Dutton's Orthopaedic Examination Evaluation and Treatment 4ed

Created in Master PDF Editor - Demo Version
Notice.pdf
Preface.pdf
CHAPTER 1 The Musculoskeletal System.pdf
CHAPTER 2 Tissue Behavior, Injury, Healing, and.pdf
CHAPTER 3 The Nervous System.pdf
CHAPTER 4 PatientClient Management.pdf
CHAPTER 5 Differential Diagnosis.pdf
CHAPTER 6 Gait and Posture Analysis.pdf
CHAPTER 7 Imaging Studies in Orthopaedics.pdf
CHAPTER 8 The Intervention.pdf
CHAPTER 9 Pharmacology for the Orthopaedic.pdf
CHAPTER 10 Manual Techniques.pdf
CHAPTER 11 Neurodynamic Mobility and.pdf
CHAPTER 12 Improving Muscle Performance.pdf
CHAPTER 13 Improving Mobility.pdf
CHAPTER 14 Improving Neuromuscular Control.pdf
CHAPTER 15 Improving Cardiovascular.pdf
CHAPTER 16 The Shoulder.pdf
CHAPTER 17 Elbow.pdf
CHAPTER 18 The Forearm, Wrist, and Hand.pdf
CHAPTER 19 Hip.pdf
CHAPTER 20 The Knee.pdf
CHAPTER 21 Lower Leg, Ankle, and Foot.pdf
CHAPTER 22 Vertebral Column.pdf
CHAPTER 23 The Craniovertebral Region.pdf
CHAPTER 24 Vertebral Artery.pdf
CHAPTER 25 The Cervical Spine.pdf
CHAPTER 26 The Temporomandibular Joint.pdf
CHAPTER 27 The Thoracic Spine.pdf
CHAPTER 28 Lumbar Spine.pdf

CHAPTER 29 The Sacroiliac Joint.pdf
CHAPTER 30 Special Populations.pdf

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Medicineisaneverchangingscience.Asnewresearchandclinicalexperiencebroadenourknowledge,changesintreatmentanddrug
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Preface
Preface
Thefourtheditionofthisbookisanupdateofinformationandbibliographyprovidedinthepreviousversionstogetherwithareorganizationof
variouschapters.
TheUnitedStatescurrentlyspendsmoremoneyonhealthcareperpersonthananyothercountryintheworld,withcurrentprojections
indicatingthat20%ofthegrossdomesticproductoftheUnitedStateswillbespentonhealthcarebytheyear2019.1Asthepopulation
continuestoage,thetreatmentofmusculoskeletalconditions,andtheirsubsequentexpenses,willalsoincrease.Thiswillplaceanincreasing
burdenonthecliniciantoprovidevalueformoneytheachievementofahealthoutcomerelativetothecostsincurred.Gonearethedays
whenacliniciancanrelyonanexpensiveshotgunapproachtotreatment.Instead,emphasisisnowplacedonoutcomessuchaspatient
satisfactionandaccuratemeasuresofclinicaloutcomes,foritistheconsistentmeasurementandreportingofclinicaloutcomesthatisthe
mostpowerfultoolinmovingtowardavaluebasedsystem.2
Tothatend,theaimofthisbookistoprovidethereaderwithasystematicandevidencebasedapproachtotheexaminationandintervention
oftheorthopaedicpatient.Suchanapproachmustbeeclecticbecausenosinglemethodworksallofthetime.Thus,thisbookattemptsto
incorporatethemostreliableconceptscurrentlyavailable.
Ihopethatthisbookwillbeseenasthebestavailabletextbook,guide,review,andreferenceforhealthcarestudentsandcliniciansinvolvedin
thecareoftheorthopaedicpopulation.
MarkDutton,PT
Commentsaboutthisbookmaybesenttomeatpt@mcgrawhill.com.
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11/23/2016 Preface|Dutton'sOrthopaedicExamination,Evaluation,andIntervention,4e|AccessPhysiotherapy|McGrawHillMedical
11/20/2016
CHAPTER1:TheMusculoskeletalSystem
CHAPTEROBJECTIVES
Atthecompletionofthischapter,thereaderwillbeableto:
1.Describethevarioustypesofbiologicaltissueofthemusculoskeletalsystem.
2.Describethetissuemechanicsandstructuraldifferencesandsimilaritiesbetweenmuscle,tendons,fascia,
andligaments.
3.Describethedifferenttypesofjointsandtheirvariouscharacteristics.
4.Definethevariousterminologiesusedtodescribethejointposition,movements,andrelationships.
5.Givedefinitionsforcommonlyusedbiomechanicalterms.
6.Describethedifferentplanesofthebody.
7.Definethebodyscenterofmassanditslocation.
8.Describethedifferentaxesofthebodyandthemotionsthatoccuraroundthem.
9.Definethetermsosteokinematicmotionandarthrokinematicmotion.
10.Differentiatebetweenthedifferenttypesofmotionthatcanoccuratthejointsurfaces.
11.Describethebasicbiomechanicsofjointmotionintermsoftheirconcaveconvexrelationships.
12.Definethetermsclosepackedandopenpacked.
OVERVIEW
Thecorrectembryonicdevelopmentofthemusculoskeletalsystemrequiresacoordinatedmorphogenesisofthe
fundamentaltissuesofthebody.Throughoutthehumanbody,therearefourmajortypesoftissues:
Epithelial.Coversallinternalandexternalbodysurfacesandincludesstructuressuchastheskinandthe
innerliningofthebloodvessels.
Connective.Connectivetissue(CT),whichincludesfourdifferentclasses:connectivetissueproper,bone,
cartilage,andbloodtissue.Intheembryo,muscletissueanditsfasciaformasadifferentiationofthe
paraxialmesodermthatdividesintosomitesoneithersideoftheneuraltubeandnotochord.Thecartilage
andboneofthevertebralcolumnandribsdevelopfromthesclerotomewhichistheanterior(ventral)part
ofthesomite.1Thedermomyotome,whichistheposterior(dorsal)partofthesomite,givesrisetothe
overlyingdermisofthebackandtheskeletalmusclesofthebodyandlimbs.1Connectivetissueprovides
structuralandmetabolicsupportforothertissuesandorgansofthebody.
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Muscle.Musclesareclassifiedfunctionallyaseithervoluntaryorinvoluntary,andstructurallyaseither
smooth,striated(skeletal),orcardiac.Thereareapproximately430skeletalmusclesinthebody,eachof
whichcanbeconsideredanatomicallyasaseparateorgan.Ofthese430muscles,about75pairsprovide
themajorityofbodymovementsandpostures.2
Nervous.Nervoustissueprovidesatwowaycommunicationsystembetweenthecentralnervoussystem
(brainandspinalcord)andmuscles,sensoryorgans,andvarioussystems(seeChapter3).
CONNECTIVETISSUE
CTproperhasaloose,flexiblematrix,calledgroundsubstance.ThemostcommoncellwithinCTproperisthe
fibroblast.Fibroblastsproducecollagen,elastin,andreticularfibers:
Collagenisagroupofnaturallyoccurringproteins.Thecollagensareafamilyofextracellularmatrix
(ECM)proteinsthatplayadominantroleinmaintainingthestructuralintegrityofvarioustissuesandin
providingtensilestrengthtotissues.TheECMisformedfromglycosaminoglycans(GAGs)subunits,long
polysaccharidechainscontainingaminosugars,andarestronglyhydrophilictoallowrapiddiffusionof
watersolublemoleculesandeasymigrationofcells.Proteoglycans,whichareamajorcomponentofthe
ECM,aremacromoleculesthatconsistofaproteinbackbonetowhichtheGAGsareattached.Thereare
twotypesofGAGs:chondroitinsulfateandkeratinsulfate.3,4Asimplewaytovisualizetheproteoglycan
moleculeistoconsideratesttubebrush,withthestemrepresentingtheproteincoreandtheGAGs
representingthebristles.5,6Glycoproteins,anothercomponentoftheECM,consistoffibronectinand
thrombospondinandfunctionasadhesivestructuresforrepairandregeneration.7
Elasticfibersarecomposedofaproteincalledelastin.Asitsnamesuggests,elastinprovideselastic
propertiestothetissuesinwhichitissituated.8Elastinfiberscanstretch,buttheynormallyreturntotheir
originalshapewhenthetensionisreleased.Thus,theelasticfibersofelastindeterminethepatternsof
distentionandrecoilinmostorgans,includingtheskinandlungs,bloodvessels,andCT.Bundlesof
collagenandelastincombinetoformamatrixofCTfascicles.Thismatrixisorganizedwithintheprimary
collagenbundlesaswellasbetweenthebundlesthatsurroundthem.9
Reticularfibersarecomposedofatypeofcollagen,whichissecretedbyreticularcells.Thesefibers
crosslinktoformafinemeshwork,calledreticulin,whichactsasasupportingmeshinbonemarrow,and
thetissuesandorgansofthelymphaticsystem,andtheliver.
Thevariouscharacteristicsofcollagendifferdependingonwhetheritislooseordensecollagen.Theanatomic
andfunctionalcharacteristicsoflooseanddensecollagenaresummarizedinTable11.Collagenousandelastic
fibersaresparseandirregularlyarrangedinlooseCTbutaretightlypackedindenseCT.10
TABLE11LooseandDenseCollagen
Fiber
JointType AnatomicLocation MechanicalSpecialization
Orientation
Dense Parallel, Ligament:bindsbonestogetherand
Composestheexternalfibrouslayerof
irregular tightly restrainsunwantedmovementatthejoints
thejointcapsule,formsligaments,bone,
connective aligned resiststensioninseveraldirections
aponeuroses,andtendons
tissue fibers Tendon:attachesmuscletobone
Loose
Random
irregular Foundincapsules,muscles,nerves,
fiber Providesstructuralsupport
connective fascia,andskin
orientation
tissue
ThevarioustypesofCT,astheyrelatetothemusculoskeletalsystem,aredescribedasfollows:
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Fascia
Fascia,forexample,thethoracolumbarfasciaandtheplantarfascia,isviewedasalooseCTthatprovides
supportandprotectiontoajoint,andactsasaninterconnectionbetweentendons,aponeuroses,ligaments,
capsules,nerves,andtheintrinsiccomponentsofmuscle.11,12Fasciamaybecategorizedasfibrousor
nonfibrous,withthefibrouscomponentsconsistingmainlyofcollagenandelastinfibers,andthenonfibrous
portionconsistingofamorphousgroundsubstance.13Threedifferenttypesoffasciahavebeenidentified,
namely,superficial,deep,andvisceralfascia.Variousthreedimensionalbiomechanicalmodelsofthehuman
fascialsystemhavebeendeveloped,whichcorrelatedysfunctionalmovementwithvariousinterrelatedabnormal
amountsoftensionthroughoutthenetworkoffascia.Inparticular,deepfasciahasbeenimplicatedinbeing
involvedwiththedeepvenousreturn,inhavingapossibleroleinproprioception,andrespondingtomechanical
tractioninducedbymuscularactivityindifferentregions.14Histologicalstudiesofdeepfasciainthelimbs
showthatitconsistsofelasticfibersandundulatedcollagenfibersarrangedinlayers.15Eachcollagenlayeris
alignedinadifferentdirection,andthispermitsacertaindegreeofstretchaswellasacapacitytorecoil.16
Tendons
Tendonsaredense,regularlyarrangedconnectivetissues,composedof70%waterand30%drymassthatattach
muscletotheboneateachendofthemuscle.Tendonsproducejointmotionbytransferringforcefrommuscle
tobone,and,whenstretched,storeelasticenergythatcontributestomovement.Also,tendonsenablethemuscle
bellytobeanoptimaldistancefromthejointuponwhichitisacting.Thecollagenfibersoftendons(7080%of
thecollagenintendonsistypeI,withtheremaining2030%ofdryweightcomposedofproteoglycans,GAGs,
elastin,andothercollagensbeingtypeIII,V,andVII)arearrangedinaquarterstaggerarrangement,which
givesitacharacteristicbandingpatternandprovideshighstrengthandstability.17Tenoblasts,orimmature
tendoncells,transformintotenocytesthatsynthesizecollagenandcomponentsoftheECMnetwork.7TheECM
surroundscollagenandtenocytesandiscomposedofseveralcomponentsforspecificfunctions(e.g.,
glycoproteins,andTenascinC,whichmayplayaroleincollagenfiberorientationandalignment).Tendon
structureishighlyregularwithcollagenformingtriplehelices(tropocollagen),whichpacktogethertoform
microfibrils,whichinterdigitatetoformfibrils,whichcoalescetoformfibers,whichcombinetoformfascicles,
whicharebundledtogethertoformatendon.18Thethicknessofeachtendonvariesandisproportionaltothe
sizeofthemusclefromwhichitoriginates.Vascularitywithinthetendonisrelativelysparseandcorresponds
withthelowermetabolic/turnoverrateofthesetissues.Withinthefasciclesoftendons,whichareheldtogether
bylooseCTcalledendotenon,thecollagencomponentsareorientedinaunidirectionalway.Endotenoncontains
bloodvessels,lymphatics,andnervesandpermitslongitudinalmovementsofindividualfascicleswhentensile
forcesareappliedtothestructure.TheCTsurroundinggroupsoffascicles,ortheentirestructure,iscalledthe
epitenon.Theepitenoncontainsthevascular,lymphatic,andnervesuppliestothetendon.Aperitendinous
sheath(paratenon),whichiscomposedoflooseareolarconnectivetissueinadditiontosensoryandautonomic
nervefibers,surroundstheentiretendon.19Thissheathconsistsoftwolayers:aninner(visceral)layerandan
outer(parietal)layerwithoccasionalconnectingbridges(mesotenon).Ifthereissynovialfluidbetweenthese
twolayers,theparatenoniscalledtenosynoviumifnot,itistermedtenovagium.9
Tendonsaremetabolicallyactiveandareprovidedwitharichandvascularsupplyduringdevelopment.20
Tendonsreceivetheirvascularsupplythroughthemusculotendinousjunction(MTJ),theosteotendinous
junction,andthevesselsfromthevarioussurroundingtissuesincludingtheparatenonandmesotenon.18
Tendonsindifferentareasofthebodyreceivedifferentamountsofbloodsupply,andtendonvascularitycanbe
compromisedbythejunctionalzonesandsitesoffriction,torsion,orcompressionanumberoftendonsare
knowntohavereducedtendonvascularity,includingthesupraspinatus,thebiceps,theAchilles,thepatellar,and
theposteriortibialtendon.18
Themechanicalpropertiesoftendoncomefromitshighlyorientedstructure.Tendonsdisplayviscoelastic
mechanicalpropertiesthatconfertimeandratedependenteffectsonthetissue.Specifically,tendonsaremore
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elasticatlowerstrainratesandstifferathigherratesoftensileloading(seeChapter2).Tendonsdeformlessthan
ligamentsunderanappliedloadandareabletotransmittheloadfrommuscletobone.9Materialandstructural
propertiesofthetendonincreasefrombirththroughmaturityandthendecreasefrommaturitythroughold
age.18Althoughtendonswithstandstrongtensileforceswell,theyresistshearforceslesswellandprovidelittle
resistancetoacompressionforce(seeChapter2).
Atendoncanbedividedintothreemainsections:21
Thebonetendonjunction.Atmosttendonboneinterfaces,thecollagenfibersinsertdirectlyintothe
boneinagradualtransitionofmaterialcomposition.Thephysicaljunctionoftendonandboneisreferred
toasanenthesis,22andisaninterfacethatisvulnerabletoacuteandchronicinjury.23Oneroleofthe
enthesisistoabsorbanddistributethestressconcentrationthatoccursatthejunctionoverabroaderarea.
Thetendonmidsubstance.Overusetendoninjuriescanoccurinthemidsubstanceofthetendon,butnotas
frequentlyasattheenthesis.
MTJ.TheMTJisthesitewherethemuscleandtendonmeet.TheMTJcomprisesnumerous
interdigitationsbetweenmusclecellsandtendontissue,resemblinginterlockedfingers.Despiteits
viscoelasticmechanicalcharacteristics,theMTJisveryvulnerabletotensilefailure(seeChapter2).24,25
Ligaments
SkeletalligamentsarefibrousbandsofdenseCTthatconnectbonesacrossjoints.Ligamentscanbenamedfor
thebonesintowhichtheyinsert(coracohumeral),theirshape(deltoidoftheankle),ortheirrelationshipstoeach
other(cruciate).26Thegrossstructureofaligamentvariesaccordingtolocation(intraarticularorextra
articular,capsular),andfunction.27Ligaments,whichappearasdensewhitebandsorcordsofCT,arecomposed
primarilyofwater(approximately66%),andofcollagen(largelytypeIcollagen[85%],butwithsmallamounts
oftypeIII)makingupmostofthedryweight.Thecollageninligamentshasalessunidirectionalorganization
thanitdoesintendons,butitsstructuralframeworkstillprovidesstiffness(resistancetodeformationsee
Chapter2).28Smallamountsofelastin(1%ofthedryweight)arepresentinligaments,withtheexceptionofthe
ligamentumflavumandthenuchalligamentofthespine,whichcontainmore.Thecellularorganizationof
ligamentsmakesthemidealforsustainingtensileloads,withmanycontainingfunctionalsubunitsthatare
capableoftighteningorlooseningindifferentjointpositions.29Atthemicroscopiclevel,closelyspaced
collagenfibers(fascicles)arealignedalongthelongaxisoftheligamentandarearrangedintoaseriesof
bundlesthataredelineatedbyacellularlayer,theendoligament,andtheentireligamentisencasedina
neurovascularbiocellularlayerreferredtoastheepiligament.26Ligamentscontributetothestabilityofjoint
functionbypreventingexcessivemotion,30actingasguidesorcheckreinstodirectmotion,andproviding
proprioceptiveinformationforjointfunctionthroughsensorynerveendings(seeChapter3)andtheattachments
oftheligamenttothejointcapsule.3133Manyligamentssharefunctions.Forexample,whiletheanterior
cruciateligamentofthekneeisconsideredtheprimaryrestrainttoanteriortranslationofthetibiarelativetothe
femur,thecollateralligamentsandtheposteriorcapsuleofthekneealsohelpinthisfunction(seeChapter
20).26Thevascularandnervedistributiontoligamentsisnothomogeneous.Forexample,themiddleofthe
ligamentistypicallyavascular,whiletheproximalanddistalendsenjoyarichbloodsupply.Similarly,the
insertionalendsoftheligamentsaremorehighlyinnervatedthanthemidsubstance.
Cartilage
Cartilagetissueexistsinthreeforms:hyaline,elastic,andfibrocartilage.
Hyalinecartilage,alsoreferredtoasarticularcartilage,coverstheendsoflongbonesandpermitsalmost
frictionlessmotiontooccurbetweenthearticularsurfacesofadiarthrodial(synovial)joint.34Articular
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cartilageisahighlyorganizedviscoelasticmaterialcomposedofcartilagecellscalledchondrocytes,
water,andanECM.
CLINICALPEARL
Chondrocytesarespecializedcellsthatareresponsibleforthedevelopmentofcartilageandthemaintenanceof
theECM.35Chondrocytesproduceaggrecan,linkprotein,andhyaluronan,allofwhichareextrudedintothe
ECM,wheretheyaggregatespontaneously.4Theaggrecanformsastrong,porouspermeable,fiberreinforced
compositematerialwithcollagen.Thechondrocytessensemechanicalchangesintheirsurroundingmatrix
throughintracytoplasmicfilamentsandshortciliaonthesurfaceofthecells.27
Articularcartilage,themostabundantcartilagewithinthebody,isdevoidofanybloodvessels,lymphatics,and
nerves.5,6Mostofthebonesofthebodyformfirstashyalinecartilage,andlaterbecomeboneinaprocess
calledendochondralossification.Thenormalthicknessofarticularcartilageisdeterminedbythecontact
pressuresacrossthejointthehigherthepeakpressures,thethickerthecartilage.27Articularcartilage
functionstodistributethejointforcesoveralargecontactarea,therebydissipatingtheforcesassociatedwiththe
load.Thisdistributionofforcesallowsthearticularcartilagetoremainhealthyandfullyfunctionalthroughout
decadesoflife.Thepatellarhasthethickestarticularcartilageinthebody.
Articularcartilagemaybegrosslysubdividedintofourdistinctzoneswithdifferingcellularmorphology,
biomechanicalcomposition,collagenorientation,andstructuralproperties,asfollows:
Thesuperficialzone.Thesuperficialzone,whichliesadjacenttothejointcavity,comprises
approximately1020%ofthearticularcartilagethicknessandfunctionstoprotectdeeperlayersfrom
shearstresses.Thecollagenfiberswithinthiszonearepackedtightlyandalignedparalleltothearticular
surface.Thiszoneisincontactwiththesynovialfluidandhandlesmostofthetensilepropertiesof
cartilage.
Themiddle(transitional)zone.Inthemiddlezone,whichprovidesananatomicandfunctionalbridge
betweenthesuperficialanddeepzones,thecollagenfibrilorientationisobliquelyorganized.Thiszone
comprises4060%ofthetotalcartilagevolume.Functionally,themiddlezoneisthefirstlineof
resistancetocompressiveforces.
Thedeeporradiallayer.Thedeeplayercomprises30%ofthematrixvolume.Itischaracterizedby
radiallyalignedcollagenfibersthatareperpendiculartothesurfaceofthejoint,andwhichhaveahigh
proteoglycancontent.Functionallythedeepzoneisresponsibleforprovidingthegreatestresistanceto
compressiveforces.
Thetidemark.Thetidemarkdistinguishesthedeepzonefromthecalcifiedcartilage,theareathatprevents
thediffusionofnutrientsfromthebonetissueintothecartilage.
Elastic(yellow)cartilageisaveryspecializedCT,primarilyfoundinlocationssuchastheouterear,
andportionsofthelarynx.
Fibrocartilage,alsoreferredtoaswhitecartilage,functionsasashockabsorberinbothweight
bearingandnonweightbearingjoints.Itslargefibercontent,reinforcedwithnumerouscollagen
fibers,makesitidealforbearinglargestressesinalldirections.Fibrocartilageisanavascular,
alymphatic,andaneuraltissueandderivesitsnutritionbyadoublediffusionsystem.36Examplesof
fibrocartilageincludethesymphysispubis,theintervertebraldisk,andthemeniscioftheknee.
Bone
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BoneisahighlyvascularformofCT,composedofcollagen,calciumphosphate,water,amorphousproteins,and
cells.ItisthemostrigidoftheCTs(Table12).Despiteitsrigidity,boneisadynamictissuethatundergoes
constantmetabolismandremodeling.Thecollagenofboneisproducedinthesamemannerasthatofligament
andtendonbutbyadifferentcell,theosteoblast.10Atthegrossanatomicallevel,eachbonehasadistinct
morphologycomprisingbothcorticalboneandcancellousbone.Corticalboneisfoundintheoutershell.
Cancellousboneisfoundwithintheepiphysealandmetaphysealregionsoflongbones,aswellasthroughout
theinteriorofshortbones.24Skeletaldevelopmentoccursinoneofthetwoways:
TABLE12GeneralStructureofBone
Site Comment Conditions Result
Mainlydevelopsunderpressure Epiphysealdysplasias Distortedjoints
Apophysisformsundertraction Jointsurfacetrauma Degenerativechanges
Epiphysis
Formsboneends Overuseinjury Fragmenteddevelopment
Supportsarticularsurface Damagedbloodsupply Avascularnecrosis
Epiphysealorgrowthplate
Responsivetogrowthandsex Physealdysplasia Shortstature
Physis hormones Trauma Deformedorangulatedgrowthor
Vulnerablepriortogrowthspurt Slippedepiphysis growtharrest
Mechanicallyweak
Remodelingexpandedboneend
Osteomyelitis Sequestrumformation
Cancellousbonehealsrapidly
Metaphysis Tumors Alteredboneshape
Vulnerabletoosteomyelitis
Metaphysealdysplasia Distortedgrowth
Affordsligamentattachment
Formsshaftofbone Abletoremodelangulation
Fractures
Largesurfaceformuscleorigin Cannotremodelrotation
Diaphysealdysplasias
Diaphysis Significantcompactcortical Involucrumwithinfection
Healingslowerthanat
bone Dysplasiagivesaltereddensityand
metaphysis
Strongincompression shape
DatafromReidDC.SportsInjuryAssessmentandRehabilitation.NewYork,NY:ChurchillLivingstone1992.
Intramembranousossification.Mesenchymalstemcellswithinmesenchymeorthemedullarycavityofa
boneinitiatetheprocessofintramembranousossification.Thistypeofossificationoccursinthecranium
andfacialbonesand,inpart,theribs,clavicle,andmandible.
Endochondralossification.Thefirstsiteofossificationoccursintheprimarycenterofossification,which
isinthemiddleofthediaphysis(shaft).Aboutthetimeofbirth,asecondaryossificationcenterappearsin
eachepiphysis(end)oflongbones.Betweentheboneformedbytheprimaryandsecondaryossification
centers,cartilagepersistsastheepiphyseal(growth)platesbetweenthediaphysisandtheepiphysisofa
longbone.Thistypeofossificationoccursintheappendicularandaxialbones.
Theperiosteumisformedwhentheperichondrium,whichsurroundsthecartilage,becomestheperiosteum.
Chondrocytesintheprimarycenterofossificationbegintogrow(hypertrophy)andbeginsecretingalkaline
phosphatase,anenzymeessentialformineraldeposition.Calcificationofthematrixfollows,andapoptosis(a
typeofcelldeathinvolvingaprogrammedsequenceofeventsthateliminatescertaincells)ofthehypertrophic
chondrocytesoccurs.Thiscreatescavitieswithinthebone.Theexactmechanismofchondrocytehypertrophy
andapoptosisiscurrentlyunknown.Thehypertrophicchondrocytes(beforeapoptosis)alsosecreteasubstance
calledvascularendothelialcellgrowthfactorthatinducesthesproutingofbloodvesselsfromthe
perichondrium.Bloodvesselsformingtheperiostealbudinvadethecavityleftbythechondrocytes,andbranch
inoppositedirectionsalongthelengthoftheshaft.Thebloodvesselscarryosteoprogenitorcellsand
hemopoieticcellsinsidethecavity,thelatterofwhichlaterformthebonemarrow.Osteoblasts,differentiated
fromtheosteoprogenitorcellsthatenterthecavityviatheperiostealbud,usethecalcifiedmatrixasascaffold
andbegintosecreteosteoid,whichformsthebonetrabecula.Osteoclasts,formedfrommacrophages,break
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downthespongybonetoformthemedullarycavity(bonemarrow).Thefunctionofboneistoprovidesupport,
enhanceleverage,protectvitalstructures,provideattachmentsforbothtendonsandligaments,andstore
minerals,particularlycalcium.Fromaclinicalperspective,bonesmayserveasusefullandmarksduringthe
palpationphaseoftheexamination.Thestrengthofboneisrelateddirectlytoitsdensity.Ofimportancetothe
clinician,isthedifferencebetweenmaturingboneandmaturebone.Theepiphysealplateorgrowthplateofa
maturingbonecanbedividedintofourdistinctzones:37
Reservezone:producesandstoresmatrix.
Proliferativezone:producesmatrixandisthesiteforlongitudinalbonecellgrowth.
Hypertrophiczone:subdividedintothematurationzone,degenerativezone,andthezoneofprovisional
calcification.Itiswithinthehypertrophiczonethatthematrixispreparedforcalcificationandisherethat
thematrixisultimatelycalcified.Thehypertrophiczoneisthemostsusceptibleofthezonestoinjury
becauseofthelowvolumeofbonematrixandthehighamountsofdevelopingimmaturecellsinthis
region.38
Bonemetaphysis:thepartofthebonethatgrowsduringchildhood.
SkeletalMuscleTissue
Themicrostructureandcompositionofskeletalmusclehavebeenstudiedextensively.Theclassoftissuelabeled
skeletalmuscleconsistsofindividualmusclecellsorfibersthatworktogethertoproducethemovementofbony
levers.Asinglemusclecelliscalledamusclefiberormyofiber.Asmusclecellsdifferentiatewithinthe
mesoderm,individualmyofibersarewrappedinaCTenvelopecalledendomysium.Bundlesofmyofibers,
whichformawholemuscle(fasciculus),areencasedintheperimysium(Fig.11).Theperimysiumis
continuouswiththedeepfascia.Thisrelationshipallowsthefasciatouniteallofthefibersofasinglemotor
unitand,therefore,adapttovariationsinformandvolumeofeachmuscleaccordingtomuscularcontraction
andintramuscularmodificationsinducedbyjointmovement.15Groupsoffasciculiaresurroundedbya
connectivesheathcalledtheepimysium(Fig.11).Underanelectronmicroscope,itcanbeseenthateachofthe
myofibersconsistsofthousandsofmyofibrils(Fig.11),whichextendthroughoutitslength.Myofibrilsare
composedofsarcomeresarrangedinseries.39
FIGURE11
Microscopicstructureofthemuscle.
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CLINICALPEARL
Thesarcomere(Fig.12)isthecontractilemachineryofthemuscle.Thegradedcontractionsofawholemuscle
occurbecausethenumberoffibersparticipatinginthecontractionvaries.Increasingtheforceofmovementis
achievedbyrecruitingmorecellsintocooperativeaction.
FIGURE12
Troponinandtropomyosinactionduringamusclecontraction.
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Allskeletalmusclesexhibitfourcharacteristics:40
1.Excitability,theabilitytorespondtostimulationfromthenervoussystem.
2.Elasticity,theabilitytochangeinlengthorstretch.
3.Extensibility,theabilitytoshortenandreturntonormallength.
4.Contractility,theabilitytoshortenandcontractinresponsetosomeneuralcommand.Thetension
developedinskeletalmusclecanoccurpassively(stretch)oractively(contraction).Whenanactivated
muscledevelopstension,theamountoftensionpresentisconstantthroughoutthelengthofthemuscle,in
thetendons,andatthesitesofthemusculotendinousattachmentstothebone.Thetensileforceproduced
bythemusclepullsontheattachedbonesandcreatestorqueatthejointscrossedbythemuscle.The
magnitudeofthetensileforceisdependentonanumberoffactors.
OneofthemostimportantrolesofCTistotransmitmechanicallytheforcesgeneratedbytheskeletalmuscle
cellstoprovidemovement.Eachofthemyofibrilscontainsmanyfiberscalledmyofilaments,whichrunparallel
tothemyofibrilaxis.Themyofilamentsaremadeupoftwodifferentproteins:actin(thinmyofilaments)and
myosin(thickmyofilaments)thatgiveskeletalmusclefiberstheirstriated(striped)appearance(Fig.12).39
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Thestriationsareproducedbyalternatingdark(A)andlight(I)bandsthatappeartospanthewidthofthe
musclefiber.TheAbandsarecomposedofmyosinfilaments,whereastheIbandsarecomposedofactin
filaments.TheactinfilamentsoftheIbandoverlapintotheAband,givingtheedgesoftheAbandadarker
appearancethanthecentralregion(Hband),whichcontainsonlymyosin.AtthecenterofeachIbandisathin,
darkZline.Asarcomere(Fig.12)representsthedistancebetweeneachZline.Eachmusclefiberislimitedby
acellmembranecalledasarcolemma(Fig.11).Theproteindystrophinplaysanessentialroleinthemechanical
strengthandstabilityofthesarcolemma.41DystrophinislackinginpatientswithDuchennemusculardystrophy.
CLINICALPEARL
Thesarcoplasmisthespecializedcytoplasmofamusclecellthatcontainstheusualsubcellularelementsalong
withtheGolgiapparatus,abundantmyofibrils,amodifiedendoplasmicreticulumknownasthesarcoplasmic
reticulum(SR),myoglobin,andmitochondria.Transversetubules(Ttubules)invaginatethesarcolemma,
allowingimpulsestopenetratethecellandactivatetheSR.
Thebasicfunctionofmuscleistocontract.Thewordcontraction,usedtodescribethegenerationoftension
withinmusclefibers,conjuresupanimageofshorteningofmusclefibersduringaresistanceexercise.However,
acontractioncanproduceshorteningorlengtheningofthemuscle,ornochangeinthemusclelength.Thus,
threetypesofcontractionarecommonlyrecognized:isometric,concentric,andeccentric(seeChapter12).
Isometriccontraction.Isometricexercisesprovideastaticcontractionwithavariableandaccommodating
resistancewithoutproducinganyappreciablechangeinmusclelength.42
Concentriccontraction.Aconcentriccontractionproducesashorteningofthemuscle.Thisoccurswhen
thetensiongeneratedbytheagonistmuscleissufficienttoovercomeanexternalresistanceandtomove
thebodysegmentofoneattachmenttowardthesegmentofitsotherattachment.42
Eccentriccontraction.Aneccentriccontractionoccurswhenamuscleslowlylengthensasitgivesinto
anexternalforcethatisgreaterthanthecontractileforceitisexerting.42Inreality,themuscledoesnot
lengthen,itmerelyreturnsfromitsshortenedpositiontoitsnormalrestinglength.Eccentricmuscle
contractions,whicharecapableofgeneratinggreaterforcesthaneitherisometricorconcentric
contractions,4345areinvolvedinactivitiesthatrequireadecelerationtooccur.Suchactivitiesinclude
slowingtoastopwhenrunning,loweringanobject,orsittingdown.Becausetheloadexceedsthebond
betweentheactinandmyosinfilamentsduringaneccentriccontraction,someofthemyosinfilaments
probablyaretornfromthebindingsitesontheactinfilamentwhiletheremainderarecompletingthe
contractioncycle.46Theresultingforceissubstantiallylargerforatorncrossbridgethanforonebeing
createdduringanormalcycleofmusclecontraction.Consequently,thecombinedincreaseinforceper
crossbridgeandthenumberofactivecrossbridgesresultsinamaximumlengtheningmuscletensionthat
isgreaterthanthetensionthatcouldbecreatedduringashorteningmuscleaction.46,47
CLINICALPEARL
Bothconcentricandeccentricmuscleactioncomprisethetypeofexercisecalledisotonic.Anisotonic
contractionisacontractioninwhichthetensionwithinthemuscleremainsconstantasthemuscleshortensor
lengthens.42Thisstateisverydifficulttoproduceandmeasure.Althoughthetermisotonicisusedinmanytexts
todescribeconcentricandeccentriccontractionsalike,itsuseinthiscontextiserroneousbecauseinmost
exerciseformsthemuscletensionduringexercisevariesbasedupontheweightused,jointvelocity,muscle
length,andtypeofmusclecontraction.42
Fourothercontractionsareworthmentioning:
Isokineticcontraction.Anisokineticcontractionoccurswhenamuscleismaximallycontractingatthe
samespeedthroughoutthewholerangeofitsrelatedlever.42Isokineticcontractionsrequiretheuseof
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specialequipmentthatproducesanaccommodatingresistance.Bothhighspeed/lowresistanceandlow
speed/highresistanceregimensresultinexcellentstrengthgains.4851Themajordisadvantageofthis
typeofexerciseisitsexpense.Also,thereisthepotentialforimpactloadingandincorrectjointaxis
alignment.52Isokineticexercisesmayalsohavequestionablefunctionalcarryover.53
Econcentriccontraction.Thistypeofcontractioncombinesbothacontrolledconcentricanda
simultaneouseccentriccontractionofthesamemuscleovertwoseparatejoints.54Examplesofan
econcentriccontractionincludethestandinghamstringcurl,inwhichthehamstringsworkconcentrically
toflexthekneewhilethehiptendstoflexeccentrically,lengtheningthehamstrings.Whenrisingfroma
squat,thehamstringsworkconcentricallyasthehipextendsandworkeccentricallyasthekneeextends.
Conversely,therectusfemorisworkeccentricallyasthehipextendsandworkconcentricallyastheknee
extends.
Isolyticcontraction.Anisolyticcontractionisanosteopathictermusedtodescribeatypeofeccentric
contractionthatmakesuseofagreaterforcethanthepatientcanovercome.Thedifferencebetweenan
eccentriccontractionandanisolyticcontractionisthat,intheformer,thecontractionisvoluntary
whereas,inthelatter,itisinvoluntary.Theisolyticcontractioncanbeusedincertainmanualtechniques
tostretchfibrotictissue(seeChapter10).
Structurescalledcrossbridgesservetoconnecttheactinandmyosinfilaments.Increasedsynthesisofactinand
myosinstimulatesnewmyofibrilsthatareaddedtotheexternallayersofthepreexistingmyofibrils.55The
myosinfilamentscontaintwoflexible,hingelikeregions,whichallowthecrossbridgestoattachanddetach
fromtheactinfilament.Duringcontraction,thecrossbridgesattachandundergopowerstrokes,whichprovide
thecontractileforce.Duringrelaxation,thecrossbridgesdetach.Thisattachinganddetachingisasynchronous,
sothatsomeareattachingwhileothersaredetaching.Thus,ateachmoment,someofthecrossbridgesare
pulling,whileothersarereleasing.
Theregulationofcrossbridgeattachmentanddetachmentisafunctionoftwoproteinsfoundintheactin
filaments:tropomyosinandtroponin(Fig.12).Tropomyosinattachesdirectlytotheactinfilament,whereas
troponinisattachedtothetropomyosinratherthandirectlytotheactinfilament.
CLINICALPEARL
Tropomyosinandtroponinfunctionastheswitchformusclecontractionandrelaxation.Inarelaxedstate,the
tropomyosinphysicallyblocksthecrossbridgesfrombindingtotheactin.Forcontractiontotakeplace,the
tropomyosinmustbemoved.
Eachmusclefiberisinnervatedbyasomaticmotorneuron.Oneneuronandthemusclefibersitinnervates
constituteamotorunitorfunctionalunitofthemuscle.Eachmotorneuronbranchesasitentersthemuscleto
innervateanumberofmusclefibers.
CLINICALPEARL
Theareaofcontactbetweenanerveandmusclefiberisknownasthemotorendplate,orneuromuscular
junction(NMJ).
ThereleaseofachemicalacetylcholinefromtheaxonterminalsattheNMJcauseselectricalactivationofthe
skeletalmusclefibers.Whenanactionpotentialpropagatesintothetransversetubulesystem(narrow
membranoustunnelsformedfromandcontinuouswiththesarcolemma),thevoltagesensorsonthetransverse
tubulemembranesignalthereleaseofCa2+ fromtheterminalcisternaeportionoftheSR(aseriesof
interconnectedsacsandtubesthatsurroundeachmyofibril).56ThereleasedCa2+ thendiffusesintothe
sarcomeresandbindstotroponin,displacingthetropomyosin,andallowingtheactintobindwiththemyosin
crossbridges(Fig.12).Wheneverasomaticmotorneuronisactivated,allofthemusclefibersthatitinnervates
arestimulatedandcontractwithallornonetwitches.Althoughthemusclefibersproduceallornone
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contractions,musclesarecapableofawidevarietyofresponses,rangingfromactivitiesrequiringahighlevelof
precision,toactivitiesrequiringhightension.
Attheendofthecontraction(theneuralactivityandactionpotentialscease),theSRactivelyaccumulatesCa2+
andmusclerelaxationoccurs.ThereturnofCa2+ totheSRinvolvesactivetransport,requiringthedegradation
ofadenosinetriphosphate(ATP)toadenosinediphosphate(ADP)*.56BecauseSRfunctioniscloselyassociated
withbothcontractionandrelaxation,changesinitsabilitytoreleaseorsequesterCa2+ markedlyaffectboththe
timecourseandmagnitudeofforceoutputbythemusclefiber.57
CLINICALPEARL
TheSRformsanetworkaroundthemyofibrils,storingandprovidingtheCa2+ thatisrequiredformuscle
contraction.
Onthebasisoftheircontractileproperties,twomajortypesofmusclefiberhavebeenrecognizedwithinskeletal
musclebasedontheirresistancetofatigue:typeI(tonic,slowtwitchfibers),andtypeII(phasicfasttwitch
fibers).TypeIImusclefibersarefurtherdividedintotwoadditionalclassifications(TypesIIAandIIB)(Table1
3).Scottetal.58subdividetypeIIfibersintothreeclassifications,includingatypeIIIC.
TABLE13ComparisonofMuscleFiberTypes
Characteristics TypeI TypeIIA TypeIIB
Size(diameter) Small Intermediate Verylarge
Resistancetofatigue High Fairlyhigh Low
Capillarydensity High High Low
Glycogencontent Low Intermediate High
Twitchrate Slow Fast Fast
Energysystem Aerobic Aerobic Anaerobic
Maximummuscleshorteningvelocity Slow Fast Fast
Majorstoragefuel Triglycerides Creatinephosphateglycogen Creatinephosphateglycogen
TypeIfibersarerichlyendowedwithmitochondriaandhaveahighcapacityforoxygenuptake.Theyare,
therefore,suitableforactivitiesoflongdurationorendurance(aerobic),includingthemaintenanceofposture.In
contrast,fasttwitchfibers,whichgenerateagreatamountoftensionwithinashortperiod,aresuitedtoquick,
explosiveactions(anaerobic),includingsuchactivitiesassprinting.ThetypeII(fasttwitch)fibersareseparated
basedonmitochondriacontentintothosethathaveahighcomplementofmitochondria(typeIIA)andthosethat
aremitochondriapoor(typeIIB).ThisresultsintypeIIBfibershavingatendencytofatiguemorequicklythan
thetypeIIAfibers(Table13).
CLINICALPEARL
Infasttwitchfibers,theSRembraceseveryindividualmyofibril.Inslowtwitchfibers,itmaycontainmultiple
myofibrils.59
Theorydictatesthatamusclewithalargepercentageofthetotalcrosssectionalareaoccupiedbyslowtwitch
typeIfibersshouldbemorefatigueresistantthanoneinwhichthefasttwitchtypeIIfiberspredominate.
Differentactivitiesplacedifferingdemandsonamuscle(Table14).59Forexample,dynamicmovement
activitiesinvolveapredominanceoffasttwitchfiberrecruitment,whereasposturalactivitiesandthoseactivities
requiringstabilizationentailmoreinvolvementoftheslowtwitchfibers.Inhumans,mostlimbmusclescontain
arelativelyequaldistributionofeachmusclefibertype,whereasthebackandtrunkdemonstratea
predominanceofslowtwitchfibers.Althoughitwouldseempossiblethatphysicaltrainingmaycausefibersto
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convertfromslowtwitchtofasttwitchorthereverse,thishasnotbeenshowntobethecase.60However,fiber
conversionfromtypeIIBtotypeIIA,andviceversa,hasbeenfoundtooccurwithtraining.61
TABLE14FunctionalDivisionofMuscleGroups
MovementGroup StabilizationGroup
PrimarilytypeIIa PrimarilytypeI
Pronetoadaptiveshortening Pronetodevelopweakness
Pronetodevelophypertonicity Pronetomuscleinhibition
Dominateinfatigueandnewmovementsituations Fatigueeasily
Generallycrosstwojoints Primarilycrossonejoint
Examples Examples
Gastrocnemius/Soleus Fibularis(peronei)
Tibialisposterior Tibialisanterior
Shorthipadductors Vastusmedialisandlateralis
Hamstrings Gluteusmaximus,medius,andminimus
Rectusfemoris Serratusanterior
Tensorfascialata Rhomboids
Erectorspinae Lowerportionoftrapezius
Quadratuslumborum Short/deepcervicalflexors
Pectoralismajor Upperlimbextensors
Upperportionoftrapezius Rectusabdominis
Levatorscapulae
Sternocleidomastoid
Scalenes
Upperlimbflexors
DatafromJullGA,JandaV.Muscleandmotorcontrolinlowbackpain.In:TwomeyLT,TaylorJR,eds.
PhysicalTherapyoftheLowBack:ClinicsinPhysicalTherapy.NewYork,NY:ChurchillLivingstone
1987:258278.
Theeffectivenessofmuscletoproducemovementdependsonsomefactors.Theseincludethelocationand
orientationofthemuscleattachmentrelativetothejoint,thelimitationsorlaxitypresentinthe
musculotendinousunit,thetypeofcontraction,thepointofapplication,andtheactionsofothermusclesthat
crossthejoint.2
CLINICALPEARL
Followingthestimulationofmuscle,abriefperiodelapsesbeforeamusclebeginstodeveloptension.The
lengthofthisperiod,theelectromechanicaldelay(EMD),variesconsiderablyamongmuscles.Fasttwitchfibers
haveshorterperiodsofEMDwhencomparedwithslowtwitchfibers.62EMDisaffectedbymusclefatigue,
musclelength,muscletraining,passivemusclestretching,andthetypeofmuscleactivation.63Atissueinjury
mayincreasetheEMDand,therefore,increasesthesusceptibilitytofutureinjuryiffullhealingdoesnot
occur.64Oneofthepurposesofneuromuscularreeducation(seeChapter14)istoreturntheEMDtoanormal
level.65
Musclesserveavarietyofrolesdependingontherequiredmovement:
Primemover(agonist).Thisisamusclethatisdirectlyresponsibleforproducingadesiredmovement.
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Antagonist.Thisisamusclethathasaneffectdirectlyoppositetothatoftheagonist.
Synergist(supporter).Thisisamusclethatperformsacooperativemusclefunctionrelativetotheagonist.
Synergistscanfunctionasstabilizersorneutralizers.
Stabilizers(fixators).Musclesthatcontractstaticallytosteadyorsupportsomepartofthebody
againstthepullofthecontractingmuscles,againstthepullofgravity,oragainsttheeffectof
momentumandrecoilincertainvigorousmovements.
Neutralizers.Musclesthatacttopreventanundesiredactionfromoneofthemovers.
Aspreviouslymentioned,dependingonthetypeofmuscularcontraction,thelengthofamusclecanremainthe
same(isometric),shorten(concentric),orlengthen(eccentric).Thevelocityatwhichmusclecontracts
significantlyaffectsthetensionthatthemuscleproducesandsubsequentlyaffectsamusclesstrengthand
power.66
Concentriccontractions.Asthespeedofaconcentriccontractionincreases,theforceitiscapableof
producingdecreases.43,45Theslowerspeedofcontractionisthoughttoproducegreaterforcesthancanbe
producedbyincreasingthenumberofcrossbridgesformed.Thisrelationshipisacontinuum,withthe
optimumvelocityforthemusclesomewherebetweentheslowestandfastestrates.Atveryslowspeeds,
theforcethatamusclecanresistorovercomerisesrapidlyupto50%greaterthanthemaximumisometric
contraction.43,45
Eccentriccontractions.Duringamaximumefforteccentriccontraction,asthevelocityofactivemuscle
lengtheningincreases,forceproductioninthemuscleinitiallyincreasestoapoint,butthenquicklylevels
off.6769Thefollowingchangesinforceproductionoccurduringaneccentriccontraction:
Rapideccentriccontractionsgeneratemoreforcethandoslowereccentriccontractions.
Duringsloweccentricmuscleactions,theworkproducedapproximatesthatofanisometric
contraction.43,45
CLINICALPEARL
Thenumberofcrossbridgesthatcanbeformedisdependentontheextentoftheoverlapbetweentheactinand
myosinfilaments.70Thus,theforceamuscleiscapableofexertingdependsonitslength.Foreachmusclecell,
thereisanoptimumlength,orrangeoflengths,atwhichthecontractileforceisstrongest.Attheoptimum
lengthofthemuscle,thereisanearoptimaloverlapofactinandmyosin,allowingforthegenerationof
maximumtensionatthislength.
Ifthemuscleisinashortenedposition,theoverlapofactinandmyosinreducesthenumberofsites
availableforthecrossbridgeformation.Activeinsufficiencyofamuscleoccurswhenthemuscleis
incapableofshorteningtotheextentrequiredtoproduceafullrangeofmotion(ROM)atalljoints
crossedsimultaneously.2,54,71,72Forexample,thefingerflexorscannotproduceaclosedfistwhenthe
wristisfullyflexed,astheycanwhenitisinneutralposition.
Ifthemuscleisinalengthenedpositioncomparedwithitsoptimumlength,theactinfilamentsarepulled
awayfromthemyosinheadssuchthattheycannotcreateasmanycrossbridges.46Passiveinsufficiency
ofthemuscleoccurswhenthetwojointmusclecannotstretchtotheextentrequiredforfullROMinthe
oppositedirectionatalljointscrossed.2,54,71,72Forexample,whenanindividualattemptstomakea
closedfistwiththewristfullyflexed,theactiveshorteningofthefingerandwristflexorsresultsin
passivelengtheningofthefingerextensors.Inthisexample,thelengthofthefingerextensorsis
insufficienttoallowfullROMatboththewristandthefingers.73
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Theforceandspeedofamusclecontractiondependontherequirementsoftheactivity,whichinturn,are
dependentontheabilityofthecentralnervoussystemtocontroltherecruitmentofmotorunits.2Themotor
unitsofslowtwitchfibershavelowerthresholdsandareeasiertoactivatethanthoseofthefasttwitchmotor
units.Consequently,theslowtwitchfibersarerecruitedfirst,evenwhentheresultinglimbmovementisrapid.74
Astheforcerequirement,speedrequirement,ordurationofactivityincreases,motorunitswithhigher
thresholdsarerecruited.TypeIIaunitsarerecruitedbeforetypeIIb.75
CLINICALPEARL
Thetermtemporalsummationreferstothesummationofindividualcontractileunits.Thesummationcan
increasethemuscularforcebyincreasingthemuscleactivationfrequency.76
Althougheachmusclecontainsthecontractilemachinerytoproducetheforcesformovement,itisthetendon
thattransmitstheseforcestothebonestoachievemovementorstabilityofthebodyinspace.9Theangleof
insertionthetendonmakeswithabonedeterminesthelineofpull,whereasthetensiongeneratedbyamuscleis
afunctionofitsangleofinsertion.Amusclegeneratesthegreatestamountoftorquewhenitslineofpullis
orientedata90degreeangletothebone,anditisattachedanatomicallyasfarfromthejointcenteraspossible.2
Justasthereareoptimalspeedsoflengthchangeandoptimalmusclelengths,thereareoptimalinsertionangles
foreachofthemuscles.Theangleofinsertionofamuscle,and,therefore,itslineofpull,canchangeduring
dynamicmovements.46Theangleofpennationistheanglecreatedbetweenthefiberdirectionandthelineof
pull.Whenthefibersofamusclelieparalleltothelongaxisofthemuscle,thereisnoangleofpennation.The
numberoffiberswithinafixedvolumeofamuscleincreaseswiththeangleofpennation.46Althoughpennation
canenhancethemaximumtension,therangeofshorteningofthemuscleisreduced.Musclefiberscancontract
toabout60%oftheirrestinglength.Sincethemusclefibersinpennatemusclesareshorterthanthenopennate
equivalent,theamountofcontractionissimilarlyreduced.Musclesthatneedtohavelargechangesinlength
withouttheneedforveryhightension,suchasthesartoriusmuscle,donothavepennatemusclefibers.46In
contrast,pennatemusclefibersarefoundinthosemusclesinwhichtheemphasisisonahighcapacityfor
tensiongenerationratherthanROM(e.g.,gluteusmaximus).
CLINICALPEARL
Skeletalmusclebloodflowincreases20foldduringmusclecontractions.77Themusclebloodflowincreasesin
proportiontothemetabolicdemandsofthetissue,arelationshipreflectedbypositivecorrelationsbetween
musclebloodflowandexercise.Asbodytemperatureelevates,thespeedsofnerveandmusclefunctions
increase,resultinginahighervalueofmaximumisometrictensionandahighermaximumvelocityof
shorteningpossiblewithfewermotorunitsatanygivenload.78Musclefunctionismostefficientat38.5C
(101F).79
Duringphysicalexercise,energyturnoverinskeletalmusclemayincreaseby400timescomparedwithmuscle
atrestandmuscleoxygenconsumptionmayincreasebymorethan100times.80ThehydrolysisofATPtoADP
andinorganicphosphate(Pi)providesthepowerformuscularactivity.Despitethelargefluctuationsinenergy
demandjustmentioned,muscleATPremainspracticallyconstantanddemonstratesaremarkableprecisionof
thesysteminadjustingtherateoftheATPgeneratingprocessestothedemand.81Therearethreeenergy
systemsthatcontributetotheresynthesisofATPviaADPrephosphorylation.Theseenergysystemsareas
follows:
Phosphagensystem.Thephosphagen,orATPPCr,systemisananaerobicprocessitcanproceed
withoutoxygen(O2).Theskeletalmusclecellstoresthephosphocreatine(PCr)andADP,ofwhichPCris
thechemicalfuelsource.Attheonsetofmuscularcontraction,PCrrepresentsthemostimmediatereserve
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fortherephosphorylationofATP.ThephosphagensystemprovidesATPprimarilyforshortterm,high
intensityactivities(i.e.,sprinting),andisthemajorsourceofenergyduringthefirst30secondsofintense
exercise,butitisalsoactiveatthestartofallexercises,regardlessofintensity.82Onceamusclereturnsto
rest,thesupplyofATPPCrisreplenished.Whilethemaximumpowerofthissystemisgreat,one
disadvantageofthephosphagensystemisthatbecauseofitssignificantcontributiontotheenergyyieldat
theonsetofnearmaximalexercise,theconcentrationofPCrcanbereducedtolessthan40%ofresting
levelswithin10secondsofthestartofintenseexercise,whichtranslatesintoasmallmaximumcapacity
ofthesystem.83
Glycolyticsystem.Theglycolyticsystemisananaerobicprocessthatinvolvesthebreakdownof
carbohydrateseitherglycogenstoredinthemuscleorglucosedeliveredthroughthebloodinto
pyruvatetoproduceATPinaprocesscalledglycolysis.Pyruvateisthentransformedintolacticacidasa
byproductoftheanaerobicglycolysis.Becausethissystemreliesonaseriesofninedifferentchemical
reactions,itisslowertobecomefullyactive.However,glycogenolysishasagreatercapacitytoprovide
energythandoesPCr,andthereforeitsupplementsPCrduringmaximalexerciseandcontinuesto
rephosphorylateADPduringmaximalexerciseafterPCrreserveshavebecomeessentiallydepleted.82
Theprocessofglycolysiscanbeinoneofthetwoways,termedfastglycolysisandslowglycolysis,
dependingontheenergydemandswithinthecell.Ifenergymustbesuppliedatahighrate,fastglycolysis
isusedprimarily.Iftheenergydemandisnotsohigh,slowglycolysisisactivated.Themaindisadvantage
ofthefastglycolysissystemisthatduringveryhighintensityexercise,hydrogenionsdissociatefromthe
glycogenolyticendproductoflacticacid.81Theaccumulationoflacticacidinthecontractingmuscleis
recognizedinsportsandresistancetrainingcircles.Anincreaseinhydrogenionconcentrationisbelieved
toinhibitglycolyticreactionsanddirectlyinterferewithmuscleexcitationcontractionandcoupling,
whichcanpotentiallyimpaircontractileforceduringanexercise.82Thisinhibitionoccursoncethemuscle
pHdropsbelowacertainlevel,promptingtheappearanceofphosphofructokinase(PFK),resultingin
localenergyproductionceasinguntilreplenishedbyoxygenstores.
CLINICALPEARL
LacticacidisthemajorenergysourceforprovidingthemusclewithATPduringexerciseboutsthatlast13
minutes(e.g.,running400800m).
Oxidativesystem.Asitsnamesuggests,theoxidativesystemrequiresO2andisconsequentlytermedthe
aerobicsystem.Thefuelsourcesforthissystemareglycogen,fats,andproteins.Thissystemisthe
primarysourceofATPatrestandduringlowintensityactivities.TheATPisresynthesizedinthe
mitochondriaofthemusclecellsuchthattheabilitytometabolizeoxygenandothersubstratesisrelated
tothenumberandconcentrationofthemitochondriaandcells.Itisworthnotingthatatnotimeduring
eitherrestorexercisedoesanysingleenergysystemprovidethecompletesupplyofenergy.Whilebeing
unabletoproduceATPatanequivalentratetothatproducedbyPCrbreakdownandglycogenolysis,the
oxidativesystemiscapableofsustaininglowintensityexerciseforseveralhours.82However,becauseof
increasedcomplexity,thetimebetweentheonsetofexerciseandwhenthissystemisoperatingatitsfull
potentialisaround45seconds.84
TherelativecontributionoftheseenergysystemstoATPresynthesishasbeenshowntodependuponthe
intensityanddurationofexercise,withtheprimarysystemusedbeingbasedonthedurationoftheevent:85
010seconds:ATPPCr.Theseburstsofactivitydevelopmusclestrengthandstrongertendonsand
ligaments,withtheATPbeingsuppliedbythephosphagensystem.
1030seconds:ATPPCrplusanaerobicglycolysis.
30secondsto2minutes:anaerobicglycolysis.Theselongerburstsofactivity,ifrepeatedafter4minutes
ofrestormildexercise,enhanceanaerobicpowerwiththeATPbeingsuppliedbythephosphagenand
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anaerobicglycolyticsystem.
23minutes:anaerobicglycolysisplusoxidativesystem.
>3minutesandrest:oxidativesystem.Theseperiodsofactivityusinglessthanmaximumintensitymay
developaerobicpowerandendurancecapabilities,andthephosphogen,anaerobicglycotic,andanaerobic
systemssupplytheATP.
RespiratoryMuscles
Althoughtherespiratorymusclessharesomemechanicalsimilaritieswithskeletalmuscles,theyaredistinct
fromskeletalmusclesinseveralaspectsasfollows:86,87
Whereasskeletalmusclesofthelimbsovercomeinertialloads,therespiratorymusclesovercome
primarilyelasticandresistiveloads.
Therespiratorymusclesareunderbothvoluntaryandinvoluntarycontrol.
Therespiratorymusclesaresimilartotheheartmuscles,inthattheyhavetocontractrhythmicallyand
generatetherequiredforcesforventilationthroughouttheentirelifespanoftheindividual.Therespiratory
muscles,however,donotcontainpacemakercellsandareunderthecontrolofmechanicalandchemical
stimuli,requiringneuralinputfromhighercenterstoinitiateandcoordinatecontraction.
Therestinglengthoftherespiratorymusclesisarelationshipbetweentheinwardrecoilforcesofthelung
andtheoutwardrecoilforcesofthechestwall.Changesinthebalanceofrecoilforceswillresultin
changesintherestinglengthoftherespiratorymuscles.Thus,simpleandeverydaylifeoccurrencessuch
aschangesinposturemayaltertheoperationallengthandthecontractilestrengthoftherespiratory
muscles.88Ifuncompensated,theselengthchangescanleadtodecreasesintheoutputofthemuscles,and
hence,areductionintheabilitytogeneratelungvolumechanges.88Theskeletalmusclesofthelimbs,on
theotherhand,arenotconstrainedtooperateataparticularrestinglength.
CLINICALPEARL
Theprimaryrespiratorymusclesofthebodyincludethediaphragmtheinternal,external,andtransverse
intercostalsthelevatorcostaeandtheserratusposteriorinferiorandsuperior.
*ThemostreadilyavailableenergyforskeletalmusclecellsisstoredintheformofATPandphosphocreatine
(PCr).ThroughtheactivityoftheenzymeATPase,ATPpromptlyreleasesenergywhenrequiredbythecellto
performanytypeofwork,whetheritiselectrical,chemical,ormechanical.
JOINTS
Arthrologyisthestudyoftheclassification,structure,andfunctionofarticulations(jointsorarthroses).Ajoint
representsthejunctionbetweentwoormorebones.Jointsareregionswherebonesarecappedandsurrounded
byCTsthatholdthebonestogetheranddeterminethetypeanddegreeofmovementbetweenthem.89An
understandingoftheanatomyandbiomechanicsofthevariousjointsisrequiredtobeabletoassessandtreata
patientthoroughly.Whenclassifiedaccordingtomovementpotential,jointsmaybeclassifiedintotwobroad
categoriessynarthrosis(nonsynovial)ordiarthrosis(synovial).
Synarthrosis
Thetypeoftissueunitingthebonesurfacesdeterminesthemajortypesofsynarthroses:89
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Fibrousjoints,whicharejoinedbydensefibrousCT.Threetypesexist:
Suture(e.g.,sutureoftheskull).
Gomphosis(e.g.,toothandmandibleormaxillaarticulation).
Syndesmosis(e.g.,tibiofibularorradioulnarjoints).Thesejointsusuallyallowasmallamountof
motion.
Cartilaginousjointsoriginallyreferredtoasamphiarthrosisjoints,arestablejointsthatallowforminimal
orlittlemovement.Thesejointsexistinhumansinoneoftwoways:synchondrosis(e.g.,manubriosternal
joints)andsymphysis(e.g.,symphysispubis).Asynchondrosisisajointinwhichthematerialusedto
connectthetwocomponentsishyalinecartilage.90Inasymphysisjoint,thetwobonycomponentsare
coveredwithathinlaminaofhyalinecartilageanddirectlyjoinedbyfibrocartilageintheformofdisksor
pads.90
Diarthrosis
Thisjointuniteslongbonesandpermitsfreebonemovementandgreatermobility.Afibroelasticjointcapsule,
whichcharacterizesthesejoints,isfilledwithalubricatingsubstancecalledsynovialfluid.Consequently,these
jointsareoftenreferredtoassynovialjoints.
Examplesinclude,butarenotlimitedto,thehip,kneeandshoulder,andelbowjoints.Synovialjointsarefurther
classifiedbasedoncomplexity:
Simple(uniaxial):asinglepairofarticularsurfacesonemale,orconvex,surfaceandonefemale,or
concave,surface.Examplesincludehingejointandtrochoid(pivot)joints.
Compound(biaxial):asinglejointcapsulethatcontainsmorethanasinglepairofmatingarticulating
surfaces.Thetwotypesofbiaxialjointinthebodyincludethecondyloidandsaddle.
Complex(triaxialormultiaxial):containanintraarticularinclusionwithinthejointclasssuchasa
meniscusordiskthatincreasesthenumberofjointsurfaces.Thetwotypesofjointinthiscategoryare
planejointsandballandsocketjoints.
Synovialjointshavefivedistinguishingcharacteristics:ajointcavitythatisenclosedbythejointcapsule,
hyalinearticularcartilagethatcoversthesurfacesoftheenclosedcontiguousbones,synovialfluidthatformsa
filmoverthejointsurfaces,synovialmembranethatlinestheinnersurfaceofthecapsule,andajointcapsule
thatiscomposedoftwolayers.90Allsynovialjointsofthebodyareprovidedwithanarrayofcorpuscular
(mechanoreceptors)andnoncorpuscular(nociceptors)receptorendingsembeddedinarticular,muscular,and
cutaneousstructureswithvaryingcharacteristicbehaviorsanddistributionsdependingonthearticulartissue
(seeChapter3).Oneintraarticularstructureworthmentioningisthearticulardiskormeniscus.Ameniscus,
whichconsistsofadenseECM,isnotcoveredbyasynovialmembraneandoccursbetweenarticularsurfaces
wherecongruityislow.Thecellsofthemeniscusarereferredtoasfibrochondrocytesbecausetheyappeartobe
amixtureoffibroblastsandchondrocytes.91Ameniscaldiskmayextendacrossasynovialjoint,dividingit
structurallyandfunctionallyintotwosynovialcavities.Completedisksoccurinthesternoclavicularanddistal
radioulnarjoints,whilethatinthetemporomandibularjointmaybecompleteorincomplete.13Peripherally
disksareconnectedtofibrouscapsules,usuallybyvascularizedconnectivetissue,sothattheybecomeinvaded
byvesselsandafferentandmotornerves.13Mechanoreceptorswithinthemeniscifunctionastransducers,
convertingthephysicalstimulusoftensionandcompressionintoaspecificelectricalnerveimpulse(seeChapter
3).92
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Synovialjointscanbebroadlyclassifiedaccordingtostructureoranalogy(Fig.13)intothefollowing
categories93:
FIGURE13
Typesofdiarthrosisorsynovialjoints.
Spheroid.Asthenamesuggests,aspheroidjointisafreelymovingjointinwhichasphereontheheadof
onebonefitsintoaroundedcavityintheotherbone.Spheroid(ballandsocket)jointsallowmotionsin
threeplanes(Fig.13)(seelater).Examplesofaspheroidjointsurfaceincludetheheadsofthefemurand
humerus.
Trochoid.Thetrochoid,orpivot,jointischaracterizedbyapivotlikeprocessturningwithinaring,ora
ringonapivot,theringbeingformedpartlyofbone,partlyofligament(Fig.13).Trochoidjointspermit
onlyrotation.Examplesofatrochoidjointincludethehumeroradialjointandtheatlantoaxialjoint.
Condyloid(ovoid).Thisjointischaracterizedbyanovoidarticularsurface,orcondyle(Fig.13).One
bonemayarticulatewithanotherbyonesurfaceorbytwo,butnevermorethantwo.Iftwodistinct
surfacesarepresent,thejointiscalledcondylar,orbicondylar.Theellipticalcavityofthejointisdesigned
insuchamannerastopermitthemotionsofflexion,extension,adduction,abduction,andcircumduction,
butnoaxialrotation.Thewristjointisanexampleofthisformofarticulation.
Ginglymoid.Aginglymoidjointisahingejoint(Fig.13).Itischaracterizedbyaspoollikesurfaceanda
concavesurface.Anexampleofaginglymoidjointisthehumeroulnarjoint.
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Ellipsoid.Ellipsoidjointsaresimilartospheroidjointsinthattheyallowthesametypeofmovement
albeittoalessermagnitude.Theellipsoidjointallowsmovementintwoplanes(flexion,extension
abduction,adduction)andisbiaxial.Examplesofthisjointcanbefoundattheradiocarpalarticulationat
thewristandthemetacarpophalangealarticulationwiththephalanges.
Planar.Asitsnamesuggests,aplanarjointischaracterizedbyflatsurfacesthatslideovereachother.
Movementatthisjointdoesnotoccuraboutanaxisandistermednonaxial.Examplesofaplanarjoint
includetheintermetatarsaljointsandsomeintercarpaljoints.
Saddle(sellar).Saddlejointsarecharacterizedbyaconvexsurfaceinonecrosssectionalplaneanda
concavesurfaceintheplaneperpendiculartoit(Fig.13).Examplesofasaddlejointincludethe
interphalangealjoints,thecarpometacarpaljointofthethumb,thehumeroulnarjoint,andthe
calcaneocuboidjoints.
Inreality,nojointsurfaceisplanarorresemblesatruegeometricformthatistheyresembleeithertheouteror
innersurfaceofapieceofeggshell.94
SynovialFluid
Articularcartilageissubjecttoagreatvariationofloadingconditions,sojointlubricationthroughthesynovial
fluidisnecessarytominimizefrictionalresistancebetweentheweightbearingsurfaces.Fortunately,synovial
jointsareblessedwithaverysuperiorlubricatingsystem,whichpermitsaremarkablyfrictionlessinteractionat
thejointsurfaces.Acartilaginouslubricatedinterfacehasacoefficientoffriction*of0.002.95Bywayof
comparison,iceonicehasahighercoefficientoffriction(0.03).95Thecompositionofsynovialfluidisnearly
thesameasbloodplasma,butwithadecreasedtotalproteincontentandahigherconcentrationofhyaluronan.96
CLINICALPEARL
Hyaluronanisacriticalconstituentcomponentofnormalsynovialfluidandanimportantcontributortojoint
homeostasis.97Hyaluronanimpartsantiinflammatoryandantinociceptivepropertiestonormalsynovialfluid
andcontributestojointlubrication.Italsoisresponsiblefortheviscoelasticpropertiesofsynovialfluid,96and
contributestothelubricationofarticularcartilagesurfaces.
Indeed,synovialfluidisessentiallyadialysateofplasmatowhichhyaluronanhasbeenadded.98Hyaluronanis
aGAGthatiscontinuallysynthesizedandreleasedintothesynovialfluidbyspecializedsynoviocytes.98,99The
mechanicalpropertiesofsynovialfluidpermitittoactasbothacushionandalubricanttothejoint.Diseases
suchasosteoarthritis,affectthethixotropicproperties(thixotropyisthepropertyofvariousgelsbecomingfluid
whendisturbed,asbyshaking)ofsynovialfluid,resultinginreducedlubricationandsubsequentwearofthe
articularcartilageandjointsurfaces.100,101Itiswellestablishedthatdamagedarticularcartilageinadultshasa
verylimitedpotentialforhealing(seeChapter2)becauseitpossessesneitherabloodsupplynorlymphatic
drainage.102
Bursae
Closelyassociatedwithsomesynovialjointsareflattened,saclikestructurescalledbursaethatarelinedwitha
synovialmembraneandfilledwithsynovialfluid.Thebursaproducessmallamountsoffluid,allowingfor
smoothandalmostfrictionlessmotionbetweencontiguousmuscles,tendons,bones,ligaments,andskin.103105
Atendonsheathisamodifiedbursa.Abursacanbeasourceofpainifitbecomesinflamedorinfected.
*Coefficientoffrictionisaratiooftheforceneededtomakeabodyglideacrossasurfacecomparedwiththe
weightorforceholdingthetwosurfacesincontact.
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KINESIOLOGY
Whendescribingmovements,itisnecessarytohaveastartingpositionasthereferenceposition.Thisstarting
positionisreferredtoastheanatomicreferenceposition.Theanatomicreferencepositionforthehumanbodyis
describedastheerectstandingpositionwiththefeetjustslightlyseparatedandthearmshangingbytheside,the
elbowsstraight,andthepalmsofthehandfacingforward(Fig.14).
FIGURE14
Theanatomicalposition.
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DirectionalTerms
Directionaltermsareusedtodescribetherelationshipofbodypartsorthelocationofanexternalobjectwith
respecttothebody.106Thefollowingarecommonlyuseddirectionalterms:
Superiororcranial.Closertothehead.
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Inferiororcaudal.Closertothefeet.
Anteriororventral.Towardthefrontofthebody.
Posteriorordorsal.Towardthebackofthebody.
Medial.Towardthemidlineofthebody.
Lateral.Awayfromthemidlineofthebody.
Proximal.Closertothetrunk.
Distal.Awayfromthetrunk.
Superficial.Towardthesurfaceofthebody.
Deep.Awayfromthesurfaceofthebodyinthedirectionoftheinsideofthebody.
MOVEMENTSOFTHEBODYSEGMENTS
Ingeneral,therearetwotypesofmotions:translation,whichoccursineitherastraightorcurvedline,and
rotation,whichinvolvesacircularmotionaroundapivotpoint.Movementsofthebodysegmentsoccurinthree
dimensionsalongimaginaryplanesandaroundvariousaxesofthebody.
PlanesoftheBody
Therearethreetraditionalplanesofthebodycorrespondingtothethreedimensionsofspace:sagittal,frontal,
andtransverse(Fig.15).
FIGURE15
Planesofthebody.
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Sagittal.Thesagittalplane,alsoknownastheanteriorposteriorormedianplane,dividesthebody
verticallyintoleftandrighthalvesofequalsize.
Frontal.Thefrontalplane,alsoknownasthelateralorcoronalplane,dividesthebodyequallyintofront
andbackhalves.
Transverse.Thetransverseplane,alsoknownasthehorizontalplane,dividesthebodyequallyintotop
andbottomhalves.
Becauseeachoftheseplanesbisectsthebody,itfollowsthateachplanemustpassthroughthecenterofgravity
(COG)orcenterofmass(COM).*Whereagravityfieldcanbeconsideredtobeuniform,theCOGandCOM
arethesame(seelater).Ifthemovementdescribedoccursinaplanethatpassesthroughthecenterofgravity,
thatmovementisdeemedtohaveoccurredinacardinalplane.Anarcofmotionrepresentsthetotalnumberof
degreestracedbetweenthetwoextremepositionsofmovementinaspecificplaneofmotion.107Ifajointhas
morethanoneplaneofmotion,eachtypeofmotionisreferredtoasaunitofmotion.Forexample,thewristhas
twounitsofmotion:flexionextension(anteriorposteriorplane)andulnarradialdeviation(lateralplane).107
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Fewmovementsinvolvedwithfunctionalactivitiesoccurinthecardinalplanes.Instead,mostmovementsoccur
inaninfinitenumberofverticalandhorizontalplanesparalleltothecardinalplanes(seethediscussionthat
follows).
AxesoftheBody
Threereferenceaxesareusedtodescribehumanmotion(Fig.16).Theaxisaroundwhichthemovementtakes
placeisalwaysperpendiculartotheplaneinwhichitoccurs.
FIGURE16
Axesofthebody.
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Mediolateral.Themediolateral(ML)orcoronal,axis,isperpendiculartothesagittalplane.
Vertical.Theverticalorlongitudinalaxisisperpendiculartothefrontalplane.
Anteroposterior(AP).TheAPaxisisperpendiculartothetransverseplane.
Mostmovementsoccurinplanesandaroundaxesthataresomewhereinbetweenthetraditionalplanesand
axes.Thus,nominalidentificationofeveryplaneandaxisofmovementisimpractical.Thestructureofthejoint
determinesthepossibleaxesofmotionthatareavailable.Theaxisofrotationremainsstationaryonlyifthe
convexmemberofajointisaperfectsphereandarticulateswithaperfectreciprocallyshapedconcavemember.
Theplanesandaxesforthemorecommonplanarmovements(Fig.17)areasfollows:
FIGURE17
Movementsofthebody.
Flexion,extension,hyperextension,dorsiflexion,andplantarflexionoccurinthesagittalplanearoundan
MLaxis.Exceptionstothisincludecarpometacarpalflexionandextensionofthethumb.
Abductionandadduction,sideflexionofthetrunk,elevationanddepressionoftheshouldergirdle,radial
andulnardeviationofthewrist,andeversionandinversionofthefootoccurinthefrontalplanearound
anAPaxis.
Rotationofthehead,neck,andtrunkinternalrotationandexternalrotationofthearmorleghorizontal
adductionandabductionofthearmorthighandpronationandsupinationoftheforearmusuallyoccurin
thetransverseplanearoundtheverticalaxis.Rotarymotionsinvolvethecurvedmovementofasegment
aroundafixedaxis,orcenterofrotation(COR).Whenacurvedmovementoccursaroundanaxisthatis
notfixed,butinsteadshiftsinspaceastheobjectmoves,theaxisaroundwhichthesegmentappearsto
moveisreferredtoastheinstantaneousaxisofrotationorinstantaneousCOR(seeMomentArm).
Armcirclingandtrunkcirclingareexamplesofcircumduction.Circumductioninvolvesanorderly
sequenceofcircularmovementsthatoccurinthesagittal,frontal,andintermediateobliqueplanes,sothat
thesegmentasawholeincorporatesacombinationofflexion,extension,abduction,andadduction.
Circumductionmovementscanoccuratbiaxialandtriaxialjoints.Examplesofthesejointsincludethe
tibiofemoral,radiohumeral,hip,glenohumeral,andthespinaljoints.
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Boththeconfigurationofajointandthelineofpullofthemuscleactingatajointdeterminethemotionthat
occursatajoint:
Amusclewhoselineofpullislateraltothejointisapotentialabductor.
Amusclewhoselineofpullismedialtothejointisapotentialadductor.
Amusclewhoselineofpullisanteriortoajointhasthepotentialtoextendorflexthejoint.Attheknee,
ananteriorlineofpullmaycausethekneetoextend,whereas,attheelbowjoint,ananteriorlineofpull
maycauseflexionoftheelbow.
Amusclewhoselineofpullisposteriortothejointhasthepotentialtoextendorflexajoint(referto
precedingexample).
CenterofGravity
EveryobjectorsegmentcanbeconsideredtohaveasingleCOG,orCOMthepointatwhichallthemassof
theobjectorsegmentappearstobeconcentrated.Inasymmetricalobject,theCOGisalwayslocatedinthe
geometriccenteroftheobject.However,inanasymmetricalobjectsuchasthehumanbody,theCOGbecomes
thepointatwhichthelineofgravitybalancestheobject.Thelineofgravitycanbestbevisualizedasastring
withtheweightontheend(aplumbline),withastringattachedtotheCOGofanobject.108Ifthehumanbody
isconsideredasarigidobject,theCOGofthebodyliesapproximatelyanteriortothesecondsacralvertebra
(S2).Sincethehumanbodyisnotrigid,anindividualsCOGcontinuestochangewithmovementwiththe
amountofchangeinthelocationdependingonhowdisproportionatelythesegmentsarerearranged.108During
staticstanding,thebodyslineofgravityisbetweentheindividualsfeet(baseofsupport).TheBOSincludes
thepartofthebodyincontactwiththesupportingsurfaceandtheinterveningarea.109Ifanindividualbends
forwardatthewaist,thelineofgravitymovesoutsideoftheBOS.ThesizeoftheBOSanditsrelationtothe
COGareimportantfactorsinthemaintenanceofbalanceand,thus,thestabilityofanobject.TheCOGmustbe
maintainedovertheBOSifanequilibriumistobemaintained.IftheBOSofanobjectislarge,thelineof
gravityislesslikelytobedisplacedoutsidetheBOS,whichmakestheobjectmorestable.108
DegreesofFreedom
Thenumberofindependentmodesofmotionatajointisreferredtoastheavailabledegreesoffreedom(DOF).
Ajointcanhaveupto3degreesofangularfreedom,correspondingtothethreedimensionsofspace.110Ifa
jointcanswinginonedirectionorcanonlyspin,itissaidtohave1DOF.111114Theproximalinterphalangeal
jointisanexampleofajointwith1DOF.Ifajointcanspinandswinginonewayonly,oritcanswingintwo
completelydistinctways,butnotspin,itissaidtohave2DOF.111114Thetibiofemoraljoint,
temporomandibularjoint,proximalanddistalradioulnarjoints,subtalarjoint,andtalocalcanealjointare
examplesofjointswith2DOF.Ifthebonecanspinandalsoswingintwodistinctdirections,thenitissaidto
have3DOF.111114Ballandsocketjoints,suchastheshoulderandhip,have3DOF.
CLINICALPEARL
Jointmotionthatoccursonlyinoneplaneisdesignatedas1DOFintwoplanes,2DOFandinthreeplanes,3
DOF.
Becauseofthearrangementofthearticulatingsurfacesthesurroundingligamentsandjointcapsulesmost
motionsaroundajointdonotoccurinstraightplanesoralongstraightlines.Instead,thebonesatanyjoint
movethroughspaceincurvedpaths.ThiscanbestbeillustratedusingCodmansparadox.
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1.Standwithyourarmsbyyourside,palmsfacinginward,thumbsextended.Noticethatthethumbis
pointingforward.
2.Flexonearmto90degreesattheshouldersothatthethumbispointingup.
3.Fromthisposition,horizontallyextendyourarmsothatthethumbremainspointingup,butyourarmisin
apositionof90degreesofglenohumeralabduction.
4.Fromthisposition,withoutrotatingyourarm,returnthearmtoyoursideandnotethatyourthumbisnow
pointingawayfromyourthigh.
Referringtothestartposition,andusingthethumbasthereference,thearmhasundergoneanexternalrotation
of90degrees.Butwhereandwhendidtherotationtakeplace?Undoubtedly,itoccurredduringthethree
separate,straightplanemotionsorswingsthatetchedatriangleinspace.Whatyouhavejustwitnessedisan
exampleofaconjunctrotationarotationthatoccursasaresultofjointsurfaceshapesandtheeffectofinert
tissuesratherthancontractiletissues.Conjunctrotationscanonlyoccurinjointsthatcanrotateinternallyor
externally.Althoughnotalwaysapparent,mostjointscansorotate.Considerthemotionsofelbowflexionand
extension.Whilefullyflexingandextendingyourelbowafewtimes,watchthepisiformboneandforearm.If
youwatchcarefully,youshouldnoticethatthepisiformandtheforearmmoveinadirectionofsupination
duringflexion,andpronationduringextensionoftheelbow.Thepronationandsupinationmotionsareexamples
ofconjunctrotations.
Mosthabitualmovements,orthosemovementsthatoccurmostfrequentlyatajointinvolveaconjunctrotation.
However,theconjunctrotationsarenotalwaysundervolitionalcontrol.Infact,theconjunctrotationisonly
undervolitionalcontrolinjointswith3DOF(e.g.,glenohumeralandhipjoints).Injointswithfewerthan3
DOF(hingejoints,suchasthetibiofemoralandulnohumeraljoints),theconjunctrotationoccursaspartofthe
movementbutisnotundervoluntarycontrol.Theimplicationsforthisbecomeimportantwhenattemptingto
restoremotionatthesejoints:themobilizingtechniquesmusttakeintoconsiderationboththerelativeshapesof
thearticulatingsurfacesaswellastheconjunctrotationthatisassociatedwithaparticularmotion(seeChapter
10).
*TheCOG,orCOM,maybedefinedasthepointatwhichthethreeplanesofthebodyintersecteachother.The
lineofgravityisdefinedastheverticallineatwhichthetwoverticalplanesintersecteachotherandisalways
verticallydownwardtowardthecenteroftheearth.
JOINTKINEMATICS
Kinematicsisthestudyofmotionanddescribeshowsomethingismovingwithoutstatingthecause.Kineticsis
thetermusedtoexplainwhyanobjectmovesthewayitdoesduetotheforcesactingonthatobject(seeChapter
2).Instudyingjointkinematics,twomajortypesofmotionareinvolved:(1)osteokinematicand(2)
arthrokinematic.
OsteokinematicMotion
ThenormalROMofajointissometimescalledthephysiologicoranatomicROM.Physiologicmovementsof
thebonestermedosteokinematics,aremovementsthatcanbeperformedvoluntarily,forexample,flexionofthe
shoulder.Osteokinematicmotionoccurswhenanyobjectformstheradiusofanimaginarycircleaboutafixed
point.Theaxisofrotationforosteokinematicmotionsisorientedperpendiculartotheplaneinwhichthe
rotationoccurs.106Thedistancetraveledbythemotionmaybeasmallarcoracompletecircleandismeasured
asanangle,indegrees.Allhumanbodysegmentmotionsinvolveosteokinematicmotions.Examplesof
osteokinematicmotionincludeabductionoradductionofthearm,flexionofthehiporknee,andsidebendingof
thetrunk.Anumberoffactorsdeterminetheamountofavailablephysiologicjointmotion,including
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theintegrityofthejointsurfacesandtheamountofjointmotion
themobilityandpliabilityofthesofttissuesthatsurroundajoint
thedegreeofsofttissueapproximationthatoccurs
theamountofscarringthatispresent115interstitialscarringorfibrosiscanoccurinandaroundthejoint
capsules,withinthemuscles,andwithintheligamentsasaresultofprevioustrauma
agejointmotiontendstodecreasewithincreasingage
genderingeneral,femaleshavemorejointmotionthanmales.
ROMisconsideredtobepathologicalwhenmotionatajointeitherexceedsorfailstoreachthenormal
physiologiclimitsofmotion(seeChapter2).90
MomentArm
Tounderstandtheconceptofamomentarm,anunderstandingoftheanatomyandmovement(kinematics)of
thejointofinterestisnecessary.Althoughmusclesproducelinearforces,motionsatjointsareallrotary.For
example,somejointscanbeconsideredtorotateaboutafixedpoint.Agoodexampleofsuchajointisthe
elbow.Attheelbowjoint,wherethehumerusandulnaarticulate,theresultingrotationoccursprimarilyabouta
fixedpoint,referredtoastheCOR.Inthecaseoftheelbowjoint,thisCORisrelativelyconstantthroughoutthe
jointROM.However,inotherjoints(e.g.,theknee)theCORmovesthroughspaceasthekneejointflexesand
extendsbecausethearticulatingsurfacesarenotperfectcircles.Inthecaseoftheknee,itisnotappropriateto
discussasingleCORratherwemustspeakofaCORcorrespondingtoaparticularjointangle,or,usingthe
terminologyofjointkinematics,wemustspeakoftheinstantaneouscenterofrotation(ICR),thatis,theCORat
anyinstantintimeorspace.Thus,themomentarmisdefinedastheperpendiculardistancefromthelineof
forceapplicationtotheaxisofrotation.
ArthrokinematicMotion
Thetermarthrokinematicsisusedtodescribethemotionsofthebonesurfaceswithinthejoint.These
movementscannotbeperformedvoluntarilyandcanonlyoccurwhenresistancetoactivemotionisapplied,or
whenthepatientsmusclesarecompletelyrelaxed.Boththephysiologic(osteokinematic)andjointplay
(arthrokinematic)motionsoccursimultaneouslyduringmovementandaredirectlyproportionaltoeachother,
withasmallincrementofarthrokinematicmotionresultinginalargerincrementofosteokinematicmotion.
Normalarthrokinematicmotionsmustoccurforafullrangeofphysiologicmotiontooccur.Mennell116,117
introducedtheconceptthatfull,painless,activeROMisnotpossiblewithoutthesemotionsandthatarestriction
ofarthrokinematicmotionresultsinadecreaseinosteokinematicmotion.Ateachsynovialarticulation,the
articulatingsurfaceofeachbonemovesinrelationtotheshapeoftheotherarticulatingsurface.Anormaljoint
hasanavailablerangeofactive,orphysiologic,motion,whichislimitedbyaphysiologicbarrierastension
developswithinthesurroundingtissues,suchasthejointcapsule,ligaments,andCT.Beyondtheavailable
passiveROM,theanatomicbarrierisfound.Thisbarriercannotbeexceededwithoutdisruptiontotheintegrity
ofthejoint.Accessoryorcomponentmotions,whicharealsonotundervoluntarycontroloccurduringactive
motion.Theseincludeexamplessuchasrotationoftheulnaduringforearmpronationandsupination.Atthe
physiologicbarrier,thereisanadditionalamountofpassiveROM.Thissmallmotion,whichisavailableatthe
jointsurfaces,isreferredtoasjointplaymotion.Thetypeandamountofmotionoccurringatthejointsurfaces
isinfluencedbytheshapeoftheirrespectivejointsurfaces.Threefundamentaltypesofjointplaymotionsexist
basedonthedifferenttypesofjointsurfaces(Fig.18):118
FIGURE18
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Arthrokinematicsofmotion.
Roll.Arolloccurswhenthepointsofcontactoneachincongruentjointsurfaceareconstantlychanging
sothatnewpointononesurfacemeetsanewpointontheoppositesurface(seeFig.18).Thistypeof
movementisanalogoustoatireonacarasthecarrollsforward.Inanormalfunctioningjoint,pure
rollingdoesnotoccuralonebutinsteadoccursincombinationwithjointslidingandspinning.Theterm
rockisoftenusedtodescribesmallrollingmotions.Rollingisalwaysinthesamedirectionasthe
swingingbonemotionirrespectiveofwhetherthesurfaceisconvexorconcave(Fig.18).Iftherolling
occursalone,itcausescompressionofthesurfacesonthesidetowhichtheboneisswingingand
separationontheotherside.
Slide.Aslideisapuretranslationifthetwosurfacesarecongruentlyflatorcurved.Itoccursifonlyone
pointonthemovingsurfacemakescontactwithnewpointsontheopposingsurface(seeFig.18).This
typeofmovementisanalogoustoacartireskiddingwhenthebrakesareappliedsuddenlyonawetroad.
Thistypeofmotionalsoisreferredtoastranslatorymotion.Althoughtherollofajointalwaysoccursin
thesamedirectionastheswingofabone,thedirectionoftheslideisdeterminedbytheshapeofthe
articulatingsurface(Fig.19).Thisruleisoftenreferredtoastheconcaveconvexrule:Ifthejointsurface
isconvexrelativetotheothersurface,theslideoccursintheoppositedirectiontotheosteokinematic
motion(seeFig.19).If,ontheotherhand,thejointsurfaceisconcave,theslideoccursinthesame
directionastheosteokinematicmotion(seeFig.19).Theclinicalsignificanceoftheconcaveconvex
ruleisdescribedinChapter10.
Spin.Aspinisdefinedasanymovementinwhichthebonemoves,butthemechanicalaxisremains
stationary.Aspininvolvesarotationofonesurfaceonanopposingsurfacearoundaverticalaxis(seeFig.
18).Thistypeofmotionisanalogoustothepirouetteperformedbyaballetdancer.Spinningrarely
occursaloneinjointsbutinsteadoccursincombinationwithrollingandsliding.Spinmotionsinthebody
includeinternalandexternalrotationoftheglenohumeraljointwhenthehumerusisabductedto90
degreesandattheradialheadduringforearmpronationandsupination.
FIGURE19
Glidingmotionsaccordingtojointsurfaces.
Asosteokinematicandarthrokinematicmotionsaredirectlyproportionaltoeachother,suchthatonecannot
occurcompletelywithouttheother,itfollowsthatifajointisnotfunctioningcorrectly,oneorbothofthese
motionsmaybeatfault.Whenexaminingapatientwithmovementimpairment,itiscriticalthattheclinician
determinewhethertheosteokinematicmotionorthearthrokinematicmotionisrestrictedsothattheintervention
canbemadeasspecificaspossible.Thisisparticularlyimportantwhentryingtoregainmotionusingtraditional
stretchingmethodswhichemployosteokinematicmotions,asthesemethodsmagnifytheforceatthejointand
causecompressionofthejointsurfacesinthedirectionoftherollingbone.Incontrast,usinganarthrokinematic
techniquetoincreasethejointplayallowstheforcetobeappliedclosetothejointsurfaceandinthedirection
thatreplicatestheslidingcomponentofthejointmechanics.
CLINICALPEARL
Twootheraccessorymotionsareusedbycliniciansinvariousmanualtechniques,compressionanddistraction:
Compression.Thisoccurswhenthereisadecreaseinthejointspacebetweenbonypartnersandalthough
itoccursnaturallythroughoutthebodywheneverajointisweightbearing,itcanbeappliedmanuallyto
helpmovesynovialfluidandmaintaincartilagehealth.
Distraction.Thisinvolvesanincreaseinthejointspacebetweenbonypartners.Thetermstractionand
distractionarenotsynonymous,astheformerinvolvesaforceappliedtothelongaxisofabone,which
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doesnotalwaysresultinthejointspaceincreasingbetweenthebonypartners.Forexample,iftractionis
appliedtotheshaftofthefemur,itresultsinaglideoccurringatthehipjointsurface,whereasifa
distractionforceisappliedatrightanglestotheacetabulum,distractionatthehipjointoccurs.
Intheextremities,osteokinematicmotioniscontrolledbytheamountofflexibilityofthesurroundingsoft
tissuesofthejoint,whereflexibilityisdefinedastheamountofinternalresistancetomotion.Incontrast,the
arthrokinematicmotioniscontrolledbytheintegrityofthejointsurfacesandthesupportingtissuesofthejoint.
Thischaracteristiccanbenotedclinicallyinachronicruptureoftheanteriorcruciateligamentoftheknee.
Uponexaminationofthatknee,thearthrokinematicmotion(jointslideorglide)isfoundtobeincreased,
illustratedbyapositiveLachmantest,buttheROMoftheknee,itsosteokinematicmotion,isnotaffected(see
Chapter20).
Incontrast,inthespine,theosteokinematicmotioniscontrolledbyboththeflexibilityofthesurroundingsoft
tissuesandbytheintegrityofthejointsurfacesandthesupportingtissuesofthejoint.Thischaracteristiccanbe
notedclinicallywhenexaminingthecraniovertebraljoint,wherearestrictioninthearthrokinematicmotion
(jointslideorglide)canbecausedbyeitherajointrestrictionoranadaptivelyshortenedsuboccipitalmuscle
(seeChapter23).
TheexaminationofthesemotionsandtheirclinicalimplicationsaredescribedinChapters4and10.
Levers
Aleverisarigidobjectthatisusedtoeithermultiplythemechanicalforce(effort)orresistanceforce(load)
appliedtoitaroundanaxis.Theeffortforceattemptstocausemovementoftheload.Forsimplicitysake,levers
areusuallydescribedusingastraightbarthatisthelever,andthefulcrum,whichisthepointonwhichthebaris
resting,andaroundwhichtheleverrotates.Thatpartoftheleverbetweenthefulcrumandtheloadisreferredto
astheloadarm.Threetypesofleversarecommonlycited:
Firstclass:occurswhentwoforcesareappliedoneithersideoftheaxis,andthefulcrumliesbetweenthe
effortandtheload(Fig.110),likeaseesaw.Examplesinthehumanbodyincludethecontractionofthe
tricepsattheelbowjoint,ortippingoftheheadforwardandbackward.
Secondclass:occurswhentheload(resistance)isappliedbetweenthefulcrumandthepointwherethe
effortisexerted(Fig.110).Themagnifyingeffectsoftheeffortrequirelessforcetomovetheresistance.
Examplesofsecondclassleversineverydaylifeincludethenutcracker,andthewheelbarrowwiththe
wheelactingasthefulcrum.Examplesofsecondclassleversinthehumanbodyincludeweightbearing
plantarflexion(risinguponthetoes)(Fig.110).Anotherwouldbeanisolatedcontractionofthe
brachioradialistoflextheelbow,whichcouldonlyoccuriftheotherelbowflexorsareparalyzed.
Thirdclass:occurswhentheloadislocatedattheendofthelever(Fig.110),andtheeffortliesbetween
thefulcrumandtheload,likeadrawbridgeoracrane.Theeffortisexertedbetweentheloadandthe
fulcrum.Theeffortexpendedisgreaterthantheload,buttheloadismovedagreaterdistance.Most
movablejointsinthehumanbodyfunctionasthirdclassleversflexionattheelbow.
FIGURE110
Classesoflevers.
Whenamachineputsoutmoreforcethanisputin,themachineissaidtohaveamechanicaladvantage(MA).
TheMAofthemusculoskeletalleverisdefinedastheratiooftheinternalmomentarmtotheexternalmoment
arm.Dependingonthelocationoftheaxisofrotation,thefirstclasslevercanhaveanMAequalto,lessthan,or
greaterthan1.110SecondclassleversalwayshaveanMAgreaterthan1.ThirdclassleversalwayshaveanMA
lessthan1.ThemajorityofmusclesthroughoutthemusculoskeletalsystemfunctionwithanMAofmuchless
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than1.Therefore,themusclesandunderlyingjointsmustpaythepricebygeneratinganddispersingrelative
largeforces,respectively,evenforseeminglylowloadactivities.110
KINEMATICCHAINS
Whenabodymoves,itdoessobyitskinematics,whichinthehumanbodytakeplacethrougharthrokinematic
andosteokinematicmovements.Theexpressionkinematicchainisusedinrehabilitationtodescribethefunction
oractivityofanextremityortrunkintermsofaseriesoflinkedchains(seeChapter12).Akinematicchain
referstoaseriesofarticulated,segmentedlinks,suchastheconnectedpelvis,thigh,leg,andfootofthelower
extremity.110Accordingtokinematicchaintheory,eachofthejointsegmentsofthebodyinvolvedina
particularmovementconstitutesalinkinthekinematicchain.Becauseeachmotionofajointisoftenafunction
ofotherjointmotions,theefficiencyofanactivitycanbedependentonhowwellthesechainlinkswork
together.119
CLINICALPEARL
Thenumberoflinkswithinaparticularkinematicchainvaries,dependingontheactivity.Ingeneral,longer
kinematicchainsareinvolvedwithmorestrenuousactivities.
Twotypesofkinematicchainsystemsarerecognized:closedkinematicchain(CKC)systemsandtheopen
kinematicchain(OKC)systems(Table15).120
TABLE15DifferentialFeaturesofOKCandCKCExercises
Exercise
Characteristics Advantages Disadvantages
Mode
1.Singlemusclegroup 1.Isolatedrecruitment 1.Limitedfunction
2.Singleaxisandplane 2.Simplemovement 2.Limitedeccentrics
Open
kinematic 3.Emphasizesconcentric pattern
3.Lessproprioceptionandjoint
chain contraction 3.Minimaljoint stabilitywithincreasedjointshear
4.Nonweightbearing compression forces
1.Multiplemuscle 1.Functional
groups recruitment
1.Difficulttoisolate
2.Multipleaxesand 2.Functional
planes movementpatterns 2.Morecomplex
Closed
3.Balanceofconcentric 3.Functional 3.Lossofcontroloftargetjoint
kinematic
andeccentric contractions
contractions 4.Compressiveforcesonarticular
4.Increased surfaces
4.Weightbearing proprioceptionand
exercise jointstability
DatafromGreenfieldBH,TovinBJ.Theapplicationofopenandclosedkinematicchainexercisesin
rehabilitationofthelowerextremity.JBackMusculoskelRehabil.19922:3851.
ClosedKinematicChain
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AvarietyofdefinitionsforaCKCactivityhavebeenproposed:
1.Palmitieretal.121defineanactivityasclosedifbothendsofthekineticchainareconnectedtoan
immovableframework,thuspreventingtranslationofeithertheproximal,ordistaljointcenter,and
creatingasituationwherebymovementatonejointproducesapredictablemovementatallotherjoints.
2.Gray122considersaclosedchainactivitytoinvolvefixationofthedistalsegmentsothatjointmotion
takesplaceinmultipleplanes,andthelimbissupportingtheweight.
3.Dillmanetal.123describethecharacteristicsofclosedchainactivitiestoincluderelativelysmalljoint
movements,lowjointaccelerations,greaterjointcompressiveforces,greaterjointcongruity,decreased
shear,stimulationofjointproprioception,andenhanceddynamicstabilizationthroughmuscle
coactivation.124
4.Kibler124definesaclosedchainactivityasasequentialcombinationofjointmotionsthathavethe
followingcharacteristics:
a.Thedistalsegmentofthekineticchainmeetsconsiderableresistance.
b.Themovementoftheindividualjoints,andtranslationoftheirinstantcentersofrotationoccursina
predictablemannerthatissecondarytothedistributionofforcesfromeachendofthechain.
Examplesofclosedkinematicchainexercises(CKCEs)involvingthelowerextremitiesincludethesquatand
thelegpress.Theactivitiesofwalking,running,jumping,climbing,andrisingfromthefloorallincorporate
closedkineticchaincomponents.AnexampleofaCKCEfortheupperextremitiesisthepushup,orwhen
usingthearmstopushdownonthearmreststoriseoutofachair.
CLINICALPEARL
Inmostactivitiesofdailyliving,theactivationsequenceofthelinksinvolvesaclosedchainwherebythe
activityisinitiatedfromafirmbaseofsupportandtransferredtoamoremobiledistalsegment.
OpenKinematicChain
ItisacceptedthatthedifferencebetweenOKCandCKCactivitiesisdeterminedbythemovementoftheend
segment.Thetraditionaldefinitionforanopenchainactivityincludedallactivitiesthatinvolvedtheend
segmentofanextremitymovingfreelythroughspace,resultinginisolatedmovementofajoint.
Examplesofanopenchainactivityincludeliftingadrinkingglassandkickingasoccerball.Openkinematic
chainexercises(OKCEs)involvingthelowerextremityincludetheseatedkneeextensionandproneknee
flexion.UpperextremityexamplesofOKCEincludethebicepscurlandthemilitarypress.
Manyactivities,suchasswimmingandcycling,traditionallyviewedasOKCactivities,includealoadonthe
endsegmentyettheendsegmentisnotfixedandrestrictedfrommovement.Thisambiguityofdefinitionsfor
CKCandOKCactivitieshasallowedsomeactivitiestobeclassifiedinopposingcategories.123Thus,therehas
beenagrowingneedforclarificationofOKCandCKCterminology,especiallywhenrelatedtofunctional
activities.
TheworksofDillmanetal.123andthenLephartandHenry125haveattemptedtoaddresstheconfusion.
Dillmanetal.123proposedthreeclassificationsofactivitytohelpclarifythegrayareabetweentheCKCandthe
OKCactivity.Theseclassificationswerebasedontheboundarycondition,eithermovableorfixed,andthe
presenceorabsenceofaloadontheendsegment.Anactivitywithafixedboundaryandnoloaddoesnotexist,
resultinginthreeclassifications:
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1.Movablenoload.Theseactivitiesinvolveamovableendwithnoloadandcloselyresembletheextreme
ofanopenchainactivity.Anexampleofthistypeofactivityishittingaballwithatennisracket.
2.Movableexternalload.Theseactivitiesinvolveamovableendwithanexternalloadandincludea
combinationofopenandclosedchainactionsbecausetheyarecharacterizedbycocontractionsofthe
musclesaroundthejoints.Anexampleofthistypeofactivityistheoverheadshoulder(military)press.
3.Fixedexternalload.Theseactivitiesinvolveafixedendwithanexternalload,andcloselyresemblethe
extremeofaclosedchainactivity.Anexampleofthistypeofactivityisthepushup.
LephartandHenrysuggestedthatafurtherdefinitioncouldbemadebyanalyzingthefollowingcharacteristics
ofanactivity:
Thedirectionofforce.
Themagnitudeoftheload.
Muscleaction.
Jointmotion.
Neuromuscularfunction.
UnderLephartandHenrysclassification,activitiescouldbesubdividedintofourgroups:
1.Activitiesthatinvolveafixedboundarywithanexternalandaxialload.Anexampleofthistypeof
activityistheuseofaslideboard.
2.Activitiesthatinvolveamovableboundarywithanexternalandaxialload.Anexampleofthistypeof
activityisthebenchpress.
3.Activitiesthatinvolveamovableboundarywithanexternalandrotaryload.Anexampleofthistypeof
activityisaresistedproprioceptiveneuromuscularfacilitation(PNF)motionpattern(seeChapter10).
4.Activitiesthatinvolveamovableboundarywithnoload.Anexampleofthistypeofactivityisposition
training.
AlthoughboththeDillmanandLephartandHenrymodelsappeartobedescribingthesameconcept,the
LephartandHenrymodelisdistinctinthatitincorporatesdiagonalorrotarycomponentstothemovements.
Thesediagonalandrotarymovementsfeatureinthevastmajorityoffunctionalactivities.
CLOSEPACKEDANDOPENPACKEDPOSITIONSOFTHE
JOINT
Jointmovementsusuallyareaccompaniedbyarelativecompression(approximation)ordistraction(separation)
oftheopposingjointsurfaces.Theserelativecompressionsordistractionsaffectthelevelofcongruityofthe
opposingsurfaces.Thepositionofmaximumcongruityoftheopposingjointsurfacesistermedtheclosepacked
positionofthejoint.Thepositionofleastcongruityistermedtheopenpackedposition.Thus,movements
towardtheclosepackedpositionofajointinvolveanelementofcompression,whereasmovementsoutofthis
positioninvolveanelementofdistraction.
ClosePackedPosition
Theclosepackedpositionofajointisthejointpositionthatresultsin:
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Themaximaltautnessofthemajorligaments.
Maximalsurfacecongruity.
Minimaljointvolume.
Maximalstabilityofthejoint.
Oncetheclosepackedpositionisachieved,nofurthermotioninthatdirectionispossible.Thisistheoftencited
reasonmostfracturesanddislocationsoccurwhenanexternalforceisappliedtoajointthatisinitsclose
packedposition.Also,manyofthetraumaticinjuriesoftheupperextremitiesresultfromfallingonashoulder,
elboworwrist,whichareintheirclosepackedposition.Thistypeofinjury,afallonanoutstretchedhandis
oftenreferredtoasaFOOSHinjury.TheclosepackedpositionsforthevariousjointsaredepictedinTable16.
TABLE16ClosePackedPositionoftheJoints
Joint Position
Zygapophyseal(spine) Extension
Temporomandibular Teethclenched
Glenohumeral Abductionandexternalrotation
Acromioclavicular Armabductedto90degrees
Sternoclavicular Maximumshoulderelevation
Ulnohumeral Extension
Radiohumeral Elbowflexed90degreesforearmsupinated5degrees
Proximalradioulnar 5degreesofsupination
Distalradioulnar 5degreesofsupination
Radiocarpal(wrist) Extensionwithradialdeviation
Metacarpophalangeal Fullflexion
Carpometacarpal Fullopposition
Interphalangeal Fullextension
Hip Fullextension,internalrotation,andabduction
Tibiofemoral Fullextensionandexternalrotationoftibia
Talocrural(ankle) Maximumdorsiflexion
Subtalar Supination
Midtarsal Supination
Tarsometatarsal Supination
Metatarsophalangeal Fullextension
Interphalangeal Fullextension
OpenPackedPosition
Inessence,anypositionofthejoint,otherthantheclosepackedposition,couldbeconsideredasanopen
packedposition.Theopenpackedposition,alsoreferredtoastheloosepackedpositionofajoint,isthejoint
positionthatresultsin:
Slackeningofthemajorligamentsofthejoint.
Minimalsurfacecongruity.
Minimaljointsurfacecontact.
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Maximaljointvolume.
Minimalstabilityofthejoint.
Theopenpackedpositionpermitsmaximaldistractionofthejointsurfaces.Becausetheopenpackedposition
causesthebruntofanyexternalforcetobebornebythejointcapsuleorsurroundingligaments,mostcapsular
orligamentoussprainsoccurwhenajointisinitsopenpackedposition.Theopenpackedpositionsforthe
variousjointsaredepictedinTable17.
TABLE17OpenPacked(Resting)PositionoftheJoints
Joint Position
Zygapophyseal
Midwaybetweenflexionandextension
(spine)
Temporomandibular Mouthslightlyopen(freewayspace)
Glenohumeral 55degreesofabduction30degreesofhorizontaladduction
Acromioclavicular Armrestingbyside
Sternoclavicular Armrestingbyside
Ulnohumeral 70degreesofflexion10degreesofsupination
Radiohumeral Fullextensionfullsupination
Proximalradioulnar 70degreesofflexion35degreesofsupination
Distalradioulnar 10degreesofsupination
Radiocarpal(wrist) Neutralwithslightulnardeviation
Carpometacarpal Midwaybetweenabductionadductionandflexionextension
Metacarpophalangeal Slightflexion
Interphalangeal Slightflexion
1030degreesofflexion1030degreesofabductionand05degreesofexternal
Hip
rotation
Tibiofemoral 25degreesofflexion
Talocrural(ankle) 10degreesofplantarflexionmidwaybetweenmaximuminversionandeversion
Subtalar Midwaybetweenextremesofrangeofmovement
Midtarsal Midwaybetweenextremesofrangeofmovement
Tarsometatarsal Midwaybetweenextremesofrangeofmovement
Metatarsophalangeal Neutral
Interphalangeal Slightflexion
CLINICALPEARL
Theopenpackedpositioniscommonlyusedduringjointmobilizationtechniques(seeChapter10).
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undefined
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Silverchair
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CHAPTER2:TissueBehavior,Injury,Healing,and
Treatment
CHAPTEROBJECTIVES
1.Describethevarioustypesofstressthatareappliedtothebody.
2.Describethevariousphysiologicalprocessesbywhichthebodyadaptstostress.
3.Definethevariouscommonmechanismsofinjury.
4.Describetheetiologyandpathophysiologyofmusculoskeletalinjuriesassociatedwithvarioustypesof
bodytissue.
5.Outlinethepathophysiologyofthehealingprocessandthevariousstagesofhealingofthevarious
connectivetissues.
6.Describethefactorsthatcanimpedethehealingprocess.
7.Outlinethemorecommonsurgicalproceduresavailableformusculoskeletalinjuries.
8.Outlinetheprinciplesbehindpostsurgicalrehabilitation.
9.Describethedetrimentaleffectsofimmobilization.
OVERVIEW
Tissuesinthebodyaredesignedtofunctionwhileundergoingthestressesofeverydayliving.Bodyweight,
friction,andairorwaterresistancearealltypesofstressesthatcommonlyactonthebody.Theabilityofthe
tissuestorespondtostressisduetothedifferingviscoelasticpropertiesofthetissue,witheachtissue
respondingtostressinanindividualmannerbasedondesign.Maintainingthehealthofthevarioustissuesisa
delicatebalancebecauseinsufficient,excessive,orrepetitivestressescanprovedeleterious.Fortunately,most
tissueshaveaninherentabilitytoselfhealaprocessthatisanintricatephenomenon.
THERESPONSEOFTISSUETOSTRESS
Kineticsisthetermappliedtodefinetheforcesactingonthebody.Postureandmovementarebothgovernedby
thebodysabilitytocontroltheseforces.Thesameforcesthatmoveandstabilizethebodyalsohavethe
potentialtodeformandinjurethebody.1Awiderangeofexternalandinternalforcesareeithergeneratedor
resistedbythehumanbodyduringdailyactivities.Examplesoftheseexternalforcesincludegroundreaction
force,gravity,andappliedforcethroughcontact.Examplesofinternalforcesincludestructuraltension,joint
compression,andjointshearforces(Fig.21).Undertherightcircumstances,thebodycanrespondandadaptto
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thesestresses.Thetermsstressandstrainhavespecificmechanicalmeanings.Stress,orload,isdefinedinunits
offorceperarea,andisusedtodescribethetypeofforceapplied.Stressisindependentoftheamountof
material,butisdirectlyrelatedtothemagnitudeofforceandinverselyrelatedtotheunitarea.2Strainisdefined
asthechangeinlengthofamaterialduetoanimposedload,dividedbytheoriginallength.2Thetwobasic
typesofstrainarealinearstrain,whichcausesachangeinthelengthofastructure,andshearstrain,which
causesachangeintheangularrelationshipswithinastructure.Itistheconcentrationofproteoglycansin
solution(seeChapter1)thatisresponsibleforinfluencingthemechanicalpropertiesofthetissue,including
compressivestiffness,sheerstiffness,osmoticpressure,andtheregulationofhydration.3
FIGURE21
Internalforcesactingonthebody.
CLINICALPEARL
Strainistheamountofelongationdividedbythelengthofthestructure.
Stressistheforceinastructuredividedbythecrosssectionalarea.
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Theinherentabilityofatissuetotolerateloadcanbeobservedexperimentallyingraphicform.Whenanystress
isplottedonagraphagainsttheresultingstrainforagivenmaterial,theshapeoftheresultingloaddeformation
curvedependsonthekindofmaterialinvolved.Theloaddeformationcurve,orstressstraincurve,ofa
structure(Fig.22)depictstherelationshipbetweentheamountofforceappliedtoastructureandthestructures
responseintermsofdeformationoracceleration.Thehorizontalaxis(deformationorstrain)representstheratio
ofthetissuesdeformedlengthtoitsoriginallength.Theverticalaxisofthegraph(loadorstress)denotesthe
internalresistancegeneratedasatissueresistsitsdeformation,dividedbyitscrosssectionalarea.Theload
deformationcurvecanbedividedintofourregions,eachregionrepresentingabiomechanicalpropertyofthe
tissue(Fig.22):
FIGURE22
Thestressstraincurve.
Toeregion.Collagenfibershaveawavy,orfolded,appearanceatrestoronslack.Whenaforcethat
lengthensthecollagenfibersisinitiallyappliedtoconnectivetissue,thisslackrangeisaffectedfirst,and
thefibersunfoldastheslackistakenup(seeCrimplater).Thetoeregionisanartifactcausedbythis
takeupofslack,alignment,and/orseatingofthetestspecimen.Thelengthofthetoeregiondependson
thetypeofmaterialandthewavinessofthecollagenpattern.
Elasticregion.Withintheelasticdeformationregion,thestructureimitatesaspringthegeometric
deformationinthestructureincreaseslinearlywithincreasingload,andaftertheloadisreleasedthe
structurereturnstoitsoriginalshape.Theslopeoftheelasticregionoftheloaddeformationcurvefrom
onepointinthecurvetoanother,whichcorrespondstothephysiologicalrangeofastructure,iscalledthe
modulusofelasticityorYoungsmodulus,andrepresentstheextrinsicstiffnessorrigidityofthestructure
thestifferthetissue,thesteepertheslope.Akeycharacteristicofpassivetendonloadingisitsstiffness
theforceinthetendondividedbytheamountoflengtheningofthetendon.4Youngsmodulusisa
numericaldescriptionoftherelationshipbetweentheamountofstressatissueundergoesandthe
deformationthatresultsstressdividedbythestrain.Theratioofstresstostraininanelasticmaterialisa
measureofitsstiffness.Youngsmodulusisindependentofspecimensizeandis,therefore,ameasureof
theintrinsicstiffnessofthematerial.ThegreatertheYoungsmodulusforamaterial,thebetteritcan
withstandgreaterforces.Mathematically,thevalueforstiffnessisfoundbydividingtheloadbythe
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deformationatanypointintheselectedrange.Allnormaltissueswithinthemusculoskeletalsystem
exhibitsomedegreeofstiffness.Largerstructureswillhavegreaterrigiditythansmallerstructuresof
similarcomposition.Stiffnessisnotnecessarilyanegativecharacteristictendonstransmitforcemore
effectivelyandefficientlywhentheyarestiffer.4
Plasticregion.Theendoftheelasticdeformationrange,andthebeginningoftheplasticdeformation
range,representsthepointwhereanincreasinglevelofstressonthetissueresultsinprogressivefailure
andmicroscopictearingofthecollagenfibers.Furtherincreasesinstrainresultinmicroscopicdamage
andpermanentdeformation.Thepermanentchangeresultsfromthebreakingofbondsandtheir
subsequentinabilitytocontributetotherecoveryofthetissue.Unliketheelasticregion,removalofthe
loadinthisregionwillnotresultinareturnofthetissuetoitsoriginallength.
Failureregion.Deformationsexceedingtheultimatefailurepoint(Fig.22)producemechanicalfailureof
thestructure,whichinthehumanbodymayberepresentedbythefracturingofboneortherupturingofa
softtissue.
CLINICALPEARL
Stiffness=force/deformation.Thegradientinthelinearportionoftheloaddeformationgraphimmediatelyafter
thetoeregionoftheloaddisplacementcurverepresentsthestiffnessvalue.Theloaddeformationcurvedoes
notindicatethevariableoftime.
Elasticmodulus=stress/strain.ThelargertheYoungsmodulusforamaterial,thegreaterstressneededfora
givenstrain.
Biologicaltissuesareanisotropic,whichmeanstheycandemonstratedifferingmechanicalbehaviorasa
functionoftestdirection.Thepropertiesofextensibilityandelasticityarecommontomanybiologictissues.
Extensibilityistheabilitytobestretched,andelasticityistheabilitytoreturntonormallengthafterlengthening
orshortening.5
CLINICALPEARL
Unloadingatendonsignificantlyinfluencesthemechanicalproperties.Forexample,onestudythatlookedatthe
effectsof4weeksofunilaterallowerlimbsuspensionfollowedby6weeksofrehabilitationfoundthatthere
wasa17%decreaseintheelasticmodulus(lowerstiffness)aftersuspension,andtherestorationofnormal
stiffnessafterrehabilitation.6
Someprotectivemechanismsexistinconnectivetissuetohelprespondtostressandstrain,includingcrimp,
viscoelasticity,creepandstressrelaxation,plasticdeformation,andstressresponse.
CLINICALPEARL
Protectivetissuemechanismsinclude:
Crimp
Viscoelasticity
Creepandstressrelaxation
Plasticdeformation
Stressresponse
Crimp
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Thecrimpofcollagenisoneofthemajorfactorsbehindtheviscoelasticpropertiesofconnectivetissue.Crimp,
acollagentissuesfirstlineofresponsetostress,isdifferentforeachtypeofconnectivetissue,providingeach
withdifferentviscoelasticproperties.Collagenfibersareorientedobliquelywhenrelaxed.However,whena
loadisapplied,thefiberslineupinthedirectionoftheappliedforceastheyuncrimp.Crimpingisseen
primarilyinligaments,tendons,andjointcapsules,andoccursinthetoephaseofthestressstraincurve(Fig.2
2).
CLINICALPEARL
Ifaloadisappliedtotheconnectivetissueandthenremovedimmediately,thematerialrecoilstoitsoriginal
size.If,however,theloadisallowedtoremain,thematerialcontinuestostretch.Afteraperiodofasustained
stretch,thestretchingtendstoreachasteadystatevalue.Realignmentofthecollagenfibersinthedirectionof
thestressoccurs,andwaterandproteoglycansaredisplacedfromthefibers.
Viscoelasticity
Viscoelasticityisthetimedependentmechanicalpropertyofamaterialtostretchorcompressovertime,andto
returntoitsoriginalshapewhenaforceisremoved.Themechanicalqualitiesofatissuecanbeseparatedinto
categoriesbasedonwhetherthetissueactsprimarilyasasolid,fluid,oramixtureofthetwo.Solidsare
describedaccordingtotheirelasticity,strength,hardness,andstiffness.Bone,ligaments,tendons,andskeletal
muscleareallexamplesofelasticsolids.Biologicaltissuesthatdemonstrateattributesofbothsolidsandfluids
areviscoelastic.Theviscoelasticpropertiesofastructuredetermineitsresponsetoloading.Forexample,a
ligamentdemonstratesmoreviscousbehavioratlowerloadswhereas,athigherloads,elasticbehaviors
dominate.7
CreepandStressRelaxation
Creepandstressrelaxationaretwocharacteristicsofviscoelasticmaterialsthatareusedtodocumenttheir
behaviorquantitatively.5
Creepisthegradualrearrangementofcollagenfibers,proteoglycans,andwaterthatoccursbecauseofa
constantlyappliedforceaftertheinitiallengtheningcausedbycrimphasceased.Creepisatimedependentand
transientbiomechanicalphenomenon.Shortdurationstresses(<15minutes)donothavesufficienttimeto
producethisdisplacementhowever,longertimescanproduceit.Oncecreepoccurs,thetissuehasdifficulty
returningtoitsinitiallength(seebelow).
Stressrelaxationisaphenomenoninwhichstressorforceinadeformedstructuredecreaseswithtimewhilethe
deformationisheldconstant.5Unlikecreep,stressrelaxationrespondswithahighinitialstressthatdecreases
overtimeuntilequilibriumisreachedandthestressequalszero,hencethelabelrelaxation.Asaresult,no
changeinlengthisproduced.
Thus,stresstoconnectivetissuescanresultinnochange,asemipermanentchange,orapermanentchangetothe
microstructureofthecollagenoustissue.Thesemipermanentorpermanentchangesmayresultineither
microfailure.
PlasticDeformation
Plasticdeformationofconnectivetissueoccurswhenatissueremainsdeformedanddoesnotrecoverits
prestresslength.Onceallofthepossiblerealignmenthasoccurred,anyfurtherloadingbreakstherestraining
bonds,resultinginmicrofailure.Onaverage,collagenfiberscansustaina3%increaseinelongation(strain)
beforemicroscopicdamageoccurs.8Followingabriefstretch,providingthechemicalbondsremainintact,the
collagenandproteoglycansgraduallyrecovertheiroriginalalignment.Therecoveryprocessoccursataslower
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rateandoftentoalesserextent.Thelossofenergythatoccursbetweenthelengtheningforceandtherecovery
activityisreferredtoashysteresis.Themorechemicalbondsthatarebrokenwithappliedstress,thegreaterthe
hysteresis.Ifthestretchisofsufficientforceandduration,andasufficientnumberofchemicalbondsare
broken,thetissueisunabletoreturntoitsoriginallengthuntilthebondsarereformed.Instead,itreturnstoa
newlengthandanewlevelofstrainresistance.Increasedtissueexcursionisnowneededbeforetension
developsinthestructure.Inessence,thishastheeffectofdecreasingthestabilizingcapabilitiesofthe
connectivetissue.
StressResponse
Exercisesmaybeusedtochangethephysicalpropertiesofbothmuscles/tendonsandligaments,asbothhave
demonstratedadaptabilitytoexternalloadswithanincreaseinstrength:weightratios.911Theimproved
strengthresultsfromanincreaseintheproteoglycancontentandcollagencrosslinks.911
CLINICALPEARL
Threebiomechanicalattributesofconnectivetissuecanhaveclinicalsignificance:
Structuralbehavior
Materialbehavior
Viscoelasticbehavior
TISSUEINJURY
Softtissueinjuriesofalltypesareextremelycommoninthegeneralpopulation.Studieshaveshownthatthereis
alinearrelationshipbetweensofttissueinjuriesandaging,withfewerthan10%ofindividualsyoungerthan34
yearsbeingaffected,incontrastto3249%ofthoseolderthan75yearsbeingaffected.12Whetherastress
provestobebeneficialordetrimentaltoatissueisverymuchdependentonthephysiologiccapacityofthe
tissuetoacceptload.Thiscapacityisdependentonsomefactors,amongthem:
Thehealthofthetissue.Healthytissuescanresistchangesintheirshape.Anytissueweakenedby
diseaseortraumamaynotbeabletoresistadequatelytheapplicationofforce.
Age.Increasingagereducesthecapacityofthetissuestocopewithstressloading.
Proteoglycanandcollagencontentofthetissue.Bothincreasingageandexposuretotraumacanresultin
unfavorablealterationsintheproteoglycanandcollagencontentofatissue.
Theabilityofthetissuetoundergoadaptivechange.Allmusculoskeletaltissuecanadapttochange.
Thiscapacitytochangeisdeterminedprimarilybytheviscoelasticpropertyofthetissue.
Thespeedatwhichtheadaptivechangeoccurs.Thisisdependentonthetypeandseverityoftheinsult
tothetissue.Insultsoflowforceandlongerdurationmayprovidethetissueanopportunitytoadapt.In
contrast,insultsofahigherforceandshorterdurationarelesslikelytoprovidethetissuetimetoadapt.
Thedistinctionbetweensuddenandrepetitivestressisimportant.Anacutestress(loading)occurswhena
singleforceislargeenoughtocauseinjuryonbiologicaltissuesthecausativeforceistermed
macrotrauma.Arepetitivestress(loading)occurswhenasingleforceitselfisinsufficienttocauseinjury
onbiologicaltissues.However,whenrepeatedorchronicstressoveraperiodcausesaninjury,theinjury
iscalledachronicinjury,andthecausativemechanismistermedmicrotrauma.Etiologicfactorsfor
microtraumaticinjuriesareoftwobasictypes:intrinsicorextrinsic.Intrinsicfactorsarephysical
characteristicsthatpredisposeanindividualtomicrotraumainjuriesandincludemuscleimbalances,leg
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lengthdiscrepancies,andanatomicalanomalies.13Extrinsicfactors,whicharethemostcommoncauseof
microtraumainjuries,arerelatedtotheexternalconditionsunderwhichtheactivityisperformed.These
includetrainingerrors,typeofterrain,environmentaltemperature,andincorrectuseofequipment.13
INJURYCLASSIFICATION
Injuriestothesofttissuescanbeclassifiedasprimaryorsecondary.
Primary,ormacrotraumatic,injuriescanbeselfinflicted,causedbyanotherindividualorentity,orcaused
bytheenvironment.1417Theseinjuriesincludefractures,subluxations,anddislocations,whichare
outsidethescopeofpracticeforaphysicaltherapist,andsprains,andstrains,whichmakeupthemajority
ofconditionsseeninthephysicaltherapyclinic.Forthepurposesoftheintervention,primaryinjuriesare
classifiedintoacute,subacute,orchronic.
Acute.Thistypeofinjuryisusuallycausedbymacrotraumaandindicatestheearlyphaseofinjuryand
healing,whichtypicallylastsapproximately46daysunlesstheinsultisperpetuated.
Subacute.Thisphaseoccursaftertheacutephaseandtypicallylastsfrom10to17daysaftertheacute
phasehasendedbutmaylastweeksinthosetissueswithlimitedcirculation,suchastendons.18
Chronic.Thistypeofinjurycanhaveseveraldefinitions.Ontheonehanditmayindicatethefinalstage
ofhealingthatoccurs2634daysafterinjurybutcanlast6monthsto1yeardependingonthetissue
involvedandtheamountoftissuedamage.Onoccasion,apersistentinflammatorystateresultsinan
accumulationofrepetitivescaradhesions,degenerativechanges,andotherharmfuleffectsreferredtoas
subclinicaladaptations(seeChapter8).
CLINICALPEARL
Anacuteonchronicinjuryinvolvesareinjuryofthetissueanacuteexacerbationofachronicinjury.
Secondaryormicrotraumaticinjuriesareessentiallytheinflammatoryresponsethatoccurswiththe
primaryinjury.19Microtraumaticinjuriesincludetendinopathy,tenosynovitis,andbursitis.
TISSUEHEALING
Fortunately,themajorityoftissueinjurieshealwithoutcomplicationinapredictableseriesofevents(Fig.23).
Themostimportantfactorregulatingtheregionaltimelineofhealingissufficientbloodflow.20Manyfactors
candeterminetheoutcomeofthetissueinjury,includingthoselistedinTable21.Also,complicationssuchas
infection,compromisedcirculation,andneuropathyhurtthehealingprocessandcancausegreatphysicaland
psychologicalstresstotheinvolvedpatientandhisorherfamily.
FIGURE23
Stagesofhealing.
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TABLE21FactorsImpactingHealing
Intrinsic(Local) Systemic Extrinsic
Extentofinjury.Microtears
Drugs.Nonsteroidalantiinflammatory
involveonlyminordamage,
Age.Theabilitytohealinjuries drugsandcorticosteroidsdecrease
whereasmacrotearsinvolve
decreaseswithage inflammationandswelling,resultingin
significantlygreater
decreasedpain
destruction
Edema.Swellingcancause
Absorbentdressings.Thedegreeof
increasedpressurethatcan
humiditygreatlyaffectstheprocessof
impedenutritiontothe Obesity.Oxygenpressureinthetissues
epithelializationtheepithelium
injuredpart,inhibit islowerinobesepatients.
regeneratestwiceasquicklyinamoist
neuromuscularcontrol,and
environment
retardthehealingprocess
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Intrinsic(Local) Systemic Extrinsic

