MSK 2: Final Exam PDF

MSK 2: Final Exam There are 50 exam questions. 25 are from material you have already been tested on, 25 are from new material after Exam 3. TMD Know the TMJ classifications and the associated signs and symptoms 1. Capsulitis / Synovitis and Fibrosis a. Capsulitis / Synovitis...

MSK 2: Final Exam There are 50 exam questions. 25 are from material you have already been tested on, 25 are from new material after Exam 3. TMD Know the TMJ classifications and the associated signs and symptoms 1. Capsulitis / Synovitis and Fibrosis a. Capsulitis / Synovitis i. Tender to palpation at TMJ lateral condyle or posterior compartment ii. Pain with biting/chewing on opposite side iii. Pain with retrusive overpressure iv. Pain with accessory motion testing b. Fibrosis i. Capsular pattern deviation toward limited side with opening and protrusion ii. Limited contralateral lateral excursion iii. Limited AROM mandibular dynamics iv. Limited mobility with TMJ accessory motion tests v. No joint sounds vi. History of trauma or surgery 2. Ankylosis a. Limited joint play mobility and mandibular ROM opening, protrusion and contralateral excursion b. Deflection of mandible towards restricted side evident during opening and protrusion c. Bony ankylosis - NO TMJ MOBILITY d. Capsular and fibrosis ankylosis - some mobility e. Usually result of joint inflammatory response as related to trauma or systematic condition 3. Mobility a. Hypomobility i. Decrease in opening (less than 30 mm) ii. Limited joint play during mobility testing iii. Pain may be present or absent iv. Etiology: trauma, surgical procedure, internal derangement (IKD), ankylosis, advanced OA b. Hypermobility i. Excessive jaw opening (greater than 55 mm) ii. Poor movement control (‘S’ pattern observed during opening) iii. Unilateral: jaw deviates to contralateral side at end of opening and protrusion iv. Etiology: joint laxity, systemic hypermobility, anatomic variability, masticatory muscle dystonia v. End range click with deviation away from hypermobile side that clicks vi. Hypermobility with accessory motion testing 4. Disk-Condyle Incoordination / IKD a. ADDWR: anterior disk displacement with reduction i. Reciprocal joint sound with opening and closing ii. ‘S’ curve with opening iii. Full AROM  b. ADDWOR: anterior disk displacement without reduction i. History of joint sounds ii. Limited opening 100, BP >160/90, resting pulse >100, RR >25 b. Fatigue, chills, night sweats 2017 CPG summary info slides. Be able to describe specific impairment classification typical presentations and choose treatment interventions for each classification of cervical spine disorders. 1. Neck pain with mobility deficits a. Exam Findings: i. Restricted ROM ii. Pain at end ROM iii. Segmental mobility deficits C and T-spine iv. Cervical and referred pain elicited via provocation of involved spine segments or musculature v. Subacute, chronic cervicoscapulothoracic strength and motor control deficits may appear b. Treatment: i. Acute (12 wks): manual therapy, mixed exercise for cervicospcaulothoracic regions, activity advice, modalities 2. Neck pain with movement coordination deficits a. Exam Findings: i. Positive cranial cervical flexion test and flexor muscle endurance test ii. Positive pressure algometry iii. Neck muscles weak/lacking endurance iv. Pain mid-range (exacerbated EROM) v. Trigger points vi. Sensory motor changes vii. Cervical and referred pain elicited by provoking involved c-spine segment b. Treatment: i. Acute (12 wks): education, pain management, manual therapy, exercise, functional training 3. Neck pain with headache (cervicogenic) a. Exam Findings: i. Positive cervical flexion / rotation test ii. Provocation of involved upper cervical segment reproduces headache iii. C-spine ROM limited - upper c-spine hypomobility iv. Cervical muscle weakness, coordination and endurance impairments v. C1 = eye orbit C1-2 = temporal C2-3 = parietal C6 = frontal b. Treatment: i. Acute (12 wks): manual therapy, exercise (motor control, strength, endurance) 4. Neck pain with radiating pain (radicular) a. Exam Findings: i. Cervical pain combined with UE radicular pain ii. Clinical exam findings consistent with CPR radiculopathy screen test results iii. Involved nerve root impairments present as dermatome or myotome deficits, hyporeflexia b. Treatment: i. Acute (12 wks): manual therapy, combine flexibility and strengthening exercise, education/counseling to maximize occupational and exercise participation levels, intermittent traction Discuss the etiology and typical presentations of myelopathy versus cervical spine radiculopathy. 