richard f. baxter-pocket guide to musculoskeletal assessment

POCKET GUIDETO MUSCULOSKELETALASSESSMENTJRICHARD f. BAXlfR, MPl

.::;Chief of Physical TherapyMunson Army Health CenterFort Leavenworth, Kansas

W.B. SAUNDERS COMPANYA Division of Harcourt Brace & CompanyPhiladelphia London Toronto Montreal Sydney Tokyo

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Chapter 11Respiratory Evaluation .

Chapter 8Hip..... 93

Chap,ter 9Knee 107

Chapter 10Foot and Ankle .

Chapter 12Inpatient Physical Therapy Cardiac Evaluation 141

Chapter 13Lower Extremity Amputee Evaluation 145

Chapter 14Neurologic Evaluation 149

Chapter 4Elbow 41

Chapter 5Wrist and Hand 55

Chapter 6Thoracic Spine 69

Chapter 7Lumbar Spine. . . . .. . . . ... . . . . .. .. . . . . . . . . . . . . . . . . . 77

Chapter 2Cervical Spine

Chapter 3Shoulder

Chapter 1Introduction

CONTENTS

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1DINTRODUCTION

KISS: "Keep It Super Simple." KISSis the essence of this quick refer-ence guide to neuromusculoskeletalevaluations and treatment optionsfor some common conditions en-countered in the clinic. This is nei-ther a comprehensive text nor an at-tempt to capture all aspects of

physical therapy and reduce them to fit a pockethandbook. This guide is meant to provide only aframework for a thorough neuromusculoskeletal eval-uation and treatment. I hope you will use this guide,as I do, to keep patient examinations organized, effi-cient, and thorough. When examining a patient, youmay find it helpful to open the guide to the body re-gion in question and lay the book on the nearestavailable flat surface.

Located at the beginning of each section is S/PtHx for subjective/patient history/profile and 0 forobjective, which are portions of the SOAGP note for-mat. The A (assessment), G (goals), and P (plan) areleft up to you, the evaluator, but the treatment op-tions portion of each section is meant to assist inthese areas. While examining a patient, you may findit necessary to glance at the outline to maintain anefficient, organized thought flow. If the correct proce-dure for performing a special test slips your mind dur-ing the examination, turn to the material after the out-line to refresh your memory. Although there are manymore special tests and modifications of the tests Ihave included, this handbook provides a basic groupof commonly used special tests; you should feel freeto write in other tests that you use in your practice.

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Chapter 15Inpatient Orthopedic Evaluation 151Appendix ADermatomes 160Appendix BSclerotomesAppendix CAuscultationAppendix 0Normal Range of Motion 163Appendix ELigament Laxity Grading Scale 161Appendix FCapsular Pattern and Closed Pack Positionsfor Selected Joints 168Appendix GRadiology 169Appendix HPhysical Agent and Modalities 111Appendix ITypes of Traction 180Appendix JNormal Values for Commonly EncounteredLaboratory Results 183Appendix KAbbreviations and Definitions 185Index 189

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The treatment options are, in fact, options; they of-fer only a starting point. There are many more treat-ment regimens, protocols, and techniques than couldbe presented in this text. In some cases, I includedtools for diagnosis or treatment that may be beyondthe scope of practice for the providers using thistext. For example, physical therapists within myscope of practice are credentialed to order radio-graphs, although this is outside the scope of practicefor many, as may be the case for treatment optionsthat include the prescription of NSAIDs. In some in-stances, I have included options that only a physicianor surgeon may consider, such as injection or sur-gery. These ideas about the continuum of care maybe helpful in patient education or useful as a re-minder of the various options available to the patientwho is referred for further intervention.

Basic outlines for respiratory, cardiac, amputee,neurologic, and acute inpatient evaluations are givento help in acute care settings. To save space, manystandard terms are abbreviated throughout the book.These are explained in Appendix K.

My sincere hope is that this guide is a useful toolfor you in the clinic and that it motivates you to con-tinued study, learning, and growth. Many physicaltherapy and physician assistant students, as well aspracticing physical therapists and physician assis-tants, have found it to be helpful, and I believe youwill too!

Subjective ExaminationAlthough not exhaustive, the following is the

framework for the subjective examination used inthe evaluation outlines throughout the text. Onlythose items that are most pertinent to each regionhave been included in an abbreviated format in thespecific body region subjective examination outlines.

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Age Sex Chief complaint Onset of Sx (insidious, from trauma or overuse) Body chart (body diagram with location of Sx,

depth/quality/type of pain, whether pain is con-stant/intermittent, interaction between pain sites,presence of paresthesia)

Duration of Sx (if insidious) MOl (if due to trauma) Nature of pain (constant/intermittent, deep/super-

ficial, boring/sharp/stabbing/hot!ache, AM/PM differ-ence in the Sx, sclerotomal or dermatomal pattern)(see Appendices A and B)

AGG (positions or activities, how long it takes toaggravate Sx and how long to recover)

Easing factors (what relieves Sx) Radiographs/CT scans/MRI/lab results

Meds Occupation/recreation/hobbies Diet/tobacco/alcohol Exercise PMH x (e.g., H/O cancer, cardiovascular disease,

HTN, adult/child illnesses) PSH x Family history Review of systems and SO

I General health/last physical examinationI Unexplained weight lossI Night painI Bilateral extremity numbness/tinglingI Systems*

*Region-specific questions are located in applicableevaluation outlines.

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*For the musculoskeletal screening examination of adjacentjoints, apply only the most sensitive tests for the most com-mon musculoskeletal abnormalities. Check AROM, PROM,GMMT. The purpose is to assist in detecting all areas ofinvolvement or additional findings that may alter the diagno-sis.

Position SequenceI. Standing

II. SittingIII. SupineIV SidelyingV Prone

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B. PostureC. Abnormalities, deformities, muscular

atrophyD. Function

III. AROM (see Appendix OJIV GMMT or myotomal screenV Special tests (per specific region)

VI. Sensation (e.g., light touch, vibration, hot/cold,sharp/dull, two-point discrimination)

VII. Palpation (e.g., defects, pain, spasm, edema/effusion, tissue density)

VIII. Joint play (per Magee' and Maitland2)

References1. Magee DJ: Orthopedic Physical Assessment, 3rd ed.

Philadelphia, WB Saunders, 19972. Maitland GD: Peripheral Manipulation, 3rd ed. Boston,

Butterworth-Heinemann, 1991.

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MusculoskeletalPulmonaryLymphaticNeurologic

SkinEndocrineCardiovascularGastrointestinalUrinary/reproductive

t Patient's goals

Objective ExaminationAlthough not exhaustive, the following is the frame-work for the objective examination used in the evalu-ation outlines throughout the text. Only those posi-tions and items that are most pertinent to eachregion have been included in an abbreviated formatin each region-specific evaluation outline.

Items to Assess in Each Position as ApplicableI. R/O other pathology by "clearing" joint above

and below or other areas that refer similar Sx*II Observation

A. Gait (e.g., cadence, stride length, weightbearing, antalgic, base of support,sequence)

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SubjectiveExamination\

t Pt Hx (region specific): nature ofpain (dermatomal or sclerotomal)?(see Appendices A and B)

t Does coughing, sneezing, strain-ing, or anything that increases intradiscal and in-trathecal pressure aggravate the Sx?

t SQ: bilateral UE numbness and tingling, recent on-set of headache, dizziness/visual disturbance/nau-sea, difficulty swallowing

t Type of work and posture/positions assumed atwork, sleeping positions, type and number of pil-lows used

t Trauma? If so, was there loss of consciousness?t Review of systems (endocrine, neurologic, cardio-

vascular, pulmonary, gastrointestinal)

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Objective ExaminationI. Standing

A. Observation1. Posture: structure and alignment in three

planesII. Sitting

A. R/O shoulder or thoracic spine pathologyB. Observation

1. Posture (C5 or C6 radiculitis/radiculopathytends to feel better with the arm restingoverhead; C7 radiculitis/radiculopathytends to feel better with the arm cradledagainst the abdomen)a. Forward headb. Rounded shouldersc. Protracted scapulae and other signs

C. AROM (note quality, rhythm, pain, assessedby estimation, inclinometer, or othermethods; apply overpressure, if necessary, tothese motions)1. Cervical flex2. Cervical ext3. Cervical sidebending4. Cervical rot5. Combined motions (e.g., chin tuck,

sidebending with rot)D. Myotomal screen and GMMT

1. Neck flex (C1-C2)2. Shoulder elevation/shrug (C3-C4)3. Shoulder abd (C5)4. Elbow flex/wrist ext (C6)5. Elbow ext/wrist flex (C7)6. Thumb IP joint ext/finger flex (C8)7. Finger add (T1)

E. MSRs

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1. Biceps (C5)2. Brachioradialis (C6)3. Triceps (C7)

F. Pathologic reflexes: Hoffmann's signG. Special tests (as applicable)

1. Foraminal encroachment: compression(Spurling's) test, distraction test

2. Thoracic outlet syndrome: Adson'smaneuver, costoclavicular syndrome test,hyperabduction test, Halstead's maneuver,Allen's test

3. VA testH. Sensation: dermatomes (see Appendix A)

III. SupineA. Special tests: upper limb tension testingB. Joint play: lat and anterior glides, cervical

distractionIV. Prone

A. Palpation: bony landmarks and soft tissueB. Joint play

1. PACVP2. PAUVP3. Transverse pressure4. Lat glides

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o SPECIAL TESTS FOR THE CERVICAL SPINE

Test Detects Test Procedure Positive Sign

Compression (Spurling'sl test' Foraminal encroachment Pt sitting and laterally flexes cervical Pt experiences radicular pain thatspine to one side. Examiner presses radiates into arm toward which head/straight down on PI's head. This cervical spine is flexedprocedure is repeated on opposite side.

