Movement  System  Impairment  Syndromes     Cervical  Spine  

Extension-­‐rotation:   Forward  head;  asymmetry  in  cervical  spinal  mm  and/or  scapula  

alignment;  pain  with  sidebend  and  extension;  weak  intrinsic  cervical  flexors;  dominant  cervical  rotators  

♦ Extension  exercises  (as  below)  ♦ Diminish  use  of  scalenes  and  SCM  for  rotation  ♦ Increase  use  of  intrinsic  cervical  rotators  

Sitting  with  back  to  wall  cervical  rotation  (with  supported  UEs)  (keep  chin  down;  do  not  lean  head  toward  side  rotating  or  sidebend  opposite  direction)  

Supine  cervical  rotation  (easier)   Facing  wall,  arms  supported-­‐active  cervical  rotation  (relax  

upper  traps)   Quadruped  cervical  rotation   Functional  Instructions  

• Work  station  centered,  avoid  prolonged  rotation  TV,  video  games;  etc,  avoid  sidebend  with  phone;  avoid  1  arm  activities  

Extension:   Forward  head:  pain  with  extension;  translation  greater  than  sagittal  

rotation:  weak  intrinsic  cervical  flexors  ♦ Strengthen  intrinsic  flexors,  improve  flexibility  of  posterior  

structures  ♦ Abdominals  (and  avoiding  thoracic  flexion)  ♦ Also  look  at  axioscapular  muscles,  posterior  thoracic  spinal  mm  

Sitting  with  back  to  wall-­‐capital  flexion   Intrinsic  cervical  flexors  in  supine  

• Capital  flexion  • Capital  flexion  with  heal  lift  (without  and  without  A)  

Intrinsic  cervical  extensors  in  prone/quadruped  • Prone  extension  (“roll”)  • Quadruped  (“roll”)  (harder  than  prone  control  scap)  

Sitting  with  back  to  wall  shoulder  abduction  and  lateral  rotation  (progression  of  capital  flexion;  recruits  traps,  rhomboids,  thoracic  spinal  mm)  

• Modifications:  arms  do  not  make  full  contact  with  wall;  fingertips  on  wall  

• Progression:  Free  weights,  resistance  bands   Sitting  with  back  to  wall  shoulder  flexion  (progression  of  

capital  flexion;  stretches  lats,  levator  scap,  strengthens  intrinsic  cervical  flexors)  

• Modifications:  scapular  plane,  palms  facing  each  other  

• Progression:  free  weights,  resistance  bands   Wall  slides:  facing  wall  shoulder  flexion  

• Modifications:  scapular  plane  • Progrssion:  resistance  bands  

Functional  instructions  • Using  computer-­‐good  thoracic  alignment,  forearms  

supported,  check  glasses   Flexion-­‐rotation:  

Decreased  cervical  lordosis,  flat  thoracic  spine;  pain  with  rotation-­‐associated  flexion;  excessive  recruitment  of  extrinsic  cervical  rotators,  anterior  and  middle  scalenes  

♦ Restore  normal  cervical  inward  curve  ♦ Avoid  flexion  of  cervical  spine  ♦ Increase  thoracic  flexion  ♦ Increase  use  of  intrinsic  cervical  rotators  ♦ Correct  sustained  aymetrical  positions  ♦ Avoid  head/neck  movements  during  body  language  

Sitting  cervical  rotation-­‐Back  to  wall;  UE  supported  (raise  chin  up  slightly,  don  not  lean  head  toward  side  rotating)  

Supine  active  cervical  rotation  (easier)   Quadruped  active  cervical  rotation  (even  easier);  allow  tspine  

to  be  slightly  flexed     Facing  wall,  arms  supported-­‐active  cervical  rotation;  relaxes  

upper  trap,  raise  head/chin  slightly   Functional  instructions:  

• Flex  cervical  spine  • Avoid  one  arm  activities  • See  flexion  syndrome  

Flexion:   Decreased  cervical  lordosis,  flat  thoracic  spine;  pain  with  flexion;  lower  

cervical  flexion  greater  than  upper  thoracic  flexion;  excessive  recruitment  of  extrinsic  neck  flexors;  poor  recruitment  of  intrinsic  neck  extensors  during  extension  

♦ Restore  normal  inward  cervical  curve  ♦ Improve  intrinsic  cervical  extensors  ♦ Avoid  prolonged  cervical  flexion  

Prone  active  cervical  extension  (as  above)  avoid  end  range   Quadruped  cervical  extension   Functional  instructions  

• Slump!  • Avoid  cervical  flexion;  lean  forward  with  hip  flex  • Raise  monitor  • Pillow  to  increase  lordosis  • Eye  glasses  

 

Thoracic  Spine   Rotation-­‐flexion:  

Pain  with  thoracic  flexion  and  rotation;  long  thoracic  paraspinals  and  scapulothoracic  muscles  (middle  trap  and  rhomboids);  short  shoulder  girdle  muscles  (  pec  minor  and  major,  latissimus  dorsi)  and  RA;  asymmetrical  obliques;  dominance  of  RA  

Common  in  crew,  squash,  golf,  diving,  running,  rotation  at  desk,  shifted  to  one  side  when  sitting,  leaning  on  1  arm  rest  

♦ Avoid  leg  crossing,  sitting  on  one  foot,  unilateral  arm  rest  ♦ Prescribe  unloading  activities  to  relieve  compression  

Quadruped  rocking   Back  to  wall  with  supported  shoulder  flexion   Inhalation  to  elevate  ribs  and  elongate  abs   Bilateral  shoulder  flexion  at  wall   Unilateral  shoulder  flexion  in  prone   Single  leg  stance  with  control  of  torso   Standing  trunck  flexion  (supported)  to  improve  hip  flex   Shoulder  flexion  in  quadruped   Prone  trunk  extension   Ab  exercises  with  UE  and  LE  motion  

Flexion:   Pain  with  thoracic  flexion  (but  not  always  painful!);  must  avoid  flexion;  

long  thoracic  paraspinals  and  scapulothoracic  muscles;  short  anterior  axioscapular  and  axiohumeral  (esp.  lats  with  a  kyphosis  lordosis),  short  RA  

Prone  trunk  ext   Sit  and  stand  back  to  wall  and  use  UE  motion   Light  ab  contraction  to  correct  kyphosis  

Rotation-­‐extension:   Pain  with  thoracic  region  that  radiates  into  lateral  and  anterior  rib  cage  

or  abdomen  caused  by  thoracic  rotation  and  extension;  (sidelying  or  sitting  up  in  exaggerated  position)  

Racquest  sports,  gymnastics,  ballet   Prevent  extension  and  rotation,  particularly  with  sitting  and  body  

language  ♦ Use  backrest;  rotate  chair  not  trunk;  avoid  unilateral  arm  rest;  

avoid  sitting  on  one  foot   Unilateral  arm  or  leg  movements  to  recruit  rotation  control  by  

abs   Prone  over  pillows,  unilateral  arm  movements  (slide  arm  up)   Quadruped  rocking   Quadruped  unilateral  shoulder  flexion  

Rotation:  

Pain  with  thoracic  rotation;  rib  cage  asymmetries;  asymmetries  in  scapulothoracic  and  thoracic  paraspinals;  short  stiff  scapulohumeral  muscles;  asymmetries  of  obliques  

Common  in  tennis,  squash,  softball,  sailing,  running;  rotation  to  one  side  at  desk,  unilateral  arm  rest,  sitting  on  one  foot  

Cue  to  reduce  motion  of  rotation   Relax  abs  and  then  perform  

Extension:   Pain  with  extension  which  occurs  too  easily;  usually  in  interscapular  

region   Common  in  dance  or  gymnastics   Teach  gentle  thoracic  flexion,  relax  paraspinals,  

See  extension  rotation   Increase  abs   Engage  abs  to  limit  thoracic  extension  or  excessive  elevation  of  

rib  cage  during  arm  elevation  (sitting,  standing,  quadruped)      

Lumbar  Spine   Rotation-­‐extension:  

Causes  of  patient’s  symptoms  are  extension  and  rotation  motions   Caused  by  facet  syndrome,  spinal  stenosis,  spondylolisthesis,  spinal  

instability,  DDD,  OA  of  spine,  herniated  intervertebral  disc   Spine  is  excessively  flexible  into  extension  and  rotation   Hip  flexors  are  stiffer  than  abdominal  muscles   Hip  abductor  muscles  are  stiffer  than  lateral  abdominal  muscles   TFL  is  stiffer  than  abdominals   Latissimus  dorsi  is  stiffer  than  abdominal  muscles   During  attempts  to  stand,  increased  back  extensors  than  hip  extensors  

♦ Treatment  does  not  emphasize  movement  in  opposite  direction  except  when  excessive  alignment  impairments  

♦ Stop  sitting  on  edge  of  chair  ♦ Stop  leaning  to  one  side  ♦ Must  maintain  hip  rotational  flexibility  ♦ Avoid  standing  with  one  hip  adductred;  avoid  sway  back  ♦ Should  contract  abdominal  muscles  isometrically  for  slight  PPT  ♦ Sitting  with  back  in  straight  back  chair  ♦ Rolling:  slide  heel  along  bend  to  flex  hip  and  knee  then  log  roll  ♦ Moving  in  bed  on  side  NOT  back  ♦ Sit  to  stand  push  with  hands  to  get  to  edge;  use  hands  to  push  up  ♦ Stair  climbing:  contract  abs  and  then  lift  leg  to  avoid  lumbar  

extension  OR  with  lifting  pahse  may  not  have  adequate  hip  flexion…needs  to  lean  forward  

♦ Walking  needs  to  take  small  slow  steps   Ther  ex  as  used  in  confirming  tests    

