MUSCULOSKELETAL 3
Errors in Clinical Reasoning:
1. Assumptions assuming shoulder pain is coming from shoulder (could be c-spine)
2. Limited number of hypotheses not everyone presents the same
3. Failure to get enough informationmaking generalizations, do a good exam!
4. Confirmation bias choosing favorite dx
5. Errors in inferring relationship of sx don’t assume 2 areas of pain in close proximity are related
Clinical Reasoning
1. Mechanism: nocioceptive, central/neurogenic, peripheral neurogenic, affective, sympathetic
2. Sources: Local, referred
3. Contributing Factors: age, sex, hx, occupation, improper technique, change of activity, personality,
family hx, weight
4. Precautions and Contraindications: CA, OA, 5 D’s, irritability
5. Prognosis: positive and negative factors
6. Management
7. List areas to test for support or negate
THERAPEUTIC EXERCISE
O Improves glucose uptake, insulin sensitivity, blood lipid profiles. Lowers blood pressure. Protects against
obesity. Decreases chronic inflammation, Improves physical function and independent living in the
elderly. Decreases cancer risk. Improves symptoms of mild/moderate depression and anxiety
Effects of Deconditioning
O Decreased muscle mass, strength, muscle capillary density and ATP production. Bone strength
decreases (white women susceptible to osteoporosis). Leads to increased reliance on carbohydrates as
an energy substrate.
US Activity Guidelines: 150 min/wk of mod intensity OR 75 min/wk of vigorous intensity (can double for
additional benefits). Mm strengthening 2x/wk.
Stage of Movement Control
O Mobility- functional range through which we move
O Stability- stable foundation for a person to move (postural setup)
O Controlled mobility – functional movement pattern. Follow optimal path of instant center of rotation.
Most efficient pathway
O Skill- final element of task
General Exercise Considerations
O “Proximal stability before distal mobility”
O Gravity eliminated v. against gravity
O Weight machine v. free weight
O Exercise progression:
Gravity lessened plane
Against gravity
Resistance: manual, PNF, theraband, weights
Straight plane-multiplanar-functional
Move from stable surface to more unstable
Lower skill level to higher
Lumbar Stabilization Mm: Transverse Abdominus, Gluteus Maximus, Pelvic Floor: kegals, Abdominal Obliques,
Erector Spinae/Multifidi, Hamstring (debatable)
Local muscles: directly provide stabilization. EX: TA, multifidi
Global muscles: generate torque across multiple segments. EX: Rectus, obliques
Pilates
Principles: Breath, Concentration, Flow, Control, Centering (movement from center), Precision ( correct
repetitions for HEP)
Aquatic Therapy Basic Principles
O Archimedes Principle- immersed body exerts same force that is placed on it
O Specific Gravity- density of water 1 g/cm2  > 1 sink and <1 float
O Pascal’s Law- pressure of fluid is exerted equally at whatever depth
O Hydrostatic Pressure- greater at the bottom of the pool; good for people with edema
O Viscosity- resistance to adjacent fluid layers sliding by one another. Allows water to be resistance.
O Buoyancy: Upward force felt in the pool due to the specific gravity and water depth
CONTRAINDICATIONS: Open wounds, Rashes, Active Infections (UTI), Incontinence, Tracheostomy, Chlorine
Allergy
SHOULDER
Tipping- due to low trap weakness, short biceps brachi, short pectoralis minor
Downward Rotation- shorten rhomboid & levator, lengthened upper trap and serratus
Winging- weak serratus, long thoracic nerve palsy
Spregel’s Deformity- hypoplastic incorrectly rotated scapula, sits too high
Impingement
Internal: Due to abnormal contact between undersurface rotator cuff and posterosuperior glenoid. May be due
to GIRD=glenohumeral internal rotation deficit
Sx: posterior shoulder pain with max ER, pain with cocking phase, deep, sharp, IR limitation, weak ER, recurrent,
common in throwers
Tx: stop throwing activity, ice, improve ROM and scap strength, mm balance, year round training program. If it is
GIRD, do posterior capsule stretching, balance GHJ and ST forces
External: Influenced by AC joint, age, mm strength, arm position, scapular weakness, capsular tightness, posture,
acromion type (1-flat, 2- curved, 3-hook)
Primary and Secondary Impingements are External
Primary Impingement
Due to decreased subacromial space or to dynamic
problems
Sx: anterior and lateral shoulder pain, limited IR and
horizontal abd.
Special Tests: +Neer, Hawkins, Painful Arc, Yocum
Tx: Joint mob, RTC and scap strengthening, modalities
prn for pain, posture education, work station
modification
Secondary Impingement
Due to GHJ instability or RTC weakness leading to
humeral head migration
Sx: altered ER/IR ratio, humeral head migration
Special Tests: Neer, Hawkins, Painful Arc, +Load &
Shift/ sulcus, apprehension/relocation test  will have
+ impingement AND + instability tests
Tx: STABILIZE, closed chain RTC and scap
strengthening, modalities prn for pain, posture
education
Direction of Dislocation:
Inferior: pain with carrying shopping bag, traction parathesia
Sulcus sign at 0- tests superior glenohumeral lig. the primary restraint
Sulcus sign at 45- primary restraint is anterior band of inferior glenohumeral band
Sulcus sign at 90- posterior band of inferior glenohumeral band
Compare side to side- may have up to 1 cm translation
Anterior- most common. MOI: forced into abd. And ER
Anterior load and shift
Apprehension test
Relocation test- more sensitive in overhead athlete
Posterior- more rare, more painful in anterior. MOI: fall of arm flexed to 90 and elbow extended
Posterior Drawer test: load and shift
Posterior fulcrum test: in supine with one hand over anterior glenohumeral joint. Elbow flexed and arm
is horizontally adducted while push posteriorly on anterior humerus
MDI- multi-directional. May have generalized ligamentous laxity on exam. Guarding, pain, and spasm may limit
instability.
