PT 790 -- Musculoskeletal I Manual PDF

**PT** **790 -- MUSCULOSKELETAL I** INTRODUCTION TO THE PATIENT MANAGEMENT MODEL AND UPPER EXTREMITY **DOCTOR OF PHYSICAL THERAPY PROGRAM** **DEPARTMENT OF PHYSICAL THERAPY** **SUMMER 2024** **Michael Masaracchio, PT, DPT, PhD, OCS, FAAOMPT** **Associate Professor and Chair** **Director of th...

**PT** **790 -- MUSCULOSKELETAL I** INTRODUCTION TO THE PATIENT MANAGEMENT MODEL AND UPPER EXTREMITY **DOCTOR OF PHYSICAL THERAPY PROGRAM** **DEPARTMENT OF PHYSICAL THERAPY** **SUMMER 2024** **Michael Masaracchio, PT, DPT, PhD, OCS, FAAOMPT** **Associate Professor and Chair** **Director of the Anatomy Lab** **Co-Chair IPE Task Force** **APTA Education Leadership Institute Class of 2022** **Long Island University** **Department of Physical Therapy** **Clinical Director Masefield and Cavallaro Physical Therapy** **President CM OrthoSports** **Vice President APTA New York** **Vice Chair ACAPT Teaching and Learning Institute** **\ ** **BONES** - Dynamic tissues that remodel - Capable of withstanding compressive and tensile forces  - Anatomical structures - Rigid framework, withstand mechanical loads - Levers for the locomotor function of muscles - Protects important organs - Organ - Hemopoietic tissue - Storage or reservoir for Ca, Mg, Na **BONE STRUCTURE** - **Osteoblasts -- calcitonin** - **Osteoclasts -- parathyroid hormone (PTH)** - **Woven bone:** low mineral content, initial phase of fracture healing random collagen arrangement, MECHANICALLY WEAKER - **Lamellar bone:** mature, organized orientation of fibers, MECHANICALLY STRONGER **BONE FORCES** - Tensile: result in elongation, easy fracture - Compressive: result in shortening, osteoporotic fracture - Shear: result in angulation, fracture more frequent in areas with more cancellous bone - Fracture: single large load or repetitive low load at a rate that exceeds the repair rate - Wolff's law: - Stress = hypertrophy - Bones weaken by 1-2% every year after 35 y.o. - Trabecular orientation follows stress pattern **BONE GROWTH** - Endochondral: most bones of body - Membranous: sutures of skull and a few other bones  **BONE DEPOSITION IS POSITIVE IN CHILDHOOD, NEUTRAL IN ADULTS, NEGATIVE IN THE ELDERLY** **CARTILAGE** - Viscoelastic tissue - Withstands shear and compressive forces - Aneural, avascular - Meniscus = articular cartilage - Chondrocytes and intracellular substance - Sponge-like behavior  **SYNOVIAL MEMBRANE** - Inner and outer layer - Large functional surface - Synovial fluid: - Viscous, pale, yellow, clear fluid - Nourishes the cartilage - Lubricates joint surface - Knee: 5mL -- knee does not like to swell - Intense swelling will shut off the quad (autogenic inhibition) - Quad inhibition post ACL: neuromuscular re-ed is first step in PT process - Any muscles inhibited post surgery need this re-ed **TENDONS AND LIGAMENTS** - Tendons: transmit loads to bones - Ligaments: prevent excessive motion and guide joint motion. Give passive stability - Closed packed position = max bony congruency - Fibroblasts + matrix Aging causes collagen which mechanical properties - Sprains - **1^st^ degree: microfailure of fibers, minimal pain, no instability** - **2^nd^ degree: partial rupture, strength 50%, pain, some instability** - **3^rd^ degree: almost complete rupture, intense pain during injury minimal pain after, severe instability. Pain subsides due to severed nerves** - Tendon mobilization prevents adhesions **PHYSICAL TISSUE STRESS MODEL** - Adaptation to stress - Effects of too little stress - Effects of too much stress - We need stress on our tissues for them to remain healthy - It is important to increase stress over time **SKELETAL MUSCLES** - 600 muscles, 50% of body weight - Contractility: 3 types of contraction - Type I: slow twitch, low load, high repetition - Type II: fast twitch, high load, low frequency  **OPTIMAL LOADING** (Glasgow 2015) The load applied to structures that maximizes physiological adaptation. - Driven by variables such as: - Tissue type - Pathological presentation (what did pt come to see the PT for) - Required tissue adaptation for eventual activity - Loading goals may include: - Increased tensile strength - Collagen reorganization - Increased muscle-tendon unit stiffness - Neural reorganization **-Previous history of cancer might signal that they have cancer again if there are signs and symptoms** **DIAGNOSTIC WORK-UP** - History and physical exam - Imaging studies - Educating and informing patients and their families about the findings and the possible treatment options **HISTORY AND PHYSICAL EXAM** - Most important aspect of the health care provider/patient interaction - **Establishes a rapport with the patient** - **History provides important clues that subsequently guides the clinical exam** **RED FLAGS** - **Cancer:** night pain, constant pain, weight loss, appetite loss, fatigue, history of cancer - **Cardiovascular:** Shortness of breath, dizziness, chest pain, pulsating pain, swollen, painful or discolored feet - **GI/GU:** Abdominal pain, heartburn, nausea, vomiting, changes with bladder function, menstrual cycle - **Neurological:** problems with hearing, swallowing or speech, severe headaches, blurry vision, problems with balance, drop attacks, sudden weakness - **Miscellaneous:** fever or night sweats, severe emotional disturbances, joint swelling without injury, pregnancy (depends on trimester there may be contraindications) **During each initial patient examination and subsequent re-examination, physical therapists must decide whether to treat the patient, refer the patient, or initiate both treatment and referral. This clinical decision is based on physical therapists recognizing patient history and physical examination red flag findings consistent with pathology that requires physician consultation and examination.** (Ross & Boissonnault, 2010) **CARDINAL SIGNS OF VERTEBRAL ARTERY DYSFUNCTION (5Ds, And 3Ns)** - **Dizziness Ataxia** - **Dysarthria (trouble speaking) Nystagmus** - **Dysphagia (trouble swallowing) Nausea** - **Diplopia (double vision) Numbness** - **Drop attack** **RED FLAGS (Ombregt, 2003; Crunk & Keyser, 2012)** - **Gradual increase in pain over prolonged time** - **Expanding pain over multiple segments** - **Elderly patient with rapid increase in pain or stiffness over 1-2 months** - **Pain increased with cough** - **Paresthesia all over body provoked by neck flexion** - **Cord symptoms** - **Unusual myotome involvement** - **Pain-less weakness** - **Limitations in SB w/o other restrictions** - **Sign of the buttocks** - **Cauda equina signs** **INTRODUCTION TO IMAGING** (Greathouse, 1994; Benson, 1995; Blackburn et al, 2009, Boissonault et al, 2023) - PTs have a long history of success using imaging in the US military system to reduce unnecessary imaging, improve client satisfaction, and decrease costs - Since 2012 PTs in Canada and Australia have had privileges to order imaging studies - Supported by the APTA since 2000 and reinforced in 2014 **ESSENTIAL QUESTIONS** 1. Will imaging results contribute to decision making or change the overall cost of care? 2. What are the objectives of imaging? Or what conditions are likely to be revealed or deemed unlikely in the differential diagnostic process 3. If imaging is indicated, which modality (or modalities) will best provide the needed information **IMAGING STUDIES -- ACR Appropriateness Criteria** - Radiography - Magnetic resonance imaging - Computed tomography - Bone scan - DEXA - Diagnostic US - Laboratory exams - Goal: choose tests that are cost effective, diagnostic, and safe for the patient  **RADIOGRAPHY** - **Most cost effective and most important initial diagnostic test in orthopedics** - Predominantly used to assess bone and joint pathology - Used to assess fracture healing and progression - **Minimum of 2 views needed (90 degrees)** - Does provide patient some exposure to radiation **Shading of Structures** - **Metal=solid white** - **Contrast media=bright white** - **Bone=white** - **Water=gray** - **Fat=gray/black** - **Air=black** **Look For The Following** - **Size and shape** - **Thickness of cortex** - **Continuity** - **Relation with other bones** - **Cartilage space** **\*Need a minimum of 2** **Degenerative disc disease** **IMPORTANCE OF TWO VIEWS**  **-Radius and ulna usually don't break at same point** **Pediatric Radiology** - **Growth plates = lines** - **Cartilaginous appearance** **MAGNETIC RESONANCE IMAGING** (McKinnis, 2014) - **Predominantly used for soft tissue lesions** - **Rotator cuff tears** - **Meniscal tears, ACL tears** - **Useful for some bony lesions** - **Osteomyelitis, osteonecrosis** - **Stress fractures** - **False positive rates -- at times over diagnosis** - **Spine** - **Signal intensity** - **T1 weighted and proton density (PD): anatomy** - **T2 weighted and short tau inversion recovery (STIR): pathology**  Rotator cuff tear **COMPUTED TOMOGRAPHY** (McKinnis, 2014; Ginat et al, 2014) - Provides 3-D info that radiographs cannot especially the cortical margins of bone - Extremely useful for certain fractures (TSAS): - **Tibial plateaus** - **Scapula fractures** - **Ankle fractures -- talus** - **Spine** - Now optimal method for detection of pulmonary emboli - High level of ionizing radiation **BONE SCAN** - Detects osteoblastic activity - Any condition that results in increased bone formation results in a hot bone scan - **Good for identifying loose THR/TKR** - **Not necessarily diagnostic specific** - High amount ionizing radiation \ **DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA)** (Lorentzon et al, 2015) - Best was to measure bone density and bone health - Upper lumbar spine and femurs are used for measurement - Images are of little value, BUT the data in numerical terms is important - Small amount of ionizing radiation - T-score between -1.0 and -2.5 SD are considered osteopenia - T-score \> -2.5 SD are considered osteoporosis **DIAGNOSTIC ULTRASOUND** (Lenza et al, 2013; Hall et al, 2015) - For muscle and tendon, US is as revealing as MRI and much less costly - New imaging modality being used more by PT to assess progress with rehabilitation - Biggest limitation is the learning curve and skill of the sonographer   Imaging Education Resources Imaging Education Manual for DPT Professional Degree Programs: https://www.orthopt.org/uploads/content\_files/ISIG/IMAGING\_EDUCATION\_MANUAL\_FINAL\_ 4.15.15..pdf (Revision in process) Texts: Greenspan A and Beltran J. Orthopaedic Imaging: A Practical Approach. 