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OMM Final Written
Terms in this set (380)
neck and upper back pain affects what age range of people
the incidence of neck and upper back pain peaks at what age range when related to MVAs?
incidence of neck and upper back pain peaks at what age range in the general population?
are males or females more affected by neck and upper back pain?
what is the number 1 reason patients seek medical care?
lower back pain
what is the number 2 reason patients seek medical care?
upper back and neck pain
what is the most common cause of neck and back pain?
mechanical neck disorder (somatic dysfunction)
what is the most frequently reported symptom in connection with whiplash?
how many patients with neck pain experience complete resolution?
about how many patients will still have neck pain after an acute episode?
after a whiplash injury how commonly do patients have persistent pain 2 years later?
29-90% of the time
how does neck pain affect society?
substantial medical costs, permanent disability
*tulsa paid 28 million over 3 years on workers comp
in the US what is the main cause of neck and back pain?
chronic stress and strains
what are some work related risk factors for neck and upper back pain?
chronic neck flexion
sitting at work
sustained arm postures
what are some non-work related risk factors for neck and upper back pain?
ergonomic factors with driving
Hx of MVA
previous neck or LB injury
somatic dysfunction of what area of the body causes head pain?
OA and AA
somatic dysfunction of what area of the body causes neck pain?
what kind of pain is typically a dull unilateral achiness?
C2-C3 cervical facet pain
what area of the cervical spine is the pain generator in 60% of patients?
C2-C3 zygapophyseal joint
muscular pressure and fasical tension can result as what nerves are compressed as they pass through the suboccipital triangle?
greater and lesser occipital nerves
what can lead to ischemic muscle pain?
chronic muscle spasm leading to decreased blood flow
what vein can be entrapped with upper cervical muscle spasm?
cervical muscle spasm and venous pressure lead to pressure and entrapment of what cranial nerves as they pass through the jugular foramen?
CN 9, 10, 11
what things should you ask about in a patient history?
pain in posterior cervical region, upper back or both
pain and difficulty moving the neck
question about trauma or injury history
question about congenital or acquired spinal or muscular conditions
ROS to look for underlying systemic conditions
where might you find some trigger points in patients with neck and upper back pain?
suboccipital, cervical or shoulder muscles; ipsilateral to head pain
how do you know if a tender point is actually a trigger point?
the pain radiates
what are some management techniques for neck pain?
avoid aggravating factors, OMT, stretch and exercise, medications, psychological, trigger point therapy, surgery is last resort
when would you resort to surgery for neck and upper back pain?
for severe vascular or neuro compression
what combination of treatment is best for patients with subacute/chronic neck pain?
spinal manipulation plus muscle relaxants (or usual medical care)
what techniques can you use to treat the somatic dysfunction in the cervical spine?
HV/LA (risk vs benefit)
what actors the origins to muscles that stabilize and extend the cervical spine?
the thoracic spine
what must you evaluate and treat in patients with mechanical neck disorder?
what could be a primary contributor to neck pain?
disturbances in thoracic spine biomechanics
where does the SANS supply to the head emerge from in the spinal cord?
what can lead to a sinus headache?
inhibited venous and lymphatic drainage from the head can cause discomfort in the head and neck
what techniques can you use to treat the thoracic spine?
what affect does treating the cervical spine and upper thoracic spine have on the SANS?
decreases irritability and increases stability of SANS tone to all cranial vessels
what are benefits of treating the neck and upper thoracics
- increased ROM
- decreased pain
- improved ADL
- return to work (shorten disability)
- reduced reliance on medication for pain relief
- improved postural effiency
what are self treatment things patients can do for neck and upper thoracic pain?
stretching exercises, book and towel stretch, correct any chronic postural problems (theres an app for that), life style issues
what is one technique you can use to retrain the deep cervical flexors?
nodding - while tucking chin forward do not allow the large muscle on the front or side of neck to contract; hold for 5-7 seconds, repeat 5x
what is another technique you can use to retrain the deep cervical flexors (while laying down)?
lie on back, lift your head with your hands until your chin tucks into your chest then with assistance of your hands use deep neck muscles to lower head
what are the other terms for whiplash?
deceleration-acceleration injury; hyperextension-hyperflexion injury
what area of the body does whiplash affect?
errywhere, its a total body injury - usually only associated with neck symptoms however
what is the mechanism of whiplash injury?
head moves in a direction opposite to the body and the abrupt motion of the neck occurs before the neck muscles can relax to permit this motion; laxity in posterior muscles causes the CNS to send a signal to tone these muscles and head is thrown forward forcing the posterior muscles into a stretched position
acute stretch reflex -- muscle contraction
what is the main reason for injury in whiplash?
