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109 Cards in this Set
- Front
- Back
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Soft tissue injuries causing
Heel Pain Achilles pain Shin splints |
Heel Pain
Plantar fascitis – at plantar aspect of heel, pain with weight bearing. 1st few steps most painful, decreases, then more painful again as WB increases Achilles tendinopathy Tendinosis, tendonitis, tenosynovitis (inflammation of lining, tendon sheath) Shin splint Anterior tibialis– lateral component Posterior tibials – medial component |
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Ankle: Rx soft tissue – maximum protection phase
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Cross-friction massage
Gentle muscle-setting (iso) ROM Avoid activities that exacerbate Support Controlled motion/return to function: Educate Warm-up Stretch Cross-friction massage Jt mobilization Muscle performance: isometric->resisted dynamic OKC/CKC balance invertors/evertors, eccentric load |
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Acute ankle sprain - protection phases
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Protection Phase:
Jt mob-inhibit pain, maintain mobility Teach RICE (PRICE... POLICE. Optimal loading) PWB with crutches Isometrics, towel curls Immobilized in neutral of slight DF and eversion |
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Acute ankle sprain: Controlled motion (phase)
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Controlled Motion:
Protect Cross-friction to ligaments Grade II mobilization Exercise tid (three times a day. vid is twice): nonweight-bearing, towel curl, alphabet (but don't invert!), ankle pumps Strength, endurance, stabilization ** (neuromuscular stuff) Anterior Talofibular is most often damaged |
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Differential diagnosis
Inversion ankle sprain |
Differential diagnosis
Inversion ankle sprain Cuboid articulation with 4- 5th Metatarsal – can be the thing causing pain Swollen and inflamed Palpate joint line Sublux of cuboid May do mobilization or US |
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Syndesmotic Ankle Sprains - “high”
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Ave fibular migration of
2.4 mm inferiorly in WB Deepens ankle mortise Tighten interosseous membrane Bearing 6.4% Increases with DF Aggressive inv/ev (DF will aggravate them) No modalities (too deep to really help) (light ROM in whirlpool could be nice) Neuromuscular Pain free stretches (get them to neutral so you can start weight bearing) |
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Traumatic soft tissue injuries
Grade 3: ankle Brostrom reconstruction: |
Grade 3:
complete tear or rupture of ATF Often CF *subluxation of the proximal tibiofibular joint (complaint of pain distal and lateral to knee joint) Brostrom reconstruction: anatomic repair suturing ATF, CF, imbrication lax ligaments, reinforced by advanced lateral portion of extensor retinaculum For someone whose Ankle “goes out” frequently (lack lateral stability) Don't do inversion Protected weight bearing 3-4 weeks Dr. Kinect (connect? Kineqt) is ankle guy here protected weight bearing 3-4 weeks * imbrication = surgical pleating and folding of tissue to realign organs and provide extra support |
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Achilles tendon rupture
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Men>woman
30-50 yrs old Intermittent exercises (weekend warrior?) + Thompson Test |
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Achilles Tendinopathy
cook et al. Manual Therapy 2002 |
Histopathology
Tendons: respond poorly to overuse, healing slow, incomplete, lacks extracellular organization Acute tendons heal with a standard triphasic response; inflammation, proliferation, and maturation But, poorly vascularized and doesn't always follow nice pattern Tendon disruption may fail to stimulate adequate inflammatory response MICROSCOPICALLY: large increase in ground substance > greater proportion of large proteoglycans than found in normal tendon Leads to Increased number of tendon cells Immigration of fibroblasts from peritendon Increased organelles responsible for protein synthesis Large amounts of ground substance, inferior collagen, and vascularity are randomly arranged and lack organization, making the tendon less load tolerant Lots of type III, and doesn't really get to type I Exercise may offer a stimulant to improving the organization of these components - Profound effect on collagen (prevent tissue from staying in early phase) |
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Haglunds deformity:
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Haglunds deformity: Bony Prominence and Bursae
Calcaneus impinge at anterior aspect of tendon Insertional tendon pain |
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Peritendinitis
vs Tendinopathy |
Swelling
Crepitus Swelling not moving with tendon Covering and vascular supply TO the tendon Tendinopathy Localized to tendon Change activity Morning pain Thicker on palpation |
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Why is palpation tenderness not a clinically useful tool for symptoms in the patella tendon (tendonopathy?)
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Palpation tenderness is not a clinically useful tool as small amounts of pressure provoke pain in tendons
Palpation tenderness has been shown not to correlate with imaging changes or symptoms in the patella tendon |
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Rx tendinopthay
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Musculotendinous strengthening…essential
Strongly biased toward eccentric Exercise appears to be the only stimulus described to date that positively influences collagen alignment Rest (previous inflammatory paradigm) will reduce pain, no improvement in musculotendinous function. Rest affects negatively > reducing collagen amount and strength Eccentric Increase speed load Alfredson etal. 1998-heavy load eccentric Curwin and Stanish 1984-speed not used pain not contraindication (intense) CKC > Detail to compensation, bias landing, etc. |
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Plantarfascitis
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pain along the plantar aspect of the heel for more than 6 months. Calcaneal tubercle, medial plantar nerve just medial to that. ASTYM, phono, soft tissue, friction massage, orthotics, night splints. But, can be very tough to rehab.
