UE Advanced DD and Interventions

pt presents to PT with reports of aching pain and paresthesia along the medial aspect of the left arm extending into ring and small fingers. the PT performs the test demonsrated in image. if test is positive which is the MOST appropriate intervention?

a. strength upper trap and levator scapulae muscles

b. perform repeated cervical extension exercises

c. stretch the pectoralis minor and scalene muscles

d. perform grade III mobilizations to the first and second ribs

c. stretch the pectoralis minor and scalene muscles

Thoracic Outlet Syndrome - Definition

compression of neurovascular bundle - brachial plexus, subclavian artery and vein, phrenic nerve in the thoracic outlet at 3 sites

Neurological TOS

most common

C8-T1

paresthesia, numbness, weak grip, loss of manual dexterity

Arterial TOS

pulselessness, poor endurance, pallor, cold extremities

Venous TOS

edema, warm, cyanosis, swelling, mottled appearance

Interscalence Triangle Special Test

Adson’s Manuever

stretches scalences, decrease pulse if artery compressed

Interscalence Triangle - Intervention

stretch the scalene muscles

Costoclavicular Space - Speical Test

Military Brace Test

shoulders retracted and depressed

costoclavicular space - Intervention

mobilization of the first rib

axillary interval (pec minor space) - special test

wright test, roos test, allen test

axillary interval (pec minor space) - intervention

stretch the pectoralis minor

ULTT1 - nerve bias

median

anterior interosseous

ULTT 2 nerve bias

median

axillary

musculocutaneous

ULTT1 mnemonic

MAIN

ULTT2 mnemonic

MAM

ULTT3 nerve bias

radial

ULTT 4 nerve bias

ulnar C8 and T1 nerve roots

A patient reports tingling and numbness in the UE. the therapist decides to perform an ULTT on the patient shown in the image below found to be positive. based on the findings which nerve root is MOST likely contributing to patient’s symptoms?

a. anterior interosseous

b. ulnar nerve

c. musculocutaneous nerve

d. radial nerve

d. radial nerve

Subacromial Impingement

anterior/lateral shoulder pain

pain at night

painful arc (60-120)

subacromial impingement - special tests

Neer, Hawkins Kennedy, Yocum, Empty Can

Rotator Cuff Tear

age > 40 (overuse cases) or traumatic

anterior/posterior/superior shoulder pain with loss of strength

pain that wakes the patient during sleep, worse at night

weakness and atrophy

rotator cuff tear - special tests

ER lag sign, drop arm, hornblower’s sign, IR lag sign, lift off sign, belly press, bear hug

SLAP - labrum tear

traumatic sudden onset

deep anterior shoulder pain

clinking/clunking/joint locking - pain with throwing or biceps loading (shoulder flexion and arm supination)

SLAP labrum tear - special test

active o’brien test, bicep load, clunk test, crank test

SLAP meaning

superior labrum anterior to posterior

AC Joint Injury

trauma that displaces the shoulder girdle inferiorly or heavy weightlifting

pain at top of the shoulder

painful arc (170-180) and pain with horizontal adduction

step deformity

AC joint injury - special test

horizontal adduction, paxinos sign, AC sheer test

Bicipital Tendinitis

age 20-45

pain with overhead movements

pain with full extension to flexion. active external rotation limited when arm is at 90 abduction

bicipital tendonitis special test

speed’s, yergasons

a pt reports right shoulder pain reproduced when reaching overhead to place an item on a high shelf and when reaching across the body to fasten a seatbelt. Neer’s test and Crank test are both negative. These findings are MOST indicative of which shoulder pathology?

a. acromioclavicular joint sprain

b. subacromial impingement

c. glenoid labral tear

d. rotator cuff tear

a. acromioclavicular joint sprain

Coracoaromial Arch

a key site of pathology and an active treatment site

superior labrum anterior posterior (SLAP) lesion is superior labrum tearing/pulling away by the biceps insertion which is under subacromial arch

A patient underwent surgical repair of a SLAP lesion 2 weeks ago. Which of the following exercises is currently CONTRAINDICATED?

a. active isometric contraction of the biceps

b. passive humeral rotation with shoulder in scapular plane

c. prone scapular retraction

d. active assisted shoulder flexion to 90 in supine

a. active isometric contraction of the biceps

Repair of SLAP lesion

when bicep tendon detached - progress cautiously

• limit passive or assisted elevation of UE to 60 for 2 weeks and limit to 90 at 3-4 weekks