contraction of muscles and injury to the muscle fibers occurs as muscles are over stretched against resistance
how does injury to the muscle occur in whiplash injury?
microscopic edema and hemorrhage combine with muscle fiber injury and lead to formation of a trigger area
with hyperextension injuries what specific injuries can occur?
anterior longitudinal ligament tear
anterior disc herniation
avulsion fracture of the vertebral body
nerve root impingement
with hyperflexion injuries what specific injuries can occur?
subluxation of facets
posterior disc herniation
posterior longitudinal ligament tear
injury to nerve root
what are some presentations of neck and back pain?
upper thoracic/shoulder pain
low back pain
what are some ways to prevent subsequent problems?
promote motion; get rid of collars, encourage daily stretching, promote normal daily activities (work/school)
how do you define scoliosis?
lateral curvature of the spine greater than 10 degrees
how many planes does scoliosis affect?
all 3 planes:
- primary lateral curvature in coronal plane
- axial rotation in horizontal plane
- reduced kyphosis and lordosis in sagittal plane
how do you classify the several types of scoliosis?
reversibility, severity, etiology
what two types of scoliosis fall under the reversibility classification?
functional and structural
which type of scoliosis is reversible under the reversibility classification?
can functional scoliosis (reduces or disappears) progress?
yes, it can progress to structural
how does functional scoliosis progress to structural?
neglect of somatic or postural dysfunction can lead to permanent deformities
what type of scoliosis could OMT/pilates eliminate?
which type of scoliosis is fixed and has tissue changes?
when classifying severity of scoliosis how is severe scoliosis classified?
greater than 50 degree curvature
what is the severity of a scoliotic curve that is 20-45 degrees?
mild scoliosis is defined as what?
5-15 degree lateral curvature
how is etiology of scoliosis classified?
idiopathic, congenital, neuromuscular
what are some neuromuscular causes of scoliosis?
neuropathy, myopathy, mesenchymal origin, trauma, tumors
what is the second most common cause of scoliosis?
what are some clue ins for neuromuscular scoliosis?
leg length discrepancy, uneven muscle spasm, poor posture, neurofibromatosis
what are some neuropathy causes of neuromuscular scoliosis?
cerebral palsy, muscular dystrophy, myelomeningocele, spinal muscular atrophy, friedreich's ataxia (spinocerebellar degeneration)
what are so mesenchymal causes of neuromuscular scoliosis?
marfan syndrome, ruler dances syndrome, congenital laxity of the joints, homocystinuria
how often is congenital scoliosis progressive?
75% of the time
what are causes of congenital scoliosis?
failure of formation (hemivertebrae), failure of segmentation (bar joining one side of adjacent vertebrae), bilateral failure of segmentation (black vertebrae)
what is the most common cause of scoliosis?
idiopathic scoliosis (80%)
how could idiopathic scoliosis possibly be inherited?
polygenetic with incomplete penetrance
tensile forces do what to vertebrae?
compression forces do what to vertebrae?
there is increased compression on the concave side in scoliosis what occurs?
since there is reduced compression on the convex side of the scoliotic curve what occurs?
growth at a normal pace, may become accelerated
when does most of the cases of idiopathic scoliosis occur?
adolescents (over 10 years old to skeletal maturity)
what age does degenerative scoliosis usually occur?
greater than 40
what is the prevalence of scoliosis according to the cobb angle?
the greater the degree of the cobb angle the more girls are affected than boys
boys or girls are more likely to require treatment of scoliosis?
girls 7x more likely
at what age do girls typically progress with scoliosis?
what are some symptoms of idiopathic scoliosis?
clothes not hanging correctly, schooliosis screen detection, no pain in adolescence usually
significant pain with scoliosis suggests what?
possible bone tumor, tethered spinal cord, trauma
idiopathic scoliosis pain can often be treatable with what?
functional scoliosis and biomechanical compensatory mechanisms are ignorantly put into what category possibly?
what group of people recommend against screening for scoliosis?
american academy of family practice
when does pediatric ortho society of north american suggest screening for scoliosis?
girls = 11 and 13
boys = 13 or 14
what is the most important initial task in managing adolescent idiopathic scoliosis?
rule out secondary causes of lateral spinal curvature
at what degree of curvature is scoliosis visible usually?
what is the most obvious finding of scoliosis?
presence of a rib hump with forward bending
what are other findings of physical exam of scoliosis?
