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ShoulderClassification impairments at Shoulder, Elbow, Wrist, and Hand
1. Pain (ex-Systemic sources: Cervical spine, dermatomes, diaphragm, heart, gallbladder, myofascial trigger points or non-systemic/localized pain)
2. Postural (muscle imbalances)3. Mobility (hypo and hyper)4. Muscle (neurological, misuse, strain)
Adhesive Capsulitiso Joint capsule becomes inflamed, fibrotic, shrunkeno Adhesions formo RC and biceps tendon shorten/changePROMo Decreased classical PROM in the capsular pattern: (ER>ABD>FLEX>IR)o Decreased accessory PROM in the capsular pattern: (P/A>inf> A/P)Muscle Lengtho Tight muscles may include: Pec minor and major, teres major, lats, subscap (Interal Rotators/Adductors)GH joint precautions
o Acutely, oscillations may irritate patient Use only to decrease pain
o Do not perform grade III, IV manips until inflammation is goneo Careful of pt dizziness after Codman’so Watch for scapular substitutions during ROM and exercises
Acute stage – focus to decrease pain and inflammation Modalities Grade I manips Codman’s Sub-max isometrics (to decrease swelling not strengthen)
Subacute Restore PROM AAROM Grade II & III mobs
Settled/chronic Focus on AROM (PROM & jt mobility should be restored)
Impairment Treatment during ACUTE stagePostural May/may not be able to improve w/exercise…depends on age
Don’t sleep on involved armRest in loose pack position
Mobility AROM – pain/limited – reduce inflammationPROM – capsular pattern, perform in painfree rangeCodman’sGrade I mobsMLT – defer
Muscle- Strength Sub-max isometrics (to decrease swelling not strengthen)
Impairment Treatment during SUBACUTE stagePostural Postural exercises to decrease forward head, rounded
shouldersLook at LB positioning (lumbar roll)
Mobility ROM – restore PROM 1st, then work on AROM in new rangeProgress to AAROM to AROM (include wand exercises)Start ER early!Muscle length – as ROM improves, begin gentle manual stretching
Muscle- Strength As PROM improves, work on AROM
Sub-max isometrics isotonics (as tolerated)Emphasize good mechanics, no substitutions
Impairment Treatment during SETTLED/CHRONIC stagePostural Progress postural exercisesMobility Grade III/IV mobs, grade III distractions
AROM progresses as PROM improvesProgress stretching to end-range w/overpressure
Strength May need to strengthen to improve scap mech to enhance alignment & proper functioning & improved posture
AC (acromioclavicular) Injury: MOI- Direct blow to areaInjury Type AC ligament CC ligament Delt-trap fascia Direction Treatment
Grade I Sprain Intact Intact Non-displaced ROMGrade II Complete Sprain Intact <25% superior Protect, no
activities until painfree
Grade III Complete Complete Injury 25-100% sup. Surgery, slingGrade VI Complete Complete Detached Post trapGrade V Complete Complete Detached 1-3x superiorGrade VI Complete Complete Detached Inferior to
acromion
AC osteoarthritis- Result of repetitive minor stresses, grade I, II separations, clavicular fractures- Symptoms
o Minor ache with throw or resisted exercise to pain with all activitieso Pain with lying on sideo Painful or painless crepituso Horizontal flexion test positive
Tendonitis (supraspinatus and biceps common)Impairment Treatment during ACUTE stagePostural Educate on proper sitting/standing postureMobility AROM defer
PROM in pain free range; Codman’sGrade I & II mobsMLT – defer
Strength Decrease inflammationStrengthening deferred
Functional limits Avoid sleeping on involved sideRest arm in ABD position to improve vascularity
Impairment Treatment during SUBACUTE stagePostural Stretch tight anterior structuresMobility PROM – Codman’s
AAROM to AROM in painfree rangeGrade II & III mobs (inferior glide)ML – use AC or gentle stretching of mm that cross GH jointTFM w/ tendon in short position to lengthened position
Strength Gentle strength to RC musclesLight MRE IR/ER w/slight distraction to decrease joint compression
Functional limits Teach pt. to function in proper planeICE after treatment
Impairment Treatment during SETTLED/CHRONIC stagePostural Further stretch anterior
Strengthen scap mm to maintain position (include SA)Mobility AROM resisted ROM (as tolerated)
Grade III & IV jt. mobs, stabilize hypermobilityML – passive stretch or active inhibition (pecs, IR, ER, Lats, teres maj, rhomboids)
Strength MSTT – increase load as pain decreasesTFMBegin strength 0-90 to avoid impingement to full ROM
