NPTE- MSK

Biceps Brachii - position of active insufficiency

Shoulder and elbow flex

forearm supination

Biceps Brachii - position of passive insufficiency

Shoulder and elbow ext

forearm pronation

Triceps Brachii - position of active insufficiency

Shoulder and elbow ext

Triceps Brachii - position of passive insufficiency

Shoulder and elbow flex

Wrist extensors - active insufficiency

Elbow flex, wrist ext

Wrist extensors - passive insufficiency

Elbow ext, wrist flex

Wrist flexors - active insufficiency

Elbow flex, wrist flex

Wrist flexors - passive insufficiency

Elbow ext, wrist ext

Hamstrings - active insufficiency

Hip ext, knee flex

Hamstrings - passive insufficiency

hip flex, knee ext

Gastrocnemius - active insufficiency

Knee flex, ankle PF

Gastrocnemius - passive insufficiency

Knee ext, Ankle DF

Insufficiency - when does it come into play?

With two joint muscles.

Active Insufficiency

When a muscle cannot shorten anymore, occurs with the agonist.

Passive Insufficiency

When a muscle cannot stretch anymore, occurs with the antagonist.

ape hand deformity

wasting of the thenar eminence of the hand occurs as a result of a median nerve palsy

thumb falls back in line with fingers as a result of pull of extensor muscles

**patient is unable to flex or oppose thumb

bishop's hand or benediction

wasting of the hypothenar muscles of the hand, interossei ms and 2 medial lumbricals due to ULNAR nerve palsy

**hyperextension of MCP joint and flexion of IP joint

claw fingers

intrinsic minus hand, caused by combination of median & ulnar nerve

results from the loss of intrinsic muscle action and the overaction of the extrinsic extensor muscles on the proximal phalanx of the fingers

MCP joints are hyperextended, and PIP and DIP joints are flexed.

drop-wrist deformity

paralyzed extensor of wrist due to radial nerve palsy.

dupuytren contracture

contracture of palmar fascia, fixed flexion deformity of MCP & PIP

usually seen in ring or little finger

affects men more than women.

mallet finger

due to rupture or avulsion of the extensor tendon at distal phalanx of finger, distal phalanx rest in flexed

position.

boutonneire deformity

extension of MCP and DIP joint

flexion of PIP joint

rupture of central tendinous slip of the extensor hood and is more common after trauma or in RA

swan neck deformity

extension of PIP

flexion of MCP & DIP due to contracture of intrinsic ma or tearing of volar plate (common in RA)

trigger finger

- results of a thickening of the flexor tendon sheath (notta's nodule), which causes sticking of the tendon when the patient attempts to flex the finger

- a low-grade inflammation of the proximal fold of flexor tendon leads to swelling and constriction in digital flexor tendon

-when patient attempts to flex the finger, the tendon sticks, and the finger "let's go," often with a snap.

- as condition worsens, eventually finger will flex but not let go, and it will have to passively extended until finally a fixed flexion deformity occurs.

***usually occurs in 3rd or 4th finger

****most often associated with RA and tends to be worse in the morning.

de quervain's tenosynovitis

inflammation the extensor pollicis brevis and the abductor pollicis longus tendons at 1st dorsal compartment **common in pregnancy

pain at anatomical snuffbox, swelling, decreased grip and pinch strength

Finkelstein's test is positive

carpal tunnel

compression of median nerve

common in pregnancy, diabetes, RA

burning, tingling, pins and needles and numbness at night

positive tinels sign / phalens

colles fracture

dorsal displacement of distal fragment of radius with radial shift of wrist and hand results in dinner fork deformity

smiths fracture

distal fragment of radius dislocates in a volar direction result in garden spade deformity

forefoot varus

- inversion of forefoot

- subtalar joint in neutral

forefoot valgus

- eversion of forefoot

- subtalar joint in neutral

Sever's Disease

age 8-13 yrs

MOI: pronation, tight gastroc-soleus, jumping or landing from height

- limited DF

- pain over posterior-inferior heel which increases with weight bearing

- pain resolves with rest

tests: squeeze test, xray

midfoot sprain

- Age 15-40

- MOI - high impact landing, foot twisted when in fixed position

- walking on toes increases symptoms on midfoot

- generalized tenderness of midfoot

- pain during passive midfoot pronation and supination while the hindfoot is stabilized