Malnutrition.Woundhealingplacesa
higherthanusualdemandona
Hemorrhage.Bleeding patientsenergyresources.Inevery Temperatureandoxygentension.
producesthesamenegative stageofwoundhealing,proteinis Hypothermiahasanegativeeffecton
effectsonhealingasdoes needed.Inaddition,adequate healing.Oxygentensionrelatestothe
theaccumulationofedema nutritionalintakeandbodystoresofall neovascularizationofthewound.
vitaminsareessential.
Poorvascularsupply.
Hormonelevels.Hormonesaffectthe
Woundshealpoorlyandata
compositionandstructureofavariety
slowerratewhentheblood
oftissues.
supplyisinadequate
Separationoftissue.A
Physicalmodalities.Thesecanbeusedto
woundthathassmooth
promoteanefficienthealingenvironment
edgesandgoodapposition
Infection.Infectioncandelayhealing foraninjurywhenusedindividually,orin
willtendtohealbyprimary
combinationwithothermodalitiesor
intentionwithminimal
exercise
scarring.
Exercise.Exercisecanhelpinthe
remodelingprocessofallconnective
Musclespasm.Spasm Generalhealth.Comorbiditycanplaya
tissues.Wolffslawstatesthattissue
causestractiononthe significantroleintheoverallhealing
remodelingandtheresponseto
alreadytorntissue, process.Forexample,diabetescan
therapeuticexercisearedeterminedbythe
preventingapproximation. impedetissuehealing
specificadaptationofthetissuetothe
imposedlevelofdemand.
Atrophy.Considera
secondaryimpairmentto
injuryandsubsequentdisuse
Degreeofscarring.Scarring
thatoccursnormally,but
hypertrophicscarring
produceskeloidswhenthe
rateofcollagenproduction
exceedstherateofcollagen
breakdown
StagesofTissueHealing
Thegeneralstagesofsofttissuehealingaredescribedhere,whereasthehealingofspecificstructuresis
describedlaterundertherelevantheadings.Aftermicrotrauma,macrotrauma,ordisease,thebodyattemptsto
healitselfthroughapredictableseriesofoverlappingeventsthatincludecoagulationandinflammation(acute),
whichbeginsshortlyaftertheinitialinjuryamigratoryandproliferativeprocess(subacute),whichbegins
withindaysandincludesthemajorprocessesofhealingandaremodelingprocess(chronic),whichmaylastfor
uptoayeardependingonthetissuetype,andisresponsibleforscartissueformationandthedevelopmentof
newtissue.14,2024
Whereassimplificationofthecomplexeventsofhealingintoseparatecategoriesmayfacilitateunderstandingof
thephenomenon,inrealitytheseeventsoccurasanamalgamationofdifferentreactions,bothspatiallyand
temporally.25
Thevarioustherapeuticapproachesthatcanbeusedduringeachofthesestagesofhealingaredescribedin
Chapter8.
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CoagulationandInflammatoryStage
Aninjurytothesofttissuetriggersaprocessthatrepresentsthebodysimmediatereactiontotrauma,which
includesaseriesofrepairanddefensiveevents.20,26Followinganinjurytothetissues,thecellularandplasma
componentsofbloodandlymphenterthewound.Capillarybloodflowisdisrupted,causinghypoxiatothearea.
Thisinitialperiodofvasoconstriction,whichlasts510minutes,promptsaperiodofvasodilation,andthe
extravasationofbloodconstituents.20Extravasatedbloodcontainsplatelets,whichsecretesubstancesthatform
aclottopreventbleedingandinfection,cleandeadtissue,andnourishwhitecells.Thesesubstancesinclude
macrophagesandfibroblasts.27Thecoagulationandplateletreleaseresultsintheexcretionofplateletderived
growthfactor(PDGF),28plateletfactor4,29transforminggrowthfactoralpha(TGF),30andtransforming
growthfactorbeta(TGF).31Themainfunctionsofacellrichtissueexudatearetoprovidecellscapableof
producingthecomponentsandbiologicalmediatorsnecessaryforthedirectedreconstructionofdamagedtissue,
whiledilutingmicrobialtoxinsandremovingcontaminantspresentinthewound.25
Inflammationismediatedbychemotacticsubstances,includinganaphylatoxinsthatattractneutrophilsand
monocytes.
Neutrophils.Neutrophilsarewhitebloodcells(WBCs)ofthepolymorphonuclear(PMN)leukocyte
subgroup(theothersbeingeosinophils,andbasophils)thatarefilledwithgranulesoftoxicchemicals
(phagocytes)thatenablethemtobindtomicroorganisms,internalizethem,andkillthem.
Monocytes.MonocytesareWBCsofthemononuclearleukocytesubgroup(theotherbeinglymphocytes).
Themonocytesmigrateintotissuesanddevelopintomacrophages,providingimmunologicaldefenses
againstmanyinfectiousorganisms.Macrophagesservetoorchestratealongtermresponsetoinjured
cellssubsequenttotheacuteresponse.32
TheWBCsoftheinflammatorystageservetocleanthewounddebrisofforeignsubstances,increasevascular
permeability,andpromotefibroblastactivity.32Othercellparticipantsincludelocalimmuneaccessorycells,
suchasendothelialcells,mastcells,andtissuefibroblasts.ThePMNleukocytes,throughtheircharacteristic
respiratoryburstactivity,producesuperoxideanionradical,whichiswellknowntobecriticalfordefense
againstbacteriaandotherpathogens.33Superoxideisrapidlyconvertedtoamembranepermeableform,
hydrogenperoxide(H2O2),bysuperoxidedismutaseactivityorevenspontaneously.32ThereleaseofH2O2may
promotetheformationofotheroxidantsthataremorestable(havealongerhalflife),includinghypochlorous
acid,chloramines,andaldehydes.32Thephagocyticcellsthatinitiatetheinnateimmuneresponseproduceaset
ofproinflammatorycytokines(e.g.,TNF,IL1,andIL6)intheformofacascadethatamplifiesthelocal
inflammatoryresponse,influencestheadaptiveimmuneresponse,andservestosignalthecentralnervous
system(CNS)ofaninflammatoryresponse(Fig.23).Theextentandseverityofthisinflammatoryresponse
dependonthesizeandthetypeoftheinjury,thetissueinvolved,andthevascularityofthattissue.17,23,3436
Localvasodilationispromotedbybiologicallyactiveproductsofthecomplementandkinincascades25:
Thecomplementcascadeinvolves20ormoreproteinsthatcirculatethroughoutthebloodinaninactive
form.25Aftertissueinjury,activationofthecomplementcascadeproducesavarietyofproteinswith
activitiesessentialtohealing.
Thekinincascadehandlesthetransformationoftheinactiveenzymekallikrein,whichispresentinboth
bloodandtissue,toitsactiveform,bradykinin.Bradykininalsocontributestotheproductionoftissue
exudatethroughthepromotionofvasodilationandincreasedvesselwallpermeability.37
Becauseofthevarietyofvascularandotherphysiologicalresponsesoccurring,thisstageofhealingis
characterizedbyswelling,redness,heat,andimpairmentorlossoffunction.Theedemaisduetoanincreasein
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thepermeabilityofthevenules,plasmaproteins,andleukocytes,whichleakintothesiteofinjury,resultingin
edema.38,39Newstroma,oftencalledgranulationtissue,beginstoinvadethewoundspaceapproximately4
daysaftertheinjury.38,39Thecompleteremovalofthewounddebrismarkstheendoftheinflammatory
process.
Clinically,thisstageischaracterizedbypainatrestorwithactivemotion,orwhenspecificstressisappliedto
theinjuredstructure.Thepain,ifsevereenough,canresultinmuscleguardingandalossoffunction.Thisis
oftenreferredtoastheprotectionphasebasedonthefocusoftheintervention.Thegoalsoftheintervention
duringthisphasearethereforetominimizepainandedema,controlinflammation,restorefull,passiverangeof
motion,preventatrophy,maintainsofttissuejointintegrity,andtoenhancefunction(seeChapter8).
Twokeytypesofinflammationarerecognized:thenormalacuteinflammatoryresponseandanabnormal,
chronic,orpersistentinflammatoryresponse.Commoncausesforapersistentchronicinflammatoryresponse
includeinfectiousagents,persistentviruses,hypertrophicscarring,poorbloodsupply,edema,repetitive
mechanicaltrauma,excessivetensionatthewoundsite,andhypersensitivityreactions.40,41Themonocyte
predominantinfiltration,angiogenesis,andfibrouschangesarethemostcharacteristicmorphologicfeaturesof
chronicinflammation.Thisperpetuationofinflammationinvolvesthebindingofneutrophilicmyeloperoxidase
tothemacrophagemannosereceptor.42
MigratoryandProliferativeStage
Thesecondstageofsofttissuehealing,characterizedbymigrationandproliferation,usuallyoccursfromthe
timeoftheinitialinjuryandoverlapstheinflammationphase.Characteristicchangesincludecapillarygrowth
andgranulationtissueformation,fibroblastproliferationwithcollagensynthesis,andincreasedmacrophageand
mastcellactivities.Thisstagehandlesthedevelopmentofwoundtensilestrength.
Afterthewoundbaseisfreeofnecrotictissue,thebodybeginstoworktorepairandclosethewound(Fig.23).
Theconnectivetissueinhealingwoundsiscomposedprimarilyofcollagen,typesIandIII43cells,vessels,and
amatrixthatcontainsglycoproteinsandproteoglycans.Proliferationofcollagenresultsfromtheactionsofthe
fibroblaststhathavebeenattractedtotheareaandstimulatedtomultiplybygrowthfactors,suchasPDGF,
TGF,fibroblastgrowthfactor(FGF),epidermalgrowthfactor,andinsulinlikegrowthfactor1,andtissue
factorssuchasfibronectin.25Thisproliferationproducesfirstfibrinogenandthenfibrin,whicheventually
becomesorganizedintoahoneycombmatrixandwallsofftheinjuredsite.44
Thewoundmatrixfunctionsasgluetoholdthewoundedgestogether,givingitsomemechanicalprotection
whilealsopreventingthespreadofinfection.However,thewoundmatrixhasalowtensilestrengthandis
vulnerabletobreakdownuntiltheprovisionalextracellularmatrix(ECM)isreplacedwithacollagenousmatrix.
Thecollagenousmatrixfacilitatesangiogenesisbyprovidingtimeandprotectiontonewandfriablevessels.
Angiogenesisoccursinresponsetothehypoxicstatecreatedbytissuedamageaswellastofactorsreleased
fromcellsduringinjury.25
Theprocessofneovascularizationduringthisphaseprovidesagranularappearancetothewoundasaresultof
theformationofloopsofcapillariesandmigrationofmacrophages,fibroblasts,andendothelialcellsintothe
woundmatrix.Onceanabundantcollagenmatrixhasbeendepositedinthewound,thefibroblastsstop
producingcollagen,andthefibroblastrichgranulationtissueisreplacedbyarelativelyacellularscar,marking
theendofthisstage.
Uponprogressingtothisstage,theactiveeffusionandlocalerythemaoftheinflammationstagearenolonger
presentclinically.However,residualeffusionmaystillbepresentatthistimeandresistresorption.45,46Froma
clinicalperspective,thisphaseisoftenreferredtoasthecontrolledmotionphase.Thetreatmentgoalsforthis
phasearetoprotecttheformingcollagen,directitsorientationtobeparalleltothelinesofforceitmust
withstand,andpreventcrosslinkingandscarcontracture(seeChapter8).
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RemodelingStage
Anoptimalwoundenvironmentlessensthedurationoftheinflammatoryandproliferativephasesandprotects
fragiletissuefrombreakdownduringearlyremodeling.Theremodelingphaseinvolvesaconversionofthe
initialhealingtissuetoscartissue.Thislengthyphaseofcontraction,tissueremodeling,andincreasingtensile
strengthinthewoundcanlastforupto1year.Fibroblastshandlethesynthesis,deposition,andremodelingof
theECM.Followingthedepositionofgranulationtissue,somefibroblastsaretransformedintomyofibroblasts,
whichcongregateatthewoundmarginsandstartpullingtheedgesinward,reducingthesizeofthewound.
IncreasesincollagentypesIandIIIandotheraspectsoftheremodelingprocessareresponsibleforwound
contractionandvisiblescarformation.Epithelialcellsmigratefromthewoundedgesandcontinuetomigrate
untilsimilarcellsfromtheoppositesidearemet.Thiscontractedtissue,orscartissue,isfunctionallyinferiorto
originaltissueandisabarriertodiffusedoxygenandnutrients.47Eventually,thenewepidermisbecomes
toughenedbytheproductionoftheproteinkeratin.Thevisiblescarchangescolorfromredorpurplethat
blancheswithslightpressure,tononblanchablewhiteasthescarmatures.
Imbalancesincollagensynthesisanddegradationduringthisphaseofhealingmayresultinhypertrophic
scarringorkeloidformationwithsuperficialwounds.Ifthehealingtissuesarekeptimmobile,thefibrousrepair
isweak,andtherearenoforcesinfluencingthecollagenifleftuntreated,thescarformedislessthan20%of
itsoriginalsize.48Contractionofthescarresultsfromcrosslinkingofthecollagenfibersandbundles,and
adhesionsbetweentheimmaturecollagenandsurroundingtissues,producinghypomobility.Inareaswherethe
skinislooseandmobile,thiscreatestheminimaleffect.However,inareassuchasthedorsumofthehand
wherethereisnoextraskin,woundcontracturecanhaveasignificanteffectonfunction.Consequently,
controlledstressesmustalwaysbeappliedtonewscartissuetohelppreventitfromshortening.20,36Scarring
thatoccursparalleltothelineofforceofastructureislessvulnerabletoreinjurythanascarthatis
perpendiculartothoselinesofforce.49
CLINICALPEARL
Despitethepresenceofanintactepitheliumat34weeksaftertheinjury,thetensilestrengthofthewoundhas
beenmeasuredatapproximately25%ofitsnormalvalue.Severalmonthslater,only7080%ofthestrength
mayberestored.50Thiswouldappeartodemonstratethattheremodelingprocessmaylastmanymonthsoreven
years,makingitextremelyimportanttocontinueapplyingcontrolledstressestothetissuelongafterhealing
appearstohaveoccurred.50
Normally,theremodelingphaseischaracterizedbyaprogressiontopainfreefunctionandactivity.Forthis
reason,thishealingphaseisoftenreferredtoasthereturntofunctionphase(seeChapter8).Thetherapeutic
goalsforthisphaseareoutlinedinChapter8.Clinically,thechronicinflammatoryresponseischaracterizedby
thesignsandsymptomsofacuteinflammation(redness,heat,edema,andpain),butatamuchlesspronounced
level.Intheidealworld,theinjuredpatientmakesasmoothtransitionthroughthevariousstagesofhealing,and
thesharpandburningacutepainisreplacedbyadullerache,whichthensubsidestoapointwherenopainis
felt.However,apersistentchronicinflammatoryresponseresultsinthecontinuedreleaseofinflammatory
productsandalocalproliferationofmononuclearcells.Themacrophagesremainintheinflamedtissueifthe
acuteinflammationdoesnotresolve,andbegintoattractlargenumbersoffibroblasts,whichinvadeand
produceincreasedquantitiesofcollagen.13Thisfailureduringthehealingphasecontinuumcanresultinchronic
pathologicchangesinthetissue.Often,theincreasedcollagenproductionresultsindecreasedextensibilityofa
jointorsofttissuestructure.Characteristicsofthischronicinflammationincludeaphysiologicresponsethatis
resistanttobothphysicalandpharmacologicintervention,resultinginafailuretoremodeladequately,an
imperfectrepair,andapersistenceofsymptoms.40,51Also,fibrosiscanoccurinsynovialstructures,andin
extraarticulartissues,includingtendonsandligamentsinbursaorinmuscle.
MUSCLEBEHAVIOR,INJURY,HEALING,ANDTREATMENT
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AsoutlinedinChapter1,skeletalmusclesprimarilyfunctiontotransmitforcesmechanicallyviatheirrespective
tendonstoprovidemovement.
Behavior
Thereareapproximately430skeletalmusclesinthebody,eachofwhichcanbeconsideredanatomicallyasa
separateorgan.Ofthese430muscles,about75pairsprovidethemajorityofbodymovementsandpostures.52
Likeanycollagenoustissue,themusculotendinousunitexhibitsviscoelasticproperties(stressrelaxation,creep,
hysteresis,etc.)allowingittorespondtoloadanddeformationappropriately,withtherateofdeformationbeing
directlyproportionaltotheappliedforcewhenconsideringtheviscousproperty.Threeimportantfactorscan
influencemuscleperformance:53
Age.Withaging,thecrosssectionalareaofmuscledecreasesdeclineandthenumberofmusclefibersare
reducedbyabout39%byage80.54TypeImusclefibersarenotaffectedmuchbyaging,buttypeIIfibers
demonstrateareductionincrosssectionalareaof26%fromage20to80,mostlikelyaresultof
denervation.55Thesechangesseemtobesecondarytothedecliningdemandofthemuscleandlackof
physicalactivity,andthuscanbeminimizedorevenreversedwithadequatetraining(seeMuscleand
Agingsection).54
Temperature.Collagenoustissueshaveaninversetemperatureelasticmodulusrelationship,especiallyat
highertemperatures,whichmeansthattemperatureelevationresultsinincreasedelasticityanddecreased
stiffness.56Thiswouldsuggestthatwarmingamusclemayconferaprotectiveeffectagainstmusclestrain
injuryaswarmermusclesmustundergogreaterdeformationbeforefailure.However,somewhat
contradictory,awarmmusclemaybepronetoinjurybecauseitundergoesgreaterdeformationtoattaina
givenload.
Immobilizationordisuse.Theeffectofrigidimmobilizationonmusclehasbeenwelldetailed(see
DetrimentalEffectsofImmobilizationsectionlater).Howevertheresultsofrestrictedmotion,inwhich
jointandassociatedmusclesarenotallowedtomovethroughthecompleterange,havenotbeenwell
studied.Biomechanically,muscleimmobilizedinashortenedpositiondevelopslessforceandstretchesto
ashorterlengthbeforebecomingsusceptibletoinjurythandoesanonimmobilizedmuscle.Amuscle
immobilizedinalengthenedpositionrespondsdifferentlygreaterforceandagreaterchangeinlengthare
requiredtocauseatearthaninnonimmobilizedmuscle.
Injury
Muscleinjurycanresultfromexcessivestrain,excessivetension,contusions,lacerations,thermalstress,and
myotoxicagents,suchassomelocalanesthetics,excessiveuseofcorticosteroids,andsnakeandbeevenoms.57
Themajorityofmuscleinjuries(>90%)arecausedeitherbyexcessivestrainofthemuscleorbycontusion.58
Musclestrainsmaybegradedbyseverity(Table22).Muscleinjuriesarethemostcommoninjuryinsports,
withanincidencevaryingfrom10%to55%ofallinjuriessustainedinsportsevents.59,60Anumberoffactors
contributetomusclestraininjury,including:53
TABLE22ClassificationofMuscleInjury
Type RelatedFactors
Increasedactivity
Unaccustomedactivity
Exerciseinducedmuscleinjury(delayed
Excessiveeccentricwork
musclesoreness)
Viralinfections
Musclecelldamage
Strains
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Type Onsetat2448hoursafterexercise
RelatedFactors
Firstdegree(mild):minimalstructuraldamage
Suddenoverstretch
minimalhemorrhageearlyresolution
Suddencontraction
Seconddegree(moderate):partialtearlarge Deceleratinglimb
spectrumofinjurysignificantearlyfunctional Insufficientwarmup
loss Lackofflexibility
Increasingseverityofstrainassociatedwithgreatermuscle
fiberdeath,morehemorrhage,andmoreeventualscarring
Thirddegree(severe):completetearmayrequire
Steroiduseorabuse
aspirationmayrequiresurgery
Previousmuscleinjury
Collagendisease
Contusions
Directblow,associatedwithincreasingmuscletraumaand
Mild,moderate,severe
tearingoffiberproportionatetoseverity
Intramuscularvs.intermuscular
DatafromReidDC.SportsInjuryAssessmentandRehabilitation.NewYork,NY:ChurchillLivingstone1992.
inadequateflexibility
inadequatestrengthorendurance
dyssynergisticmusclecontraction
insufficientwarmup
inadequaterehabilitationfromthepreviousinjury
Adistractionstrainoccursinmuscletowhichanexcessivepullingforceisapplied,resultingin
overstretching.58Acontusionmayoccurifamuscleisinjuredbyaheavycompressiveforce,suchasadirect
blow.Atthesiteofthedirectblow,ahematomamaydevelop.Twotypesofhematomacanbeidentified:61
1.Intramuscular.Thistypeofhematomaisassociatedwithamusclestrainorbruise.Thesizeofthe
hematomaislimitedbythemusclefascia.Clinicalfindingsmayincludepainandlossoffunction.
2.Intermuscular.Thistypeofhematomadevelopsifthemusclefasciaisruptured,andtheextravasated
bloodspreadsintotheinterfascialandinterstitialspaces.Thepainisusuallylessseverewiththistype.
Healing
Skeletalmusclehasconsiderableregenerativecapabilities,andtheprocessofskeletalmuscleregenerationafter
injuryisawellstudiedcascadeofevents.6264Theessentialprocessofmuscleregenerationissimilar,
irrespectiveofthecauseofinjury,buttheoutcomeandtimecourseofregenerationvaryaccordingtothetype,
severity,andextentoftheinjury.62,65,66Broadlyspeaking,therearethreephasesinthehealingprocessofan
injuredmuscle:thedestructionphase,therepairphase,andtheremodelingphase.61
DestructionPhase
Thepathologyofskeletalmuscledamagevaries,dependingontheinitiatingcause.Muscledamagecanoccur
duringtheprolongedimmobilityofhospitalizationandfromexternalsourcessuchasmechanicalinjury.67One
ofthepotentialconsequencesofmuscleinjuryisatrophy.Theamountofmuscleatrophythatoccursdependson
theusagepriortobedrestandthefunctionofthemuscle.67Antigravitymuscles(suchasthequadriceps)tendto
havegreaterpotentialforatrophythanantagonistmuscles(suchasthehamstrings).Researchhasshownthata
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singleboutofexerciseprotectsagainstmuscledamage,withtheeffectslastingbetween6weeks68and9
months.69
Muscleresistancetodamagemayresultfromaneccentricexerciseinducedmorphologicchangeinthenumber
ofsarcomeresconnectedinseries.70Thisfindingappearstosupportinitiatingareconditioningprogramwith
gradualprogressionfromlowerintensityactivitieswithminimaleccentricactionstoprotectagainstmuscle
damage.67,71Ifamuscleisseverelyinjured,themusclefibersandtheirconnectivetissuesheathsaretotally
disrupted,andagapappearsbetweentheendsoftherupturedmusclefibersafterthemusclefibersretract.64
Thisphaseischaracterizedbythenecrosisofmuscletissue,degeneration,andaninfiltrationbyPMN
leukocytesashematomaandedemaformatthesiteofinjury.
RepairPhase
Therepairphaseusuallyinvolvesthefollowingsteps:
Hematomaformation.Thegapbetweentherupturedendsofthefibersisatfirstfilledbyahematoma.
Duringthefirstday,thehematomaisinvadedbyinflammatorycells,includingphagocytes,whichbegin
disposalofthebloodclot.64
Matrixformation.Bloodderivedfibronectinandfibrincrosslinktoformaprimarymatrix,whichactsas
ascaffoldandanchoragesitefortheinvadingfibroblasts.63,64Thematrixgivestheinitialstrengthfor
woundtissuetowithstandtheforcesappliedtoit.72FibroblastsbegintosynthesizeproteinsoftheECM.
Collagenformation.TheproductionoftypeIcollagenbyfibroblastsincreasesthetensilestrengthofthe
injuredmuscle.Anexcessiveproliferationoffibroblastscanrapidlyleadtoanexcessiveformationof
densescartissue,whichcreatesamechanicalbarrierthatrestrictsorconsiderablydelayscomplete
regenerationofthemusclefibersacrossthegap.61,64
Duringthefirstweekofhealing,theinjurysiteistheweakestpointofthemuscletendonunit.Thisphasealso
includesregenerationofthestriatedmuscle,productionofaconnectivetissuescar,andcapillaryingrowth.The
regenerationofthemyofibersbeginswiththeactivationofsatellitecells,locatedbetweenthebasallaminaand
theplasmamembraneofeachmyofiber.73
Satellitecells,myoblasticprecursorcells,proliferatetoreconstitutetheinjuredarea.66Duringmuscle
regeneration,itispresumedthattrophicsubstancesreleasedbytheinjuredmuscleactivatethesatellitecells.74
Unlikethemultinucleatedmyofibers,thesemononuclearcellsmaintainmitoticpotentialandrespondtocellular
signalsbyenteringthecellcycletoprovidethesubstrateformuscleregenerationandgrowth.73
Thesatellitecellsproliferateanddifferentiateintomultinucleatedmyotubesandeventuallyintomyofibers,
whichmatureandincreaseinlengthanddiametertospanthemuscleinjury.Manyofthesemyoblastscanfuse
withexistingnecrosedmyofibersandmaypreventthemusclefibersfromcompletelydegenerating.73
Thefinalstageintheregenerativeprocessinvolvestheintegrationoftheneuralelementsandtheformationofa
functionalneuromuscularjunction.75,76Providedthatthecontinuityofthemusclefiberisnotdisrupted,andthe
innervation,vascularsupply,andECMareleftintact,musclewillregeneratewithoutlossofnormaltissue
architectureandfunction.77
RemodelingPhase
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Inthisphase,theregeneratedmusclematuresandcontractswiththereorganizationofthescartissue.Thereis
oftencompleterestorationofthefunctionalcapacityoftheinjuredmuscle.Thetensilestrengthofthehealing
muscletissueincreasesovertime.However,whereasnormalintramuscularcollagenoustissuehasagreater
proportionoftypeIcollagenthantypeIIIcollagen,initiallyafterinjury,typeIIIcollagendemonstratesa
significantincreaseovertypeIcollagenintheareaofrepair.Overtime,theproportionoftypeItotypeIII
collagenreturnstonormal.Controlledmobilityandstressarekeyconsiderationsinthepostacuteperiodto
allowscarformation,muscleregeneration,correctorientationofnewmusclefibers,andthenormalizationofthe
tensilepropertiesofmuscle.
Treatment
Theinterventiondependsonthestageofhealing(seeChapter8).Thefollowingprinciplesshouldguidethe
clinicianwhenrehabilitatingamuscleinjury:53
Preventioniseasierthantreatment.Patienteducationisimportanttoinformthepatientabouttheexpected
durationandextentofsymptoms,andanyprecautionsorcontraindicationstopreventreinjuryor
disruptionofthehealingprocess.
Controlledmobilityandactivityarebest.
Medicationsandmodalitiescanbeimportantadjunctstocare.
Itisimportanttodevelopstrong,flexibletissueusingpainastheguidingfactor.
ThetypicalexerciseprogressioninvolvesPROM,thenAAROM,thenAROM,andthensubmaximalisometrics,
initiallyinaprotectiverangebeforeprogressingthroughouttherange.Oncethepatientcantoleratesubmaximal
isometrics,aprogressiontomaximalisometricsismadeatmultianglesandthenthroughouttherange,before
progressingtoprogressiveresistiveexercises.
MuscleandAging
Withage,thereisareductionintheabilitytoproduceandsustainthemuscularpower.Thisagerelated
phenomenon,termedsenescencesarcopenia,canresultina2025%lossofskeletalmusclemass(seeChapter
30).78
CLINICALPEARL
Sarcopenia(sarco=muscle,penia=lackof)isnotadisease,butratherrefersspecificallytotheuniversal,
involuntarydeclineinleanbodymassthatcanoccurwithage,primarilyasaresultofthelossofskeletalmuscle
volume.
Sarcopeniahasimportantconsequences.Thelossofleanbodymassreducesfunction,andlossofapproximately
40%ofleanbodymassisfatal.79,80Sarcopeniaisdistinctfromwastinginvoluntaryweightlossresultingfrom
inadequateintake,whichisseeninstarvation,advancedcancer,oracquiredimmunodeficiencysyndrome.
Whileavarietyofstudieshaveinvestigatedtheunderlyingmechanismsandtreatmentsofagerelatedmuscle
loss,veryfewepidemiologicstudieshavelookedattheprevalence,incidence,pathogenesis,andconsequences
ofsarcopeniainelderlypopulations.Itislikelythatthedeterminantsofsarcopeniaaremultifactorialandinclude
geneticfactors,environmentalfactors,andagerelatedchangesinmuscletissue.81
Theeffectsofagingonmusclemorphologyhavebeenstudied.Agingcausesadecreaseinmusclevolume,82
withtypeIIfiberapparentlybeingmoreaffectedbygradualatrophy.83Specifically,thereisadisproportionate
atrophyoftypeIIamusclefiberswithaging.Theselossesofmuscularstrengthandmusclemasscanhave
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importanthealthconsequencesbecausetheycanpredisposetheelderlytodisability,anincreasedriskoffalls
andhipfractures,andadecreaseinbonemineraldensity.
CLINICALPEARL
Whenolderpeoplemaintainmuscularactivity,thelossesinstrengthwithagearereducedsubstantially.Age
relatedmusclefiberatrophyandweaknessmaybecompletelyreversedinsomeindividualswithresistance
training(seeChapter30).
TENDONBEHAVIOR,INJURY,HEALING,ANDTREATMENT
AsoutlinedinChapter1,tendonsprimarilyfunctiontotransmitforcebetweenmuscleandbone.84
Behavior
Theorganizationofthetendondeterminesitsmechanicalbehavior.Astendonshavemoreparallelcollagen
fibersthanligaments,andlessrealignmentoccursduringinitialloading,thetoeregionoftheloaddeformation
curveissmallerintendonsthaninligaments.85Thecomplianceoftendonsvaries.Tendonsofthedigitalflexors
andextensorsareverystiff,andtheirlengthchangesverylittlewhenmuscleforcesareappliedthroughthem.In
contrast,thetendonsofsomemuscles,particularlythoseinvolvedinlocomotionandballisticperformance,are
moreelastic.Forexample,theAchillestendonisstretchedduringthelatestancephaseingaitasthetriceps
suraeisstretchedastheankledorsiflexes.Nearthebeginningoftheplantarflexioncontraction,themuscle
activationceasesandenergystoredinthestretchedtendonhelpstoinitiateplantarflexion.Therestingtendon
hasaslightlycrimpedorwavelikeappearance.Asforceisappliedtothetendon,astraighteningofthecrimp
resultsinthetoeregionintheloaddeformationcurve(Fig.22),wherelittleforceisrequiredtochangetendon
length.84Totaltendonstrains(percentagedeformity)of12%resultinthestraighteningofthecrimppatternof
unloadedtendoncollagen.Strainsof26%arewelltoleratedbymosthealthytendons.However,withastrain
higherthan6%,incompletetearsstarttooccurwithinthetendon,andcompletestructuralfailuretypically
occursintherangeof810%.86Astheloadincreasesbeyondthetoeregion,thecollagenfibrilsstretch,creating
thelinearregionoftheloaddeformationcurve(Fig.22).84Mosttendonslikelyfunctioninthetoeandearly
linearregionsunderphysiologicalloadingconditions.87
CLINICALPEARL
Astheamountofcrimpinatendondecreaseswithage,thetoeregionbecomessmaller.
Tendontissuehomeostasisisbasedontheabilityofthetendoncellstosenseandrespondtomechanicalload
throughmechanotransduction.88AswithallCT,tendonshaveapositiveadaptiveresponsetorepeated
physiologicmechanicalloading,whichresultsinbiologicandmechanicalchanges.Atendoncanresisttensile
stressinthedirectionalofitsfibersorientationbecauseofthecollagenstructure,anditcanresistsome
compressivestressbecauseofitsproteoglycancontent.Thetotalamountofloadthetendoncanresistandthe
amountitstretchesduringloadingdependonitscrosssectionalarea,composition,andlength.However,
tendonscanadaptstructurallyormateriallytochangesinthemechanicalenvironmentasaresultofload
conditions.87Theexactlevelofmechanicalandbiologicalstimulationrequiredtomaintainnormaltendon
homeostasisisnotcurrentlyknown,butiswidelybelievedthatanabnormallevelofstimulation(underloador
overload)mayplayaroleinthepathogenesisoftendinopathy.88Straininjuriesarecommonatthe
musculotendinousjunction(MTJ),theweakestpointinthemuscletendonunit.89
CLINICALPEARL
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TheMTJisthelocationofmostcommonmusclestrainscausedbytensileforcesinanormalmuscletendon
unit.90,91Inparticular,apredilectionforatearneartheMTJhasbeenreportedinthebicepsandtricepsbrachii,
rotatorcuffmuscles,flexorpollicislongus,fibularis(peroneus)longus,medialheadofthegastrocnemius,rectus
femoris,adductorlongus,iliopsoas,pectoralismajor,semimembranosus,andtheentirehamstringgroup.57,59,92
Injury
Tendinopathyisaclinicalsyndrome,oftenbutnotalwaysimplyingoveruseofatendon,characterizedbya
combinationofpain,diffuseorlocalizedswelling,andimpairedperformance.93Recently,ithasbeen
recommendedthatthetermtendinopathyreplacethetraditionaltermtendinitisfordescribingtendon
pathology.94Tendinitis,whichisseentoamuchlesserextent(<3%),isassociatedwiththeclassicalsignsof
inflammationusuallyobservedduringtheearlyreparativephase.95However,confusingtheissueisthefactthat
thenoninflammatoryetiologyoftendinopathyhaslatelybeenquestioned,asinflammationmayplayaroleinthe
initialphaseofthedisease.96Thismaybebecausethetendoninsertionandbursasurroundingthetendonare
commonsitesofclassicalinflammationasaresponsetorepetitivestress,becauseoftheirgreaterdensityof
bloodvesselsandnerves,97whereasthetendonproperismostlyaneuralandavascularanddoesnot,under
normalconditions,exhibitclassicalinflammatoryresponses.98,99Tendonoveruseinjurieshavebeenreportedto
accountfor3050%ofinjuriesinsportsand30%ofallgeneralpractitionerconsultationsformusculoskeletal
injuries.100Tendonsthattransmitlargeloadsundereccentricandelasticconditions,suchastheAchillesand
patellartendons,aremoresubjecttoinjury.101Thus,inthelowerextremity,chronictendonoveruseaccountsfor
30%ofallrunningrelatedinjuries,typicallyinvolvingthepatellarorAchillestendons.102Intheupper
extremities,thesupraspinatus,andextensorcarpiradialisbrevistendonsappeartobethemostvulnerable.
Theetiologyoftendinopathyisstillunclearhowever,histologicalevidenceconsistentlydemonstratesan
absenceofprostaglandinmediatedinflammation.103Thecommonpathologicalconditionsassociatedwith
tendinopathyaretendinosisandperitendinitis97:
Tendinosis.Tendinosisisanintratendinousdegenerativelesionwithoutaninflammatorycomponent(the
suffixosisisindicativeofadegenerativeprocessratherthananinflammatorydisorder).104This
conditionischaracterizedbythehistopathologicalfindingsofcollagendisorganizationandfiber
separation,increaseinmucoidgroundsubstance,hypercellularity,andnerveandvesselingrowthbut
mostlywithoutsignsofintratendinousinflammation(tendinitis).99
Peritendinitis.Thisconditionisanacuteorchronicinflammationofthethinmembrane,paratenon,
surroundingthetendon,ofteninducedbyrepetitiveexerciseandcharacterizedbylocalswellingand
infiltrationofinflammatorycells.95
Specimenstakenfromtorntendonsshowdisorientationofcollagenfibers,thinningofthefibers,myxoid
degeneration,chondroidmetaplasia,calcification,andvascularinfiltration.105
Althoughsportsactivityisthemostcommonsourceoftendinopathy,itcanbeworkrelated,drugrelated(e.g.,
cortisone,cyclosporine,statins,andquinoloneantibiotics),orduetoametabolicdisordersuchasdisturbed
glucosemetabolismandatherosclerosis.97Mosttendontraumatendstooccurfromloading(suddenoverloador
repetitive),orrapidunloading.Thismechanicalloadingisanabolicbyupregulatingcollagengeneexpression
andincreasingsynthesisofcollagenproteins,whichpeaksaround24hoursafterexerciseandremainselevated
forupto7080hours.97Simultaneously,thereisadegradationofcollagenproteins,althoughthetimingofthis
catabolicpeakoccursearlierthantheanabolicpeak,resultinginanetlossofcollagenaroundthefirst2436
hoursaftertraining,followedbyanetgainincollagen.99Thiswouldtendtoindicatethatacertainrestitution
timeintervalinbetweenexerciseboutsiscriticalforthetissuetoadaptandtoavoidanetcatabolicsituation.
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Mechanicaloverloaddoesnotseemtobetheonlyfactortoexplainatendoninjuryandmayevenbemerelya
permissivefactor,allowingthetendonproblemtobecomesymptomatic.106
CLINICALPEARL
Tendonsbecomeweaker,stiffer,andlessyieldingasaresultofthevascular,cellular,andcollagenrelated
alterationsthatoccurwithaging.85
Whileitiseasytounderstandwhyasuddenoverloadcoulddamageatendon,itismoredifficulttounderstand
whytheapplicationofnormalloads,repeatedfrequently,cancausetendondamage.Repetitiveloadingcan
occurasaresultofexternalfactors,suchasanatomicpredispositionresultingfrominflexibility,weakness,or
malposition,excessivecompression,andfriction.107109
CLINICALPEARL
Rapidforceapplicationorreleaseismorelikelytocausetendondamagethanthesameloadapplied
gradually.110
Musclephysiologyexperimentshaveshowntheforceincreasesasthevelocityofactivemusclelengthening
(eccentric)increaseswhiletheoppositeistrueduringconcentric(shortening)muscleactivations(seeChapter1).
Indeed,thetendonisexposedtolargerloadsduringeccentricloading,especiallyifthemovementoccurs
rapidly.111,112Almostallconcentriccontractionsareprecededbyalengthening(eccentric)whilethemuscleis
active.Thisactivationpatternstretchestheelasticelementsinthemuscletendonunitandcontributesto
movementifthemuscleisallowedtoshortenimmediatelyafterbeinglengthened.87
CLINICALPEARL
EstimatesoftheBureauofLaborStatistics113indicatethatchronictendoninjuriesaccountfor48%ofreported
occupationalillnesses,whereasoveruseinjuriesinsportsaccountfor3050%ofallsportsinjuries.114
Terminologyregardingtendonpathologyhasbeensomewhatconfusing.Tendoninjuriesaretypicallyclassified
aseitheracuteorchronic.
Acuteinjuries.Acuteinjuriesincludethoseinwhichthetimeandmethodofinjuryareknown.87Acute
injuriesincludetendonruptureandpartialtendontears.Tendinopathycanbegradedaccordingtoseverity:
GradeI:Painonlyafteractivitydoesnotinterferewithperformanceoftengeneralizedtenderness
disappearsbeforethenextexercisesession.
GradeII:Minimalpainwithactivitydoesnotinterferewithintensityordistanceusuallylocalized
tenderness.
GradeIII:Paininterfereswithactivityusuallydisappearsbetweensessionsdefinitelocal
tenderness.
GradeIV:Paindoesnotdisappearbetweenactivitysessionsseriouslyinterfereswiththeintensity
oftrainingsignificantlocalsignsofpain,tenderness,crepitus,andswelling.
GradeV:Paininterfereswithsportandactivitiesofdailylivingsymptomsoftenchronicor
recurrentsignsoftissuechangesandalteredassociatedmusclefunction.
Chronicinjuries.Chronictendoninjuriesarenottypicallyassociatedwithaknownonsetorwith
inflammationbutinvolverepetitiveloadingthatdamagesthetendon.
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CLINICALPEARL
Thetermtendinopathyhasbeenusedtodescribeanyabnormalconditionofthetendon.
Achronictendoninjuryischaracterizedbythepresenceofdensepopulationsoffibroblasts,vascular
hyperplasia,anddisorganizedcollagen.115Thedisorganizedcollagenistermedangiofibroblastic
hyperplasia.116ItisthoughtthatthisdisorganizationresultsfromafailureoftheECMtoadapttochanges,
resultingindisorderedhealingwiththeabsenceofinflammatorycells.Degenerativetendinopathyoccursin
approximatelyonethirdofthepopulationolderthan35yearsofage.117Althoughitiscommonlypresumedthat
painresultsfromaninflamedstructure,itisnotclearwhytendinosisispainful,giventheabsenceofacute
inflammatorycells,norisitknownwhythecollagenfailstomature.Necropsystudieshaveshownthatthese
degenerativechangesalsomaybepresentinasymptomatictendons.118Thedegreeofdegenerationincreases
withageandmayrepresentpartofthenormalagingprocess.90Thedegenerationappearstobeactivityrelated,
aswell(seeChapter30).90
Thetypicalclinicalfindingfortendinopathyisastrongbutpainfulresponsetotheresistanceoftheinvolved
musculotendinousstructure.
Healing
Therearesomefactorsthathandlethepoorhealingpotentialoftendinoustissue,andtheseinclude:
Theoxygenconsumptionbytendons(andligaments)is7.5timeslowerthanskeletalmuscle,resultingin
alowermetabolicrate.119
Thebloodvesselsdonotextendbeyondtheproximalthirdofthetendon.
Healingcancreateadhesionformationandeventhoughremodelingoccurs,thebiochemicaland
mechanicalpropertiesareneverthesameasnormaltendontissue.
Ifanacutetendoninjurydisruptsvasculartissueswithinthetendon,itresultsinawellstudiedhealingprocess
involvingthreeoverlappingphases120:
Inflammatoryresponse:Thisoccursasahematomaformswithinerythrocytesandactivatedplatelets.This
isfollowedbytheinfiltrationofinflammatorycells,includingneutrophils,monocytes,andmacrophages
thatmigratetotheinjurysitetoremovedebris.Shortlyafter,chemotacticsignalsinducefibroblaststo
startsynthesizingcollagen.104Followinginjury,theinitialinflammatorystagetriggersanincreasein
glycosaminoglycans(GAG)synthesiswithindays,rapidlyfollowedbysynthesisoftypesIandIII
collagen,suchthatthehealingwoundcanbesubjectedtolowlevelsofforcewithinamatterof
days.87,121124
Repair:Thisphaseinvolvesthedepositionofcollagenandtendonmatrixcomponents.
Remodeling:Duringthisphasethecollagenbecomesmorestructuredandorganized,althoughtheinjured
siteneverachievestheoriginalhistologicormechanicalfeaturesofahealthyuninjuredtendon.
Unlikemostsofttissuehealing,healingtendonsposeaparticularproblemastheyrequirebothextensibilityand
flexibilityatthesiteofattachment.19,122124Ajudiciousapplicationofforceisnecessarytoencouragecollagen
synthesisandcollagenfibercrosslinking,whichinturnfacilitatesthenewcollagenfibrilstoaligninthe
directionofforceapplication(seeChapter8).87
Treatment
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Whilethetreatmentfortendinopathyappearsrelativelystraightforward,tendinopathiesaredifficulttogradein
termsofguidingtreatmentorprognosis.Sinceinflammatoryinfiltratesarelargelyabsentintendinopathy,itis
recognizedthatantiinflammatorystrategiesareineffectiveforthiscondition.Thisshiftinunderstandingof
pathophysiologyhaspromptedtheuseofinterventionssuchaseccentricexercisestobeconsideredasaviable
optionforrehabilitation.125Forexample,theeccentricheeldropexerciseiscommonlyusedinclinicalpractice
forAchillestendinopathyalthoughthemechanicalpropertiesarenotclear.Table23outlinessomeguidelines
fortreatment.
TABLE23EccentricBasedTreatmentforChronicTendinopathy
Principlesand
Description
Method
Ageneralizedexercisesuchascyclingorlikejoggingthatdoesnotcauselocalpainor
1.Warmup
discomfortlocalheatingmodality,suchashotpackultrasound
2.Stretchingto Aminimumoftwo30secondstaticstretchesoftheinvolvedmusculotendinousunitand
improveflexibility itsantagonist(s)
Threesetsof10repetitions,withabriefrestorstretchbetweeneachset.Symptoms
shouldbefeltafter20repetitions(i.e.,between20and30repetitions)atalevelsimilarto
thatfeltduringactivities.
3.Completionofthe
Ifpainisfeltbeforethe20threpetition,eitherthespeedofmovementisreduced,orthe
specificeccentric
loadisdecreased
exercise
Ifnopainisexperiencedby30repetitions,thespeedorloadisincreased.
Theintensityofsubsequenttreatmentsisbasedonthepatientsresponsetotheprevious
treatment
4.Repeatflexibility
Seestep2
exercises
5.Applyice Iceisappliedfor1015minutestothepainfultopalpationarea
DatafromCurwinSL.Tendonpathologyandinjuries:Pathophysiology,healing,andtreatmentconsiderations.
In:MageeD,ZachazewskiJE,QuillenWS,eds.ScientificFoundationsandPrinciplesofPracticein
MusculoskeletalRehabilitation.St.Louis,MO:WBSaunders2007:4778.
Somebiomechanicalfactorsareimportanttoconsiderduringthetreatmentoftendinopathies,whichinclude:4
Tendonmechanicalpropertiesinhealthyindividualsmayrespondtoexercisebyincreasingstiffnessifa
specificthresholdisexceeded.
Tendonmechanicalpropertiesareaffectedbyavarietyofcommonconditions(e.g.,bedrest,
tendinopathy,andrupture),usuallybydecreasingstiffness.
Exercisesthattargetstendonstiffnesslikelywillneedtohitaspecificthreshold,andpossiblyfrequency,
tobeeffective.
Treatmentoftendinosisinvolvesamultifacetedapproach,whichincludes:87
Theidentificationandremovalofallnegativeinternaland/orexternalforces/factors.
Theestablishmentofastablebaselinefortreatment.
Thedeterminationofthetensileloadstartingpoint
Aprogressionoftheloadingprogramaccordingtothepatientssymptoms.Eccentrictrainingproduces
around20%moreloadonthetendoncomparedwithconcentrictraining.126Studieshaveshownthat
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exercise,particularlyeccentricbasedexercise(Table23),haspositiveeffectsonthemechanicaland
structuralpropertiesoftendons:
Nakamuraetal.127demonstratedthateccentricexercisescontributedtostableangiogenesisinearly
tendoninjurywhereasconcentricexercisesdidnot.Dailyeccentricexerciseswereclinically
beneficialandnotharmfultotendonmicrocirculation.
Knoblochetal.128showedinacontrolledstudythatintendinosislesions,aneccentricloading
programresultedinasignificantdecreaseintheparatenonvascularityandpainwhilenotchanging
theoxygensaturationoftheparatenontissues.
Shalabietal.129demonstrateddecreasedtendonvolume,decreasedmagneticresonanceimaging
(MRI)signalinthetendinosislesions,andimprovedclinicalpainscoresinpatientswithAchilles
tendinosiswhoweretreatedwitheccentrictrainingregimens.
Dimitriosetal.130reportedthateccentrictrainingandstaticstretchingexercisescombinedwere
superiortoeccentrictrainingalonetoreducepainandimprovefunctioninpatientswithpatellar
tendinopathy.
Conversely,immobilizationadverselyaffectsthebiomechanicalpropertiesofatendon,resultingin
decreasedtensilestrength,increasedstiffness,andareductionintotalweight.85
Thecontrolofpain.
Addressingtheentirekineticchain.
Also,othermodesofconservativetreatmentcanbeincorporatedincluding:104
Extracorporealshockwavetherapy(ESWT).Chenetal.131demonstratedthatESWTpromotedtendon
healinginacollagenaseinducedtendinopathyofarattendon.Rompeetal.132showedinarandomized
controlledtrialthateccentricexercise,combinedwithESWT,wasmoreeffectivethaneccentricexercise
alone.Incontrast,Zwerveretal.133foundthatwhenESWTwasusedasasolitarytreatmentduringthe
competitiveseason,itdemonstratednobenefitoverplacebotreatmentinthemanagementofactively
competingjumpingathleteswithpatellartendinopathywhohadsymptomsforlessthan12months.134
Nonsteroidalantiinflammatoryagents(NSAIDs)andcorticosteroids.Althoughsteroidshavebeen
commonlyusedinthetreatmentoftendinosis,theirbenefitappearstobelimitedtoshortterm
improvementinpain(i.e.,<6weeks),asthereisnoevidencetosuggestlongtermimprovement.135This
lackofefficacyislikelyexplainedbytheabsenceofinflammationasasignificantfactorintendinosis
pathology.
Sclerosingtreatments.Severalstudieshavedemonstratedthatsclerosingtreatmentaidsinthe
neovascularizationoftendinosislesions.136,137
Plateletrichplasma(PRP).PRPappearstobeapromisinginterventionfortendinosislesions.138,139
Nitricoxide.Nitricoxideisanimportantcellsignalmoleculeandappearstobeinvolvedinnumerous
tissuetypes,responsestomechanicalloading,modulatingtendonhealing,andcollagensynthesis.140
Matrixmetalloproteinaseinhibitors.Thisisarecentinterventionfortendinosis.Matrixmetalloproteinase
inhibitorsaimtodecreasethecatabolicenzymaticactivityintendinosislesions.141
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Ifthepatientfailstoimprove,theclinicianmustconsiderthefollowingpossibilities:87
Incorrectloadingmagnitudeorprogression
Incorrectdiagnosis
Noncompliance
Anunrecognizedexternalfactor
LIGAMENTBEHAVIOR,INJURY,HEALING,ANDTREATMENT
AsoutlinedinChapter1,ligamentsfunctiontobindbonestogetheratornearthemarginsofbonyarticulation.
Behavior
Becauseoftheirfunctionasjointstabilizers,whenaligamentisdamaged,thereisalossofnormalkinematic
relationshipsbetweentheconnectedbones,withthedegreeoflossbasedonseverity.Structuralchangesoccurin
ligamentsasafunctionofage.Inmiddleage,bothligamentsandboneinsertionsitesbegintoweaken,resulting
inprogressivelossesinstructuralstrengthand,intheelderly,ligamentslosemass,stiffness,strength,and
viscosity.7Hormonelevelscanalsoaffectligamentsproducinggenderspecificalterations.Forexample,ithas
beenreportedthatjointandligamentlaxitycanchangeduringpregnancyduetothepresenceofthehormone
relaxin,andduringdifferentphasesofthemenstrualcycle.142,143Finally,ligamentcomplexesareextremely
sensitivetoloadandloadhistory,suchthatloaddeprivationcausesarapiddeteriorationinligamentbiochemical
andmechanicalproperties,whichresultsinanetlossinligamentstrengthandstiffness.144146Conversely,
movementhasbeenshowntomaintainnormalligamentbehavior,althoughitisnotclearhowmuchmovement
isrequiredtomaintainbaselineligamentbehaviors.147Exerciseappearstoincreaseligamentstrengthand
stiffness.
Injury
Inanyparticularpositionofajoint,severalligamentsaroundthejointsarelikelytobeinatautstate.Ifan
externalloadisthenappliedtothatjoint,thoseligamentsthataretautwillabsorbthegreatestamountofenergy.
Iftheloadissufficienttodeformatautligamentpastitselastic(recovery)limit,theligamentwillfail,andother
ligaments,orstructureswillsimultaneouslybecomerecruitedintotension.7Dependingonthesizeoftheload,a
subsequentinjurycanalsooccurtootherligamentsorstructures.Itis,therefore,unlikelyforatrulyisolated
ligamentinjuryevertooccur.7Pointtenderness,jointeffusion,andahistoryoftrauma,areallcharacteristicofa
ligamentousinjury.Ligamentinjuries,referredtoassprains,maybegradedbyseverity(Table24).Stresstests
appliedperpendiculartothenormalplaneofjointmotioncanhelpdistinguishbetweengradeIIandgradeIII
ligamentinjuries.IngradeIIIinjuries,significantjointgappingoccurswiththeapplicationofthestresstest.148
However,becauseofpatientdiscomfortandguardingagainstpossiblepain,itisdifficulttoassessjointlaxityby
clinicalexaminationalone.Currently,cliniciansoftenuseancillarytestssuchasarthrometryorMRIwhen
diagnosingandgradingsofttissueinjuries.
TABLE24LigamentInjuries
Grade Description SignsandSymptoms Implications
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Mildpain
Littleornoswelling
Somejointstiffness Minimalfunctionalloss
Somestretchingortearing Minimallossofstructuralintegrity
I(mild) Earlyreturntotrainingsome
oftheligamentousfibers Noabnormalmotion
protectionmaybenecessary
Minimalbruising
Tendencyforrecurrence
Moderatetoseverepain
Needprotectionfromriskof
Jointstiffness
Sometearingand furtherinjury
II Significantstructuralweakeningwith
separationofthe Mayneedmodified
(moderate) abnormalmotion
ligamentousfibers immobilization
Oftenassociatedhemarthrosisand
Maystretchoutfurtherwith
effusion
time
Severepaininitiallyfollowedbylittleor
Needsprolongedprotection
nopain(totaldisruptionofnervefibers)
III Totalruptureofthe Surgerymaybeconsidered
Profuseswellingandbruising
(complete) ligament Oftenpermanentfunctional
Lossofstructuralintegritywithmarked
instability
abnormalmotion
Healing
Theprocessofligamenthealingfollowsthesamecourseofrepairaswithothervasculartissues.However,
intraarticularligamentssuchastheanteriorcruciateligament(ACL)donothealaswellasextraarticular
ligaments,becauseintraarticularligamentshavealimitedbloodsupplyandthesynovialfluidmaysignificantly
hinderaninflammatoryresponse.85Thehealingofextraarticularligaments,however,occursinfouroverlapping
phases.
PhaseI:Hemorrhagic
Afterdisruptionofthetissue,thegapisfilledquicklywithabloodclot(hematoma).PMNleukocytesand
lymphocytesappearwithinseveralhours,triggeredbycytokinesreleasedwithintheclot.ThePMNleukocytes
andlymphocytesrespondtoautocrineandparacrinesignalstoexpandtheinflammatoryresponseandrecruit
othertypesofcellstothewound.76
PhaseII:Inflammatory
Macrophagesarrivewithin2448hoursandarethepredominantcelltypewithinseveraldays.Macrophages
performphagocytosisofnecrotictissuesandalsosecretemultipletypesofgrowthfactorsthatinduce
neovascularizationandtheformationofgranulationtissue.Bythethirddayaftertheinjury,thewoundcontains
macrophages,PMNleukocytes,lymphocytes,andmultipotentialmesenchymalcells,growthfactors,and
platelets.Thegrowthfactorsarenotonlychemotacticforfibroblastsandothercells,butalsostimulatefibroblast
proliferationandthesynthesisofcollagentypesI,III,andV,aswellasnoncollagenousproteins.149,150
PhaseIII:Proliferation
Thelastcelltypetoarrivewithinthewoundisthefibroblast.Althoughdebatecontinues,itcurrentlyisthought
thatfibroblastsarerecruitedfromneighboringtissueandthesystemiccirculation.151Thesefibroblastshave
abundantroughendoplasmicreticulumandbeginproducingcollagenandothermatrixproteinswithin1weekof
injury.Bythesecondweekafterthedisruption,theoriginalbloodclotbecomesmoreorganizedbecauseof
cellularandmatrixproliferation.Capillarybudsbegintoform.Although,thetotalcollagencontentisgreater
thaninthenormalligamentortendon,thecollagenconcentrationislower,andthematrixremainsdisorganized.
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PhaseIV:RemodelingandMaturation
PhaseIVismarkedbyagradualdecreaseinthecellularityofthehealedtissue.Thematrixbecomesdenserand
longitudinallyoriented.Collagenturnover,watercontent,andtheratioofcollagentypesItoIIIbeginto
approachnormallevelsoverseveralmonths.152Anintegratedsequenceofbiochemicalandbiomechanical
signalsarecriticaltoligamentremodeling.Thesesignalsregulatetheexpressionofstructuralandenzymatic
proteins,includingdegradationenzymessuchascollagenase,stromelysin,andplasminogenactivator.149The
healedtissuecontinuestomaturebutwillneverattainnormalmorphologiccharacteristicsormechanical
properties.Ligamentinjuriescantakeaslongas3yearstohealtothepointofregainingnearnormaltensile
strength,153althoughsometensilestrengthisregainedbyaboutthefifthweekfollowinginjury,dependingon
theseverity.22,154156Aligamentmayhave50%ofitsnormaltensilestrengthby6monthsafterinjury,and
80%after1year.157159
Treatment
Immobilizationanddisusedramaticallycompromisethestructuralmaterialpropertiesofligaments,resultingin
asignificantdecreaseintheabilitytoresiststrainsandabsorbenergy.85Forcesappliedtotheligamentduring
itsrecoveryhelpittodevelopstrengthinthedirectionthattheforceisapplied.157161Severalstudieshave
shownthatactivelyexercisedligamentsarestrongerthanimmobilizedones.Thus,itisimportanttominimize
periodsofimmobilizationandtostresstheinjuredligamentsprogressivelywhileexercisingcautionaboutthe
biomechanicalconsiderationsforspecificligaments.162Thecurrentconceptisthatverylowcyclicalloadson
ligamentspromotescarproliferationandmaterialremodeling,thusmakingthescarstrongerandstiffer
structurally163,164and,possibly,materially.7Inconjunctionwithexercise,itappearsthattheuseofice
immediatelyafterligamentinjurydecreasesbleeding,swelling,andinflammation,165whereasheat,whenused
afterthefirst48hoursappearstoincreasebloodflow(seeChapter8).However,itisnotknownwhethericeor
heathaveanyeffectonscarformation,oronthequalityorquantityofligamenthealing.
Thesurgicalrepairoftornligamentendshasbeennotedinthepasttoinducefasterandstrongerhealingthrough
aprocessthatislikenedtoregenerationratherthanscarformation.7,166However,althoughsurgicallyrepaired
extraarticularligamentshealwithdecreasedscarformationandarestrongerthanunrepairedligamentsinitially,
thisstrengthadvantagemightnotbemaintainedastimeprogresses.19
Currently,somebiologicalapproachesarebeingusedtoimproveligamentrepair,includingtheuseofgrowth
factorsandgenetherapy:7
Growthfactors.Growthfactorsaremoleculesthatmodifycellproliferationorthesecretionofproteins.
Thusfar,theusesofgrowthfactorsinligamenthealinghavedemonstratedvariableresults.
Genetherapy.Genetherapyreferstothemodificationofthegeneticexpressionofcells.Theintroduction
ofmarkerandtherapeuticgenesintoligamentsusingvectorshasdemonstratedinitialsuccesswith
evidenceoffunctionalalterations.167Also,genetransferhasbeenusedtomanipulatethehealing
environment,openingthepossibilityofgenetransfertoinvestigateligamentdevelopment.167
JOINTBEHAVIOR,INJURY,HEALING,ANDTREATMENT
AsdescribedinChapter1,theamountofmotionavailableatajointisbasedonanumberoffactors,including
thetypeofjoint,theshapeofthearticulatingsurfaces,thehealthofthejointandthesurroundingtissues,andthe
loaddeformationhistoryofthejoint.
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Todiscusstheseconcepts,itisimportanttohaveanunderstandingofthenormalbarriersthatcanbefeltduring
movement.Threedistinctareasorzonesarerecognized:168
Neutralzone:thezoneinwhichthereislittleornointernalresistanceofferedbythetissuestomovement
andtherangeinwhichthecrimpofthetissueisbeingtakenup.Increasesinthesizeoftheneutralzone
resultinthefeelingorperceptionthatthecrimpistakenuplaterintherangeofmotion.Suchincreases
canoccurbecauseofinjury,andjointinstability,jointdegeneration,andmuscledysfunction(leadingto
lossofmuscularcontrolofthemovement).169Incontrast,thesizeoftheneutralzonemaybedecreased
byosteophyteformation,surgicalfusion,musclespasm,musclestrengthening,oradaptivetissue
shortening.
Elasticzone:thezoneinwhichthefirstbarrierorrestrictionofmovementoccurs.Thiszoneoccursatthe
endoftheneutralzoneafterthecrimphasbeentakenup,andtensionstartstobuildwithinthetissues.
Theelasticzoneextendsfromthecrimpareathroughthephysiologicalbarrier(endofactivemovement)
andtowardtheanatomicbarrier(endofpassivemovement).Theelasticzonecanbeincreasedbyinjuryto
thejointstructures,mobilizationtechniques,andmusclelengthening,andbedecreasedbyosteophyte
formation,surgicalfusionorrepair,musclehypertrophy,orimmobilization.
Plasticzone:thezoneinwhichdeformationofthetissueisextendedbeyondthetissueselasticrecoiland
thetissuebeginstodeform.Ifthedeformationissufficient,aninjurycanoccur.
Behavior
Theworkingrelationshipofadoorhingeanddoorstopisagoodanalogywhendescribingjointmotionbehavior,
inwhichthehingerepresentsthejoint,andthedoorstoprepresentstherestrictionimposedbytheintegrityofthe
jointandthesurroundingtissues.Justasthedoorstoppreventsthedoorfromswingingtoofaranddamagingthe
wall,theintegrityofthejointanditssurroundingstructuresservetopreventthejointmovingpastthenormal
rangeofmotionandincurringinjury.
Threedescriptorsareusedtodescribenormalandabnormaljointmotion:
Hypomobile.Ifthemovementofajointislessthanthatconsiderednormal,orwhencomparedwiththe
samejointontheoppositeextremity,itmaybedeemedhypomobile.Hypomobilitycanbesecondaryto
anyofthefollowing:170
Jointfixation.Thiscanoccurwhenthejointisstuckattheextremeoftherangeofmotion
secondarytoasuddenmacrotrauma,aprolongedorrepeatedmicrotrauma,oramicrotrauma
imposedoninstability.Clinicalfindingsassociatedwithajointfixationincludelimitationofgross
motionorconjunctrotationtowardthelimitation.Also,thecliniciannotesthattheendfeelinthe
directionoppositethefixationisabnormalandhasaratherfirmcapsularendfeel(seeChapter4).
Myofascialhypomobility.Thisiscausedbymuscleshortening(scars,contracture,oradaptivetissue
changes).Clinicalfindingsformyofascialhypomobilityincludeanelasticendfeelandaconstant
lengthphenomenon.Theconstantlengthphenomenonoccurswhentheamountofmovement
availableatonejointisdependentuponthepositioninwhichanotherjointisheld.Forexample,
duringasupinestraightlegraise,duetotheanatomy(length)ofthehamstrings,theamountof
availablehipflexionisdecreasedifthekneeismaintainedinafullyextendedpositionasopposed
towhenthekneeisallowedtoflex.
Articularhypomobility.Thiscanbecausedbyintraarticularswellingoranintraarticularbleed.
Clinicalfindingsforanarticularhypomobilityincludeaspasm,oremptyendfeel,often
accompaniedwithacapsularpattern(seeChapter4).Anarthrosisisalimitationofjointmotion
withoutinflammation.
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Pericapsularhypomobility.Thisiscausedbycapsularorligamentousshortening,whichcreatesa
capsularpatternofrestrictionthatdoesnotdemonstratetheconstantlengthphenomenon.Alsoa
prematurefirm/hardcapsularendfeelexistsifthejointisnotinflamed,orpossiblyaspasmendfeel
ifthejointisinflamed.
Hypermobile.Ajointthatmovesmorethanisconsiderednormal,orwhencomparedwiththesamejoint
ontheoppositeextremity,maybedeemedhypermobile.Laxity,afunctionoftheligamentandjoint
capsuleresistance,isatermusedtoimplythatanindividualhasanexcessivejointrangeofmotionbut
cancontrolthemovementofthejointinthatextrarange.Hypermobilitymayoccurasageneralized
phenomenonorbelocalizedtojustonedirectionofmovement,asfollows:
Generalizedhypermobility.Themoregeneralizedformofhypermobility,asitsnamesuggests,
referstothemanifestationsofmultiplejointhyperlaxity/hypermobility.Thistypeofhypermobility
canbeseeninacrobats,gymnasts,andthoseindividualswhoaredoublejointed.Also,
generalizedhypermobilityoccurswithgeneticdiseasesthatincludejointhypermobilityasan
associatedfinding,suchasEhlersDanlossyndrome(seeChapter5),osteogenesisimperfecta,and
Marfanssyndrome.
Localizedhypermobility.Localizedhypermobilityislikelytooccurasareactiontoneighboring
stiffness.Forexample,acompensatoryhypermobilitymayoccuratajointwhenaneighboringjoint
orsegmentisinjuredandbecomeshypomobile.Thisdecreaseinmovementoftheneighboringjoint
isoftentheresultofthebodysinitialresponsetotrauma,whichisareflexiveincreaseinthetone
ofthemusclesinanattempttostabilizetheaffectedarea.Overtime,theprolongedincreasedtonus
mayresultinadecreasedbloodsupplyandanincreaseinthebuildupoflacticacid.Also,the
nociceptorsresponseinthemuscleorthejointcapsulemayresultinaninhibitionofthesegmental
muscles,which,inturn,mayleadtouncoordinatedmovementsandproducemyofascialtrigger
points.
CLINICALPEARL
Adistinctionmustbemadebetweenlaxity,hypermobility,andflexibility.
Laxity:anormalfindingunlessassociatedwithsymptoms
Hypermobility:alaxityassociatedwithsymptomsmanifestedbythepatientsinabilitytocontroljoint
duringmovement,especiallyatendrange.171
Flexibilityisafunctionofcontractiletissueresistanceprimarily,butalsoasafunctionofligamentand
jointcapsuleresistance(seeChapter13).Twotypesarerecognized:171
Static:relatedtotheavailablerangeofmotioninoneormorejoints
Dynamic:relatedtostiffnessandeaseofmovement
Unstable.Incontrasttoahypermobilejoint,anunstablejointisassociatedwithapotentialorreal
pathologicstateasitinvolvesadisruptionoftheosseousandligamentousstructuresofthatjointasthe
resultofsomeappliedexternalload.Theterminstability,specificallyrelatedtothejoint,hasbeenthe
subjectofmuchresearch.172187Instabilityimpliesthatanindividualhasincreasedjointrangeofmotion
anddoesnothavetheabilitytostabilizethejoint(lossofneuromuscularcontrol).Thislossofcontrol
resultsinpain,weakness,andtransitorydeformity.Jointstabilitymaybeviewedasafactorofjoint
integrity,elasticenergy,passivestiffness,andmuscleactivation.
Jointintegrity.Jointintegrityisenhancedinthoseballandsocketjointswithdeepersockets,or
steepersides,asopposedtothosethatareplanarandshallower.Jointintegrityisalsodependenton
theattributesofthesupportingstructuresaroundthejoint,andtheextentofanylocaljointdisease.
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Onesuchstructureistheintraarticulardisk,whichispresentinanumberofjoints,includingthe
tibiofemoraljoint(meniscus),theacromioclavicularjoint,thetemporomandibularjoint,the
sternoclavicularjoint,andthedistalradioulnarjoint.
Muscleactivation.Musclesandtendons(seeChapter1)canprovidestaticstabilization(isometric
contraction)anddynamicstabilization(agonistconcentricandantagonisteccentriccontractions
seeChapter12).Passivestabilityisprovidedwhenthecontractileunitisonastretch.Intrinsic
musclefactorsaffectingstabilizationincludetemporalsummation,lengthtensionrelationships,
forcevelocityrelationships,andmusclearchitecture(seeChapter1).Muscleactivationcanprovide
twoformsofstabilizationthroughtheuseofstabilizerandmobilizermuscles.Thestabilizer
musclescontractfirsttoprovideastablebasefromwhichthemobilizermusclescanfunctionto
positionajointforfunctionaluse.Forexample,inthespine,thestabilizermusclesaredividedinto
twogroups:localstabilizersandglobalstabilizers(seeChapter28).168Fromarehabilitation
standpoint,beforeretrainingthemobilizermuscles,theclinicianmustensurethatthestabilizer
musclesareperformingcorrectly.Thisistheconceptbehindcorestabilizationorstabilization
retrainingprogressions(seeChapters12and14).
Passivestiffness.Passivestiffnessisprovidedbytheligaments,capsules,skin,joints,bones,and
othercollagenoustissue.Aninjurytothesepassivestructuresthatresultsinaninherentlossinthe
passivestiffnessresultsinjointlaxity.188Individualjointshaveapassivestiffnessthatincreases
towardthejointsendrange.Dysfunctionofthepassivesystemisduemostcommonlyto
mechanicalinjury,overuseorrepetitivestress,jointdegeneration,oradiseaseprocess(e.g.,
rheumatoidarthritis).168
Muscleactivation.Thecentralandperipheralnervoussystemsprovidecontrolthroughneural
feedforwardandfeedbackmechanismsfrombothactive(musclespindles,andGolgitendonorgans)
andpassivesystems(jointafferents)allofwhichhelpdetermineposition,load,andjointdemands,
whilesimultaneouslycontrollingthecontractilesystemtoinitiateconsciousandunconscious
movement(seeChapter3).168Muscleactivationincreasesstiffness,bothwithinthemuscleand
withinthejoint(s)itcrosses.189However,thesynergistandantagonistmusclesthatcrossthejoint
mustbeactivatedwiththecorrectandappropriateactivationintermsofmagnitudeortiming.A
faultymotorcontrolsystemmayleadtoinappropriatemagnitudesofmuscleforceandstiffness,
allowingajointtobuckleorundergosheartranslation.189
Pathologicbreakdownoftheabovefactorsmayresultinclinicalinstability.Instabilityismostobviousin
movementsthatareexecutedtooquicklyorincaseswheretheloadsplacedonthejointaretoogreatforthe
patienttocontrol.Forassessmentpurposes,instabilitycanbedividedintothreetypes:
Translationalreferstoalossofcontrolofthesmall,arthrokinematicjointmovementsthatoccurwhenthe
patientattemptstostabilizethejointduringmovement.
Anatomicalreferstoexcessiveorgrossphysiologicalmovementinthejoint,whichcanleadtoabnormal
patternsofcoupledandtranslationalmovements.190
Functionaloccurswhentheseverityoftheinstabilityadverselyaffectsapatientsfunctionandcaninclude
bothtranslationalandanatomicalinstability.Functionalinstabilitymayresultinthefollowing:191193
Longtermnonacutepainorshorttermepisodicpain
Earlymorningstiffness
Inconsistentfunctionanddysfunction(e.g.,fullrangeofmotionbutabnormalmovement,which
mayincludeangulation,hinging,ordeviation)
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Afeelingofapprehensionorgivingway.
MethodstoenhancejointstabilityareprovidedinChapter12.
Injury
Usingthedoorhingeandstopanalogyagain,itcanbeseenthatbothtoomuchmotion(resultingindamageto
thewall)andtoolittlemotion(resultinginaninabilitytogetthroughthedooropening)canbedisadvantageous.
Similarconsequencescanbeseenatajoint:ahypermobilejointmayhaveinsufficientstabilitytoprevent
damageoccurring,whereasahypomobilejointmayprovideinsufficientmotionatthejointforittobe
functional.Hypermobilejointsusuallypreservetheirstabilityundernormalconditions,remainingfunctionalin
weightbearing,andwithincertainlimitsofmotion.
Pathologicbarriers,whichcanoccuranywhereintherangeofmotion,arerestrictionstoamovementthatoccur
asaresultofapathologicprocess.Thecausesofpathologicbarriersincludemicrotraumaormacrotrauma,
musclespasm,edema,pain,andadaptiveshorteningorlengtheningofthetissue.Threetypesofpathologic
barriersarerecognized:168
Motionbarrier.Thistypeofbarrierisrelatedtomusclehypertonus,musclespasm,adaptivemuscle
shortening,intraarticularblock,ormusclepain.
Collagenbarrier.Thistypeofbarrierresultsfromapathologicprocessaffectingcollagenoustissues,and
usuallyresultsinadaptiveshorteningorpain,shiftingthemotionbarriertotheleft(earlierintotherange
ofmotion),resultinginadecreaseinrangeofmotion.
Neurodynamicbarrier.Thistypeofbarrieristheresultofapathologicprocessofneuraltissuesthatmust
undergolengtheningandshorteninginthecourseofrangeofmotionandismanifestedbythepresenceof
neurologicalsignsthatcommonlyrestrictmovementneuraltension(seeChapter11).
Healing
Thehealingofthejointsurfacesisdescribedinthenextsection(ArticularCartilageBehavior,Injury,Healing,
andTreatment).Inthosecaseswherethejointrestrictioniscausedbymusclehypertonus,musclespasm,
adaptivemuscleshortening,intraarticularblock,musclepain,adaptiveshorteningofthelocalandsurrounding
softtissues,neuraltension,thereareanumberofmanualtechniquesandprescribedexercisesthatcanaccelerate
thereturntofunction(seeChapters10and11).
Treatment
Itisessentialtodistinguishpatientswhohavegreatermobilityinalltheirjoints(generalizedhypermobility)
fromthosewhoforsomeotherreasonhaveoneorafewjointsthataremoremobilethantherest(localized
hypermobility).Whileinterventionisunlikelytobeeitherwarrantedorofbenefitwithgeneralized
hypermobility,theinterventionforalocalizedhypermobilityshouldaddressanyneighboringhypomobility.
ARTICULARCARTILAGEBEHAVIOR,INJURY,HEALING,AND
TREATMENT
Behavior
ArticularcartilageisanavascularandaneuraltissuecomposedofchondrocytesandECM.Articularcartilage
consistsoftwophases:afluidphaseandasolidphase.Wateristheprincipalcomponentofthefluidphase,
contributingupto80%ofthewetweightofthetissue.ThesolidphaseischaracterizedbytheECM,whichis
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porousandpermeable.194Inadults,thearticularcartilagematrixisseparatedfromthesubchondralvascular
spacesbythesubchondralplate.Thethicknessofthearticularcartilageatvariousjointsvaries.Forexample,the
articularcartilageofthekneeishighlyvariableinnature,withanaveragedepthof24mm.195Duetoits
avascularity,articularcartilagehaslowmetabolicactivityandpoorregenerativecapacity.194Nutritionofthe
articularcartilageoccursbydiffusionfromthesynovialfluid.Chondrocytes,whichaccountfor5%ofthewet
weightofarticularcartilage,areresponsibleforthedevelopment,maintenance,andrepairoftheECM(see
Chapter1).Withoutadirectsupplyofnutrientsfrombloodvesselsorlymphatics,chondrocytesdepend
primarilyonananaerobicmetabolism.Chondrocytesinloadedjointsexperiencehydrostaticcompressive,
tensile,andshearforces.
CLINICALPEARL
AgedeterminesthecompositionoftheECM,aswellastheorganizationofchondrocytesandtheirresponseto
externalfactorssuchascytokines.196Withincreasingage,therearezonalchangesinthedistributionof
chondrocytes,althoughthetotalnumberofchondrocytesremainsessentiallyunchanged.However,with
increasingage,thereisadecreaseinthehydrationofthematrix,withacorrespondingincreaseincompressive
stiffnessresultinginincreasedforcesfortheunderlyingsubchondralbone.197
Providedthejointloadforcesareappliedatanappropriatelevel,normalarticularcartilagestructure,and
functionwillbemaintained.Specifically,theintermittenthydrostaticpressureisbelievedtomaintainhealthy
cartilageincontrasttoshearstresses,prolongedstaticloading,ortheabsenceofloading.198Incontrast,
immobilizationresultsindegenerativechangesthataresimilartothoseseeninosteoarthritis(OA).The
developmentofdiseasesuchasOAisassociatedwithdramaticchangesincartilagemetabolism.Thisoccurs
whenthereisaphysiologicalimbalanceofdegradationandsynthesisbychondrocytes.199
Thebiomechanicalbehaviorsofarticularcartilagearebestunderstoodwhenthetissueisusedasabiphasic
medium(fluidandsolid).197Thesolidphasecontainscollagenandproteoglycanswhilethefluidphaseis
composedofwaterandions.Thesolidphasehashighfrictionalresistancetofluidflow,thuslowpermeability,
whichcausesahighinterstitialfluidpressurizationinthefluidphase.194Therelationshipbetweenproteoglycan
aggregatesandinterstitialfluidprovidescompressiveresistancetoarticularcartilagethroughnegative
electrostaticrepulsionforces.197Theinitialandrapidapplicationofarticularcontactforcesduringjointloading
causesanimmediateincreaseininterstitialfluidpressure,whichcausesthefluidtoflowoutoftheECM,
generatingalargefrictionaldragonthematrix.200Thisfluidpressureprovidesasignificantcomponentoftotal
loadsupport,therebyreducingthestressactinguponthesolidcollagenproteoglycanmatrix.201Whenthe
compressiveloadisremoved,interstitialfluidflowsbackintothetissue.Thelowpermeabilityofarticular
cartilagepreventsfluidfrombeingquicklysqueezedoutofthematrix,andthetwoopposingbonesand
surroundingcartilageconfinethecartilageunderthecontactsurface,whichservestorestrictmechanical
deformation.197
Articularcartilageisviscoelasticandexhibitstimedependentbehaviorwhensubjectedtoaconstantlocal
deformation.56
Themeniscus,whenpresentinajoint(itcanbefoundintheknee,temporomandibular,wrist,acromioclavicular,
andsternoclavicularjoints),playsanintegralroleinthehealthandfunctionofajoint.Inlaymanterms,the
meniscusisoftenreferredtoascartilage,especiallywhenreferencingtheknee(seeChapter20).Themeniscus
typicallyactstodispersejointloadsandreducefrictionduringmovement.
Injury
Asarticularcartilageisavascular,itisnotcapableofproducinganinflammatoryresponse,whichisan
importantcomponentofrepair.Multiplefactorsareinvolvedincartilagebreakdown,including:198
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AnimbalancebetweenECMsynthesisanddegradation.OAinvolvesafocallossofarticularcartilage
withthevariablereactionofthesubchondralbone.Specifically,OAisadiseaseprocessresultingfromthe
failureofchondrocytestorepairdamagedarticularcartilageinsynovialjoints.202Intheearlystagesof
chondrocyteinjury,damagetothecellularmembraneresultsinaninfluxofintracellularcontentsthat
causesadecreaseinthemetaboliccapacityofthecell,disruptingproteoglycanproductionand
concentration.195Increasedsynthesisofdestructivetissueproteasessuchasmatrixmetalloproteinases
increasedchondrocyteapoptosis,andinsufficientECMgeneration,resultinacartilagematrixthatis
unabletowithstandnormalmechanicalstresses.203Thisleadstoprogressivecartilageloss,subchondral
boneremodeling,osteophyteformation,andsynovialinflammation.204
Stressdeprivation(immobilization,bedrest)
Developmentaletiologiesleadingtoanabnormalforcetransmission(e.g.,developmentalhipdysplasia,
coxavalgus,genuvalgum)
Jointsurfaceincongruityandjointinstability
Disease(rheumatoidarthritis)
Injuriestothearticularcartilagecanbedividedintothreedistincttypes:
Type1injuries(superficial)involvemicroscopicdamagetothechondrocytesandECM(cellinjury).
Type2injuries(partialthickness)involvemicroscopicdisruptionofthearticularcartilagesurface
(chondralfracturesorfissuring).85Thistypeofinjuryhastraditionallyhadanextremelypoorprognosis
becausetheinjurydoesnotpenetratethesubchondralboneand,therefore,doesnotprovokean
inflammatoryresponse.85
Type3injuries(fullthickness)involvedisruptionofthearticularcartilagewithpenetrationintothe
subchondralbone,whichproducesasignificantinflammatoryprocess.85Thisinflammatoryprocess,OA,
isasignificanthealthproblemworldwide,affectingapproximately10%ofmenand18%ofwomenover
60daysofage.205OAtypicallyaffectsweightbearingjointsandisamajorcauseofmorbidity,disability,
andpain.206TheonsetofOAincreaseswithage,anduptohalfofpeopleover50yearsofagereport
symptomaticOA.206
CLINICALPEARL
Previousjointinjury,obesity,andoccupationalactivityhaveallbeenassociatedwithanincreasedriskofknee
andhipOA.However,levelsofphysicalactivityandsportsspecificityremaininconclusiveasriskfactors.207
Theclinicalsignsandsymptomsofanarticularinjuryincludeimpairedmobility,impairedmuscleperformance,
impairedbalance,andactivitylimitationsandparticipationrestrictions.Thedegreetowhichthepatientis
incapacitateddependsontheextentofthearticulardamage,andanycomorbiditythatnegativelyimpactsthe
clinicalcourse,suchasobesityandcardiovasculardisease.TwoofthemorecommonarticulardisordersareOA
andrheumatoidarthritis(RA)(seeChapter5).
MeniscalInjuries.Ameniscalinjurycanoccurinanyofthejointsinwhichitpresides,butitisthemeniscal
injuryofthekneethatisthemostcommonlyencounteredbythephysicaltherapist.Meniscaltearsattheknee
canleadtodisability,andtheirsurgicaltreatmentincreasesthelongtermriskofkneeOAfourfold(seeChapter
20).208Theabilityofameniscustohealisbasedlargelyonitsbloodsupply,whichisafactorofthelocationof
theinjury.Theouter2530%ofthemenisciisknowntobevascular.209Tearsinthevascularregionare
repairableaswellastearsextendingintotheavascularmidsubstanceifvascularityisstimulated.209Thevarious
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treatmentoptionsformeniscalinjuriesofthekneearedescribedinChapter20.Thevarioustreatmentoptions
formeniscalinjuriesofthetemporomandibularjointaredescribedinChapter26.
Healing
Thebodysresponsetoarticularcartilagedefectsresultingfromtraumauponimpactloadingdependsonthe
lesiondepth.198However,itiswellknownthatthecapacityofcartilageforrepairislimited.Thehealingof
articularcartilageisdescribedhere.Injuriesofthearticularcartilagethatdonotpenetratethesubchondralbone
becomenecroticanddonotheal.Theselesionsusuallyprogresstothedegenerationofthearticularsurface.210
Althoughashortlivedtissueresponsemayoccur,itfailstoprovidesufficientcellsandmatrixtorepaireven
smalldefects.211,212
Injuriesthatpenetratethesubchondralboneundergorepairasaresultofaccesstothebloodsupplyofthebone.
Theserepairsusuallyarecharacterizedasfibrous,fibrocartilaginous,orhyalinelikecartilaginous,dependingon
thespecies,theage,andthelocationandsizeoftheinjury.213However,thesereparativetissues,eventhosethat
resemblehyalinecartilagehistologically,differfromnormalhyalinecartilagebothbiochemicallyand
biomechanically.Thus,by6months,fibrillation,fissuring,andextensivedegenerativechangesoccurinthe
reparativetissuesofapproximatelyhalfofthefullthicknessdefects.214,215Similarly,thedegeneratedcartilage
seeninosteoarthrosisdoesnotusuallyundergorepairbutinsteadprogressivelydeteriorates.210
CLINICALPEARL
Viscosupplementation,orintraarticularinjectionsofhyaluronicacid,hasbeenusedtotreatOA.Theproposed
mechanismsofactionresultsinthephysicalpropertiesofthehyaluronicacid,aswellastheantiinflammatory,
anabolic,localanalgesic,andchondroprotectiveeffects.85Numerousstudieshavesupportedtheeffectivenessof
otherpotentialchondroprotectiveagentsincludingchondroitinsulfateandglucosaminesulfateforthereliefof
symptomsofOAbasedonclinicaltrialsandshorttermfollowup.85
Treatment
TheprevalentstrategyformanagingOAistoexhaustconservativemeasurestodelaymajorreconstructivejoint
surgery,particularlyinyoungeradults.216Pharmacologicalpaincontrolremainsthemainstayoftreatmentfor
symptomatickneeOA,specificallyNSAIDs,opioidanalgesics,andintraarticularcorticosteroidinjections.216
Attheknee,inpatientswithmedialunicompartmentalOA,valgusunloaderbracesareusedtoreduceexternal
varusmomentsandmedialcompartmentloadtoimprovepainandfunction.216Intraarticular
viscosupplementationhasbecomeincreasinglycommonforthetreatmentofsymptomatickneeOA,butits
efficacyremainscontroversial.217,218Morerecently,therehasbeenincreasedfocusonthepotentialroleof
mesenchymalstemcellsinthemanagementofOA.
AppropriatesurgicalmanagementofOAisdeterminedbyspecificpatientssymptoms,clinicalandradiographic
findings,circumstances,andexpectations.216Forexample,whileayoungerpatientwithanisolateduni
compartmentalOAatthekneemaybenefitfromahightibialosteotomyorunicompartmentalknee
arthroplasty,apatientwithadvanced,multiplecompartmentalOAismorelikelytobenefitfromatotalknee
arthroplasty.
Fromaphysicaltherapyperspective,therehabilitationprotocolsdifferbylesionlocationandbysurgical
technique(seeChapters19and20),butthecommongoalsofconservativetreatmentaretodecreasejointpain
andimprovefunctionthroughacombinationofmodalities,patienteducation,lowimpactaerobicexercise,and
rangeofmotionandstrengtheningexercises.
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BONEBEHAVIOR,INJURY,HEALING,ANDTREATMENT
Behavior
Fromdevelopmenttodegradation,bonehealthisinfluencedbydiet,hormonelevels,andbiomechanics.219
Bonematrixcomprisesthreeelements:organic,mineral,andfluid.Aboneofhighmineraldensitymaybeless
likelytoendureastressinjurybecauseitcanbetterwithstandrepetitiveapplicationsofforce.Itisthemineral
contentthatdistinguishesbonefromotherconnectivetissues,andprovidesthebonewithitscharacteristic
stiffnesswhileprovidingamineralstoragesystem.Collagenorientationingrowingandmaturebonehasbeen
linkedtothemechanicalbehaviorofindividuallayersofbone(lamellae),andthedifferenttypesofbone.
Duringnormalactivity,corticalbonesustainsloadswellwithinthelinearregionoftheloaddeformationcurve
(Fig.22),sothatthebonebendsbutdoesnotsustainpermanentdeformation(elasticdeformation).However,
evenwhenmaintainedwithinthelinearregion,ifloadsaresustainedrepetitivelyoverashortperiod,changesin
thebonemayresult(plasticdeformation).Forexample,compressiveforcesshortenbone,andtensileforces
elongatebone.Boneisstrongestincompressionandweakestintension.
Whenloadsaresustainedthatexceedthelinearregion,microarchitecturaldamagecanoccur.Trabecular,or
cancellousbone,isanisotropicinnature,whichmeansitsmechanicalbehaviordiffersindifferentdirections,or
amongvariouspartsofthestructure.
CLINICALPEARL
Exerciserelatedincreasesincorticalthicknessandbonemineralcontentsuggestthatexercisecanbeapotent
stimulusforboneremodeling.220
Injury
Asignificantinjurytoaboneisreferredtoasafracture.Somedifferenttypesoffracturesandfracturepatterns
arerecognized(Fig.24)(Table25).Ofallthedifferenttypesoffractures,thestressfractureistheonemost
commonlyencounteredbythephysicaltherapist.Astressfractureisafatiguefractureofabonecausedby
repeatedsubmaximalstress.221Theforcerequiredtogenerateastressfractureislessthanthemaximum
toleratedbybone,butitsrepetitiveapplicationcausesadisruptioninthebonehomogeneity.222Stressfractures
havebeensuggestedtoaccountforapproximately10%ofallathleticinjuries.223226Althoughthesiteofstress
fracturevarieswithdifferentsportsandactivities,8090%ofstressfracturesoccurinthelowerlimbs,withthe
tibiabeingthemostcommonlyinjuredbone,accountingforapproximately50%ofallcases.227Clinically,
stressfracturescanbedifficulttodiagnoseduetoawiderangeofpotentialdifferentialdiagnoses,includingsoft
tissueinjuries,compartmentsyndromes,infection,andotheroveruseconditions.Thus,thediagnosisofastress
fractureiscontingentuponadetailedclinicalexaminationthatincorporatesthepatienthistoryandcontributing
riskfactors,aswellasathoroughphysicalexamination,andismostoftenconfirmedwithradiologicalimaging
(scintigraphy,orMRI).227Aprematurereturntofullactivitymayincreasetheriskofcomplications.219For
example,ifacompleteunionisnotobtainedpriortoreturntofullactivity,anathleterisksdelayedunionor
nonunion.221Becauseoftheirtendencytohavenonunionordelayedunion,certainstressfracturesareclassified
ashighrisk,including:219
FIGURE24
Fracturetypes.A:Transverse.B:Oblique.C:Spiral.D:Comminuted.E:Avulsion.
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TABLE25TypesofFractures
Typesof
Description
Fracture
Avulsion Aninjurytothebonewhereatendonorligamentpullsoffapieceofthebone.
Whenthereisaclosedfracturethereisnobrokenskinthefracturedbonedoesnotpenetrate
Closed
theskin(butmaybeseenundertheskin)andthereisnocontusionfromexternaltrauma.
Afracturethathasmorethantwofragmentsofbonewhichhavebrokenoff.Itisahighly
Comminuted
unstabletypeofbonefracturewithmanybonefragments.
Complete Afractureinwhichthebonehasbeencompletelyfracturedthroughitsownwidth.
Complex Thistypeoffracturedboneseverelydamagesthesofttissuewhichsurroundsthebone
Thebonebreaksandfragmentsofthebonepenetratethroughtheinternalsofttissueofthebody
Compound
andbreakthroughtheskinfromtheinside.Thereisahighriskofinfectionifexternalpathogenic
(open)
factorsenterintotheinteriorofthebody.
Occurswhentheboneiscompressedbeyonditslimitsoftolerance.Thesefracturesgenerally
occurinthevertebralbodiesasaresultofaflexioninjuryorwithouttraumainpatientswith
Compression
osteoporosis.Compressionfracturesofthecalcaneusarealsocommonwhenpatientsfallfroma
heightandlandontheheel.
Afractureoftheepiphysisandphysisgrowthplate.Theseinjuriesareclassifiedusingthe
Epiphyseal
SalterHarrisclassification.
Thepathologyofthistypeoffractureincludesanincompletefractureinwhichonlyonesideof
thebonebreaks.Theboneusuallyisbentandonlyfracturedoftheoutsideofthebend.Itis
Greenstick
mostlyseeninchildrenandisconsideredastablefractureduetothefactthatthewholebonehas
notbeenfractured.Aslongastheboneiskeptrigid,healingisusuallyquick.
Thisbonefractureinvolvesminimaltraumatotheboneandsurroundingsofttissues.Itisan
incompletefracturewithnosignificantbonedisplacementandisconsideredastablefracture.In
Hairline
thistypeoffracturethecrackonlyextendsintotheouterlayerofthebonebutnotcompletely
throughtheentirebone.ItisalsoknownasaFissurefracture.
Occurswhenonefragmentisdrivenintoanother.Thistypeoffractureiscommonintibial
Impaction
plateaufractures.
Oblique Afracturewhichgoesatanangletotheaxisofthebone.
Apathologicfractureoccurswhenabonebreaksinanareathatisweakenedbyanotherdisease
Pathologic process.Causesofweakenedboneincludetumors,infection,osteoporosisorosteopenia,and
certaininheritedbonedisorders.
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Typesof
Description
Fracture
Inthispattern,abonehasbeenbrokenduetoatwistingtypemotion.Itishighlyunstableand
Spiral maybediagnosedasanobliquefractureunlessacorrectxrayhasbeentaken.Thespiralfracture
resemblesacorkscrewtypewhichrunsparallelwiththeaxisofthebrokenbone.
Thesefracturesmayextendthroughalloronlypartofthewaythroughthebone.Thesetypesof
fracturesarefarmorecommoninwomen.Theyoftenoccurinthespine,andlowerextremity
(mostofteninthefibula,tibia,ormetatarsals).Stressfracturesoccurinavarietyofagegroups,
Stress rangingfromyoungchildrentoelderlypersons.Stressfracturesdonotnecessarilyoccurin
associationwithahistoryofincreasedactivity.Therefore,itisimportanttorememberthatthe
absenceofahistoryoftraumaorincreasedactivitydoesnoteliminatethepossibilityofstressor
insufficiencyfractureasacauseofmusculoskeletalpain.
anteriortibialdiaphysis
lateralfemoralneck
patella
medialmalleolus
navicular
fifthmetatarsalbase
proximalsecondmetatarsal
sesamoids(greattoe,tibial)
talus
femoralhead
Lowriskstressfracturesincludethefollowing:
posteromedialtibial
metatarsals
calcaneus
cuboid
cuneiform
fibula
medialfemoralneck
femoralshaft
pelvis
CLINICALPEARL
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Numerousstudieshavesuggestedthattheuseofultrasoundoratuningforkcanbeusedforthediagnosisof
stressfractures.Withultrasound,theelicitationofpainastheultrasoundisappliedoverthefracturesitehas
beensuggestedtobeagooddiagnosticindicatorofanunderlyingstressfracture.Thevibrationofatuningfork
overthedamagedperiosteumtoproducepainhasalsobeenadvocatedasadiagnostictool.However,the
findingsfromastudybySchneidersetal.227didnotsupportthespecificuseofultrasoundoratuningforkas
standalonediagnostictests.
Anotherfracturetypethatcanbeseenintheclinic,especiallyinthoseindividualswithknownosteoporosisor
osteopenia,isthepathologicalfracture(seeChapter5).
Healing
Bonehealingisacomplexphysiologicprocessthatfollowsanorderlycascadeofevents.Thestrikingfeatureof
bonehealing,comparedwithhealinginothertissues,isthatrepairisbytheoriginaltissue,notscartissue.
Regenerationisperhapsabetterdescriptorthanrepair.Thisislinkedtothecapacityforremodelingthatintact
bonepossesses.Likeotherformsofhealing,therepairofbonefractureincludestheprocessesofinflammation,
repair,andremodelinghowever,thetypeofhealingvaries,dependingonthemethodoftreatment.Inclassic
histologicterms,fracturehealinghasbeendividedintotwobroadphases:primaryfracturehealingand
secondaryfracturehealing(Fig.25).
FIGURE25
Fracturehealing.
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Primaryosteonal(cortical)healing,involvesadirectattemptbythecortextoreestablishitselfonceithas
becomeinterrupted.Inprimarycorticalhealing,boneononesideofthecortexmustunitewithboneon
theothersideofthecortextoreestablishmechanicalcontinuity.
Secondarycallushealinginvolvesresponsesintheperiosteumandexternalsofttissueswiththe
subsequentformationofacallus.Themajorityoffractureshealbysecondaryfracturehealing.
Withinthesebroaderphases,theprocessofbonehealinginvolvesacombinationofintramembranousand
endochondralossification(seeChapter1).Thesetwoprocessesparticipateinthefracturerepairsequencebyat
leastfourdiscretestagesofhealing:thehematomaformation(inflammationorgranulation)phase,thesoft
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callusformation(reparativeorrevascularization)phase,thehardcallusformation(maturingormodeling)phase,
andtheremodelingphase.228
Hematomaformation(inflammatory)phase.Initially,thetissuevolumeinwhichnewboneistobe
formedisfilledwiththematrix,generallyincludingabloodclotorhematoma(Fig.25).85Atthisphase,
thematrixwithintheinjurysiteisborderedbylocaltissues,whichalsoareoftentraumatizedresultingin
focalnecrosisandreducedbloodflow.85Aneffectivebonehealingresponsewillincludeaninitial
inflammatoryphasecharacterizedbythereleaseofavarietyofproducts,includingfibronectin,PDGF,
andTGF,anincreaseinregionalbloodflow,invasionofneutrophilsandmonocytes,removalofcell
debris,anddegradationofthelocalfibrinclot.
Softcallusformation(reparativeorrevascularization)phase.Thisphaseischaracterizedbythe
formationofconnectivetissues,includingcartilage,andformationofnewcapillariesfrompreexisting
vessels(angiogenesis).Duringthefirst710daysoffracturehealing,theperiosteumundergoesan
intramembranousboneformationresponse,andhistologicevidenceshowsformationofwovenbone
opposedtothecortexwithinafewmillimetersofthesiteofthefracture.Anydifferentiationisstrongly
influencedbythelocaloxygentensionandthemechanicalenvironment,aswellasbysignalsfromlocal
growthfactors.85Bythemiddleofthesecondweek,abundantcartilageoverliesthefracturesite,andthis
chondroidtissueinitiatesbiochemicalpreparationstoundergocalcification.Thus,thecallusbecomesa
triplelayeredstructureconsistingofanouterproliferatingpart,acartilaginousmiddlelayer,andaninner
portionofnewbonytrabeculae(Fig.25).Thecartilageportionisusuallyreplacedwithbonetissueasthe
healingprogresses.
Hardcallusformation(modeling)phase.Thisphaseischaracterizedbythesystematicremovalofthe
initialmatrixandtissuesthatformedinthesite,primarilythroughosteoclasticandchondroclasts
resorption,andtheirreplacementwithmoreorganizedlamellarbone(wovenbone)alignedinresponseto
thelocalloadingenvironment.85Thecalcificationoffracturecalluscartilageoccursbyamechanism
almostidenticaltothatwhichtakesplaceinthegrowthplate.Thiscalcificationcanoccureitherdirectly
frommesenchymaltissue(intramembranous)orviaanintermediatestageofcartilage(endochondralor
chondroidroutes).Osteoblastscanformwovenbonerapidly,buttheresultisrandomlyarrangedand
mechanicallyweak.Nonetheless,bridgingofafracturebywovenboneconstitutesthesocalledclinical
union.Oncecartilageiscalcified,itbecomesatargetfortheingrowthofbloodvessels.Radiographically,
afractureisconsideredhealedwhenthereisprogressivecallusformationtothepointwherethefracture
lineisnolongervisible.
Remodelingphase.Byreplacingthecartilagewithbone,andconvertingthecancellousboneintocompact
bone,thecallusisgraduallyremodeled.Duringthisphase,thewovenboneisremodeledintothestronger
lamellarbonebytheorchestratedactionofosteoclastboneresorptionandosteoblastboneformation(Fig.
25).
Radiologicallyorhistologically,fracturegapbridgingoccursbythreemechanisms228:
1.Intercorticalbridging(primarycorticalunion).Thismechanismoccurswhenthefracturegapisreduced
bynormalcorticalremodelingunderconditionsofrigidfixation.Thismodeofhealingistheprinciple
behindrigidinternalfixation.229
2.Externalcallusbridgingbynewbonearisingfromtheperiosteumandthesofttissuessurroundingthe
fracture.Smalldegreesofmovementatthefracturestimulateexternalcallusformation.230Thismodeof
healingistheaiminfunctionalbracing231andintramedullarynailing.
3.Intramedullarybridgingbyendostealcallus.Normalperiodsofimmobilizationfollowingafracture
rangefromasshortas3weeksforsmallbonestoabout8weeksforthelongbonesoftheextremities.
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Oncethecastisremoved,itisimportantthatcontrolledstressescontinuetobeappliedtothebone
becausetheperiodofbonehealingcontinuesforupto1year.232,233
Thethreekeydeterminantsoffracturehealingarethebloodsupplyandthedegreeofmotionexperiencedbythe
fractureends.
Angiogenesisistheoutgrowthofnewcapillariesfromexistingvessels.Thedegreeofangiogenesisthat
occursdependsonwellvascularizedtissueoneithersideofthegapandsufficientmechanicalstabilityto
allownewcapillariestosurvive.Angiogenesisleadstoosteogenesis.
Theamountofmovementthatoccursbetweenfractureendscanbestimulatoryorinhibitorytothe
cascadeofboneformation,dependingontheirmagnitude.Excessiveinterfragmentarymovementprevents
theestablishmentofintramedullarybloodvesselbridging.However,smalldegreesofmicromotionhave
beenshowntostimulatebloodflowatthefracturesiteandstimulateperiostealcallus.234Thisconceptis
exploitedbysomeavailablebonestimulators(seeAugmentedHealing).Successfulrestorationofosseous
morphologyandinternalarchitectureisconditionalontheremodelingprocess.AccordingtoWolffslaw,
boneremodelsalonglinesofstress.235Boneisconstantlybeingremodeledasthecircumferentiallamellar
boneisresorbedbyosteoclastsandreplacedwithdenseosteonalbonebyosteoblasts.236
Theenvironmentisanotherfactor,whichmodulatestherepairprocesshormoneshaveanimpacton
osteoblasticandosteoclasticactivities(Table26).
TABLE26TheEffectofHormonesonHealing
Hormone EffectonHealing Mechanism
Calcitonin Positive Decreasedosteoclasticactivity
Thyroidhormone Positive Increasesrateofboneremodeling
Parathyroidhormone Positive Increasesrateofboneremodeling
Growthhormone Positive Increasesamountofcallus
DatafromFrenkelSR,KovalKJ.Fracturehealingandbonegrafting.In:SpivakJM,DiCesarePE,Feldman
DS,etal.,eds.Orthopaedics:AStudyGuide.NewYork,NY:McGrawHill1999:2328.
AugmentedHealing
Todate,sometechniqueshavebeendevelopedtoaccomplishaquickerandmorecompletehealingoffractures.
Theseincludethefollowing:
Pulsedelectromagneticfields(PEMF).Atechniquemostcommonlyusedforthetreatmentofnonunion
fractures,failedfusions,andcongenitalpseudarthrosis.PEMFuseselectricalenergytodirectaseriesof
magneticpulsesthroughinjuredtissuesuchthateachmagneticpulseinducesatinyelectricalsignalthat
stimulatescellularrepair.
Ultrasound.Thereissomeevidencethatpulsedultrasoundmayreducefracturehealingtimeforfractures
bystimulatingalocalhyperemia,anincreaseinaggregategeneexpression,increasedmineralization,and
morerapidendochondralossification.237
Directcurrent.Directcurrentstimulationsurroundingthefracturesitehasbeenobservedtodecreasethe
oxygentensionwithaconcomitantriseinlocalpHintheregionoftheanode.238,239
Demineralizedbonematrix(DBM).DBMderivedfromhumantissueshasdemonstratedtheabilitytoaid
inthestimulationofanosteoinductiveandanosteoconductiveresponseallowingforimprovedbone
growthandfusion.240242Therearecurrentlytwotypes:
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Osteoinductive:thereareseveralcommerciallyavailableDBMsubstances,eachwithdifferent
amountsofDBMcontainingosteoinductiveproteins.
Osteoconductive:osteoconductivityreferstotheabilityofsomematerialstoserveasascaffold
ontowhichbonecellscanattach,migrate,andgrowanddivide.Inthisway,thebonehealing
responseisconducted,throughthegraftsite.
Treatment
Decidingthemodeoffracturemanagementrequiresamultifacetedapproach.Theinitialmedicalapproach
involvesstabilizationofthefracturesite,whichpreventsfurtherbloodlossandresetsmuscletension.The
medicalteamdecideswhethersurgeryisrequiredorwhetheraconservativeapproach,suchascastingwouldbe
morebeneficial.Ifcastingischosen,thepatientmaybereferredforphysicaltherapy.Duringtheperiodof
casting,submaximalisometricsareinitiated.Onceaclinicalunionhasbeenconfirmed(thefracturelineisno
longervisible),therangeofmotionexercisesareusuallyinitiated.
SurgicalOptionsforFractures
Theadvantageofoperativetreatmentistheanatomicalreductionoffracturefragmentsandearlymobilization.
PercutaneousPinning
Percutaneouspinningisaminimallyinvasiveformofinternalfixationinwhichfracturesarepinnedusing
Kirschnerwires.Thepinsaredriventhroughtheskinandcortexofthebone,acrossthereducedfracture,and
intotheoppositecortex.243Thismodeiscommonlyusedinfracturesofthephalanges,metacarpals,distal
radius,proximalhumerus,andmetatarsals.Thedisadvantageofthistypeoftreatmentisthatthepinscanbend
orbreak,andtheycannotprovideabsolutestability.
ExternalFixation
Thismodeoftreatmentmaintainstractionandalignmentofthebonewithouttheneedtoconfinethepatienttoa
bed.Thethreadedtractionpinsareinsertedintotheboneproximalanddistaltothefracturesite,andthefracture
ismanuallyreducedandfixedinpositionwithcarbonfiberbarsspanningthefracturesiteoutsidetheskin.243
Usingfinewiresinacircularfixator,acrossthesubchondralmetaphysis,istheleastdamagingtothemedullary
bloodsupply.228Thistypeoffixationmayprovideenoughstabilitytoallowrapidendostealhealingwithout
externalcallus.244
OpenReductionandInternalFixation
Theaimofthismodeoftreatmentistoreduceanatomicallyandprovideabsolutestabilitytoasmanyofthe
fracturefragmentsaspossible.243Afracturethatisrigidlyinternallyfixedproducesnoperiostealcallusand
healsbyacombinationofendostealcallusandprimarycorticalunion.228
LockingPlates
Lockingplatesarefracturefixationdeviceswiththreadedscrewholes,whichallowscrewstothreadtotheplate
andfunctionasafixedanglescaffold.
IntramedullaryNailing
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Fracturefixationwithintramedullarynailsproviderelativestabilityunlessthenailislockedproximallyand
distallyandhastightfixationatthefracturesite,thefixationmayhaverotationalandangularinstability.243An
intermedullarynailblocksendostealhealingbutallowsenoughmovementtotriggerperiostealcallus.228Early
mobilizationofpatientsafterfemoralandtibialroddingisamajoradvancecomparedtotheprolonged
immobilizationintraction.243
NonoperativeOptionsforFractures
Nonoperativetreatmentisusuallyreservedfornondisplacedfractureswithalowriskofdisplacement,for
displacedfracturesthatarestableafteracceptablereductionisachieved,orforpatientsforwhomanesthesiaand
surgeryarecontraindicated.243Mostfractures,especiallyintheupperextremity,canbemanagedwithout
surgeryifacceptablereductioncanbeachievedbyclosedmeans.Avarietyofnonoperativedevicescanbeused
totreatfractures:243
Splintsandfracturebraces:noncircumstantialcoapteddevicesthatliealongoneormoresurfacesofan
extremitythataremadeofprefabricatedmaterial(moldedplastic)orplaster,andsecuredwithanelastic
bandage.Theaimofthistypeofsplintingistoimmobilizeorpassivelycorrectstablefractures,andtheir
useisusuallytemporary,usedfordaystoafewweeks.
Castingprovidesrigidcircumferentialsupportintowhichappropriateholesandthreepointfixationcanbe
incorporated.Castingmoreeffectivelyimmobilizesfracturefragmentsthaneithersplintingorbracing.
Castingisparticularlyusefulformaintainingreductionoftheankle,tibia,pediatricforearm,anddistal
radiusfractures.
Skeletaltractionisappliedeithermanuallyorviaweightsandpulleystoovercometheshorteningforceof
musclesacrossthefracturesite.Theconfigurationoftheskeletaltractionvariesaccordingtothespecific
boneinvolved,butitsuseisdwindlingduetothesuccessfuldevelopmentofsurgicalreductionand
internalfixation.
POSTSURGICALHEALING
Althoughmanymusculoskeletalconditionscanbetreatedconservatively,surgicalinterventionisoftenindicated
forcasesinwhichasufficienttraumaticordegenerativeinjuryhasoccurred.Overtheyears,thenumberof
surgicalproceduresfororthopaedicconditionshasincreasedconsiderably.However,althoughsurgerycanoften
correctthepresentingproblem,forthepostsurgicalpatienttoreturntoanappropriateleveloffunction,some
formofpostsurgicalrehabilitationisusuallyrequired.Indeed,anumberofstudieshavereportedthatskilled
interventionfollowingmostsurgicalproceduresofthemusculoskeletalsystemallowsapatienttoachieve
greaterindependenceandcontroloverhisorherlifeinashortertimeframethanpatientswhodonotreceive
theseinterventions.245,246
PostsurgicalComplications
Althoughsurgicalprocedurescanoffermanybenefits,theyarenotwithouttheircomplications.Someofthe
moreseriousofthesecomplicationsincludethefollowing:
Postsurgicalinfection.Postsurgicalinfectionsareperhapsthegreatestchallengefacingthemodernday
surgeon.Atanyonetime,9%ofhospitalizedpatientsarebeingtreatedforanosocomial
infection.247Staphylococcusaureus,coagulasenegativestaphylococci,Enterococcusspp.,and
Escherichiacoliremainthemostfrequentlyisolatedpathogens.Anincreasingproportionofinfectionsare
causedbyantimicrobialresistantpathogens,suchasmethicillinresistantS.aureus(MRSA),orby
Candidaalbicans.248Microorganismsmaycontainorproducetoxinsandothersubstancesthatincrease
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theirabilitytoinvadeahost,producedamagewithinthehost,orsurviveonorinhosttissue.Forexample,
manygramnegativebacteriaproduceanendotoxinthatstimulatescytokineproduction.Inturn,cytokines
cantriggerthesystemicinflammatoryresponsesyndromethatsometimesleadstomultiplesystemorgan
failures.248Incertainkindsofsurgicalprocedures,somepatientcharacteristicshavebeenfoundtobe
possiblyassociatedwithanincreasedriskofaninfection.Theseincludecoincidentremotesiteinfections
orcolonization,diabetes,cigarettesmoking,systemicsteroiduse,obesity(>20%ofidealbodyweight),
extremesofage,poornutritionalstatus,andperioperativetransfusionofcertainbloodproducts.248250
Althoughphysicaltherapistsarenotdirectlyinvolvedinsurgicalprocedures,theyareapotentialmodeof
transmissionforinfections.Handwashinghasbeenfoundtobeanimportantinfectioncontrolmeasure,
althoughimprovingcompliancewithhandwashinghasbeenachallengeformosthospitalinfection
controlprograms.251
Venousthromboembolism.Athrombus,orbloodclot,isanobstructionofthevenousorarterialsystem.If
athrombusislocatedinoneofthesuperficialveins,itisusuallyselflimiting.Venousthromboembolism
isavasculardiseasethatmanifestsasdeepveinthrombosis(DVT)orpulmonaryembolism(PE).ADVT
mostcommonlyappearsinthelowerextremityandistypicallyclassifiedasbeingeitherproximal
(affectingthepoplitealandthighveins)ordistal(affectingthecalfveins).ProximalDVTisthemost
dangerousformoflowerextremityDVTbecauseitismorelikelytoprovokealifethreateningPE(see
later).
CLINICALPEARL
DVTiscausedbyanalterationinthenormalcoagulationsystem.Thisalterationinthefibrinolyticsystem,
whichactsasasystemofchecksandbalances,resultsinafailuretodissolvetheclot.Iftheclotbecomes
dislodged,itentersintothecirculatorysystemthroughwhichitcantraveltobecomelodgedinthelungs(PE),
obstructingthepulmonaryarteryorbranchesthatsupplythelungswithblood.Iftheclotislargeandcompletely
blocksavessel,itcancausesuddendeath.
CertainpatientsareatincreasedriskforDVT:252256
Strongriskfactorsincludeafracture(pelvis,femur,andtibia),hiporkneereplacement,majorgeneral
surgery,majortrauma,orspinalcordinjury.Arecentstudyindicatedthatupto60%ofpatients
undergoingtotalhipreplacementsurgerymaydevelopaDVTwithoutpreventativetreatment.257,258
Moderateriskfactorsincludearthroscopickneesurgery,centralvenouslines,chemotherapy,congestive
heartorrespiratoryfailure,hormonereplacementtherapy,malignancy,oralcontraceptivetherapy,
cerebrovascularaccident,pregnancy/postpartum,previousvenousthromboembolism,andthrombophilia.
Weakriskfactorsincludebedrestgreaterthan3days,immobilityduetositting(e.g.,prolongedair
travel),increasingage,laparoscopicsurgery,obesity,pregnancy/antepartum,andvaricoseveins.
TheassociationofDVTwithvenousstasis,vesselwalldamage,andhypercoagulabilitywasfirstproposedby
Virchowin1859.259
CLINICALPEARL
Venousstasis:themajorcontributingfactorsthatincreasebloodpoolinginthelowerextremitiesaregeneral
anesthesiaassociatedwithadecreaseinbloodflowvelocity,increasedage,hypotension,varicosities,congestive
heartfailure,postsurgicalimmobility,andpossiblyobesity.
Vesselwalldamage:severalintraoperativefactorsduringhipsurgery,suchaslimbpositioning,hipdislocation,
localtrauma,andretractionoflocalstructuresanteriortothehiphavebeendemonstratedtoleadtofemoralvein
injuryandsubsequentendothelialdamage.260
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Hypercoagulability:avarietyofcongenitalandacquiredconditionsareassociatedwithhypercoagulablestates,
includingabnormalitiesoffibrinogenand/orplasminogen,adenocarcinoma,pregnancy,systemiclupus
erythematosus,andnephroticsyndrome.
TwothirdsofthefatalitiesresultingfromDVToccurwithin30minutesoftheinitialsymptoms.261263Both
DVTandPEcanbesymptomaticorasymptomatic.ClinicalsignsofaDVThavetraditionallybeendescribedas
includingswellingoftheextremity,tenderness,orafeelingofcrampingofthecalfmusclesthatincreaseswhen
theankleisdorsiflexed(positiveHomanssign)orwithweightbearing,vascularprominence,elevated
temperature,tachycardia,andinflammationanddiscolorationorrednessoftheextremity.However,apurely
clinicaldiagnosisisfraughtwithahighincidenceoffalsepositivesandnegatives.Musculoskeletalconditions
thatmaymimicsymptomsassociatedwithDVTincludehematoma,myositis,tendinopathy,Bakerscyst,
synovitis,osteomyelitis,andtumors.264TheclinicaldecisionruledescribedbyWellsetal.(Table27)265269is
beingmostcommonlyrecommendedforoutpatientssuspectedofhavingDVT.270,271Moreaccuratediagnostic
procedures,outsidethescopeofphysicaltherapy,includecontrastvenography,DopplerandBmodeultrasound,
venousdupleximaging,impedanceplethysmography,andI125fibrinogenuptake.
TABLE27ClinicalDecisionRuleforOutpatientsSuspectedofHavingaProximalDeepVeinThrombosis
ClinicalFinding Scorea
Activecancer(within6monthsofdiagnosisorpalliativecare) 1
Paralysis,paresis,orrecentplasterimmobilizationoflowerextremity 1
Recentlybedridden>3daysormajorsurgerywithin4weeksofapplicationofclinicaldecisionrule 1
Localizedtendernessalongdistributionofthedeepvenoussystem(assessedbyfirmpalpationinthe
centeroftheposteriorcalf,thepoplitealspace,andalongtheareaofthefemoralveinintheanterior 1
thighandgroin)
Entirelowerextremityswelling 1
Calfswellingby>3cmcomparedwithasymptomaticlowerextremity(measured10cmbelowtibial
1
tuberosity)
Pittingedema(greaterinthesymptomaticlowerextremity) 1
Collateralsuperficialveins(nonvaricose) 1
AlternativediagnosisaslikelyorgreaterthanthatofDVT(mostcommonalternativediagnoseson
2
cellulitis,calfstrain,andpostoperativeswelling)
aScoreinterpretation:0,probabilityofproximallowerextremitydeepveinthrombosis(PDVT)of3%(95%
confidenceinterval=1.75.9%)1or2,probabilityofPDVTof17%(95%confidenceinterval=1223%)3,
probabilityofPDVTof75%(95%confidenceinterval=6384%).
DatafromWellsPS,AndersonDR,BormanisJ,etal.Valueofassessmentofpretestprobabilityofdeepvein
thrombosisinclinicalmanagement.Lancet.350:17951798,1997.
PreventionisthekeywithDVT.Methodsofpreventionmaybeclassifiedaspharmacologicaland
nonpharmacological.PharmacologicalpreventionincludesanticoagulantdrugssuchaslowdoseCoumadin
(warfarin),lowmolecularweightheparin,adjusteddoseheparin,andheparinantithrombinIIIcombination.
Thesedrugsworkbyalteringthebodysnormalbloodclottingprocess.Secondtierdrugsincludedextran,
aspirin,andlowdosesubcutaneousheparin.Nonpharmacologicalpreventionattemptstocounteracttheeffects
ofimmobility,includingcalfandfoot/ankleexercises,andcompressionstockings.Arecentstudyhasshown
thatsubstantialhyperemia(amean22%increaseinvenousoutflow)occursaftertheperformanceofactive
anklepumpsfor1minute,andvenousoutflowremainsgreaterthanthebaselinelevelfor30minutesreachinga
maximum12minutesaftertheseexercises.258Althoughthisdoesnotprovidesufficientevidencethatexercise
alonepreventsDVT,itsuggeststhattheactiveanklepumpdoesinfluencevenoushemodynamics.Finally,
inferiorvenacava(IVC)filtersandgreenfieldfiltersmaybeemployedwithapatientwhohasacontraindication
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toanticoagulation,previouscomplicationswithanticoagulants,orifanticoagulantshaveprovedineffectivein
thepast.
Pulmonaryembolus.272Thisisapartofthespectrumofdiseasesassociatedwithvenous
thromboembolism.Undernormalconditions,microthrombi(tinyaggregatesofredcells,platelets,and
fibrin)areformedandlysedcontinuallywithinthevenouscirculatorysystem.Thisdynamicequilibrium
ensureslocalhemostasisinresponsetoinjurywithoutpermittinguncontrolledpropagationofaclot.
Underpathologicalconditions,microthrombimayescapethenormalfibrinolyticsystemtogrowand
propagate.PEoccurswhenthesepropagatingclotsbreaklooseandembolizetoblockpulmonaryblood
vessels.PEmostcommonlyresultsfromDVToccurringinthedeepveinsofthelowerextremities,
proximaltoandincludingthepoplitealveinsandintheaxillaryorsubclavianveins(deepveinsofthearm
orshoulder).PEisanextremelycommonandhighlylethalpostsurgicalconditionthatisaleadingcause
ofdeathinallagegroups.AgoodclinicianactivelyseeksthediagnosisassoonasanysuspicionofPE
whatsoeveriswarranted,becausepromptdiagnosisandtreatmentcandramaticallyreducethemortality
rateandmorbidityofthedisease.Unfortunately,thediagnosisismissedmoreoftenthanitismade
becausePEoftencausesonlyvagueandnonspecificsymptoms.Symptomsthatshouldprovokea
suspicionofPEmustincludechestpain,chestwalltenderness,backpain,shoulderpain,upperabdominal
pain,syncope,hemoptysis,shortnessofbreath,painfulrespiration,newonsetofwheezing,anynew
cardiacarrhythmia,oranyotherunexplainedsymptomreferabletothethorax.Itisimportanttoremember
thatmanypatientswithPEareinitiallycompletelyasymptomaticandmostofthosewhodohave
symptomshaveanatypicalpresentation.Pulmonaryangiographyremainsthecriterionstandardforthe
diagnosisofPEbutisrapidlybeingreplacedbymultidetectorcomputedtomographicangiography
(MDCTA),sincethelattermodalityissignificantlylessinvasive,iseasiertoperform,andoffersequal
sensitivityandspecificity.
Poorwoundhealing.Woundhealingabnormalitiescausegreatphysicalandpsychologicalstresstothe
affectedpatientsandareextremelyexpensivetotreat.Therateofhealinginacutesurgicalwoundsis
affectedbybothextrinsicfactors(surgicaltechnique,tensionofwoundsuturing,maintenanceofadequate
oxygenation,cigarettesmoking,preventionoreradicationofinfection,andtypesofwounddressing)and
intrinsicfactors(presenceofshockorsepsis,controlofdiabetesmellitus,andtheage,nutritional,and
immunestatusofthepatient).273Althoughmanystudieshavedocumentedrelationshipsbetween
malnutritionandpoorwoundhealing,theoptimalnutrientintaketopromotewoundhealingisunknown.
Itisknown,however,thatvitaminsA,C,andE,protein,arginine,zinc,andwaterplayaroleinthe
healingprocess.274
Scarsandadhesions.Asurgeryisaformofcontrolledmacrotraumatothemusculoskeletalsystem.The
tissuesrespondtothistraumainmuchthesamewaythattheydotoanyotherformoftraumaorinjury.As
partofthepostsurgicalrehabilitationprocess,theinvolvedstructureisusuallyimmobilizedtoprotectthe
surgicalsitefrominjury.However,prolongedimmobilizationofaconnectivetissuecanproduce
significantchangesinitshistochemicalandbiomechanicalstructure.Thesechangesincludeafibrofatty
infiltrationthatcanprogressintofibrosis,creatingadhesionsaroundthehealingsite,andanincreasein
themicroscopiccrosslinkingofcollagenfibersresultinginanoveralllossofextensibilityofthe
connectivetissues.145,275278Unlikeconnectivetissue,whichismatureandstablewithlimitedpliability,
scartissueismorevulnerabletobreakdown.22,44,279281Fortunately,controlledandskilledtherapeutic
interventionscanreversethedetrimentaleffectsofshorttermimmobilization.Theseincludemobilization
oftheconnectivetissuewithpassivemobilitytechniquesoractiverangeofmotionthathelptorestorethe
extensibilityofthetissue.Toassistwiththeoverallhealingoftheincision,scarmobilizationtechniques
maybeperformedtothepatientstolerancewithlotion.
DETRIMENTALEFFECTSOFIMMOBILIZATION
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Continuousimmobilizationofconnectiveandskeletalmuscletissuescancausesomeundesirableconsequences.
Theseincludethefollowing:
Cartilagedegeneration.282Immobilizationofajointcausesatrophicchangesinarticularcartilage
throughareductionofmatrixproteoglycansandcartilagesoftening.283Softenedarticularcartilageis
vulnerabletodamageduringweightbearing.Thereductionofthematrixproteoglycansconcentrationhas
beendemonstratedtobehighestinthesuperficialzonebutalsooccursthroughouttheuncalcified
cartilage,diminishingwithdistancefromthesurfaceofthearticularcartilage.284
Decreasedmechanicalandstructuralpropertiesofligaments.Oneearlystudy11showedthatafter8
weeksofimmobilization,thestiffnessofaligamentdecreasedto69%ofcontrolvalues,andevenafter1
yearofrehabilitation,theligamentdidnotreturntoitspriorlevelofstrength.
CLINICALPEARL
Followingaperiodofimmobilization,connectivetissuesaremorevulnerabletodeformationandbreakdown
thannormaltissuessubjectedtosimilaramountsofstress.285
Decreasedbonedensity.144,232,286Theinteractionsamongsystemicandlocalfactorstomaintainnormal
bonemassarecomplex.Bonemassismaintainedbecauseofacontinuouscouplingbetweenbone
resorptionbyosteoclastsandboneformationbyosteoblasts,andthisprocessisinfluencedbyboth
systemicandlocalfactors.287Mechanicalforcesactingonbonestimulateosteogenesis,andtheabsence
ofsuchforcesinhibitsosteogenesis.Markedosteopeniaoccursinotherwisehealthypatientsinstatesof
completeimmobilizationorweightlessness.288,289Inchildren,bonehasahighmodelingrateandappears
tobemoresensitivetotheabsenceofmechanicalloadingthanboneinadults.290
Weaknessoratrophyofmuscles.Muscleatrophyisanimbalancebetweenproteinsynthesisand
degradation.Generalandselectivemuscleatrophycanoccurwithimmobilization.Generalmuscle
atrophytypicallyoccursinonejointmusclesastwojointmusclesarelessimmobilizedbytypical
immobilizationmethods.291SelectivemuscleatrophyoccursmoreoftenintypeIfibersastheyaremore
susceptibletotheeffectsofinactivityand,astheirnumbersdecline,theproportionoftypeIIafibers
increases.292
CLINICALPEARL
Structuralandmetabolicchangesinmusclecellscanbeginwithin2hoursofcompleteimmobilization,293and
disuseatrophycanresultinalossinthecrosssectionalareaofmusclebyasmuchas1417%within3hoursor
upto42%inafewweeks.294Theeffectsofimmobilizationalsoincludechangestothemyotendinousjunction,
evidencedbya50%redirectioninmuscletendoncontactareaandloweredGAGlevelsatthejunction.295
InadditiontothoseeffectslistedinTable28,immobilizationcanhavethefollowingnegativeeffectson
muscle:
TABLE28StructuralChangesintheVariousTypesofMuscleFollowingImmobilizationinaShortened
Position
MuscleFiberTypeandChanges
Structural FastOxidative
SlowOxidative FastGlycolytic
Characteristics Glycolytic
Numberoffibers Moderatedecrease Minimalincrease Minimalincrease
Diameteroffibers Significantdecrease Moderatedecrease Moderatedecrease
Fiberfragmentation Minimalincrease Minimalincrease Significantincrease
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MuscleFiberTypeandChanges
Structural FastOxidative
SlowOxidative FastGlycolytic
Characteristics Glycolytic
Minimaldecreaseand
Myofibrils Wavy
disoriented
Degeneratedand
Nuclei Degeneratedandrounded Degeneratedandrounded
rounded
Moderatedecrease, Moderatedecrease, Minimaldecrease,
Mitochondria
degenerated degenerated degenerated,swollen
Sarcoplasmic Minimaldecrease,orderly
Minimaldecrease Minimaldecrease
reticulum arrangement
Minimaldecrease,
Myofilaments Moderatedecrease Minimaldecrease,wavy
disorganized
Zband Moderatedecrease Faintorabsent
Vesicles Abnormalconfiguration
Basementmembrane Minimalincrease
Registerof Irregularprojections,shifted

