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157 Cards in this Set
- Front
- Back
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a shallow ball and socket that gives up stability for crazy ROM
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Glenohumeral joint
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SCAPTION
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humerus 90* of aBduction, 30* forward flexion (basically, the scapular plane)
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How many muscles are required in any shoulder movement?
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17 – all of them can go through any shoulder ROM
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Widens and deepens the glenoid fossa.
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GLENOID LABRUM loose at top, tight at bottom
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The only osseous connection of the shoulder to thorax is the?
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STERNOCLAVICULAR JOINT [SCJ]
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DASED
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Deformity, Abrasions, Scars, Edema, Discoloration
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BLT w M
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Bones, Ligaments, Tendons, Muscle
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MALT
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Malpositions, Anomalies, Landmarks, Tenderness
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3 PRIMARY shoulder areas
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GHJ, ACJ, SCJ
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5 secondary shoulder areas
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STA, CT junction, spinal and sternal attachments of upper 3 ribs *STA is ScapuloThoracic Articulation
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common viscera-somatic referral patterns to shoulder
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Heart/Lungs/Liver/Gallbladder
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POMP of shoulder would assess
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Flexion, Extension, Adduction (across body), Abduction, Internal and external rotation w/ arm at side then w/ arm at 90* aBd.
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4 evaluative directions for shoulder
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Protraction and Retraction both w/ GHJ flexed to 90*, Elevation and Depression (passive!)
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In any given ROM, always note (2)
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crepitus or pain
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Name 7 basic shoulder tests (a SAD CAW Lies)
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Supraspinatus Stress/Press test, Apley's scratch test, Dugas' test, Codman's drop, Apprehension sign, Wright's test, LIE test
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What is the sentence you can remember for 7 basic shoulder tests?
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a SAD CAW Lies.
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Lie test
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Ask can your patient lie on their shoulder? Pain during such may indicate arthritis, bursitis, tendonitis, or sprained ligaments of ACJ or SCJ.
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Questions to ask yourself:
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Will I...help? Make it worse? Leave it alone? Evaluate progress how? (outcomes assessment)
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Where does subscapularis attach, according to the notes
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lesser tubercle
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Facets on which each rotator attaches
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Supraspinatus = superior, Infraspinatus = middle, Teres minor = inferior facet, Subscapularis = lesser tubercle
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D/dx for 6 week shoulder pain sharp over deltoid onset after weekend activities at beach
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Sprain, capsular tear, subacromial bursitis, labrum (Bankart's) tear or SLAP lesion, bicipital tendinitis, supraspinatus impinge, biceps, ROTATOR CUFF
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Apley's scratch test
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over top: combined lateral/external rotation and aBduction. Under: combined medial/internal rotation and aDDuction
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Supraspinatus press test/Stress test
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done first w/ thumb up, then with thumb down. Full can supraspinatus test. Empty can if negative, then points to supraspinatus impingement.
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Codman's Drop Arm test
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If patient can hold arm up, it's negative for suprasp. Injury. **Have pt slowly lower arm down to side. Painful arc may result. If yes, (+)
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NEER's impingement test
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vs. impingement sign? Firmly stabilize scapula over acromion, raise arm into full flexion while maintaining internal rotation.
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why does Neer's sign test the supraspinatus?
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The full flexion w/ internal rotation grinds greater tubercle into acromion, impinging esp. the supraspinatus tendon.
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Hawkins-Kennedy test
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Pt in James Bourne position killing man w/ book, elbow up. Support their elbow while cranking down on their wrist. [+] supraspinatus impingement
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Gerber's lift off test
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As though pt. Trying to reach opposite scap, they flat hand then lift. You push back against hand. SUBSCAPULARIS weakness.
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What can you do if the patient fails Gerber's Lift off for SUBSCAP mm?
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Pinch and Stretch – pincer subscap while pt slowly lifts arm over head. Three passes.
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4 second ischemic compression rule
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At least 4 seconds needed for pt to perceive and respond to MFTP work. Give at least 6-8 second hold on trigger points.
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Bimanual Thumb Thenar Grasp/Proximal Humerus w/ Knee Extension supine
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Mobilization w/ distraction (supine) for GHJ circular motion and figure-8 motion. Pt humerus b/w your knees. Also internal/external rot and A-P glide.
