Tissue Types, Injury Classification & Functional Testing

Review of Tissue Types

• Anatomical properties of tissue should be checked.
• H.O.P.S. includes History, Observation, Palpation, and Special tests.
• S.O.A.P. includes Subjective (what the patient is telling), Objective (bruising, swelling), Assessment (indices of suspicion and severity, anatomical structure) and Plan.
• S.H.A.R.P. includes Swelling, Heat, Altered function, Redness, and Pain.
• Injury classification consists of identifying the MOI (Mechanism of Injury), whether it is acute or chronic, and Signs and Symptoms.
• S&S consist of Symptoms (what the patient feels and reports) and Signs (measurable aspects the clinician finds).
• Secondary complications are possible.
• Myositis ossificans and Compartment syndrome are examples of secondary complications.
• Risk factors should be checked to assess why injuries happen.
• Strains often occur with muscle weakness and fatigue.
• Clinical assessment should be performed.

Functional Testing

• History includes DOI (Date of Injury) and MOI.
• PQRST assesses provoke/palliative factors, quality, region/radiating/referred pain, severity/scale, and timing (morning vs. night).
• Observations include postural and gait analysis.
• AROM (Active Range of Motion), PROM (Passive Range of Motion).
• End feels are assessed during Functional Testing.
• Normal end feels are Hard (bone to bone), Soft (soft tissue approximation), and Firm (tissue stretch).
• Abnormal end feels include Muscle spasms, Capsular (feel earlier in range), Bony block, and Empty/ no end feel.
• Resisted testing should be Isometric, assessing strength, weakness, bilateral differences, and pain.

Special Tests

• Palpations involve feeling for deformity, heat, sensation, etc.
• Interpretation of findings is important.

Acute Shoulder Injuries

• Focus should revolve around Clavicle fracture
• MOI for Clavicle Fracture are direct blows or FOOSH (Fall on Outstretched Hand).
• Injured structure includes the clavicle.
• Pain is present with palpation and all arm movements
• It is found with an X-ray and tuning fork.

Bankart Lesion

• MOI is results from shoulder dislocation or subluxation
• Injured structure pertains to the anterior inferior labrum of the shoulder
• Pain with lesions occurs during overhead movements and abduction and external rotation of patients
• Special tests used are Apprehension and Relocation tests.

Hill-Sachs Lesion

• MOI comes from anterior shoulder dislocation.
• Injured structure refers to the Articular cartilage of the humeral head
• Pain with this presents itself during overhead movements and abduction and external rotation.
• Special tests include Apprehension test and X-ray to see lesion on humeral head.

Humeral Fracture

• MOI comes from direct blows or FOOSH (Fall on Outstretched Hand).
• Injured structure to the humerus.

Biceps Tendon Rupture

• MOI is a huge sudden pull on biceps or overstretch
• Injured structure pertains to the Proximal tendon of the long head of biceps
• Pain is present during flexion and supination
• Special tests include observing Visibly deformity (popeye) and Ludington's test.

GH Subluxation

• MOI occurs with Excessive abduction and external rotation, direct blows or FOOSH (Fall on Outstretched Hand).
• The injured structure Glenohumeral joint.
• Pain happens during Abduction and external rotation and overhead movements
• Apprehension test is included.

Posterior GH Dislocation

• MOI include FOOSH (Fall on Outstretched Hand) or Axial load through flexed adducted arm
• Injured structure includes the Posterior capsule of GH joint
• Pain with this comes during Supination and Abduction and external rotation.
• Special test is the Posterior apprehension test

Anterior GH Dislocation

• MOI is Direct blow to posterior shoulder or Excessive abduction and external rotation.
• Injured structure is the Anterior capsule of GH joint.
• Pain causes Numbness/tingling and Passive horizontal adduction and internal rotation
• Use the Anterior apprehension test

SLAP Lesion

• MOI is associated when the patient has FOOSH or Result from shoulder dislocation.
• Injured structure includes Superior labrum of shoulder and Disruption of long head of biceps tendon
• Pain occurs during Overhead movements or Elbow and shoulder flexion
• Tests done are O'Briens test and Yergason's test.