sarcomeres withtime
Fattyinfiltration Minimalincrease
Minimalincreasebetween
Collagen
fibers
Minimalincreased
Macrophages Minimalincreasedinvasion Minimalincreasedinvasion
invasion
Satellitecells Minimalincrease
Targetcells Minimalincrease
DatafromGossmanMR,SahrmannSA,RoseSJ.Reviewoflengthassociatedchangesinmuscle.Experimental
evidenceandclinicalimplications.PhysTher.62:17991808,1982,withpermissionfromAPTA.
changeinmusclerestinglength
decreaseintotalmuscleweight
increaseinmusclecontractiontime
decreaseinmuscletensionproduced
decreaseinproteinsynthesis
increaseinlactateconcentrationwithexercise
Theextentofthenegativeimpactofimmobilizationdependsonthegeneralhealthofthepatient,durationofthe
immobilization,andthepositionofthelimbduringimmobilization.Theclinicianmustrememberthatthe
restorationoffullstrengthandrangeofmotionmayprovedifficultifmusclesareallowedtohealwithoutearly
activemotion,orinashortenedposition,andthatthepatientmaybepronetorepeatedstrains.153Thecauseof
muscledamageduringexercisedrecoveryfromatrophyinvolvesanalteredabilityofthemusclefiberstobear
themechanicalstressofexternalloads(e.g.,weightbearing)andmovementassociatedwithexercise.Strenuous
exerciseofatrophiedmusclecanresultinprimaryorsecondarysarcolemmaldisruption,swellingordisruption
ofthesarcotubularsystem,distortionofthecontractilecomponentsofmyofibrils,cytoskeletaldamage,and
extracellularmyofibermatrixabnormalities.67Thesepathologicchangesaresimilartothoseseeninhealthy
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youngadultsaftersprintrunningorresistancetraining.67Itappearsthattheactofcontractingwhilethemuscle
isinastretchedorlengthenedposition,knownasaneccentriccontraction,canresultintheseinjuries.296Thus,
rangeofmotionexercisesshouldbestartedoncetheswellingandtendernesshavesubsidedtothepointthatthe
exercisesarenotundulypainful.153
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undefined
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CHAPTER3:TheNervousSystem
CHAPTEROBJECTIVES
1.Describethevariouscomponentsofthecentralandperipheralnervoussystems.
2.Describetheanatomicandfunctionalorganizationofthenervoussystem.
3.Describethevariouscomponentsanddistributionsofthecervical,brachial,andlumbosacralplexuses.
4.Describethedifferencebetweenbalanceandproprioception.
5.Describetheroleproprioceptionplaysinfunction.
6.Describeanddifferentiateamongthevariousjointmechanoreceptors.
7.Recognizethecharacteristicsofalesiontothecentralnervoussystem.
8.Outlinetheneurophysiologyofpainandthemethodsbywhichpainiscontrolled.
9.Defineconcussionanddescribeitsassociatedsignsandsymptoms.
10.Listthefindingsandtheimpairmentsassociatedwiththemorecommonperipheralnervelesions.
11.Performacomprehensiveexaminationoftheneurologicsystem.
12.Describesomeofthecommonpathologiesofthenervoussystem.
OVERVIEW
Inordertoperformacomprehensiveneuromusculoskeletalexamination,theclinicianmusthaveaclear
understandingoftheanatomy,physiology,andfunctionofthevariouscomponentsofthenervoussystem,and
beabletorecognizethosesignsandsymptomsthatindicateacompromiseofthenervoussystem.
Thenervoussystemiscomposedofonlytwoprincipaltypesofcellsneuronsandsupportingcells.The
neuron,whichisclassifiedaccordingtostructureorfunction,servestostoreandprocessinformation,andisthe
functionalunitofthenervoussystem.Thesupportingcellcalledtheneuroglialcell,orsimplyglial,functionsto
providestructuralandmetabolicsupportfortheneurons.1Unlikemanycells,neuronscannotdividebymitosis
buttheydohavesomecapabilitytoregenerate.Incontrast,glialcellsretainlimitedmitoticabilities.
Anatomy
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Thehumannervoussystemcanbesubdividedintotwoanatomicdivisions:thecentralnervoussystem(CNS),
comprisingthebrainandthespinalcord,andtheperipheralnervoussystem(PNS),formedbythenervesand
ganglia(clusterofnervecellbodieslocatedoutsideoftheCNS)outsideofthebrainandspinalcord.ThePNSis
furthersubdividedintosomaticandautonomicdivisions.Thesomaticdivision,whichincludesthecranial(with
theexceptionofcranialII)andthespinalnerves,innervatestheskin,themuscles,andthejoints,whilethe
autonomicdivisioninnervatestheglandsandthesmoothmuscleofthevisceraandthebloodvessels.2
Althoughneuronscomeinvarioussizesandshapes,therearefourfunctionalpartsforeachnervefiber(Fig.3
1):
FIGURE31
Schematicdrawingofaneuron.(Reproduced,withpermission,fromChapter9.NerveTissue&theNervous
System.In:MescherAL.eds.JunqueirasBasicHistology:Text&Atlas,13e.NewYork,NY:McGrawHill
2013.)
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Dendrite.Dendritesserveareceptivefunctionandreceiveinformationfromothernervecells,orthe
environment.
Axon.Theaxoncylinder,inwhichthereisabidirectionalflowofaxoplasm,conductsinformationand
nutritiontothenervecellsandthetissuesthatthenerveinnervates.Manyaxonsarecoveredbymyelin,a
lipidrichmembrane.Inmyelinatedfibers,thereisadirectproportionalrelationshipbetweenfiber
diameterandconductionvelocity.3Thismembraneisdividedintosegments,approximately1mmlong,
bysmallgaps,callednodesofRanvier,inwhichthemyelinisabsent.4Myelin,whichhasahighelectrical
resistanceandlowcapacitance,servestoincreasethenerveconductionvelocityofneuraltransmissions
throughaprocesscalledsalutatoryconduction.TheSchwanncellisresponsibleforlayingdownmyelin
aroundaxons.
Cellbody.Thecellbodycontainsthenucleusofthecellandhasimportantintegrativefunctions.
Axonterminal.Theaxonterminalisthetransmissionsiteforactionpotentials,themessengersofthe
nervecell.
Peripheralnervesareenclosedinthreelayersoftissueofdifferingcharacter.Fromtheinsideoutward,theseare
theendoneurium,perineurium,andepineurium.1Thenervefibersembeddedinendoneuriumformafuniculus
surroundedbyperineurium,athinbutstrongsheathofconnectivetissue.Afluidexistsintheendoneurial
spaces,whichfollowingnerveinjurycanproduceintraneuraledema,whichinturncanplayamajorrolein
acuteandchronicnervelesions.3Thenervebundlesareembeddedinalooseareolarconnectivetissue
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framework,calledtheepineurium.Theepineuriumthatextendsbetweenthefasciclesistermedtheinnerorthe
interfascicularepineurium,whereasthatsurroundingtheentirenervetrunkiscalledtheepifascicular
epineurium.5Theconnectivetissueoutsidetheepineuriumisreferredtoastheadventitiaofthenerveorthe
epineuraltissue.5Althoughtheepineuriumiscontinuouswiththesurroundingconnectivetissue,itsattachment
isloose,sothatnervetrunksarerelativelymobile,exceptwheretetheredbyenteringvesselsorexitingnerve
branches(seeChapter11).6Therearenoconnectivetissuecomponentsinthespinalnervescomparabletothe
epineuriumandtheperineuriumoftheperipheralnerveatleasttheyarenotdevelopedtothesamedegree.7As
aresult,thespinalnerverootsaremoresensitivetobothtensionandcompression.Thespinalnerverootsalso
aredevoidoflymphaticsand,thus,arepredisposedtoprolongedinflammation.8
Thecommunicationofinformationfromonenervecelltoanotheroccursatjunctionscalledsynapses,wherea
chemicalisreleasedintheformofaneurotransmitter.Adifferenceinconcentrationexistsacrossthecell
membraneofpotassium,sodium,andchlorideions.Theseionscanselectivelypermeateionchannelsinthe
membranesothatanunequaldistributionofnetchargeoccurs.Therestingmembranepotentialresultsfroman
internalnegativityresultingfromtheactivetransportofsodiumfrominsidetooutsidethecell,andpotassium
fromoutsidetoinsidethecell.3
CLINICALPEARL
Membranepotentialrangesbetween70and90mV.
CentralNervousSystem
TheCNSconsistsofthebrainandanelongatedspinalcord.Thespinalcordparticipatesdirectlyinthecontrol
ofbodymovements,theprocessingandtransmissionofsensoryinformationfromthetrunkandthelimbs,and
theregulationofvisceralfunctions.2Thespinalcordalsoprovidesaconduitforthetwowaytransmissionof
messagesbetweenthebrainandthebody.Thesemessagestravelalongthepathways,ortracts,thatarefiber
bundlesofsimilargroupsofneurons.Thesetractsmaydescendorascend.
CLINICALPEARL
Aggregatesofspinaltractsarereferredtoascolumnsorlemnisci.
Thespinalcordisnormally4245cmlonginadultsandiscontinuouswiththemedullaandbrainstematits
upperend(Fig.32A).4Theconusmedullarisservesasthedistalendofthecord,and,inadults,theconusends
attheL1orL2levelofthevertebralcolumn.Aseriesofspecializations,thefilumterminalesandthecoccygeal
ligament,anchorthespinalcordandtheduralsacinferiorlyandensurethatthetensileforcesappliedtothe
spinalcordaredistributedthroughoutitsentirelength.9Thespinalcordhasanexternalsegmentalorganization.
Eachofthe31pairsofspinalnervesthatarisefromthespinalcordhasananterior(ventral)rootandaposterior
(dorsal)root,witheachrootconsistingofonetoeightrootletsandbundlesofnervefibers.4Aspinal(sensory)
ganglion(posterior[dorsal]rootganglion),aswellingthatcontainsnervecellbodies,islocatedintheposterior
(dorsal)root(Fig.32B)ofatypicalspinalnerve(Fig.32B).4
FIGURE32
Schematicillustrationofthespinalcord.(Reproduced,withpermission,fromChapter1.Back.In:MortonDA,
ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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Threemembranes,ormeninges,envelopthestructuresoftheCNS:duramater,arachnoid,andpiamater(Fig.3
3).Themeningesandrelatedspacesareimportanttoboththenutritionandtheprotectionofthespinalcord.The
cerebrospinalfluidthatflowsthroughthemeningealspaces,andwithintheventriclesofthebrain,providesa
cushionforthespinalcord.Themeningesalsoformbarriersthatresisttheentranceofvariousnoxious
organisms.
FIGURE33
Schematicillustrationoftherelationshipoftheduramater,arachnoid,andpiamater.(Reproduced,with
permission,fromChapter15.Scalp,Skull,andMeninges.In:MortonDA,ForemanK,AlbertineKH.eds.The
BigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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DuraMater
Theduramater(Latin,toughmother)(Fig.33)istheoutermostandthestrongestofthemembranesandis
composedofaninnermeningeallayerandanoutermostperiosteallayer.Thedurarunsuninterruptedfromthe
interiorofthecraniumthroughtheforamenmagnumandsurroundsthespinalcordthroughoutitsdistribution
fromthecraniumtothecoccyxatthesecondsacrallevel(S2).9Theduraalsoisattachedtotheposterior
surfacesofC2andC3.10
Theduraformsaverticalsac(duralsac)aroundthespinalcord,anditsshortlateralprojectionsblendwiththe
epineuriumofthespinalnerves.Theduraisseparatedfromthebonesandtheligamentsthatformthewallsof
thevertebralcanalbyanepiduralspace,whichcanbecomepartlycalcifiedorevenossifiedwithage.4
Arachnoid
Thearachnoidisathinanddelicateavascularlayer,coextensivewiththeduramaterandthepiamater(Fig.3
3).Eventhoughthearachnoidandthepiamaterareinterconnectedbytrabeculae,thereisaspacebetweenthem,
calledthesubarachnoidspace(Fig.33),whichcontainsthecerebrospinalfluid.Thesupposedlyrhythmicflow
ofthiscerebrospinalfluidistherationaleusedbycraniosacraltherapiststoexplaintheirtechniques,although
thereisnoevidenceofthisfindingintheliterature.
PiaMater
Thepiamater(Fig.33)isthedeepestofthelayers.Itisintimatelyrelatedandfirmlyattached,viaconnective
tissueinvestments,totheoutersurfaceofthespinalcordandthenerveroots.Thepiamaterconveystheblood
vesselsthatsupplythespinalcordandhasaseriesoflateralspecializations,thedenticulate(dentate)ligaments,
whichanchorthespinalcordtotheduramater.9Theseligaments,whichderivetheirnamefromtheirtoothlike
appearance,extendthewholelengthofthespinalcord.
PeripheralNervousSystem:SomaticNerves
ThesomaticportionofthePNSconsistsofthecranialnerves(CNs)andthespinalnerves.
CranialNerves
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TheCNs,typically,aredescribedascomprising12pairs,whicharereferredtobytheRomannumeralsIthrough
XII(Fig.34).TheCNrootsenterandexitthebrainstemtoprovidesensoryandmotorinnervationtothehead
andthemusclesoftheface.CNI(olfactory)andCNII(optic)arenottruenervesbutratherfibertractsofthe
brain.TheexaminationoftheCNsystemisdescribedlaterinthischapter(seesectionOrthopaedicNeurologic
Testing).
FIGURE34
TheCNs.(Reproduced,withpermission,fromChapter17.CranialNerves.In:MortonDA,ForemanK,
AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
CNI(olfactory).Theolfactorytract(Fig.34)arisesfromtheolfactorybulbontheinferioraspectofthe
frontallobe,justabovethecribriformplate.Fromhereitcontinuesposteriorlyastheolfactorytractand
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terminatesjustlateraltotheopticchiasm.Theolfactorynervehandlesthesenseofsmell.
CNII(optic).Thefibersoftheopticnervearisefromtheinnerlayeroftheretinaandproceedposteriorly
toenterthecranialcavityviatheopticforamen,toformtheopticchiasm(Fig.34).Thefibersfromthe
nasalhalfoftheretinadecussatewithintheopticchiasm,whereasthosefromthelateralhalfdonot.The
opticnervehandlesvision.
CNIII(oculomotor).Theoculomotornervearisesintheoculomotornucleusandleavesthebrainonthe
medialaspectofthecerebralpeduncle(Fig.34).Itthenextendsfromtheinterpeduncularfossaandruns
betweentheposteriorcerebralarteryandthesuperiorcerebellarartery,beforeleavingthecranialcavity
andenteringthecavernoussinusbywayofthesuperiororbitalfissure.Thesomaticportionofthe
oculomotornervesuppliesthelevatorpalpebraesuperiorismusclethesuperior,medial,andinferior
rectusmusclesandtheinferiorobliquemuscles(Fig.34).Thesemuscleshandlesomeeyemovements.
Thevisceralefferentportionofthisnerveinnervatestwosmoothintraocularmuscles:theciliaryandthe
constrictorpupillae.Thesemuscleshandlepupillaryconstriction.
CNIV(trochlear).Thetrochlearnervearisesfromthetrochlearnucleus,justcaudaltotheoculomotor
nucleusattheanteriorborderoftheperiaqueductalgray(PAG)matter(Fig.34).Thefiberscrosswithin
themidbrainandthenemergecontralaterallyontheposteriorsurfaceofthebrainstem,beforeenteringthe
orbitviathesuperiororbitalfissure,tosupplythesuperiorobliquemuscle.
Note:BecausenervesIII,IV,andVIareexaminedtogether,CNVisdescribedafterCNVI.
CNVI(abducens).Theabducensnerveoriginatesfromtheabducensnucleuswithintheinferioraspect
ofthepons.Itslongintracranialcoursetothesuperiororbitalfissuremakesitvulnerabletopathologyin
theposteriorandmiddlecranialfossa.Thenerveinnervatesthelateralrectusmuscle.
CNV(trigeminal).Thetrigeminalnerveissonamedbecauseofitstripartitedivisionintothemaxillary,
ophthalmic,andmandibularbranches(V1,V2,andV3respectivelyinFig.34).Allthreeofthese
branchescontainsensorycells,buttheophthalmicandthemaxillaryareexclusivelysensory,thelatter
supplyingthesoftandhardpalate,maxillarysinuses,upperteethandupperlip,andmucousmembraneof
thepharynx.Themandibularbranchcarriessensoryinformationbutalsorepresentsthemotorcomponent
ofthenerve,supplyingthemusclesofmastication,bothpterygoids,theanteriorbellyofdigastric,tensor
tympani,tensorvelipalatini,andmylohyoid.
Thespinalnucleusandthetractofthetrigeminalnervecannotbedistinguishedeitherhistologicallyoronthe
basisofafferentreceptionfromthecervicalnerves.Consequently,theentirecolumncanbeviewedasasingle
nucleusand,legitimately,maybecalledthetrigeminocervicalnucleus.
CNVII(facial).Thefacialnerveismadeupofasensory(intermediate)root,whichconveystaste,anda
motorroot,thefacialnerveproper,whichsuppliesthemusclesoffacialexpression,theplatysmamuscle,
andthestapediusmuscleoftheinnerear(Fig.34).Theintermediateroot,togetherwiththemotornerve
andCNVIII,travelsthroughtheinternalacousticmeatustoenterthefacialcanalofthetemporalbone.
Fromhere,theintermediatenerveswellstoformthegeniculateganglionandgivesoffthegreater
superficialpetrosalnerve,whicheventuallyinnervatesthelacrimalandsalivaryglandsviathe
pterygopalatineganglionandthechordatympaninerve,respectively.Thefacialnerveproperexitsthe
skullthroughthestylomastoidforamen.
CNVIII(vestibulocochlear).Thevestibulocochlearnervesubservestwodifferentsenses:balanceand
hearing.Thecochlearportionofthenervearisesfromspiralganglia,andthevestibularportionarises
fromthevestibulargangliainthelabyrinthoftheinnerear(Fig.34).Thecochlearportionisconcerned
withthesenseofhearing,whereasthevestibularportionisapartofthesystemofequilibrium,the
vestibularsystem.
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Thevestibularsystemincludesthevestibularapparatusoftheinnerear,thevestibularnucleiandtheirneural
projections,andtheexteroreceptorsthroughoutthebody,especiallyintheuppercervicalspineandtheeyes.11
Theapparatusoftheinnerearconsistsofthestaticlabyrinth,whichcomprisesthreesemicircularcanals(SCC)
(Fig.35),eachorientatedatrightanglestotheother.Thelabyrinthincludesspecializedsensoryareasthatare
locatedintheutricleandthesaccule(Fig.35),withinwhichotolithsarelocated(Fig.35).
FIGURE35
Theapparatusoftheinnerear.(Reproduced,withpermission,fromChapter19.Ear.In:MortonDA,Foreman
K,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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AseriesoffilamentslinethebasementmembraneoftheSCCandprojectintoendolymph,whichdeformsthese
filamentswhenheadmotionoccurs.Thisdeformationisregisteredbyreceptorcells,andwhensudden
perturbationsoccur,thefrequencyofnerveimpulsesalongtheafferentnervesupplyofthecellbodyisaltered.
UnlikethefilamentsoftheSCC,thefilamentsoftheutricleandsacculedonotprojectintoendolymphbut
insteadinsertintoagelatinousmass,withinwhichtheotolithisembedded.Deformationofthesefilamentsis
producedbytheweightoftheotolithagainstthecilia,asthegelatinousmassisdisplacedduringhead
movement.
Theotolithsareresponsibleforprovidinginformationaboutgravitationalforces,aswellasverticaland
horizontalmotion.Thefilamentsofthesacculealsoprovideinformationaboutverticalmotion.Atrest,the
endolymphaticfluid,orthegelatinousmembrane,isstationary.Whenmotionoftheheadoccurs,the
endolymphaticfluid,orthegelatinousmembrane,initiallyremainsstationarybecauseofitsinertia,whilethe
canalsmove.Thisrelativemotionproducesadraggingeffectonthefilamentsandeitherincreasesordecreases
thedischargerate,dependingonthedirectionofshear.Attheendoftheheadmovement,thefluidandthe
membranecontinuetomove,andtheciliaarenowdraggedintheoppositedirectionbeforecomingtorest.In
essence,theSCCreceptorstransmitapositivesignalwhenmovementbegins,nosignalwhenthemotionhas
finished,andanormallevelafterthesensorycellhasreturnedtoitsoriginalposition.Asthisoccurs,other
sensorycellsorientatedintheoppositedirectionreactinthereversefashion.
CLINICALPEARL
TheSSCdetectorsaresosensitivethattheycandetectangularaccelerationsaslowas0.2degreespersecond,12
arateofaccelerationthatwouldturntheheadthrough90degreesin30secondsandproduceaterminalvelocity
of6degreespersecond:aboutasfastasthemovementofthesecondhandofawatch.13
CNIX(glossopharyngeal).Theglossopharyngealnerve(Fig.34)containsasomaticmotor,visceral
efferent,visceralsensory,andsomaticsensoryfiber.Themotorfibersoriginateinthenucleusambiguous,
leavingthelateralmedullatojointhesensorynerve,whicharisesfromcellsinthesuperiorandpetrous
ganglia.Theglossopharyngealnerveexitstheskullthroughthejugularforamenandservessome
functions,includingsupplyingtastefibersfortheposteriorthirdofthetongue.
CNX(vagus).Thefunctionsofthevagusnerve(Fig.34)arenumerousandincludethemotor
parasympatheticfiberstoalltheorgansexceptthesuprarenal(adrenal)glands,fromitsorigindowntothe
secondsegmentofthetransversecolon.Thevagusalsocontrolssomeskeletalmuscles,including:
Cricothyroidmuscle
Levatorvelipalatinimuscle
Salpingopharyngeusmuscle
Palatoglossusmuscle
Palatopharyngeusmuscle
Superior,middle,andinferiorpharyngealconstrictors
Musclesofthelarynx
Thevagusnerveisthusresponsibleforsuchvariedtasksasheartrate,gastrointestinalperistalsis,sweating,
speech,andbreathing.Italsohassomeafferentfibersthatinnervatetheinner(canal)portionoftheouterear.
CNXI(accessory).Theaccessorynerveconsistsofacranialcomponentandaspinalcomponent.The
cranialrootoriginatesinthenucleusambiguousandisoftenviewedasanaberrantportionofthevagus
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nerve.Thespinalportionofthenervearisesfromthelateralpartsoftheanteriorhornsofthefirstfiveor
sixcervicalcordsegmentsandascendsthroughtheforamenmagnum.Thespinalportionoftheaccessory
nervesuppliesthesternocleidomastoid(SCM)andthetrapeziusmuscles(Fig.34).
CNXII(hypoglossal).Thehypoglossalnerveisthemotornerveofthetongue,innervatingtheipsilateral
sideofthetongue(Fig.34)aswellasformingthedescendenshypoglossi,whichanastomoseswithother
cervicalbranchestoformtheansahypoglossi.Thelatter,inturn,innervatestheinfrahyoidmuscles.
SpinalNerves
Thereareatotalof31symmetricallyarrangedpairsofspinalnerves,eachderivedfromthespinalcord.14The
spinalnervesaredividedtopographicallyintoeightcervicalpairs(C18),12thoracicpairs(T112),fivelumbar
pairs(L15),fivesacralpairs(S15),andacoccygealpair(Fig.32A).
Theposterior(dorsal)andanterior(ventral)rootsofthespinalnervesarelocatedwithinthevertebralcanal(Fig.
32B).Theportionofthespinalnervethatisnotwithinthevertebralcanal,andthatusuallyoccupiesthe
intervertebralforamen,isreferredtoasaperipheralnerve.Asthenerverootsbegintoexitthevertebralcanal,
theymustpenetratetheduramaterbeforepassingthroughduralsleeveswithintheintervertebralforamen.The
duralsleevesarecontinuouswiththeepineuriumofthenerves.
Essentially,therearefourbranches,orrami,ofspinalnerves:4
Posterior(dorsal)rami(Fig.32B).Thistypeusuallyconsistsofamedialsensorybranchandalateral
motorbranch.
Anterior(ventral)rami(Fig.33B).ExceptinthethoracicnervesT212,theanterior(ventral)ramiofthe
spinalnervescombineandthensplitagainintonetworksofnervesreferredtoasnerveplexuses.Thereare
fourplexusesofspinalnerves:thecervical,brachial,lumbar,andsacral.
Communicatingrami.Theramiserveasaconnectionbetweenthespinalnervesandthesympathetic
trunk.Onlythethoracicandupperlumbarnervescontainawhiteramuscommunicans,butthegrayramus
ispresentinallspinalnerves.
Meningealorrecurrentmeningeal(alsoknownassinuvertebral).Thesenervescarrysensoryand
vasomotorinnervationtothemeninges.
Therearethreefunctionaltypesofnervefibersinthemajornervetrunks,whichvaryinquantitydependingon
theparticularnerve:afferent(sensory),autonomic(visceralefferent)(seePNS:AutonomicNervousSystem
[ANS]),andmotor(somaticefferent)(Table31).ThefasternervefiberssuchasAdeltafibersaremore
concernedwithspeedandqualityofhumanmovementwhereastheCfibersconductfarmoreslowlyandare
moreinvolvedwithnociceptionand,bythecompoundstheyrelease,thehealthofsurroundingtissue.3
TABLE31ClassificationofAfferent,Cutaneous,andEfferents
Type ConductionVelocity(m/s) Function
Afferents
I 70120 Provideinputfrommuscleandtendonreceptors
II 3672 Afferentsfrommusclespindles
III 2768 Pressure/nociceptiveafferentsfromjointsandaponeuroses
IV 14 Pain
Cutaneous
A, 3070 Tactilereceptors
A 1230 Coldfastnociception
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Type ConductionVelocity(m/s) Function

C 0.51.0 Warmthtissuedamagenociception
Efferents
60100 Extrafusalmusclefibers
1030 Intrafusalmusclefibers
B 330 Preganglionicautonomic
C 0.52.0 Postganglionicautonomic
Afferent(sensory)Nerves
Thesensorynervescarryafferents(anerveconveyingimpulsesfromtheperipherytotheCNS)fromaportion
oftheskin.Theyalsocarryefferents(anerveconveyingimpulsesfromtheCNStotheperiphery)totheskin
structures.Whenasensorynerveiscompressed,symptomsoccurintheareaofthenervedistribution.Thisarea
ofdistribution,calledadermatome,isawelldefinedportionoftheskinandfollowsthesegmentaldistribution
oftheunderlyingmuscleinnervation.Figure36isanapproximaterepresentationofthevariousdermatomeson
theanteriortrunkforthecervicalandthoracicnerves.However,thereisnocurrent,diagnosticallyaccurate
dermatomeillustration,andsoitisimportanttorememberthattextbookscommonlyusedinmedicalandallied
healthprogramscontainmultiple,conflictingdermatomemaps,mostofwhichrelyonresearchfromthe
1940s.15Forexample,themajorityshowthecutaneousdistributionofthefourthlumbarspinalnerve(L4
dermatome)eitherrunningfromthelateralaspectofthethightothemedialsideofthegreattoe,orconfinedto
themedialportionofthelegdistaltotheknee.15Consequently,anydiagnosisrelatedtotheintegrityofthe
nervoussystemcannotbebasedonsensorytestingalone.
FIGURE36
Segmentaldistributionofthebody.(Reproduced,withpermission,fromChapter2.AnteriorThoracicWall.In:
MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill
2011.)
CLINICALPEARL
Adermatomeistheareaofskinsuppliedbyasinglenerveroot.Paindermatomeshavelessoverlapthan
lighttouchdermatomes.16
Amyotomeisamuscleorgroupofmusclessuppliedbyasinglenerveroot.
Asclerotomeisanareaofboneorfasciasuppliedbyasinglenerveroot.
Examplesofsensorynervesinthebodyarethelateral(femoral)cutaneousnerve(LCN)ofthethigh(Fig.37),
thesaphenousnerve,andtheinterdigitalnerves(seelater).
FIGURE37
LCNofthethigh.
CLINICALPEARL
DiscrepanciesexistintheliteratureregardingtheanatomyandincidenceoftheC1posterior(dorsal)roots,
ganglia,andrami.InastudybyTubbsetal.17,30adultcadavers,withameanageof72yearswereexamined.
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C1andC2spinalnerveswereidentifiedin100%ofthespecimensexamined.In46.6%ofspecimens,C1
posterior(dorsal)rootletswereidentifiedandofthese,28.5%hadanassociatedposterior(dorsal)rootganglion.
In50%ofspecimens,thespinalaccessorynervejoinedwithposterior(dorsal)rootletsofC1.C1inthesecases
didnotpossessadorsalrootganglion.Thus,inthoseindividualswhodonothaveaC1posterior(dorsal)root,
thereisnoC1dermatome.However,ifpresent,theC1dermatomecoversasmallareainthecentralpartofthe
neckclosetotheocciput.4
Motor(somaticefferent)
Themotornervescarryefferentstomusclesandreturnsensationfrommusclesandassociatedligamentous
structures.Anynervethatinnervatesamusclealsomediatesthesensationfromthejointuponwhichthatmuscle
acts.Examplesofamotornerveincludethesuprascapularnerveandtheposterior(dorsal)scapularnerve.A
hierarchicalrecruitmentpatternexistsinthenervoussystemformusclerecruitmentcalledthelawof
parsimony.18Thelawofparsimonystatesthatthenervoussystemtendstoactivatethefewestmusclesor
musclefiberspossibleforthecontrolofagivenjointaction.Thishierarchicalpatternofmusclerecruitment
makespracticalsensefromanenergyperspective.18
CLINICALPEARL
Amixednerveisacombinationofskin,sensory,andmotorfiberstoonetrunk.Someexamplesofamixed
nervearethemediannerve,theulnarnerveattheelbowasitentersthetunnelofGuyon,thefibular(peroneal)
nerveattheknee,andtheilioinguinalnerve.
CervicalPlexus
Theeightpairsofcervicalnervesarederivedfromcordsegmentsbetweentheleveloftheforamenmagnumand
themiddleoftheseventhcervicalvertebra.19ThespinalnervesfromC3toC7,exitingfromtheintervertebral
foramen,divideintoalargeranterior(ventral)ramusandasmallerposterior(dorsal)ramus.Theanterior
(ventral)ramusofthecervicalspinalnervetravelsonthetransverseprocessinananteriorlateraldirectionto
formthecervicalplexusandbrachialplexus.Theposterior(dorsal)ramusofthespinalnerverunsposteriorly
aroundthesuperiorarticularprocess,supplyingthefacet(zygapophyseal)joint,ligaments,deepmuscles,and
skinoftheposterioraspectoftheneck.9
Eachnervejoinswithagraycommunicatingramusfromthesympathetictrunkandsendsasmall,recurrent
meningealbranchbackintothespinalcanaltosupplythedurawithsensoryandvasomotorinnervation.Italso
branchesintoanteriorandposteriorprimarydivisions,whicharemixednervesthatpasstotheirrespective
peripheraldistributions.Themotorbranchescarryafewsensoryfibersthatconveyproprioceptiveimpulses
fromtheneckmuscles.
CLINICALPEARL
Twostudies20,21thatanalyzedmagneticresonanceimaging(MRI)andcomputedtomography(CT)imagesof
thecervicalintervertebralforamenfoundthatthecervicalnerverootislocatedinthelowerpartofthe
interpedicularforamenandoccupiesthemajorinferiorpartoftheintertransverseforamen.Anteriorly,
compressionofthenerverootsislikelycausedbyprotrudingdiscsandosteophytesoftheuncovertebralregion,
whereasthesuperiorarticularprocess,theligamentumflavum,andtheperiradicularfibroustissuesoftenaffect
thenerveposteriorly.2225
Posteriorprimarydivisions.TheC1(suboccipital)nerveistheonlybranchofthefirstposteriorprimary
divisions.Itisamotornerve,servingthemusclesofthesuboccipitaltriangle,withveryfew,ifany,
sensoryfibers.19
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Anteriorprimarydivisions.Thecervicalplexusisformedbytheanteriorprimarydivisionsofthefirst
fourcervicalnerves(C14)(Fig.38).
Cervicalplexus(C14).
Sensorybranches(seeFig.36).
Smalloccipitalnerve(C2,3).Thisnerve(Fig.38)suppliestheskinofthelateraloccipitalportionofthe
scalp,theuppermedianpartoftheauricle,andtheareaoverthemastoidprocess.19
Greatauricularnerve(C2,3).Thisnerve(Fig.38)suppliessensationtotheearandthefaceviathe
ascendingramusofthemandible.Thenerveliesonorjustbelowthedeeplayeroftheinvestingfasciaof
theneck.Itarisesfromtheanteriorramiofthesecondandthirdcervicalnervesandemergesfrombehind
thesternocleidomastoid(SCM)muscle,beforeascendingonittocrossovertheparotidgland.
Cervicalcutaneousnerve(cutaneouscoli)(C2,3).Thisnervesuppliestheskinovertheanteriorportion
oftheneck.
Supraclavicularbranches(C3,4).Thesenervessupplytheskinovertheclavicleandtheupperdeltoid
andpectoralregions,aslowasthethirdrib.
Communicatingbranches.Theansacervicalisnerve(Fig.38)isformedbythejunctionoftwomain
nerveroots,derivedentirelyfromanterior(ventral)cervicalrami.Aloopisformedatthepointoftheir
anastomosis,andsensoryfibersarecarriedtotheduraoftheposteriorfossaoftheskullviatherecurrent
meningealbranchofthehypoglossalnerve.ThecommunicationwiththevagusnervefromC1isof
undeterminedfunction.
Muscularbranches.CommunicationwiththehypoglossalnervefromC1toC2(Fig.38)carriesmotor
fiberstothegeniohyoidandthyrohyoidmusclesandtothesternohyoidandsternothyroidmusclesbyway
ofthesuperiorrootoftheansacervicalis(Fig.38).Thenervetothethyrohyoidbranchesfromthe
hypoglossalnerveandrunsobliquelyacrossthehyoidbonetoinnervatethethyrohyoid.Thenervetothe
superiorbellyoftheomohyoidbranchesfromthesuperiorroot(Fig.38)andentersthemuscleatalevel
betweenthethyroidnotch,andahorizontalplane2cminferiortothenotch.Thenervestothesternohyoid
andsternothyroidshareacommontrunk,whichbranchesfromtheloop(Fig.38).Thenervetothe
inferiorbellyoftheomohyoidalsobranchesfromtheloop(Fig.38).Theloopismostfrequentlylocated
justdeeptothesitewherethesuperiorbelly(ortendon)oftheomohyoidmusclecrossestheinternal
jugularvein.ThereisabranchtotheSCMmusclefromC2,andtherearebranchestothetrapeziusmuscle
(C34)viathesubtrapezialplexus.
FIGURE38
Thecervicalplexus.(Reproduced,withpermission,fromChapter25.OverviewoftheNeck.In:MortonDA,
Smallerbranchestotheadjacentvertebralmusculaturesupplytherectuscapitislateralisandrectuscapitis
anterior(C1),thelonguscapitis(C2,4)andlonguscolli(C14),thescalenusmedius(C3,4)andscalenus
anterior(C4),andthelevatorscapulae(C35).
Thephrenicnerve(C35)(seeFig.38)passesobliquelyoverthescalenusanteriormuscleandbetweenthe
subclavianarteryandtheveintoenterthethoraxbehindthesternoclavicular(SC)joint,whereitdescends
verticallythroughthesuperiorandmiddlemediastinumtothediaphragm.19Motorbranchessupplythe
diaphragm.Sensorybranchessupplythepericardium,thediaphragm,andpartofthecostalandmediastinal
pleurae.
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CLINICALPEARL
Thephrenicnerveisthelargestbranchofthecervicalplexusandplaysavitalroleinrespiration.
Phrenicnerveinvolvementhasbeendescribedinseveralneuropathies,includingcriticalillness,polyneuropathy,
GuillainBarrsyndrome,brachialneuritis,andhereditarymotorandsensoryneuropathytype1.26,27The
symptomsdependlargelyonthedegreeofinvolvement,andwhetheroneorbothofthenervesareinvolved.19
Unilateralparalysisofthediaphragmcausesfewornosymptomsexceptwithheavyexertion.
Bilateralparalysisofthediaphragmischaracterizedbydyspneaupontheslightestexertionanddifficulty
withcoughingandsneezing.26,27
Phrenicneuralgia,whichcanresultfromnecktumors,aorticaneurysm,andpericardialorother
mediastinalinfections,ischaracterizedbypainnearthefreeborderoftheribs,beneaththeclavicle,and
deepintheneck.26,27
BrachialPlexus
Thebrachialplexus(Fig.39)arisesfromtheanteriordivisionsofthefifthcervicalthroughthefirstthoracic
nerveroots,withoccasionalcontributionsfromthefourthcervicalandthesecondthoracicroots.Therootsof
theplexus,whichconsistofC5andC6,jointoformthesuperior(upper)trunkC7becomesthemiddletrunk,
andC8andT1jointoformtheinferior(lower)trunks.Eachofthetrunksdividesintoanteriorandposterior
divisions,whichthenformcords(Fig.39).Theanteriordivisionsoftheupperandmiddletrunkformthelateral
cord,theanteriordivisionoftheinferior(lower)trunkformsthemedialcord,andallthreeposteriordivisions
unitetoformtheposteriorcord.Thethreecords,namedfortheirrelationshiptotheaxillaryartery,splittoform
themainbranchesoftheplexus.Thesebranchesgiverisetotheperipheralnerves:musculocutaneous(lateral
cord),axillaryandradial(posteriorcord),ulnar(medialcord),andmedian(medialandlateralcords).28
Numeroussmallernervesarisefromtheroots,thetrunks,andthecordsoftheplexus.Peripheralnerveinjuries
oftheupperextremityandtheirrespectiveclinicalfindingsarelistedinTable32.
FIGURE39
Thebrachialplexus.(Reproduced,withpermission,fromChapter29.OverviewoftheUpperLimb.In:Morton
DA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
TABLE32PeripheralNerveInjuryRelatedtotheCordsoftheBrachialPlexus
CordandNerve LevelofInjury MotorLoss CutaneousLoss
Allmusclesinnervatedbyradial
Posteriorcord: Plexusproximalto nerve Throughoutradialand
radial(C5T1) axillarynerve Allmusclesinnervatedbyaxillary axillarydistribution
nerve
Axilla(brachioaxillary Triceps(medialandlateralheads)and Posteriorbrachial
angle) anconeus cutaneous
Allmusclesinnervatedbyradial Posteriorantebrachial
Spiralgroove
nerveexceptmedialheadoftriceps cutaneous
Proximaltolateral Brachialis,brachioradialis,ECRL,
epicondyle andECRB
Supinator,allmusclesinnervatedby Superficialradial
ArcadeofFrohse
posteriorinterosseousnerve (Wartenbergsyndrome)
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CordandNerve LevelofInjury MotorLoss CutaneousLoss