asymmetry, leg length inequality, skin lesions, hairy patches, neuro exam
what test is most specific for scoliosis?
forward bending test (adams)
how do you know if an adam's test is positive?
asymmetry of rib cage (thoracic hump) or paraspinal muscle masses (lumbar)
what special test can be used for scoliosis but requires a radiograph?
inclinometer (scoliometer) of 5-7 degrees - measures trunk rotation
7 degrees of trunk rotation with the inclinometer indicates how much of a degree of scoliosis?
how are the ribs positioned with scoliosis on the concave side?
how are the ribs positioned with scoliosis on the convex side?
which way do the vertebrae and spinous processes rotate with scoliosis?
toward the concavity - rotated and sidebent away from convexity
the posterior bulge or hump is on which side in scoliosis?
the convex side
there will be increased or decreased disk thickness on the concave side in scoliosis?
which side convexity would predispose a patient to greater cardiac and pulmonary morbidity
why is there greater cardiac and pulmonary morbidity with the left side convexity?
decreased EDV, decreased SV --> increased HR
severe scoliosis can have what affect on pulmonary function?
restricted chest wall motion, decreased vital capacity and total lung capacity
how do you name a scoliotic curve?
direction of the curve, type of curve and how it is identified
when naming a curve for the direction of the curve do you base the name off of the convex side or the concave side?
when naming a curve based on the type of curve where is it based on?
how do you identify a curve when naming a curve?
by the vertebral apex and vertebrae involved
what is the most common scoliotic curve?
double major curve - usually right thoracic, and left lumbar
what is the most common single scoliotic curve?
what two types of curves are not very common?
junctional thoracolumbar and junctional cervicothoracic
what views do you need on radiographs for scoliosis?
PA and lateral views
how do you measure the cobb angle (what do you use)?
based off radiograph
what is the cobb angle?
measure of curve magnitude in coronal plane
how do you measure the cobb angle?
angle made by line drawn along superior end plate of upper vertebrae in curve and inferior end plate of lowest vertebrae in curve
when is skeletal growth complete?
18-24 months after menarche
what are the imaging studies for skeletal maturity?
iliac crest and ischial tuberosity - apophysis
rib - epiphysis
vertebrae - growth plate
hand - distal radial epiphysis
amount of calcification present in the apophysis of the iliac crest
grade 5 is fusion of the apophysis to the ilium, end height increase
goals of overall treatment
2. quality of life
4. back pain
5. psychological well being
6. progression into adulthood
7. breathing function
8. scoliosis cobb degrees
9. need of further treatment
what is the objective of conservative therapy?
to stop curve progression at puberty or even reduce it
to prevent or treat resp dysfunction
to prevent or treat spinal pain syndromes
to improve asthetics via postural corrections
1. Observation 36, 12, 8, 6, 3 months.
2. Outpatient PT/OMT
3. Night time Rigid Bracing (8-12 hrs)
4. Inpatient Rehab
5. Specific Soft Bracing
6. Part Time Rigid Bracing (12-20 hrs)
7. Full time Rigid Bracing or cast (20-24 hrs)
how many curves naturally progress after maturity?
at what degree of curvature do curves usually progress?
greater than 30 degrees
which type of curves are most likely to progress?
single thoracic curves
by how much do curves averagely progress?
what are some techniques patients can use to help with their curvature?
what is the the goal of OMT with scoliosis
directed at optimizing mobility; improves the strength of musculature, stretches tight tissues, corrects somatic dysfunctions
what type of scoliosis should you not use HVLA for?
structural (can use in functional)
scoliosis is often associated with what cranial dysfunction?
what is the threshold for surgery with scoliosis?
kids = thoracic curve greater than 50 by skeletal maturity
adults = severe pain appearance and pulmonary complications
what is done in surgery for scoliosis?
implantation of herrington rods
what is a new surgical treatment for scoliosis that allows for adjustment?
vertical expandable prosthetic titanium rib
what are the risk factors for progression of the curve?
future skeletal growth (monitor closely in puberty); size of curve at diagnosis; greater the degree of curve the greater the risk for progression; the greater the amount of growth after the onset of the curve the greater the risk for progression
other risk factors for progression of the curve?
female, pregnancy, positive family history, laxity of skin and joints (CT defects), concomitant disease
a curve 30-50 degrees progresses how much over lifetime?
a curve 50-75 degrees progresses how much over a lifetime?
