Subjective and Objective Assessment in Evaluation

• Subjective assessment is critical in evaluation

Key Elements of Subjective Assessment

• Patients offer information about their symptoms
• Open-ended questions gather specific details
• Non-verbal cues influence assessment outcome
• Determine injury events (MOI), symptoms, and pain profile
• Identify the patient's primary complaint
• Obtain medical history

Objective Assessment Overview

• Physical indicators of a condition are observed
• Elements include:
  • Observable/visual inspection of movement and visible conditions
  • AROM to assess affected areas, agonist contraction, antagonist stretch, inert tissue stretch
  • PROM assesses antagonist stretch and inert tissues via therapist-guided joint movement
  • Restricted movements: determine agonist contraction through neutral isometric contraction
  • Neurological assessment: ensures no neurological issues
  • Special tests and palpation

Active Range of Motion (AROM) Insights

• AROM provides insight into:
  • Inert and antagonist stretch
  • Agonist contraction
  • Patient's willingness to move
  • Areas of soreness
  • Movement quality
  • Available Range of Motion (ROM)

Passive Range of Motion (PROM) Details

• PROM occurs when the therapist moves the patient's joint while they relax
• It provides stretch information but also helps identify if pain occurs at the end of ROM and for detecting lesions in inert tissues
• PROM is crucial when assessing end feel

End Feel Assessment

• End feel is assessed during PROM
• Normal end feel types include:
  • Soft tissue approximation: soft, spongy, gradual, painless stop (muscle bellies meet)
  • Bony end feel: abrupt/non-yielding endpoint, without pain
  • Capsular end feel: abrupt, firm endpoint with slight yield and leathery feeling
• Abnormal end feel types include:
  • Springy block: internal joint issue causing a bouncy rebound during ROM
  • Spasm/stretch: involuntary contraction preventing motion due to pain (guarding); rubbery feel before expected ROM end
  • Abnormal capsule: endpoint occurs before expected ROM
  • Empty: no end feel due to significant pain; no mechanical resistance, likely soft tissue injury, bursitis, tumor, or neoplasm

Resisted Testing

• Resisted testing involves isometric contraction of the target tissue (agonist) in a neutral position, avoiding antagonist or inert tissue stretch
• Reveals information about pain in contractile tissues, and indicates nerve function level
  • Strong, painless contraction suggests the nerve is working and the muscle is healthy
  • Weak contraction indicates nerve may be affected
  • Strong, painful contraction suggests the nerve is fine, but the muscle is injured

Special Tests

• Special tests assist in differential diagnosis
• Allows for injury grading, manual muscle testing, and specific assessment of muscles and ligaments
• Muscle strength testing differs from isometric resistance testing; manual muscle testing Uses the Oxford scale

Shoulder Complex Anatomy

• The shoulder complex includes:
  • Humerus
  • Scapula: forms the glenohumeral joint, articulates via the A/C and S/C joints, and connects to the thoracic wall

Shoulder Girdle

• The shoulder girdle:
  • Connects the upper limb to the axial skeleton
  • Includes the clavicle and scapula
  • Clavicle: attaches medially to the sternal manubrium and laterally to the acromion

Common Shoulder Injuries

• Common shoulder injuries include:
  • Separations (A/C)
  • Dislocations (glenohumeral and S/C)
  • Fractures (clavicle, humerus, and scapula)
  • Tendonitis/osis (rotator cuff)
  • Strains (rotator cuff and scapular stabilizers)

Sternoclavicular (S/C) Joint

• The sternoclavicular(S/C) joint:
  • Formed by the articulation of the clavicle and manubrium
  • Exhibits poor bony stability; relies on strong ligament attachments; a disc provides shock absorption
  • Direct connection between the upper extremity and trunk
  • Clavicle should move forward, back, upward, and rotationally
  • Crucial for abduction
• Anterior Dislocations:
  • Typically from indirect trauma
  • Force applied to the anterolateral clavicle while the shoulder is rolled back
• Posterior Dislocations:
  • Typically from direct blow to the anteromedial clavicle, or a blow to the posterolateral shoulder causes the shoulder to roll forward
  • High re-injury incidence due to poor bony congruency