1. Cervical Myelopathy a. Multilevel bilateral UE/LE weakness b. Usually no sensory deficits c. Hyperreflexia d. Positive UMN tests e. Positive romberg f. Early signs = gait disturbances, clumsy hand, lhermitte’s sign, spastic paresis 2. Cervical Radiculopathy a. Unilateral single level weakness b. Unilateral dermatomal sensation deficit c. Unilateral positive ULTT d. Diminished reflexes (single level) e. Early signs = pain + sensory deficits followed by strength Myelopathy Radiculopathy Patient Reports Leg stiffness, hand weakness Unilateral or bilateral UE numbness/weakness Pain radiates from neck region to UE or body Screening Hyperreflexia, hand atrophy Dermatome, myotome, CPR testing Diagnostic Findings Stenosis, narrowing of spinal Symptoms relieved by shoulder canal and subsequent abduction test compressive force to spinal cord Causes Osteophytes, disc herniation, Nerve root (not SC) constriction ligamentum hypertrophy Disc herniation 6 Variables that form the CPR for Thoracic Manipulation to treat neck pain 1. Symptoms < 30 days 2. No symptoms distal to shoulder 3. No aggravation of symptoms while looking up (extension) 4. FABQPA score < 12 5. Diminished upper T-spine kyphosis 6. Cervical extension ROM < 30° Canadian C Spine Rule. Memorize. Save a life. 1. Does the patient have any high-risk factor that mandates radiography? i. Age ≥ 65 ii. Dangerous mechanism (fall, axial load, MVA, bike) iii. Paresthesias in extremities b. Yes → obtain radiographs c. No → question 2  2. Does the patient have any of the following low risk factors to allow safe assessment of ROM? i. Simple rear-end MVA ii. Assumes sitting position in waiting room iii. Ambulatory at any time iv. Delayed onset of neck pain v. Absence of midline C-spine tenderness b. No → obtain radiographs c. Yes → question 3 3. Is the patient able to actively rotate the neck 45° to left and right? a. No → obtain radiographs b. Yes → no radiographs needed Clinical Prediction Rule for Cervical Radiculopathy 1. Cervical rotation less than 60° 2. Positive Suprling’s A test 3. Positive distraction test 4. Positive ULTT Degenerative Disc Disorders of the C spine- what level does this typically occur and what are the signs and symptoms? 1. Spondylosis a. Joint structures and discs affects, common 40+ b. Mostly presents C5/6 and C6/7 c. Related to poorly attenuated shear forces (anterior forward head position) 2. Stenosis a. Narrowing of spinal canal caused by disc bulging, herniation, or boney morphology b. Can cause cervical myelopathy or radiculopathy T SPINE ULTT. Know them. 1. ULTT 1 Median and Anterior Interosseous Nerves C5-7 a. Shoulder depression, abduction 110°, ER with elbow at 90° b. Forearm supination, wrist and finger extension, elbow extension (contralateral SB) 2. ULTT 2 Median, Musculocutaneous, and Axillary Nerves a. Shoulder depression, abduction 10°, ER with elbow at 90° b. Forearm supination, wrist and finger extension, elbow extension (contralateral SB) 3. ULTT 3 Radial Nerve a. Shoulder depression, abduction 20-30°, IR b. Forearm pronation, wrist finger and thumb flexion, elbow extension (contralateral SB) 4. ULTT 4 Ulnar Nerve, C8 and T1 Nerve Roots a. Shoulder depression, abduction 110°, ER b. Forearm pronation, wrist and finger extension, elbow flexion (contralateral SB) What is Thoracic Outlet Syndrome? Compression neuropathy (brachial plexus, subclavian artery and vein) Local findings, peripheral findings, absence, and positive response to scalene block of injection Interscalene triangle, costoclavicular space, subcoracoid space, or sterno costovertebral space What are common impairments associated with TOS? 1. Intermittent brachial plexus and vascular symptoms a. Pain, paresthesia, numbness, weakness, discoloration, swelling 2. Muscle length-strength imbalance a. Shoulder: tight anterior and medial, weak posterior and lateral 3. Faulty postural awareness 4. Poor endurance of postural muscles 5. Poor clavicle and anterior rib mobility 6. Shallow respiratory pattern (upper thoracic breathing) 7. Nerve tension symptoms when brachial plexus is stretched What is the clinical presentation of a compressor or releaser and why? What tests help you identify compressors or releasers? 1. Compressors a. Symptoms when performing overhead activities i. Brachial plexus make a U-shaped turn over clavicle ii. Intermittent: blood supply returns when arm is lowered b. Occupation usually involves overhead work c. ROOs Test / EAST Test 2. Releasers a. Symptoms primarily at night i. Traction effect, venous pooling ii. Gradually releases when go to bed, takes 6 hours for symptoms b. Occupation involves more sedentary-type of work c. Large, heavy arms and poor posture d. Cyriax Release Test Identify all the impairment-based classifications of thoracic spine disorders based on the description of PIP’s and Non-PIP’s. Be able to identify best treatment interventions for thoracic spine impairments (include T4). 