Posteriorcord:
axillarynerve Axilla(quadrangular
space) Teresminoranddeltoid Lateralarm
(C56)
Plexus(proximaltothe
Medialandlateral joiningofthemedial Throughoutmedian,
Allmusclesinnervatedbymedian,
cord:median andlateralcords) musculocutaneous,and
musculocutaneous,andulnarnerves
nerve(C5T1) thoracicoutlet ulnardistributions
syndrome
LigamentofStruthers
proximaltomedial Pronatorteres
epicondyle
Cubitalfossaexit
Pronatorteres,FCR,FDS,PL,and
betweentwoheadsof
lumbricalesIandII
thepronatorteres
Palmarbranch:radialhalf
ofthumb
Anteriorinterosseous:FDP(IandII),
Digitalbranch:posterior
FPL,andPQmedianmuscular
Forearm (dorsal)tipsofthumb,
branch:Thenarmuscles(APB,FPB,
index,andmiddlefinger
andOP)andlumbricalesIandII
andradialhalfofring
finger
Lateral: Coracobrachialis
musculocutaneous Coracobrachialis Biceps
nerve(C57) Brachialis
Lateralantebrachial
Elbow cutaneousnerve:Lateral
forearm
Posteriorandanterior
FCU,FDP,adductorpollicis,
Cubitaltunnel aspectsontheulnarsideof
lumbricales,andinterossei
thehand
Betweenthetwoheads
FDPandFCU
oftheFCU
Deepbranch:allhandmuscles
Medial:ulnarnerve(C8
Proximaltowrist innervatedbytheulnarnerve
T1)
Superficialbranch:Palmarisbrevis
Musclesofthehypothenareminence
Guyoncanal Ulnaraspectofthehand
(handofbenediction)andinterossei
ECRL,extensorcarpiradialislongusECRB,extensorcarpiradialisbrevisFCR,flexorcarpiradialisFDS,
flexordigitorumsuperficialsPL,palmarislongusFDP,flexordigitorumprofundusFPL,flexorpollicislongus
PQ,pronatorquadratusAPB,abductorpollicisbrevisFPB,flexorpollicisbrevisOP,opponenspollicisFCU,
flexorcarpiulnarisDIP,distalinterphalangeal.
FromtheRoots
Theoriginoftheposterior(dorsal)scapularnerve(C5)frequentlysharesacommontrunkwiththelong
thoracicnerve(Fig.39).Theformerpassesthroughthescalenusmediusanteriorinternally,andscalenus
posteriorlaterally,withthepresenceofsometendinoustissues.Leavingthelongthoracicnerve,itoften
givesbranchestotheshoulderandthesubaxillaryregion,beforethebranchesjointhelongthoracicnerve
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again.Theposterior(dorsal)scapularnervesuppliestherhomboidsandthelevatorscapulaemuscles.
Posterior(dorsal)scapularnervelesionscanresultfromaforwardpostureoftheheadandtheneckasthis
positionincreasestensionintheanteriorcervicalspine,producingthepotentialforhypertonicityand
hypertrophyofthemedialscalene.29Thechiefcomplaintisusuallyoneofscapularpainradiatingtothe
lateralshoulderandarm.
AsmallbranchfromC5passestothephrenicnerve.
SmallerbranchesfromC6toC8extendtothescaleniandlonguscollimuscles.
ThefirstintercostalnerveextendsfromT1.
Thelongthoracicnerve(C57)ispurelyamotornervethatoriginatesfromtheanterior(ventral)ramiof
thefifth,thesixth,andtheseventhcervicalroots(Fig.39).Itisthesoleinnervationtotheserratus
anteriormuscle.Thefifthandthesixthcervicalroots,alongwiththeposterior(dorsal)scapularnerve,
passthroughthescalenusmediusmuscle,whereastheseventhcervicalrootpassesanteriortoit.30The
nervethentravelsbeneaththebrachialplexusandclavicletopassoverthefirstrib.Fromthere,it
descendsalongthelateralaspectofthechestwall,whereitinnervatestheserratusanteriormuscle.The
longthoracicnerveextendsasfarinferiorastheeighthortheninthrib.Itslongandrelativelysuperficial
coursemakesitsusceptibletoinjuryfromanyofthefollowingcauses.10,3133
Entrapmentofthefifthandsixthcervicalroots,astheypassthroughthescalenusmediusmuscle.
Compressionofthenerveduringtractiontotheupperextremitybytheundersurfaceofthescapula,asthe
nervecrossesoverthesecondrib.
Compressionandtractiontothenervebytheinferiorangleofthescapuladuringgeneralanesthesia,or
withvigorouspassiveabductionofthearm.
Lesionsofthelongthoracicnervearecommonandarethesinglemostcommonperipheralnervelesionat
theshoulder.Themostcommoncauseoflongthoracicnerveinjuryresultsfromcarryingaheavyobject
ontheshoulder.Othercausesincludepostinfection,postinjection,postpartum,andpostoperative
origins.34Similartootherperipheralnerveinjuries,traumatothenervecanbecausedbyadirectblowor
atractionforcetothenerve.Thetractioninjurycanoccurwhenconcurrentheadrotationaway,side
bendingaway,andneckflexion,arecoupledwiththearmpositionedoverhead.3537Othermechanisms
thathavebeenattributedtolongthoracicnervedysfunctionincludeliftingweightsoverhead,drivinga
golfball,andservingatennisball.38
Thetypicalclinicalpresentationincludesthefollowing:
Vaguepainintheneckandthescapularegion.
Aninabilitytofullyelevatethearmoverhead.
ShoulderflexionandabductionareweakandlimitedinAROMduetothelossofthetrapeziusserratus
anteriorforcecouple(seeChapter16).Theclinicianshouldnotethepresenceofwingingofthescapula
whentestingtheserratusanterior.
Conservativeinterventionincludesprotectionoftheserratusanteriorwithabraceorrestraint,34,37,39galvanic
stimulationtotheserratusanterior,muscletaping,40strengtheningexercisesfortherhomboids,pectoralis,
trapezius,andserratusanteriormuscles.35,38,41Theaveragerateofreturnrangesfrom37months30,34to2
years.38
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FromtheTrunks
Anerveextendstothesubclaviusmuscle(C56)fromthesuperior(upper)trunk,orfifthroot.Thesubclavius
muscleactsmainlyonthestabilityoftheSCjoint,withmoreorlessintensity,accordingtothedegreeofthe
clavicularinteractionwiththemovementsoftheperipheralpartsofthesuperiorlimb,andseemstoactasa
substitutefortheligamentsoftheSCjoint.42
Thesuprascapularnerveoriginatesfromthesuperior(upper)trunkofthebrachialplexusformedbytherootsof
C5andC6(seeFig.39)atErbspoint.
FromtheCords
Themedialandlateralpectoralnervesextendfromthemedialandlateralcords,respectively(seeFig.3
9).Theysupplythepectoralismajorandpectoralisminormuscles.Thepectoralismajormusclehasdual
innervation.43Thelateralpectoralnerve(C57),whichismoremedialinthemuscle,travelswiththe
thoracoacromialvessels,andinnervatestheclavicularandsternalheads.Themedialpectoralnerve(C8
T1)sharesacoursewiththelateralthoracicvesselsandprovidesinnervationtothesternalandcostal
heads.44Themaintrunkofthesenervescanbefoundneartheoriginofthevascularsupplyofthemuscle.
Thethreesubscapularnervesfromtheposteriorcordconsistof:
Theuppersubscapularnerve(C56),whichsuppliesthesubscapularismuscle(seeFig.39).
Thethoracodorsalnerve,ormiddlesubscapularnerve,whicharisesfromtheposteriorcordofthe
brachialplexuswithitsmotorfibercontributionsfromC6,C7,andC8(seeFig.39).Thisnerve
coursesalongtheposteriorlateralchestwall,alongthesurfaceoftheserratusanterior,anddeepto
thesubscapularis,givingrisetobranchesthatsupplythelatissimusdorsi.
Thelowersubscapularnerve(C56)totheteresmajorandpartofthesubscapularismuscle(see
Fig.39).
Sensorybranchesofthemedialcord(C8T145,46orT1alone46)comprisethemedialcutaneous
(antebrachial)nervetothemedialsurfaceoftheforearmandthemedialcutaneous(brachial)nerve
tothemedialsurfaceofthearm(seeFig.39).
ObstetricBrachialPlexusLesions
Thepathomorphologicspectrumoftraumaticbrachialplexusimpairmentsmostoftenincludescombinationsof
varioustypesofinjuries:compressionofspinalnerves,tractioninjuriesofspinalrootsandnerves,andavulsions
ofspinalroots.47Iftherootletsaretraumaticallydisconnectedfromthespinalcord,theynormallyexitthe
intraduralspaceinrarecases,however,theymayalsoremainwithintheduralspace.
Brachialplexusinjuriesaremostcommonlyseeninchildrenandusuallyarecausedbybirthinjuries,although
moreadvancedbirthingtechniquesandanincreaseinthenumberofCaesarianbirthsintheUnitedStatesare
producingadeclineinincidence.However,difficultdeliveriescontinuetocausesuchlesions.48Although
multiplepotentialriskfactorshavebeencited,includingmaternaldemographicvariables,diabetes,
hypertension,priorCaesariandelivery,uterineabnormalities,inductionoflabor,prolongedsecondstage
(adjustedbyparityandepiduraluse),assistedvaginaldelivery,andneonatalbirthweight,nospecificriskfactor
hasbeenidentified.49Stretch(neurapraxiaoraxonotmesis)andincompleterupturearemorecommonin
obstetricbrachialplexuspalsythancompleteruptureoravulsion.
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Obstetricalbrachialplexuspalsyisclassifiedintoupper(involvingC5,C6,andusuallyC7roots),lower
(predominantlyC8andT1),andtotal(C5C8andT1)plexuspalsies.50,51Upperbrachialplexuspalsy,although
describedfirstbyDuchenne,52ironicallybearsthenameErbspalsy.53Mostcasesofobstetricbrachialplexus
palsyinvolveErbspalsy,andthelesionisalwayssupraclavicular.Lowerbrachialplexuspalsyisextremelyrare
inbirthinjuries46,54andisreferredtoasKlumpkespalsy.55
TheinfantwithErbspalsytypicallyshowstheclassicwaiterstippostureoftheparalyzedlimb.56,57Thearm
liesinternallyrotatedatthesideofthechest,theelbowisextended(paralysisofC5,6)orslightlyflexed
(paralysisofC5C7),theforearmispronated,andthewristandthefingersareflexed.Thispostureoccurs
becauseofparalysisandatrophyofthedeltoid,biceps,brachialis,andbrachioradialismuscles.58
Klumpkesparalysisischaracterizedbyparalysisandatrophyofthesmallhandmusclesandflexorsofthewrist
(thesocalledclawhand).Prognosisofthistypeismorefavorable.IfthesympatheticramiofT1areinvolved,
Hornersyndrome(ptosis,enophthalmos,facialreddening,andanhydrosis)maybepresent.
CLINICALPEARL
Mononeuropathy:injurytoasingleperipheralnerve(e.g.,theradialnerve).
Polyneuropathy:involvementofmorethanoneperipheralnerve.Occursinsuchsystemicdiseasesas
diabetes.
PeripheralNervesoftheUpperQuadrant
Peripheralnervesaresubjecttoentrapmentatvariousanatomicallocationsintheupperextremities.
SpinalAccessoryNerve
Thespinalaccessory,orsimplytheaccessory,nerveisformedbytheunionofCNXI(seeCranialNerves)and
thespinalnerverootsofC3andC4,andinnervatesthetrapeziusandtheSCMmuscles.Thus,dysfunctionof
thisnervecausesparalysisoftheSCMandthetrapeziusmuscles.
Isolatedlesionstothisnerveresultfromforcesactingacrosstheglenohumeral(GH)joint.Combinedlesionsof
thespinalaccessoryandtheaxillarynerveresultfromforcesactingbroadlyacrossthescapulothoracicjoint.
Theselesionsareassociatedwithfracturesoftheclavicleand/orscapulaandsubclavianvascularlesions.59
Thesuperficialcourseofthenervealsomakesitsusceptibletoinjuryduringoperativeproceduresorblunt
trauma,60andtostretchtypeinjuries,61,62suchasduringamanipulationoftheshoulderunderanesthesia.63
However,thestretchtypeinjuriesdonotalwaysinvolvetheSCM.64Accessorynerveparesiscanalsoresult
fromaseriouspathologysuchasatumoratthebaseoftheskull,orfromsurgery.65
Clinicalfindingsforthisconditioninclude:
neck,shoulder,andmedialscapularpain
decreasedcervicallordosis
adownwardlyrotatedscapula
wingingofthescapula
trapeziusweakness,especiallywithactivearmelevation.
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Aconfirmatorytestincludesresistedadductionofthescapulawhiletheclinicianappliescounterpressureatthe
medialborderoftheinferiorscapularangle.Thiswillhighlightweaknessontheaffectedside.
Conservativeinterventionforthisconditioninvolvespatienteducationtoavoidtractiontothenerve,specific
upper,middle,andlowertrapeziusstrengthening,neuromuscularelectricalstimulationtotheupperandlower
trapezius,cervicalproprioceptiveneuromuscularfacilitation(PNF)techniques,scapularPNFtechniques,prone
onelbowsscapularstabilizationexercises(seeChapter25),andshoulderelevationstrengthening.McConnell
tapingisalsousedtofacilitatethemiddleandlowertrapeziusmuscle.63
SuprascapularNerve(C56)
Thesuprascapularnerve(Fig.39)travelsdownwardandlaterallybehindthebrachialplexusandparalleltothe
omohyoidmusclebeneaththetrapeziustothesuperioredgeofthescapula,throughthesuprascapularnotch.The
roofofthesuprascapularnotchisformedbythetransversescapularligament.Thesuprascapulararteryandvein
initiallyrunwiththenerveandthenrunabovethetransversesuprascapularligamentoverthenotch.After
passingthroughthenotch,thenervesuppliesthesuprascapularmuscle.Italsoprovidesarticularbranchestothe
GHandacromioclavicular(AC)jointsandprovidessensoryandsympatheticfiberstotwothirdsofthe
shouldercapsule,andtotheGHandACjoints.Thenervethenturnsaroundthelateraledgeofthescapular
spinetoinnervatetheinfraspinatus.
Itiscommonlytaughtthatthesuprascapularnerveprovidesthemotorsupplytothesupraspinatusand
infraspinatusmusclesandsensoryinnervationtotheshoulderjointbutthatithasnocutaneousrepresentation.
However,cutaneousbranchesarepresentintheproximalonethirdofthearm,6668andtheirdistribution
overlapswiththatofthesupraclavicularandaxillarynerves.
CLINICALPEARL
Painrelatedtosuprascapularnerveentrapmentmayradiatetothelateralneckorposteriorandlateralaspectsof
theGHcapsulearea.
Thesuprascapularnervemaybeinjuredbycompression,traction,orlaceration.69AdirectblowatErbspoint
cancauseacompressiontypeinjury.69Compressionneuropathyofthesuprascapularnerveoftenoccursinthe
scapularnotchunderthetransversescapularligament,oratthespinoglenoidnotch.Thiscompressionoccurs
throughextraneuralinflammation,lipomaorcystdevelopment,scarringfollowingdistalclavicleresection,or
ligamententrapment.29,35,70,71
Inthecaseofaligamententrapment,thecausecanbeacutetraumaresultingfromafallonanoutstretchedhand
(FOOSH),scapularfracture,oroveruseinjuriesinvolvingrepetitiveoverheadmotions.70,72,73Entrapmentof
thisnervemaybemisdiagnosedasrotatorcufftendonitis,atearoftherotatorcuff,orcervicaldiskdisease.72,74
Asthesuprascapularnerveisamixednerve,thepatientpresentationusuallyincludesthefollowing:
Adull,deepacheattheposteriorandlateralaspectsoftheshoulder,whichmayhaveaburningquality.
Muscleatrophyandweaknessofthesupraspinatusandinfraspinatus.
ChangesinGHbiomechanicswithanincreaseofscapularelevationoccurringduringarmelevation.This
mayproduceimpingementlikefindingsandcomplicatethediagnosis.
FullexternalrotationoftheGHjointandpassivehorizontaladductionarepainful.75Electromyography
(EMG)isthedefinitivetestforsuprascapularneuropathy.76
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Conservativeinterventionincludesrest,ice,analgesics,andaseriesofperineuralinjectionsofcorticosteroidto
helpreduceneuralinflammation.Ahomeexerciseprogramofscapularpivoterstrengthening(seeChapter16),
scapulohumeralcoordinationexercises(seeChapter16),andactivityspecifictrainingmaybeindicated.35
Surgicalintervention,involvingneurolysis,cystremoval,ortheexcisionofthetransversescapularligamentis
indicatedifsymptomspersist.
MusculocutaneousNerve(C56)
Themusculocutaneousnerve(Fig.310)istheterminalbranchofthelateralcord,whichinturnisderivedfrom
theanteriordivisionoftheupperandmiddletrunksofthefifththroughseventhcervicalnerveroots.77,78
FIGURE310
Themusculocutaneous(C56)nerve.(Reproduced,withpermission,fromChapter29.OverviewoftheUpper
Limb.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:
McGrawHill2011.)
Thenervearisesfromthelateralcordofthebrachialplexusattheleveloftheinsertionofthepectoralis
minor78,79andproceedscaudallyandlaterally,givingoneormorebranchestothecoracobrachialis,before
penetratingthismuscle38cmbelowthecoracoidprocess.78,80Thenervethencoursesthrough,andsupplies,
thebicepsbrachiiandbrachialismuscles,beforeemergingbetweenthebicepsbrachiiandthebrachioradialis
muscles25cmabovetheelbow(seeFig.311).Atthislevel,nowcalledthelateralcutaneous(antebrachial)
nerveoftheforearm,itdividesintoanteriorandposteriordivisionstoinnervatetheanteriorlateralaspectofthe
forearm(Fig.310).78
FIGURE311
Themusculocutaneous(C56)andaxillary(C56)nerves.(Reproduced,withpermission,fromAppendixC.
SpinalNervesandPlexuses.In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill
2013.)
Atraumaticisolatedmusculocutaneousneuropathiesarerare.Reportedcaseshavebeenassociatedwith
positioningduringgeneralanesthesia,81peripheralnervetumors,andstrenuousupperextremityexercise
withoutapparentunderlyingdisease.8285Mechanismsproposedfortheexerciserelatedcasesinclude
entrapmentwithinthecoracobrachialis,8284aswellastractionbetweenaproximalfixationpointatthe
coracobrachialisandadistalfixationpointatthedeepfasciaattheelbow.78Injurytothisnervecanalsoresult
fromdemandingphysicalworkinvolvingshoulderflexionandrepetitiveelbowflexionwithapronated
forearm.82,85,86Althoughrare,anisolatedlesiontothemusculocutaneousnervecanresultinweaknessofthe
biceps,coracobrachialis,andbrachialis(Table32).ThesemuscleshelpstabilizetheelbowandtheGHjoint
andmaintainthestaticpositionofthearm.87
Thetypicalclinicalpresentationincludes:
Reportsorevidenceofmusclewastingandsensorychangestothelateralsideoftheforearm
weaknessofthebiceps,brachialis,andcoracobrachialis
diminishedbicepsreflex
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decreasedsensationatthelateralforearmand
positiveEMGstudy.
Conservativeinterventionincludescessationofthestrenuousactivityandagradualreturntoactivitywith
resolutionofsymptoms.85
CLINICALPEARL
Althoughamusculocutaneouslesionwouldbeexpectedtodemonstrateaweaknessofelbowflexion,onewould
notexpecttoseeweaknessinallshouldermotions,withaninjuryisolatedtotheproximalmusculocutaneous
nerve.
AxillaryNerve(C56)
Theaxillarynerveisthelastnerveoftheposteriorcordofthebrachialplexusbeforethelatterbecomesthe
radialnerve(seeFig.311).Theaxillarynervearisesasoneoftheterminalbranchesoftheposteriorcordofthe
brachialplexus,withitsneuralorigininthefifthandsixthcervicalnerveroots.Theaxillarynervecrossesthe
anteriorinferioraspectofthesubscapularismuscle,whereitthencrossesposteriorlythroughthequadrilateral
spaceanddividesintotwomajortrunks.Alongitscourseacrossthesubscapularmuscle,theaxillarynerve
releasesitsfirstarticularbranchtotheinferioranteriorGHjointcapsule.Theposteriortrunkoftheaxillary
nervegivesabranchtotheteresminormuscleandtheposteriordeltoidmuscle,beforeterminatingasthe
superiorlateralcutaneous(brachial)nerveofthearm(seeFig.311).Theanteriortrunkcontinues,giving
branchestosupplythemiddleandanteriordeltoidmuscle.
Theaxillarynerveissusceptibletoinjuryatseveralsites,includingtheoriginofthenervefromtheposterior
cord,theanteriorinferioraspectofthesubscapularismuscleandGHjointcapsule,thequadrilateralspace,and
withinthesubfascialsurfaceofthedeltoidmuscle(Table33).
TABLE33InjuryFindingsRelatedtoNervesoftheBrachialPlexus
Inabilitytoabductthearmbeyond90degree
Spinalaccessorynerve
Paininshoulderwithabduction
Musculocutaneous
Weakelbowflexionwithforearmsupinated
nerve
Painonflexingfullyextendedarm
Longthoracicnerve Inabilitytoflexfullyextendedarm
Wingingofscapulaat90degreeofforwardflexion
Increasedpainonforwardshoulderflexion
Suprascapularnerve Painincreasedwithscapularabduction
Painincreasedwithcervicalrotationtooppositeside
Axillarynerve Inabilitytoabductarmwithneutralrotation
Supraspinatusandinfraspinatusweaknessandatrophy(ifcompressionpriorto
Suprascapularnerve
innervationofsupraspinatus)
compressionorinjury
Infraspinatusweaknessandatrophyalone(ifcompressionatthespinoglenoidnotch)
SymptomsreproducedbyRoostest,Wrightmaneuver,Adsontest,orhyperabduction
Thoracicoutlet test(variable)
syndrome DiminutionofpulsewithAdsontest,Wrightmaneuver,Halstedtest,orhyperabduction
test(variable)
Historyoftractionforcetoneckrotation,necksidebending,shoulderabduction,or
shoulderexternalrotation,withsimultaneousscapulaandclaviculardepression
Tendernessoverbrachialplexus
Brachialplexus Weaknessinmusclesinnervatedbyinvolvedportionoftheplexus
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(stingerorburner) C5(deltoid,supraspinatus,andinfraspinatus)mostcommonlyinvolved
C6(elbowflexors)secondmostcommonlyinvolved
Sensorylossininvolvednervedistribution
Transientburningandpain
AxillarynervelesionsmayresultfromacuteGHdislocation,surgerytotheGHcomplex,blunttraumatothe
axilla,secondaryhematomaandfibrousformation,entrapment,andtractioning.35,86,88,89
Thetypicalclinicalpresentationincludes:
deeppainintheaxilla,orintheanteriorshoulderinthecaseofaGHdislocation
tinglinginthedeltoidaspectoftheshoulder
atrophymaybeseeninthedeltoidandteresminor
weaknesswhenelevatingthearminflexionandabduction35
manualmuscletestingwillrevealaweaknessofthedeltoidandteresminorand
sensorytestingshouldhighlightalossofsensationatthelateraldeltoidregion.
Thediagnostictestforthislesionistoaskthepatienttoabductthearmto90degreesandtobringitbackinto
horizontalextension.Apatientwithanaxillarylesionwilldemonstrateextremedifficultywiththis.90
Interventionforthislesionisinitiallyconservativeandconsistsofthermalmodalities,protection,and
strengtheningexercises.35Surgicalexplorationmaybeindicatedincasesofcompletedenervation.
RadialNerve(C68,T1)
Theradialnerve(Fig.312)isthelargestbranchofthebrachialplexus.Originatingatthelowerborderofthe
pectoralisminorasthedirectcontinuationoftheposteriorcord,itderivesfibersfromthelastthreecervicaland
firstthoracicsegmentsofthespinalcord.Duringitsdescentdownthearm,theradialnerveaccompaniesthe
profundaarterybehind,andaround,thehumerusandinthemusculospiralgroove.Itpiercesthelateral
intermuscularseptumandreachestheloweranteriorsideoftheforearm,whereitsterminalbranchesarise.
FIGURE312
Theradialnerve(C68,T1).(Reproduced,withpermission,fromAppendixC.SpinalNervesandPlexuses.In:
WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill2013.)
CLINICALPEARL
Theradialnerveisfrequentlyentrappedatitsbifurcationintheregionoftheelbow,wherethecommonradial
nervebecomesthesensorybranchandadeeporposteriorinterosseousbranch.
Theradialnervecrossestheelbowimmediatelyanteriortotheradialhead,justbeneaththeheadsoftheextensor
originoftheextensorcarpiradialisbrevis(ECRB),andthendivides,withthedeepbranchrunningthroughthe
bodyofthesupinatormuscletotheposterioraspectoftheforearm.
Theradialnerveinthearmsuppliesthetriceps,theanconeus,andtheupperportionoftheextensorsupinator
groupofforearmmuscles.Intheforearm,theposteriorinterosseousnerveinnervatesallofthemusclesofthe
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sixextensorcompartmentsofthewrist,withtheexceptionoftheECRBandextensorcarpiradialislongus
(ECRL).
Theskinareassuppliedbytheradialnerveincludetheposterior(dorsal)cutaneous(brachial)nerveofthearm,
totheposterior(dorsal)aspectofthearmtheposterior(dorsal)cutaneous(antebrachial)nerveoftheforearm,
totheposterior(dorsal)surfaceoftheforearmandthesuperficialradialnerve,totheposterior(dorsal)aspectof
theradialhalfofthehand(seeFig.312).Theisolatedareaofsupplyisasmallpatchofskinovertheposterior
(dorsal)aspectofthefirstinterosseousspace(seeFig.312).
Fourradialnerveentrapmentsarecommonlycited:highradialnervepalsy,posteriorinterosseousnerve
syndrome(PINS),radialtunnelsyndrome,andsuperficialradialnervepalsy(seeChapter17).Themajor
disabilityassociatedwithradialnerveinjuryisaweakgrip,whichisweakenedbecauseofpoorstabilizationof
thewristandthefingerjoints(Table33).Inaddition,thepatientdemonstratesaninabilitytoextendthethumb,
thewrist,andtheelbow,aswellastheproximalphalanges.Pronationoftheforearmandadductionofthethumb
alsoareaffected,andthewristandthefingersadoptapositiontermedwristdrop.Thetricepsandotherradial
reflexesareabsent,butthesensorylossisoftenslight,owingtooverlappinginnervation.
Thesiteoftheentrapmentoftheradialnervecanoftenbedeterminedbytheclinicalfindings,asfollows:
Iftheimpairmentoccursatapointbelowthetricepsinnervation,thestrengthofthetricepsremainsintact.
Iftheimpairmentoccursatapointbelowthebrachioradialisbranch,somesupinationisretained.
Iftheimpairmentoccursatapointintheforearm,thebranchestothesmallmusclegroups,extensorsof
thethumb,extensorsoftheindexfinger,extensorsoftheotherfingers,andextensorcarpiulnarismaybe
affected.
Iftheimpairmentoccursatapointontheposterioraspectofthewrist,onlysensorylossonthehandis
affected.
Conservativeinterventionforaradialnervelesiondependsonthelocationandtheseverity.Aswithall
peripheralnerveinjuries,everyattemptmustbemadetomaintaintheappropriatefunctionofthemuscleor
musclesinnervatedbythenerve,whilehelpingtopreventcontractureinthosemusclesantagonistictothe
denervatedmusclebyusingstretchingtechniques.Inaddition,musclestrengtheningisprescribedforthose
uninvolvedagonisticandsynergisticmuscles.
MedianNerve(C68,T1)
Thetrunkofthemediannervederivesitsfibersfromthelowerthree(sometimesfour)cervicalandthefirst
thoracicsegmentofthespinalcord.Althoughithasnobranchesintheupperarm,thenervetrunkdescends
alongthecourseofthebrachialarteryandpassesontotheanterioraspectoftheforearm,whereitgivesoff
muscularbranches,includingtheanteriorinterosseousnerve.Itthenentersthehand,whereitterminateswith
bothmuscularandcutaneousbranches(Fig.313).Thesensorybranchesofthemediannervesupplytheskinof
thepalmaraspectofthethumbandthelateral2fingersaswellasthedistalendsofthesamefingers(seeFig.
313).
FIGURE313
Themediannerve(C68,T1).(Reproduced,withpermission,fromAppendixC.SpinalNervesandPlexuses.
In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill2013.)
Theanteriorinterosseousnervearisesfromtheposterioraspectofthemediannerve,approximately5cmdistal
tothemedialhumeralepicondyle,andpasseswiththemaintrunkofthemediannervebetweenthetwoheadsof
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thepronatorteres.28Itcontinuesalongthepalmaraspectoftheflexordigitorumprofundus(FDP)andthen
passesbetweentheFDPandtheflexorpollicislongus(FPL),runningincloseproximitytotheinterosseous
membrane,toenterthepronatorquadratus.28Theanteriorinterosseousnerveprovidesmotorinnervationtothe
FPLthemedialpartofFDP,involvingtheindexandsometimesthemiddlefingerandtothepronator
quadratus.Italsosendssensoryfiberstothedistalradioulnar,radiocarpal,intercarpal,andcarpometacarpal
joints.91VariationsinthedistributionofthenervehavebeennoteditmaysupplyallornoneoftheFDPand
partoftheflexordigitorumsuperficialis.92
Theclinicalfeaturesofmediannerveimpairment(Table33),dependingonthelevelofinjury,includethe
following:19
Paralysisisnotedintheflexorpronatormusclesoftheforearm(resultinginweaknessorlossof
pronation),allofthesuperficialpalmarmuscles,excepttheflexorcarpiulnaris(FCU),andallofthedeep
palmarmuscles,excepttheulnarhalfoftheFDPandthethenarmusclesthatliesuperficialtothetendon
oftheFPL.
Atthewrist,thereisweakflexionandradialdeviation,andthehandinclinestotheulnarside.
Inthehand,anapehanddeformitycanbepresent(seeFig.313).Thisdeformityisassociatedwith
aninabilitytoopposeorflexthethumborabductitinitsownplane
aweakenedgrip,especiallyinthethumbandindexfinger,withatendencyforthesedigitsto
becomehyperextendedandthethumbadducted
aninabilitytoflexthedistalphalanxofthethumbandindexfinger
weaknessofmiddlefingerflexionand
atrophyofthethenarmuscles.
Thereisalossofsensationtoavariabledegreeoverthecutaneousdistributionofthemediannerve,most
constantlyoverthedistalphalangesofthefirsttwofingers.
Painispresentinmanymediannerveimpairmentsanywherealongitsdistribution.
Atrophyofthethenareminenceisseenearly.Atrophyoftheflexorpronatorgroupsofmusclesinthe
forearmisseenafterafewmonths.
Theskinofthepalmisfrequentlydry,cold,discolored,chapped,andattimeskeratotic.
Themostcommonconditionassociatedwithmediannerveentrapmentiscarpaltunnelsyndrome(seeChapter
18).ThevariousinterventionsformediannerveentrapmentarediscussedinChapters17and18.
UlnarNerve(C8,T1)
Theulnarnerveisthelargestbranchofthemedialcordofthebrachialplexus.Itarisesfromthemedialcordof
thebrachialplexusandcontainsfibersfromtheC8andT1nerveroots,althoughC7maycontributesomefibers
(Fig.314).Theulnarnervecontinuesalongtheanteriorcompartmentofthearm,anditpassesthroughthe
medialintermuscularseptumatthelevelofthecoracobrachialisinsertion.Astheulnarnervepassesintothe
posteriorcompartmentofthearm,itcoursesthroughthearcadeofStruthers,whichisapotentialsiteforits
compression.
FIGURE314
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Theulnarnerve(C8,T1).(Reproduced,withpermission,fromAppendixC.SpinalNervesandPlexuses.In:
WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill2013.)
Attheleveloftheelbow,theulnarnervepassesposteriortothemedialepicondyle,whereitpassesthroughthe
cubitaltunnel.Fromthere,theulnarnervepassesbetweenthetwoheadsoftheFCUoriginandtraversesthe
deepflexorpronatoraponeurosis.ThisaponeurosisissuperficialtotheFDP,butdeeptotheFCUandflexor
digitorumsuperficialismuscles.93,94
CLINICALPEARL
Theintraneuraltopographyoftheulnarnervediffersatvariouslevelsofthearm.Atthemedialepicondyle,the
sensoryfiberstothehandandthemotorfiberstotheintrinsicmusclesaresuperficial,whereasthemotorfibers
toFCUandFDParedeep.95Thismayexplainthecommonfindingincubitaltunnelsyndrome(seeChapter
17)ofsensorylossandweaknessoftheulnarlyinnervatedintrinsicmuscles,butrelativesparingoftheFCUand
FDP.96
Theulnarnerveenterstheforearmbycoursingposteriortothemedialhumeralcondyleandpassingbetweenthe
headsoftheFCU,beforerestingontheFDP97(seeFig.314).Itthencontinuesdistallytothewristpassing
betweentheFCUandtheFDPmuscles,whichitsupplies.Proximaltothewrist,thepalmarcutaneousbranchof
theulnarnervearises.Thisbranchrunsacrossthepalmaraspectoftheforearmandthewristoutsideofthe
tunnelofGuyontosupplytheproximalpartoftheulnarsideofthepalm.Afewcentimetersmoredistallytothe
tunnel,aposterior(dorsal)cutaneousbrancharisesandsuppliestheulnarsideofthedorsumofthehand,the
posterior(dorsal)aspectofthefifthfinger,andtheulnarhalfoftheforefinger.Theulnarnervesuppliesthe
FCU,theulnarheadoftheFDP,andallofthesmallmusclesdeepandmedialtothelongflexortendonofthe
thumb,exceptthefirsttwolumbricales(seeFig.314,indicatedbyterminalbranchesinhand).Itssensory
distributionincludestheskinofthelittlefingerandthemedialhalfofthehandandtheringfinger(seeFig.3
14).
Theclinicalfeaturesofulnarnerveimpairment(Table33)includethefollowing:19
Clawhand(seeFig.314),resultingfromtheunopposedactionoftheextensordigitorumcommunisin
thefourthandfifthdigits.
Aninabilitytoextendthesecondanddistalphalangesofanyofthefingers.
Aninabilitytoadductorabductthefingers,ortoopposeallthefingertips,asinmakingaconewiththe
fingersandthethumb.
Aninabilitytoadductthethumb.
Atthewrist,flexionisweakandulnardeviationislost.Theulnarreflexisabsent.
Atrophyoftheinterosseousspaces(especiallythefirst)andofthehypothenareminence.
Alossofsensationontheulnarsideofthehandandringfingerand,mostmarkedly,overtheentirelittle
finger.
Partiallesionsoftheulnarnervemayproduceonlymotorweaknessorparalysisofafewofthemuscles
suppliedbythenerve.Lesionsthatoccurinthedistalforearmoratthewristsparethedeepflexorsandthe
FCU.
TheconservativeinterventionsforthevariousulnarnerveentrapmentsarediscussedinChapters17and18.
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ThoracicNerves
Inthethoracicregion,thereisgreatvariabilityinthetopographyofthenervesandthestructuresthatthey
serve.98Typically,thespinalrootarisesfromthelateralendofthespinalnervebut,in25%ofcases,thespinal
rootismadeupoftwopartsthatarisefromthesuperiorborderofthespinalnerve.99Thethoracicspinalnerves
aresegmentedintoposterior(dorsal)primaryandanterior(ventral)primarydivisions.Aselsewhere,the
dermatomesofthisregionareconsideredtorepresentthecutaneousregioninnervatedbyonespinalnerve
throughbothofitsrami.100
Anterior(Ventral)Rami
Thereare12pairsofthoracicanterior(ventral)rami.Theanterior(ventral)rami(anteriorbranches)fromT2
throughT11becomeintercostalnerves.The12thanterior(ventral)ramus,thesubcostalnerve,islocatedbelow
thelastrib.Theintercostalnervehasalateralbranch,providingsensorydistributiontotheskinofthelateral
aspectofthetrunk,andananteriorbranch,supplyingtheintercostalmuscles,parietalpleura,andtheskinover
theanterioraspectofthethoraxandtheabdomen.Alloftheintercostalnervesmainlysupplythethoracicand
theabdominalwalls,withtheuppertwoalsosupplyingtheupperlimb.Thethoracicanterior(ventral)ramiof
T36supplyonlythethoracicwall,whereasthelowerfiveramisupplyboththethoracicandtheabdominal
walls.Thesubcostalnervesuppliesboththeabdominalwallandtheglutealskin.
Eachanterior(ventral)ramusisconnectedwithanadjacentsympatheticganglionbygrayandwhiterami
communicantes(Fig.315).Thecommunicatingramiarebranchesofthespinalnervesthattransmitsympathetic
autonomicfiberstoandfromthesympatheticchainofganglia.Thefiberspassfromspinalnervetochain
gangliathroughthewhiteramusandinthereversedirectionthroughthegray.Inthecervical,lowerlumbar,and
sacrallevels,onlygrayramiarepresentandfunctiontoconveyfibersfromthesympatheticchaintothespinal
nerves,amechanismthatensuresthatallspinalnervescontainsympatheticfibers.
FIGURE315
Thoracicspinalnerves.(Reproduced,withpermission,fromChapter5.SuperiorandPosteriorMediastina.In:
2011.)
Fromeachintercostalnerve,acollateralandlateralcutaneousbranchleavebeforethemainnervereachesthe
costalangle.Theintercostobrachialnervearisesfromthelateralcollateralbranchofthesecondintercostal
nerve,piercestheintercostalmusclesinthemidaxillaryline,andthentraversesthecentralportionoftheaxilla,
whereaposterioraxillarybranchgivessensationtotheposterioraxillaryfold.Fromhere,thenervepassesinto
theupperarmalongtheposteriormedialbordertosupplytheskinofthisregion101andtoconnectwiththe
posteriorcutaneousbranchoftheradialnerve.
Posterior(Dorsal)Rami
Thedistributionofallposterior(dorsal)ramiissimilar.Thethoracicposterior(dorsal)ramitravelposteriorly,
closetothevertebralzygapophysealjoints,beforedividingintomedialandlateralbranches:
Themedialbranchessupplytheshort,mediallyplacedbackmuscles(theiliocostalisthoracis,spinalis
thoracis,semispinalisthoracis,thoracicmultifidusrotatoresthoracis,andintertransversariimuscles)and
theskinofthebackasfarasthemidscapularline.Themedialbranchesoftheuppersixthoracicposterior
(dorsal)ramipiercetherhomboidsandtrapezius,reachingtheskinincloseproximitytothevertebral
spines,whichtheyoccasionallysupply.
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Thelateralbranchessupplysmallerbranchestothesacrospinalismuscles.Thelateralbranchesincreasein
sizethemoreinferiortheyare.Theypenetrate,orpass,thelongissimusthoracistothespacebetweenit
andtheiliocostaliscervicis,supplyingboththesemuscles,aswellasthelevatorescostarum.The12th
thoraciclateralbranchsendsafilamentmediallyalongtheiliaccrest,whichthenpassesdowntothe
anteriorglutealskin.
Asmentionedpreviously,therecurrentmeningealorsinuvertebralnerveisfunctionallyalsoabranchofthe
spinalnerve.Thisnervepassesbackintothevertebralcanalthroughtheintervertebralforamen,supplyingthe
anterioraspectoftheduramater,outerthirdoftheannularfibersoftheintervertebraldisks,vertebralbody,and
theepiduralbloodvesselwalls,aswellastheposteriorlongitudinalligament.102
Thethoracicnervesmaybeinvolvedinthesametypesofimpairmentsthataffectotherperipheralnerves.Aloss
offunctionofone,ormore,ofthethoracicnervesmayproducepartialorcompleteparalysisoftheabdominal
muscles,andalossoftheabdominalreflexesintheaffectedquadrants.Withunilateralimpairmentsofthe
nerve,theumbilicususuallyisdrawntowardtheunaffectedsidewhentheabdomenistensed(Beevorsign),
indicatingaparalysisofthelowerabdominalmusclesasaresultofalesionatthelevelofthe10ththoracic
segment.
Aspecificsyndrome,calledtheT4syndrome,103105hasbeenshowntocausevaguepain,numbness,and
paresthesiaintheupperextremityandgeneralizedposteriorheadandneckpain.
LumbarPlexus
Thelumbarplexus(Fig.316)isformedfromtheanterior(ventral)nerverootsofthesecond,third,andfourth
lumbarnerves(inapproximately50%ofcases,theplexusalsoreceivesacontributionfromthelastthoracic
nerve),astheyliebetweenthequadratuslumborummuscleandthepsoasmuscle.Itthentravelsanteriorlyinto
thebodyofthepsoasmuscletoformthe,femoral,obturatornerves,andLCNofthethigh.
FIGURE316
Thelumbarplexus.(Reproduced,withpermission,fromChapter34.OverviewoftheLowerLimb.In:Morton
L1,L2,andL4divideintoupperandlowerbranches(seeFig.316).TheupperbranchofL1formsthe
iliohypogastricandilioinguinalnerves.ThelowerbranchofL1joinstheupperbranchofL2toformthe
genitofemoralnerve(seeFig.316).ThelowerbranchofL4joinsL5toformthelumbosacraltrunk.
Iliohypogastricnerve(T12,L1)(seeFig.317).Thisnerveemergesfromtheupperlateralborderofthe
psoasmajorandthenpasseslaterallyaroundtheiliaccrestbetweenthetransversusabdominisandinternal
obliquemuscles,beforedividingintolateralandanteriorcutaneousbranches.Thelateral(iliac)branch
suppliestheskinoftheupperlateralpartofthethighwhiletheanterior(hypogastric)branchdescends
anteriorlytosupplytheskinoverthesymphysis.
Ilioinguinalnerve(L1)(seeFig.317).Thisnerveissmallerthantheiliohypogastricnerve.Itemerges
fromthelateralborderofthepsoasmajortofollowacourseslightlyinferiortothatoftheiliohypogastric,
withwhichitmayanastomose.Itpiercestheinternaloblique,whichitsuppliesbeforeemergingfromthe
superficialinguinalringtosupplytheskinoftheuppermedialpartofthethighandtherootofthepenis
andscrotumormonspubisandlabiummajores.Anentrapmentofthisnerveresultsinpaininthegroin
region,usuallywithradiationdowntotheproximalinnersurfaceofthethigh,sometimesaggravatedby
increasingtensionontheabdominalwallthroughstandingerect.
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Genitofemoralnerve(L1,2)(seeFig.317).Thisnervedescendsobliquelyandanteriorlythroughthe
psoasmajorbeforeemergingfromtheanteriorsurfaceofthepsoasanddividingintogenitalandfemoral
branches.Thegenitalbranchsuppliesthecremastericmuscleandtheskinofthescrotumorlabia,whereas
thefemoralbranchsuppliestheskinoftheuppermiddlepartofthethighandthefemoralartery.
FIGURE317
Branchesofthelumbarplexus.(Reproduced,withpermission,fromChapter11.PosteriorAbdominalWall.In:
2011.)
CollateralmuscularbranchessupplythequadratuslumborumandintertransversariifromL1andL4,andthe
psoasmusclefromL2andL3(Fig.317).ThelowerbranchofL2,allofL3,andtheupperbranchofL4split
intoasmallanteriorandalargeposteriordivision(seeFig.316).Thethreeanteriordivisionsunitetoformthe
obturatornervethethreeposteriordivisionsunitetoformthefemoralnerve,andtheLCNofthethigh(seeFig.
316).
PeripheralNervesoftheLumbarPlexus
Theperipheralnervesofthelumbarplexusaresubjecttoentrapmentatvariousanatomicallocationsinthe
lowerextremities.PeripheralnerveentrapmentsyndromesofthelowerextremityarelistedinTable34.
TABLE34PeripheralNerveEntrapmentSyndromesoftheLowerExtremity
Lower
Extremity
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Symptomsincludeburningorlancinatingpain
immediatelyfollowingtheabdominaloperation.The
painextendsfromthesurgicalincisionlaterallyinto
theinguinalregionandsuprapubicregion.
Discomfortmayoccurimmediatelyoruptoseveral
yearsaftertheprocedureandmaylastformonthsto
years.Thisdiscomfortispossiblybecauseofthe
formationofscartissueintheregion.Occasionally,
thepainmayextendintothegenitaliaduetothe
significantoverlapwithothercutaneousnerves.Loss
ofsensationisusuallyminimalandnotproblematic.
Iliohypogastricnerveentrapmentcausingsymptoms
similartotrochantericbursitisrefractoryto
conventionaltherapyhasbeenreported.
Theiliohypogastricnerveisrarelyinjured
Onexamination,painandtendernessareusually
inisolation.Themostcommoncausesof
presentintheareaofscarringorentrapment.
injuryaresurgicalprocedures.These
Hyperesthesiaorhypoesthesiamayoccurinthearea
includetransverselowerabdominal
suppliedbythisnerve.Diagnosisisdifficultdueto
incisions,asinhysterectomies,orinjuries
thesmallareaofcutaneoussupplythatthisnerve
fromproceduressuchasinguinal
provides.Theremaybeoverlapinsensorysupply
herniorrhaphyandappendectomies.The
withthegenitofemoralandilioinguinalnerves.
injuriesmainlyoccuriftheincision
Threemajorcriteriaareusedtodiagnosethisnerve
extendsbeyondthelateralmarginofthe
injury.Thefirstisahistoryofsurgicalprocedurein
inferiorrectusabdominisfibers.The
thelowerabdominalarea,althoughspontaneous
Iliohypogastric damagecanresultfromdirectsurgical entrapmentcanoccur.Paincanusuallybeelicitedby
nerve trauma,suchaspassingasuturearound
palpatinglaterallyaboutthescarmargin,andthe
thenerveandincorporatingitintothe
painusuallyradiatesinferomediallytowardthe
fascialrepair,orpostoperativeentrapment
inguinalregionandintothesuprapubicandproximal
inscartissueorneuromaformation.
genitalarea.Second,adefiniteareaofhypoesthesia
Sportsinjuriessuchastraumaormuscle
orhyperesthesiashouldbeidentifiedintheregionof
tearsofthelowerabdominalmusclesmay
supplyoftheiliohypogastricnerve.Third,
alsoresultininjurytothenerve.Itmay
infiltrationofalocalanestheticintotheregionwhere
alsooccurduringpregnancyduetothe
theiliohypogastricandilioinguinalnervesdepartthe
rapidlyexpandingabdomeninthethird
internalobliquemuscleandwheresymptomscanbe
trimester.Thisiscalledtheidiopathic
reproducedonphysicalexaminationbypalpation
iliohypogastricsyndromeandisrare.
shouldprovidesymptomaticrelief.
Ifnoreliefisobtainedwithinjection,adifferent
etiologyshouldbesoughtforthediscomfort.
Alternatediagnosesincludeupperlumbarorlower
thoracicnerverootpathologyordiscogenicetiology
ofthepain.Iftheiliohypogastricnerveisclearly
identifiedasthesourceofpainandafavorable
responseisnotobtainedtolocalanestheticinjection,
thensurgicalexplorationandresectionofthenerve
shouldbeconsidered.Noreliableelectrodiagnostic
techniquesareavailabletodefinetheintegrityofthis
nerve,althoughneedleEMGofthelowerabdominal
musculaturemayserveasanadjunctinthe
diagnosis.
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Symptomscouldincludehyperesthesiaor
hypoesthesiaoftheskinalongtheinguinalligament.
Causesofinjuryincludelowerabdominal
Thesensationmayradiatetothelowerabdomen.
incisions(Pfannenstiel),pregnancy,iliac
Painmaybelocalizedtothemedialgroin,labia
boneharvesting,appendectomy,inguinal
majoraorscrotum,andtheinnerthigh.The
herniorrhaphy,inguinallymphnode
characteristicsofthepainmayvaryconsiderably.
dissection,femoralcatheterplacement,
Patientsmaybeabletoassociatetheirpainclearly
orchiectomy,totalabdominal
withatraumaticeventorwiththesurgical
Ilioinguinal hysterectomy,andabdominoplasty.Nerve
procedure.
nerve injurycanalsooccuridiopathically.The
Painandtendernessmaybepresentwithapplication
prevalenceofinjurywithsurgeryhas
ofpressurewherethenerveexitstheinguinalcanal
declinedduetotheuseoflaparoscopic
inupto75%ofpatients.Sensoryimpairmentis
procedures.Tearingofthelowerexternal
commoninthedistributionofthenervesupplynoted
obliqueaponeurosismayalsocause
above.Symptomsusuallyincreasewithhip
injurytothisnerve.Thisinjuryhasbeen
extension(patientswalkwiththetrunkinaforward
reportedinhockeyplayers.
flexedposture).Painmayalsobereproducedwith
palpationmedialtotheASIS.
Thediagnosiscanbemadeonthebasisoflocal
infiltrationofanestheticwithorwithoutsteroidand
shouldresultinreliefwithin10min.Unfortunately,
noelectrodiagnostictechniquesareavailableto
readilytestthisnerve.AbdominalneedleEMGmay
behelpfulindeterminingtheseverityofnerve
injury,butEMGisnotsensitiveorspecific.
Hypesthesiaovertheanteriorthighbelowthe
inguinalligament,whichishowitisdistinguished
Nerveinjurymayresultfromhernia
fromtheiliohypogastricandilioinguinalnerve.
repair,appendectomy,biopsies,and
Groinpainisacommonpresentationofneuralgia
Caesariandelivery.Injurymayalsooccur
fromnerveinjuryorentrapment.Thepainmaybe
duetointrapelvictraumatotheposterior
worsewithinternalorexternalrotationofthehip,
Genitofemoral abdominalwall,retroperitoneal prolongedwalking,orevenwithlighttouch.
nerve hematoma,pregnancy,ortraumatothe
Differentialdiagnosesincludeinjurytothe
inguinalligament.Fortunately,injuryto
ilioinguinalandgenitofemoralnervesaswellasL1
thisnerveisrare,evenwithopen
2radiculopathies.Someanatomicoverlapmayexist
herniorrhaphy.
withthesupplyoftheilioinguinalandgenitofemoral
nerves,whichmakesthediagnosissomewhat
difficulttoestablish.
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Aprotruding,pendulousabdomen,asseeninobesity
andpregnancy,pushestheinguinalligamentforward
anddownwardanddragsthenervewithitoverthe
kink.Theangulationofthenerveisalsoexaggerated
withextensionofthethighandrelaxedwithflexion.
Entrapmentusuallyoccursattheinguinal
Extensionalsotensesthefascialataandmayaddto
ligament.Thepeakincidenceforthis
thecompressionfromthefront.Therefore,itis
conditionisinmiddleage.Differential
commontoencountermeralgiaparestheticain
diagnosesincludelumbarradiculopathies
individualswhoareobeseandinwomenduringtheir
anddiscogenicornerverootproblemsat
lasttrimesterofpregnancy.
L2andL3.Theentrapmentmaybefrom
Thesymptomsoftenareaccentuatedwithwalking
intrapelviccauses,extrapelviccauses,or
Lateral downslopesandstairs,prolongedstandinginthe
mechanicalcauses.Intrapelviccauses
cutaneous erectposture,and,sometimes,lyingflatinbed.The
wouldincludepregnancy,abdominal
nerve(LCN) patientlearnstorelievesymptomsbyplacinga
tumors,uterinefibroids,diverticulitis,or
(lateral pillowbehindthethighsandassumingaslightly
appendicitis.Injuryhasbeendescribedin
femoral hunchedposturewhilestanding.
casesofabdominalaorticaneurism.
cutaneous)of Themainsymptomsareanuncomfortable
Examplesofextrapelviccausesinclude
thethighLCN numbness,tingling,andpainfulhypersensitivityin
traumatotheregionoftheASIS(e.g.,a
(meralgia thedistributionoftheLCN,usuallyinthe
seatbeltfromamotorvehicleaccident),
paresthetica) anterolateralthighdowntotheupperpatellaregion.
tightgarments,belts,girdles,orstretch
Decreasedappreciationofpinprickiselicited,
fromobesityandascites.Mechanical
togetherwithahyperpathicreactiontotouchand
factorsincludeprolongedsittingor
evenanafterdischargephenomenonofpersistent,
standingandpelvictiltfromleglength
spontaneoustinglingafterthetouch.Deepdigital
discrepancy.Diabetescanalsocausethis
pressuremedialtotheASISmaysetoffshooting
neuropathyinisolationorintheclinical
paresthesiadownthelateralthigh.
settingofapolyneuropathy.
Thediagnosisisconfirmedwithanerveblockusing
0.5%bupivacaineinjectedafingersbreadthmedial
totheASIS.Theresultinganesthesiaoverthe
sensoryterritoryoftheLCNshouldbeconcomitant
withthecompletecessationofpainandtingling.
Multipleetiologieshavebeenproposedto
explainthecompressionorirritationof
thesciaticnervethatoccurswiththe
piriformissyndrome:
Hypertrophyofthepiriformis
muscle.
Trauma.Trauma,directorindirect,
tothesacroiliacorglutealregion
canleadtopiriformissyndrome
andisaresultofhematoma
formationandsubsequentscarring Sixclassicfindings:
betweenthesciaticnerveandthe
shortexternalrotators. 1.Ahistoryoftraumatothesacroiliacand
glutealregions
Hipflexioncontracture.Aflexion
contractureatthehiphasbeen 2.Painintheregionofthesacroiliacjoint,
associatedwithpiriformis greatersciaticnotch,andpiriformismuscle
syndrome.Thisflexioncontracture thatusuallycausesdifficultywithwalking
increasesthelumbarlordosis,
3.Acuteexacerbationofpaincausedbystooping
whichincreasesthetensioninthe
orlifting(andmoderatereliefofpainby
pelvicfemoralmuscles,asthese
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musclestrytostabilizethepelvis tractionontheaffectedextremity,withthe
andspineinthenewposition.This patientinthesupineposition)
increasedtensioncausesthe
involvedmusclestohypertrophy 4.Apalpablesausageshapedmass,tenderto
Piriformis palpation,overthepiriformismuscleonthe
withnocorrespondingincreasein
syndrome affectedside
thesizeofthebonyforamina,
resultinginneurologicalsignsof
sciaticcompression. 5.Apositivestraightlegraise
Gender.Femalesaremore 6.Glutealatrophy,dependingonthedurationof
commonlyaffectedbypiriformis thecondition.Otherclinicalsignsincludepain
syndrome,withasmuchasa6:1 andweaknessinassociationwithresisted
femaletomaleincidence. abductionandexternalrotationoftheinvolved
thigh,palpable,andlocalmusclespasm
Ischialbursitis. (palpableintheobturatorinternusor,less
commonly,inthepiriformismuscle)
Pseudoaneurysmoftheinferior
glutealartery.
Theneurologicexaminationisusuallynormal.
Excessiveexercisetothehamstring Anexaminationofthehipandlowerlegusually
muscles. demonstratesrestrictedexternalrotationofthehip
andlumbosacralmuscletightness.
Inflammationandspasmofthe
piriformismuscle.Thisisoftenin
associationwithtrauma,infection,
andanatomicalvariationsofthe
muscle.
Anatomicalanomalies.Local
anatomicalanomaliesmay
contributetothelikelihoodthat
symptomswilldevelop.
Thesymptomsofafemoralneuropathymayinclude
painintheinguinalregionthatispartiallyrelieved
byflexionandexternalrotationofthehipand
dysesthesiaovertheanteriorthighandanteromedial
Diabeticamyotrophyisthemostcommon leg.Patientscomplainofdifficulty,withwalkingand
causeoffemoralnerveneuropathy. kneebucklingdependingontheseverityofthe
Openinjuriescanoccurfromgunshots, injury.Thenervegivesrisetothesaphenousnerve
knifewounds,glassshards,orneedle inthethightherefore,numbnessinthisdistribution
punctureinsomemedicalprocedures. canbepresent.Anteriorkneepainmayalsobe
Femoralnerve Themostworrisomecomplicationof presentduetothesaphenousnervesupplytothe
majortraumatothefemoraltriangle patella.Onexamination,patientsmaypresentwith
regionisanassociatedfemoralartery weakhipflexion,kneeextension,andimpaired
injury. quadricepstendonreflexandsensorydeficitinthe
Mostentrapmentneuropathiesoccur anteromedialaspectofthethigh.Painmaybe
belowtheinguinalligament. increasedwithhipextension.Ifcompressionoccurs
attheinguinalregion,nohipflexionweaknessis
present.Sensorylossmayoccuralongthemedial
aspectofthelegbelowtheknee(saphenous
distribution).
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Heatdevelopedbymethylmethacrylatein Electrodiagnostictestingistypicallyperformedfor
atotalhiparthroplastycaninjurethe diagnosisbutisalsoimportanttodeterminethe
femoralnerve.Pelvicproceduresthat extentoftheinjuryandtodetermineprognosisof
requirethelowerextremitytobe recovery.Withelectrodiagnostictesting,either
positionedinanacutelyflexed,abducted, surfaceorneedleelectrodeslateraltothefemoral
andexternallyrotatedpositionforlong arteryintheinguinalregionisusedforstimulation.
periodscancausecompressionbyangling Thestimulationcanbeperformedaboveandbelow
thefemoralnervebeneaththeinguinal theinguinalligament.Diskelectrodesfromthe
ligament. vastusmedialisareusedtorecordstimulation.
Thenervemaybecompromisedby Asaphenousnervesensorystudymayalsobe
pressurefromafetusinadifficultbirth. performed(continuationofthesensoryportionofthe
Pelvicfracturesandacutehyperextension femoralnerveoverthemedialaspectofthelegand
ofthethighmayalsocauseanisolated ankle).Needleexaminationshouldbecompletedfor
femoralnerveinjury. theparaspinalmusclesaswellastheiliopsoas(also
Pelvicradiation,appendicealorrenal L23)andhipadductorssuppliedbytheobturator
abscesses,andtumorscancausefemoral nervetodeterminethepresenceofrootorplexus
nerveinjuriesaswell.Thenervecanalso injuryversusperipheralnerveinjury.Theneedle
beinjuredbyacompartmentlike EMGisusuallythemostrevealingportionofthe
compressionfromahemorrhagefrom electrodiagnostictest.Theexaminermustlooknot
hemorrhagicdisordersoranticoagulant onlyfordenervationpotentialsbutalsoforany
use. activemotorunits.
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Symptomsofentrapmentmayincludeadeepaching
sensationinthethigh,kneepain,andpossibly
paresthesiasinthecutaneousdistributionofthe
saphenousdistributioninthelegandthefoot.The
infrapatellarbranchmayalsobecomeentrappedon
itsown.Thisisbecauseitpassesthroughaseparate
forameninthesartoriusmuscletendon,oritmay
coursehorizontallyacrosstheprominenceofthe
medialfemoralepicondyle,whereitmaybeexposed
totrauma.Patientsreportparesthesiasandnumbness
abouttheinfrapatellarregionthatisworsewith
flexionofthekneeorcompressionfromgarments
andbraces.
Saphenousnerveentrapmentisafrequently
overlookedcauseofpersistentmedialkneepainthat
occursinpatientswhoexperiencetraumaordirect
blowstothemedialaspectoftheknee.Asthisisa
Thesaphenousnervecanbecome purelysensorynerve,weaknessshouldnotbenoted
entrappedwhereitpiercestheconnective withanisolatedinjuryofthisnerve.Ifweaknessis
tissueattheroofofHuntercanal, present,lookforaninjuryofthefemoralnerveor
resultingininflammationfromasharp possiblyanupperlumbarradiculopathy,particularly
angulationofthenervethroughthe ifthighadductionispresent(obturatornerve).
structureandthedynamicforcesofthe Deeppalpationproximaltothemedialepicondyleof
musclesinthisregion.Thisresultsin thefemurmayreproducethepainandcomplaints.
contractionandrelaxationofthefibrous Someweaknessmaybepresentbecauseofguarding
Saphenous tissuethatimpingesthenerve.Thenerve ordisuseatrophyfromthepain,butnodirect
nerve canalsobeinjuredfromanimproperly weaknesswillresultfromthenerveimpingement.
protectedkneeorlegsupportduring Sensorylossinthesaphenousdistributionmaybe
operation.Itmaybeinjureddueto presentonexamination.Noweaknessshouldbe
neurilemoma,entrapmentbyfemoral presentinthequadricepsmusclesorthehip
vessels,directtrauma,pesanserine adductors.
bursitis,varicoseveinoperations,and Thediagnosismaybemadeonthebasisofinjection
medialkneearthrotomiesandmeniscus oflocalanestheticalongthecourseofthenerveand
repairs. proximaltotheproposedsiteofentrapment.Nerve
conductiontechniquesareavailabletoassessneural
conductioninthemainbranchofthesaphenous
nerveortheterminalbranches.Theroutinetestsmay
bedisappointingwithpersonswithsubcutaneous
adiposetissueorswelling.Asidetoside
comparisonofthenerveshouldbemadeandmust
demonstratealesionconsistentwiththepatients
complaints.Asomatosensoryevokedpotentialtest
canalsobeperformedandtheresultscomparedwith
thoseofthecontralateralsidefordiagnosis,although
thistestmaybecumbersomeandtimeconsuming.
Nofindingsshouldbepresentonneedleexamination
ofthemuscleduringEMG.Needleexamination
shouldincludethequadricepsmusclesandthe
adductorlongustoassessforbothfemoraland
obturatornerveinjury.Iffindingsarepresentinboth
ofthesemuscles,thenparaspinalmusclesdefinitely
shouldbeexaminedtoruleoutradiculopathy.
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Painbehindthekneeorinthecalfmuscleswhenthe
Compressionoftibialnerveasitpasses
footisdorsiflexed.Hypesthesiaoranesthesiaofthe
throughthepoplitealfossa.Usually
entireplantarsurfaceofthefoot.
causedbyanenlargedBakerscyst
Poplitealfossa Incompleteflexionofthekneejoint.
(whichmayalsocompressthecommon
(tibialnerve) Weaknessofthegastrocnemius,tibialisposterior,
fibularandsuralnerves).Othercauses
flexorhallucislongus,flexordigitorumlongus,and
includeproliferationofthesynovialtissue
theintrinsicmusclesofthefoot(exceptforthe
inpatientswithrheumatoidarthritis.
extensordigitorumbrevis).
Compressionoftheposteriortibialnerve
behindthemedialmalleolus,ortarsal
tunnelsyndrome,isanuncommon
entrapmentneuropathy.Theroofofthe
tunnelisformedbytheflexor
retinaculumstretchedbetweenthemedial
malleolusandthecalcaneus.Thetarsal
bonesarethefloor.Numerousfibrous
septaebetweentheroofandthefloor
subdividethetunnelintoseparate
compartmentsatvariouspoints.The
contentsofthetarsaltunnelatits
proximalendare,fromfronttoback,(1)
Earlysymptomsareburning,tingling,and
theflexordigitorumlongustendon,(2)
dysestheticpainovertheplantarsurfaceofthefoot.
theposteriortibialistendon,(3)the
Characteristically,thepainissetoffbypressingor
posteriortibialarteryandvein,(4)the
rubbingovertheplantarskin,sometimeswithafter
posteriortibialnerve,and(5)theflexor
dischargephenomenon.ATinelsignoftenisevident
hallucislongustendon.Thenervehas
overthecourseofthemainnerveoritsbranches,
threeterminalbranches.Itbifurcatesinto
andthepainmaybeaggravatedbyforcedeversion
Tarsaltunnel themedialandlateralplantarnerves
anddorsiflexionoftheankle.Inadvancedcases,the
within1cmofthemalleolarcalcaneal
intrinsicflexorsofthegreattoeareweakand
axisin90%ofcasestheother10%are
atrophied,producinghollowingoftheinstep.The
23cmproximaltothemalleolus.
lateraltoesmayalsoshowclawingduetoparalysis
Thecalcanealbranchusuallycomesoff
oftheintrinsictoeflexorsandtheposterior(dorsal)
thelateralplantarfascicles,butaround
digitalextensors.Thecalcanealbranchoftenis
30%leavethemainnervetrunkjust
sparedbecauseofitsproximaltakeoff.
proximaltothetunnel.Distally,the
medialandlateralplantarnervestravelin
separatefascialcompartments.The
medialbranchsuppliestheintrinsic
flexorsofthegreattoeandthesensation
overthemedialplantarsurfaceofthefoot
inclusiveofatleastthefirstthreetoes.
Thelateralbranchsuppliesallofthe
intrinsicsthatcauseextensionofthe
interphalangealjoints,aswellas
sensationoverthelateralplantarsurface
ofthefoot.Thecalcanealbranchprovides
sensationtotheheel.
EMG,electromyographyASIS,anterosuperioriliacspineLCN,lateralcutaneousnerve.
ModifiedfromHollisMH,LemayDE.NerveEntrapmentSyndromesoftheLowerExtremity2005.Available
at:http://www.emedicine.com/orthoped/topic422.htm.
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ModifiedfromPangD.NerveEntrapmentSyndromes2004.Availableat:
http://www.emedicine.com/med/topic2909.htm.
FemoralNerve(L24)
Thefemoralnerve,thelargestbranchofthelumbarplexus,arisesfromthelateralborderofthepsoasjustabove
theinguinalligament.Thenervedescendsbeneaththisligamenttoenterthefemoraltriangleonthelateralside
ofthefemoralartery,whereitdividesintoterminalbranches.Abovetheinguinalligament,thefemoralnerve
suppliestheiliopsoasmuscle,and,inthethigh,itsuppliesthesartorius,pectineus,andquadricepsfemoris
muscles.
Thesensorydistributionofthefemoralnerveincludestheanteriorandmedialsurfacesofthethighviathe
anteriorfemoralcutaneousnerveandthemedialaspectoftheknee,theproximalleg,andarticularbranchesto
thekneeviathesaphenousnerve(Fig.318),thelargestcutaneousbranchofthefemoralnerve.Thesaphenous
nerveexitsfromtheadductor(Hunters,orsubsartorial)canal,descendsunderthesartoriusmuscle,andthen
windsaroundtheposterioredgeofthesartoriusmuscleatitstendonportion.
FIGURE318
Thefemoral(L24)andobturator(L24)nerves.(Reproduced,withpermission,fromAppendixC.Spinal
NervesandPlexuses.In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill2013.)
Theinfrapatellarbranchpiercesthesartoriusmuscleandcoursesanteriorlytotheinfrapatellarregion.
Thedescendingbranchpassesdownthemedialaspectofthelegand,atthelowerthirdoftheleg,divides
intotwobranches.Oneofthebranchesofthedescendingportionofthesaphenousnervecoursesalong
themedialborderofthetibiaandendsattheankle,whiletheotherbranchpassesanteriortotheankleand
isdistributedtothemedialaspectofthefoot,sometimesreachingasfarasthemetatarsophalangealjoint
ofthegreattoe.
Entrapmentofthesaphenousnerveoftenresultsinmarkedpainatthemedialaspectoftheknee.
Femoralnervepalsyhasbeenreportedafteracetabularfracture,cardiaccatheterization,totalhiparthroplasty,or
anteriorlumbarspinalfusion,andspontaneouslyinhemophilia.106108
CLINICALPEARL
Anentrapmentofthefemoralnervebyaniliopsoashematomaisthemostlikelycauseoffemoralnerve
palsy.109Directblowstotheabdomenorahyperextensionmomentatthehipthattearstheiliacusmusclemay
produceaniliacushematoma.
ObturatorNerve(L24)
Theobturatornerve(seeFig.318)arisesfromthesecond,third,andfourthlumbaranteriordivisionsofthe
lumbarplexusandemergesfromthemedialborderofthepsoas,nearthebrimofthepelvis.Itthenpasses
behindthecommoniliacvesselsonthelateralsideofthehypogastricvesselsandtheureter,anddescends
throughtheobturatorcanalintheupperpartoftheobturatorforamentothemedialsideofthethigh.Whilein
theforamen,theobturatornervesplitsintoanteriorandposteriorbranches.
Theanteriordivisionoftheobturatornervegivesanarticularbranchtothehipjointnearitsorigin.It
descendsanteriortotheobturatorexternusandadductorbrevis,deeptothepectineusandadductorlongus
andsuppliesmuscularbranchestotheadductorslongusandbrevis,thegracilis,and,rarely,tothe
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pectineus.101Theanteriordivisiondividesintonumerousnamedandunnamedbranches,includingthe
cutaneousbranchestothesubsartorialplexusanddirectlytoasmallareaofskinonthemiddleinternal
partofthethigh,vascularbranchestothefemoralartery,andcommunicatingbranchestothefemoral
cutaneousandaccessoryobturatornerves.
Theposteriordivisionoftheobturatornervepiercestheanteriorpartoftheobturatorexternus,whichit
suppliesanddescendsdeeptotheadductorbrevis.Italsosuppliestheadductorsmagnusandbrevis(ifit
hasnotreceivedsupplyfromtheanteriordivision)andgivesanarticularbranchtothekneejoint(seeFig.
318).
Theobturatornervemaybeinvolvedbythesamepathologicprocessesthataffectthefemoralnerve.Disability
isusuallyminimal,althoughexternalrotationandadductionofthethighareimpaired,andcrossingofthelegsis
difficult.Thepatientmayalsocomplainofseverepain,whichradiatesfromthegroindowntheinneraspectof
thethigh(seeFig.318).110,111
LCNoftheThigh
TheLCNofthethigh(Fig.37)ispurelysensoryandisderivedprimarilyfromthesecondandthirdlumbar
nerveroots,withoccasionalcontributionsfromthefirstlumbarnerveroot.112,113Sympatheticafferent,and
efferentfibersarealsocontainedwithinthenerve.114Thenerveleavesthelumbarplexusandnormallyappears
atthelateralborderofthepsoas,justproximaltothecrestoftheilium.Fromhere,itcourseslaterallyacrossthe
anteriorsurfaceoftheiliacus(coveredbyiliacfascia)andapproachesthelateralportionoftheinguinalligament
posteriortothedeepcircumflexiliacartery.Thenerveusuallycrossesbeneaththeinguinalligament,just
inferiormedialtotheanteriorsuperioriliacspine(ASIS).115ThesiteatwhichtheLCNexitsthepelvisvaries.
Meralgiaparesthetica(seeTable34),thetermusedtodescribeLCNentrapment(seeChapter5),hasbeen
reportedwitheachofthefiveknownvariantsasfollows:116
Thesplitlateralattachmentoftheinguinalligament.Asthenervecurvesmediallyandinferiorlyaround
theASIS,itmaybesubjectedtorepetitivetraumainthisosteofibroustunnel.117
Thenervemaypassposteriortotheinguinalligamentandanteriortoasharpridgeofiliacusfascia,which
canleadtoabowstringdeformityofthenervewhenthepatientissupine.118
Occasionally,theLCNentersthethighwithinorbeneaththesubstanceofthesartoriusmuscle.119
SeveralcaseshavebeenreportedinwhichtheLCNcrossesovertheiliaccrestlateralandposteriortothe
ASIS.Thenervetypicallyliesinagrooveintheiliumandissubjecttopressurefromtightgarmentsor
belts.118,119
Thenervemayexitthepelvisinmultiplebranches,withentrapmentofasinglebranch.120
Alternatively,thenervemaybeabsent,withabranchfromthefemoralnervearisingbelowtheinguinal
ligament,oritmaybereplacedbytheilioinguinalnerve.121
SacralPlexus
Thelumbosacraltrunk(L45)descendsintothepelvis,whereitenterstheformationofthesacralplexus.The
sacralplexus(Fig.316)isformedbytheanterior(ventral)ramioftheL4andL5andtheS1throughS4nerves
andliesontheposteriorwallofthepelvis,anteriortothepiriformisandposteriortothesigmoidcolon,ureter,
andhypogastricvesselsinfront.TheL4andL5nervesjoinmedialtothesacralpromontory,becomingthe
lumbosacraltrunk.TheS1throughS4nervesconvergewiththelumbosacraltrunkinfrontofthepiriformis
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muscle,formingthebroadtriangularbandofthesacralplexus.Thesuperior(upper)threenervesoftheplexus
divideintotwosetsofbranches:themedialbranches,whicharedistributedtothemultifidimuscles,andthe
lateralbranches,whichbecomethemedialclunealnerves.Themedialclunealnervessupplytheskinoverthe
medialpartofthegluteusmaximus.Thelowertwoposteriorprimarydivisions,withtheposteriordivisionofthe
coccygealnerve,supplytheskinoverthecoccyx.
CollateralBranchesofthePosteriorDivision
SuperiorGlutealNerve
Therootsofthesuperiorglutealnerve(L4,5S1)arisewithinthepelvisfromthesacralplexus(seeFig.316)
andenterthebuttockthroughthegreatersciaticforamen,abovethepiriformis.Thenerverunslaterallybetween
gluteusmediusandgluteusminimus,whichitinnervatesbeforeterminatinginthetensorfascialata,whichit
alsosupplies.Becausethenervepassesbetweentheglutealmuscles,itisatriskduringsurgeryonthehip.122
InferiorGlutealNerve
Theinferiorglutealnerve(L5S1,2)passesbelowthepiriformismuscleandthroughthegreatersciaticforamen
andtravelstothegluteusmaximusmuscle(seeFig.316),whichitserves.Nervestothepiriformisconsistof
shortsmallerbranchesfromS1andS2.
SuperiorClunealNerve
Themedialbranchofthesuperiorclunealnervepassessuperficiallyovertheiliaccrest,whereitiscoveredby
twolayersofdensefibrousfascia.Whenthemedialbranchofthesuperiorclunealnervepassesthroughthe
fasciaagainsttheposterioriliaccrestandtheosteofibroustunnelconsistingofthetwolayersofthefasciaand
thesuperiorrimoftheiliaccrest,thepossibilityofirritationortraumatothenerveisincreased,makingthisa
potentialsiteofnervecompressionorconstriction.123
PosteriorCutaneous(Femoral)NerveoftheThigh
Theposteriorcutaneous(femoral)nerve(PCN)ofthethighconstitutesacollateralbranch,withrootsfromboth
theanteriorandtheposteriordivisionsofS1andS2andtheanteriordivisionsofS2andS3(Fig.316).Perineal
branchespasstotheskinoftheuppermedialaspectofthethighandtheskinofthescrotumorlabiummajores.
Despiteitscloseproximitytothesciaticnerve,however,injurytothePCNofthethighisquiterare.
CollateralBranchesoftheAnteriorDivision
Collateralbranchesfromtheanteriordivisionsextendtothequadratusfemorisandgemellusinferiormuscles
(fromL4,L5,andS1)andtotheobturatorinternusandgemellussuperiormuscles(fromL5,S1,andS2).
SciaticNerve
Thesciaticnerve(Fig.319)isthelargestnerveinthebody.ItarisesfromtheL4,L5,andS1throughS3nerve
rootsasacontinuationofthelumbosacralplexus.Thenerveiscomposedoftheindependenttibial(medial)and
commonfibular(peroneal)(lateral)divisions,whichareusuallyunitedasasinglenervedowntothelower
portionofthethigh.Thetibialdivisionisthelargerofthetwodivisions.Althoughgrosslyunited,thefunicular
patternsofthetibialandcommonfibular(peroneal)divisionsaredistinct,andthereisnoexchangeofbundles
betweenthem.Thecommonfibular(peroneal)nerveisformedbytheupperfourposteriordivisions(L4,5S1,
2)ofthesacralplexus,andthetibialnerveisformedfromallfiveanteriordivisions(L4,5S13).
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FIGURE319
Thesciaticnerve(L4,5,S13).(Reproduced,withpermission,fromAppendixC.SpinalNervesandPlexuses.
Thesciaticnerveusuallyexitsthepelvisthroughtheanteriorthirdofthegreatersciaticforamen.124Also
runningthroughthegreatersciaticforamenisthesuperiorglutealartery,thelargestbranchoftheinternaliliac
artery,anditsaccompanyingvein.
Numerousvariationshavebeendescribedforthecourseofthesciaticnerve,includingcasesinwhichthesciatic
nervepassesthroughthepiriformis,andcasesinwhichthetibialdivisionpassesbelowthepiriformiswhilethe
commonfibular(peroneal)divisionpassesaboveorthroughthemuscle.Itseemsthatthetibialdivisionalways
enterstheglutealregionbelowthepiriformis,andthevariabilityisinthecourseofthecommonfibular
(peroneal)division.Typically,thesciaticnervedescendsalongtheposteriorsurfaceofthethightothepopliteal
space,whereitusuallyterminatesbydividingintothetibialandcommonfibular(peroneal)nerves(seeFig.3
19).Innervationoftheshortheadofthebicepsfemoriscomesfromthecommonfibular(peroneal)division,the
onlymuscleinnervatedbythisdivisionabovetheknee.Ramifromthetibialtrunkpasstothesemitendinosus
andthesemimembranosusmuscles,thelongheadofthebicepsfemoris,andtheadductormagnusmuscle.
Inmostreportsofsciaticnerveinjury,regardlessofthecause,thecommonfibular(peroneal)divisionis
involvedmorefrequentlyandoftensuffersagreaterdegreeofdamagethanthetibialdivisionitssusceptibility
toinjurybeingrelatedtoseveralanatomicfeatures.
Injurytothesciaticnervemayresultindirectlyfromaherniatedintervertebraldisk(protrudednucleuspulposus)
ormoredirectlyfromahipdislocation,localaneurysm,ordirectexternaltraumaofthesciaticnotch,thelatter
ofwhichcanbeconfusedwithacompressiveradiculopathyofthelumbarorsacralnerveroot.125Followingare
someusefulcluestohelpdistinguishthetwoconditions:
Painfromanirritatedlumbarspinalnerveroot(radiculopathy)shouldnotsignificantlychangewiththe
introductionofhiprotationduringthestraightlegraisetest(Chapter11),whereasifthereisasciatic
nerveentrapmentbythepiriformismuscle,painislikelytobeaccentuatedbyintroducinghipinternal
rotationtothestraightlegraise,whichstretchesthemusclefibers,andrelievedbymovingthehipinto
externalrotation.
Sciaticneuropathyproducessensorychangesonthesoleofthefoot,whereaslumbosacralradiculopathy
generallydoesnotunlessthereisapredominantS1involvement.
CompressiveradiculopathybelowtheL4levelcausespalpableatrophyoftheglutealmuscles,whereasa
sciaticentrapmentsparesthesemuscles.
Thesciatictrunkisfrequentlytenderfromrootcompressionattheforaminallevel,whereasitisnot
normallytenderinasciaticnerveentrapment.126
Individualcasereportsofboneandsofttissuetumorsalongthecourseofthesciaticnervehavebeendescribed
asararecauseofsciatica.127,128
TibialNerve
Thetibialnerve(L4,5S13)isformedbyallfiveoftheanteriordivisionsofthesacralplexus,thusreceiving
fibersfromthelowertwolumbarandtheupperthreesacralcordsegments.Inferiorly,thenervebeginsitsown
courseintheupperpartofthepoplitealspace,beforedescendingverticallythroughthisspace,andpassing
betweentheheadsofthegastrocnemiusmuscle,tothedorsumoftheleg.Theportionofthetibialtrunkbelow
thepoplitealspaceiscalledtheposteriortibialnervetheportionwithinthespaceiscalledtheinternalpopliteal
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nerve(Fig.320).Entrapmentoftheposteriortibialnervecanoccurwithinthefibroosseouspassageway
posteriortothemedialmalleolus.Thisentrapmentisreferredtoastarsaltunnelsyndrome(seeChapter21).The
tibialnervesuppliesthegastrocnemius,plantaris,soleus,popliteus,tibialisposterior,flexordigitorumlongus,
andflexorhallucislongusmuscles(seeFig.320).
FIGURE320
Thetibialnerve(L4,5,S13).(Reproduced,withpermission,fromAppendixC.SpinalNervesandPlexuses.
Suralnerve.Thesuralnerve(seeFig.320)isasensorybranchofthetibialnerve.Itisformedbythe
lateralsuralcutaneousnervefromthecommonfibular(peroneal)nerveandthemedialcalcanealnerve
fromthetibialnerve.Thesuralnervesuppliestheskinontheposteriorlateralaspectofthelowerone
thirdofthelegandthelateralsideofthefoot.
Terminalbranchesofthetibialnerve.Inthedistalleg,thetibialnervelieslaterallytotheposterior
tibialvessels,anditsuppliesarticularbranchestotheanklejointandtotheposteromedialaspectofthe
ankle.Fromthispoint,itsterminalbranchesincludethefollowing:
Medialplantarnerve(comparabletothemediannerveinthehand).Thisnervesuppliestheflexor
digitorumbrevis,abductorhallucis,flexorhallucisbrevis,andfirstlumbricalmusclesandsensory
branchestothemedialsideofthesole,theplantarsurfacesofthemedial3toes,andtheterminal
endsofthesametoes(seeFig.320).
Lateralplantarnerve(comparabletotheulnarnerveinthehand).Thisnervesuppliesthesmall
musclesofthefoot,exceptthoseinnervatedbythemedialplantarnerve,andsensorybranchesto
thelateralportionsofthesole,theplantarsurfaceofthelateral1toes,andthedistalphalangesof
thesetoes(seeFig.320).Theinterdigitalnervesaremostcommonlyentrappedbetweenthesecond
andthird,andthethirdandfourth,webspaces,andtheintermetatarsalligamentsasaresultofa
forcedhyperextensionofthetoes,eventuallyresultinginaninterdigital(Mortons)neuroma(see
Chapter21).
Medialcalcanealnerve.Asitpassesbeneaththeflexorretinaculum,thetibialnervegivesoff
medialcalcanealbranchestotheskinoftheheel.Anirritationofthisnervemayresultinheelpain.
CommonFibular(Peroneal)Nerve
Thecommonfibular(peroneal)nerve(L4,5S12)isformedbyafusionoftheupperfourposteriordivisionsof
thesacralplexus,andthusderivesitsfibersfromthelowertwolumbarandtheuppertwosacralcordsegments
(seeFig.321).Inthethigh,itisacomponentofthesciaticnerveasfarastheupperpartofthepoplitealspace.
Thenervegivesoffsensorybranchesinthepoplitealspace.Thesesensorybranchesincludethesuperiorand
inferiorarticularbranchestothekneejointandthelateralsuralcutaneousnerve(seeFigs.320and321).
FIGURE321
Thecommonperonealnerve(L4,5,S1,2).(Reproduced,withpermission,fromAppendixC.SpinalNervesand
Plexuses.In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill2013.)
Attheapexofthepoplitealfossa,thecommonfibular(peroneal)nervebeginsitsindependentdescentalongthe
posteriorborderofthebicepsfemorisandthencrossesthedorsumofthekneejointtotheupperexternalportion
ofthelegneartheheadofthefibula.Thenervecurvesaroundthelateralaspectofthefibulatowardtheanterior
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aspectofthebone,beforepassingdeeptothetwoheadsofthefibularis(peroneus)longusmuscle,whereit
dividesintothreeterminalrami:therecurrentarticular,superficial,anddeepfibular(peroneal)nerves.
Therecurrentarticularnerveaccompaniestheanteriortibialrecurrentartery,supplyingthetibiofibular
andkneejoints,andatwigtothetibialisanteriormuscle.
Thesuperficialfibular(peroneal)nervearisesdeeptothefibularis(peroneus)longus(seeFig.321).It
thenpassesforwardanddownwardbetweentheperoneimusclesandtheextensordigitorumlongus
muscle,tosupplythefibularis(peroneus)longusandbrevismuscles,andprovidesensorydistributionto
thelowerfrontoftheleg,thedorsumofthefoot,partofthebigtoe,andadjacentsidesofthesecondto
fifthtoesuptothesecondphalanges.Entrapmentofthisnerveisoftenconfusedwithanintervertebral
diskherniationinvolvingtheL5nerverootbecauseitcausespainoverthedistallateralaspectoftheleg
andtheankle.
Thedeepfibular(peroneal)nervepassesanteriorandlateraltothetibialisanteriormuscle,betweenthe
fibularis(peroneus)longusandtheextensordigitorumlongusmuscles,andtothefrontoftheinterosseous
membraneandsuppliesthetibialisanterior,extensordigitorumlongus,extensorhallucislongus,and
fibularis(peroneus)tertiusmuscles(seeFig.321).Attheleveloftheanklejoint,thedeepfibular
(peroneal)nervepassesbehindtheextensorhallucislongustendonandliesbetweenitandtheextensor
digitorumlongustendon.Thedeepfibular(peroneal)nervedividesintoamedialandlateralbranch
approximately1.5cmabovetheanklejoint.Theseterminalbranchesextendtotheskinoftheadjacent
sidesofthemedialtwotoes(medialbranch),totheextensordigitorumbrevismuscle(lateralbranch),and
theadjacentjoints(seeFig.321).Whenthedeepfibular(peroneal)nerveisentrapped,thereisa
complaintofpaininthegreattoe,whichcanbeconfusedwithaposttraumatic,complexregionalpain
syndrome(formerlyreferredtoasreflexsympatheticdystrophy).
CLINICALPEARL
Comparedwiththetibialdivision,thecommonfibular(peroneal)divisionisrelativelytetheredatthesciatic
notchandtheneckofthefibulaandmay,therefore,belessabletotolerateordistributetension,suchasthat
occursinacutestretchingorwithchangesinlimbpositionorlength.
Aninsidiousentrapmentofthecommonfibular(peroneal)nerve(anditisveryvulnerable,especiallyatthe
fibularneck)canbeconfusedwithsymptomsofaherniatedintervertebraldisk,tendinopathyofthepopliteus
tendon,mononeuritis,idiopathicfibular(peroneal)palsy,intrinsicandextrinsicnervetumors,andextraneural
compressionbyasynovialcyst,ganglioncyst,softtissuetumor,osseousmass,oralargefabella.129Traumatic
injuryofthenervemayoccursecondarytoafracture,dislocation,surgicalprocedure,applicationofskeletal
traction,oratightcast.129
Thepainfromanentrapmentofthecommonfibular(peroneal)nerveistypicallyonthelateralsurfaceofthe
knee,theleg,andthefoot.Lateralkneepainisacommonproblemamongpatientsseekingmedicalattention,
andentrapmentofthecommonfibular(peroneal)nerveisfrequentlyoverlookedinthedifferentialdiagnostic
considerations,especiallyintheabsenceoftraumaorthepresenceofapalpablemassattheneckofthefibula.
PudendalandCoccygealNerves
Thepudendalandcoccygealnervesarethemostcaudalportionsofthelumbosacralplexusandsupplythe
perinealstructures(Fig.322).
FIGURE322
Thepudendalandcoccygealplexuses.(Reproduced,withpermission,fromAppendixC.SpinalNervesand
Plexuses.In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:McGrawHill2013.)
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Thepudendalnervesuppliesthecoccygeus,levatorani,andsphincteraniexternusmuscles.Thepudendal
nerveisamixednerve,andalesionthataffectsitoritsascendingpathwayscanresultinvoidingand
erectiledysfunctions.130Alesionintheafferentpathwaysofthepudendalnerveisoftensuspected
clinicallybysuggestivepatienthistories,includingorganicneurologicdiseaseorneurologictrauma.
Lesionsarealsosuspectedwhenaneurologicphysicalexaminationtoassessthefunctionofsignal
segmentsS2,S3,andS4isabnormal.Thepudendalnervedividesinto:
theinferiorhemorrhoidalnervestotheexternalanalsphincterandadjacentskin
theperinealnerveand
theposterior(dorsal)nerveofthepenis.
Thecoccygealnervesarethesmallsensoryanococcygealnervesderivedfromthelastthree
segments(S4,5C).Theypiercethesacrotuberousligamentandsupplytheskinintheregionofthe
coccyx.
PeripheralNervousSystem:AutonomicNervousSystem
Theautonomicnervoussystem(ANS)isthedivisionofthePNSthatisresponsiblefortheinnervationof
smoothmuscle,cardiacmuscle,andglandsofthebodythatarenotusuallyundervoluntarycontrol.Thus,it
functionsprimarilyatasubconsciouslevel.
TheANShastwocomponents,sympathetic(Fig.323)andparasympathetic(Fig.324),eachofwhichis
differentiatedbyitssiteoforiginaswellasthetransmittersitreleases.131Ingeneral,thesetwosystemshave
antagonisteffectsontheirendorgans.
FIGURE323
Sympatheticdivisionoftheautonomicnervoussystem(lefthalf).(Reproduced,withpermission,fromChapter
20.TheAutonomicNervousSystem.In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,NY:
McGrawHill2013.)
FIGURE324
Parasympatheticdivisionoftheautonomicnervoussystem(lefthalf).(Reproduced,withpermission,from
Chapter20.TheAutonomicNervousSystem.In:WaxmanSG.eds.ClinicalNeuroanatomy,27e.NewYork,
NY:McGrawHill2013.)
NeuromuscularControl
Neuromuscularcontrolinvolvestheintegrationofmotorlearningandmotorcontrolwhichiscontrolledbythe
descendingmotorsystems.Thesesystemsincludethecorticospinaltracts,therubrospinaltract,the
vestibulospinaltracts,andthereticulospinaltracts:
Corticospinaltract:criticalforskilledvoluntarymovementthroughoutthebody.132,133Therearetwo
maindivisionsofthecorticospinaltract,thelateralcorticospinaltractandventral(anterior)corticospinal
tract.Mostofthecorticospinalfibers(approximately80%)crossovertothecontralateralsideinthe
medullaoblongata(pyramidaldecussation)andtravelinthelateralcorticospinaltract.Tenpercententer
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thelateralcorticospinaltractonthesameside.Theremaining10%crossoveratthelevelthattheyexitthe
spinalcord,andthesetravelintheanteriorcorticospinaltract.
Rubrospinaltract:importantforrapid,coordinatedmovementoftheentirelimb,especiallywhenthe
reachinvolvesadaptingthehandorfoottotheshapeofanobject.134
Vestibulospinaltracts:involvedwithintegratinginformationfromthevestibularsystemtocontroleye
movements,headandneckmovements,andposturalreactionsforbalance.
Reticulospinaltracts:activatedintheearlystagesofmovement,includingmovementplanning,tohelp
initiatetheproperstateintheposturalcontrolsystemandtheproximallimbtosupportthedistal
movementthatistooccur.135
Mobilityandstabilityrelyuponthecombinationofmusculoskeletalpropertiesandneuralcontrol.Itisbelieved
thattherearecertainprogramsformovementpatternsthatareinherentintheCNSandthatthesenaturally
developduringthematurationprocessoftheCNS.Forexample,gaitonalevelsurfaceiscontrolledbyasetof
neuralcircuitsknownasacentralpatterngenerator(CPG).Thelocomotioninitiatingsystemsinthebrainstem
relyuponthereticulospinaltractsastheprincipalrouteforinitiationandregulationoflocomotion.136The
parametersofgait(e.g.,cadence)dependontheenvironmentaldemands.Whenwalkingmustoccuronunusual
surfaces,theCPGcontinuestooperatebutwithinputfromthelateralcorticospinalandrubrospinalsystemsto
translatethevisualperceptionandallowaccurateplacementofthefoot.137,138
InmuchthesamewayasthereisaCPGforlocomotion,thenervoussystemhasanumberofbuiltincorrections
forposturalstabilitytheabilitytomaintainastableuprightstanceagainstinternalandexternalperturbations
thatcanoccurrapidlyandautomaticallytocounteracttheseperturbations(seeBalance,later).OnceaCPGis
formed,theindividualnolongerhastoconcentrateonperformingtheactivity,butcandosowithverylittle
corticalinvolvement.Themotorprogramforeachoftheseactivitiesissavedinanengram(ahypothetical
meansbywhichapatternedresponsehasbeenstabilizedatthelevelofunconsciouscompetence)withinthe
cerebralcortex.139141Thousandsofrepetitions(practice)arerequiredtobegintheengramformation,and
millionsareneededtoperfectit.141Skilledperformanceisdevelopedinproportiontothenumberofrepetitions
ofanengrampracticedjustbelowthemaximallevelofabilitytoperform.142,143
Theremainingmotorresponsesrelyonprocessingandplanningatdifferentlevels:spinalcord,thebrainstem
andcerebellum,andthecerebralcortex.Thecomplexityofthenecessaryprocessingaffectsthespeedofmotor
responses,withspinalreflexesrepresentingtheshortestneuronalpathwayandconsequentlythemostrapid
responsetoafferentstimuli.Certainactions,suchassigningonesname,donotrequiresensoryinformationfor
modification.Thesemovementsaresaidtobeunderopenloopcontrol.Othermovements,suchasreflexively
withdrawingthefootfrompainfulstimuli,relyonfeedbackfromthesensorysystem.Thistypeofcontrolis
referredtoasclosedloopcontrol.Inafeedback(reactionary)controlsystem,parametersaremonitoredand
comparedtoareferencesetpoint.Ifmonitoredparametersfalloutsidetheboundariesofthesetpoint,the
controllertriggersaresponsethatwillcorrectthesystem(e.g.,athermostatsystemthatregulatesroom
temperature).144Incontrast,feedforward(anticipatory)actionsdifferinthattheyanticipatepending
disturbancesandacttopreparethesystem(e.g.,anindividualanticipatestheneedformilkandbuyssome
beforetheexistingmilkrunsout).144Feedforwardactionsarebasedonknowledgeorpreviousexperience.
Evidencesuggeststhatbothfeedforwardandfeedbackcontrolmechanismscontributetodynamicstability.145
Thesensorimotorsystemprovidesthedirectionthatmusclesrequiretoachieveintegratedmultiplanar
movementsthroughvariousfeedforwardandfeedbackcontrols.144
CLINICALPEARL
Motorprogramsarecodeswithinthenervoussystemthatwheninitiated,producecoordinatedmovement
sequences.146Theseprogramsareusuallyundercentralcontrol,thesensoryinputisusedextensivelyin
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selectingtheappropriatemotorprogram,inmonitoringwhetherornotmovementisconsistentwith
expectations,andinreflexivelymodulatingthemovementsothatitisspecifictoenvironmental
variables.146,147
WhentheCNSissuccessfulatplanningthebest,oroptimal,strategy:148
alljointsofthekineticchainarecontrolledinbothangularandtranslatoricmotions,whileallowingthe
necessaryrangeofmotionrequiredforthetask
spinalpostureandorientationwillbecontrolledbothwithinandbetweenregionsandbeappropriatefor
thetask
posturalequilibriumwillbemaintained
efficientmovement(i.e.,abilitytoadaptappropriately)willbeavailableinthesystemtodampenand
controlmultiplepredictableandunpredictablechallengesofvaryingloadsandriskinpotentiallychanging
environmentsand
respiration,continence,andinternalorgansupportandfunctionwillbemaintained.
Failuretomaintainanyoftheabovefeaturesisanindicationthatthepatientisusinganonoptimalstrategyfor
thetask.
Apatientcannotsucceedinfunctionalandrecreationalactivitiesifhisorherneuromuscularsystemisnot
preparedtomeetthedemandsofthespecificactivities.149Twokeycomponentsinvolvedinmeetingthe
demandsofneuromuscularcontrolareproprioceptionandkinesthesia.
Proprioception
Proprioceptionisconsideredaspecializedvariationofthesensorymodalityoftouch,whichplaysanimportant
roleincoordinatingmuscleactivityandinvolvestheintegrationofsensoryinputconcerningstaticjointposition
(jointpositionsensibility),jointmovement(kinestheticsensibility),velocityofmovement,andtheforceof
muscularcontraction(fromtheskin,muscles,andjoints).150,151Proprioceptioncanbebothconscious,as
occursintheaccurateplacementofalimb,andunconscious,asoccursinthemodulationofmuscle
function.151,152
Allsynovialjointsofthebodyareprovidedwithanarrayofreceptorendings(nociceptors,thermoreceptors,and
mechanoreceptors)thatareimbeddedinarticular,muscular,andcutaneousstructureswithvaryingcharacteristic
behaviorsanddistributions(Table31).Thesereceptorsprovideinformationforthesomatosensorysystem
whichmediatessignalsrelatedtomultiplesensorymodalities(pain,temperature,andproprioception).The
nociceptorsprovideinformationwithregardtopainwhilethethermoreceptorsprovidefeedbackrelatedto
temperature.Themechanoreceptors,whicharestimulatedbymechanicalforces(softtissueelongation,
relaxation,compression,andfluidtension),areusuallyclassifiedintothreegroupsbasedonreceptortype:joint,
muscle,orcutaneous.TherearefourprimarytypesofjointreceptorsthatincludePaciniancorpuscles,Ruffini
endings,Golgitendonorgan(GTO)likeendings,andbarenerveendings.19,153,154
CLINICALPEARL
Thetermmusculotendinouskinesthesiareferstothecapacityformusculotendinousstructurestocontribute
proprioceptioninformation.Twotypesofmusclereceptorsarecommonlydescribed:musclespindlesandGTO
(Box31).Itismostlikelythatthemuscleandjointreceptorsworkcomplementarytooneanotherinthis
complexafferentsystem,witheachmodifyingthefunctionoftheother.155Themusclespindlefunctionsasa
stretchreceptor,whereastheGTOfunctionsasamonitorforthedegreeoftensionwithinamuscleandtendon.
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BasedontheextensiveworkofVoss,156Pecketal.157proposedthatintheextremities,smallermuscleswith
highmusclespindleconcentrations,arrangedinparallelwithlarger,lessspindledensemuscles,function
primarilyaskinestheticmonitors.158
Box31MuscleSpindleandGTOMuscleSpindle
Musclespindlesareencapsulatedspindleshapedstructureslyinginparallelwithskeletalmusclefibersinthe
musclebelly.Essentially,thepurposeofthemusclespindleistocomparethelengthofthespindlewiththe
lengthofthemusclethatsurroundsthespindle.Spindleshavethreemaincomponents1:
Intrafusalmusclefibers.212long,slender,andspecializedskeletalmusclefibers.Thecentralportionof
theintrafusalfiberisdevoidofactinormyosinand,thus,isincapableofcontracting.Asaresult,these
fibersarecapableofputtingtensiononthespindleonly.Theseintrafusalfibersareoftwotypes:nuclear
bagfibersandnuclearchainfibers.Nuclearbagfibersprimarilyserveassensitivitymetersforthe
changinglengthsofthemuscle.2,3Nuclearchainfiberseachcontainasingleroworchainofnucleiand
areattachedattheirendstothebagfibers.
Sensoryneuronendingsthatwraparoundtheintrafusalfibers.Thesensoryneuronsareafferents
structures(groupsIaandIIafferents)thatsendinformationregardingstaticmusclelengthandchangesin
musclelengthtothedorsalrootgangliaofthespinalcord.ThegroupIaafferentsrelayinformation
regardingratesofchange,whereasthegroupIIafferentsrelayinformationregardingsteadystatemuscle
length.
Motoraxons.Whilemusclesareinnervatedbyalphamotorneurons,musclespindleshavetheirown
motorsupply,namelygammamotorneurons.
Themusclespindlecanbestimulatedintwodifferentways:
Bystretchingthewholemuscle,whichstretchesthemidportionofthespindleanddepolarizetheIa
afferents.Iaafferentdepolarizationcantriggertwoseparateresponses1:
Amonosynapticordisynapticspinalreflex
Alonglooptranscorticalreflex
Bycontractingonlytheendportionoftheintrafusalfibers,excitingthereceptor(evenifmusclelength
doesnotchange).
Ifthelengthofthemusclessurroundingthespindleislessthanthatofthespindle,adecreaseinintrafusalfiber
afferentactivityoccurs.Forexample,aquickstretchappliedtoamusclereflexivelyproducesaquick
contractionoftheagonisticandsynergisticmuscle(extrafusal)fibers.Thishastheeffectofproducingasmooth
contractionandrelaxationofmuscleandeliminatinganyjerkinessduringmovement.ThefiringofthetypeIa
phasicnervefibersisinfluencedbytherateofstretch:thefasterandgreaterthestimulus,thegreatertheeffect
oftheassociatedextrafusalfibers.3,4
GolgiTendonOrgans
GTOsaresmall,encapsulatedstructuresspacedinseriesalongthemusculotendinousjunctionthatbecome
activatedbystretch.1Incontrasttothemusclespindle,GTOsfunctiontoprotectmuscleattachmentsfromstrain
oravulsion,byusingapostsynapticinhibitorysynapseofthemuscleinwhichtheyarelocated.5Thesignals
fromtheGTOmaygobothtolocalareaswithinthespinalcordandthroughthespinocerebellartractstothe
cerebellum.6Thelocalsignalsresultinexcitationofinterneurons,whichinturninhibittheanteriormotor
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neuronsoftheGTOsownmuscleandsynergist,whilefacilitatingtheantagonists.6Thisistheorizedtoprevent
overcontraction,orstretch,ofamuscle.5
1.RoseJ.Dynamiclowerextremitystability.In:HughesC,ed.MovementDisordersandNeuromuscular
InterventionsfortheTrunkandExtremitiesIndependentStudyCourse18.2.5.LaCrosse,WI:Orthopaedic
Section,APTA,Inc.2008:134.
2.GriggP.Peripheralneuralmechanismsinproprioception.JSportRehabil.19943:117.
3.SwashM,FoxK.Musclespindleinnervationinman.JAnat.1972112:6180.
4.WilkKE,VoightML,KeirnsMA,etal.Stretchshorteningdrillsfortheupperextremities:theoryandclinical
application.JOrthopSportsPhysTher.199317:225239.
5.deJarnetteB:SacroOccipitalTechnique.NebraskaCity,NE:MajorBertranddeJarnette,DC1972.
6.PollardH,WardG.Astudyoftwostretchingtechniquesforimprovinghipflexionrangeofmotion.JMan
PhysiolTher.199720:443447.
Ruffiniendings.Theseslowadapting,lowthresholdstretchreceptorsareimportantposturalmediators,
signalingactualjointpositionorchangesinjointpositions.159Theyareprimarilylocatedontheflexion
side(detectthestretchthatoccurswiththeextensionofthejoint)ofthejointcapsule,butarealsofound
inligaments,primarilyneartheoriginandtheinsertion.147,160Thesereceptorscontinuetodischarge
whilethestimulusispresentandcontributetothereflexregulationofposturaltone,tocoordinationof
muscleactivity,andtoaperceptionalawarenessofjointposition.Anincreaseinjointcapsuletensionby
activeorpassivemotion,posture,mobilization,ormanipulationcausesthesereceptorstodischargeata
higherfrequency.154,161
Paciniancorpuscles.Thesearerapidlyadapting,lowthresholdreceptorsthatfunctionprimarilyin
sensingjointcompressionandincreasedhydrostaticpressureinthejoint.162Theyareprimarilylocatedin
thesubcapsularfibroadiposetissue,thecruciateligaments,theannulusfibrosus,ligaments,andthefibrous
capsule.Thesereceptorsareentirelyinactiveinimmobilejointsbutbecomeactiveforbriefperiodsatthe
onsetofmovementandduringrapidchangesintension.Theyalsofireduringactiveorpassivemotionof
ajoint,orwiththeapplicationoftraction.Thisbehaviorsuggeststheirroleasacontrolmechanismto
regulatethemotorunitactivityoftheprimemoversofthejoint.
GTOlikereceptors.ThesereceptorsalsoreferredtoasGolgiligamentorgansarefoundinthejoint
capsule,ligaments,andmenisci.163Theseslowadaptingandhighthresholdreceptorsfunctiontodetect
largeamountsoftension.Theyonlybecomeactiveattheextremesofmotionsuchaswhenstrongmanual
techniquesareappliedtothejointorwhenajointreachestheendofitsphysiologicalrange.Their
functionisprotectivetopreventfurthermotionthatwouldoverdisplacethejoint(ajointprotective
reflex),andtheirfiringisinhibitorytothosemusclesthatwouldcontributetoexcessiveforces.
Barenerveendings.Thesehighthreshold,nonadapting,freenerveendingreceptorsareinactiveunder
normalcircumstancesbutbecomeactivewithmarkedmechanicaldeformationortension.164,165They
mayalsobecomeactiveinresponsetodirectmechanicalorchemicalirritation,andtheirsensitivity
usuallyincreaseswhenajointisinflamedorswollen.166
Thus,theCNSisorganizedinahierarchicalandparallelfashionwiththecorticalcentersofthebrainbeingthe
locationofthemostcomplexprocessing,andthespinalcordbeingthelocationofthemostbasicprocessing.147
Attheupperendofthehierarchy,themotorcortexhasamotorprogram,definedasanabstractplanof
movementthat,wheninitiated,resultsintheproductionofacoordinatedmovementsequence.144,146Atthe
lowerendofthehierarchy,specificmotorunitsmustacttoaccomplishthemovement.Rapidmotorresponsesto
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somatosensoryfeedbackmediatedinthespinalcordarereferredtoasspinalreflexes.147Thesereflexactions
includepreparatoryposturaladjustments167andreactionmovements.Theformerarepreprogrammedneural
mechanisms.ThelatteroccurtoofastforthelongloopfeedbackoftheCNS,sotheyareautomaticandoccur
subconsciously(seeSupraspinalReflexeslater).Althoughthehierarchyiswellestablished,researchsuggests
thesecomponentsalsoworkinparallelsothatanyofthecomponentsmaypredominateincontrollingsome
aspectsofmovementthesystemisbuiltforefficiencyandredundancy.144
CLINICALPEARL
Proprioceptioncanplayaprotectiveroleinanacuteinjurythroughreflexmusclesplintingviastimulationofthe
musclespindles.168
Proprioceptiveinformationisrelayedtothecerebralcortexbyoneofthetwomajorascendingsystems,the
dorsalcolumn,andthespinothalamictract.Onceprocessedandevaluated,theproprioceptiveinformationis
capableofinfluencingmuscletone,motorexecutionprograms,andcognitive,somaticperceptionsorkinesthetic
awareness.155,169AllofthisinformationhelpsgenerateasomatosensoryimagewithintheCNS.155
Theabilityofajointtoremainstabledependsinpartonitsresistancetomotionwhensubjectedtoexternal
loads,referredtoasitsdegreeofstiffness.Ajointsstiffnessistheresultofthreecomponents:passivefactors
associatedwiththematerialpropertiesofthemusculotendinoustissuesactiveintrinsicpropertiesassociated
withthecrossbridgeattachmentandlengthtensionpropertiesofthemusclesthatcrossthejoint(seeChapter1)
andreflexesassociatedwithlengthfeedbackandforcefeedbackfrommusclespindles,tendonorgans,andthe
influenceofothersomatosensoryfeedbackonthefusimotorsystem.147
Followinganinjury,alterationsoccurwiththestiffnessofajointandinthenormalrecruitmentpatternand
timingofmuscularcontractions.170Thesealterationsarethoughttoresultfromanadjustmentintheratioof
musclespindlestoGTOactivityandadisruptionoftheproprioceptivepathway.145,171,172Anydelayin
responsetimetoanunexpectedloadplacedonthedynamicrestraintscanexposethestaticrestraintstructuresto
excessiveforces,increasingthepotentialforinjury.173Inaddition,proprioceptivedeficitshavebeenimplicated
ascontributingtobalanceimpairments(seeBalance)followinglowerextremityandtrunkinjuriesor
pathologies.Thus,thefocusofneuromuscularrehabilitationmustbedirectedtowardcreatinganenvironment
thatpromotestherestorationanddevelopmentofmotorresponsesandproprioceptioninthepresenceofaltered
sensoryinput(seeChapter14).174
Fatiguemayalsoplayapartininjury,particularlyifthefatigueproducesadominanceofagonistsorantagonists
overtheother.172Fatiguealsoreducesthecapabilityofamuscletoabsorbordissipateloads.Itseemsplausible
thatsomeformsofmusclespindledesensitization,orperhapsligamentrelaxationandGolgitendon
desensitization,occurwithexcessivefatigue.175Thismaythenleadtoadecreasedefferentmuscleresponseand
reducedabilitytomaintainbalance.
Proprioceptivedeficitscanalsobefoundwithaging,176arthrosis,177andjointinstability.152,168,170,171,178181
Kinesthesia
Kinesthesia,asubmodalityofproprioception,referstothesenseofmovementofthebodyoroneofthe
segments.Althoughthearticularreceptorsquiteclearlyplayaveryactiverole,thestretchreflexcontrolledby
twoothersensors,themusclespindle,andtheGTO,arealsoimportant.Informationaboutmovementsense
travelsupthespinocerebellartract(Box32).
Box32SpinocerebellarTract
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Thespinocerebellartractconductsimpulsesrelatedtothepositionandmovementofmusclestothecerebellum.
Thisinformationenablesthecerebellumtoaddsmoothnessandprecisiontopatternsofmovementinitiatedin
thecerebralhemispheres.Spinocerebellarimpulsesdonotreachthecerebrumdirectlyand,therefore,haveno
consciousrepresentation.Fourtractsconstitutethespinocerebellarpathwaytheyaretheposterior
spinocerebellar,cuneocerebellar,anteriorspinocerebellar,androstralspinocerebellartracts.
Theposteriorspinocerebellartractconveysmusclespindleortendonorganrelatedimpulsesfromthelowerhalf
ofthebody(belowtheleveloftheT6spinalcordsegment)thecuneocerebellartractisconcernedwithsuch
impulsesfromthebodyaboveT6.Thegrainofinformationcarriedinthesetwotractsisfine,ofteninvolving
singlemusclecellsorportionsofamuscletendoncomplex.Amuchbroaderrepresentationiscarriedbythe
individualfibersoftheanteriorandrostralspinocerebellartracts.
Theaxonsconductingimpulsesfrommusclespindles,tendonorgans,andskininthelowerhalfofthebodyare
largetypeIa,typeIb,andtypeIIfibers,thecellbodiesofwhichareinthespinalgangliaofspinalnervesT6and
below.
CLINICALPEARL
Duringaconcentricmusclecontraction,themusclespindleoutputisreducedbecausethemusclefibersare
eithershorteningorattemptingtoshorten,whereasduringaneccentriccontraction,themusclestretchreflex
generatesmoretensioninthelengtheningmuscle.158,182,183
MotorLearningandSkillAcquisition
Motorlearningisacomplexsetofinternalprocessesthatinvolvestherelativelypermanentacquisitionand
retentionofaskillortaskthroughpractice.184186Thoughmotorskillsvarywidelyintypeandcomplexity,the
learningprocessthatindividualsutilizetoacquiretheseskillsissimilar.187
CLINICALPEARL
Learning,unlikeperformance,isnotsomethingthatcanbedirectlymeasured.Rather,wemeasurebehaviorand
inferlearningwhenthechangeinbehaviorseemsrelativelypermanent.188However,learningcanbemeasured
indirectlyusingretentiontestsortransfertests.
Retentiontest:involvesallowingsufficienttimebetweenpracticeandtestingtoassesswhethera
relativelypermanentchangehasoccurred.
Transfertests:involvestheabilitytotransferaskillusedinonetasktoothersituations.
Performanceinvolvestheacquisitionofaskill.Achangeinperformanceisdependentuponpracticeor
experience.
Learninginvolvesboththeacquisitionandretentionofaskill.Twomaintypesoflearningare
recognized:188
Declarativethelearningoffacts.
Procedurallearningthatisdependentonpractice,association(associatingaparticularstimulus
withanotherstimulus,orcertainstimuluswithacertainresponse,orcertainresponsewithacertain
result),andadaptation(makingadjustmentsbasedonpreviousresults),habituation(filteringout
irrelevantstimuli),andsensitization(integrationofrelevantstimuli).
Forlearningtooccurtheremustbeagoal.Inherentintheideaofthegoalismotivation.188
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Motortask.Therearethreebasictypesofmotortasksorskills:146,189
Discrete:involvesamovementwitharecognizablebeginningandend.Forexample,throwinga
ball,oropeningadoor.
Serial:involvesaseriesofdiscretemovementsthatarecombinedinaparticularsequence.For
example,thesequenceoftasksthatareinvolvedingettingoutofachairwhenusingcrutches.
Continuous:involvesrepetitive,uninterruptedmovementsthathavenodistinctbeginningand
ending.Examplesincludewalkingandcycling.
StagesofMotorLearning
FittsandPosner190proposedthreestagesofmotorlearning:191
Cognitive.Thisstage,whichischaracterizedbythelearnersconsciousattempttodeterminewhatexactly
needstobedoneinastepbystepmanner,beginswhenthepatientisfirstintroducedtothemotortask.
Thisstagerequiresgreatconcentrationandattentionalcapacity.Duringthisphasetherearevariable
performancesfilledwitherrorsbecausethelearnermustdeterminetheobjectiveoftheskillaswellasthe
relationalandenvironmentalcuestocontrolandregulatethemovement.Duringthisstage,sincethe
learnerismoreconcernedwithwhattodoandhowtodoit,theclinicianshouldprovidefrequentand
explicitpositivefeedbackusingvariousformsoffeedback(verbal,tactile,visual),andallowtrialand
errortooccurwithinsafelimits.
Associative.Thisstagecommenceswhenthelearnerhasacquiredthebasicmovementpatternandisless
concernedabouteverydetailandismoreconcernedwithperformingandrefiningtheskills.Bythisstage,
theimportantstimulihavebeenidentified,andtheirmeaningisknown.Consciousdecisionsaboutwhatto
dobecomemoreautomaticandthepatientconcentratesmoreonthetaskandappearslessrushed.During
thisphase,theclinicianshouldbegintoincreasethecomplexityofthetask,emphasizeproblemsolving,
avoidmanualguidance,andvarythesequenceoftasks.
Autonomous.Thisstage,whichrequiresextensivepracticetoreach,ischaracterizedbyanefficientand
nearlyautomatickindofperformance.Movementsareaccurate,veryconsistent,andefficiently
produced.187Forexample,whenwalkingoccursautomaticallywithoutconsciousthought.Duringthis
phase,theclinicianshouldsetupaseriesofprogressivelymoredifficultactivitiesthepatientcando
independently,suchasincreasingthespeed,thedistance,andthecomplexityofthetask.
CLINICALPEARL
Mostpatientsinrehabilitationareoftenintheassociatedstagebecausetheyarefamiliarwiththeskillsthey
needtoperform,themovementforaparticularskillmaybealteredandneedtobelearnedbecauseof
neuromusculardysfunction.174
Practice
Practice,repeatedlyperformingamovementorseriesofmovementsinatask,isprobablythesinglemost
importantvariableinlearningamotorskill.189,191Thevarioustypesofpracticeformotorlearningareas
follows:189
Partversuswhole.
Part.Ataskisbrokendownintoseparatecomponents,andtheindividualcomponents(usuallythe
moredifficultones)arepracticed.Aftermasteryoftheindividualcomponents,thecomponentsare
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combinedinasequencesothatthewholetaskcanbepracticed.
Whole.Theentiretaskisperformedfrombeginningtoendandisnotpracticedinseparate
components.
Blocked,random,andrandomblocked.
Blocked.Thesametaskorseriesoftasksisrepeatedlyperformedunderthesameconditionsandin
apredictableorder.Forexample,consistentlypracticingwalkinginastraightlineonaflatsurface.
Random.Slightvariationsofthesametaskarecarriedoutinanunpredictableorder.Forexample,a
patientcouldpracticewalkingonvariouswalkingsurfacesandindifferentdirections.
Randomblocked.Variationsofthesametaskareperformedinrandomorder,buteachvariationof
thetaskisperformedmorethanonce.Forexample,thepatientwalksonaparticularsurfaceand
thenrepeatsthesametaskasecondtimebeforemovingontoadifferentsurface.
Massedversusdistributed.
Massed.Involvesparticipationinalongboutofpractice,wheresubstantiallylesstimeisspentin
restcomparedtothetimespentpracticingduringthepracticeperiod.Thedisadvantagesofthistype
ofpracticearethatthepatientisnotabletoreflectonhisorherperformancebetweenpractices,and
thereismorepotentialforfatigueandanincreasedlikelihoodofaslightdetrimentforlearning.146
Distributed.Thistypeofpracticeinvolvesparticipationinaseriesofpracticesthroughouttheday.
Theadvantageofthistypeofpracticeisthatthepatientisabletoreflectonhisorherperformance
betweenpracticesand,therefore,correctpreviousmistakes.
Physicalversusmental.
Physical.Themovementsofataskareactuallyperformed.
Mental.Acognitiverehearsalofhowamotortaskistobeperformedoccurspriortoactuallydoing
thetask.
Constantversusvaried.
Constant.Occurswhentheskillisrepeatedlypracticedwithoutchanginganything.Forexample,
shootinghoopsfromonlythefoulline.
Varied.Occurswhenaparameterischangedthroughoutthepracticesession.Forexample,shooting
hoopsfromvariousareasofthecourt.Contrarytopopularbelief,repetitionofthesamemovement
patternmaybeasuboptimalmethodoflearningaskillcomparedtoutilizingvariations,thelatterof
whichcanstimulatethebraintofindoptimalsolutionstounanticipatedeventsmoreeffectively.192
Feedback
Secondonlytopractice,feedbackisconsideredthenextmostimportantvariablethatinfluenceslearning.The
varioustypesoffeedbackassociatedwithmotorlearningareasfollows:189
Intrinsicversusextrinsic(augmented).
Intrinsic.Intrinsicfeedback,orinternalfocus,isanaturalpartofthetask.146Itcantaketheformof
asensorycue(proprioceptive,kinesthetic,tactile,visual,orauditory),orsetofcues,inherentinthe
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executionofthemotortask.Forexample,thefeedbackcanconsistofdirectionsaboutbody
movements(e.g.,Landwithyourfeetshoulderwidthapart).193Thefeedbackcanalsoarisefrom
withinthelearnerandbederivedfromtheperformanceofthetask.
Extrinsic.Extrinsicfeedback,orexternalfocus,issupplementalfeedbackthatisnotnormallyan
inherentpartofthetaskbutisdirectedtowardtheoutcomeoreffectsofthemovement(e.g.,
Imaginesittingdownonachairwhenlanding).194Thistypeoffeedbackcanincludesensory
cues(verbal,visual,orauditory).Itisthoughtthatanexternalfocusofattentionenhancesthe
productionofeffectiveandefficientmovementpatterns.195Thisisbecausewhenaskillislearned,
importantbrainresourcesarenotbeingusedtomemorizemovementsduringanactivityandcan
thereforebefocusedmoreonmovementcontrolandotherfactors(i.e.,environmentalconditions,
positionofotherpeople,etc.).187
Knowledgeofresults(KR)versusknowledgeofperformance(KP).
KR:immediate,posttask,extrinsicfeedbackabouttheoutcomeofamotortask.Thistypeof
feedbackisprimarilyreservedforinstanceswhenindividualsareunabletogeneratethistypeof
informationforthemselves,orwhentheinformationmayserveasamotivationaltool.146
KP:feedbackgivenaboutthenatureorqualityoftheperformanceofthemotortask.Thistypeof
feedbackbetterfacilitatesmotorskilllearningthanKR.
Feedbackaboutperformancecanbeprovidedatvarioustimes:
ContinuousversusIntermittent.
Continuousisongoing.Thistypeoffeedbackimprovesskillacquisitionmorequicklyduringthe
initialstageoflearningthanintermittentfeedback.
Intermittentoccursirregularly,randomly.Intermittentfeedbackhasbeenshowntopromotelearning
moreeffectivelythancontinuousfeedback.
Immediate,delayed,andsummary.
Immediateisgivendirectlyafterataskiscompleted.Thistypeoffeedbackisusedmostfrequently
duringthecognitive(initial)stageoflearning.
Delayedisgivenafteranintervaloftimeelapses,allowingthelearnertoreflectonhowwellor
poorlyataskwasdone.Thistypeoffeedbackpromotesretentionandgeneralizabilityofthelearned
skills.
Summaryisgivenabouttheaverageperformanceofseveralrepetitionsofthemovementortask.
Thistypeoffeedbackisusedmostfrequentlyduringtheassociativestageoflearning.
SkillAcquisition
Patla196describesseverallocomotorcontrolsystemsthatactonandinteractwiththemusculoskeletalsystemto
influencetheexpressionofskilledlocomotorbehavior.Thesesystemsincludecorelocomotorpattern,dynamic
equilibrium,activepropulsion,weightsupport,maintainingstructuralintegrity,minimizationofenergy
expenditure,steeringandaccommodation,andcognitivespatialmapping.196Steeringandaccommodationand
cognitivespatialmappingrequiretheindividualtoadjusttochangesinthephysicalenvironment(e.g.,unlevel
terrain,obstacles,andslipperyconditions)orothercontextualdemands(e.g.,crowds,beinginahurry)that
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requiretheabilitytonavigateandadjusttochangesindirection,path,orspeed.Anumberoftheoriesofskill
acquisitionhavebeenproposedwithrespecttotheabilitytoadjusttotheenvironment:
Openversusclosedskills.Open(temporalandspatialfactorsinanunpredictableenvironment)andclosed
skills(spatialfactorsonlyinapredictableenvironment),existalongacontinuum.Usingasportasan
example,aclosedskillcouldincludeshootingafoulshotinbasketball.Aneverydayexampleofaclosed
skillisdrinkingfromacup.Anexampleofanopenskillineverydaylifewouldbesteppingontoa
movingwalkway,whereasinsportanopenskillwouldinvolvethrowingatouchdownpass.Whileclosed
skillsallowanindividualtoevaluatetheenvironmentandperformthemovementwithoutmuch
modification,openskillsrequiremorecognitiveprocessinganddecisionmakinginchoosingand
adjustingthemovement.174Openandclosedskillscanbeviewedasacontinuum,wheretheperceptual
andhabitualnatureofataskdetermineswhetherthetaskisopenorclosed.
Gentiletaxonomyofmotortasks.197Thisisatwodimensionalclassificationsystemforteachingmotor
skills.Usingtheconceptthatmotorskillsrangefromsimpletocomplex,Gentileexpandedthepopular
onedimensionalclassificationsystemofopenandclosedskillstocombinetheenvironmentalcontext
togetherwiththefunctionoftheaction:189,191
Theenvironmental(closedoropen)contextinwhichthetaskisperformed.Regulatoryconditions
(otherpeople,objects)intheenvironmentmaybeeitherstationary(closedskills)orinmotion
(openskills).
Theintertrialvariability(absentorpresent)oftheenvironmentthatisimposedonthetask.When
theenvironmentinwhichataskissetisunchangingfromoneperformanceofatasktothenext,
intertrialvariabilityisabsenttheenvironmentalconditionsarepredictable.Forexample,walking
onaflatsurface.Intertrialvariabilityispresentwhenthedemandschangefromoneattemptor
repetitionofthetasktothenext.Forexample,walkingovervaryingterrain.
Theneedforapersonsbodytoremainstationary(stable)ortomove(transport)duringthetask.
Skillsthatrequirebodytransportaremorecomplexthanskillsthatrequirenobodytransportas
therearemorevariablestoconsider.Forexample,abodytransporttaskcouldincludewalkingina
crowdedshoppingmall.
Thepresenceorabsenceofmanipulationofobjectsduringthetask.Whenapersonmustmanipulate
anobject,theskillincreasesincomplexitybecausethepersonmustdotwothingsatonce
manipulatetheobjectcorrectlyandadjustthebodyposturetofittheefficientmovementofthe
object.
Balance
Balance,orposturalcontrol,isacomplexmotorcontroltaskinvolvingthedetectionandintegrationofsensory
informationtoassessthepositionandmotionofthebodyinspaceandtheexecutionofappropriate
musculoskeletalresponsestocontrolbodypositionwithinitsstabilitylimits,andwithinthecontextofthe
environmentandtask,whetherstationaryormoving.198Postureistherelativepositionofthevariouspartsof
thebodywithrespecttooneanother,totheenvironment,andtogravity(seeChapter6).199
Balanceresultsfromanintegrationofthreecomponents:199
Thenervoussystem,whichprovidessensoryprocessingfortheperceptionofbodyorientationinspace,
whichisprovidedlargelybythevisual,vestibular,andsomatosensorysystems.Thesensorymotor
integrationprovidesmotorstrategiesfortheplanning,theprogramming,andtheexecutionofbalance
responses.200
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Visualsystem.Thevisualsystem,whichinvolvesCNII,III,IV,andVI,assistsinbalancecontrolby
providinginputaboutthepositionoftheheadorthebodyinspace(seeSupraspinalReflexeslater)
thedirectionandspeedofheadmovements,thepositionoftheheadrelativetotheenvironment,
andtheorientationoftheheadtomaintainalevelgaze.Throughthevestibuloocularinput,signals
fromthemusclespindlesintheextraocularmuscles,thepositionoftheeyeballiscontrolledsothat
avisualimageismaintainedonthefovea.Thecoordinationofeyemovementsduringgazeisa
complexaffairandiscontrolledbyefferentsignalsfromthetrochlear,theabducens,andthe
oculomotornucleiviathefourth,thesixth,andthethirdCNs,respectively(refertothediscussion
ofcervicoocularandvestibularreflexeslaterinthischapter).12Coordinationofthesenucleiis
achievedbygazecentersinthereticularformation,themidbrain,andthecortex,andbythe
cerebellum,whichhavefibersthatprojectintothethreeeyemusclenucleiandcontroltheorbital
movementsconcernedwithslowandrapideyemovements.12Visuallossorspecificdeficitsin
acuity,depthperception,contrastsensitivity,andperipheralvisioncanimpairbalanceandleadto
falls.201204
Vestibularsystem.Thevestibularsystem,withcontributionsfromtheinnerear(seeCranial
Nerves),providesinformationaboutmovementandspatialorientation.Vestibulardysfunction,
whichcanhaveamyriadofcausesrunningthegamutfromaviralinfectiontoatraumaticbrain
injury,isacommoncauseoffalls.205VestibularrehabilitationisdiscussedinChapter23.
Somatosensorysystem.Thissystemprovidesinformationaboutproprioceptionandkinesthesia,
whichhasalreadybeendiscussed.Reducedsomatosensationinthelowerextremitiescausedby
peripheralneuropathy,theaged,andindividualswithdiabeteshavebeenassociatedwithbalance
deficitsandanincreasedriskoffalls.206,207
Thevisual,vestibular,andsomatosensoryinformationissubconsciouslycombinedtoproducethe
brainssenseoforientationandmovement.Somatosensoryinformationhasthefastestprocessing
timeforrapidresponses,followedbyvisualandvestibularinputs.188ItistheroleoftheCNSto
suppressanyinaccurateinputfromonesystemandtocombinetheappropriatesensoryinputsfrom
theothertwosystems,aprocesscalledthesensoryorganization.
Musculoskeletalcontributionsincludingposturalalignment,flexibility,jointintegrity,muscle
performance,andmechanoreceptorsensation.
Contextualeffectsthatinteractwiththenervousandthemusculoskeletalsystems.Theseeffectsinclude
whethertheenvironmentisclosed(predictablewithnodistractions)oropen(unpredictableandwith
distractions),thesupportsurface,theamountoflighting,theeffectsofgravityandinertialforcesonthe
body,andthecharacteristicsofthetask(newvs.welllearned,predictablevs.unpredictable,singlevs.
multiple).
Impairedbalancecanbecausedbyinjuryordiseasetoanyofthestructuresinvolvedinthestagesof
informationprocessing.Evenifthethreecomponentsmentionedareworkingeffectively,alossofbalance
controlwilloccuriftheseinternalmechanismsareoverwhelmed.
CLINICALPEARL
Proprioceptionandbalancearenotsynonymous.Proprioceptioncanbeconsciousorunconsciouswhereas
balanceistypicallyconscious.
Anindividualsbalanceisgreatestwhenthebodyscenterofmass(COM)ismaintainedoveritsbaseofsupport
(BOS).Functionaltasksrequiredifferenttypesofbalancecontrol,including:198
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Staticbalancecontrol:involvesmaintainingastableantigravitypositionwhileatrest,suchaswhen
standingandsitting.
Dynamicbalancecontrol:theabilitytostabilizethebodywhenthesupportsurfaceismoving,orwhen
thebodyismovingonastablesurface,suchasduringsittostandtransfersorwalking.
Automaticposturalreactions:theabilitytomaintainbalanceinresponsetounexpectedexternal
perturbations,suchasstandingonabusthatsuddenlydecelerates.
AnticipatoryandCompensatoryPosturalAdjustments
Anticipatoryposturaladjustmentsoccurinresponsetointernalperturbationssuchasvoluntarymovementsof
thebodybyactivatingmusclesynergiesoftheposturalmusclesinadvanceoftheactualperturbation.Research
hasshownthatanticipatoryposturaladjustmentsarehighlyadaptableandvaryaccordingtothetask
demands.208Forexample,posturalmusclesinstandinghumansareactivatedpriorto(andduring)voluntary
movementofanupperlimbandarespecifictothismovementapersonpullingonthehandlewhenstanding.
Anticipatoryposturaladjustmentshavealsobeenstudiedduringlegmovements,209,210trunk
movements,211,212armmovementsinstandingsubjects,213,214andduringloadreleasefromextended
arms.215217
Whileanticipatoryreactionsareinitiatedbythesubject,compensatoryreactions,whichoccurlater,areinitiated
bysensoryfeedbacktriggeringsignals.Withanticipatoryreactions,theCNStriestopredictpostural
perturbationsassociatedwithaplannedmovementandminimizethemwithanticipatorycorrectionsina
feedforwardmanner,whilecompensatoryreactionsdealwithactualperturbationsofbalancethatoccurbecause
ofthesuboptimalefficacyoftheanticipatorycomponents.Feedforward(openloopmotorcontrol)isutilizedfor
movementsthatoccurtoofasttorelyonsensoryfeedback,orfortheanticipatoryaspectsofposturalcontrolto
beinitiated.Incontrast,closedloopcontrolisutilizedduringprecisionmovementsthatrequiresensory
feedbacksuchaswhenstandingonanunsteadysurface.
AutomaticPosturalResponses
Tomaintainbalance,thebodymustcontinuallyadjustitspositioninspacetokeepitsCOMoveritsBOS.A
certainamountofanteroposteriorandlateralswaynormallyoccurwhilemaintainingbalance.Forexample,
normalanteroposteriorswayinadultsis12degreesfromthemostposteriortothemostanteriorposition.218If
theswayexceedsthelimitsofstability,somestrategymustbeemployedtoregainbalance.Horakand
Nashner219describeseveraldifferentfeedforwardcontrolstrategiesusedtomaintainbalance.Thefeedforward
controlisproducedbymotorprogramsthatarepreprogrammedcollectionsofmotorsignalswiththegoalof
achievingaspecifictask.Thegoaloftheautomaticposturalresponses,includingtheankle,thehip,andthe
steppingstrategies,aredesignedtoadjustthebodysCOMsothatthebodyismaintainedwithintheBOSto
preventthelossofbalanceorfalling.
Theanklestrategy,inwhichmusclesaroundtheanklesareusedtoprovideposturalstabilityinthe
anteroposteriorplane,isemployedwithsmallperturbations.Theanklestrategyisutilizedtomaintainthe
bodysCOMsafelywithintheBOSduringquietstancebyautomaticallyactivatingthevariousankle
musclestocounteractbodyswayindifferentdirections.
Thehipstrategy,inwhichmusclesaroundthehipandthetrunk(gluteusmedius,iliopsoas,thoracic
paraspinals,andtensorfasciaelatae)arerecruited,isemployedwithlargerperturbationsduringquiet
stance.
Theweightshiftstrategyisamovementstrategyutilizedtocontrolmediallateralperturbationsinvolving
shiftingthebodyweightlaterallyfromonelegtotheother.
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Thesuspensionstrategy,whichinvolvesloweringthebodysCOMbyflexingtheknees,causing
associatedflexionoftheanklesandthehipsoraslightsquattingmotion.
Thesteppingstrategy,inwhichastepistakentomaintainposturalcontrol,isemployedifthetwo
previousstrategiesareinsufficient.
Mosthealthyindividualsusecombinationsoftheabovestrategiestomaintainbalancedependingonthecontrol
demands.199
BalanceControlduringActivitiesofDailyLiving(ADLs).DuringallADLs,sensoryinformationwithregardto
balanceistransmittedcentrally,processed,andaresponseisthenselectedforexecution.Complextaskstake
longertoprocessandprogramthansimpletasks.Oneofthemostcommonwaysinwhichbalanceischallenged
duringADLsiswhenliftingaheavyobject.Topreventalossofbalanceduringthelift,thebodyadjuststhe
positionoftheCOM.Forexample,whenaloadisliftedinfrontofthebody,theCOMisshiftedforwardin
anticipationofthemagnitudeoftheexpectedload.Thisdisplacementofthebodyisbasedonanestimatemade
bytheCNS,whichusespreviousexperiencewiththeload,orwithotherobjectsofsimilarphysical
properties.220Astheliftbegins,abackwardhorizontallinearmomentumisgeneratedtoallowthepersonlifting
theloadtomovetowardanuprightposture.Bymakingsubtleadjustmentstothesecompensations,adifferent
loadcanbeliftedusingdifferentpostures.Forexample,individualstendtoflexthehipsandkneesmoreand
shifttheirweightbackwhenliftingaheavyloadthanwhenliftingalightload.220
TheNeurophysiologyofPain
A2011reportbytheInstituteofMedicineindicatedthatattentiontoindividualpatientdifferencestopainisof
paramountimportance.221Painisconsideredanemotionalexperiencethatishighlyindividualizedand
extremelydifficulttoevaluate.Itiswellestablishedthathealthstatusandconcomitantconditions,suchas
psychologicalfactors,caninfluencethepainexperience.222,223Intrinsicbiologicalfactors,includinggenetics,
age,andsex,arealsoknowntoinfluencehowanindividualexperiencespain.223,224
CLINICALPEARL
Patientsattitudes,beliefs,andpersonalitiesmaystronglyaffecttheirimmediateexperienceofacutepain.
TypesofPain
Pain,whichisthemostcommondeterminantforapatienttoseekintervention,isabroadandsignificant
symptomthatcanbedescribedusingmanydescriptors.Inaddition,thepainperceptionandtheresponsetothe
painfulexperiencecanbeinfluencedbyvariouscognitiveprocesses,includinganxiety,tension,depression,past
painexperiences,andculturalinfluences.225Perhaps,thesimplestdescriptorsforpainareacuteandchronic.
Acutepaincanbedefinedasthenormal,predictedphysiologicalresponsetoanadversechemical,thermal,or
mechanicalstimulusassociatedwithsurgery,trauma,andacuteillness.226Thistypeofpainusually
precipitatesavisittoaphysician,becauseithasoneormoreofthefollowingcharacteristics:227
Itisnewandhasnotbeenexperiencedbefore.
Itissevereanddisabling.
Itiscontinuous,lastingformorethanseveralminutes,orrecursveryfrequently.
Thesiteofthepainmaycausealarm(e.g.,chestandeye).
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Inadditiontothesensoryandaffectivecomponents,acutepainistypicallycharacterizedbyanxiety.This
mayproduceafightorflightautonomicresponse,whichisnormallyusedforsurvivalneeds.This
autonomicreactionisalsoassociatedwithanincreaseinsystolicanddiastolicbloodpressure,adecrease
ingutmotilityandsalivaryflow,increasedmuscletension,andpupillarydilation.19,228
CLINICALPEARL
Hyperalgesiaisanincreasedresponsetoanoxiousstimulus.Primaryhyperalgesiaoccursatthesiteof
injury,whereassecondaryhyperalgesiaoccursoutsidethesiteofinjury.
Allodyniaisdefinedaspaininresponsetoapreviouslyinnocuousstimulus.
Referredpainisasiteadjacentto,oratadistancefrom,thesiteofaninjurysorigin.Referredpaincan
occurfrommuscle,joint,andviscera.Forexample,thepainfeltduringamyocardialinfarctionisoften
feltintheneck,shoulders,andbackratherthaninthechest,thesiteoftheinjury.
Acutepainfollowingtrauma,ortheinsidiousonsetofamusculoskeletalcondition,istypicallychemicalin
nature.Althoughmotionsaggravatethepain,theycannotbeusedtoalleviatethesymptoms.Incontrast,
cessationofmovement(absoluterest)tendstoalleviatethepain,althoughnotnecessarilyimmediately.The
structuresmostsensitivetochemicalirritationinorderofsensitivityare:
Theperiosteumandjointcapsule
Subchondralbone,tendon,andligament
Muscleandcorticalbone
Thesynoviumandarticularcartilage
CLINICALPEARL
Theachingtypeofpain,associatedwithdegenerativearthritisandmuscledisorders,isoftenaccentuatedby
activityandlessenedbyrest.Painthatisnotalleviatedbyrest,andthatisnotassociatedwithacutetrauma,may
indicatethepresenceofaseriousdisordersuchasatumororananeurysm.Thispainisoftendescribedasdeep,
constant,andboringandisapttobemorenoticeableandmoreintenseatnight.229
Chronicpainistypicallymoreaggravatingthanworrying,lastsformorethan6months,andhasthefollowing
characteristics:227
Ithasbeenexperiencedbeforeandhasremittedspontaneously,oraftersimplemeasures.
Itisusuallymildtomoderateinintensity.
Itisusuallyoflimitedduration,althoughitcanpersistforlongperiods(persistentpain).
Thepainsitedoesnotcausealarm(e.g.,kneeandankle).
Therearenoalarmingassociatedsymptoms.
However,patientswithchronicpainmaybemorepronetodepressionanddisruptedinterpersonal
relationships.230233
Thesymptomsofchronicpaintypicallybehaveinamechanicalfashion,inthattheyareprovokedbyactivityor
repeatedmovementsandreducedwithrestoramovementintheoppositedirection.
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CLINICALPEARL
Referredpain,whichcanbeeitheracuteorchronic,ispainperceivedtobeinanareathatseemstohavelittleor
norelationtotheexistingpathology.
TheGuidetoPhysicalTherapistPractice234hassuggestedthatcategorizationofpainbasedonsignsand
symptomsshouldbeaprimarygoalofthediagnosticprocess.Incontrast,someresearchershavesuggestedthat
apainmechanismbasedpaindiagnosisbemadetoassistindirectingtreatment.235,236
TransmissionofPain
Anociceptiveneuronisonethattransmitspainsignals.Thenociceptivesystemisnormallyaquiescentsystem
requiringstrong,intense,potentiallydamagingstimulationbeforeitbecomesactivated.182Anytissuethat
containsfreenerveendingsinvolvedwithnociceptioniscapableofbeingasourceofpain.Painreceptors
(nociceptors),unlikeotherreceptors,arenonadaptinginnaturethatis,theywillcontinuetofireforaslongas
thestimulusispresent.Itisapparentthatmanyperipheralnociceptorsarepolymodal.Nociceptorstimulation
canonlyoccurinoneofthefollowingthreeways:183
Mechanicaldeformationresultingintheapplicationofsufficientmechanicalforcestostress,deform,or
damageastructure.
Excessiveheatorcold.
Thepresenceofchemicalirritantsinsufficientquantitiesorconcentrations.Keymediatorsthathavebeen
identifiedincludebradykinin,serotonin,histamine,potassiumions,adenosinetriphosphate,protons,
prostaglandins,nitricoxide,leukotrienes,cytokines,andgrowthfactors.226Theeffectsofthesemediators
involvebindingtospecificreceptors,activationofionchannelsfordepolarization,activationof
intracellularsecondmessengersystems,andreleaseofarangeofneuropeptidestopromoteneurogenic
inflammation,andalterationofneuronalpropertiesbymodifyinggenetranscription.182,226
OneofthemostfundamentalinfluencesonnociceptorsensitivityisthepHofthesurroundingtissue.182High
localprotonconcentrationsareknowntooccurinmanyinflammatorystates,andtheconsequentreductioninpH
cancontributetosensitizationandactivationofpolymodalnociceptors.182,237
ThetransmissionofpaintotheCNSoccursviatwodistinctpathways,whichcorrespondtothetwodifferent
typesofpain:fastconductingAdeltaandslowconductingCfibers(Table31),althoughnotallofthefibersare
necessarilynociceptors.Eachofthesetypesoffibershasdifferentpaincharacteristics:Adeltafibersevokea
rapid,sharp,lancinatingpainreactionCfiberscauseaslow,dull,crawlingpain.
RapidPain
Thefast,ordermatomal,painsignalsaretransmittedintheperipheralnervesbysmall,myelinatedAfibersat
velocitiesbetween6and30m(20and98ft)persecond.Thefastpainimpulseisasignaltellingthesubjectthat
athreatispresentandprovokinganalmostinstantaneousandoftenreflexiveresponse.Thissignaloftenis
followedasecondormorelaterbyadullerpainthattellsofeithertissuedamageorcontinuingstimulation.
SlowPain
Slow,orsclerotomal,painistransmittedinevensmallerandunmyelinatedCnervefibersatmuchslower
velocities,between0.5and2m(1.6and6.6ft)persecond.Onenteringtheposterior(dorsal)hornofthespinal
cord,thepainsignalsfrombothvisceralandsomatictissuesdooneofthefollowingthreethings:
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Synapsewithinterneuronsthatsynapsedirectlywithmotornervesandproducereflexmovements.
Synapsewithautonomicfibersfromthesympatheticandparasympatheticsystemsandproduceautonomic
reflexes.
Synapsewithinterneuronsthattraveltothehighercentersinthebrain.
ThefastsignalsoftheCfibersterminateinlaminaeIandVoftheposterior(dorsal)horn(Fig.325).
Heretheyexciteneurons(internuncialneurons,segmentalmotorneurons,andflexorreflexafferents)that
sendlongfiberstotheoppositesideofthecordandthenupwardtothebraininthelateraldivisionofthe
anteriorlateralsensorypathway(lateralspinothalamictract(Box33).
TheslowsignalsoftheCfibersterminateinlaminaeIIandIIIoftheposterior(dorsal)horn(Fig.325).
MostofthesignalthenpassesthroughanothershortfiberneurontoterminateinlaminaV.Here,the
neurongivesoffalongaxon,mostofwhichjoinswiththefastsignalaxonstocrossthespinalcordand
continueupwardinthebraininthesamespinaltract.Approximately,7590%ofallpainfibersterminate
inthereticularformationofthemedulla,pons,andmesencephalon.Fromhere,otherneuronstransmitthe
signaltothethalamus,hypothalamus(pituitary),limbicsystem,andthecerebralcortex.
FIGURE325
Laminasofthegraymatterofthespinalcord.(Reproduced,withpermission,fromWaxmanSG:Clinical
Neuroanatomy,26thed,McGrawHill,2010.)
Box33SpinothalamicTract
Thespinothalamictracthelpsmediatethesensationsofpain,cold,warmth,andtouchfromreceptorsthroughout
thebody(excepttheface)tothebrain.14Laterallyprojectingspinothalamicneuronsaremorelikelytobe
situatedinlaminaeIandV.Mediallyprojectingcellsaremorelikelytobesituatedinthedeepposterior(dorsal)
hornandintheanterior(ventral)horn.Mostofthecellsprojecttothecontralateralthalamus,althoughasmall
fractionprojectsipsilaterally.5Spinothalamicaxonsintheanteriorlateralquadrantofthespinalcordare
arrangedsomatotopically.Atcervicallevels,spinothalamicaxonsrepresentingthelowerextremityandcaudal
bodyareplacedmorelaterally,andthoserepresentingtheupperextremityandrostralbody,moreanterior
medially.6,7
Mostoftheneuronsshowtheirbestresponseswhentheskinisstimulatedmechanicallyatanoxiousintensity.
However,manyspinothalamictractcellsalsorespond,althoughlesseffectively,toinnocuousmechanical
stimuli,andsomerespondbesttoinnocuousmechanicalstimuli.8Alargefractionofspinothalamictractcells
alsorespondtoanoxiousheatingoftheskin,whileothersrespondtostimulationofthereceptorsinmuscle,9
joints,orviscera.10
Spinothalamictractcellscanbeinhibitedeffectivelybyrepetitiveelectricalstimulationofperipheralnerves,11
withtheinhibitionoutlastingthestimulationby2030minutes.Someinhibitioncanbeevokedbystimulation
ofthelargemyelinatedaxonsofaperipheralnerve,buttheinhibitionismuchmorepowerfulifsmall
myelinatedorunmyelinatedafferentsareincludedinthevolleys.12Thebestinhibitionisproducedby
stimulationofaperipheralnerveinthesamelimbastheexcitatoryreceptivefield,butsomeinhibitionoccurs
whennervesinotherlimbsarestimulated.Asimilarinhibitionresultswhenhighintensitystimuliareappliedto
theskin,withaclinicaltranscutaneouselectricalnervestimulator(TENS)unitinplaceofdirectstimulationofa
peripheralnerve.13
Asthespinothalamictractascends,itmigratesfromalateralpositiontoaposteriorlateralposition.Inthe
midbrain,thetractliesadjacenttothemediallemniscus.Theaxonsofthesecondaryneuronsterminateinoneof
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anumberofcentersinthethalamus.
1.WillisWD.ThePainSystem.Basel:Karger1985.
2.SpillerWG,MartinE.Thetreatmentofpersistentpainoforganicorigininthelowerpartofthebodyby
divisionoftheanteriorlateralcolumnofthespinalcord.JAMA.191258:14891490.
3.GowersWR.Acaseofunilateralgunshotinjurytothespinalcord.TransClinLond.187811:2432.
4.VierckCJ,GreenspanJD,RitzLA.Longtermchangesinpurposiveandreflexiveresponsestonociceptive
stimulationfollowinganteriorlateralchordotomy.JNeurosci.199010:20772095.
5.WillisWD,CoggeshallRE.SensoryMechanismsoftheSpinalCord.2nded.NewYork,NY:PlenumPress
1991.
6.WillisWD,TrevinoDL,CoulterJD,etal.Responsesofprimatespinothalamictractneuronstonatural
stimulationofhindlimb.JNeurophysiol.197437:358372.
7.HyndmanOR,VanEppsC.Possibilityofdifferentialsectionofthespinothalamictract.ArchSurg.
193938:10361053.
8.FerringtonDG,SorkinLS,WillisWD.Responsesofspinothalamictractcellsinthesuperficialdorsalhornof
theprimatelumbarspinalcord.JPhysiol.1987388:681703.
9.KenshaloDR,LeonardRB,ChungJM,etal.Responsesofprimatespinothalamicneuronstogradedandto
repeatednoxiousheatstimuli.JNeurophysiol.197942:13701389.
10.MilneRJ,ForemanRD,GieslerGJ,etal.Convergenceofcutaneousandpelvicvisceralnociceptiveinputs
ontoprimatespinothalamicneurons.Pain.198111:163183.
11.ChungJM,FangZR,HoriY,etal.Prolongedinhibitionofprimatespinothalamictractcellsbyperipheral
nervestimulation.Pain.198419:259275.
12.ChungJM,LeeKH,HoriY,etal.Factorsinfluencingperipheralnervestimulationproducedinhibitionof
primatespinothalamictractcells.Pain.198419:277293.
13.LeeKH,ChungJM,WillisWD.InhibitionofprimatespinothalamictractcellsbyTENS.JNeurosurg.
198562:276287.
CLINICALPEARL
Painandnociceptiveinputcanexertastronginfluenceonmotorfunctionandemotionalstate.182
Thecentralpathwaysforprocessingnociceptiveinformationbeginatthelevelofthespinalcord(and
medullary)posterior(dorsal)horn.Aswiththeperiphery,theposterior(dorsal)hornofthespinalcordcontains
manytransmittersandreceptors,bothidentifiedandaccepted,includingseveralneuroactivepeptides(substance
P,calcitoningenerelatedpeptide,somatostatin,neuropeptideY,andgalanin),excitatoryaminoacids(aspartate
andglutamate),inhibitoryaminoacids(aminobutyricacidandglycine),nitricoxide,thearachidonicacid
metabolites,theendogenousopioids,adenosine,andthemonoamines(serotoninandnoradrenaline).238Thislist
indicatesthattherearediversetherapeuticpossibilitiesforthecontrolofthetransmissionofnociceptive
informationtothebrain.
CLINICALPEARL
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Severalcompounds,classifiedasbiogenicaminetransmittersorneuroactivepeptides,existthatcanfacilitateor
inhibitsynapticactivity.
Interneuronalnetworksintheposterior(dorsal)hornareresponsiblenotonlyforthetransmissionofnociceptive
informationtoneuronsthatprojecttothebrain,butalsoforthemodulationofthatinformation.Theinformation
ispassedtootherspinalcordneurons,includingtheflexormotorneuronsandthenociceptiveprojectionneurons
(e.g.,certainpatternsofstimulationcanleadtoenhancedreflexactionsandthesensitizationofprojection
neuronsandincreasednociceptivetransmission).Otherinputsresultintheinhibitionofprojectionneurons.
Asmallnumberoffastfibersarepasseddirectlytothethalamus,andthentothecerebralcortex,bypassingthe
brainstem.Itisbelievedthatthesesignalsareimportantforrecognizingandlocalizingpain,butnotfor
analyzingit.Oftheslowsignals,none,oratleastveryfew,avoidthereticularsystem.Becausemostofthefast,
andalloftheslow,painsignalsgothroughthereticularformation,theycanhavewiderangingeffectsonalmost
theentirenervoussystem.
LaminaV(Fig.325)istheareaforconvergence,summation,andprojection.Theresponseofthecellsin
laminaVdependslargelyontheintensityofthestimulus.Highintensitystimulationleadstofacilitationofthe
cell,andrelativelyeasytransmissionacrossthecordtotheothersideand,fromhere,upward.Moregentle
stimulationinhibitsthistransmission.Thisinhibitionis,accordingtotheory,theresultofpreandpostsynaptic
effectsproducedbythecellsoflaminaeIIandIII.Thus,theneteffectatlaminaVwilldeterminewhetherthe
painsignalisrelayedupward.Ifmildmechanoreceptorinputdominates,thepainsignalisstoppedatthispoint.
If,however,paininputdominates,orifthemechanoreceptorinputistoostrong,transmissionofthepainsignal
occurs.
Theneurophysiologicalmechanismsresponsibleforthegenerationandmaintenanceofpaincanbedividedinto
separatecategories239:
Nociceptive:painthatispredominantlydrivenbyactivationofperipheralnociceptivesensoryfibers.The
patternofpainassociatedwiththistypeislocalizedtotheareaofinjury/dysfunction,
mechanical/anatomicinnature,intermittentandsharpwithmovement/mechanicalprovocation,anddull
orthrobbingatrest.Thistypeofpainrespondswelltopostureeducation,musclestretching,joint
mobilization,motorcontrolexercises,andmusclestrengthening.
Peripheralneuropathic:painattributedtoalesionordysfunctioninthedorsalhornorcervicotrigeminal
nucleusorperipheralnerve.Thistypeofpainistypicallyreferredinadermatomalorcutaneous
distributionandisassociatedwithahistoryofnerveinjury,pathology,ormechanicalcompromise.
Pain/symptomprovocationoccurswithmechanical/movementteststhatmove/load/compressneural
tissue.
Centralsensitization:applicationofneuralsignalingintheCNSthatelicitspainhypersensitivity.Central
sensitizationresultswhenrepetitivenociceptiveinputcausesanincreaseintheexcitabilityofthespinal
cordneuronsreceivingthenoxiousinputandadjacentspinalcordneuronsreceivingnonnoxiousinput.
Theresultisamplificationofpaininformationinthebrain,resultinginwhathasbeentermedawindupin
bothcentralandPNSprocesses,whichcausespainandnormalcentralinhibitorymechanismsthathelpto
balanceactivationofpaincenters.240Increasefacilitationandreducedinhibitionofcentralsystempain
processingcenterscancausemusclepainthroughacombinationofalteredcentralpainperceptionand
possibleantidromiceffects.241Centralsensitizationcanalsoresultinreferredpainlocatedoutsidethe
localtissuecausingthepain.242Muscleswithsustainednociceptiveinputorwithprolongedmuscle
guardingmaydeveloptriggerpointsthat,whenpalpated,resultinregional,dull,achypaindistalfromthe
muscleitself.243Thistypeofpain,whichhasadisproportionateandunpredictablepattern,respondswell
tocognitivebehaviortreatment,aerobicexercise,strengthtraining,andmanualtherapy.
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Overthelastdecade,researchershavebeguntoinvestigatetheinfluenceofpainonpatternsofneuromuscular
activationandcontrol.182Ithasbeensuggestedthatthepresenceofpainleadstoinhibitionordelayedactivation
ofmusclesormusclegroupsthatperformkeysynergisticfunctionstolimitunwantedmotion.244Thisinhibition
usuallyoccursindeepmuscles,localtotheinvolvedjoint,thatperformasynergisticfunctioninordertocontrol
jointstability.245247Itisnowalsobecomingapparentthatinadditiontobeinginfluencedbypain,motor
activity,andemotionalstatecan,inturn,influencepainperception.182,248
Itisimportanttoassumethatallreportsofpainbythepatientareseriousinnatureuntilprovenotherwisewitha
thoroughexamination.249
CLINICALPEARL
Ingeneral,thegreaterthedegreeofpainradiation,thegreaterthechancethattheproblemisacuteorthatitis
occurringfromaproximalstructureorboth.
Althoughthepainintensityandthefunctionalresponsetosymptomsaresubjective,patternsofpainresponseto
stimulationofthepaingeneratorarequiteobjective(e.g.,antalgicgait).250
Referredpaincanbegeneratedby251
theconvergenceofsensoryinputfromseparatepartsofthebodytothesameposterior(dorsal)horn
neuronviaprimarysensoryfibers(convergenceprojectiontheory)230,252254
secondarypainresultingfromamyofascialtriggerpoint(MTrP)255
sympatheticactivityelicitedbyaspinalreflex256and
paingeneratingsubstances.230
MacNab257recommendsthefollowingclassificationforreferredpain/symptoms:
Viscerogenic
Vasculogenic
Neurogenic
Psychogenic
Spondylogenic
ViscerogenicSymptoms
Thepain/symptomsinthiscategorycanbereferredfromanyviscerainthetrunkorabdomen.Visceralpaincan
beproducedbychemicaldamage,ischemia,orspasmofthesmoothmuscles.
Viscerogenicpainmaybeproducedwhenthenociceptivefibersfromtheviscerasynapseinthespinalcordwith
someofthesameneuronsthatreceivepainfromtheskin.Whenthevisceralnociceptorsarestimulated,some
aretransmittedbythesameneuronsthatconductskinnociceptionandtakeonthesamecharacteristics.Visceral
painhasfiveimportantclinicalcharacteristics:
Itisnotevokedfromallviscera.
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Itisnotalwayslinkedtovisceralinjury.
Itisdiffuseandpoorlylocalized.
Itisreferredtootherlocations.
Itisoftenaccompaniedbyautonomicreflexes,suchasnauseaandvomiting.
ViscerogenicpaintendstobediffusebecauseoftheorganizationofvisceralnociceptivepathwaysintheCNS.
Thisorganizationdemonstratesanabsenceofaseparatepathwayforvisceralsensoryinformationandalow
proportionofvisceralafferentnervefiberscomparedwiththoseofsomaticorigin.
Painarisingfromproblemsintheperitoneum,pleura,orpericardiumdiffersfromthatofothervisceral
impairmentsbecauseoftheinnervationofthesestructures.Theparietalwallsofthesestructuresaresupplied
extensivelywithbothfastandslowpainfibersand,thus,canproducethesharppainofsuperficialimpairments.
CLINICALPEARL
Avisceralsourceofthesymptomsshouldalwaysbesuspectedifthesymptomsarenotalteredwithmovement
orpositionchanges.
Ingeneral,symptomsfromamusculoskeletalconditionareprovokedbycertainpostures,movements,or
activitiesandrelievedbyothers.However,thisgeneralizationmustbeviewedassuch.Itisalsoimportantto
rememberthatmusculoskeletalstructurescanrefersymptoms(Table35).Determiningthemechanismoften
willclarifythecauseofthesymptoms.Inaddition,whatappearstobeamusculoskeletalinjurycanactuallybea
systemicproblem(seeChapter5).Forexample,acutelowbackpain(LBP)canresultinsymptomsofvarying
intensityanddistributionthatcanbecausedbyneuromuscularstructuresaswellasunderlyingorcoexisting
systemicpathology(Table36),suchasagastrointestinalpathology(Table37).
TABLE35MusclesMostLikelytoReferPaintoaGivenArea
Location PotentialMusclesInvolved
Chestpain Pectoralismajor
Pectoralisminor
Scaleni
Sternocleidomastoid(sternal)
Sternalis
Iliocostaliscervicis
Subclavius
Externalabdominaloblique
Sideofchestpain Serratusanterior
Latissimusdorsi
Abdominalpain Rectusabdominis
Externalabdominaloblique
Transversusabdominis
Iliocostalisthoracis
Multifidi
Quadratuslumborum
Pyramidalis
Lowthoracicbackpain Iliocostalisthoracis
Multifidi
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Location PotentialMusclesInvolved
Serratusposteriorinferior
Rectusabdominis
Latissimusdorsi
Lumbarpain Gluteusmedius
Multifidi
Iliopsoas
Longissimusthoracis
Iliocostalislumborum
Iliocostalisthoracis
Rectusabdominis
Pelvicpain Coccygeus
Levatorani
Obturatorinternus
Adductormagnus
Piriformis
Obliquusinternusabdominis
Buttockpain Gluteusmedius
Quadratuslumborum
Gluteusmaximus
Iliocostalislumborum
Longissimusthoracis
Semitendinosus
Semimembranosus
Piriformis
Gluteusminimus
Rectusabdominis
DatafromTravellJG,SimonsDG.MyofascialPainandDysfunctionTheTriggerPointManual.Baltimore,
MD:Williams&Wilkins1983.
TABLE36Signs/SymptomsSuggestiveofBackPainduetoSystemicPathology
History Insidiousonsetandprogressivepatternofpain
Sacralpainofnontraumaticorigin
Malignantdisease
Excessivefatigue
Chronicimmunosuppressivemedicationuse
Chroniccorticosteroidorintravenousdruguse
Traumarelatedtophysiologicalchangesassociatedwithaging(i.e.,osteoporosis)
Age Youngerthan20yearsandolderthan45years
Nocturnalbackpainthatdisruptssleep
Painthatcausesconstantmovementormakesthepatientcurlup
Painthatisunrelievedwithrestorrecumbency
Painthatisunaffectedbyexertionoractivity
Paindescription Severe,persistentbackpainwithfullandpainlessmovementofthespine
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Backpainaccompaniedbymultiplejointpainorsustainedmorningstiffness
Paindescribedasthrobbingorpulsatingsensation
Constitutional Fever,sweats,nausea,orvomitingsymptoms
Palpablepulsatingmassintheabdomen
Severe/progressivebilateralweaknessoflowerextremities
Neurologicalfindingspersistinglongerthan1mo
Other Bowelorbladderincontinence
Urinaryretention
Urinarytractinfection
Constipation
DatafromStowellT,CioffrediW,GreinerA,etal.Abdominaldifferentialdiagnosisinapatientreferredtoa
physicaltherapyclinicforlowbackpain.JOrthopSportsPhysTher.200535:755764.
TABLE37PotentialAreasofCutaneousReferralfromVariousViscera
VisceralOrgan PainReferral
Heart(T15),bronchi,andlung Understernum,baseofneck,overshoulders,overpectorals,anddownoneor
(T24) botharms(L>R)
Esophagus(T56) Pharynx,lowerneck,arms,midlinechestfromuppertolowersternum
Gastric(T610) Lowerthoracictoupperabdomen
Gallbladder(T79) Upperabdomen,lowerscapular,andthoracolumbar
Pancreas Upperlumbarorupperabdomen
Upperlumbar,occasionallyanteriorabdomenapproximately45cmlateralto
Kidneys(T10L1)
umbilicus
Urinarybladder(T1112) Lowerabdomenorlowlumbar
Uterus Lowerabdomenorlowlumbar
DatafromHeadH.StudiesinNeurology.London:OxfordMedicalPublications1920.
Signsandsymptomsthatcouldincreasesuspicionforagastrointestinalpathologyincludeareportofpainthat
hasnospecificmechanismofinjury,isunrelatedtoactivity,andthatoccursfollowingeating.Inaddition,
reportsofnightpainunrelatedtomovement,fever,unexpectedweightloss,nausea/vomiting,bowel
dysfunction,andfoodintoleranceshouldalsohighlightthepossibilityofagastrointestinalsource.Anabdominal
palpationexaminationcanbeusedtoidentifygrossmasses,pulsatingmasses,and/orpain.258Palpatoryfindings
oftenderness,grossabnormalmasses,orabnormalpulsationsareindicativeofabroadrangeofabdominal
pathologies,includingtumor,aneurysm,obstruction,andinfection.
VasculogenicSymptoms
Vasculogenicsymptomstendtoresultfromvenouscongestionorarterialdeprivationtothemusculoskeletal
areas.Vasculogenicpainmaymimicawidevarietyofmusculoskeletal,neurologic,andarthriticdisorders,
becausethistypeofpainisoftenworsenedbyactivity.Anexampleofavasculogeniccauseofsymptomsoccurs
withanabdominalaorticaneurysm(Table38).258,259
TABLE38CommonSignsandSymptomsofPathologiesAssociatedwithAbdominalandBackPain
Pathology/Condition Signs/Symptoms
Abdominalaorticaneurysm(AAA) Painlocatedincentrallumbarregion
Palpablepulsatingabdominalmass
Paindescribedaspulsatingorthrobbing
Patientunabletofindcomfortableposition
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Pathology/Condition Signs/Symptoms
HistoryofAAAorvascularclaudication
Cancer(i.e.,pancreatic,ovarian,andprostatemetastasisto
Nightpainthatdisruptssleep
spine)
Painthatisunrelievedbyrest
Unexplainedweightloss
Feverandsweats
Extremefatigue
Alteredgastrointestinalorgenitourinary
function
Colickyabdominalpain
Intestinalobstruction(i.e.,volvulus,adhesions,tumor,and Abdominaldistention
functional) Nausea/vomiting/sweating
Constipation
Gastrointestinalinfection/inflammation(i.e.,peritonitis, Abdominalpainandmuscleguarding
appendicitis,andpancreatitis) Reboundtenderness
Anymovementaggravatespain
Fever,chills,sweating,andvomiting
Painrelievedbysittingandleaningforward
(pancreatitis)
Renaldisorders(i.e.,nephrolithiasis,urinarytractinfection,and Severepainalongupperurinarytractpain
pyelonephritis) pattern
Alteredurinarytractfunction(frequency,
urgency,anddysuria)
Hematuria
Gynecological(i.e.,endometriosis,pelvicinflammatory
Lumbopelvicandlowerabdominalpain
disease,andovariancysts)
Cyclicalpain,nausea,andvomiting
Dysmenorrhea
Abnormaluterinebleeding
DatafromStowellT,CioffrediW,GreinerA,etal.Abdominaldifferentialdiagnosisinapatientreferredtoa
physicaltherapyclinicforlowbackpain.JOrthopSportsPhysTher.200535:755764.GoodmanCC,
BoissonnaultWG,FullerKS.Pathology:ImplicationsforthePhysicalTherapist,2nded.Philadelphia,PA:WB
Saunders2003.
Tohelpexcludeavasculogeniccause,itisimportanttoreviewthecardiopulmonary,hematologic,and
neurologicsystemsduringtheexamination.Clinicalevidenceofarterialinsufficiencyincludeslowerextremity
asymmetry,skinconditionchanges,skintemperatureandcolorchanges,anddiminishingpulses.
Dopplerexamination,whichisnotwithinthescopeofphysicaltherapypractice,isthecornerstoneofthe
vascularexamination.Thistestexaminesbloodflowinthemajorarteriesandveinsinthearmsandthelegswith
theuseofultrasound.Theultrasoundtransducerproduceshighfrequencysoundwavesthatechoofftheblood
vessels,resultinginaswishingnoiseduringbloodflow.Afasterflowproducesahigherpitchandasteeper
waveform.Inthelowerextremity,segmentalpressuresareusuallytakenfromsixsites:
Highthigh
Abovetheknee
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Belowtheknee
Ankle
Forefoot
Digit
Apressuregradientoflessthan20mmHgisnormal,2030mmHgisborderline,andgreaterthan30mmHgis
consideredabnormal.Pressuredifferencesoflessthan20mmHgbetweenlimbsareconsiderednormal.
Afterthesegmentalpressuresofthelowerextremityaremeasured,brachialpressureonbothsidesismeasured.
Comparisonsaremadebetweenanklearm,forefootarm,anddigitarmratios.Normalvaluesare>1forthe
anklearmindex,>0.75fortheforefootarm,and>0.65foreachdigitarmindex.
NeurogenicSymptoms
Theneurologictissuescomprisethosetissuesthatareinvolvedinnerveconduction.Neurogeniccausesof
symptomsmayinclude:
tumorcompressingandirritatinganeuralstructureofthespinalcordorthemeninges
spinalnerverootirritation
peripheralnerveentrapmentand
neuritis.
PsychogenicSymptoms
Itiscommontofindemotionalovertonesinthepresenceofpain,particularlywithlowbackandneckpain.
TheseovertonesarethoughttoresultfromaninhibitionofthepaincontrolmechanismsoftheCNSfromsuch
causesasgrief,thesideeffectsofmedications,orfearofreinjury.Somatosensoryamplificationreferstothe
tendencytoexperiencesomaticsensationasintense,noxious,anddisturbing.Barskyetal.260introducedthe
conceptofsomatosensoryamplificationasanimportantfeatureofhypochondriasis.Somatosensory
amplificationisobservedinpatientswhoseextremeanxietyleadstoanincreaseintheirperceptionofpain.
ThetermnonorganicwasproposedbyWaddelletal.261todefinetheabnormalillnessbehaviorsexhibitedby
patientswhohavedepression,emotionaldisturbance,oranxietystates.Thepresenceofthreeofthefollowing
fiveWaddellsignshasbeencorrelatedsignificantlywithdisability:262
Superficialornonanatomictendernesstolighttouchthatiswidespreadandreferspaintootherareas.
Simulationtests.Theseareaseriesofteststhatshouldbecomfortabletoperform.Examplesincludeaxial
loadingofthespinethroughthepatientsheadwithlightpressuretotheskullandpassivehipand
shoulderrotationwiththepatientpositionedstanding.NeitherofthesetestsshouldproduceLBP.Ifpainis
reportedwiththesetests,anonorganicoriginshouldbesuspected.
Distractiontest.263Thistestinvolvescheckingapositivefindingelicitedduringtheexaminationonthe
distractedpatient.Forexample,ifapatientisunabletoperformaseatedtrunkflexionmaneuver,thesame
patientcanbeobservedwhenaskedtoremovehisorhershoes.Adifferenceof4045degreesis
significantforinconsistency.
Regionaldisturbances.Thesesignsincludesensoryormotordisturbancesthathavenoneurologicbasis.
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Overreaction.Thisincludesdisproportionateverbalization,muscletension,tremors,andgrimacingduring
theexamination.
TheSomatosensoryAmplificationRatingScale(SARSTable39)isaversionoftheWaddellsnonorganic
physicalsigns,whichhasbeenmodifiedtoallowforamoreaccurateappraisalofthepatientwithexaggerated
illnessbehavior.260
TABLE39SomatosensoryAmplificationRatingScale
Examination Percent Scorea
Sensoryexamination
1.Nodeficitordeficitwelllocalizedtodermatome 0
Deficitrelatedtodermatome(s)butsomeinconsistency 1
Nondermatomalorveryinconsistentdeficit 2
Blatantlyimpossible(i.e.,splitdownmidlineorentirebodywithpositivetuningforktest) 3
2.Amountofbodyinvolved:
Evaluatesimilartoburn(%ofsurfaceareasforanentirelegis18%) <15% 0
1535% 1
3660% 2
>60% 3
Motorexamination
1.Nodeficitordeficitwelllocalizedtomyotomes 0
Deficitrelatedtomyotome(s)butsomeinconsistency 1
Nonmyotomalorveryinconsistentweakness,exhibitscogwheelingorgivingway,
2
weaknessiscoachable
Blatantlyimpossible,significantweaknessthatdisappearswhendistracted 3
<15% 0
1535% 1
2.Amountofbodyinvolved
3660% 2
>60% 3
Tenderness
1.Notendernessortendernessclearlylocalizedtodiscrete,anatomicallysensiblestructures 0
Tendernessnotwelllocalized,someinconsistency 1
Diffuseorveryinconsistenttenderness,multipleanatomicstructuresinvolved(skin,
2
muscle,bone,etc.)
Blatantlyimpossible,significanttendernessofmultipleanatomicstructures(skin,muscle,
3
bone,etc.),whichdisappearswhendistracted
<15% 0
2.Amountofbodyinvolved
1535% 1
3660% 2
>60% 3
Additionaltests:distractiontests
DistractionSLRratingdeterminedbythedifferenceinmeasurementsbetweensupineand <20
0
seated degrees
2045
1
degrees
>45
2
degrees
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Examination Percent Scorea