7th ed. LWW, 2020. Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. 3rd ed. Elsevier, 2018. Malone TR, Hazle C, Grey ML. Imaging for the Health Care Practitioner. McGraw Hill; 2016. Malone TR, Hazle C, Grey ML. Imaging in Rehabilitation. McGraw Hill; 2008. McKinnis LN. Fundamentals of Musculoskeletal Imaging. 5th ed. FA Davis, 2021. Rawat M. Atlas of Musculoskeletal Ultrasound of the Extremities. 1st ed. Slack. 2020. Swain J, Bush KW, Brosing J. Diagnostic imaging for physical therapists, 1st ed. Saunders, 2009. PT Specific Websites: General Radiology Info Imaging Guidelines Imaging Examples Imaging Tutorials Cases/Case Reports Diagnostic Ultrasound European Society of Musculoskeletal Radiology **LABORATORY TESTS** - Used to help detect inflammatory process, malignancy, or rheumatologic disorders - Two most common in orthopedics - **C-reactive protein** - **Erythrocyte sedimentation rate** - Negative result can usually rule out systemic origin - CBC - Synovial fluid analysis - D-dimer -- potential for blood clots developing **EDUCATING / INFORMING PATIENTS** - Surgical options - Conservative options - Explaining the procedures **Risks** - **Infection** - **Fracture** - **DVT/PE** - **Anesthesia** - **Arthritis** - **Loss of reduction** - **Nerve damage** **SURGERY ON MUSCLES, TENDONS, AND LIGAMENTS** - Fasciotomy: cut fascia - Tenorrhaphy / tendon graft (plantaris / palmaris longus): suture tendon - Tenolysis: free tendon from scar tissue - Tenotomy / tendon lengthening: cut tendon - Tendon transfer: move tendon - Ligamentous repair: suture ligament - Ligamentous reconstruction: use graft to make new ligament **POSTOPERATIVE CARE** - Distal neurologic and vascular exam - Pain management - Deep vein thrombosis/pulmonary embolus - Immobilization/healing times - PRICE vs POLICE vs PEACE and LOVE **PAIN MANAGEMENT** - Pain: a subjective sensation that is an emotional response to nociception - Nociception: sum of 4 separate components - Tissue damage which leads to transduction of a nerve impulse - Transmission to the spinal cord where the 3^rd^ component occurs modulation - **Perceived in the cerebral cortex (perception)** - NSAIDs: aspirin, ibuprofen, naproxen, COX-2 inhibitors (decreased GI problems, allergic reactions) - Opioids: addictive **PAIN** - No way to directly measure pain -- we assume the patient is telling the truth - Nervous system is altered in the presence of chronic pain - Nociceptors sprout more endings - Sensitivity thresholds are lowered - New nociceptors are grown - Chemicals released at nerve endings that are inflammatory - The primary somatosensory area for the painful region expands into adjacent regions (smudging) - Perceived pain is often at a site distal or adjacent to injury site - **Pain alters movement** - Pain affects emotional state - Pain not altered by position or motion may be suspicious for a visceral source - Psychosocial stress increases pain perception - Increases wound healing time - Decreases immunity - In the US 126.1 million adults (38%) experience pain over a 3mo period, with 25.3 million (7.5%) suffering from chronic pain daily (Nahin et al 2015) - In 1990, 1/7 individuals suffered with chronic pain, it is now 1/4 (82,500 individuals) (Woolf et al 2003) **DEEP VEIN THROMBOSIS / PULMONARY EMBOLUS** - DVT/PE potentially life-threatening disorder - Diagnosis - **Clinically -- Homan's sign, Wells CPR** - **Medically -- Doppler, CT, Venogram** - Treatment - Anti-coagulants - NSAIDS - Compression stockings, movement **REST / IMMOBILIZATION** - It was considered necessary for healing - **RESPECT NATURE** - Atrophy, osteoporosis, thrombosis, pressure sores - Low back pain: activity as tolerated is better than bed rest **IMPAIRMENT / FUNCTION** - Poor link between tissue damage and impairment, and impairment and function - Ex: some with massive knee destruction due to OA have little pain; whereas others with minimal OA have major pain - Ex: spinal ROM is not correlated to overall function **HEALING RATES FOR TISSUES** - Time - Factors affecting healing - Age - Nutrition - Comorbidities - Stress - Smoking  **CHARACTERISTICS OF OPTIMAL AND SUB-OPTIMAL LOADING** **OPTIMAL LOADING** **SUB-OPTIMAL LOADING** -------------------------------------------------------------- --------------------------------------------- Directed to appropriate tissues Non-specific generalized loading Loading through functional ranges Loading through limited ranges of movement Blend of compressive, tensile, and shear loading Loading exclusively in a single manner Variability in magnitude, direction, duration, and intensity Constant, unidirectional load Include neural overload Minimal neural stimulus Tailored to individual characteristics Generic, non-individualized Functional Non-functional, isolated, segmental loading **INFECTIONS** - **Pathogenesis: bacteria gain entry, start inflammatory process, and spread** - **Redness with or without streaks, swelling, heat, pain, loss of function, fever** - **Implanted synthetic or allograft material increase risk of infection** - **Patients with diabetes, AIDS, cancer, or compromised immune system are more susceptible to infections** - **Common infections: osteomyelitis (bone), septic arthritic (joint/synovium), cellulitis (connective tissue)** **Treatment** - Antibiotics for 6 weeks (bacterial resistance), oral or IV route - Methicillin resistant staph aureus (MRSA) - Surgery: - Surgical evacuation of infected joint - Removal of infected bone (osteomyelitis after 24hrs) - Implantable antibiotics - Reconstructions after infection is treated - Local wound care **OSTEOARTHRITIS** - 250,000 million adults worldwide - Major progress in the last 30 yrs. - Millions of Americans have joint replacement every year - 1% annual failure rate - Degenerative, post-traumatic, inflammatory - Imaging: X-rays and symptoms do not always correlate - Degeneration of articular cartilage - DJD - \>60 y/o, 25% of women, 15% of men - \>75 y/o, \>80% - Result of overuse, injury, idiopathic, obesity, joint infections, congenital abnormalities, malalignment **Pathology** - **Chondromalacia: cartilage softening** - **Fissuring/fibrillation** - **Osteophytes** - **Subchondral bone sclerosis** - **Loose bodies** - **Synovial effusion** **Diagnosis and Treatment** - **Swelling, pain, crepitus, limited ROM, stiffness** - **Radiographs** - **Psychological support** - **Meds** - **Splints/braces** - **PT/Education** - **Surgery: osteotomy, arthroplasty, arthrodesis, mosaicplasty, microfracture** **RHEUMATOID ARTHRITIS (bilateral, younger than OA)** - **Most common form of inflammatory arthritis (3% of women, 1% of men)** - **Polyarticular, symmetrical involvement, rheumatoid factor in 80%** - **Upper C/S commonly involved sometimes can result in brain stem compression** - **Tx: protection during exacerbation, activity during remission, C1-C2 arthrodesis** **Pathology** - **Synovial membrane** - **Pannus leads to cartilage necrosis** - **Ankylosis** - **Rheumatoid nodules** - **Morning stiffness** - **Joint effusion, deformity** **Clinical Features** - Pain, swelling, limited ROM , progressive deformities, loss of function - Morning stiffness, stiffness with inactivity - Generalized malaise and fatigue can be present at onset of disease - Diagnosis based on at least 4/7 findings that continue for 6 weeks (ARA) - No laboratory study is diagnostic but 80% will have elevated Rh factors or elevated IgM/IgG  **Medical Management** - NSAIDS: GI and renal complications, pain relief (Voltaren, Ibuprofen, Naproxen, - Disease modifying RA drugs: prevent activation of inflammatory process - Glucosamine: safe, effective mainly in pts. with advanced arthritis - Injections: cortisone (provides pain relief but causes osteoporosis), hyaluronic acid (to improve synovial fluid viscosity) - Braces **\ ** **GOUT** - Genetics -- males (20X) - Increase in uric acid, leads to the formation of crystals which deposit into joints and can lead to degenerative changes - Most commonly in the knee and