Bursitis- Subacromial and subdeltoid are the most common- Acute
o Spontaneous, rapid onseto Severe debilitating paino Resolves rapidlyo Exam
All motions limited Empty end-feel Tender over bursa
- Chronico Associated with impingemento Exam
Impingement signs Painless restricted motions May have mild capsular restrictions due to disuse
Categorizing shoulder pathology>35 – degenerative aging process
Factors includeo Overuseo Postureo Acromion shape; ACJ, DJD
o Post &/or inf capsule tightnesso RC/biceps weakness or fatigueo SH rhythm
<35 – microtrauma to muscle, tendon, capsule & ligamentous tissue (often due to laxity)
Shoulder instability/laxity – dislocationsContraindications with Shoulder Instability:• Anything that increases mobility of GH jt– Contraindicated therapeutic interventions: • Joint manipulation (for mechanical effects) • Manual passive stretching • End range of motion activities
Classification of impingement groups (for impingement syndrome)Group 1(Greater than age >35)
Pure impingementNo instability-Due to: overuse, posture, acromion shape, posterior and/or inferiorcapsule tightness, RC or biceps weakness, SH rhythm-Impingement Syndrome-Impingement of the RC, bursa, or biceps tendon under the CA arch (anterior portion)
-Often in the area of hypovascularity of the Supraspinatus and bicepstendonExam:-ROM: lack IR, ER, HADD-RC imbalance: dominant Supraspinatus-Radiology: hooked acromion, AC DJD
Group 2(Less than age <35- microtrauma due to laxity)
Primary instability due to microtrauma with impingement IIA – internal impingement IIB – subacromial impingement
Exam:-Laxity tests-Relocation test most sensitive-ROM: increased with external rotation
Group 3(AMBRI- Atraumatic, Multidirectional, Bilateral, Rehabilitation- Inferior capsule shift recommended)
Primary instability due to hyperelasticity with impingement IIIA – internal impingement IIIB – subacromial impingement
Multidirectional Laxity: AMBRI Patients
Group 4(TUBS- Traumatic Unidirectional, Bankart, Surgery recommended)
Pure instability (traumatic)No impingement-Can occur at any age but usually in younger people-Unidirectional laxity : TUBS Patients
Neer’s classification for impingement syndromeStage I Edema & inflammation
<25 yrs old painful arc btw 60-120 deg +/- decreased ROM
significant subacromial inflamm reversible treatment – conservative
Stage II Fibrosis & tendinitis 25-40 yrs old crepitus due to subacromial scarring catching sensation limitation of AROM & PROM not reversible w/activity mods may need bursectomy or CA lig resection
Stage III Bone spurs & tendon ruptures >40 yrs old decreased ROM; AROM worse than PROM atrophy weakness of ABD/ER Biceps tendon involved Not reversible (prog disability) Treatment – acromioplasty or RC repair
RC tears & repairsStage Impairment TreatmentACUTEMAX protection0-6 weeks post-op
Surgical healingSwelling
Ice, E-stimPossibly gentle massage
ACUTEMAX protection0-6 weeks post-op
Mobility ROM – decreased & painfulCodman’s & PROM (painfree range)Grade I & II mobs
ACUTEMAX protection0-6 weeks post-op
Strength Deferred
ACUTEMAX protection0-6 weeks post-op
Functional limitation
Educate about resting in ABD positionEducate about precautions based on protocol ROM limitations
Stage Impairment TreatmentSUBACUTEMod Protection6-12 weeks post-op
Mobility AAROM, begin AROM when MD ok’edGrade II & III mobs, as needed
SUBACUTEMod Protection6-12 weeks post-op
Strength AAROM to AROMLight isometricsMRE ~8 weeks, if ok w/MD
SUBACUTEMod Protection6-12 weeks post-op
Functional limits Out of slingEducate to avoid/reaching overhead
Stage Impairment TreatmentSETTLED/CHRONICMin protection12wks – 1 yr post-op
Mobility Begin passive stretching to end-range where limitedGrade III & IV mobs
SETTLED/CHRONIC Strength Strengthen IR/ER 1st specific
Min protection12wks – 1 yr post-op
deltoid & RC exercisesBe cautious w/eccentrics
SETTLED/CHRONICMin protection12wks – 1 yr post-op
Functional limits Progress back to functional activity
Thoracic outlet syndromeSigns
Forward head, rounded shoulders Hypertrophied scalenes Upper respiratory breather Raised/limited 1st rib Restricted upper thoracic mobility Tight pec minor/major Hypertrophied pec minor
Symptoms Deep aching, not well defined Raynaud’s Pallor, coldness, claudication Intermittent edema, venous
engorgement Cyanoses Dorsal scapular pain Parasthesias into the hand
Peripheral nerve injuries Long thoracic N.