SLRsupineatlessthan45degrees 3
Standingflexionversuslongsittest
Ratingdeterminedbytwofactors 1
<20
DifferencebetweenhipROM,standingversussupine 0
degrees
2040
1
degrees
4150
2
degrees
>50
3
degrees
Distancemeasurementfrommiddlefingertotoes,standingversussupine(longsit) <5cm 0
610cm 1
1118cm 2
>18cm 3
Totalscorepossible 27
SLR,straightlegraiseROM,rangeofmotion.
aSARSscoresof5orgreaterareindicativeofinappropriateillnessbehavior.Thehigherthescore,thegreater
theexaggeratedbehavior.
DatafromBarskyAJ,GoodsonJD,LaneRS,etal.Theamplificationofsomaticsymptoms.PsychosomMed.
198850:510519.
CLINICALPEARL
ItisimportanttorememberthattheWaddellandSARSassessmenttoolsarenotdesignedtodetectwhether
patientsaremalingering,butonlytoindicatewhethertheyhavesymptomsofanonorganicorigin.
SpondylogenicSymptoms
Anumberofconditionscanaffectthemusculoskeletalsystem,frequentlyproducingpain.Theseinclude
infections(e.g.,osteomyelitis),inflammatorydisorders,neoplasms,andmetabolicdisorders.Severalfindings
arehelpfulindiagnosingsuchpathologicprocesses.Thesefindingsmayinclude:
severeandunrelentingpain
thepresenceofafever
bonetendernessand
unexplainedweightloss.
PainControlMechanisms
OneoftheearliestpaincontrolmechanismswasproposedbyMelzackandWall264whopostulatedthat
interneuronsinthesubstantiagelatinosafunctionedlikeagatetomodulatesensoryinput.Theyproposedthat
thesubstantiagelatinosainterneuronprojectedtothesecondorderneuronofthepaintemperaturepathway
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locatedinlaminaV,whichtheycalledthetransmissioncell.Itwasreasonedthatifthesubstantiagelatinosa
interneuronweredepolarized,itwouldinhibitthetransmissionofcellfiringand,thus,decreasefurther
transmissionofinputascendinginthespinothalamictract.Thedegreeofmodulationappearedtodependonthe
proportionofinputfromthelargeAfibersandthesmallCfibers,sothatthegatecouldbeclosedbyeither
decreasingCfiberinputorincreasingAfiber(mechanoreceptive)input.Thegatetheorywas,andis,supported
bypracticalevidence(e.g.,rubbingasoreareaappearstodecreasethepain),althoughtheexperimental
evidenceforthetheoryislacking.Researchershaveidentifiedmanyclinicalpainstatesthatcannotbefully
explainedbythegatecontroltheory.265Aproblemwiththistheoryisthatthereisevidencetosuggestthatthe
Abetafibersfromthemechanoreceptordonotsynapseinthesubstantiagelatinosa.Inthiscase,themodulation
atthespinalcordlevelmustoccurinlaminaV,wherethereisasimplesummationofsignalsfromthepain
fibersandthemechanoreceptorfibers.However,severeorprolongedpaintendstohavethesegmentidentifying
allinputaspainful,andsummationmodulationhaslittle,ifany,effect.
MelzackandWallexpandeduponthegatetheoryandarguedthatthegatecouldbemodifiedbyadescending
inhibitorypathwayfromthebrain,orbrainstem,266suggestingthattheCNSapparentlyplaysapartinthis
modulationinamechanismcalledcentralbiasing.
Numerousinvestigationshavesincebeenmadeofwhatisknownasthedescendinganalgesiasystems.The
thalamusrepresentsthefinallinkinthetransmissionofimpulsestothecerebralcortex,processingalmostall
sensoryandmotorinformationpriortoitstransfertocorticalareas.Thekeybrainsitesinvolvedinpain
perceptionincludetheanteriorcingulatecortex,anteriorinsularcortex,primarysomatosensorycortex,
secondarysomatosensorycortex,anumberofregionsinthethalamusandcerebellum,and,interestingly,areas
suchasthepremotorcortexthatarenormallylinkedtomotorfunction.182,267Indeed,itisclearthatboththe
basalganglia(associatedwithplannedaction),thePAGofthemidbrainregion,andtheraphenucleusinthe
ponsandthemedullareceivenociceptiveinputaswellascoordinatingimportantaspectsofmovementand
motorcontrol.182,268,269
ThePAGareaoftheupperponssendssignalstotheraphemagnusnucleusinthelowerponsandtheupper
medulla.Thisnucleusrelaysthesignaldownthecordtoapaininhibitorycomplexlocatedintheposterior
(dorsal)hornofthecord.ThenervefibersderivedfromthePAGareasecreteenkephalinandserotonin,whereas
theraphemagnusreleasesenkephalinonly.ThePAGisalsobelievedtobeinvolvedincomplexbehavioral
responsestostressfulorlifethreateningsituationsortopromoterecuperativebehaviorafteradefensereaction.
EnkephalinisbelievedtoproducepresynapticinhibitionoftheincomingpainsignalstolaminaeItoV,thereby
blockingpainsignalsattheirentrypointintothecord.270Itisfurtherbelievedthatthechemicalreleasesinthe
upperendofthepathwaycaninhibitpainsignaltransmissioninthereticularformationandthethalamus.The
inhibitionfromthissystemiseffectiveonbothfastandslowpains.
Inthecortex,anegativefeedbackloop,calledthecorticofugalsystem,originatesattheterminationpointofthe
varioussensorypathways.271Excessivestimulationofthisfeedbackloopresultsinasignalbeingtransmitted
downfromthesensorycortextotheposteriorhornofthelevelfromwhichtheinputarose.Thisresponse
produceslateralorrecurrentinhibitionofthecellsadjacenttothestimulatedcell,therebypreventingthespread
ofthesignal.Thisisanautomaticgaincontrolsystemtopreventoverloadingofthesensorysystem.
Finally,twootherneuroactivepeptides,betaendorphinanddynorphin,havebeendiscovered,bothofwhichare
theorizedtobeusedasanalgesicsinthebodytonumbordullpaininadditiontopromotingfeelingsofwell
beingandincreasingrelaxation.
NonpharmacologicalControlofPain
ThepharmacologicalcontrolofpainisdiscussedinChapter9.Clinicianscanuseseveralnonpharmacological
therapeuticinterventionstomanagepain.Theseinclude:
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Transcutaneouselectricalnervestimulation(TENS).TENSisfrequentlyusedtotreatanumberofpain
conditionsincludingbackpain,osteoarthritis,infibromyalgiatonameafew(seeChapter8).
Interferentialcurrent(seeChapter8).Clinically,interferentialcurrenttherapyisbeneficialfortreating
painfulconditionssuchasosteoarthriticpain.Thepotentialmechanismsbehindthispaincontrolinclude
anincreaseinbloodflow,andthesamemechanismsasTENSsegmentalinhibitionandactivationof
descendinginhibitorypathways
Thermalphysicalagents(seeChapter8).
Cryotherapy(seeChapter8).
Manualtherapy(seeChapter10).
Exercise(seeChapters1215).
Patienteducation.Patientscanbeeducatedonpainmanagementtechniques(relaxation,cognitive
behavioralapproaches,andbiofeedback),positionsandactivitiestoavoid,andpositionsandactivitiesto
adopt.
Concussion
Aconcussionisclassifiedasaformofmildtraumaticbraininjury(TBI)thatresultsfromtraumatothehead.272
TheCentersforDiseaseControlandPreventionprovideamoredescriptivedefinition:acomplex
pathophysiologicalprocessaffectingthebrain,inducedbytraumaticbiomechanicalforcessecondarytodirector
indirectforcestothehead.Alossofconsciousnessisnotnecessarytodiagnosisconcussion.Thereareusually
nofindingsonroutineimagingsuchasCTwithaconcussion,whichcomplicatesthediagnosis.273While
concussionscanoccurinnearlyeverywalkoflife,thegreatestfrequencyoccursincollisionandcontactsports,
includingfootball,lacrosse,hockey,rugby,soccer,andbasketball.Itisestimatedthat3.8millionconcussions
occurannually.274Whilethemajorityofpatientswithasportsrelatedconcussionmayrecoverwithina7to10
dayperiod,childrenandadolescentsrequiremoretimetorecoverthandocollegiateorprofessionalathletes.275
Persistenceofsymptomsbeyondthegenerallyacceptedtimeframeforrecoverymayrepresentaprolonged
concussion,ormayheraldthedevelopmentofpostconcussionsyndrome(PCS).276
CLINICALPEARL
BasedonafactsheetavailablefromtheCentersforDiseaseControlandPrevention
(http://cdc.gov/concussion/HeadsUp/high_school.html),anindividualwhoissuspectedofsufferingfroma
concussionshouldnotbeleftaloneandshouldbebroughttotheemergencydepartmentifanyofthefollowing
ispresent:
aheadachethatworsens,
drowsinessorinabilitytobewokenup,
inabilitytorecognizepeopleorplaces,
repeatedvomiting,
worseningconfusion/irritability,
seizures,
hemiparesis/hemisensoryloss,
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unsteadiness,or
slurredspeech.
Sexdifferencesamongconcussedathletesarewelldocumentedanddemonstratedissimilaritiesbetweenmale
andfemaleathletesthatrangefromanthropometrics,neuromuscular,andstrengthdifferences,topostconcussion
symptomsandcognitivedysfunctionsthatcaninfluenceanindividualsrecoverytime.277Therearenumberof
potentialexplanationsforthisdisparity:277
Femaleshavelongercervicalspinesegmentsandmaynotbeasefficientattransmittingimpactforces
fromtheirheadintotheirtorsoviatheircervicalmusculatureduringaconcussiveevent.
Femalesmayalsobemorelikelytoseekmedicaltreatmentforconcussionsymptomsandtohonestly
reportsymptomswhentheysufferaconcussion.
Withincreasedawarenessoftherateofconcussioninjuryinsportsandthepotentialdetrimentallongterm
effects,anumberofeffortshavebeenmadetoidentifythehealthconsequencesofrepeatedblowstothehead
whileconcurrentlyseekingtoimplementstrategiestobetterprotecttheathletefromtheseinjuries.278Itis
importanttonotethatconcussionmayormaynotinvolvealossofconsciousness,andcanresultina
constellationofphysical,cognitive,emotional,andsleeprelatedsymptoms.279Acutesignsandsymptomsofa
concussionincludeconfusion,lossofconsciousness,posttraumaticamnesia,retrogradeamnesia,balance
deficits,dizziness,visualproblems,personalitychanges,fatigue,sensitivitytolight/noise,numbness,and
vomiting.280Chronicsignsandsymptomsofaconcussionhaveadegreeofoverlapandincludecognitive
deficitsinattentionormemory,andatleasttwoormoreofthefollowingsymptoms:fatigue,sleepdisturbance,
headache,dizziness,irritability,affectivedisturbance,apathy,orpersonalitychange.281Sincemostcognitive
deficitsresolvewithin13monthsafteramildTBIinthemajorityofpatients,thereisconsiderablecontroversy
regardingPCSbecauseofthenonspecificityofitssymptoms.282Thefollowingtwofindingscanhelpdetermine
whethertheprolongedsymptomsreflectaversionoftheconcussionpathophysiologyoramanifestationofa
secondaryprocess,suchaspremorbidclinicaldepression:283
1.Ifsymptomsthatwereexperiencedearlyaftertheinjuryareexacerbatedbyexertion,butimprovedwith
rest,thentheoriginalconcussionpathophysiologyislikelypersisting.
2.Ifongoingsymptomsareexacerbatedwithminimalactivityandnolongerrespondtorest,thismay
representpsychologicalsymptomsrelatedtoprolongedinactivityandfrustrationwithinabilitytoreturnto
usualactivities.
Concussionshavetraditionallybeendiagnosedthroughaclinicalexaminationperformedbyahealthcare
professionalonthesidelineatthetimeofinjury.Onthoseoccasionswhentheassessmentisnotperformedon
thesidelines,itiscriticalthatthecliniciandeterminesacleardescriptionofthemechanismandforceofthehead
trauma,thenumberandseverityofsymptoms,andahistoryofanypriorconcussions,includingmechanism,
symptomtype,andduration.272Thenature,burden,anddurationofsymptomsappeartobetheprimary
determinantofinjuryseverityinconcussion.272,284Ahistoryofmultipleconcussionsappearstoincreasethe
riskforPCS.276
Thediagnosisandsubsequentmanagementofconcussioncontinuestoevolveandseveraltestsnowexistto
identifythedeficitsfoundinthispopulation.Whatisclearisthatconcussionsymptomsmaybeimmediateafter
injury,orappearinadelayedfashionseveralhourspostinjury,soitisimportanttostayvigilant.273Thesideline
assessmentofconcussionisbestaccomplishedwithstandardizedinstrumentsthatarewidelyavailable,
includingtheSportConcussionAssessmentTool2(SCAT2),272whichhasbeenadoptedbynearlyevery
professionalsportsteamandmanycollegeteams.TheModifiedMaddocksScore285canbeusedtoassess
orientationbyaskingtheathleteaboutgameeventsthatdayandtheweekbefore.273Thephysicalexamination
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shouldincludeanassessmentofconcentration(e.g.,drillssuchasstatingthemonthsoftheyearinreverse),
memory(recallofthreewordsat5minutes),thecervicalspine,gait,balance,cerebellartesting(e.g.,fingerto
nosetest),andanexaminationoftheCNs,particularlyextraocularmotion,sincePCSpatientscanhave
persistentabnormalitiesofsmoothpursuitsaccadiceyemovements.272,276,286Othertestsinclude,the
ImmediatePostconcussionAssessmentandCognitiveTesting(ImPact),thepostconcussionsymptomscale,and
theBalanceErrorScoringSystem(BESS)(seeNeuromuscularControlandBalanceTesting).Thecervicalspine
shouldalsobecarefullyassessed.Currentrecommendationsarethattheathleteundergobaselinetestinginthese
areaspriortotheseasonand,ifaconcussionissuspected,undergothesamebatteryoftestssothatscoresmay
becompared.
Astandardizedprocessprojectingthelengthofrecoverytimeafterconcussionhasremainedanelusivepieceof
thepuzzle.Therecoverytimeassociatedwithsuchaninjuryoncediagnosedcanlastanywherefromoneweek
toseveralmonths.Parentsaretypicallyadvisedtokeepthepatientatrestand,foratleast24hours,tohavethe
patientavoidstrenuousactivity,recreationaldrugs,alcohol,sleepingmedication,andaspirinornonsteroidal
antiinflammatorydrugs.
Obviously,movestowardpreventionwouldseemprudent.Themostcommonattemptedpreventionstrategyof
concussionhasoccurredwithAmericanFootballthathasseenmodificationstohelmetsthatincludeinnovations
indesign,padding,mouthguards,andproductmaterials.However,despiteaggressiveenforcementofhelmet
andprotectivepaddinguse,epidemiologicalandlaboratorystudieshavenotshownsignificantreductionsin
concussioninstancesortheextentofconcussiveinjurytothebrain.287Onehypothesisisthatsuchdevicesand
equipmentdolittletonothingtopreventormitigatetherapidaccelerationanddecelerationofthebrainand
relatedfluidsinsidetherigidcranium.278Basedonthescienceoffluiddynamics,sloshreferstothemovement
ofliquidinsidecontainersthatarealsotypicallyundergoingmotion.Whentheheadisexposedtorapid
acceleration/deceleration,thebrainmaybeatriskforsloshinducedinjuryastissuesofdifferingdensity(i.e.,
blood,spine,brain,andskull)decelerateatdifferentrates,therebycreatingshearandcavitation(vaporbubble
creationandimplosion).278
Currentmanagementguidelinesrecommendaperiodofcognitiveandphysicalrestintheearlypostinjury.
However,thereisnoscientificevidencethatprolongedrestformorethanseveralweeksinconcussedpatientsis
beneficial.276Neurocognitiverehabilitation,whichusescognitivetaskstoimprovecognitiveprocessesand
attentionprocesses,canbeusedoncetheconcussionsymptomshavesubsided.276Oncethepatientis
asymptomaticatrest,aprogressionfromlightaerobicactivitysuchaswalking,tosportorworkspecific
activitiescanbeintroduced.272TheCantu288gradingscalehasbeenhelpfulinassessingseverityofconcussion
andformakingreturntoplaydecisions(seeTable310).
TABLE310CantuGradingScale
Grade Description
1 Includesposttraumaticamnesialessthan30minutesandnolossofconsciousness
2 Definedaslossofconsciousnesslessthan5minutes,oramnesia30minutesto24hours
3 Includeslossofconsciousnessgreaterthan5minutesoramnesiagreaterthan24hours
DatafromCantuRC.Posttraumaticretrogradeandanterogradeamnesia:pathophysiologyandimplicationsin
gradingandsafereturntoplay.JAthlTrain.200136:244248.
OrthopaedicNeurologicTesting
Anexaminationofthetransmissioncapabilityofthenervoussystemcanbeperformedaspartoftheorthopaedic
examinationtodetectthepresenceofeitheranuppermotorneuron(UMN/CNS)lesion,alowermotorneuron
(LMN/PNS)lesion,orboth.Inessence,neurologicaltissueistestedduringactive,passive,andresisted
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isometricmovement,aswellasthosetestsspecifictothenervoussystem(e.g.,reflextesting,sensorytesting).
NeurodynamicmobilitytestingiscoveredinChapter11.
UMNsarelocatedinthewhitecolumnsofthespinalcordandthecerebralhemispheres.AnUMNlesion,also
knownasacentralpalsy,isalesionoftheneuralpathwayabovetheanteriorhorncellormotornucleiofthe
CNS.SignsandsymptomsassociatedwithanUMNlesionfollow.
CLINICALPEARL
AnUMNlesionischaracterizedbyspasticparalysisorparesis,littleornomuscleatrophy,hyperreflexive
musclestretch(deeptendon)reflexesinanonsegmentaldistribution,andthepresenceofpathologicsignsand
reflexes.
Nystagmus.Nystagmusischaracterizedbyaninvoluntarylossofcontroloftheconjugatemovementof
theeyes(aroundoneormoreaxes)involvedwithsmoothpursuitorsaccadicmovement.Whentheeyes
oscillatelikeasinewave,itiscalledpendularnystagmus.Ifthenystagmusconsistsofdriftsinone
directionwithcorrectivefastphases,itiscalledjerknystagmus.Themorebenigntypesofnystagmus
includetheproprioceptivecausesofspontaneousnystagmus,posturalnystagmus,andnystagmusthatis
elicitedwithheadpositioningorinducedbymovement(vestibularnystagmus).Aunidirectional
nystagmusisrelatedtothegeometricrelationshipoftheSSC,withachangeinheadpositionoften
exacerbatingthenystagmus.Ontheotherhand,acentralvestibularnystagmus,whichiscausedbydisease
ofthebrainstemorthecerebellum,exhibitsbidirectionalitytothenystagmus(i.e.,leftbeatingonleft
gazeandrightbeatingonrightgaze).289Themoreseriouscausesofnystagmusinclude,butarenot
limitedto,vertebrobasilarischemia,tumorsoftheposteriorcranialfossa,intracranialbleeding,
craniocervicalmalformations,andautonomicdysfunction.Differentiationbetweenthebenignandserious
causesofnystagmusisobviouslyveryimportant.
Proprioceptivenystagmusoccursimmediatelyuponturningthehead(i.e.,thereisnolatentperiod).
Theischemictypeofnystagmushasalatentperiodandisusuallyonlyevidentwhenthepatientsneckis
turnedtoapositionandmaintainedthereforaperiodofafewsecondsupto3minutes.290,291
Dysphasia.Dysphasiaisdefinedasaproblemwithvocabularyandresultsfromacerebrallesioninthe
speechareasofthefrontalortemporallobes.Thetemporallobereceivesmostofitsbloodfromthe
temporalbranchofthecorticalarteryofthevertebrobasilarsystemandmaybecomeischemic
periodically,producinganinappropriateuseofwords.
Wallenbergsyndrome.Thisistheresultofalateralmedullaryinfarction.292Classically,sensory
dysfunctioninlateralmedullaryinfarctionischaracterizedbyselectiveinvolvementofthespinothalamic
sensorymodalitieswithdissociateddistribution(ipsilateraltrigeminalandcontralateral
hemibody/limbs).293However,variouspatternsofsensorydisturbancehavebeenobservedinlateral
medullaryinfarctionthatincludescontralateralorbilateraltrigeminalsensoryimpairment,restricted
sensoryinvolvement,andaconcomitantdeficitoflemniscalsensations.294,295
Ataxia.Ataxiaisoftenmostmarkedintheextremities.Inthelowerextremities,itischaracterizedbythe
socalleddrunkensailorgaitpattern,withthepatientveeringfromonesidetotheotherandhavinga
tendencytofalltowardthesideofthelesion.Ataxiaoftheupperextremitiesischaracterizedbyalossof
accuracyinreachingfor,orplacing,objects.Althoughataxiacanhaveanumberofcauses,itgenerally
suggestsCNSdisturbance,specificallyacerebellardisorder,oralesionoftheposteriorcolumns.296298
Spasticity.299301Spasticityisdefinedasamotordisordercharacterizedbyavelocitydependentincrease
(resistanceincreaseswithvelocity)intonicstretchreflexeswithexaggeratedtendonjerks,resultingfrom
hyperexcitabilityofthestretchreflex.Thespinalcordexperiencesspinalshockimmediatelyfollowing
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anytraumacausingtetraplegiaorparaplegia,resultinginthelossofreflexesinnervatedbytheportionof
thecordbelowthesiteofthelesion.Thedirectresultofthisspinalshockisthatthemusclesinnervatedby
thetraumatizedportionofthecord,theportionbelowthelesion,aswellasthebladder,becomeflaccid.
Spinalshock,whichwearsoffafter24hoursand3monthsafterinjury,canbereplacedbyspasticityin
some,orallofthesemuscles.
Spasticityoccursbecausethereflexarctothemuscleremainsanatomicallyintact,despitethelossofcerebral
innervationandcontrolviathelongtracts.Duringspinalshock,thearcdoesnotfunction,butasthespine
recoversfromtheshock,thereflexarcbeginstofunctionwithouttheinhibitoryorregulatoryimpulsesfromthe
brain,creatinglocalspasticityandclonus.
CLINICALPEARL
MedicaletiologiesforincreasedspasticityincludeaneworenlargedCNSlesion,genitourinarytractdysfunction
(infection,obstruction,etc.),gastrointestinaldisorders(bowelimpaction,hemorrhoids,etc.),venousthrombosis,
fracture,musclestrain,andpressureulcers.
Dropattack.Adropattackisdescribedasalossofbalanceresultinginafall,butwithnolossof
consciousness.Becauseitistheconsequenceofalossoflowerextremitycontrol,itisneveragoodor
benignsign.Thepatient,usuallyelderly,fallsforward,withtheprecipitatingfactorbeingextensionofthe
head.Recovery,providingnothingisinjuredinthefall,isusuallyimmediate.Causesinclude:
avestibularsystemimpairment302
neoplasticandotherimpairmentsofthecerebellum303
vertebrobasilarcompromise304(seeChapter24)
suddenspinalcordcompression
thirdventriclecysts
epilepsyand
type1Chiarimalformation.305
Wernickesencephalopathy.Thisisanimpairment,typicallylocalizedtotheposterior(dorsal)partof
themidbrain,306thatproducestheclassictriadofabnormalmentalstate,ophthalmoplegia,andgait
ataxia.307
Verticaldiplopia.Ahistoryofdoublevisionshouldalertthecliniciantothiscondition.Patientswith
verticaldiplopiacomplainofseeingtwoimages,oneatopordiagonallydisplacedfromtheother.308
Dysphonia.Dysphoniapresentsasahoarsenessofthevoice.Usually,nopainisreported.Painless
dysphoniaisacommonsymptomofWallenbergsyndrome.294
Hemianopia.Thisfinding,definedasalossinhalfofthevisualfield,isalwaysbilateral.Avisualfield
defectdescribessensorylossrestrictedtothevisualfieldandarisesfromdamagetotheprimaryvisual
pathwayslinkingtheoptictractandstriatecortex(seesectionSupraspinalReflexes).
Ptosis.Ptosisisdefinedasapathologicdepressionofthesuperioreyelidsuchthatitcoverspartofthe
pupil.ItresultsfromapalsyofthelevatorpalpebraeandMllersmuscle.
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Miosis.Miosisisdefinedastheinabilitytodilatethepupil(damagetosympatheticganglia).Itisoneof
thesymptomsofHornersyndrome.
Hornersyndrome.Thissyndromeiscausedbyinterferencewiththecervicothoracicsympatheticoutflow
resultingfromalesionof(1)thereticularformation,(2)thedescendingsympatheticsystem,and(3)the
oculomotornervecausedbyasympatheticparalysis.309TheotherclinicalsignsofHornersyndromeare
ptosis,enophthalmos,facialreddening,andanhydrosis.IfHornersyndromeissuspected,thepatient
shouldimmediatelybereturnedorreferredtoaphysicianforfurtherexamination.
Dysarthria.Dysarthriaisdefinedasanundiagnosedchangeinarticulation.Dominantornondominant
hemisphericischemia,aswellasbrainstemandcerebellarimpairments,mayresultinalteredarticulation.
TheLMNbeginsatthemotorneuronandincludestheposterior(dorsal)andanterior(ventral)roots,spinal
nerve,peripheralnerve,neuromuscularjunction,andmusclefibercomplex.310TheLMNconsistsofacell
bodylocatedintheanteriorgraycolumnanditsaxon,whichtravelstoamusclebywayofthecranialor
peripheralnerve.LesionstotheLMNcanoccurinthecellbodyoranywherealongtheaxon.ALMNlesionis
alsoknownasaperipheralpalsy.Theselesionscanbetheresultofdirecttrauma,toxins,infections,ischemia,or
compression.ThecharacteristicsofaLMNlesionincludemuscleatrophyandhypotonus,diminishedorabsent
musclestretch(deeptendon)reflexoftheareasservedbyaspinalnerverootoraperipheralnerve,andabsence
ofpathologicsignsorreflexes.
CLINICALPEARL
ThedifferingsymptomsbetweenanUMNlesionandaLMNlesionaretheresultofinjuriestodifferentpartsof
thenervoussystem.LMNimpairmentinvolvesdamagetoaneurologicstructuredistaltotheanteriorhorncell,
whereasUMNimpairmentinvolvesdamagetoaneurologicstructureproximaltotheanteriorhorncell,namely,
thespinalcordorCNS.
TheScanningExamination
DesignedbyCyriax,311theupper(Table311)andlower(Table312)quarterscanningexaminationsarebased
onsoundanatomicandpathologicprinciples.Theclinicianmustchoosewhichscanningexaminationtouse,
basedonthepresentingsignsandsymptoms.
TABLE311UpperQuarterScanningMotorExamination
Muscle Root
MuscleTested PeripheralNerve
Action Level
Shoulder Primarily
Deltoid Axillary
abduction C5
Elbow Primarily
Bicepsbrachii Musculocutaneous
flexion C6
Elbow Primarily
Tricepsbrachii Radial
extension C7
Wrist Extensorcarpiradialislongus,brevis, Primarily
Radial
extension andextensorcarpiulnaris C6
Wrist Flexorcarpiradialisandflexorcarpi Primarily Mediannerveforradialisandulnarnervefor
flexion ulnaris C7 ulnaris
Finger Flexordigitorumsuperficialis,flexor Primarily Mediannerveforsuperficialisandbothmedian
flexion digitorumprofundus,andlumbricales C8 andulnarnervesforprofundusandlumbricales
Finger Primarily
Posterior(dorsal)interossei Ulnar
abduction T1
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TABLE312LowerQuarterScanningMotorExamination
Root
MuscleAction MuscleTested PeripheralNerve
Level
Femoraltoiliacusandlumbar
Hipflexion Iliopsoas L12
plexustopsoas
Kneeextension Quadriceps L24 Femoral
Bicepsfemoris,semimembranosus,and
Hamstrings L4S3 Sciatic
semitendinosus
Dorsiflexionwith Primarily
Tibialisanterior Deepfibular(peroneal)
inversion L4
Primarily
Greattoeextension Extensorhallucislongus Deepfibular(peroneal)
L5
Primarily
Ankleeversion Fibularis(peroneus)longusandbrevis Superficialfibular(peroneal)nerve
S1
Primarily
Ankleplantarflexion Gastrocnemiusandsoleus Tibial
S1
Hipextension Gluteusmaximus L5S2 Inferiorglutealnerve
Thepurposeofthescanningexaminationsistohelpruleoutthepossibilityofsymptomreferralfromother
areas,toensurethatallpossiblecausesofthesymptomsareexamined,andtoensureacorrectdiagnosis.
Thescanningexaminationistypicallyappliedtopatientspresentingwithneuromusculoskeletalcomplaintsand
differsfromthefiveelementsofpatient/clientmanagementfromTheGuideinthatthelattercanbeusedasa
systemtoapproachvirtuallyanytypeofpatient,rangingfromapediatricpatientwithapermanentneurological
conditiontoapatientwithaseriousinjurytotheintegument,suchasaburnpatient.312Theothermajor
differencebetweenthetwoapproachesisthatthescanningexaminationisdesignedtoidentifyaspecific
pathoanatomicaldysfunction,whileTheGuideworkswithinmovementbaseddiagnosticcategoriesknownas
practicepatterns.312Thus,thetestsusedinthescanningexaminations(Table313)mayproduceamedical
diagnosis(e.g.,intervertebraldiskprotrusion,prolapse,orextrusionacutearthritisspecifictendinopathy
musclebellytearspondylolisthesisorlateralrecessstenosis)ratherthanaphysicaltherapyone.313
TABLE313ComponentsoftheScanningExaminationandtheStructuresTested
Component Description
Active Willingnesstomove,ROM,integrityofcontractileandinerttissues,patternofrestriction
ROM (capsularornoncapsular),qualityofmotion,andsymptomreproduction
Passive
Integrityofinertandcontractiletissues,ROM,endfeel,andsensitivity
ROM
Resisted Integrityofcontractiletissues(strengthandsensitivity)
Stress Integrityofinerttissues(ligamentousdiskstability)
Dural Duralmobility
Neurologic Nerveconduction
Dermatome Afferent(sensation)
Myotome Efferent(strengthandfatigability)
Reflexes AfferentefferentandCNS
ROM,rangeofmotion.
Often,thescanningexaminationdoesnotgenerateenoughsignsandsymptomstoformulateaworking
hypothesisoradiagnosis.Anegativescanningexaminationdoesnotimplythattherewerenofindingsrather,
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theresultsofexaminationwereinsufficienttogenerateadiagnosisuponwhichaninterventioncouldbebased.
Inthiscase,furthertestingwiththetestsandmeasuresoutlinedinTheGuidearerequiredinordertoproceed.
Thethoroughnessofthescanningexaminationisinfluencedbybothpatienttoleranceandprofessional
judgment.Ageneralguidelineisthattheexaminationmustcontinueuntiltheclinicianisconfidentthatthe
patientssymptomsarenottheresultofaseriousconditionthatdemandsmedicalattention.
Thetestsincludedinthescanningexaminationarestrengthtesting,sensationtesting(lighttouchandpinprick),
musclestretchreflexes,andthepathologicalreflexes(Table313).Thevarioustestsofthescanning
examinationsspecifictothecervical,thoracic,andlumbarspinearedescribedintherelevantchapters.
Althoughtwostudies314,315questionedthevalidityofsomeaspectsoftheselectivetissuetensionexamination,
nodefinitiveconclusionsweredrawnfromthesestudies.ThescarcityofresearchtorefutetheworkofCyriax
wouldsuggestthatitsprinciplesaresoundandthatitsuseshouldbecontinued.
ComplaintsofDizziness
Althoughmostcausesofdizzinesscanberelativelybenign,dizzinessmaysignalamoreseriousproblem,
especiallyifitisassociatedwithtraumatotheneckortheheadorwithmotionsofcervicalrotationand
extension(e.g.,vertebralarterycompromise).Theclinicianmustascertainwhetherthesymptomsresultfrom
vertigo,nausea,giddiness,unsteadiness,orfainting,amongothers.Nauseaisanuneasinessofthestomachthat
oftenaccompaniestheurgetovomitbutdoesnotalwaysleadtotheforciblevoluntaryorinvoluntaryemptying
ofstomachcontentsintothemouth(vomiting).Ifvertigoissuspected,thepatientsphysicianshouldbe
informed,forfurtherinvestigation.However,inandofitself,vertigoisnotusuallyacontraindicationtothe
continuationoftheexamination.DifferentialdiagnosisincludesprimaryCNSdiseases,vestibularandocular
involvement,and,morerarely,metabolicdisorders.316Apatientcomplainingofdizzinesscanbeclassifiedinto
foursubtypes(Table314).Carefulquestioningcanhelpinthedifferentiationofthecause.Thisdifferentiation
isimportant,ascertaintypesofdizzinessareamenabletophysicaltherapyinterventions(Table315)others
producecontraindicationstocertaininterventions,whilestillothercausesofdizzinessrequiremedical
referral.317Thepresenceofpresyncopewouldsuggestcompromiseofthefunctionofthecerebralhemispheres
orthebrainstem.317Differentconditionscancauseeitherapancerebralhypoperfusion(Table316)ora
selectivehypoperfusionofthebrainstem,thelatterofwhichincludesvertebrobasilarinsufficiency,
vertebrobasilarinfarction,andsubclavianstealsyndrome.317Thepresenceofvertigo,nystagmus,hearingloss
ortinnitus,andbrainstemsignscanhelpthecliniciandifferentiatebetweenacentraloraperipheralvestibular
lesion(Table317).317Peripheralvertigoismanifestedwithgeneralcomplaintssuchasunsteadinessand
lightheadedness.Centralvertigoisusuallycausedbyacerebellardisorder,anischemicprocess,oradisturbance
ofthevestibularsystem(Table318).Cervicalvertigo,ontheotherhand,maybeproducedbylocalizedmuscle
changesandreceptorirritation.291
TABLE314TheFourSubtypesofDizziness
Subtype Description
Afalsesensationofmovementofeitherthebodyortheenvironment,usuallydescribedas
Vertigo
spinning,whichsuggestsvestibularsystemdysfunction
Usuallyepisodicwithanabruptonsetandoftenassociatedwithnauseaorvomiting
Thedysfunctioncanbelocatedintheperipheralorcentralvestibularsystem
Oftenaccompaniedbyothersignsandsymptomsincludingimpulsion(thesensationthatthe
bodyisbeinghurledorpulledinspace),oscillopsia(thevisualillusionofmovingbackand
forthorupanddown),nystagmus,gaitataxia,nausea,andvomiting
Describedasasensationofanimpendingfaintorlossofconsciousness,whichisnotassociated
Presyncope
withanillusionofmovement
Maybeginwithdiminishedvisionoraroaringsensationintheears
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Subtype Description
Maybeaccompaniedbyatransientneurologicalsigns,e.g.,dysarthria,visualdisturbances,and
extremityweakness
Resultsfromconditionsthatcompromisethebrainssupplyofblood,oxygen,orglucose
Asenseofimbalancewithoutvertigo,orasensethatafallisimminent,whichisgenerally
Disequilibrium
attributedtoneuromuscularproblems
Theunsteadinessorimbalanceoccursonlywhenerectanddisappearswhenlyingorsitting
Mayresultfromvisualimpairment,peripheralneuropathy,musculoskeletaldisturbancesand
mayincludeataxia
Other Describedasavagueorfloatingsensationwiththepatienthavingdifficultyrelatingtospecific
dizziness feelingtotheclinician
Includesdescriptionsofalightheadedness,heavyheadedness,orwoozinessthatcannotbe
classifiedasanyofthethreeprevioussubtypes
Themaincausesofthissubtypearepsychiatricdisordersincludinganxiety,depression,and
hyperventilation
DatafromBalohRW.Approachtothedizzypatient.BaillieresClinNeurol.19943:453465DrachmanDA,
HartCW.Anapproachtothedizzypatient.Neurology.197222:323334HansonMR.Thedizzypatient.A
practicalapproachtomanagement.PostgradMed.198985:99102,107108EatonDA,RolandPS.Dizziness
intheolderadult,Part2.Treatmentsforcausesofthefourmostcommonsymptoms.Geriatrics.200358:46,
4952EatonDA,RolandPS.Dizzinessintheolderadult,Part1.Evaluationandgeneraltreatmentstrategies.
Geriatrics.200358:2830,3336HuijbregtsP,VidalP.Dizzinessinorthopaedicphysicaltherapypractice:
classificationandpathophysiology.JManManipTher.200412:199214SimonRP,AminoffMJ,Greenberg
DA.ClinicalNeurology.4thed.Stanford,CT:AppletonandLange1999.
TABLE315SignsandSymptomsIndicativeofPathologiesAmenabletoSolePhysicalTherapyManagement
BPPV Precipitatedbypositioning,movement,orotherstimuli(seebelow)
Shortlatency:15seconds
Briefduration:<30seconds
Fatigablewithrepeatedmotion
Associatedsignsandsymptoms:nystagmus,nausea,andattimesvomiting
Occursinpeopleolderthan40yearswithpeakincidenceofonsetinthesixthdecade
Rareinpeopleunder20years
Medicalhistoryofheadtrauma,labyrinthineinfection,surgicalstapedectomy,chronic
suppurativeotitismedia,anddegenerativechangestotheinnerearmayindicatenonidiopathic
BPPV
PosteriorSCC Patientscomplainofdizzinesswhentheyquicklytransfertoasupineposition,especially
BPPV whentheheadisturnedtotheaffectedside
PositiveresponseofvertigoandapogeotropictorsionalnystagmusonipsilateralHallpikeDix
maneuver
Patientsalsocomplainofdizzinesswhentheyquicklytransfertoasupineposition,especially
AnteriorSCC
whentheheadisturnedtotheaffectedside,butthereislessspecificityastothedirectionof
BPPV
headrotation
BilateralpositiveresponseonHallpikeDixmaneuverwithvertigoandgeotropictorsional
nystagmusonipsilateraltest
HallpikeDixmaneuvermayalsocausedownbeatingverticalnystagmus
Positiveresponseonstraightheadhangingtest
HorizontalSCC Dizzinessisbroughtonwhenrollingoverinsupinebutcanalsooccurwithflexionand
BPPV extensionoftheheadorwhentransferringfromsupinetoupright
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AbilaterallypositivetestwithapurelyhorizontalnystagmusonHallpikeDixmaneuver.The
nystagmuswillbegeotropicbeatinginthedirectionofthefaceturnordownsideear.
Nystagmuswilloccurinbothdirectionsbutisgenerallystrongerwhentheheadisturned
towardtheaffectedside
Positiverolltest
Positivewalkrotatewalktesttoaffectedside
Cervicogenic Intermittentpositioningtypedizziness
dizziness Precipitatedbyheadandneckmovement
Nolatencyperiod:onsetofsymptomsisimmediateuponassumingtheprovokingposition
Briefdurationbutmaylastminutestohours
Fatigablewithrepeatedmotion
Associatedsignsandsymptoms:nystagmus,neckpain,suboccipitalheadaches,sometimes
paresthesieinthetrigeminalnervedistribution
Possiblelateralheadtiltduetotightnessofthesternocleidomastoidoruppertrapezius
Possibleforwardheadposture
Medicalhistoryofcervicalspinetraumaanddegeneration
MotiondysfunctionintheuppercervicalsegmentsonAROMandPIVMtesting
Positivenecktorsiontest:nystagmuswithreproductionofdizziness
Musculoskeletal Subjectivecomplaintsofweaknessandunsteadiness
impairments Insidiousonset
PosturaldeviationsnegativelyaffectingthelocationoftheCOGinrelationtotheBOS:trunk
flexion,hipflexion,kneeflexion,andankleplantarflexioncontractures
Decreasedtrunkextension,hipextension,kneeextension,andankledorsiflexiononROM
testing
Lossofstrengthandenduranceinantigravitymuscles
Impairedjointpositionsenselowerextremity
BPPV,benignparoxysmalpositionalvertigoSCC,semicircularcanalPIVM,passiveintervertebralmotion.
DatafromHuijbregtsP,VidalP.Dizzinessinorthopaedicphysicaltherapypractice:historyandphysical
examination.JManManipTher.200513:221250.
TABLE316CharacteristicsofPancerebralHypoperfusion
Pancerebral
Description
Hypoperfusion
Vasovagal Parasympathetichyperactivitycausesadecreaseincardiacoutputwithasubsequent
presyncope decreaseincerebralbloodflow
Rarelyoccursintherecumbentposition
Cardiovascular Shouldbesuspectedwhensyncopeoccurswiththepatientinarecumbentposition,duringor
presyncope afterphysicalactivity,oranypatientwithaknownmedicalhistoryofheartdisease
Migraine Characterizedbyaheadachethatisusuallyunilateralandofapulsatilequality
Nausea,photophobia,vomiting,andlassitudearefrequentlyassociatedwithmigraine
Takayasus
MostcommoninAsiandescentwomen.
disease
Canoccurafterexercise,standing,orheadmovementandisassociatedwithimpairedvision
andconfusion.
Carotidsinus Pressureonthecarotidsinusduetoatightcollarorlocalnecktumorwillcausevagal
syndrome stimulation,leadingtobradycardiaandsubsequentsyncope.
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Pancerebral
Description
Hypoperfusion
Orthostatic Syncopeandpresyncopehappenwhenrapidlyrisingtoastandingposition,standing
hypotension motionlessforprolongedperiods,andstandingafterprolongedrecumbency.
Hyperventilationcauseshypocapnia,whichinturnresultsincerebralvasoconstrictionand
Hyperventilation
CNShypoperfusion.
Coughrelated Syncope(andpresyncope)maybecausedbyanincreaseinintracranialpressuredueto
syncope coughingwithresultantcerebralhypoperfusion.
Micturition
Episodesoccurmainlyinmenatnightbefore,during,oraftermicturition.
syncope
Peripheralbloodpooling,vagusinducedbradycardia,andprolongedrecumbencyarelikely
responsible.
Glossopharyngeal Theresultofaglossopharyngealvagalreflexcircuitcausingtransientbradyarrhythmiathat
neuralgia resultsincerebralhypoperfusion.
Askingthepatientwhetherthedizzinessoccursmainlywhenheorshehasnoteatenmay
Hypoglycemia
clueinthecliniciantohypoglycemiaasthecauseforthedizziness.
DatafromHuijbregtsP,VidalP.Dizzinessinorthopaedicphysicaltherapypractice:Classificationand
pathophysiology.JManManipTher.200412:199214.
TABLE317DifferentialDiagnosticCharacteristicsofCentralVersusPeripheralVertigo
CentralLesions PeripheralLesions
Vertigo Oftenconstant Oftenintermittent
Lesssevere Severe
Nystagmus Sometimesabsent Alwayspresent
Uniormultidirectional Unidirectional
Maybevertical Neververtical
Hearinglossortinnitus Rarelypresent Oftenpresent
Brainstemsigns Typicallypresent Neverpresent
DatafromSimonRP,AminoffMJ,GreenbergDA.ClinicalNeurology.4thed.Stanford,CT:Appletonand
Lange1999HuijbregtsP,VidalP.Dizzinessinorthopaedicphysicaltherapypractice:Classificationand
TABLE318CentralVestibularDisorders
Disorder Description
Manydrugintoxicationsyndromesproduceglobalcerebellardysfunctionincluding
Drugintoxication
alcohol,sedativehypnotics,anticonvulsants,hallucinogens,andstreetdrugs
Wernickes Comprisesthediagnostictriadofataxia,ophthalmoplegia(lateralrectuspalsy),and
encephalopathy confusion
Inflammatory ViralcerebellarinfectionscanoccurinpatientswithSt.Louisencephalitis,AIDS
disorders dementiacomplex,andmeningealencephalitis
Rarelythefirstsymptomofmultiplesclerosisbutiscommonduringthecourseofthe
Multiplesclerosis
disease
Alcoholiccerebellar
Usuallyoccursinpatientswithahistoryof10ormoreyearsofbingedrinking
degeneration
Phenytoininduced Longtermtreatmentwithphenytoin(antiepilepticmedication)mayproduceaglobal
cerebellardegeneration cerebellardegeneration
Hypothyroidism Mostcommoninmiddleagedorelderlywomen
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Disorder Description
Gaitataxiaistheprominentfinding
Paraneoplastic Appearstoinvolveantibodiestotumorcellantigenscrossreactingwithcerebellar
cerebellardegeneration Purkinjecells
Hereditary
Autosomaldominantspinocerebellarataxiascharacterizedbyadultonset,slowly
spinocerebellar
progressivecerebellarataxia,e.g.,Friedrichsataxia
degenerations
Autosomalrecessivedisorderwithanonsetbeforeageof4yrandglobalcerebellar
Ataxiatelangiectasia
involvement
Wilsonsdisease Adisorderofthecoppermetabolismwithcopperdepositioninmultiplebodytissues
CreutzfeldtJakob
Characterizedbydementia,cerebellarsigns,andgaitataxia
disease
Posteriorfossatumors Presentwithheadache,ataxia,nausea,vomiting,vertigo,andCNpalsies
Posteriorfossa
Type1ArnoldChiarimalformationmayhavecerebellarinvolvement
malformations
Familialparoxysmal
Ahereditaryrecurrentataxiaassociatedwithnystagmusanddysarthria
ataxia
DatafromHuijbregtsP,VidalP.Dizzinessinorthopaedicphysicaltherapypractice:Classificationand
Dizzinessprovokedbyheadmovementsorheadpositionscouldindicateaninnereardysfunction.
Dizzinessprovokedbycertaincervicalmotions,particularlyextensionorrotation,alsomayindicate
vertebralarterycompromise.Dizzinessresultingfromvertebralarterycompromiseshouldbeassociated
withothersignsandsymptoms,whichcouldincludeneckpainandnausea.Thepainassociatedwith
vertebralarterycompromisedevelopsononesideoftheneckinonefourthofpatientsandusuallyis
confinedtotheupperanterolateralcervicalregion.75Persistent,isolatedneckpainmaymimicidiopathic
carotidynia,especiallyifitisassociatedwithlocaltenderness.Painisalsousuallytheinitialmanifestation
ofacarotidarterydissection,andthemediantimetotheappearanceofothersymptomsis4days.75
DizzinessassociatedwithtinnitusorahearinglosscouldindicateatumorofCNVIII.
Dizzinesscanoccurifthecalcareousdepositsthatlieonthevestibularreceptorsaredisplacedtonewand
sensitiveregionsoftheampullaoftheposteriorcanal,evokingahypersensitiveresponsetostimulation
withcertainheadpositionsormovements.318,319TheDixHallpiketestcanbeusedtohelpdetermineif
thecauseofthepatientsdizzinessisavestibularimpairment(benignparoxysmalpositionalvertigo,or
BPPVseeChapter23),resultingfromanaccumulationofutricledebris(otoconia),whichcanmove
withintheposteriorSCCandstimulatethevestibularsenseorgan(cupula).Thistestusuallyisperformed
onlyifthevertebralarterytestandcervicalinstabilitytestsdonotprovokesymptoms.Thetestinvolves
havingtheclinicianmovethepatientrapidlyfromasittingtoasupinepositionwiththeheadturnedso
thattheaffectedear(provocativeposition)is3045degreesbelowthehorizontaltostimulatetheposterior
SCC.8Theendpointofthetestiswhenthepatientsheadoverhangstheendofthetable,sothatthe
cervicalspineisextended(Fig.326).Apositivetestreproducesthepatientssymptomsofvertigoand/or
nystagmus.
Dizzinessassociatedwitharecentchangeinmedicationissuggestiveofanadversedrugreaction.320
FIGURE326
TheDixHallpikemaneuver.
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StrengthTesting
Amyotomeisdefinedasamuscleorgroupofmusclesservedbyasinglenerveroot.Keymuscleisperhapsa
moreaccurateterm.Manualmuscletestingistraditionallyusedbythecliniciantoassessthestrengthofa
muscleormusclegroupthatisrepresentativeofthesupplyfromaparticularnerveroot.Valuableinformation
canbegleanedfromthesetests,including:
Theamountofforcethemuscleiscapableofproducingandwhethertheamountofforceproducedvaries
withthejointangle.
Whetheranypainorweaknessisproducedwiththecontraction.
Theenduranceofthemuscleandhowmuchsubstitutionoccursduringthetest.
Fromtheneurologicperspective,strengthtestingassessesthenervesupplyingthemuscle(Tables319and3
20).Muscleweakness,ifelicited,maybecausedbyanUMNlesion(alongwithspasticity,hyperactivereflexes,
etc.),injurytoaperipheralnerve,pathologyattheneuromuscularjunction,anerverootlesion,oralesionor
disease(myopathy)ofthemuscle,itstendons,orthebonyinsertionsthemselves.321Pain,fatigue,anddisuse
atrophycanalsocauseweakness.Forsuspectednerverootlesions,keymuscletestingisthemethodofchoice,
andtheclinicianattemptstodetermineifthereareanyspecificpatternsofmuscleweakness(weaknessinother
musclesservedbythesamenerveroot).However,asmanualmuscletestingwasoriginallydevelopedto
examinemotorfunctioninpatientswithpolio,aLMNsyndrome,itsusemaybeinappropriateforpatientswith
anUMNsyndrome.MoreinformationaboutstrengthtestingisprovidedinChapter4.
TABLE319EvidenceBasedTestsUsingManualMuscleTestingtoDetectCervicalRadiculopathy
ManualMuscleTest Reliability(kappa) Sensitivity Specificity LR+ LR DOR QUADASScore
Deltoid 0.62 24 89 2.18 0.85 2.55 10
Biceps 0.69 24 94 4 0.8 4.84 10
Extensorcarpiradialis 0.63 12 90 1.2 0.97 1.23 10
Triceps 0.29 12 94 2 0.93 2.13 10
Flexorcarpiradialis 0.23 6 89 0.54 1.05 0.51 10
Abductorpollicisbrevis 0.39 6 84 0.37 1.12 0.33 10
DatafromWainnerRS,FritzJM,IrrgangJJ,etal.Reliabilityanddiagnosticaccuracyoftheclinical
examinationandpatientselfreportmeasuresforcervicalradiculopathy.Spine.200328:5262.
TABLE320EvidenceBasedTestsUsingManualMuscleTestingtoDetectLumbarRadiculopathy
Segmental MuscleorMuscleGroup Reliability LR QUADAS
Sensitivity Specificity LR+ DOR
Level Tested (kappa) Score
L5S1 Greattoeextensorsa NT 48 50 0.95 1.1 0.9 3
Greattoeextensorsb NT 79 NT NA NA NA 3
Hipextensorsc NT 9 89 0.77 1.03 0.75 7
Ankleplantarflexorsc NT 28 100 NA NA NA 7
L45 Greattoeextensorsa NT 74 50 1.5 0.52 2.9 3
Hipextensorsc NT 12 96 3 0.92 3.3 7
L34 Greattoeextensorsa NT 100 50 NA NA NA 3
Ankledorsiflexorsc NT 33 89 3.03 0.75 4.04 7
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Segmental MuscleorMuscleGroup Reliability LR QUADAS

Sensitivity Specificity LR+ DOR
Level Tested (kappa) Score
aKnutssonB.Comparativevalueofelectromyographic,myelographic,andclinicalneurologicalexaminationsin
diagnosisoflumbarrootcompressionsyndrome.ActaOrthopScandSupp.196149:1135.
bHakeliusA,HindmarshJ:Thecomparativereliabilityofpreoperativediagnosticmethodsinlumbardisc
surgery.ActaOrthopScand.197243:234.
cKerrRS,CadouxHudsonTA,AdamsCB.Thevalueofaccurateclinicalassessmentinthesurgical
managementofthelumbardiscprotrusion.JNeuroNeurosurgPsychiatry.198851:169173.
ReflexTesting
Aspreviouslydiscussed,areflexisasubconscious,programmedunitofbehaviorinwhichacertaintypeof
stimulusfromareceptorautomaticallyleadstotheresponseofaneffector.Theresponsecanbeasimple
behavior,movement,oractivity.Indeed,manysomaticandvisceralactivitiesareessentiallyreflexive.The
circuitrythatgeneratesthesepatternsvariesgreatlyincomplexity,dependingonthenatureofthereflex,with
eachinfluencedbyahierarchyofcontrolmechanisms.Themusclestretchreflex(myotaticordeeptendon)is
oneofthesimplestknownreflexes,dependingonjusttwoneuronsandonesynapse,322whichisinfluencedby
corticalandsubcorticalinput,andfromthestimulationoftwotypesofreceptors:theGTOandthemuscle
spindle.Thus,tendonreflexactivitydependsonthestatusofthelargemotorneuronsoftheanteriorhorn(alpha
motorneurons),themusclespindleswiththeafferentsfibers,andthesmallanteriorhorncells(gammaneurons)
whoseaxonsterminateonthesmallintrafusalmusclefiberswithinthespindles.323
CLINICALPEARL
Althoughusedextensively,thetermdeeptendonreflexisamisnomerbecausetendonshavelittletodowiththe
responseotherthanbeingresponsibleformechanicallytransmittingthesuddenstretchfromthereflexhammer
tothemusclespindle.Inaddition,insomemusclesthestretchreflexeshavenotendons.323
Musclestretchreflexesareelicitedbyashort,sharptapwiththereflexhammerdeliveredtothetendonofa
gentlyextendedmuscle.Thephysiologyofamusclestretchreflexisdescribedusingthequadricepsreflexasan
example.Thetapofareflexhammeronthetendonofthequadricepsfemorismuscle,asitcrossesthekneejoint
(Fig.327),causesabriefstretchofthetendonandthemusclebellywheretheGTOandthemusclespindleare
stimulated.Impulsesareconductedalongtheaxonsofthesemotorneuronstotheneuromuscularjunctions,
excitingtheeffectors(quadricepsfemorismuscle),andproducingabrief,weakcontraction,whichresultsina
momentarystraighteningoftheleg(kneejerk).322Thestretchreflexcanbedividedintothefollowingtwo:
FIGURE327
Thephysiologyofamyotaticreflex.
Dynamicstretchreflex,inwhichtheprimaryendingsandtypeIafibersareexcitedbyarapidchangein
length.ThespeedofconductionalongthetypeIafibersandthemonosynapticconnectioninthespinal
cordensurethataveryrapidcontractionofthemuscleoccurstocontrolthesuddenandpotentially
dangerousstretchofthemuscle.Thedynamicstretchreflexisoverwithinafractionofasecond,buta
secondarystaticreflexcontinuesfromthesecondaryafferentnervefibers.
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Staticstretchreflex.Aslongasastretchisappliedtothemuscle,boththeprimaryandthesecondary
endingsinthenuclearchaincontinuetobestimulated,causingprolongedmusclecontractionforaslong
astheexcessivelengthofthemuscleismaintained,therebyaffordingamechanismforprolonged
oppositiontoprolongedstretch.
Themostimportantobservationduringreflexexaminationisthereflexsamplitude.323Whenaloadissuddenly
removedfromacontractingmuscle,shorteningoftheintrafusalfibersreversesboththedynamicandthestatic
stretchreflexes,causingbothsuddenandprolongedinhibitionofthemusclesuchthatrebounddoesnotoccur.
CLINICALPEARL
Althoughseveraltypesofreflexhammersarepopulartoday,nostudyhasdemonstratedanyhammertobe
superiortoanother.
Reflexintegrityisdefinedastheintactnessoftheneuralpathinvolvedinareflexandtheassessmentofreflexes
isextremelyimportantinthediagnosisandlocalizationofneurologiclesions.1,324Thetestingofthemuscle
stretchreflexprovidestheclinicianwithadirectwayofassessingthePNSandanindirectwayofexaminingthe
CNS.Sixoftheseareregularlytested(Tables321and322):thebiceps(C5),brachioradialis(C6),andtriceps
(C7)intheupperextremity,andthequadriceps(L4),extensordigitorumbrevis(L5S1),andAchilles(S1)in
thelowerextremities.Itisworthnotingthatitisdifficulttoelicitareflexresponsewiththeextensordigitorum
brevistest,whichiswhyitisnotoftenperformed.
TABLE321CommonDeepTendonReflexes
PertinentCNS
Reflex SiteofStimulus NormalResponse
Segment
Jaw Mandible Mouthcloses CNV
Biceps Bicepstendon Bicepscontraction C56
Brachioradialistendonorjustdistalto Flexionofelbowand/or
Brachioradialis C56
musculotendinousjunction pronationofforearm
Distaltricepstendonaboveolecranon
Triceps Elbowextension C78
process
Patella Patellartendon Legextension L34
Medial
Semimembranosustendon Kneeflexion L5,S1
hamstrings
Lateral
Bicepsfemoristendon Kneeflexion S12
hamstrings
Tibialis Tibialisposteriortendonbehindmedial Plantarflexionoffootwith
L45
posterior malleolus inversion
Achilles Achillestendon Plantarflexionoffoot S12
CN,cranialnerve.
TABLE322EvidenceBasedNeurologicReflexTests
LR QUADAS
Test StudyDescription Reliability Sensitivity Specificity LR+ DOR
Score
Retrospectivestudyof67
patients,seenduringa4year
Hoffmanns period,withcervicalpathology NT 0 0 0 0 0 6
requiringsurgicalcorrectiona
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LR QUADAS
Score
16asymptomaticpatientswith
apositiveHoffmannsreflex
wereprospectivelystudiedwith NT 94 NT NA NA NA 7
cervicalradiographsandMRIb
36patientswithcervical
NT 82 NT NA NA NA 3
myelopathywhohadhadMRIc
165patients,ofwhom124had
NT 58 74 2.23 0.57 3.93 8
imagingofthespinalcanald
Twoexaminersindependently
assessed100patientsreceiving
neck/shoulderphysical 98%
Babinski examinationswithasetof66 NT NT NA NA NA NA
agreement
clinicaltestsdividedintonine
categoriese
Aprospectivestudyof144
patientswithdiagnosisofbrain NT 0 NT NA NA NA 6
deathf
Assessedthefrequencyofthe
Babinskiresponseafterplanter
stimulationbyexposingthefeet
byremovalofthebedsheetor NT 80 90 8 0.05 156 7
socksin10patientswith
neurologicdiseaseand10
controlsubjects
81childrenwithspastic
NT 76 NT NA NA NA 11
cerebralpalsywereexaminedg
65patientswhounderwent
Lhermittesign MRIofthecervicalspinewere NT 3 97 1 1 1 8
prospectivelyevaluatedh
Ablinded,prospective
BicepsDTR diagnosticteststudyof82
forcervical patientswithsuspectedcervical 0.73kappa 24 95 4.8 0.8 6 10
radiculopathy radiculopathyorcarpaltunnel
syndromei
neck/shoulderphysical
examinationswithasetof66 94% NT NT NA NA NA NA
clinicaltestsdividedintonine
categoriese
TricepsDTR diagnosticteststudyof82
forcervical patientswithsuspectedcervical NT 3 93 0.42 1.04 0.4 10
radiculopathy radiculopathyorcarpaltunnel
syndromei
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LR QUADAS
Score
examinationswithasetof66 agreement NT NT NA NA NA NA
clinicaltestsdividedinto9
categoriese
183subjectsprospectively
analyzed(96cervical
radiculopathies,45normal
studies,and42abnormal
electrodiagnosticfindingsother
thanradiculopathy)j
NT 14 92 1.75 0.93 1.87 9
diagnosticteststudyof82
Brachioradialis patientswithsuspectedcervical
NT 6 95 1.2 0.98 1.21 10
DTR radiculopathyorcarpaltunnel
syndromei
examinationswithasetof66 agreement NT NT NA NA NA NA
clinicaltestsdividedinto9
categoriese
183subjectsprospectively
analyzed(96cervical
radiculopathies,45normal
studies,and42abnormal NT 17 94 2.8 0.88 3.2 9
electrodiagnosticfindingsother
thanradiculopathy)j
Quadriceps 205patientsoperateduponfor
NT 100 65 NA NA NA 3
DTR(L34) herniatedintervertebraldiscsk
AchillesDTR 205patientsoperateduponfor
NT 80 76 3.36 0.26 12.8 3
(L5S1) herniatedintervertebraldiscsk
100patientswithlumbardisk
protrusionswerestudiedto
relatehistoryandclinicalsigns NT 87 89 7.91 0.15 54.2 7
tothemyelogramsandsurgical
findingsl
Aprospectivestudyof88
subjectstoevaluatethe
Extensor extensordigitorumbrevisdeep
digitorum tendonreflex(EDBR)ina NT 14 91 1.56 0.95 1.64 8
brevisDTR normalpopulationandin
(L5S1) patientswithL5andS1
radiculopathiesm
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aDennoJJ,MeadowsGR.Earlydiagnosisofcervicalspondyloticmyelopathy.Ausefulclinicalsign.Spine.
199116:13531355.
bSungRD,WangJC.CorrelationbetweenapositiveHoffmannsreflexandcervicalpathologyinasymptomatic
individuals.Spine.200126:6770.
cWongTM,LeungHB,WongWC.Correlationbetweenmagneticresonanceimagingandradiographic
measurementofcervicalspineincervicalmyelopathicpatients.JOrthopSurg.200412:239242.
dGlaserJ,CureJ,BaileyK,etal.CervicalspinalcordcompressionandtheHoffmansign.IowaOrthopJ.
200121:4952.
eBertilsonBC,GrunnesjoM,StrenderLE.Reliabilityofclinicaltestsintheassessmentofpatientswith
neck/shoulderproblemsimpactofhistory.Spine.200328:22222231.
fDeFreitasG,AndreC.AbsenceoftheBabinskisigninbraindeath.JNeurol.2005252:106107.
gGhoshD,PradhanS.Extensortoesignbyvariousmethodsinspasticchildrenwithcerebralpalsy.JChild
Neurol.199813:21620.
hUchiharaT,FurukawaT,TsukagoshiH.Compressionofbrachialplexusasadiagnostictestofcervicalcord
lesion.Spine.199419:21703.
iWainnerRS,FritzJM,IrrgangJJ,etal.Reliabilityanddiagnosticaccuracyoftheclinicalexaminationand
patientselfreportmeasuresforcervicalradiculopathy.Spine.200328:5262.
jLauderTD,DillinghamTR,AndaryM,etal.Predictingelectrodiagnosticoutcomeinpatientswithupperlimb
symptoms:arethehistoryandphysicalexaminationhelpful?ArchPhysMedRehabil.200081:43641.
kKnutssonB.Comparativevalueofelectromyographic,myelographicandclinicalneurologicalexaminationsin
diagnosisoflumbarrootcompressionsyndrome.ActaOrthopScand.Suppl.196149:1135.
lKerrRS,CadouxHudsonTA,AdamsCB.Thevalueofaccurateclinicalassessmentinthesurgical
managementofthelumbardiscprotrusion.JNeurolNeurosurgPsychiatry.198851:16973.
mMarinR,DillinghamTR,ChangA,etal.Extensordigitorumbrevisreflexinnormalsandpatientswith
radiculopathies.MuscleNerve.199518:5259.
CLINICALPEARL
Theabdominalandcremasterreflexes(superficialskinreflexes)aredecreasedorabsentonthesideaffectedby
acorticospinaltractlesionand,thus,serveasadjunctstothemusclestretchandplantarreflexes.325
MUSCLESTRETCHREFLEXES
Toperformamusclestretchreflex,thechosentendonisnormallystruckdirectlyandsmartlywiththereflex
hammer.Anexceptionisthebicepsreflex,whichisbesttestedbytappingthethumb,whichhasbeenplaced
overthetendon.Thelimbtobetestedshouldberelaxedandinaflexedorsemiflexedposition.TheJendrassik
maneuvercanbeusedduringtestingtoenhanceamusclereflexthatisdifficulttoelicit.326
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Fortheupperextremityreflexes,thepatientisaskedtocrosstheanklesandthentoisometricallyattempt
toabductthelegs.
Forthelowerextremityreflexes,thepatientisaskedtointerlockthefingersandthentoisometrically
attempttopulltheelbowsapart(Fig.328).
FIGURE328
Jendrassikmaneuverusedduringtestingtoenhanceamusclereflex.
CLINICALPEARL
Intheelderly,upto50%withoutneurologicdiseaselackanAchillesreflexbilaterally,327andsmallpercentages
(35%)ofnormalindividualshavegeneralizedhypereflexia.328
Twomusclestretchreflexscalescanbeusedtogradeareflex:NationalInstituteofNeurologicalDisordersand
Stroke(NINDS)scaleandtheMayoClinicscale.TheNINDSscaleusesthefollowingfivepointgrading
system:
0,absent(areflexia).Theabsenceofareflexsignifiesaninterruptionofthereflexarc.
1,slightandlessthannormal(hyporeflexia).
2,inthelowerhalfofnormalrange.
3,intheupperhalfofnormalrange(brisk).
4,enhancedandmorethannormal(hyperreflexive).Includesclonusifpresent.Ahyperreflexivereflex
denotesareleasefromcorticalinhibitoryinfluences.
OneoftheproblemswiththeNINDSscaleisthatitdoesnothaveaseparatecategoryfornormal,makingit
necessarytochoosebetweenalownormalandahighnormal.
TheMayoClinicusesthefollowingninepointscale:329
Absent:4
Justelicitable:3
Low:2
Moderatelylow:1
Normal:0
Brisk:+1
Verybrisk:+2
Exhaustibleclonus:+3
Continuousclonus:+4
Anabsentorexaggeratedreflexissignificantonlywhenitisassociatedwithoneofthefollowing:330
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Thereflexisunusuallybriskcomparedwithreflexesfromahigherspinallevel.
TheexaggeratedreflexesareassociatedwithotherfindingsoftheUMNdisease.
TheabsentreflexesareassociatedwithotherfindingsofLMNdisease.
Thereflexamplitudeisasymmetric.Reflexasymmetryhasmorepathologicsignificancethantheabsolute
activityofthereflexabilateralpatellareflexof3islesssignificantthana3ontheleftanda2onthe
right.Additionally,incaseswherethereflexfindingsaresymmetrical,buteitherelevatedordepressed,
furtherinvestigationisrequired.Forexample,apatientpresentingwithsymmetricallybriskpatellatendon
andAchillesstretchreflexes,whilesimultaneouslyhavingabsentstretchreflexesintheupperextremity,
requiresfurtherinvestigation(thisisatypicalfindingwithamyotrophiclateralsclerosisorLouGehrig
disease,amixedUMNandLMNpathology).312
Thefindingsfromthemusclereflextestingcanoccurasageneralized,orlocal,phenomenon:
Generalizedhyporeflexia.Thecausesofgeneralizedhyporeflexiarunthegamutfromneurologicdisease,
chromosomalmetabolicconditions,andhypothyroidismtoschizophreniaandanxiety.228
Nongeneralizedhyporeflexia.Generally,anasymmetricallydepressedorabsentreflexissuggestiveof
pathologythatisimpactingthereflexarcdirectly,suchasaLMNlesionorsensoryparesis,whichmaybe
segmental(root),multisegmental(caudaequina),ornonsegmental(peripheralnerve).Nongeneralized
hyporeflexiacanresultfromperipheralneuropathy,spinalnerverootcompression,andcaudaequina
syndrome.Itisthusimportanttotestmorethanonereflexandtoevaluatetheinformationgleanedfrom
theexamination,beforereachingaconclusionastotherelevanceofthefindings.
Inthosesituationsdemonstratinganelevatedorbriskreflex,theCNSsnormalroleofintegratingreflexesmay
havebeendisrupted,indicatinganUMNlesion,suchasabrainstemorcerebralimpairment,spinalcord
compression,oraneurologicdisease.However,thedistinctionhastobemadebetweenabriskreflexandthe
onethatishyperreflexive.Trueneurologicalhyperreflexiacontainsacloniccomponentandissuggestiveof
CNS(UMN)impairment.Theclinicianalsoshouldnoteanyadditionalrecruitmentthatoccursduringthereflex
contractionofthetarget.Abriskreflexisanormalfinding,providedthatitisnotmaskingahyperreflexia
causedbyanincorrecttestingtechnique.Unlikehyperreflexia,abriskreflexdoesnothaveacloniccomponent.
Aswithhyporeflexia,theclinicianshouldassessmorethanonereflexbeforecomingtoaconclusionabouta
hyperreflexia.ThepresenceofanUMNimpairmentcanbeconfirmedbythepresenceofthepathologicreflexes
(seenextsection).
CLINICALPEARL
Eventhoughmusclestretchreflexeshavelongbeenassumedtobegoodobjectivesigns,theinterraterreliability
ofmusclestretchreflexgradingforthesamesubjectisquitevariableandsubjectiveduetobothpatientand
physicianfactors.329,331
PathologicReflexes
Therearetwobasicpathologicreflexes:theBabinskianditsvariants(Chaddock,Oppenheim,Gordon,etc.)and
theHoffmananditsvariants(ankleandwristclonus)(Table323).Anumberofprimitivereflexesarenormally
integratedbyindividualsastheydevelop.Pathologicreflexesoccurwhenaninjuryoradiseaseprocessresults
inalossofthisnormalsuppressionbythecerebrumonthesegmentallevelofthebrainstemorthespinalcord,
resultinginareleaseoftheprimitivereflex.332Thus,thepresenceofpathologicreflexesissuggestiveofCNS
(UMN)impairmentandrequiresanappropriatereferral.
TABLE323PathologicReflexes
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Reflex ElicitingStimulus PositiveResponse Pathology

Reflex ElicitingStimulus
Strokingoflateral PositiveResponse
Extensionofbigtoeandfanningoffoursmall Pathology
Pyramidaltractlesion
Babinski
aspectofsideoffoot toesnormalreactioninnewborns organichemiplegia
Strokingoflateralside
Chaddock offootbeneathlateral Sameresponseasabove Pyramidaltractlesion
malleolus
Strokingof
Oppenheim anteromedialtibial Sameresponseasabove Pyramidaltractlesion
surface
Squeezingofcalf
Gordon Sameresponseasabove Pyramidaltractlesion
musclesfirmly
Passiveflexionofone
Brudzinski Similarmovementoccursinoppositelimb Meningitis
lowerlimb
Flickingofterminal Reflexflexionofdistalphalanxofthethumb Increasedirritabilityof
Hoffmann phalanxoftheindex, andofdistalphalanxoftheindexormiddle sensorynervesintetany
middle,orringfinger finger(whicheveronewasnotflicked) pyramidaltractlesion
Abnormalities
Electricshocklikesensationthatradiatesdown (demyelination)in
Lhermitte Neckflexion
spinalcolumnintoupperorlowerlimbs posteriorpartofcervical
spinalcord
Babinski.Inthistest,theclinicianappliesnoxiousstimulitosoleofthepatientsfootbyrunninga
pointedobjectalongtheplantaraspect(Fig.329).333Apositivetest,demonstratedbyextensionofthe
greattoe(extensortoesign)andasplaying(abduction)oftheothertoes,isindicativeofaninjurytothe
corticospinaltract.334336Anegativefindingisslighttoeflexion,smallerdigitsgreaterthanthegreattoe.
AsBabinskiobserved,334thepyramidaltractsarenotwelldevelopedininfants,andthesesigns,which
areabnormalpasttheageof3years,areusuallypresent.
GondaAllen.TheGondaAllensignisavariantoftheBabinski.Thepatientispositionedinsupine.
Graspingthepatientsfoot,theclinicianprovidesaforcefuldownwardstretchorsnapsthedistalphalanx
ofthesecondorfourthtoe(Fig.330).Apositiveresponseistheextensortoesign.337TheGondaAllen
methodisconsideredmoresensitivethantheclassicBabinskimethod.338
AllenCleckley.TheAllenCleckleysignisanothervariantoftheBabinski.Thesetupisexactlythe
sameasfortheGondaAllentest.theclinicianprovideseitherasharpupwardflickofthesecondtoeor
pressureoverthedistalaspectorballofthetoe(Fig.331).Apositiveresponseistheextensortoe
sign.338
Oppenheimsign.Thepatientispositionedinsupine.Theclinicianappliesnoxiousstimulialongtheshin
ofthepatientstibiabyrunningafingernaildownwardtowardthefoot(Fig.332).Apositivetest,
demonstratedbytheextensortoesign,istheoreticallyindicativeofUMNimpairment.However,the
diagnosticvalueofthistestisasyetunknown.339
Chaddocksign.Thepatientispositionedinsupineorsitting.Theclinicianstrokesthelateralmalleolus
fromproximaltodistalwithasolid,relativelysharpobject(Fig.333).Apositiveresponseistheextensor
toesign.Thediagnosticvalueofthistestisasyetunknown.339
Schaefersign.Thepatientispositionedinsupineorsitting.Theclinicianprovidesasharp,quicksqueeze
oftheAchillestendon(Fig.334).Apositiveresponseistheextensortoesign.Thistestremains
unstudiedfordiagnosticvalue.
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Hoffmann.TheHoffmannsign,alsoreferredtoasthedigitalreflex,thesnappingreflex,Tromnersign
andJakobsonsign,istheupperlimbequivalentoftheBabinski.However,unliketheBabinski,some
normalindividualscanexhibitaHoffmannsign.325Theclinicianholdsthepatientsmiddlefingerand
brisklypinchesthedistalphalanx,therebyapplyinganoxiousstimulustothenailbedofthemiddlefinger
(Fig.335).325Apositivetestisadductionandoppositionofthethumbandslightflexionofthefingers.
Therearenoknownstudiesassessingtheinterexaminerreliabilityofthistest(Table318),andits
significanceremainsdisputedintheliterature.DennoandMeadows340devisedadynamicversionofthis
testtoassistinthediagnosisofearlyspondyloticcervicalmyelopathy,whichinvolvedthepatient
performingrepeatedflexionandextensionoftheheadbeforebeingtestedfortheHoffmannsign.
Crossupgoingtoesign.ThisisanothervariationoftheBabinski.Thepatientispositionedinsupine.
Theclinicianpassivelyraisestheoppositelimbintohipflexion(Fig.336)andtheninstructsthepatient
toholdtheleginflexionwhiletheclinicianappliesadownwardforceontheleg.Apositivetestis
associatedwithgreattoeextensionoftheoppositelegduringresistancethehipflexion.Ofthefewstudies
ofthistest,WilloughbyandEason341foundthetesttohavelittlevalueasasensitiveindicatorofa
pyramidaltractlesionin125normalsubjectsand192patientswithneurologicaldisordersduetothehigh
frequencyoffalsepositivesignsinnormalsubjectsandpatientswithotherneurologicaldisorders.
Clonus.Thepatientispositionedinsupineorsitting.Thetechniquecanbeappliedtothewrist(sudden
wristextension)ortotheankle(suddendorsiflexion)(Fig.337).Thestretchisthenmaintained.A
positiveresponseismorethanthreeinvoluntarybeatsoftheankleorwrist(twotothreetwitchesare
considerednormal).Insomepatients,thereisamoresustainedclonusinothers,thereisonlyavery
shortlivedfinding.Duringthetesting,thepatientshouldnotflextheneck,asthiscanoftenincreasethe
numberofbeats.ApositivetestistheoreticallyindicativeofUMNimpairment,butthediagnosticvalue
ofthistestisasyetunknown.
FIGURE329
Babinski.
FIGURE330
GondaAllensign.
FIGURE331
AllenCleckleysign.
FIGURE332
Oppenheimsign.
FIGURE333
Chaddocksign.
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FIGURE334
Schaefersign.
FIGURE335
Hoffmanreflex.
FIGURE336
Crossupgoingtoesign.
FIGURE337
Clonus.
Otherpathologicalreflexesinclude:
Invertedradial(supinator)reflex.Theinvertedradialreflexsign,introducedbyBabinski,iscommonly
usedinclinicalpracticetoassesscervicalmyelopathy.Therearetwocomponentsofthisabnormalreflex:
(1)anabsenceofcontractionofthebrachioradialismusclewhenthestyloidprocessoftheradiusistapped
(Fig.338),and(2)ahyperactiveresponseofthefingerflexormuscles(Fig.338)aresponsethatis
subservedbyalowerspinalcordsegment(C8).342Todate,itisunknownwhetherthesigncorrelateswith
thepresenceorseverityofmyelopathy.Indeed,anisolated,invertedsupinatorreflexmaybeavariationof
anormalclinicalexamination.343Theoretically,atrueresponseislikelyrelatedtoincreasedalphamotor
neuronexcitabilitybelowthelevelofthelesionhowever,apossiblecontributionofthedynamicmuscle
spindlescannotbeexcluded.
Fingerescapesign.Thepatientispositionedinsitting.Theclinicianasksthepatienttoholdallofhis/her
fingersinextensionandadduction.Apositivesigninvolvestheinvoluntaryflexionandabductionwithin
1minuteoftheextendedandadductedfingerswhenheldstatically.Todatetherehasonlybeenone
study344thatexaminedthesensitivityofthefingerescapesign,whichidentifiedasensitivityof55%ina
sampleof36subjectswithmyelopathy.
Palmomentalreflex.Thepatientispositionedinsupineorsitting.Anumberofmethodstoelicitthis
reflexhavebeenadvocated.Theclinicianmaystrokethethenareminenceofthehandinaproximalto
distaldirectionwithareflexhammer(Fig.339)ormaystrokethehypothenareminenceinasimilar
fashion.Theprocedurecanberepeateduptofivetimestodetectacontinuousresponse.Iftheresponse
diminishes,thetestisconsiderednegative.Apositivetestiscontractionofthementalisandorbicularoris
musclescausingwrinklingoftheskinofthechinandslightretraction(andoccasionallyelevationofthe
mouth).AstudybyOwenandMulley345foundthatthereflexisoftenpresentinnormalpeopleandmay
beabsentindiseasestates.Thestudyconcludedthattestingmerelyforthepresenceorabsenceofthe
reflexlacksbothspecificityandsensitivity,butthatastrong,sustained,andeasilyrepeatablecontraction
ofthementalismuscle,whichcanbeelicitedbystimulationofareasotherthanthepalm,ismorelikelyto
indicatecerebraldamage.Anotherstudy346founddiagnosticvalueinusingcombinationsoftwoorthree
pathologicreflexestodistinguishbetweenneurologicallydamagedpatientsandnormalagematched
controls.
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Beevorsign.Thepatientispositionedinsupine,withthekneesflexedandbothfeetflatonthebed.The
patientisaskedtoraisetheheadagainstresistance,cough,orattempttositupwiththehandsresting
behindthehead.347Theclinicianobservesformotionattheumbilicus,whichshouldremaininastraight
line.Beevorsign,anupwarddeflectionoftheumbilicusonflexionoftheneck,istheresultofparalysisof
theinferiorportionoftherectusabdominismuscle,sothattheupperfiberspredominate,pullingthe
umbilicusupward.TheconditionmaybecausedbyspinalcordinjuryatorbelowthelevelofT10.300
FIGURE338
Invertedradial(supinator)reflex.
FIGURE339
Palmomentalreflex.
CLINICALPEARL
Beevorsignisacommonfindinginpatientswithfacioscapulohumeraldystrophy,evenbeforefunctional
weaknessofabdominalwallmusclesisapparent,butisabsentinpatientswithotherfacioscapulohumeral
disorders.348
Lhermittesymptomorphenomenon.Thisisnotsomuchapathologicreflexasitisasymptom,
describedasanelectricshocklikesensationthatradiatesdownthespinalcolumnintotheupperorthe
lowerlimbswithflexionoftheneckwiththepatientinthelongsitposition(Fig.340).Itmayalsobe
precipitatedbyextendingthehead,coughing,sneezing,bendingforward,ormovingthelimbs.349
Lhermittessignismostprevalentinpatientswithmultiplesclerosis,350cervicalspondyloticmyelopathy,
cervicalradiationinjury,andnecktrauma.351SmithandMcDonald352postulatedthatthereisan
increasedmechanosensitivitytotractiononthecervicalcordofinjuredaxonslocatedwithintheposterior
(dorsal)columns.Althoughaherniateddiskisananteriorlyplacedlesionandthespinothalamictractis
usuallymoreaffectedthantheposteriorcolumns,flexionoftheneckwillproducestretchingofthe
posterioraspectsofthecord,butnottheanteriorpartatthesiteoftheimpairment,andthismayexplain
thisparticularsymptom.Todate,therearenoreportsinvestigatingtheinterexaminerreliabilityofthis
test.Onestudy353reportedasensitivityof27%,specificityof90%,positivepredictivevalueof55%,and
negativepredictivevalueof75%fortheactiveflexionandextensiontest,whichpartlyresemblesthistest.
MendelBechtrewsign.Thepatientispositionedinsupineorsitting.Thecliniciantapsonthedorsal
aspectofthecuboidboneusingthesharpendofareflexhammer(Fig.341).Apositiveresponseis
flexionofthefourlateraltoes.Thistestremainsunstudiedfordiagnosticvalue.
FIGURE340
Lhermittesymptom.
FIGURE341
MendelBechtrewsign.
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SupraspinalReflexes
Thesupraspinalreflexesproducemovementpatternsthatcanbemodulatedbydescendingpathwaysandthe
cortex.Anumberofprocesses,whichareinvolvedinlocomotorfunction,areorientedaroundthesereflexesand
arereferredtoasrightingreflexes.Rightingreflexescanbesubcategorizedasthefollowing:visualrighting
reflexes,labyrinthinerightingreflexes,neckrightingreflexes,bodyonheadrightingreflexes,andbodyonbody
rightingreflexes.Theprimarypurposeoftherightingreflexesistomaintainaconstantpositionoftheheadin
relationtoadynamicexternalenvironment.
Theheadandtheneckareareasofintensereflexactivity.Headmovements,whichoccuralmostconstantly,
mustberegulatedtomaintainnormaleyeheadnecktrunkrelationshipsandtoallowforvisualfixationduring
headmovements(Table324).Thevisualfieldandpathwayareimportantregulatorsofposturalcontrol.Visual
inputforposturalcontrolhelpsfixatethepositionoftheheadandtheuppertrunkinspace,primarilysothatthe
COGofthetrunkmaintainsitspositionoverthewelldefinedlimitsoffootsupport.Asidefromthevisualfield
itselfprovidinganimportantsourceofposturalcontrol,theextraocularmusclesmayalsoprovideproprioceptive
informationthroughtwodistinctpathwaysintotheoculomotornuclei,oneservingtogenerateeyerotations,
whiletheotherprovidingsensoryinformationregardingeyealignmentandstabilization.354,355
TABLE324ReflexActivitiesInvolvingtheCervicalSpine
Reflex ElicitingStimulus MotorResponse Purpose
Neckmovementthat Assistswithpostural
Alterationofmuscletonein
Tonicneckreflex producesstretchtomuscle stabilityandenhances
trunkandextremities
spindles coordination
Neckmovementthat Eccentriccontractionofthe Maintainssmoothand
Cervicocollicreflex producesstretchtomuscle cervicalmusclesthatoppose controlledcervical
spindles theinitiatingmovement movement
Neckmovementthat Assistsinadjustmentsof
Cervicorespiratory
producesstretchtomuscle Alterationinrespiratoryrate respirationwithchangesin
reflex
spindles posture
Neckmovementthat Assistsinpreventionof
Cervicosympathetic
producesstretchtomuscle Alterationinbloodpressure orthostatichypotension
reflex
spindles withchangesinposture
Trigeminocervical Protectsagainstblowsto
Touchstimulustoface Headretraction
reflex face
Neckmovementthat
Cervicoocular Movementofeyesinopposite Maintainsgazefixation
producesstretchtomuscle
reflex directionofneckmovement duringmovementsofhead
spindles
Vestibuloocular Headmovementstimulating Movementofeyesinopposite Maintainsgazefixation
reflex semicircularcanals directionofheadmovement duringmovementsofhead
Movementofeyesinthe
Visualtargetmovingacross Maintainsgazefixationon
Smoothpursuit directioninwhichtargetis
retinalfield movingtarget
moving
Newvisualtargetinretinal Movementofeyesinthe
Saccades Fixateseyesonnewtarget
field directionofnewtarget
Visualtargetmovingacross Movementofeyesinopposite
Maintainsgazefixationon
Optokineticreflex retinalfield,causing directionofperceivedhead
movingtarget
perceivedmovementofhead movement
Reproduced,withpermission,fromChapter3.NormalFunctionoftheCervicalSpineII:Neurophysiologyand
Stability.In:MurphyDR:ConservativeManagementofCervicalSpineSyndromes.NewYork:McGrawHill,
2000.
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Whilethevisualandvestibularsystemsareindividuallytwoofthemostimportantprovidersofinformation,itis
theirconstantinteractionwitheachotherandwithcervicalmechanoreceptors(particularlytheshortrange
rotators,i.e.,theobliquuscapitisposteriorinferior,rectuscapitisposteriormajor,spleniuscapitis,andSCM)that
makesthecontrolofuprightposturepossible,especiallywhenconsideringtheircombinedroleinthereflex
modulationofmusculartonethroughvariousgroupsofposturalmuscles:356
Vestibuloocularreflex(VOR).TheVORisstimulatedbymovementoftheheadinspaceandcreates
certaineyemovementsthatcompensateforheadrotationsoraccelerations.TheVORmaybesubdivided
intothreemajorcomponents:
TherotationalVOR,whichdetectsheadrotationthroughtheSCC.
ThetranslationalVOR,whichdetectslinearaccelerationoftheheadviatheutricleandsaccule.
Theocularcounterrollingresponse,oroptokineticreflex,whichadaptseyepositionduringhead
tiltingandrotation.
TheVORcanbetestedinanumberofways:
Dynamicvisualacuity.320AfterestablishingbaselinevisualacuitywithaSnellenchart,thistest
measuresvisualacuitywithconcurrentheadmovement.Thepatientsheadismovedfromsidetosideata
frequencyof1HzwhilethepatientreadstheSnellenchart.Adecreasebytwolinesissuspiciousand,by
threeormore,isindicativeofanabnormalVOR.
Dollsheadtest.320Theclinicianfacesthepatient,whofixesgazeonthecliniciansnose.Theclinician
thenoscillatesthepatientshead30degreessidetosideat0.51Hz.Eyemovementsthatarenotsmooth
butinterruptedbysaccadestowardthefixationtargetindicatebilateralvestibularlesions.
Headshakingnystagmustest.320Theclinicianholdsthepatientsheadfirmly,withthepalmsofthe
handsagainstthepatientscheeks,andproducesaseriesofrapidbutsmallhorizontalheadturnsfor
approximately30seconds,withthepatientseyesclosed.Uponopeningtheeyes,thenystagmuswillbeat
awayfromthesideofaunilateralperipheralvestibularlesion,ortowardthelesionedsideinpatientswith
Mniredisease.
Headthrusttest.320Thepatientfixatesgazeonthecliniciansnose.Theclinicianthenmovesthe
patientsheadinahorizontalplaneinarapid,passivemannerwithunpredictabletiminganddirection.If
thereflexivemovementoftheeyesisinappropriate(toobigortoosmall),acorrective(saccadic)
movementwilloccur.Apatientwithvestibularlosswillhavedifficultyinmaintaininggazefixation,
requiringacorrectivesaccade(fasteyemovement)tomaintaingazefixationonthenose.Presenceofthis
correctiveactionmayindicatealesionofthevestibularnerve.357
Thecervicoocularreflex.Thecervicoocularreflexservestoorienteyemovementtochangesinneck
andtrunkposition.Visualfixationathighspeedsrequiresthecontractionoftheextraocularmusclesto
alloweyemovementstocounteracttheeffectoftheheadmovements,eveniftheheadisturninginthe
oppositedirection.Theabilitytotrackandfocusonamovingtargetthatismovingacrossavisualfieldis
termedsmoothpursuitandrequiresagreaterdegreeofvoluntarycontrolthanthecervicoocularand
VORscanprovide.Theareainthebrainstemwherethisintegrationofhorizontaleyemovementstakes
placeistheparamedianpontinereticularformation.Theabilitytoreadabookortoscanapagerequires
saccadiceyemovements.Unlikesmoothpursuit,saccadescanoccurwithavisualstimulus,bysound,
verbalcommand,ortactilestimuli.However,likesmoothpursuit,saccadesaregeneratedinthe
paramedianpontinereticularformation.Thecervicoocularreflexcanbetestedusingthreemethods:
Visualfixation.Thepatientisseatedandisaskedtolookstraightaheadandfocusonthetipofa
pencil,whichisheldbytheclinicianatanarmslengthfromthepatient.Thetestisrepeated,with
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thepatientseyesturnedtotheextremesofhorizontalandverticalgazeandthepenciltippositioned
accordingly.
Smoothpursuitcanbetestedbyhavingthepatientfixhisorhergazeonanobjectplaceddirectlyin
front.Theobjectisthenmovedtotheright,whilethepatientfollowsitwiththeeyes.Theclinician
lookstoseeifthepatienthasanydifficultytrackingtheobject.Anabnormalresponseisobservedif
thepatientsfixationonthetargetmovingsynchronouslywiththeheadisinterruptedbyrapideye
movementsorsaccades,whichindicatesthatthepursuitisnotholdingtheeyeonthemovingtarget.
Theobjectismovedbacktothestartpositionbeforebeingmovedtotheleft,whilethepatientagain
followsitwiththeeyes.Theobjectcanthenbemovedinvariousdirections,combininghorizontal,
vertical,anddiagonalmovements,totestifthepatientcanfollowtheobjectwiththeeyeswithout
saccadicmovements.
Saccadetest.Thepatientisaskedtorapidlymovetheeyesbackandforthbetweentwowidely
spacedtargetswhilekeepingtheheadstill.Anabnormalfindingisifthepatienttakesmultipleeye
movements,ratherthanasinglejump,toexactlyfixonatarget.
Difficultywiththesetestsmayindicatealesionofthecerebellum,reticularformation,cerebralcortex,oraCN
lesion(oculomotor,trochlear,orabducens).357
Thecervicocollicreflex(CCR).TheCCRservestoorientthepositionoftheheadandtheneckin
relationtodisturbedtrunkposture.Actingsimilarlytoastretchreflex,thisreflexinvolvesreflexive
correctionofcervicalspinepositionthroughcocontractionofspecificcervicalmuscles.
Thevestibulocollicreflex(VCR).TheVCRmaintainsposturalstabilitybyactivelystabilizingthehead
relativetospace,throughreflexivecontractionofthosecervicalmusclesoppositetothedirectionof
cervicalspineperturbation.Itshouldbenotedthatthisreflexisdistinctandlargelydissociatedfromthe
vestibulospinalreflex,whichorientstheextremitiestothepositionoftheheadandtheneck.356
TheCCRandVCRreflexesappearperfectlysuitedthroughtheirdynamicandsomatotopiccharacteristicsto
compensateforpositionaldisturbancesoftheheadandtheneckwithrespecttothetrunk.358360
SensationandSensibilityTesting
Sensationistheconsciousperceptionofbasicsensoryinput.Sensibilitydescribestheneuraleventsoccurringat
theperiphery,nervefibers,andnervereceptors.Sensationiswhataclinicianreeducates,whereassensibilityis
whatacliniciansassesses.361Theassessmentofsensibilityinvolvesanunderstandingoftheentireperipheral
andcentralsensorypathwaysfromtheskintothethalamus.
Alteredsensoryperceptionscanresultfrominjuriestoperipheralnervesorfromspinalnerverootcompression.
Theposterior(dorsal)rootsofthespinalnervesarerepresentedbyrestrictedperipheralsensoryregionscalled
dermatomes(Fig.342).Theperipheralsensorynervesarerepresentedbymoredistinctandcircumscribedareas
(seeFig.342).Paresthesiaisasymptomofdirectinvolvementofthenerveroot.Paresthesiacanbedefinedas
anabnormalsensationofpinsandneedles,numbness,orprickling.Furtherirritationanddestructionofthe
neuralfibersinterferewithconduction,resultinginamotororsensorydeficit,oracombinationofboth.Itis,
therefore,possibleforanerverootcompressiontocausepuremotorparesis,apuresensorydeficit,orboth,
dependingonwhichaspectofthenerverootiscompressed.Ifpressureisexertedfromabovethenerveroot,
sensoryimpairmentmayresult,whereascompressionfrombelowcaninducemotorparesis.Painresultsifthere
isirritationoftheneuralfibers.Ingeneral,ifapatienthasasensorydeficitinvolvingaperipheralnerve,heor
sheisabletoaccuratelylocalizetheareaofanesthesia.362Sensoryorsensibilitytestingexaminestheintegrity
andtheintactnessofcorticalsensoryprocessing,includingproprioception,pallesthesia(theabilitytosense
mechanicalvibration),stereognosis(theabilitytoperceive,recognize,andnamefamiliarobjects),and
topognosis(theabilitytolocalizeexactlyacutaneoussensation).324
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FIGURE342
Approximatelowerextremitydermatomes.(Reproduced,withpermission,fromChapter34.Overviewofthe
LowerLimb.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:
McGrawHill2011.)
Twotypesofsensibilitycanbeassessed:363
Protective.Thisisevidencedbytheabilitytoperceivepinprick,touch,andtemperature.
Functional.Thisisevidencedbyareturnofsensibilitytoalevelthatenablesthehandtoengageinfull
ADLs.
CLINICALPEARL
Thereexistsahierarchyofsensibilitycapacity363,364:
Detection.Thisisthesimplestleveloffunctionandrequiresthatthepatientbeabletodistinguisha
singlepointstimulusfromnormallyoccurringatmosphericbackgroundstimulation.
Innervationdensityordiscrimination.ThisrepresentstheabilitytoperceivethatstimulusAdiffersfrom
stimulusB.
Quantification.Thisinvolvesorganizingtactilestimuliaccordingtodegree,texture,etc.
Recognition.Thisisthemostcomplicatedleveloffunction,andinvolvestheidentificationofobjectswith
thevisionoccluded.
Basedonthehierarchyofsensibilitycapacity,testingisclassifiedneurophysiologicallyintofourtypes:
thresholdtests,stresstests,innervationdensitytests,andsensorynerveconductionstudies.365
Thresholdtests.ExamplesofthresholdtestsincludevibratorytestingandSemmesWeinstein
monofilamenttesting(seeSpecificSensoryTests).
Stresstests.Stresstestsarethosethatcombinetheuseofsensorytestswiththeactivitiesthatprovokethe
symptomsofnervecompression.Thesetestsarehelpfulincasesofpatientreportsofmildnerve
compressionwhennoabnormalitiesaredetectedbybaselinesensorytesting.Examplesofstresstests
includethePhalenstestatthewrist(seeChapter18).
Innervationdensitytests.Theseareaclassofsensoryteststhattesttheabilitytodiscriminatebetweentwo
identicalstimuliplacedclosetogetherontheskin.Thesetestsarehelpfulinassessingsensibilityafter
nerverepairandduringnerveregeneration(seeSpecificSensoryTests).366
Sensorynerveconductionstudies.Sensorynerveconductionstudiesareelectrophysiologicteststhat
assesstheconductionofsensoryactionpotentialsalonganervetrunk.365Thesetestsrequireonlypassive
cooperationofthepatient,notsubjectiveinterpretationofastimulus.Aslowingofnerveconduction
velocityoranalterationinpotentialamplitudesindicatesacompressionorpartiallacerationofthe
nerve.10
Afullexaminationofthesensorysysteminvolvesspecifictestingofpain,temperature,pressure,vibration,
position,anddiscriminativesensations.Forpatientswithnoapparentneurologicsymptomsorsigns,an
abbreviatedexaminationmaybesubstituted.
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SpecificSensoryTests
Sensation
Origin.Lateralspinothalamictract(seeBox32).
Thesegmentalinnervationoftheskinhasahighdegreeofoverlap,especiallyinthethoracicspine,
requiringthattheclinicianteststhefullareaofthedermatome.Thisisdonetoseekouttheareaof
sensitivity,orautogenousarea,whichisasmallregionofthedermatomewithnooverlap,andtheonly
areaofadermatomethatissuppliedexclusivelybyasinglesegmentallevel.367Therearetwo
componentstothedermatometests:
Lighttouch.Informationaboutlighttouch,twopointdiscrimination,vibration,andproprioceptionare
carriedbytheposterior(dorsal)columnmediallemniscaltract.Lighttouchtestsforhypoesthesia
throughoutthedermatome.Intermsofsensationloss,lighttouchisthemostsensitiveandthefirsttobe
affectedwithpalsy.Ifthelighttouchtestispositive,theareasofreducedsensationaremappedoutforthe
autogenousarea,andthenthepinpricktestisperformedtomapoutthewholeoftheautogenousarea.8
Theuseofavibratingtuningforkhasbeenfoundtobeavalidandreliabletestofthefunctionalintegrity
ofthelargemyelinatednervefibers.368
Pinprick.Informationaboutpainiscarriedbythelateralspinothalamictract(seeBox32).Thepinprick
testexaminesfornearanesthesiaintheautonomous,nooverlaparea.Thistestisperformedusingasharp
safetypin,occasionallysubstitutingthebluntendforthepointasastimulus.Pinpricktestingisthemost
commonwayofdeterminingthesensorylevelcausedbyaspinalcordlesion,becauseinformation
aboutpain,temperature,andcrudetouchiscarriedbythespinothalamictract.326Wheninvestigatingan
areaofcutaneoussensoryloss,itisrecommendedthattheclinicianbeginsthepinpricktestintheareaof
anesthesiaandworksoutwarduntiltheborderofnormalsensationislocated.313Theclinicianstimulates
intheaforementionedpatternsandasksthepatientIsthissharpordull?or,whenmakingcomparisons
usingthesharpstimulus,Doesthisfeelthesameasthis?(Note:Itisimportantthattheclinicianusesas
lightatouchasthepatientcanperceiveandnot,underanycircumstances,presseshardenoughtodraw
blood).Pinpricksensationisdifficulttotestbecauseofthenaturalvariationsinthepressureputonthepin
andthesensitivityofdifferentpartsoftheskin.
Table325outlinessomeofthestudiesthathavebeenperformedtoassessthereliability,sensitivity,and
specificityofvarioussensibilitytestsindetectingradiculopathy.
TABLE325SensibilityTestingforRadiculopathy
NerveorDermatome Reliability LR QUADAS
Method Sensitivity Specificity LR+ DOR
Tested (kappa) Score
Light
Axillary 0.69 NT NT NA NA NA NA
toucha
Light
Musculocutaneous 0.67 NT NT NA NA NA NA
toucha
Light
Radial 0.31 NT NT NA NA NA NA
toucha
Light
Median 0.73 NT NT NA NA NA NA
toucha
Light
Ulnar 0.59 NT NT NA NA NA NA
toucha
C5 Pinprickb 0.67 29 86 2.07 0.82 2.51 10
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NerveorDermatome Reliability LR QUADAS