most noticeable when getting out of bed in the morning, upon standing after sitting for longer than 1 hour During walking, pain is most noticeable at the terminal stance/pre-swing phase of gait |
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Flexibility Exercises
for foot/ankle |
Flexibility Exercises
Stretch DF- stand, seated, long sitting Pull MTPs back PF-manual soft tissue, mobs MTP flexion/extension, great toe extension Plantar fascia-massage horizontal and longitudinal, roll ball. MTP per study |
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Neuromuscular control exercises for foot/ankle
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Isometrics
Drawing Pick up marbles Raise medial longitudinal arch Roll ball Rocker board |
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open chain exercises for ankle
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PF with band
Isometric eversion/inversion Eversion/inversion with band Adduction with inversion-towel Abduction with eversion-towel Dorsiflexion iso, with band |
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Closed-chain exercises for ankle
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Stabilization
bilateral stance, unilateral, stable, less stable Dynamic Strength Training seated, standing Perturbations Resisted walking Functional Progression |
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Degenerative ankle/foot (conditions)
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Fixed pronation, hallux valgus foot, hallux rigidus,
dorsal sublux proximal phalanx on metarsal heads RA Rigidity – losing MTP extension, messes up gait Everted calcaneus, pronated forefoot |
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Ankle Arthrodesis
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Fusion
Most frequently used surgery for late-stage arthritis of ankle or more of the joints of the foot Procedure of choice for relatively young, post-traumatic arthritis, gross instability ankle & hindfoot. Could also be failed TAA (total ankle arthroplasty) Deformities, RA, JRA TAA – provides pain relief while preserving functional motion of the ankle and therefore, reduces stress on adjacent joints more effectively than arthrodesis. Cementless, bio-growth fixation → immobilizer, PWB 5-10 DF, 20-25 PF Won't invert/evert Non WB for 4-8 weeks |
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Triple arthrodesis of the hindfoot, a simultaneous fusion of the ____, _____, and ____ joints
Rx: |
Triple arthrodesis of the hindfoot, a simultaneous fusion of the talonavicular, talocalcaneal, and calcaneocuboid joints
Rx: Passive stretch Pfs Mobilize talus on tibia Closed kinetic chain (edema massage...) |
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Postoperative Management - ankle
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Weight bearing per MD
boot/without immobilizer low intensity isometric ROM-PF/DF Elevate edema massage AROM-MTP’s, ankle towel curl/intrinsic strengthening |
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Mobilization With Movement
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Plantarflexion
hand on anterior distal tibia provide posterior glide, create a passive end-range plantarflexion moment, causing talus to roll anteriorly Dorsiflexion place the web space of both hands around the neck of the talus with the palms on the dorsum of the foot. Belt provides pain-free anterior gliding force |
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HIP
Motions (arthrokinimatics) |
HIP
Motions (arthrokinimatics) femur flexion – posterior motion Convex on concave Pelvis anterior = anterior Built for stability and weight-bearing Labrum has thick superior portion |
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Posterior Pelvic Tilt
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PSIS moves posteriorly and inferiorly
Results in hip extension and lumbar spine flexion Functional Motions! Think about them in clinic when Patient talks about when his back hurts |
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Pelvic shift – anterior translation
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Rest on Y ligament
Relative hip ext, lumbar ext And often knee hyperextension Stretch ALL in lumbar and PLL in thoracic |
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Lateral pelvic tilt - hip hike or drop
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Hip Hike: elevation of iliac crest
relative hip adduction lumbar spine flexes toward (concavity) (Quadratus lumborum) Hip or Pelvic Drop: lowering relative hip abduction spine flex away (convexity) (Gluteus medius) |
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Pelvic rotation
unsupported LE |
Unsupported LE
swings forward (trunk opposite) (femur IR) = forward rotation [in clinic, use motions of legs to create motion with obese patient, engage abdominals and glutes – stabilize in standing while doing therapeutic exercise] posterior rotation-pelvis backward (trunk opposite) (femur ER) Muscles: hip rotators in synergy with oblique abdominals, transversus abdominis, and multifidus |
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Pelvifemoral – relationship of pelvis and lumbar spine
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Lumbopelvic rhythm
head upper trunk initiate flexion pelvis shift posterior maintain COG Eventually facets and interspinous ligaments reach limits Trunk extensors -> Glut max & Hamstrings-> Full ROM –soft tissue- extensor muscles, fasciae, hip ex |
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Pathomechanics of hip
Abnormal movement or muscle deficiency at the hip has effects on |
Pathomechanics
Abnormal movement or muscle deficiency at the hip has effects on big picture. Spine, knees, ankles.. proximal or distal effect. Genu valgus, Q-angle, hyperpronation (pronated limb is shorter - correct with orthotic and strengthening). Lots of reasons for coming in with lateral tracking and diffuse knee pain (some people interpret it as patellar motion, others as femur internal rotation). Lots of treatment options – strengthening, stretching, bracing... Looking at biomechanics – walking lunge, forward step down, fast walking |
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Soft Tissue considerations at hip
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Decreased Flexibility – pelvic region has decreased ability to transmit forces and work efficiently
extensors / flexors (tight iliopsoas pulls on spine) Muscle Weakness Hip abductor, extensor, ER Could come in with posterior tib tendonitis, or various other things – could be from faulty positioning because of weakness Muscle Imbalances Short TFL / Glut max (insert on IT band) Weak Glut medius/dominance TFL Dominance two-joint hip flexor Weak glut/dominance hamstring Asymmetrical leg length Anteversion->IR femur->genu valgum & pes planus Picture of anteversion, pes planus |
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Hip muscles - concentric and eccentric actions
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Concentric and Eccentric
Flexors control hip extension at end stance; concentric to initiate swing forward flexion of trunk in stance phase Extensors control flexor moment during loading; glut max initiate hip extension Abductors lateral shift over weak side |