Extension:   Similar  to  extension-­‐rotation;  motions  that  contribute  to  lumbar  

extension  increase  symptoms   Thoracic  kyphosis,  swayed  back,  lumbar  lordosis,  anterior  pelvic  tilt   Stiff  hip  flexors,  stiff  latissimus  dorsi   Hip  flexors  are  more  dominant  than  abdominals;  back  extensors  

dominant  hip  extensors;  external  oblique  long  and  weak  ♦ Primary  objective  is  to  correct  lumbar  lordosis;  increase  

abdominal  activity   Heel  slides   External  oblique  exercises  in  chapter  7   Bilateral  knee  to  chest   Hip  abduction  and  lateral  rotation  from  flexion   Shoulder  flexion  to  decreased  kyphosis   Sidelying  hip  abduction   Prone  knee  flexion  preventing  anterior  tilt   Prone  hip  lateral  rotation  to  stretch  TFL  

Quadruped  rocking  back   Sitting  use  back  of  chair,  footstool,  contract  abs   Standing  wall  slides  with  lumbar  flexion   Shoulder  flexion  with  abs  contracted  

♦ Contract  abs  when  driving  manual  transmission,  rotate  hip    

Rotation:   Rotation  cause  of  pain;  not  common  to  find  only  rotation  

syndrome…sidebending  may  also  be  classified  as  rotation   Transient  symptoms   May  have  broad  pelvis  with  narrow  trunk,  leg-­‐length  discrepancy  (bony),  

hip  antetorsion  or  retrotorsion,  scoliosis   Lumbar  spine  is  flexible  into  rotation  and  lateral  flexion  in  lower  

segments;  also  during  hip  motions  of  adduction  and  rotation   Paraspinals  are  stiffer  than  lateral  abdominal  muscles;  inadequate  

recruitment  of  external  oblique  and  contralateral  internal  oblique;  dominance  of  rectus;  TFL,  hip  abductor    may  be  short  or  stiff  

♦ Prevent  rotation!   Rocking  backward   Supine  hip  abduction/lateral  rotation  from  flexion   Hip  adduction/medial  rotation   Abduction  of  shoulder  on  diagonal  135  degrees  with  weight  

and  then  return  movement  of  shoulder  adduction  to  90  degrees  

Prone  knee  flexion  and  hip  lateral  rotation   Quadruped  rocking  backward  to  improve  extensibility  of  hips   Quadruped  unilateral  shoulder  flexion   Sitting  knee  extension   Standing  lateral  flexion  with  support  at  lateral  side  of  waist  

  Rotation-­‐flexion:  

Most  likely  candidate  it  male  18  to  45  years  old;  they  have  less  hips  flexion  flexibility,  are  taller,  and  have  longer  tibias  

Pain  associated  with  sitting,  bending,  and  twisting   Flat  lumbar  spine,  leg-­‐length  discrepancy,  hip  retrotorsion  or  antetorsion,  

PPT,  hip  extension,  swayback,  large  abdomen   Lumbar  spin  eis  more  flexible  into  flexion  and  rotation  than  hamstring  

and  glute  max  muscles  are  extensible   Hamstring  muscle  are  stiffer  than  back  extensors   With  swayback  posture,  rectus  provides  more  trunk  support  than  back  

extensors   Rectus,  TFL,  and  hamstring  short  and  stiff  

♦ Primary  objective  is  the  improve  control  by  abs  to  prevent  rotational  movements;  improve  back  extensor  strength;  improve  hip  flexion  

Supine  hip  and  knee  flexion,  place  folded  towel  under  back   SKTC   Hip  abduction-­‐lateral  rotation  from  flexion   Sidelying  hip  lateral  rotation;  hip  abduction;  hip  adduction   Prone  knee  flexion  and  then  hip  rotation;  also  hip  extension  

with  knee  flexed  also  works  on  back  extensor;  prone  shoulder  flexion  

Quadruped  rocking  backward   Sitting  knee  extension  with  spine  against  straight-­‐back  chair   Standing  forward  bending  at  hips,  lateral  flexion  with  support  

at  side  of  thorax  at  L4/L5  ♦ Elevate  seat  to  prevent  lumbar  flexion,  move  to  edge  before  

standing    

Flexion:   Most  often  acute  herniated  disk   Sitting  with  lumbar  spine  flexed  with  head  and  shoulders  forward  of  the  

spine   Structurally  flat  back   Tall  with  long  trunk   Long  tibias   High  iliac  crests  

SKTC   Shoulder  flexion  with  inhalation  to  stretch  abs   Prone  shoulder  flexion,  prone  hip  extension   Quadruped  rocking  back  with  hip  flexion   Sitting  knee  extension   HS  stretch  15-­‐20  minutes  at  a  time   Standing  forward  bend  with  hip  flexion   Stretch  abs  with  shoulder  flexion  

   

Hip   Femoral  anterior  glide:  

With  and  without  medial  rotation   Caused  by  inadequate  posterior  glide  of  femoral  head  during  flexion;  

excessive  length  of  anterior  capsule   Generalized  hip  pain,  iliopsoas  tendinopathy   NO  ACTIVE  HIP  FLEXION.    STRETCHING  IS  CONTRAINDICATED   Also  iliopsoas  bursitis,  AVN,  stress  fracture  of  lesser  trochanter  or  femur,  

OA   Short  lateral  rotators  (without  medial  rotation)   Anteverted  hip,  genu  valgus,  swayback,  PPT,  poor  definition  of  glutes,  hip  

medial  rotation,  hip  extension,  hyperextended  knees,  pronated  foot   TFL  is  more  dominant  than  iliopsoas;  also  more  dominant  than  PGM   Hamstrings  dominant  over  glute  max   Medial  hamstring  is  more  dominant  than  lateral  

♦ Improve  posterior  glide  of  femur  ♦ Reverse  altered  hip  flexor  dominance…shorten  iliopsoas  ♦ Correct  hip  hyperextension  and  medial  rotation  if  present  

Quadruped  rocking  back  most  important,  perform  first   Supine  passive  hip  flexion  (may  need  slight  lateral  rotation  and  

abduction)   Prone  knee  flexion  preventing  pelvic  anterior  tilt  or  rotation  or  

hip  joint  abduction  or  rotation  to  stretch  ITB   Prone  hip  IR  to  increase  extensibility  of  ER   Prone  hip  extension  ONLY  with  pillow  under  hips  to  avoid  

stretching  anterior  capsule   Hip  extension  with  knee  flexed  ONLY  with  pillow   Sidelying  hip  abduction  with  slight  lateral  rotation  and  

extension   Sitting  knee  extension  with  slight  lateral  rotation   Isometric  hold  of  hip  flexion  at  end  range   Standing  SLS  contract  glute  max  for  ER   Sit  to  stand  without  allowing  hip  medial  rotation  

♦ Do  not  sit  with  legs  crossed    

Femoral  anterior  glide  with  lateral  rotation:   Adductor  strain   Hockey  and  ice-­‐skating   Anterior  structures  are  stretched,  posterior  lateral  rotators  taut   Pain  in  groin  worse  in  weight  bearing;  often  occurs  with  hip  extension  

and  lateral  rotation;  but  may  occur  with  flexion  and  lateral  rotation   Femoral  anteversion,  tibial  torsion,  rigid  foot,  PPT,  hip  extension,  knee  

hyperextension,  hip  lateral  rotation   Lateral  rotators  are  recruited  over  medial  rotators;  hamstrings  dominant  

over  glute  max  

Short  hip  extensors,  glute  max,  lateral  rotators,  hamstrings,  piriformis   Weak  glute  max,  abductor  medial  rotator  (TFL?  Unsure  by  text),  iliopsoas,  

weak  semimembranosus  and  semitendinosus  ♦ Improve  posterior  glide  ♦ Decrease  dominance  of  hip  extensor  lateral  rotator  muscles  ♦ Improve  medial  rotators  

Hook-­‐lying  adduct  and  rotate  hip  medially  then  reverse  but  limit  excursion  in  lateral  direction  (second  part  not  always  added)  

Prone  knee  flexed,  rotate  medially   Sidelying  abduction  with  medial  rotation  and  flexion   Quadruped  rocking   Sitting  isometric  iliopsoas   Standing  forward  bend  with  hips  while  knees  flexed  

♦ When  sitting  lean  forward  from  hips  ♦ Avoid  crossing  legs  

  Hip  adduction:  

With  or  without  medial  rotation   Medial  rotation:  PGM,  glute  max,  post  capsule  and  lateral  rotators  are  

weak  or  long,  TFL  short…could  be  weak  too;  quads  could  be  weak   All  hip  abductor  muscles  are  weak  or  long   Short  hip  adductors   Causes  wide  pelvis,  genu  valgus,  apparent  leg  length,  pronated  foot,  sleep  

on  side   Sometimes  causes  piriformis  syndrome;  also  IT  band  fasciitis   Pain  in  glute  medius,  deep  hip  pain,  trochanteric  bursitis,  sciatica   Peroneal  fascia  may  also  be  tight  causing  entrapment  of  peroneal  nerve   Sartorius  is  often  used  for  hip  abduction  in  side-­‐lying  

♦ Improve  hip  abductor  and  lateral  rotators   Walk  with  cane  if  antalgic   Prone  hip  abduction,  glute  set,  isometric  lateral  rotation  (heel  

squeeze)   Sidelying  hip  lateral  rotation/abduction  

♦ When  standing,  even  distribution  of  weight  ♦ No  crossing  legs  ♦ Stand  at  least  every  30  minutes  and  tighten  glutes  ♦ Do  not  allow  knee  to  come  together  when  standing  ♦ Pillow  is  sidelying  between  knees  

IF  TFL  WEAK  OR  STRAINED:   Supine  hip  abduction  with  medial  rotation   Active  hip  and  knee  flexion   Sidelying  hip  abduction   Prone  knee  flexion;  hip  lateral  rotation  to  stretch  ITB   Sitting  knee  extension  without  medial  rotation  

Sit  to  stand  avoiding  adduction  and  medial  rotation   SLS  with  glute  contraction   Walking  using  a  cane,  contract  glue  at  heel-­‐strike  

  Hip  extension  with  knee  extension  syndrome:  

Insufficient  participation  of  glute  max  during  hip  extension  or  quads  during  knee  extension  