1. Mobility Deficits a. Thoracic Mobility Deficits i. Examination Findings: 1. Restricted ROM 2. Restricted PIVM in T-spine and ribs 3. No UE radicular symptoms 4. Muscle imbalances 5. Postural deviations ii. Proposed Interventions: 1. Mobility exercises 2. T-spine and rib mobilization/manipulation 3. Self-mobilization techniques 4. Postural exercises b. Thoracic Mobility Deficits with UE Referred Pain i. Examination Findings: 1. Restricted ROM 2. Restricted PIVM in T-spine and ribs 3. UE symptoms 4. Positive ULTT  5. Muscle imbalances 6. Postural deviations ii. Proposed Interventions: 1. Mobility exercises 2. T-spine and rib mobilization/manipulation 3. ULTT mobilization exercises 4. Self-mobilization techniques 5. Postural exercises c. T4 Syndrome i. Classified under thoracic hypomobility with UE referred pain ii. Examination Findings: 1. UE paresthesia 2. Upper T-spine pain with or without symptoms into neck or head 3. Limited mobility (peak stiffness T3-5) 4. Positive ULTT 1 and slump test 5. Headache, hyperhydrosis, night symptoms 6. Tenderness with palpation T2-7 d. Thoracic Mobility Deficits with Neck Pain i. Examination Findings: 1. T-spine mobility deficits with AROM 2. Mobility deficits with PIVM of upper T-spine and ribs 3. No symptoms distal to shoulder 4. Neck pain with associated cervical spine impairments 5. Muscle imbalances 6. Postural deviations ii. Proposed Interventions: 1. T-spine and rib mobilization/manipulation 2. Mobility exercises 3. Self-mobilization techniques 4. Postural exercises 5. Treatment of cervical impairments a. (refer to above for CPR for T-spine manipulation for Tx of neck pain) e. Mobility Deficits with Shoulder Impairments i. Examination Findings: 1. Stiff T-spine with shoulder AROM 2. Restricted PIVM in upper T-spine and ribs 3. Shoulder impingement / RC signs 4. Muscle imbalances 5. Postural deviations ii. Proposed Interventions: 1. Mobility exercises 2. T-spine and rib mobilization/manipulation 3. Self-mobilization techniques 4. Postural exercises 5. RC exercises (scapular stabilization) f. Thoracic Mobility Deficits with LBP i. Examination Findings: 1. Stiff T-spine with thoracolumbar AROM 2. Restricted PIVM testing  3. Lumbar impingements 4. Muscle imbalances 5. Postural deviations ii. Proposed Interventions: 1. Mobility exercises 2. T-spine and rib mobilization/manipulation 3. Lumbar rehabilitation program 4. Self-mobilization techniques 5. Postural exercises 2. Movement Coordination Impairments (instability) a. Thoracic Clinical Instability i. Examination Findings: 1. History of trauma or T-spine surgery 2. Provocation of symptoms with sustained WB posture 3. Relief of symptoms with non WB postures 4. Hypermobility with loose end-feel with PIVM testing 5. Poor strength (2/5) or thoracic muscles 6. Shaking / poor controlled motion with thoracic AROM ii. Proposed Interventions: 1. Postural education 2. Thoracic stabilization exercises 3. Parascapular exercises 4. Mobilization / manipulation above and below hypermobile regions 5. Ergonomic correction 3. Thoracic Outlet 4. Osteoporosis FB and BB arthrokinematics, T spine kinematics and mobilization to facilitate 1. Forward Bend (30-40°) a. Opening of facets b. PA transverse process of same vertebrae 2. Backward Bend (20-25°) a. Closing of facets b. Central PA on spinous process 3. Rotation (30°) and Lateral Flexion (25°) a. Opening of contralateral facet i. PA transverse process of adjacent vertebrae or transverse vertebral pressure (TVP) Ankylosing Spondylitis. Progressive inflammatory disease that affects T-spine and rib joints Primary PE = limited chest expansion Insidious onset in late adolescence or early adulthood c/c = AM backache, pain and stiffness more than 30 minutes Pain better with exercise but NOT with rest, pain second half of night, alternating butt pain Visceral referral thoracic spine pain masqueraders. Know them. 1. Liver and Gallbladder → right ribs and below right inferior angle of scapula 2. Heart → between shoulder blades, left chest and down inner left arm 3. Stomach → between ribs and middle of back  4. Pancreas → upper left stomach and mid left back Compression fracture presentation, MOI. 1. Traumatic Compression Fracture a. Any age, axial loading on a flexed spine (frequently T12, L1-2) b. Acute immediate pain, all movements painful, often 10 or more discs involved, seldom neurological lesion occur 2. Spontaneous Compression Fracture a. 60+, female, osteoporosis, 1 or more vertebrae collapse gradually or suddenly b. Acute = severe pain, gradual = chronic pain c. Findings: i. Kyphosis, C and L pain, pain with