Exam step Finding/impairmentStructural inspectionAROM
PROM
Scapular wingingScap winging w/FLEX, ABD, SCAP (20-30 deg limited)Decreased AROM bc weak SA
May/may not = hyper/hypomobileMay have impingement bc lack of scap movement
Muscle strength SA = 0/5Shoulder Flex = 4/5Other mm = WNL w/scap manually stabilize
P for T Negative or possible tender subacromion area
Suprascapular N. Exam step Finding/impairmentPain assessment Pain at posterior, lateral shoulderStructural inspection May see atrophy of innervated mmAROM
PROM
Possible decreased ABD & ER
Examine for hyper/hypomobilityMuscle strength Weak ER & ABD
Pain if impingement developed
Axillary N. ****same as above****ElbowCapsular pattern for the elbow flexion > extension, pronation= supination
Nerve disorders at the elbow- Ulnar Nerve
o Cubital tunnel syndrome Referred to: Ulnar side of the hand and 4th and 5th phalanx
- Radial Nerve (Motor Only)o Deep radial compressed by ECRB or supinatoro Superficial radial caused by direct trauma to lateral radius
Referred to: dorsum of the radial palm to PIP of 1st thru 4th phalanx- Medial Nerve
o Pronator syndrome- compressed at the pronator teres Referred to: radial palm and 1st thru 4th phalanx
Joint hypomobility (non-op)ACUTE PROTECTION SUBACUTE/CHRONIC CONTROLLED
MOTIONCommon impairments
Jt. effusion Mm guarding Pain (@ rest)
Educate pt.Decrease inflammGr I/II distractionMaintain ROMMaintain function
Common impairments
Cap. Pattern Firm end-feel Decreased
joint play Pro/sup
restricted(OA)
Increase soft tissue & joint mob
HEP Gd III/IV mob Manual & self
stretchingIncrease strength & function
Myositis ossificansExam step Finding/impairmentPalpate for Cond. Increased warmth/firmness of brachialis regionAROM/PROM Elbow ext > flex (and painful)
End range elbow flex is painful due to muscle being compressedMSTT/MMT Resisted elbow flexion causes increased painPalpate for Tender. Palpation of the brachialis mm is painful
Tendonitis of the elbow- TreatmentACUTE SUBACUTE CHRONIC/SETTLEDIce/splintNo AROMPROM in pain free rangeGrade I mobsStop the aggravating activityOnly non-stressful activities
Keep icingAAROM – AROM in pain free rangeGently stretch 1 joint at a timeTFM as toleratedLight MRE****find the cause****
Ice pre/post exerciseAdd resistance to AROMIncrease intensity of passive stretching, inhibition tech, be specific to the mmGrade III/IV mobsDeeper TFMProgress weights/T-bandsWork on endurance!
