MSK Basics (NPTE)

active insufficiency

the inability of a 2 joint muscle to shortner simultaneously at both joint

→ strengthen these muscles

passive insufficiency

the inability of a 2 joint muscle to lengthen simultaneously at both joint

→ stretch these joint

Scapular upwards rotators

• upper traps

• serratus anterior

• lower traps

→ abduction = concentric movement

scapular downward rotators

• lats

• pec minor

• levator scapulae

• rhomboids

→ adduction = concentric movement

scapular protractors

• Pectoralis major & minor

• Serratus Anterior

scapular retractors

• lower & middle traps

• rhomboids

tibia rotating laterally

open chain locking

tibia rotating medially

open chain unlocking

femur rotating medially

closed chain locking

femur rotating laterally

closed chain unlocking

Upper Crossed Syndrome

slouching / forward neck posture

• facilitated: SCM/Pecs & upper traps/levator scap

• inhibited: deep cervical flexors & low traps/serratus ant

Lower Crossed Syndrome

Pregnant posture

• inhibited: abdominals & glutes min/med/max

• facilitated: hip flexors & thoraco-lumbar extensors

Glide grade 1

small amplitude at beginning range

» for pain and ROM limitation

Glide grade 2

Large amplitude within range

» for pain and ROM limitation

Glide grade 3

Large amplitude up to full range limit

» for limitation

Glide grade 4

small amplitude at the limit

» for limtiation

scapular elevators

• upper traps

• rhomboids

• levator scap

scapula depressors

• pec major & minor

• lower traps

• lattiumus dori

Neuropraxia (Sunderland 1)

Symptoms:

• pain w/o muscle wasting

• weakness & numbness

• affected proprioception

minutes - days recovery

• segmental demyelination

• action potential slowed or blocked at point— normal above and below

• due to mild ischemia from nerve compression/traction

Axonotmesis (Sunderland 2 & 3)

Symptoms:

• pain

• muscle wasting

• complete motor > sensation lost

months long recovery (1mm/day)

• loss of axonal continuity but connective tissue intact

• wallerian degeneration distally

• result of prolonged compression/stretch causing necrosis

Neutrotmesis (Sutherland 3, 4, & 5)

Symptoms:

• muscle wasting w/o pain

• complete motor/sensory functions lost

surgical intervention required

• complete severance of nerve fiber

• disruption of connective tissue coverings

• result of gunshot/stab wounds, avulsion, rupture

C-spine Capsular Pattern

side flexion = rotation

extension

GHJ Capsular Pattern

ER

Abduction

IR

ACJ Capsular Pattern

horizontal adduction

full elevation

Prox RUJ Capsular Pattern

supination = pronation

Thumb Capsular Pattern

abduction

extension

T-spine Capsular Pattern

side flexion = rotation

extension

L-spine Capsular Pattern

side flexion = rotation

extension

Hip Capsular Pattern

flexion

abduction

IR

Upper Trap Stretch

rotate towards, side bend opp, flex

Levator Scap Stretch

side bend opp, rotate opp (down)

Scalene Stretch

extend, side bend opp, rotate towards (up)

SCM Stretch

side bend opp, rotate towards (up)

ULTT1

Median Nerve (C5-7)

• shoulder abd (~110)

• elbow ext

• forearm sup

• wrist & fingers ext

• neck bent away

ULTT2

Median, Musculocutaneous, Axillary Nerves

• shoulder abd (~10), ER

• elbow ext

• forearm supination

• wrist & fingers ext

• neck bent away

ULTT3

Radial Nerve

• shoulder IR, abd (~40), ext (~25)

• wlbow ext

• forearm pronated

• wrist & fingers flex

• neck bent away

ULTT4

Ulnar Nerve (C8-T1)

• shoulder abd, ER

• elbow flex

• wrist & finger extension

• neck bent away

Adhesive Capsulitis Stage 1

• 0-3 months

• achey shoulder at rest, pain at night when laying on it, sharp pain at end ROM

  • pain increases with movement

• some loss of ER & Abd ROM

Adhesive Capsulitis Stage 2 (Painful/Freezing Stage)

• 3-9 months

• progressive loss of ROM and persistence of pain

• loss of ROM in all planes

  • ER > Abd > IR

• thickening of capsule

• very painful

Adhesive Capsulitis Stage 3 (Frozen Stage)

• 9-15 months

• significant loss of ROM

• painful stiffening of shoulder (only with movements)

• atrophy of rotator cuff, biceps, deltoid, triceps

• poor scapulohumeral rhythm → scapular hike

  • should be 2:1 GHJ to scap, but it’s reversed

• loss of axillary fold

Adhesive Capsulitis Stage 4 (Thawing Stage)

• 15-24 months

• pain lessens but stiffness persists

• slow & steady recovery

Saturday Night (Crutch) Palsy

• axilla injury → very high nerve palsy

• MOTOR

  • loss of elbow extension

  • wrist and digit extension loss

  • weak supination

• SENSORY

  • paraesthesia posterior lateral arm, forearm, wrist, posterior aspect of thumb and radial 2.5 fingers

High Radial Nerve Injury

• humerus spiral groove or shaft fracture

• MOTOR

  • triceps spared!!