flexion and extension ii. Limited and painful rotation d. Diagnostic Cluster to Screen for Osteoporotic Vertebral Compression Fracture i. Age > 52 ii. Absence of LE pain iii. BMI < 22 iv. Not regular exerciser v. Female vi. (CBL: 4/5 = moderate value to rule in an osteoporotic VBF Basic Rib Biomechanics: 1. Pump: T1-6 2. Bucket: T7-10 3. Caliper: T11-12 SHOULDER Review the anatomy of the shoulder with particular attention to the glenoid labrum Narrow, wedge-shaped structure surrounding glenoid Thicker inferiorly, thinner superiorly Superior and anterosuperior less vascular Increases concavity of glenoid fossa by 50% SAPS. Intrinsic/Extrinsic Factors for Primary SAPS. 1. Intrinsic Factors a. CAC ligament hypertrophy, inflamed bursa/tendon 2. Extrinsic Factors a. SA bone spur, type 3 acromion, resting posture, poor scapular stabilization, muscle force couple imbalance, posterior capsular hypomobility Impairments associated with SAPS presentations 1. Limited ER MMT 2. Limited GH passive mobility (posterior capsular tightness) and/or GIRD 3. Shortened pec minor 4. Scapular muscle weakness and/or motor control impairment SAPS cluster CPR. 1. Neer Sign  2. Hawkins-Kennedy 3. Jobe Empty Can 4. Painful Arc 5. Pain / Weakness with resisted ER What tests for SIS are used to evaluate if symptoms result from impaired scapular control or weakness of SA/LT? 1. Scapular Assistance Test (SAT) 2. Scapular Retraction Test How do you address Primary and Secondary SAPS impairments? 1. Primary = joint and ST mobilization, scapular and RC strengthening 2. Secondary = scapular and RC strengthening Risk factors for RC pathology Smoking, hypercholesterolemia, family hx of RCTs Tear Worsening: 60+ years, smoker, high activity level, limited PT outcome expectations RCT: What does that look like? Painful ROM arc Loss of AROM flexion and abduction ADL’s difficult (weakness, inability to use UE overhead) Disrupted sleep (pain) Symptoms do not always sync with clinical radiological exam evidence Classification of RCT? 1. Location a. Superior Tear = supraspinatus b. Superior-Posterior Tear = supraspinatus or infraspinatus c. Superior-Anterior Tear = supraspinatus, infraspinatus, subscapularis, long-head of biceps 2. Tendons Involved 3. Size of Tear a. Massive = > 5cm OR involve subscap + supra and infraspinatus Surgical management of RCT: who is appropriate for early surgery vs conservative management? 1. Early Surgical Candidates a. Under 40 years old with full thickness tears b. > 1-1.5 cm acute tears 2. Conservative Management a. 70+ years with chronic tears b. Particle thickness tears c. < 1 cm full thickness tears Post-op RCR Goals/timeline. 1. 0-6 weeks a. Wound healing, protect repair, gradual ↑ PROM, ↓ pain/inflammation, modify ADL’s b. Sling use 4-6 weeks post-op c. End phase 1 goal = 120° passive flexion and 30° ER d. Massive tears, extend to subscap: ER limited 30° PROM for 6 weeks  2. 6-12 weeks a. Obtain full PROM, begin AROM, isometrics, begin CCK 3. 12-20 weeks a. Gradual strength and endurance, neuromuscular control, gradual functional activity restoration 4. 20+ weeks a. Non-painful AROM, maximize strength, endurance, power; advance functional activity RCR post-op complications. 1. Patient noncompliance weeks 0-6 increases rate of retear or non-healing by 152x 2. Complication rate after arthroscopic ranges 5-10% 3. Most common complication = stiffness 4. Infection 5. Retear Force couples at the shoulder? 1. Subscapularis and Infraspinatus a. Provide dynamic GH stability by creating compressive joint reaction force b. Resists superior pull of deltoid during abduction, creates fulcrum for HH rotation on glenoid 2. Deltoid and Rotator Cuff a. Deltoid and Pecs → destabilize GHJ in anterior/superior direction b. RC ⇒ compressive force offsets deltoid and pec destabilization effect Labral Pathology presentation. Fraying degenerative changes or tear + sulcus sign → increased inferior humeral translation May describe single traumatic event Often complain of pain during sports (popping, clicking, “deep anterior pain”, pain with specific mvms) Inability to perform sport at high level SLAP Lesion MOI. 1. Episodes of subluxation and dislocation 2. FOOSH 3. Traction on arm from lifting heavy object 4. Traumatic episode 5. Repetitive microtrauma 6. Degenerative changes Difference between Bankart, Reverse Bankart, Hill Sachs lesions. Bankart = labral tear 3-6 o’clock, anterior instability ○ MOI = arm in ER position during fall or excessive force applied to arm while ER and elevated Reverse Bankart = labral tear 6-11 o’clock, posterior instability ○ MOI = bench press, stiff arm block, MVA Hill Sachs Lesion = anterior rim of glenoid impacts posterolateral HH during dislocation