Distraction test' Foraminal encroachment PI sitting. Examiner places one hand Pain in neck and into UE is relieved orunder PI's chin and other hand around decreased when cervical spine isocciput. Examiner slowly lifts PI's head. distracted

Ouadrant position' Foraminal encroachment PI sitting. PI performs combined ext, lat Pain radiates into arm toward whichflex, and rot. This reduces size of head/cervical spine is extended, laterallyintervertebral foramen. flexed, and rotated

Reproduction of PI's SxHave PI keep eyes open to observenystagmus if it occurs (indicative of VAcompression, causing lack of bloodsupply to brain stem and cerebelluml

Vertebral artery test/neck ext-rot test'

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Test 1

Test 2

Upper limb tension test (brachial plexustension testl' (median nerve biasl

VA compression or occlusion

Rules out inner ear as cause ofdizziness

Dural/meningeal irritation or nerve rootimpingement (similar to SLR test in LEI

Pt sitting and places cervical spine incombined ext and rot such that PI islooking back over shoulder. Pt must keepeyes open. This is performed to eachside for 20 sec.

PI standing. Examiner stabilizes PI'shead by holding PI's head with hands.PI then rotates trunk and holdsmaximum rot for 20 sec to each side.

PI supine. Examiner takes PI's UE intoglenohumeral abd (110 deg approxl,forearm supination, wrist and finger ext,shoulder ER 190 deg approxl. elbow extand neck lat flex away from testingside.

Rapid eye movements, pupils dilate,dizziness, syncope, IightheadednessControversy exists in medical communityconcerning this test. Some suggest thatit possesses low sensitivity' Apply atyour own risk, and use caution with thistest. Examiner should first have Ptperform cervical rot to see if thisproduces Sx of VA insufficiency beforeproceeding to described test position.

Same as for test 1If Sx were not induced, cause ofdizziness was most likely not an innerear problem

Radicular pain/paresthesia into testedUE

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SPECIAL TESTS FOR THE CERVICAL SPINE Continued


Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root Pt supine. Examiner depresses PI's Radicular pain/paresthesia into testedtension testl' (Radial nerve biasl impingement (similar to SLR test in LEI shoulder, extends elbow, flexes PI's UE

thumb into palm, pronates forearm, andulnarly deviates wrist.

Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root Pt supine. Examiner depresses PI's Radicular pain/paresthesia into testedtension test)' (ulnar nerve bias) impingement (similar to SLR test in LEI shoulder, pronates forearm, extends UE

wrist. flexes elbow, and abducts arm.

Hoffmann's sign' (pathologic reflex for Corticospinal tract lesion of spinal cord Examiner grasps and stabilizes PI's hand Induced flex of thumb and other fingersUE similar to Babinski sign for LEI and "flicks" distal phalanx of middle

finger in direction of ext (causing aquick stretch of finger flexors)

Thoracic outlet syndrome See Shoulder Special Tests andThoracic Outlet Syndrome Tests table inChapter 3

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Special Condition

Acute cervical radiculitis orradiculopathy (may be caused by discbulge/HNP or narrowing ofintervertebral foramenl

Hx/Symptoms

CS-C6 and C6-

TREATMENT OPTIONS FOR THE CERVICAL SPINE Continued

Special Condition Hx/Symptoms Signs/Objective Findings Treatment Options

Cervical spondylosis (ODD) C5-C6 and C6-C7 most commonly AM stiffness that is eased with AROM exercises several times per dayinvolved movement but worsens later in day with Cervical isometrics (painfree)Nerve root/spinal cord pressure continued activity Cervical traction (intermittent)common from foraminal encroachment Radiograph may confirm and showand spinal stenosis, resulting in decreased disc space and osteophytes/ Moist heatradicular Sx spurring Pt education (neck carel/self-treatment

Cervical DJO (involves facet jointsl Upper cervical Pain and stiffness with rest that AROM exercises several times per dayGradual onset improves with movement Cervical isometrics (painfreelForward head posture AROM rot and lat ftex most limited Cervical traction (intermittentlCrepitus Palpable thickening of facet joint Moist heat

margins Pt education (neck carel/self-treatmentRadiograph may confirm Soft tissue mobilization

Muscle strain or contusion

Acute torticollis ("wry neck"lFrom acute facet locking

Muscle pain/sorenessHx of trauma/overuse

Hx of unexpected movement or pro-longed prone lying with head rotated toone sideSharp pain that is unilateral and welllocalized

Tender soh tissue with palpationARDM limited by pain

Protective deformity of lat flex and rotaway from painMuscle guardingNeurologic system: normal

First, ensure PI is stable/no Fx

Acute: Relative rest, ice for first 48-72hours, moist heat with interferentialelectrical stimulation or ultrasound withelectrical stimulation after initial 72hours, add ARDM to tolerance

Subacute/chronic' ARDM, SCM and up-per trapezius stretching, shoulder rolls,cervical isometrics (painfreel. posturaleducation

Acute: supine lying to unload facet, ice,gentle manual distraction in line with de-formityGentle PROM away from painful sideCervical collar for 2-3 days to unloadfacets

Subacute/chronic: muscle energy tech-niques to regain ARDM, progress to cer-vical isometrics

Continu"d ...

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Bihliography

References1. Magee DJ: Orthopedic Physical Assessment, 3rd ed.

Philadelphia, WB Saunders, 1997.2. Bland JH: Disorders of the Cervical Spine: Diagnosis and

Medical Management, 2nd ed. Philadelphia, WB Saunders, 1994.3. Maitland GD: Vertebral Manipulation, 4th ed. Boston,

Butterworths, 1973.4. Cote P, Kreitz BG, Cassidy JD, Thiel H: The validity of the

extension-rotation test as a clinical screening procedure beforeneck manipulation: A secondary analysis. J Manipulative PhysiolTher 19:159-164,1996.

5. Butler DS: The upper limb tension test revisited. In Grant R(ed): Physical Therapy of the Cervical and Thoracic Spine, 2nd ed.New York, Churchill Livingstone, 1994.

6. Kandell ER, Schwartz JH, Jessell TM (eds): Principles ofNeural Science, 3rd ed. New York, Elsevier Science Publishing,1991 .

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy PrinCiples andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Highland TR, Dreisinger TE, Vie LL, et al: Changes in isometricstrength and range of motion of the isolated cervical spineafter eight weeks of clinical rehabilitation. Spine17(Supplement 6)S77-S82, 1992.

Jones H, Jones M, Maitland GD: Examination and treatment bypassive movement. In Grant R (ed): Physical Therapy of theCervical and Thoracic Spine, 2nd ed. New York, ChurchillLivingstone, 1994.

Kisner C, Colby LA: Therapeutic Exercise: Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Magarey ME: Examination of the cervical and thoracic spine. InGrant R (ed): Physical Therapy of the Cervical and ThoracicSpine, 2nd ed. New York, Churchill Livingstone, 1994.

Saunders HD, Saunders R: Evaluation, Treatment and Preventionof Musculoskeletal Disorders: Spine, 3rd ed, vol 1. Chaska,Minnesota, Educational Opportunities, 1993.

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SubjectiveExamination

SQ, if applicable: night pain, bilateral UE numb-ness/tingling, unexplained weight loss)

Review of systems (cardiovascular, pulmonary, gas-trointestinal)

Pt Hx (region specific): which isthe dominant UE, radicular Sx (der-matomal or sclerotomal)? (see Ap-pendices A and B)

Functional limitations

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A. Observation1. Posture2. Abnormalities, deformities, atrophy

B. AROM (note quality, scapulohumeral rhythm,pain, and common substitutions)1. Shoulder flex (165-180 deg)2. Shoulder ext (50-60 deg)3. Shoulder abd (170-180 deg)4. Shoulder horizontal abd and add

C. PROM if lacking AROM in any motionsD. Special tests (as applicable)

1. Impingement: impingement relief testII. Sitting

A. R/O cervical pathology (see Special Tests forthe Cervical Spine in Chapter 2)

B. Observation1. Posture2. Abnormalities, deformities, atrophy

C. AROM may also be assessed in sittingD. PROM if lacking AROM in any motionsE. GMMT and myotomal screen

1. Shoulder elevation/shrug (C3-C4)2. Shoulder abd (C5)3. Shoulder flex (C5-C7)4. Shoulder ext5. Elbow flex/wrist ext (C6)6. Elbow ext/wrist flex (C7)7. Thumb IP joint ext/finger flex (C8)8. Finger add (T1)

F. MSRs, if applicable1. Biceps (C5-C6)2. Brachioradialis (C5-C6)

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3. Triceps (C7)G. Special tests (as applicable)

1. Instability: anterior/posterior apprehensiontests, relocation test. sulcus sign

2. Biceps tendinitis/tendon instability:Yergason's, Speed's, Ludington's, and THLtests

3. Impingement: painful arc test, Hawkin'simpingernent test, impingement relief test,Neer's impingement test

4. Rotator cuff tear: drop-arm test,supraspinatus test (empty can test)

5. Thoracic outlet syndrome: Adson'smaneuver, costoclavicular syndrome test.or Halstead's maneuver; hyperabductionsyndrome test

H. Sensation: LT and 2-point discriminationI. Palpation

1. Tendons of the rotator cuff2. Bicipital groove/biceps tendon3. Bony landmarks

III. SupineA. Special tests (as applicable)

1. Impingement: impingement relief test(may be performed standing or supine)

2. Joint playa. AP glideb. Long-axis distractionc. AP motions of the clavicle at the AC

and SC jointsIV. Prone

A. AROM1. Shoulder IR (70-80 deg)2. Shoulder ER (80-90 deg)

B. GMMT1. Shoulder IR2. Shoulder ER

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SPECIAL TESTS FOR THE SHOULDER


m 191 lei TNeer's impingement test' 2 Impingement of long head of biceps PI sitting or standing. PI's arm is passively Reproduction of PI's Sx

tendon and/or supraspinatus tendon elevated through forward flex by examiner,forcing greater tubercle of humerus againstacromion.

Hawkin's impingement test' Impingement of inflamed supraspinatus Pt sitting or standing. Examiner forward Reproduction of PI's Sxtendon flexes PI's arm to 90 deg, and flexes PI's

elbow to 90 deg, then passively internallyrotates shoulder, forcing supraspinatustendon against coracoacromial ligament.