Clavicle Fractures

• Clavicle fractures
  • are commonly fractured in sports
  • Can be injured by force toward the midline also can be injured by force from the superior or anterior direction
• Symptoms include:
  • Middle 1/3 of the clavicle drops with the outer fragment along with pain, localized tenderness, swelling abd loss of function
  • Spasm in traps and SCM
  • Arm held to body with elevated shoulder
  • Scapula assumes protracted position

Acriomioclavicular (A/C) Joint

• The Acriomioclavicular (A/C) joint is where injuries are called separations and is stabilized by:
  • Coracoclavicular ligaments (conoid, trapezoid)
  • Acromioclavicular ligaments
  • Capsule
• Injury through direct force impacting the point of the shoulder with the arm adducted, or indirect force from a fall on an outstretched hand
• Severity graded from 1-6

Acriomioclavicular (A/C) Joint Separation Grades

• Grade 1: small AC joint capsule tear, no instability, pain on palpation
• Grade 2: complete joint capsule/ligament tear, small coracoclavicular tear, vertical stability remains with a slight a-p spring
• Grade 3 Acriomioclavicular (A/C) Joint degrees: The acromioclavicular and coracoclavicular ligaments completely tear, is shown to be highly unstable, and had step deformity and a positive Cross Flexion or Scarf and Paxino Test

Managing A/C Injuries Grade 1

• Clinically stable but painful; athletes can return when pain subsides
• Use a sling and tape for comfort
• Apply POLICE/PEACE & LOVE principles to maintain shoulder movement for a quicker return
• Maintain ROM, strength, and function while the patient works thru clinically stable injury pain

Managing A/C Injuries Grade 2

• Unstable injury, maintains vertical stability but is anterior-posterior unstable
• Address inflammation with POLICE/PEACE & LOVE
• Stabilize with tape
• Repair with gentle AROM or AAROM, progressing to full ROM, and begin shoulder isometrics, and scapular stabilizer

Managing A/C Injuries Remodelling

• Focus includes full shoulder strength
• Scapulothoracic mechanics
• Full function based on return-to-play criteria

Conditions for Returning from Shoulder Girdle Injuries

• Medical clearance and full ROM
• Strength at 90% of the unaffected side
• Full function to perform sport-specific activities; strength for injury protection during gameplay; use of protection for the joint is also vital

Expected recovery times for A/C injuries

• Grade 1 (7-10 days)
• Grade 2 (2-3 weeks)
• Grade 3 (4-12 weeks)
• Grade 4-6 (surgical)

Glenohumeral Joint Features

• The glenohumeral joint is a ball and socket joint with a Humeral head approximately 3x larger than the laterally facing glenoid
• Labrum deepens the socket, enhancing joint stability, the scapula and its stabilizers must be coordinated, additionally during movement
• During movement, the scapula must rotate to support the humerus

Glenohumeral Static Shoulder Supports

• Labrum
• Capsule
• Glenohumeral ligaments

Dynamic Shoulder Supports

• Rotator cuff muscles
• Scapular stabilizers

Glenohumeral Joint Support

• The mobility in the joint will compromise stablity
• The joint is Posterior and Superiorly supported by the spine of the scapula, acromion, thick capsule, RC muscles crossing posterior joint and anteriorly by:
  • Biceps
  • Joint capsule and ligaments
  • Minimal bony support
• Capsule and ligaments around the joint provide static stabilization with thickenings
• Superior, middle, and inferior glenohumeral ligaments rotate with movement
• In abduction and external rotation, the anterior IGHL fans out to prevent shoulder subluxation

Dynamic Stabilizers of the Rotator Cuff

• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres minor

Normal Movement Patterns of the Shoulder

• Scapula remains stable for the first 30 degrees of movement
• Setting phase allows scapular stabilizers to engage
• A 2:1 ratio exists between humerus and scapula movement
• Scapula needs to support humerus movement
• Force transmits into the glenoid if not

Shoulder Abduction

• Deltoid support comes after the first 20 degrees as supraspinatus iniitates shoulder abduction (0-90 degrees) thru use of upper traps
• Above 90 degrees, lower fibers of traps and serratus anterior drive motion, and the deltoid takes over after initiations

Traumatic Shoulder Dislocation

• Characterized as "torn loose" due to trauma injuring one area

Atraumatic Shoulder Dislocation

• Atraumatic Shoulder Dislocation is described as being"born loose"
• Loose in multiple directions that cannot be tightened with rehab before surgery