- weightbearing lateral and anterior posterior radiographs

Metatarsal Stress Fracture

age 15-45

MOI: overuse

symptoms increase with WB activities on forefoot

tenderness over the fracture site

tests: palpation, ultrasound, tuning fork, bone scan, MRI, SCT

tarsal tunnel syndrome

age 25-50

MOI: posttraumatic, rapid weight gain, fluid retention, inflammatory, abnormal foot/ankle biomechanics or a valgus foot deformity

- symptoms on medial malleolus, distribution of posterior tibuial nerve down into the medial arch and plantar furface of foot and toes

- symptoms increase with excessive pronation in walking or runnin g

- pronated foot, pes planus can be observed

- passive plantarflexion and eversion painful

- resisted toe flexion painful

test: tinels sign positive

morton's neuroma

age: 40-60

MOI: gradual

weight bearing increases symptoms on sole of foot

pronated foot or flattened arch can be observed

passive toe extension painful

tenderness with palpation of web space or toes

anterior compartment syndrome

- Increased pressure in anterior compartment of leg causing an ischemic condition of the leg

- MOI - direct trauma, muscle hypertrophy, fracture

severe cramping, diffuse pain and tightness

pain decrease with rest and increases with activity

pain worsens with stretching

tender and tight compartment on palpation

**6's: pain, pallor, paresis, paresthesia, pulselessness, palpable tenderness

medial tibial stress syndrome (shin splints)

age 15-30

moi: overuse

pain on anterior lower leg, posterior-medial leg

active combined PF and IV painful

resisted PF and EV painful

tenderness on posteromedial calf

anterior tibialis tendinitis

age: 15-45

moi: overuse

symptoms increase with repetitive DF on anterior lower leg

combined active PF and IV movements painful

passive PF painful

resisted DF painful

tenderness over anterolateral lower leg

posterior tibialis tendinitis

- Age 20-40

- MOI- overuse with a flat pronated foot

- pain on medial ankle

- swelling and tenderness of medial ankle

- active and passive PF and EV painful

- resisted IV with PF painful

gastrocnemius strain

- Age 20-40

- MOI- sudden overload

pain in upper calf

heel raise increases symptoms

antalgic gait

active and passive DF painful and limited with knee extended

pain on resisted PF

tender mid to upper calf on palpation

achilles tendinitis

age: 20-40

MOI: overuse

jumping and running increases symptoms on posterior ankle

slight swelling in posterior ankle

active and passive DF painful and limited

passive DF limited with knee in extended position

resisted PF painful

plantar fascitis

age: 20-60

moi: gradual w/ unknown cause

painful sole of foot under heel when WB

pain in morning

pronated foot or flattened arch

passive great toe extension painful

plantar aspect of heel is tender on palpation

test: windlass

iliotibial band friction syndrome

Age 25-55; MOI- overuse

Pain with repetitive movements, climbing or descending stairs

Lateral knee pain diffuse & hard to localize

Localized tenderness at lateral femoral condyle.

posterior cruciate ligament injury

forced blow to anterior tibia in knee flexed, dashboard or falling into the flexed knee

- hyperflexion

- popping sound

- pain posterior aspect of knee

- aggravated with kneeling

test: posterior sag, posterior drawer, reverse lachman

MCL and LCL injury

valgus forces across medial joint line of knee

lateral collateral ligament- traumatic varus force across knee

- symptoms increase with varus stress (LCL) and valgus stress (MCL)

anterior cruciate ligament injury

age: 15-45

contact and noncontact MOI

contact: glow to the lateral side of knee (valgus force)