Hamstrings  contract  when  the  foot  is  fixed  to  extend  the  knee   Hamstring  strain  (caused  by  being  hip  extensor  or  knee  extensor)  also  by  

intrinsic  lateral  rotators  of  hip  insufficient   Pain  at  ischial  tuberosity;  pain  along  HS  muscle  belly,  pain  with  hip  ext  or  

knee  flex   Swayback,  hip  extension,  medial  hip  rotation,  knee  hyperextension,  ankle  

PF   Hip  flexion  is  stiff  due  to  HS  hypertrophy  

♦ Improve  strength  of  synergistic  muscles;  do  not  use  HS   Quadruped  rocking  backward   Supine  unilateral  hip  and  knee  flexion   SLR  DO  NOT  allow  opposite  HS  to  contract   Prone  hip  extension  with  hip  flexed  with  pillow…slight  lateral  

rotation  is  good  to  add   Heel  squeeze   Sidelying  hip  abduction  with  slight  ER   Sitting  knee  extension  without  extending  or  medially  rotating  

hip   Sit  to  stand  with  body  leaning  forward   Strengthen  iliopsoas  if  swayback!   Standing  SLS  with  glute  contraction   Step  up  bringing  thigh  to  knee  

♦ Posture:  avoid  hip  or  knee  (hyper)extension;  glute  contract  at  heel  strike;  return  from  forward  bending  glute  max  contraction  not  forward  swaying  hips    

Femoral  accessory  hypermobility:   Early  degenerative  changes  in  the  hip  joint,  but  without  great  loss  of  

motion;  some  could  have  labral  tears   Subtle  impairments  of  superior  glide  with  rotation   Compression  into  joint;  may  occur  with  stretching  of  rectus  or  HS   Distraction  should  alleviate  during  stretches   Deep  pain  in  anterior  groin,  anteromedial  thigh   Slight  antalgic  gait   Assess  prone  passive  knee  flexion;  greater  trochanter  will  laterally  rotate  

or  glide  superiorly  (flexion  of  hip);  knee  extension;  rotate  medially   Dominance  of  HS  over  glute  max;  quads  and  TFL  over  iliopsoas  

♦ Reduce  hyper  mobility;  improve  extensibility  of  hamstrings  and  quads   Quadruped  hip  abd  and  ER  rocking  backward  until  femur  

rotates  laterally;  but  DO  NOT  stretch  intrinsic  hip  rotators   Prone  knee  flexion,  stopping  with  rotation  of  femur;  distraction  

is  helpful   Side-­‐lying  hip  abduction  in  neutral   Sitting  knee  extension  until  medial  rotation  of  femur   Isometric  iliopsoas  in  sitting   Eliminate  all  weight  training  of  quads  and  HS   Exercise  iliopsoas,  glute  medius,  glut  minimus,  hip  ERs   No  cycling!  

  Femoral  hypomobility:  

DJD  with  capsular  signs   Marked  limitation  in  flexion,  extension,  rotation,  abduction,  adduction   Pain  deep  in  joint  and  referred  to  inner  or  anterior  thigh   Joint  stiffens  after  rest   Limited  hip  extension  so  exaggerated  pelvis  rotation  or  anterior  tilt  

during  stance  phase;  also  lumbar  extension  and  rotation   Hip  flexion  contracture   Leg  length  discrepancy   Dominant  hip  flexor  muscles;  work  on  hip  extensors  strength  

♦ Primary  objective  is  to  maintain  as  much  ROM  as  possible   Standing  long-­‐axis  distraction  with  4-­‐7#  weight  can  try  medial  

and  lateral  rotation   Supine  SKTC  to  stretch  hip  flexors  (DO  NOT  PLACE  WEIGHT—

CAUSES  ANT.  DISPLACEMENT  OF  FEMORAL  HEAD)   Quadruped  rocking  back  pushing  with  hands   Prone  knee  flexion   Hip  lateral  rotation  with  knee  flexion   Hip  abduction   Standing  wall  slides   Walking  glute  contraction  with  heel  strike   If  compensating  with  lumbar  extenson,  flex  knees   Sitting  on  wedge  if  does  not  have  90  degrees  of  flexion   Sitting  to  standing  front  edge  of  chair  

  Hip  lateral  rotation:  

Characterized  by  insufficient  participation  of  intrinsic  hip  lateral  rotator  muscles  (piriformis,  obturators,  gemelli,  quadratus  femoris)  

Shortened  piriformis  with  sciatica   Pain  just  above  gluteal  fold  down  posterior  aspect  of  thigh  to  knee   Misdiagnosed  as  HS  strain   Hip  retrotorsion  

Hip  lateral  rotators  are  stiff  than  medial  rotators  ♦ Stretch  into  medial  rotation  

Quadruped  with  hip  abducted  and  ER;  rock  backward   Avoid  sitting  for  prolonged  periods   Also  avoid  hip  extension  and  lateral  rotation  

  Femoral  lateral  glide  with  short-­‐axis  distraction:  

Similar  to  adduction  syndrome  except  laxity  of  abductor  muscles  severe  enough  to  cause  femoral  head  to  glide  laterally  to  point  of  subluxation  

Prominent  greater  trochanter,  anterior  to  midline  and  distal  of  the  center  of  the  acertabulum  

Must  flex,  abduct,  and  rotate  femur  laterally  with  one  hand  and  guide  proximal  femur  at  trochanter  into  appropriate  alignment  

Femur  medially  rotates  and  adducts;  weak  glute  medius   During  abduction,  flexes  and  medially  rotates   Prone  extension  also  medial  rotation   Wide  pelvis,  prominent  trochanters  

♦ Eliminate  laxity  of  hip  abductors;  avoid  subluxation  of  femur   NO  QUADRUPED   Supine  heel  slide  keeping  neutral  rotation   Prone  hip  abduction  and  lateral  rotation   Isometric  hip  lateral  rotation  (heel  squeeze)   Hip  extension  with  knee  flexed   Sidelying  abduction  with  ER   Sitting  knee  extension  with  neutral  femur   Standing  SLS  ER   Avoid  crossing  legs  or  standing  with  hip  in  adduction  

   

Knee  (tibiofemoral)   Tibiofemoral  rotation  (TFR)  with  valgus  or  varus:  

Characterized  by  knee  pain  associated  with  impaired  rotation  of  the  tibiofemoral  joint;  excessive  rotation  between  the  the  tibia  and  femur  can  be  seen  during  tests  of  alignment,  movement,  and  functional  activities  

Pain  along  joint  line,  peripatellar  regions,  or  at  the  insertion  of    ITB   Pain  with  walking  stair  climbing   Ballet  dancers,  runner,  equestrians,  sedentary  workers   Valgas  TFLVal  

• Excessive  medial  rotation  or  adduction  of  femur  relative  to  tibia;  or  excessive  lateral  rotation  or  abduction  of  the  tibia  relative  to  the  femur  resulting  in  knee  valgus  

• More  common  in  men  • PFPS,  ITB  friction  syndrome  • Reduced  extensibility  of  TFL-­‐ITB  • Poor  hip  lateral  rotators  and  hip  abductors;  poor  tibial  lateral  rotators  

♦ Correct  TFRVal  during  functional  activities  ♦ Improve  hip  lateral  rotators,  abductors,  and  tibial  medial  rotators  ♦ Increase  extensibility  TFL-­‐ITB  ♦ Address  foot  PRN  

Correct  hyperextension   Align  knees  over  feet  with  neutral  rotation  of  femur  and  tibia   Correct  femoral  IR;  contract  glutes  and  hip  lateral  rotators  

DO  NOT  CORRECT  FOR  TIBIAL  OR  FEMORAL  TORSION   Gait  contract  glutes   Weight  shift  with  unilateral  contraction  (glute  med  and  lateral  

rotators)   Walk  with  feet  apart  to  shift  adduction  moment  to  medial  knee   Sit  to  stand  quadriceps  and  glutes,  lean  forward  (squeeze  your  

rear  and  keep  knee  over  2nd  toe  do  not  let  knees  come  together.    Can  use  TBand  around  distal  femurs  

Lift  foot  while  driving,  do  not  cross  legs   Hip  lateral  rotator  isometrics  in  prone,  hip  abduction  in  prone,  

hip  abd  with  lateral  rotation  in  sidelying,  hip  lateral  rotation  against  resistance  bands  in  sitting,  lunges;  hip  extension  in  prone  with  knee  flexed  progress  to  standing  hip  ext  with  bands;  SLS  glute  contraction  and  then  with  opposite  LE  motion  

TFL-­‐ITB  extensibility  prone  knee  flexion  (bilateral),  prone  hip  lateral  rotation,  2joint  hip  flexor  test  stretch,  ober  test,  abs  

Posterior  X  taping   Orthotics  to  correct  pronation   Proprioception  and  balance  

Varus  TFRVar  • Excessive  rotation  of  tibiofemoral  joint,  but  with  knee  varus  

• Varus  thrust  during  gait;  common  with  posterolateral  corner  injury  (hip  IR  and  knee  hyperextension)  

• Associated  with  OA  of  medial  knee  • Toe  out  to  reduce  symptoms  • Mild  to  moderate  laxity  of  LCL  • Reduced  extensibility  of  TFL-­‐ITB;  poor  performance  of  hip  lateral  

rotators  and  abductors  • Often  ankle  DF  and  pronation  are  limited  

♦ Correct  TFRvar  during  functional  activities  ♦ Improve  performance  of  hip  lateral  rotators  ♦ Improve  shock  absorption  during  gait  

Improve  alignment  by  unlocking  knees,  align  knees  over  feet  with  neutral  rotation  of  hips  by  decreasing  hip  IR  (contract  glutes)  

Heel-­‐to-­‐toe  gait  pattern  for  shock  absorption   Toe  out  gait,  walk  with  feet  slightly  closer  together   SPC  in  ipsilateral  side!    De-­‐weight  medial  knee   Hip  ER  strength   X  taping  

  Tibiofemoral  hypomobility  syndrome:  

Limitation  in  physiologic  motion  of  the  knee,  OA   Pain  with  WB,  walking,  standing,  stairs,  relieved  with  rest   Knee  flexion  in  standing   Decreased  extensibility  of  hip  flexors,  HS,  ankle  plantarflexors   Poor  performance  of  glutes,  lateral  rotators,  gastrocs,  quads  

♦ Improve  knee  flexion  and  extension  ROM  ♦ Improve  performance  of  glutes,  hip  ERs,  quads,  gastrocs  ♦ Improve  aerobic  conditioning  ♦ Educate  on  functional  activities  ♦ Caution  against  repetitive  rotation  of  knee  with  foot  fixed  ♦ Consider  compression  forces  ♦ Assistive  device  PRN  

Gait  with  heel-­‐to-­‐toe  pattern   Sit-­‐to-­‐stand—egde  of  chair,  contract  quads  and  glutes,  NO  ADD   20-­‐30  minutes  change  position   fitness   strengthening  exercises  as  in  TFRVal   also  gastroc  strengthening,  abs  and  quads   IF  MALALIGNMENT  OR  LAXITY  NO  QUAD  STRENGTHENING.    