Painful arc' test Pathology of subacromial origin (e.g., Pt sitting or standing. Pt abducts arm in Reproduction of Sx in a 60-120 deg arc.impingement, rotator cuff tendinitisl neutral position (no IR or ERI Pain stops or is dramatically reduced when

humeral head glides inferiorly."No pain --> pain --> no pain"

NW

Impingement relief test' Helps confirm Ox of impingement Pt standing, performs active flex and abd3-5 times while examiner records locationof onset of painful arc range. Pt asked togive a subjective indication of amount ofpain. Test is then repeated while examinerapplies a gentle inferior or posteroinferiorglide just before onset of recorded painfularc. PI is then asked again to give asubjective indication of amount of pain.Test may be modified to a supine position

Outcomes and their interpretations are asfollows:Complete relief of pain: indicates thathumeral head is capable of moving undersubacromial arch without impinging. Thisindicates contractile tissue as primary causeand recommend a Rx regimen aimed attraining contractile tissue to balance forcecouple and scapulohumeral rhythm le.g.,strengthening, proprioception, scapularstabilizationl.Partial relief of pain at same point in rangeof motion: suggests that, in addition tocontractile tissue weakness, noncontractiletissue is involved. Joint mobilization inaddition to strengthening and re-educationshould be part of Rx regimen.No relief or reduction of pain: indicatesinability of humeral head to depress becauseof noncontractile tissue tightness. As part oftreatment program, perform jointmobilization to restore accessory motions toachieve inferior and posteroinferior glide ofhumeral head. Inability to reduce pain bystretching and joint mobilization mayindicate pathology other than impingementas source of pain.

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N~ SPECIAL TESTS FOR THE SHOULDER Continued


Stability TestsAnterior apprehension test' Anterior instability PI sitting, standing, or supine. Examiner Pt has look of alarm or apprehension and

places PI's shoulder in abd and ext rot (90 resists further motion. PI may also have paindeg/90 deg). Then examiner applies an ext with this movement.rot force.

Relocation test' Anterior instability PI supine. Same procedure as apprehension PI's alarm or apprehension disappears, paintest. Upon finding a positive anterior may be relieved, and further ext rot isapprehension test, maintain that position allowedand apply a posterior force with one hand tothe PI's arm.

Sulcus sign' Inferior instability Pt standing or sitting with arm by side and Sulcus (gapl appears at glenohumeral jointwith shoulder muscles relaxed. Examiner Must compare with uninvolved shouldergrasps PI's forearm below elbow and pullsdistally/inferiorly.

Posterior drawer sign' Posterior instability PI supine. Examiner grasps PI's proximal Posterior displacement can be felt as thumbforearm with one hand and flexes elbow 120 slides along lat aspect of coracoid processdeg. Then examiner positions PI's shoulder PI may also have apprehensionin 80-120 deg abd and 20-30 deg flex.With other hand, examiner stabilizes PI'sscapula. As PI's arm is internally rotated andflexed, examiner attempts to sublux humeralhead with thumb.

load-shift test'

Miscellaneous TestsCross-arm adduction test'

AC joint shear test'

Yergason's test"

Speed's test'

Anterior, posterior, or multidirectionalinstability

AC joint pathology

AC joint lesion/DJD

Unstable biceps tendon due to THl tearCould also detect biceps tenosynovitis

Bicipital tendinitis

Pt sitting. First, examiner places one handover PI's clavicle and scapula for stability.Then, grasping proximal arm near humeralhead, examiner "loads" humeral head suchthat it is in a neutral position in glenoidfossa. Examiner then applies an anterior orposterior force, noting amount of translationand end-feel.

Pt sitting. Examiner horizontally adducts(passive) PI's arm across chest wall.PI sitting. Examiner cups hands, with onehand on PI's scapula and other hand overclavicle and then squeezes, causing a shearforce at AC joint.Pt sitting or standing. PI's elbow flexed 90deg, with arm at side of body. Examinerresists at wrist while PI attempts tosupinate a pronated forearm.

Pt sitting or standing. PI's shoulder is flexedwith forearm supinated, and elbow iscompletely extended. Examiner palpatesbiceps tendon in bicipital groove and forcesarm down in ext as PI resists.

Excessive displacement anteriorly,posteriorly, or both compared withuninvolved shoulder

Reproduction of PI's Sx at AC joint

Reproduction of Pt's Sx at or excessivemotion in AC joint

localized reproduction of PI's Sx in bicipitalgroove

Reproduction of PI's Sx localized to bicipitalgroove

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1 SPECIAL TESTS FOR THE SHOULDER Continued

Test I Detects Test Procedure Positive Sign

Ludington's test" I Rupture of long head of biceps tendon Pt sitting or standing. Pt clasps both hands Examiner feels tendon on uninvolved sideon top of head and interlocks fingers. Pt but not on involved side during contractionthen simultaneously contracts and relaxes of biceps muscleI biceps muscles while examiner palpatesbiceps tendon proximally at bicipital groove.

Apley's scratch test' Functional method of assessing shoulder Pt performs combined IR with add in Gives examiner an idea of functionalin IR and ER attempt to touch or "scratch" opposite capacity/AROM of Pt's shoulders

scapula. Second motion involves combined This is recorded by the anatomic landmarkER with abd in attempt to place hand that Pt is able to reach and touch (e.g., tobehind head and touch top of opposite inferior angle of scapula1shoulder.

Drop-arm test' Rotator cuff tear (specifically, Pt sitting or standing. Examiner passively Arm drops suddenly to side because ofsupraspinatus tendon) abducts PI's shoulder to 90 deg. Pt is then weakness and/or pain

instructed to maintain arm in that position.Examiner then presses inferiorly on PI's arm.

Supraspinatus test (empty Torn supraspinatus muscle or tendon Pt sitting or standing. Pt in "empty can .. Reproduction of PI's Sx or weaknesscan testI' Supraspinatus tendinitis position 90-deg shoulder abd, 30-deg Compare with uninvolved side

Neuropathy of suprascapular nerve horizontal abd, and maximum IR. Examinerresists PI's attempt to abduct.

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Test*

Adson's maneuver"

Costoclavicular syndrome test"

Hyperabduction syndrometest 14

Halstead's maneuver'

L

Detects

Entrapment in scalene triangle

Entrapment between 1st rib and clavicle

Entrapment between coracoid processand pectoralis minor

Entrapment in scalene triangle

Test Procedure

Pt sitting. Examiner locates Pt's radial pulse.Pt then rotates head toward test shoulderand extends head/neck. Examiner thenexternally rotates and extends Pt's shoulderas Pt takes a deep breath and holds it.

Pt sitting. Examiner palpates radial pulseand then draws PI's shoulder down andback (depression and retractionI.Pt sitting. Examiner palpates radial pulseand hyperabducts Pt's arm so that PI's armis overhead. Pt takes a deep breath andholds it.

Pt sitting. Examiner palpates radial pulse. Ptthen rotates head away from test shoulderand extends head/neck. Examiner thenexternally rotates and extends PI's shoulder,applying downward traction as Pt takes adeep breath and holds it.

Positive Sign

Reproduction of pain and paresthesia intested UE with diminished or absent pulse




'These tests detect subclavian artery and brachial plexus entrapment.

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TREATMENT OPTIONS FOR THE SHOULDER


Impingement syndrome Pain with overhead motion or when Positive painful arc Acute: relative rest, ice, NSAIDshand is placed behind back Positive Hawkin's impingement test Gentle ROM ICodman's/pendulum, wandPain may refer down lat arm or anterior Positive Neefs impingement test exercisesIhumerus Must R/O cervical pathology Subacute/chronic: isometric shoulder flex!

Check for instability that may be allowing exVIR/ER exercises progressing to isotonicimpingement (tubing or free weights) as Sx improveCheck for tight posterior and/or inferior May consider ultrasound to aid in healing/capsule or muscle imbalance improve blood flowPI may have poor posture as a causative Shoulder proprioception exercisesfactor Closed chain shoulder stabilization leg.,

quadruped position and examiner appliesperturbation to Pt)Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises le.g., push-up with a plus, seated press-upsIPosterior/inferior capsule stretch ifindicatedAvoid overhead activities/work thataggravates Sx

Nto

Supraspinatus tendinitis Pain with overhead motion or whenhand is placed behind backPain may refer down lat arm or anteriorhumerus

Key finding is exquisite pain with resistedmovement involving supraspinatus muscleipositive supraspinatus/empty can test)R/O cervical pathologyWill also have positive impingement tests

Acute: relative rest. ice, NSAIDsGentle ROM iCodman's, wand exercises)Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsl as Sx improveSupraspinatus-specific exercisesMay consider ultrasound to aid in healing/improve blood flowClosed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt)Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises le.g., push-up with a plus, seated press-upsIPosterior/inferior capsule stretching ifindicatedAvoid overhead activities/work thataggravates Sx

COli till "I'd ...

~ TREATMENT OPTIONS FOR THE SHOULDER ContinuedSpecial Condition Hx/Symptoms Signs/Objective Findings Treatment Options

Bicipital tendinitis Pain over anterior shoulder Exquisite tenderness to palpation over Acute: Relative rest, ice, NSAIDsDoes Pt perform repetitive curls/elbow bicipital groove Gentle ROM ICodman's, wand exercisesIflex against high resistance at work or Mayor may not have positive Vergason's Avoid AGG and initiate Pt educationrecreation/weight lifting? or Speed's testsPt may report "snapping" in region of May have exquisite pain with resisted Subacute/chronic: isometric shoulder flex/bicipital groove horizontal add of shoulder that is in 90 ext/IR/ER exercises progressing to isotonic

deg ER Itubing or free weightsl as Sx improve(avoid strenuous resistance in earlyCheck for posterior capsule tightness phaseslR/O cervical pathology IR stretch (towel/door stretch)

May consider ultrasound to aid in healing/improve blood flow or phonophoresis/iontophoresis for pain relief and todecrease inflammationShoulder proprioception exercisesClosed chain shoulder stabilization le.g"quadruped position and examiner appliesperturbation to Pt)Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises (e.g., push-up with a plus, seated press-ups)

w....