causing a divot Post-op Bankart Repair general protocol guidelines. No overhead motion for 4 weeks Sling for 2-3 weeks, sleep in for 4 weeks No excessive ER, extension or elevation Protect surgical repair Review MDI pathology/ classification system, associated factors, and tests for same 1. Acute Instability a. Severe pain, inability to use shoulder in functional activities b. Transient neurovascular symptoms c. Moderate to severe apprehension of dislocation d. Temporary disability in ADLs 2. Chronic Instability a. Recurrent shoulder pain with activity b. Recurrent subluxations with certain movements, positions and/or activities c. Decreased tolerance to certain activities d. Progressive episodes of reinjury with increased pain and disability Review MDI optimal strengthening exercise recommendations (first target scapular stabilizers, traps, SA!). 1. Joint Proprioception 2. PNF 3. Perturbation Training 4. Wall wash exercises 5. Hand walking on treadmill 6. Progress push-ups 7. Bodyblade 8. Plyometric training Review which exercises target specific shoulder muscles. 1. Supraspinatus → full can (standing, prone) 2. Infraspinatus and Teres Minor a. Sidelying ER, prone ER at 90° abd, ER at 30° 3. Subscapularis a. IR 30 or 90°, IR diagonal extension 4. Serratus Anterior a. Push up +, dynamic hug, serratus punch at 120° 5. Lower Trap a. Prone full can, prone ER at 90° abd, prone horizontal abd at 90°, abd with ER, bilateral ER 6. Middle Trap a. Prone row, prone horizontal abd at 90°, abduction with ER 7. Upper Trapezius a. Shrug, prone row, prone horizontal abd at 90, abduction with ER 8. Rhomboids and Levator Scapulae a. Prone row, prone horizontal abd at 90, abduction with ER, prone extension with ER Review Clavicle Fractures (most common location), non-surgical treatment management. 1. Group I: Middle Third a. Most common (80% of clavicle fractures) 2. Group II: Lateral Third a. Type 1 - nondisplaced 3. Group III: Medial Third (close to sternum) a. Least common, ~5% Non-Surgical Treatment  Sling, brace, usually 3-4 weeks Review all special tests for the shoulder (lab and lecture), know what structure or pathology the test is assessing, and know how to interpret test results. Primary SAPS 1. Empty Can → supraspinatus 2. Hawkins → supraspinatus 3. Neer → supraspinatus or biceps 4. Painful Arc → 60-120° 5. Yocum’s Secondary SAPS 1. Apprehension → anterior instability 2. Relocation → anterior instability 3. Anterior Release → anterior instability 4. Load / Shift → anterior, posterior, inferior instability 5. Hyperabduction → inferior instability 6. Sulcus Sign → inferior instability (superior labral tear) 7. Posterior Instability Test Labral Pathology 1. Clunk Test 2. Grind Test (compression-rotation test) 3. Biceps Tension Test (resisted shoulder flexion) 4. O’Brien (active compression test) 5. Biceps Load Test Full Thickness RCT 1. Drop Arm → supraspinatus and infraspinatus 2. ERLS → supraspinatus and infraspinatus 3. IRLS → subscapularis RC Muscles 1. Isometric ER → infraspinatus and teres minor 2. Hornblower’s Sign → teres minor 3. Bear Hug → subscapularis 4. Belly Press → subscapularis RCT Subscapularis Pathology 1. Positive Bear Hug 2. Positive Belly Press 3. Weak IR (MMT, lift off test) Adhesive Capsulitis: Know risk factors for adhesive capsulitis and CPG Guidelines for treatment. 1. Risk Factors a. Diabetes, female, elevated blood glucose levels, hypothyroidism, age 40-65, previously experienced AV in other arm 2. CPG Guidelines a. Highly Irritable i. Pain-free arcs of ROM, 1-5 second stretches (PROM, AROM) ii. Manual therapy iii. Activity modification iv. Modalities for short term pain relief (heat, ice, stim) v. Intraarticular steroid injection  b. Moderately Irritable i. 5-15 second stretches respecting pain (PROM, AROM, AAROM) ii. Manual therapy (higher grade posterior glide) iii. Activity modification iv. Modalities c. Low Irritability i. EROM stretch with OP, TERT TSA versus reverse TSA post-op protocol guidelines. 1. TSA = sling use 4 weeks, followed by 4 weeks progressive AA and AROM, then strengthening a. delayed ROM (4-weeks post-op) and initiating only 30° ER ROM 2. Reverse TSA = 6 weeks post-op immobilization ELBOW What is the capsular pattern of the elbow? Flexion > Extension Differential diagnosis: serious conditions and MSK masqueraders presenting as elbow pain 1. Serious Conditions with elbow pain referral presentation: a. Acute MI b. Pancoast Tumor c. Esophageal Motor Disease 2. Masqueraders with acute onset elbow pain/edema, ROM loss a. Gout and Pseudogout b. Septic Arthritis c. Cellulitis d. Cancer e. Abscessed Wound f. Haemarthrosis Tendon Pathology Spectrum 1. Tendinopathy a. Non-rupture injury of the tendon or peritendon aggravated by mechanical loading b. Bicipital = repetitive elbow hyperextension with forearm pronation 2. Tendinitis a. Acute condition with cell mediated inflammatory response 3. Tendinosis a. Chronic degenerative tendon pathology, characterized by an abundance of fibroblasts, vascular hyperplasia, and unstructured collagen Review the four primary functions of the elbow during pitching. 