great toe - Medications -- NSAIDS (indomethacin), COX-2 inhibitors, allopurinol, corticosteroids - Treatment consists on education on diet, quick identification and treatment of the condition and treatment/protection of the involved joint. **PSORIATIC ARTHRITIS** - Chronic, erosive inflammatory disorder of unknown etiology - Effects males and females equally - Medications -- acetaminophen, NSAIDS, corticosteroids, DMARDs, and biologic response modifiers (Enbrel) - Treatment consists of joint protection and treatment, as well as light aerobic activity **ANKYLOSING SPONDYLITIS** - Progressive, inflammatory disorder of unknown etiology that initially affects the axial skeleton; men 3X more than women - Initial onset (usually mid and lower back pain for 3 months or greater), before fourth decade of life, can also have morning stiffness, and sacroilitis - Results in kyphotic deformity of the cervical and thoracic spine, loss of lumbar lordosis - Medications -- NSAIDS, corticosteroids, cytotoxic drugs - Blood tests -- assess for HLA-B27 antigen may be helpful, but not diagnostic - Treatment consists of education on relaxation, activity modification, aerobic exercise, flexibility, encouragement of extension exercises **FRACTURES / TRAUMA** - Structural break in continuity of the bone from either direct/indirect injury - Associated injuries: muscles, brain, spinal cord, nerve, viscera, vessels - Cortical bone (compact bone) withstands compression and shear forces better than tensile/shear - Cancellous bone (spongy bone): compression fracture **Causes** - Single traumatic incident - Repetitive stress - Fatigue or stress fracture (tibia, fibula, MT) - Abnormal weakening - Pathological fracture **Bone healing** - Bone does not scar! - Endochondral ossification - Primary healing: no callus, result of internal fixation - Secondary healing: callus formation (wearing a cast) **Phases of Healing** - **Stage A:** tissue destruction (torn vessels), hematoma formation, fracture becomes "sticky" initial callus (cartilage) acts as internal splint - **Stage B:** cell proliferation, hematoma is gradually absorbed, cartilage is replaced by woven bone, mineralization, vascularization - **Stage C:** consolidation, proliferating cells become osteogenic, osteoclasts absorb dead bone, decreased motion, osteoblastic activity fills in the gap between the fragments - **Stage D:** remodeling, woven bone is replaced by lamellar bone **Time Required to Heal** - Age, femoral fracture (3 weeks at birth, 8 weeks at 8 years, 12 weeks at 12 years, 20 weeks at \>20 years) - Children & Adolescents (6-18yo) - 2^nd^ most rapid physical growth cycle - Growing bones are more likely to bend than break (greenstick) - Periosteum and more osteoblast activity when young - Site (surrounded by muscles faster than intra-articular, cancellous faster than cortical, oblique and spiral heal faster than transverse) - Transverse might disconnect periosteum - Undisplaced faster than displaced. Undisplaced is fractured but is still aligned - Blood supply **Classification -- Site** - Epiphyseal - Metaphyseal - Diaphyseal - Intra-articular (in the joint) - Open reduction internal fixation surgery - Susceptible to develop arthritis - Fracture -- dislocation **Classification -- Extent** - Complete - Incomplete -- most common in children - Hairline (crack) - Buckle - Greenstick -- fracture on the tension side  **TYPES OF FRACTURES** **\ ** **Classification -- Relationship of Fragments** - Undisplaced - Displaced - Translated - Angulated - Rotated - Distracted - Overriding - Impacted **Classification -- Skin** - Closed: the skin is intact - Open (compound): the bone has communicated with the environment, risk of infection - Avulsion fracture: tendon or ligament is avulsed with a small piece of bone **Delayed Union** - Delayed union = has not healed within 6 months - Causes - Inadequate blood supply - Infection - Incorrect immobilization and fixation **Non-Union** - Non-union = absence of clinical radiographic healing after 4-6 months; develops to pseudarthrosis - Causes - Distraction, separation - Interposition of soft tissue between fragments - Excessive movement, poor blood supply - Treatment: - Increase of mechanical forces (best) - Electrical stimulation (low intensity) - Ultrasound (low intensity) - Bone grafts **Malunion** - Healing in an unsatisfactory position (angulation, rotation, shortening) -- poor alignment - Causes: failure to reduce fracture adequately, failure to hold reduction - Adults: anatomic reduction - Children: angular deformities remodel with time unless they are away from bone ends **Principles of Fracture Treatment** - Reduce - Hold - Restore function **Treatment of Closed Fractures** - **Undisplaced fractures** - Protection alone (without reduction or immobilization) - **Displaced fractures** - Stable: closed reduction and immobilization -- i.e. cast or brace - Unstable: closed reduction by continuous traction (skin/skeletal), immobilization - **Severely comminuted and unstable** - Closed reduction via manipulation and external fixation - **Avulsion fractures, intra-articular fractures** - Open reduction internal fixation (ORIF) **Pathological Fracture** - Pathologically weak bone - Fracture is caused by normal forces - Osteoporosis, neoplasms, non-cancerous bone cysts - Healing takes place except in osteomyelitis **Fracture Complications** - Skin injuries (burn, laceration, ulcers) - Vascular injuries (arterial division, compartment syndrome) - Venous thrombosis and pulmonary embolism - Neurological injuries (brain, spinal cord, peripheral nerves) - Myositis ossificans (ossification of muscles) - Volkmann's contracture (ischemic contracture of muscles) - Gas gangrene - Tetanus - Infection (osteomyelitis) - Post-traumatic osteoporosis **Complex Regional Pain Syndrome** - Cause: surgery, trauma, immobilization - Symptoms: hyperalgesia, skin color/temperature changes, hyperhidrosis, swelling - Tx: PT, medication, nerve blocks, dorsal column stimulator, progressive loading **Nerve Injuries** **Fracture Differences in Children** - Fractures more common - Stronger and active periosteum - Physis (growth plate) = weakest part of the bone - More rapid fracture healing - At risk for apophysitis - Inflammation at musculotendinous junction over growth plate - Due to repetitive stresses, especially during longer periods of growth - Can result in avulsion fracture - Diagnostic problems - Spontaneous correction of deformities - Different complications - Different treatment **Salter Harris (Epiphyseal Growth Plate) Fractures** - **Type I:** separation of epiphysis without fracture, closed reduction - **Tremendous healing potential** - **Type II:** most common, parallel to plate, triangular shaped metaphyseal fragment, closed reduction - **Tremendous healing potential** - **Type III:** intra-articular, from joint surface to epiphyseal plate (separation), ORIF - **Good healing potential** - **Type IV:** intra-articular, from joint surface to metaphysis, perfect reduction necessary, poor prognosis - **Poor healing** - **Type V:** crushing force to one side of epiphysis, premature closure, angulatory deformity, poor prognosis - Maximum point of tenderness is typically at the physis - When young, fracturing growth plate is BAD  **Healing of Growth Plate Fractures** - I-III: temporary disturbance, return to normal in 4 weeks - Growth disturbance (85% uncomplicated): - Type of injury (I-V), open/closed - Age - Blood supply - Method of reduction - Velocity and force **TYPE 3 TYPE 4 TYPE 5** **\ ** **IMPORTANT CONCEPTS TO MUSCULOSKELETAL PATIENT MANAGEMENT** 1. Sackett's Model of EBP 2. The Guide to PT Patient Management Model (Rehab Cycle) 3. ICF Classification a. Body structure and function impairments b. Activity limitations c. Participation restrictions ### EXAMINATION FOR MUSCULOSKELETAL DISORDERS: THE BASIC SKILL SET Items 1-13 represent the typical sequencing of an examination. This sequence represents the most essential and common elements of the examination in the most logical sequence for an entry level physical therapist. Clinically, the elements and sequence may be modified depending on various environmental or patient factors. In your clinical internships, you should not be rigidly attached to this one approach, but be open to the situation and what your supervisor suggests. For the purposes of the musculoskeletal course sequence, we will use this sequence consistently. ***It is vital the steps are memorized and you know it backwards and forwards please.