Subacromial/subdeltoid bursitis Pain at superior portion ofglenohumeral jointPain at night with difficulty sleepingPaln may radiate down arm

Marked restriction of shoulder flex andabdTenderness to palpation over deltoidaround acromionDistraction of glenohumeral joint inferiorlymay relieve SxR/O cervical pathology

Acute: relative rest. ice, NSAIDs,phonophoresis or iontophoresis

Subacutelchronic: gentle prom (Codman's)progressing to AAROM (wand, pulleylIsometric shoulder flex/ext/IR/ER exercisesprogressing to isotonic (tubing or freeweightsl as Sx improveJoint mobilizationMay consider ultrasoundClosed chain shoulder stabilization (e.g.,quadruped position and examiner appliesperturbation to Pt)Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises (e.g., push-up with a plus. seated press-upsIPt education to avoid overhead activities/workAvoid overhead work/activities thataggravate Sx

WN

TREATMENT OPTIONS FOR THE SHOULDER Continued


Anterior shoulder instability (after Hx of acute traumatic abd-ER injury Positive apprehension and/or relocation Acute: radiographs to R/O Hill-Sach's orsubluxation or dislocation) Ifall on outstretched arm or grasp of test Bankhart lesion (if Pt being seen for the

arm during throwing motion! Positive load-shift test (with anterior first time!translation! Protection (immobilization and PI education

to avoid shoulder ER with abdl. ice, NSAIOsGentle ROM (Codman's, wand exercisesi inpainfree and apprehension-free range

Subacute/chronic: isometric shoulder ftex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsI as Sx improveShoulder proprioception exercisesClosed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to PtlWork on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises le.g., push-up with a plus, seated press-ups!Pylometrics progressing to least stableosition

ww

Posterior instability (aftersubluxation or dislocation)

Hx of trauma Positive posterior drawer signPositive load-shift test (with posteriortranslation)

Refer PI to orthopedic surgeon if stabilitynot improvingAcute: radiographs lif PI being seen forfirst timelProtection (immobilization and Pteducation), ice, NSAIDsGentle ROM (Codman's, wand exercises) inpainfree and apprehension-free rangeSubacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsl as Sx improveShoulder proprioception exercisesClosed chain shoulder stabilization (e.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises (e.g., push-up with a plus, seated press-upsIPt education to avoid overhead activities/work that aggravates SxRefer Pt to orthopedic surgeon if stabilitynot improving

COlltllllU'd T


Special Condition

Multidirectional instability

Hx/Symptoms

Pt C/O instability and may be able todemonstratePt may have pain or impingement typeSx due to excessive movement/laxity ofglenohumeral joint

Signs/Objective Findings

Positive sulcus signPositive load-shift test (with both anteriorand posterior translation!

Treatment Options ~

Acute relative rest. Ice, NSAIOsGentle ROM ICodman's, wand exercises)Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weights! as Sx improveShoulder proprioception exercisesClosed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises le.g., push-up with a plus, seated press-upslPt education to avoid activities/work thataggravates Sx or places PI in an unstablepositionIf stability does not improve over severalmonths of aggressive rehabilitation, referPt to orthopedic surgeon

w(Jl

Rotator cuff tear May have Hx of FOOSH, throwing, orlifting injuryMay be seen in older individuals as aresult of degeneration of rotator cuff

Positive drop-arm testPositive impingement signsPositive painful arc testWeakness of specific rotator cuff musclesMay observe abnormal scapulohumeralmotion li.e.. scapular hiking before upwardrotl

Acute: relative rest, ice, NSAIDsGentle ROM ICodman's exercisesI

Subacute/chronic: isometric rotator cuffstrengthening progressing to isotonicItubing or free weights) as Sx improveShoulder proprioception exercisesClosed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises le.g., push-up with a plus, seated press-ups)If severity of tear warrants, surgicalintervention/repair may be necessary

C lit III ...

wOl



AC joint separation Hx of fall onto shoulder Depending on severity of injury, Pt mayor Immobilization in Kenny-Howard/AC jointmay not have a noticeable "step-off" from sling (type I. 1 wk; type II, 2 wks; type III,clavicle to acromion IV, or V. until Sx subsidelPositive AC joint shear test IcePositive cross-arm adduction test Early ROM within limits of painTenderness to palpation over involved AC Progress to general rotator cuff andjoint shoulder strengthening as Sx subside

Rx of type III still controversial; somerecommend surgical Rx, and others haveobtained good results with nonoperativeRx. However, acute Rx of type III shouldbe the same as for a type II injury. Seethe Cook, Dias, and Mulier entries in theBibliography for treatment options.

For type IV and V injuries, surgery is moreof a consideration. See the Cook and Diasentries in the Bibliography for treatmentoptions.

Adhesive capsulitis

Thoracic outlet syndrome

Common for ages 40-60 yrSeveral weeks' Hx of shoulder pain andrestrictionPt may not be able to pull wallet fromback pocket or fasten clothes thatfasten in back

Sx include pain and paresthesia andpossibly muscle weakness in shoulder,arm, and/or handVery similar to cervical radiculitis/radiculopathy

Restricted ARDM in a clear capsularpattern IER > abd > IRI

Positive thoracic outlet syndrome testsMust differentiate from cervical pathology

Acute: ice, NSAIDs, pain-relievingmodalities in initial stagesCodman's exercises for 2-3 min every 1-2hr

Subacute/chronic: after pain subsidessomewhat. begin stretching to increaseER, abd, and IR through wand exercisesand joint mobilizationUltrasound to axilla to heat joint capsulebefore joint mobilization and AAROM/stretches (remember to addressglenohumeral, scapulothoracic, and ACjoints)

NSAIOsAvoid AGGStretch appropriate structures causing SxNeural stretch (scalenes, levator scapulae,pectoralis minorlStrengthen scapular stabilizers

(f)IoCrom:JJ

38 -------------

References

1. Neer CS, Welsh RP: The shoulder in sports. Orthop ClinNorth Am 8583-591,1977.

2. Neer CS: Impingement lesions Clin Orthop 173:70-77,1983.

3. Hawkins RJ, Bokor DJ: Clinical evaluation of shoulderproblems. In Rockwood CA, Matsen FA (eds): The Shoulder.Philadelphia, WB Saunders, 1990.

4. Kessell L, Watson M The painful arc syndrome J BoneJoint Surg Br 59:166-172,1977.

5. Corso G: Impingement relief test: An adjunctive procedureto traditional assessment of shoulder impingement syndrome. JOrthop Sports Phys Ther 22: 183-192, 1995.

6. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

7. Gerber C. Ganz R: Clinical assessment of instability of theshoulder. J Bone Joint Surg Br 66:551-556, 1984.

8. Silliman JF, Hawkins RJ: Clinical examination of theshoulder complex. In Andrews JR, Wilk KE (eds) The Athlete'sShoulder New York, Churchill Livingstone, 1994.

9 Davies GJ, Gould JA, Larson RL Functional examinationof the shoulder girdle. Phys Sports Med 9:82-104, 1981

10. Yergason RM: Supination sign. J Bone Joint Surg Am13160,1931.

11. Ludington NA: Rupture of the long head of the bicepsflexor cubiti muscle. Ann Surg 77:358-363, 1923.

12. Adson AW, Coffey JR Cervical rib: A method of anteriorapproach for relief of symptoms by division of the scalenusanticus. Ann Surg 85:839-857, 1927.

13 Falconer MA, Weddell G: Costoclavicular compression ofthe subclavian artery and vein. Lancet 2539-544, 1943

14. Wright IS: The neurovascular syndrome produced byhyperabduction of the arms Am Heart J 29: 1-19, 1945.

BibliographyBoissonnault WG, Janos SC Dysfunction, evaluation, and

treatment of the shoulder. In Donatelli R, Wooden MJ (eds):Orthopaedic Physical Therapy. New York, Churchill Livingstone,1989.

Cook DA, Heiner JP: Acromioclavicular joint injuries: A reviewpaper. Orthop Rev 19510-516,1990.

Dias JJ, Gregg PJ: Acromioclavicular joint injuries in sport:Recommendations for treatment: Sports Med 11:125-132,1991.

-------------- 39

Ellman H: Diagnosis and treatment of rotator cuff tears. ClinOrthop 25464-74, 1990.

Hawkins RJ, Abrams JS: Impingement syndrome in the absenceof rotator cuff tear (stages 1 and 21. Orthop Clin North Am18373-382, 1987.

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders. Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Itoi E, Tabata S: Conservative treatment of rotator cuff tears. ClinOrthop 275:165-173,1992.

Karas SE: Thoracic outlet syndrome. Clin Sports Med 9:297-310,1990.

Kisner C, Colby LA: Therapeutic Exercise. Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Mulier 1. Stuyck J, Fabry G: Conservative treatment ofacromioclavicular dislocation: Evaluation of functional andradiological results after six years' follow-up. Acta Orthop Belg59255-262, 1993.

Neviaser RJ, Neviaser TJ: The frozen shoulder Diagnosis andmanagement: Clin Orthop 223:59-63, 1987.

Pink M, Jobe FW: Shoulder injuries in athletes. Orthopedics1139-47, 1991.

0:Wo--.J::JoI(f)

-nr-------------41

illHBOW

SubjectiveExamination Pt Hx (region specific): dominant

hand, radicular Sx (dermatomal orsclerotomal) 7 (see Appendices Aand B)

SO (if applicable)soco.-JW

mr-eoo:2

42 ---------------


A. Observation1. Posture

a. Carrying angle for males (normal 5-10deg valgus)

b. Carrying angle for females (normal 15deg valgus)

II. SittingA. R/O cervical or shoulder pathologyB. Observation

1. Posture2. Atrophy or deformities3. Edema

C. AROM1. Elbow flex (140-150 deg)2. Elbow ext (0 deg)3. Elbow pronation (70-80 deg)4. Elbow supination (80-90 deg)

D. GMMT and myotomal screen1. Shoulder elevation/shrug (C3-C4)2. Shoulder abd (C5)3. Shoulder flex (C5-C7)4. Elbow flex/wrist ext (C6)5. Elbow ext/wrist flex (0)6. Forearm pronation/supination7. Thumb IP joint ext/finger flex (C8)8. Finger add (T1)

E. MSRs, if applicable1. Biceps (C5)2. Brachioradialis (C6)3. Triceps (0)

F. Special tests (as applicable)1. Instability: varus/valgus stress test

2. Epicondylitis: tests for lateral and medialepicondylitis

3. Nerve impingement/entrapment tests:Tinel's sign at the elbow, Wartenberg's sign,elbow flex test, test for pronator teressyndrome

G. Sensation: LT and 2-point discriminationH. Palpation

1. Soft tissue2. Bony landmarks

I. Joint play1. Radial and ulnar deviation (similar to valgus/

varus testing)2. Ulnar distraction with the elbow in 90 deg

flex3. AP glide of radius

43

soa:l-lW

...