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Bimanual Thumb Thenar Grasp/ Proximal Humerus w/ knee extension prone
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Better for taller table. Pt humerus b/w your knees. Circular and figure-8, P-A glide.
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Codman's PENDULUM arm EXERCISES
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Back & forth, Side to side, Internal circles, External circles, weights added
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Supine GHJ RHYTHMIC Stabilization (dynamic GHJ loading)
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Pt supine, arm up at 90* hold 30 sec. Then circles w/in 10* limit. “Knock arm out of balance,' then with 1lb. Weight
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BATON (or wand) excercises from active care class
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standing preferred. Supine best after surgery/early rehab. Pt uses pole to intro cardinal ROM's
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General MOTION rotator cuff exercises
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1-5lb. Standing 4 motions: forward flexion (90*), Scaption, all the way to 90* sides aBduction, down the back into Extension maximal.
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Number of reps and sets for general MOTION rotator cuff exercises
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3 sets/ 5-12 reps
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Isometric exercises for INTERNAL rotators
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Estab PAIN FREE arc of motion. Pt stands at wall/door w/ bent elbow. Pushes 10-20% max effort for 30 sec. Go 10* past tension.
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isometric exercises for EXTERNAL rotators
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Estab PAIN FREE arc of motion. Pt stands at wall/door w/ bent elbow. Pushes 10-20% max effort for 30 sec. Go 10* past tension.
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Side posture GH exercises Level I
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LYING FLYES: (abduction) straight arm w/ 1lb while on side on table. LYING 'L' FLYES same but arm 90* for external rotation.
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Level II side posture exercises for GH
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Lying flyes for abduction,Standing (or seated) “L” Flyes for external rotation, Lying “L” flyes for external rotation. All 2 or 3 sets/ 10-12 reps each arm
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What should you find out before you recommend stretching of GHJ?
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if patient is HYPERmobile due to mm or capsular injury. Monitor closely for instability or worsening sx esp if home exercises.
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Pec Stretch I
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corner or doorway stretch, humeri parallel to floor and elbows bent (90*). Hold one rep 5-10 seconds
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Pec Stretch II
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corner or doorway stretch. Arms angled UP and bent elbows. Increases stretch. Hold one rep 5-10 seconds.
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Pole pec stretch
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arms aB 30-45* and extended to just behind back, 30*. Holding handrail, steps forward, stretches pecs. 3 reps.
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Front deltoid and biceps stretch
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arms aB 30-45* and extended behind back to tolerance. Pt holds support or doc can hold arms and pt. Steps forward. One rep, 5-10 sec
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External rotator stretch
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No clue. For internal stretch of GHJ. Fist on iliac crest w/ GHJ @ ~45* aB. With opposite hand, pt holds onto elbow and pulls forward. ???
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Which test looks like a good way to dislocate pt shoulder, esp. if you help?
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External rotator stretch w/ assistance. Doc support hand on their shoulder, pulls their bent elbow/fist on hip towards doc. Pt sues.
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Most frequently injured rotator cuff mm?
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Supraspinatus = superior, Infraspinatus = middle, Teres minor = inferior facet, Subscapularis = lesser tubercle
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Most clinically relevant rotator cuff mm?
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Subscapularis
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W/ most shoulder conditions, the first GHJ motion lost is?
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External rotation and aBduction
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Classic presentation of frozen shoulder arm aBduction?
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Pt elevates entire shoulder to facilitate arm aBduction = frozen
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APPREHENSION test (shoulder 90*, elbow 90*)
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Trepidation on pt part indicates hx of instability or dislocation (do NOT do if suspect dislocation). Arm 90*, doc slow external rotate
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Scapulohumeral rhythm:
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First 30* arm abduction occurs GHJ. Then scapulothoracic articulation at 2:1 ratio w/ GHJ abducting while STA rotates superiorly.
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Trigger points in lower part of levator scap result in ______ cervical malposition
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UPPER
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Trigger points in upper levator scap result in lower cervical malpositions. WHY?
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the twist of levator scap.