Torn Loose Dislocation

• Anterior
  • 95% of dislocations.
  • Forced external rotation usually abducted or FOOSH (fall on outstretched hand) is a common MOI
  • Patient holds arm slightly externally rotated/abducted, limited ROM/altered shoulder contour

Inferior Dislocations

• 1% of Dislocations
• Excessive abduction is the MOI
• Pushes head of the humerus inferiorly out of the glenoid
• Similar signs and symptoms to anterior dislocation

Posterior Dislocations

• 4% of Dislocations
• Can be caused by muscle pull, dislocation, seizure, or shock
• Arm is in flexion and adduction
• Force on the hand pushes the head of the humerus posteriorly
• Patient Holds arm to the side with a hand on the abdomen
• Unable to move their arm laterally or upward

Subluxing Shoulders

• Born Loose
• Individuals who have Chronic Insatbilty
• AMBRI - multiple joint laxity in multiple directions, frequent subluxations
• Repetitive Stress can cause joint issues
• "Dead arm" with subluxation of the humerus can cause traction, impingement, weakness and numbness

Shoulder Injury Management

• Inflammatory Phase - P.O.L.I.C.E./PEACE & LOVE, joint protection, gentle ROM, and isometric strength training
• During the inflammatory phase, make sure the shoulder is'nt externally rotated or abducted
• Repair Phase - Pain and swelling subsides, but remain at risk of dislocation
• Regain ROM, work above shoulder height and functional strength
• Remodeling Phase - Focus on returning to sport and regaining prior function
• Restore range and add power

The Rotator Cuff Function

• Move the Shoulder
• Abduction -supraspinatus
• Internal Rotation - Subscapularis
• Medial Rotation - Teres Minor and Infraspinatus
• Acts as a Medial Head Stabilizer

Rotator Cuff

• Tears and Strains are common less then 25
• They are related to to Acute Overload and Twitching that limit function
• They are graded 1-3
• Reversible and Easily Healed by Rehab
• Can be diagnosed with the Drop Arm Test

Rotator Cuff Injuries in Older Athletes

• (35 and OLder)
• Pain with activity above the shoulder
• Have Slower Onset
• Causes the to not sleep on it or be able to put there arm above there head
• Postitive Impingement
• Form of Tendinsois

Impingement

• Primary Impingement occurs due to the way the acromion is shaped
• Secondary Impingement is caused by Weak Scapula or bad Humeral rotation
• It Causes Supscap to bunch because the humerus is too hHigh in flexion
• ROM from 60-120% for Pain

Muscular Imbalance

• Supraspinatus is used when Shoulder Abduction is initiated for the first 20 degress
• When Paralleled Deltoid cannot Initiate Abduction but can be utilized above 20 degress

Shoulder Pain Symptoms

• Diffuse Pain Above Acromion
• Increase Pain when lifting arms
• Hard to sleep

Body Alignment

• Used in Observational Sections
• Check for Static Posture

Sagittal Plane

• Use a line from the ear down to evaluate

Posture Deivations in the Sagittal Plane

• Forward Head - Chin Sticking
• Extended Upper C Spine
• Can cause a Lower C Spine
• Rounded Shoulders - Kypnosis
• Tightness in subcoipatal and neck and Elongation - Front Neck

Rounded Shoulders

• Humeral Head anterior
• rotated interna
• Minor Pecs
• Weak Trap / Romboid
• Restricted Movement in Scapula

Kyphosis

• More curve in Thoracic Curve.
• Tight Minor pec
• Weak Erector Spinae
• Forward Head

Lordosis

• Increased curve in the Lumbar
• Increase Pelvic Tilt
• Weak and Elongated abomdials
• Hamstrings

Swayback

• Anterior Shifting of Pelvis
• Tight Hip extensive
• Weak Aboms

Flatback

• Increased Postieror Pelvic Tilt
• Less Lordosis
• Weak Hip Flexons

Frontal Posture Observstion

• Head
• Shoulder
• scap
• arm distance
• glutes
• Knees
• ankles

Scoliosis

• Defiormity of spines
• C AND S curve can be measure easly on X-Ray
• structural and non-structural
• The Angle must reach 10 degrees
• Doctor choses Verbrae and measured them

Scoliois Curve

• The curve and the apex needs to be right
• 90% curve right
• if curve is left its tumor - neuromscailar disorder