It  will  accelerate  degeneration…use  functional  sit<-­‐>stand,  step  up,down,  partial  wall  squats  

Hip  and  knee  extension  in  supine  with  opposite  hip  held  to  chest  

Knee  flexion  in  prone  

Hip  ER  in  prone   Ankle  DF  with  knee  extended   Knee  extension  in  sitting  to  improve  HS  extensibility   Accessory  and  physiologic  mobilizations   Distraction  mobilization   Bracing   Neuromuscular  training  

  Knee  extension  without  and  with  patellar  superior  glide:  

Knee  pain  associated  with  quad  dominance  that  results  in  excessive  pull  on  the  patella,  patellar  tendon,  or  tibial  tubercle…poor  hip  extensors  

KextSG—patellar  tendon  and  retinacula  are  relatively  more  flexible  than  quads,  patella  moves  superiorly  in  trochlear  grove  

Runners,  football  linemen,  dancers,  jumping   Insall-­‐Salvati  ratio  1.67   Often  shift  body  weight  posteriorly  like  in  squat   Short  rectus  femoris   Poor  performance  of  glutes  and  hamstrings  

♦ Decrease  stiffness  of  quads  ♦ Improve  glute  and  HS  contribution  to  hip  ext  ♦ Increase  inferior  glide  and  decrease  superior  glide  of  patella  

KextSG   Sitting-­‐reduce  amount  of  knee  flexion  to  reduce  pain   Sitting  manual  inferior  glide   Gait—increase  push  off   Sit  to  standedge  of  chair,  flex  at  hips  and  contract  glutes   Reduce  quad  strengthening  exercises   Resistive  glutes  and  HS   Prone  hip  extension  with  knee  flexed   Weight  shifting   SLS   Hip  extension  in  standing  with  resistance   Lunges   Squats   Prone  knee  flexion  stretch  (  may  need  towel  under  distal  thigh  

to  allow  patella  to  move)  or  2  joint  hip  flexor  test  position—avoid  anterior  tilt  or  pelvic  rotation  KextSG  need  to  stabilize  patella  during  stretching,  may  need  tape  

Patellar  taping  KextSG   Patella  inferior  glides  and  mobilizations  with  movement  

  Knee  hyperextension:  

Knee  pain  associated  with  an  impaired  knee  extensor  mechanism   Dominance  of  HS  and  poor  performance  of  glutes  and  quads   Must  rule  out  TFR  syndrome  first  

Pain  in  peripatellar  region  or  tibiofemoral  joint  aggravated  by  prolonged  standing  or  activities  requiring  rapid  knee  extension  (swimming  martial  arts  race  walkers)  

Soft  tissues  of  posterior  knee  are  primarily  responsible  for  resistance  needed  to  prevent  extension  

Compresses  fat  pat,  stretches  ACL   Short  stiff  gastroc  (not  always),  short  HS   Poor  glute  max  and  quads  

♦ Decreased  hyperextension  of  knee  ♦ Improve  glute  max  and  quads  ♦ Decrease  recruitment  of  HS  

Relax  knees,  correct  PPT   Use  heel-­‐to-­‐toe  pattern,  walk  with  knees  slightly  flexed   Step  up  lifting  body  up  and  forward,  not  knee  backward   Prone  hip  ext  with  knee  flexed  pillow  under  belly  to  prevent  

hyperextension   Weight  shifting   SLS   Resisted  hip  ext   Sit  to  stand   Wall  sits   Step  ups   Lunges   Squats   Sitting  knee  ext  with  ankle  DF  for  HS  and  gastroc  flexibility   Taping  posterior  X  or  McConnell  taping  under  knee   Proprioception,  balance,  and  perturbations  

  Patellar  lateral  glide:  

Knee  pain  as  a  result  of  impaired  patellar  relationship  within  the  trochlear  groove  

Imbalance  between  vastus  lateralis  and  vastus  medialis  obliquus     May  also  have  tight  ITB   Pain  with  stairs,  running,  squatting   Often  secondary  diagnosis  with  TFR  or  knee  hyperextension   Short  stiff  lateral  patella  retinaculum,  may  also  have  short  glute  max  as  it  

pulls  on  ITB  ♦ Decrease  stiffnss  of  TFL-­‐ITB  ♦ Improve  quads  

Sitting—reduce  knee  flexion…initially  sitting  with  thighs  abducted  due  to  stiff  ITB  and  then  gradually  adducte  

Sit  to  stand  use  quads  at  edge  of  chair   Stairs-­‐glutes  and  quads   Sit-­‐to-­‐stand-­‐>step-­‐ups-­‐>lateral  step  ups-­‐>squats-­‐>lunges-­‐

>step-­‐downs  

Avoid  open  chain  60-­‐90  degrees   Prone  knee  flexion  for  ITB  stretch,  2joint  hip  flexor  length  

stretch   Manual  stabilization  of  patella  or  with  tape   Strengthen  PGM  and  glute  max   Patellar  mobilization  

     

Foot  and  Ankle   Pronation:  

Pronation  at  the  foot  and  ankle  during  weight  bearing  activities  that  is  excessive  and/or  when  there  is  insufficient  movement  of  the  foot  in  the  direction  of  supination  

Pronation  can  occur  in  hindfoot,  midfoot,  and/or  forefoot   Plantarfascia,  PTT,  anterior  tibialis  muscle,  tibial  nerve,  Achilles  tendon,  

metatarsal  heads,  interdigital  nerves,  medial  column  joints   Calcaneal  eversion,  medial  bulge  (prominence  of  talonavicular  joint),  low  

medial  longitudinal  arch,  forefoot  abduction,  splayed  forefoot  often  have  hip  IR,  knee  IR,  femoral  anteversion,  medial  tibial  torsion,  genu  valgus  

Subtalar  neutral  with  forefoot  varus…then  get  compensatory  calcaneal  eversion  or  forefoot/midfoot  pronation…could  also  be  valgus  hindfoot  

Excessive  calcaneal  eversion  in  early  and  midstance  phases;  excessive  arch  flattening  in  midstance,  and/or  insufficient  supination  in  later  stance  

Poor  contraction  of  gastroc   Increased  pressure  through  medial  aspect  of  foot  and  2-­‐3  met  heads  with  

calluses  in  these  areas   When  running,  often  have  midfoot  or  forefoot  contact…increasing  stress  

on  gastroc  and  post.  Tib.   Cue  to  contract  gastroc  and  post  tib  to  lift  heel  and  raise  medial  

longitudinal  arch   Contract  glutes  on  heel  strike   Gastroc-­‐SLHR  calcaneus  should  invert  and  elevate   Weak  post  glute  medius,  glute  max,  intrinsic  hip  lateral  rotators  

♦ Walking/running  contract  gastroc  by  lifting  the  heel  ♦ Raise  medial  longitudinal  arch  ♦ Contract  glute  muscles  ♦ Hit  with  heel  first  ♦ PRE  PF,  PF-­‐inv,  HR,  single-­‐leg  hopping  ♦ Towel  crunches  ♦ Posterior  hip  strengthening  ♦ Runners  stretch,  dropping  heel  off  step,  long  sitting  towel  DF  

(gastroc  and  soleus)  ♦ Talocrural  joint  posterior  glide  or  distraction  ♦ DF  splint  ♦ Limited  EDL  flexibility—needs  stretching  ♦ 1st  MTP  dorsiflexion  stretch  ♦ Anterior  glide  of  1st  MTP  joint  ♦ Shoe  prescription  ♦ Orthoses  ♦ Taping  

  Supination:  

Supination  of  the  foot  during  heel  strike  to  midstance  

Can  occur  in  hindfoot,  midfoot,  or  forefoot   Plantar  aponeurosis,  peroneal  tendon,  Achilles  tendonitis,  met  heads,  

lateral  column  joints   Calcaneal  inversion,  lateral  bulge,  high  medial  longitudinal  arch,  forefoot  

adduction,  narrow  forefoot;  hip  lateral  rotation,  knee  lateral  rotation;  subtalar  neutral  is  hindfoot  or  forefoot  varus  with  limited  joint  mobility;  can  also  have  valgus  hindfoot;  plantarflexed  first  ray  (dropped  first  ray)  

Walking  and  running  usually  impairment  includes  calcaneal  inversion  at  heel  strike  and  it  remains  that  way  through  push  off;  absence  of  pronation;  lateral  WB;  late  whip  to  medial  side  during  push  off;  can  cause  varus  motions  at  knee;  increased  pressure  at  met  heads,  particularly  the  1st  MTP;  cues  to  soften  landing  with  knee  flexion  or  roll  medially  sooner;  can  post  the  heel  laterally  to  encourage  eversion;  arch  support  to  increase  contact  area  

Single  leg  hopping  high  hopper   Decreased  talocrural  DF  during  late  stance  results  in  early  heel  rise  or  

transfer  of  weight  laterally   Limited  1st  MTP  DF  results  in  transfer  of  force  medial  at  late  stance  or  

keeps  forece  lateral   Limited  subtalar  joint  eversion   Calluses  on  1st  and  5th  met  heads  

