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Differential Diagnosis:

MSK Pathos:
Upper Extremities: Shoulder
Pathology S/S: Presentation T&M: Confirmation Associated pathos
External Primary  Intermittent mild pain with Hawkins’ Kennedy, Rotator cuff tear
Impingement: overhead activities, over age Neer, supine
Stage I 35 impingement
External Primary  Mild to moderate pain with Hawkins’ Kennedy, RC, bicep
Impingement: overhead activities or Neer, supine tendonitis
Stage II strenuous activies impingement
External Primary  Pain at rest or with activities, Hawkins’ Kennedy, RC tear, bicep
Impingement: night pain may occur, Neer, MMT RC mm, tendonitis, labral
Stage III scapular or rotator cuff empty can test, supine patho, instability
weakness impingement
Rotator Cuff  Mostly d/t impingement Neer impingement test, Overpowering
Tendonitis  Weak supraspinatus Hawkins kennedy Deltoid- superior
 Excessive use of UE translating of
following prolonged disuse humeral head
 Painful arc active ABD 60-
120 degrees
 Shoulder shrugs/push ups arm
ABD to 90 to strengthen UT
and SA
 PLOF 4-6 wks
Rotator Cuff  Classic night pain, weakness Positive empty can test, Associated with
tears (full noted predominately in ABD drop arm test, lift off scapular instability,
thickness) and ER, loss of motion sign, supraspinatus test impingement
 Pain in lateral arm/deltoid pain with palpation,
 Shoulder instability MMT RC
Adhesive  Inability to perform ADLs Capsular pattern Diabetes, thyroid,
Capsulitis owing to loss of motion—loss ER>ABD>IR cardiopulmonary
of motion may be perceived disorders
as weakness - Joint hypomobility
 Acute = PROM limited d/t ROM (AROM/PROM)
pain and guarding
 Chronic = lateral brachial
region- PROM limited d/t
stiffness
Recovery 12-24 mo
Anterior  Apprehension to mechanical Anterior apprehension Bankart lesion,
Instability shifting limits activities test. SLAP lesion,
 slipping, popping, or sliding MMT RC and scap Hills-Sach fracture
may present stabilizers. J (fx. Of
 Apprehension usually posterolateral
associated with horizonatal Joint capsule laxity ant > humeral head d/t
abd and ER. post
 Anterior or posterior pain impact), Axillary
may be present. Apprehension test, load nerve disruption
 Weak scapular stabilizers and shift
Posterior  Occurs with horizontal ADD Apprehension, load and
Instability and IR shift, relocation
 Slipping/popping of the
humerus posteriorly
 Flexion/IR with loading
Biceps Tendonitis Repeated overhead movements Yerganson’s Throwing,
Full ABD and ER Speeds swimming, raquet
Sx. Only recommended when Pain with resisted athletes
conservative treatment fails 6 supination Impingement, RC
mo tendonitis, GH
instability

TOS  Compression places: scalene  Adson’s test  Postural habits


triangle, clavical-1st rib, pec  Roos test  congenital
minor and thorax  Wright test
 Bad postural habits- fward  Costoclavicular
should/fwd head

FOREARM- HAND
Pathology S/S: Presentation T&M: Associated Management
Confirmation findings
Lateral  Mostly ECRB  Cozens, Mills,  Activities with  Acute stage:
Epicondylitis  Pain with gripping Lateral repetitive wrist avoid gripping
 Gradual onset Epicodylitis extension activities,
 Pain with resisted  Resistive testing lifting with
extension  Rule out radial palm down
nerve entrapment  Conterforce
brace on the
extensor
tendons –
decompression
Medial  Pronator teres, FCR  Medial  Baseball,  Stretching wrist
Epicondylitis epicondylitis test pitching, golf, flexor/pronators
swimming  Brace/splint
 Activities
requiring active
pronation
 UCL damage
 Ulnar nerve
irritation
Ulnar  Repetitive valgus  Valgus stress test  Overhead  Resolution of
collateral stress throwing inflammation
Ligament  Pain along medial  Strengthening
injuries elbow  Taping
 Medial ligament
instability
Elbow  posterior dislocations  observation  Elbow 
dislocations most common  palpation hyperextension
 rapid swelling injuries
 olecranon pushed post  FOOSH
 Avulsion
fractures-
medial
epicondyle
 MCL sprain
Carpal  Sensory  Phalen’s test  Most common  Radial
Tunnel changes/paresthesia  Tinel’s sign 35-55 y/o deviation
 Median nerve  Carpal women should be
distribution – lateral compression  Repetitive use, avoided
hand + thumb-3rd digit  Need to rule out RA,
 Night pain, mm cervical preganancy,
atrophy (ABD radiculopathy DM,
pollicis/thenar mm), hypothyroidism
decreased grip strength 