1. Wrist Flexor-Pronator Group and other muscles help UCL generate varus torque on medial side of elbow during arm cocking 2. Increase in triceps activity, decrease in biceps activity, and centrifugal force due to rotation of the shoulders generated a large elbow extension angular velocity needed to help accelerated the ball 3. A large eccentric elbow flexion torque was needed to decelerate the elbow before full extension could be reached  4. Contraction of all muscles tested after ball release helped the elbow ligaments apply a large compression force to prevent distraction Review throwing injuries with particular attention to medial tension overload and all the structures it negatively impacts. 1. Medial Tension Overload - muscle, capsule/ligament, bone a. Medial Epicondyle Apophysis (little league elbow) b. Medial Epicondyle Avulsion Fracture c. UCL Strain/Rupture 2. Lateral Compression Overload 3. Extensor Overload a. Mainly triceps, conservative treatment stretch triceps Contributors to Valgus overload presentations? 1. Repetitive overuse 2. Weak physeal cartilage growth centers 3. Rapid long bone growth muscle length catch-up 4. Underlying soft tissue laxity 5. Movement dysfunction Recognize Little League Elbow presentation 1. MOI = traction overuse injury at medial elbow 2. Demographics = 8-14 year old throwing athletes or tennis players 3. Symptoms = pain with medial epicondyle palpation and valgus stress test at the elbow 4. Progression = medial epicondyle avulsion fracture Know intimately the signs and symptoms of posterior (radial n) and anterior interosseous nerve syndromes. 1. Radial Nerve: Posterior Interosseous Nerve Syndrome a. Symptoms = pain 5 cm distal to lateral epicondyle, aching posterior forearm, weakness of finger extensors b. Clinical Signs = impairment of forearm muscles, functional wrist drop or wrist extension with radial deviation (difficulty or unable to stabilize wrist for proper hand function), no sensory involvement c. Comparable Sign = resisted supination with elbow @ 0° (provoke symptoms) d. Management = immobilization 4-6 weeks, wear splint AROM, 8-12 weeks surgical decompression 2. Anterior Interosseous Nerve Syndrome a. Symptoms = weakness of pinch, pain usually not associated with this b. Clinical Signs = weakness of FPL and FDP of index and middle finger, pinch deformity, no sensory loss c. Management = 4-6 weeks splinting, gradual removal AROM, 8-12 weeks surgical intervention LET: Review Elbow Tendinopathy 2022 CPG update. Pay attention to modifiable and non-modifiable risk factors, therapeutic exercises & interventions recommended for LET. Four locations for pain (cyriax) 1. Tenoperiosteal junction of ECRB at lateral epicondyle 2. ECRL attachment 3. Joint line  4. Musculotendinous junction Tests ○ Cozen’s, Mill’s, 3rd digit resisted extension Risk Factors ○ Non-Modifiable: Female sex, smoking history, RC injury, De Quervain’s, CTS, Oral Corticosteroid Use ○ Modifiable: Low job control, low social support, heavy tool handling, 2+ hours repetitive wrist/elbow extension daily, repetitive forearm twisting/rotating screwing movements Interventions ○ Level B Isometric, concentric and/or eccentric resisted exercise Multimodal resisted wrist extension exercise WITH manual therapy Taping Dry needling ○ Eccentric exercise recommendations Daily, 3 sets of 15, 30 second rest between sets Each repletion = 4 second completion Sufficient load that patient experiences discomfort performing ○ Level C Instrument assisted soft tissue massage, soft tissue mobilization techniques ○ Not Recommended Deep cross friction massage Ergonomics advice Be able to identify classic presentations of median (carpal tunnel syndrome, pronator syndrome) and ulnar nerve (cubital tunnel syndrome) compressive neuropathies. Compressive Neuropathy - conservative management is recommended if: ○ Symptoms are intermittent ○ 2-point discrimination remains intact ○ Muscle atrophy is absent 1. Median Nerve Injuries a. Injured by: i. Trauma (laceration, fracture, dislocation) ii. Pinched or compressed/traction above elbow, passing through pronator teres, or passing through wrist b. Pronator Syndrome i. Symptoms = anterior elbow pain, tenderness, cramping anterior forearm, paraesthesias that radiates distally to hand, pinch weakness Sensory deficit palmar aspect of 2, 3, and half 4 ii. Clinical Signs = pain with resisted pronation, tenderness pronator teres palpation, weakness of FPL < FDP of thumb, index and middle fingers, and pronator quadratus iii. Non-Op Management Rest immobilize 4-6 weeks then gradual splint removal Pt education to avoid repetitive flex/ext, sup/pron and static pronation Nerve glides Massage to pronator to break up adhesions c. Carpal Tunnel  i. Symptoms = numbness, tingling, pain, clumsiness, weakness, night symptoms increased and remain through day, sometimes radiating/referred pain to the shoulder ii. Clinical Signs = decreased sensation median nerve distribution, atrophy of thenar muscles, + phalens, + tinels, + pinch OCD versus Panner’s at the elbow. 