contracture, ganglion cysts, and carpal tunnel syndrome.
• Dupuytren’s Contracture: Thickening of the palmar fascia, leading to finger contracture. Usually affects the 4th and 5th digits and is associated with age, genetics, and vibrating tools.
• Ganglion Cyst: Fluid-filled cysts often on the dorsal wrist, which can cause pain if they press on nerves.
• Lunate Subluxation/Dislocation: Results from hyperextension injuries, causing pain, swelling, and deformity.
• Olecranon Bursitis: Inflammation of the bursa at the elbow tip, often due to trauma or prolonged pressure.
• DeQuervain’s Tenosynovitis: Inflammation of the tendons at the base of the thumb, causing pain and swelling, common in repetitive thumb movements.
• Heberden & Bouchard’s Nodes: Osteoarthritis-related bony growths at the DIP and PIP joints.
• Rheumatoid Arthritis (Swan-Neck Deviation): Hyperextension of PIP joints and flexion of DIP joints due to muscle/tendon imbalance.
• Trigger Finger: Irritation of the flexor tendon sheath, causing finger locking or catching.
• Carpal Tunnel Syndrome (CTS): Compression of the median nerve in the carpal tunnel, leading to numbness, tingling, and weakness in the hand.
• Pronator Teres Syndrome: Compression of the median nerve at the elbow, causing pain and numbness in the forearm and hand.
• Thoracic Outlet Syndrome (TOS): Compression of the brachial plexus and subclavian vessels, leading to pain, numbness, and weakness in the arm.

Assessment of Elbow, Wrist, and Hand

• AROM/PROM/RROM: Assess range of motion in flexion, extension, supination, and pronation.
• Special Tests:
  • Tinel’s Test: Tapping over the median nerve to elicit tingling (positive for CTS).
  • Phalen’s Test: Wrist flexion for 1 minute to reproduce CTS symptoms.
  • Finkelstein’s Test: Ulnar deviation of the wrist to test for DeQuervain’s tenosynovitis.
  • Watson Test: Scaphoid instability test.
  • ROOS Test: For TOS, involves arm abduction and repetitive hand movements.

Treatment Considerations for Elbow, Wrist, and Hand

• CTS: Reduce edema, maintain ROM, and decrease compression of the median nerve.
• TOS: Address postural malalignment, reduce compression of the neurovascular bundle, and treat trigger points in scalenes and pectoralis minor.

Common Shoulder Pathologies

• Thoracic Outlet Syndrome (TOS): Compression of nerves and vessels in the thoracic outlet, causing pain, numbness, and weakness in the arm.
• Frozen Shoulder (Adhesive Capsulitis): Pain and stiffness in the shoulder, progressing through freezing, frozen, and thawing stages.
• Impingement Syndrome: Compression of rotator cuff tendons and subacromial bursa, causing pain with overhead movements.
• Shoulder Bursitis: Inflammation of the bursa, often due to repetitive motions.
• Bankart & SLAP Lesions: Labral tears, often due to trauma or repetitive shoulder motions.
• Rotator Cuff Lesions: Tendinitis or tears in the rotator cuff tendons, causing pain and weakness.
• Shoulder Dislocation/Subluxation: Partial or complete displacement of the humeral head from the glenoid cavity.

Assessment of Shoulder

• AROM/PROM/RROM: Assess flexion, extension, abduction, adduction, and rotation.
• Special Tests:
  • Apprehension Test: For anterior shoulder instability.
  • Sulcus Sign: For inferior shoulder instability.
  • Jerk Test: For posterior shoulder instability.
  • Empty Can Test: For supraspinatus tendon pathology.
  • Hawkins-Kennedy Test: For shoulder impingement.
  • Speed’s Test: For biceps tendinitis or SLAP lesions.

Joint Positions in relation to Mobility

• Shoulder (Capsular): External rotation > abduction > internal rotation limitation.
• Non-Capsular: Restriction inconsistent with capsular pattern.

Inert vs. Contractile Tissue Patterns:

• Inert Tissue (ligaments, joint capsules): Pain with both active and passive movement in the same direction.
• Contractile Tissue (muscles, tendons): Pain with active movement in one direction and passive movement in the opposite direction.

Myotomes & Muscle Actions

• C5: Shoulder abduction (deltoid, supraspinatus).
• C6: Elbow flexion, wrist extension.
• C7: Elbow extension, wrist flexion.
• C8: Finger flexion.
• T1: Finger abduction/adduction.

Special Tests Overview

• CTS: Tinel's, Phalen's.
• TOS: Adson's, ROOS.
• Frozen Shoulder: Apley Scratch Test.
• Impingement Syndrome: Hawkins-Kennedy.
• Rotator Cuff Lesions: Empty Can, Speed's.
• Cervical Disc Herniation: Spurling's.
• Lumbar Disc Herniation: Straight Leg Raise, Slump Test.

Joint Mobilizations Applied

• Increase Shoulder Abduction: Inferior glide.
• Increase Shoulder External Rotation: Anterior glide.
• Increase Elbow Flexion: Anterior glide.
• Increase Wrist Extension: Volar glide.

Proprioceptive Neuromuscular Facilitation (PNF)

• PNF can be used to increase ROM.
• Stretching is applied to tight antagonist muscles (e.g., stretching pectoralis major for shoulder external rotation).

Pain Types & Associated Tissues

• Dull/Aching: Muscle, ligament.
• Sharp/Shooting: Nerve compression.
• Burning: Neural irritation.
• Deep, Boring: Bone pathology.