GH Sprain

• MOI: Forceful abduction and external rotation
• Injured structure: GH ligaments
• Pain: Maintaining throwing position or Localized around GH joint
• Test: Apprehension test

AC Joint Sprain

• MOI: Direct blow or FOOSH
• Injured structure: AC ligament
• Pain can be found during Cross body adduction or pain with the Step deformity
• Horizontal adduction test is used to check

SC Joint Sprain

• MOI: Indirect force through humerus, Blow to clavicle, or FOOSH
• Injured structure: SC ligament
• Pain with Horizontal adduction or Shrugging
• Play test is done

Chronic Shoulder Issues

• Atraumatic osteolysis of distal clavicle: MOI: Repetitive trauma or injury to distal clavicle

• Injured structure: Distal clavicle

• Pain with Resisted horizontal adduction or Overhead movements

• Special test:Cross body adduction and positive Shear test

Epiphyseal Fracture (Little League Shoulder)

• MOI: Repetitive medial rotation and adduction or Direct blow or fall
• Injured structure: Proximal humerus
• Pain: Palpation over growth plate, Bearing weight, or Throwing
• Test: X-ray

Tackler's Exocytosis

• MOI: Repeated blows to the upper arm
• Injured structure: Bony outgrowth on anterolateral humerus
• Pain: Direct impact or Overhead movements
• Palpation or taking an X-ray

Rotator Cuff Impingement

• MOI: Repetitive overhead movements
• Injured structure: Rotator cuff (primarily supraspinatus
• Pain: Resisted shoulder abduction and external rotation, Painful arc (70-120), Sleeping on involved side
• Test: Empty can test, Neer's test, Hawkins Kennedy test, Drop arm

Bicipital Tendinitis

• MOI: Repetitive overhead activities
• Injured structure: Long heads of biceps tendon
• Pain: Resisted flexion
• Test: Yergason's

Supraspinatus Strain

• MOI: Repeated overhead movements or Excessive heavy lifting
• Injured structure: Supraspinatus muscle
• Pain: Abduction and external rotation
• Test: Empty can or Drop arm

Biceps Strain

• MOI: Repeated overhead movements
• Injured structure: Biceps tendon
• Pain: Flexion and supination
• Test: Yergasons or Speeds

Subacromial Bursitis

• MOI: Acute: direct trauma falling in a shoulder or Chronic: repeated overhead movements
• Injured structure: Subacromial bursa
• Pain: Overhead movements, Shoulder abduction in painful arc (60-120) or Internal rotation
• Test: Hawkins Kennedy test or Neer's test

Acute Elbow/Arm Injuries

• Olecranon Avulsion Fracture
  • Sudden forceful triceps contraction or Pushing off
  • Injured Structure: Triceps tendon pulls off piece of the olecranon
  • Pain: Elbow extension or Palpation
  • Special Test: Active elbow extension or X-ray

Nightstick Fracture

• MOI: FOOSH or Direct blow from a blocking object
• Injured structure: Shaft of ula
• Pain: Pronation and supination and during Wrist and elbow movements
• Special Test Compression test or Tuning fork

LH Biceps Tenson Rupture (Distal Attachment)

• MOI: Sudden forceful eccentric contraction
• Injured structure: Distal attachment of tendon of LH biceps
• Pain with: flexion and Supination
• Special Test: Functional range of motion testing

Triceps Brachii Rupture

• MOI: Direct blow to posterior elbow or Uncoordinated triceps contraction during fall
• Injured Structure: Tendon of triceps brachii
• Pain: Elbow extension, If full tear → no extension
• Special Test: MRI or X-ray

Ulnar Dislocation

• MOI: Hyperextension or Sudden violent valgus force
• Injured structure: Proximal ula.
• Pain with: Any movements of the arm or X-ray
• Testing involves valgus stress

Proximal Radial Head Dislocation

• MOI: Traction of an extended pronated upper arm
• Structure: Proximal radial head.
• Pain with: Pronation and supination

Anterior Capsulitis

• MOI: FOOSH
• Structure: Anterior portion of elbow joint capsule.
• Pain: Elbow extension with flexion.
• Special Test: Elbow extension, Valugs stress test

RCL sprain

• MOI- FOOSH or Direct trauma
• Injured: RCL
• Pain occurs both through palpitation and lateral side of the elbow as well as from gripping or varus force

UCL Sprain

• MOI: FOOSH, Direct blow, Valgus force
• Injured structure: UCL
• Pain: Palpation, Medial elbow, Passive wrist flexion and ulnar deviation
• Special test would use Valgus stress test

Annular Ligament Sprain

• MOI: FOOSH or Forceful pronation or supination
• Structure pertains to the Annular ligament
• Pain with Pronation and supination, and with Resisted flexion
• Special test: a Valgus is used.