... SPECIAL TESTS FOR THE ELBOW

r

Test

Varus stress test for elbow'

Valgus stress test for elbow'

Tests for lat epicondylitis'

Method 1

Method 2

Tests for med epicondylitis'

linel's sign (at elbow)'

Wartenberg's sign'

Elbow flex test'

Test for pronator teres syndrome'

Detects

Rupture of RCLVarus instability also associated withanterior radial head dislocation andannular ligament disruption

Rupture of UCL

Lat epicondylitis

Lat epicondylitis

Med epicondylitis,

Regeneration rate of sensory fibers ofulnar nerve

Ulnar neuritis (entrapment may be atelbowl

Cubital tunnel syndrome

Impingement of median nerve bypronator teres muscle

Test Procedure

PI's arm is stabilized with one ofexaminer's hands placed at elbow andother hand placed above PI's wrist. PI'shumerus is placed in full IR, and elbowis slightly flexed (15-20 degl asexaminer applies varus force.

PI's arm is stabilized with one ofexaminer's hands at elbow and otherhand placed above PI's wrist. PI'shumerus is placed in full ER, and elbowis slightly flexed (15-20 degl asexaminer applies valgus force.

Examiner palpates lat epicondyle whilepronating PI's forearm and flexing PI'swrist fully with ulnar deviation andextending PI's elbow.

Examiner resists ext of middle fingerdistal to PIP joint, stressing extensordigitorum muscle and tendon.

Examiner palpates med epicondyle,supinates PI's forearm, and extends PI'selbow and wrist fully with radialdeviation.

Examiner taps area of PI's ulnar nerve ingroove behind medial epicondyle.

Pt sits with hand resting on table.Examiner passively spreads PI's fingersand asks Pt to bring fingers together.

Pt completely flexes elbow and holds itfor 5 min.

PI sits with elbow flexed 90 deg.Examiner then attempts to supinate andextend PI's elbow as PI resists.

Positive Sign

Laxity of involved elbow compared withuninvolved Inote amount of laxity and end-feel)

Pain/reproduction of PI's Sx over lathumeral epicondyle

Pain/reproduction of PI's Sx over lathumeral epicondyle

Pain/reproduction of PI's Sx over medhumeral epicondyle

ling ling sensation in ulnar nerve distributionof forearm and hand distal to point oftappingMost distal point at which abnormalsensation is felt represents limit of nerveregeneration

Inability to adduct 5th digit back to otherfingers

lingling/paresthesia in ulnar nervedistribution

lingling/paresthesia in median nervedistribution

I TREATMENT OPTIONS FOR THE ELBOW

Special Condition

UCL rupture

Hx/Symptoms

Hx of elbow dislocation, throwinginjury, or chronic overloading, as in athrowing athlete


Positive valgus stress test of elbowMayor may not have tenderness overattachments of UCL

Treatment Options

Acute: sling/immobilizer, ice, NSAIDsRefer to orthopedic surgeon. Surgerymay be considered

Postop: sling for a few days to 1 wk;maintain fingers/wrist AROM and gripstrength

Cast brace 130-120 degl for 4 wk;allow AROM within this ROMCast brace 10-120 degl for 8 wk;allow AROM within this ROM andbegin strengthening between 8-12wk postop. Begin with isometricelbow ftex/ext and wrist radial/ulnardeviation; progress to isotonic andisokinetic strengthening. In finalstages, functional/return to sportactivity should be initiated.Resume throwing at 6 mo

,

Posterior elbow subluxation/dislocation Hx of FOOSH injury with shoulderabducted or elbow in hyperextension

Radiograph confirms subluxation ordislocationDislocation normally requires relocationby medical personnelFx are common Ibeware!)Be sure to perform a neurovascularassessment

Cast bracing times and ROM limitationsmay vary, but AROM within allowablerestrictions noted above and progressivestrengthening should progress asclinically reasonable and as patienttolerates.Acute: ice, elevation, NSAIDsIf cleared by orthopedic surgeon (no Fxthat require ORIF or prevent initiation ofrehabilitationl, may begin immediatemotionMaintain wrist and hand motion andstrength

No instability: immediate unlimitedmotion without braceValgus instability: immediateunlimited motion in a cast brace withforearm fully pronatedUnstable In extension: immediatemotion in cast brace that blocks fullextension. Extension block may begradually eliminated over 3-6 wk.

Subacute/chronic: begin isometric elbowflex/ext!pronation/supination and wristradial and ulnar deviation. Progress toisotonic and isokinetic strengthening.

( l 11111111 cl ..

I TREATMENT OPTIONS FOR THE ELBOW Continued

Special Condition Hll/Symptoms Signs/Objective Findings Treatment Options

Lateral epicondylitis (tennis elbow) Hx of overuse, heavy lifting, repetitive Local tenderness to palpation over Acute: decrease inflammation lice,motions such as filing/keyboard work/ common wrist extensor origin (Iat NSAIDs, phonophoresis or iontophoresis)tennis strokes (forceful pronation and humeral epicondyle) Relative restsupinationi AGG: resisted wrist and middle finger Epicondylar splint

extPositive lat epicondylitis tests Subacute: stretching wrist extensors and

flexorsR/O C6 radiculitis or radiculopathyTransverse friction massage

R/O posterior interosseous nerve Isometric strengthening for wrist flex/entrapmentext/radial and ulnar deviation (initiallyperformed with elbow flexed, thenprogress to performing exercises withelbow extended)Chronic: progress isometrics to isotonicsStrength and endurance training isfocused primarily on wrist extensorsPt education

Med epicondylitis (golfer'S elbow)

Olecranon bursitis

Hx of high-intensity flex/pronation/grippingPain during activity that increases afteractivity

Hx of direct trauma to olecranonprocess

Local tenderness over med humeralepicondyleAGG: PROM into full wrist ext andresisted isometric wrist flex withforearm pronationPositive med epicondylitis tests

Swelling and erythema over olecranonprocessExquisite tenderness directly overolecranon process and swollen bursa

Acute: decrease inflammation (ice,NSAIDs, phonophoresis or iontophoresis)Relative restEpicondylar splint

Subacute: stretching wrist flexors andextensorsTransverse friction massageIsometric strengthening for wrist flex/ext/radial and ulnar deviation (initiallyperformed with elbow flexed, thenprogress to performing exercises withelbow extended)Chronic: progress isometrics to isotonicsStrength and endurance training isfocused primarily on wrist flexorsPt education

Ice, NSAIOs, phonophoresis oriontophoresisMay consider padding area forprotection

Ctmtillllcd T

~ TREATMENT OPTIONS FOR THE ELBOW ContmuedSpecial Condition

Compression at elbow

Pronator teres syndrome (median nervecompressed at pronator teres muscle)

Anterior interosseous syndrome (branchof median nerve)

Hx/Symptoms

Paresthesia in thumb, index finger, andmiddle finger that is aggravated byactivityWeakness in muscles of forearm andhand innervated by median nerve

Paresthesia in thumb, index finger, andmiddle finger that is aggravated byactivityWeakness in muscles of forearm andhand innervated by median nerve

Hx of sudden severe forearm pain thatresolves in a few hoursNo reported loss of sensation


Loss/weakness of pronator teres musclein addition to muscles of handinnervated by median nerveR/D cervical pathology

Resisted forearm pronation and elbowflex reproduce SxPronator teres muscle is spared whencompression is at this level vs. elbow(i.e., MMT of pronator teres reveals nodeficitlR/D cervical pathology

Weakness of FPL, PO, and FOPPt unable to pinch tip to tip or flex DIPjoints of digits 2 and 3 (positive pinchtestlKey is no loss of sensationR/D cervical pathology

Treatment Options

Relative rest and NSAIDsSplintingUltrasound and soft tissue mobilizationPhonophoresis or iontophoresisSurgical decompression if conservativeRx fails

Relative rest and splinting for 4-6 wkNSAIDsDecrease AGGUltrasound and soft tissue mobilizationSurgical decompression or steroidinjections if conservative Rx fails

Relative rest and splinting for 4-6 wkNSAIDsDecrease AGGUltrasound and soft tissue mobilizationSurgical decompression or steroidinjections if conservative Rx fails

(J1....

Palmar cutaneous nerve compression

Carpal tunnel syndrome

Radial Nerve Neuropathies

Radial tunnel syndrome (compression ofradial nerve at elbowl

Superficial radial nerve compression

Posterior interosseous nerve syndrome

Pain over thenar eminence andproximal palm

See Special Tests for the Wrist andHand table in Chapter 5

Pain over lat humeral epicondyleTenderness reported along line of radialnerve over radial headNumbness in radial nerve distribution inhand

Numbness/decreased sensation overdorsoradial hand

Reported normal sensation Inoparesthesia)May have Hx of lat epicondylitis orincreased use of supinator muscles

Positive linel's sign at palmar mediannerve site

Resisted middle finger ext reproduces Sxmore intensely than in lat epicondylitisResisted supination may also reproduceSxR/D cervical pathology and latepicondylitis

Positive linel's sign over superficialbranch of radial nerveR/D cervical pathology

Reproduced Sx with forced wrist ext ordigital compression when wrist is in flexWrist may deviate radially with wrist ext.Pt unable to extend thumb or fingers atMCP jointsR/D cervical pathologyR/D lat epicondylitis

Padding area of injuryPhonophoresis or iontophoresisLocal steroid injections

Relative restSplintingNSAIDsUltrasound and soft tissue mobilizationPhonophoresis or iontophoresisNeural stretching

Remove tight wristwatch/band that maybe causing compression.Rest and splinting

Relative restSplintingNSAIDsAddress aspects of job/ADLs requiringincreased use of supinator musclesSurgical decompression if conservativeRx fails

52

Bibliography

1. Regan WD, Morrey BF: The physical examination of theelbow. In Morrey BF (ed): The Elbow and Its Disorders, 2nd ed.Philadelphia, WB Saunders, 1993.