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Yergason's test
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Doc palp BICIPTAL GROOVE. Pt flexes affected elbow. Pt resists effort to extend arm and attempt to supinate. Pain over intertubercular sulcus (+)
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Abbot-Saunder's test
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Doc palp BICIPITAL GROOVE. Arm out in aB w/ hand prone. Doc guides wrist into supination at 120* then lowers arm. Pop/click – bicipital tendinitis.
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When lowering arm in Abbot Saunders test, pay attention to?
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painful arc on descent (could be bicipital tendinitis or torn bicipital ligament)
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SPEEEEEED test
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Doc palp BICIPITAL GROOVE. Arm flexed to 90* (bent elbow) doc holds wrist and provides resistance while pt tries to raise and supinate. Pop/click – bicipital tendinitis.
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SCARF test
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passive horizontal adduction/crossover test: VERY sensitive for ACJ sprain. Doc pulls pt arm across and over opposite shoulder. (+) pain ACJ sprain
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O'BRIEN test
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100% for LABRAL TEAR or ACJ SPRAIN: Pt thumbs down approx sternum/breast height, doc overpressures. Now thumb up w/ same. Pain on thumbs down but not thumbs up is (+) for ACJ sprain or labral tear.
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If O'Brien's positive on top of shoulder?
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ACJ sprain
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If O'Brien's positive pain deep inside shoulder?
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LABRAL tear (internal derangement of some sort)
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Bimanual Digital Grasp/Scapulothoracic Mobilization (side posture)
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hand in back pocket side posture postion – doc reach thru crooked arm to inf scap border, push S-I on AC joint, figure 8 + circular scap rotations
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Bimanual digital thenar Grasp/Scapula; I-S glide of scapula (prone)
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Thumb-index web contact under inferior angle, outside hand stabilize acromion and lift I-S (Trager move w/ a filet of scapula)
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Interlaced Digital/Proximal Humerus; M-L glide of G/H joint w/ 90* flexion (supine)
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pt on back. Doc kneels, grasps pt humerus at axilla in regular two hand grip, pull/traction GH medial to lateral. Brace pt elbow against your cephalad shoulder
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Interlaced Digital/Proximal Humerus; Superior -Inferior glide of GHJ w/ 90* flexion (supine)
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Different from M-L! Same kneeling move but now pt elbow braced against doc inside shoulder. Distract S-I (head to toe)
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Palmar/Olecranon; Anterior-Posterior (A-P) glide of the glenohumeral joint (supine)
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Slide pt to side of table. Sling/cradle pt shoulder in your outside hand, hold olecranon w/ inside hand. Push olecranon down towards floor/A-P
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Three Point Contact/Proximal Humerus grasp; Maximal External rotation GHJ
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Kneel. Pt arm abducted. Let their post forearm rest on your knee. Sup hand twists externally on upper humerus. Inf hand lifts elbow. Doc elbow pushes down pt wrist.
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Thumb Web/Axilla w/ Knee Extension LAD of GHJ (supine)
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intergenu on forearm (accd to photo). Thumb web in their axilla (yes, you are internally rotating wrist so be careful) LONG AXIS TRACTION arm
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Thumb Web/Axilla w/ Knee Extension ROTATION (internal or external) of GHJ (supine)
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Intergenu on forearm (accd to photo). Regular grip at axilla both hands, twist internal or external rotation. Distract w/ knees.
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Reinforced Palmar/Olecranon; A-P glide of glenohumeral joint
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move you did to K for adhesive capsulitis
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2 was to stretch rhomboids:
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Pt crosses wrists and grasps own hands, extending elbows fully. Pt seated and does a Jimmy Durante (cha cha cha) on knees
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Home shoulder rehab for flexion, aBduction, and extension of shoulder
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PULLEY & WALL WALK (pt walks up wall in flexion/abduction of fingers. Use height marker. Careful of painful arc)
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Be able to perform neuro eval C5-T1 w/ peripheral nerve sensory patches, too.
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Shoulder III is about TOS
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ALLEN test
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Humerus parallel to floor while pumping fist. Occlude both arteries and let either radial or ulnar go; watch reperfusion time. NOT a TOS test but done before doing the TOS tests.
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WRIGHT test
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Perform on unaffected arm first for baseline. Palpate distal radial pulse; raise pt arm slowly to 180* max. Occlusion or pain is positive TOS.