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Clinical manifestation of
-Iliopsoas bursitis - Trochanteric bursitis |
Iliopsoas bursitis
Repetitive flexion Running or swimming Trochanteric bursitis Lateral hip, lateral thigh And knee to insertion ITB Worse periods of standing With weight shifted to Involved side |
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Procedures - Total Hip arthroplasty
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Total Hip arthroplasty- OA (most common) underlying pathology
posterolateral: CONTRAINDICATIONS flexion beyond 90*, adduction across mid-line, IR. * HIGHEST RISK POSTOP DISLOCATION (always be educating about precautions) Muscles (piriformis) released and reattached. Lead with toe when walking to avoid IR. Transfer to good side. Also see anterior approach – retract muscles but don't detach. Full weight bearing, they can flex. (avoid aggressive abduction and extension) |
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Procedures: Hybrid total hip arthroplasty
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Hybrid total hip arthroplasty
Hip replacement with a cemented femoral component and a noncemented acetabular component. Younger individual has porous bones that will infiltrate. Random Mahon notes: Methyl methacrylate (cement) – full weight bearing Osteoporotic, poor bone, elderly |
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Procedures - Hip Arthrodesis
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Hip Arthrodesis
surgical fusion of surfaces of joint. *Salvage procedure |
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OA of the hip:
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OA of the hip:
most common arthritic disease of the hip Pathology usually in regions undergoing the greatest loading forces, such as along the superior weight-bearing surface of the acetabulum Pain > groin, anterior thigh, knee. Stiffness at rest, progressive decrease ROM typically IR and extension (are decreased) High incidence of knee pain (¼? 1/3? with hip have knee pain) |
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Clinical Prediction Rule for OA (of the hip?)
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Self reported squatting aggravates symptoms
Active hip flexion causes lateral hip pain Scour test with adduction causes lateral hip pain or groin pain Active hip extension causes pain Passive IR is less than or equal to 25˚ (lots of people barely get 10*) 3 of 5 likelihood of OA increased from 29% to 68% probability 4 of 5 likelihood increased to 91% |
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MWM – use it most with which joint?
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MWM – use it most with HIP joint
Three techniques supine position Use mobilization belt to produce pain-free, inferolateral glide |
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Stretching = any therapeutic maneuver designed to...
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Stretching any therapeutic maneuver designed to increase the extensibility of soft tissue
thereby improving flexibility and ROM by elongating structures that have adaptively shortened and have become hypomobile over time |
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Exercise techniques to stretch
range-limiting two-joint muscles |
Rectus Femoris
Prone stretch Standing stretch Hamstring – leg up with anterior pelvic tilt SLR Doorway Chair/Table Bilateral toe touching Tensor Fascia latae and IT band stretches supine side-lying standing |
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Pros/cons of open-chain exercises
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Individual can learn to isolate muscle activity and control specific motions
Many functional activities do have nonweight-bearing component |
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Develop control of hip abduction
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Gluteus medius, gluteus minimus, TFL
Supine abduction Side-Lying abduction Standing abduction |
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Develop control of hip extension
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Gluteus Maximus
Supine or prone squeeze buttocks Hip extension with knee flexion-forward flexed Quadruped (often hamstring wants to be dominant, so flexion helps target the glutes) Standing |
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Develop strength and control hip ER
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Piriformis
Gemellus s/I, Obturator i/e Prone isometric-knee 10” apart Side-lying: Clam Clam then abduct Seated Prone |
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Develop strength and control hip flexion
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Iliopsoas and rectus femoris
Conservative - Supine heel slides Standing hip and knee flexion Stand straight-leg hip flexion |
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Develop strength and control
hip adduction |
Adductor magnus
Brevis, longus, pectineus, gracilis Side-lying adduction Standing adduction |
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Pros of closed kinetic chain
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Involve all muscles of chain-not limited to hip (whole kinetic chain, work patterns)
antagonistic two-joint muscles Control force of gravity, momentum for balance Balance/stab as well as strength/function |
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Closed-chain exercises for hip
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Closed-chain isometric exercises:
Alternate isometric and rhythmic stabilization Single leg stabilization Closed-chain dynamic: Bridging Wall Slides Partial mini-squats Single-limb Deadlift Step-ups and step-downs Partial and Full lunges |
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Studies on the effects of mobilization on hip muscle torque
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Effect of grade IV inferior hip joint mobilization on hip abductor torque. Compared with grade I inferior hip joint mobilization, grade IV inferior hip joint mobilization showed a statistically significant increase in hip abductor torque and was consistent with other studies demonstrating that the use of a grade IV non-thrust mobilization improves strength immediately post intervention in healthy individuals.
Usefulness of posterioranterior (P-A) hip joint mobilization in improving strength of the gluteus maximus muscle. control group received Grade I P-A mobilization and experimental group received Grade IV P-A mobilization. Statistically significant difference between the hip extensor torque of the two groups with a 14% increase in strength for the experimental group and only a 4% increase in strength for the control group. |
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Gluteal Muscle Activation During Common Therapeutic exercises
__-__% MVIC (max voluntary isometric contraction) is conducive for muscle strength gains |
50-60% MVIC (max voluntary isometric contraction)
is conducive for muscle strength gains |
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Why is Gluteus Medius a "pretty important guy"?