2. Lister G: The Hand: Diagnosis and Indications, 2nd ed. NewYork, Churchill Livingstone, 1984

3. Hertling 0, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

4. Moldaver J: Tinel's sign: Its characteristics and significance.J Bone Joint Surg Am 60:412-413, 1978.

5. Hunter JM, Schneider LH, Mackin EJ, Callahan AD leds):Rehabilitation of the Hand: Surgery and Therapy, 3rd ed. St. Louis,CV Mosby, 1990.

6. Magee OJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

7. Spinner M, Linscheid RL: Nerve entrapment syndromes. InMorrey BF (ed): The Elbow and Its Disorders, 2nd ed.Philadelphia, WB Saunders, 1993

------------53

References

Dellon AL, Hament W, Gittelshon A. Nonoperative managementof cubital tunnel syndrome: An 8-year prospective study.Neurology 431673-1678, 1993.

Fess EE, Philips CA: Hand Splinting: Principles and Methods, 2nded. St. Louis, CV Mosby, 1987

Galloway M, Demaio M, Mangine R: Rehabilitative techniques inthe treatment of medial and lateral epicondylitis. Orthopedics15:1089-1096,1992.

Hertling 0, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.Kisn~r C, Colby LA: Therapeutic Exercise: Foundations and

Techniques, 2nd ed. Philadelphia, FA Davis, 1990.Linscheid RL, O'Driscol1 SW: Elbow dislocations. In Morrey BF

(ed): The Elbow and Its Disorders, 2nd ed. Philadelphia, WBSaunders, 1993.

Lister G: The Hand: Diagnosis and Indications, 2nd ed. New York,Churchill Livingstone, 1984.

Nirschl RP: Muscle and tendon trauma: Tennis elbow. In MorreyBF led): The Elbow and Its Disorders, 2nd ed. Philadelphia,WB Saunders, 1993.

O'Driscol1 SW: Classification and spectrum of elbow instability:Recurrent instability. In Morrey BF led): The Elbow and ItsDisorders, 2nd ed. Philadelphia, WB Saunders, 1993.

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54--------------

Schantz K, Riegels-Nielsen P: The anterior interosseous nervesyndrome. J Hand Surg Sr 17:510-512,1992.

Spinner M, Linscheid RL: Nerve entrapment syndromes. InMorrey SF (ed): The Elbow and Its Disorders, 2nd ed.Philadelphia, WS Saunders, 1993.

Yocum LA: The diagnosis and nonoperative treatment of elbowproblems in the athlete. Clin Sports Med 8:439-451,1989.

m.-------- 55WRIST ANO HANO

SubjectiveExaminationt Pt Hx (region specific): dominant

hand, functional limitationst SO (if applicable)

oz

CJ'I

:2::JJ(f)----lzoIzo

56-------------

Objective ExaminationI. Sitting

A. R/O cervical pathology (see Chapter 2),shoulder and elbow involvement/pathology

B. Observation1. Posture2. Atrophy or deformities

C. AROM (note quality, pain)1. Wrist flex (70-80 deg)2. Wrist ext (65-80 deg)3. Wrist radial (15-25 deg) and ulnar deviation

(30-40 deg)4. Digits flex/ext5. Opposition of digits

D. PROM (same motions'if AROM limited)E. GMMT and myotomal screen

1. Elbow flex/wrist ext (C6)2. Elbow ext/wrist flex (C7)3. Finger flex (C8)4. Finger abd (T1)5. Grip strength with dynomometer

F. MSRs1. Biceps (C5)2. Brachioradialis (C6)3. Triceps (C7)

G. Special tests (as applicable)1. Carpal tunnel syndrome: Phalen's test,

Tinel's sign at the wrist2. Ulnar nerve paralysis: Froment's sign3. Other tests for neuropathy: wrinkle (shrivel)

test, sweat test, pinch test4. Vascular disorder/compromise: Allen's test5. Tenosynovitis/de Quervain's disease:

Finkelstein's test

-------------- 57

6. Contractures: Bunnel-Littler test, test fortight retinacular ligaments

7. Dislocation/instability: varus/valgus stress ofdigits maneuver, hyperabduction

H. Sensation: LT, 2-point discrimination, sharp/dull, hot/cold, monofilaments

I. Palpation1. Anatomic landmarks, especially the

anatomic "snuff box"2. Soft tissue

J. Joint play1. AP glides2. Lat glides3. Radial and ulnar deviation4. Long-axis distraction

ozIozf-(f)a:S

(]Ico

III SPECIAL TESTS FOR THE WRIST AND HAND


Nerve Lesiol

Phalen's test (wrist flex test!'- 2 Carpal tunnel syndrome Method 1: Pt has elbows on table with Tingling in thumb, index finger, middlehands up and wrists flexed for 1 min finger, and lat half of ring fingerMethod 2: Pt places dorsal surface ofhands together, fully flexing wrists, and

< holds for 1 min

Tinel's sign at wrist' Carpal tunnel syndrome Examiner taps over carpal tunnel at Tapping causes tingling/paresthesia intoCan also be used to chart regeneration wrist thumb, index finger, and middle fingerof lost sensory fibers Tingling is distal to point of tapping

Wrinkle (shrivell test' Denervation of fingers PI's fingers are placed in warm water for Failure of fingers to wrinkle; normal fingersapprox 30 min. Examiner then removes wrinkle, but denervated fingers remainPI's fingers and observes whether skin smoothover pulp of fingers is wrinkled.

Sweat test (ninhydrin sweat test)S.6

2-point discrimination test (static)'

Pinch test'

Froment's sign'

Denervation of fingers

Decreased hand sensation

Compromised anterior interosseousnerve

Ulnar nerve paralysis

PI's hand is cleaned thoroughly andwiped with alcohol. Pt then waits 5-30min and avoids contacting any othersurface with fingers. Fingertips are thenpressed with moderate pressure againstgood-quality bond paper that has notbeen touched. Fingers are held there for15 sec and traced on the paper with apencil. Paper is then sprayed withninhydrin reagent to stain sweat areaspurple. Allow 24 hours to dry.

Using an object with 2 points separatedby a known distance, apply lightpressure to fingertips with 2 pointssimultaneously.

Pt attempts to pinch using only tips ofthumb and index finger or thumb andmiddle finger.

Pt attempts to grasp a piece of paperbetween thumb and index finger (add ofthumb). Examiner then attempts to pullpaper away.

No change in color, indicating lack ofsweating

Inability to distinguish 2-point touch withmore than 6-mm separation of points

Pt unable to pinch tip-to-tip and has toresort to pulp-to-pulp pinch owing toweakness of FOP

PI's terminal phalanx of thumb flexesbecause of paralysis/weakness of adductorpollicis

(j)o

III SPECIAL TESTS FOR THE WRIST AND HAND Continued


Wartenberg's sign" 9 Ulnar nerve neuritis/paralysis Pt sits with hand resting with palm flat Inability to adduct the 5th digit to otheron table. Examiner passively spreads PI's fingersfingers and asks Pt to bring fingers backtogether.

Miscellaneous Conditions

Finkelstein's test 10 Tenosynovitis in thumb IAPL and EPBI Pt makes fist with thumb held beneath Reproduction of PI's Sx over APL and EPBin de Ouervain's disease flexed fingers. Examiner stabilizes PI's tendons

forearm and ulnarly deviates PI's wrist.

Bunnel-Littler test" Differentiate tight intrinsic muscles MCP joint held slightly extended while PIP joint unable to flex. If MCP joint is thenfrom PIP joint capsular tightness examiner moves PIP joint into flex if flexed a few deg and PIP joint is able to

possible. flex, it was due to tight intrinsic muscles. IfPt unable to flex PIP joint in either position,it was due to tight joint capsule.

Test for tight retinacularligaments"

Varus and valgus stress test"

Allen's test"

Differentiate tight retinacular ligamentsfrom capsular tightness

Ligamentous instability of digitcollateral ligamentsUseful in gamekeepers/skiers thumb

Occlusion of radial or ulnar artery

PIP joint held in neutral position whileexaminer flexes DIP joint

Examiner grasps and stabilizes testfinger.Examiner then applies varus and valgusforce at MCP, PIp, or DIP joint.

Pt makes and relaxes fist several timesand then squeezes fist tight to forceblood out of palm. Examiner appliespressure over radial and ulnar arteries.Examiner then releases one artery. Handshould immediately flush red. Repeat forother artery.

Pt unable to flex DIP joint. If PIP joint isthen flexed and DIP joint flexes easily, itwas due to tight retinacular ligaments. IfDIP joint unable to flex in either position, itwas due to tight joint capsule

Laxity compared with uninvolved side

Failure of hand to flush red immediately

0>N

!l TREATMENT OPTIONS fOR THE WRIST AND HAND


Hypothenar hammer syndrome Hx of using palm of hand to push, Positive Allen's test Acute: rest from AGG("dunker's hand," injury to ulnar pound, or twist R/D other conditions such as thoracic Subacute/chronic: modify activity with returnarteryl Pt reports coldness in fingers and palm outlet syndrome, Raynaud's disease, or to sport

Pt reports tenderness over hypothenar Buerger's disease If not improving, may require surgeryeminence

Scaphoid Fx Hx of FODSH injury Tenderness to palpation in anatomic Acute: immobilization in short arm spicaPt points to pain in anatomic " snuff "snuff box cast for a stable, nondisplaced Fx; surgerybox Limited/painful wrist motion for displaced Fx

Distal pole of scaphoid may be tender Postop: protective splinting, scaron palmar surface mobilization, edema prevention, ARDM,May be revealed on radiograph; not isometric wrist/finger flex and ext wristalways able to tell on radiograph until radial and ulnar deviation, progressing toosteonecrosis/avascular necrosis has isotonic PREs and functional strengtheningbegun activities, progressive hand weight-bearing

activities lin later phases)Post casting: same as after surgery, exceptno scar mobilization

0>W

Presier's disease (osteonecrosis/avascular necrosis of scaphoid)

Kienbock's disease (osteonecrosis/avascular necrosis of lunate)

Lunate dislocation

Hx of FDDSH injuryPt points to pain In anatomic "snuffbox"

Hx of FODSH injuryPt points to pain over area of lunate

Trauma to hand in hit or fall

Tenderness to palpation in anatomic"snuff box"Limited/painful wrist motionDecreased grip strengthRadiograph shows "fat strap" in middleof scaphoid where bone resorption isoccurring

Dorsal tenderness over lunate withlocalized swellingDecreased grip strengthRadiograph becomes mottled, and lunateprogressively deforms, eventually fusingto radius

May be apparent in AP view as awedge-shaped mass and in lat view inwhich capitate does not articulate with"cup" of lunate (which is rotatedanteriorly out of its normal position)

Resection of scaphOidProsthetic scaphoid implant also possibleVascularized bone graft surgery

Postop: protective splinting, scarmobilization, edema prevention, ARDM,isometric wrist/finger flex and ext, wristradial and ulnar deViation, progressing toisotonic PREs and functional strengtheningactivities, progressive hand weight-bearingactivities (in later phases)Immobilization for 2-3 moMay require resection of lunate andimplantation of a prosthetic lunate

Postop: protective splinting, scarmobilization, edema reduction, ARDM,isometric wriSt/finger flex and ext, wristradial and ulnar deviation, progressing toisotonic PREs and functional strengtheningactivities, progressive hand weight-bearingactivities lin later phasesIRefer Pt to orthopedic surgeon

(olllilllli I ....