♦ Walking  and  running  soften  landing,  hit  more  centrally  on  the  heel  ♦ ROM  as  in  pronation  syndrome  ♦ Footwear  prescription  ♦ Orthoses—not  for  everyone—only  if  significant  structural  

variations,  recurrent  problem  ♦ Taping  for  arch  support,  Achilles  taping  

  Insufficient  dorsiflexion:  

Insufficient  talocrural  DF;  occurs  during  midstance  to  pushoff  or  during  swing  phase…no  supination  or  pronation  impairment  

Plantar  aponeurosis,  Achilles  tendinitis,  posterior  calcaneal  bursa,  anterior  tibialis  muscle,  deep  fibular  nerve,  talocrural  joint  pain,  met  heads  

Walking  and  running:early  heel  rise,  knee  hyperextension,  increased  progression  angle—3  ways  to  compensate  

Poor  eccentric  use  of  gastrocs   Footwear—lift  heel  above  toe  

♦ Walking  and  running—active  contraction  of  gastroc  and  soleus  ♦ Joint  mobilization  to  increase  talocrural  DF  ♦ Tape  anterior  progressing  inferiorly  and  posteriorly  on  sides  of  

talus  to  calcaneus  ♦ Also  use  towel  for  self  mobilization  during  closed  chain  activities  ♦ Footwear  prescription  ♦ Heel  lift  

  Hypomobility:  

Limitation  in  physiological  and  accessory  motions  of  foot  and  ankle;  degenerative  changes  or  long  immobilization  

Calf  is  atrophied   Foot  and  ankle  are  large  due  to  edema   Decreased  step  length  on  uninvolved  side,  decreased  stance  time  on  

involved,  increased  progression  angle,  little  heel  strike,  little  push  off,  knee  may  hyperextend,  often  requires  assistive  device  unable  to  run  or  hop  

Limited  motion  throughout;  limited  strength  throughout;  unable  to  complete  SLHR  

Lack  of  balance  ♦ Aggressive  ROM  treatment  plan—prolonged  stretching  with  

braces,  casts,  joint  mobilization  and  manipulation  ♦ Tband  PRE-­‐>heel  raise  on  machine-­‐>B/L  HR-­‐>SLHR-­‐>dynamic  

bilateral  and  single-­‐leg  hopping,  cutting,  sport  specific  ♦ EO/EC  solid,  uneven  progress  to  marching,  kicking  balls,  walking  

backward  ♦ Large  shoe;  steel  shank  in  sole  of  shoe,  rocker  at  the  toes  ♦ Total  contact  orthosis,  heel  lift  

  Proximal  tibiofibular  glide:  

Posterior  and/or  superior  motion  of  fibula  on  tibua  during  HS  contraction   Pain  in  posterolateral  or  lateral  aspect  of  tibtib  joint  and  associated  

history  of  lateral  ankle  sprains   Pain  with  resisted  HS  contraction   Limited  HS  length  and  limited  talocrural  DF   Stabilization  of  fibula  decreases  symtpoms   Positional  fault  after  ankle  sprain  or  movement  impairment  as  result  of  

HS  contraction  ♦ Glide  fibular  ♦ Increase  HS  flexibility  ♦ Increase  talocrural  DF  ♦ Tape!  

   

Shoulder   Scapular  downward  rotation:  

Impaired  scapular  movement,  which  often  causes  or  is  associated  with  impaired  humeral  motion,  insufficient  scapular  upward  rotation;  inferior  angle  does  not  reach  midaxillary  line  • Could  be  tendinopathy,  impingement,  tear,  thoracic  outlet,  

humeralsubluxation,  instability,  neck  pain  with  or  without  radiating  pain,  AC  joint  pain,  SC  joint  pain  

Structure:  thoracic  kyphosis,  scoliosis,  large  breasts,  obesity,  heavy  arms,  long  trunk  and  short  arms  

Impairments:  short  deltoids,  short  supraspinatus  (leads  to  humeral  abd),  excessive  length  of  trap,  stiff  levator  and  rhomboids  

Often  combined  with  shoulder  abduction  syndrome   Downward  rotation  of  rhomboids  and  levator  dominant  over  traps  and  

serratus  ;  short  pec  minor  can  interfere  with  upward  rotation  because  of  ant  tilt;  lat  downward  pull  on  humerus  and  inf.  Angle  of  scapula  depressing  shoulder  girdle  

Sit  with  arms  supported   Eliminate  resistive  exercises  requiring  scapular  add  with  

shoulder  less  than  120  degrees   Avoid  shoulder  shrugs,  except  with  shoulders  flexed   Supine  shoulder  flexion,  assist  with  opposite  UE  for  scapular  

upward  rotation   Quadruped  rocking  

Scapular  depression:   Similar  to  downward  rotation  except  rhomboids  and  levator  are  not  

short;  upper  trap  long  and  weak,  lats  and  pec  major  and  pec  minor  short   Impingement,  tear,  subluxation,  AC  pain,  neck  pain  with  or  without  

radiating  pain,  pain  in  trap  or  levator,  thoracic  outlet   Scapula  depressed  and  fails  to  elevate  sufficiently  during  GH  flexion/abd  

(depression  can  occur  at  last  phase  90  degrees  or  initial  phase  0  degrees)   Long  neck,  narrow  shoulders,  long  trunk,  short  arms,  heavy  arms,  large  

breasts   Clavicle  horizontal,  superior  angle  lower  than  2nd   Upper  trap  does  not  elevate,  lower  trap  is  more  dominant  than  upper  trap  

Passive  support   Shoulder  shrugs  with  shoulder  flexed  at  120  degrees   Shoulder  flexion  with  emphasis  on  correcting  depression  

Scapular  abduction:   Excessive  scapular  abduction  during  GH  flex/abd,  axillary  border  of  

scapula  protrudes  more  than  ½  inch  beyond  thorax  or  inf  angle  reaches  beyond  midaxillary  line  

Impingement,  anterior  subluxation,  tendinopathy  (biceps,  infraspinatus,  supraspinatus),  infradeltoid  bursitis,  interscapular  pain  in  rhomboids  and  middle  traps,  SC  joint  pain  

First  half  shoulder  flexion  mostly  GH  joint,  2nd  half  1  to  1  

Excessive  length  of  trapezius,  maybe  rhomboids,  short  serratus  anterior   When  prone,  scapula  will  abduct  with  GH  lateral  rortation   Kyphosis,  long  arms,  large  thorax,  large  breasts,  abducted  scapula,  medial  

rotation  of  humerus  can  pull  scapula  into  abduction  (pec  major),  lateral  rotation  of  humerus  (short  lateral  rotators),  quadruped  scapular  abduction  from  shortening  of  serratus  or  stiffness  of  scapulohumeral  muscles  because  limits  horizontal  add  of  GH  adductions  

Shortness  of  deltoid  or  supraspinatus  causes  humeral  abduction  which  then  pulls  scapula  into  abducted  position;  hypertrophied  pec  major  

Stretch  glenohumeral  and  thoracohumeral  muscles   Increase  strength  of  lower  and  middle  trap   Scapular  adduction   Slide  arms  up  wall,  then  adduct  scapulae,  progress  to  facing  

away  from  wall,  progress  to  prone   Stretch  pec  major  and  minor   Stretch  medial  and  lateral  rotation  with  weights  in  supine   Stretch  scapulohumeral  muscles  with  back  to  wall  with  passive  

shoulder  adduction   Scapular  winging  and  tilting:  

Inability  to  flex  shoulder  actively  above  120  degrees  with  serve  winging  indicates  denervation  

GH  impingement,  tendinopathy,  bursitis,  tear,  thoracic  outlet   Tilt  of  inferior  angle  or  wing  of  vertebral  border;  can  occur  during  return  

from  elevation   Short  or  weak  serratus  anterior,  short  pec  minor,  short  scapulohumeral  

muscles   Stretch  pec  minor   Retrain  serratus   Quadruped  rocking  from  heels  forward   Elbow  flexed  to  120  back  against  wall  shoulder  flex  to  60  

degrees  to  control  winging   Humeral  anterior  glide:  

Pain  is  present  in  the  anterior  or  anteromedial  aspect  of  shoulder  joint.    Pain  is  increased  with  shoulder  IR,  hyperextension,  horizontal  abduction,  also  shoulder  flexion  80  to  180  degrees,  pain  along  biceps.    Could  have  ant.  Dislocation  

More  than  1/3  humeral  head  anterior  to  acromion,  humeral  head  anterior  to  distal  humerus,  slight  indentation  posteriorly  

Anterior  joint  capsule  more  flexibile  than  posterior  capsule  or  lateral  rotators  

Pec  major  more  active  than  subscapularis   Dominance  of  teres  minor  and  infraspinatus  over  subscapularis  as  

shoulder  depressor   Passive  IR  in  supine  with  90  degree  abduction   Horizontal  adduction  supine  (passive)  

Shoulder  flexion  with  lateral  rotation,  lean  into  wall  (facing  it)  to  allow  for  inferior/posterior  glide  

Stretch  pec  major   After  all  of  these,  then  strengthen  subscapularis  prone  

shoulder  abducted  to  90,  elbow  flexed  to  90,  isometric  end  range  IR,  as  progress  allow  50  degrees  of  motion  

Quadruped  rock  backward  by  pushing  with  arms  to  increase  posterior  glide  of  humerus  

Humeral  superior  glide:   Pain  anterior  and  lateral  aspects  of  acromion  during  shoulder  abduction,  

IR,  ER   Impingement,  Tendinopathy,  bursitis,  biceps  tendinopathy,  calcific  

tendinitis,  rotator  cuff  tear,  early  adhesive  capsulitis   During  elevation,  excessive  proximal  motion  of  head  of  humerus  against  

acromion  results  in  impingement  of  humeral  head  against  AC  ligament  or  acromion,  often  accompanied  by  scapular  downward  rotation  

Shoulders  can  be  elevated  (humerus)  or  depressed  (scapula)   Humeral  motion,  particularly  superior  glide  is  more  flexible  than  scapular  

motion  BUT  scapular  motion  is  more  because  in  superior  position  humerus  cannot  abduct  as  much  