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Concentrically abduct hip
Isometrically stabilize the pelvis Eccentrically control hip adduction and IR “Pretty important guy” |
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Exercises for Glute Med
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Hip clams 90˚
Hip clams 30-60˚ side-lying hip abduction Single limb squat Single limb dead lift Lateral band walks Forward lunge Sideways lunge Transverse lunge Multiplanar hops Sagittal Frontal Transverse plane |
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% MVIC of Glute med and glute max during different exercises
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Glut medius
Side-lying hip abduction 81% Single limb squat 64 ** Lateral band walk 61 Single-limb deadlift 58 ** Sideways hop 57 ** Not as good... Sideways lunge 39 Clam with 60˚ hip flexion (not bad for piriformis) 38 ** - in weight bearing, need core strength/stability So – maybe want lower one for someone who's super symptomatic Could tolerate it. Depends on patient whether you want open/closed Chain, or high vs. low EMG Minimize EMG on tissue that's “on fire” and work on other guys Glut Maximus Single-limb squat 59 Single-limb deadlift 59 Transverse lunge 49 not as good... Clam with 30˚ hip flexion 34 Lateral band walk 27 |
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Greater trochanteric pain syndrome (GTPS)
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Greater trochanteric pain syndrome (GTPS)
Pathomechanics? Weakness? Exam findings Trendelenburg’s sign Pain on resisted abduction Pain on resisted IR MRI Looked at presentation and significance. Gluteus medius tendon pathology is important in defining GTPS. Trendelenburg's sign is the most sensitive and specific physical sign for the detection of gluteus medius tears Probably not a large tear, but it's killing them 11 patients (45.8%) had a gluteus medius tear 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients) |
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Tibiofemoral joint
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Along with PF joint is intra-articular
Biaxial Modified hinge Medial & Lateral meniscus Anterior/lateral stability by cruciates Medial/lateral stability by MCL and LCL (pcl?) 2 asymmetrical condyles-medial longer-distal femur (1.7cm) Medial tibial plateau larger than lateral |
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Knee Menisci
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Improve congruency
Connected to tibial condyles by coronary ligaments, to each other by transverse lig Med meniscus attached to joint capsule and MCL, anterior and posterior cruciate lig, and semimembranosus muscle (more efficiency/capability, more vulnerable to damage) Lateral meniscus attach to PCL and tendon of popliteus through capsular connection. Kisner and Colby Lateral meniscus has greater mobility because it does not attach to the LCL and capsular attachment interrupted by passage of popliteus tendon Orthopaedic Examination Dutton Meniscus has vasculature. Careful with post-op flexion (none beyond 90 for # of weeks – prevent torque) |
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Arthrokinematics of the knee in open and closed kinetic chain
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OKC: concave plateaus slide in the same direction as the bone motion. TKE results in tibia externally rotating on the femur; with flexion tibia rotates internally
CKC: motion of femur on fixed, convex condyles slide in the direction opposite bone direction |
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Screw-home mechanism
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Tibia fixed, weight bearing, TKE results in femur rotating internally > medial condyle slides farther posterior than lateral. As knee is unlocked the femur rotates laterally
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Patellofemoral Joint
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Sesmoid bone in quadriceps tendon-patella
Articulates with intercondylar trochlear groove on the anterior aspect of the distal portion of the femur (narrow groove/notch may contribute to incidence of ACL injury in females) Articulating surface covered with smooth hyaline cartilage (thickest in body – 7 mm?) Embedded in anterior capsule and connected to tibia by ligamentum patella Retinacula: lateral superficial and deep (deep to IT and comes in with biceps femoris tendon) Accessory motion > superior with extension (inferior with flexion) May contribute to decreased ROM and extensor lag |
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Patellar Function
Compressive forces??? Surgery???? |
Increase the moment arm of the quadriceps tendon
redirects forces exerted by the quadriceps (of picture of alta, Mahon says→ “it's like riddin' high big time” → ) Compressive forces??? Between 60* knee flexion to full flexion Inferior part of patella engaging in groove Surgery???? Look for common impairments: Quad lag – lacking active knee extension Lack full knee flexion Weak quad and hamstring |
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Joint capsule and synovium of knee
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Ascends anteriorly ~ two fingerbreadths above the patella to form suprapatellar pouch
Inferiorly attaches along edge of the tibial plateau, with exception of intercondylar eminence Synovial membrane lines inner portion of knee joint/capsule excludes cruciate ligaments from inner portion of knee joint Thus cruciates extrasynovial yet intra-articular |
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Considerations for patellar tracking?