Compartment Syndrome

• MOI: Secondary condition of elbow or forearm fracture or dislocation
• Injured structure: Muscle compartments of the forearm
• Pain: Passive stretching in the compartment, Rest, Tingling, Absence of pulse
• Special test: Compartment pressure measurement

Chronic Conditions

Radial Tunnel Syndrome

• MOI: Repetitive wrist and elbow movements lead to complications during activities
• Injured structure pertaints to the Radial nerve
• Pain: Resisted wrist extension, Supination that can cause further inflammation and pain
• Special Test: Tinel's tap at radial tunnel, Resisted supination

Medial Epicondylitis (Golfer's Elbow)

• MOI: Occurs with Repeated medial tension/valgus forces placed on the arm during the acceleration phase of throwing.
• Structure involved here is the Medial epicondyle or Common flexor tendon.
• Pain comes with Gripping or with Resisted wrist flexion and pronation

Lateral Epicondylitis (Tennis Elbow)

• MOIs are Eccentric loading of extensor muscles during deceleration phase or of throwing.
• Structures involved is the Common extensor tendon and the Lateral epicondyle
• Pain comes with Gripping; Resisted extension and radial deviation, including Passive wrist flexion
• Cozen's tests are included with Passive wrist flexion test with Special Test

Brachioradialis Tendonitis

• MOI: Repetitive lifting, throwing, swinging motion can cause injuries
• Structure involved here is the Brachioradialis tendon
• Pain comes with Elbow flexion, Pronation and supination, Gripping
• Test: Resisted elbow flexion or Passive pronation and supination test

Pronator Teres

• MOI is Repetitive pronation of the forearm (throwing, gripping)
• Injured structure: Pronator teres muscle
• Pain with Forearm pronation and elbow flexion, Palpation of pronator teres, Gripping
• Palpation helps test this condition.

Supinator Strain

• MOI: Repetitive forearm supination
• Injured structure pertains to the Supinator muscle
• Pain with Forearm supination or Elbow extension
• Special Test: Palpation to locate Resisted supination and any Supinator

Volkmann Contracture

• MOI involves Crush injuries or fractures that increase pressure
• Involved structure: Muscles of the forearm, Clawlike deformity
• Pain: Severe forearm, or with Decreased sensations
• Tests: Clawlike deformity, or Compartment syndrome test

Olecranon Bursitis

• MOI is Fall on flexed elbow, Constant leaning on elbow and too much Repetitive pressure when doing activities
• Structure: Olecranon bursa
• Pain with Direct pressure on bursa or Flexion

Acute injuries of the wrist/hand:

Fractures of the Scaphoid Carpal Bone

• MOls include FOOSH with wrist in extension of the joint
• Structure involves the Scaphoid carpal bone
• Pain by putting Palpation and pressure over floor of anatomical snuffbox or Wrist with radial deviation testing
• Involves Scaphoid compression diagnostic test.

Colles's Fracture

• MOI includes FOOSH in hyperextension
• Structure involves Distal radius fracture with dorsal displacement
• Pain with Any wrist movements loss of wrist and Crepitus with any activity.
• X-ray will be needed

Smith Fracture

• MOI: FOOSH with wrist in flexion
• Injured structure: Distal radial fracture with palmar displacement
• Pain with Any wrist movement, Loss of wrist movement, Limited wrist extension
• X-ray is used as Special Test

Galeazzi fracture

• MOI: FOOSH or with Direct trauma to forearm
• Structure deals with a Fracture of the distal 1/3rd of the radius or Dislocation of the distal radioulnar joint
• Pain with the Wrist and forearm movement.

Boxer's fracture

• MOI: Punching object with closed fist
• Injured structure: 5th metacarpal
• Pain while Fist formation, putting Flexion and extension of wrist and fingers, including Gripping with certain movements.

Mallet Finger

• MOI deals with Objects hitting end of finger when finger is straight
• Involved Structure includes Extensor tendon by creating attachment issues on DIPS with each movement
• Pain and injury has created an inability to use or extend finger
• Special test: lack of DIP extension

Jersey Finger

• MOI is Forceful extension of finger when in flexion to put pressure on tendons
• Injured structure: Flexor digitorum profundus tendon
• Pain causes a inability to do anything with injured finger
• Special test Jersey finger test (inability to flex DIP)

Boutonniere Deformity:

• MOI involves the body when one does Forced rapid flexion
• Can be identified here are the Blunt trauma of dorsal during PIP
• Injured structure is Central movement in extensor tendon of the finger
• Pain in the PIP
• Use of wrist flexion or extension (Elson test to measure and diagnose)

Distal Radial Ulnar Joint Dislocation

• MOI: FOOSH or Direct trauma to wrist or forearm
• Injured structure: Distal radial ulnar joint
• Pain: Pronation and supination, Flexion and extension or at times, Gripping of wrist movement
• Palpation of the Joint is the proper diagnostic method.