Strengthen below horizontal focusing on deltoid, RTC, scpulothracic muscularture. Include
proprioception exercises and general coordination tasks
Labral Tear
Special Tests: Clunk (low sensitivity), crank (high sensitivity), O’Brien (pain relieved when arm ER), Anterior slide
test (hands on hips, pt resists an anterior and superior force), Speeds test (for biceps tendinitis or SLAP)
Tx: goal is to restore motion and increase static and dynamic stability
Posterior RTC strengthening, increase scapular control and strength, work in retraction to decrease load on
labrum
Rotator Cuff Rupture
Signs: shoulder hike, limited AROM, full PROM, infraspinatus wasting
Special tests: drop arm test, lag sign (90° for supraspinatus, 45° for infraspinatus), may also have + Hawkins and
+ Neer’s test
Acromioclavicular Tests
Sx: pain at end range and with cross-body adduction
Special Tests: crossover/horizontal adduction test, O’Brien (high specificity and sensitivity), Acromioclavicular
Resisted Extension test
Stiff Shoulder/Adhesive Capsulitis
Causes: idiopathic, traumatic, postoperative
Postoperative/Trauma: restricted ROM in certain planes, may be multiple directions or globally, self limits ROM,
spasm or capsular end feel
Population: 3 F’s  fat, female, 40
Signs/sx: presents with hx of restriced motion and insidious onset, global stiffness, limitation in ER/ABD, FLEX,
tightness/adherence of inferior capsule
Phases/Tx:
1. Painful (freezing stage)
2. Stiff (frozen stage)
Goal is to decrease spasm end feel
-Warm up
-Warm up affected area (heat, arm bike)
-AAROM
-AAROM exercises (pulley)
-Joint mobs/PROM/manual stretch
-PROM with end range joint mobilization (to stretch,
-Isometrics/isotonics
move it)
-Self-stretching
-Sub max isometrics
- HEP needs to be done 8-10x/day
-Soft tissue massage
3. Resolution (thawing stage)
4. Maintenance
-Warm up
-Stretch for a YEAR
-Single plane/multiplane mobs, end range mobs
-RTC program
-Continue with strength (progress to theraband)
-Return to PT if feel they are losing ROM
-HEP 4-6x/day
Constitutional Symptoms
Fever, diaphoresis (sweating), night sweats, nausea/vomiting, diarrhea, pallor (pale), dizziness/syncope, fatigue,
weight loss
Pleural Pain: decreases when laying on affected side. Localized pain worse with respiration (deep breathes,
especially in)
Bacterial Endocarditis: painful sx 1-2 joints with warmth and redness
Pericarditis: substernal pain, coughing occurs, pain radiates to shoulder.
Aortic Aneurysm: sudden severe chest pain, tearing sensation (#1), may have pain through chest, neck, back,
but not down arms
Hepatic and Biliary causes: referred shoulder pain is occasionally the only sx. Usually occurs with mid-back,
scapular and RIGHT shoulder pain.
Epigastric pain: substernal or upper abdominal pain, radiate to back (duodenal ulcer), pain in anterior neck
(upper esophagus), xiphoid process to back (lower esophagus)
Reflux Esophagitis (GERD): lower substernal pain, sx of squeezing, gripping, “heartburn”, laying down, acidic
foods, peppermint, caffiene makes worse.
Cholecystitis: pain in right upper quadrant, may have epigastric pain too, abrupt onset, nausea, vomiting, chills,
dark urine, jaundice, if gallbladder it will be worst after greasy/fatty food
Breast: referral pattern around chest into axilla, neck, posterior shoulder girdle, into the back at breast level,
may have pain down 4th and 5th digits, pain most commonly due to fibrocystic changes and hormones/menstrual
cycle changes. Look for skin dimpling/pooling=tumor. Differentiate between breast pain and pectoralis pain
GYN issues: left shoulder pain due to ruptured ectopic pregnancy with associated abdominal bleeding. Left
shoulder pain after laprscope
Shoulder is the 2nd most common area for referred systemic pain- do not hesitate to refer.
ELBOW
Lateral Epicondylitis
Special tests/sx: Mills test, Cozens (full pronation, resisted wrist extension, radial dev.), resisted 3rd finger
extension, pain with resisted wrist extension, may show hyperalgesia
Tx: ultrasound, iontophroesis, counterforce bracing, scaphoid manip, ice, transverse friction massage, stretch,
strengthen, cervical/thoracic manip, change tennis technique/size of racket
Abducted Ulna
Signs/sx: limited wrist extension, increased carrying angle, radius appears longer, altered triangle, other soft
tissue and neural sx
Tx: MWM-passive lateral glide with pain-free grip exercise
Little Leaguer’s Elbow
Occurs due to repetitive valgus stress, an avulsion lesion of medial apophysis
Sx: pain and medial elbow tenderness, constant elbow discomfort/stiffness, may have numbness and + Tinel’s at
elbow
Tx: Rest and rehab (stability, incorporate core strength) #1 problem are parents
Nursemaid’s Elbow
Soft tissue injury in preschool age children. Due to traction force on elbow allowing radial head to slip through
annular ligament
Tx: manip