Method Sensitivity Specificity LR+ DOR
Tested (kappa) Score
C6 Pinprickb 0.28 24 66 0.70 1.15 0.61 10
C7 Pinprickb 0.40 28 77 1.21 0.93 1.30 10
C8 Pinprickb 0.16 12 81 0.63 1.08 0.58 10
T1 Pinprickb 0.46 18 79 0.85 1.03 0.82
aJepsenJR,LaursenLH,HagertCG,etal.DiagnosticaccuracyoftheneurologicalupperlimbexaminationI:
interraterreproducibilityofselectedfindingsandpatterns.BMCNeurol.20066:8.
bWainnerRS,FritzJM,IrrgangJJ,etal.Reliabilityanddiagnosticaccuracyoftheclinicalexaminationand
patientselfreportmeasuresforcervicalradiculopathy.Spine.200328:5262.
Temperature
Origin.Lateralspinothalamictract.
Test.Usingtwotesttubes,filledwithhotandcoldwater,thecliniciantouchestheskinandasksthe
patienttoidentifyhotorcold.Theimpulsesfortemperaturesensationtraveltogetherwithpain
sensationinthelateralspinothalamictract.Thetestingofskintemperaturecanalsohelptheclinicianto
differentiatebetweenavenousandanarterialinsufficiency.313Withvenousinsufficiency,anincreasein
skintemperatureisusuallynotedintheareaofocclusion,andtheareaalsoappearsbluishincolor.Pitting
edema,especiallyaroundtheankles,sacrum,andhands,alsomaybepresent.However,ifpittingedemais
presentandtheskintemperatureisnormal,thelymphaticsystemmaybeatfault.Witharterial
insufficiency,adecreaseinskintemperatureisusuallynotedintheareaofocclusion,andtheareaappears
whiter.Itisalsoextremelypainful.
Pressure
Origin.Spinothalamictract.
Test.Firmpressureisappliedtothepatientsmusclebelly.
SensoryThreshold
Origin.Posterior(dorsal)column/mediallemniscaltract(Box34).
Thresholdtestsmeasuretheintensityofthestimulusnecessarytodepolarizethecellmembraneand
produceanactionpotentialtheabilitytodetect.Thresholdtestsarehelpfulinassessingdiminished
sensibilityinnervecompressionsandinmonitoringnerverecoveryaftersurgicaldecompression.365,369
ExamplesofthresholdtestsincludevibratorytestingandSemmesWeinsteinmonofilamenttesting.
Test.Vibrationtestingisperformedusinga128Hztuningforkappliedtoabonyprominencesuchasthe
ulnaorradiusintheupperextremity,andthepatellaortibiainthelowerextremity.Thepatientisaskedto
reporttheperceptionofboththestartofthevibrationsensationandthecessationofvibrationon
dampening.Thetimedifference(inseconds)isrecordedandcomparedwiththeuninvolvedside.
Alternatively,avibrometer,suchastheBioThesiometercanbeused.365TheBioThesiometerisan
electricallycontrolledtestinginstrumentthatproducesvibrationatafixedfrequency(120Hz)with
variableamplitude.Thevibratingheadisappliedtothepatientsfingertip,andtheamplitudeisslowlyand
graduallyincreased.Thethresholdisrecordedasthevoltagerequiredtoperceivethevibratory
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stimulus.365Theclinicianappliesaseriesoffivetrialstodeterminethecumulativeabilityofcorrect
responses.Apositivetestisdecreasedabilitytoreportwhenthevibrationisappliedandreportsof
vibrationdampeningwhilestillbeingapplied.Ifvibrationsenseisabsent,theclinicianshouldretest,
movingproximallyalongtheextremity.
Test.Theassessmentofcutaneoussensibilitywasfirstdescribedin1899,usinghorsehairsofvarying
thickness.370In1960,Semmesetal.371madethetestingproceduremoreexactingwhentheyintroduced
theuseofpressuresensitivenylonmonofilamentsmountedontoLuciterods(Fig.343).These
monofilaments,whicharegradedaccordingtothickness,arecalibratedtoexertspecificpressures.Each
kitconsistsof20probes,eachnumberedfrom1.65to6.65,anumberthatrepresentsthelogarithmof10
multipliedbytheforceinmilligramsrequiredtobowthefilaments.372Thepatientisblindfolded,orturns
away,duringtheexaminationandtheclinicianapplieseachfilamentperpendiculartotheskinuntilthe
filamentbends,startingwiththefilamentwiththelowestnumberandgraduallymovingupthescaleuntil
thepatientfeelsonebeforeorjustasitbends.373,374Thetestisrepeatedthreetimesforconfirmation.375
FIGURE343
SemmesandWeinsteinfilamenttesting.
Box34Posterior(Dorsal)MedialLemniscusTract
Theposterior(dorsal)mediallemniscustractconveysimpulsesconcernedwithwelllocalizedtouchandwith
thesenseofmovementandposition(kinesthesia).Itisimportantinmomenttomoment(temporal)andpointto
point(spatial)discriminationandmakesitpossibleforapersontoperformatasksuchasputtingakeyinadoor
lockwithoutlightortovisualizethepositionofanypartofhisorherbodywithoutlooking.Lesionstothetract
fromdestructivetumors,hemorrhage,scartissue,swelling,infections,anddirecttrauma,amongothers,abolish
ordiminishtactilesensationsandmovementorpositionsense.Thecellbodiesoftheprimaryneuronsinthe
posterior(dorsal)columnpathwayarelocatedinthespinalganglion.Theperipheralprocessesoftheseneurons
beginatreceptorsinthejointcapsule,muscles,andskin(tactileandpressurereceptors).
CLINICALPEARL
Acrosssectionalmultigroupcomparisonstudy376thatexaminedthreescreeningsensorytests(theSemmes
Weinstein10gmonofilamentexamination,superficialpainsensation,andvibrationbytheonoffmethod)
foundallthreescreeningteststobesignificantlyandpositivelycorrelatedwithnerveconductionstudies.
PositionSense(Proprioception)
Origin.Posterior(dorsal)column/mediallemniscaltract(seeBox34).
Test.Proprioceptionherereferstoanawarenessofthepositionofjointsatrest.Thepatientistestedfor
his/herabilitytoperceivepassivemovementsoftheextremities,especiallythedistalportions.The
cliniciangraspsthepatientsbigtoe,holdingitbyitssidesbetweenthethumbandtheindexfinger,and
thenpullsitawayfromtheothertoestoavoidfrictionandtopreventextraneoustactilestimulationfrom
indicatingachangeofposition.313Downanduparedemonstratedtothepatientastheclinician
movesthepatientstoeclearlydownwardandupward,respectively.Then,withhisorhereyesclosed,the
patientisaskedforanupordownresponseastheclinicianmovesthetoeinasmallarc.This
movementisrepeatedseveraltimesoneachside,avoidingsimplealternationofthestimuli.Ifposition
senseisimpaired,thentheclinicianshouldretest,movingproximallyalongtheextremity.Alternatively,
thepatientisaskedtoduplicatethepositionwiththeoppositeextremity.Thejointpositionsense
componentofproprioceptioncanalsobeassessedthroughthereproductionofbothactiveandpassive
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jointrepositioningwiththepatientblindfolded.Theclinicianpositionsthelimbtobetestedatapreset
targetangleandholdsitthereforaminimumof10secondstoallowthepatienttoprocessmentallythe
targetangle.313Followingthis,thelimbisreturnedtothestartingposition.Thepatientisthenaskedto
movethelimbtothepresetthetargetangle.Theangulardisplacementisrecordedastheerrorindegrees
fromthepresettargetangle.
MovementSense(Kinesthesia)
Test.Thepatientisaskedtoindicateverballythedirectionofmovementwhiletheextremityisinmotion.
Theclinicianmustgripthepatientsextremityoverneutralborders.
Stereognosis
Test.Thepatientisaskedtorecognize,throughtouchalone,varioussmallobjectssuchascomb,coins,
pencils,andsafetypinsthatareplacedinhisorherhand.
Graphesthesia
Test.Thepatientisaskedtorecognizeletters,numbers,ordesignstracedontheskin.Usingabluntobject,
thecliniciandrawsanimageonthepatientspalm,askingthepatienttoidentifythenumber,theletter,or
thedesign.
NeuromuscularControlandBalanceTesting
Assessmentofneuromuscularcontrolcanbeexaminedclinicallybyassessingtheabilityofthesubjectto
maintainposturalcontrolwithinagivenBOS.Anumberofbalancetesttypesarerecognized:199
Staticbalancetests.StaticbalancetestsrequirethepatienttomaintaintheBOSwhileminimizing
movementofbodysegmentsandtheCOM.377Thisincludesobservationofthepatientmaintaining
differentpostures.Standardizedtestsincludethesinglelegbalancestancetest,Rombergtestsharpened
(tandem)Romberg,storkstandtest,timedstancebattery,andtheBalanceErrorScoringSystem(BESS)
(Table326).TheBESSconsistsofthreestancesperformedonafirmsurface:doublelegstance(hands
onthehipsandfeettogether)(Fig.344),singlelegstance(SLS)(standingonthenondominantlegwith
handsonhips)(Fig.345),andatandemstance(standingwiththenondominantfootbehindthedominant
footinaheeltotoefashion)(Fig.346),followedbythesametestsonafoamsurface(Figs.347to349)
withtheeyesclosed.Anyerrors(openingtheeyes,stumblingorfallingoutoftheposition,liftingthe
handsofthehips,liftingtheforefootorheel,stepping,abductingthehipbymorethan30degrees,or
failingtoreturntothetestpositionformorethan5seconds)countedduringeach20secondtrial.The
reliabilityoftheBESSrangesfrommoderate(<0.75)togood(>0.75)whenassessingstaticbalancewhile
somestudiesreportreliabilitycoefficientsbelowclinicallyacceptablelevels.378TheBESScandetect
balancedeficitsinparticipantswithconcussionandfatigue.378
Dynamicbalancetests.Dynamicbalancetestsareusedtoassesstheabilitytomaintainbodycontrol
withinaBOSduringafunctionaltaskthatrequiresmovementoftheCOM.379,380Thisincludes
observationofthepatientstandingorsittingonanunstablesurfaceorperformingposturaltransitionsand
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functionalactivities.Standardizedtestsincludethefunctionalreachtest,multidirectionalreachtest,cross
overreachtest,andthestarexcursionbalancetest(Table326).
Anticipatoryposturalcontroltests.Thisincludesobservationofthepatientcatchingaball,openingdoors,
liftingobjectsofdifferentweights.
Reactiveposturalcontroltests.Thisincludesobservationofthepatientsresponsestopushes(smallor
large,sloworrapid,anticipatedandunanticipated).Standardizedtestsincludethepulltest,backward
release,andposturalstresstest(Table326).
Sensoryorganizationtests.Thiscanbetestedusingtheclinicaltestofsensoryintegrationonbalance,also
calledtheFoamandDometest(Table326).
Vestibulartests.Thisincludesobservationfornystagmusandvertiginouspositions.Standardizedtests
includetheDixHallpikemaneuver(seeDizzinesssection),VORtesting(seeReflexTestingsection),
oculomotortests(seeCNExaminationsection),Fukudasteppingtest(Table326),andthedizziness
handicapinventory(Table326).
Balanceduringfunctionalactivities.Functionaltasksareobservedtotestthepatientsabilityto
demonstratemobility(theabilitytomovefromonepositiontoanotherindependentlyandsafely),static
posturalcontrol(theabilitytomaintainposturalstabilityandorientationwiththeCOMoverthebase
supportandthebodyatrest),dynamicposturalcontrol(theabilitytomaintainstabilityandorientation
withtheCOMovertheBOSwhilepartsofthebodyareinmotion),andskill(theabilitytoconsistently
performcoordinatedmovementsequencesforthepurposesofinvestigationandinteractionwiththe
physicalandsocialenvironment)duringfunctionaltasks.381Individualsover65tendtowalkwitha
slowerselfselectedgaitspeed,ashorterstridewidth,andanincreaseindoublesupporttime(seeChapter
6).Someofthesechangesaretheinevitableeffectsofaging(seeChapter30)whileothersaredueto
pathologyordisuse.Inaddition,elderlypatientstendtodemonstrateincreasedgaitvariability.For
example,elderlyindividualstendtogothroughadecreasedrangeofdorsiflexionduring
midstance.382,383However,significantchangesingaitarenotnotedunlessmultiplejointsareinvolved,
orthereareimpairmentsinothersystemssuchaslossofstrengthormotorcontrol.Bloemetal.384ina
studyofindividualsagedover88notedthat20%ofthesubjectsexhibitedunimpairedgait.Anotherstudy
hasdemonstratedthatthosewhoexhibitsenilegaitdisordersaremorelikelytogoontodevelopdementia
anddieearlierthanagematchedindividualswhowalknormally.385Thisraisestheenticingpossibility
thatgaitchangesassociatedwithagingmayactuallybeanearlymanifestationofpathologiessuchas
subtlewhitematterchanges,vestibulardysfunction,musculoskeletaldisorders,orvisualchanges.385
Whatisknownisthatsensorysystemimpairmentshaveatremendousimpactongaitandthattrainingto
improveproprioceptioncanimprovegaitparametersandsafety.386Standardizedtestsforthisincludethe
Tinettiperformanceorientedmobilityassessment(Table326),timedupandgotest(Table326),Berg
balancescale(Table326),gaitabnormalityratingscale(seeChapter6),andtheFunctionalGait
Assessment(seeChapter6).Returningtodemandingphysicalactivityrequiresmoreadvancedfunctional
testing,suchashoptests(seeChapter4).
Safetyduringgait,locomotion,orbalance.Thisincludesdocumentationofthepatientsfallhistoryanda
homeassessment.Agerelatedbalancedysfunctionscanoccurthroughanumberofmechanismsincluding
gradualdegenerativechangesinthevestibularapparatusoftheinnerear,aninabilitytointegratesensory
information,andmuscleweakness.Inaddition,somediseases(benignparoxysmalpositionalvertigosee
Chapter23),cerebrovasculardisease,Mniresdisease,cerebellardysfunction,vertebrobasilarartery
insufficiency,andcardiacdiseasecommoninagingpopulationscanleadtofurtherdeteriorationin
balancefunction.Balancedisorderscanalsobeassociatedwithanumberofothercausesincluding:
medications,
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posturalhypotension,and
visual/auditorydeficits.
TABLE326BalanceandFunctionalAssessmentTests
Test Description
Assessesthepatientsabilitytostandwiththefeetparallelandtogetherwiththeeyesopenand
thenclosedfor30seconds.Withtheeyesopen,thevision,proprioception,andvestibular
systemsprovideinputtothecerebellumtomaintaintruncalstability.Ifthereisamildlesionin
thevestibularorproprioceptionsystems,thepatientisusuallyabletocompensatewiththe
eyesopen.Whenthepatientclosestheireyes,however,visualinputisremovedandinstability
canbeprovoked(apositiveRombergsign).Patientswithavestibularlesiontendtofallinthe
Romberga directionofthelesion.bIfthereisamoresevereproprioceptiveorvestibularlesion,orifthere
isamidlinecerebellarlesioncausingtruncalinstability,thepatientwillbeunabletomaintain
thispositionevenwiththeireyesopen.bNotethatinstabilitycanalsobeseenwithlesionsin
otherpartsofthenervoussystemsuchastheUMNsorLMNsorthebasalganglia,sothese
shouldbetestedforseparatelyinotherpartsoftheexam.TheRombergtesthaspredictive
validitywithregardtorecurrentfallsovera6monthperiodinpatientswithParkinsons
disease:sensitivitywas65%andspecificitygreaterthan90%.c
Sharpened Assessesthepatientsabilitytostandwiththefeetintheheeltotoepositionwiththearms
(tandem) foldedacrossthechestandeyesclosedfor1min.Therationaleforthistestisthesameasfor
theRomberg.TheataxicpatientwillprefertostandwithawiderBOSandwillshow
Romberga reluctancewhenaskedtostandwiththefeetclosetogether.
Assessesthepatientsabilitytostandononelegwithoutshoesandwiththearmsplacedacross
thechestwithoutlettingthelegstoucheachother.Modificationsincludethetestbeing
performedonfirmandcompliantsurfacesandwitheyesopenandclosed.Five30second
trialsareperformedforeachleg,withthemaximumpossiblescoreof150secondsperleg.
Scoringcanbethetotalnumberoflossesofbalanceinagiventimeperiodorastheamountof
timebeforealossofbalanceoccurs.EMGevidencedemonstratessignificantmuscle
Singleleg activationofthegluteusmediusduringsinglelegstanceinordertokeepthepelvisleveltothe
5
balancestanced ground. Therefore,asinglelegstancepositionmayrevealdysfunctionofthehipabductors
ontheipsilateralside.Provocationofpainduring30secondsofsinglelegstancehasshown
excellentsensitivity(100%)andspecificity(97.3%)indetectingtendinopathyofthegluteus
mediusandminimus.7Intheacutestageofvestibularloss,apatientwillbeunabletoperform
thistestehowever,patientswhohaveacompensatedvestibularlossmaytestnormal.eThis
screeningtestisnotspecifictovestibularloss,aspatientswithotherbalancedisordersmay
havedifficultyperformingsinglelegstancee
Assessesthepatientsabilitytostandonbothfeetwiththehandsonthehips,thenliftoneleg
andplacethetoesofthatfootagainstthekneeoftheotherleg.Oncommandfromthetester,
Storkstandf thepatientthenraisestheheeltostandonthetoesandtrytobalanceaslongaspossible
withoutlettingeithertheheeltouchthegroundortheotherfootmoveawayfromtheknee.
Normaladultsshouldbeabletobalancefor2030secondsoneachleg
Functional
reachgandthe Bothofthesetestsrequirethepatienttoreachindifferentdirectionsasfaraspossiblewithout
Multidirectional changingtheBOS
reachh
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Test Description
Atestoflowerextremityreachthatchallengesanindividualsbalanceandposturalstability.
Thepatientbalancesontheinvolvedlegatthecenterofacircleplacedonthefloor,witheight
linesextendingfromthecenterat45degreeincrements.Whilemaintainingthesingleleg
stanceinthecenterofthecircle,theindividualisaskedtomaximallyreachinthe8designated
vectorsordirectionswiththeoppositelowerextremity.Thevectorsarenamedinreferenceto
Starexcursion
thestanceleg.Theindividualisaskedtotouchthefurthestpointoneachlinewiththereach
balance
footandreturntothestartpositionwhilemaintainingbalance.Thetestintendstodemonstrate
(SEBT)8 dynamicbalancedeficitsbycomparingtheperformanceoftheinvolvedlimbtothe
uninvolvedlimbastheabilitytoreachadistantpointalongagivenvectorrequiresa
combinationofposturalstability,strength,andcontrolledmotiononthestanceleg.Itisworth
notingthatastrengtheningprogramtargetingthegluteusmediuscanimproveSEBT
performance.6
TheYbalancetest,amodificationoftheSEBT,incorporatesreachabilityinonlytheanterior,
posteriormedial,andposteriorlateraldirections.Hipabductionstrengthandhipextension
Ybalancetest9 strengthhaveshownsignificantcorrelationtoposteriormedialandposteriorlateralreach
distances,respectively.2
Thistestisdesignedtoassessbalancewhilemovingintoapositionthatcommonlyprovokes
paininpatientswithintraarticularhippathology.Theindividualispositionedinthesingleleg
stancepositionand,withthecontralateralhand,isaskedtoreachasfaraspossibleacrossthe
Crossover bodytotouchthefloorandreturntoanerectposturewhilethestancefootremainsinfull
reachtest 4 contactwiththefloor.Thedistancetheindividualreachesisthenrecorded.Reachdistanceis
thoughttobelessontheinvolvedsideofpatientswithintraarticularhippathologyduetothe
factthatpatientswithintraarticularsourcesofregionalhippainhaveareductionofinternal
rotationandflexionatthehipjoint.
Theclinicianstandsbehindthepatientandasksthepatienttomaintaintheirbalancewhen
Pulltestk pulledbackward.Theclinicianpullsbackbrisklytoassessthepatientsabilitytorecover,
beingcarefultopreventthepatientfromfalling
Thepatientisaskedtostandwithfeetshoulderwidthapart.Theclinicianplacestheirhand
betweenthepatientsscapulaeandthepatientisaskedtoleanbackagainsttheclinicians
Backward hand.Oncethepatientisleaningbackwardintotheclinicianshand,theclinician
releasel unexpectedlyremovesthesupport.Theamountofforcecreatedbythepatientsleanshouldbe
sufficienttoinvokealossofbalancethatrequiresachangeintheBOS(i.e.,atleastone
backwardstep).
ThePSTmeasuresanindividualsabilitytowithstandaseriesofdestabilizingforcesapplied
Posturalstress atthelevelofthesubjectswaist.Scoringoftheposturalresponsesisbasedonaninepoint
test(PST)m ordinalscale,whereascoreof9representsthemostefficientposturalresponseandascoreof
0representsacompletefailuretoremainupright.
Thistestassessestheabilityofanindividualtomaintainbalanceinsixdifferentconditions
includingdoublelegstance,singlelegstance,andtandemstanceonfirmandfoamsurfaces
withtheeyesclosedandthehandsplacedonthehips.Eachconditionisattemptedfor20
Balanceerror
secondswhilethecliniciannotesthenumberoferrors,ordeviations,fromthespecificstance
scoringsystem
position.Anerrorisrecordediftheindividualopenstheeyes,steps,stumblesandfallsoutof
(BESS)1 position,removeshandsfromthehips,flexesorabductsthehipbeyond30degrees,orliftsthe
toesorheelsofftheground.Forapopulationagedbetween20and54years,theaverage
numberoferrorswasfoundtobebetween11and13.3
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Test Description
Thistestmeasuresanindividualsabilitytobalanceundersixdifferentsensoryconditions:
1.Standingonafirmsurfacewiththeeyesopen
2.Standingonafirmsurfacewiththeeyesclosed
3.StandingonafirmsurfacewearingadomemadefromamodifiedJapaneselantern
4.Standingonafoamcushionwiththeeyesopen
Clinicaltestof
sensory 5.Standingonfoamwiththeeyesclosed
Integrationon
balance(foam 6.Standingonfoamwearingthedome
anddometest)n
Foreachoftheseconditionsthepatientstandswiththefeetparallelandthearmsatthesides
orthehandsonthehipsaminimumofthree30secondtrialsofeachconditionareperformed.
Patientswithvestibulopathywillhavedifficultymaintaininganuprightposture.eIndividuals
whorelyheavilyonvisualinputforbalancewillbecomeunstableorfallinconditions2,3,5,
and6,whereasthosewhorelyheavilyonsomatosensoryinputsshowdeficitswithconditions
4,5,and6.
Thetestisperformedbyhavingthepatientstandwiththeeyesclosedandthearmsextended
Fukuda forwardtoshoulderheight.Thepatientisaskedtomarchinplacefor50stepsatthepaceofa
steppingtesto briskwalk.Progressiveturningtowardonesideof30degreesormoreisconsideredapositive
testandindicatesaunilateralperipheralvestibulardeficit.
Thistestassessesapersonsperceptionoftheeffectsofabalanceproblemandtheemotional,
Dizziness physical,orfunctionaladjustmentsthatthepersonmakes.Questionnaireconsistsof25items
handicap thataredividedintofunctional(nineitems),emotional(nineitems),andphysical(seven
inventoryp items)subscales.Eachitemisassignedavalueof4forayes,2pointsforasometimes,and0
pointsforano.
TheBerg
balancescale This14itemscalewasdevelopedtomeasurebalanceamongolderpeoplewithimpairmentin
balancefunctionbyassessingtheperformanceoffunctionaltasks.
(BBS)q
Patientsaretimed(inseconds)whenperformingtheTUGunderthreeconditions:
1.TUGalonefromsittinginachair,standup,walk3m,turnaround,walkback,andsit
down
Timedupand 2.TUGCognitivecompletethetaskwhilecountingbackwardfromarandomlyselected
numberbetween20and100
go(TUG)testr
3.TUGmanualcompletethetaskwhilecarryingafullcupofwater
Thetimetakentocompletethetaskisstronglycorrelatedtoleveloffunctionalmobility(i.e.
themoretimetaken,themoredependentinactivitiesofdailyliving)
Tinetti
performance
oriented Easilyadministeredtaskorientedtestthatmeasuresanadultsgaitandbalanceabilities.Rates
mobility theabilityofanindividualtomaintainbalancewhileperformingactivitiesofdailyliving
assessment relatedtasks.Componentsincludebalance,lowerandupperextremitystrength.
(POMA)s
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FIGURE344
Doublelegstanceonfirmsurface.
FIGURE345
Singlelegstanceonfirmsurface.
FIGURE346
Tandemstanceonfirmsurface.
FIGURE347
Doublelegstanceonfoamsurface.
FIGURE348
Singlelegstanceonfoamsurface.
FIGURE349
Tandemstanceonfoamsurface.
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Fallsintheelderlyareoftenassociatedwithsignificantmorbidityandcanbemarkersofpoorhealthand
decliningfunction.387Elderlypatientswithknownriskfactorsforfallingshouldbequestionedaboutfallsona
periodicbasis.Recurrentfalls,definedasmorethantwofallsina6monthperiod,shouldbeassessedfor
treatablecauses.Itisparticularlyimportanttoassesshousingarrangements,environmentalhazards,alcoholuse,
andcompliancewithmedications.
Severalfunctionalbalancemeasureshaveexhibitedastrongcorrelationwithahistoryoffalling.Thesesimple
tests,whichcanalsobeusedtomeasurechangesinmobilityafterinterventionshavebeenapplied,are
quantifiableandcorrelatewellwiththeabilityofolderadultstoambulatesafelyintheirenvironment.
TimedSLS.Thepatientstandsunassistedononeleg(byflexingtheoppositekneetoallowthefootto
clearthefloor)for30seconds.Thechoiceofwhichlegtostandoncanbedeterminedbythepatientbased
onpersonalcomfort.Thecliniciantimesthepatientsonelegbalanceusingawatch.Theabilityto
maintainSLSgenerallydecreaseswithincreasingage.Onestudy135foundthatolderadultsinthe
communitycouldmaintaintheSLSfor10secondsabout89%ofthetimeandnursinghomeresidentsfor
45%ofthetime.
ThetimedUp&Gotest.ThetimedUp&Gotestmeasures,inseconds,thetimetakenbyan
individualtostandupfromastandardarmchair(seatheightofapproximately46cm/18.4in,armheight
65cm/25.6in),walkadistanceof3m(10ft),turn,walkbacktothechair,andsitdownagain.Thepatient
wearshis/herregularfootwearanduseshis/hercustomarywalkingaid(none,cane,orawalker).The
subjectwalksthroughthetestoncebeforebeingtimedinordertobecomefamiliarwiththetest.Eithera
wristwatchwithasecondhandorastopwatchcanbeusedtotimetheperformance.
Theoverallphysicalfunctionshouldalsobeassessed.Thisisaccomplishedbyevaluatingthepatients
ADLsandinstrumentalADLs.Theinterventionisdirectedatdeterminingtheunderlyingcauseofthefall,
theidentificationofrisks,andinpreventingrecurrencethroughpatientandfamily/caregivereducationon
safetyissues(adequatelighting,contrastingcolors,andreductionofclutter).Functionaltrainingshould
includesittingtostandtransfers,walkingandturning,andstairnegotiation.Therapeuticexercisesshould
bedesignedtoaddressanystrengthandflexibilitydeficits,andbalanceand/orgaitdeficits.Itisimportant
torememberthatfrailtyisnotanaturalconsequenceofaging(seeChapter30).Physicalactivity
throughouttheagingyearscanproduceanumberofphysiologicbenefits:
Substantialimprovementsincardiovascularfunctioning.
Asignificantimpactonthemaintenanceofindependenceinoldage.
Thepreventionand/orpostponementofageassociateddeclinesinflexibility,balance,andcoordination.
Incontrast,disuseexacerbatestheagingprocess.Interventionstrategiestopreventdisabilityfrom
immobilityshouldincludethefollowingwhilemonitoringvitalsigns:
Minimizedurationofbedrest.Avoidstrictbedrestunlessabsolutelynecessary.Thepatientshouldbe
allowedtostand3060secondsduringtransfers(bedtochair).
Encouragesittingupatatableformeals,andgettingdressedinstreetclotheseachday.
Encouragedailyexerciseasabasisofgoodcare.Exercisesshouldemphasizebalanceandproprioception,
strengthandendurance,coordinationandequilibrium,aerobiccapacity,andposture.
Designpossiblewaystoenhancemobilitythroughtheuseofassistivedevices(e.g.,walkingaids,
wheelchairs)andmakingthehomeaccessible.Ifthepatientisbedbound,properbodyalignmentshould
bemaintained,andthepatientshouldchangepositionseveryfewhours.Pressurepaddingandheel
protectorsmaybeusedtoprovidecomfortandpreventpressuresores.
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Encouragesocializationwithfamily,friends,orcaregivers.
Regularchecksofskinintegrity,protectiveanddiscriminatorysensations
Coordination
Voluntarymovementpatternsinvolvefunctionallylinkedmusclesorsynergiesthatactcooperativelytoproduce
anactionandaredefinedbyprecisespatialandtemporalorganization.Themovementpatternscanbeassessed
usingvarioussimplecoordinationtasks.
Fingertonosetest.320Inthefingertonosetest,thepatientisaskedtomovetheindexfingertothetipof
thenoseorthechinwiththeeyesopen,whiletheclinicianobservesthequalityofarmmotion(Fig.350).
Closingtheeyeseliminatesvisualsubstitution.Mildcerebellarataxiaresultsinanintentiontremornear
thebeginningandtheendofthemovementwithpossibleovershootingofthetarget.388
Fingertofingertest.320Withthefingertofingertest,thepatientattemptstotouchhisorherfingertothe
cliniciansfinger(Fig.351).Horizontalovershootingimplicatesaunilaterallabyrinthinelesionvertical
overshootingoccursinpatientswithmidlinelesionstothemedullaoblongataorthebilateralcerebellar
flocculus.
Heeltoshintest.320Theheeltoshintest,whichtestsforlegataxia,involveshavingthesupinepatient
tracktheheelofthefootsmoothlyupanddownthecontralateralshin(Fig.352).Alternatively,the
patientcanbepositionedinsittingandcanbeaskedtotouchthegreattoetothecliniciansfinger.
FIGURE350
Fingertonosetest.
FIGURE351
Fingertofingertest.
FIGURE352
Heeltoshintest.
TonalAbnormality
Anexaminationoftoneconsistsofinitialobservationofrestingpostureandpalpation,andpassivemotion
testing,andactivemotiontestingwhileobservingforanyabnormalities.313
Spasticity
Spasticityisdefinedasavelocitydependentresistancetopassivestretch.Largerandquickerstretchesproducea
strongerresistanceofthespasticmuscle.
Claspedknifephenomenon.Duringrapidmovement,initialhighresistance(spasticcatch)maybe
followedbyasuddeninhibitionorlettinggoofthelimb(relaxation)inresponsetoastretchstimulus.
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Clonus.Thisisanexaggerationofthestretchreflexandischaracterizedbycyclical,spasmodic
alternationofmuscularcontractionandrelaxationinresponsetosustainedstretchofthespasticmuscle.
Rigidity
Rigidityisdefinedasanincreasedresistancetoallmotions,renderingbodypartsstiffandimmovable.
Cogwheelphenomenon.Thisisaratchetlikeresponsetopassivemovement,characterizedbyanalternate
givingandincreasedresistancetomovement.
Leadpiperigidity.Characterizedbyconstantrigiditythroughouttherangeofmotion,thisfindingis
commoninpatientswithParkinsondisease.
Hypotonia
Hypotoniaandflaccidityarethetermsusedtodefinedecreasedorabsentmusculartone.Thisstateismanifested
byadiminishedresistancetopassivemovement,dampenedorabsentstretchreflexes,andlimbsthatareeasily
moved.
Dystonia
Dystoniaisahyperkineticmovementdisordercharacterizedbyadisorderedtoneandinvoluntarymovements
involvinglargeportionsofthebody.DystoniatypicallyresultsfromaCNSlesionbutcanbeinherited.
Posturing
Incasesofsignificantbrainlesions,thebodycanadopttwocharacteristicpositions:
Decorticatepositioning.Upperextremitiesareheldinflexionandthelowerextremities,inextension.
Decerebratepositioning.Upperandlowerextremitiesareheldinextension.
CNExamination
Withpractice,theentireCNexaminationcanbeperformedinapproximately5minutes(Table327).362The
followingrhymemaybeusedtohelpremembertheorderandtestsfortheCNexamination:389
TABLE327CNsandMethodsofTesting
Function
Nerves Afferent(Sensory) Efferent(Motor) Tests
Unilateralidentificationoffamiliar
IOlfactory Smell
odors(e.g.,chocolateandcoffee)
Visualacuity,peripheralvision,and
IIOptic Sight
pupillarylightreflex
Voluntarymotor:levatorof
eyelidsuperior,medial,and Upward,downward,andmedialgaze
IIIOculomotor
inferiorrectiandinferior reactiontolight
obliquemuscleofeyeball
Autonomic:smoothmuscle
ofeyeball
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Function
Nerves Afferent(Sensory) Efferent(Motor) Tests
Voluntarymotor:superior Extraoculareyemovements:
IVTrochlear obliquemuscleofeyeball downwardandlateralgaze
Touch,pain:skinof
Cornealreflexsensationaboveeye,
face,mucous
Voluntarymotor:musclesof betweeneyeandmouth,belowmouth
VTrigeminal membranesofnose,
mastication toangleofjawclenchteeth,push
sinuses,mouth,and
downonchintoseparatejaws
anteriortongue
Voluntarymotor:lateral
VIAbducens Lateralgaze(eyeabduction)
rectusmuscleofeyeball
Voluntarymotor:facial Facialexpressions(closeeyestight,
Taste:anteriortwo musclesAutonomic: smileandshowteeth,andwhistleand
VIIFacial
thirdsoftongue lacrimal,submandibular,and puffcheeks)andidentifyfamiliar
sublingualglands tastes(e.g.,sweetandsour)
VIII
Hearingtestsandbalanceand
Vestibulocochlear Hearing/equilibrium
coordinationtests
(acousticnerve)
Voluntarymotor:
Visceralsensibility
IX unimportantmuscleof Gagreflex,abilitytoswallow,and
(pharynx,tongue,and
Glossopharyngeal pharynxAutonomic:parotid phonation
tonsils)taste
gland
Touch,painpharynx,
Voluntarymotor:musclesof
larynx,trachea,bronchi,
palate,pharynx,andlarynx Gagreflex,abilitytoswallow,and
XVagus andlungs
Autonomic:involuntary speech(phonation)
Taste:tongueand
muscleandglandcontrol
epiglottis
Voluntarymotor:movement
ofheadandshoulders
XIAccessory Resistedheadandshouldershrug
sternocleidomastoidand
trapeziusmuscles
Tongueprotrusion(ifinjured,tongue
XII Voluntarymotor:movement
deviatestowardinjuredside)and
Hypoglossal oftongue
inspectionoftongueforatrophy
Smellandsee
Andlookaround,
Pupilslargeandsmaller.
Smile,hear!
Thensayah
Andseeifyoucanswallow.
Ifyoureleftinanydoubt,
Shrugandstickyourtonguerightout.
CNI(Olfactory)
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Thesenseofsmellistestedbyhavingthepatientidentifyfamiliarodors(e.g.,coffee,lavender,andvanilla)with
eachnostril.Theclinicianshouldavoidirritantodorsthatcanstimulatethetrigeminalnerve.
CNII(Optic)
Theopticnerveistestedbyexaminingvisualacuityandconfrontation.Althoughtheformaltestingofvisual
acuityispresentedhere,inreality,itissufficienttotestthisaspectofCNIIatthesametimethatCNIII,IV,and
VIarebeingtested.
VisualAcuity
Thisisatestofcentralvision.Ifpossible,theclinicianshoulduseawelllitSnelleneyechart.Thepatientis
positioned20ftfromthechart.Patientswhousecorrectivelensesotherthanreadingglassesshouldbe
instructedtousethem.Thepatientisaskedtocoveroneeyeandtoreadthesmallestlinepossible.Apatient
whocannotreadthelargestlettershouldbepositionedclosertothechart,andthenewdistancenoted.The
cliniciandeterminesthesmallestlineofprintfromwhichthepatientcanidentifymorethanhalftheletters.The
visualacuitydesignatedatthesideofthisline,togetherwiththeuseofglasses,ifany,isrecorded.
Visualacuityisexpressedasafraction(e.g.,20/20),inwhichthenumeratorindicatesthedistanceofthepatient
fromthechartandthedenominatorthedistanceatwhichanormaleyecanreadtheletters.
ConfrontationTest
Thisisaroughclinicaltestofperipheralvisionthatalsohighlightsalossofvisioninoneofthevisualfields.
Thepatientandthecliniciansitfacingeachother,withtheireyeslevel.Boththelateralandmedialfieldsof
visionaretested.Theentirelateralfieldistestedwithbotheyesopen,andthemedialfieldistestedbycovering
oneeye.Whentestingthemedialfieldofvision,thepatientcoverstheeyethatisdirectlyoppositetothe
cliniciansown(notdiagonallyopposite).
Witharmsoutstretchedandhandsholdingasmallobjectsuchasapencil,theclinicianslowlybringstheobject
intotheperipheralfieldofvisionofthepatient.Thisisperformedfromeightseparatedirections.Eachtimethe
patientisaskedtosaynowassoonasheorsheseestheobject.Duringtheexamination,theclinicianshould
keeptheobjectequidistantbetweenhisorherowneyeandthepatientssothatthepatientsvisualfieldcanbe
comparedtothecliniciansown.
CNIII(Oculomotor),CNIV(Trochlear),andCNVI(Abducens)
ThesethreeCNsaretestedtogether.Theclinician:
Inspectsthesizeandtheshapeofeachpupilforsymmetry.
Teststheconsensualpupillaryresponsetolight.Thisistestedbyhavingthepatientcoveroneeyewhile
theclinicianobservestheuncoveredeye.Theuncoveredeyeshouldundergothesamechangesasthe
coveredbyfirstdilating,andthenconstrictingwhenthecoveredeyeisuncovered.
Looksfortheabilityoftheeyestotrackmovementinthesixfieldsofgaze.Thestandardtestisto
smoothlymoveatargetinanHconfigurationandtheninthemidlinejustaboveeyeleveltowardthe
baseofthenose(convergence).8Thepatientshouldbeabletosmoothlytrackatargetatmoderatespeed,
withoutevidenceofnystagmus.
Looksforptosisoftheuppereyelids.
CNV(Trigeminal)
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Thepatientisaskedtoclenchtheteeth,andtheclinicianpalpatesthetemporalandmassetermuscles.Thethree
sensorybranchesofthetrigeminalnervearetestedwithpinprickclosetothemidlineofthefacebecausethe
skinthatismorelateralisoverlappedbythenervesoftheface.8Thejawmusclestretchreflexisassessedfor
thepresenceofhyperreflexia(Fig.353).
FIGURE353
Jawtendonreflexassessment.
CNVII(Facial)
Theclinicianinspectsthefaceatrestandinconversationwiththepatientandnotesanyasymmetry.Thepatient
isaskedtosmile.Ifthereisanyasymmetry,thepatientisaskedtofrownorwrinkletheforehead.Lossor
reducedabilitytosmileandfrowniscausedbyaperipheralpalsy,whereasthelossofthesmile,only,iscaused
byasupranuclearlesion.8
CNVIII(Vestibulocochlear)
Thevestibularnervecanbetestedinanumberofways,dependingontheobjective.Balancetestingassessesthe
vestibulospinalreflex.CaloricstimulationcanbeusedtoassesstheVOR.TheVORcanalsobeassessedby
testingtheabilityoftheeyestofollowamovingobject.
Theclinicianassessesthefunctionofthecochlearcomponentofthenervehearingbygentlyrubbingtwo
fingersequidistantfromeachofthepatientsearssimultaneouslyorbyusinga256Hztuningforkandasking
thepatienttoidentifyinwhichearthenoiseappearstobetheloudest.
Therearethreebasictypesofhearingloss389
Conductive.Thistypeofhearinglossappliestoanydisturbanceintheconductionofthesoundimpulseas
itpassesthroughtheearcanal,thetympanicmembrane,themiddleear,andtheossicularchaintothe
footplateofthestapes,whichissituatedintheovalwindow.Asageneralrule,anindividualwith
conductivehearinglossspeakssoftly,hearswellonthetelephone,andhearsbestinanoisyenvironment.
Sensorineural.Thistypeofhearinglossappliestoadisturbanceanywherefromthecochleathroughthe
auditorynerveandontothehearingcenterinthecerebralcortex.Asageneralrule,anindividualwitha
perceptivehearinglossusuallyspeaksloudly,hearsbetterinaquietenvironment,andhearspoorlyina
crowdandonthetelephone.
Mixed.Thistypeofhearinglossisacombinationofconductiveandsensorineural.
Ifhearinglossispresent,thentheclinicianshouldtestforlateralizationandcompareairandboneconduction.
Lateralization
Theclinicianplacesatuningforkoverthevertex,middleoftheforehead,orfrontteeth.Thepatientisasked
whetherthevibrationisheardmoreinoneear(Webertest).Normalindividualscannotlateralizethevibrationto
eitherear.Inconductiondeafness(e.g.,thatcausedbymiddleeardisease),thevibrationisheardmoreinthe
affectedear.Insensorineuraldeafness,thevibrationisheardmoreinthenormalear.
AirandBoneConduction
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Airconductionisassessedbyplacingthetuningforkinfrontoftheexternalauditorymeatus,whereasbone
conductionisassessedbyplacingthetuningforkonthemastoidprocess(Rinnetest).Inanormalindividual,the
tuningforkisheardlouderandlongerbyairthanbyboneconduction.Inconductiondeafness,boneconduction
hearingisbetter.Insensorineuraldeafness,bothairandboneconductionarereduced,althoughairconductionis
thebetterofthetwo.
CNIX(Glossopharyngeal)
Thegagreflexisusedtotestthisnerve,butthistestisreservedforseverelyaffectedpatientsonly.
CNX(Vagus)
Theclinicianlistenstothepatientsvoiceandnotesanyhoarsenessornasalquality.Thepatientisaskedtoopen
themouthandsayAah,whiletheclinicianwatchesthemovementsofthesoftpalateandpharynx.Thesoft
palateshouldrisesymmetrically,theuvulashouldremaininthemidline,andeachsideoftheposteriorpharynx
shouldmovemedially.
CNXI(SpinalAccessory)
Frombehindthepatient,thecliniciannotesanyatrophyorfasciculationinthetrapeziusmusclesandcompares
eachside.Thepatientisaskedtoshrugbothshouldersupwardagainsttheclinicianshand.Thestrengthof
contractionshouldbenoted.
Thepatientisaskedtoattempttoturnhisorherheadtoeachsideagainsttheclinicianshand.Thecontraction
oftheSCMandtheforceofcontractionshouldbenoted.
CNXII(Hypoglossal)
Theclinicianinspectsthetongue,asitliesonthefloorofthemouth,lookingforfasciculation.Thepatientis
thenaskedtostickoutthetongue.Theclinicianlooksforasymmetry,atrophy,ordeviationfromthemidline.
Thepatientisaskedtomovethetonguefromsidetoside,asthecliniciannotessymmetryofmovement.
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CHAPTER4:Patient/ClientManagement
CHAPTEROBJECTIVES
1.Understandtheprinciplesandconsiderationsofacomprehensiveexamination.
2.Outlinethevariousdisablementmodelsandthestrengthsandweaknessesofeach.
3.Explainthedifferencebetweenimpairmentandfunctionallimitation.
4.Listthecomponentsinvolvedinthecontinuumofcare.
5.Takeacompletehistory.
6.Explaintheimportanceofthesystemsreview.
7.Listthecomponentsofthetestsandmeasuresportionoftheexamination.
8.Understandthevalueofacompleteobservationofthepatientandtheinformationthatcanbegleanedfromsuch
anassessment.
9.Describethedifferencesbetweenatraditionalexaminationandapostsurgicalexamination.
10.Explainthedifferencesbetweentheexaminationandtheevaluation.
11.Explainhowtodeterminewhetheratechniqueisclinicallyuseful.
12.Outlinethecomponentsofclinicaldocumentation.
OVERVIEW
Patient/clientmanagementcomprisesfiveelements1:
1.Acomprehensiveexaminationofthepatient.
2.Evaluationofthedataandtheidentificationofproblems.
3.Establishmentofthediagnosisbasedonimpairmentofbodystructureandfunction,activitylimitations
(functionallimitations),andparticipationrestrictions(disability).
4.Determinationoftheprognosisandtheplanofcare(POC)basedonpatientorientedgoals.
5.ImplementationofappropriateinterventionsasoutlinedinthePOC.
Theexaminationprocessinvolvesacomplexrelationshipbetweentheclinicianandthepatient.Theaimsofthe
examinationprocessaretoprovideanefficientandeffectiveexchangeandtodeveloparapportbetweentheclinician
andthepatient.Thesuccessofthisinteractioninvolvesamyriadoffactors.Successfulcliniciansarethosewho
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demonstrateeffectivecommunication,soundclinicalreasoning,criticaljudgment,creativedecisionmaking,and
competence.
Theprimaryresponsibilityofaclinicianistomakedecisionsinthebestinterestofthepatient.Althoughtheapproachto
theexaminationshouldvarywitheachpatient,andfromconditiontocondition,thereareseveralfundamental
componentstotheexaminationprocess.Theprinciplesoutlinedinthischapterandintegratedthroughoutthistext,are
basedontheviewsofanumberofexperts,212aswellasprinciplesIhavelearned,andused,overtheyears.
Allcliniciansshouldcommittobeinglifelongstudentsoftheirprofessionandshouldstrivetowardaprocessof
continualselfeducation.Partofthisprocessinvolvestheutilizationoftheexpertiseofmoreexperiencedclinicians.
Thisnecessitatesthattheearlyyearsofpracticearespentinanenvironmentinwhichthenoviceissurroundedbyastaff
ofvaryinglevelsofclinicalandlifeexperiences,bothofwhichcanserveasvaluableresources.Thecliniciancanalso
improvebyinvestingtimeinreadingrelevantmaterial,attendingcontinuingeducationcourses,completinghomestudy
courses,watchingvideosspecializingintechniques,andobservingexceptionalclinicians.Exceptionalcliniciansare
thosewhodemonstrateexcellenttechnicalskills,combinedwithexcellentpeopleskills.
CLINICALPEARL
Fromthepatientspointofview,thereisnosubstituteforinterest,acceptance,andespeciallyempathyonthepartofthe
clinician.13
Finally,onemustalsoneverforgetthatthepatientcanserveasthemostvaluableresource.Eachinteractionwitha
patientisanopportunitytoincreaseknowledge,skill,andunderstanding.Integraltothisrelationshipispatient
confidentiality.Exceptwhendiscussingthepatientsconditionwithotherclinicianswiththeobjectofteachingor
learning,theclinicianshouldnotdiscussthepatientsconditionwithanyonewithoutthepatientspermission.
Muchaboutbecomingaclinicianisbeingabletocommunicatewiththepatient,thepatientsfamily,andtheother
membersofthehealthcareteam.Thenonverbalcuesareespeciallyimportantbecausetheyoftenareperformed
subconsciously.Specialattentionneedstobepaidtononverbalcommunicationsuchasvoicevolume,postures,
gestures,andeyecontact.Theappearanceoftheclinicianisalsoimportantifaprofessionalimageistobeprojected.
Communicationbetweentheclinicianandthepatientbeginswhentheclinicianfirstmeetsthepatientandcontinues
throughoutanyfuturesessions.Communicationinvolvesinteractingwiththepatientusingtermsheorshecan
understand,andbeingsensitivetoculturaldiversityasappropriate.Theintroductiontothepatientshouldbehandledin
aprofessionalyetempathetictone.Listeningwithempathyinvolvesunderstandingtheideasbeingcommunicatedand
theemotionbehindtheideas.Inessence,empathyisseeinganotherpersonsviewpoint,sothatadeepandtrue
understandingofwhatthepersonisexperiencingcanbeobtained.
Attheendofthefirstvisitandatsubsequentvisits,theclinicianshouldaskifthereareanyquestions.Eachsession
shouldhaveclosure,whichmayincludeahandshakeifappropriate.
DisablementModels
Perhapsoneofthemostimportantdevelopmentsinhealthcareinthepastfewdecadeshasbeentheincreased
recognitionoftheimportanceofthepatientsperceptionofhealthandfunctionaloutcomes.14Thisincreasedrecognition
hasshiftedthefocusofthephysicaltherapyexamination,evaluation,andsubsequentdiagnosistotherecognitionof
impairmentsandtheirrelationshiptoanyfunctionallimitationordisability.
Thefieldofphysicaltherapyhaslongrecognizedthetraditionalbiomedicalapproachestopainhavebeenproblematic
indescribingpatientfunctioning.15Thisisduemainlytothefactthatthereisaninconsistentrelationshipbetweenpain
andfunctioning,andthefactthatpainmaynotbethepatientschiefconcern.Ideally,adisablementmodelisdesigned
todetailthefunctionalconsequencesandrelationshipsofpain,disease,impairment,andfunctionallimitations.Many
disablementmodelshavebeenproposedovertheyears,mostofwhicharebasedontheNagioriginalmodelwhich
depictedtherelationshipbetweenthefollowingseriesoflinkedevents:16,17
Pathology/Pathophysiology(thepresenceofdisease),whichmayleadtoimpairments(anatomicandstructural
abnormalities),whichmayinturnleadtofunctionallimitations(restrictionsinbasicphysicalandmentalactions),which
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maythenprogresstodisability(difficultyindoingactivitiesofdailylife).TheGuideofPhysicalTherapistPractice18
employedterminologyfromtheNagidisablementmodel,butalsodescribeditsframeworkasbeingconsistentwith
otherdisablementmodels.Althoughadegreeofinevitabilityisimpliedinmanyofthedisablementmodels,many
factorscanhaveanimpactonthepathologydisabilitypathwayordisablementprocess.
In2001theExecutiveBoardoftheWorldHealthOrganization,inanattempttoprovideacommonlanguageusedbyall
healthprofessionsfordocumentationandcommunication,approvedtheInternationalClassificationofFunctioning,
DisabilityandHealth(WHOICF).TheWHOICFframeworkincludesallofthefollowingelements:thehealth
condition,bodyfunctions/structures,activity,participation,andcontextualfactors,allofwhichareinterrelatedandcan
potentiallyhaveanimpactoneachother.TheWHOICFplaceslessemphasisondiseaseandgreateremphasison
componentsofhealthratherthanconsequencesofdisease(i.e.,participationratherthandisability)and
environmentalandpersonalfactorsasimportantdeterminantsofhealth.ThetwomaincomponentsoftheWHOICF
model,whichprovidesamethodthatconsidersbiological,individual,andsocialcontributions,arefunctioningand
disability,andcontextualfactors:15,19
1.Part1:Functioninganddisability.Functioninganddisabilityconsidertherelationshipsamongthephysical
phenomenaandwithintheindividualthatarerepresentedbythedomainsofbodyfunctionsandstructures,
activities,andparticipation.Part1isfurthersubdividedintotwocomponents:
i.Bodyfunctionsandstructures.Bodyfunctionsandstructuresareassessedintermsofchangeina
physiologicalfunctionandanatomicalstructuresuchthatadeficitinbodystructureisassociatedwitha
deficitinfunctionalmobility.15Forexample,limitedkneeflexionrangeofmotionmaybeassociatedwith
limitationintheabilitytoascendstairs.
ii.Activitiesandparticipation.Anactivityinvolvestheexecutionofataskoraction(e.g.,movingfromsitting
tostanding),whileparticipationisdefinedasinvolvementinlifeaffairs(e.g.,theabilitytodriveacar).
Thus,functioningischaracterizedbytheintegrityofbodyfunctionsandstructures,andtheabilityto
participateinlifeactivities.
2.Part2:Contextualfactors.Eachcomponentoffunctioninganddisabilitycanbebrokendownintostandard
categoriesreferredtoascontextualfactors.Part2isalsofurthersubdividedintotwocomponents:environmental
andpersonalcontextualfactors,bothofwhichcaninfluencefunctioninganddisability:
i.Environmentalfactors,includingenvironmentalbarriersandfacilitatorstoboththecapacityand
performanceofactionsandtasksindailyliving.Theseincludesocialattitudes,architecturalcharacteristics,
legalandsocialstructures,aswellasclimate,andterrain.
ii.Personalfactors,includingage,sex,ethnicbackground,depressionorcomorbidity(e.g.,pressuresores,
contractures,urinarytractinfections),andsocioeconomicstatus.
Characteristicsofanillnessthatarenotamenabletomodificationmaybetermedcontextualvariables.Contextual
factorscanbeviewedassecondaryconditionsthatmayinfluencethelevelofdisabilitybutarenotdirectlyrelatedtothe
diseaseprocessitself.20Broaderdefinitionsfortheseconditionsincludeselfconcept,work,andsocialparticipation,
healthrelatedeconomicconsequencesfortheindividualorfamily,andotherfamilymembers.21,22
Inadditiontothesetwobasiccomponents,theWHOICFhasanextensivelistofdescriptions,classifications,and
codingforallofthefunctionsandstructuresofallbodysystems,personalactivitiesandparticipation,and
environmentalfactors.TheWHOICFmodelhasbeenadvocatedinthephysicaltherapyliteratureasapotential
successortotheNagimodelbecauseitexplicitlyacknowledgesbidirectionalrelationshipsamongdomainsoffunction
andcontextualfactors,whilerecognizingtheimpactofthepatientsaffective,social,andenvironmentalfactorsthat
maybeeitherbarriersorfacilitatorstothephysicaltherapyprognosis.15
Thevariousdisablementmodelsintroducedanumberoftermsthroughouttheyearswhicharedescribedinthe
followingsections.
HealthCondition
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TheoriginaltermthatNagiused,pathology,isperhapsselfexplanatory.Itreferstoanydiagnoseddisease,injury,
disorder,orabnormalconditionthatis(1)characterizedbyaparticularclusterofsignsandsymptomsand(2)
recognizedbyeitherthepatientorclinicianasabnormal.18,23,24Althoughknowledgeofpathologyandpathophysiology
canhelptheclinicianpredicttherange,severity,andprognosisofaparticularcondition,amedicaldiagnosisdoesnot
telltheclinicianhowtomanagethepatient.Incontrast,thetermhealthconditionbetteridentifiestheimpactofa
conditiononfunction.TheWHOICFframeworkreferstoacuteorchronicdiseases,disorders,orinjuriesthathavean
impactonapersonslevelofactivity.Whilethepresenceofpathologymayleadtodistressorinterferencewith
functionalstatus,differentpeoplewiththesameconditioncanbeimpacteddifferently.Forexample,considertheimpact
thathiposteoarthritiswouldhaveonsomeonewhohasadeskjob,comparedtothatofamanuallaborer.While
pathologyisprimarilyidentifiedatthecellularlevelandisusuallydeterminedbythephysiciansmedical
diagnosis,18,24itdoesnotnecessarilytellthecliniciantheunderlyingetiology,orhowthedisease/dysfunctionmanifests
itselfasanalterationin,orattributeof,anindividualshealthstatus.Determiningtheunderlyingetiologyisimportantin
creatinganoptimalmanagementplan.Itisthusimportanttodeterminewhethertheabnormalmovementresultedfrom
thetissuepathology,orwhethertheabnormalmovementcausedthetissuepathology.15Forexample,ifapatient
presentswithachiefconcernofshoulderpainwithoutahistoryoftraumaticonset,theclinicianmustdeterminewhether
theshoulderpainwascausedbyanabnormalmovementpattern,amuscleimbalance,adiseaseprocess,apostural
dysfunctionorwhetherthepainisbeingreferredfromelsewhere,tonamebutafewpotentialcauses.
Impairment
TheGuidetoPhysicalTherapistPracticedefinesimpairmentasanylossorabnormalityofanatomic,physiologic,
mental,orpsychologicalstructureorfunctionthatboth(1)resultsfromunderlyingchangesinthenormalstate,and(2)
contributestoillness.18TheICFmodelsubdividesimpairmentsintoimpairmentsofbodyfunctionandbodystructure
whereimpairmentscanbeviewedasabnormalitiesofstructureorfunctionasindicatedbysignsandsymptoms.
Physicaltherapiststypicallyencounterpatientswithimpairmentsofbodyfunctionand/orbodystructureofthe
followingsystems:musculoskeletal,neuromuscular,integumentary,andcardiovascular/pulmonary.
Impairmentsofbodyfunctionandbodystructurehavethepotentialtocreatepainandsubtlealterationsinthenormal
functionsoftheinvolvedjointandsurroundingtissues.Suchimpairmentscanbemanifestedobjectively,forexample,
byimpairedbalanceorcoordination,reducedrangeofmotion,articulardeformity,abnormalgait,andthelossofmuscle
performance(strength,power,endurance),orproprioception.Impairmentscanalsobemanifestedsubjectively,for
example,throughpain,tenderness,morningstiffness,orfatigue.
Thus,impairmentreferstosomeformofloss.Lossorlossofusereferstoachangefromthenormalorpreexisting
state.Thetermnormalreferstoarangerepresentinghealthyfunctioningthatcanvarywithage,gender,andother
factorssuchasenvironmentalconditions.Forexample,thenormalrangeofmotionforkneeflexionisdeemedtobe150
degrees.24Althoughalossofmorethan70degreesofkneeflexionmaypreventapatientfromperformingsuch
activitiesasgettinginandoutofabathtuborwalkingupanddownsteps,thepatientmaystillbeabletoambulate
aroundthehouse.
TheICFmodeldescribesprimary,secondary,andcompositeimpairments.Primaryimpairmentsarisedirectlyfromthe
healthcondition,whereassecondaryimpairmentsmaybetheresultofapreexistingimpairment.Acomposite
impairmentistheresultofmultipleunderlyingcausesthattypicallyarisesfromacombinationofprimaryorsecondary
impairments.Asanexample,considerapatientwithlowbackpain.Inthisscenario,thepatientmayexhibitprimary
impairmentsofbodyfunction,suchaslimitedrangeofmotionofthetrunk,pain,andmuscleguardingduringthe
examination.Thesecondaryimpairmentmaybeosteoarthritisofthehipthatproducedachangeinthepatientsgait
pattern,alteringthebiomechanicsofthelowerextremity,andresultinginlowbackpain.Acompositeimpairment
wouldbealossofbalanceandcoordinationasaresultofboththelowbackpainandtheosteoarthritisofthehip.
Oneofthegoalsoftheexaminationprocessistodeterminewhichimpairmentsarerelatedtothepatientsfunctional
limitationswhilerememberingthatimpairmentsaffectpeopleindifferentways.Forexample,intwopatientswitha
rotatorcufftendinitis,theimpairmentofonemaybegreaterthantheotherduetopain.Theperceptionofpainishighly
individual,anddifferentindividualsmaybeimpairedbypaintodifferentdegrees.
Oneofthegoalsoftheexaminationprocessistodeterminewhichimpairmentsarerelatedtothepatientsfunctional
limitationsthefunctionallyrelevantimpairmentsandtodeterminewhetherthereareanyunderlyingcauses.
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FunctionalLimitation
Afunctionallimitationcanbedefinedasarestrictionoftheabilitytoperformafundamentalphysicalaction,task,or
activityinanefficient,typicallyexpected,orcompetentmanner.18Inotherwords,functionallimitationsarerestrictions
inperformingexpectedbasicphysicalandmentalactions.Examplesofsuchfunctionallimitationsincludedifficulty
withwalking,andaninabilitytoputonshoes.Thevastmajorityofthetraditionaltestsusedinphysicaltherapyclinics,
suchasrangeofmotionandstrength,aremeasuresofimpairmentsandnotfunction.Measurementsoffunctional
limitationsincludesensorimotorperformancetestingduringsuchactivitiesaswalking,climbing,bending,transferring,
lifting,andcarrying.18Itisimportantthatthesemeasurementsassessthepatientsabilitytoperformtasksthatthe
patientfeelsareimportant.Theprocessofidentifyingmeaningful,achievablefunctionalgoalsshouldbeacollaborative
effortbetweentheclinicianandthepatient,thepatientsfamily,orthepatientssignificantother.18Toidentify
functionalgoals,RandallandMcEwen25recommendthefollowingsteps:
1.Determinethepatientsdesiredoutcomeoftheintervention.
2.Developanunderstandingofthepatientsselfcare,work,andleisureactivitiesandtheenvironmentsinwhich
theseactivitiesoccur.
3.Establishgoalswiththepatientthatrelatetothedesiredoutcomesusingthefollowingquestions25,26:
i.Ifyouweretoconcentrateyourenergiesononethingforyourself,whatwoulditbe?
ii.Whatactivitiesdoyouneedhelpwiththatyouwouldratherperformyourself?
iii.Whatareyourconcernsaboutreturningtowork,home,school,orleisureactivities?
iv.Whataboutyourcurrentsituationwouldyouliketobedifferentinabout6months?Whatwouldyouliketo
bethesame?
Oncethegoalshavebeenagreedupon,theclinicianmustwritethegoalssothattheycontainthefollowing
elements:25,27
Who(thepatient)
Willdowhat(activities)
Underwhatconditions(thehomeorworkenvironment)
Howwell(theamountofassistanceornumberofattemptsrequiredforsuccessfulcompletion)
Bywhen(targetdate)
Thus,thefunctionalexaminationcreatesafunctionaldiagnosiswithfunctionalgoals.Oncethesefunctionalgoalsare
established,thecliniciancangradethemaccordingtodifficulty.Functionaltaskscanreproducethewholetaskinits
entiretyorcanbreakdownthetaskintoitsrequiredfundamentalcomponentsandthephysicaldemandsnecessaryto
performeachtask.Regainingthesmallerrequirementsmayconstitutetheshorttermgoalswhereascompletionofthe
wholetaskmaybecomethelongtermgoal.Forexample,exercisestoimprovesittostandtransferscouldbeinitiated
byhavingthepatientperformtricepspushupsonthechairhandle,performbilateralminisquats,orexerciseontheleg
pressbeforeprogressingtothefullfunctionalactivity.
ParticipationRestrictionsandDisability
ThetermDisabilitywasusedintheNagidisablementmodel.TheICFmodelusesthetermParticipationRestrictions.
Bothtermsmaybedefinedashavingdifficultyintheperformanceofsocialrolesandtaskswithinasocioculturaland
physicalenvironment(fromhygienetohobbies,errands,tosleep),asaresultofahealthorphysicalproblem.21,28,29
Bothdisability,andparticipationrestrictions,describesomethingthatmaybetemporaryorpermanent,andisthegap
betweenwhatapersoncandoandwhatthepersonneedsorwantstodo.TheICFdefinitionisnotjustrelatedtoany
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healthimpairmentormedicalcondition,asitcanencompassanyactivitylimitationorparticipationrestrictionalthough
amedicalconditionorimpairmentmaycauseorcontributetodisability.
Itisimportantthattheclinicianavoidviewingthedisablementprocessasaunidirectionalpathwaywithaninevitable
progressiontodisability.Variousfactors,includingthepatientslevelofinteractionwiththeenvironment,thepatients
copingskills,andthepotentialeffectsofrehabilitation,maycauseabidirectionalinteractionorreversalbetweenthe
componentsofthedisablementprocess.18,30Thisbidirectionalinteractionmaybereferredtoastheenablingprocess.30
Thetermhealthrelatedqualityoflifeisoftenusedinterchangeablywiththetermsfunctionalstatus,healthstatus,and
healthoutcomes.Thedefinitionsoftheseterms,however,mightrangefromnegativelyvaluedaspectsoflife,suchas
death,tomorepositivelyvaluedaspects,suchassocialfunctioningorhappiness.21,22,3135
Clearly,theroleofaphysicaltherapististoeitherreducetheimpactofdisabilityor,betterstill,preventthedisability
fromoccurringwheneverpossible.TheGuideoutlinesthreepreventioncategories:1
Primary.Preventionofdiseaseinasusceptibleorpotentiallysusceptiblepopulationthroughspecificmeasures
suchasgeneralhealthpromotionoffers.
Secondary.Effortstodecreasedurationofillness,severityofthedisease,andsequelaethroughearlydiagnosis
andpromptintervention.
Tertiary.Effortstodecreasethedegreeofdisabilityandpromoterehabilitationandrestorationoffunctionin
patientswithchronicandirreversiblediseases.
Earlypreventativemeasurescaninvolveaddressingmodifiableriskfactors.Modifiablefactorsarecharacteristicsthatan
individualcancontroloradjust.Theimpactthatthemodifiablefactorshaveonthepathologydisabilitypathwayor
disablementprocesscandependonboththecapacitiesoftheindividualandtheexpectationsthatareimposedonthe
individualbythoseintheimmediatesocialandoccupationalenvironment.36Specificexamplesofmodifiablepatient
factorsincludethefollowing:
Thepatientsactivitylevel.Anumberofstudieshavemadeassociationsbetweenlowphysicalactivitylevelsand
theonsetofdisability.3748
Thepatientsreactiontotheillness.Differentculturalbackgroundsareassociatedwithdifferentbeliefsabout
pain,copingstrategies,expressionsofpain,andresponsetohealthcare.49,50Thetermsickrolehasbeenusedto
defineastatusaccordedtotheindividualbyhimselforherselfandothermembersofsocietythatmaybevariably
associatedwithamedicalcondition.36Anindividualssickrolereflectsnotonlyhisorherprimaryconditionbut
alsoanyadditionalorsecondaryconditions.51,52
Thepatientseducationalbackground.Patientswithlessformaleducationtendtohaveanincreasedfrequencyof
disability.53,54
Thepatientscompensatoryandcopingstrategies.Somepeoplesimplydonothavetheemotionalandsocial
resourcestodealwithlife,particularlyintimesofadversity.55
Thepatientspaintoleranceandmotivation.Variousstudies50,56haverevealedbothethnicandgender
differencesinresponsetobothclinicalandexperimentalpain.Specifically,investigatorshaverecentlyindicated
thatAfricanAmericansreportgreaterlevelsofpainthanwhitesforsuchconditionsasglaucoma,acquired
immunodeficiencysyndrome,migraine,headache,jawpain,postoperativepain,myofascialpain,anginapectoris,
jointpain,nonspecificdailypain,andarthritis.57Interpretationsofsuchfindingsremaindifficult,however,
becauseofpotentialgroupdifferencesindiseaseseverityandphysicianmanagement.57Therearealsodisparate
reportsaboutgenderdifferencesinsensitivitytopaininhumansandinanimals,indicatingthatwomenhavea
lowertoleranceofpainthanmen.5860Whetherwomenaremorewillingtoreportpainthanmenare,or
experiencepaindifferentlythanmendo,isunclear.Whateverbethereasonsforthedifferencesinpaintolerance
andmotivation,thereisperhapsareasontosupposethatimprovedpaintoleranceandmotivationmightbe
instrumentalinreducingimpairmentanddisability.ThechronicpainadaptationmodelofLundetal.61describes
adecreasedactivationofthemusclesduringmovementsinwhichtheyactasagonistsandanincreasedactivation
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duringmovementsthatrequirethattheyadopttheroleofantagonists.Thesechangesinmuscleactivation,
characteristicofseveraltypesofchronicmusculoskeletalpain,aredescribedasanormalprotectiveadaptationto
avoidfurtherpainandpossibledamage.61
Thepatientspersonalandhealthhabits.Thelinkbetweendisabilityandhealthbehavior,suchasexcessive
alcoholuse,issubtlebecausetherearemanypotentialpathways.Thelinkbetweenbodyweightandboth
morbidityandmortalityhasbeenexaminedextensively,butrelativelylittleresearchhasinvestigatedtherelation
betweenbodyweightanddisability.Amongthestudiesthathaveinvestigatedthisrelation,thefindingsare
inconsistent.6265
Thepatientslevelofsocialsupport.Thefamilyistheprimaryunitofsocietyandtheoneinwhichtheearliest
andmostpowerfulsociallearningoccurs.36Theliteratureontheroleofthefamilyinthedevelopmentand
maintenanceofchronicpainanddisabilityisextensive.Dysfunctionalfamilysystemsmaypromote,permit,and
maintainchronicpainanddisability.36
Thepatientsmaritalstatus.Considerableresearchshowsthatthespousesreactioncanmodifythebehaviorof
patientswithchronicpainanddisability.36
Theextenttowhichthepatientisinvolvedinlitigationandcompensation.Fewissuesarounddisabilityhave
givenrisetomorecontroversiesthanthequestionoflitigation,compensation,andsecondarygain.Anecdotal
clinicalandlegalexperienceshowsgeneralagreementthatsomeclaimantsmagnifyorexaggeratetheirsymptoms
anddisabilitytovaryingdegreesduringthemedicalexaminationcarriedoutspecificallyforlegalproceedings.36
TheExamination
Anexaminationreferstothegatheringofinformationfromthechart,othercaregivers,thepatient,thepatientsfamily,
caretakers,andfriendsinordertoidentifyanddefinethepatientsproblem(s),andtodesignaninterventionplan.18In
addition,theexaminationallowsthecliniciantoconfirmtheirpreexaminationhypothesisregardingthepathologyand
movementdysfunctionunderlyingthepatientssymptomsanddisablement.15Incontrast,anevaluationisthelevelof
judgmentnecessarytomakesenseofthefindingsinordertoidentifyarelationshipbetweenthesymptomsreportedand
thesignsofdisturbedfunction.18
Obtainingthenecessaryinformationtodeterminetheclinicalpresentationofthepatientssymptoms,isanimportant
initialstepinthediagnosticprocess.Theinformationobtainedwillguidethephysicalexaminationforthepurposeof
identifyingspecificimpairmentsandfunctionallimitationsthatareassociatedwiththeinjury.Theexaminationisan
ongoingprocessthatbeginswiththepatientreferral,orinitialentryintothehealthsystemandcontinuesthroughoutthe
courseofrehabilitation.Duringtheexaminationphase,theclinicianhypothesizestheclinicalproblemthenchoosesand
implementsmeasurestotestthehypotheses.Theexaminationmustbeperformedinasystematicmannerwithscientific
rigorthatfollowsapredictableandstrictlyorderedthoughtprocess.Thepurposeoftheexaminationistoobtain
informationthatidentifiesandmeasuresachangefromnormal.Thisisdeterminedusinginformationrelatedbythe
patient,inconjunctionwithclinicalsignsandfindings.Theexaminationshouldnotbeviewedasanalgorithm.Rather,it
isaframeworkthathasspecificpointsthatcanbeappliedtovarioussituations.Thestrengthofanexaminationrelieson
theaccuracyofthefindingsofthetestingprocedures.Diagnostictestsaredividedintotwomaincategories:66
1.Teststhatresultinadiscreteoutcometheypermitinterpretationsfromthetestaspresent/absent,disease/not
disease,mild/moderate/severe.
2.Teststhatresultinacontinuousoutcometheyprovidedataonaninterval,orascaleofmeasurement,suchas
degreesofrangeofmotion.
Forthecliniciantoformulateanappropriateinterpretationandanaccuratefinaldiagnosis,thetestschosenmustbe
useful.Reliability,validity,andsignificanceareessentialindeterminingtheusefulnessofatest(seeEvaluation):
Reliability.Atestisconsideredreliableifitproducesprecise,accurate,andreproducibleinformation.67
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Validity.Testvalidityisdefinedasthedegreetowhichatestmeasureswhatitpurportstobemeasuring,andhowwellit
correctlyclassifiesindividualswithorwithoutaparticulardiseasecondition.6870
Significance.Thetermsignificanceisusedinstatisticstodescribetheprobabilityofsomethinghappening.
CLINICALPEARL
Theclinicianmustalwaysrememberthatmeasurementsmayappeartobeobjectivebutthattheinterpretationofany
measurementisalwayssubjective.71
Patientdiscomfortshouldalwaysbekepttoaminimum.Itisimportantthatexaminationproceduresonlybeperformed
tothepointatwhichsymptomsareprovokedorbegintoincreaseiftheyarenotpresentatrest.
Theexaminationconsistsofthreecomponentsofequalimportance:(1)patienthistory,(2)systemsreview,and(3)tests
andmeasures.18Thesethreecomponentsarecloselyrelated,inthattheyoftenoccurconcurrently.Onefurtherelement,
observation,occursthroughout.
History
Thehistorytaking,specifictoeachjoint,isdetailedineachofthechapters.Thehistoryusuallyprecedesthesystems
reviewandthetestsandmeasurescomponentsoftheexamination.Wheneveritoccurs,itshouldalwaysbeusedin
conjunctionwiththefindingsfromthesystemreviewandthetestsandmeasuresratherthanperformedinavacuum.
Oneofthepurposesofthehistory(Table41)istocollectenoughclinicaldatatoestablishadiagnostichypothesisthat
willfocustheexaminationintermsofacompletedifferentialdiagnosisatthelevelofpathology,determiningany
potentialunderlyingetiology,andprioritizingthetestsandmeasurestobeused,especiallyiftheclinicianhasagood
understandingoftheunderlyinganatomyandbiomechanics.Therehasbeenarecenttrendtoputlessemphasisonthe
historyandusetheresultsfromimagingstudiestodetermineaclinicaldiagnosis,whichisironicgiventhefactthat
muchofthesediagnostictestswouldbeunnecessaryifmoreattentionwaspaidtotheclinicalexamination.72Indeed,
multiplestudieshavedemonstratedtheincidenceofMRIabnormalitiesinthespine,73theshoulder,74theknee,75and
otherareasinnormalsubjects.Obviously,animproperdiagnosisleadstoinappropriatetreatment.
TABLE41DataGeneratedfromaPatientHistory
Includesinformationaboutthepatientsage,height,weight,andmaritalstatusandprimary
Generaldemographics
languagespokenbythepatient.a
Includesinformationaboutthepatientssocialhistory,includingsupportsystems,familyand
Socialhistoryandsocial caregiverresources,andculturalbeliefsandbehaviors.1Anindividualsresponsetopainand
habits dysfunctionis,inlargepart,determinedbyhisorherculturalbackground,socialstanding,
educationalandeconomicalstatus,andanticipationoffunctionalcompromise.b
Includesinformationaboutthepatientsoccupation,employment,andworkenvironment,
includingcurrentandpreviouscommunityandworkactivities.1Theclinicianmustdetermine
thepatientsworkdemands,theactivitiesinvolved,andtheactivitiesorposturesthatappear
tobeaggravatingtheconditionordeterminethefunctionaldemandsofaspecificvocational
Occupation/employment oravocationalactivitytowhichthepatientisplanningtoreturn.Workrelatedlowback
injuriesandrepetitivemotiondisordersoftheupperextremitiesarecommoninpatients
whoseworkplacesinvolvephysicallabor.Habitualposturesmaybethesourceoftheproblem
inthosewithsedentaryoccupations.Patientswhohavesedentaryoccupationsmayalsobeat
increasedriskofoveruseinjurieswhentheyarenotatwork,asaresultofrecreational
pursuits(theweekendwarrior).
Includesinformationaboutthepatientsdevelopmentalbackgroundandhandorfoot
Growthand dominance.Developmentalorcongenitaldisordersthattheclinicianshouldnoteincludesuch
development conditionsasLeggCalvPerthesdisease,cerebralpalsy,Downsyndrome,spinabifida,
scoliosis,andcongenitalhipdysplasia.
Theclinicianshouldbeawareofthelivingsituationofthepatient,includingentrancesand
Livingenvironment exitstothehouse,thenumberofstairs,andthelocationofbathroomswithinthehouse.
Includesinformationaboutthepatientscurrentandpriorleveloffunction,withparticular
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Functionalstatusand referencetothetypeofactivitiesperformedandthepercentageoftimespentperforming
activitylevel thoseactivities.
Itisimportantforthecliniciantodeterminewhetherthepatienthashadsuccessiveonsetsof
similarsymptomsinthepast,becauserecurrentinjurytendstohaveadetrimentaleffecton
Pasthistoryofcurrent
thepotentialforrecovery.Ifthepatientshistoryindicatesarecurrentinjury,theclinician
condition
shouldnotehowoften,andhoweasily,theinjuryhasrecurredandthesuccessorfailureof
previousinterventions.
Includesinformationwithregardtoallergies,childhoodillnesses,andprevioustrauma.In
addition,informationonanyhealthconditions,suchascardiacproblems,highbloodpressure,
ordiabetes,shouldbeelicited,asthesemayimpactexercisetolerance(cardiacproblemsand
highbloodpressure)andspeedofhealing(diabetes).Ifthesurgicalhistoryisrelatedtothe
Pastmedical/surgical
currentproblem,theclinicianshouldobtainasmuchdetailaboutthesurgeryaspossiblefrom
history
thesurgicalreport,includinganycomplications,precautions,orpostsurgicalprotocols.
Althoughthisinformationisnotalwaysrelatedtothepresentingcondition,itdoesaffordthe
cliniciansomeinsightastothepotentialimpactorresponsetheplannedinterventionmay
haveonthepatient.
Certaindiseases,suchasrheumatoidarthritis,diabetes,cardiovasculardisease,andcancer,
Familyhistoryand havefamilialtendencies.Thegeneralhealthstatusreferstoareviewofthepatientshealth
generalhealthstatus perception,physicalandpsychologicalfunction,aswellasanyspecificquestionsrelatedtoa
particularbodyregion,orcomplaint.1
aGuidetophysicaltherapistpractice.PhysTher.2001:81513595.
bJudgeRD,ZuidemaGD,FitzgeraldFT.Themedicalhistoryandphysical.In:JudgeRD,ZuidemaGD,FitzgeraldFT,
eds,ClinicalDiagnosis.4thed.Boston,MA:Little,BrownandCompany1982:919.
CLINICALPEARL
AstudybyOSheaetal.76foundthatthecorrectdiagnosisofkneeinjurieswasmadein83%ofpatientsutilizingthe
historyandphysicalexaminationalone.
Theotherpurposeofthesubjectiveexaminationistodevelopaworkingrelationshipwiththepatientandtoestablish
linesofcommunicationwiththepatient.Ideally,theinterviewofapatientshouldbeconductedinaquiet,welllitroom
thatoffersameasureofprivacy.Toencouragegoodcommunication,theclinicianandthepatientshouldbeatasimilar
eyelevel,facingeachother,withacomfortablespacebetweenthem(approximately3ft).Theclinicianmustrecordthe
historyinasystematicfashionsothateveryquestionhasapurpose,andnosubjectareasareneglected.Formal
questioningusingaquestionnaire(Table42)helpstoensurethatalloftheimportantquestionsareasked.Abodychart
(Fig.41)canbeusedtoascertainthespecificlocationandthenatureofthesymptoms.Discussingtheinformation
providedonthemedicalhistoryformwiththepatienthelpstoestablisharapportwiththepatient.Knowingthe
importanceofeachquestionisbasedonthedidacticbackgroundoftheclinician,asistheabilitytoconvertthepatients
responsesintoaworkinghypothesis.Forexample,ifthepatientreportsthatlumbarflexionrelievestheirlowbackpain,
butthatlumbarextensionaggravatesit,theclinicianneedstoknowwhichstructuresarestressedinlumbarextension,
butunstressedinlumbarflexion.
TABLE42SampleMedicalHistoryQuestionnaire
GENERALMEDICALHISTORYGENERALINFORMATION
PhysicianDiagnosis:_____________________ Date:____________________
LastName_____________________ FirstName____________________
Theinformationrequestedmaybeneededifyouhaveamedicalemergency.
______________________________________________________________
Persontobenotifiedinemergency____________Phone___________________Relationship____________
Areyoucurrentlyworking?(Y)or(N)Typeofwork:Ifnot,why?
GENERALMEDICALHISTORY
Pleasecheck()ifyouhavebeentreatedfor:
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()Heartproblems ()Lungdisease/problems

()Faintingordizziness ()Arthritis
()Shortnessofbreath
()Swollenandpainfuljoints
()Calfpainwithexercise ()Irregularheartbeat
()Severeheadaches
()Stomachpainsorulcers
()Recentaccident ()Painwithcoughorsneeze

()Headtrauma/concussion ()Backorneckinjuries
()Muscularweakness ()Diabetes
()Cancer ()Stroke(s)

()Jointdislocation(s)
()Balanceproblems
()Brokenbone
()Muscularpainwithactivity

()Difficultysleeping ()Swollenanklesorlegs
()Frequentfalls ()Jawproblems

()Unexplainedweightloss
()Circulatoryproblems
()Tremors
()Epilepsy/seizures/convulsions

()Highbloodpressure(hypertension) ()Chestpainorpressureatrest
()Kidneydisease ()Allergies(latex,medication,food)
()Liverdisease ()Constantpainunrelievedbyrest

()Weaknessorfatigue ()Pregnancy
()Hernias
()Nightpain(whilesleeping)

()Blurredvision ()Nervousoremotionalproblems

()Bowel/bladderproblems
()Anyinfectiousdisease(TB,AIDS,hepatitis)
()Difficultyswallowing ()Tingling,numbness,orlossoffeeling?Ifyes,
()Awoundthatdoesnotheal where?
()Unusualskincoloration
()Constantpainorpressureduringactivity
Doyouusetobacco?(Y)or(N) Ifyes,howmuch?
Areyoupresentlytakinganymedicationsordrugs?(Y)or
(N)
Ifyes,whatareyoutakingthemfor?
1.Pain
Onthelineprovided,markwhereyourpainstatusistoday.
_________________________________________________________________
Nopain Mostseverepain
2.Function.Onascaleof010with0beingabletoperformallofyournormaldailyactivities,and10beingunableto
performanyofyournormaldailyactivities,giveyourselfascoreforyourcurrentabilitytoperformyouractivitiesof
dailyliving._________________
Pleaselistanymajorsurgeryorhospitalization:
Hospital:__________________Approx.Date:____________________
Reasons:
Hospital:__________________Approx.Date:____________________
Reasons:
Haveyourecentlyhadanxray,MRI,orCTscanforyourcondition?(Y)or(N)
Facility:__________________Approx.Date:____________________
Findings:_______________________
Pleasementionanyadditionalproblemsorsymptomsyoufeelareimportant:
________________________________________________
Haveyoubeenevaluatedand/ortreatedbyanotherphysician,physicaltherapist,chiropractor,osteopath,orhealthcare
practitionerforthiscondition?(Y)or(N)Ifyes,pleasecirclewhichone.
FIGURE41
Bodychart.
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Atransferofaccurateinformationmustoccurbetweenthepatientandtheclinician.Themethodofquestioningshould
bealteredfrompatienttopatient,asthelevelofunderstandingandansweringabilitiesvariesbetweeneachindividual.
Ingeneral,theinterviewshouldflowasanactiveconversation,notaquestionandanswersession.Asuccessfullearning
processrequiresthecliniciantohavepatience,focus,andselfcriticism.6
Openendedquestionsorstatements,suchasTellmewhyyouareheretoday,areusedinitiallytoencouragethe
patienttoprovidenarrativeinformation,helpdeterminethepatientschiefcomplaint,andtodecreasetheopportunityfor
biasonthepartoftheclinician.77Morespecificquestions,suchasHowdidthispainbegin?areaskedasthe
examinationproceeds(Table43).Thespecificquestionshelptofocustheexaminationanddeterirrelevantinformation.
Theclinicianshouldprovidethepatientwithencouragingresponses,suchasanodofthehead,whentheinformationis
relevantandwhenneededtosteerthepatientintosupplyingthenecessaryinformation.Neutralquestionsshouldbe
usedwheneverpossible.Thesequestionsarestructuredinsuchawaysoastoavoidleadingthepatientintogivinga
particularresponse.Leadingquestions,suchasDoesithurtmorewhenyouwalk?shouldbeavoided.Amoreneutral
questionwouldbe,Whatactivitiesmakeyoursymptomsworse?
TABLE43ContentsoftheHistory
HistoryofCurrentCondition
Didtheconditionbegininsidiouslyorwastraumainvolved?
Howlonghasthepatienthadthesymptoms?
Wherearethesymptoms?
Howdoesthepatientdescribethesymptoms?
Reportsaboutnumbnessandtinglingsuggestneurologiccompromise.Reportsofpainsuggestachemicalor
mechanicalirritant.Painneedstobecarefullyevaluatedintermsofitssite,distribution,quality,onset,frequency,
nocturnaloccurrence,aggravatingfactors,andrelievingfactors.
PastHistoryofCurrentCondition
Hasthepatienthadasimilarinjuryinthepast?
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Wasittreatedordiditresolveonitsown?Ifitwastreated,howwasittreatedanddidinterventionhelp?
Howlongdidthemostrecentepisodelast?
PastMedical/SurgeryHistory
Howisthepatient'sgeneralhealth?
Doesthepatienthaveanyallergies?
MedicationsPatientisPresentlyTaking
OtherTestsandMeasures
Hasthepatienthadanyimagingtestssuchasxray,MRI,CTscan,bonescan?
HasthepatienthadanEMGtest,oranerveconductionvelocitytest,whichwouldsuggestcompromisetomuscle
tissueand/orneurologicsystem?
SocialHabits(PastandPresent)
Doesthepatientsmoke?Ifso,howmanypacksperday?
Doesthepatientdrinkalcohol?Ifso,howoftenandhowmuch?
Isthepatientactiveorsedentary?
SocialHistory
Isthepatientmarried,livingwithapartner,single,divorced,orwidowed?
Isthepatientaparentorsingleparent?
FamilyHistory
Isthereafamilyhistoryofthepresentcondition?
GrowthandDevelopment
Isthepatientrightorlefthanded?
Werethereanycongenitalproblems?
LivingEnvironment
Whattypeofhomedoesthepatientliveinwithreferencetoaccessibility?
Isthereanysupportathome?
Doesthepatientuseanyextrapillowsorspecialchairstosleep?
Occupation/Employment/School
Whatdoesthepatientdoforwork?
Howlonghasheorsheworkedthere?
Whatdoesthejobentailintermsofphysicalrequirements?
Whatlevelofeducationdidthepatientachieve?
FunctionalStatus/ActivityLevel
Howdoesthepresentconditionaffectthepatient'sabilitytoperformactivitiesofdailyliving?
Howdoesthepresentconditionaffectthepatientatwork?
Howdoesthepatient'sconditionaffectsleep?
Isthepatientabletodrive?Ifso,forhowlong?
CT,computedtomographyEMG,electromyogramMRI,magneticresonanceimaging.
DatafromClarnetteRG,MiniaciA.Clinicalexamoftheshoulder.MedSciSportsExerc.1998:3016.
InadditiontothedetailslistedinTable43,thehistorycanhelptheclinicianto:
1.determinethechiefcomplaint,itsmechanismofinjury,itsseverity,anditsimpactonthepatientsfunction.Itis
worthrememberingthatapatientschiefcomplaintcansometimesdifferfromthechiefconcern,butbothshould
beaddressed.
2.determinetheirritabilityofthesymptoms.Irritabilityistheamountofactivitynecessarytocausesymptom
worseningorimprovement.15
3.establishabaselineofmeasurements.
4.ascertainwhichmedicationsthepatientiscurrentlytakingandwhethertheyareprescribedoroverthecounter
(seeChapter9).
5.elicitinformationaboutthepasthistoryofthecurrentcondition.
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6.determinethegoalsandtheexpectationsofthepatientfromthephysicaltherapyintervention.Itisimportantthat
theclinicianandthepatientdiscussanddeterminemutuallyagreeduponanticipatedgoalsandexpected
outcomes.Thediscussioncanhelpthecliniciandeterminewhetherthepatienthasrealisticexpectationsorwill
needfurtherpatienteducationconcerninghisorherconditionandtypicalrecoverytimeframes.
CLINICALPEARL
Itisimportanttorememberthatsymptomscanbeexperiencedwithoutthepresenceofrecognizedclinicalsignsandthat
signscanbepresentintheabsenceofsymptoms.Theformerscenarioismorecommon,butthelattercanoccurwhena
pathologicreflexorpositivecranialnervetest(seeChapter3)isdetectedintheabsenceofanysubjectivecomplaints.In
suchascenario,apositivefindingcouldbeafalsepositiveresult,oritcouldbeprognostic.4
elicitreportsofpotentiallylifethreateningsymptoms,orredflags,thatrequireanimmediatemedicalreferral(see
Chapter5).Examplesincludereportsofpainmadeworsebyrestbutbetterwithactivity,feverorchills,anda
suddenorinsidiousonsetofsymptoms.
Therearekeyquestionsineverysubjectiveexaminationofinquiriesregarding:78
thepatientsage,generalhealth,andmedications
themodeofonsetofsymptoms
thelocationandbehaviorofsymptoms,suchasaggravatingandrelievingfactors
theresultsofanyimagingstudies
theimpactofthepatientspain/symptomsonsleeping
thepatientscurrentoccupation/leisure/sportsactivitiesanddesiredlevelsofactivitiesandgoalsand
thepatientsthoughts,beliefs,andfeelingsaroundtheirproblem.
Age,Ethnicity,Gender,Morphology,andFamilyHistory
Certainconditionsarerelatedtoage,ethnicity,gender,morphology,andfamilyhistory.Forexample,
Degenerativeandoverusesyndromesaremorefrequentintheover40agegroup.
Cervicalspondylosisisoftenseeninpersons25yearsofageorolder,anditispresentin60%ofthoseolderthan
45yearsand85%ofthoseolderthan65yearsofage.7981
Theonsetofankylosingspondylitisoftenoccursbetweentheagesof15and35years.82
Bothosteoporosisandosteoarthritisaremoreoftenassociatedwiththeolderpopulation.
DiseasessuchasLeggPerthesdiseaseorScheuermannsareseeninadolescentsorteenagers.
Prostatecancerhasahigherincidenceinmenolderthan50yearsofage.83
AmongAfricanAmericansintheUnitedStates,1in600hassicklecellanemia.84
CaucasiansexperiencehigherosteoporoticfractureratesthaneitherAsiansorAfricanAmericans.85
Somediseases,suchashypertensionandrenaldisease,aremoreprevalentinAfricanAmericanpopulationsthan
amongCaucasians.86,87
BasalcellcarcinomaandmelanomaaremorecommonamongCaucasians.
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Themaletofemaleratioofbladdercanceris2:1to4:1andthediseaseistwiceascommoninmaleCaucasiansas
inAfricanAmericanmenintheUnitedStates.88,89
Breastcanceristhemostfrequentlydiagnosedcancerandthesecondleadingcauseofcancerrelateddeaths
amongwomenintheUnitedStates.90
Melanomaistheleadingcauseofcancerdeathinwomenaged2536years.91
Anteriorkneepaincausedbypatellofemoralsyndromeismostcommoninyoungteenagegirlsandyoungmenin
their20s.92
Obesityhasbeenlinkedtomanydiseasessuchasdiabetes,cardiovasculardisease,anddegenerativejointdisease.
Manydiseasescanbelinkedtofamilyhistory,includingdiabetes,cardiovasculardisease,andCharcotMarie
Toothdisease.
ModeofOnsetofCurrentCondition
Thisportionofthehistorytakingcanprovetobethemostchallengingasitinvolvesthegatheringofbothpositiveand
negativefindings,followedbythedisseminationoftheinformationintoaworkinghypothesis.Anunderstandingofthe
patientshistoryofthecurrentconditioncanoftenhelpdeterminetheprognosisandguidetheintervention.
Theclinicianshoulddeterminethecircumstancesandmannerinwhichthesymptomsbeganandtheprogressionof
thosesymptoms.6Theonsetandduration(stage)ofsymptomsprovideclinicianswithinformationastowhetherthe
injuryisacuteorchronic.Thisinformationisveryimportantinthatthemechanismsofacertaininjurymaybesimilar
however,thetimeassociatedwithsymptompresentationmaydiffersignificantly.93Forexample,anacutemusclestrain
injurythatoccursduringasportwillpresentwithimmediatepainandaneasilyidentifiablemechanism.Conversely,a
musclestraininjurythatoccursthroughanoverusemechanismmaypresentinsidiously.93Establishingasymptom
timelinecanhelpthecliniciancollectinformationaboutthedurationofsymptoms.94Thesymptomtimelineisabrief
descriptionthatlistsanysignificanteventduringthecourseofthepatientssymptomssuchasthenumberoftimesthat
thesymptomsimproved,thenumberoftimesthatthesymptomsworsen,anyinterventionsthatweretried,andanyvisits
tohealthcareprovidersthatoccurred.15
Themodeofonset,orthemechanismofinjury,isusuallyeitheramajortraumaticeventoverashortperiodoftime,
suchasafallormotorvehicleaccident(macrotraumatic),oraseriesofminortraumaticeventsoveraprolongedperiod
oftime,suchasthehabitualuseofalifting/sitting/trainingtechnique(microtraumatic)eitherofwhichcangivecluesas
totheextentandnatureofthedamagecaused.However,itisimportanttorememberthatthepatientsdescriptionof
injurymechanismshouldbeinterpretedwithcautionbecausethemechanismascribedtotheonsetofsymptomscouldbe
falselyassumed,causingthecliniciantooverlookthepresenceofananotherpathology.15
Iftheinjuryistraumatic,theclinicianshoulddeterminethetimeofonset,andthespecificmechanismintermsofboth
thedirectionandtheforce,andrelatethetimeandmechanismtothepresentingsymptoms.Iftheinjuryisrecent,an
inflammatorysourceofpainislikely.Asuddenonsetofpain,associatedwithtrauma,couldindicatethepresenceofan
acuteinjurysuchasasofttissuetearorevenafracture,whereasimmediatepainandlockingaremostlikelytoresult
fromanintraarticularblock.Jointlockingandtwingesofpainmayindicatealoosebodyismovingwithinthejoint.
Reportsofajointgivingwayusuallyindicatejointinstability,orareflexinhibitionorweaknessofmuscles.Aninjury
thatisnotrecentbutwhichthesymptomshavepersistedcouldindicateabiomechanicaldysfunction.Oftentimesa
particularmotionorposturemaycontinuetoaggravatethecondition.
Iftheonsetisgradualorinsidious,theclinicianmustdetermineifthereareanypredisposingfactors,suchaschangesin
thepatientsdailyroutinesorexerciseprograms.Symptomsofpain,orlimitationsofmovement,withnoapparent
reason,areusuallyaresultofinflammation,earlydegeneration,repetitiveactivity(microtrauma),orsustained
positioningandpostures.95However,suchsymptomsmayalsobeassociatedwithsomethingmoreserious,suchasa
vascularinsufficiency,atumor,oraninfection.
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Ifpainispresent,thecliniciansmajorfocusshouldbetoseekthecauseandmethodstocontrolit.Painmaybe
constant,variable,orintermittent.
Variablepainispainthatisperpetual,butthatvariesinintensity.Variablepainusuallyindicatestheinvolvement
ofbothachemicalandamechanicalsource.Themechanicalcauseofconstantpainislessunderstoodbutis
thoughttobetheresultofthedeformationofcollagen,whichcompressesorstretchesthenociceptivefreenerve
endings,withtheexcessiveforcesbeingperceivedaspain.96Thus,specificmovementsorpositionsshould
influencepainofamechanicalnature.
Chemical,orinflammatory,painismoreconstantandislessaffectedbymovementsorpositionsthanmechanical
pain.
Intermittentpainisunlikelytobecausedbyachemicalirritant.Usually,thistypeofpainiscausedbyprolonged
postures,alooseintraarticularbody,oranimpingementofamusculoskeletalstructure.
CLINICALPEARL
Constantpainfollowinganinjurycontinuesuntilthehealingprocesshassufficientlyreducedtheconcentrationof
noxiousirritants.
Unfortunately,thesourceofthepainisnotalwayseasytoidentify,becausemostpatientspresentwithbothmechanical
andchemicalpain.
Finally,theclinicianshoulddetermineifthisisthefirstepisoderequiringtreatment,orifaspecificinterventionhas
beenusedinthepastforthesameconditionand,ifso,theclinicianshouldaskabouttheeffectivenessofthat
intervention.Ifitisarepeatepisode,theclinicianshouldascertainhowlongittooktorecoverfromthepreviousone,
andwhattherapywasbeneficialifany.
Location
Theclinicianshoulddeterminethelocationofthesymptomsbecausethiscanindicatewhichareasneedtobeincluded
inthephysicalexamination.However,itmustberememberedthatthelocationofsymptomsformanymusculoskeletal
conditionsisquiteseparatefromthesource,especiallyinthoseperipheraljointsthataremoreproximal,suchasthe
shoulderandthehip.Forexample,acervicaldysfunctioncanproducesymptomsthroughouttheupperextremity.The
termreferredisusedtodescribesymptomsthathavetheiroriginatasiteotherthanwherethepatientfeelsthe
symptoms(seeChapter3).Forexample,painduetoosteoarthritisofthehipisoftenfeltintheanteriorgroinandthigh.
Thetermradicularisusedtodescribethedistributionofsymptomsassociatedwithnerverootcompression,inwhich
thesymptomsradiatefromthesource.Forexample,apatientwhohasacompressedspinalnerveinthecervicalspine
mayfeelthesymptomsintheneckandthroughoutcertainareasintheupperextremity.Theconceptsofreferredand
radicularsymptomsareoftendifficultforapatienttounderstand,soitisimportantthattheclinicianprovidean
explanationsothatthepatienthasabetterunderstandingandcananswerquestionsaboutsymptomstheymight
otherwisehavefeltirrelevant.
Informationabouthowthelocationofthesymptomshaschangedsincetheonsetcanindicatewhetheraconditionis
worseningorimproving.Ingeneral,asaconditionworsens,thepaindistributionbecomesmorewidespreadanddistal
(peripheralized).Astheconditionimproves,thesymptomstendtobecomemorelocalized(centralized).Abodychart
maybeusedtorecordthelocationofsymptoms(seeFig.41).
CLINICALPEARL
Symptomsthataredistalandsuperficialareeasierforthepatienttospecificallylocalizethanthosethatareproximaland
deep.
Iftheextremityappearstobethesourceofthesymptoms,theclinicianshouldattempttoreproducethesymptomsby
loadingtheperipheraltissues.Ifthisprovesunsuccessful,afullinvestigationofthespinalstructuresmustensue.
BehaviorofSymptoms
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Thepresenceofpainshouldnotalwaysbeviewednegativelybytheclinician.Afterall,itspresencehelpstodetermine
thelocationoftheinjury,anditsbehavioraidstheclinicianindeterminingthestageofhealingandtheimpactithason
thepatientsfunction.Forexample,whetherthepainisworsening,improving,orunchangingprovidesinformationon
theeffectivenessofanintervention.Inaddition,agradualincreaseintheintensityofthesymptomsovertimemay
indicatetotheclinicianthattheconditionisworseningorthattheconditionisnonmusculoskeletalinnature(Table4
4).6,97
TABLE44DifferentiationBetweenMusculoskeletalandSystemicPain
MusculoskeletalPain SystemicPain
Usuallydecreaseswithcessationofactivity Reducedbypressure
Generallylessensatnight Disturbssleep
Aggravatedwithmechanicalstress Notaggravatedbymechanicalstress
Usuallycontinuousorintermittent Usuallyconstantorinwaves
DatafromMeadowsJ.OrthopaedicDifferentialDiagnosisinPhysicalTherapy.NewYork,NY:McGrawHill1999.
Maitland7introducedtheconceptofthedegreeofirritability.Anirritablestructurehasthefollowingcharacteristics:
Aprogressiveincreaseintheseverityofthepainorsymptomswithmovementoraspecificposture.Anabilityto
reproduceconstantpainwithaspecificmotionorpostureindicatesanirritablestructure.
Symptomsincreasedwithminimalactivity.Anirritablestructureisonethatrequiresverylittletoincreasethe
symptoms.
Increasedlatentresponseofsymptoms.Symptomsthatdonotresolvewithinafewminutesfollowingamovement
orpostureindicateanirritablestructure.
AccordingtoMcKenzieandMay,95theinterventionforthepatientwhosesymptomshavealowdegreeofirritability,
andwhicharegraduallyresolving,shouldfocusonlyoneducationinitially.However,iftheimprovementceases,a
mechanicalinterventionmaythenbenecessary.95
Thefrequencyanddurationofthepatientssymptomscanhelpthecliniciantoclassifytheinjuryaccordingtoitsstage
ofhealing:acute(inflammatory),subacute(migratoryandproliferative),andchronic(remodeling)(Table45)(see
Chapter2).
TABLE45StagesofHealing
Stage GeneralCharacteristics
Areaisred,warm,swollen,andpainful.Painispresentwithoutanymotion
Acuteorinflammatory
ofinvolvedarea
Subacuteortissueformation
Painusuallyoccurswithactivityormotionofinvolvedarea
(neovascularization)
Chronicorremodeling Painusuallyoccursaftertheactivity
Acuteconditions:typicallypresentfor710days.
Subacuteconditions:typicallypresentfor10daystoseveralweeks.
Chronicconditions:typicallypresentformorethanseveralweeks.
Inthecaseofamusculoskeletalinjurythathasbeenpresentwithoutanyformalinterventionforafewmonths,thereisa
goodpossibilitythatadaptiveshorteningofthehealingcollagenoustissuehasoccurred,whichmayresultinafailureto
heal,andthepersistenceofsymptoms.95Thepersistenceofsymptomsusuallyindicatesapoorerprognosis,asitmay
indicatethepresenceofachronicpainsyndrome.Chronicpainsyndromeshavethepotentialtocomplicatethe
interventionprocess(seeChapters2and5).95
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Ifthefrequencyanddurationofthepatientssymptomsarereportedtobeincreasing,itislikelytheconditionis
worsening.Conversely,adecreaseinthefrequencyanddurationofthesymptomsgenerallyindicatethattheconditionis
improving.
Oneofthesimplestmethodstoquantifytheintensityofpainistousea10pointvisualanalogscale(VAS).TheVASis
anumericallycontinuousscalethatrequiresthepainlevelbeidentifiedbymakingamarkona100mmline,orby
circlingtheappropriatenumberina110series(Table46).98Thepatientisaskedtoratehisorherpresentpain
comparedwiththeworstpaineverexperienced,with0representingnopain,1representingpainthatisminimally
perceived,and10representingpainthatrequiresimmediateattention.99
TABLE46PatientPainEvaluationForm
Name:
_________________________________________________________________________________________________
Date:_____________________________ Signature:________________________
Pleaseusethethreescalesbelowtorateyourpainoverthepast24hours.Usetheupperlinetodescribeyourpainlevel
rightnow.
Usetheotherscalestorateyourpainatitsworstandbestoverthepast24hours.
RATEYOURPAIN:0=NOPAIN,10=EXTREMELYINTENSE
1. Rightnow 0 1 2 3 4 5 6 7 8 9 10
2. Atitsworst 0 1 2 3 4 5 6 7 8 9 10
3. Atitsbest 0 1 2 3 4 5 6 7 8 9 10
Ifthebehaviorofthesymptomsincludeslockingorgivingway,theclinicianmustelicitfurtherdetailsaboutthecauses
ofthehypomobility,thehypermobility,ortheinstability(seeChapter2).
AggravatingandEasingFactors
Ofparticularimportancearethepatientschiefcomplaintandtherelationshipofthatcomplainttospecificaggravating
activitiesorpostures,asthesemaypointtothetissueoforiginforsymptoms.Questionsmustbeaskedtodetermine
whetherthepainissufficienttopreventsleeportowakethepatientatnight,andtheeffectthatactivitiesofdailyliving,
work,sex,andsoforth,haveonthepain.
Musculoskeletalconditionsaretypicallyaggravatedbymovementandalleviatedwithrest.Morespecifically,
musculotendinousstructuresmaygeneratepainwitheithershorteningorlengtheningwhilenoncontractiletissuesmay
generatepainwithlengthening.15Ifnoactivitiesorposturesarereportedtoaggravatethesymptoms,theclinicianneeds
toprobeformoreinformation.Forexample,ifapatientcomplainsofbackpain,theclinicianneedstodeterminethe
effectthatwalking,bending,sleepingposition,prolongedstanding,andsittinghaveonthesymptoms.Sittingor
standinguprightincreasesthelumbarlordosisandcanaggravatesymptomsinapatientwithananteriorinstabilityofthe
lumbarspine,spondylolisthesis,stenosis,oralumbarzygapophysealjointirritation.Sittinginaslouchedposture
typicallyaggravatessymptomsofalumbardiskprotrusionorasacroiliacjointdysfunction.Nonmechanicaleventsthat
provokethesymptomscouldindicateanonmusculoskeletalsourceforthepain:97
Eating.Painthatincreaseswitheatingmaysuggestgastrointestinal(GI)involvement.
Stress.Anincreaseinoverallmuscletensionpreventsmusclesfromresting.
Cyclicalpain.Cyclicalpaincanoftenberelatedtosystemicevents(e.g.,menstrualpain).
Ifaggravatingmovementsorpositionshavebeenreported,theyshouldbetestedattheendofthetestsandmeasures
portionoftheexaminationtoavoidanyoverflowofsymptoms,whichcouldconfusetheclinician.
CLINICALPEARL
Anyrelievingfactorsreportedbythepatientcanoftenprovidesufficientinformationtoassisttheclinicianwiththe
interventionplan.
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NatureoftheSymptoms
Naturereferstothepatientsdescriptionofsymptoms.15Itisimportanttorememberthatpainperceptionishighly
subjectiveandisdeterminedbyanumberoffactors.Theclinicianmustdeterminewhetherpainistheonlysymptom,or
whetherthereareothersymptomsthataccompanythepain,suchasbowelandbladderchanges,tingling(paresthesia),
radicularpainornumbness,weakness,andincreasedsweating.
Bowelorbladderdysfunction.Thisfindingusuallyindicatesacompromise(compression)ofthecaudaequina.
Paresthesia.Peripheralneuropathiescanmanifestasabnormal,frequentlyunpleasantsensations,whichapatient
mayvariouslydescribeasnumbness,pinsandneedles,andtingling.100Whenthesesensationsoccur
spontaneouslywithoutanexternalsensorystimulus,theyarecalledparesthesias(Table47).100Patientswith
paresthesiastypicallydemonstrateareductionintheperceptionofcutaneousandproprioceptivesensations.The
seriousnessoftheparesthesiadependsonitsdistribution.Althoughcomplaintsofparesthesiacanbetheresultof
arelativelybenignimpingementofaperipheralnerve(seeChapter3),thereasonsforitspresencecanvaryin
severityandseriousness.
Radicularpain.Thistypeofpainisproducedbynerverootirritationandistypicallydescribedassharpor
shooting.Anynumbnessthathasadermatomalpatternindicatesspinalnerverootcompression.Radiatingpain
referstoanincreaseinpainintensityanddistribution.Radiatingpaintypicallytravelsdistallyfromthesiteofthe
injury.
Weakness.Anyweaknessshouldbeinvestigatedbythecliniciantodeterminewhetheritistheresultofspinal
nerverootcompression,peripheralnervelesion,disuse,inhibitionresultingfrompainorswelling,injurytothe
contractileorinerttissues(muscle,tendon,bursa,etc.),oramoreseriouspathologysuchasafracture(seesection
MusclePerformance:Strength,Power,andEnduranceinthelaterdiscussionoftestsandmeasures).
Increasedsweating.Thisfindingcanhaveamyriadofcauses,rangingfromincreasedbodytemperature,asa
resultofexertion,fever,apprehension,andcompromise,totheautonomicsystem.Nightsweatsareofparticular
concernbecausetheyoftenindicatethepresenceofasystemicproblem.101
TABLE47CausesofParesthesia
ParesthesiaLocation ProbableCause
Lip(perioral) Vertebralarteryocclusion
Bilaterallowerorbilateralupperextremities Centralprotrusionofdiskimpingingonspine
Allextremitiessimultaneously Spinalcordcompression
Onehalfofbody Cerebralhemisphere
Segmental(indermatomalpattern) Diskornerveroot
Gloveandstockingdistribution Diabetesmellitusneuropathyandleadormercurypoisoning
Halfoffaceandoppositehalfofbody Brainstemimpairment
QualityofSymptoms
Thequalityofthesymptomsdependsonthetypeofreceptorbeingstimulated(seeChapter3).
StimulationofthecutaneousAnociceptorsleadstoprickingpain.102
StimulationofthecutaneousCnociceptorsresultsinburningordullpain.103
Activationofthenociceptorsinmusclebyelectricalstimulationproducesachingpain.104
Electricalstimulationofvisceralnervesatlowintensitiesresultsinvaguesensationsoffullnessandnausea,but
higherintensitiescauseasensationofpain.105
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Becausemotorandsensoryaxonsruninthesamenerves,disordersoftheperipheralnerves(neuropathies)usuallyaffect
bothmotorandsensoryfunctions(seeChapter2).
Motivationalaffectivecircuitsmayalsomimicpainstates,mostnotablyinpatientswithanxiety,neuroticdepression,or
hysteria.106ThemnemonicMADISONoutlinesthebehavioralindicatorsthatsuggestmotivationalaffective
pain107,108:
1.Multiplecomplaints,includingcomplaintsaboutunrelatedbodyparts.
2.Authenticityclaimsinanattempttoconvincetheclinicianthatthesymptomsexist.
3.Denialofthenegativeeffectthepainishavingonoverallfunction.
4.Interpersonalvariability,manifestedbydifferentcomplaintstodifferentcliniciansorsupportstaff.
5.Singularityofsymptoms,whereinthepatientrequestsspecialconsiderationbecauseofhisorhertypeandlevelof
pain.
6.Onlyyou,wherebytheclinicianisplacedataspeciallevelofexpertise.
7.Nothingworks.Thisisoftenasourceoffrustrationandselfdoubtonthepartoftheclinician.
Adescriptionofpainiscommonlysoughtfromthepatient.Becausepainisvariableinitsintensityandquality,
describingthepainisoftendifficultforthepatient.TheMcGillPainQuestionnaire(MPQ)109wasthefirstsystematic
attempttouseverbaldescriptorstoassessthequalityofthepatientssymptoms,andhasbeenthemostwidelyused
instrumentinpainresearchandpractice(Table48).TheMPQisaninventoryof78paindescriptorsdistributedacross
20subcategories(with6additionaldescriptorsinthepresentpainindex).Thesubcategoriesarefurthergroupedinto
threebroadcategories,termedsensory,affective,andevaluative,respectively,inadditiontoamiscellaneouscategory.
Theimplicationisthateachwordreflectsaparticularsensoryqualityofpain.
TABLE48ModifiedMcGillPainQuestionnaire
PatientsName________________________________________________________Date_____________________
Directions:Manywordscandescribepain.Someofthesewordsarelistedbelow.Ifyouareexperiencinganypain,
check()everywordthatdescribesyourpain.
Flickering
Quivering
Pulsing
A.
Throbbing
Beating
Pounding
Jumping
B. Flashing
Shooting
Pricking
Boring
C.
Drilling
Stabbing
Sharp
D. Cutting
Lacerating
Pinching
Pressing
E. Gnawing
Cramping
Crushing
Tugging
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F. Pulling
Wrenching
Hot
Burning
G.
Scalding
Searing
Tingling
Itchy
H.
Smarting
Stinging
Dull
Sore
I. Hurting
Aching
Heavy
Tender
Taut
J.
Rasping
Splitting
Tiring
K.
Exhausting
Sickening
L.
Suffocating
Fearful
M. Frightful
Terrifying
Punishing
Grueling
N. Cruel
Vicious
Killing
Wretched
O.
Blinding
Annoying
Troublesome
P.
Intense
Unbearable
Spreading
Radiating
Q.
Penetrating
Piercing
Tight
Numb
R. Drawing
Squeezing
Tearing
Cool
S. Cold
Freezing
Nagging
Nauseating
T. Agonizing
Dreadful
Torturing
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KEYTOPAINQUESTIONNAIRE
GroupA:Suggestsvasculardisorder
GroupsBH:Suggestsneurogenicdisorder
GroupI:Suggestsmusculoskeletaldisorder
GroupsJT:Suggestsemotionaldisorder
SCORINGGUIDE:ADDUPTOTALNUMBEROFCHECKS():
Total:48=NORMAL
810=Focusingtoomuchonpain
1016=Maybehelpedmorebyaclinicalpsychologistthanbyaphysicaltherapist
>16=Unlikelytorespondtotherapyprocedures
Thepatientisaskedtoindicateonabodydiagramthelocationofthepainandtoratehisorhersymptomsbasedonthe
20categoriesofverbaldescriptorsofpain.110The20categoriesarerankedaccordingtoseverity.111Thepatientisthen
askedtodescribehowthepainchangeswithtime(continuous,rhythmic,orbrief)andhowstrongthepainis(mild,
discomforting,distressing,horrible,orexcruciating).
ThemostcommonlyreportedmeasuretheMPQinstrumentprovides,thepainratingindextotal,givesanestimateof
overallpainintensity.Thismeasure,obtainedbysummingallthedescriptorsselectedfromthe20subclasses,hasa
possiblerangeof078.Separatescoresforeachclassmaybeobtainedbysummingthevaluesassociatedwiththewords
selectedfromsubclassesthatcomprisethatdimension.Scoresforeachofthesedimensionsvaryinrangefrom0to42
forthesensoryclass,0to14fortheaffectiveclass,and0to5fortheevaluativeclass(seeTable48fortheScoring
Guide).
ThestrengthoftheMPQisitsabilitytodistinguishpatientswithasensorypainexperiencefromthosewhohavean
affectivepainexperience.TheMPQhasbeenfoundtobesensitivetointerventioneffects112andtohaveahightest
retestreliability109andgoodconstructvalidity.113
Symptommagnification,anexaggeratedsubjectiveresponsetosymptomsintheabsenceofadequateobjectivefindings,
isanincreasinglycommonoccurrenceintheclinic.Thepatientswhodisplaythistypeofbehaviorareadifficult
populationtodealwith.Thecausesofsymptommagnificationcanbecategorizedintotwomainpatienttypes:
1.Patientswithapsychosomaticoverlayandthosewhosesymptomshaveapsychogeniccause.
2.Patientswhoareinvolvedinlitigation.
TheconceptofmalingeringisdiscussedinChapter5.
PatientGoals
Theclinicianshoulddeterminewhatlevelofphysicalactivityisrequiredbythepatient.Specifically,whatarethe
requirementsforworkandleisure,andsport?Inaddition,theclinicianshouldaskthepatientabouthisorhercurrent
levelofactivityanddeterminethetypeofactivity,frequency,andintensity,andhowtheresponsescomparewiththe
answersfromthepreviousquestion.Finally,theclinicianshouldascertainwhatthepatientstherapygoalsare.For
example,askingasimplequestionlikeArethereanythingsyouwouldliketodobutarenotdoingbecauseofyour
painorinjury?
ImagingStudies
Itisimportantforthecliniciantodeterminewhetherthepatienthasundergoneanyimagingstudiesand,ifso,theresults
ofthosestudies.TherolethatimagingstudiesplayintheexaminationandevaluationprocessesisoutlinedinChapter7.
Itisimportanttorememberthat,ingeneral,imagingtestshaveahighsensitivity(fewfalsenegatives)butlow
specificity(highfalsepositiverate),soarethususedintheclinicaldecisionmakingprocesstotestahypothesis,but
shouldnotbeusedinisolation.
Basedonthehistory,theremaybetimeswhentheextentoftheremainderoftheexaminationmayhavetobelimited.
Thedecisiontolimittheexaminationisbasedonthepresenceofanysubjectivefeaturesthatindicatetheneedfor
caution(seeSystemsReview).Thesefeaturesinclude114:
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1.anirritableorseveredisorder
2.worseningsymptoms
3.subjectiveevidenceofthepotentialinvolvementofvitalstructures,suchasthevertebrobasilarsystem,thespinal
cordorthecentralnervoussystem(CNS),orthespinalnerveroots
4.symptomsthatdonotbehaveinapredictablemanner.
Observation
Observationalinformationformsthebasisoftheearlyclinicalimpression.Itis,inessence,thebeginningoftheclinical
searchforpatientconsistencyandreliability.Observationofthepatientbeginswhenthepatiententerstheclinic.Asthe
cliniciangreetsthepatientandtakeshimorhertothetreatmentroom,aninitialobservationismade.Thisearly
observationcanprovidetheclinicianwithinformationthatincludes,butisnotlimitedto,howthepatientholdsthe
extremity,whetheranantalgicgaitispresent,andhowmuchdiscomfortappearstobepresent.Themoreformal
observationofeachbodyareaisincludedineachoftherelevantchapters.Muchcanbelearnedfromthorough
observation115:
Howdoesthepatientarisefromaseatedpositiontogreettheclinician,easilyorinaguardedmanner?
Doesthepatientlookdirectlyintotheeyesoftheclinicianorlookaway?Isthereanervousnessorfearpresent?
Isthereanexaggeratedpainresponse,asdemonstratedbyfacialexpressionand/orvoicedcomplaints?
Doesthepatientsittothesidewiththemajorityofweightononebuttockwhiletheoppositelegisextended,a
positionassociatedwithalumbarspinalnerverootsyndrome?116118
Inthecaseofanadult,isaspouse,orsignificantother,inattendanceanddoessuchapresenceseemappropriate?
Ifthepresenceappearsinappropriate(signsoffear,questionsalwaysansweredbythespouse/significantother,
overlyattentivespouse/significantother,etc.),someformofabuseoccurringathomeshouldbesuspected.
Inthecaseofachild,isthereanyunexplainedorexcessivebruising,anddoestheparentorguardianappeartobe
answeringforthechild?Thesefindingscouldindicatesomeformofabuseoccurringathome.
Doesthepatientrequireassistanceinambulation,transferring,orchangingofclothing?
Dotheobservationfindingsmatchthefindingsfromthehistory?
Throughoutthehistory,systemsreview,andtestsandmeasures,collectiveobservationsformthebasisfordiagnostic
deductions.Someoftheobservationsmademaybeverysubtle.Forexample,hoarsenessofthevoicecouldsuggest
laryngealcancer,whereasaweakened,thickened,andloweredvoicemayindicatehypothyroidism.119Warm,moist
handsfeltduringahandshakemayindicatehyperthyroidism.119Cold,moisthandsmayindicateananxiouspatient.
Patientsreactdifferentlytoinjury.Somepatientsmayexaggeratethesymptomsthroughfacialexpressionsandgestures
whereasothersremainstoic.Patientsmayappearcalmandpleasant,defensive,angry,apprehensive,ordepressed.
Anxiouspatients,orpatientsinseverepain,oftenappearrestless.Cliniciansmustlearntoadopttheirapproachesto
thesedifferentreactions.Forexample,ananxiousorapprehensivepatientmayrequiremorereassurancethanacalmand
pleasantpatient.
Muchoftheobservationinvolvesassessmentofposture(seeChapter6).Posturaldeviationsnegativelyaffectingthe
locationofthecenterofgravityorcenterofmassinrelationtothebaseofsupportmayresultinapatientcomplaining
ofpainand/ordysfunctionwheninsustainedpositions.Changesinthecontoursofthebodyshapeorposturecanbeso
specificthatitoftenispossibletoisolatethesinglemuscleinvolved,themovementsaffected,andtherelatedjoint
dysfunctionfromobservationalone.120Forexample,achangeinasofttissuecontourascomparedtotheotherside
couldindicatemuscleatrophy.Thesedeviationsandchangespromptafurthermusculoskeletalexaminationtodetermine
thecauseandpotentialmanagementstrategies.Ifthereareanyobviousdeformities,theclinicianmustdetermine
whethertheyarestructuralorfunctional:
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Structural:thosedeformitiespresentatrest.Forexample,torticollis,andkyphosis.
Functional:deformitiesthataretheresultofassumedposturesandwhichdisappearwhenthepostureischanged.
Forexample,functionalscoliosisisduetoaleglengthdiscrepancythatdisappearswhenthepatientbends
forward(seeChapter27).
Thepatientspositionofcomfortcanprovidetheclinicianwithvaluableinformation.Forexample,patientswithlateral
recessspinalstenosisofthelumbarspine,congestiveheartfailure,orpulmonarydiseaseoftenpreferthesittingposition,
whereaspatientswithpericarditisoftensitandleanforward.119Patientswithaposteriorlaterallumbardiskherniation
oftenprefertostandorlieratherthansit.
SystemsReview
Theinformationfromthehistoryandthesystemsreviewservesasaguidefortheclinicianindeterminingwhich
structuresandsystemsrequirefurtherinvestigation.Thesystemsreviewisthepartoftheexaminationthatidentifies
possiblehealthproblemsthatrequireconsultationwith,orreferralto,anotherhealthcareprovider(Table49).18The
systemsreviewconsistsofalimitedexaminationoftheanatomicandphysiologicstatusofallsystems(i.e.,
musculoskeletal,neurological,cardiovascular,pulmonary,integumentary,GI,urinarysystem,and
genitoreproductive).18Thesystemsreviewincludesthefollowingcomponents:18
TABLE49SignsandSymptomsRequiringImmediateMedicalReferral
Signs/Symptoms CommonCause
Anginapainnotrelievedin20minutes Myocardialinfarction
Anginapainwithnausea,sweating,andprofusesweating Myocardialinfarction
Bowelorbladderincontinenceand/orsaddleanesthesia Caudaequinalesion
Immunologicalallergyor
Anaphylacticshock
disorder
Signs/symptomsofinadequateventilation Cardiopulmonaryfailure
Patientwithdiabeteswhoisconfused,islethargic,orexhibitschangesinmentalfunction Diabeticcoma
Appendicitisor
PatientwithpositiveMcBurney'spointorreboundtenderness
peritonitis
Suddenworseningofintermittentclaudication Thromboembolism
Aorticaneurysmor
Throbbingchest,back,orabdominalpainthatincreaseswithexertionaccompaniedbya
abdominalaortic
sensationofaheartbeatwhenlyingdownandpalpablepulsatingabdominalmass
aneurysm
DatafromGoodmanCC,SnyderTEK.DifferentialDiagnosisinPhysicalTherapy.Philadelphia,PA:WB
Saunders1990StowellT,CioffrediW,GreinerA,etal.Abdominaldifferentialdiagnosisinapatientreferredtoa
physicaltherapyclinicforlowbackpain.JOrthopSportsPhysTher.2005:35755764.
Forthecardiovascular/pulmonarysystem,theassessmentofheartrate,respiratoryrate,bloodpressure,and
edema.Therearefoursocalledvitalsignsthatarestandardinmostmedicalsettings:temperature,heartrate,
bloodpressure,andrespiratoryrate.Painisconsideredbymanytobeafifthvitalsign.121130Theclinician
shouldmonitoratleastheartrateandbloodpressureinanypersonwithahistoryofcardiovasculardiseaseor
pulmonarydisease,orthoseatriskforheartdisease.131
Temperature.Bodytemperatureisoneindicationofthemetabolicstateofanindividualmeasurementsprovide
informationconcerningbasalmetabolicstate,possiblepresenceorabsenceofinfection,andmetabolicresponseto
exercise.132Normalbodytemperatureoftheadultis98.4F(37C).However,atemperatureintherangeof
96.599.4F(35.837.4C)isnotatalluncommon.Feverorpyrexiaisatemperatureexceeding100F
(37.7C).133Hyperpyrexiareferstoanextremeelevationoftemperatureabove41.1C(or106F).132
Hypothermiareferstoanabnormallylowtemperature(below35Cor95F).Thetemperatureisgenerallytaken
byplacingthebulbofathermometerunderthepatientstonguefor13minutes,dependingonthedevice.Inmost
individuals,thereisadiurnal(occurringeveryday)variationinbodytemperatureof0.52F.Thelowestebbis
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reachedduringsleep.Menstruatingwomenhaveawellknowntemperaturepatternthatreflectstheeffectsof
ovulation,withthetemperaturedroppingslightlybeforemenstruation,andthendroppingfurther2436hours
priortoovulation.133Coincidentwithovulation,thetemperaturerisesandremainsatasomewhathigherlevel
untiljustbeforethenextmenses.Itisalsoworthnotingthatinadultsolderthan75yearsofage,andinthosewho
areimmunocompromised(e.g.,transplantrecipients,corticosteroidusers,personswithchronicrenalinsufficiency,
oranyonetakingexcessiveantipyreticmedications),thefeverresponsemaybebluntedorabsent.132
Heartrate.Inmostpeople,thepulseisanaccuratemeasureofheartrate.Theheartrateorpulseistakentoobtain
informationabouttherestingstateofthecardiovascularsystemandthesystemsresponsetoactivityorexercise
andrecovery.132Itisalsousedtoassesspatencyofthespecificarteriespalpated,andthepresenceofany
irregularitiesintherhythm.132Whentheheartmusclecontracts,bloodisejectedintotheaorta,andtheaorta
stretches.Atthispoint,thewaveofdistention(pulsewave)ismostpronounced,butrelativelyslowmoving(35
m/s).Asittravelstowardtheperipheralbloodvessels,itgraduallydiminishesandbecomesfaster.Inthelarge
arterialbranches,itsvelocityis710m/sinthesmallarteries,itis1535m/s.Whentakingapulse,thefingers
mustbeplacednearthearteryandpressedgentlyagainstafirmstructure,usuallyabone.Thepulsecanbetaken
atanumberofpoints.Themostaccessibleisusuallytheradialpulse,atthedistalaspectoftheradius.Sometimes,
thepulsecannotbetakenatthewristandistakenattheelbow(brachialartery),attheneckagainstthecarotid
artery(carotidpulse),behindtheknee(poplitealartery),orinthefootusingthedorsalispedisorposteriortibial
arteries.Thepulseratecanalsobemeasuredbylisteningdirectlytotheheartbeat,usingastethoscope.One
shouldavoidusingthethumbwhentakingapulse,asithasitsownpulsethatcaninterferewithdetectingthe
patientspulse.Thenormaladultheartrateis70beatsperminute(bpm),witharangeof6080bpm.Arateof
greaterthan100bpmisreferredtoastachycardia.Normalcausesoftachycardiaincludeanxiety,stress,pain,
caffeine,dehydration,orexercise.Arateoflessthan60bpmisreferredtoasbradycardia.Athletesmaynormally
havearestingheartratelowerthan60.Thenormalrangeofrestingheartrateinchildrenisbetween80and120
bpm.Therateforanewbornis120bpm(normalrange70170bpm).
CLINICALPEARL
Thereisnormallyatransientincreaseinpulseratewithinspiration,followedbyaslowingdownwithexpiration.22
Respiratoryrate.Thenormalchestexpansiondifferencebetweentherestingpositionandthefullyinhaled
positionis24cm(females>males).Theclinicianshouldcomparemeasurementsofboththeanteriorposterior
diameterandthetransversediameterduringrestandatfullinhalation.Normalrespiratoryrateisbetween8and
14perminuteinadultsandslightlyquickerinchildren.Thefollowingbreathingpatternsarecharacteristicof
disease:133
CheyneStokesrespiration,characterizedbyaperiodic,regular,sequentiallyincreasingdepthofrespiration,
occurswithseriouscardiopulmonaryorcerebraldisorders.
Biotsrespiration,characterizedbyirregularspasmodicbreathingandperiodsofapnea,isalmostalways
associatedwithhypoventilationduetoCNSdisease.
Kussmaulsrespiration,characterizedbydeep,slowbreathing,indicatesacidosis,asthebodyattemptstoblowoff
carbondioxide.
Apneusticbreathingisanabnormalpatternofbreathingcharacterizedbyapostinspiratorypause.Theusualcause
ofapneusticbreathingisapontinelesion.
Paradoxicalrespirationisanabnormalpatternofbreathing,inwhichtheabdominalwallissuckedinduring
inspiration(itisusuallypushedout).Paradoxicalrespirationisduetoparalysisofthediaphragm.
Bloodpressure.Bloodpressureisameasureofvascularresistancetobloodflow.132Thenormaladultblood
pressurecanvaryoverawiderange.Theassessmentofbloodpressureprovidesinformationaboutthe
effectivenessoftheheartasapumpandtheresistancetobloodflow.ItismeasuredinmmHgandisrecordedin
twonumbers.Thesystolicpressureisthepressurethatisexertedonthebrachialarterywhentheheartis
contracting,andthediastolicpressureisthepressureexertedonthearteryduringtherelaxationphaseofthe
cardiaccycle.132TheJNC7reportreleasedinMay2003hasaddedanewcategoryofprehypertensionandhas
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establishedmoreaggressiveguidelinesformedicalinterventionofhypertension.Thenormalvaluesforresting
bloodpressureinadultsare:
normal:systolicbloodpressure<120mmHganddiastolicbloodpressure<80mmHg
prehypertension:systolicbloodpressure120139mmHgordiastolicbloodpressure8090mmHg
stage1hypertension:systolicbloodpressure140159mmHgordiastolicbloodpressure9099mmHg
and
stage2hypertension:systolicbloodpressure160mmHgordiastolicbloodpressure100mmHg.
Thenormalvaluesforrestingbloodpressureinchildrenare:
systolic:birthto1month,6090mmHgupto3yearsofage,75130mmHgandover3yearsofage,90140
mmHg
diastolic:birthto1month,3060mmHgupto3yearsofage,4590mmHgandover3yearsofage,5080
mmHg.
Orthostatichypotensionisdefinedasadropinsystolicbloodpressurewhenassuminganuprightposition.Orthostatic
hypotensioncanoccurasasideeffectofantihypertensivemedications(seeChapter9),andincasesoflowblood
volumeinpatientswhoarepostoperativeordehydrated,andinthosewithdysfunctionoftheautonomicnervoussystem,
suchasthatwhichoccurswithaspinalcordinjuryorpostcerebrovascularaccident.132Activitiesthatmayincreasethe
chanceoforthostatichypotension,suchasapplicationofheatmodalities,hydrotherapy,pooltherapy,moderateto
vigorousexerciseusingthelargemuscles,suddenchangesofposition,andstationarystanding,shouldbeavoidedin
susceptiblepatients.132Thenormalsystolicrangegenerallyincreaseswithage.Thepressureshouldbedeterminedin
boththearms.Causesofmarkedasymmetryinbloodpressureofthearmsincludethefollowing:errorsin
measurements,markeddifferenceinarmsize,thoracicoutletsyndromes,embolicocclusionofanartery,dissectionofan
aorta,externalarterialocclusion,coarctationoftheaorta,andatheromatousocclusion.133
Edema.Edemaisanobservableswellingfromfluidaccumulationincertainbodytissues.Edemamostcommonly
occursinthefeetandlegs,whereitisalsoreferredtoasperipheraledema.Swellingoredemamaybelocalizedat
thesiteoftheinjuryordiffusedoveralargerarea.Ingeneral,theamountofswellingisrelatedtotheseverityof
theinjury.However,insomecases,seriousinjuriesproduceverylimitedswelling,whereas,inothers,minor
injuriescausesignificantswelling.Edemaoccursasaresultofchangesinthelocalcirculationandaninabilityof
thelymphaticsystemtomaintainequilibrium.Theswellingistheresultoftheaccumulationofexcessfluidunder
theskin,intheinterstitialspacesorcompartmentswithinthetissuesthatareoutsideofthebloodvessels.Mostof
thebodysfluidsthatarefoundoutsideofthecellsarenormallystoredintwospaces:thebloodvessels(referred
toasbloodvolume)andtheinterstitialspaces(referredtoasinterstitialfluid).Generally,thesizeoflymphnodes
isdependentonthesizeofthedrainagearea.Usually,thecloserthelymphnodeistothespinalcord,thegreater
thesizeofthelymphnode.Theneckistheexceptiontotherule.Invariousdiseases,excessfluidcanaccumulate
ineitheroneorbothoftheinterstitialspacesorbloodvessels.Anedematouslimbindicatesapoorvenousreturn.
Pittingedemaischaracterizedbyanindentationoftheskinafterthepressurehasbeenremoved.Areportofrapid
jointswelling(within24hours)followingatraumaticeventmayindicatebleedingintothejoint.Swellingofa
jointthatismoregradual,occurring824hoursfollowingthetrauma,islikelycausedbyaninflammatoryprocess
orsynovialswelling.
Themoreseriousreasonsforswellingincludefracture,tumor,congestiveheartfailure,anddeepveinthrombosis.
Fortheintegumentarysystem,theassessmentofskinintegrity,skincolor,andthepresenceofscarformation.The
integumentarysystemincludestheskin,thehair,andthenails.Theexaminationoftheintegumentarysystemmay
revealmanifestationsofsystemicdisorders.Theoverallcoloroftheskinshouldbenoted.Cyanosisinthenails,
thehands,andthefeetmaybeasignofacentral(advancedlungdisease,pulmonaryedema,congenitalheart
disease,orlowhemoglobinlevel)orperipheral(pulmonaryedema,venousobstruction,orcongestiveheart
failure)dysfunction.132Palpationoftheskin,ingeneral,shouldincludeassessmentoftemperature,texture,
moistness,mobility,andturgor.132Skintemperatureisbestfeltoverlargeareasusingthebackoftheclinicians
hand.Anassessmentshouldbemadeastowhetherthisislocalizedorgeneralizedwarmth:132
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Localized.Maybeseeninareasoftheunderlyinginflammationorinfection.
Generalized.Mayindicatefeverorhyperthyroidism.
Skintextureisdescribedassmoothorrough(coarse).Skinmobilitymaybedecreasedinareasofedemaorin
scleroderma.
Forthemusculoskeletalsystem,thegrossassessmentofsymmetry,therangeofmotion,strength,weight,and
height.
Fortheneuromuscularsystem,ageneralassessmentofgrosscoordinatedmovement(e.g.,balance,locomotion,
transfers,andtransitions).Inaddition,theclinicianobservesforperipheralandcranialnerveintegrityandnotes
anyindicationofneurologicalcompromisessuchastremorsorfacialtics.
Forcommunicationability,affect,cognition,language,andlearningstyle,thecliniciannoteswhetherthepatients
communicationlevelisageappropriatewhetherthepatientisorientedtoperson,place,andtimeandwhetherthe
emotionalandbehavioralresponsesappeartobeappropriatetohisorhercircumstances.Itisimportanttoverify
thatthepatientcancommunicatetheirneeds.Theclinicianshoulddeterminewhetherthepatienthasagood
understandingofhisorhercondition,theplannedintervention,andtheprognosis.Theclinicianshouldalso
determinethelearningstylethatbestsuitsthepatient.
TheScanningExamination
TheCyriaxscanning(screening)examination(seeChapter3)traditionallyfollowsthehistoryandisoftenincorporated
aspartofthesystemsreview,especiallyif:
Therearesymptomswhennohistoryoftraumaispresent.
Thereisnohistorytoexplainthesignsandsymptoms.
Thesignsandsymptomsareunexplainable.
Thescanningexaminationshouldbecarriedoutuntiltheclinicianisconfidentthatthereisnoseriouspathologypresent
andisroutinelycarriedoutunlessthereissomegoodreasonforpostponingit(e.g.,recenttrauma,inwhichcasea
modifieddifferentialdiagnosticexaminationisused).4Theupperquarterscanningexamination(Table311)is
appropriateforupperthoracic,upperextremity,andcervicalproblems,whereasthelowerquarterscanningexamination
(Table312)istypicallyusedforthoracic,lowerextremity,andlumbosacralproblems.Thepreferredsequenceofthe
scanningexaminationisoutlinedinTable410.
TABLE410TypicalSequenceofUpperorLowerQuarterScanningExaminations
1.Initialobservation:involveseverythingfrominitialentryofthepatient,includinggait,demeanor,standingand
sittingpostures,obviousdeformitiesandposturaldefects,scars,radiationburns,creases,andbirthmarks
2.Patienthistory
3.Scanningexamination
4.Activerangeofmotion
5.Passiveoverpressure
6.Resistivetests
7.Deeptendonreflexes
8.Sensationtesting
9.Specialtests
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Negativescan
If,attheendofthescan,theclinicianhasdeterminedthatthepatient'sconditionisappropriateforphysicaltherapybut
hasnotdeterminedadiagnosistotreatthepatient,theclinicianneedstoperformfurthertesting
Positivescan(resultsinadiagnosis)
1.Specificinterventions(traction,manualtechniques,andspecificexercises)canbegivenifthediagnosisisone
thatwillbenefitfromphysicaltherapy.
2.Patientisreturnedtophysicianformoretestsifsignsandsymptomsarecauseforconcern.
ThetestsoftheCyriax134upperorlowerquarterscanningexamination(Table313)canbeusedto:
Examinethepatientsneurologicstatus.Theteststhatcomprisethescanningexaminationaredesignedtodetect
neurologicweakness,thepatientsabilitytoperceivesensations,andtheinhibitionofthemusclestretchreflexes
andotherreflexesbytheCNS,whichwouldhighlightthepresenceofalesiontothecentralorperipheralnervous
systems(seeChapter3).
Helpdeterminewhetherthesymptomsarebeingreferred.
Confirmorrefutethephysiciansdiagnosis.
Helpruleoutanyseriouspathology,suchasafractureoratumor.
Assessthestatusofthecontractileandinerttissues.134
Contractile.Thetermcontractiletissue,asdefinedbyCyriax,isabitofamisnomer,becausetheonlytrue
contractiletissueinthebodyisthemusclefiber.However,includedunderthistermarethemusclebelly,tendon,
tenoperiostealjunction,submuscular/tendinousbursa,andbone(tendoosseousjunction),becauseallarestressed
tosomedegreewithamusclecontraction.
Inert.Inerttissue,accordingtoCyriax,includesthejointcapsule,theligaments,thebursa,thearticularsurfacesof
thejoint,thesynovium,thedura,thebone,andthefascia.
N.B.:Thetendoosseousjunctionandthebursaeareplacedineachofthesubdivisions,owingtotheircloseproximityto
contractiletissueandtheircapacitytobecompressedorstretchedduringmovement.
Generateaworkinghypothesis.
Theentirescanningexaminationshouldtakenomorethanafewminutestocomplete.
Ifadiagnosisisrenderedfromthescan,aninterventionmaybeinitiatedusingtheguidelinesoutlinedinTable411.The
scanorthehistory,orboth,alsomayhaveindicatedtotheclinicianthatthepatientsconditionisintheacutestageof
healing.Althoughthisisnotadiagnosisinthetruesense,itcanbeusedforthepurposeoftheinterventionplan.
TABLE411ScanFindingsandInterventions
Conditions Findings Protocol
Diskprotrusion,
prolapse,and Severepain Gentlemanualtractioninprogressiveextension
extrusion
Anteriorposterior Flexionandextension
Tractionand/ortractionmanipulationinextension
instability reductiongreaterthanrotation
PRICEMEM(protection,rest,ice,compression,elevation,
Arthritis Hotcapsularpattern
medication,electrotherapeutics,andmanualtherapy)
Subluxationof
Onedirectionrestricted Exercisesinpainfreedirection
segment
Arthrosisofsegment Alldirectionsrestricted Exercisesinpainfreedirection
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Conditions Findings Protocol