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EDEN test / COSTOCLAVICULAR test
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In Evans, p261, doc stands behind seated pt. Palps both radial pulses same time. Pt abducts and active shoulders back and down. Can flex cervical or hold breath. Drop in patency or reproduced pain = TOS
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Difference between Eden's and Military/Soldier's positon?
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Eden's is active; Soldier's is passive.
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SOLDIER'S/MILITARY position
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While palpating the radial pulse of seated pt, doc passively brings pt shoulder down and back. Can ask extend neck. Repro pain or diminished pulse = TOS
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ADSON'S test
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Adson's for Anterior scalene: palp radial pulse, pt extends neck and looks back at doctor/pulse/same side. Repro pain/down pulse = NVB compression by scalene causing TOS
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Adson's REVERSE
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same as Adson's but for MIDDLE scalene; pt extends neck and looks away from doc/pulse/arm being tested. NVB compress by middle scalene causing TOS
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SCARF test is VERY specific for?
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ACJ sprain
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O'BRIEN test is very sensitive and very specific for what two injuries?
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ACJ and LABRAL tear of GH
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A posture to teach patients with TOS
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TOP GUN posture against wall
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Inside Web/Proximal Humerus; Outside web/distal humerus; M-L glide of GHJ w/ arm at side
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(supine) for TOS: Get low; your inside hand in axilla, outside hand on outer supracondylar area. Crank in opposite directions then impulse M-L. Really a distraction of GHJ.
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Hypothenar PROXIMAL clavicle; S-I glide of SCJ (supine)
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TOS: Kneel. Pt arm abducted, resting on your knee. Stabilize and distract arm while HYPOthenar to medial CLAVICLE @ STERNOCLAVICULAR joint S-I. Patient covers.
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Hypothenar DISTAL clavicle; S-I glide of AC joint (supine)
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TOS: Kneel. Pt arm abducted, resting on your knee. Stabilize and distract arm while HYPOthenar to lateral CLAVICLE @ ACROMIOCLAVICULAR joint S-I. Patient covers.
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Reinforced Thenar/Proximal Clavicle; I-S glide of SCJ (seated)
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TOS seated: Adjusting hand under their arm around to clavicle at SCJ joint. Support hand over their other shoulder onto your hand. Lean them back into your chest. I-S
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Web/Distal Clavicle; S-I glide of SCJ (seated)
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TOS: pt seated. Doc knee up on table, pt arm draped over. Traction arm while calcaneal hand on SCJ would impulse S-I. Like stuffing a trashcan that's too full.
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Web/Distal Clavicle; S-I glide of ACJ (seated)
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TOS: pt seated. Doc knee up on table, pt arm draped over. Traction arm while calcaneal hand on ACJ would impulse S-I. Like stuffing a sleeping bag back into the sack.
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Distal Proximal/Clavicle, Thenar/Manubrium; Distraction (LAD) of SCJ (seated)
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TOS: seated. Reach under their arm to clavicle and over their arm to sternum. Thenar contacts. Distract (separate them at the SCJ joint) Vector: M-L LAD
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Rehab home exercises TOS
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Fingertip Rhomboid strengthening exercise (back to wall, fingers touch, retract scaps); EGOSCUE METHOD; arms out supine, pinch scaps together, small internal then external circles, then repeat prone/thumbs down, keeping scaps retracted seriously
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Egoscue method addresses?
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TOS via rhomboid strengthening. Circles in air at sides first supine back, forward, then prone back and forward.
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TOS stretches
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from previous lab: rhomboid stretches w/ clasped hands and also one w/ crossed hands on knees (legs passively stretch as abducted.)
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Structures that can cause lateral elbow pain
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Radial head articulation, LCL, aponeurosis tear, lateral epicondylitis, radial head fx or subluxation, neural entrapments, etc.
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Cubital tunnel is also called the
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proximal ulnar tunnel and ulnar groove
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Where is the median nerve regarding the elbow?
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Cubital fossa
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Peripheral nerves to examine w/ elbow
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Musculocutaneous and Radial (Muscle cars; kiss my guns! Radials brake hard if you try to run.)
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Is ALLEN's test a TOS test?
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NO but should be performed before any exam procedure requiring pulse strength/patency eval.