De  Inflammation of EPB  Finkelstein’s test  new 


Quervain’s and Abd poll longus  palpation mothers/post-
 Pain and inflammation pregancy
at base of thumb  Repeitive
trauma –
racquet
sports/heavy
lifting
 Superficial
branch of radial
nerve
Colles’  Most common wrist  Visual inspection  FOOSH  Immobilized 5-
Fracture fracture  Subjective  Median nerve 8 weeks
 “dinner fork” reporting compression
deformity- dorsal  Osteoporosis =
displacement of distal risk factore
radius
 Radial shift of wrist
and hand
Dupuytren’s  Banding on palm and  Observation  Affects men >  Flexibility
Contracture digit flexion  Palpation women exercises
contracture  ROM
 Palmar fascia  Splints
contracture
 Usually MCP and PIP
of 4th-5th digits (non-
diabetes)
 3rd-4th digits (diabetes)
Boutonniere  rupture of central  Observation  Trauma  Flexibility
Deformity tendinous slip of  palpation  RA  Splinting
extensor hood  Taping
 MCP extension, DIP
extension, PIP flexion
Swan Neck  Contracture of intrinsic  Observation  Trauma 
Deformity mm  Palpation  RA
 Dorsal subluxation of  Bunnel-littler test
lateral extensor
tendons
 Flexion of MCP,
flexion of DIP,
extension of PIP
Mallet finger  Rupture/avulsion of  Observation  Trauma 
extensor tendon at DIP  palpation  Forced flexion
 Flexion of DIP joint

UCL  Most common  Valgus force to  Trauma and 


ligament ligament injury in the the thumb MCP valgus force
Sprain: hand  Movement > 30-
thumb  “gamekeeper’s 35 degrees =
thumb”, “skier’s positive test
thumb”
 Pain, tenderness,
swelling near MCP jt
of thumb
 Instability/joint
weakness with
grabbing objects
Signs and Symptoms of Peripheral Nerve Involvement: UE

Nerve Presentation MM affected & Associated


Pathos
Spinal Accessory  Inability to ABD arm > 90  UT
Nerve  Pain in shoulder on ABD  CN damage/CVA
 SCI

Long Thoracic Nerve  Pain on flexing fully extended arm  Serratus anterior
 Winging of scap at 90 forward  Erb’s palsy
flexion  SCI C7 and above
 Decreased shoulder protraction and
upward rotation
Suprascapular nerve  Increased pain w/ shoulder flexion  Infraspinatus, supraspinatus
 Shoulder ER weaknesss  Erb’s palsy
 Pain w/ABD  SCI above C6
 Pain w/ cervical rot to opposite side
Axillary Nerve  Inability to ABD arm w/neutral  Deltoid, teres minor
rotation  Shoulder dislocation
 C5 SCI

Ulnar Nerve  Medial elbow pain  FCU, hypotenar mm, ½ Flexor


 Parasthesias ulnar distrib digitorum
 Tinel’s sign  Trauma in cubital tunnel,
dislocation, DJD
Median Nerve  Aching pain laterally  Pronator teres
 Weakness of forearm flexor mm  Flexor digitorum
 Tinel’s sign (wrist)  Repetitive gripping activities
 Parasthesias medially  Typing
Radial Nerve  Lateral elbow pain  Triceps
 Pain over supinator  ECU, ECR, ED
 Overhead activities/throwing
Lower Extremity: HIP