Non Structure Scolioic

• Can be treated
• disappear on flexion
• Muscle spasm

Structure Scoliocic

• Bone Defiormity
• HUMP Present on forward flexion (Adam's forward Bend Test)
• Vertebrae rotation
• From Gentics birth or pathathic

Overuse Injuries in Lower Extremity

• How can you improve them
• Low Chain
• Static
• Running from ground

Q Angle

• Measured from femur and tibia
• The more pull laterally the stronger this angle is
• larger then 20 needs PT to avoid OA or knee injury

Collapse Mechanism

• Weak Glute Medius
• Hip adduction, femoral internal rotation and knee valgus
• Pressure Under patella

Knee Motion

• Extension and Flexion take place bottom of the leg and knee
• Twisting takes place under mensiuc

Knee Mechanicm

• Medially Lock Knee to Extension
• Externallly the tibia will roate
• Locks knee and alings Pat

Static Foot

• Focus on medially art
• Spring Ligament
• Tibal Posteror

Planus Flat

• Decrease Meduam
• Over Pronat

Pesavus

• High Arch
• High stiffedness
• Over Spinat

Transverse Arch Of Foot

• Extends Trasel Bones
• Protect Soft tisse

Platar Fasia

• Originates form tuberal
• goes to 5 slip

Windlass Mechanism

• Helps with Heavy Loads A. food on gorudn is lifted B. Pulls MT down

Gait Cycle

• 60-40% Stand and swign
• weigh bearing
• contact with ground twice At Midstance body support by 0-1 leg

Pronation

• absorb phase
• Too Little Too Much
• 3 phases Eversion Dorsiflexion Abduction unlock foot for impact

Spinat

• joints lock
• toe off
• use great amouth
• aid with cuboid
• inverstion abduction and plantarflexion

Walking and Running Gati Cycle

• Runnings doesn't have simulataneously contact with walking gath
• Heal Strike works has absorbers
• rigid for at push off
• lateral hean 80%

Exessive Spinat

• causes medial rotatil of legs
• screws home needs external rotation
• can caused Patetller tracking issues

Lower limb and pain can come from

• posture
• alighment
• function
• extrinsic

Turf toe

• capsule team / ligaments
• hype extent >100 deg
• platar ligament tear
• sport with artificial tun
• Hyper - dorsis
• pain in joints
• visibility
• weak push off

Sesamodits

30 percent of injuries great toe hyper extend pain in great toe better doest bear weights

Mortat Nueroma

• web b/w 2 and 3 toes
• nerve pinches
• walking on rocks
• feet

Planar Fascitsis

• extended to are extended
• short mt
• arch and transfers
• provides shock absorption

Overuse fascits

• loading and pain and excessive
• people with atypical aches

Sybungial Hermatoma

• Bleed

Ingron Toenails

• Lateral pressuRe

The Ankle Stats

• bone and shape
• passive and dynamic
• mortise distal fib, medial, lateral mall

Lateral Malleolus

• longer and more posterior

The Taluss

_ has no muscle

• convex for tib and fib
• trochler widest anterior
• flexions help mort

Fliula

• best boney stab
• the fibula is externally rotating
• together

Ottawa Rules

• Bone Tenderness - mall zone
• 4 steps of weights
• Middle

Static Ankle Stat

• Fibourse weak
• ankle is strength ened
• 0 ligaments

ATFL Anatomy

• weak
• lateral mailes
• 2 bundles

CFL Anatomy

• 3 x strongs
• not direc
• stabitilzer ankle

Other Ankel LigAnat

• positoer ligament
• tight plantar

Dynamic Ank Stat

• concentrically or eccentrically

Muscle of the anterior aspect may contract to slow the plantar flexion component of supination and protect lateral ligaments

Sprains

• most sports
• outer, sindess, and medeall

Ligaments

• Wave/Crimp

• loading loading

• while loaded

• deltoid

Strain

• Causing pain/Everion
• Lateral tests increase payi

ATFL

• plantar in flex Most commong inversion mol PAins

CFL Ankl

• Dosiflexions
• Paine

High Ankle and Fractues

• FRACTues
• Eversion. ex rot
• FIB Helps

if any injur use delta , interior tilt and fIb and toibula

Syndes

- 10 percen

Btoot

Assess

• exculsions
• TESTS