*** **[PLEASE MEMORIZE]** 1. **Review of patient reported materials** (note: ideally this occurs prior to seeing the patient) a. Intake form, pain diagram, functional scales b. Radiological and/or other information from medical sources 2. **Initial observation** 3. **History** 4. **Review of Systems** c. Cardiopulmonary, Integumentary, Musculoskeletal, Nervous, Communication ability (as needed) **Decision: Refer out / continue exam / focus exam on specific** **Structures** 5. **Screening Exam (Assess Neuro Symptoms if Necessary)** 6. **Structural Inspection** 7. **Movement Analysis** d. Demonstration of what hurts e. UE functional motions 8. **Active Range of Motion** 9. **Passive Range of Motion** f. Osteokinematic (end-feel) g. Arthrokinematic (end-feel) 10. **Resistive Tests** h. Muscle selective tension test i. Manual muscle test 11. **Muscle Length if needed** 12. **Special Tests** 13. **Palpation for Tenderness** **BODY CHART / PAIN DIAGRAM FOR PATIENT INTAKE FORMS** ### - Patient intake paperwork often includes a body chart / pain diagram - You may find it helpful to use a blank body chart to mark the location, quality, and quantity of each of the symptoms that the patient describes during the interview to keep yourself organized. - A complete body chart assists the clinician in screening for red flags, recognizing clinical patterns, developing hypotheses, and deciding which objective tests to perform to support or refute their hypotheses. ### EXAMINATION PROCESS **1. Review of patient reported materials: Intake forms** - Ideally, the patient will have filled out intake forms and functional outcome measures ahead of time (Oswestry, Neck Disability Index, etc) - Include the majority of the relevant history, including potential red flags, a body chart, and a pain scale - Allows the therapist to have a fundamental understanding of the scope of the problem and a good idea if referral to another practitioner is necessary. Knowing about the complaint before greeting the patient allows the therapist to make more specific and productive observations upon greeting the patient - I would also strongly urge you not to review diagnostic tests (radiographs, MRIs, etc) until the end of the examination, so that your exam is not biased by those results. **2. Initial Observation** TWO primary tasks: 1. *Establishing rapport with your patient from the initial handshake* When you greet the patient, you are letting them know that you are available to them and that they have your attention. Establishing rapport with your patient is critical to your ability to help them. Be warm, confident, but not arrogant, polite but in charge, and understand their problem without making it yours. The level of rapport with patients is a distinguishing factor between adequate therapists and exceptional therapists. 2. *Observing their movement, affect, posture, and ability to communicate.* In an unobtrusive manner, you must observe all that you can about the patient as you move toward the more formal and private part of the examination. Do they move from the chair easily? Observe their gait. Is their face held in an expression of pain or do they moan? Do they speak clearly and in an articulate way? What is their posture like? Do they use a cane or need a caregiver? Essentially, you are beginning the process of getting to know them. **3. History** Purpose: identify if red flags are present and understand the location and nature of the complaint and its severity, irritability, the potential mechanism, and its impact on function (SINSS). \*\**Many experienced clinicians can diagnose the patient's condition using **ONLY** the information in the history\*\** The importance of listening to the patient tell their story in their own words should not be overestimated. Although the patient may not know the causative factor for their problem, they know what the problem is, and the information they provide is vital to developing your hypothesis. As with observation, the history affords the therapists a unique opportunity to achieve rapport with the patient. **General considerations for the history:** a. **Physical environment, seating relative to patient, no interruptions** b. **Red flags**: a. Let the patient know that you are going to address their current concerns soon, but you would first like to review their intake form and medical history with them. b. The intake form should include many medical screening questions, but when present, they need to be discussed briefly with the patient to investigate their contribution to the patient's general health and current condition. c. If an intake form is not available, you must ask the medical screening questions yourself. d. *You are responsible for the General Health Checklist (below), which is essentially a general list of potential red flag symptoms. At a minimum, every patient should be* questioned regarding the following, either verbally, by intake form, or both: **MEMORIZE THIS LIST** c. **General Health Checklist:** a. **Fatigue which decreases function** b. **Malaise** c. **Fever/chills:** significant if greater than 99.5 for more than 2 weeks d. **Weight loss/gain:** significant if greater than 5%-10% body weight over 3-6 months that is unexplained (i.e. not conscious diet or exercise) e. **Dizziness, lightheadedness** f. **Paresthesia/numbness** (not unilateral radiculopathy, but bilateral or in non-dermatomal distribution, e.g., saddle anesthesia) two arms = red flag g. **Weakness** h. **Nausea/vomiting** i. **Change in mentation/cognitive abilities** **For every YES answer, you must determine, in this sequence, ORDER MATTERS:** 1. Is there an explanation for it? 2. Has the patient mentioned this to a physician? 3. If the physician is aware of it, has it become worse? If there is a reasonable explanation and/or the physical is already aware and is managing the condition, then there is no need for immediate referral which would delay physical therapy intervention. d. **Pain:** Every exam should include some type of objective documentation of pain (VAS, Body chart, NPRS, etc.) e. **Body Chart:** used as an organizational tool to explicitly identify all symptomatic areas or "problem areas" and their characteristics e. Location f. Quality g. Quantity **General Approach After Red Flag Screening** - The patient wants to talk about how they feel NOW, but first you need to hear about THEN (i.e., how the condition started), in order to obtain the natural course of the disorder. You need to explain this to the patient and assure them that you will listen to their current complaints very soon. - DO NOT ASK LEADING QUESTIONS You do not want to bias the patient's answers with assumptions hidden in your questions. Instead use open ended questions. - *Leading question (incorrect): "Did the 5-hour plane ride give you that burning pain in your back again?"* - *Open-ended questions (correct): "How did you feel during the plane ride?"* - Demonstrate active listening by briefly summarizing what you heard and asking for further information when needed. - *Example: "What I heard you say is that lying on your right side makes the pain less intense. What other activities or positions relieves the pain?"* **[Questions for the History]: MEMORIZE** 1. Why have you come to see me today? a. Differentiate between pain and loss of function 2. **MUST ASK ABOUT ANY RED FLAG OR MEDICAL ITEMS HERE** 3. When did the pain (or other complaint) first start? b. When was the first occurrence if several years ago? c. When did the current episode start? 4. Where is/are the pain/symptoms? d. SPECIFIC anatomic location of pain/complaint have the patient point to each area of pain/complaint e. Avoid putting words in the patient's mouth. Instead of assuming that they have "pain," ask about their "symptoms" and then use the patient's words to avoid bias, i.e. "heaviness in my arm" or "tingling in my foot." 5. I would also like to quickly review this chart with you to ensure that I have a complete understanding of your symptoms. Do you have any symptoms in any of the following areas? f. Using the body chart as a guide, ask about each body region / joint within the upper or lower quarter depending on the location of patient's primary complaint g. Mark where symptoms are and are not on your blank body chart 6. How did the pain/symptoms begin? h. SPECIFIC mechanism of injury i. *Incorrect: "I fell down"* ii. *Correct: "I fell with my arm outstretched in front of me, with my elbow extended, and landed on my hand"* i. Overuse injuries may not have a clear causative event, in which case the next question is vital 7. How has it changed since it first began? j. Intensity, location, frequency, irritability 8. How do you feel now? k. Pain scale: QUANTITY 0-10 and QUALITY of EACH problem area (P) 9. How does it change over the course of a day? l. Worse in the AM or PM 10. Have you ever experienced this before? 11. What makes it worse? 12. What makes it better? 13. When you have this symptom (P1), do you also have this other symptom (P2)? m. You should ask this question in reference to each aggravating factor n. You may choose to use the phrase instead, "When this symptom (P1) gets worse, what happens to this other symptom (P2)?" o. Patient has neck pain with pins and needles in thumbs. "When you have the neck pain, do you also feel the pins and needles at the same time" 14. How does this affect your daily function? p. SPECIFIC examples related to things such as sleep disturbance, work related activities, daily activities, recreational or leisure activities 15. Are you taking any medications for any reason? q. Related to general health r. To manage this pain 16. What are your goals for physical therapy? 17. Have you seen a physician for this / do you plan to see a physician? 