Malalignment and tracking considerations |
Quad
Patella tendon Boney restraints of trochlear groove (shallow groove leads to lateral tracking?) Passive Dynamic Don't laterally glide patella! Could Do medial, anterior, superior Q-angle: male 12*, female 16* Malalignment and tracking considerations Increased Q-angle Muscle and fascial tightness: Tight IT band and lat retinaculum Tight ankle PF Medial tibial torsion Rectus femoris Hip muscle weakness Lax medial capsule or insufficient VMO With lateral tracking, get bone on bone action theoretically (patellar facets and groove) |
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Patella contact and compressive forces
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Contact:
Full knee extension superior to trochlear groove 15˚ flexion inf border articulates w/ superior aspect groove (contact) >90˚ quad tendon in trochlea groove Compressive forces: Joint reaction force increases between 30-60˚ Squat inc til 90˚ OKC jt reaction force ~ 30˚ w/ free wt at ankle OKC (open kinetic chain) peak compression at 75˚ w/ variable resistance |
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Muscle function- quads
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Closed-chain function: Quadriceps - extension
Patella: Increase distance of the quadriceps tendon from the knee joint axis (do quad set for patellar mobility with immobilized leg) Torque: peak between 70˚ and 50˚ standing: knee extension Greatest 60-30˚ |
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Muscle function at knee
Hamstring-2 joint -> Gastrocnemius-function as Popliteus- Pes anserine- |
Hamstring-2 joint -> contract more efficiently when lengthened over the hip
Gastrocnemius-function as knee flexor, but 1˚ function is to support posterior capsule Popliteus-support posterior capsule unlock knee Popliteus trigger-point Pes anserine-medial stability and rotation of tibia CKC |
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Manual techniques for knee
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Mostly for hypomobility
Grade I II joint distraction: loose packed 25˚-45˚ inhibit pain, improve ROM, cartilage health Patella mobilizations: Supine, side-lie MWM: more effective with loss of flexion lateral or medial glide tibial plateau-> flex/extension IR tibia for flexion IR tibia for flexion-foot on chair Friction Massage: PFPS -> medial tipping , friction massage along lateral border (patello femoral posterior structures??) |
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Exercise strategies for knee
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Heel prop
Gravity assisted wall-slide Self stretching on a step-standing Self stretch seated-flexion Foam roller IT SAQ LAQ Hamstring curls, RDL, gym ball Scooting on wheeled chair TKE Resisted minisquats Forward step with resistance Lateral step-up with resistance |
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Recent advances in the rehabilitation of Anterior Cruciate Ligament Injuries
Wilk et al JOSPT March 2012 |
Full passive knee extension (weights on knee? Strap-down? Prevent arthrofibrosis)
Immediate motion Immediate PWB – partial weight bearing |
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Principles of ACL Rehabilitation
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Principles of ACL Rehabilitation
Full passive knee extension (prevent arthrofibrosis) Restore patellar mobility (quad's on vacation, may do functional stim if mobility is lost.) Reduce postoperative inflammation (swelling leads to muscle inhibition) -WBAT, w/ 2 crutches, brace locked (don't be too eager to get off crutches – bad mechanics) -increase pain and swelling and concomitant Full ROM by 4-6 weeks (0-90* at 5-7 days, 0-110? later) Re-establish voluntary quadriceps Restore neuromuscular control – front step-downs, lateral step-downs, single front step down – strong correlation between functional outcome (dr. Mahon likes lateral step down) Plyometrics Gradual increase applied loads MCL injuries are managed nonoperatively more often than ACL, PCL, or LCL injuries Imposing controlled loads on the knee while protecting the graft from excessive stresses Do neuromuscular reeducation toward the end after they're fatigued |
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TKA
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Cementless fixation WBAT to TTWB (toe-touch) Can get aggressive (non cemented has porous coat and bone infiltrates it. Younger people might have non-cemented)
SLR supine and prone be careful with side ABD for several weeks (varus/valgus stress) High impact per surgeon |
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How does Early High-Intensity Rehabilitation Following TKA affect outcomes according to
Bade and Stevens-Lapsley JOSPT Dec 2011? Differences in the groups? |
According to Bade and Stevens-Lapsley, how much does quad strength drop 1 month post TKA?
60% That's pretty profound. Wants to become knee flexion contracture because they can't do quad set. What was the criteria to decrease the intensity level of the subsequent session? C/o decreased walking endurance Soreness 2 hours or greater Decreased ROM by 5* or more (take note and think about whether it was from your PT or them at home) Increased knee jt swelling 2 cm or more Increase resting numerical verbal pain 2 points or more Differences in the groups? HI had an additional month of therapy Intensity and difficulty |
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Functional performance measures at knee:
What was the MDC (minimal detectable change) in the first 1.5 months for the TUG and 6MW? What postoperative time frame had the most pronounced improvements compared to the control? |
What was the MDC (minimal detectable change) in the first 1.5 months for the TUG and 6MW
TUG 2.49 seconds 6 MW 61.34 What postoperative time frame had the most pronounced improvements compared to the control? 3.5 weeks |
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GH Joint arthrokinematics:
Physiological Motion Accessory Humerus Roll Slide/Glide |
Physiological Motion Accessory
Humerus Roll Slide/Glide Convex on concave! opposite Horizontal adduction anterior posterior IR @ 0* abduction anterior posterior Horizontal abduction posterior anterior ER @ 0* abduction posterior anterior Abduction superior inferior |
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Beyond mid range elevation, the overall displacement of the Head of the
humerus in normal joints is Reported posterior displacement of humeral head during end-range... Contradictions to convex/concave rule Take home – |
Beyond mid range elevation, the overall displacement of the Head of the
humerus in normal joints is anterior with sh flexion and posterior with extension Harryman, et al. J Bone Joint Surgery Am 1990 Reported posterior displacement of humeral head during end-range Horizontal abduction w/ humerus @ 90* and full ER; yet… Anterior displacement in subjects with anterior instability Howel, et al. J Bone Joint Surgery Am 1988 Contradictions to convex/concave rule. Harryman – cadaver study. Howel – radiographic Study. Without anterior laxity, reported posterior displacement. Take home – be thorough and look at clinical presentation. |
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Stability of GH jt
Static Dynamic |
Static:
Superior capsule, sup GH lig, coracohumeral lig R taut Adhesive and cohesive forces of synovial fluid & negative joint pressures Upward inclination of glenoid & labrum GH lig limit excessive translation Dynamic: Rotator cuff, deltoid, long head biceps brachii, pectoralis major, lat, t major When elevated; RTC & deltoid, elbow action Long head biceps stabilizes against humeral elevation |
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Long head of the biceps stabilizes against humeral elevation, and
Contributes to anterior stability of GH joint by resisting |
Long head of the biceps stabilizes against humeral elevation, and
Contributes to anterior stability of GH joint by resisting torsional forces When the shoulder is abducted and ER Kumar, et al. Clin Orthop 1989 Bassett, et al. J Biomech 1990 Rodosky, et al. Am J Sports Med 1994 When patient comes in an everything hurts, working on biceps and triceps can be therapeutic |
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What are the most important static constraints to anterior translation of the humeral head in mid-range abduction/ER?