TestsandMeasures
Thetestsandthemeasures(Table412)componentoftheexamination,whichservesasanadjuncttothehistoryandthe
systemsreview,involvesthephysicalexaminationofthepatient.Beforeproceedingwiththetestsandmeasures,the
clinicianmustobtainvalidconsentandafullexplanationmustbeprovidedtothepatientastowhatproceduresaretobe
performedandthereasonsforthese.Thechosentestsusedbytheclinicianmustbebasedonthepatientshistoryorthe
presentation.Attimes,acompleteexaminationcannotbeperformed.Forexample,ifthejointtobeexaminedistoo
acutelyinflamed,theclinicianmaydefersomeoftheexaminationstothesubsequentvisit.
TABLE412TestsandMeasures
Aerobiccapacityandendurance
Anthropometriccharacteristics
Arousal,attention,andcognition
Assistiveandadaptivedevices
Circulation(arterial,venous,andlymphatic)
Cranialandperipheralnerveintegrity
Environmental,home,andwork(job,school,andplay)barriers
Ergonomicsandbodymechanics
Gait,locomotion,andbalance
Integumentaryintegrity
Jointintegrityandmobility
Motorfunction(motorcontrolandlearning)
Muscleperformance(strength,power,andendurance)
Neuromotordevelopmentandsensoryintegration
Orthotic,protective,andsupportivedevices
Pain
Posture
Prostheticrequirements
Rangeofmotion(includingmusclelength)
Reflexintegrity
Selfcareandhomemanagement(ADLsandIADLs)
Sensoryintegrity(includingproprioceptionandkinesthesia)
Ventilationandrespirationandgasexchange
Work,community,andleisureintegrationorreintegration
ADLs,activitiesofdailylivingIADLs,instrumentalactivitiesofdailyliving.
DatafromAmericanPhysicalTherapyAssociation:Guidetophysicaltherapistpractice.PhysTher.2001:81S13S95.
Thetestsandthemeasuresnowcurrentlyusedinphysicaltherapyhavebeenlargelyinfluencedbytheworkofanumber
ofcliniciansovertheyears,includingCyriax,134137Maitland,7,138Grieve,139Kaltenborn,5Butler,12Sahrmann,11and
McKenzie.140
CLINICALPEARL
Thephysicalexaminationmustbemodifiedbasedonthehistoryforexample,theexaminationofanacutelyinjured
patientdiffersgreatlyfromthatofapatientinlessdiscomfortordistress.Inaddition,theexaminationofachilddiffers
insomerespectsfromthatofanadult(seeChapter30).
Thetraditionalgoalsofthephysicalexaminationhavebeentodeterminethestructureinvolved,reproducethepatients
symptoms,confirmorrefutetheworkinghypothesis,andestablishanobjectivedatabaseline.6,141Morerecently,the
focusoftheexaminationhasshiftedtoincludetheidentificationofimpairments,functionallimitations,disabilities,or
changesinphysicalfunctionandhealthstatusresultingfrominjury,disease,orothercauses.Thisinformationisthen
usedthroughtheevaluationprocesstoestablishthediagnosisandtheprognosis,andtodeterminetheintervention.18
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Thephysicalexaminationmustbesupportedbyasmuchscienceaspossiblesothatthedecisionaboutwhichtest(s)to
useduringtheexaminationshouldbebasedonthebestavailableresearchevidence.AccordingtoSackettet
al.,142evidencebasedpractice(EBP)involvestheintegrationofbestresearchevidencewithclinicalexpertiseand
patientvalues.Deliveryofhighqualityhealthcarethatisevidencebased,costeffective,individuallytailored,and
sustainablerequiresacoordinatedstrategy.143Knowledgetranslation(KT),adynamicanditerativeprocessthat
includessynthesis,dissemination,exchangeandethicallysoundapplicationofknowledge,144isaprocesstofacilitate
theconsiderationofresearchevidenceandclinicalpractice.143TheKTconceptwasfirstintroducedbytheCanadian
InstitutesofHealthResearch(CIHR)in2000,andhassincespawneddefinitionsfromtheWorldHealthOrganization
(WHO)andtheNationalInstituteonDisabilityandRehabilitationResearch(NIDRR).TheWHOdefinedKTasthe
synthesis,exchange,andapplicationofknowledgebyrelevantstakeholderstoacceleratethebenefitsofglobalandlocal
innovationinstrengtheninghealthsystemsandimprovingpeopleshealth,145andtheNIDRRdefineditasthe
multidimensional,activeprocessofensuringthatnewknowledgegainedthroughthecourseofresearchultimately
improvesthelivesofpeoplewithdisabilities,andfurtherstheirparticipationinsociety.146TheKTapproachexpands
theclinicianfocusedEBPviewasitisaninteractiveprocesscharacterizedbyeffectiveexchangesbetweenresearchers
whocreatenewknowledgeandthosewhoimplementit.Theemphasisisonapplicationandonconsiderationofthe
multiplefactorsthatmayinfluencewhethertheapplicationissuccessfulandsustained.147KTstrategieshaveemerged
asapotentialsolutiontothechallengesofconsistentlyusingresearchevidencetoguideclinicalpracticeandsupportan
optimalchangeinclinicalpracticebehaviors.147Anumberofframeworkshavebeendevelopedtoprovideatemplate
forconsiderationofthemultiplekeyfactorsthatinfluencewhethertheapplicationissuccessful.Perhapsthemostwell
knownistheknowledgetoaction(KTA)developedbyGrahametal.,148whichconsistsofacomplexanddynamic
processwithboundariesthatarefluidandpermeablesuchthatthefollowingphasesmayoccurconsecutivelyor
concurrently:
Knowledgecreation:thecollectionofpromisingprinciplesandpractices
Adaptingtolocalcontext:adaptingtheprinciplesandpractices
Assessingbarriers:assessingandaddressingasmanybarriersaspossible
Selection,tailoring,andimplementationofinterventions:involvesanynecessarytrainingoreducation
Monitoringknowledgeuse/pilotimplementation:observing
Evaluationofcontentandprocess:receivingfeedback
Sustainingknowledgeuse:determiningsuccesses/weaknesses
Thegatheringofevidencemustoccurinasystematic,reproducible,andunbiasedmannertoselectandinterpret
diagnostictestsandtoassesspotentialinterventions.149TheEBPprocessgenerallyoccursinfivesteps:150
Formulatingaclinicalquestionincludingdetailsaboutthepatienttypeorproblem,theinterventionbeing
considered,acomparisonintervention,andtheoutcomemeasuretobeused.
Searchingforthebestevidence,whichcanincludesearchonOvid,EMBASE,PubMed,PEDro,orothermedical
searchenginedatabase,usingthekeywordsfromtheclinicalquestion.
Criticalappraisaloftheevidence.Ingeneral,therearetwotypesofclinicalstudiesthosethatanalyzeprimary
dataandthosethatanalyzesecondarydata.151Studiesthatcollectandanalyzeprimarydataincludecasereports
andseriesandcasecontrols,crosssectional,cohort(bothprospectiveandretrospective),andrandomized
controlledtrials.151Analysisofsecondarydataoccursinsystematicreviewsorametaanalysis.Asystematic
reviewisusedtoanswerquestionsabouttheevidencesupportingorrefutingtheeffectivenessorefficacyofan
intervention.152Asystematicreviewmaybeextendedtoincludeametaanalysis,astatisticalprocedureusedto
numericallysummarizetheincludedstudiestreatmenteffect.153Thus,ametaanalysiscanincreasestatistical
powerbyprovidingasingle,overallmeasureofthetreatmenteffect,enhancingtheclinicalinterpretationof
findingsacrossseveralstudies.152Anotherwaytobroadlycategorizestudiesisexperimental,wherean
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interventionisintroducedtosubjects,orobservational,inwhichnoactivetreatmentisintroducedtothe
subjects.151
Applyingtheevidencetothepatient.
Evaluationoftheoutcome.
Thechoiceofwhichteststouseshouldbebasedonpretestprobabilities,whichareusedtoassessthediagnostic
possibilityofadisorder.Theresultsfromthesetestsarethencombinedwithvaluejudgmentstoarriveatthecorrect
diagnosis.Unfortunately,manytestsandproceduresusedinphysicaltherapypracticearenot,asyet,evidencebased.
Thisisparticularlytruewiththesocalledspecialtests(seeSpecialTests).Indeed,manyofthepurportedlyeffective
specialtestslistedinmanyorthopaedictextsexhibitsuchpoordiagnosticaccuracythatonly50%ofpatientswhohavea
positivetestresultarefoundtohavetheconditionthatthetestissupposedtodetect.149,154WithoutEBP,cliniciansfail
toprovidetheconsumerwithscientificevidenceregardingclinicallyeffectiveandcosteffectivepractice.Throughout
thistext,whereverpossible,thesourcesofevidencewillbeidentifiedforeachoftheexaminationandintervention
techniquesdescribed.However,inaneverchangingprofession,itisultimatelythereadersresponsibilitytoremain
updatedwithpracticerecommendationsanddecidetheappropriatenessoftheevidenceforeachoftheirpatientsintheir
ownuniqueclinicalsetting.
ActivePhysiologicalRangeofMotionoftheExtremities
Activemovementsoftheinvolvedareaaretypicallyperformedbeforepassivemovements.Duringthehistory,the
clinicianshouldhavededucedthegeneralmotionsoractivitiesthataggravateorprovokethesymptoms.Any
movementsthatareknowntobepainfulareperformedlast.Therangeofmotionexaminationshouldbeusedtoconfirm
theexactdirectionsofmotionthatelicitthesymptoms.Thediagnosisofrestrictedmovementintheextremitiescan
usuallybesimplifiedbycomparingbothsides,providedthatatleastonesideissymptomfree.Undernormal
circumstances,thenormal(symptomfree)sideistestedfirstasthisallowsthecliniciantoestablishabaselinewhilealso
showingthepatientwhattoexpect.Activerangeofmotion(AROM)testingmaybedeferredifsmallandunguarded
motionsprovokeintensepainbecausethismayindicateahighdegreeofjointirritabilityorotherseriouscondition.The
normalAROMforeachofthejointsisdepictedinTable413.
TABLE413ActiveRangesofJointMotions
Joint Action DegreesofMotion
Flexion 0170to180
Extension 050to60
Shoulder Abduction 0170to180
Internalrotation 060to100
Externalrotation 080to90
Elbow Flexion 0145
Pronation 090
Forearm
Supination 090
Flexion 090
Extension 070
Wrist
Radialdeviation 025
Ulnardeviation 035
Flexion 0115to120
Extension 010to15
Abduction 045
Hip
Adduction 020to30
Internalrotation 030to45
Externalrotation 030to45
Knee Flexion 0120to130
Plantarflexion 050
Talocrural
Dorsiflexion 020
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Joint Action DegreesofMotion

Inversion 030
Subtalar
Eversion 020
AROMtestinggivestheclinicianinformationaboutthefollowing:
Thequantityofavailablephysiologicmotion.
Thepresenceofmusclesubstitutions.
Thewillingnessofthepatienttomove.
Theintegrityofthecontractileandtheinerttissues.
Thequalityofmotion.Apainfularcduringarangeofmotion,withorwithoutapainfullimitationofmovement,
indicatesthepresenceofaderangement.155Forexample,theremaybeanarcofpainbetween60and120degrees
ofshoulderabduction,indicatinganimpingementofthestructuresundertheacromionprocessorthe
coracoacromialligament.
Symptomreproduction.Dependingonwhereintherangeofmotionthepainisexperiencedcanprovidethe
clinicianinformationastothestageofhealingandthedegreeoftissueirritability.Ifthepainisexperiencedbythe
patientbeforethetissuelimitationisfelt,itislikelyanacuteinjuryorthereisanactivestageofadiseasepresent.
Inthisscenario,thetissuesarelikelyhighlyirritablenecessitatingagentleapproach.Ifthepainexperienced
occursconcurrentlywiththetissuelimitation,theconditionistypicallyinthesubacutestageofhealing.Ifthe
painisexperiencedaftertissuelimitationismet,thecliniciancanusemoreaggressivetechniquessuchas
stretchingandjointmobilizations.
Thepatternofmotionrestriction(e.g.,capsularornoncapsular,openingorclosingrestrictionseelater).
FullandpainfreeAROMsuggestsnormalcyforthatmovement,althoughitisimportanttorememberthatnormalrange
ofmotionisnotsynonymouswithnormalmotion.156Normalmotionimpliesthatthecontrolofmotionmustalsobe
present.Thiscontrolisafactorofmuscleflexibility,jointstability,andcentralneurophysiologicmechanisms(see
Chapter3).Thesefactorsarehighlyspecificinthebody.157Alossofmotionatonejointmaynotpreventthe
performanceofafunctionaltask,althoughitmayresultinthetaskbeingperformedinanabnormalmanner.For
example,theactofwalkingcanstillbeaccomplishedinthepresenceofakneejointthathasbeenfusedintoextension.
Becausetheessentialmechanismsofkneeflexionduringthestanceperiod,andfootclearanceintheswingperiod,are
absent,thepatientcompensatesfortheselossesbyhikingthehipontheinvolvedside,bysidebendingthelumbarspine
totheuninvolvedside,andthroughexcessivemotionofthefoot.
Singlemotionsinthecardinalplanesareusuallytestedfirst.Thesetestsarefollowedbydynamicandstatictesting.
Dynamictestinginvolvesrepeatedmovements.Statictestinginvolvessustainingaposition.Sustainedstaticpositions
maybeusedtohelpdetectposturalsyndromes.155McKenzieadvocatestheuseofrepeatedmovementsinspecific
directionsinboththespineandtheextremities.Repeatedmovementscangivethecliniciansomevaluableinsightinto
thepatientscondition:155
Internalderangementstendtoworsenwithrepeatedmotions.
Symptomsofaposturaldysfunctionremainunchangedwithrepeatedmotions.
Painfromadysfunctionsyndromeisincreasedwithtissueloadingbutceasesatrest.
Repeatedmotionscanindicatetheirritabilityofthecondition.
Repeatedmotionscanindicatetotheclinicianthedirectionofmotiontobeusedaspartoftheintervention.Ifpain
increasesduringrepeatedmotioninaparticulardirection,exercisinginthatdirectionisnotindicated.Ifpainonly
worsensinpartoftherange,repeatedmotionexercisescanbeusedforthepartoftherangethatispainfree,or
thatdoesnotworsenthesymptoms.
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Painthatisincreasedaftertherepeatedmotionsmayindicatearetriggeringoftheinflammatoryresponse,and
repeatedmotionsintheoppositedirectionshouldbeexplored.
Combinedmotiontestingmaybeusedwhenthesymptomsarenotreproducedwiththecardinalplanemotions(flexion,
extension,abduction,etc.),therepeatedmotions,orthesustainedpositions.Compressionanddistractionalsomaybe
addedtoalloftheactivemotiontestsinanattempttoreproducethesymptoms.
PassivePhysiologicalRangeofMotionoftheExtremities
Passivemotionsaremovementsperformedbytheclinicianwithouttheassistanceofthepatient.Passiverangeofmotion
(PROM)isperformedintheanatomicrangeofmotionforthejointandnormallydemonstratesslightlygreaterrangeof
motionthanactivemotionthebarriertoactivemotionshouldoccurearlierintherangethanthebarriertopassive
motion.
Ifthepatientcancompletethefullactivephysiologicalrangeofmotioneasily,withoutpresentingpainorother
symptoms,thenpassivetestingofthatmotionisusuallyunnecessary.However,iftheactivemotiondoesnotreproduce
thepatientssymptoms,becausethepatientisavoidingthepainfulpartoftherange,ortheAROMappearsincomplete,
itisimportantthattheclinicianperformsgentle,passiveoverpressure.Painthatoccursatthemidendrangeofactive
andpassivemovementissuggestiveofacapsularcontractionorascartissuethathasnotbeenadequately
remodeled.155Painduringpassiveoverpressureisoftenduetothestretching,orpinchingofnoncontractilestructures,
orstretchingofthecontractilestructures.158Thus,PROMtestinggivestheclinicianinformationabouttheintegrityof
thecontractileandinerttissues,andwithgentleoverpressure,theendfeel.Cyriax134introducedtheconceptoftheend
feel,whichisthequalityofresistanceencounteredbytheclinicianatendrange.Thepointatwhichresistanceis
encounteredisevaluatedforqualityandtenderness.Additionalforcesfromtheclinicianareneededastheendrangeofa
jointisreached,andtheelasticlimitsarechallenged.Thisspacetermedtheendplayzonerequiresaforceof
overpressuretobereachedsothatwhenthatforceisreleased,thejointspringsbackfromitselasticlimits.Theendfeel
canindicatetotheclinicianthecauseofthemotionrestriction(Tables414and415).
TABLE414NormalEndFeels
Type Cause CharacteristicsandExamples
Abruptandunyieldinggivesimpressionthatfurther
forcingwillbreaksomething
Examples:
Bony Producedbybonetoboneapproximation Normal:elbowextension
Abnormal:cervicalrotation(mayindicate
osteophyte)
Stretcheswithelasticrecoilandexhibitsconstantlength
phenomenonfurtherforcingfeelsasifitwillsnap
something
Examples:
Producedbymuscletendonunitmayoccur Normal:wristflexionwithfingerflexion,the
Elastic
withadaptiveshortening straightlegraise,andankledorsiflexionwiththe
kneeextended
Abnormal:decreaseddorsiflexionoftheanklewith
thekneeflexed
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Type Cause CharacteristicsandExamples

Veryforgivingendfeelthatgivesimpressionthatfurther
normalmotionispossibleifenoughforcecouldbe
applied
Examples:
Producedbycontactoftwomusclebulkson
Softtissue eithersideofaflexingjointwherejoint Normal:kneeflexionandelbowflexionin
approximation rangeexceedsotherrestraints extremelymuscularsubjects
Abnormal:elbowflexionwithobesesubject
Variousdegreesofstretchwithoutelasticitystretchability
isdependentonthicknessoftissue
Strongcapsularorextracapsularligamentsproducehard
capsularendfeel,whereasthincapsuleproducessofter
one
Impressiongiventoclinicianisthatiffurtherforceis
applied,somethingwilltear
Capsular Producedbycapsuleorligaments Examples:
Normal:wristflexion(soft),elbowflexionin
supination(medium),andkneeextension(hard)
Abnormal:inappropriatestretchabilityforspecific
jointiftoohard,mayindicatehypomobilitydueto
arthrosisandiftoosoft,hypermobility
DatafromMeadowsJTS.ManualTherapy:BiomechanicalAssessmentandTreatment,AdvancedTechnique.Calgary:
TABLE415AbnormalEndFeels
Type Causes CharacteristicsandExamples
Reboundsensationasifpushingofffroma
rubberpad
Examples:
Producedbyarticularsurfacereboundingfrom
Springy intraarticularmeniscusordiskimpressionisthatif Normal:none
forcedfurther,somethingwillgiveway
Abnormal:kneeflexionorextensionwith
displacedmeniscus
Squishysensationasjointismovedtowardits
endrangefurtherforcingfeelsasifitwillburst
joint
Examples:
Boggy Producedbyviscousfluid(blood)withinjoint
Normal:none
Abnormal:hemarthrosisatknee
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Type Causes CharacteristicsandExamples

Abruptandtwangyendtomovementthatis
unyieldingwhilethestructureisbeingthreatened
butdisappearswhenthreatisremoved(kicks
back)
Withjointinflammation,itoccursearlyinrange,
especiallytowardclosepackedposition,to
preventfurtherstress
Withirritablejointhypermobility,itoccursatend
ofwhatshouldbenormalrange,asitprevents
excessivemotionfromfurtherstimulatingthe
nociceptor
Producedbyreflexandreactivemusclecontractionin SpasmingradeIImuscletearsbecomesapparent
responsetoirritationofnociceptor,predominantlyin asmuscleispassivelylengthenedandis
Spasm
articularstructuresandmuscleforcingitfurtherfeelsas accompaniedbyapainfulweaknessofthat
ifnothingwillgive muscle
Note:Muscleguardingisnotatrueendfeel,asit
involvescocontraction
Examples:
Normal:none
Abnormal:significanttraumaticarthritis,
recenttraumatichypermobility,andgrade
IImuscletears
Limitationofmotionhasnotissueresistance
component,andresistanceisfrompatientbeing
unabletotoleratefurthermotionduetosevere
Producedsolelybypainfrequentlycausedbyserious painitisnotsamefeelingasvoluntaryguarding,
andseverepathologicchangesthatdonotaffectjointor butratheritfeelsasifpatientisbothresistingand
muscleandsodonotproducespasmdemonstrationof tryingtoallowmovementsimultaneously
Empty Examples:
thisendfeelis,withexceptionofacutesubdeltoid
bursitis,defactoevidenceofseriouspathologyfurther
forcingsimplyincreasespaintounacceptablelevels Normal:none
Abnormal:acutesubdeltoidbursitisand
signofthebuttock
Lightresistanceasfromconstantlightmuscle
contractionthroughoutlatterhalfofrangethat
doesnotpreventendofrangebeingreached
Nottrulyanendfeel,asfacilitatedhypertonicitydoes resistanceisunaffectedbyrateofmovement
Facilitation notrestrictmotionitcan,however,beperceivednear Examples:
endrange
Normal:none
Abnormal:spinalfacilitationatanylevel
DatafromMeadowsJTS.ManualTherapy:BiomechanicalAssessmentandTreatment,AdvancedTechnique.Calgary:
CLINICALPEARL
Onestudythatlookedattheintraandinterraterreliabilityofassessingendfeel,andpainandresistancesequencein
subjectswithpainfulshouldersandknees,foundtheendfeeltohavegoodintraraterreliability,butunacceptable
interraterreliability.159
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Althoughsomecliniciansfeelthatoverpressureshouldnotbeappliedinthepresenceofpain,thisiserroneous.Most,if
notall,oftheendfeelsthatsuggestacuteorseriouspathologyaretobefoundinthepainfulrange,includingspasmand
theemptyendfeel.
Assessingtheendfeelisveryimportantinjointsthathaveonlyverysmallamountsofthenormalrange,suchasthose
ofthespine.Thetypeofendfeelcanhelpthecliniciandeterminethepresenceofdysfunction.Forexample,ahard,
capsularendfeelindicatesapericapsularhypomobility,whereasajammedorapathomechanicalendfeelindicatesa
pathomechanicalhypomobility.Anormalendfeelwouldindicateanormalrangewhereasanabnormalendfeelwould
suggestanabnormalrange,eitherhypomobileorhypermobile.Anassociationbetweenanincreaseinpainandabnormal
pathologicendfeelscomparedwithnormalendfeelshasbeendemonstrated.160
Theintensityoftheplannedinterventionisbasedonthetypeoftissueresistancetomovement,andontheacutenessof
thecondition,whichisdemonstratedbytheendfeel(Table416).134Thisinformationmayindicatewhetherthe
resistanceiscausedbypain,muscle,capsuleligament,disturbedmechanicsofthejoint,oracombination.
TABLE416AbnormalBarrierstoMotionandRecommendedManualTechniques
Barrier Endfeel Technique
Pain Empty None
Pain Spasm None
Pain Capsular Oscillations(I,IV)
Jointadhesions Earlycapsular Passivearticularmotionstretch(IV)
Muscleadhesions Earlyelastic Passivephysiologicmotionstretch
Hypertonicity Facilitation Muscleenergy(Hold/relax,etc.)
Bone Bony None
CLINICALPEARL
AccordingtoCyriax,ifactiveandpassivemotionsarelimitedorpainfulinthesamedirection,thelesionisintheinert
tissue,whereasiftheactiveandpassivemotionsarelimitedorpainfulintheoppositedirection,thelesionisinthe
contractiletissue.134
Thequantityandqualityofmovementrefertotheabilityofthepatienttoachieveendrangewithoutdeviationfromthe
intendedmovementplane.
Boththepassiveandactivephysiologicalrangesofmotioncanbemeasuredusingagoniometer(seeChapter13),which
hasbeenshowntohaveasatisfactorylevelofintraobserverreliability.161163Visualobservationinexperienced
clinicianshasbeenfoundtobeequaltomeasurementsbygoniometry.164Althoughnormativevaluesforarangeof
motionexist,thesymmetrybetweensidesshouldbeusedtodetermineindividualdifferences.Goniometricmeasurement
ofthejointsisdescribedinChapter13.
Therecordingofarangeofmotionvaries.TheAmericanMedicalAssociationrecommendsrecordingtherangeof
motiononthebasisoftheneutralpositionofthejointbeingzero,withthedegreesofmotionincreasinginthedirection
thejointmovesfromthezerostartingpoint.24Aplussign(+)isusedtoindicatejointhyperextensionandaminussign
()toindicateanextensionlag.Themethodofrecordingchosenisnotimportant,providedtheclinicianchoosesa
recognizedmethodanddocumentsitconsistentlywiththesamepatient.
CapsularandNoncapsularPatternsofRestriction
Cyriaxintroducedthetermscapsularandnoncapsularpatternsofrestriction,whichlinkimpairmenttopathology(Table
417).Acapsularpatternofrestrictionisalimitationofpainandmovementinajointspecificratio,whichisusually
presentwitharthritis,orfollowingprolongedimmobilization.134Thus,thePROMforthatjointwillbelimitedina
capsularpattern,andtherewillbedecreasedjointplaymovement.Itisworthrememberingthataconsistentcapsular
patternforaparticularjointmightnotexistandthatthesepatternsarebasedonempiricalfindingsandtradition,rather
thanonresearch.159,165
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TABLE417CapsularPatternsofRestriction
Joint LimitationofMotion(PassiveAngularMotion)
Glenohumeral Externalrotation>abduction>internalrotation(3:2:1)
Notruecapsularpatternpossiblelossofhorizontaladductionandpain(andsometimesslight
Acromioclavicular
lossofendrange)witheachmotion
Sternoclavicular Seeacromioclavicularjoint
Humeroulnar Flexion>extension(4:1)
Humeroradial Notruecapsularpatternpossibleequallimitationofpronationandsupination
Notruecapsularpatternpossibleequallimitationofpronationandsupinationwithpainatend
Superiorradioulnar
ranges
Notruecapsularpatternpossibleequallimitationofpronationandsupinationwithpainatend
Inferiorradioulnar
ranges
Wrist(carpus) Flexion=extension
Radiocarpal Seewrist(carpus)
Carpometacarpal Flexion=extension
Midcarpal Flexion=extension
Carpometacarpal1 Retroposition
Carpometacarpals2
Fan>fold
5
Metacarpophalangeal
Flexion>extension(2:1)
25
Interphalangeal25
Proximal(PIP) Flexion>extension(2:1)
Distal(DIP) Flexion>extension(2:1)
Hip Internalrotation>flexion>abduction=extension>othermotions
Tibiofemoral Flexion>extension(5:1)
Superiortibiofibular Nocapsularpatternpainatendrangeoftranslatorymovements
Talocrural Plantarflexion>dorsiflexion
Talocalcaneal
Varus>valgus
(subtalar)
Midtarsal Inversion(plantarflexion,adduction,andsupination)
Talonavicular
>Dorsiflexion
calcaneocuboid
Metatarsophalangeal
Extension>flexion(2:1)
1
Metatarsophalangeals
Flexionextension
25
Interphalangeals25
Proximal Flexionextension
Distal Flexionextension
DatafromCyriaxJ.TextbookofOrthopaedicMedicine,DiagnosisofSoftTissueLesions.8thed.London:Bailliere
Tindall1982.
Anoncapsularpatternofrestrictionisalimitationinajointinanypatternotherthanacapsularoneandmayindicatethe
presenceofajointderangement,arestrictionofonepartofthejointcapsule,oranextraarticularlesionthatobstructs
jointmotion.134
Apositivefindingforjointhypomobilitywouldbeareducedrangeinacapsularornoncapsularpattern.The
hypomobilitycanbepainful,suggestinganacutesprainofastructure,orpainless,suggestingacontractureoran
adhesionofthetestedstructure.Significantdegenerationofthearticularcartilagepresentswithcrepitus(jointnoise)on
movementwhencompressionofthejointsurfacesismaintained.
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Whileanabnormalmotionistypicallydescribedasbeingreduced,theabnormalmotionmayalsobeexcessive(see
Chapter2).Excessivemotionisoftenmissedandiserroneouslyclassifiedasnormalmotion.Tohelpdeterminewhether
themotionisnormalorexcessive,PROM,intheformofpassiveoverpressure,andtheendfeelareassessed.
CLINICALPEARL
ApprehensionfromthepatientduringAROMthatlimitsamovementatnearorfullrangesuggestsinstability,whereas
apprehensionintheearlypartoftherangesuggestsanxietycausedbypain.
ActivePhysiologicalRangeofMotionoftheSpine
Activephysiologicintervertebralmobility,oractivemobility,testsofthespinewereoriginallydesignedbyosteopaths
toassesstheabilityofeachspinaljointtomoveactivelythroughitsnormalrangeofmotion,bypalpatingoverthe
transverseprocessesofajointduringthemotion(seealsoPositionTestingoftheSpine).Theoretically,bypalpating
overthetransverseprocesses,thecliniciancanindirectlyassessthemotionsoccurringatthezygapophysealjointson
eithersideoftheintervertebraldisk.However,theclinicianmustrememberthat,althoughitisconvenienttodescribe
thevariousmotionsofthespineoccurringinacertaindirection,theseinvolvetheintegrationofmovementsofamulti
jointcomplex.
Thehumanzygapophysealjointsarecapableofonlytwomajormotions:glidingupwardandglidingdownward.Ifthese
movementsoccurinthesamedirection,flexionorextensionofthespineoccurs,whileifthemovementsoccurin
oppositedirections,sideflexionoccurs.
Osteopathsusethetermsopeningandclosingtodescribeflexionandextensionmotions,respectively,atthe
zygapophysealjoint.Undernormalcircumstances,anequalamountofglidingoccursateachzygapophysealjointwith
thesemotions.
Duringflexion,bothzygapophysealjointsglidesuperiorly(open).
Duringextension,bothzygapophysealjointsglideinferiorly(close).
Duringsideflexion,onejointisglidinginferiorly(closing),whiletheotherjointisglidingsuperiorly(opening).
Forexample,duringrightsideflexion,therightjointisglidinginferiorly(closing),whiletheleftjointisgliding
superiorly(opening).
Bycombiningflexionorextensionmovementswithsideflexion,ajointcanbeopenedorclosedtoitslimits.Thus,
flexionandrightsideflexionofasegmentassessestheabilityoftheleftjointtoopenmaximally(flex),whereas
extensionandleftsideflexionofasegmentassessestheabilityoftheleftjointtoclosemaximally(extend).
Thereisapointthatmaybeconsideredasthecenterofsegmentalrotation,aboutwhichallsegmentalmotionmust
occur.Inthecaseofazygapophysealjointimpairment(hypermobilityorhypomobility),itispresumedthatthiscenter
ofrotationwillbealtered.
Ifonezygapophysealjointisrenderedhypomobile(i.e.,thesuperiorfacetcannotmovetotheextremeofsuperioror
inferiormotion),thenthepuremotionsofflexionandextensioncannotoccur.Thisresultsinarelativeasymmetric
motionofthetwosuperiorfacets,astheendoftherangeofflexionorextension,isapproached(i.e.,asideflexion
motionwilloccur).However,thissideflexionmotionwillnotbeaboutthenormalcenterofsegmentalrotation.The
structureresponsibleforthelossofzygapophysealjointmotion,whetheritisamuscle,diskprotrusion,orthe
zygapophysealjointitself,willbecomethenewaxisofvertebralmotion,andanewcomponentofrotationabouta
verticalaxis,normallyunattainable,willbeintroducedintothesegmentalmotion.Thedegreeofthisrotationaldeviation
isdependentonthedistanceoftheimpairmentfromtheoriginalcenterofrotation.
Becausethezygapophysealjointsinthespineareposteriortotheaxisofrotation,anobviousrotationalchange
occurringbetweenfullflexionandfullextension(inthepositionofavertebralsegment)isindicativeofzygapophyseal
jointmotionimpairment.
Byobservinganymarkedandobviousrotationofavertebralsegmentoccurringbetweenthepositionsoffullflexion
andfullextension,onemaydeducetheprobablepathologicimpairment.
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CLINICALPEARL
Activemotioninducedbythecontractionofthemusclesdeterminesthesocalledphysiologicrangeofmotion,166
whereaspassivelyperformedmovementcausesstretchingofnoncontractileelements,suchasligaments,anddetermines
theanatomicrangeofmotion.
Theactivemobilitytestsofthespinearedescribedintheappropriatechapters.
PassivePhysiologicalRangeofMotionoftheSpine
Thepassivephysiologicintervertebralmobility,orpassivemobility,testsusethesameprinciplesastheactive
physiologicintervertebralmobilityteststoassesstheabilityofeachjointinthespinetobemovedpassivelythroughits
normalrangeofmotion.Duringextension,thespinousprocessesshouldapproximatewhereas,duringflexion,they
shouldseparate.
Ifthepainisreproduced,itisusefultoassociatethepainwiththeonsetoftissueresistancetogainanappreciationofthe
acutenessoftheproblem.Thepassivemobilitytestsofthespinearedescribedintheappropriatechapters.
Mobility
Mobilitycanbeviewedasafactorofrangeofmotion,flexibility,andaccessoryjointmotion(seeChapter13):
Thetermrangeofmotionreferstothedistanceanddirectionajointcanmove,andismeasuredusinga
goniometer.
Flexibilityreferstothepassiveextensibilityofconnectivetissuethatprovidestheabilitytomoveajointorseries
ofjointsthroughafull,nonrestricted,injury,andpainfreeROM.Theextensibilityandhabituallengthof
connectivetissuearefactorsofthedemandsplaceduponit(seeChapter2).Thesedemandsproducechangesin
theviscoelasticpropertiesand,thus,thelengthtensionrelationshipofamuscleormusclegroup,resultinginan
increaseoradecreaseinthelengthofthosestructures.Adecreaseinthelengthofthesofttissuestructures,or
adaptiveshortening,isverycommoninposturaldysfunctions.Althoughsometypesofflexibility(e.g.,straight
legraise)canbemeasuredusingagoniometer,mosttypesareassessedusingspecifictests.Amoresubjectivetest
forflexibilityincludesanexaminationoftheendfeel,whichcandetectalossofmotionresultingfromthe
excessivetensionoftheagonistmuscle.
Accessoryjointmotion.Accessoryjointmotionistheamountofthearthrokinematicglidethatoccursatthejoint
surfaces,termedjointplay(seeChapter1).
Theexaminationofmobilityisperformedtodetermineifaparticularstructure,orgroupofstructures,hassufficient
movementtoperformadesiredactivity.Decreasedmobilitycanbeproducedby
restrictedaccessoryjointmotion
tissuedamagesecondarytotrauma
prolongedimmobilization
disease
hypertonia.Hypertonicmusclesthataresuperficialcanbeidentifiedthroughobservationandpalpation.
Observationwillrevealthemuscletoberaised,andlightpalpationwillprovideinformationabouttension,asthe
musclewillfeelhardandmaystandoutfromthosearoundit.
Mobilitycanbemeasuredobjectivelyusingstandardizedtests,oragoniometer.Visualobservation,whichhasbeen
foundtohaveavariabilityof30%inpatientswithlowbackpainandsciatica,mayalsobeused.167
JointIntegrity
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Jointintegritytestingcanprovidevaluableinformationaboutthestatusofeachjointanditscapsule.Kaltenborn5
introducedtheconceptofmotionrestrictionofajointbasedonitsarthrokinematics.Inorderforajointtofunction
completely,boththeosteokinematicandarthrokinematicmotionshavetooccurnormally(seeChapter1).It,therefore,
followsthatifajointisnotfunctioningcompletely,eitherthephysiologicrangeofmotionislimitedcomparedwiththe
expectednorm,orthereisnoPROMavailablebetweenthephysiologicbarrierandtheanatomicbarrier.Aspreviously
mentioned,theassessmentoftheendfeelcanhelpdeterminethecauseoftherestriction.Ingeneral,thephysiologic
motioniscontrolledbythecontractiletissues,whereastheaccessorymotioniscontrolledbytheintegrityofthejoint
surfacesandthenoncontractile(inert)tissues.Thisguidelinemaychangeinthecaseofajointthathasundergone
degenerativechanges,whichcanresultinadecreaseinthephysiologicmotions(capsularpatternofrestriction).Itis
importantthattheinterventiontorestorethecompletefunctionofthejointisaimedatthespecificcause.
Jointpainanddysfunctiondonotoccurinisolation.168,169Variousdifferentmeasurementscaleshavebeenproposed
forjudgingtheamountofaccessoryjointmotionpresentbetweentwojointsurfaces(seeChapter10),mostofwhichare
basedonacomparisonwithacomparablecontralateraljoint,usingmanuallyappliedforcesinalogicalandprecise
manner.170Intheextremities,thesetestsarereferredtoaspassivearticularmobilityorjointglidetests.Inthespine,
thesetestsarereferredtoasthepassivephysiologicaccessoryintervertebralmotiontesting.
CLINICALPEARL
Ingeneral,iftheconcaveonconvexglideofthejointsurfacesisrestricted,thereisacontractureofthetrailingportion
ofthecapsule,whereasiftheconvexonconcaveglideofthejointsurfacesisrestricted,thereisaninabilityofthe
movingsurfacetoglideintothecontractedportionofthecapsule.
Thepassivearticularmobilitytestsinvolvetheclinicianassessingthearthrokinematic,oraccessory,motionsusingjoint
glides,anddeterminingwhethertheglideishypomobile,normal,orhypermobile(seeChapter2).57
Accessorymotionsareinvoluntarymotions.Withfewexceptions,musclescannotrestricttheglidesofajoint,especially
iftheglidesaretestedintheopenpackedpositionofaperipheraljointand,attheendofavailablerange,inthespinal
joints.
Thus,iftheclinicianassessestheaccessorymotionofthejointbyperformingajointglide,informationaboutthe
integrityoftheinertstructureswillbegiven.Therearetwoscenarios:
1.Thejointglideisunrestricted.Anunrestrictedjointglideindicatestwodifferingconclusions:
a.Theintegrityofboththejointsurfaceandtheperiarticulartissueisgood.Ifthejointsurfaceandthe
periarticularstructuresareintact,thepatientslossofmotionmustbetheresultofacontractiletissue.The
interventionforthistypeinvolvessofttissuemobilizationtechniquesdesignedtochangethelengthofa
contractiletissue.
b.Thejointglideisunrestrictedbutexcessive.Thisisverydifficulttodetect,butifpresent,mayindicatea
pathologicalhypermobilityorinstability,oritmaybenormalfortheindividual.Inthesecases,theendfeel
canprovidesomeusefulinformation.Theinterventionforthistypeconcentratesonstabilizingtechniques
designedtogivesecondarysupporttothejointthroughmuscleaction.
2.Thejointglideisrestricted.Ifthejointglideisrestricted,thejointsurfaceandtheperiarticulartissuesare
implicatedasthecauseofthepatientslossofmotion,althoughaspreviouslymentioned,thecontractiletissues
cannotdefinitivelyberuledout.Theinterventionforthistypeoffindinginitiallyinvolvesaspecificjoint
mobilizationtorestoretheglide.Oncethejointglideisrestoredfollowingthesemobilizations,theosteokinematic
motioncanbeassessedagain.Ifitisstillreduced,thecontractiletissuesarelikelytobeatfault.Distractionand
compressioncanbeusedtohelpdifferentiatethecauseoftherestriction.
a.Distraction.Distractionisaforceimpartedpassivelybytheclinicianthatresultsinadistractionofthejoint
surfaces.Itisnotsynonymouswithtraction(seeChapter1).Ifthedistractionislimited,acontractureof
connectivetissueshouldbesuspected.
Ifthedistractionincreasesthepain,itmayindicateatearofconnectivetissue(e.g.,jointcapsule)andmay
beassociatedwithincreasedrange.
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Ifthedistractioneasesthepain,itmayindicateaninvolvementofthejointsurface.
b.Compression.Compressionistheoppositeforcetodistractionandinvolvesanapproximationofthejoint
surfaces(seeChapter1).
Ifthecompressionincreasesthepain,aloosebodyoraninternalderangementofthejointmaybepresent.Ifthe
compressiondecreasesthepain,itmayimplicatethejointcapsule.
Thus,byassessingthesejointmotions,thecliniciancandeterminethe
causeofalimitationinajointsphysiologicrangeofmotion
theendfeelresponseofthetissues
stageofhealing
theintegrityofthesupportstructures(e.g.,ligaments)ofajoint(e.g.,theintegrityoftheanteriorcruciateligament
istestedwiththeLachmantest).
Basedontheinformationgleanedfromthejointglide/accessorymotionassessment,thecliniciancanmakeaclinical
decisionastowhichinterventiontouse.Ifthejointglideisfelttoberestricted,andthereisnoindicationofabonyend
feelorsevereirritability,jointmobilizationtechniquesareused.Ifthejointglideisfoundtobeunrestricted,the
clinicianmaydecidetoemployatechniquethatincreasestheextensibilityofthesurroundingconnectivetissues,suchas
muscleenergy,becauseabnormalshortnessoftheseconnectivetissues,includingtheligaments,thejointcapsule,and
theperiarticulartissues,canrestrictjointmobility.
CLINICALPEARL
Cautionmustbeusedwhenbasingclinicaljudgmentssolelyontheresultsofaccessorymotiontesting,becausefew
studieshaveexaminedthevalidityandreliabilityofaccessorymotiontestingofthespineorextremities,andlittleis
knownaboutthevalidityofthesetestsformostinferences.170Astudyofthepredictedvalueofpositiveandnegative
testresults,inadditiontothesensitivityandspecificityofthevarioustests,wouldbeofvalue.170
PositionTestingintheSpine
Thepositiontestsareosteopathicscreeningtestsusedtocomparetherelativepositionofaspecificzygapophyseal
joint(s)withthejoint(s)below(seeappropriatechapters).Aswithallscreeningtests,positiontestingisvaluablein
focusingtheattentionofthecliniciantoaspecificareabutisnotappropriateformakingadefinitivestatement
concerningthemovementstatusofthesegment.However,whencombinedwiththeresultsofthepassiveandactive
movementtesting,positiontestshelptoformaworkinghypothesis.
MusclePerformance:Strength,Power,andEndurance
Strengthmeasuresthepowerwithwhichmusculotendinousunitsactacrossabonejointleverarmsystemtoactively
generatemotion,orpassivelyresistmovementagainstgravityandvariableresistance.24
AccordingtoCyriax,painwithacontractiongenerallyindicatesaninjurytothecontractiletissueorjoint.134This
suspicioncanbeconfirmedbycombiningthefindingsfromthetypeofsymptom,thesymptomduration,thesymptom
distribution,andtheendfeel(Table418).Cyriaxreasonedthatifyouisolateandthenapplytensiontoastructure,you
canmakeaconclusionastotheintegrityofthatstructure.134Hisworkalsointroducedtheconceptoftissuereactivity.
Tissuereactivityisthemannerinwhichdifferentstressesandmovementscanaltertheclinicalsignsandsymptoms.
Thisknowledgecanbeusedtogaugeanysubtlechangestothepatientscondition.171
TABLE418DifferentialDiagnosisofContractile,Inert,andNeuralTissueInjury
ContractileTissue InertTissue NeuralTissue
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Cramping,dull,and
Pain Dullsharp Burningandlancinating
ache
Paresthesia No No Yes
Duration Intermittent Intermittent Intermittentconstant
Dermatomaldistribution No No Yes
Peripheralnervesensory Yes(ifperipheralnerve
No No
distribution involved)
Boggyandhard
Endfeel Musclespasm Stretch
capsular
Inadditiontoexaminingtheintegrityofthecontractileandinertstructures,strengthtestingmaybeusedtoexaminethe
integrityofthekeymuscles(seeChapter3).Painwithmuscletestingmayindicateamuscleinjury,ajointinjury,ora
combinationofboth.Painthatoccursconsistentlywithresistance,atwhateverthelengthofthemuscle,mayindicatea
tearofthemusclebelly.Theweaknesselicitedwithmuscletestingmustbedifferentiatedbetweenweaknessthroughout
therangeofmotion(pathologicalweakness)andweaknessthatonlyoccursincertainpositions(positionalweakness).
AccordingtoCyriax,134,136strengthtestingcanprovidetheclinicianwiththefollowingfindings:
Aweakandpainlesscontractionmayindicatepalsyoracompleteruptureofthemuscletendonunit.Themotor
disorderassociatedwithperipheralneuropathyisfirstmanifestedbyweaknessandadiminishedorabsenttendon
reflex(seeChapter3).100
Astrongandpainlesscontractionindicatesanormalfinding.
Aweakandpainfulcontraction.AstudybyFranklin172indicatedthattheconditionsrelatedtothisfindingneed
toincludenotonlyseriouspathology,suchasasignificantmuscletearoratumor,butrelativelyminormuscle
damageandinflammationsuchasthatinducedbyeccentricisokineticexercise.158
AstrongandpainfulcontractionindicatesagradeIcontractilelesion.
Painthatdoesnotoccurduringthetest,butoccursuponthereleaseofthecontraction,isthoughttohaveanarticular
source,producedbythejointglidethatoccursfollowingthereleaseoftension.
CLINICALPEARL
Painthatoccurswithresistance,accompaniedbypainattheoppositeendofthepassiverange,indicatesmuscle
impairment.
Thedegreeofcertaintyregardingthefindingsjustdescribeddependsonacombinationofthelengthofthemuscle
tested,andtheforceapplied.Tofullytesttheintegrityofthemuscletendonunit,amaximumcontractionmustbe
performedinthefullylengthenedpositionofthemuscletendonunit.Althoughthispositionfullyteststhemuscle
tendonunit,therearesomeproblemswithtestinginthismanner:
Thejointanditssurroundinginerttissuesareinamorevulnerablepositionandcouldbethesourceofthepain.
Itisdifficulttodifferentiatebetweendamagetothecontractiletissueofvaryingseverity.Thedegreeof
significancewiththefindingsinresistivetestingdependsonthepositionofthemuscleandtheforceapplied
(Table419).Forexample,painreproducedwithaminimalcontractionintherestpositionforthemuscleismore
stronglysuggestiveofacontractilelesionthanpainreproducedwithamaximalcontractioninthelengthened
positionforthemuscle.
Asamusclelengthens,itreachesapointofpassiveinsufficiency,whereitisnotcapableofgeneratingits
maximumforceoutput(seeChapter1).
TABLE419StrengthTestingRelatedtoJointPositionandMuscleLength
MuscleLength Rationale
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Muscleinpositionofpassiveinsufficiency
Tightenstheinertcomponentofthemuscle
Fullylengthened
Testsformuscletears(tendoperiostealtears)whileusingminimalforce
Muscleinstrongestposition
Midrange
Testsoverallpowerofmuscle
Muscleinitsweakestposition
Fullyshortened
Usedforthedetectionofpalsies,especiallyifcoupledwithaneccentriccontraction
Ifthesamemuscleistestedontheoppositeside,usingthesametestingprocedure,theconcernaboutthelengthofthe
muscleisremoved,becausethefocusofthetestistoprovideacomparisonwiththesamemuscleontheoppositeside,
ratherthantoassesstheabsoluteforceoutput.
Toassessstrength,strengthvaluesusingmanualmuscletesting(MMT)havetraditionallybeenusedbetweensimilar
musclegroupsonoppositeextremities,orantagonisticratios.Thisinformationisthenusedtodeterminewhethera
patientwasfullyrehabilitated.Itshouldbenotedthatthereisconsiderablevariabilityintheamountofresistancethat
normalmusclescanholdagainst.Theapplicationofresistancethroughoutthearcofmotion(maketestoractive
resistancetest)inadditiontoresistanceappliedatonlyonepointinthearcofmotion(breaktest),whichisusedmore
often,canhelpinjudgingthestrengthofamuscle.158ThevarioustechniquesforassessingmusclestrengthusingMMT
aredescribedinChapter12.
CLINICALPEARL
PerhapsthemostobviousproblemofusingthebreaktestmethodduringMMTisthatthetestsmaydemonstrate
substantialceilingeffectsthatdependonthecharacteristicsoftheclinician.173Forexample,smallcliniciansmayfindit
difficulttobreakmusclecontractions,sotheymaytendtounderestimateweaknesswhencomparedtolarge
clinicians.174
Duringalltesting,stabilizationofthebodypartonwhichthemuscleoriginates,inadditiontocarefulavoidanceof
substitutionbyothermusclegroups,areemphasized.Substitutemotionsarecompensatorymovementpatternscaused
bymuscleactionofastrongeradjacentagonistmuscle,oramusclegroupthatnormallyservesasastabilizer.
Substitutionsbyothermusclegroupsduringtestingindicatethepresenceofweakness.Itdoesnot,however,tellthe
clinicianthecauseoftheweakness.Properalignmentisdeterminedbythedirectionofthemusclefibersandthelineof
pullofthemuscletobetested(seeChapter12).Thealignmentorpositionofthepatientorthelimbwithrespectto
gravitymayalsobeimportantbasedonthegradeanticipated.
CLINICALPEARL
MMThasbeenshowntobelesssensitiveindetectingstrengthdeficitsinstrongermusclesthaninweakermuscles.158
Severalscaleshavebeendevisedtoassessmusclestrength.Forexample,Janda175useda05scalewiththefollowing
descriptions:
Grade5:N(normal).Anormal,verystrongmusclewithafullrangeofmovementandonethatisableto
overcomeconsiderableresistance.Thisdoesnotmeanthatthemuscleisnormalinallcircumstances(e.g.,when
attheonsetoffatigueorinastateofexhaustion).Iftheclinicianishavingdifficultydifferentiatingbetweena
grade4andagrade5,theeccentricbreakmethodofmuscletestingmaybeused.Thisprocedurestartsasan
isometriccontraction,butthentheclinicianappliessufficientforcetocauseaneccentriccontractionorabreak
inthepatientsisometriccontraction.
Grade4:G(good).Amusclewithgoodstrengthandafullrangeofmovement,andonethatisabletoovercome
moderateresistance.Thesubjectivityinvolvedinagrade4scoreisoneofthemajorcriticismsofMMTasthe
gradingrequiresthecliniciantoassignanordinalnumbertoasubjectiveevaluationofresistanceofferedbythe
patient.
Grade3:F(fair).Amusclethatcanmovethroughitscompleterangeofmovementagainstgravitybutonlyifno
additionalresistanceisapplied.Ifthemusclestrengthislessthangrade3,thenthemethodsadvocatedinmuscle
testingmanualsmustbeused.158
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Grade2:P(poor).Averyweakmusclethatisonlyabletomovethroughitscompleterangeofmotioniftheforce
ofgravityiseliminated.
Grade1:T(trace).Amusclewithevidenceofslightcontractilitybutdemonstratesnoeffectivemovement.
Grade0.Amusclewithnoevidenceofanycontractility.
ThegradingsystemsforMMTproduceordinaldatawithunequalrankingsbetweengrades.Forexample,thegrades5
(normal)and4(good)typicallyencompassalargerangeofamusclesstrength,whilethegradesof3(fair),2(poor),
and1(trace)includeamuchnarrowerrange.158Ifthepopularmethodstogrademusclesareanalyzed,thefrailtiesand
similaritiesbecomeobvious.Ifthemusclestrengthislessthangrade3,thesetestinggradesareuseful,butitisthe
gradesof3andhigherthatproducethemostconfusion.Someoftheconfusionarisesfromthedescriptionsofmaximal,
moderate,andminimal,orconsiderable,whichremovesmuchoftheobjectivityfromthetests.
CLINICALPEARL
StudieshavedemonstratedthatreliabilityinMMTdependsonthespecificmusclebeingexamined.Forexample,
Florenceetal.176foundhighreliabilityintheproximalmusclesasopposedtothedistalmuscles,andBarretal.177
foundtheupperbodymusclestobemorereliablytestedthanthelowerbodyones.178
Strengthtestingmustelicitamaximumcontractionofthemusclebeingtestedifitistobedeemedavalidtest.The
followingstrategiesensurethatthisoccurs:
1.Placingthejointthatthemuscletobetestedcrosses,in(orcloseto)itsopenpackedposition.Thisstrategyhelps
protectthejointfromexcessivecompressiveforces,andthesurroundinginertstructuresfromexcessivetension.
2.Placingthemuscletobetestedinashortenedposition.Thisputsthemuscleinanineffectivephysiologicposition
andhastheeffectofincreasingmotorneuronactivity.
3.Usinggravityminimizedpositions.Thisstrategyavoidstheeffectoftheweightofthemovingbodysegmenton
forcemeasurements.Forexample,totestthestrengthofthehipabductors,thepatientispositionedinsupineso
thatthemuscleactionpullsinahorizontalplanerelativetotheground.158
4.HavingthepatientperformaneccentricmusclecontractionbyusingthecommandDontletmemoveyou.
Becausethetensionateachcrossbridgeandthenumberofactivecrossbridgesisgreaterduringaneccentric
contraction(seeChapter1),themaximumeccentricmuscletensiondevelopedisgreaterwithaneccentric
contractionthanwithaconcentricone.
5.Breakingthecontraction.Itisimportanttobreakthepatientsmusclecontraction,inordertoensurethatthe
patientismakingamaximaleffortandthatthefullpowerofthemuscleisbeingtested.Althoughforcevalues
determinedwithmakeandbreaktestsarehighlycorrelated,breaktestsusuallyresultingreaterforcevaluesthan
maketests,179,180sotheyshouldnotbeusedinterchangeably.
6.Holdingthecontractionforatleast5seconds.Weaknessresultingfromnervepalsyhasadistinctfatigability.The
muscledemonstratespoorendurancebecauseusuallyitisonlyabletosustainamaximummusclecontractionfor
about23secondsbeforecompletefailureoccurs.Thisstrategyisbasedonthetheoriesbehindmuscle
recruitment,whereinanormalmuscle,whileperformingamaximumcontraction,usesonlyaportionofitsmotor
units,keepingtheremainderinreservetohelpmaintainthecontraction(seeChapter1).Apalsiedmuscle,withits
fewerfunctioningmotorunits,hasveryfew,ifany,motorunitsinreserve.Ifamuscleappearstobeweakerthan
normal,furtherinvestigationisrequired,asfollows:
a.Thetestisrepeatedthreetimes.Muscleweaknessresultingfromdisusewillbeconsistentlyweakand
shouldnotbecomeweakerwithseveralrepeatedcontractions.Incontrast,apalsiedmusclebecomesweaker
witheachcontraction.
b.Anothermusclethatsharesthesameinnervationistested.Knowledgeofbothspinalandperipheralnerve
innervationwillaidtheclinicianindeterminingwhichmuscletoselect(seeChapter3).
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7.Comparingfindingswiththeuninvolvedside.Onestudyfoundnostatisticallysignificantdifferenceinforce
betweenthedominantandnondominantlowerextremitiesbutdidfindthedifferencebetweenthedominantand
nondominantupperextremities.181Sapega182recommendsthatthedifferenceinmuscleforcebetweensidesof
greaterthan20%probablyindicatesanabnormality,whilethedifferenceof1020%possiblyindicatesan
abnormality.
Asalways,thesetestscannotbeevaluatedinisolationbuthavetobeintegratedintoatotalclinicalprofile,before
drawinganyconclusionaboutthepatientscondition.
CLINICALPEARL
MMTisanordinallevelofmeasurement182andhasbeenfoundtohavebothinterandintraraterreliability,especially
whenthescaleisexpandedtoincludeplusorminusahalforafullgrade.69,183,184Trainingtostandardizedtesting
positions,stabilization,andgradingcriteriaresultedinhigheragreementandcorrelationcoefficientsbetweentesters.
Althoughthegradingofmusclestrengthhasitsroleintheclinic,andtheabilitytoisolatethevariousmusclesisvery
importantindeterminingthesourceofnervepalsy,specificgradingofindividualmusclesdoesnotgivetheclinician
muchinformationontheabilityofthestructuretoperformfunctionaltasks.Inaddition,measurementsofisometric
muscleforcearespecifictoapointorsmallrangeinthejointrangeexcursionand,thus,cannotbeusedtopredict
dynamicforcecapabilities.185187
CLINICALPEARL
Musclefunctiontestingshouldaddresstheproductionandcontrolofmotioninfunctionalactivities.Althoughthereis
generalagreementabouttheroleofthetrunkandpelvicmusculatureinnormalfunctioningofthevertebralcolumn,
protectionagainstpain,andrecurrenceoflowbackdisorders,140,188,189moreresearchisneededtodeterminetherole
offunctionalstrengthintheextremities.Partofthefunctionalassessmentincludesanassessmentofthosemusclesthat
arepronetoweakness,whichcanprovidetheclinicianwiththefollowinginformation:190
Thestrengthofindividualmusclesormusclegroupsthatformafunctionalunit.
Nature,range,andqualityofsimplemovementpatterns.
Therelationshipbetweenthestrengthandtheflexibilityofamuscleormusclegroup.
Theabilityofthewholebodytoperformatask.
Morerecently,theuseofquantitativemuscletesting(QMT)hasbeenrecommendedtoassessstrength,asitproduces
intervaldatathatdescribeforceproduction.QMTmethodsinclude:
Theuseofhandhelddynamometers.AlthoughmorecostlyandtimeconsumingthanMMT,handheld
dynamometrycanbeusedtoimproveobjectivityandsensitivity.Patientsaretypicallyaskedtopushagainstthe
dynamometerwithamaximalisometriccontraction(maketest),orholdapositionuntiltheclinicianandthe
dynamometeroverpowerthemuscleproducinganeccentriccontraction(breaktest).158Normativeforcevalues
forparticularmusclegroupsbypatientageandgenderhavebeenreported,withsomeauthorsincluding
regressionequationsthattakeintoaccountbodyweightandheight.191
CLINICALPEARL
Dependingonthestudy,handhelddynamometershavedemonstratedgoodtoexcellentintratesterreliabilityandpoorto
excellentintertesterreliability.192196
Theuseofanisokineticdynamometer.Thisisastationary,electromechanicaldevicethatcontrolsthevelocityof
themovingbodysegmentbyresistingandmeasuringthepatientseffortsothatthebodysegmentcannot
acceleratebeyondapresetangularvelocity.158Isokineticdynamometersmeasuretorqueandrangeofmotionasa
functionoftime,andcanprovideananalysisoftheratiobetweentheeccentriccontractionandconcentric
contractionofamuscleatvariouspositionsandspeeds.197Thisratioisaptlynamedtheeccentric/concentric
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ratio.198Theratioiscalculatedbydividingtheeccentricstrengthvaluebytheconcentricstrengthvalue.Various
authors199,200havedemonstratedthattheupperlimitofthisratiois2.0andthatlowerratiosindicate
pathology.198,201Alternatively,thesamerecommendationsforMMTadvocatedbySapega182canbeused:a
differenceinmuscleforcebetweensidesofgreaterthan20%probablyindicatesabnormality,whilethedifference
of1020%possiblyindicatesabnormality.Toensurethevalidityofisokineticdynamometrymeasurements,
calibrationofequipmentisnecessaryandshouldbeperformedeachdayoftesting,atthesamespeedanddamp
settingduringthetesting.202
Oneofthemajorcriticismsofmuscletestingistheoverestimationofstrengthwhenamuscleisweakasidentifiedby
QMT,comparedtothesamemusclebeinggradedasnormalbyMMT,suchthatatheoreticalpercentagescorebasedon
MMTislikelytogrosslyoverestimatethestrengthofapatient.178Forexample,Beasley203showedthat50%ofknee
extensorstrengthneededtobelostbeforeMMTwasabletoidentifyweakness.
StudiesthatcomparethereliabilityofMMTandQMToftencometotheconclusionthatMMTmaybeconsistentand
reliable,butitisunabletodetectsubtledifferencesinstrength.174,204Thus,althoughMMTresultsaremoreconsistent,
thevariationproducedbyQMTcanappreciatedifferencesinstrengthundetectableinMMT.178
Regardlessofthetypeofmuscletestingused,theprocedureisinnatelysubjectiveanddependsonthesubjectsabilityto
exertamaximalcontraction.Thisabilitycanbenegativelyimpactedbysuchfactorsaspain,poorcomprehension,
motivation,cooperation,fatigue,andfear.
CLINICALPEARL
Voluntarymusclestrengthtestingwillremainsomewhatsubjectiveuntilaprecisewayofmeasuringmusclecontraction
isgenerallyavailable.24Thisisparticularlytruewhendeterminingnormalandgoodvalues.
FunctionalTesting
WithintheWHOICFmodel,activityistheexecutionofataskoraction,andparticipationisdefinedasinvolvementin
lifeaffairs.Measurementofactivityandparticipationlimitationscanbecompletedusingoneofthefollowing
methods:15
Questionnairebasedmeasurements.Thesemeasurementstypicallyinvolvetheuseofpencilandpaperformsto
collectinformationaboutthepatientsphysicalormentalwellbeingintermsoflimitationsatthelevelsofactivity
andparticipation.Measuresofresponsivenesshavecommonlybeenreportedasstatisticallysignificantchange
scores,whichareusefulinestablishingthethresholdofchangeneededbeyondmeasurementerror.205These
minimalclinicallyimportantdifferences(MCIDs)inperformancemeasureshavebecomecommonlyused
outcomemeasures(seealsoMDCinOutcomessection).Responsiveness,asinvestigatedwiththeMCID,
indicateswhetherapatientexperiencesabeneficialchangefollowingtreatmentthatwouldmandateachangein
patientmanagement,intheabsenceoftroublesomesideeffects,excessivecosts,andinconveniences.205,206Itis
theorizedthatthereportingofMCIDprovidesamoredefiniteresponseofimprovementtherebyreducingthe
chanceforerrorpotentiallyassociatedwithminimalimprovementscores.207
Functionbasedmeasurements.Theseinstruments,oftenreferredtoasfunctionalperformancemeasures,measure
theabilitytodemonstratetheskillfulandefficientassumption,maintenance,modification,andcontrolof
voluntaryposturesandmovementpatterns.18Functionalperformancemeasures,whichtypicallyinvolveasetof
proxymovementsthatmimicacertainfunction,orthecriticalelementsofthatfunction,haveoftenbeen
criticized,asdetailedtestingoftheirmeasurementpropertieshasnotbeenextensivelyreported.205
Physicalperformancemeasurements.Thesemeasurementsareusedfortheathleticpopulationtomeasure
muscularstrength,power,andendurance(seelater).
Priortoinitiatinganintervention,itisimportantforthecliniciantodeterminewhatfunctionalfactorsare
importanttothepatient,andwhatfunctionsarenecessaryforthepatienttoperformworkrelated,recreational,or
socialactivities.Itisworthrememberingthatinsurancecompaniestypicallyreimbursebasedonintervention
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goalsthatimproveworkrelatedandfunctionalabilities,andnotonthosegoalsthatenhanceapatientsabilityto
performrecreationalorathleticpursuits.
Anumberofvariablesaffectfunction.Theseincludeage,gender,physicalcapacity(strength,power,flexibility,
dexterity,agility,speed,muscularendurance,cardiovascularendurance,coordination,andskill),healingstatus(phaseof
healing,weightbearingstatus,precautions/contraindications,andcomorbidities),andpsychologicalprofile(motivation,
fear,andcopingmechanisms).208
Functionaltestingisacomplexandmultifactorialprocessinwhichtheclinicianmakesadeterminationaboutthe
patientsleveloffunctionalindependencebasedonprinciplesofphysiology,biomechanics,andmotorbehavior208:
Physiology.Relevantphysiologicalissuesincludethefunctionsofbodystructuresandsystems,theextentofthe
injury,andthepatientshealingstatus,energysystems,adaptation,andoverallfitnesslevel.
Biomechanics.Biomechanicalconsiderationsincludefunctionalanatomy,direction/planesofmotionandstress,
kinematics(time,distance,position,displacement,velocity),andkinetics(force,torque,mass,acceleration,
inertia,momentum).
Motorbehavior.Motorbehaviorissuesincludeproprioception,perception,transfer,practice,learning,control,
coordination,andperformance.
PhysicalPerformance
Fourcategoriesofphysicalperformancetestshavebeenidentified209:
1.Movement
2.Balance
3.Hop/jump
4.Agility
Thefirsttwocategoriestendtobethefocusinthemajorityofearlyrehabilitationprotocols,whereasthelasttwotendto
beusedwiththosepatientswhoplantoreturntosportsorahighlevelofphysicalactivity.Eachofthesecategoriesis
nowdescribed.
Movement
Thistypeoftestevaluatesapatientsabilitytoperformaspecificmotorpattern.Themovementpatternschosenmay
oftenreplicatecommontasksormovementsthatareperformedbytheindividualonaregularbasisaspartofhis
occupation,activity,orsport.Forexample,movingfromthestandingpositiontoasittingposition.Thecriteriafor
simplepatternsarethatthemovement120,175
isperformedexactlyinthedesireddirection
issmoothandofaconstantspeed
followstheshortestandmostefficientpath
isperformedinitsfullrange.
Thecriteriaformorecomplexmovementpatternsareasfollows120:
Synchronizationbetweentheprimarymoversinthedistalregionswiththosemoreproximal.
Smoothpropagationofmotionfromoneregionofthebodytoanother.
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Absenceofinefficientmovementpatternsormusclerecruitment.
Optimalrelationshipsbetweenthespeedofmotioninitiatedinoneregionandthespeedofmotioninother
regions.
Massmovementpatternsinvolvecombinedmotionsofthejointswithinthekineticchain,dependingonthedesired
motion.210Forexample,amasspatternofthelowerextremitycouldinvolvehip,knee,andankledorsiflexion,withthe
rotationandabductionadductioncomponentvarying.Advancedmovementpatternsinvolvesuchcombinationsaship
extension,kneeflexion,andplantarflexion,orhipflexion,kneeextension,anddorsiflexionmotionsthatoccurwith
normalgait.210
Balance
Thistypeoftestassessesthepatientsabilitytodemonstrateposturalcontrolandbalanceusingeitherstaticbalancetests
ordynamicbalancetests(seeChapter3).
TheFunctionalMovementsScreen(FMS)isarelativelynewassessmenttoolthatattemptstoaddressthequalityof
multiplemovementfactors,includingbalance,withthegoalofpredictinggeneralriskofmusculoskeletalconditionsand
injuries.211214TheoriginalintentoftheFMSwastoidentifyfunctionalmovementdeficitsandasymmetriesthatmay
bepredictiveofgeneralconditionsandinjuries,withtheultimategoalofbeingabletomodifytheidentifiedmovement
deficitsthroughindividualizedexerciseprescription.215Thus,specificexercisesandactivitiesareavoideduntilthe
requiredmovementcompetencyisachieved.TheFMSconsistsofsevenfundamentalmovementcomponenttests(Table
420).
TABLE420TheFunctionalMovementsScreen(FMS)
Score
Task Scoreof3 Scoreof2 Scoreof1
of0
Kneedoesnottouch
behindheel,doweland
Kneetouchesboardbehindheel,dowel Lossofbalanceis
feetdonotremainin
andfeetremaininsagittalplane,dowel noted,inabilityto Pain
Inlinelunge(testboth sagittalplane,dowel
contactsremain(head,thoracicspine, achievestart during
rightandleftsides) contactsdonotremain,
sacrum),dowelremainsvertical,no position,inabilityto test
dowelremainsvertical,
torsomovementnoted. touchkneetoboard.
movementisnotedin
torso.
Footclearscord(doesnottouch)and
Alignmentislost
remainsdorsiflexedaslegisliftedover
betweenhips,knees,and
hurdle.Hips,knees,andanklesremain Contactbetweenfoot Pain
Hurdlestep(testboth ankles,movementis
alignedinthesagittalplane,minimalto andhurdle,lossof during
rightandleftsides) notedinthelumbar
nomovementisnotedinthelumbar balanceisnoted test.
spine,dowel,andhurdle
spine,dowel,andhurdleremain
donotremainparallel.
parallel.
Performedwithheels
Performedwithheelson
on26inboard.If
26inboard.Upper
Uppertorsoisparallelwithtibiaor anyofthefour
torsoisparallelwithtibia Pain
towardvertical,femurbelow criteriaarenotmet
Deepsquat ortowardvertical,femur during
horizontal,kneesarealignedoverfeet, whenthesquatis
belowhorizontal,knees test
dowelalignedoverfeet. performedwithheels
arealignedoverfeet,
ontheboard,the
dowelalignedoverfeet.
scoreis1
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Score
Task Scoreof3 Scoreof2 Scoreof1
of0
Quadrupedrotary Onediagonalrepetition
stability(testboth (liftarmandlegfrom
Oneunilateralrepetition(liftarmand
rightandleftsides).If oppositesidesofbody),
legfromsamesideofbody),keepspine Pain
painisnotedduring keepsspineparallelto Inabilitytoperform
paralleltoboard,kneeandelbowtouch during
quadrupedflexion, board,kneeandelbow diagonalrepetition.
inlineovertheboardandthenreturnto test
rotarystabilityis touchinlineoverthe
thestartposition.
scoredas0.Otherwise, boardandthenreturnto
scoringisasfollows thestartposition.
Themalleolusofthetestedlower Themalleolusofthe Themalleolusofthe
extremityislocatedintheregion testedlowerextremityis testedlower
betweenmidthighandanterior locatedintheregion extremityislocated
Activestraightleg Pain
superioriliacspineofoppositelower betweenthemidthigh intheregionbelow
raise(testbothright during
extremity,theoppositehipremains andkneejointlineof thekneejointlineof
andleftsides). test
neutral(hipdoesnotexternallyrotate), oppositelowerextremity oppositelower
toesremainpointingup,oppositeknee whileothercriteriaare extremitywhileother
remainsincontactwithboard. met. criteriaaremet.
Shouldermobility(test
bothrightandleft
sides).Ifpainisnoted Pain
Fistsarewithin1.5hand Fistsarenotwithin
astheelbowislifted, Fistsarewithinonehandlength. during
lengths. 1.5handlengths.
shouldermobilityis test.
scoredas0.Otherwise,
scoringisasfollows:
Trunkstabilitypush Performonerepetition
up(testbothrightand thethumbsarealigned Unabletoperform
Performonerepetitionthethumbsare
leftsides).Ifpainis withchinformalesand onerepetitionwith Pain
alignedwithforeheadformalesand
notedduringaprone clavicleforfemales, thumbsalignedwith during
chinsforfemales,bodyisliftedasone
pressup,pushupis bodyisliftedasoneunit chinformalesand test
unit(nosaginthelumbarspine).
scoredas0.Otherwise, (nosaginthelumbar clavicleforfemales.
scoringisasfollows: spine).
Inlinelunge(Fig.42)
Hurdlestep(Fig.43)
Deepsquat(Fig.44)
Quadrupedrotarystability(Fig.45)
Activestraightlegraise(Fig.46)
Shouldermobility(Fig.47)
Trunkstabilitypushup(Fig.48)
FIGURE42
Inlinelunge.
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FIGURE43
Hurdlestep.
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FIGURE44
Deepsquat.
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FIGURE45
Quadrupedrotarystability.
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FIGURE46
Activestraightlegraise.
FIGURE47
Shouldermobility.
FIGURE48
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Trunkstabilitypushup.
Forthecomponentteststhatarescoredforboththerightandleftsides,thelowestscoreisusedwhencalculatingthe
FMScompositescore.Eachofthesemovementcomponenttestsisscoredonascaleof03,withthesumcreatinga
componentscorerangingfrom0to21points.Ithasbeensuggestedthatacompositescorethatislessthanorequalto
14ontheFMSmaysuggesthigherinjuryrisk,butthatascoregreaterthan14doesnotruleoutfutureinjuryrisk.216
Unfortunately,asyet,interpretationofFMSscoresislimitedbythescantevidenceinwidelyaccessiblejournals.For
example,Hartiganetal.217concludedthatoneofthecomponentsoftheFMS,theinlinelunge,wasnotrelatedto
balance,power,orspeed.However,otherstudieshaveadvocateditsuse.218220
Hop
Thistypeoftest,whichassessestheabilityofanindividualtoabsorbimpactonthelowerextremity,andtooftenchange
direction,istypicallyusedtoidentifysidetosidedifferencesbetweenthedynamicfunctionofthelowerextremities.In
general,hoptestsarequantifiedineitherdistanceortime.Singleleghoptestsarecommonlyusedforreturntosport
assessmentastheymimiclowerextremityfunctionaldemandsthatchallengestability:generationofpower,acceleration
anddecelerationofbodyweight,dynamiccontroloftriplanarforces,andmaintenanceofposturalstability.221
Performanceduringhopteststhatmeasuresdistanceiscommonlystandardizedtothelengthofthelimborexpressedas
thelimbsymmetryindex(LSI).222TheLSIisapercentagevalueofonelimbversustheotherandiscalculatedby
comparingtheperformanceoftheinvolvedanduninvolvedlimb(LSI=involved/uninvolved*100%forthedistance
measuresandLSI=uninvolved/involved*100%forthetimedhop).223IthasbeenuniversallyacceptedthatnormalLSI
isbetween85%223and90%.224
Themostcommonlyusedsingleleghoptestsinclude:
Singlehopfordistancetest.Thistestmeasuresthedistancetraveledinananteriordirectionusingasingle,
unilateralhop.Thepatientisaskedtostandononelimbandtohopasfarforwardaspossible,landingonthe
samelimb,andtomaintainthelandingforaminimumof2secondswhilethetoemeasurement(tothenearest
centimeter)isrecorded.Weaknessofthehipgirdlemusculaturemayresultinpoorpropulsion,poorperformance
absorption,andpoorcontrolofthefrontalplanelandingmechanics.222
6mtimedhoptest.Thistestmeasuresthetimerequiredforanindividualtohopunilaterallyforadistanceof6m.
Thepatientisaskedtoperformlargeoneleghopsinseriesoverthe6m,whichistimedtothenearestonetenth
ofasecond.
Triplehopfordistancetest.Thepatientisaskedtoperformthreehopsasfaraspossible,landingonthesameleg
andmaintainingthelandingforaminimumof2secondswhilethetoemeasurement(tothenearestcentimeter)is
recorded.Thedistancesofthetwolegsmaythenbecompared.Thistesthasbeenshowntobeastrongpredictor
ofisokineticstrengthofthehamstringsandquadriceps,225andasaselfreportedfunctionaloutcomescoreforthe
knee.226
6mtimedcrossoverhoptest.Thepatientisaskedtoperformthreelateralhopsasfaraspossiblecrossingovera
15cmwidestripmarkingoneachhopandtomaintainlandingafterthethirdhopfor2seconds.Thefirstofthe
threehopsislateralwithrespecttothedirectionofthecrossover(measuredtothenearestcentimeter).
Sidehoptest.Thistestmeasurestheamountoftimeittakesanindividualtohoplaterallybackandforthona
singlelimbovera30cmdistancefor10repetitions.227Healthycontrolshavedemonstratedameanof8.20
secondsforfemalesand7.36secondsformales.227
Figure8hoptest.Thistestrequirestheindividualtohoponasinglelimbtwicearoundthecourseoftwocones
set5mapart.228AnLSI0.81secondshasbeenestablishedastheacceptabledifferencebetweensizeto
discriminatenormalfunction.227
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Squarehoptest.Toperformthistest,theindividualstandsonasinglelimbinthecenterofa4040cmsquare
andisthenaskedtohopasfastaspossibleout,thenbackintothecenterofthesquareforeachcorrespondingside
ofthesquare,beforeswitchinglegs(atotalofeighthopstocompleteacyclearoundthesquare).228Thetime
requiredtocompletefivecyclesisrecorded.
Agility
Thesetests,commonlyreferredtoasjumptestsorfieldagilitytests,arebipedallocomotiveteststhatrequirean
individualtoruninapredeterminedpatternofteninvolvingcutting,pivoting,andchangingdirectiontosimulatesport
specificmovements.Jumptestsareperformedbilaterallyso,unlikehoptests,cannotbecomparedtotheoppositeside
foranalysis.229Examplesofcommonlyusedjumptestsinclude:222
Theverticaljumptest.Thistest,whichallowstheindividualtosquattoadepthofhisorherchoicejustpriorto
takeoff,measurestheverticaldisplacementofthecenterofmassdeterminedbyanindividualsverticaljump
value.
Thesquatjumptest.Thistest,unliketheverticaljumptest,isperformedfromastaticstartposition.
Thedropjumptest.Theindividualstepsfroma40cmbox,landswithbothfeet,thenquicklyperformsa
maximumverticalleap.
Numerousfieldagilitytestshavebeenusedintheliterature:222
TheTtest.Thistestrequiresforwardandbackwardrunsandlateralshufflesinbothdirections.
Modifiedagilitytest(MAT).Thistest,whichisdesignedtohighlightlimbasymmetry,requirestheindividualto
performcuttingandshufflingtoonlyoneside.TheMATisatimedtestinwhichtheindividualperforms15mof
forwardandbackwardrunning,sideshuffling,andcutting.Thepatternsarethenrepeatedontheothersideto
allowforacomparisonofasymmetrybetweenthetwosides.
SelfReportMeasures
Selfefficacy,whichdescribesapersonsownbeliefthatheorshecansuccessfullyexecutebehaviorinordertomeeta
desiredoutcome,playsacriticalroleinthemanagementofneuromusculoskeletalconditions.Strongselfefficacyhas
beenfoundtopredictpositivetreatmentoutcomes,andabetterprognosis,230whereasweakselfefficacypredictslong
termdisability.231Themostcommonmethodforassessingselfefficacyisbyaselfreportquestionnaire.232Selfreport
outcomeinstrumentsfallintooneoffourcategories:generic,diseasespecific,regionspecific,andpatientspecific.Self
reportmeasuresinvolvethepatientratinghisorherperformanceduringactivitiessuchaswalking,stairclimbing,or
sportingactivitybasedontheabilitytoperformatask,difficultywiththetask,helpneededforthetask,andpainduring
performanceofthetask.
Generic.Genericinstrumentsassesstheglobalwellbeingofthepatientandareusefulincomparinggroupsof
subjectswithawiderangeofconditions.
Diseasespecific.Diseasespecificinstrumentsdeterminetheimpactadisease/dysfunctionhasonthepatient.151
Asaresultofthisfocusonadiseasestate,thelikelihoodofincreasedresponsivenessishigher.Someexamplesof
theprimaryfocusoftheseinstrumentsincludepopulations(rheumatoidarthritis),symptoms(backpain),and
function(activitiesofdailyliving).151Forexample,theFearAvoidanceBeliefsQuestionnaire(FABQ),233which
wasoriginallydesignedtohelpmeasurehowmuchfearandavoidanceimpactedapatientwithlowbackpain,
therebyhelpingtoidentifythosepatientsforwhompsychosocialinterventionsmaybebeneficial(Table421).
However,thescalecanbemodifiedtoapplytopatientswithothertypesofchronicpainasonlytwoitems
mentionthewordback.ThescoringfortheFABQisoutlinedinTable422.Thedisadvantageofadisease
specificoutcomeisthatgeneralinformationislost.
Regionspecific.Regionspecificinstrumentscontainitemsthatarespecifictoaparticularareaofthebodyand
usefulinassessingtheeffectofdiseaseprocessesonthatregion.Examplesofregionspecificinstrumentsinclude
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theWesternOntarioandMcMasterUniversitiesOsteoarthritisindex(WOMAC),234andtheHipDisabilityand
OsteoarthritisOutcomeScore(HOOS).235
Patientspecific.Patientspecificinstrumentsallowindividualstocreateitemsthatassessissuestheyfeelare
important.Theseinstrumentsareusefulinanalyzingthesameindividualoveranextendedperiodoftime,butmay
notallowcomparisontoothersubjectsallpatients.Forexample,thePatientSpecificFunctionalScale(PSFS)236
isdesignedtoassessfunctionalchange,primarilyinapatientpresentingwithamusculoskeletaldisorder(see
Outcomessection).
TABLE421FABQ
Instructions:Herearesomeofthethingsthatotherpatientshavetoldusabouttheirpain.Foreachstatement,please
scoreitfrom0to6tosayhowmanyphysicalactivitiessuchasbending,lifting,walking,ordrivingaffectorwould
affectyourbackpain.
Statements
1.Mypainiscausedbyphysicalactivity.
2.Physicalactivitymakesmypainworse.
3.Physicalactivitymightharmmyback.
4.Ishouldnotdophysicalactivitiesthat(might)makemypainworse.
5.Icannotdophysicalactivitiesthat(might)makemypainworse.
Thefollowingstatementsareabouthowyournormalworkaffectsorwouldaffectyourbackpain:
6.Mypainwascausedbymyworkorbyanaccidentatwork.
7.Myworkaggravatedmypain.
8.Ihaveaclaimforcompensationformypain.
9.Myworkistooheavyforme.
10.Myworkmakesorwouldmakemypainworse.
11.Myworkmightharmmyback.
12.Ishouldnotdomynormalworkwithmypresentpain.
13.Icannotdomynormalworkwithmypresentpain.
14.Icannotdomynormalworktillmypainistreated.
15.IdonotthinkthatIwillbebacktomynormalworkwithin3months.
16.IdonotthinkthatIwilleverbeabletogobacktothatwork.
DatafromWaddellG,NewtonM,HendersonI,etal.AFearAvoidanceBeliefsQuestionnaire(FABQ)andtheroleof
fearavoidancebeliefsinchroniclowbackpainanddisability.Pain.1993:521571568.
TABLE422FABQScoringa
Response Points
0
Completelydisagree 1
2
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Response Points
3
Unsure 4
5
Completelyagree 6
Fearavoidancebeliefsaboutwork(scale1)=(pointsforitem6)+(pointsforitem7)+(pointsforitem9)+(pointsfor
item10)+(pointsforitem11)+(pointsforitem12)+(pointsforitem15)
Fearavoidancebeliefsaboutphysicalactivity(scale2)=(pointsforitem2)+(pointsforitem3)+(pointsforitem4)+
(pointsforitem5)
Itemsnotinscale1or2:18131416
Interpretation:
minimalscalescores:0
maximumscale1score:42(7items)
maximumscale2score:24(4items)
Thehigherthescalescoresthegreaterthedegreeoffearandavoidancebeliefsshownbythepatient
Performance:
Internalconsistency(alpha)0.88forscale1and0.77forscale2
aDatafromWaddellG,NewtonM,HendersonI,etal.AFearAvoidanceBeliefsQuestionnaire(FABQ)andtheroleof
fearavoidancebeliefsinchroniclowbackpainanddisability.Pain.1993:52157168.
Itisgenerallyrecommendedthatwhenevaluatingpatientoutcomes,bothadiseasespecificandgenericoutcome
instrumentshouldbeused.151
Throughoutthistext,numerousselfreportmeasurementtoolsareoutlinedineachoftheappropriatechapters.
AerobicCapacityandEndurance
Aerobiccapacityenduranceistheabilitytoperformworkorparticipateinactivityovertime,usingthebodysoxygen
uptake,delivery,andenergyreleasemechanisms(seeChapter15).18Clinicalindicationsfortheuseofthetestsand
measuresforthiscategoryarebasedonthefindingsfromthehistoryandsystemsreview.Theseindicationsinclude,but
arenotlimitedto,pathology,pathophysiology,andimpairmenttothe18:
cardiovascularsystem(e.g.,abnormalheartrate,rhythm,andbloodpressure)
endocrine/metabolicsystem(e.g.,osteoporosis)
multiplesystems(e.g.,traumaandsystemicdisease)
neuromuscularsystem(e.g.,generalizedmuscleweaknessanddecreasedendurance)
pulmonarysystem(e.g.,abnormalrespiratorypattern,rate,andrhythm).
Theaerobiccapacityandenduranceofapatientcanbemeasuredusingstandardizedexercisetestprotocols(e.g.,
ergometry,steptests,timeordistancewalkorruntests,andtreadmilltests)andthepatientsresponsetosuchtests(see
Chapter15).18
AnthropometricCharacteristics
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Anthropometriccharacteristicsaretraitsthatdescribebodydimensions,suchasheight,weight,girth,andbodyfat
composition.18Theuseofananthropometricexaminationandthesubsequentmeasurementsvaries.Clearly,ifa
noticeableamountofeffusionorswellingispresent,thesemeasurementsserveasanimportantbaselinefromwhichto
judgetheeffectivenessoftheintervention.
Circulation
CirculationisdefinedbyTheGuideasthemovementofbloodthroughorgansandtissuestobothdeliveroxygenand
removecarbondioxideandcellularbyproducts.18Circulationalsoinvolvesthepassivemovementoflymphthrough
channels.Theexaminationofthecirculationincludesanexaminationofthosecardiovascularsignsnottestedinthe
aerobiccapacityandenduranceportion,andtheanthropometriccharacteristicsportionoftheexamination,includingthe
patientsphysiologicresponsetopositionchange,aninspectionofthenailbeds,capillaryrefill,andmonitoringofthe
pulsesoftheextremities.
Ingeneral,theposterior(dorsal)pedispulseisusedinthelowerextremitiestoassessthepatencyofthelowerextremity
vessels,whereastheradialpulseisusedfortheupperextremities.
Work,Environmental,andHomeBarriers(Job,School,andPlay)
Work,environmental,andhomebarriersarethephysicalimpedimentsthatkeeppatientsfromfunctioningoptimallyin
theirsurroundings.18
ErgonomicsandBodyMechanics
Ergonomicsistherelationshipbetweentheworkertheworkthatisdonetheactions,tasks,oractivitiesinherentinthat
work(job,school,andplay)andtheenvironmentinwhichthework(job,school,andplay)isperformed.18Body
mechanicsaretheinterrelationshipsofthemusclesandjoints,astheymaintainoradjustpostureinresponsetoforces
placedonorgeneratedbythebody.
Itisnotwithinthescopeofthistexttodetailthescientificandengineeringprinciplesrelatedtoergonomics,andthe
numeroustestsusedtoquantifythesemeasures.Ergonomics,asitrelatestoposture,isdiscussedinChapter6and
withintherelatedchapters.
Gait,Locomotion,andBalance
Gaitanalysisisanimportantcomponentoftheexaminationprocess(seeChapter6)andshouldnotbereservedonlyfor
thosepatientswithlowerextremitydysfunction.Althoughtheactofwalkingisoftentakenforgranted,normaland
reciprocalgaitrequiresafinelytunedseriesofreflexes.237Theexaminationofgaitisperformedtohighlightany
breakdownwithinthesereflexes,includingimbalancesofflexibilityorstrength,orcompensatorymotions.238The
analysisofgaitisdescribedinChapter6.
Gait,likeposture,variesbetweenindividuals,andagaitthatdiffersfromnormalisnotnecessarilypathologic.
Balanceisanessentialcomponentofsportparticipationandforactivitiesofdailyliving(seeChapter3).Duringthe
history,thepatientmaydescribesymptomsofdizziness,lightheadedness,asenseofimpendingfaint,orpoorbalance.
Nauseaandvomitingarecommoncomplaintsinbalancedisorders.TheassessmentofbalanceisdiscussedinChapter3.
Orthotic,Adaptive,Protective,andAssistiveDevices
Thesedevicesareimplementsandequipmentusedtosupportorprotectweakorineffectivejointsormusclesandserve
toenhanceperformance.18Examplesofsuchdevicesincludecanes,crutches,walkers,reachers,andanklefootorthoses.
Posture
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Posturedescribestherelativepositionsofdifferentjointsatanygivenmoment.97Theposturalexaminationgivesan
overallviewofthepatientsmusclefunctioninbothchronicandacutepainstates.Theexaminationenablestheclinician
todifferentiatebetweenpossibleprovocativecauses,suchasstructuralvariations,alteredjointmechanics,muscle
imbalances,andtheresidualeffectsofpathology.TheassessmentofpostureisdetailedinChapter6andintherelevant
chapters.
Work(Job,School,andPlay),Community,andLeisureIntegrationandReintegration
Inshort,thiscategoryreferstotheprocessofassumingorresumingrolesandfunctions.
SelfcareandHomeManagement(IncludingActivitiesofDailyLivingandInstrumentalActivitiesofDailyLiving)
Thisportionoftheexaminationaddressesthepatientsperceptionofhisorhercondition,namelyissuesregardingthe
patientsperceptionoftheirfunctionallevelandqualityoflife.
Palpation
Palpationisafundamentalskillusedthroughouttheexamination.BothGerwinetal.239andNjooandandvander
Does240foundthattrainingandexperienceareessentialinperformingreliablepalpationtests.Hoppenfeld241advocates
anapproachtopalpationthatisorganizedbyregion.Underthissystem,thepalpationofbonystructuresoccurs
separatelyfromthepalpationofthesofttissues.Whilethismaybehelpfultotheclinician,timeconstraintsoftendictate
thatthetwoareexaminedconcurrently.Palpation,whichcanplayacentralroleintheperformanceofseveralmanual
therapytechniques,242isperformedto243,244
checkforanyvasomotorchangessuchasanincreaseinskintemperaturethatmightsuggestaninflammatory
process.
localizespecificsitesofswelling.
determinethepresenceofmuscletremors,and/orfasciculations.
identifyspecificanatomicstructuresandtheirrelationshiptooneanother.
identifysitesofpointtenderness.Hyperalgicskinzonescanbedetectedusingskindrag,whichconsistsof
movingthepadsofthefingertipsoverthesurfaceoftheskinandattemptingtosenseresistanceordrag.
identifysofttissuetexturechangesormyofascialrestriction.Normaltissueissoftandmobileandmovesequally
inalldirections.Abnormaltissuemayfeelhard,sensitive,orsomewhatcrunchyorstringy.245
locatechangesinmuscletoneresultingfromtriggerpoints,musclespasm,hypertonicity,orhypotonicity.
However,astudybyHsiehetal.246foundthatamongnonexpertphysicians,physiatricorchiropractic,trigger
pointpalpationisnotreliablefordetectingtautbandandlocaltwitchresponse,andonlymarginallyreliablefor
referredpainaftertraining.Themostusefuldiagnostictesttodetectthesechangesistocreateafoldinthetissue
andtostretchit.247Thetissueshouldbesoftandsupple,andthereshouldbenoresistancetothestretch.
determinecirculatorystatusbycheckingdistalpulses.
detectchangesinthemoistureoftheskin.
locateanydeformitythatmaybesuggestiveofafracture,severemuscleortendonlesion,orvascular
compromise.
Thepertinentpalpationtechniquesforeachofthejointsaredescribedintherelevantchapters.
SpecialTests
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Specialtestsforeachareaaredependentonthespecialneedsandstructurebeingtested.Numeroustestsexistforeach
joint.Withafewnotableexceptions,thereliabilityofmostorthopedictestingiseitherpoororunproven.Therefore,the
clinicianiswisetoavoidoverrelianceonlabelingaspecifictestaspositiveornegative.248Rather,thepatientsresponse
toprovocativemaneuversshouldbecarefullynotedandbeusedtoprovideaframeworkwithinwhichtheclinician
buildsacompletepictureoftheclinicalentity.248Inaddition,theclinicianshouldusemorethanoneexamination
maneuvertomakethediagnosis.Onestudy249reportedimprovedsensitivity,specificity,andpositivepredictivevalue
oftheutilizationofcombinationsoftestsratherthanusingtestsinisolation.
Thespecialtestsareonlyperformedifthereissomeindicationthattheywouldbehelpfulinarrivingatadiagnosis.The
testshelpconfirmorimplicateaparticularstructureandmayalsoprovideinformationastothedegreeoftissuedamage.
Inthejointsofthespine,examplesofspecialtestsincludedirectionalstresstests(posterioranteriorpressuresand
anterior,posterior,androtationalstressing),jointquadranttesting,vasculartests,andrepeatedmovementtesting.
Examplesofspecialtestsintheperipheraljointsincludeligamentstresstests(i.e.,Lachmanfortheanteriorcruciate
ligament),articularstresstesting(valgusstressappliedattheelbow),andglenohumeralimpingementtests.Specialtests
canbecategorizedaccordingtointent:
Provocativetests.Provocativetestsincludethosethataredesignedtoputstressonaninvolvedstructureand
reproducethepainthathasbroughtthepatientintotheclinicwhilerulingouttheinvolvementofotherstructures.
Althoughpalpationfitsthecriteriaasaprovocativetest,itsimportancetotheexaminationwarrantsitsown
section.ExamplesofotherprovocativetestsincludetheSpurlingstest(cervicalforaminalencroachmenttest)to
detectapotentialcervicalradiculopathy,thethoracicoutlettests,theneurodynamicmobilizationstests(e.g.,the
straightlegraiseseeChapter11)thatassessforneuraladhesionsandnerverootproblems,andtheselective
tissuetensiontestsdesignedbyCyriax.137Thesetests,whichbytheirverynaturearedesignedtoreproducethe
patientssymptoms,shouldbeusedjudiciously,andonlyafterconsultationwiththepatienttodescribethereasons
forthetesting.
Clearingtests.Thepurposeoftheclearingtestsistoremoveastructureorregionasapotentialsourceofthe
patientsproblem.Theclearingtestsaretypicallyusedwhenapatientpresentswithsymptomsineitherthelower
extremitiesorupperextremities.Forexample,inapatientcomplainingofshoulderpain,theclinicianmust
determineifthesymptomsarelocalorarereferred.Tohelpinthisdecisionmakingprocess,thecervicalspine
mustbeclearedsoitcanberuledoutasapotentialsource.Thiscanbedonethroughacombinationofneckside
bending,rotation,andextensioninanefforttoreproducethesymptoms.Ifthesymptomsarenotreproducedwith
thesemaneuvers,thecervicalspineisunlikelytobeanobvioussourceofthesymptoms.Becausethecervical
spinehasthepotentialtoreferpainthroughouttheentireupperextremity,itisalwaysaworthyconsiderationasa
causeofsymptomsintheshoulder,theelbow,thewristandthehand.Similarly,becausethelumbarspineandthe
sacroiliacjointhavethepotentialtorefersymptomsintothelowerextremities,theyshouldalwaysbeconsidered
incasesofhip,knee,andankleandfootsymptoms.Inaddition,neighboringjointsshouldalwaysbeconsidered
aspotentialcausesofsymptomsuntilcleared.
Thespecialtestsforeachofthejointsaredescribedinthevariouschaptersofthisbook,withemphasisplacedonthose
thatareevidencebased.Theinterpretationofthefindingsfromthespecialtestsdependsontheskillandexperienceof
theclinician,aswellasthedegreeoffamiliaritywiththetests.Whilespecialtestsareassociatedwithfalsepositiveand
falsenegativeresults,apositivetestfindinginconjunctionwithotheraspectsoftheexaminationishighlysuggestiveof
pathology.158
ReflexandSensoryTesting
ReflexandsensorytestingiscoveredinChapter3.Theneurologicalexaminationisonlycarriedoutiftheclinicianfeels
thenervoussystemisinvolved,oriftheclinicianisunsureastowhetherthereisanyneurologicalinvolvement.
NeuromeningealMobilityTests
Theneurodynamicmobilitytests,describedinChapter11,examineforthepresenceofanyabnormalitiesofthedura,
bothcentrallyandperipherally.Thesetestsareusedifaduraladhesionorirritationissuspected.Thetestsemploya
sequentialandprogressivestretchtothedurauntilthepatientssymptomsarereproduced.12Theoretically,ifthedurais
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scarred,orinflamed,alackofextensibilitywithstretchingoccurs.Becausethesinuvertebralnerveinnervatesthedural
sleeve,thepaincausedbyaninflamedduraisfeltbythepatientatmultisegmentallevelsandisdescribedashavingan
achelikequality.Ifthepatientexperiencessharporstabbingpainduringthetest,amoreseriousunderlyingcondition
shouldbesuspected.
Evaluation
Physicaltherapistsareresponsibleforthoroughlyexaminingeachpatientandtheneithertreatingthepatientaccording
toestablishedguidelinesorreferringthepatienttoamoreappropriatehealthcareprovider.250Oncetheexaminationis
complete,theclinicianshouldbeabletoaddandsubtractthevariousfindings,determinetheaccuracyoftheworking
hypothesis,andmakeanevaluation,whichinvolvesdevelopingthediagnosis,theprognosis,andtherealisticPOC.251
AccordingtoGrieve,139anevaluationisthelevelofjudgmentnecessarytomakesenseofthefindings,inorderto
identifyarelationshipbetweenthesymptomsreportedandthesignsofdisturbedfunction.Thus,whiletheevaluationis
usedtodeterminethediagnosis,theprognosis,andthePOC,itisthediagnosisthatguidestheintervention.
Afterdetermininganinitialworkinghypothesis,theclinicianmustmakeafundamentaldecisionbasedonthe
following:15
Referthepatientoutforadditionalconsultationandtreatment,
Initiatephysicaltherapyinterventionorcontinuethephysicaltherapyexamination,or
Initiatebothaphysicaltherapyinterventionandreferral.
CLINICALPEARL
ThediagnosisandprognosisarecriticaltoshapingthefinalPOC.Aphysicaltherapydiagnosisreferstotheclusterof
signsandsymptoms,syndromes,orcategoriesandisusedtoguidethephysicaltherapistindeterminingthemost
appropriateinterventionstrategyforeachpatient.252
ClinicalDecisionMaking
Patientsmaybereferredtophysicaltherapywithanonspecificdiagnosis,anincorrectdiagnosis,ornodiagnosisat
all.253Informationderivedfromthehistory,physicalexamination,andotherinvestigationsisusedtorevisepriorbeliefs
aboutthelikelihoodofagivendiagnosisoroutcomebyamagnitudeproportionaltotherelativestrengthofthat
information.254Theapplicationofsuchmethods,particularwithinadiagnosticcontext,hasbeentermedprobabilistic
reasoning.255,256Withinaprobabilisticframework,perfectpredictionsarenotanticipated,anderrorisknowingly
accepted.257Thus,thegoalofprobabilisticreasoningisnottopredictoutcomeswithcertaintybut,rather,togenerate
predictionsthataremoreoftenlesswrongthanthosegeneratedbyothermethods.256
Adiagnosiscanonlybemadewhenallpotentialcausesforthesignsandsymptomshavebeenruledout,sotheclinician
shouldresisttheurgetocategorizeaconditionbasedonasmallnumberoffindings.Thebestindicatorofthe
correctnessofadiagnosisisthequalityofthehypothesisconsidered,becauseiftheappropriatediagnosisisnot
consideredfromthestart,anysubsequentinquirieswillbemisdirected.258Ultimately,giventheroleofphysical
therapistsasmovementspecialists,taskanalysisshouldformthebasisofthediagnosis.259Onceimpairmentshavebeen
highlightedadeterminationcanbemadeastothereasonforthoseimpairments,andtherelationshipbetweenthe
impairmentsandthepatientsfunctionallimitationsordisabilities.
Decisionmakingencompassestheselectionoftestsduringtheexaminationprocess,interpretationofdatafromthe
detailedhistoryandexamination,establishmentofthediagnosis,estimationoftheprognosis,determinationof
interventionstrategies,sequenceoftherapeuticprocedures,andestablishmentofdischargecriteria.252Thedecision
makingprocessisamultifacetedfluidprocesswhichcombinestacitknowledgewithaccumulatedclinical
experience.260Theexperiencedclinicianisabletorecognizepatternsandextrapolateinformationfromthemusing
forwardreasoning,todevelopanaccurateworkinghypothesis.261Thiscanbeaccomplishedthroughanestimateofthe
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proportionalcontributionoftissuepathologyandimpairmentclusterstothepatientsfunctionallimitations.262Many
physicaltherapistsaretaughttodirecttheirorthopedicevaluationtowardclassifyingpatientsbasedonapathoanatomic
model,suchassignsandsymptomsconsistentwithrotatorcufftear.Therationalebehindsuchapproachisthatby
usingthesamelabelsandlanguageasthereferringphysicians,communicationwillbeenhanced.263However,as
physicaltherapiststreatmovementrelatedimpairmentsratherthanstructuralanatomicalabnormalities,suchlabeling
createsadisconnectbetweenthediagnosticandtreatmentprocesses.263Thus,bychangingthefocusofthelabeltothe
humanmovementsystem,thediagnosischangestoapathokinesiologicmodel,wherethediagnosticprocessfocuseson
identificationofcharacteristicmovementimpairments.263,264Suchalabel,withitsfocusonthepatternsorclustersof
movementimpairments,providesabetterguidetotheinterventionandthesettingofgoals.Theremaybecaseswhen
providingadiagnosticlabelcanbecombinedwiththerelevantmovementimpairment.Forexample,shouldermobility
deficitassociatedwithcapsularcontracturehelpsdifferentiateasimilarclinicalpresentationinthecaseofglenohumeral
osteoarthritis.263
Usingthisinformation,theclinicianputsavalueonexaminationfindings,byconsideringrelevantenvironmental,
social,cultural,psychological,medical,andphysicalfindings,andclusterstheinformationintorecognizable,
understandable,oridentifiablediagnoses,dysfunctions,orclassificationsyndromes.262AccordingtoKahney,265the
expertseemstodolessproblemsolvingthanthenovicebecausetheformerhasalreadystoredsolutionstomanyofthe
clinicalproblemspreviouslyencountered.266
Oneoftheproblemsfortheclinicianishowtoattachrelevancetoalloftheinformationgleanedfromtheexamination.
Thisjudgmentprocesscanbeviewedasacontinuum.Atoneendofthecontinuumisthenovicewhousesveryclearcut
signposts,whileattheotherendthereistheexperiencedclinicianwhohasavastbankofclinicalexperiencesfrom
whichtodraw.266Anexpertisabletoseemeaningfulrelationships,possessenhancedmemory,isskilledinqualitative
analysis,andhaswelldevelopedreflectionskills.260Thiscombinationofskillsallowstheexperttosystematically
organizetheinformationtomakeefficientandeffectiveclinicaldecisions.
Whatdifferentiatesdiagnosisbythephysicaltherapistfromdiagnosisbythephysicianisnottheprocessitself,butthe
phenomenabeingobservedandclarified.267Sackettetal.149proposedthreestrategiesofclinicaldiagnosis:
Patternrecognition.Thisischaracterizedbythecliniciansinstantaneousrealizationthatthepatientconformstoa
previouslylearnedpatternofdisease.
Historyandphysicalexamination.Thismethodrequiresthecliniciantoconsiderallhypothesesofthepotential
etiology.
Hypotheticodeductivemethod.Inthismethod,theclinicianidentifiesearlycluesandformulatesashortlistof
potentialdiagnoses.
Thecliniciansknowledgebaseiscriticaltotheevaluationprocess.258Experiencedcliniciansappeartohaveasuperior
organizationofknowledge,andtheyuseacombinationofhypotheticodeductivereasoningandpatternrecognitionto
derivethecorrectdiagnosisorworkinghypothesis.258
Anumberofframeworkshavebeenappliedtoclinicalpracticeforguidingclinicaldecisionmakingandproviding
structuretothehealthcareprocess.268,269Whiletheearlyframeworkswerebasedondisablementmodels,themore
recentmodelshavefocusedonenablementperspectivesusingalgorithms.Analgorithmisasystematicprocess
involvingafinitenumberofstepsthatproducesthesolutiontoaproblem.Algorithmsusedinhealthcareallowfor
clinicaldecisionsandadjustmentstobemadeduringtheclinicalreasoninganddecisionmakingprocessbecausethey
arenotprescriptiveorprotocoldriven.260Themostcommonlyusedalgorithminphysicaltherapyisthehypothesis
orientedalgorithmforclinicians(HOAC)designedbyRothsteinandEchternach.270TheHOACisdesignedtoguide
theclinicianthroughtheevaluationtotheinterventionplanningwithalogicalsequenceofactivities,andrequiresthe
cliniciantogenerateworkinghypothesesearlyintheexaminationprocess,thelatterofwhichisastrategyoftenusedby
expertclinicians.
Whenintegratingevidenceintoclinicaldecisionmaking,anunderstandingofhowtoappraisethequalityofthe
evidenceofferedbyclinicalstudiesisimportant.Oneofthemajorproblemsinevaluatingstudiesisthatthevolumeof
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literaturemakesitdifficultforthebusycliniciantoobtainandanalyzealloftheevidencenecessarytoguidetheclinical
decisionmakingprocess.67Theotherprobleminvolvesdecidingwhethertheresultsfromtheliteraturearedefinite
enoughtoindicateaneffectotherthanchance.Judgingthestrengthoftheevidencebecomesanimportantpartofthe
decisionmakingprocess.Clinicalpredictionrules(CPRs)functiontoproduceestimatesofthelikelihoodofatarget
diagnosis,prognosis,ortreatmentoutcomethat,inturn,informedclinicaldecisionmaking.271ACPRisinitially
derivedusingmultivariablestatisticalprocedurestoidentifywhichaspectsofapatientspresentationareindependently
relatedtoacertaindiagnosisoroutcome.272Thetoolthenundergoesaprocessofvalidation,wherebyitisappliedto
newgroupsofpatientsindifferentsettingstoevaluateitsabilitytoaccuratelypredictthatsamediagnosis/outcome.272
ValidatedCPRssubsequentlyundergoimpactanalysis,bywhichtheyaretestedtodeterminewhethertheirclinical
applicationleadstoimprovedpatientoutcomesorefficienciesinresourceconsumption.272
CLINICALPEARL
CPRs,acommonapplicationofprobabilisticreasoninginhealthcare,aretoolsdesignedtoassistcliniciansin
decisionmakingwhencaringforpatients.Forexample,Flynnetal.273designedaCPRtoidentifypatientswith
lowbackpainmorelikelytobenefitfromlumbopelvicthrustmanipulation.Thestudyidentifiedthatthe
probabilityofsuccessfromthisinterventionincreasedfrom45%to95%whenfourormorefactorswerepresent,
includingpreciseestimatesofthetoolsensitivityandspecificity.Thesedatawerethenusedtohelpcalculatemore
preciseestimatesoftheposttestprobabilityofafallinpatientswhowereeitherpositiveornegativeonthe
CPR.256ItisimportanttorememberthataCPRthathasnotundergonevalidationisnotrecommendedforusein
practiceasitmayreflectchancestatisticalassociationsorbespecifictothepatientsampleorsettingfromwhichit
wasderived.272,274
Clinicalpracticeguidelines(CPGs),astheirnamesuggests,areamethodbywhichdiagnosticlabelsareusedto
directtreatment,guidebestpractice,andinformprognosis.
Clinimetrics.15Avarietyoftestpropertiesareusedtodeterminetheadequacyofagiventest,andthesetest
characteristicsarecollectivelycalledclinimetricproperties.Clinimetricpropertiesincludetwosetsofquantitative
estimates:
1.Validity,reliability,andresponsiveness(seetext).
2.Feasibilityofthetest.Feasibilityconsidersthepracticalconstraintsofcompletingandinterpretingatest.
Factorsthatimpactfeasibilityincludecomfortandconvenienceforthepatientandclinician.
Thestandardfortheassessmentoftheusefulnessofatestorinterventionistheclinicaltrial,thatis,aprospectivestudy
assessingtheeffectandvalueofatestorinterventionagainstacontrolinhumansubjects.275Unfortunately,manyofthe
experimentalstudiesthatdealwithphysicaltherapytopicsarenotclinicaltrials,becausethereisnocontroltojudgethe
efficacyofthetestorintervention,andtherearenotestsorinterventionsfromwhichtodrawcomparisons.276
CLINICALPEARL
Feasibilityandpilotstudiesarepreliminarystudiesconductedspecificallyforthepurposesofestablishingwhetheror
notafulltrialwillbefeasibletoconduct,andthatallthenecessarycomponentsofatrialwillworkproperlytogether.277
Inessence,feasibilitystudiesareusedtohelpdeveloptrialinterventionsoroutcomemeasures,whereaspilotstudies
replicateinminiature,aplannedfullsizerandomizedclinicaltrial.278,279
Thebestevidenceformakingdecisionsaboutinterventionscomesfromrandomizedcontrolledtrials,systematic
reviews,andevidencebasedCPGs(Table423).280Theidealclinicaltrialincludesablinded,randomizeddesignanda
controlgroup.Arandomizedclinicaltrial(RCT)isconductedtocomparetwo(ormore)treatments,ortreatmenttoa
controlorcomparisongroup.277Itmaybepossibletodiscriminatebetweenhighandlowqualitytrialsbyaskingthree
simplequestions:280
TABLE423RandomizedControlledTrials,SystematicReviews,andClinicalPracticeGuidelines
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Involveexperimentsonpeople.
Lessexposedtobias.
Ensurescomparabilityofgroups.
Typically,volunteersagreetoberandomlyallocatedtogroupsreceivingoneofthefollowing:
Treatmentandnotreatment
Randomized
controlledtrials Standardtreatmentandstandardtreatmentplusanewtreatment
(RCTs)
Twoalternatetreatments
Thecommonfeatureisthattheexperimentalgroupreceivesthetreatmentofinterestandthecontrol
groupdoesnot.
Attheendofthetrial,outcomesofsubjectsineachgrouparedeterminedthedifferenceinoutcomes
betweengroupsprovidesanestimateofthesizeofthetreatmenteffect.
Reviewsoftheliteratureconductedinawaythatisdesignedtominimizebias.
Canbeusedtoassesstheeffectsofhealthinterventions,theaccuracyofdiagnostictests,orthe
prognosisforaparticularcondition.
Systematic Usuallyinvolvecriteriatodeterminewhichstudieswillbeconsidered,thesearchstrategyusedto
reviews locatestudies,themethodsforassessingthequalityofthestudies,andtheprocessusedtosynthesize
thefindingsofindividualstudies.
Particularlyusefulforbusyclinicianswhomaybeunabletoaccessalltherelevanttrialsinanareaand
mayotherwiseneedtorelyupontheirownincompletesurveysofrelevanttrials.
Recommendationsformanagementofaparticularclinicalcondition.
Involvecompilationofevidenceconcerningneedsandexpectationsofrecipientsofcare,theaccuracy
Clinical
ofdiagnostictests,andeffectsoftherapyandprognosis.
practice
Usuallynecessitatestheconductofoneorsometimesseveralsystematicreviews.
guidelines
Maybepresentedasclinicaldecisionalgorithms.
Canprovideausefulframeworkuponwhichclinicianscanbuildclinicalpractice.
DatafromMaherCG,HerbertRD,MoseleyAM,etal.Criticalappraisalofrandomizedtrials,systematicreviewsof
randomizedtrialsandclinicalpracticeguidelines.In:BoylingJD,JullGA,eds.GrievesModernManualTherapy:The
VertebralColumn.Philadelphia,PA:ChurchillLivingstone2004:603614PetticrewM.Systematicreviewsfrom
astronomytozoology:mythsandmisconceptions.BMJ.2001:32298101.
1.Weresubjectsrandomlyallocatedtoconditions?Randomallocationimpliesthatanonsystematic,unpredictable
procedurewasusedtoallocatesubjectstoconditions.
2.Wasthereblindingofassessorsandpatients?Blindingofassessorsandpatientsminimizestheriskoftheplacebo
effectandtheHawthorneeffect,anexperimentalartifactthatisofnoclinicalutility,wherepatientsreportbetter
outcomesthantheyreallyexperiencebecausetheyperceivethatthisiswhatisexpectedfromthem.281
3.Wasthereanadequatefollowup?Ideally,allsubjectswhoenterthetrialshouldsubsequentlybefollowedupto
avoidbias.Inpractice,thisrarelyhappens.Asageneralrule,lossestofollowupoflessthan10%avoidserious
bias,butlossestofollowupofmorethan20%causepotentialforseriousbias.
CLINICALPEARL
Longthoughtofasapsychologicalresponse,placebo(inLatin,Ishallplease)anditsnegativeconversenocebo(in
Latin,Ishallharm)arerealpsychobiologicalresponsestohealthcareinteractions.282Placeboandnocebophenomena
areinfluencedbyclinicianbehavior,whichaffectsboththepatientsandthecliniciansexperiencesandmeetsatthe
pointwhentheclinicianswishtodogoodequalsthepatientsdesiretobehelped.282Thisphenomenon,coupledwith
therapeuticinterventions,iswheretheartandscienceofmedicineworktogetheramixtureoftheclinicianframinga
positivetherapeuticexperienceandtheuseofevidencebasedinterventions.283
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Numerousphysicaltherapytestsexistthataredesignedtohelptheclinicianruleoutsomeofthemanypossible
diagnoses.Regardlessofwhichtestischosen,thetestmustbeperformedreliablybytheclinicianinorderforthetestto
beavaluableguide.
Reliability
Reliabilitydescribestheextenttowhichatestormeasurementisfreefromerror.Itistherepeatabilityofthe
measurementbetweenclinicians,betweengroupsofpatients,overtime.15Atestisconsideredreliableifitproduces
precise,accurate,andreproducibleinformation.67Twotypesofreliabilityareoftendescribed:
Intrarater.Determineswhetherthesamesingleexaminercanrepeatthetestconsistently.
Interrater.Determineswhethertwoormoreexaminerscanrepeatatestconsistently.
Reliabilityisquantitativelyexpressedbywayofanindexofagreement,withthesimplestindexbeingthepercentage
agreementvalue.Thestatisticalcoefficientsmostcommonlyusedtocharacterizethereliabilityofthetestsandmeasures
aretheintraclasscorrelationcoefficient(ICC)andthekappastatistic(),bothofwhicharebasedonstatistical
models284:
TheICCisareliabilitycoefficientcalculatedwithvarianceestimatesobtainedthroughananalysisofvariance
(Table424).285TheadvantageoftheICCovercorrelationcoefficientsisthatitdoesnotrequirethesamenumber
ofraterspersubject,anditcanbeusedbytwoormoreratersorratings.285
Thestatisticisachancecorrectedindexofagreementthatovercomestheproblemofchanceagreementwhen
usedwithnominalandordinaldata.286Withnominaldata,thestatistic,isappliedafterthepercentage
agreementbetweentestershasbeendetermined.However,withhigherscaledata,ittendstounderestimate
reliability.287Theoretically,thestatisticcanbenegativeifanagreementisworsethanchance.Practically,in
clinicalreliabilitystudies,thestatisticusuallyvariesbetween0.00and1.00.287Thestatisticdoesnot
differentiateamongdisagreementsitassumesthatalldisagreementsareofequalsignificance.287
Standarderrorofmeasurement(SEM).TheSEMreflectsthereliabilityoftheresponsewhenthetestisperformed
manytimesandisanindicationofhowmuchchangetheremightbewhenthetestisrepeated.287IftheSEMis
small,thenthetestisstablewithminimalvariabilitybetweentests287.
TABLE424IntraclassCorrelationCoefficientBenchmarkValues
Value Description
<0.75 Poortomoderateagreement
>0.75 Goodagreement
>90 Reasonableagreementforclinicalmeasurements
DatafromPortneyL,WatkinsMP.FoundationsofClinicalResearch:ApplicationstoPractice.Norwalk,CT:Appleton
&Lange1993.
Validity
Thevalidityofatestisdefinedasthedegreetowhichthetestmeasureswhatitpurportstobemeasuring,andhowwell
itcorrectlyclassifiesindividualswithorwithoutaparticulardisease.6870Atestisconsideredtohavediagnostic
accuracyifithastheabilitytodiscriminatebetweenpatientswithandwithoutaspecificdisorder.288Thereareseveral
typesoftestvaliditythatshouldbeconsideredwhenevaluatingforinclusioninthephysicaltherapyexamination:15
Constructvalidity.Thistypeofvalidityrepresentsthelevelofagreementbetweenameasurementandtheideait
purportstomeasure.Toestablishadequateconstructvalidityofameasurement,themeasurementshouldprovide
similarresultsasothermeasurementsthatareintendedtomeasurethesamevariable.Inaddition,the
measurementshouldprovidedifferentresultsfromothermeasurementsoftheoreticallydifferentideas.
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Convergentvalidityistheagreementbetweentwodifferentmeasurementsofthesamevariable.Divergentvalidity
istheextenttowhichtwomeasurementsoftheoreticallyseparateideasareunrelated.
Contentvalidity.Thistypeofvalidityistheextenttowhichameasurementreflectstheidea(content)thatit
preparestomeasure.Measurementswithhighcontentvaliditydemonstrateamoreaccuraterepresentationofthe
variablebeingmeasured.
Criterionrelatedvalidity.Thistypeofvalidityisanestimateoftheextenttowhichthetestcansubstitutefor
anothertest,whichmaybeagoldstandardtestoratestofarelatedvariable.Criterionrelatedvalidityis
commonlyassessedasconcurrentvalidityandpredictedvaliditywhereconcurrentvalidityisthemeasureof
associationbetweentwomeasurementstakenatthesametime,andwherepredictabilityisanestimateofthe
abilityofameasurementtoforecastafuturemeasurementoroutcome.
Facevalidity.Thistypeofvalidityisanapproximationthatameasurementappearstoreflectthevariablethatthe
measurementisintendedtoestimate.Forexample,palpationofthehandandwristisconsideredtohavehighface
validity,becauselocationsforpalpationreflectthetypicallocationsofanatomicalstructures.
Inordertodetermineifatestisbothreliableandvalid,thetestmustbeexaminedinaresearchstudyand,preferably,
multiplestudies.
Validityisdirectlyrelatedtothenotionofsensitivityandspecificity.Thesensitivityandspecificityofanyphysicaltest
todiscriminaterelevantdysfunctionmustbeappreciatedtomakemeaningfuldecisions.289Sensitivityistheabilityof
thetesttopickupwhatitistestingfor,andspecificityistheabilityofthetesttorejectwhatitisnottestingfor.
Sensitivityrepresentstheproportionofpatientswithadisorderwhotestpositive.Atestthatcancorrectlyidentify
everypersonwhohasthedisorderhasasensitivityof1.0.SnNoutisanacronymforwhenthesensitivityofa
symptomorsignishigh,anegativeresponserulesoutthetargetdisorder.Thus,asocalledhighlysensitivetest
helpsruleoutadisorder.Thepositivepredictivevalueistheproportionofpatientswithpositivetestresultswho
arecorrectlydiagnosed.Responsivenessisthecharacteristicofsensitivitytotruechangeordifferencebetween
measurements.Measurementchangesmayberelevantwithinthesamepatientovertimemeasurement
differencesmaybeclinicallyimportantbetweensubjectswithandwithoutacertainpathology.15
Specificityistheproportionofthestudypopulationwithoutthedisorderthattestnegative.290Atestthatcan
correctlyidentifyeverypersonwhodoesnothavethetargetdisorderhasaspecificityof1.0.SpPinisanacronym
forwhenspecificityisextremelyhigh,apositivetestresultrulesinthetargetdisorder.Thus,asocalledhighly
specifictesthelpsruleinadisorderorcondition.Thenegativepredictivevalueistheproportionofpatientswith
negativetestresultswhoarecorrectlydiagnosed.
CLINICALPEARL
Interpretationofsensitivityandspecificityvaluesiseasiestwhentheirvaluesarehigh.254Atestwithaveryhigh
sensitivity,butlowspecificity,andviceversa,isoflittlevalue,andtheacceptablelevelsaregenerallysetatbetween
50%(unacceptabletest)and100%(perfecttest),withanarbitrarycutoffatabout80%.290
Oncethespecificityandsensitivityofthetestareestablished,thepredictivevalueofapositivetestversusanegative
testcanbedeterminediftheprevalenceofthedisease/dysfunctionisknown.Forexample,whentheprevalenceofthe
diseaseincreases,apatientwithapositivetestismorelikelytohavethedisease(afalsenegativeislesslikely).A
negativeresultofahighlysensitivetestwillprobablyruleoutacommondisease,whereasifthediseaseisrare,thetest
mustbemuchmorespecificforittobeclinicallyuseful.
CLINICALPEARL
Collectively,estimatesofvalidity,reliability,andresponsivenessmaybecalledpsychometricproperties.15
Thelikelihoodratio(LR)istheindexmeasurementthatcombinessensitivityandspecificityvaluesandcanbeusedto
gaugetheperformanceofadiagnostictest,asitindicateshowmuchagivendiagnostictestresultwilllowerorraisethe
pretestprobabilityofthetargetdisorder.290,291
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Diagnostictestsareusedforthepurposeofdiscovery,confirmation,andexclusion.292Testsfordiscoveryandexclusion
musthavehighsensitivityfordetectionwhereasconfirmationtestsrequirehighspecificity.293
Fourmeasurescontributetosensitivityandspecificity(Table425):
TABLE42522Table
Disease/Outcome
Present Absent
Positive(+) a(true+ve) b(false+ve)
Test
Negative() c(falseve) d(trueve)
Truepositive.Thetestindicatesthatthepatienthasthediseaseorthedysfunction,andthisisconfirmedbythe
goldstandardtest.
Falsepositive.Theclinicaltestindicatesthatthediseaseorthedysfunctionispresent,butthisisnotconfirmedby
thegoldstandardtest.
Falsenegative.Theclinicaltestindicatestheabsenceofthedisorder,butthegoldstandardtestshowsthatthe
diseaseordysfunctionispresent.
Truenegative.Theclinicalandthegoldstandardtestagreethatthediseaseordysfunctionisabsent.
Thesevaluesareusedtocalculatethestatisticalmeasuresofaccuracy,sensitivity,specificity,negativeandpositive
predictivevalues,andnegativeandpositiveLRs,asindicatedinTable426.Anotherwaytosummarizediagnostictest
performanceusingTable425isviathediagnosticoddsratio(DOR):DOR=true/false=(a*d)/(b*c).TheDORofa
testistheratiooftheoddsofpositivityindiseaserelativetotheoddsofpositivityinthenondiseased.Thevalueofa
DORrangesfrom0toinfinity,withhighervaluesindicatingbetterdiscriminatorytestperformance.Avalueof1means
thatatestdoesnotdiscriminatebetweenthosepatientswiththedisorderandthosewithout.
TABLE426DefinitionandCalculationofStatisticalMeasures
Statistical
Definition Calculation
Measure
Theproportionofpeoplewhowerecorrectlyidentifiedaseitherhavingornot (TP+TN)/(TP+FP
Accuracy
havingthediseaseordysfunction +FN+TN)
Theproportionofpeoplewhohavethediseaseordysfunctionandwhotest
Sensitivity TP/(TP+FN)
positive
Theproportionofpeoplewhodonothavethediseaseordysfunctionandwhotest
Specificity TN/(FP+TN)
negative
Positive
Theproportionofpeoplewhotestpositiveandwhohavethediseaseor
predictive TP/(TP+FP)
dysfunction
value
Negative
Theproportionofpeoplewhotestnegativeandwhodonothavethediseaseor
predictive TN/(FN+TN)
dysfunction
value
Howlikelyapositivetestresultisinpeoplewhohavethediseaseordysfunction Sensitivity/(1
PositiveLR
ascomparedtohowlikelyitisinthosewhodonothavethediseaseordysfunction specificity)
Howlikelyanegativetestresultisinpeoplewhohavethediseaseordysfunction (1
NegativeLR
ascomparedtohowlikelyitisinthosewhodonothavethediseaseordysfunction sensitivity)/specificity
TP,truepositiveTN,truenegativeFP,falsepositiveFN,falsenegative.
DatafromFritzJM,WainnerRS.Examiningdiagnostictests:anevidencebasedperspective.PhysTher.2001,81:1546
1564PowellJW,HuijbregtsPA.Concurrentcriterionrelatedvalidityofacromioclavicularjointphysicalexamination
tests:asystematicreview.JManManipTher.2006:14E19E29.
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CLINICALPEARL
TheDORvaluerisessteeplywhensensitivityorspecificitybecomesnearperfect.
Thequalityassessmentofstudiesofdiagnosticaccuracy(QUADAS)294isanevidencebasedqualityassessmenttool
currentlyrecommendedforuseinsystematicreviewsofdiagnosticaccuracystudies(DAS).TheaimofDASisto
determinehowgoodaparticulartestisatdetectingthetargetcondition.DASallowthecalculationofvariousstatistics
thatprovideanindicationoftestperformancehowgoodtheindextestisatdetectingthetargetcondition.These
statisticsincludesensitivity,specificity,positiveandnegativepredictivevalues,positiveandnegativeLRs,and
diagnosticsoddsratios.TheQUADAStoolisalistof14questionswhichshouldeachbeansweredyes,no,or
unclear(Table427).Ascoreof10orgreaterofyesanswersisindicativeofahigherqualitystudy,whereasascore
oflessthan10yesanswerssuggestsapoorlydesignedstudy.Throughoutthistext,theQUADASscoreisused(if
known)toevaluatethevariousphysicaltherapyexaminationtests.
TABLE427TheQUADASToola
Item Yes No Unclear
1. Wasthespectrumofpatientsrepresentativeofthetypeofpatientwhowillreceivethetest? () () ()
2. Wereselectioncriteriaclearlydescribed? () () ()
3. Isthereferencestandardlikelytocorrectlyclassifythetargetcondition? () () ()
Isthetimeperiodbetweenreferencestandardandindextestshortenoughtobereasonablysure
4. () () ()
thatthetargetconditiondidnotchangebetweenthetwotests?
Didthewholesampleorarandomselectionofthesample,receiveverificationusingareference
5. () () ()
standardofdiagnosis?
6. Didpatientsreceivethesamereferencestandardregardlessoftheindextestresult? () () ()
Wasthereferencestandardindependentoftheindextest(i.e.,theindextestdidnotformpartof
7. () () ()
thereferencestandard)?
8. Wastheexecutionoftheindextestdescribedinsufficientdetailtopermitreplicationofthetest? () () ()
Wastheexecutionofthereferencestandarddescribedinsufficientdetailtopermitits
9. () () ()
replication?
Weretheindextestresultsinterpretedwithoutknowledgeoftheresultsofthereference
10. () () ()
standard?
Werethereferencestandardresultsinterpretedwithoutknowledgeoftheresultsoftheindex
11. () () ()
test?
Werethesameclinicaldataavailablewhentestresultswereinterpretedaswouldbeavailable
12. () () ()
whenthetestisusedinpractice?
13. Wereuninterpretable/intermediatetestresultsreported? () () ()
14. Werewithdrawalsfromthestudyexplained? () () ()
aDatafromWhitingP,RutjesAW,ReitsmaJB,etal.ThedevelopmentofQUADAS:atoolforthequalityassessmentof
studiesofdiagnosticaccuracyincludedinsystematicreviews.BMCMedResMethodol.2003,3:25.
PrognosisandPlanofCare
Theprognosisisthepredictedoptimalleveloffunctionthatthepatientwillattainwithinacertaintimeframe.This
informationhelpsguidetheintensity,duration,andfrequencyoftheinterventionandaidsinjustifyingtheintervention.
Prognosticstudieshavebecomeidentifiedasaresearchpriorityashealthcareprovidersattempttodifferentiatebetween
patientswithamorefavorableprognosisandthosewithapoorprognosis.295Thegoalistoeitheridentifybaseline
characteristicsthatareassociatedwithaspecificoutcomeatagivenpointordeterminethosecharacteristicsthattendto
haveagoodprognosisregardlessoftreatmentprovided.296,297Thesedeterminationswillallowforamoreintensive
approachtopatientswithapoorgeneralprognosis,andalessintensiveapproachtothosewhoareinclinedtoimprove
regardlessofintervention.296
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Theprognosisrepresentsasynthesis,basedonanunderstandingoftheextentofpathology,premorbidconditions,the
abilityofsurroundingtissuestructurestocompensateintheshortorlongterm,thehealingprocessesofthevarious
tissues,thepatientsage,foundationalknowledge,theory,evidence,experience,andexaminationfindings,andtakes
intoaccountthepatientssocial,emotional,andmotivationalstatus.259,262Anumberofstudieshavedemonstrateda
significantrelationshipbetweenpatientexpectationsandoutcomes,298303includingonebyBishopetal.304which
reportedthatmorethan80%ofpatientsexpectedthatmanualtherapytothecervicalspinewouldprovidereliefof
symptoms,preventionofdisability,andimprovementofactivitylevelandsleep.Anotherstudy298notedthatlowor
negativeexpectationsbeforetreatmentaffectedoutcome6monthsaftertreatment.Itwouldseemapparentthata
physicaltherapistcanconsciouslyorunconsciouslyshapepatientexpectations,andthusinfluenceoutcomes,through
placebo(positive)ornocebo(negative)pathways.283
Thepatientsaspirationsandpatientidentifiedproblems,togetherwiththoseproblemsidentifiedbytheclinician,
determinethefocusofthegoals.259Thepatientandclinicianshouldcometoanagreementregardingthemost
importantproblems,aroundwhichcareshouldbefocused,andtogetherestablishrelevantgoals.259Ideally,ineach
patientencounter,theclinicianshouldstrivetodiscoverthepatientsexpectationandthendeliverandexceedittothe
extentthatitdoesntcausemoreharm.283
Patienteducationandpatientresponsibilitybecomeextremelyimportantindeterminingtheprognosis.Typicallythe
goalofarehabilitationprogramistoreturnthepatient/athletetothepreinjurylevelusingthepatientsuninjuredsideas
thegoldstandard.Thismaysometimesbeinadequateasinmostcasesthecliniciandoesnotknowwhatthepreinjury
levelactuallywas.Instead,thegoalofeveryrehabilitationprogramshouldbetoobtainanenhancedandimprovedlevel
ofwholebodyfunctionalability.305Inaddition,therehabilitationprogramshouldidentify,address,andcorrectall
specificpredisposingfactorsthatmayleadtoanotherinjurybyaddressingthephysical,biomechanical,environmental,
andpsychologicalfactorsofthewholepersonduringtherehabilitationprocess.305
ThePOCisorganizedaroundthepatientsgoals.ThephysicaltherapistsPOCconsistsofconsultation,education,and
intervention.ProceduralinterventionsarecoveredinChapter8.
PatientParticipationinPlanning
Thepatientsaspirationsandpatientidentifiedproblems,togetherwiththoseproblemsidentifiedbytheclinician,
determinethefocusofthegoals.259Thepatientandclinicianshouldcometoanagreementregardingthemost
importantproblems,aroundwhichcareshouldbefocused,andtogetherestablishrelevantgoals.259Patienteducation
andpatientresponsibilitybecomeextremelyimportantindeterminingtheprognosis.
AnticipatedGoalsandExpectedOutcomes
Thisincludesthepredictedpositiveeffectsonthe:
Disorderorcondition
Dysfunction
Functionallimitationsanddisabilities
Preventionoffutureoccurrences
Health,fitness,andwellnessofthepatient
Patient/clientSatisfaction
Theinterventionistypicallyguidedbyshortterm(anticipatedgoals)andlongterm(expectedoutcomes)goals,which
aredynamicinnature,beingalteredasthepatientsconditionchanges,andstrategieswithwhichtoachievethosegoals
basedonthestagesofhealing.
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Themostsuccessfulinterventionprogramsarethosethatarecustomdesignedfromablendofclinicalexperienceand
scientificdata,withthelevelofimprovementachievedbeingrelatedtogoalsettingandtheattainmentofthosegoals.
ThefollowinginformationmustbeincludedwithinthePOCbasedontheanticipatedgoals.
Frequencyoftreatments,includinghowoftenthepatientwillbeseenperdayorperweek.
Whatinterventionsthepatientwillreceive,includingtheuseofanymodalities,therapeuticexercise,andany
specializedequipment.
Plansfordischarge,includingpatientandfamilyeducation,equipmentneeds,andreferraltootherservicesas
appropriate.
Thedocumentedgoalsshouldbelistedinorderofprioritywiththemostimportantormorevitalfunctional
activitieslistedfirst.
Shortterm(anticipated)goals.Shorttermgoalsaretheinterimstepsalongthewaytoachievingthelongterm
goals.Thepurposesoftheshorttermgoalsinclude:
Tosettheprioritiesoftheintervention.
Todirecttheinterventionbasedonthespecificneedsandproblemsofthepatient.
Toprovideamechanismtomeasuretheeffectivenessoftheintervention.
Tocommunicatewithotherhealthcareprofessionals.
Toprovideanexplanationoftherationalebehindthegoaltothirdpartypayers.
Thetimeframeforshorttermgoalscanbebasedonthenexttimethepatientwillbeseen.
CLINICALPEARL
Examplesofshorttermgoalsbasedonthefacility(withandwithoutusingabbreviations):
Acutecare:Indep.walkeramb.onlevelsurfaces50%PWBonRLEfor50ftw/i3d.Thepatientwillambulate
independentlywithawalkerfor50feetwith50%partialweightbearingoftherightlowerextremitywithinthree
days.
Outpatientorthopedicclinic:Pt.willRkneeAROMto090within2d.toassistwithamb.Thepatientwill
increaserightkneeflexionactiverangeofmotionto090degreeswithintwodaystoassistwithambulation.
Longterm(expectedoutcomes)goals.Longtermgoalsarethefinalproductofatherapeuticintervention.The
purposesoflongtermgoalsarethesameasthoseforshorttermgoals.Longtermgoalstypicallyusefunctional
termsratherthansuchitemsasdegreesofrangeofmotion,orgradesofmusclestrength.Examplesoftypical
longtermgoalswouldinclude:
Thepatientwillbeindependentwithtransferson/offtoilet,supinesit,andsitstandandwithambulationfor
100ftusinganassistivedeviceattimeofdischarge.
Thepatientwillbeindependentwithambulationonlevelandunevensurfacesandstairnegotiationwithout
assistivedeviceattimeofdischarge.
Coordination,Communication,andDocumentation
Coordination
Thephysicaltherapistisresponsibleforthecoordinationofphysicaltherapycareandservices.
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Communication
Communicationwithalloftheindividualsinvolvedinapatientscareistypicallyprovidedeitherverballyorthrough
writtendocumentation.Muchaboutbecomingaclinicianrelatestoanabilitytocommunicatewiththepatient,the
patientsfamily,andtheothermembersofthehealthcareteam.Itisimportanttorememberthatlisteningisoftenmore
criticalthanspeaking.Specialattentionneedstobepaidtoculturaldiversityandtononverbalcommunicationsuchas:
Facialexpression.Thefacialexpressionshouldbeoneofinterestandconcern.
Voicevolume.Thevoicevolumeshouldbeatalevelthatissufficientforthepatienttohear.Avoidspeaking
loudlywhenpossible,especiallytothosewhoarehardofhearing.
Posture.Anuprightandattentivepostureispreferable.
Touch.Anytouch,basedonrespectforthepatientsculturalpreferencesandpersonalboundaries,usedshouldbe
confidentandfirm.
Gestures.Gesturesshouldbelimitedtothosedescribingaparticularactivity.
Physicalcloseness.Comfortwithphysicalclosenessvariesaccordingtoculture.IntheUnitedStates,adistanceof
18into4ftisconsiderednormalforaprofessionaldistance.
Eyecontact.Maintainingeyecontactenhancestrustanddemonstratesattentiveness.
Eyelevel.Wheneverpossible,theclinicianshouldalterhisorherpositionsothattheeyelevelbetweenpatient
andclinicianisthesame.Forexample,ifthepatientissitting,theclinicianshouldassumeasittingposition.
Theappearanceofthecliniciancanconveyanairofprofessionalism.Mostinstitutionshaveadresscode.
CLINICALPEARL
Learntobeagoodlistenerby:
Lookingatthepersonwhoistalkingandgivehimorheryourfullattention
Makingappropriateeyecontact
Showingunderstandingbysummarizingandaskingforconfirmation
Lettingthespeakerfinishthepointtheyweremaking
Showinginterest
Beingrespectful
Communicationbetweentheclinicianandthepatientbeginswhentheclinicianfirstmeetsthepatientandcontinues
throughoutanyfuturesessions.Communicationinvolvesinteractingwiththepatientusingtermsheorshecan
understand.Theintroductiontothepatientshouldbehandledinaprofessionalyetempathetictone.Listeningwith
empathyinvolvesunderstandingtheideasbeingcommunicatedandtheemotionbehindtheideas.Particularlyimportant
aspectsofempathyaretherecognitionofpatientsrights,potentialculturaldifferences,typicalresponsestoloss,andthe
perceivedroleofspiritualityinhealthandwellnesstothepatient.
CLINICALPEARL
Apatientsprivacyanddignityshouldbemaintainedatalltimes.Privacyincludesthepatientspersonalspace.
Wheneverappropriate,theclinicianshouldaskpermissionfromthepatientbeforecarryingoutanaction(movingthe
patientsbelongingsoffthebedsidetable,sittingdown,etc.)
Giventhenatureofthephysicaltherapyprofession,physicaltherapistsinteractfrequentlywithpeoplewithdisabilities.
Whenwritingorspeakingaboutpeoplewithdisabilities,itisimportanttoputthepersonfirst.Groupdesignationssuch
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astheblindorthedisabledareinappropriatebecausetheydonotreflecttheindividuality,equalityordignityof
peoplewithdisabilities.Similarly,wordslikenormalpersonimplythatthepersonwithadisabilityisnotnormal,
whereaspersonwithoutadisabilityisdescriptivebutnotnegative.Etiquetteconsideredappropriatewheninteracting
withpeoplewithdisabilitiesisbasedprimarilyonrespectandcourtesy.Outlinedbelowaretipstohelpwhen
communicatingwithpersonswithdisabilitiesprovidedbytheOfficeofDisabilityEmploymentPolicytheMedia
Project,ResearchandTrainingCenteronIndependentLiving,UniversityofKansas,Lawrence,KSandtheNational
CenterforAccessUnlimited,Chicago,IL.
GeneralTips
Whenintroducedtoapersonwithadisability,itisappropriatetooffertoshakehands.Peoplewithlimitedhanduseor
whowearanartificiallimbcanusuallyshakehands(shakinghandswiththelefthandisanacceptablegreeting).Ifyou
offerassistancetoapersonwithadisability,waituntiltheofferisaccepted,thenlistentooraskforinstructions.
Addresspeoplewhohavedisabilitiesbytheirfirstnamesonlywhenextendingthesamefamiliaritytoallothers.
CommunicatingwithIndividualswhoareBlind,orVisuallyImpaired
Theclinicianshouldspeaktotheindividualwhenheorsheisapproached,andspeakinanormaltoneofvoice.When
conversinginagroup,theclinicianshouldremembertoidentifythemselvesandthepersontowhomheorsheis
speaking.Theclinicianshouldnotattempttoleadtheindividualwithoutfirstaskingallowthepersontoholdyourarm
andcontrolherorhisownmovements.Directactionshouldbegivenusingdescriptivewordsgivingthepersonverbal
informationthatisvisuallyobvioustoindividualswhocansee.Forexample,ifyouareapproachingaseriesofsteps,
mentionhowmanysteps.Ifyouareofferingaseat,gentlyplacetheindividualshandonthebackorarmofthechairso
thatthepersoncanlocatetheseat.Attheendofthesession,theclinicianshouldtelltheindividualthatheorsheis
leaving.
CommunicatingwithIndividualswhoareDeaforHardofHearing
Theclinicianshouldgainthepatientsattentionbeforestartingaconversation(e.g.,tapthepersongentlyonthe
shoulderorarm),andthenlookdirectlyattheindividual,facethelight,speakclearly,inanormaltoneofvoice,and
keepthehandsfromobstructingthemouth.Short,simplesentencesshouldbeused.Ifthepatientusesasignlanguage
interpreter,theclinicianshouldspeakdirectlytotheperson,nottheinterpreter.Iftheclinicianplacesaphonecall,heor
sheshouldletthephoneringlongerthanusual.IfaTextTelephone(TTY)isnotavailable,theclinicianshoulddial711
toreachthenationaltelecommunicationsrelayservice,whichwillfacilitatethecall.
CommunicatingwithIndividualswithMobilityImpairments
Wheneverpossible,theclinicianshouldpositionhimselforherselfatthewheelchairuserseyelevelwithoutleaningon
thewheelchairoranyotherassistivedevice.Neverpatronizepeoplewhousewheelchairsbypattingthemontheheador
shoulder.Donotassumethatanindividualinawheelchairwantstobepushedaskfirst.
CommunicatingwithIndividualswithSpeechImpairments
Ifthecliniciandoesnotunderstandsomethingthepatientsaid,heorsheshouldnotpretendthattheydidbutshouldask
theindividualtorepeatwhatheorshesaidandthenrepeatitback.Tohelpthepatient,theclinicianshouldtrytoask
questionswhichrequireonlyshortanswersoranodofthehead.Theclinicianshouldnotspeakfortheindividualor
attempttofinishherorhissentences.Iftheclinicianishavingdifficultyunderstandingtheindividual,writingshouldbe
consideredasanalternativemeansofcommunicating,butonlyafteraskingtheindividualifthisisacceptable.
CommunicatingwithIndividualswithCognitiveDisabilities
Wheneverpossible,theclinicianandpatientshouldcommunicateinaquietorprivatelocation,andshouldbeprepared
torepeatwhatissaid,orallyorinwriting.Itisimportantthattheclinicianbepatient,flexibleandsupportive,andthe
clinicianshouldwaitfortheindividualtoaccepttheofferofassistancedonotoverassistorbepatronizing.
Attheendofthefirstvisitandatsubsequentvisits,theclinicianshouldaskifthereareanyquestions.
Documentation
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Documentationinhealthcareincludesanyentryintothepatient/clientrecord.Thisdocumentation,consideredalegal
document,becomesapartofthepatientsmedicalrecord.TheSOAP(Subjective,Objective,Assessment,Plan)note
formathastraditionallybeenusedtodocumenttheexaminationandinterventionprocess.
Subjective:informationabouttheconditionfromthepatientorfamilymember.
Objective:measurementaclinicianobtainsduringthephysicalexamination.
Assessment:analysisofproblemsincludingthelongandshorttermgoals.
Plan:aspecificinterventionplanfortheidentifiedproblem(s).
Thepurposesofdocumentationareasfollows:306
Todocumentwhatthecliniciandoestomanagetheindividualpatientscase.
Torecordexaminationfindings,patientstatus,interventionprovided,andthepatientsresponsetotreatment.
Tocommunicatewithallothermembersofthehealthcareteamthishelpsprovideconsistencyamongthe
servicesprovided.Thisincludescommunicationbetweenthephysicaltherapistandthephysicaltherapist
assistant.
Toprovideinformationtothirdpartypayers,suchasMedicareandotherinsurancecompanieswhomake
decisionsaboutreimbursementbasedonthequalityandcompletenessofthephysicaltherapynote.
Tohelpthephysicaltherapistorganizehis/herthoughtprocessesinvolvedinpatientcare.
Tobeusedforqualityassuranceandimprovementpurposesandforissuessuchasdischargeplanning.
Toserveasasourceofdataforqualityassurance,peerandutilizationreview,andresearch.
PatientRelatedInstruction
PatienteducationisanimportantcomponentofthePOC.Thereareprobablyasmanywaystoteachastherearetolearn.
Theclinicianneedstobeawarethatpeoplemayhaveverydifferentpreferencesforhow,when,where,andhowoften
theylearn(seeChapter8).
Outcomes
Theassessmentofchangeinapatientssymptomsandfunctionovertimeisessentialtobothclinicalpracticeand
research.307Outcomesmeasurementisaprocessthatdescribesasystematicmethodtogaugetheeffectivenessand
efficiencyofaninterventionindailyclinicalpractice.308Effectivenessinthiscontextreferstotheoutcomeofan
interventionduringtherigorsofordinaryandcustomarycaredelivery.308Theefficiencyofaninterventionisafactorof
utilization(e.g.,numberofoutpatientvisits,lengthofinpatientstay)withthecostsofcareandoutcome.Thetrendin
usingoutcomemeasuresinthedecisionmakingprocessisconsistentwiththeevidencebasedapproach(EBP)and
representsthefinalstepintheevaluationofclinicalperformance.18,309Theclinicianshouldbeabletoevaluateand
choosetheappropriateoutcomemeasureforaspecificpatientpopulationsincethecaliberofinformationthatan
outcomemeasurementprovidesisafunctionofthesophistication,predictability,andaccuracyofthetoolsor
instrumentsused.310Measurementinstrumentsmustbeabletodetectachangewhenithasoccurredandtoremain
stablewhenachangehasnotoccurred.311Thebetterthesophistication,predictability,andaccuracyofthemeasurement
tool,thelesschancethereisforerrorsinmeasurementthatmakeitdifficulttoascertainwhethertrueprogresshas
occurred.Inanefforttocounteractthepotentialforthesemeasurementerrors,thetermminimaldetectablechange
(MDC)hasbeenintroduced.TheMDCisdefinedastheminimalamountofchangethatexceedsmeasurementerror.311
TheMDCisastatisticalmeasureofmeaningfulchangeandisrelatedtoaninstrumentsreliability.311Althoughvarious
methodsforcalculatingtheMDChavebeenproposedaconsensushasyettobereachedastowhatistheoptimal
method.312Unfortunately,statisticallysignificantchangeusingtheMDCmaynotindicatethatthechangeisclinically
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relevant.Theminimallyclinicallyimportantdifference(MCID)isameasureofclinicalrelevanceandindicatesthe
amountofchangeinscalepointsthatmustoccurbeforethechangemaybeconsideredmeaningful.313Thesensitivityof
theMCIDisrepresentedbythenumberofpatientstheoutcomemeasurecorrectlyidentifiesashavingchangedan
importantamountdividedbyallofthepatientswhotrulychangedanimportantamount.314ThespecificityoftheMCID
isrepresentedbythenumberofpatientstheoutcomemeasurecorrectlyidentifiesasnothavingchangedanimportant
amountdividedbyallofthepatientswhotrulydidnotchangeanimportantamount.314Although,itistemptingtomake
theassumptionthattheminimumlevelofstatisticalchange(MDC)wouldbelessthanorequaltotheMCID,the
relationshipbetweentheMDCandtheMCIDscoresisyettobedetermined.313
Partoftheproblemindesigninganoutcomemeasurementtoolisthatfunctionishighlyindividual,withmultiplelevels
ofdifficultyandahighdegreeofspecificity.Inadditiontotheclinicalandstatisticalmeasures,thesuccessofan
interventionisbasedontheperspectiveofthestakeholder.311,315Forexample,tothepatient,successmaybe
consideredasthereliefofsymptoms.Tothepayersofhealthcare,asuccessfuloutcomeislikelyviewedasonethat
involvedcostefficientpatientmanagement.311Clinicianstendtodefinegoodoutcomesasthelearningoflongterm
managementstrategies,reliefofsymptoms,andimprovedfunction.315
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undefined
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Allrightsreserved.
Silverchair
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CHAPTER5:DifferentialDiagnosis
CHAPTEROBJECTIVES
1.Understandtheimportanceofdifferentialdiagnosis.
2.Recognizesomeofthesignsandsymptomsthatindicatethepresenceofaseriouspathology.
3.Discusstheconceptofmalingering.
4.Describewhycertainsignsandsymptoms(redflags)requiremedicalreferral.
5.Describethevariousinfectivediseasesandinflammatorydisordersthattheorthopaedicclinicianmay
encounter.
6.Describethevariousneoplasticandmetabolicdiseasesthatcanimpacttheorthopaedicpatient.
7.Discussthedifferencesbetweenfibromyalgiaandmyofascialpainsyndrome.
8.Listthevarioussystemicormedicalpathologiesthatcanmimicmusculoskeletalpathologyinthevarious
bodyregions.
OVERVIEW
AnimportantcomponentoftheVision2020statementsetforthbytheAmericanPhysicalTherapyAssociation
(ATPA)isachievingdirectaccess.1WiththemajorityofU.S.statesnowpermittingdirectaccesstophysical
therapists,manyphysicaltherapistsnowhavetheprimaryresponsibilityforbeingthegatekeepersofhealthcare
andformakingmedicalreferrals.InlightoftheAPTAsmovementtowardrealizingVision2020,an
operationaldefinitionofautonomouspracticeandtherelatedtermautonomousphysicaltherapistpractitioneris
definedbytheAPTAsBoardasfollows:
Autonomousphysicaltherapistpracticeispracticecharacterizedbyindependent,selfdetermined
professionaljudgmentandaction.
AnautonomousphysicaltherapistpractitionerwithinthescopeofpracticedefinedbytheGuideto
PhysicalTherapistPracticeprovidesphysicaltherapyservicestopatientswhohavedirectand
unrestrictedaccesstotheirservices,andmayreferasappropriatetootherhealthcareprovidersandother
professionalsandfordiagnostictests.2
Throughthehistoryandphysicalexamination,physicaltherapistsdiagnoseandclassifydifferenttypesof
informationforuseintheirclinicalreasoningandintervention.3TheGuideclearlyarticulatesthephysical
therapistsresponsibilitytorecognizewhenaconsultationwith,orreferralto,anotherhealthcareprovideris
necessary.4Thisresponsibilityrequiresthattheclinicianhaveahighlevelofknowledge,includingan
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understandingoftheconceptsofmedicalscreeninganddifferentialdiagnosis.Theresultsofanumberofstudies
havedemonstratedthatphysicaltherapistscanprovidesafeandeffectivecareforpatientswithmusculoskeletal
conditionsinadirectaccesssetting.57Indeed,inastudybyChildsetal.,8physicaltherapistsdemonstrated
higherlevelsofknowledgeinmanagingmusculoskeletalconditionsthanmedicalstudents,physicianinternsand
residents,andmostphysicianspecialistsexceptfororthopaedists.Inaddition,physicaltherapiststudents
enrolledineducationalprogramsconferringthedoctoraldegreeachievedhigherscoresthantheirpeersenrolled
inprogramsconferringthemastersdegree.8Furthermore,licensedphysicaltherapistswhowereboardcertified
achievedhigherscoresandpassratesthantheircolleagueswhowerenotboardcertified.8
Inanefforttoaidthedifferentialdiagnosisofmusculoskeletalconditionscommonlyencounteredbyphysical
therapists,screeningtoolshavebeendesignedtohelprecognizepotentialseriousdisorders(redoryellow
flags).9
Redflagfindingsaresymptomsorconditionsthatmayrequireimmediateattentionandsupersede
physicaltherapybeingtheprimaryproviderofservice(Table51),astheyaretypicallyindicativeof
nonmechanical(nonneuromusculoskeletal)conditionsorpathologiesofvisceralorigin.
Yellowflagfindingsarepotentialconfoundingvariablesthatmaybecautionarywarningsregardingthe
patientscondition,andthatrequirefurtherinvestigation.Examplesincludedizziness,abnormalsensation
patterns,fainting,progressiveweakness,andcirculatoryorskinchanges.
TABLE51RedFlagFindings
History PossibleCondition
Constantandseverepain,
Neoplasmandacuteneuromusculoskeletalinjury
especiallyatnight
Unexplainedweightloss Neoplasm
Lossofappetite Neoplasm
Unusualfatigue Neoplasmandthyroiddysfunction
Visualdisturbances
(blurrinessorlossof Neoplasmorneurologicdysfunction
vision)
Frequentorsevere
Neoplasmorneurologicdysfunction
headaches
Armpainlasting>23
mo
Persistentrootpain Neoplasmorneurologicdysfunction
Radicularpainwith
coughing
Painworseningafter1
Neoplasm
mo
Paralysis Neoplasmorneurologicdysfunction
Trunkandlimb
paresthesia
Bilateralnerverootsigns
Neoplasm,spinalcordcompression,andvertebrobasilarischemia
andsymptoms
Signsworsethan
Neoplasm
symptoms
Difficultywithbalance
SpinalcordorCNSlesion
andcoordination
Feverornightsweats Commonfindingsinsystemicinfectionandmanydiseases
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Frequentnauseaor
History PossibleCondition
Commonfindingsinmanydiseases,particularlyofthegastrointestinalsystem
vomiting
Uppercervicalimpairment,vertebrobasilarischemia,craniovertebralligamenttear,
Dizziness
innereardysfunction,CNSinvolvement,andcardiovasculardysfunction
Shortnessofbreath Cardiovascularand/orpulmonarydysfunctionandasthma
Quadrilateralparesthesia Spinalcordcompression(cervicalmyelopathy)andvertebrobasilarischemia
CNS,centralnervous
system.
DatafromMeadowsJ.ARationaleandCompleteApproachtotheSubAcutePostMVACervicalPatient.
Calgary,AB:SwodeamConsulting1995.
Stithetal.10describetheredflagfindingsfoundwithinthepatientshistory,whichindicateaneedforareferral
tothephysician.Thepresenceofanyofthefollowingfindingsduringthepatienthistory,systemsreview,and/or
scanningexamination(seeChapters3and4)mayindicateseriouspathologyrequiringmedicalreferral:
Fevers,chills,ornightsweats.Thesesignsandsymptomsarealmostalwaysassociatedwithasystemic
disordersuchasaninfection.11
Recentunexplainedweightchanges.Anunexplainedweightgaincouldbecausedbycongestiveheart
failure,hypothyroidism,orcancer.12Anunexplainedweightlosscouldbetheresultofagastrointestinal
disorder,hyperthyroidism,cancer,ordiabetes.12
Malaiseorfatigue.Thesecomplaints,whichcanhelpdeterminethegeneralhealthofthepatient,maybe
associatedwithasystemicdisease.11
Unexplainednauseaorvomiting.Thisisneveragoodsymptomorsign.11
Unilateral,bilateral,orquadrilateralparesthesias.Thedistributionofneurologicsymptomscangivethe
cliniciancluesastothestructuresinvolved.Quadrilateralparesthesiaalwaysindicatesthepresenceof
centralnervoussystem(CNS)involvement.
Shortnessofbreath.Shortnessofbreathcanindicateamyriadofconditions.Thesecanrangefrom
anxietyandasthmatoaseriouscardiacorpulmonarydysfunction.11
Dizziness.Thedifferentialdiagnosisofdizzinesscanbequitechallenging.Patientsoftenusetheword
dizzinesstorefertofeelingsoflightheadedness,varioussensationsofbodyorientation,blurryvision,or
weaknessinthelegs.
Nystagmus.Nystagmusischaracterizedbyarhythmicmovementoftheeyes,withanabnormalshifting
awayfromfixationandrapidreturn.13Failureofanyoneofthemaincontrolmechanismsformaintaining
steadygazefixation(thevestibuloocularreflexandagazeholdingsystem)resultsinadisruptionof
steadyfixation(seeChapter3).
Bowelorbladderdysfunction.Bowelandbladderdysfunctionmayindicatecompromiseofthecauda
equina.Caudaequinasyndromeisassociatedwithcompressionofthespinalnerverootsthatsupply
neurologicfunctiontothebladderandbowel.Amassivediskherniationmaycausespinalcordorcauda
equinacompression.Oneoftheearlysignsofcaudaequinacompromiseistheinabilitytourinatewhile
sittingdown,becauseoftheincreasedlevelsofpressure.Themostcommonsensorydeficitoccursover
thebuttocks,posteriorsuperiorthighs,andperianalregions(thesocalledsaddleanesthesia),witha
sensitivityofapproximately0.75.14Analsphinctertoneisdiminishedin6080%ofcases.14,15Rapid
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diagnosisandsurgicaldecompressionofthisabnormalityisessentialtopreventpermanentneurologic
dysfunction.
Severepain.Aninsidiousonsetofseverepainwithnospecificmechanismofinjury.
Painatnightthatawakensthepatientfromadeepsleep,usuallyatthesametimeeverynight,andwhich
isunrelatedtoamovement.Thisfindingmayindicatethepresenceofatumor.
Painfulweakness.Thepresenceofapainfulweaknessalmostalwaysindicatesseriouspathology,
includingbutnotlimitedtoacompleteruptureofcontractiletissueornervepalsy.
Agradualincreaseintheintensityofthepain.Thissymptomtypicallyindicatesthattheconditionis
worsening,especiallyifitcontinuesduringrest.
Radiculopathy.Neurologicsymptomsassociatedwithmorethantwolumbarlevelsormorethanone
cervicallevel.WiththeexceptionofcentralprotrusionsoradisklesionatL4throughL5,diskprotrusions
typicallyonlyaffectonespinalnerveroot.Multiplelevelinvolvementcouldsuggestthepresenceofa
tumororothergrowth,oritmayindicatesymptommagnification.Thepresenceorabsenceofobjective
findingsshouldhelpdeterminethecause.
Performingamedicalscreenisaninherentstepinmakingadiagnosisforthepurposeofdecidingwhethera
patientreferraliswarranted,butthemedicalscreenperformedbythephysicaltherapistisnotsynonymouswith
differentialdiagnosis.Differentialdiagnosisinvolvestheabilitytoquicklydifferentiateproblemsofaserious
naturefromthosethatarenot,usingthehistoryandphysicalexamination.Problemsofaseriousnatureinclude,
butarenotlimitedto,visceraldiseases,cancer,infections,fractures,andvasculardisorders.Thepurposeofthe
medicalscreenistoconfirm(orruleout)theneedforphysicaltherapyinterventiontheappropriatenessofthe
referralwhetherthereareanyredflagfindings,redflagriskfactors,orclustersofredflagsignsand/or
symptomsandwhetherthepatientsconditionfallsintooneofthecategoriesofconditionsoutlinedinthe
Guide.16BoissonnaultandBass17notedthatscreeningformedicaldiseaseincludescommunicatingwitha
physicianregardingalistorpatternofsignsandsymptomsthathavecausedconcernbutnottosuggestthe
presenceofaspecificdisease.3
Inclinicalpractice,physicaltherapistscommonlyuseacombinationofredflagfindings,thescanning
examination,andthesystemsreviewtodetectmedicaldiseases.Thecombinedresultsprovidethephysical
therapistwithamethodtogatherandevaluateexaminationdata,poseandsolveproblems,infer,hypothesize,
andmakeclinicaljudgments,suchastheneedforapatient/clientreferral.16
Systemicdysfunctionordiseasecanpresentwithseeminglybizarresymptoms.Thesesymptomscanprovetobe
veryconfusingtotheinexperiencedclinician.Complicatingthescenarioisthatcertainpatientswhoare
pursuinglitigationcanalsopresentwithequallybizarresymptoms.Thesepatientsmaybesubdividedintotwo
groups:
1.Thosepatientswithalegitimateinjuryandcauseforlitigationwhogenuinelywanttoimprove.
2.Thosepatientswhoaremerelymotivatedbythelureofthelitigationsettlementandwhohavenointention
ofshowingsignsofimprovementuntiltheircaseissettled.Termedmalingerers,thesepatientsarea
frustratinggroupforclinicianstodealwith,because,likethenonorganicpatienttype,theydisplay
exaggeratedcomplaintsofpain,tenderness,andsuffering.
Malingeringisdefinedastheintentionalproductionoffalsesymptomsortheexaggerationofsymptomsthat
trulyexist.18Thesesymptomsmaybephysicalorpsychologicalbuthave,incommon,theintentionof
achievingacertaingoal.Anyindividualinvolvedinlitigation,whethertheresultofamotorvehicleaccident,
workinjury,oraccident,hasthepotentialformalingering.19Malingeringcanbethoughtofassynonymouswith
faking,lying,orfraud,anditrepresentsafrequentlyunrecognizedandmismanagedmedicaldiagnosis.18
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Unfortunately,duetothesimilaritybetweenmalingerersandnonorganicpatients,thisdeceptionoftencausesa
significant,negativeresponsefromthecliniciantowardmalingerersandnonorganicpatientsalike.
Itismostimportantthattheclinicianaddressesanysuspecteddeceptioninastructuredandunemotionalmanner
andthatinteractionswiththepatientbeperformedinaproblemoriented,constructive,andhelpfulfashion.18
CLINICALPEARL
Thediagnosisofmalingeringshouldbemadebasedontheproductionofactionsintheattainmentofaknown
goal,withoutelaborationofthoseactionsbasedonthenegativeemotionalresponseoftheclinician.18
Withveryfewexceptions,patientsinsignificantpainlookandfeelmiserable,moveextremelyslowly,and
presentwithconsistentfindingsduringtheexamination.Incontrast,malingererspresentwithseveresymptoms
andexaggeratedresponsesduringtheexamination,butcanoftenbeobservedtobeinnoapparentdistressat
othertimes.Thisisparticularlytrueifthemalingeringpatientisobservedinanenvironmentoutsideofthe
clinic.
However,itcannotbestressedenoughthatallpatientsshouldbegiventhebenefitofthedoubtuntilthe
clinician,withahighdegreeofconfidence,canruleoutanorganiccauseforthepain.
Anumberofclinicalsignsandsymptomscanalertthecliniciantothepossibilityofapatientwhois
malingering.Theseinclude:
subjectivecomplaintsofparesthesiawithonlystockinggloveanesthesia(conditionsincludingdiabetic
neuropathyandtheT4syndromemustberuledout)
inappropriatescoringontheOswestryLowBackDisabilityQuestionnaire(Table52),NeckDisability
Index(Table53),andMcGillPainQuestionnaire(seeChapter4)
musclestretchreflexesinconsistentwiththepresentingproblemorsymptoms
cogwheelmotionofmusclesduringstrengthtestingforweaknessand
theabilityofthepatienttocompleteastraightlegraiseinasupineposition,butdemonstratingdifficulty
inperformingtheequivalentrange(kneeextension)inaseatedposition.
TABLE52OswestryLowBackDisabilityQuestionnaire
PLEASEREAD:Thisquestionnaireisdesignedtoenableustounderstandhowmuchyourlowbackpainhas
affectedyourabilitytomanageyoureverydayactivities.PleaseanswereachsectionbymarkingtheONEBOX
thatmostappliestoyou.Werealizethatyoufeelthatmorethanonestatementmayrelatetoyourproblem,but
pleasejustmarktheoneboxthatmostcloselydescribesyourproblematthispointintime.
Name:
Date:
Section1PainIntensity
Thepaincomesandgoesandisverymild
Thepainismildanddoesnotvarymuch
Thepaincomesandgoesandismoderate
Thepainismoderateanddoesnotvarymuch
Thepaincomesandgoesandissevere
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Thepainissevereanddoesnotvarymuch
Section2PersonalCare
IhavenopainwhenIwashordress
Idonotnormallychangemywayofwashinganddressingeventhoughitcausessomepain
IhavehadtochangethewayIwashanddressbecausetheseactivitiesincreasemypain
BecauseofpainIamunabletodosomewashinganddressingwithouthelp
BecauseofpainIamunabletodomostwashinganddressingwithouthelp
BecauseofpainIamunabletodoanywashinganddressingwithouthelp
Section3Lifting(Skipifyouhavenotattemptedliftingsincetheonsetofyourbackpain.)
Canliftheavyweightswithoutincreasingmypain
Canliftheavyweightsbutitincreasesmypain
Painpreventsmefromliftingheavyweightsoffthefloor
PainpreventsmefromliftingheavyweightsoffthefloorbutIcanmanageiftheyareconveniently
positioned,e.g.,onatable
PainpreventsmefromliftingheavyweightsbutIcanmanagelighttomediumweightsiftheyare
convenientlypositioned
Icanonlyliftverylightweightatthemost
Section4Walking
IhavenopainwhenIwalk
IhavesomepainwhenIwalkbutitdoesnotpreventmefromwalkingnormaldistances
Painpreventsmefromwalkinglongdistances
Painpreventsmefromwalkingintermediatedistances
Painpreventsmefromwalkingshortdistances
Painpreventsmefromwalkingatall
Section5Sitting
Sittingdoesnotcausemeanypain
IcansitaslongasIneedto,providedIhavemychoiceofchair
Painpreventsmefromsittingmorethan1h
Painpreventsmefromsittingmorethanh
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Painpreventsmefromsittingmorethan10min
Painpreventsmefromsittingatall
Section6Standing
Standingdoesnotcausemeanypain
IhavesomepainwhenIstandbutitdoesnotincreasewithtime
Painpreventsmefromstandingmorethan1h
Painpreventsmefromstandingmorethanh
Painpreventsmefromstandingmorethan10min
Painpreventsmefromstandingatall
Section7Sleeping
IhavenopainwhenIlieinbed
IhavesomepainwhenIlieinbedbutitdoesnotpreventmefromsleepingwell
Becauseofpainmysleepisreducedby25%
Painpreventsmefromsleepingatall
Section8SexLife(ifapplicable)
Mysexlifeisnormalandcausesnopain
Mysexlifeisnormalbutincreasesmypain
Mysexlifeisnearlynormalbutisverypainful
Mysexlifeisseverelyrestricted
Mysexlifeisnearlyabsentbecauseofpain
Painpreventsanysexlifeatall
Section9SocialLife
Mysociallifeisnormalandcausesnopain
Mysociallifeisnormalbutincreasesmypain
Painhasnosignificanteffectonmysociallife,apartfromlimitingmymoreenergeticinterests(sports,
etc.)
PainhasrestrictedmysociallifeandIdonotgooutoften
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Painhasrestrictedsociallifetomyhome
Ihavenosociallifebecauseofpain
Section10Traveling
IhavenopainwhenItravel
IhavesomepainwhenItravelbutnoneofmyusualformsoftravelmakeitworse
TravelingincreasesmypainbuthasnotrequiredthatIseekalternativeformsoftravel
IhavehadtochangethewayItravelbecausemyusualformoftravelincreasesmypain
Painhasrestrictedallformsoftravel
Icanonlytravelwhilelyingdown
TABLE53NeckDisabilityIndex
Thisquestionnairehasbeendesignedtogivethedoctorinformationastohowyourneckpainhasaffectedyour
abilitytomanageineverydaylife.PleaseanswereverysectionandmarkineachsectiononlytheONEBOX
thatappliestoyou.Werealizeyoumayconsiderthattwoofthestatementsinanyonesectionrelatetoyou,but
pleasejustmarktheboxthatmostcloselydescribesyourproblem.
Section1PainIntensity
Ihavenopainatthemoment
Thepainisverymildatthemoment
Thepainismoderateatthemoment
Thepainisfairlysevereatthemoment
Thepainistheworstimaginableatthemoment
Section2PersonalCare(Washing,Dressing,etc.)
Icanlookaftermyselfnormallywithoutcausingextrapain
Icanlookaftermyselfnormallybutitcausesextrapain
ItispainfultolookaftermyselfandIamslowandcareful
Ineedsomehelpbutmanagemostofmypersonalcare
Ineedhelpeverydayinmostaspectsofselfcare
Idonotgetdressed,Iwashwithdifficultyandstayinbed
Section3Lifting
Icanliftheavyweightswithoutextrapain
Icanliftheavyweightsbutitgivesextrapain
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Painpreventsmefromliftingheavyweightsoffthefloor,butIcanmanageiftheyareconveniently
positioned,forexample,onatable
Painpreventsmefromliftingheavyweights,butIcanmanagelighttomediumweightsiftheyare
convenientlypositioned
Icanliftverylightweights
Icannotliftorcarryanythingatall
Section4Reading
IcanreadasmuchasIwanttowithnopaininmyneck
IcanreadasmuchasIwanttowithslightpaininmyneck
IcanreadasmuchasIwantwithmoderatepaininmyneck
Ican'treadasmuchasIwantbecauseofmoderatepaininmyneck
Icanhardlyreadatallbecauseofseverepaininmyneck
Icannotreadatall
Section5Headaches
Ihavenoheadachesatall
Ihaveslightheadacheswhichcomeinfrequently
Ihavemoderateheadacheswhichcomeinfrequently
Ihavemoderateheadacheswhichcomefrequently
Ihavesevereheadacheswhichcomefrequently
Ihaveheadachesalmostallthetime
Section6Concentration
IcanconcentratefullywhenIwanttowithnodifficulty
IcanconcentratefullywhenIwanttowithslightdifficulty
IhaveafairdegreeofdifficultyinconcentratingwhenIwantto
IhavealotofdifficultyinconcentratingwhenIwantto
IhaveagreatdealofdifficultyinconcentratingwhenIwantto
Icannotconcentrateatall
Section7Work
IcandoasmuchworkasIwantto
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Icanonlydomyusualwork,butnomore
Icandomostofmyusualwork,butnomore
Icannotdomyusualwork
Icanhardlydoanyworkatall
Icantdoanyworkatall
Section8Driving
Icandrivemycarwithoutanyneckpain
IcandrivemycaraslongasIwantwithslightpaininmyneck
IcandrivemycaraslongasIwantbecauseofmoderatepaininmyneck
IcantdrivemycaraslongasIwantbecauseofmoderatepaininmyneck
Icanhardlydriveatallbecauseofseverepaininmyneck
Icantdrivemycaratall
Section9Sleeping
Ihavenotroublesleeping
Mysleepisslightlydisturbed(lessthan1hsleepless)
Mysleepismildlydisturbed(12hsleepless)
Mysleepismoderatelydisturbed(23hsleepless)
Mysleepisgreatlydisturbed(35hsleepless)
Mysleepiscompletelydisturbed(57hsleepless)
Section10Recreation
Iamabletoengageinallmyrecreationactivitieswithnoneckpainatall
Iamabletoengageinallmyrecreationactivities,withsomepaininmyneck
Iamabletoengageinmost,butnotallofmyusualrecreationactivitiesbecauseofpaininmyneck
Iamabletoengageinafewofmyusualrecreationactivitiesbecauseofpaininmyneck
Icanhardlydoanyrecreationactivitiesbecauseofpaininmyneck
Icantdoanyrecreationactivitiesatall
Note:FortheOswestryLowBackDisabilityandtheNeckDisabilityIndexeachofthe10itemsisscoredfrom
05.Themaximumscoreistherefore50.Theobtainedscorecanbemultipliedby2toproduceapercentage
score.Occasionally,arespondentwillnotcompleteonequestionoranother.Theaverageofallotheritemsis
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thenaddedtothecompleteditems.Theamountofdisabilitycanbedeterminedusingthefollowing:
04=nodisability514=mild1524=moderate2534=severeabove34=complete.
CLINICALPEARL
Whateverthereasoningormotivationbehindthemalingeringpatient,thesuccessratefromtheclinicians
viewpointwillbelow,andsoitiswellworthrecognizingtheseindividualsfromtheoutset.
Incontrasttothemalingeringpatient,isthepatientthatpresentswithpsychogenicsymptoms.Thistypeof
patienttendstoexhibitanexaggerationofthesymptomsintheabsenceofobjectivefindings.Psychogenic
symptomsarecommoninpatientswithanxiety,depression,orhysteria,makingitimportantfortheclinicianto
determinethelevelofpsychologicalstressinapatientwhodemonstratessymptommagnification.Waddellet
al.20haveproposedanumberofcharacteristicsofthisillnessbehavior(Table54).
TABLE54WaddellTestforNonorganicPhysicalSigns
Test InappropriateResponse
Tenderness Superficial,nonanatomictolighttouch
Simulation
Axialloading Axialloadingonstandingpatient'sskullproduceslowbackpain
Rotation Passive,simultaneousrotationofshouldersandpelvisproduceslowbackpain
Distraction Discrepancybetweenfindingsonsupineandseatedstraightlegraising
Regionaldisturbances
Weakness Givingway(Cogwheel)weakness
Sensory Nondermatomalsensoryloss
Overreaction Disproportionatefacialexpression,verbalization,ortremorduringexamination
DatafromWaddellG,McCullochJA,KummelE,etal.Nonorganicphysicalsignsinlowbackpain.Spine.
19805:117125.
INHERITEDDISEASES
EhlersDanlosSyndrome
EhlersDanlossyndrome(EDS)isaninheritedheterogeneousconnectivetissuedisordercharacterizedby
varyingdegreesofskinhyperextensibility,jointhypomobility,jointdislocations,musculoskeletalpain,and
vascularfragility.21Inheritanceisautosomaldominant,autosomalrecessive,orXlinked.Therearesixmajor
types:21,22
Classical.Thistypeischaracterizedbythepresenceofskinhyperextensibilitywithatrophicscarsin
individualswithjointhypomobility.
Hypermobility.Thistypeischaracterizedbyhypermobilejointsandsomedegreeofskin
hyperextensibility.Thistypeisassociatedwiththemostdebilitatingmusculoskeletalmanifestations,and
jointpainisreportedby100%ofpatients.
Vascular.Thistypeischaracterizedbyfragilevisceraand,therefore,hasthemostseriousconsequences.
Kyphoscoliosis.Thistypeischaracterizedbyseverehypotoniaandscoliosis.
Arthrochalasia.Thistypeischaracterizedbyseverehypermobilityandjointdislocations.
Dermatosparaxis.Thistypeischaracterizedbyfragile,sagging,andredundantskin.
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Thediagnosisofthisconditionbeginswithacompletehistory.ThetypicalhistorywithEDSincludesreportsof
jointdislocations,subluxations,pain,easybruising,easybleeding,orpoorwoundhealing.21Thephysical
examinationincludesanevaluationofrangeofmotion.JointhypermobilityisassessedusingtheBeighton
criteriascale(Table55),whereamaximumscoreof9pointsispossible,andascoreof>4defines
hypermobility.23Theskinisassessedforitsconsistency,thepresenceofdystrophicscars,striae,brown
discoloration(secondarytohemosiderindepositionatareasofrepetitivetraumaandbruising),and
hyperextensibility.21
TABLE55BeightonCriteriaforGeneralizedJointHypermobility
Finding Score(Points)
Forwardflexionofthetrunkwithkneesfullyextendedsothatthepalmsofthehandrestflat
1point
ontheflooronepoint
1pointforeach
Hyperextensionoftheelbowsbeyond10degrees
elbow
1pointforeach
Hyperextensionofthekneesbeyond10degrees
knee
1pointforeach
Passiveappositionofthethumbstotheflexoraspectoftheforearm
hand
1pointforeach
Passivedorsiflexionofthelittlefingersbeyond90degrees
hand
DatafromBeightonP,SolomonL,SoskolneCL.ArticularMobilityinanAfricanPopulation.AnnRheumDis.
197332413418.
Physicaltherapycanbeusedtoenhancemusculotendinousstrength,neuromuscularcoordination,andjoint
proprioceptiontomaximizefunction,minimizesymptoms,andimprovejointstability.21
INFECTIVEDISEASES
Osteomyelitis
Osteomyelitisisanacuteorchronicinflammatoryprocessoftheboneanditsmarrowsecondarytoinfection
withpyogenicorganismsorothersourcesofinfection,suchastuberculosis,orspecificfungalinfections
(mycoticosteomyelitis),parasiticinfections(Hydatiddisease),viralinfections,orsyphiliticinfections(Charcot
arthropathy).Thefollowingarethetwoprimarycategoriesofacuteosteomyelitis:
Hematogenousosteomyelitis.Itisaninfectioncausedbybacterialseedingfromtheblood.Themost
commonsiteistherapidlygrowingandhighlyvascularmetaphysisofgrowingbones.
Directorcontiguousinoculation.Thistypeofosteomyelitisiscausedbydirectcontactwiththetissue
andbacteriaduringsurgery,apenetratingwound,orasaresultofpoordentalhygiene.
Diseasestatesknowntopredisposepatientstoosteomyelitisincludediabetesmellitus,sicklecelldisease,
acquiredimmunedeficiencysyndrome,IVdrugabuse,alcoholism,chronicsteroiduse,immunosuppression,and
chronicjointdisease.Clinicalsignsandsymptomsassociatedwithosteomyelitisincludefever(approximately
50%ofcases),fatigue,edema,erythema,tenderness,andreductionintheuseoftheextremity.
CLINICALPEARL
Themostcommonclinicalfindinginpatientswithosteomyelitisisaconstantpainwithmarkedtendernessover
theinvolvedbone.
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NEUROLOGICDISORDERS
AmyotrophicLateralSclerosis
Amyotrophiclateralsclerosis(ALS),commonlyreferredtoasLouGehrigsdisease,isaneurodegenerative
progressivedisorderthatcausesrapidlossofmotorneuronsinthebrainandspinalcord,leadingtoparalysisand
death.Diagnosisisbasedsolelyonclinicaldata.ThediagnosisofALSdependsupontherecognitionofa
characteristicconstellationofsymptomsandsignsandsupportiveelectrophysiologicalfindings.Forclinically
definiteALSdiagnosis,UMNandLMNsignsinbulbarandtwospinalregionsorinthreespinalregionsare
required.TheLMNweaknessandmuscleatrophyinvolvesbothperipheralnerveandmyotomaldistributions.
TheclinicalhallmarkofALSisthecoexistenceofmuscleatrophy,weakness,fasciculations,andcramps
(causedbyLMNdegeneration),togetherwithhyperactiveorinappropriatelybriskmusclestretchreflexes,
pyramidaltractsigns,andincreasedmuscletone(duetocorticospinaltractinvolvement).24Musclecrampsare
oftenalreadypresentbeforeothersymptomsdevelop.Mostpatientspresentwithasymmetrical,distalweakness
ofthearmorleg.Thesymptomsusuallyprogressfirstintheaffectedextremityandthengraduallyspreadto
adjacentmusclegroupsandremoteipsilateralorcontralateralregions.Althoughdisabilityisusuallylimitedin
theearlystages,ALSprogressesrelentlessly.Mostpatientsareultimatelyunabletowalk,careforthemselves,
speak,andswallow.24However,thereisusuallynoclinicalinvolvementofpartsoftheCNSotherthanthe
motorpathways.24
Respiratoryweaknessduetohighcervical(phrenicnerve,C4)andthoracicspinalcordinvolvementisthemost
commoncauseofdeathinALS,ofteninconjunctionwithaspirationpneumonia.24
GuillainBarrSyndrome
GuillainBarrsyndrome(GBS)ischallengingtoidentifybecauseofitsmultitudeofpresentationsand
manifestations.GBSmaybedefinedasapostinfectious,acute,paralyticperipheralneuropathy.Itcanaffectany
agegroupalthoughthereisapeakincidenceinyoungadults.GBSappearstobeaninflammatoryorimmune
mediatedcondition.
Themajorityofpatientsdescribeanantecedentfebrileillness.Upperrespiratoryinfectionsareseenin50%of
casesandarecausedbyavarietyofviruses.Theillnessisusuallyanacuterespiratoryorgastrointestinal
conditionthatlastsforseveraldaysandthenresolves.Thisisfollowedin12weeksbythedevelopmentofa
progressiveascendingweaknessorparalysis,whichisusuallysymmetric.Theprogressionoftheweaknessor
paralysiscanbegradual(13weeks)orrapid(12days).Thepatientreportsdifficultyorinstabilitywith
walking,arisingfromachair,andascendingordescendingstairs.Associatedsignsandsymptomsinclude
cranialnerveinvolvement(facialweakness),paresthesias,sensorydeficits,difficultyinbreathing,diminished
musclestretchreflexes,autonomicdysfunction(tachycardiaandvasomotorsymptoms),oropharyngeal
weakness,andocularinvolvement.25
ThedifferentialdiagnosisofGBSisquitelargeandincludesthespectrumofillnessescausingacuteorsubacute
paralysis.Theseincludespinalcordcompression(myelopathy),UMNdisorders,poliomyelitis,transverse
myelitis,polyneuropathy,SLE,polyarteritisnodosa,myastheniagravis,andsarcoidosis.25
AllpatientswithsuspectedGBSshouldbehospitalizedforvigilantmonitoringbecauseofthehighriskof
respiratoryfailure,whichoccursinapproximatelyonethirdofpatients.25
Syringomyelia
Syringomyeliaisadiseasethatproducesfluidcontainingcysts(syrinx)withinthespinalcord,oftenassociated
withstenosisoftheforamenmagnum.Thesyrinxcanoccurwithinthespinalcord(syringomyelia)orbrainstem
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(syringobulbia).Syringomyeliahasbeenfoundinassociationwithvariousdisorders,includingspinalcolumnor
brainstemabnormalities(scoliosis,KlippelFeilsyndrome,ChiariImalformation),intramedullarytumors,and
traumaticdegenerationofthespinalcord.ChiariImalformationisthemostcommonconditioninpatientswith
syringomyelia.
Painfuldysesthesias,whichhavebeendescribedvariouslyasburningpain,pinsandneedlessensations,and
stretchingorpressureoftheskin,occurinupto40%ofpatientswithsyringomyelia.26Thepaintendstoarisein
adermatomalpatternandisaccompanied,inmostcases,byhyperesthesia.
Radiologicfeaturesthatsuggestsyringomyeliaincludeanincreaseinthewidthanddepthofthecervicalcanal,
bonyabnormalitiesatthecraniovertebraljunction,diastematomyelia,andoccipitalizationoftheatlas.
INFLAMMATORYDISORDERS
Perhaps,themostcommoninflammatorydisordersofthemusculoskeletalsystemaretherheumatoiddiseases.
RheumatoidArthritis
Rheumatoidarthritis(RA)canbedefinedasachronic,progressive,systemic,inflammatorydiseaseof
connectivetissue,characterizedbyspontaneousremissionsandexacerbations(flareups).Itisthesecondmost
commonrheumaticdiseaseafterosteoarthritis(OA),butitisthemostdestructivetosynovialjoints.UnlikeOA,
RAinvolvesprimarytissueinflammationratherthanjointdegeneration.Althoughmostindividualswho
developRAdosointheirearlytomiddleadulthood,someexperienceiteitherearlier(JuvenileRAsee
Chapter30)orlater.
AlthoughtheexactetiologyofRAisunclear,itisconsideredoneofmanyautoimmunedisorders.Abnormal
immunoglobulin(Ig)GandIgMantibodiesdevelopinresponsetoIgGantigens,toformcirculatingimmune
complexes.Thesecomplexeslodgeinconnectivetissue,especiallysynovium,andcreateaninflammatory
response.Inflammatorymediators,includingcytokines(e.g.,tumornecrosisfactor),chemokines,andproteases,
activateandattractneutrophilsandotherinflammatorycells.Thesynoviumthickens,fluidaccumulatesinthe
jointspace,andapannusforms,erodingjointcartilageandbone.Bonyankylosis,calcifications,andlossof
bonedensityfollow.
RAtypicallybeginsinthejointsofthearmorhand.Theindividualcomplainsofjointstiffnesslastinglonger
than30minutesonawakening,pain,swelling,andheat(synovitis).UnlikewithOA,thedistalinterphalangeal
jointsofthefingersusuallyarenotinvolvedinRA.
ThesignsandsymptomsofRAvaryamongindividuals,dependingontherateofprogressofthedisease.A
completemusculoskeletalexaminationhelpsdiagnosethedisease.Clinicalmanifestationsincludebothjoint
involvementandsystemicproblemssomeareassociatedwiththeearlystagesofRA,whereasothersareseen
laterinadvanceddisease.
Complaintsoffatigue,anorexia,lowgradefever,andmildweightlossarecommonlyassociatedwithRA.As
thediseaseworsens,jointsbecomedeformed,andsecondaryosteoporosis(seeMetabolicDisease)canresult
infractures,especiallyinolderadults.Handandfingerdeformitiesaretypicalintheadvancedstagesofthe
disease.Palpablesubcutaneousnodules,oftenappearingontheulnarsurfaceofthearm,areassociatedwitha
severe,destructivediseasepattern.Asthediseaseprogressesoveryears,systemicmanifestationsincreaseand
potentiallylifethreateningorganinvolvementbegins.Cardiacproblems,suchaspericarditisandmyocarditis,
andrespiratorycomplications,suchaspleurisy,pulmonaryfibrosis,andpneumonitis,arecommon.RAcan
affectbodyimage,selfesteem,andsexualityinolderadults.ThepersonwithRAlosescontroloverbody
changes,ischronicallyfatigued,andeventuallymayloseindependenceinactivitiesofdailyliving(ADLs).Asa
reactiontotheselosses,individualsmaydisplaythephasesofthegrievingprocess,suchasangerordenial.
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Somepeoplebecomedepressed,feelinghelplessandhopelessbecausenocurepresentlyexistsforthecondition.
Chronicpainandsufferinginterferewithqualityoflife.
ThephysicaltherapyexaminationofthepatientwithRAinvolves:
measurementofindependencewithfunctionalactivities
measurementofjointinflammation
measurementofjointrangeofmotionand
determinationoflimitingfactorsincludingpain,weakness,andfatigue.
BecauseRAaffectsmultiplebodysystems,lessensthequalityoflife,andaffectsfunctionalability,theapproach
tomanagingthepatientwiththisconditionmustbeinterdisciplinary.Managementtypicallyincludesdrug
therapy,physicaland/oroccupationaltherapy,andrecreationaltherapy.Someclientsalsoneedpsychologic
counselingtohelpcopewiththedisease.
RestandenergyconservationarecrucialformanagingRA(Table56).Pacingactivities,obtainingassistance,
andallowingrestperiodshelpconserveenergy.Positioningjointsintheiroptimalfunctionalpositionhelpto
preventdeformities.AmbulatoryandadaptivedevicescanhelpindividualsmaintainindependenceinADLs.For
example,alonghandledshoehornmayhelpinputtingonshoes.Velcroattachmentsonshoesoftenareabetter
optionthanlaces.Styrofoamorpapercupsmaycollapseorbend,whereasahardplasticorchinacupmaybe
easiertohandle.Theclinicianshouldalsoreviewprinciplesofjointprotectionwiththepatientandfamilyand
provideadaptiveequipmentasneededtoperformADLsindependently.
TABLE56InterventionStrategiesforRheumatoidArthritis
Objective Intervention Example
Therapeuticheattodecreaserigidityof
joints,increasetheflexibilityoffibrous
Heatapplications:
tissue,anddecreasepainandmusclespasm
Aquatictherapy
Massage,usuallyappliedwithheat
Instructionsonthewearingofwarmpajamas,
treatmentandbeforestretching,canbeused
Paincontrol sleepingbag,andelectricblanket
torelievepainandpreventadhesions
Paraffinforhands
Therapeuticcoldcanbeusedforanalgesic
Ultrasound
andvasoconstrictionpurposesininflamed
Heatingpadsmoistheatbetterthandryheat
jointsduringtheacuteperiod.Caremustbe
takentoavoidadverseeffects
Asneededbalancerestwithactivitybyusing
splinting(articularresting)
Restingsplintsareusedtorestthejointinthe
appropriatepositionintheacuteperiod
Jointprotectionstrategies Dynamicsplintsareusedtoexertadequateforce
Minimizingthe
Splinting thatthetissuecantolerateandprovidesufficient
effectsof
Restfromabuse jointvolume
inflammation
Bodymechanicseducation Functionalsplintsareusedtoprotectthejointin
thecourseofactivity
Stabilizersplintsareusedincasesofpermanent
contractures.Gradualcastingcanbeusedto
applyastretchtothecontracture
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Objective Intervention Example