• only perform passive humeral rotation with shoulder in scapular plane for first 2 weeks

avoid tension on the biceps (elbow extension with shoulder extension) for the first 4-6 weeks

avoid active biceps contraction for 6 weeks

Rotator Cuff Rehab

initiate with isometrics

resisted exercises should not cause pain

rotator cuff strength before large primary movers

AROM for shoulder flexion and abduction must be done without shoulder hiking

no CKC 6 weeks

dynamic strengthening at 8 weeks (small tear), 12 weeks (large tear)

light functional activities 6+ weeks

a clinician is evaluating a patient with concerns of shoulder pain and concludes that this patient is potentially in the freezing stage of idiopathic frozen shoulder? which of the following is MOST accurately describes this stage?

a. pain that increases with movement and is present at night? loss of ER with intact rotator cuff strength

b. pain at rest with limited motion in all direction

c. pain only on movement. atrophy of deltoid, biceps, triceps, and rotator cuff muscles

d. minimal pain with significant capsular restriction from adhesions

b. pain at rest with limited motion in all direction

Adhesive Capsulitis - Stage 1

0-3 months

mild signs and symptoms - achy at rest, sharp at extremes ROM

capsular pattern - loss of ER and abduction present

synovitis more than contracture of capsule

Adhesive Capsulitis - Stage 2

Freezing/Painful

3-9 months with progressive loss of ROM and persistance of pain

motion loss in this stage reflects loss of capsular volume and a response to painful synovitis

loss of motion in all planes, pain in most of range

Adhesive Capsulitis - Stage 3

Frozen

9-15 months

painful stiffening of the shoulder and a significant loss of ROM

pain only with movements

atrophy of RTC, deltoid, biceps and triceps muscles

poor scapulohumeral rhythm with scapular hike

loss of axillary fold and ROM with capsular restriction

Adhesive Capsulitis - Stage 4

Thawing

15-24 months

pain lessens but stiffness persists

slow and steady recovery

Adhesive Capsulitis - Treatment

corticosteroid injection by MD

stretching determind by patient irritability

joint mobilization

joint mobilization for frozen shoulder

posterior inferior glide

a at presents with elbow pain that has gradually developed over few months. on exam tenderness over medial epicondyle and pain with resisted forearm pronation and wrist flexion. passive wrist extension with elbow extended reproduces symptoms. no sensory deficits present in UE. What is MOST likely diagnosis?

a. tennis elbow

b. pronator teres syndrome

c. golfer’s elbow

d. ulnar collateral ligement sprain

c. golfer’s elbow

Lateral Epicondylitis

lateral aspect of elbow pain

extensor carpi radialis brevis involved - activities w/ repeated wrist extension/grasping increase pain (gradual overuse)

lateral epicondylitis special test

cozen’s, mills, maudsley test

lateral epicondylitis treatment

offload to reduce pain and gradual progressive strengthening of wrist extensors

medial epicondylitis

anteromedial aspec of elbow pain

pronator teres + flexor carpi radialis involved - activties involing repeated wrist flexion increases pain (gradual overuse)

medial epicondylitis special test

medial epicondylitis test

medial epicondylitis treatment

offload to reduce pain and gradual progressive strengthening of wrist flexors

Nursemaid’s elbow

age 2-3 years

longitudinal traction on an extended elbow partial slippage of annular ligament over head of radius

position of arm - arm at side, with hand pronated (palm down), radial nerve can get injured

treatment: manipulation

DeQuervain’s Tenosynovitis

tenderness over lateral wrist and thumb

abductor pollicis longus and extensor pollicis brevis muscles are affected

severe pain with wrist ulnar deviation and thumb flexion and adduction

DeQuervain’s Tenosynovitis - Special Test

Finkelstein’s Test

DeQuervain’s Tenosynovitis Mnemonic

AbPL and EPB

apple and extra peanut butter

Carpal Tunnel Syndrome

tingling/numbness in the median nerve distribution of hand

repetitive activities and sustained positioning of wrist aggravates pain

thenar muscle atrophy seen in later stages

nigh pain

Carpal Tunnel Syndrome - special test

phalen’s test, tinel’s sign

distal radius fracture - colle’s fracture

dorsal displacement of distal fragment of radius

due to FOOSH injury

leads to dinner fork deformity

distal radius fracture - smith fracture

volar displacement of distal fragment of radius

due to fall on flexed wrist

leads to garden spade deformity

a pt who is postpartum, presents to PT with 2 month hx of pain along radial side of R wrist. pt reports pain worsens while lifting and carrying their infant and when gripping objects. on exam, tenderness over first dorsal compartment of the wrist. Phalen’s and tinels are negative. ROM of thumb limited d/t pain. Which of the following is most appropriate