18. Is there anything else you want to tell me? **Body chart example** **P1 = numbness and tingling in both hands** **P2 = numbness and tingling throughout both arms (anterior and posterior)** - **= no symptoms** **\* = patient's primary complaint**  **4. Review of Systems (ROS) -- George et al (JOSPT 2015)** If necessary, this may be a good time to have the patient change into appropriate clothes for the physical therapy examination. The **ROS** is a limited (gross) examination designed to determine two things: a\. Should the patient be referred to another type of health care practitioner? b\. Which structures and systems require further investigation? **The ROS does NOT diagnose or rule in or out specific diagnoses** **Primary Systems Reviewed:** **[Clinical Pearls]**: - The reality of clinical practice is that you never have as much time as you desire for each patient. This necessitates **EFFICIENCY** in your examination. - The medical screening you performed during the history and the review of systems helps guide your clinical decision making in selecting the key examination procedures. - It is currently a matter of debate as to whether or not outpatient physical therapists should assess vitals. However, best practice dictates that at least BP should be assessed for every patient, at least at the initial examination to gather baseline data. - In addition to the presence of potential red flags, you should be cautious and consider referral for patients presenting with pain that does not change with movement or position changes. **Decision... After the history and ROS you have a choice (Finucane 2020):** 1. **Continue to examine and potentially treat the patient without referral to another practitioner** 2. **Refer the patient to an appropriate healthcare practitioner** 3. **Continue with the examination and/or treatment with caution and also refer to the appropriate healthcare practitioner** **5**. **Screening Exam** The screening exam should be performed when the history identifies any symptoms that indicate the possible presence of radiculopathy or stenosis. That is, symptoms which may be coming from the spine and impingement of nerves: **weakness, loss of sensation, numbness, or tingling.** **The primary question answered by the screening exam is:** **Is the complaint arising from the tissue/location that it appears to be coming from, or are the localized symptoms really coming from the spine?** Example: Is lateral elbow pain caused by tennis elbow or is it referred pain from a C7 nerve root involvement? **Performing the Upper Quarter Screening Exam** Preface your exam by explaining to the patient what you are doing. You are attempting to determine the source of the symptoms in the upper extremity, and specifically to determine if the symptoms may be coming from the spine. You should ask the patient to tell you if anything, you do changes the symptoms, making them better or worse, or a different quality. Do not bias your patient by using the word pain. **UPPER QUARTER -- can all be performed in sitting** I. **AROM of cervical spine** a. Flexion b. Extension c. Side bending right and left d. Rotation right and left II. **Overpressure to cervical spine** e. If AROM is full and without symptoms, give gentle overpressure f. If AROM is painful, be cautious with overpressure III. **AROM of all UE joints** g. Expectation: if there is an UE problem, the joint/muscle in question will hurt, but others should be pain-free IV. **Myotomes** h. Resisted isometric tests in midrange for 5 seconds. NOT a true MMT. i. Put the patient in the position and say "Hold here. Don't let me move you." j. Focus is on force production and if it can be sustained for 5 seconds i. **C4 = scapular elevation** ii. **C5 = shoulder abduction** iii. **C6 = elbow flexion and wrist extension** iv. **C7 = elbow extension and wrist flexion** v. **C8 = finger flexion/thumb extension** vi. **T1 = finger abduction** V. **Dermatomes** k. Specific anatomic locations are used to test nerve roots l. Have the patient close their eyes m. Lightly touch (**not swipe**) locations on the UE n. Begin with the uninvolved side first o. Use the following TWO phrases in sequence to assess side to side differences in sensation *"Say yes when I touch you." "Does it feel the same on both sides?"* vii. **C4 = top of shoulder** viii. **C5 = lateral shoulder** ix. **C6 = digit 1 MCP (posterior)** x. **C7 = digit 3 MCP (posterior)** xi. **C8 = digit 5 MCP (posterior)** xii. **T1 = medial forearm** VI. **Reflexes** p. C5/C6 = elbow flexion q. C7 = elbow extension VII. **Special tests (for screening upper quarter, please note position)** r. Spurling test (cervical spine) **SITTING** s. Distraction test (cervical spine) **SITTING/SUPINE** t. Upper limb tension test (median nerve) **SUPINE -- only exception for completing the whole UE screening examination in sitting** **DIFFERENTIATING NERVE ROOT vs PERIPHERAL NERVE DISORDERS** A key feature of diagnosing neurological symptoms in the extremities is determining if the lesion is at the nerve root or peripheral nerve level. **In general, if both the myotome and dermatome of a nerve root is affected, it is likely to be a nerve root.** **If only the sensation or muscle innervation of a single peripheral nerve is affected, it is likely to be a peripheral nerve.** NOTE: Muscles innervated proximal to the site of nerve injury are spared. Abundant overlap in sensory and motor innervation between the different structures increases the diagnostic difficulty. +-----------------+-----------------+-----------------+-----------------+ | **Pathology** | **Motor | **Sensory | **Reflex | | | Deficit** | Deficit** | Deficit** | +=================+=================+=================+=================+ | **NERVE ROOTS** | | | | +-----------------+-----------------+-----------------+-----------------+ | **C5 | Shoulder | Lateral | Biceps | | radiculopathy** | abduction | superior | | | | | shoulder | | +-----------------+-----------------+-----------------+-----------------+ | **C6 | Elbow flexion | Digit 1 | Brachioradialis | | radiculopathy** | | | | | | Wrist extension | | | +-----------------+-----------------+-----------------+-----------------+ | **C7 | Elbow extension | Digit 3 | Triceps | | radiculopathy** | | | | | | Wrist flexion | | | +-----------------+-----------------+-----------------+-----------------+ | **C8 | Finger flexion | Digit 5 | None | | radiculopathy** | | | | +-----------------+-----------------+-----------------+-----------------+ | **T1 | Finger | Medial forearm | None | | radiculopathy** | abduction | | | +-----------------+-----------------+-----------------+-----------------+ | **PERIPHERAL | | | | | NERVES** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Suprascapular | External | None | None | | C5-C6** | rotation | | | | | | | | | | Shoulder | | | | | abduction | | | +-----------------+-----------------+-----------------+-----------------+ | **Musculocutane | Elbow flexion | Lateral forearm | Biceps | | ous | | | | | C5-C7** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Axillary | Shoulder | Lateral | None | | C5-C6** | abduction | superior | | | | | shoulder | | +-----------------+-----------------+-----------------+-----------------+ | **Radial | Elbow extension | Web space | Triceps | | (C6-T1)** | | between thumb | | | | Wrist extension | and index | | | | | | | | | MCP extension | | | +-----------------+-----------------+-----------------+-----------------+ | **Median | Pronation | Distal anterior | None | | (C6-T1)** | | aspect digits | | | | Wrist flexion | 1-3 | | | | | | | | | Radial | | | | | deviation | | | | | | | | | | Thenar muscles | | | +-----------------+-----------------+-----------------+-----------------+ | **Ulnar | PIP/DIP | Distal | None | | (C8-T1)** | extension | anterior/poster | | | | | ior | | | | Finger AB/ADD | aspect ½ digit | | | | | 4, all of 5 | | | | Ulnar deviation | | | +-----------------+-----------------+-----------------+-----------------+ **6.** **Structural Inspection** a. GET CONSENT b. Whenever possible, the patient should expose the body region being examined, taking into consideration modesty and privacy in the environment c. Structural inspection involves palpation (not to determine tenderness) and visual observation to determine the following 1. Skin condition 2. Muscle tonicity 3. Edema 4. Temperature 5. Scars 6. Moistness or dryness 7. Symmetry of landmarks **Your first decision is identifying which part(s) of the body require inspection**. - All spinal (cervical, thoracic, lumbar) problems, as well as all hip and shoulder problems, require inspection of the spine. Shoulder and hip problems (even without nerve root symptoms) require spinal inspection because the motion at those joints is so dependent on normal spinal function (regional interdependence). - Non-shoulder upper extremity problems (elbow, wrist, ankle, etc.) require examination of the spine if the symptoms and screening exam point to any potential central/spinal involvement (nerve roots, brachial plexus, thoracic outlet, etc.). If not, you do not need to look at the spine. Visual Observation - Symmetry of landmarks - Shoulders (acromion): the dominant shoulder is usually lower - Ears - ASIS - Iliac crests: to be done in both standing and sitting - PSIS - Scapulae - Spine: lordosis, kyphosis, forward head - Upper Extremity: humeral head IR, rounded shoulders, scapula protraction, horizontal clavicles - Lower Extremity: in-toeing (anteversion), out-toeing (retroversion), genu recurvatum, genu valgum/varum, subtalar pronation/supination **EXAMPLES OF POSTURE TYPES FROM KENDALL 5^th^ ed.