Cubital tunnel syndrome(Ulnar Nerve Compression)-TreatmentACUTE SUBACUTE CHRONIC/SETTLEDTreat any swelling/warmth w/modalitiesNo AROM @ elbowAROM of neighboring jointsPROM in pain free rangeGrade I mobsStretch to prevent contract.Defer strengthening
AAROM AROM to elbowGentle PROM mild discomfortGrade II/III joint mobsContinue w/modalities + massage to FCULight manual/mechanical RE to bis/tris & ulnar n. mm
AROM active RE to UEPROM, passive stretching to elbow & wrist, especially intrinsicsGrade III/IV joint mobsStrengthen wrist flexors & intinsics (ulnar n.)Gripping/fine motor therapy
Treat the cause of compress.Consider bracing at night
Continue treating the causeNeuromobilizations
Increase intensity of neuromobilizations
Overuse syndromes- Lateral Epicondylitis (Tennis Elbow)
o Tendonitis of the wrist extensorso Common Extensor Tendon- ECRB most common
- Medial Epicondylitis (Golfers Elbow)o Tendonitis of the wrist flexorso Common Flexor Tendon- FCR and pronator teres most common
- Triceps tendonitis: Distal triceps- Antecubital tendonitis: Distal biceps
WRIST AND HANDCapsular patternsWrist Flexion = ExtensionIP of digits 2-5 flexion(more limited)> extensionMCP digits 2-5
Open packo Slight flexion
Closed packo Full flexion
Length-tension relationship Wrist position controls length of extrinsic muscles
o Wrist extension for gripo Wrist flexion stability for finger extension
Hand function Extensor hood
o Made up of: Extensor digitorum Dorsal and palmar interossei Lumbricals
o Reciprocal motion of MCP flexion and IP extension interosseio Lumbricals remove tension from FDP and assists IP extensiono Isolated contraction of Extensor Digitorum causes clawing motion
Hand Grips Power grip(Primarily isometric function)
o Cylindrical gripo Spherical gripo Hook gripo Lateral prehensiono Major gripping force extrinsic finger flexorso Compressive force ED which also increase stability
Precision patterns(Object does not come in contact with palm)o Between thumb and fingerso Compressive force extrinsic muscleso Object manipulation
Interossei abduct and adduct Thenar muscles control thumb Lumbricals help move object away from palm
o Tip to tipo Pad to pado Pad to side prehension
Combined gripso Digits 1 & 2 precision o Digits 3-5 powero Pinch
Nerve disorders Median nerve
o Carpal tunnel most common Ulnar nerve
o Guyon’s canal most common
Rheumetoid Arthritis- RAStage Acute RemissionPFC Massage/Modalities Massage/ModalitiesAROM Painfree AROM/PROM AAROM w/progression to active exercise
PROM Classical Painfree AROM/PROM- DON’T STRETCH! Gentle stretching
PROM Accessory Grade I & II manips Grade I & II manipsPossibly Grade III
MLT Painfree AROM/PROM Gentle stretching (intrinsics)MMT Gentle muscle setting Light-moderate resistance exercise
o Active Pt. education Joint protection- NO STRETCHING Active exercise if possible
o Remission Improve function
Flexibility Muscle performance CV endurance
Nonimpact or low impact conditioning Swimming Bike Water aerobics
o RA and other Hand Deformities Swan neck Boutonniere deformity Ulnar drift Volar sublux of triquetrium Ulnar sublux or carpals Z deformity of thumb
Osteoarthritis- OAo Acute stage
Achiness and stiffness lessen w/movement Inflammation
Affects prehension and ADLso Advanced stages
Capsular laxity hypermobility/instability Contractures develop as it progresses
Limits in flexion and extension firm capsular end feel Muscle weakness
o Weak grip strengtho Poor muscle endurance
o Protection phase Control pain
Grade I & II manips Splinting Modify activities
Educate pt. Maintain joint & tendon mobility
PROM/AAROM/AROM Heat Aquatics Muscle setting (multiple angle)
o Controlled motion and Return to function phase Increase joint play and accessory motion
Grade III and IV manips Improve joint tracking Mulligan