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A-IGHL
= anterior inferior glenohumeral Most Important As shoulder brought into abduction & ER the anteroinferior aspect of the capsule and the anterior band of the inferior glenohumeral ligament are the most important static constraints to anterior translation of the humeral head Murray et al, Scand J Med Sci Sports 2012 |
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What are the most important static constraints to anterior translation of the humeral head in full abduction/ER?
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IGHL Complex
Most Important |
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AC joint
Arthrokinematics Stability |
Triaxial joint
Weak capsule reinforced trapezoid & conoid No muscles that specifically cross this joint Convex lateral facet on lateral end of clavicle articulates with concave facet on the acromion of the scapula ARthro: Motions with scapula the acromial surface slides in the same direction of the scapula-surface concave stability: coracoclavicular ligament and others |
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SC joint
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Incongruent , triaxial, saddle-shaped w/ disk
Medial end clavicle convex superior to inferior and concave anterior to posterior The superior-lateral portion of the manubrium and first costal cartilage is concave superior to inferior and convex anterior to posterior Anatomical attachment of shoulder complex. |
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Arthrokinematics SC joint
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Motions of clavicle occur as a result of scapular motions of elevation, depression, protraction (abduction), and retraction (adduction)
Same = forward/backward. Opposite = elevation(mob inferior)/depression(mob superior) Rotation of clavicle occurs as an accessory motion when the humerus is elevated >90* and the scapula upwardly rotates |
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Functional articulation of shoulder
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Scapulothoracic Articulation
Upward/downward rotation frontal plane Internal/external rotation vertical axis/transverse plane Anterior/posterior horizontal axis 3 rotations, 2 translations Upward and downward rotation seen w/ clavicular motion @ SC and rotation at AC-occur concurrent w/ hum. occur with full elevation of humerus |
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What muscles
are the greatest muscular contributors to scapular stability and mobility ON THE FINAL |
The upper and lower trapezius & the serratus anterior
are the greatest muscular contributors to scapular stability and mobility ON THE FINAL |
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Active arm motions
- what stabilizes and controls scapula |
Muscles stabilize and control scapula
Facilitates congruency in glenohumeral ball and socket (anatomically unstable joint) effective length-tension relationship-stable base for RTC (paramount for optimal function) stabilize and move humerus/elevate acromion force transfer Drives rehab – bursitis could be due to excessive scapular mobility |
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Muscle actions:
Upper and lower trapezius and serratus anterior -> Serratus anterior -> Rhomboids -> |
Upper and lower trapezius and serratus anterior -> upwardly rotate scapula with elevation
Serratus anterior -> protracts the scapula on the thorax to align scapula during flexion or pushing Rhomboids -> downwardly rotate and retract scapula in synchrony with lats, teres major, and RTC Stabilize scapula through balance of forces |
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Faulty posture - slouching
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Increased kyphosis decreases posterior tilting and ER of the scapula during
Elevation of the arm (leads to quicker subacromial impingement) Muscle length and strength imbalances occur in scapular and humeral mm Alter mechanics of GH joint (tight pec minor – prevents posterior tilt by pulling on coracoid. Stretch weakness and shortened weakness on opposite sides) Forward tilt > decreased flexibility of the pect minor, levator scapula, and scalenus Muscles and weakness in serratus anterior and trapezius Humerus is abducted and IR GH IR less flexible; ER weaken Solem-Bertoft et al, 1993 The anterior aspect of the subacromial space narrowed as the shoulder moved from a retracted position to a protracted position Upper and lower trapezius and serratus anterior |
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For effective shoulder function, you need
Know this! |
For effective shoulder function, you need
Scapula > movement and stability. Dynamic relationship of mobility/stability Balance of strength in IR/ER Thoracic extension and axial extension of the cervical spine (manipulations for shoulder patients – address limitations) Know this |
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Suprahumeral space
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Acromion & coracoacromial ligament
Subacromial /subdeltoid bursa Subcoracoid bursa Supraspinatus mm and tendon Superior portion of GH capsule Biceps tendon All fair game to get pinched/irritatied Everything below acromion |
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Shoulder Girdle Function - scapulohumeral rhythm
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Scapulohumeral Rhythm
scapula with humerus allows for 150-180˚ flexion or abduction 2:1 ratio > 2˚glenohumeral:1˚ scapular Scapular motion > upward rotation, posterior tilt, scapula ER During humeral elevation synchronous motion of scapula allows for Effective length-tension relationship AND congruency humeral head & fossa Upper and lower trap and serratus cause upward rotation scapula Weakness or paralysis, results in scapula downward rotated. Deltoid and supraspinatus reach active insufficiency-cannot elevate arm During elevation pect minor is lengthened as scapular upwardly rotates Restricted scapular movement from shortened pect minor, results in impingement |