**  **7. Movement Analysis (look for symmetry and efficiency of movement)** a\. Demonstration of the patient selected motion that hurts - Be careful if it is extremely painful or if there is risk involved - Provides information about what is **REALLY** important to the patient b\. Demonstration of standardized upper and/or lower extremity motions - Bring the chin to the chest - Look up to the ceiling - Bring the chin to the midpoint of the right and left clavicles - Touch the base of the spine of the scapula with the opposite hand - Touch the inferior angle of the scapula with the opposite hand - Squat - Step down test **8**. **Active Range of Motion** a. Quantity: goniometry or visual estimation b. Quality: grimacing, difficulty, lack of neuromuscular control, etc c. With/without pain: if painful, assess the following - Anatomic location of the pain - Quantity (0-10) - Quality (dull, sharp, achy, tingling, numbness, etc) - Where in the range is the pain? d. Be familiar with normal ranges of motion from T&M, but understand that there is variability. Always use the uninvolved side as a baseline **A Discussion of Normal and Abnormal AROM** Many people function "normally" without pain while having less than normal textbook range of motion, i.e. within functional limits (WFL). The relevance of ROM should be considered within the context of the patient as a whole, with side-to-side symmetry dictating normal ranges of motion for that individual. - **The specific joint and the direction matter** - Example: a loss of only 5 degrees of ankle DF will create a large difference in gait function, whereas, a loss of 20 degrees of knee flexion will have much less of an impact on function. - **Functional range is more important than normal range** - Knee flexion for stairs: 110 degrees - Ankle DF for gait flat surfaces: 10 degrees - Ankle DF for descending stairs: 30 degrees - Hip extension for gait level surfaces: 10 degrees - Shoulder flexion for reaching high shelf: 150 degrees **WHAT TO EXAMINE** - What hurts when it is moved? Note: this will include any spinal motion that has been linked to the primary complaints in the screening exam - What does not move normally? Either the patient reports this as a limitation in movement, or you have observed it during the movement analysis. **Upper extremity:** examine the joint or joints as determined above, plus for the UE examine the **joints above and below the involved joint**. -Example: Measure elbow flexion, and then wrist flexion and shoulder flexion **Lower extremity:** *because the LE typically functions in a closed-kinetic chain, always check the **AROM of all joints of the LE when any joint is involved**.* -Example: Ankle injury? Ankle, knee, and hip as well *Examples:* 1. ***Elbow injury would require AROM of the shoulder, elbow, and wrist*** 2. ***Shoulder injury would require AROM of the shoulder, elbow and CT spine*** 3. ***Hip injury would require AROM of the entire LE, plus lumbar spine*** **HOW TO EXAMINE** Estimate visually if AROM is WNL - If AROM is WNL, then no goniometry is necessary and you may document WNL for the appropriate joints. If you have any doubt about the range being normal, MEASURE with the goniometer. - AROM and PROM testing are often combined, with PROM immediately following the AROM of each joint. - If the AROM is normal, PROM throughout the range is NOT needed as we know the range is without a problem. - **However, passive overpressure into end-range following AROM is REQUIRED in order to determine the end-feel and any symptoms that arise with the overpressure. A joint is not cleared until overpressure has been applied.** - IF AROM is not WNL, goniometry is required for AROM and PROM. - PROM should be measured immediately after AROM in all planes. - Overpressure should be applied at the end of the passive motion. - For spinal complaints, AROM in all planes with overpressure is required. If there is a loss of normal AROM it is necessary to measure with a goniometer or inclinometer. **9**. **Passive Range of Motion (osteokinematic, arthrokinematic)** a. **Osteokinematic:** passive motion of the bones throughout the range of motion. Passive motion provides different information than AROM because the patient's muscles are not required to perform the motion. Therefore, motivation and weakness are extracted from the possible causative factors limiting the motion. +-------------+-------------+-------------+-------------+-------------+ | | **Only AROM | **Both AROM | **AROM sig. | | | | is | and PROM | \> PROM** | | | | limited;** | are | | | | | | limited** | | | | | **PROM is | | | | | | normal** | | | | +=============+=============+=============+=============+=============+ | | **AROM sig. | **AROM ≈ | **AROM sig. | | | | \< PROM** | PROM** | \< PROM** | | +-------------+-------------+-------------+-------------+-------------+ | **Possible | Contractibi | Joint | Contractibi | Patient is | | cause(s)** | lity | mobility | lity | apprehensiv | | | problem: | problem | problem | e | | | | and/or soft | | and | | | Examples: | tissues | AND | guarding | | | | length | | | | | - Agonist | deficits | Joint | | | | muscle | | mobility | | | | weaknes | (Examples | problem | | | | s | of soft | and/or soft | | | | | tissue: | tissues | | | | - Agonist | antagonist | length | | | | muscle | muscle, | deficits | | | | spasm | fascia, | | | | | | nerve, | | | | | - Pain | tendon, | | | | | inhibit | skin, etc.) | | | | | ing | | | | | | agonist | | | | | | muscle | | | | | | contrac | | | | | | tion | | | | | | | | | | | | - Agonist | | | | | | musculo | | | | | | tendinous | | | | | | adhesio | | | | | | n | | | | | | | | | | | | - Agonist | | | | | | neuromu | | | | | | scular | | | | | | control | | | | | | problem | | | | +-------------+-------------+-------------+-------------+-------------+ | **Potential | - Muscle | Joint | Refer to | Determine, | | Primary | weaknes | mobility | interventio | isolate and | | Interventio | s: | problem: | ns | address the | | n(s)** | *Active | Joint | for the | cause(s), | | | range | mobilizatio | same | e.g. pain, | | - Depend( | of | n | possible | past | | s) | motion | | causes | experience | | on the | exercis | Soft tissue | | | | identif | e, | length | | Relaxation | | ied | active- | deficit: | | training | | cause(s | assistive | *stretching | | | | ) | range | *; | | Increasing | | | of | soft tissue | | the surface | | - Therape | motion | mobilizatio | | area of | | utic | exercis | n | | PT's | | exercis | e | | | support or | | es | and/or | | | contact | | are | resista | | | | | italici | nce | | | | | zed | exercis | | | | | | e* | | | | | | | | | | | | - Muscle | | | | | | spasm: | | | | | | manual | | | | | | therapy | | | | | | ; | | | | | | thermot | | | | | | herapy | | | | | | | | | | | | - Pain | | | | | | inhibit | | | | | | ing | | | | | | muscle | | | | | | contrac | | | | | | tion: | | | | | | address | | | | | | the | | | | | | pain | | | | | | and | | | | | | prefera | | | | | | bly | | | | | | the | | | | | | source | | | | | | of the | | | | | | pain | | | | | | | | | | | | - Musculo | | | | | | tendinous | | | | | | adhesio | | | | | | n: | | | | | | manual | | | | | | therapy | | | | | | | | | | | | - Neuromu | | | | | | scular | | | | | | control | | | | | | problem | | | | | | : | | | | | | *neurom | | | | | | uscular | | | | | | trainin | | | | | | g/re-educat | | | | | | ion* | | | | +-------------+-------------+-------------+-------------+-------------+ **LAB: Practice PROM all planes of the shoulder as demonstrated by instructor** b. **Arthrokinematic:** describes what happens as one joint surface moves relative to another (roll, slide, spin). Without these arthrokinematics, osteokinematic cannot occur normally. Shoulder flexion Active ROM: 0-75 Passive ROM: 0-120 Might be contractile tissue problem or nerve issue *Example: if someone had a limitation in shoulder abduction (osteokinematic), there may be a failure off the humeral head to inferiorly glide (arthrokinematic).