Dominance  of  deltoid  over  supraspinatus  and  other  rotator  cuff…decreased  with  elbow  flexed  

Restriction  of  posterior,  inferior  and  lateral  capsule   Both  lateral  and  medial  rotators  can  be  short  

Correct  scapular  depression   Supine  medial  and  lateral  rotation  ROM   Prone  lateral  rotation  using  infraspinatus  and  teres  minor…not  

deltoid!   NO  ER  with  shoulder  in  adduction   Shoulder  flexion  with  elbow  bent!  Can  use  downward  pressure  

to  depress  head  of  humerus   No  leaning  on  hand  or  elbow  

Shoulder  medial  rotation:   Pain  at  lateral  and  anterior  aspects  of  humeral  head  in  region  of  acromion   Pain  between  80  and  180  degrees  of  flexion   Insufficient  lateral  rotation  stresses  subacromial  structures  and  causes  

impingement  of  soft  tissues   Impingement,  tendinopathy,  bursitis,  bicipial  tendinopathy,  calcific  

tendinitis,  rotator  cuff  tear,  early  adhesive  capsulitis   Humerus  is  medially  rotated  even  at  middle  and  end  range  of  elevation   Can  be  caused  by  broad  hips/narrow  shoulders,  cubital  fossa  is  medial   Lateral  rotators  are  more  extensible  than  medial  rotators…but  lateral  

rotators  may  be  stiff  if  scapular  in  abduction   Overuse  of  pec  major  and  teres  major  (sawing,  water  siing,  windsurfing)   Dominant  latissimus  dorsi  

Shortness  of  pec  major  will  limit  flexion  without  IR;  short  lat  can  do  it  also  

Stretch  medial  rotators   Restrain  scapula  while  shoulder  flexed   Prone  shoulder  ER  without  scapular  motion  (use  adductors  

and  serratus  to  stabilize)  (may  need  1/10  normal  effort)   Glenohumeral  hypomobility:  

Adhesive  capsulitis  and  frozen  shoulder   Range  is  limited  40-­‐50%  in  all  directions   Movement  occurs  more  readily  in  scapulothoracic  joint   Flexion  and  abduction,  excessive  scapular  elevation  and  trunk  motion   Medial  rotation,  anterior  tilt  of  scapula   Dominant  muscle  is  deltoid   All  scapulohumeral  muscles  are  short   Excessive  length  of  serratus  anterior  and  lower  trap   All  GH  muscles  weak  

Self  range   Passive  shoulder  flexion  with  elbow  bent   Passive  flexion  by  leaning  into  wall   Supine  50-­‐85  degrees  abduction  and  horizontal  flexion,  hold  

weight,  pull  into  medial  rotation,  must  prevent  anterior  glide  of  humerus  and  tilt  of  scapula  

Abduction  avoided  until  75%  ER   ER  should  be  performed  in  adducted  position  and  abducted  

position   Rocking  backward  in  quadruped  for  posterior/inferior  glide  

   

Elbow   Wrist  extension  with  forearm  pronation:  

Lateral  elbow  pain  provoked  by  gripping  and  lifting  activities  resulting  in  overuse  of  wrist  extensors  

ECRL  (elbow  extended),  ECRB  (flexed)…test  with  wrist  extension   Underuse  of  biecps  and  supinator   Excessive  wrist  extension   Excessive  GH  abduction   Wrist  extensors  short….may  cause  medial  rotation  of  humerus  instead  of  

pronation  of  wrist  ♦ Improve  alignment  and  movement  patterns  of  wrist,  forearm,  

elbow,  and  shoulder  ♦ Increase  elbow  flexion  and  forearm  supinated  ♦ Increase  flexibility  wrist  and  finger  extensors  and  finger  flexors  ♦ As  pain  decreases,  strengthen  wrist  extensors,  forearm  pronators,  

and  supinators  very  gradually  ♦ Forearm  strap,  splint  to  immobilize  wrist  

  Elbow  hypomobility:  

Significant  limitation  of  accessory  and  physiological  motion  of  the  elbow;  flexion  loss  is  usually  greater  than  extension;  usually  also  have  loss  of  supination  and  pronation  

Often  due  to  prolonged  immobilization  of  trauma   Movement  impairments  of  excessive  elbow  flexion,  forearm  pronation  

and  associated  GH  extension;  elbow  is  often  swollen   Compensatory  scapular  anterior  tilt  or  shoulder  extension  during  elbow  

extension;  scapular  adduction  and  posterior  tilt  shoulder  flexion  and  trunk  extension  during  elbow  flexion;  shoulder  adduction  and  lateral  rotation  during  supination;  shoulder  abduction  and  medial  rotation  during  prontation  

Capsular  end-­‐feel  AROM  and  PROM  about  equal  ♦ Primary  focus  is  to  increased  AROM  and  PROM,  at  least  -­‐30  

degrees  extension,  130  degrees  flexion,  50  degrees  pronation  and  supination  

♦ Edema  and  scar  management  ♦ AROM,  PROM  ♦ Hold-­‐relax,  contract-­‐relax  ♦ Joint  mobilization  ♦ Splinting  ♦ Heat  modalitis  ♦ Push  through  increased  symptoms  

  Elbow  flexion  (Cubital  Tunnel  syndrome):  

Prolonged  or  repeated  elbow  flexion  places  excessive  stresses  on  ulnar  nerve  at  medial  elbow  

May  be  associated  with  forearm  pronation,  wrist  flexion  or  extension,  and  shoulder  abduction  

Shoulder  abduction,  forearm  pronation  and  wrist  extension  elongate  the  nerve;  FCU  contraction  compresses  the  nerves  

Numbness  and  tingling  n  the  small  and  ring  fingers;  pain  in  medial  elbow;  deep  ache  in  proximal  forearm,  weak  grip  (late  stage)  

Increased  with  elbow  flexion  during  sleep,  pressure  on  medial  elbow;  resisted  elbow  flexion  and  wrist  flexion  

Habitual  elbow  flexion,  wrist  flexion  with  ulnar  deviation,  could  have  claw  hand  or  Wartenberg  sign  (abd  of  5th  digit);  avoiding  elbow  flexion  past  70  degrees  decreases  symptoms  

FCU  could  be  stiff  or  short   Could  also  have  shoulder  girdle  impairments  such  as  scapular  depression   Should  test  grip,  lateral,  three-­‐point  pinch,  and  Froment   Test  palmar  and  dorsal  interossei,  4th  &  5th  lumbricals,  adductor  pollicis,  

FDP  of  4th  &  5th  fingers  and  FCU  ♦ If  no  weakness  or  sensory  loss,  conservative  treatment;  if  

weakness  develops  consult  physician  ♦ 4  weeks  to  6  months  ♦ pt  education  on  avoiding  repetitive  activities  or  prolonged  

postures  of  elbow  flexion  greater  than  70  degrees,  direct  pressure  to  medial  elbow,  forearm  pronation,  and  wrist  flexion.    Minimize  valgus  force  

♦ increase  flexibility  of  FCU  ♦ nerve  glide  ♦ correct  scapular  impairments  ♦ PROM  of  MCP  and  IP  is  loss  of  AROM  ♦ Elbow  pad  ♦ Anti-­‐claw  splint  

  Elbow  valgus  syndrome  with  and  without  extension:  

Excessive  valgus  of  elbow  resulting  in  laxity  or  sprain  of  UCL   Common  in  baseball  pitches  and  racquet  sports   Often  associated    with  ulnar  nerve  injury   May  progress  to  pain  with  extension  

♦ Increase  strength  of  wrist  flexors  and  forearm  pronator  ♦ (with  extension)  also  emphasis  eccentric  control  of  biceps  brachii  

to    decrease  forces  on  the  posterior  elbow  ♦ avoid  resisted  horizontal  adduction  and  medial  rotation  of  

shoulder  ♦ (with  extension)  also  avoid  end  ROM  extension  

restore  normal  elbow,  forearm,  and  wrist  ROM   minimize  elbow  contracture   stretch  wrist  and  finger  extensors   strengthen  wrist  flexors  and  progress  to  pronation  

as  tenderness  decreases  strengthen  elbow  flex/ext,  wrist  flex/ext,  forearm  pronation  and  supination    progression:  isometric,  concentric,  eccentric  

after  6  weeks  can  do  valgus  loading  exercises   correct  shoulder  girdle  impairments  of  GH  ER,  scapular  

adduction,  posterior  tilt,  and  ER   (with  extension)  eccentric  control   (without  extension)  hinged  brace  to  prevent  valgus;  (with  

extension)  taping  or  splinting  to  avoid  extension    

Elbow  extension:   Posterior  elbow  pain  at  end-­‐range  of  elbow  extension  

• Normal  or  excessive  elbow  joint  ext  ROM  (source  is  joint  structures)  • Limited  (source  of  pain  is  muscle,  tendon,  joint)  

♦ Avoid  end  ROM  ♦ Improve  biceps  eccentric  control  ♦ Taping  or  splinting  to  avoid  end-­‐range  ext  

  Nerve  entrapment  

Posterior  Forearm  Nerve  Entrapment:  • Includes  radial  tunnel  (RT)  and  posterior  interosseous  nerve  

syndrome  (PINS)  associated  with  compression  of  deep  branch  of  radial  nerve  

• RT  minimal  loss  of  strength,  but  painful   Increase  biceps,  decrease  wrist  extensors   Avoid  wrist  extension,  forearm  pronation  &  supination,  elbow  

extension   Increase  flexibility  of  wrist    extensors,  finger  extensors,  and  

supinator   Can  also  stretch  wrist  and  finger  flexors   Address  shoulder  impairments   Splint  90  degrees  elbow  flex,  wrist  ext,  forearm  supinated   Modalitis  US  1mHz  1.0  W/cm2  15  minutes,  TENS,ionto,  cryo  

• PINS  may  have  pain,  but  significant  muscle  weakness  no  sensory  loss   PROM  to  fingers  and  thumb  flexion  and  extension;  AROM  and  

strength  as  innervation  returns   Splint  dynamic  thumb  and  finger  extension   Decompression  of  nerve  after  3  months  