1. OCD: Osteocondritis Dissecans a. Prevalence adolescent baseball pitchers and gymnasts (WB/overhead) b. MOI = repetitive microtrauma = vascular susceptibility c. Early diagnosis key, treatment based upon lesion d. Stages: i. Edema in soft tissue, hyperemic bone ii. Deformation of the epiphysis (growth plate) iii. Necrotic bone replaced with granular tissue e. Capitellum OCD: i. Loss of elbow ROM ii. Lateral elbow tenderness iii. Mechanical Elbow Dysfunction Signs → grinding, clicking, locking f. Conservative Management i. Limit Activity - NWB, discontinue pitching/overhead throwing ii. Possible immobilization iii. ROM to avoid contracture 2. Panner’s Disease a. Epicondyle apophysitis of immature skeletal growth center b. Degenerative changes in capitellum → necrosis followed by regeneration, recalcification bone stages c. Non-traumatic self-limiting d. Prognosis: i. Revascularized blood supply is possible if elbow forces (stress, loading, impact) are minimized ii. Surgery not typically indicated iii. Outcome success = linked to early recognition/detection Etiology of Heterotopic Ossification at the elbow. Trauma, surgery, neural trauma, burns, genetic disorders Review special tests for the elbow 1. Valgus Stress Test → MCL 2. Varus Stress Test → LCL 3. LET: Cozen’s, Mill’s, Maudsley’s 4. MET: Reverse Cozen’s 5. Elbow Nerve Entrapment - rock, paper, scissors, ok a. Rock → flexors, median nerve b. Paper → extensors, posterior interosseous / radial nerve c. Scissors → finger abd/adduction, dorsal and palmar interossei, ulnar nerve d. Ok → median and anterior interosseous nerves 6. Tinel’s Sign → cubital tunnel syndrome and ulnar nerve entrapment 7. Elbow Flexion Test → cubital tunnel 8. Wartenberg Sign → pinky abduction at rest, ulnar nerve palsy  9. Wartenberg Syndrome → radial nerve WRIST/HAND Tuft Fx presentation and tx Fracture of distal phalanx of digit Healing: may occur with a fibrous union instead of ossification Associated Issues: subungual hematoma, pain hypersensitivity Short duration immobilization: DIP in extension 2-3 weeks ○ Followed by gentle AROM DIP joint Be able to differentiate (Colles versus Smith’s, Barton’s fractures) and MOI’s associated with the same. 1. Colles a. MOI = FOOSH (wrist hyperextended, forearm supination) b. Extra-articular, involves angular dorsal displacement of distal radius fracture segment 2. Smith’s a. MOI = FOOSH (wrist flexion, forearm pronated) b. Extra-articular, involves volar displacement of distal radius fracture segment 3. Barton’s a. MOI = wrist subluxation b. Articular, either dorsal or volar fragment Scaphoid fracture prevalence, presentation, complications, healing rates, treatment considerations. 1. Prevalence a. 68% of all carpal fractures b. Young, active population c. 70-80% occur at waist of bone; 10-20% at proximal pole 2. Presentation a. MOI = FOOSH (wrist in hyperextension and radial deviation) b. Diagnosis made on clinical signs i. Anatomical snuff box pain ii. Swelling in region of scaphoid iii. History of injury c. Dull, deep radial wrist pain d. Tenderness to palpation e. Wrist swelling 3. Complications a. Often mistaken for wrist sprain, sometimes unperceivable on x-ray → delayed diagnosis → increases likelihood of non-union and necrosis of proximal fracture fragment 4. Healing Rate a. Healing time ranges 5 - 20+ weeks, depends on level of fracture and direction of fracture line b. Middle Third (waist) = 10-12 weeks c. Proximal 1/3 (poor vascularity) = 12+ weeks d. Distal 1/3 (rare, rich vascularity) = 4-8 weeks 5. Treatment Considerations a. Immobilize in cast or thumb-spica orthosis b. Repeat radiographs @ 2 weeks c. MRI for patients with persistent symptoms and negative plain films d. Nonsurgical Treatment  i. Casting 9-12 weeks ii. Electrical stimulation device iii. PT goals = improve wrist ROM and strength e. Surgical Treatment i. Pin, bone graft, screw f. Post-Op PT i. Control pain and swelling, then strengthen and stabilize muscles around wrist joint ii. Exercises to improve fine motor control and dexterity Symptoms of a nonunion scaphoid fracture? Pain when using wrist See nonunion x-rays Pt cannot remember injury Gradual increase in pain MOI and treatment of Boxer’s fx? Metacarpal neck fracture, pinky knuckle most common MOI = punch with a closed fist (axial compressive load thru ulnar hand side) Tx = usually closed reduction - cast or orthosis immobilization in intrinsic plus position What is Bennett's fracture? Fracture and dislocation Phase 1: immobilization after reduction, pinning or other ORIF is lengthy ○ 8 weeks full time followed by 3 weeks part time Complications of a 1st MC fracture? 