* **Roll: caused by contraction of muscles** **Glide: we cause the glide** **MODEL FOR GRADES OF MOBILIZATION FORCE: ARTHROKINEMATICS** R1: first point of resistance R2: End of range before anatomical limit (point of tissue failure) Note: R1 and R2 are defined individually for each patient and clinical presentation, and often change within and between sessions. **elbow flexion hurts, elbow extension stretch hurts? Bicep strain problem** Amplitude = amount of movement R1 = first resistance R2 = end range of motion +-----------------+-----------------+-----------------+-----------------+ | **Grade** | **Description** | **Primary | **Symptom | | | | Treatment | Irritability** | | | | Goal** | | +=================+=================+=================+=================+ | Grade I | Small amplitude | Pain modulation | Moderate to | | | at the | | High | | | beginning of | | | | | the range | | | | | before any | | | | | resistance | | | | | | | | | | (Before R1) | | | +-----------------+-----------------+-----------------+-----------------+ | Grade II | Large amplitude | Pain modulation | Moderate to | | | at the | | High | | | beginning of | | | | | the range | | | | | before any | | | | | resistance | | | | | | | | | | (Before R1) | | | +-----------------+-----------------+-----------------+-----------------+ | Grade III | Large amplitude | Increase | Low | | | in mid-range | mobility | | | | working into | | | | | resistance and | | | | | towards the end | | | | | of resistance\ | | | | | (50% between R1 | | | | | and R2) | | | +-----------------+-----------------+-----------------+-----------------+ | Grade IV | Small amplitude | Increase | Low | | | mid-range | mobility | | | | working into | | | | | resistance and | | | | | towards the end | | | | | of resistance | | | | | | | | | | (50% between R1 | | | | | and R2) | | | +-----------------+-----------------+-----------------+-----------------+ | Grade IV++ | Small amplitude | Increase | Low | | | at end range | mobility | | | | (R2) | | | +-----------------+-----------------+-----------------+-----------------+  **End-feel:** Each joint has a specific normal end-feel (see table below), which represents the quality of passive overpressure at the end of a joint's available range of motion. In the presence of pathology, pain, or dysfunction, the end-feel may vary. a. **Pain before resistance -- acute injury** b. **Pain during resistance -- subacute injury** c. **Pain after resistance -- chronic injury** +-----------------------------------+-----------------------------------+ | **Normal End-feels** | **Abnormal End-feels** | +===================================+===================================+ | [Soft] | [Boggy] | | | | | Soft tissue approximation | Swelling | | | | | [Firm / Capsular] | [Empty] | | | | | Capsular stretch | Pain | | | | | [Elastic] | Hypermobility | | | | | Muscle stretch | Joint obstruction | | | | | [Hard] | [Guarding] | | | | | Bone contacting bone | Apprehension | | | | | | Fear | | | | | | \*\*Or any "normal" end-feel at | | | an inappropriate joint or range | | | of motion | +-----------------------------------+-----------------------------------+ **Discuss difference between elastic vs. firm end-feel for deciding joint mobs vs stretching of a musculotendinous unit.** **Elastic end-feel = stretch** **Capsular restriction = bang into glide (mobilization)** **Bony block = nothing PT can do** **Firm capsular end-feel = mobilize** **Glenohumeral joint is very important for closed-packed, loose-packed, etc.** **UPPER EXTREMITY JOINT POSITIONS AND NORMAL END-FEELS** +-----------------+-----------------+-----------------+-----------------+ | **JOINT** | **CLOSED-PACKED | **LOOSE-PACKED* | **CAPSULAR | | | ** | * | PATTERN** | | **End-feel** | | | | | | | **(Resting)** | | +=================+=================+=================+=================+ | Glenohumeral | Maximal AB | 55-70° AB | ER limited more | | | | | than AB limited | | *Flex / Ext = | and ER | 30° Horizontal | more than IR | | tissue stretch* | | ADD | | | | | | | | *AB = bone to | | Neutral | | | bone or tissue | | rotation | | | stretch* | | | | | | | | | | *ER / IR = | | | | | tissue stretch* | | | | | | | | | | *Horizontal ADD | | | | | = tissue | | | | | stretch or soft | | | | | tissue | | | | | approximation* | | | | | | | | | | *Horizontal AB | | | | | = tissue | | | | | stretch* | | | | +-----------------+-----------------+-----------------+-----------------+ | Sternoclavicula | Depression of | Semi-elevation | Pain at extreme | | r | shoulder | of shoulder | range of | | | | | movement | | Not defined | | | | +-----------------+-----------------+-----------------+-----------------+ | Acromioclavicul | Shoulder | Shoulder | Pain at extreme | | ar | elevation | depression | range of | | | | | movement | | Not described | | | | +-----------------+-----------------+-----------------+-----------------+ | Humeroulnar | Maximal | 70° of flexion | Flexion \> | | | extension and | | extension | | *Flex = soft | supination | 10° supination | | | tissue* | | | | | | | | | | *Ext = bony* | | | | +-----------------+-----------------+-----------------+-----------------+ | Humeroradial | 90° flexion | Maximum | Flexion \> | | | | extension and | extension, | | *Flex = soft | 5° supination | supination | | | tissue* | | | | | | | | | | *Ext = bony* | | | | +-----------------+-----------------+-----------------+-----------------+ | Proximal | 5° supination | 35° supination | Supination = | | radioulnar | | | pronation | | | Full extension | 70° flexion | | | *Sup = firm* | | | | | | | | | | *Pron = firm* | | | | +-----------------+-----------------+-----------------+-----------------+ | Distal | 5° supination | 10° supination | Supination = | | radioulnar | | | pronation | | | | | | | *Sup = firm* | | | | | | | | | | *Pron = firm* | | | | +-----------------+-----------------+-----------------+-----------------+ | Radiocarpal | Extension with | 10° wrist | Flexion = | | | RD | flexion | extension | | *Flex / Ext = | | | | | tissue stretch* | | Slight UD | | | | | | | | *RD / UD = | | | | | tissue stretch* | | | | +-----------------+-----------------+-----------------+-----------------+ | Midcarpal | Extension with | 10° wrist | Not defined | | | UD | flexion | | | *Flex / Ext = | | | | | tissue stretch* | | Slight UD | | | | | | | | *RD / UD = | | | | | tissue stretch* | | | | +-----------------+-----------------+-----------------+-----------------+ | Carpometacarpal | Not defined | Not defined | Equal | | | | | limitation in | | Not defined | | | all planes | +-----------------+-----------------+-----------------+-----------------+ | CMC Thumb | Full thumb | Mid-abduction | AB limited the | | | opposition | | greatest, | | *Flex / Ext = | | Mid-flexion | followed by | | tissue stretch* | | | extension | | | | | | | *AB / AD = | | | | | tissue stretch* | | | | +-----------------+-----------------+-----------------+-----------------+ | Metacarpophalan | Full flexion | Slight flexion | Flexion = | | geal | | | extension | | | | | | | *Flex / Ext = | | | | | tissue stretch* | | | | | | | | | | *AB / AD = | | | | | tissue stretch* | | | | +-----------------+-----------------+-----------------+-----------------+ | Interphalangeal | Full extension | Slight flexion | Flexion = | | | | | extension | | *Flex = tissue | | | | | stretch* | | | | | | | | | | *Ext = tissue | | | | | stretch* | | | | +-----------------+-----------------+-----------------+-----------------+ **Capsular Patterns** - PROM will determine if the joint has a capsular pattern or not. - A capsular pattern exists when the entire capsule is "shortened" limiting motion of the joint in all planes. - However, because of the unique nature of each joint and the unique nature of the ligaments (which are often thickenings of the capsule), the loss of range of motion in the joint is not uniform in all planes. That is, the joint may lose some motion in all directions but lose more motion in some directions than in others. - The most common clinical problem that is relevant for a capsular pattern is the glenohumeral joint which will be mostly limited in ER, then next most limited in AB and then next most limited in IR. This is highly suggestive of adhesive capsulitis in the shoulder. **Mobilize originally in loose-packed position and then try closed-pack position** **LAB EXERCISES** **AROM/PROM** The goal of this exercise is to compare sides in AROM, PROM, and end-feel. Comparison of sides is typically more informative than comparing a person to normative values. Normal ROM values are important for general comparisons, but even more critical is the relationship between AROM and function. **Exercise 1.** Break up into groups of 2 and perform AROM, PROM, and end-feel assessments of both shoulders of your partner. Use the sheet below to record quantity of AROM and PROM, and type of end-feel. Estimate range visually no goniometers. **Note: perform AROM in a gravity resisted position. PROM and end-feel should be assessed supine.** **Assessment** **Right Shoulder** **Left Shoulder** ------------------------------------------------------------------------------------------------- -------------------- ------------------- -------- -------- -------- -------- -------- -------- -------- -------- **ER** **IR** **AB** **FL** **EX** **ER** **IR** **AB** **FL** **EX** **AROM** (quantity, quality, and pain) **PROM (**quantity, quality, and pain) **End-feel (**soft tissue, bony, elastic, capsular) or abnormal (springy, boggy, spasm, empty)) **Exercise 2.** Practice on the MCP of the index finger of your partner grading hypermobile, normal, or hypomobile (practice using to convex-concave rule to increase motion, for example if flexion were limited) **General Procedures** a. Patient relaxed with joint supported b. Examiner relaxed c. Position of joint in loose pack d. Only ONE joint at a time e. Locate the joint line f. One hand stabilizes g. One hand mobilizes h. Bunch of skin if possible i. Do not squeeze down on body part j. If doing distraction pull perpendicular to joint surface k. If doing glides translate parallel to joint surface **Exercise 3.