a. splinting with thumb spica and activity modification

b. eccentric strengthening of AbPL and EPB

c. median nerve gliding and nighttime wrist splint

d. tendon gliding exercises with progressive thumb strengthening

a. splinting with thumb spica and activity modification

Boutonniere Deformity

extension of MCP and DIP, flexion of PIP

result of rupture of central tendinous slip of the extensor hood

most common after trauma or in RA

Swan Neck Deformity

extension of PIP, flexion of MCP and DIP

due to contracture of intrinsic muscles or tearing of volar plate

common in RA

Mallet Finger

due to rupture or avulsion of the extensor tendon at distal phalanx of finger

distal phalanx at rest in flexed position

always traumatic (not RA)

Mallet Finger

splint with a finger extension splint for 6-8 weeks

Ulnar Nerve Motor Innervation - Mnemonic

MAFIA

Ulnar Nerve MAFIA meaning

medial lumbricals (on 4th and 5th digits)

adductor pollicis

FCU/FDP ulnar side

interossei

abductor digiti minimi

Ulnar Nerve - sensory innervation

hypothenar eminence

medial 1.5 digits dorsal and palmar aspects

Based on the patients presentation which of the following is the MOST likely diagnosis?

a. cubital tunnel syndrome

b. carpal tunnel syndrome

c. guyon’s canal syndrome

d. cervical radiculopathy

a. cubital tunnel syndrome

Which of the following actions is MOST likely to be different for this patient to perform?

a. opposing thumb to the tip of the small finger

b. pinching a key firmly between the thumb and side of the index finger

c. extending the wrist against gravity

d. flexing the distal interphalangeal joint of the index finger against resistance

b. pinching a key firmly between the thumb and side of the index finger

cubital tunnel syndrome

ulnar nerve entrapment between two heads of FCU

cubital tunnel syndrome - MOI

prolonged elbow flexion, fractures, spurs, arthritis

cubital tunnel syndrome - sensory or motor first

sensory

cubital tunnel syndrome - sensory symptoms

pain/sensory symptoms at 4th/5th digits (dorsal and palmar)

hypothenar (below little finger)

cubital tunnel syndrome - motor symptoms

weakness in FDP ¾
hypothenar muscles, ulnar interossei, adductor pollicis

cubital tunnel syndrome - tests

symptoms worst with elbow flexion test

positive forment’s (FPL substitutes for weak adductor pollicis)

wartenberg sign (inability to adduct the little finger)

tinels sign positive at elbow

guyon’s canal syndrome - MOI

history of heavy gripping, twisting, activities involving pressure (bicycling)

guyon’s canal syndrome - symptoms

motor - weakness in hypothenar muscles, ulnar interossei, adductor pollicis — NO FDP

sensory - pain/symptoms at 4th/5th digits (only palmar); hypothenar

guyon’s canal syndrome - test

froment’s

wartenberg sign

tinel’s sign positive at wrist

TMJ - opening of mouth (ROM)

depression of mandible

35-55 mm

opening of mouth muscle

lateral pterygoid

TMJ - closing of mouth muscles

elevation

temporalis, masseter, medial pterygoid

closing of mouth muscle mnemonic

MMT

protrusion of mandible

7 mm

medial/lateral pterygoid

retraction of mandible

3-4 mm

temporalis

lateral deviation of mandible

10-15 mm

lateral/medial pterygoid

a patient presents to PT clinic with reports of R sided jaw discomfort during chewing. on examination mouth opening measures 52 mm, and the jaw deviates to the left during the final phase of opening. there is no audible clicking and pain is minimal. which of the following is MOST likely diagnosis?

a. R TMJ hypomobility

b. R TMJ disc displacement with reduction

c. R TMJ hypermobility

d. R TMJ synovitis

c. R TMJ hypermobility

TMJ Hypomobility

decreased mouth opening and deviation to same side

TMJ Hypermobility

increased mouth opening

deviation to opposite side

TMJ disc displacement with reduction

clicking heard

no deviation

no difficulty with mouth opening

TMJ synovitis

pain and limited mouth opening

no deviation

TMJ Capsulitis

pain

limited mouth opening and deviation to same side