  • wrist drop & thumb extension weakness

• SENSORY

  • posterior arm spared!!

  • paraesthesia posterior lateral arm, forearm, wrist, posterior aspect of thumb and radial 2.5 fingers

Radial Tunnel Syndrome

• compression of PIN in the radial tunnel (near the supinator)

  • overuse injury

• NO motor or sensory weakness!!!

• pain ~5cm distal to lateral epicondyle

  • mimics lateral epicondylitis

• pain on radial aspect of forearm

• aggravated by resisted supination

  • finger extension w elbow extension (like lateral epicondylitis)

  • forearm pronation and wrist flexion

Posterior Interosseous Nerve Syndrome

• compression of PIN between two heads of the supinator muscle

• pure MOTOR nerve

• pain in deep forearm and lateral elbow

• weakness of wrist extensors

• dropped fingers and thumb

• ECRL function preserved → wrist ext and radial deviation can occur (but are probably weak)

Wartenberg Syndrome

• Cheiralgia Paresthetica— compression of superficial sensory branch under ECRL and brachioradialis

• trauma/tight watch/handcuffs

• pain or sensory disturbances on radial side of dorsum of hand + first 3.5 digits

  • reproduced with flexion and ulnar deviation

• NO MOTOR LOSS

• tinel’s sign +ve at compression site

Adhesive Capsulitis Treatment

• corticosteroid injections

• stretching determined by irritability

• joint mobilizations → posterior +/- inferior glide!!!!

  • breaks adhesions in capsule

  • Stage 1 or 2: grade I or II (bc they’re in pain)

  • Stage 3 or 4: grade III or IV (to improve ROM)

• manipulation under anaesthesia

• US, E-stim

  • should not be the first line of treatment

• patient education

Anterior Shoulder Instability

• most common

• abduction, ER, extension

• load & shift test

• anterior apprehension test

Treatment:

• posterior capsule stretching

• stability exercises for scapula & rotator cuff

• avoid chest press, pull down, push ups early on

• AVOID GLIDES!

Posterior Shoulder Instability

• rare presentation

• from fall or pushing something heavy

• flexion, IR, horizontal adduction

• posterior apprehension test

• jerk or kim test

Treatment:

• stability exercises

• avoid push ups and weight bearing early on

• AVOID GLIDES!

Inferior Shoulder Instability

• very rare presentation

  • CVA

• carrying heavy handbag/objects

• sulcus sign

Treatment:

• stability exercises

• avoid weighted shrugs/elbow curls

• AVOID GLIDES!

External Rotation Lag Sign

• infraspinatus

• supraspinatus

Hornblower’s Test

• teres minor

Empty Can Test

• supraspinatus

Neer’s Test

• impingement

Yocum Test

• impingement

  • arm to opposite shoulder, elbow up

Painful Arc

60-120 → impingement of GHJ

170-180 → AC joint

Sever’s Disease

• heel pain caused by swelling and irritation at growth plate

  • tight gastroc/soleus complex & achilles

  • repetitive stress activities

    • running, jumping, dancing

  • recent growth spurt

• common in 8-13 year olds

• S&S:

  • limited DF

  • TTP over posterior-inferior heel

  • P inc with WB and resolves with rest

  • +ve squeeze test

    • also diagnoses achilles rupture

  • diagnosed with X-ray

Anterior Compartment Syndrome

• pain, pallor, paraesthesia, paralysis, pulselessness

• medical emergency!

  • fasciotomy needed

• trauma to anterior lower leg → increased risk

• pain or tightness in anterior lower leg

• weakness of DF and toe extensors

• edema

Chronic Exertional Compartment Syndrome

• repetitive activities (running, jumping, dancing) causing exercise-induced swelling

• no pain at rest

  • begins shortly after beginning activity

• pain or tightness in anterior lower leg

• weakness of DF and toe extensors

• edema

• possible numbness/tingling

• Intervention:

  • activity modifications

  • strengthening

  • stretching

  • NSAIDs

Ottawa Ankle Rules

when to refer for imaging suspecting fracture:

• inability to bear weight for > 4 steps

• tenderness at tips of malleolus or distal 6cm

• tenderness at navicular (medially) or base of 5th

Medial Scapular Winging

• serratus anterior weakness

OR

• long thoracic nerve palsy

Lateral Scapular Winging

• upper traps & rhomboids weakness

OR

• spinal accessory nerve palsy

OR

• dorsal scapular nerve palsy

McKenzie Method

herniated disc exercise progression

1. prone with pillows under hips

2. prone no pillows

3. prone propped on elbows

4. prone press ups

5. standing

William Flexion Progression Series

treatment for spinal stenosis

1. posterior pelvic tilt

2. single knee to chest

3. double knee to chest

4. partial sit up

5. hamstring stretch (long sitting)

6. hip flexor stretch

7. squat

Low Back Manipulation Criteria

patient score >/= 4/5

• duration of symptoms <16 days

• no symptoms distal to knee

• lumbar hypermobility

• at least 1 hip with >35 degrees IR

• fear-avoidance beliefs questionnaire <19

Low Back Traction Criteria

• low back pain with radiation into buttock, posterior thigh, posterior calf

• peripheralization of symptoms on extension

• positive crossed SLR

• signs of nerve root compression