Mobility w/movement Lateral glide of wrist while pt. actively moves Other hand passively stretches at end range
Improve mobility, strength & function
Tenosynovitis/Tendonitiso Protection phase
Splint Cross fiber friction in elongated position Tendon gliding exercises to prevent adhesions Multiangle muscle setting Painfree ROM
o Controlled motion and return to function phase Progress intensity of massage, exercise, and stretching
Dynamic exercises Be careful of eccentric exercises- May provoke symptoms
Traumatic Lesions Sprain
o Possible impairments Hypermobility
Torn ligaments Pain
o Management Maintain mobility Minimize stress to healing tissue
Laceration of tendons
o Flexor tendon zones Zone 1
FDP insert insert of FDS
FDP, A4 & A5 pulleys Unable to fully make fist
Zone 2 FDS insert palmar
crease (prox to neck of MCP)
FDS, FDP tendons, annular pulleys
Unable to flex PIP & DIP if both severed
No mans land Zone 3
Neck of MCP distal carpal tunnel FDP, FDS, lumbricals MCP flexion affected
Zone 4 Carpal tunnel FDP, FDS, FPL Nerve injury
Zone 5 Proximal to wrist Flexor tendons of digits and wrist
o Loss of finger & wrist flexiono Damage to median & ulnar nerves possible
o Extensor Tendon Zones Zone 1
DIP region No active DIP extension Flexion contracture Swan neck deformity
Zone 2 Middle phalanx Same as Zone 1
Zone 3 PIP region Central slip damaged Possibly lateral bands Cannot extend PIP from 90° Boutonniere deformity Prone to adhesion forming
o Multiple soft tissue attachmentso Broad bone-tendon interface
Volar splintso Wrist in 30° active flexion
o MCP in neutralo Splint limits PIP flexion (30°) and DIP flexion (20-25°)
Zone 4 Proximal phalanx Same as Zone 3
Zone 5 Apex MCP joint EDC, EIP, EDM damaged Unable to extend MCP
Zone 6 Dorsum of hand Retinaculum and multiple tendons damaged Bowstring effect of tendons Loss of wrist and digit extension
Zone 7 Wrist Same as Zone 6
o Repairs Balance between protection & movement
Excess movement tendon rupture Early ROM important to prevent contractures1. Immediate primary repair: Done within 24 hours of injury2. Delayed primary repair: Done within 10 days3. Secondary repair: Done 10 days to 3 weeks post injury4. Late reconstruction: Done well beyond 3-4 weeks post injury
o Direct repair no longer possible, Tendon graft necessaryo Treatment
Immobilization PIP extensor joint: 4-6 weeks DIP extensor joint: 6-8 weeks Flexor tendons
o Early movement important Decreases edema Maintains tendon gliding Decreases adhesion forming Increases synovial fluid production Increases tensile strength of tendon
o Position of immobilization Zones 1-3
Wrist & MCP flexion, PIP & DIP extension Zone 4
MCP flexion 70°, neutral wrist
Management for flexor tendon laceration
Max Protection PhaseModerate
Protection phaseMinimum Protection
Phase/return to functionTiming 1-3 days postop to 5 weeks 4-8 weeks 8 weeks postopSplintin
gSplint (dorsal blocking splint
w/dynamic traction)-Static blocking
splint (day)-Night splint for
Splinting discontinued
protection
Exercise-Very low controlled stresses
-Passive & active exercises-Place & hold
Tendon gliding & blocking
-Place & hold-AROM
Gradual progressive resistance exercises
Goals-Control pain & edema-Wound management
-Prevent adhesions
-Safely increase stresses
-Full AROMFull activity by 12 weeks
Colles Fractureo FOOSHo Distal radiuso Complications
Capsule tightness UCL sprain Avulsion fx CRPS complications Malalignment Carpal tunnel syndrome
Volar sublux of lunate Rupture of EPL
Malalignment of Lister’s tubercle
Colle’s FractureAcute Sub-acute Chronic
Posture
Not likely to see in acute phase.-Avoid exercise
-Educate pt. about posture
- Holds arm to side Educate pt. to use normal swing motion
-Codmans
Palpation for Condition
Swelling RICE
AROMLimited in all directions AAROM & AROM as