Pathology S/S: Presentation T&M: Confirmation Management


Avascular  Impaired blood supply to  Tenderness w/ palpation  Joint protection
Necrosis femoral head at the hip joint  Aquatic therapy
 Capsular pattern- ROM  Antalgic gait pattern 
decreased flex, abd, IR
 Pain in the groin
Trochanteric  Inflammation d/t direct  PROM, AROM, MMT  Injections
Bursitis trauma, ITB irritation  Pain with resisted hip  Stretching- ITB, ER,
 Lateral hip pain ABD and flexion quads, hip flexors
 Common in RA  PROM ER and ABD  Orthotics
 LLD, hx. of lateral hip pain  Gait deviation correct
sx., running sports
ITB  Tight ITB, abnormal gait  Noble compression test  ITB stretching
tightness  Ober’s test  Gait pattern correction
 Assessment/correction
of joint restrictions
 Shoe assessment
Piriformis  Low back pain  ER weakness  Joint oscillations
Syndrome  Pain with pirif mm  Piriformis test (S/L)  Correction of mm
palpation/post thigh  Restriction in IR imbalances
 Sciatic nerve pain (L5-  Uneven sacral base  Stretching
S1)  Muscle energy
 Can be caused by  Strain-counterstrain
excessive foot pronation-
abnormal femoral IR
 Exaggerated lumbar
lordosis, prolonged sitting
Lower Extremity: KNEE
Pathology S/S: Presentation T&M: Confirmation Management/Prognosis
ACL Sprain –  Single plane anterior  Lachman’s  Autograft = most
Grade III instability  Anterior drawer common reparir
 “unhappy triad” = MCL, ACL,  Brace unlocked once
med. Meniscus quad control observed
 Most vuln @ 6-8wks

 Graft mature 12-16


post-op

 PLOF 5-6 mo.


MCL  Medially directed force or  Positive valgus stress  PLOF 4-8 weeks
Sprain— twisting of the knee test
Grade II  Mm weakness  Full ext/ 30 degrees of
 Instability of the joint flex
 Swelling  + MRI
Osteoarthritis  Primary = aging  Restive testing  Avoid overexertion
 Secondary = trauma, obesity,  ROM (AROM and and fatigue
genetics, RA, metabolic PROM)
disorders  Functional testing
 Deep aching pain  X-ray to dx.
 Decrease ROM and crepitus
 Increased incidence of sprains
and strains around joints with
RA
Patellofemoral  Patella pulled laterally during  Point tenderness  Avoid deep squats
Pain extension lateral border during strengthening
 ant knee pain  Crepitus with  Biofeedback and
 Increased w/stair climbing, compression taping
jumping, prolonged sitting  Abnorm Q angle  Stretch hamstrings,
with knees at 90 (Norm Q angle 12-13) ITB, TFL, RF
 Weakness of VM  Clarke’s test
 PLOF 4-6 weeks
 Contributing factors: Differential Dx, =
Patella alta, excessive patellar tendonitis =
pronation, excessive knee anterior portion of the
valgus, tightness in LE mm superior tibia

Meniscal  Rotation, flexion, and  McMurray’s test  ROM/isom


Injuries compression forces with fixed  Apley’s test  PRE
foot  Thessaly’s Test  Functional exercises
 Joint line pain and tenderness  Conservative tx.
 Complaint of “catching” or Before sx.
“locking”  Tear in outer 1/3 more
likely to heal b/c blood
supply
Lower Extremity: LOWER LEG/ANKLE/FOOT
Pathology S/S: Presentation T&M: Confirmation Presentation/Prognosis
Anterior  Increased compartmental  Pain increased w/passive  Surgical intervention-
Compartment pressure resulting in stretching or active use of fasciotomy
Syndrome ischemia tib ant.
 Trauma, fx., overuse,  Comparing circumferential
mm hypertrophy measurements before and
 Swelling/pressure after exercise
feeling in lower leg
 Parasthesias in
distribution of deep
peroneal nerve
Achilles  Swelling over the distal  Thompson’s test  Rest 2-3 weeks
Tendon tendon  Unable to stand on their  Heel lift
Rupture  Palpable defect in the toes
tendon above the  PLOF 6-7 mo
calcaneal tuberosity
 Pain/weakness with
plantar flexion
Lateral ankle  Pain lateral ankle  Anterior drawer (ant talo  Strengthening
sprain  instability fib)  Proprioceptive/balance
 Recurrent sprains  Talar tilt (deltoid + exercises
common calcaneal fib)
 PLOF 2-6 weeks
Plantar  Medial calcaneal heal  Tight achilles tendon  Heel inserts and foot
Fasciitis pain  Development of heel spurs orthotics
 Excessive pronation,  Intrinsic mm
endurance sports = risk strengthening
factor  Return to function 8
 Pain in the am weeks
 Radiates prox to calf or
distally to toes  PLOF up to 12 mo
 Pain that “moves
around”
Tarsal Tunnel  Entrapment of posterior  Tinel sign  Orthosis
Syndrome tibial nerve w/in tarsal  neurodynamics
tunnel
 Excessive pronation,
overuse, trauma
 Pain, numbness,
paresthesia along medial
ankle to plantar surface
of foot
SPINE:
Pathology S/S: Presentation T&M: Confirmation Presentation
Prognosis
Scoliosis  Named by convex direction of curve  Forward bend test  Pt. with curve
 Rib hump on thoracic region of convex  Most common 12-14 <25 degrees
side children monitored
 Shoulder height higher on convex side  LLD every 3mo
and hip lower
 More anterior shoulder and pelvis on  Cobb Method
the c/l side d/t rotation  10 degrees = dx
 < 25 = conservative
 25-40 orthotic
 > 40 = surgery