1 degree per year
what is an indication of significant progression of a curve?
increase in the curvature by 5 degrees or more between initial and follow up x-rays within 5 months of each other
what are red flags in scoliosis?
deviation to one side during forward bending test
sudden rapid progression in previously stable curve
extensive progression in pt after skeletal maturity
abnormal neuro findings
what are the components of the female reproductive organs?
uterus, tubes, ovaries
what are the components of the male reproductive organs?
what are the muscles of the pelvic diaphragm?
iliococcygeus, pubococcygeus, coccyges (coccyjesus lol)
what is the sympathetic innervation to the uterus and cervix?
what actions do the sympathetics have on the uterus and cervix?
constricts uterine fundus, relaxes cervix
what is the sympathetic to the gonads?
what is the sympathetic innervation to the penis and clitorus and vagina?
what is the sympathetic action of the penis, clitoris and vagina?
increased vascular constriction, ejaculation
what is the prostate sympathetic innervation?
what is the action of the sympathetics on the prostate?
what is the parasympathetic innervation to the ovaries and testes?
what is the parasympathetic innervation to the uterus and prostate?
pelvic splanchnic S2-S4
what is the action of the parasympathetics on the uterus and prostate?
relaxes uterine fundus, constricts cervix
what is the parasympathetic innervation to the penis, clitoris and vagina?
pelvic splanchnic (S2-S4)
what is the parasympathetic action on the penis, clitoris and vagina?
erection of the penis and clitoris, increased glandular secretion in vagina
what is the cause of 10% of all GYN visits and 20-30% of lararoscopies in the US?
choleric pelvic pain
what are the causes of chronic pelvic pain?
GYN (endometriosis, adhesions)
urologic (IC, bladder spasms)
GI (UC, Chron's, IBS)
Psych (depression, trauma)
MS (somatic dysfunction)
how should you treat chronic pelvic pain?
surgery, medication, counseling, OMT
what are some techniques for chronic pelvic pain?
LIPLSIP, S/CS to pelvis/sacrum/lumbar, pelvic diaphragm release*
, lumbopelvic release
* LS decompression
definition of dysmenorrhea?
menstrual pain so severe it interferes with daily activity or requires mediction
how prevalent is dysmenorrhea?
14% of school or work absences
what might be a cause of dysmenorrhea?
prostaglandin E2 and F release or decreased pain threshold
- causing uterine contraction and localized ischemia
traditional therapies for dysmenorrhea?
NSAIDs, nutritional, hormonal contraceptives
what are some history questions for dysmenorrhea?
primary or secondary? trauma or depression?
what are some specific manipulative techniques for dysmenorrhea
LIPLSIP, sacral rocking, LS decompression, visceral release
what is pain with intercourse (can be with or without penetration)
what are the causes of dyspareunia?
multifactorial; somatic components usually due to hypertonic pelvic floor muscles (bulbocavernosi)
how prevalent is dyspareunia?
27% lifetime prevalence of sexually active women
what physical exam findings might you see with dyspareunia?
very difficult vaginal exam, may have a tender umbilicus
what are some treatment techniques for dyspareunia?
LIPLSIP, pelvic diaphragm release, perineal myofascial release
what are other treatments used in dyspareunia?
PT, valium suppositories, botox
can you use OMT in pregnancy?
how do you treat pregnant patients with OMT?
where patient is most comfortable, use the patients weight to help you
TQ FOR SURE
*** what are contraindications to OMT in pregnancy?
chorioamnionitis, cord prolapse, PPROM, placental abruption
relative contraindications to OMT in pregnancy?
early pregnancy, HVLA, CV4
what are common antepartum complaints?
round ligament pain
how do you treat LBP in antepartum with OMT?
how do you treat dysuria in antepartum with OMT?
how do you treat mastalgia in antepartum with OMT?
chest wall release
how do you treat constipation in antepartum with OMT?
sacral rocking, visceral release
what are indications for OMT in the intrapartum period?
induction of labor (prime uterus), labor pains, dystocia (NOT shoulder dystocia), perineal stretching (reduce lacerations and need for episiotomy)
where is uterine pain from?
where is pain from descent of the fetal head from?
what OMT technique is indicated in the intrapartum period for induction of labor?
sacral rocking, uterine manipulation
what OMT technique is indicated in the intrapartum period for labor pains?