TREATMENT OPTIONS FOR THE WRIST AND HAND C t' donmue


Gamekeeper's/skier's thumb Hx of traumatic ext or abd of thumb Instability of UCL of thumb Grade I: aggressive nonoperativePt points to pain over ulnar side of Acute: ulnar side of MCP joint tender, rehabilitationMCP joint

swollen Grade II and III: surgery

Chronic: UCL instability and functional Rehabilitation the same for nonoperative

difficulty; volar subluxation of proximaland postoperative treatment:

phalanx Thumb spica cast for 3 wk with MCPjoint flexed 20--30 deg and IP joint leftfree to move to prevent scarring ofextensor mechanismRemovable splint afterward for 3 morewk, gentle AROMContinue to work on regaining full ROM;begin isometric strengthening,progressing to isotonics and functionalstrengthening activities

Rheumatoid arthritis in hand Pt C/O pain and inflammationAtraumatic

Positive RF on blood testMust R/O septic jointsTenosynovitis on dorsum of wrist whereextensor tendons crossSnapping or locking of tendon in sheathwith movementContractureDeformities include ulnar deviation of dig-its, swan neck, boutonniere, mallet fingerMuscle weaknessInstability

Rx based on stageControl inflammationPreserve integrity and maintain function ofall tissuesFocus on joint systems, not isolated jointsRespect painAvoid deforming positionsConserve energyMaintain muscle strength and ROMPI education

Stenosing tenosynovitis of APLand EPB (de Ouervain's diseasel

PI reports aching pain above radial sty-loid that radiates down hand and uparm

AGG: wrist and thumb motion

Positive Finkelstein's testTenderness and crepitus in first extensorcompartmentR/O scaphoid Fx and carpometacarpal ar-thritis at thumb

Acute: ice, NSAIDs, phonophoresis or ionto-phoresis, may require cortisone/lidocaineinjection, splint to relax APL and EPB (15-deg wrist ext. 40-deg carpometacarpal abd,10 deg MP joint flex, and IP joint left freelSubacute: isometrics for forearm and handspecific for pinch and grip strengthGentle passive stretchIntermittent release from splintAROM to tolerance and progress to isotonicPREs to increase forearm, grip, and pinchingstrength

( "',,,/lid.

8l TREATMENT OPTIONS FOR THE WRIST AND HAND Continued

Splinting and relative restIf unresolving, refer PI to orthopedicsurgeon for aspiration and possible surgicalexcision

Palpable, tender, solid mass at WristPI reports painful lump/mass at WristWeight bearing such as push-upsaggravates Sx

Ganglion cyst {at dorsoradlal orvolar radial wrist; can also occurat the flexor tendon sheath in thedistal palm or dorsal DIP jointi


Carpal tunnel syndrome Insidious onset Positive Phalen's test PI education lavoid repetitive wrist flex-ext{compression of median nerve as Nocturnal burning pain in hand often Positive Tiners sign at wrist motions or prolonged wrist flexiit passes through carpal tunnel at reported Paresthesia in median nerve distribution NSAIDswristi Pt reports loss of digital dexterity that of hand Forearm spl int to prevent constant wrist flex

interferes with ADLs At later stages, Pt may have thenar {splint holds wrist in neutral to 30-deg extlatrophy and/or ape hand deformity Tendon gliding exercises"R/D entrapment of median nerve at Wear splint 24 hr per dayelbow or C6 radiculitis/radiculopathy Surgical decompression may be required if

conservative Rx fails

Trigger thumb and trigger finger Pt may describe "locking," "catching:' Palpation of proximal flexor tendon may Refer Pt to orthopedic surgeon, who mayor "snapping" of thumb or finger Iring be painful consider a steroid injectionor middle finger most commoni

"Catching" is usually palpable as tendon If problem persists, surgical release ofPt may C/O Sx being worse on slides through pulley tendon sheath may be performed

Iawakening and diminishing as Pt"limbers up" digit

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68 --------------

Bunt TJ, Malone JM, Moody M, et al: Frequency of vascular injurywith blunt trauma-induced extremity injury. Am J Surg160:226-228, 1990.

Cailliet R: Hand Pain and Impairment. 3rd ed. Philadelphia, FADavis, 1982.

Fess EE, Philips CA: Hand Splinting: Principles and Methods, 2nded. St. Louis, CV Mosby, 1987.

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Kahler DM, McCue FC: Metacarpophalangeal and proximalinterphalangeal joint injuries of the hand, including the thumb.Clin Sports Med 11 :57-75, 1992.

Korkala OL, Kuokkanen HOM, Eerola MS: Compression-staplefixation for fractures, non-unions, and delayed unions of thecarpal scaphoid. J Bone Joint Surg Am 74:423-426, 1992.

Lister G: The Hand: Diagnosis and Indications, 2nd ed. New York,Churchill Livingstone, 1984.

Newland CC: Gamekeeper's thumb. Orthop Clin North Am2341-48,1992.

Philips CA: Rehabilitation of the patient with rheumatoid handinvolvement. Phys Ther 691091-1098, 1989.

Rutherford RB: Vascular Surgery, 4th ed. Philadelphia, WBSaunders, 1995.

Spinner M, Spencer PS: Nerve compression lesions of the upperextremity: A clinical and experimental review. Clin Orthop104:46-66,1974.

Wadsworth LT: How to manage skier's thumb. Phys Sports Med20:69-78, 1992.

Wilgis EFS, Yates AY: Wrist pain. In Nicholas JA, Hershman EB(eds): The Upper Extremity in Sports Medicine. St. Louis, CVMosby, 1990.

------------69mTHORACIC SPIN[

SubjectiveExaminationt Pt Hx (region specific): Does

coughing, sneezing, straining, oranything that increases intradiscaland intrathecal pressure aggravate

the Sx? Sx with breathing? Does any particular posture aggravate Sx?

Radicular Sx (dermatomal or sclerotomal)? (seeAppendices A and B)

SOt Review of systems (cardiovascular,

gastrointestinal, pulmonary)

wZQ...(f)Uu

70 --------------- --------------71

Objective Examination 1. Shoulder elevation/shrug (C3-C4)2. Shoulder abd (C5)

I. Standing Elbow flex/wrist ext (C6)A. R/O lumbar spine pathology

3.4. Elbow ext/wrist flex (C7)

B. R/O nonmusculoskeletal abnormalities andtumors of the renal, pulmonary, 5. Thumb IP ext/finger flex (C8)cardiovascular, and gastrointestinal systems 6. Finger add (T1)

C Observation 7. Hip flex (L1-L4)1. Gait 8. Knee ext (L2-L4)2. Posture (e.g, scoliosis, dowager's hump, 9. Great toe ext (L5) (or supine)

kyphosis) E. MSRD. AROM (note quality, pain) using methods 1. Knee jerk (L3-L4)

such as fingertip to floor or down side of leg 2. Hamstring (L5)0) or an inclinometer 3. Ankle jerk (S 1) w1. Thoracic flex z

F. Pathologic reflexes (if applicable*) 0...--l 2. Thoracic ext UJI U0 3. Thoracic sidebending 1. Babinski's u::0:t> 2. Clonus

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spondylolisthesis: Treatment by internal fixation and bone-graftingof the defect. J Bone Joint Surg Am 70: 15-24, 1988.

BibliographyGrieve GP: Common Vertebral Joint Problems. New York,

Churchill Livingstone, 1981.Hertling D, Kessler RM: Management of Common

Musculoskeletal Disorders: Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Kisner C, Colby LA: Therapeutic Exercise: Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

McKenzie RA: The Lumbar Spine: Mechanical Diagnosis andTherapy. Wellington, New Zealand, Spinal Publications, 1991.

Saunders HD, Saunders R: Evaluation, Treatment and Preventionof Musculoskeletal Disorders: Spine, 3rd ed, vol. 1. Chaska,MN, Educational Opportunities, 1993.

Schonstrom N: Lumbar spinal stenosis. In Twomey LT, Taylor JR(eds): Physical Therapy of the Low Back. New York, ChurchillLivingstone, 1994.