Spondylolisthesis  Forward slippage of the vertebrae  Back pain increased  Flexion


 Most common at L4-5 w/exercise, lifting overhead, exercises
 Compression of L4 nerve root prolonged standing,  Mm stretching
 Degenerative, pathologic, congenital extension, walking up  Postural re-ed
o Congenital dx. during growth spurts incline  Traction
(12-16)
Spinal Stenosis  Narrowing of the lumbar/intervertebral  Worse w/lumbar extension  Flexion
foramina  Stooped posture exercises
 Gradual onset, worsening of chronic  Positive quadrant testing  Positional
pain at the midline spine gapping
 B?L weakness, parasthesias,  Traction
hyperreflexia if spinal cord
compression
Disc Herniation  Twisting/bending/loading of spine  MRI  Extension
 Can occur acutely or gradually  EMG exercises
 Risk factors = obesity, job  Slump test, SLF
requirements  MMT, sensation, DTR
 LBP, unilateral radicular pain
 s/s exaggerated by walking, sitting,
standing, coughing
SIJ conditions  Degenerative changes  SI gapping  SIJ gapping
 Trauma  SI compression manip
 Post-partum  Gaenslen’s test  Mm energy
 Forton’s finger sign (pain pinpointed  Sacral thrust  Pelvic floor
right at PSIS)  Thigh Thrust strengthening
 Palpation/pelvic alignment
TMJ:
S/S, Presentation Management/Prognosis
TMJ  Joint noise, joint locking, lateral  Joint mobility
deviation, forward head  Inferior glide = primary glide- gaps joint
 Risk factors = chewing on one  Relocation of anteriorly displaced disc
side, eating tough, clenching,  Postural re-ed
grinding teeth  Flexibility and mm strengthening
 20-40 yo most common  Night splints
 Mm pain, limited jaw motion,
headache, tenittus
 Restricted movement of the
unaffected side
 Deviation toward the affected side
 Postural re-ed

SURGICAL PROCEDURES: OTHO PROTOCOLS


Upper Extremity:
Surgery/Injury Indications/Precautions Management/interventions
Rotator Cuff  Post-op: sling immobilization: 6 weeks  1-6 weeks: PROM, AAROM
Tear +Repair  Acute stage ice, activity modification,  6-8 week: general ROM,
gentle ROM, ice, and rest neuromuscular control,
 If deltoid repair performed passive ext is isometrics, PRE
avoided initially  12-14 : task specific strength
 Repair weakest ~ 3wks post-op (lifting/carrying)
 24-28 weeks:
recreational/activities
 4-6 mo—PLOF/ functional
activities
 1 year: dynamic overhead
activities – return to sport
Shoulder  Anterior instability/ bankart repair  AROM soon after sx.
stabilization sx.: o Avoid ER, ext, horiz ADD  Don’t be overly aggressive in
capsular/labral o Avoid resisted IR getting full ROM early
repairs
 SLAP repair (superior labrum)  Can begin isometrics before
o Avoid contracting/stretching biceps getting full ROM
 Posterior capsule
o Immobilized in sling- “hand shake”
position
o Avoid IR, flex, horiz ADD
Total Shoulder  Indications for reverse total shoulder =  Early post-op (~1-6 wks):
rotator-cuff deficits that can’t be repaired PROM and AAROM, NO end
 Post op arm immobilization, elbow at 90 range stretching, isometrics
 No rotation past 30-40 degrees
first 3 weeks post-op
 AROM at 6wks
 No driving for several weeks
post op
 4-12 weeks progress to
increased ROM, PRE, functional
exercises
Flexor tendon  Distal extremity immobilized 3-4 weeks  Early interventions = edema
injuries/repairs post-op control, PROM, wound
of the hand  Rubber band traction to maintain IP joints in management
30-50 degrees flexion  4 weeks post-op = resisted
extension and passive flexion in
splint
 Soft tissue management
 AROM extension 1st before
AROM flex
 Resistive exercises when FULL
AROM achieved