L/S decompression, LIPLSIP
what OMT technique is indicated in the intrapartum period for dystocia?
sacral rocking, pelvic diaphragm release
what OMT technique is indicated in the intrapartum period for perineal stretching?
myofascial release of the perineum
what are reasons for postpartum OMT?
adress structural changes, hormonal changes and breastfeeding
what are structural changes to address in the postpartum?
postural imbalance, pubic pain from delivery
what breastfeeding changes can be addressed with OMT?
mastitis and mastalgia, lymphatic congestion
if there is autonomic dysfunction postpartum what are some techniques to use?
sacral rocking, cranial manipulation, chapman's reflexes
what are some techniques used in postpartum for mastitis and breast feeding?
chest wall release, breast manipulation, shotgun thoracics
why is OMT good for pregnancy?
decreased need for pain med, faster return to normal after delivery
movements used to potentiate, accentuate, or compensate for impairment in physiologic motion (movements needed to move a paralyzed limb)
self-reversing and nonresistant adaptation
angle of the lumbosacral junction as measured by the inclination of the superior surface of the first sacral vertebrae to the horizontal ; usually measured from standing lateral x-ray films; aka ferguson's angle
lumbosacral lordotic angle
objective quantification of lumbar lordosis typically determined by measuring the angle between the superior surface of the second lumbar vertebrae and the superior surface of the first sacral segment; best measured by standing lateral x-ray film
traumatic disease occurring at the insertion of muscles where recurring concentration of muscle stress provokes inflammation with strong tendency toward fibrosis and calcification; inflammation of the muscular or tendinous attachment to bone
extension - regional
historically straightening in the sagittal plane of spinal region; fryette's regional extension
viewing from the side; imaginary line in a coronal plane which in theory is the ideal posture. passes through lateral condyle of the of knee, greater trochanter, lateral head of the humerus at tip of shoulder to external auditory meatus. if it would a plane in the body it would go through the middle third lumbar and anterior third of sacrum. used to eval the AP curves of the spine
dysfunctional segmental behavior where a single vertebrae and an adjacent rib respond to the same regional motion tests with identical asymmetric behaviors (rather than opposing) suggests visceral reflex inputs
observed association between superior and inferior vertebrae, paired two by two. the cervical and superior thoracic biomechanics act in a synchronous manner with the lumbar and inferior thoracic biomechanics
1. every posterior spinal nerve root supplies a specific region of the skin although fibers from adjacent spinal segments may invade such a region
2. when a muscle receives a nerve impulse to contract, its antagonist receives simultaneously, an impulse to relax
OMT-percussion vibrator technique
manipulative technique involving the special application of mechanical vibratory force to treat SD
pelvic declination (delving unleveling)
pelvic rotation about an A-P axis
represents the ratio of the measurements determined from a postural radiograph
1. (y) from the vertical line originating at sacral promontory to the intersection of the horizontal line from the anterior superior position of the pubic bone (x) same horizontal line
2. normal values are age related and increase in subjects with sagittal plane postural decompensation
3. PI = X/Y
painful low back condition characterized by hypertonicity of psoas muscle. syndrome consists of constellation of typically related signs and symptoms
typical posture of psoas syndrome
flexion at the hip and side bending of lumbar to the side of the most hypertonic psoas muscle
typical gait of psoas syndrome
typical pain pattern for psoas syndrome
LBP frequently accompanied by pain on lateral aspect of lower extremity, extending no lower than the knee
typical associated SD with psoas syndrome
since it is a long restrictor muscle, hypertonicity is associated with flexed dysfunctions of upper lumbars, and extended dysfunction of L5
distribution of body mass away from ideal when postural homeostatic mechanisms are overwhelmed. in all cardinal planes. classified by major planes affected
muscle primarily responsible for causing a specialized joint action
sacral base declination (unleveling)
with patient sitting or standing, any deviation of sacral base from the horizontal in coronal plane. rotation of the sacrum is generally about AP axis
treatment involving injection of proliferate solution at the osseous-ligamentous junction
2. treatment involving injection of irritating substance into weakened CT , intended response it for fibrous proliferation with shortening/strengthening of tissues injected
somatic dysfunction - linkage
dysfunctional segmental behavior where a single vertebra and adjacent rib respond in to the same regional motion tests with identical asymmetric behaviors (rather than opposing) suggests visceral reflex inputs
unequal size and or facing of the zygapophyseal joints of the vertebra
what are the 4 articular surfaces of the shoulder joint?
sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
what joint is the principle articulation of the shoulder joints?
what are the three bones of the shoulder girdle?
clavicle, scapula, proximal humerus
what covers the head of the humerus and the face of the glenoid fossa?
how is the glenohumeral joint stabilized?
loosely constrained within thin capsule, bounded by surrounding muscle and ligaments
what is the ring of fibrous tissue surrounding the glenoid fossa, assisting in stabilization?
the shoulder's great mobility is largely due to what factors?
shallow depth of the glenoid and limited contact between the glenoid and the humeral head
the glenohumeral joint performs how much of the motion of the shoulder?
the scapulothoracic performs how much of the motion of the shoulder?
what two joints are the primary movers of the shoulder?
glenohumeral and scapulothoracic
what is the most common somatic dysfunction of the shoulder?
limited internal and external rotation
what are the motions of the shoulder?
