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