tolerated. Maintain ROM of Shoulder/elbow/fingersProgress to full
end range
PROM Classical
Capsular pattern progress to endrange stretches
Progress as tolerated-passive
stretching in HEP
PROM Accessory
Hypomobile Grade II & III manips, soft tissue work
Grade III & IV manips
MMTGenerally weak UE light MRE progressing to
weights, t-band
Progress MRE & isotonics
-use functional activities
Skier’s thumbo Sprain of UCL of 1st MCP jointo Hyperabduction force to thumbo Signs & symptoms
Tender to palpation and swelling over UCL Pain w/pinching + adduction stress testing
Scaphoid fractureo FOOSHo Signs & symptoms
Tender over snuffbox Especially palmar side
Possible swelling Decreased ROM X-rays 4 views
If negative, treat as fx and reorder films in 2 weeksTFCC Tear- Triangular Fibrocartilage Complex
Loading wrist in pronation Usually 2° to ulnar impaction Signs & symptoms
Pain on ulnar side or wrist Swelling Decrease grip strength Tender distal to ulnar Styloid process Click w/ulnar deviation
CRPS(RSD)- Complex Regional Pain Sydrome (Reflex Sympathetic Dystrophy)o Type I
Triad of symptoms Sensory Autonomic Motor
Stages Stage 1
o Acuteo Persistent paino Edemao Warm skin
Stage 2o Dystrophico Same as Stage 1 o Deteriorating changes to tissues & nailso Hair losso 3 weeks – 3 months post
Stage 3o Atrophico Same as Stage 2o Add cold skino Atrophy of skin, soft tissue, muscle & boneo 6-9 months post
o Type II(Causalgia)- Specific Nerve Associated with CRPS Precedes w/partial injury of peripheral nerve or major branches Symptoms same as Type I
Only in region of specific nerve Symptoms unique to Type II
Electrical shooting sensation of pain Hyperalgesia in nerve distribution Swelling & trophic changes very discrete Usually NO CHANGE in bone metabolism
Treatment Decrease pain
o Gradual desensitization TENS Fluidotherapy Contrast baths
o Elevated massage Maintain or increase ROM
o Small, gentle active and passive therapieso Dynamic & static splinting
Increase strengtho Posture correction
Reduce edemao Elevation & compressiono Massage distal proximal
Carpal Tunnel Syndromeo Signs & symptoms
Night pain Tingling, numbness, pain Usually insidious unless following trauma Decreased strength/sensation in median nerve distribution Pain referred proximally + Tinels, Phalens, Reverse Phalens
Carpal Tunnel SyndromeAcute Subacute Settled
InspectionAtrophy of thenar muscles Reduce
inflammation, night splint
Wean from splint-Continue to
decrease inflammation
AROM/PROM Classical
Decreased w/pain in carpal tunnel decrease inflammation
AAROM/AROM to UE
-Begin light passive stretching
Increase vigorousness of passive stretch-Progress AROM
w/hand weights as tolerated
PROM AccessoryPossible limited pisiform and/or lunate
Grade I manipGrade II & III manips Grades III & IV manips
MMTdecreased strength in median nerve
distribution defer
Isometrics to elbow & wrist
-Light MRE to thumb & intrinsics
-Pinching activities-Open/close fingers
Grip strengthening-HEP rubberbands
-Fingertip pushups-Functional tasks
Special TestsDecreased grip strength rest, decrease
inflammationMovement Clumsiness avoid extreme wrist Look at ergonomics
Analysis flex/ext
NeurovascularDecreased strength/sensation in median nerve distribution rest, splint, remove
causative factors
Neural mobs as indicated
Modes of exerciseMuscle setting MRE
Isometrics Isotonics
Isokinetics
Eccentrics
Plyometric
Test grades Exercises0 PROM1 (Trace) AAROM2-/2 (Poor) AAROM/AROM in GL
AAROM against gravity2+/3 (P+/ Fair)
AAROM/AROM against gravityResistive in GL
3+/5 (Fair) Resistive against gravity
Intervention progression
Injury pain management flexibility strength proprioception endurance power skilled activity full activity
Include tissue healing, pain free functional activity & pt. education
Recommended