1. 180 degree flexion
2. 60 degree extension
3. 180 degree abduction
4. 50 degree adduction
5. 90 degree internal and external rotation
when dealing with shoulder pain what are other areas that should be considered to treat/assess?
cervicals, ribs, and thoracic spine
what is the most commonly torn rotator cuff muscle?
what is the action of the supraspinatus?
abduction (with deltoid)
which muscle is the stabilizer of the glenohumeral joint?
what are the attachments of the supraspinatus?
supraspinatus fossa to greater tubercle of humerus
which rotator cuff muscle performs external rotation?
infraspinatus (with theres minor)
what are the attachments of the infraspinatus?
infraspinatus process to greater tubercle of humerus
what is the action of the teres minor?
what are the attachments of the teres minor?
lateral border of the scapula to greater tubercle of humerus
what rotator cuff muscle performs internal rotation and adduction?
what are the attachments for the subscapularis?
sub scapular fossa to the lesser tubercle of the humerus and glenohumeral capsule
what is the innervation to the rotator cuff muscles?
all innervated by C5-C6
what are the muscles of the rotator cuff
you better know this by now...
SItS - supraspinatus, infraspinatus, teres minor, subscapularis
what is the action of the teres major?
extend, internal rotation and adduction (teres minor was external rotation FYI)
what is the origin of the teres major?
inferior angle of the scapula
what is the insertion of teres major?
medial lip of the inter tubercular sulcus of the humerus
what is the action of the latissimus dorsi?
internal rotation and adduction of the humerus
what is the insertion of the latissimus dorsi?
intertubercular groove of humerus
what is the origin of the latissimus dorsi?
spinous processes of lower thoracic vertebrae and ribs, thoracolumbar fascia, crest of ilium, inferior angle of scapula
what is the action of the deltoid?
what is the action of the biceps?
flexion and supination
what is the origin of the deltoid?
clavicle, acromion, scapular spine
what is the insertion of the deltoid?
what is the origin of the biceps?
coracoid process and supraglenoid tubercle
what is the insertion of the biceps?
radius and bicipital aponeurosis
what is the action of pec minor?
stabilizes scapula and raises ribs in inspiration
what is the action of serratus anterior?
the three parts mainly pull scapula forward, however can assist in lifting ribs when shoulder girdle is fixed
what is the innervation to the serratus anterior?
long thoracic nerve (C5-C7)
What physical exam finding will you see if long thoracic nerve is damaged?
what is the origin of the serratus anterior?
what is the insertion of the serratus anterior?
anterior medial border of the scapula
what is the insertion for pec minor?
what is the origin for pec minor?
what is the term used for relaying sensation from a section of skin to the brain; area of skin innervated by a single spinal nerve
what are the dermatomes for the shoulder?
what are some examples of the major pathologies of the shoulder leading to pain?
impingement syndrome, labral tears, rotator cuff tears, adhesive capsulitis, tendonitis, AC separation, osteoarthritis, SD, cervical radiculopathy
if the pain is cramping/dull/achy what is probably injured?
if the pain is sharp/shotting what is probably injured?
if the pain is deep, nagging, dull what is probably injured?
if the pain is sharp, severe what type of injury occurred?
if the pain is throbbing, diffuse what might be the cause of injury?
vascular or visceral
if your patient had a seizure and has lost their ability to passively or actively rotated affected arm externally what is the probable diagnosis?
posterior shoulder dislocation
if a patient has night time shoulder pain what is the probably diagnosis?
if patient has generalized ligamentous laxity what is the probable diagnosis?
if patient hears clunking sound or has pain with overhead motion what is the most likely diagnosis?
pain radiating below the elbow and decreased cervical ROM what is the diagnosis?
cervical disc disease
shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement what is diagnosis?
glenohumeral joint instability
supraspinatus/infraspinatus wasting what is diagnosis?
rotator cuff tear; supra scapular nerve entrapment
scapular winging, trauma, recent viral illness what is diagnosis?
serratus anterior or trapezius dysfunction
what are red flags in association with shoulder pain?