- ACL, MCL, and medial meniscus injury (terrible/unhappy triad)

noncontact: tibia ER on planted foot, forceful hyperextension

immediate swelling of knee and popping sound

feeling of instability

symptoms worsen with WB

pain at end ranges

pain with resisted knee rotation

test: anterior drawer, pivot shift, lachmans

sinding-larsen-johansson syndrome

traction apophysitis of the inferior pole of the patella

pain with activities such as cycling, athletics, resisted knee extension

test: xray fragmentation of tibial tubercle or irregular calcification

osgood schlatter disease

age 8-13 years in female

age 10-15 in male

onset- sudden

traction apophysistis of tibial tubercle

visible lump over the site

pain with activities such as running, jumping, kneeling, stairs)

knee extension resistance or stressing quads increased symptoms

anterior knee pain

quadriceps muscle tear

age 20-40

moi: sudden eccentric overload

squatting increases symptoms

bruising and/or swelling can occur over anterior thigh/knee

knee flexion is limited

combined hip ext and hip flexion painful

tenderness over anterior thigh

prepatellar bursitis

age 15-50

inflammation of bursa due to recurrent micro trauma of anterior knee

MOI: direct trauma to the anterior aspect of the knee

pain increases with kneeling

local swelling, fluctuation

patellar tendinopathy (jumpers knee)

- Age 15-30

- Inflammation of patellar tendon

- Onset- gradual

- MOI- gradual (repeated eccentric overloading during deceleration activities)

pain increases with squatting and jumping

end range knee flexion painful

tender patellar tendon (inferior or superior to patella)

test: patellar grind test, single leg hip test, high step up test

patellofemoral syndrome (runner's knee)

age: 20-50

moi: trauma, tight ITB, gmax, and TFL

worsen symptoms after prolonged sitting (moviegoers sign), stairs, and kneeling

end range knee flexion painful

tenderness on anterior knee especially with patella compression

anterior knee swelling

test: clarke test

keinbocks disease

lunate fracture; blood supply to one of the small bones of the wrist is interrupted

worsened pain with wrist flexion and extension

myositis ossificans

-common in brachialis muscle as result of trauma, aggressive stretching

-avoid stretching, massage, resistive exercises, Heat

brachialis strain

-pain on anterior aspect of distal part of the arm, possible tenderness in muscle belly

-painful resisted elbow flexion with forearm pronation

bicep tendon rupture

-Swelling

-Ecchymosis

-palpable gap in biceps tendon

-Weak elbow flexion and supination

anterior interosseous nerve syndrome

weakness of flexor pollicus longus and flexor digitorum profundus to index finger

weakness of pronator quaradus

median nerve branch

olecranon bursitis

-student's elbow, elbow bursitis

-swelling over posterior elbow

pulled elbow syndrome / nursemaid's elbow

-Age 2-3 years

-Longitudinal traction on an extended elbow --> partial slippage of Annular ligament over the head of radius and radio capitellar jt

-Position of arm - Arm at side, with hand pronated (palm down)

-Radial nerve can get injured

supracondylar fracture

distal humeral fracture

common in kids

typically AIN (branch of median nerve) and brachial artery involvement

complications: volkmanns ischemic contracture, gun stock deformity (reduced carrying angle), high incidence of malunion

requires ORIF

medial epicondylitis

Degenerative condition of pronator teres and flexor carpiradialis at medial epi

overuse in sports or jobs that require strong grip and excessive pronation

pain at passive wrist extension and active wrist flexion

ulnar nerve

lateral epicondylitis

chronic degenerative condition of ECRB at its proximal attachment to the lateral epicondyle of humerus

- repetitive wrist extension or strong grip with wrist extended overloading of ECRB

- painful passive wrist flexion and active wrist extension

SICK scapula

Age 20-40 yrs. Scapular malposition, inferior medial border prominence, coracoid pain and malposition, kinesis abnormalities of scapular movement.