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Clavicular Elevation with Rotation with Humeral Motion
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First 30˚ of upward rotation of scapula occurs with
elevation of the clavicle at the SC joint coracoclavicular ligament becomes taut clavicle rotates 38˚ to 55˚ about longitudinal axis allows the scapula to rotate an additional 30˚ @ AC jt |
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External Rotation of the Humerus with Elevation
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External Rotation of the Humerus with Elevation
During elevation of the arm, humerus externally rotates allows greater tubercle of humerus to clear coracoacromial arch Shoulder replacement patients have limited ER, so limited elevation In vivo study of elevation flexion, scapular plane, and abduction Demonstrated 55˚ ER in all planes. During abduction ER occurred Up to 125˚ followed by some IR, forward flexion ER occurred until 50˚ then plateaued. ER occurred again from 110˚ to 160˚. During Elevation in the scapular plane ER occurred throughout. Stokdiijk, et al. Clin Biomech 2003 |
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Deltoid- Rotator Cuff and Supraspinatus Mechanisms
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Deltoid force/vector causes upward translation of humerus (impingement) (don't strengthen deltoid after shoulder replacement – work on infraspinatus, teres minor, supraspinatus, etc. for stability/control of head of humerus)
infraspinatus, teres minor, subscapularis produce stabilizing compression and downward translation of the humerus in the glenoid deltoid & three rotators result in balance of forces that elevate humerus and control humeral head supraspinatus > stabilizing compressive force & slight upward translation during arm elevation |
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SHoulder: referred pain and nerve injury
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Referred pain in shoulder region
Cervical Spine: Vertebral joints between C3 and C4 or between C4 and C5 Nerve roots C4 and C5 Referred pain from Related Tissues: Dermatome C4 trapezius to tip of shoulder Dermatome C5 deltoid region and lateral arm Diaphragm upper trapezius region Gallbladder irritation: pain at the tip of the shoulder and posterior scapular region If you can't find anything during your history/exam, start thinking about referred pain (not, guy comes in with shoulder pain, “I think you have a heart attack, sir Not |
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Nerve disorders in the Shoulder Girdle:
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Nerve disorders in the Shoulder Girdle:
Brachial plexus in the thoracic outlet Suprascapular nerve in suprascapular notch Radial nerve in the axilla |
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Management of Shoulder Disorders and Surgeries
Joint hypomobility: non opperative management |
Glenohumeral Joint
Related pathologies and etiology of symptoms: RA & OA Traumatic arthritis Postimmobilization arthritis or stiff shoulder Idiopathic frozen shoulder/adhesive capsulitis Clinical signs and symptoms arthritis: Acute: pain, muscle guarding, limited-usually ER and abduction. Pain radiating below elbow, may disturb sleep Subacute: capsular tightness consistent with capsular pattern (ER, abduction) pain at end range of motion, limited joint play Chronic: progressive capsular restriction, magnifies limited motion capsular pattern. Significant loss of motion, ache localized to deltoid region |
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Management of Shoulder Disorders and Surgeries
Idiopathic Frozen Shoulder |
Adhesive capsulitis
STAGE I: gradual onset of pain, increases w/ movement, present at night. Loss of ER with intact RTC strength. Duration < 3 months. Not seeing atrophy, but diffuse pain STAGE II: “freezing stage” persistent and more intense pain, particularly @ rest. Motions restricted all directions. Cannot be restored with an injection. Between 3 and 9 months STAGE III: “Frozen stage” pain only with movement, significant adhesions, limited GH motions, atrophy deltoid, RTC, triceps. Between 9 and 15 months. Not in pain anymore, but can't move STAGE IV: “Thawing stage” minimal pain, no synovitis, significant capsular restrictions from adhesions. Between 15 to 24 months Management guidelines are progressed based on continuum of stages and are the same As for acute-max protection stages 1 & 2, subacute-controlled motion stage 3, chronic-return to function stage 4 |
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Frozen shoulder
Common structural and functional impairments: Functional Limitations |
Common structural and functional impairments:
Night pain and disturbed sleep during acute flares Pain w/motion often @ rest during acute flares Mobility: decreased joint play & ROM > usually ER-abduction; some IR-flexion Functional Limitations Inability to reach overhead, behind the head, out to the side, and behind the back. Thus difficult dressing, fastening behind back, reach back pocket, reach out of car window, self-grooming, and eating Difficulty lifting weighted objects Limited ability to sustain repetitive activities Faulty posture: protracted and anterior tilted scapula Decreased arm swing during gait Muscle performance: general weakness and poor endurance GH muscles With overuse of the scapular muscles -> pain upper trapezius, levator, post cervicals Substitution for limited GH motion w/ increased scapular motion, especially elevation |
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GH joint Hypomobility:
Management-Protection phase Know this |
Control pain, edema, muscle guarding;