1. persistant nighttime pain - cancer
2. weight loss, fatigue, night sweats, fevers - cancer
3. discolored or painful extremities - vascular compromise
4. associated cardiovascular symptoms (SHOB, chest heaviness, lightheadedness) - MI
5. problems with coordination/balance - stroke
what are the necessary physical exam components for shoulder examination?
palpation, ROM (passive and active), test sensation, test muscle strength (score out of 5), reflexes (triceps, biceps, brachioradialis), specific cervical testing (spurlings), specific shoulder testing
what are clinical features of cervical herniation?
sensory loss in shoulder, and hand; absent or weak reflexes in biceps, triceps and brachioradialis; horner's syndrome, motor weakness in biceps, triceps, deltoid and interossei
apley scratch test
loss of range of motion, rotator cuff problem
supraspinatus tendon impingement
drop arm test
rotator cuff tear
cross arm test
AC joint arthritis
cervical nerve root disorder; head rotated to affected shoulder, axial load applied
anterior glenohumeral instability; anterior force on humerus
same as apprehension test but posterior force on humerus; anterior glenohumeral instability
inferior glenohumeral instability
biceps tendon instability or tendonitis
biceps tendon instability or tendonitis
what are other names for impingement syndrome?
subacromial impingement, painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, thrower's shoulder
what is impingement syndrome?
impingement of the shoulder tendons and/or bursa causing pain - due to lack of appropriate space or joint motion
what is a risk factor for impingement syndrome?
overhead activity of the shoulder, especially if repetitive
if the pain is worse at night, persistent and affects ADLs what might be occurring?
what are complications of impingement syndrome?
tendinitis, calcific tendinitis, tendinosis, labral tears, bursitis
if impingement syndrome is not treated appropriately what may occur?
rotator cuff tendons may start to thin and tear
during physical examination a patient has pain with passive movement of the shoulder when a downward force is applied at the acromion what is happening?
"painful arc" of impingement syndrome is described how?
actively elevated arm in scapular plain; positive test when pain occurs 60-120 degrees abduction
what is occurring in impingement syndrome?
subacromial is diminished pinching structures under acromion and coracoacromial ligament
what is the first test to order if you suspect impingement syndrome?
when might athletes return to play with impingement syndrome?
when pain has resolved enough to allow for normal ROM and near normal strength
what two special tests will be positive in impingement syndrome?
beer's and hawkin's kennedy
how might a rotator cuff tear present?
similar to impingement syndrome with anterolateral shoulder pain exacerbated by overhead activities; pain at night when sleeping on that side; shoulder weakness and loss of ROM
what will be noted during the physical exam with rotator cuff tears?
pain and weakness on external rotation with possible loss of active ROM; full passive ROM
where will there be tenderness in rotator cuff tears?
greater tubercle (supraspinatus)
what are the shoulder tests for rotator cuff tears?
drop arm and empty can test
what are risk factors for rotator cuff tears
increased age, degeneration with chronic impingement, trauma
what are you looking for on XR with rotator cuff tears?
proximal migration of the humeral head
what is the treatment for rotator cuff tears?
conservative for older/weaker; surgical for acute and youger pts
if there is a full tear of the rotator cuff tendons which test will be positive?
what is the special test for AC arthritis?
cross arm test
what is AC arthritis?
breakdown of cartilage, abnormal bony growths or bone spurs in joint
what will patients complain of with AC arthritis?
difficulty swinging golf club or putting on seat belt
what are two major causes of AC separation?
direct blow to superior aspect of the shoulder with arm abducted or lateral blow to deltoid area
how is AC separation graded?
6 grades from sprain to complete rupture of AC and CC ligaments
physical exam findings of AC separation?
swelling and tenderness over AC; palpable stepped deformity between acromion and clavicle
what view of the shoulder confirms AC separation?
what is the special test for AC separation?
what is the cause of labral tears?
trauma, traction, compression, direct blow
what are the common complaints in labral tears?
pain with overhead activities and decreased function; popping, clicking, catching
what do you use to image a label tear?
what special test can be used for labral tears?
O-briens (not super specific)
what is indicative of glenohumeral instability?
symptomatic abnormal translation of the humeral head on the glenoid
what are the patient complaints in glenohumeral instability?
pain, weakness, recurrent dislocations
what are the special tests for glenohumeral instability?
apprehension test, sulcus sign
what directions can you have glenohumeral instability?
anterior, posterior, multidirectional
what is indicative of a positive sulcus sign?
presence of a sulcus lateral to the acromion
what is biceps tendonitis?
isolated inflammation of the proximal biceps tendon
what are risk factors for biceps tendonitis?
age and overuse activities - NOT TRAUMA
Where do patients complain of pain in biceps tendonitis?
over anterior aspect of the shoulder which radiates down the biceps
what are the special tests for biceps tendonitis?
speeds and yergasons
what is found on imaging with biceps tendonitis?