1. Malunion 2. Chronic subluxation of MC trapezial joint from malunion 3. Joint instability and/or post-traumatic arthritis 4. Loss of pinch strength from pain and instability may necessitate metacarpophalangeal arthrodesis Be able to recognize by picture specific hand deformities (Mallet, Boutonniere, Swan-Neck, Heberdon’s nodule, ulnar drift). Review all Lab special tests for the wrist /hand. Know which test you would choose if trying to determine specific structural abnormalities (TFCC, scaphoid instability, lunate dislocation, CMC DJD, intrinsic mm tightness vs joint restriction)? 1. TFCC (triangular fibrocartilage complex) a. Linscheid Test b. TFCC Load Test 2. Scaphoid Instability a. Finger Extension or ‘Shuck Test’ b. Watson (scaphoid shift) Test 3. Lunate Dislocation a. Murphy’s Sign b. Lunotriquetral Ballottement (reagan’s) Test 4. CMC DJD a. Grind test 5. Intrinsic Muscle Tightness vs Joint Restriction a. Bunnel-Littler (finchietto-bunnell) Test i. PIP joint flexes fully if intrinsic muscles are tight ii. Does not flex fully if capsule is tight Carpal Fracture therapy management phases (be able to identify Phase I-III and activities included in each phase accurately). 1. Phase 1 a. ROM of all uninvolved joint of UE (minimize stiffness and reduce edema) b. Edema and pain control measures 2. Phase 2 a. Begins when fracture is stable enough for cast to be removed b. Focus on wrist, thumb and composite flexion c. AAROM added when AROM plateaus and is pain free d. Static or dynamic wrist splint between exercise sessions (support and protection) e. Light normal use and therapeutic activities can be introduced to encourage motion 3. Phase 3 a. Begins when fracture fully healed b. Dynamic splinting for wrist flexion or extension or for composite flexion may be necessary c. Grip strengthening initiated immediately and wrist strengthening should follow once a pain-free passive range has surpassed active (PROM > AROM) De Quervain’s: tendons involved and treatment. APL and EPB tendons Tx = splinting, iontophoresis, isolated stretch Intrinsic Plus Position. Prevents intrinsic contracture MCP joints flexed 60-70°, IP joints fully extended, thumb in fist projection, wrist held in extension at 10° less than maximal Know clinical signs/features of RSD/CRPS 1. Pain 2. Skin changes 3. Swelling  4. Movement disorder 5. Spreading (localized → diffuse) a. Continuity type b. Mirror image c. Independent type 6. Bone changes 7. Duration FIBROMYALGIA What differentiates a tender point from a trigger point? 1. Tender Points a. Occur in muscle, ligament, tendon or periosteal tissue b. Elicit local rather than refer pain to adjacent areas upon sustained stimulation 2. Trigger Points a. Local spot within a firm area of muscle (taut band) that elicits a characteristic pattern of radiating pain, tingling or numbness in response to sustained pressure What are the criteria the ACR (American College of Rheumatology) use to determine the diagnosis of fibromyalgia? 1. Chronic widespread pain ≥ 3 months duration 2. Axial skeletal pain (neck, back or middle chest pain), and pain in 4 body quadrants 3. 11 out of 18 possible tender points a. Occiput, lower lateral neck, trapezius muscle, supraspinatus muscle, second rib, lateral epicondyle, gluteal, greater trochanter, inner knee Known risk factors for fibromyalgia 1. Genetic Factors a. Relative of FM pts at higher risk for FM 2. Environmental Factors a. Physical trauma b. Infections (lyme disease, hepatitis C) c. Psychosocial Stress (work, family, life-changing events, early life adversity, abuse) 3. Gender a. Women diagnosed ~7x more often than men EULAR systematic review and currently updated literature regarding fibromyalgia treatment effectiveness: What do you recommend for your patient (best evidence) 1. Exercise! a. Start slowly b. Initiate low level exercise participation for 5 min a day then increase by 1 min per session every 3-4 days gradually building towards 30-40 min, 3 times/wk c. Consider low-impact exercises, aquatic exercise, gentle mindfulness based exercise (yoga, tai-chi) 2. Lifestyle approach