Anterior  Forearm  Nerve  Entrapment:  • Pronator  syndrome  (PS)  and  anterior  interosseous  nerve  syndrome  

(AINS)  • AINS  compression  of  motor  branch  of  median  nerve  in  proximal  

forearm,  loss  of  strength,  no  sensory  changes;  weakness  of  FPL,  FDP  to  index  finger,  pronator  quadratus  

• PS  minimal  loss  of  strength,  but  painful,  may  have  sensation  changes  

If  no  change  8-­‐12  weeks  refer  back  to  physician   Avoid  repeated  grasping  and  forearm  pronation  and  

supination   Increase  flexibility  of  pronator  teres,  finger  flexors,  biceps  

brachii,  median  nerve   Improve  strength  of  supinator  and  shoulder  girdle   Static  splint  elbow  90,  forearm  neutral,  wrist  25  ext   Modalitis  US,  estim,  ionto  

  Wrist  flexion  with  forearm  pronation:  

Golfer’s  elbow   Overuse  of  wrist  flexors  and  forearm  pronators  

♦ Stretch  and  strengthen  muscles  isometric  to  isotonic  concentric  to  eccentric  

♦ Initially  elbow  flexed  when  working  on  wrist  ROM  ♦ Forearm  strap  ♦ Modalities    

Ulnoumeral  and  radiohumeral  multidirectional  accessory  hypermobility:   Elbow  pain  with  impaired  rotation  of  the  elbow  joint  (increased  rotation  

of  ulna  and  radius  related  to  humerus)   Includes  posterolateral  rotatory  instability  

   

Wrist  (Proposed  Syndromes)   Flexion   Extension   Wrist  flexion  or  extension  with  radial  or  ulnar  deviation   Wrist  hypomobility   Accessory  hypermobility  

   

Hand   Insufficient  finger  and/or  thumb  flexion:  

Most  commonly  secondary  to  trauma,  injury,  or  prolonged  immobilization  

Causes:   Flexor  tendon  adhesion   Extensor  tendon  adhesion   Shortness  of  extrinsic  extensors   MP  collateral  ligament  shortness  and/or  adhesion   IP  joint  dorsal  capsule  shortness  and/or  adhesion   Shortness  of  oblique  retinacular  ligament   Shortness  of  interossei  and  lumbricals   Swan  neck  deformity   Ligament  sprain   Weakness  of  finger  or  thumb  flexors   Rupture  of  finger  or  thumb  flexors  

Inability  to  make  fist,  difficulty  gripping  objects,  difficulty  using  hand  for  functional  activities  

Resting  alignment  of  decreased  flexion;  MP  extension  with  increased  IP  flexion  and  adducted  thumb  (stiff  hand  posture)  

Joint  adjacent  to  limited  joint  will  flex  more  readily   During  finger  flexion,  wrist  or  fingers  move  into  extension  if  finger  

extensors  are  short,  during  finger  flexion,  wrist  flexes  if  finger  joint  structures  are  the  source  of  limited  finger  flexion  

Assess  for  ligament  integrity,  joint  accessory  motion   Test  length  of  extrinsic  finger  or  thumb  flexors,  extrinsic  finger  or  thumb  

extensors,  and  interossei  muscles   Test  strength  

• Hypomobility  ♦ Flexor  tendon  adhesion:  AROM<PROM,  extrinsic  finger/thumb  

flexor  length  tests  +,  palpable  adherence,  strong  MMT  in  limited  range   Retrograde  massage  over  flexors;  passive  stretch  composite  

finger  extension;  static  splint;  tendon  gliding;  isolated  DIP  active  flexion;  isolated  PIP  flexion  (other  fingers  extended  passively);  resisted  flexion;  dynamic  splint  in  extension;  Russian  for  active  flexion,  ultrasound  over  adhesion,  UE  strengthening  

♦ Extensor  tendon  adhesion:  AROM<PROM,  extrinsic  finger/thumb  extensor  length  tests  +,  palpable  adherence,  strong  MMT  in  limited  range   Retrograde  massage  over  adhesion;  passive  or  active  stretches  

(composite  finger  flexion,  flexion  glove,  active  wrist  flexion  with  dumbbell);  active  extension;  resisted  extension;  

static/progressive  splinting  into  flexion;  moist  heat;  Russian  stim;  ultrasound,  UE  resistance  

♦ Extensor  muscle  shortness:  normal  AROM,  PROM  extension,  extrinsic  extensor  muscle  length  test  +   Same  as  extensor  tendon  adhesion  

♦ MCP  collateral  ligament  shortness  or  adhesion:  equal  limitation  PROM,  AROM  regardless  of  position  of  adjacent  joints,  firm  end  feel,  decreased  PA  glide  of  proximal  phalanx  on  metacarpal   AROM  and  PROM  to  specific  structure;  blocking  exercises;  joint  

mobilization  (volar  glide  and  distraction  to  increase  flexion);  passive  PIP  extension  (usu.  Also  limited  with  flexion  syndrome)  and  dorsal  joint  mobilization;  static  splints;  dynamic  splints  (glove,  progressive  flexion  splint  and  progressive  extension  splint);  CPM;  hot  pack/cold  pack/paraffin;  estim,  US  

♦ IP  joint  dorsal  capsule  shortness  or  adhesion:  AROM,  PROM  equal  regardless  of  position  of  adjacent  joints,  firm  end  feel,  decreased  PA  of  more  distal  phalanx  on  more  proximal  one   Same  as  MCP  collateral  ligament  shortness  

♦ Shortness  of  oblique  retinacular  ligament:  short  ORL  test  (DIP  joint  flexion  limited  with  PIP  extended  but  not  with  PIP  flexed);  Boutonniere  deformity  possible   Simultaneous  DIP  flexion  with  PIP  extension  (active,  passive,  

resistive)  ♦ Shortness  of  Interossei  and  Lumbricals:    composite  passive  finger  

flexion  can  be  normal  with  short  interossei  because  not  stretched  when  MP  are  flexed;  composite  extension    can  be  normal,  not  stretched  over  IP  joints,  TTP  muscle  bellies   Passive  stretch  MP  in  full  extension  and  passively  flex  IP  joints;  

active  MP  ext  IP  flex;  active/passive  MP  abd  and  add  with  IP  joints  flexed;  resistive  hook  grip,  static/dynamic  splint  in  same  ext/flex  pattern;  patient  education  to  avoid  intrinsic-­‐plus  position  

♦ Swan  neck  deformity:  PIP  hyperextension,  MP  &  DIP  flexed   Caused  by  hypermobility  of  PIP  (lax  volar  plate),  intrinsic  

shortness,  mallet  finger,  fx  of  middle  phalanx  with  shortening,  extensor  tendon  adhesion  over  dorsum  of  hand,  extensor  tendon  shortness,  nonfunctional  FDS,  volar  subluxation  of  MP  

Active  and  passive  stretch;  active  and  passive  composite  finger  and  wrist  flexion  to  maintain  EDC  length;  pt  education  to  avoid  faulty  movement  patterns;  night  splint  with  MPs  in  ext  and  IP  flexion;  button  hole  splint  during  day  

♦ Ligament  sprain  • Force  Production  Deficit  

♦ Weakness  of  finger  and/or  thumb  flexors:  active  less  than  passive,  strength  2/5,  passive  ROM  normal   Progressive  overload;  every  other  day  3  sets  of  15  reps;  more  

often  at  grades  <3+/5  ♦ Rupture  of  finger  and/or  thumb  flexors:  absent  active  function,  

passive  is  normal,  absent  tenodesis,  sudden  onset  with  audible  pop   See  MD  

  Insufficient  finger  and/or  thumb  extension:  

Insufficient  finger  and  thumb  extension  AROM   It  may  be  caused  by  

♦ Flexor  tendon  adhesion   Retrograde  massage,  passive  stretching  to  flexors,  static  splint  

in  extension,  active  flexion  (composite  and  blocked),  differential  tendon  gliding,  resisted  flexion,  static  progressive/dynamic  splinting  into  extension,  moist  heat,  Russian  stim,  US,  PRE  for  UE  

♦ Extensor  tendon  adhesion   Retrograde  massage,  passive  and  active  stretches  to  extensors,  

flexion  glove,  active  extension  (composite  and  blocked),  differential  tendon  gliding,  resisted  extension,  static  progressive/dynamic  splinting  into  flexion,  moist  heat,  Russian  stim,  US,  PRE  of  UE  (order:  circular  massage,  active  exercise,  retrograde  massage  with  active  exercise,  composite  stretching  passively,  dynamic  or  static  progressive  splinting,  resistive)  

♦ Flexor  shortness   Passive  or  active  PIP  extension  to  stretch  volar  plate,  joint  

mobilization  (dorsal  glide),  static  progressive  splints,  dynamic  splints  to  PIP  (20-­‐30  minutes  6-­‐8  times/day),  anti-­‐claw  splint  (encourage  PIP    extension  with  MP  extension  blocked  by  splint),  CPM  (stage  I  or  after  tenolysis),  hot/cold  packs,  paraffin,  estim  for  active  assistive  contraction,  US  

♦ MP,  PIP,  DIP  volar  plate  or  accessory  collateral  ligament  shortness  or  adhesion   Same  as  flexor  shortness  

♦ Shortness  of  ORL   Active,  passive,  resistive  exercises  into  simultaneous  PIP  ext  

and  DIP  flex  ♦ Shortness  of  interossei  and  lumbricals  

Passive  stretch  (MP  in  extension  while  passively  flexing  the  IP),  active  hook  fist,  active  and  passive  MP  joint  abduction  or  adduction  (IPs  flexed,  MP  extended),  resistive  hook  grip,  static  progressive/dynamic  splinting  ,  pt  education  to  avoid  prolonged  grip,  frequent  stretching  

♦ Ligament  sprain  ♦ Weakness  of  EDC  or  thumb  extensors  

Progressive  overload  3x10-­‐15  every  other  day  ♦ Weak  interossei  and  lumbricals  

Clawing  due  to  ulnar  nerve  injury,  anti-­‐claw  splints,  PROM  (MP  flex  and  IP  extension  if  loss  of  AROM)  