XR usually normal
what is the treatment for biceps tendonitis?
begin with NSAIDs, OMM and ROM exercises; can consider steroid injection
what is characterized by pain and gradual loss of both active and passive ROM
adhesive capsulitis (active and passive loss is the same)
what are causes of adhesive capsulitis?
usually idiopathic but associated with women, diabetes and may follow immobilization or prolonged inflammation
what does imaging show in adhesive capsulitis?
XR negative - clinical diagnosis
what is the treatment for adhesive capsulitis?
OMM, patience/persistence, home exercises
what neurologic shoulder pain disorder can be associated with URIs?
when you stretch a nerve root what is felt
if a patient complains of pain with radiation into arm without trauma and their is no loss of ROM what is occurring?
neurologic shoulder pain
what is the special test for neurologic shoulder pain?
what does a positive spurling test indicate?
herniation or osteophytes
what is a positive spurling test?
what can lead to narrowed neural foramen and spinal canal stenosis causing cervicogenic neck pain?
spondylosis, degenerative disk disease, formation of bony spurs, buckling of ligamentum flavum, herniation of disk material
if you have acute shoulder pain what is the best initial study?
what is usually the next study to order after an XR in shoulder pain?
what are OMT options for shoulder?
spencer technique, AC/SC - muscle energy, ribs, T and C spine - HVLE, ME, Still, counterstain, MFR (scapulothoracic release)
what are other considerations for shoulder treatment?
additional meds, slings, referral to ortho or PT, home exercises
what is thoracic outlet syndrome?
group of clinical syndromes characterized by impingement of nerves or vascular structures at the thoracic outlet leading to symptoms in the upper extremity or the neck
what is the presentation of thoracic outlet syndrome?
neuropathy and paresthesias - especially in ulner nerve distribution(MC); pain in the arms and occasionally in the neck; weakness and occasional atrophy, fatiguability, vascular changes
anterior and middle scalene, first rib, subclavian artery and vein, brachial plexus - trunk and ulnar nerve specifically
is the subclavian vein usually in the thoracic outlet "triangle"
no usually escapes - rarely will have edema
what are some triggers of thoracic outlet syndrome?
prolonged, repeated overhead activity, SD of upper ribs, lower cervicals, clavicle, scapula, upper thoracic, weight lifting (muscle hypertrophy), trauma, anomalous ribs or cervical rib, clavicle deformity
special tests for TOS?
EAST (elevated arm stress test), adson's, costoclavicular maneuver, hyperabduction test, radiology and neuro testing
look toward affected side - positive if diminished pulse when patient takes a breath in
what are the four variations of thoracic outlet syndrome?
anterior scalene syndrome, cervical rib syndrome, costoclavicular syndrome, hyperabduction syndrome
what is the most common variation of thoracic outlet syndrome?
anterior scalene syndrome
what is involved in anterior scalene syndrome
brachial plexus or subclavian
how do you diagnose anterior scalene syndrome?
adson's test - compresses structures against first rib
what increases your risk for anterior scalene syndrome?
what is involved in the cervical rib syndrome?
subclavian artery more often than brachial plexus
how do you test for cervical rib syndrome?
modified adson's (look away from affected side) - swings cervical rib
what structures are involved in costoclavicular syndrome?
subclavian artery and vein more than brachial plexus
what is the main anatomical issue associated with costoclavicular syndrome?
narrowing of space between the clavicle and first rib
how do you diagnose/eval costoclavicular syndrome?
costoclavicular maneuver - military posture --> trying to recreate clavicular pressure on artery
what is the problem with hyperabduction syndrome?
pec minor - not really in thoracic outlet; involves neurovascular bundle
what is the diagnostic test for hyperabduction syndrome
hyperabduction test - positive if symptoms or diminished pulse
treatment for TOS?
a. Surgery to remove first rib?
b. OMM addressing the cervical spine, ribs 1-3 (held inspired), upper thoracics, scapula, AC, SC, Spencer
c. Ergonomics/lifestyle changes - stop doing the activity that hurts them
how do patients with carpal tunnel present?
thumb, second finger, third finger and half of 4th finger pain, neuropathy, paresthesias, weakness, fatiguability, atrophy of thenar eminence
what are diagnostic tests for carpal tunnel?
phalen's and tinel's
if phalen and tinsel's are negative does this rule out carpal tunnel?
no - it is a clinical diagnosis
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