Extensor tendon  Immobilized for 6-8 weeks with DIP joints  6 weeks post-op AROM w/
repairs of hand in neutral prox IP joints in neutral
 Proximal repairs immobilized w/wrist and  Early intervention = edema
digital joints in ext for 4 weeks control/PROM

Lower Extremity
Surgery/Injury Indications/Precautions Management/interventions
Total Hip  Cemented hips: can tolerate full  Early rehab: decreasing inflammation,
Replacement WB immediately post-op PROM, mm setting, AROM
 Noncemtended hip TTWB up to 6  Progression: PRE, endurance training,
wks functional training
 Hospital d/c- ext to neutral and flex to
 Posteriolateral approach- avoid 90 degrees
IR, ADD, flexion > 90 for 3-6 mo
 Direct lateral: avoid flexion > 90,
ADD, extension, ER, and ADD
 Anteriolateral approach: avoid
flexion > 90, Ext, ER, ADD

 Complications = DVT, PE, HO
ORIF femoral  NWB for 1-2 wks  Early rehab: ambulation, ROM
fracture  Depending on approach TFL, glut  Isotonic strengthening postponed until
med, Vastus lat may be affected mm have healed
 Fx of greater troch—glut med affected
 S/S of fixation failure: persistent  Fx of the lesser troch—iliopsoas
thigh/groin pain, LLD, limb in
ER, Trendelenburg sign
Total Knee  WBAT immediately post-op,  Early Rehab (1-3wks) = mm re-ed, soft
Replacement  Ambulation w/cane @ wk 3 tissue mobs, edema reduction, PROM,
 FWB @ wk 4 AROM, isometrics
 Begin resisted exercises @ wk 2-3
 Noncemented TTWB up to 6wks Progress to endurance exercises, PRE,
 Avoidance of forceful mobs into functional activities
flexion  Knee flexion requirements for ADLs-
 15-20 yr lifespan minimum 90 degrees, 105 degrees sit to
 Avoid squatting, quick pivoting, stand
pillows under knees, low sitting
 PLOF 8-12 wks
ACL repairs  Brace protection initial post-op:  Early interventions = pain control,
~ 20-70 degrees flex edema control, PROM/AROM,
isometrics
 NWB ~ 1wk then WBAT  Progress to closed chain/functional
 Weaned from brace between wk exercises
2-4 post-op  Avoid open chain exercises 0-45
degrees
 Graft most vulnerable 6-8wks
post-op RETURN TO SPORT
 Hamstring graft = cautious  No pain/effusion
w/flexion exercises  Full ROM
 Graft ~100% at 12-16wks  NO instability
 Quad strength 85-90% opposite leg
 Hamstring strength 90-100% opposite
 Functional testing (i.e. S/L hop) 85-90%
opposite leg

 PLOF 4-6 mo
Achilles Tendon  Pt. will be casted in slight PF  Regaining ROM as soon as possible
Repairs initially  Caution w/ exercises that stretch
 NWB 1st several weeks post-op Achilles or require active PF until
 Bracing 6-8 weeks for surgical tendon healed
repair  Use of heel lift to not stress the tendon
 Non-surgical serial casting 10
wks  PLOF 6-7 mo
SPINE

Laminectomy  Usually performed for disc  NO BLT


protrusion/spinal stenosis  Restrictions on extension
 Complete laminectomy = more  Body mechanics/postural training
instability immediately post-op
Spinal Fusions  Cervical fusions = anterior  Outpatient PT 6 weeks post-op
approach  Body mechanics, posture, core stabs
 Lumbar fusions = posterior
approach
 NO BLT