** Repeat exercise 2 using the shoulder joint **10. Resistive Tests** **Muscle Selective Tissue Tension Test (MSTT):** performed in mid-range and are isometric. These are not strength tests per se, but rather designed to acquire further information about which structures may be injured. Dr. James Cyriax originally developed these classifications and it should be noted that they are not evidence-based, but form the foundation of orthopedic examination. a. **Strong and painful -- minor injury of musculoskeletal complex** b. **Weak and painful -- major injury of musculoskeletal complex** c. **Weak and painless -- total tear of musculoskeletal complex or nerve dysfunction** d. **Strong and painless -- no injury** **Manual Muscle Tests:** can be done as break tests in mid-range or throughout the range. Note: MMT are not valid in the presence of pain. However, since they are commonly performed anyway in the clinic, a notation should always be documented when pain is present. *Example: MMT = 4/5 with 4/10 verbal pain rating* Note: If a screening exam has already been performed, then some muscles/actions many not need to be repeated during muscle strength testing, as myotome testing resembles an isometric mid-range break test. However, other key muscles still require thorough examination. Keep in mind, that the intention behind myotome testing and MMT is different. MMT for **post-operative** patients is mandatory unless contra-indicated by post-operative restrictions. Many patients will NOT be appropriate candidates for muscle force testing immediately post-surgery. For example, testing the hamstring following ACL reconstruction using a hamstring graft on day 1 is contra-indicated. Similarly, we need to demonstrate caution if performing a MMT will place excessive stress on a tissue, thus causing further tissue damage. **Which muscles to test?** Choosing which muscles to test is not as clear as the rules for range of motion. Therefore, specific examples will be given as we cover each of the joints throughout the musculoskeletal sequence. In general, it will be important to assess the strength/endurance of key muscles for each body region as they relate to the function of the musculoskeletal system. There are common muscles that are prone to weakness at each region (see below). That being said, there will be times that you will need to assess the strength of other muscles crossing the involved joint. **Muscles Prone to Weakness** Upper Quadrant: - Rotator cuff - Lower trapezius - Middle trapezius - Serratus anterior - Deep neck flexors - Lower cervical extensors Lower Quadrant: - Hip abductors - Hip extensors - Hip external rotators - Multifidus - Transverse abdominis - Tibialis posterior **11. Muscle Length** Primarily used for two joint muscles such as hamstrings, quads, latissimus dorsi, pectoralis major, etc. Note**:** We will attempt to avoid the term "tight muscles" in this class. Tight does not tell you if the muscle has shortened connective tissue or is hypertonic, or both. Although commonly used by patients, I highly recommend becoming aware of the vague meaning of the term. **12. Special Tests** Specific to each joint. In theory, these tests rule in or out specific diagnoses. Each special test has a certain sensitivity and specificity (SpIN and SnOUT) that determines its clinical utility. Note: Special tests should not be used exclusively to determine if a patient does or does not have a pathology, as very few special tests tell you anything conclusively. They should be used in conjunction with other exam findings and with the full understanding of their limitations. In certain instances, combining or clustering special tests is a better way to make use of the information that tests are giving you. **13. Palpation** Find the pain, if possible. This is left to the end of the exam to avoid increasing pain during the earlier portions of the exam. It is usually very important to the patient that you "find" the place where it hurts. The information you derive can be tissue tone and irritability. ### Evaluation The evaluation gathers the known information into general categories and makes initial assessments about the general nature of the problem. It is a first step toward a diagnosis. **EVALUATING THE INFORMATION GAINED** +-----------------+-----------------+-----------------+-----------------+ | **Information | **Grade/clarifi | **Source of | **Relevance of | | type** | cation** | Information** | Information** | +=================+=================+=================+=================+ | **Red Flags** | Generally based | Intake form, | Should I be | | | on system | History, ROS | treating this | | | involved | | patient? | | | (Cardiopulmonar | | | | | y, | | Referral out? | | | Musculoskeletal | | | | | , | | | | | etc.) | | | +-----------------+-----------------+-----------------+-----------------+ | **Acute, | As defined | History | In general, | | Sub-acute, | here---only | | symptoms that | | Chronic** | based on TIME | | are chronic | | | --not tissue | | take longer to | | ([as timeline | inflammation. | | change because | | only]{.underlin | It needs to be | | the underlying | | e}) | combined with | | pathology or | | | physical exam | | mechanical | | | findings | | causative | | | (reactivity). | | factors are | | | | | more stable and | | | Authors vary | | ongoing. This | | | but typically: | | is important in | | | | | setting | | | Acute: 24-48 | | expectations | | | hours | | for patients. | | | | | Chronic pain | | | Sub-acute 48 | | almost always | | | hours -12 weeks | | involves | | | | | greater degrees | | | Chronic: | | of psychosocial | | | greater than 12 | | involvement, | | | weeks | | which may also | | | | | influence the | | | | | rate of change | | | | | toward health. | | | | | Chronic | | | | | injuries can be | | | | | intermittent in | | | | | their | | | | | presentation--- | | | | | with | | | | | varying levels | | | | | of tissue | | | | | irritability | | | | | (next | | | | | category). | | | | | Truly acute | | | | | injuries (1-2 | | | | | days) are | | | | | almost always | | | | | related to high | | | | | "tissue" | | | | | irritability. | +-----------------+-----------------+-----------------+-----------------+ | **Tissue** | High = pain | History; | Most commonly | | **reactivity | [before]{.under | Physical exam | provides | | (irritability)* | line} | when tissue is | information on | | * | resistance | stressed | the | | | felt---simply | (compressed or | inflammatory | | (what happens | moving the | stretched) or | state and | | when the | joint around | palpated | consequently | | therapist | | | important in | | stresses the | Medium = pain | | terms of how | | tissue by | [as]{.underline | | your treatment | | taking the | } | | will be | | joint to full | resistance is | | directed. For | | range) | felt | | example: If | | | | | High---manual | | | Low = pain | | therapy is | | | [after]{.underl | | Grade I or II | | | ine} | | oscillations to | | | resistance is | | reduce pain | | | felt | | (and commonly | | | | | modalities) and | | | | | begin motion, | | | | | if Medium you | | | | | can begin some | | | | | stretch, and if | | | | | low can more | | | | | aggressively | | | | | stretch. | +-----------------+-----------------+-----------------+-----------------+ | **Functional** | High = pt. | History | Subjects with | | reactivity | cannot carry | | high | | | out functional | | "functional" | | (what happens | activity due to | | reactivity may | | when the | pain | | need more | | patient | | | emphasis on | | attempts | Med = can | | inflammation | | function) | perform | | reduction and | | | activity but | | on education | | | has complaints | | about the | | | during | | avoidance of | | | | | physical | | | Low = can | | stressors. | | | perform | | Those with low | | | activity with | | "functional" | | | no complaint | | reactivity can | | | | | be progressed | | | | | faster with | | | | | more emphasis | | | | | on motion | | | | | correction and | | | | | strength and | | | | | conditioning. | +-----------------+-----------------+-----------------+-----------------+ | **Physical | Was this a | History | Traumatic | | Stress** | one-time | | events create a | | (mechanical | traumatic | | known cause | | causation) | event, or the | | that is | | | result of low | | unlikely to | | | levels of | | reoccur and | | | physical stress | | therefore | | | repeated many | | efforts are | | | times | | aimed primarily | | | (microtrauma) | | at tissue | | | | | recovery. | | | | | Overuse | | | | | requires more | | | | | investigative | | | | | work to | | | | | determine the | | | | | underlying | | | | | movement | | | | | dysfunction or | | | | | to decrease the | | | | | offending | | | | | physical stress | +-----------------+-----------------+-----------------+-----------------+ | **Anatomic | Where symptoms | History, | Any patient | | location** | occur (e.g., | Screening Exam, | with neurologic | | | pain, | Physical Exam | symptoms should | | | paresthesias) | | have a screeng | | | may be in a | | exam to | | | different | | determine if | | | location than | | the causation | | | the true tissue | | may be a more | | | problem (e.g. | | central nerve | | | radiculopathy) | | element | | | | | (peripheral | | | | | nerve, nerve | | | | | root, spinal | | | | | cord | | | | | compre