Sinaki M, Lutness MP, Iistrup DM, et al: Lumbar spondylolisthesis:Retrospective comparison and three-year follow-up of twoconservative treatment programs. Arch Phys Med Rehabil70:594-598, 1989.

m------------93I!IHIP

SubjectiveExaminationt Pt Hx (region specific): H/O

trauma, "snapping," "popping," or"grinding"

t SQ, if applicable

0...I

-------------- 9594--------------

Objective Examination Wilson-Barstow maneuver first forimproved symmetryI Standing E. Sensation

A. R/O spine or SI joint pathology 1. DermatomesB. Observation 2. Nerve fields

1. Gait F. Palpation2. Posture 1. Pubic tubercles/rami

a. Leg length (i.e., PSIS/ASIS level) 2. Inguinal ligament3. Function (e.g., squat) 3. ASIS

C. Special tests 4. Iliac crest1. Trendelenburg's test 5. Greater trochanter

II Sitting 6. Surrounding soft tissue/muscleA. AROM G. Joint play

1. Hip ER (40-50 deg) 1. Long axis and lateral distraction2. Hip IR (35-45 deg) 2. Compression

co B. GMMT IV. Sidelying(L

I1. Hip flex (test sidelying if status poor or A. GMMT

IIJ worse) 1. Hip abd (test both supine if status poor or co

2. Hip ER/IR (test supine if status poor or below)worse) 2. Hip add (test both supine if status poor or

III. Supine below)A. R/O knee pathology B. Special testsB. Observation 1. ITB: Ober's testC. AROM Prone

1. Hip flex (120-130 deg) A. AROM2. Hip abd (40-45 deg) 1. Hip ext (10-20 deg)3. Hip add (20-30 deg) B. GMMT4. Hamstring length 1. Hip ext

D. Special tests (as applicable) C. Special tests (as applicable)1. DJD/hip joint pathology: Scouring test, 1. Anteversion: Craig's test

Faber's test (vs. SI joint) 2. Coxa vara or dislocation: Nelaton's line and2. Hip flexor length test: Thomas's test Bryant's triangle

3. Piriformis syndrome: sign of the buttock D. Sensation4. Stress fracture: percussion test 1. Dermatomes

5. Leg length (apparent vs. true): perform 2. Nerve fields

dlH I 8CDOJ

rn

oo

III SPECIAL TESTS FOR THE HIP Continued


True leg length' Leg length PI supine. Examiner measures ASIS to tip of Difference in measurements greater than 1-1.5 cmmed malleolus. Use Wilson-Barstow maneuver(see belowl. Relative length of tibia may betested with Pt prone and knee flexed 90 deg.Thumbs placed on sales of feet Note relativeheights of thumbs

Apparent leg length10 Lateral pelvic tilt (could be AP Pt supine. Examiner measures distance from Difference in measurementsrotated) tip of xiphoid process or umbilicus to med

malleolus

Wilson-Barstow Used for symmetrization before leg Pt supine. Examiner stands at PI's feet and No positive sign. This is used to ensure symmetrymaneuver l1 length measurement palpates med malleoli with thumbs. Pt flexes before measuring leg lengthknees and then pushes off with heels to liftpelvis from table. Pt returns pelvis to table,and examiner passively extends PI's knees andcompares positions of malleoli. Tape measurecan then be used to measure from ASIS todistal portion of med malleolus

I TREATMENT OPTIONS FOR THE HIP

o....


DJD Groin or greater trochanter pain (especially Increased Sx after activity Iwalking, runningi ARDMwith weight bearing!. may also extend into lat Increased Sx when hip in closed pack Maintain flexibilityor posterior thigh to knee position, positive scouring or Faber's tests Decrease stress on hip with activity Ilose weight,Insidious onset ROM limitations in a capsular pattern exercise in a swimming pool, use assistive devicesIncreased Sx with cold weather such as a caneiAM stiffness and night ache Strengthen hip ext rotators and abductors

Trochanteric bursitis May be insidious, or Pt may report specific Tenderness to palpation directly over greater Acute' relative rest. ice, NSAIDs, avoid AGG,event of feeling a "pop" as ITB snapped over trochanter phonophoresisliontophoresis, ultrasoundgreater trochanter May have positive Dber's test or Faber's Subacute/chronic: begin ITB stretchingMay have HID direct blow to hip test lor both) If conservative Rx fails, refer Pt to orthopedicPain in lat hip that may refer along lat thigh surgeon; orthopedic surgeon may inject or surgicallyto knee excise bursaIncreased Sx with stairs, walking uphill, orside lying on involved side

Iliopectineal bursitis Insidious onset Tenderness to palpation in femoral triangle Acute.' relative rest, ice, NSAlDs, phonophoresis,Pain in groin or femoral triangle Increased Sx with resisted hip flex and full ultrasound

passive hip ext Subacutelchronic: hip flexor stretchingMay have positive Faber's test

COllfllllWr! ~

oN

I TREATMENT OPTIONS FOR THE HIP Continued


Piriformis syndrome Pt may have Sx similar to radiculopathy, with Positive SLR, positive sign of the buttock, Ultrasound, piriformis stretchingpain Isharp/burning) in buttocks (unilateral) tenderness to palpation in sciatic notch Avoid AGGextending down LE Increased Sx with hip ER or resisted ER If Sx fail to resolve/improve after 2-3 wk, mayPI may report that sitting or sitting in poorlycushioned chair reproduces Sx

consider referral to orthopedic surgeon or pain clinicfor injection

Legg-Calve-Perthes Groin, med thigh, and/or med knee pain Antalgic gait Refer Pt to orthopedic surgeondisease Iwithout knee pathology) Pt has decreased ROM in abd, IR, and flex

Sx in 3 to 8 year olds and in males most Radiographs show flattened or resorbedcommon femoral head

Slipped capital femoral Insidious onset or may follow trauma Antalgic gait Refer Pt to orthopedic surgeonepiphysis Sx in males during puberty and obese Pts PI's hip automatically externally rotates

most common when he/she flexes hipHip &/or med thigh pain Radiograph confirms

--'

ow

Meralgia paresthetica(entrapment of latfemoral cutaneousnervel

Pubic ramus stress Fx

Femoral neck stress Fx

Pain/paresthesia In lat and antenor thighPt may have had direct blow to iliac crest!ASISOveruse of abdominal muscles from sit-upsPt may wear tight belt or pants, causing Sx

Groin pain of insidious onsetCommonly occurs in short individual whooverstrides to keep up with others whenwalking/running le.g., military formationjAggravated by activity and relieved by rest

Groin, hip, and/or med thigh pain of insidiousonsetRecent Increase In physical activity/trainingAggravated by activity and relieved by rest

R/O radiculopathy from backPt may be obese (putting pressure on nerveas it passes over ASISIPalpate along iliac crest/ASIS and inguinalligament in attempt to reproduce Sx

Antalgic gaitTenderness to palpation on pubic ramusPossibly adductor spasmBone scan consistent with stress Fx

Positive percussion testBone scan consistent with stress Fx

Avoid AGGEventually subsides on ownMay use ice for anesthetic benefit. Modalities andsoft tissue mobilization if entrapment suspectedrather than trauma

Rest and crutchesAfter Sx subside, change training methods/schedule.Return to physical conditioning gradually

RestPt should be on crutches immediately becausecontinued full weight bearing and physical activitymay result in displaced femoral neck Fx anddisruption of blood supply to femoral head

co

104--------------

References

1. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

2. Ober FR The role of the iliotibial band and fascia lata as afactor in the causation of low-back disabilities and sciatica J BoneJoint Surg Am 18:105-110, 1936.

3. Kendall FP, McCreary EK Muscles: Testing and Function,3rd ed. Philadelphia, Williams & Wilkins, 1983

4. Gajdosik R, Lusin G: Hamstring muscle tightness:Reliability of an active-knee-extension test. Phys Ther631085-1090, 1983

5. Gajdosik RL, Rieck MA, Sullivan DK, Wightman SE:Comparison of four clinical tests for assessing hamstring musclelength. J Orthop Sports Phys Ther 18:614-618, 1993.

6. Cameron DM, Bohannon RW: Relationship between activeknee extension and active straight leg raise test measurements. JOrthop Sports Phys Ther 17:257-260, 1993.

7. Maitland GD: Peripheral Manipulation, 3rd ed. Boston,Butterworth-Heinemann, 1991.

8. Beetham Wp, Pollwy HF, Slocumb CH, Weaver WF:Physical Examination of the Joints. Philadelphia, WB Saunders,1965.

9. Adams JC: Outline of Orthopaedics, 9th ed. London,Churchill Livingstone, 1968.

10. Hoppenfeld S: Physical Examination of the Spine andExtremities. Norwalk, CT, Appleton & Lange, 1976.

11. Woerman AL: Evaluation and treatment of dysfunction inthe lumbar-pelvic-hip complex. In Donatelli R, Wooden MJ (eds):Orthopaedic Physical Therapy New York, Churchill Livingstone,1989.

Bibliography

Barton PM: Piriformis syndrome A rational approach tomanagement. Pain 47:345-352, 1991.

Bunnell WP: Legg-Calve-Perthes disease. Pediatr Rev 7:299-304,1986.

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders. Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Jankiewicz JJ, Hennrikus WL, Houkom JA: The appearance of thepiriformis muscle syndrome in computed tomography andmagnetic resonance imaging: A case report and review of theliterature. Clin Orthop 262:205-209, 1991.

Kisner C, Colby LA: Therapeutic Exercise Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Schoenecker PL: Legg-Calve-Perthes disease: A review paper.Orthop Rev 15:561-574,1986.

105

0...J:

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IiIr-------------107

~KNH

Subjective. ati

Pt Hx (region specific): Functionallimitations. locking/popping/giving-way. swelling (if trauma. did itswell and how quickly)

t If traumatic. was there a "pop" at the time of theinjury?

t Type of shoes (especially runners and runningshoes): proper type. age of shoes. wear pattern

t SQ, if applicable

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108 --------------


A. R/O spine pathologyB. Observation

1. Gait2. Posture (e.g., genu recurvatum, genu

valgum, genu varum)3. Function (e.g., squat, 1-leg hop)

II. SittingA. GMMT

1. Knee ext (test sidelying if status poor)III. Supine

A. R/O ankle or hip pathologyB. Observation

1. Posture (e.g., quadriceps angle, leg lengthdifferences, other alignment problems)

2. Measure or grade effusionC. AROM

1. Knee flex (135-145 deg)2. Knee ext (0 deg)

D. Special tests (as applicable)1. Ligament: Lachman's test, varus and

valgus tests at 0 and 30 deg, anterior andposterior drawer tests, pivot-shift te

richard f. baxter-pocket guide to musculoskeletal assessment

Documents

appendix gradiology

appendix adermatomes

appendix kabbreviations

appendix fcapsular pattern

appendix hphysical agent

appendix jnormal values

appendix itypes of traction

neurologic evaluation