Lunate Dislocation/Subluxation

• MOI includes FOOSH or Fractures of distal radius or ulna

• The Lunate carpal fracture is the structure

• Pain with Flexion and extension and with Pronation and supination.

• Used X-ray examination and palpation. of injury.

RCL Sprain (Wrist/Hand)

• FOOSH injuries are caused by the Varus forces
• Pain can be found while the patient is in Unlar deviation and Extension
• This pain can also occur during Pronation or Supination

UCL Sprain (Wrist/Hand)

• FOOSH conditions can occur with force
• Pain here can be felt in the hand from all movements
• Special test includes Valgus stress test and is verified with a Palpation of injury

Skier's Thumb

• Involves Valgus stress test of the thumb, or with simple X-ray.
• FOOSH injuries during activity
• Special tests include the abduction of Thumb or pinch grip

Overuse Hand/Wrist issues

Bowlers Thumb

• Most common to have pain in this area from pressure or movement
• If issues persists compression of the digital nerve
• Pain during activity and Special test is always checked

Carpal Tunnel Syndrome

Occurs with Repetitive flexion and extension of the wrist

• Structures show Prolonged compression of the nerve Numbness is a common symptom

Cyclists Palsy

• Numbness can occur during activities due to constant compression of the wrist
• Entrapment of the nerve -Use of handlebar while ridding biking

Distal Posterior Interosseous nerve Syndrome

Occuring pressure from the handlebars of the bike/motorcyle Injured structure

• Entrapment of ulnar nerve on hook of hamate and pisiform

De Quervain's tenosynovitis

• MOI: Repetitive use of thumb with ulnar deviation
• Structures: Abductor pollicis longus or Extensor pollicis brevis.
• A pain can occur to the patient

TFCC

With repetitive wrist and gripping

• Special Test Compression of TFCC

Gymnasts Wrist

• Repetitive loading and compression Tests:
• Injured: Distal growth plate
• Check with palpation
• Flexion extension
• X-ray

Glossary of Terms

• Valgus force: Force that travels through a joint from laterally to medially.
• Varus force: A force that travels through a joint from medially to laterally.
• Anisotropic: Muscles having different strengths depending on the angle of the applied force.
• Sequelae: A secondary complication or condition resulting from another condition.
• Crepitus: The crunching, cracking, or popping sound within a joint when it moves.
• Syndesmosis: An immovable joint held together by connective tissue.
• Goniometer: A tool measuring angles and ROM (Range of Motion) of joints.
• Ecchymosis: Medical term for bruising of the skin.
• Etiology: Medical term for the cause of an illness, condition, or disease.
• Aponeurosis: A thin sheet of connective tissue connecting muscles to bones, acting as a tendon.
• Case Study 1: Athlete landing on an outstretched hand is a sign of potential fractures

Key facts and special tests:

• A 30-year-old athlete playing in an ultimate Frisbee tournament lands on an outstretched hand with the wrist hyperextended, reporting generalized wrist pain closer to the thumb side and limited range of motion.

• Suspected Conditions:

• Scaphoid fracture

• Distal radial ulnar ligament sprain

• Distal radioulnar joint dislocation/subluxation

• Distal radial fracture

• Thenar eminence contusion

• Lunate subluxation/dislocation

• Special Tests:

• For scaphoid fracture: Scaphoid compression test, Palpation of anatomical snuffbox.

• For distal radial ulnar ligament sprain: Ulnar deviation

• For distal radioulnar joint dislocation/subluxation: Observe for joint deformity/swelling

• Case Study 2: 45-year-old recreational golfer with right wrist pain, worse after shifts and holding a golf club.

Conditions and Tests:

• Suspected Conditions:

• Radial nerve entrapment

• Radial collateral ligament sprain

• Bowler's thumb (compression of the ulnar digital nerve) Additional Diagnostic Steps: What functional/special tests may be painful?

• Radial nerve entrapment: Passive wrist extension.

• Radial collateral ligament sprain: Varus stress test.

• Bowler's thumb: Compression of the ulnar digital nerve on the medial aspect of the web space

• Case Study 3: 20-year-old soccer goalie with mallet finger from catching a hard shot.

Key Diagnostic movements and structures:

• Injury details are found with special tests listed in this document
• The test helps with DIP, and or PIP movement
• In addition x-rays can be checked to see a lateral
• Distal bands and Lateral structure in the upper body is a potential fracture
• With the above, spilt
• Do not any flexion of inger
• X-ray should then be sent

Review of anatomical properties of tissue, injury classification (MOI, acute/chronic, S&S), and functional testing. Includes methods like H.O.P.S. and S.O.A.P. to assess injuries. Secondary complications and risk factors are also discussed to understand why injuries occur.