test: scapular assistance test, scapular reposition test

acromioclavicular joint sprain

fall on tip of shoulder or outstretched arm

- step deformity (3rd degree) at point of shoulder

- painful palpation

- horizontal adduction and elevation painful

subacromial bursitis

repetitive overhead activity

painful arc 60-120 of abduction

active abduction and MR is limited

passive MR with 90 degrees shoulder abduction is painful

test: hawkins kennedy test, neer

bicep tendinitis

age 20-45

repetitive overhead activity

longhead gets impinged b/w bicipital groove and anterior acromion

pain with overhead movements

pain with full extension to flexion

resisted elbow flexion painful

test: speed, yergason

rotator cuff tendinitis

Inflammation of RC tendons due to impingement by acromion

painful overhead movements and resisted abduction

limited active abduction

piriformis syndrome

posterior hip and sacral pain

increased pain with sitting, squatting, or ER of hip, radiates to posterior thigh

limited hip IR

hallux rigidus

pain with big toe extension and gait

chronic, osteoarthritis

foot pain due to compensating to decrease toe ext

fused or partially fused first MP joint

toe off phase altered by supination so pressure is on lateral toes

excessive wear on lateral toes

hallux valgus

may be asymptomatic

around first MCP

chronic

secondary lesions: bunions, bursitis, corns, calluses

lateral deviation of big toe

excessive pronation and compensation strategies

metatarsalgia

soreness of middle metatarsals

abnormal mechanical stress, arthritis

plantar foot pain and fatigue with WB

callus over mid metatarsals

hypermobile or pronated foot

antalgic gait, prontated

special test: metatarsalgia

open / resting position of glenohumeral joint

40-55 degrees abduction

30 degrees horizontal adduction

*scapular plane

close-packed position of glenohumeral joint

maximum abduction and external rotation

open / resting position of the humeroulnar joint

70 degrees flexion

10 degrees supination

close-packed position of the humeroulnar joint

full extension and supination

open / resting position of sternoclavicular joint

arm resting by side

open / resting position of acromioclavicular joint

arm resting by side

close-pack position of sternoclavicular joint

maximum shoulder elevation

close-pack position of acromioclavicular joint

arm abducted to 90 degrees

what is the open / resting position of vertebrae?

midway b/w flexion and extension

what is the close-pack position of vertebrae?

maximal extension

what is open / resting position of the hip?

30 degrees flexion

30 degrees abduction

slight ER

what is the close-pack position of the hip?

full extension, abduction, IR

what is the open / resting position of the knee?

25 degrees flexion

what is the close-pack position of the knee?

full extension and ER

what is the open / resting position of the talocrural joint?

mid inversion / eversion

10 degrees pf

what is the close-pack position of the talocrural joint?

full dorsilexion

what is the open / resting position of the subtalar joint?

midway b/w extreme ranges of position

what is the close-pack position of the subtalar joint?

full inversion

what is the open / resting position of the midtarsal and tarsometatarsal joint?

midway b/w extreme ranges of position

what is the close-pack position of the midtarsal and tarsometatarsal joint?

full supination

what is the open pack / resting position of the proximal radioulnar joint?

70 degrees flexion

35 degrees supination

*distal radioulnar is 10 degrees supination

what is the close-pack position of the proximal radioulnar joint?

5 degrees supination

*same for distal radioulnar

what is the open / resting position of the humeroradial joint?

full extension and supination

what is the close-pack position of the humeroradial joint?

90 degrees flexion

5 degrees supination

what is the open / resting position of the midcarpal joint?

neutral or slight flexion with UD

what is the close pack position of the midcarpal joint?

full extension with UD

glenohumeral arthrokinematics

convex on concave

Abd: superior roll, inferior glide

Flex: anterior roll, posterior glide

glenohumeral abduction arthokinematics

superior roll

inferior glide

glenohumeral flexion arthrokinematics

anterior roll

posterior glide