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96-98% of TOS is caused by
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compression
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With most elbow conditions, palpation that causes pain is likely due to
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the structure being palpated
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Elbow injuries can refer to the
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shoulder and wrist
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4 cardinal elbow ROM
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Flexion, Extension, Pronation, Supination
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cubital fossa is on ______ surface, while cubital ____ is posterior
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fossa anterior, tunnel posterior and medial
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Nerve most sensitive to heavy metal
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RADIAL
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MILL's test
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Lateral epicondylitis test: keep pt wrist flexed the entire time, overpressure to max stretch extensor. + lateral elbow pain
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COZEN's test
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Lateral epicondylitis: biker chicks wrist extension, forearm prone. Inability to resist doc overpressure. + lateral elbow pain
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GOLFER's test
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Medial epicondylitis: can do version I wrist flexion or version II arm fully extended, wrist fully extended. Overpress wrist. Pain or weakness.
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Elbow dynamomter test
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3 times
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KAPLAN'S test
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Elbow: dynamometer. Max effort and pain. If CHOPAT strap helps, the extensor injury positive and indicates lateral epicondylitis.
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HANDSHAKE test
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PROTNATOR TERES SYNDROME of elbow: just like shaking hands. Doc also presses p.t. While attempting to supinate wrist and straighten pts arm. Pronator teres strain or PTS (syndrome) of MEDIAN nerve entrapment. AIN branch. Mimics CTS.
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What muscle syndrome of elbow often mimics CTS?
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PTS Pronator Teres Syndrome
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Valgus stress test for elbow
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MCL stress. Do closed packed (full extension) then open packed (30*). Do not grip over radial head. If instability present, STOP
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Varus stress test for elbow
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LCL stress. Do closed then open packed positions. Varus stress can cause pain at a dysfunctional or injured radial head.
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Varus and Valgus stress test positives indicate
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MCL or LCL sPrain (ligaments)
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Soft tissue elbow stretches
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Wrist extensor stretch and Wrist flexor stretch (on desk or table). Hold 10-12 sec.
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What are Dr. Homack's two favorite thing?
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Kittens and outcomes assessments.
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When performing cross friction massage on extensor group, do not exceed patient's pain level of
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5 or 6 out of 10. Spend 30-60 sec. Per area. After massage, have pt perform stretches. Cryotherapy okay
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Web/Distal Humerus, forearm Grasp Pull; LAD (radiohumeral and ulnohumeral)
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seated or standing. Doc grasp above carpals at styloids. WEB contact to humerus. Distract. Impulse LAD
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Thumb/Radius push/ distal Forearm Grasp; P-A glide in pronation of the radial head
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Looks just like Mill's test. Impulse would be be P-A. Remember to maintain wrist flexion
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Thumb-Indes web/Proximal ULNA elbow in FLEXION; a-P glide of the ulna
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Mid-Hypothenar/knife-edge contact. Pt elbow resting on doc knee up on table. Doc knife edge in cubital fossa, fulcrum wrist. Impulse proximal ULNA A-P
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HAMMER twist for elbow
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Mallet. Have pt attempt full 180 degrees. Can isolate to elbow by bending elbow to 90*. Repeatedly pronates and supinates forearm like Dynaflex.
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3 muscles of snuff box
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AEE Longus Brevis Longus: Abductor pollicis longus, Extensor pollicis brevis, Extensor pollicis longus APL/EPB/EPL
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Where should you Tinel tap for CTS?
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past the crease of the wrist
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WRINGING TEST can demonstrate
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pain in carpal tunnel or subluxation/dislocation of carpals due to a fracture
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Where can the median nerve be entrapped? ******
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under prox head of pronator teres, cubital fossa, and in carpal tunnel
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Medial borders of carpal tunnel
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pisiform and hook of hamate (borders of tunnel of Guyon and medial border of carpal tunnel)
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Lateral borders of the carpal tunnel
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tubercles of scaphoid (proximal) and trapezium (distal)
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TINEL tap at carpal tunnel and tunnel of Guyon
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Tap ONCE. Can also perform at ulnar groove/cubital tunnel. Really can be done wherever a peripheral nerve passes.
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PHALEN's test
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fail! Hands down. Max flex wrists and hold 30 sec. Diminishes size of carpal tunnel. + pain or paresthesia median n. CTS.