immobilize to provide rest, decrease pain intermittent periods passive, assisted motion within pain free/protected ROM & gentle oscillations gentle soft tissue mob Trying to stay pain-free with this person Maintain soft tissue and joint integrity and mobility if increased pain or irritability>dosage too strong or technique should be modified. If restrictions stretch after inflammation subsides PROM pain free all planes > avoid faulty posture Passive jt distraction grade I and II Pendulums Gentle muscle isometrics/setting stimulate Blood flow Maintain integrity and function Education, elevate for edema, cervical ROM Let them know that they shouldn't push in to pain (to unload the dishwasher, etc) – repetitive microtrauma irritates tendon. Like after you bite your cheek it's easier to bite your cheek again – quit hurting yourself so it can heal! Work capsule and scap stabilizers first (instead of full anatomical movements) Know this |
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GH joint Hypomobility:
Management-Controlled Motion Phase Know this and last slide: Stage III frozen shoulder, not in super acute phase |
Control pain, edema, joint effusion
Progressively increase joint and soft tissue mobility Self-mobilization, stretching, manual stretch Inhibit mm spasm, correct faulty posture hiking sh. Improve joint tracking Improve muscle performance posture, trunk stability Know this and last slide: Stage III frozen shoulder, not in super acute phase |
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GH joint Hypomobility:
Management-Return to Function Phase |
Progressively increase flexibility and strength
Prepare for functional demands Stage IV frozen shoulder |
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GH management:
Postmanipulation Under Anesthesia (MUA) |
GH management:
Postmanipulation Under Anesthesia (procedure – get them going as soon as possible after) Inflammatory reaction-acute lesion Surgical intervention if manipulation unsuccessful Arm elevated overhead in abduction and ER Therapeutic exercise same day-IR/ER @ 90˚ Joint mobs-caudal glide Sleep with abduction-3 weeks |
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Joint Hypomobility:
Nonoperative management Acromioclavicular and Sternoclavicular Joints |
Acromioclavicular and Sternoclavicular Joints
Related Pathologies and Etiology of Symptoms Overuse syndromes Subluxation or dislocation Hypomobility Common Structural and Functional Impairments Pain-localized, with horizontal adduction Painful arc toward end range shoulder elevation Hypermobile w/ trauma; hypomobile w/ arthritis functional limitations Limited ability to perform sustained forceful movements Inability to reach/perform overhead |
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Acromioclavicular and Sternoclavicular Joints
Nonoperative Management of AC or SC joint strain or hypermobility |
Acromioclavicular and Sternoclavicular Joints
Nonoperative Management of AC or SC joint strain or hypermobility Minimize joint load-be careful of weightbearing Cross-fiber massage to capsule or ligaments ROM GH and scapulothoracic Increase strength shoulder complex Nonoperative Management of AC or SC joint strain or hypomobility AC-Anterior glide clavicle on acromiom SC-posterior glide to increase retraction; superior glide to increase depression SC- anterior glide to increase protraction; caudal glide to increase elevation |
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GH joint surgery and postop management
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Glenohumeral Arthroplasty
Total shoulder Arthroplasty TSA Hemiarthroplasty-humeral head replaced Reverse total shoulder arthroplasty rTSA (more significant now days – proximal part convex, head of humerus concave. Rotator cuff pretty much trashed – mechanics are changed and now deltoid elevates the arm) Indications Pain – this is why they get surgery Loss of mobility |
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Glenohumeral Arthroplasty
Procedures |
Glenohumeral Arthroplasty
Procedures Late stage OA -> TSA or hemiarthroplasty…RTC intact. Unconstrained TSA > replace glenoid component and humeral surface replaced rTSA > reverses the ball and socket. Glenoid fossa is replaced with a convex Glenospherical component and humeral head with stemmed cup. Semiconstrained TSA if RTC can be repaired and function improved Hemiarthroplasty > articular surface and underlying bone of humerus have deteriorated, but glenoid fossa intact Doctor will write max amount of ER/IR, etc. Range of motion may be limited by hardware – providing stability SEMICONSTRAINED: bone grafting at glenoid Provides deeper cavity (like the labrum) |
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Complications with glenohumeral arthroplasty higher with
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Higher in patients w/ the following
Deficient RTC OA Preoperative chronic instability |
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Post-op management considerations for glenohumeral arthroplasty
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Considerations
Integrity of RTC-intact progress more rapidly Intraoperative ROM Unconstrained TSA and sufficient stability: equal intraoperative shoulder elevation 140˚ - 150˚ shoulder ER 45˚ - 50˚ more constrained, deficient RTC, capsuloligamentous laxity focus on develop dynamic stability rTSA ROM 0˚ - 20˚ ER for 3 months ROM 90˚ - 120˚ elevation for 3 months Posture |
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Glenohumeral arthroplasty:
Maximum Protection Phase 1st postop day to 4-6 weeks. |
Immobilization and Postoperative Positioning
TSA immobilizer may be weaned RTC or rTSA immobilizer 3-4 weeks Exercise Progression Maximum Protection Phase 1st postop day to 4-6 weeks. Short ex sessions pain control; mobility adjacent jts; restore shoulder mobility MOBILITY: plane scapula, ER less than 30˚, no end range codman’s, self-assisted @ 3-4 weeks, self-assisted reaching active @ 4 weeks TSA, isometrics 4-6 weeks rTSA limited lift 1# 6 weeks; ER 0-20˚, elevate 90-120˚ 3 mo rTSA hyperextension, supporting body weight also reaching behind back (irritating, not going to do that for a while – bra fastening, wallet in back pocket... be careful) KNOW THESE |