♦ Radial  Nerve  injury  with  paralysis  of  finger  and  thumb  extensors   AROM,  PROM  to  all  joints,    splint:  dynamic  finger  MP  and  

thumb  extension  splint  at  all  times  except  for  PROM  exercises,  wrist  cock  up  at  night  

♦ Rupture  of  finger  or  thumb  extensors    

Insufficient  thumb  palmar  abduction  and/or  opposition:   Insufficient  thumb  palmar  abduction  and/or  opposition  

• Force  production  deficit  (decreased  strength)    ♦ Passive  thumb  abduction  and/or  opposition  >  AROM  ♦ 2/5  strength  APB,  OP  

• Hypomobility  (physiological  and  accessory  motion)  • Possible  median  nerve  injury  with  contracture  of  thumb  muscles  

♦ PROM  normal  and  greater  than  AROM  ♦ Strength  1/5  

Opposition  splint  to  prevent  contracture,  thumb  web  active  and  passive  stretching  to  prevent  contracture,  APB  &  OP  strengthening  

If  contracted:  Opposition  splint  for  functional  use,  DC  to  motor  point  3x/day  10  reps,  web  stretching  

• Contracture  ♦ Active  abduction  and/or  opposition  =  PROM  and  limited  ♦ Palpable  scar  ♦ Accessory  motions  CMC  decreased  ♦ End  range  pain  with  PROM  

Progressive  stretching  of  webspace  using    Otoform  K  or  elastomer  with  splinting,  active  and  passive  web  space  stretching,  practice  grasping  with  stretched  web  space  

• Subluxation    secondary  to  OA  of  CMC  joint  (joint  pain  and  stiffness,  limited  motion)  (repeated  needlework,  use  of  scissors)  ♦ AROM  =  PROM  ♦ Swelling  CMC  joint  ♦ Adduction  deformity  of  CMC  joint  ♦ Likely  decreased  accessory  motions  ♦ Pain  in  multiple  direction  

Joint  protection  strategies,  build  up  pencil,  avoid  strong  grip  and  pinch,  use  jar  opener,  splint  thumb  spica  (forearm  or  hand  based),  if  MP  hyperextends  splint,  paraffin  

• Decreased  1st  web  space,  muscle  atrophy,  scar  • Inability  to  maintain  longitudinal  arch  of  thumb  • Muscle  length  test  of  adductor  pollicis,  FPB  • Swanso’s  crank  and  grind  • Shoulder  sign  test  

  Thumb  carpometacarpal  accessory  hypermobility:  

Pain  at  CMC  joint,  but  alignment  and  movement  impairments  occur  at  all  joints  

CMC  may  be  extended/abducted  or  adducted/flexed   Can  have  MP  flexion  with  IP  extension  OR  MP  hyperextension  and  IP  

flexion   Adductor  pollicis  and  FPB  are  overused  in  relation  to  APL,  APB,  opponens  

pollicis,  EPB,  FPL   MUST  HAVE  MODIFIABLE  MOVEMENT  PATTERN—(no  neuro  or  late  

stage  arthritis)   Pain  in  CMC  with  pinch;  c/o  weak  thumb   Writers,  hairdressers,  surgeons   Inability  to  maintain  the  arc  of  pinch   Movement  pattern  for  thumb  extension:    

• CMC  extends  more  than  MP  (boutonniere  MP  flexion  IP  extension)    ♦ Avoid  CMC  extension  (decrease  use  of  APL)  ♦ Increase  MP  extension  (increase  use  of  EPB)  ♦ Avoid  IP  extension  (increase  use  of  FPL,  decrease  thumb  

intrinsics)  • OR  MP  extends  more  than  CMC  (swan  neck  MP  hyperextension  IP  

flexion)  ♦ Increase  CMC  extension  and  abduction  (increase  APL)  ♦ Increase  IP  extension  (increase  EPL)  ♦ Avoid  excessive  MP  extension  (increase  FPB)  

• OR  CMC  adducts;  EPL  dominates  APL  ♦ Abduct  CMC  slightly  then  extend  

Movement  pattern  for  thumb  flexion:    • CMC  flexes  more  readily  than  MP    

♦ Maintain  CMC  in  extension  and  abduction  (increase  us  of  APL)  ♦ Flex  MP  (increase  use  of  FPB  at  longer  length)  

• OR  CMC  remains  abducted  and  extended  while  MP  flexes  excessively  and  IP  maintain  ext  ♦ Increase  flexion  at  IP  and  CMC  ♦ Avoid  excessive  MP  flexion  and  IP  ext  (decrease  use  of  thumb  

intrinsics)  • OR  CMC  adducts  and  supinates  

♦ CMC  abducted  and  in  neutral  by  strengthening  OP  and  APB   Movement  pattern  for  thumb  abduction:  MP  abducts  more  than  CMC  

♦ Block  MP  abduction  with  splint  and  work  on  CMC  palmar  abduction  (increase  extensibility  of  adductor  pollicis  with  use  of  APB)  

AROM  =  PROM,  may  be  painful  abduction  and  extension   +  Swanson’s  crank  and  grind   May  have  swollen  CMC,  TTP,  crepitus,  decreased  pinch  strength  

♦ Primary  treatment  is  to  educate  patient  to  maintain  arc  of  thumb  during  active,  functional,  and  resisted  isometric  thumb  movements  

♦ Abduction  for  CMC  joint  not  MP  or  IP   Once  all  movement  patterns  normal,  strengthen  muscle   Splinting:  stabilize  CMC,  correct  MP  alignment  to  help  CMC  alignment   Modify  tools  ,  avoid  grip  and  pinch,  dycem  to  open  jar,  key  holder,  build  

up  circumference  of  grip  on  handles,  build  up  pencil    

Finger  (or  thumb)  flexion  with  rotation:   Normal  alignment  of  finger  is  not  maintained  during  finger  flexion  (1  or  

more  of:  longitudinal  arch,  neutral  rotation,  or  neutral  abduction/adduction  of  finger)  

Finger  AROM  and  strength  are  usually  normal   Must  have  modifiable  movement  impairment  to  be  considered  in  this  

class   Don’t  forget  upper  part  of  kinetic  chain   Pain  in  MCP  or  PIP   Lots  of  typing,  carrying  bag  by  handle  with  finger  in  UD,  grasping  golf  

club,  cutting  hair,  music  • MP  flexion  with  IP  extension  (loss  of  longitudinal  arc  of  finger)  and  UD  

of  MP  during  flexion  ♦ Interossei  on  one  side  is  overused  relative  to  opposite  interossei  

and  to  the  ED  (MP  joint),  the  FDP  and  FDS  (IP  joints)  • Rotation  of  finger  at  MP  during  resisted  isometric  finger  flexion  • Index  figer  MP  adducts  and  supinates  rather  than  staying  in  neutral  

rotation  during  index  finger  flexion  with  abd  (overuse  of  1st  PI  over  1st  DI)  

Shortness  of  interossei  on  one  side   Increase  use  of  finger  flexors  over  interossei   Neutral  rotation,  normal  longitudinal  arc   Stretch  interossei  

  Finger  (or  thumb)  flexion  without  rotation:  

Poorly  localized  symptoms  in  the  hand,  wrist,  forearm   Repetitive  activity   Don’t  forget  upper  part  of  kinetic  chain  

• MP  flexion  with  IP  extension  ♦ Overuse  of  both  interossei  over  FDS,  FDP,  ED  

Correct  arc  of  finger  by  increasing  MP  extension  (use  ED)  and  increase  IP  flexion  (use  FDP  and  FDS)  

• Flexion  of  MP  with  PIP  hypertext,  DIP  flexion  (swan-­‐neck)  ♦ Laxity  of  volar  plate  at  PIP)  ♦ Overuse  of  interossei  over  FDS,  FDP,  ED  

Increase  MP  extension  (use  ED)  and  increase  PIP  flexion  (use  FDS)  

• Flexion  of  PIP  with  DIP  hyperextension  (boutonniere)  ♦ Overuse  of  FDS  relative  to  FDP  and  laxity  of  volar  plate  at  DIP  

Increase  DIP  flexion  (use  FDP)   Shot  ORL  

Educate  to  maintain  arc  and  neutral  rotation  of  fingers   Stretch  antagonistic  muscles   Resistive  after  able  to  perform  movement  pattern  correctly   Modify  tools  used  at  work,  musical  instruments   Splint  to  stretch  

  Source  or  regional  impairment  of  hand:  

       

Sacpular  alignment:  vertebral  borders  vertical  &  2.5-­‐3  inches  from  vertebrae;  10  degrees  ant.  Tilt,  30-­‐40  degrees  IR,  between  T2-­‐T7    Thoracic  alignment:  kyphosis,  posterior  trunk  sway,  flat  back,  rotation,  scoliosis    Rib  cage  alignment:  subcostal  angle  90  degrees  widening  of  subcostal  angle:  obese,  poor  ab  strength;  short  Int.  oblique,  long  ex.  Oblique  (too  many  sit  ups!)  elevation:  overdeveloped  pectoral  muscles  narrowing  of  subcostal  angle:  overdeveloped  abs    Sternum:  pectus  excavatum,  pectus  carinatum    Footwear:     Heel  counter—posterior  component  around  the  heel—should  be  firm  and  fit  snugly—important  in  pronation     Density—increased  for  pronation,  cushioned  for  supination       (if  neutral  calcaneus,  pronation  at  midfoot—density  should  be  only  at  medial  midfoot,  vice  versa       Flexibility—should  only  bend  at  toe  break—should  match  with  MTP  joint  line     Heel-­‐to-­‐toe  height—lifted  heel  to  compensate  for  limited  DF  (common  in  pronation  and  supination)     Arch  support—often  not  substantial,  can  add  scaphoid  or  navicular  pads     Last  shape—straight,  semi-­‐curved,  curved—bisection  of  heel  to  toe  (longitudinal)  into  equal  parts…fit  to  patient…do  not  try  to  change  foot  by  changing  last,  straight  for  pronation,  curved  for  supination