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PRAYER sign
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Pray you pass this exam. Hold 30 sec to stretch median n. in carpal tunnel. + pain or paresthesia median n. =CTS
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WRINGING test
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Pt wrings out a rolled up towel. Pain thru Median n.=CTS. False positives for fx, TFCC sprain, arthritis
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FLICK test/sign
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Pt reports waking at night to shake out hand d/t tingling, pain or numbness. Highly correlated to CTS.
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most frequent cumulative trauma disorder
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CTS
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Pulsating tingling at tunnel of Guyon
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vascular structure putting pressure on a neurologic structure
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De-innervation of digtal nerves test
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Inability of fingers to wrinkle/prune/shrivel in water. Only evident w/in first few months of injury
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Subluxation of radial head and carpals may cause
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mechanical alteration of carpal tunnel, predisposing patient to CTS
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BRACELET test
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2 parts: first both hands around distal ulna and radius. Squeeze. Sharp pain indicates arthritic djd, esp. RA. 2Nd part pt makes FIST, localizes pain.
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If squeezing wrist during bracelet test relieves pain?
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Diastatis of radioulnar joint. Speeder board and LAD
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FINGER FLEXION test
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positive: incomplete index finger flexion, thumb spared = FLEXOR DIGITORUM MFTP. Positive: incomplete finger flexors of digits 2-4, SCALENE MFTP's
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TFCC eval at ulnomeniscotriquetral structures
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Triangular Fibrocartilage Complex: Thumb to pisiform, crooked index to ulnar styloid. Squeeze/pinch. Relief is positive for TFCC injury
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TFCC ranges of motion evaluation
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Grasp wrist and hand on either side of wrist crease: A-Pshear, P-A shear, Scaphoid shift test w/ doc thumb, Varus & Valgus. = ULNAR COLLATERAL ligament prob
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SUPINATION LIFT test
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TFCC. Face patient like slap hands game. Elbows at 90*. Doc provides resistance and pt tries to push upward. TFCC injury if pain local to ulnar side of wrist.
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What test places the TFCC under load via posterior shear?
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Supination lift test
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Hand grip dynamomter for wrist
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CTS: weakness or pain due to carpal tunnel. And first mm affected in CTS hand ins ABDUCTOR POLLICIS BREVIS, supplied by median n. after passes thru CT. If Median being compressed, the APB cannot provide base for fingers to work against when gripping dynamomter.. Weakness, pain, paresthesia.
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soft tissue problem to d/dx from true CTS?
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PTS Pronator Teres Syndrome
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Soft tissue wrist stretch (new)
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Thenar and hypothenar cross stretch. Interlace fingers and spread their palm, just like you did for 13 years as a massage therapist.
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Transverse carpal ligament stretch is also called
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the carpal tunnel stretch
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Reinforced Hypothenar/Radius; M-L compression of distal radioulnar joint
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Speeder board, distal ulna on drop piece.
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Reinforced Thumbs/Carpal/ A-PO/P-A glide of individual carpals
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any carpal; reinforced thumb. For adjustment, ask pt to lean back slightly. Extend slightly for either P-A or flex for A-P. Impulse STRAIGHT DOWN.
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Bilateral Thenar/Proximal (or distal) Carpal row; A-P/P-A glide or tilt intercarpal joints
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stand outside patient, encircle their wrist w/ a sandwich grip. Doc squeeze, carpals distract. Fingers will flex, extend and separate if done correctly.
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Hand grasp pull w/ forearm stabilization/ LAD intercarpal joints
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Same as elbow LAD but now hand crosses wrist. Traction. Small impulses may be given
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Bimanual Palmar grasp/Hand w/ Axillary Stabilization manipulation for sustained LAD intercarpal joints
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Stand to side of pt, grasp hand in both of yours, brace w/ your humerus against their bicep and traction. Lean back for further traction.
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Thumb Index/Ulnomeniscotriquestral joint A-P glide
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same intention to pinch pisiform to ulnar styloid. Pt stands away in High 5 position. Doc to side.
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Rehab for wrists
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COINS on backs of hands to create floating fingers while typing. Ice bucket -water and ice, pt goes through cardinal wrist motions. Limit 5-10 min.
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