Preventing Acutestage:passiveandactiveassistedtoavoid
limitationand jointcompression
restoringROM Subacute/chronicstage:activeexercises,passive
inaffected Rangeofmotionandstretchingexercises
stretchingorcontractrelaxtechniques
joints
Acuteandsubacutestages:isometricexercises
progressingcautiouslytoresistive
Subacute/chronicstages:strengtheningexercises
thatavoidsubstitutionsandminimizeinstability,
atrophy,deformity,pain,andinjury
Chronicstage:judicioususeofconcentric
Maintaining Resistiveexercises exercise
andimproving Enduranceexercises Provisionofencouragementtoexercisefunand
strength Electricalstimulation recreationalactivitiesofmoderateintensityand
30mindurationperday
Swimming
TaiChi
Shorttermelectricalstimulationisusefulin
casesofexcessivemuscleatrophyandinthose
whocannotexercise
Tomaintainjointrangeofmotion,patients
shouldspend20min/dinpronetostretchthehip
Ensuring
flexorsandquadricepsassessleglength
normalgrowth Postureandpositioning
discrepancyinstandingandavoidscoliosis
and Mobilityandassistivedevices
Extendedcombhandles,thickerspoons,
development
shoehorns
Clotheswitheasyopeningsand/orVelcro
Strengtheningexercisesandotherpainreliefmeasures,suchastheuseoficeandheat,canbeprescribed.Ice
applicationisusedforhot,inflamedjoints.Heatisusedforpainfuljointsthatarenotacutelyinflamed.Showers,
hotpacks(nottooheavy),andparaffindipsareidealforheatapplication.
SomeRApatientshaveassociatedsyndromes.TwosuchsyndromesareSjogrenandFeltysyndromes.Sjogren
syndromeischaracterizedbydrynessoftheeyes(keratoconjunctivitis),mouth(xerostomia),andothermucous
membranes.Feltysyndromeischaracterizedbyleukopeniaandhepatosplenomegaly,oftenleadingtorecurrent
infections.ItencompassesadiversegroupofpathogenicmechanismsinRA,allofwhichresultindecreased
levelsofcirculatingneutrophils.
NosingletestorgroupoflaboratorytestscanconfirmadiagnosisofRA,buttheycansupportthefindingsfrom
thepatientshistoryandthephysicalfindings.Anumberofimmunologictests,suchastherheumatoidfactor
andantinuclearantibodytiter,areavailabletoaiddiagnosis.Normalvaluesdiffer,dependingontheprecise
laboratorytechniqueused.
Gout
Goutisthemostcommonformofinflammatoryarthritisinmenolderthan40yearsandappearstobeonthe
increase.27IntheUnitedStates,theselfreportedprevalenceofgoutalmosttrebledinmenaged4564years
between1969and1981.28Therisingprevalenceofgoutisthoughttostemfromdietarychanges(highpurine
dietandhabitualalcoholingestion),obesity,environmentalfactors,increasinglongevity,subclinicalrenal
impairment,andtheincreaseduseofdrugscausinghyperuricemia,particularlydiuretics.29Highbloodlevelsof
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uricacidleadtoinflammation,jointswelling,andseverepain.Symptomsarecausedbydepositsofsodium
urateorcalciumpyrophosphatecrystalsinjointsandperiarticulartissues.
Onsetisusuallysudden,oftenduringthenightorearlymorning.Theclassicfindingofgoutyarthritis(gout)is
warmth,swelling,cutaneouserythema,andseverepainofthefirstmetatarsophalangeal(MTP)joint(podagra).
However,otherjointsmayalsobeinvolved.Theseincludetheshoulder,knee,wrist,ankle,elbow,orfingers.
Fever,chills,andmalaiseaccompanyanepisodeofgout.Astheconditionbecomeschronic,thepatientmay
reportmorningstiffnessandjointdeformity,progressivelossoffunction,ordisability.Chronicgouty
nephropathymayoccur.
Differentialdiagnosisincludescellulitis,septicarthritis,RA,bursitisrelatedtoabunion,sarcoidosis,multiple
myeloma,andhyperparathyroidism.
Treatmentisgearedtowardpharmacologiccontrolofserumuricacidlevels.
AnkylosingSpondylitis
Ankylosingspondylitis(AS,alsoknownasBekhterevorMarieStrmpelldisease)isachronicrheumatoid
disorderthataffects13per1,000people.Thepatientisusuallybetween15and40years.Thereisa1020%
riskthatoffspringofpatientswiththediseasewilllaterdevelopit.30Althoughmalesareaffectedmore
frequentlythanfemales,mildcoursesofASaremorecommoninthelatter.31
Ahumanleukocyteantigen(HLA)haplotypeassociation(HLAB27)hasbeenfoundwithASandremainsone
ofthestrongestknownassociationsofdiseasewithHLAB27,butotherdiseasesarealsoassociatedwiththe
antigen.Creactiveproteinhasonly53%sensitivityand70%specificityinspondyloarthropathies(X20).32
ThoracicinvolvementinASoccursalmostuniversally.Thediseaseincludesinvolvementoftheanterior
longitudinalligamentandossificationoftheintervertebraldisk,thoraciczygapophysealjoints,costovertebral
joints,andmanubriosternaljoint.Thismultijointinvolvementofthethoracicspinemakesthecheckingofchest
expansionmeasurementsarequiredtestinthisregion.
Intime,ASprogressestoinvolvethewholespineandresultsinspinaldeformities,includingflatteningofthe
lumbarlordosis,kyphosisofthethoracicspine,andhyperextensionofthecervicalspine.Thesechanges,inturn,
resultinflexioncontracturesofthehipsandknees,withsignificantmorbidityanddisability.31
ThemostcharacteristicfeatureofthebackpainassociatedwithASispainatnight.33Patientsoftenawakenin
theearlymorning(between2and5am)withbackpainandstiffnessandusuallyeithertakeashowerorexercise
beforereturningtosleep.31Backacheduringthedayistypicallyintermittent,irrespectiveofexertionorrest.31
Calinetal.34describefivescreeningquestionsforAS:
1.Istheremorningstiffness?
2.Isthereanimprovementindiscomfortwithexercise?
3.Wastheonsetofbackpainbeforeage40years?
4.Didtheproblembeginslowly?
5.Hasthepainpersistedforatleast3months?
Usingatleastfourpositiveanswerstodefineapositiveresult,thesensitivityofthesequestionswas0.95,and
specificitywas0.85.34
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PeripheralarthritisisuncommoninAS,butwhenitoccurs,itisusuallylateinthecourseofthecondition.35
Peripheralarthritisdevelopingearlyinthecourseofthediseaseisapredictorofdiseaseprogression.36The
arthritisusuallyoccursinthelowerextremitiesinanasymmetricdistribution,withtheinvolvementofthe
axialjoints,includingshouldersandhips,morecommonthaninvolvementofmoredistaljoints.31,37
Theinspectionusuallyrevealsaflatlumbarspineandgrosslimitationofextension,andsidebendinginboth
directions(capsularpattern).Inaddition,theglidesofthecostotransversejointsanddistractionofthe
sternoclavicularjointsaredecreased.Mobilitylosstendstobebilateralandsymmetric.Thereislossofspinal
elongationonflexionintheMcRaesmodificationoftheSchobertest,38,39althoughthiscanoccurinpatients
withchroniclowbackpain(LBP),orspinaltumors,andisthusnotspecificforinflammatory
spondylopathies.40TheMcRaesmodifiedSchobertestisperformedwiththepatientstandingupright.The
clinicianmarksthespinousprocessofL5withapen,andthencreatesamark10cmabovetheL5and5cm
belowL5inthemidline.Thepatientisthenaskedtobendforwardmaximally,andthedistancebetweenthe
upperandlowermarksismeasured.Patientswithnormalmobilityofthespinehaveanincreaseofatleast5cm
inthemeasureddistancefromupright(15cm)tomaximalflexion(shouldbe>20cm).38,39Thepatientmay
relateahistoryofcostochondritis,and,uponexamination,ribspringingmaygiveahardendfeel.Basalrib
expansionoftenisdecreasedwiththechestexpansiontest.Thechestexpansiontestisperformedwiththe
patientshandselevatedandfoldedbehindthehead.Thecliniciantakesacircumferentialmeasurementofthe
patientschestatthelevelofthefourthintercostalspace,orjustbelowthebreastinfemales.Chest
circumferenceismeasuredafteramaximalforcedexpirationandagainafteramaximalinspiration.The
expansionshouldbe>5cm.Expansionof<2.5cmisabnormal.38,39
Asthediseaseprogresses,thepainandstiffnesscanspreaduptheentirespine,pullingitintoforwardflexion,so
thatthepatientadoptsthetypicalstoopedoverposition.Thepatientgazesdownward,theentirebackis
rounded,thehipsandkneesaresemiflexed,andthearmscannotberaisedbeyondalimitedamountatthe
shoulders.41
LongitudinalstudiesinpatientswithAShaverevealedthatdeformitiesanddisabilityoccurwithinthefirst10
yearsofdisease.36Mostofthelossoffunctionoccursduringthefirst10yearsandcorrelatessignificantlywith
theoccurrenceofperipheralarthritis,radiographicchangesofASinthespine,andthedevelopmentoftheso
calledbamboospine.
Anexerciseprogramisparticularlyimportantforthesepatientstomaintainfunctionalspinaloutcomes.42The
goalofexercisetherapyistomaintainthemobilityofthespineandinvolvedjointsforaslongaspossibleandto
preventthespinefromstiffeninginanunacceptablekyphoticposition.Astrictregimenofdailyexercises,
whichincludepositioning,spinalextensionexercises,breathingexercises,andexercisesfortheperipheral
joints,mustbefollowed.Severaltimesaday,patientsshouldliepronefor5minutes,andtheyshouldbe
encouragedtosleepproneorsupineonahardmattressandavoidthesidelyingposition.Swimmingisthebest
routinesport.
PsoriaticArthritis
Psoriaticarthritis,whichisaninflammatoryformofarthritisassociatedwithachronicskinconditioncalled
psoriasis,affectsmenandwomenwithequalfrequency,withitspeakonsetinthefourthdecadeoflife,although
itmayoccurinchildrenandinolderadults.37Psoriaticarthritiscanmanifestinoneofanumberofpatterns,
includingdistaljointdisease(affectingthedistalinterphalangealjointsofthehandsandfeet),asymmetric
oligoarthritis,polyarthritis(whichtendstobeasymmetricinhalfthecases),andarthritismutilans(asevere
destructiveformofarthritisandaspondyloarthropathythatoccursin40%ofpatients,butmostcommonlyinthe
presenceofoneoftheperipheralpatterns).37Patientswithpsoriaticarthritishavelesstendernessoverboth
affectedjointsandtenderpointsthanpatientswiththeclassicRA.43
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ThespondyloarthropathyofpsoriaticarthritismaybedistinguishedfromASbythepatternofthesacroiliitis.44
WhereassacroiliitisinAStendstobesymmetric,affectingbothsacroiliacjointstothesamedegree,ittendsto
beasymmetricinpsoriaticarthritis,37andpatientswithpsoriaticarthritisdonothaveasseverea
spondyloarthropathyaspatientswithAS.30
Anotherarticularfeatureofpsoriaticarthritisisthepresenceofdactylitis,tenosynovitis(oftendigital,inflexor
andextensortendonsandintheAchillestendon),andenthesitis.44Thepresenceoferosivediseaseinthedistal
interphalangealjointsistypical.44
Naillesionsoccurinmorethan80%ofthepatientswithpsoriaticarthritisandhavebeenfoundtobetheonly
clinicalfeaturedistinguishingpatientswithpsoriaticarthritisfrompatientswithuncomplicatedpsoriasis.45
Otherextraarticularfeaturesincludeiritis,urethritis,andcardiacimpairmentssimilartothoseseeninAS,
althoughlessfrequently.44
Treatmentforpsoriaticarthritisisdirectedatreducingandcontrollinginflammation,withmildercasesof
psoriaticarthritisoftenbeingtreatedwithNSAIDsalone.Moreseverecasesaretreatedusingdiseasemodifying
antirheumaticdrugsorbiologicalresponsemodifierstohelppreventirreversiblejointdestructionanddisability.
NEOPLASTICDISEASE
BenignTumors:OsteoblastomaandOsteoidOsteoma
Osteoblastomaandosteoidosteomaarebenignboneformingtumorswithsimilarclinicalfindings.
Osteoblastomaisasolitaryboneneoplasm.Itismostcommoninthevertebraeofchildrenandyoung
adults.Shortandflatbonesaremorecommonlyaffectedthanthelongbones(76.5%vs.23.5%).46Inthe
vertebrae,thebodyisonlyrarelyaffectedprimarilyusually,itisinvolvedonlysecondarilybytumors
extendingfromothersegmentsofthesameorthenearestvertebra.46
Osteoidosteomaisabenignosteoblastictumorofunknownetiology.Itoccursmostofteninthelong
bones,althoughthespineisthelocationof10%ofallosteoidosteomas.47
Painfulscoliosisisawellrecognizedpresentationofspinalosteoidosteomaandosteoblastomaandis
thoughttobecausedbypainprovokedmusclespasmonthesideofthelesion.46
MalignantTumors
Metastaticdiseaseofthespineisthemostfrequentneoplasticdisorderoftheaxialskeleton.Malignanttumors
canbeprimaryorsecondary.
1.Primary.Primarytumorsincludethefollowing:
a.Multiplemyeloma.Myelomaisaplasmacelltumor.Itisthemostcommonmalignantprimarybone
tumor.Earlyinitscourse,itcaneasilybeoverlookedasthecauseofbackpain.Common
presentationsofmyelomaincludebonepain,recurrentorpersistentinfection,anemia,renal
impairment,oracombinationofthese.Somepatientsareasymptomatic.Presentingfeatures,which
requireurgentspecialistreferral,include:
1.persistent,unexplainedbackacheassociatedwithlossofheightandosteoporosis
2.symptomssuggestiveofspinalcordornerverootcompression.
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b.Chordoma.Chordomasareraretumorsofnotochordalorigin,representingapproximately5%ofall
malignanttumorsofbone.48Theytypicallyareslowgrowing,locallyaggressivetumors.
Chordomasusuallyarediagnosedinpatientswithpainorsymptomscausedbycompressionofthe
surroundingstructures.Theclinicalpresentationinitiallymaybemildinnature,leadingto
considerabledelayinseekingmedicalattention.Vertebralchordomasinvolvethespinalcordand
nerverootsprogressively,resultinginpain,numbness,motorweakness,and,eventually,paralysis.
c.Osteosarcoma.Osteosarcomaisarelativelyuncommonmalignancy.Thepeakincidenceof
osteosarcomaoccursintheseconddecade,withanadditionalsmallerpeakaftertheageof50
years.49Thesetumorstypicallyariseinthemetaphysealregionsoflongbones,withtherib,distal
femur,proximaltibia,andproximalhumerusrepresentingthefourmostcommonsites.The
metaphysisofthevertebraisalsopredilected.46Osteosarcomasfrequentlypenetrateanddestroythe
cortexoftheboneandextendintothesurroundingsofttissues.
Theinitialclinicalsymptomofamalignanttumorisfrequentlypainintheaffectedarea,whichmay
alsobeassociatedwithlocalizedsofttissueswellingorlimitationofmotionintheadjacentjoint.50
2.Secondary.Metastasestothespinemostcommonlyarisefrombreastandlungcancerandfrom
lymphoma.51,52Lesionsassociatedwiththemetastasisofprimarytumorsfromthebreast,prostate,
kidney,andthyroidandlesionsassociatedwithlymphomaandmyelomaaccountfor75%ofallspinal
metastases.51,52Whenlungcancerisincluded,thepercentageisgreaterthan90%.53Theclinicalfindings
forasecondaryspinaltumoraresimilartothoseofaprimarytumor.
METABOLICDISEASE
Osteoporosis
Morethan10millionadultsintheUnitedStateshaveosteoporosis,80%ofwhicharewomen,butalmost3
millionmalesareaffectedaswell.54Osteoporosisorosteopeniacanresultfromaninsufficientboneformation
(lowbonemass),excessiveboneresorption,oracombinationofthesetwophenomena(seeChapter1).The
resultisdecreasedbonemineraldensity(BMD)andaprogressivelossoftrabecularconnectivitythatis
irreversibleanddiminishesthebonequalityintermsofitsmechanicalresistancetodeformityunderloading.55
Inadditiontothelossofbonemass,thereisalsonarrowingoftheboneshaftandwideningofthemedullary
canal.Osteoporosiscausespathological(fragility)fracturesofthevertebraeandfracturesofotherbonessuchas
theribs,proximalhumerus,distalforearm,proximalfemur(hip),andpelvis.However,withappropriatecare,
osteoporosis,fractures,andresultantdisabilitycanbeprevented.
Osteoporosishasbeenclassifiedintotwobroadgeneraltypes:type1(postmenopausal)andtype2
(involutional).56Type2osteoporosisgenerallyisseenintheolderagepopulationandhasbeenreferredtoas
senileosteoporosis.56
CLINICALPEARL
Womenaremorepronetodeveloposteoporosisbecauseofthecontributionofthelossofestrogentoaccelerated
bonelossinthepostmenopausalfemalepopulation.
Ithasbeenestimatedthat15%ofpostmenopausalCaucasianwomenintheUnitedStatesand35%ofwomen
olderthan65yearshaveosteoporosis.56Further,50%ofwomenolderthan50yearshaveosteopeniaofthe
femoralneck,and20%haveosteoporosisatthissite.57Theincidenceofhipfracturerisesdramaticallywithage
to3.4per100inthe6574yearoldagegroupand9.4per100inthoseolderthan85years.55Thepresenceofa
significantvertebralfracture(seeVertebralFracture)isassociatedwithincreasedmortality.58Patientswith
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thesefragilityfractureshavearelativeriskofdeaththatisninetimesgreaterthanhealthycounterparts.59
Approximately20%ofwomenwithvertebralfractureshaveanotherfractureofadifferentbonewithinayear.58
Numerousriskfactorshavebeenidentifiedascontributingtothelikelihoodthatanindividualwilldevelopbone
loss.Geneticsplaysamajorrole,andfemalegender,positivefamilyhistory,andracialcharacteristicsassociated
withCaucasian,Asian,orHispanicbackgroundincreasetheriskofosteoporosis.60Lowbodyweight(lessthan
85%idealbodyweight,orlessthan127lb)hasalsobeencorrelatedwiththedevelopmentofosteoporosis.56
Modifiableriskfactorsassociatedwithosteoporosisincludeearlyoriatrogenicmenopause,pregnancyatan
earlyage,smoking,sedentarylifestyle,alcoholism,lowbodyfat,lowcalciumintake,highcaffeineintake,
prolongedbedrest,andanorexia.56,61,62Medicationssuchascorticosteroids,somediuretics,andthyroid
hormonepreparationscanalsoincreasebonelossandtheriskofosteoporosissignificantly.63,64
Thepopulationsmostvulnerabletodevelopingosteoporosisincludethefollowing:65
Womenaged65yearsandolder.
Postmenopausalwomenyoungerthan65yearswiththeriskfactorsforfracture,suchaslowbodyweight,
priorfracture,orhighriskmedicationuse.
Womenduringthemenopausaltransitionwithclinicalriskfactorsforfracture.
Menaged70yearsandolder.
Menyoungerthan70yearswithclinicalriskfactorsforfracture.
Adultswithafragilityfracture.
Adultswiththediseaseorcondition,orwhoaretakingmedicationsassociatedwithlowbonemassor
boneloss.
Inadditiontoriskfactorsforthedisease,thereareindependentriskfactorsforfractures,includinguseof
medicationsinelderlypatientswithadverseCNSsideeffects,balanceproblems,poormusclestrength,visual
impairment,homeenvironmentalfactorssuchasstairs,andmedicalcomorbiditiesthatincreasethelikelihoodof
falls.55,61
DiagnosisofosteoporosisdefinedintermsofBMDusingdualxrayabsorptiometry(DXA)consistsoftheT
score2.5standarddeviationsbelowtheyoungsexmatchedmeanasestablishedbytheWorldHealth
Organization(WHO).However,BMDalonehaslowsensitivity,sothatthemajorityofosteoporoticfractures
willoccurinindividualswithBMDvaluesabovetheosteoporosisthreshold,typicallyintheosteopenicrange
(Tscoreoflessthan1andgreaterthan2.5SD).Asaresult,theinitialdiagnosisofosteoporosisoftenoccurs
followinganosteoporotic,orfragility,fracture.Although,aphysicaltherapistmaynotbeabletoorderBMD
testing,aDXAcanberecommendedtotheprimarycarephysicianifthetherapistsuspectsheorsheistreatinga
patientwithanundiagnosedlowBMD.Itisimportanttobeabletoidentifythispatienttypesothatsaferchoices
canbemadewithregardtothetypesofintervention.Atpresent,theonlydiagnostictoolavailablethatiswithin
thescopeofpracticeofthephysicaltherapististheidentificationofthoseriskfactorspreviouslymentioned,66
orthroughtheuseoftoolsdevelopedforthemedicalcommunity.OnesuchtoolistheFRAX,afracturerisk
assessmenttool,whichisopenlyavailableattheUniversityofSheffieldwebsite(http://www.shef.ac.uk/FRAX).
Thespecificeffectsofphysicalactivityonbonehealthhavebeeninvestigatedinseveralstudies.62,63,6670The
conclusionsdrawnfromthesestudiessuggestthatthereis:
strongevidencethatphysicalactivityearlyinlifecontributestohigherpeakbonemass69
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someevidencethatresistanceandhighimpactexercisearelikelythemostbeneficialforprevention
someevidencethathighintensityaerobicexercise(7090%ofmaximalheartrate)mayreverseor
attenuateBMDlossand
someevidencethathighloadlowrepetitionroutinesaremoreeffectiveatincreasingBMDthanlowload
highrepetitionregimens.
Exerciseduringthemiddleyearsoflifehasnumeroushealthbenefits,buttherearefewstudiesontheeffectsof
exerciseonBMD.69Exerciseduringthelateryears,inthepresenceofadequatecalciumandvitaminDintake,
probablyhasamodesteffectonslowingthedeclineinBMD,butitisclearthatexerciselateinlife,evenbeyond
age90years,canincreasemusclemassandstrengthtwofoldormoreinfrailpersons.69
Randomizedclinicaltrialsofexercisehavebeenshowntoreducetheriskoffallsbyapproximately25%,71,72
butthereisnoexperimentalevidencethatexerciseaffectsfracturerates.69Italsoispossiblethatregular
exercisersmightfalldifferently,therebyreducingtheriskoffracturecausedbyfalls,butthishypothesisrequires
testing.69
Theavailabilityofnew,effectivedrugtherapiesinthepastdecadehasrevolutionizedtheinterventionfor
osteoporosis,anditisimportantthatcliniciansatleastbeawareoftheinterventionoptions.Manyhormonaland
hormonereplacementtherapiesarealsoavailable.Experimentalevidenceindicatesthatslowreleasesodium
fluorideandlowdoseparathyroidhormonearecapableofincreasingboneformationandthuspreventingbone
lossinwomenwhoareestrogendeficient.73
Diagnostictoolshavefocusedonbonedensity.Newminimallyinvasiveproceduresarefindingaplaceamong
interventionsforpatientswithosteoporoticfractures.Forexample,theuseofinjectedhydroxyapatitethat
cementsintodistalradiusfracturesforpercutaneousstabilizationhasshownefficacyasaninterventionfor
patientswiththistypeoffracture.74
CLINICALPEARL
Itshouldbetheresponsibilityofthehealthcareproviderstoeducatetheiryoungfemalepatientsaboutthe
benefitsofsufficientexerciseandtherecommendeddietarycalciumintaketobuildhealthybone.
Whatisknownaboutpreventionisthatakeyfactorinthedevelopmentofosteoporosisinlaterlifeisadeficient
levelofpeakbonemassatphysicalmaturity,75andthatphysicalactivityandcalciumintakeplaysubstantial
rolesinthedevelopmentofbonemassduringthesedevelopmentalyears.76
Osteomalacia
Osteomalaciaistheleastcommonofthetraditionalformsofthemetabolicbonediseases.Itischaracterizedby
impairmentofbonemineralization,leadingtoanaccumulationofunmineralizedmatrixorosteoidinthe
skeleton.77Amongthecausesofosteomalacia,themostimportantaredisordersofvitaminDavailability,
synthesis,oraction.78
Clinically,osteomalaciaismanifestedbyprogressivegeneralizedbonepain,muscleweakness,hypocalcemia,
andpseudofractures.Initslatestages,osteomalaciaischaracterizedbyawaddlinggait.79Osteomalaciais
believedtoberareintheUnitedStatesbecauseoftheroutinefortificationofmilkandafewotherfoodswith
vitaminD.However,patientswithvariousgastrointestinaldiseasesareknowntobeatrisk.79
PagetDisease
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Pagetdisease(osteitisdeformans)oftheboneisanosteometabolicdisorder.Thediseaseisdescribedasafocal
disorderofacceleratedskeletalremodelingthatmayaffectoneormorebones.Thisremodelingproducesa
slowlyprogressiveenlargementanddeformityofmultiplebones.
Despiteintensivestudiesandwidespreadinterest,theetiologyofPagetdiseaseremainsobscure.Thepathologic
processconsistsofthreephases:
PhaseI.Anosteolyticphasecharacterizedbyprominentboneresorptionandhypervascularization.
PhaseII.Ascleroticphase,reflectingpreviouslyincreasedboneformationbutcurrentlydecreased
cellularactivityandvascularity.
PhaseIII.Amixedphase,withbothactiveboneresorptionandcompensatoryboneformation,resulting
inadisorganizedskeletalarchitecture.Thebonesbecomespongelike,weakenedanddeformed.
Complicationsincludepathologicfractures,delayedunion,progressiveskeletaldeformities,chronicbonepain,
neurologiccompromiseoftheperipheralandCNSwithfacialorocularnervecompressionandspinalstenosis,
andpageticarthritis.
Involvementofthelumbarspinemayproducesymptomsofclinicalspinalstenosis.Involvementofthecervical
andthoracicspinemaypredisposepatientstomyelopathy.
Althoughthisdisordermaybeasymptomatic,whensymptomsdooccur,theyoccurinsidiously.Pagetdiseaseis
managedeithermedicallyorsurgically.
GENERALIZEDBODYPAIN
Whendiscussingtheissueofdifferentialdiagnosiswithgeneralizedbodypain,itiswellworthmentioningtwo
conditions:fibromyalgia(FM)andmyofascialpainsyndrome(MPS).Althoughtheseconditionsshareseveral
features,theyaredistinctentitieswhosephysicalfindingsandinterventionsdiffersignificantly.80
Fibromyalgia
PrimaryFMisacommonformofnonneuropathicchronicneuromuscularpain,whichispoorlyunderstood.FM
ischaracterizedbywidespreadandgeneralizedbodyachesofatleast3monthsduration,whichcancausepain
orparesthesias,orboth,inanonradicularpattern.8183FMisnotadisease,butratherasyndromewitha
commonsetofcharacteristicsymptoms,includingconstitutionalsymptomsoffatigue,nonrestorativesleep,and
thepresenceofadefinednumberoftenderpoints.84
TherelationshipoftenderpointstoFMhasbeenthefocusofmuchresearch,8588and,accordingtothecriteria
oftheAmericanCollegeofRheumatology,apositivetenderpointisdefinedasapointthatbecomespainful(not
merelytender)whenapproximately4kgofpressureisapplied.89Apositivetenderpointcountof11ormoreof
18standardizedsites,whenpresentincombinationwiththehistoryofwidespreadpain,yieldsasensitivityof
88.4%andaspecificityof81.1%inthediagnosisofFM.
Thepathologyandpathophysiologyofthetenderpointremainelusive.Normally,smallCfibersintheskinare
activatedbychemical,mechanical,orthermalstimuli(seeChapter3).Theimpulsesaresentupthe
spinothalamictracttothebrainwheretheyareprocessed.InFM,theconstantbombardmentofnoxiousinputsto
Cfibersleadstocentralsensitization(allodynia).90Asaconsequence,large,myelinatedAdeltafibersbegin
carryingsomesignalsnormallytransmittedbytheCfibers.Centralsensitizationfurtherexpandstoinvolve
autonomicallymediatedBfibers.Ithasalsobeenhypothesizedthatthemyalgiasmayresultfromneurohumoral
changesratherthanlocalmetabolicorpathophysiologicfeatures.91PrevalenceofFMisabout1020times
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greaterinwomenthaninmen,althoughthereasonforthisisunknown.Sleepstudiesshowthatstage4sleepis
themostinterruptedhowever,sleepdisturbancesarecommoninthegeneralpopulationandthusnotendemicto
FMpatients.92
ThemedicalinterventionforFMincludestheprescriptionofdrugsthatinfluencechemicalsintheascending
anddescendingpaintracts,chemicalsthatinfluencecerebralfunction,nonsteroidals,andmusclerelaxants.90A
multifacetedphysicaltherapyapproachinvolvingcardiovascularfitnesstraining,sprayandstretch,strengthand
endurancetraining,massage,andelectrotherapeuticandphysicalmodalities,includingmicrostimulation,may
helptoreducesomeofthediseasesconsequences.93
MyofascialPainSyndromes
MPSsarecloselyassociatedwithtenderareasthathavecometobeknownasmyofascialtriggerpoints(see
Chapter10).83,9497Dysfunctionaljointsarealsoassociatedwithtriggerpointsandtenderattachmentpoints.98
MPSoftenmanifestswithsymptomssuggestiveofneurologicdisorders,includingdiffusepainandtenderness,
headache,vertigo,visualdisturbances,paresthesias,incoordination,andreferredpainthatoftencanbeclarified
bythemusculoskeletalandneurologicexamination.99MPSshouldalwaysbeconsideredasadiagnosisinthe
presenceofpersistentpain.96,100104
DIFFERENTIALDIAGNOSISWITHINSPECIFICREGIONS
Theintentofthefollowingsectionsistoprovidethephysicaltherapistwithpotentialdiagnosesbasedonthe
locationofsymptoms.ItwasGrievewhocoinedthetermmasqueraderstoindicatethoseconditionsthatmay
notbemusculoskeletalinoriginandthatmayrequireskilledinterventionelsewhere.Toaidtheclinicianinthe
detectionofthesemasqueraders,bothneuromusculoskeletaldisorders,andseriousunderlyingmedical
conditionsareincludedinthefollowingsections,accordingtothevariousbodyregions.Althoughnotinclusive,
thesediagnosesshouldprovidetheclinicianwithalistofpossibilitiestoencouragedivergentthinkingduring
eachexamination.
CAUSESOFHEAD,FACE,EYE,ANDTEMPOROMANDIBULAR
JOINTSYMPTOMS
Thecausesofhead,face,andtemporomandibularjointsymptomsinclude,butarenotlimitedto,thoselistedin
Table57.
TABLE57PotentialCausesofHeadandFacialPain
Trauma
Headache
Occipitalneuralgia
Osteoarthritis
Rheumatoidarthritisandrelatedrheumatoidarthritisvariants(dermatomyositisandtemporalarteritis)
Lymedisease
Fibromyalgia
Arteriovenousmalformation
Intracranialinfection(meningitis)
Cerebrovasculardisease
Tumor
Encephalitis
Systemicinfections
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Multiplesclerosis
Miscellaneous
Trauma
Headpainiscommonfollowingtraumatotheheadandneck.Thetraumaticepisodesthatdonotproduce
profoundneurologicdamagearetermedconcussions(contusions)(seeChapter3).Aconcussionisnotalways
associatedwithsomedegreeoflossofconsciousnessandtypicallyinvolvesasuddenacceleration(or
deceleration)force,whichcausesthebraintomovesuddenlywithintheskull.Foralossofconsciousnessto
occur,theseforcesmustdisconnectthealertingsysteminthebrainstem,resultinginatemporarylackof
activityinthereticularformation,probablysecondarytohypoxiaresultingfrominducedischemia.105Itis
estimatedthatavelocityofonly20mphcancauseconcussionfrominertialloading(noheadimpact)inmost
healthyadults(seeChapter3).106
Headache
Headachesareacommoncomplaint.Approximately8595%oftheadultpopulationintheUnitedStates
experienceaheadacheduringagiven1yearperiod,107althoughonly1.72.5%ofpatientsvisittheemergency
departmentwithacomplaintofaheadache,108withmostchoosingtotreatthemselveswithoverthecounter
medications.109,110
Headaches,ingeneral,canbegroupedintotwomaindivisions:primaryorsecondary,andbenignornonbenign.
Primaryheadaches,asdefinedbytheInternationalHeadacheSociety,111aretheresultofsomeunderlying
structuralabnormalityordiseaseprocess,andincludemigraine,cluster,tensiontype,andotherprimary
causessuchascervicalmusculoskeletaldysfunction.
Secondaryheadachesaretheresultofanunderlyingpathologicprocessincludinganginapectoris,and
myocardialinfarction.112
Benignheadaches.Theoriginofbenignheadachescanvary.Commoncausesincludeneurologic(trigeminal
neuralgia[TN],cervicalneuralgia,atypicalfacialpain,posttraumatic,andpostlumbarpuncture),
musculoskeletal(tensionheadache,occipitalheadache,andcervicogenicheadache),andvascular(migraine,
cluster,andhypertension).111Otherheadaches,suchaschronicdailyandrebound,arethoughttoberelatedtoa
combinationofneurologicandmusculoskeletalcauses(seelater).OA,RA,andrelatedRAvariants
(dermatomyositisandtemporalarteritis,andsystemiclupuserythematosus),Lymedisease,FM,andcomplex
regionalpainsyndrome(CRPS)(formerlyknownasreflexsympatheticdystrophy[RSD]seeChapter18)have
alsobeenindicatedasadditionalsourcesofheadandneckpain.113Diseasesofthesinus(maxillarysinusitis,
frontalsinusitis,ormalignancy),diseasesoftheeye(inflammationoftheirisandglaucoma),andinfectionand
inflammationoftheearapparatusmayalsocauseheadaches.111Sensitivitytotappingoverthesinusesisfairly
diagnosticforsinusitis,whereasdiminishedvisionischaracteristicofglaucoma.111
Nonbenign.MedicalexpertshavecreatedtheacronymSNOOPfordiagnosisofredflagsinthose
presentingwithheadacheswhoneedimmediateattention:114
SSystemic(e.g.,fever,chills,nightsweats)
NNeurological(e.g.,abnormalneurologicalfindings)
OOnsetsudden(headachepeakswithinoneminuteofonset)
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OOnsetaftertheageof50years
PPatternchange(increasinginfrequency,associatedwithValsalvamaneuver,aggravatedbyposturesthat
changecranialorhighpressure).
MigraineHeadache
Migrainesareequallydistributedamongthesexesinchildhood,buttwooutofeverythreeadultswithmigraine
headachesarewomen.113AccordingtotheInternationalHeadacheSociety,111therearetwotypesofmigraine
headaches:Amigrainewithoutaura(commonmigraine),andmigrainewithaura.Themigrainewithoutaura
typeinvolvesepisodeslasting472hours,andsymptomsthataretypicallyunilateralandwithapulsating
qualityofmoderateorsevereintensity,whichisthoughttoresultfromachangeinthebloodvesselsofthe
brain.Thistypeofheadacheisaggravatedbyroutinephysicalactivityandisassociatedwithnausea,
photophobia,andphonophobia.
Amigrainewithauratypeischaracterizedbyreversibleaurasymptoms,whichtypicallydevelopgraduallyover
morethan4minutesbutlastnolongerthan60minutes.111
Itisthoughtthatmigraineheadachesareadifferentexpressionofacommonunderlyingproblem.113Aswith
clusterheadaches(seebelow),ithaslongbeenrecognizedthatmigraineheadachesareexacerbatedby
disturbancesorirregularitiesinsleeppatterns.112
ClusterHeadache
Clusterheadachesaresevere,unilateral,retroorbitalheadaches.Thistypeofheadacheismorecommoninmen
thaninwomen.Astheirnamesuggests,clusterheadachesoccuringroupsorclusters,andtheytendtooccurat
predictabletimesofday.Clusterheadachesmayalsodevelopbecauseofspecificsleepdisorders,suchassleep
apnea,bruxism,orsleepdeprivation.112
Clusterheadachesareoftenaccompaniedbynasalcongestion,eyelidedema,rhinorrhea,miosis,lacrimation,
andptosis(droopingeyelid)onthesymptomaticside.112Theseheadachescanlastfrom15to180minutesif
untreated.111
Unlikemigrainesufferers,whofeelobligedtoliedownduringasevereheadache,individualswithcluster
headachesfeelbetterduringaheadachebyremaininginanerectpostureandmovingabout.113Cluster
headachesarethoughttoresultfromvasodilationinbranchesoftheexternalcarotidartery,becausetheyoften
aretriggeredbyvasodilatingsubstances,suchasnitroglycerineandalcohol.115
TensionTypeHeadache
ThetermtensiontypeheadacheisdesignatedbytheInternationalHeadacheSocietytodescribewhatwas
previouslycalledtensionheadache,musclecontractionheadache,psychomyogenicheadache,stressheadache,
ordinaryheadache,andpsychogenicheadache.111TheInternationalHeadacheSocietydistinguishesbetweenthe
episodicandthechronicvarietiesoftensiontypeheadachesanddividesthemintotwogroups:thoseassociated
withadisorderofthepericranialmusclesandthosenotassociatedwiththistypeofdisorder.111
Tensionheadaches,whichconstituteupto70%ofheadachesandwhichoccurmoreofteninwomenthanin
men,arethoughttoresultfromemotionalstress.113,116Theyarecharacterizedbyabilateral,nonthrobbingache
inthefrontalortemporalareas(Fig.51)andbyspasmorhypertonusoftheneckmuscles.115Unlikemigraine
headaches,thetensiontypeheadache,istypicallyrelievedbyphysicalactivityandusuallyrespondswelltosoft
tissueandspecifictractiontechniques.
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FIGURE51
Distributionofsymptomsandsignsinatensionheadache.(Reproduced,withpermission,fromChapter6.
Headache&FacialPain.In:GreenbergDA,AminoffMJ,SimonRP.eds.ClinicalNeurology,8e.NewYork,
NY:McGrawHill2012.)
BenignExertionalHeadache
Benignexertionalheadache(BEH)hasbeenrecognizedasaseparateentityformorethan70years.117
CharacteristicfeaturesofBEHinclude:118
Aheadachethatisspecificallybroughtonbyphysicalexercise,particularlywithstrainingandValsalva
typemaneuvers,suchasthoseseeninweightlifting
bilateralandthrobbingatonsetandmaydevelopmigrainousfeaturesinpatientssusceptibletoamigraine
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durationof5minutesto24hours
preventedbyavoidingexcessiveexertionand
noassociationwithanysystemicorintracranialdisorder.
Clearly,themajordifferentialdiagnosistobeconsideredinthissituationwouldbeasubarachnoidhemorrhage,
whichneedstobeexcludedbyappropriateinvestigations.
EffortInducedHeadache
Effortheadacheshavebeenreportedtobethemostcommontypeofheadacheinathletes.119Theseheadaches
differfromBEHinthattheyarenotnecessarilyassociatedwithpowerorstrainingtypesofexercise.The
clinicalfeaturesofthiseffortheadachesyndromeinclude:118
anonsetofamildtosevereheadachewithaerobictypeexercise
morefrequencyinhotweather
vasculartypeheadache(i.e.,throbbing)
ashortdurationofaheadache(46hours)
provokingexercisemaybemaximalorsubmaximal
thepatientmayhaveprodromalmigrainoussymptoms
theheadachetendstorecurinindividualswithexercise
thepatientmayhaveapasthistoryofamigraine
normalneurologicalexaminationandinvestigations.
OccipitalHeadache
Anoccipitalheadacheisfeltbymanyclinicianstobereferredaspainfromacervicaldisorder,especiallywhen
cervicaltractiontemporarilydecreasestheheadache.
Theunderlyingmusculoskeletalmechanismforthistypeofheadacheisoftenstructural,includingcervical
hypomobilityorhypermobility,jointsubluxation,anddegenerativebonychanges.Postures,movements,or
activitiesthatputastrainontheneckhavebeenassociatedwithheadaches.120Inonestudy,12151%ofpatients
associatedtheirheadacheswithsustainedneckflexionduringreading,studying,typing,ordrivingacar.
ThereisconsiderablesensoryinputintotherootofC1,butnotfromacutaneoussource(seeOccipital
Neuralgialater)(seeChapter3).122Experimentshaveconfirmedaclosetrigeminocervicalrelationship.123,124
Becausetheheadandneckcompriseonefunctionalunit,cervicalmusculoskeletaldisorderscancontributeto
head,temporomandibular,orfacialpainwithorwithoutneckpain.125Cervicalheadachesaredescribedin
moredetailinChapter23.
HypertensionHeadache
Hypertensionheadachesusuallyoccurinindividualswithdiastolicreadingsabove120mmHg,althoughthe
intensityoftheseheadachesdoesnotnecessarilyparalleltheheightofthebloodpressurelevels.126Typically,
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theheadachebeginsintheearlymorning,reachingapeakuponawakeningandthendiminishesoncethepatient
risesandbeginshisorherdailyactivity.127Theheadacheisusuallydescribedasanonlocalized,dull,and
throbbingachethatisaggravatedbyactivitiesthatincreasebloodpressure,suchasbending,coughing,or
exertion.128Thedistributionoftheheadachecanvaryandmayextendovertheentirecranium.127
ExternalCompressionHeadache
Thisentity,formerlyknownasswimgoggleheadache,manifestswithpaininthefacialandtemporalareasthat
resultsfromwearingexcessivelytightfacemasksorswimminggogglesandisthuscommonlyseenin
swimmersanddivers.118,129Theetiologyisbelievedtoberelatedtocontinuousstimulationofcutaneous
nervesbytheapplicationofpressure,althoughneuralgiaofthesupraorbitalnervehasalsobeenimplicated.118
IdiopathicCarotidyniaHeadache
Idiopathiccarotidyniaisassociatedwithagradualonsetofaunilateralheadache,unilateralfacialororbitalpain,
butitmaybeaninstantaneous,excruciating,thunderclapheadachethatmimicsasubarachnoid
hemorrhage.130Thepainismostcommonlylocatedinthefrontotemporalarea,butoccasionallyinvolvesthe
entirehemicraniumortheoccipitalarea.130Themedianintervalbetweentheonsetofneckpainandthe
appearanceofothersymptomsis2weeks,whereasothersymptomsoccuronlyapproximately15hoursafterthe
onsetofaheadache.130
ChronicDailyHeadache
Chronicdailyheadaches,followingtraumatotheheadorneck,areacommonoccurrence,131withtheduration
oftheseheadachesunrelatedtotheseverityortypeoftrauma.132,133Theseheadachestypicallyconsistofa
groupofdisordersthatcanbesubclassifiedintoprimaryandsecondarytypes.134
Theprimarychronicdailyheadachedisordersincludeatransformedmigraine,chronictensiontype
headache,newdailypersistentheadache,andhemicraniacontinua.Thistypeofheadacheisdefinedasa
constanttensionheadachewithmigrainousexacerbations.135,136
Thesecondarychronicdailyheadachesincludecervicalspinedisorders,headacheassociatedwith
vasculardisorders,andnonvascularintracranialdisorders.
Thechronicdailyheadacheusuallyevolvesovertimefromanepisodicmigraine,butthecauseisstill
controversial.Individualssufferingfromchronicdailyheadacheoftensufferfromareboundheadacheaswell.
Areboundheadacheinvolvestheworseningofheadpaininchronicheadachesufferers.Itiscausedbythe
frequentandexcessiveuseofnonnarcoticanalgesics.137Severalstudieshavedemonstratedthatasmanyas
threequartersofpatientswithchronicdailyheadachesufferfromdruginducedreboundheadache.138,139
Theroleoftraumainchronicdailyheadaches,however,maybeunderstated.Tensionheadachesmaywell
initiateaheadacheinpatientspredisposedbysomepreviousandforgottentraumaticincident.
PosttraumaticHeadache
Inadditiontotheimmediatepainfollowingaheadinjury,posttraumaticheadache,amoreprolongedand
enduringheadache,maydevelop.140Thiscondition,resemblingeitheramigraineortensiontypeheadache,
maylastforweeks,months,oryears.Itmayalsobeassociatedwithposttraumaticsyndrome,whichincludesa
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varietyofsymptoms,suchasirritability,insomnia,anxiety,seizure,amnesia,depression,andreducedabilityto
concentrate.140
Themoreseriouscausesofaheadacheassociatedwithtraumaincludesubduralhematoma,epiduralhematoma,
intracerebralhematoma,aneurysm,subarachnoidhemorrhage,orcerebralcontusion.
Theclinicianshouldattempttoestablishtheoverallhealthofthepatientthroughareviewofthesystems:115
Nervoussystem.Thephysicalexaminationofthenervoussystemcanincludesensoryandmotortesting
ofthecranialandspinalnerves,reflextesting,andanexaminationofgait,balance,andcoordination.The
needforsuchtestingoftencanbedeterminedbythepresenceofthesignsandsymptoms.
Cardiovascularsystem.Fluctuationsinbloodpressureareoftenassociatedwithheadaches.
Endocrinesystem.Headachesmaybeassociatedwithhormonalchangesandhormonalreplacement
therapy.141
Musculoskeletalsystem.Anexaminationmustbemadeofthemiddle(seeChapter25)anduppercervical
segments(seeChapter23),andthetemporomandibularjoint(seeChapter26).Inaddition,athorough
posturalexaminationshouldbeperformedtoassessformuscleimbalancesandoverallalignment(see
Chapter6).Relativeflexibilityandstrengthareassessedduringupperlimbmovements.Finally,the
clinicianshouldexamineformyofascialtriggerpoints,andthepresenceofadverseneuraltension(see
Chapter11).
OccipitalNeuralgia
Occipitalneuralgiaisarareneuralgicdisorderthatinvolvesthegreateroccipitalnerve.142Thegreateroccipital
nerveoriginatesfromthesecondcervicalroot(C2).Occipitalneuralgiaisaheadachesyndromethatis
characterizedbyanoccipitalandsuboccipitalheadachethatmayradiatetothefrontal,periorbital,retroorbital,
maxillary,andmandibularregions.143Itmayalsobeassociatedwithneckpain,dizziness,paresthesiasor
hyperesthesiaoftheposteriorscalp,andlossofthenormalcervicallordosis.Occipitalneuralgiaismore
commoninwomenthaninmen.144Thepainusuallyawakensthepatientfromsleepinthemorningbutmay
occuratanytimeofday.144Thecausesofoccipitalneuralgiainclude:
scalptraumafromadirectblow
compressionneuropathy
sustainedcontraction(spasm)oftheposteriorneckmuscles,142especiallythesemispinaliscapitis,
obliquuscapitisinferior,andtrapeziusmuscles145
hyperextensioninjuryandresultantcompressionoftheganglionandrootofC2
fractureoftheatlasoraxis
gout
mastoiditis
OAofthecraniovertebraljoints.
Diagnosisisusuallymadeusingpalpationoverthegreateroccipitalnerveasitpassesthesuperiornuchalline.
Theinterventionforpatientswithoccipitalneuralgiainvolvesinfiltratingthenervewithamixtureoflocal
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anestheticandcorticosteroid.145
GlossopharyngealNeuralgia
Thecauseofaglossopharyngealneuralgiais,atpresent,unknown,althoughmostauthorsplacethesiteof
disturbanceintheregionoftheposteriorroot146,147orinthenervetract.148Glossopharyngealneuralgiais
characterizedbyintenseunilateralattacksofpainintheretrolingualarea,radiatingtothedepthoftheear.128
Thepain,typically,isaggravatedbymovementorcontactwiththepharynx,especiallywithswallowing.
TrigeminalNeuralgia
TN,orticdouloureux,isaseverechronicpainsyndromecharacterizedbydramatic,briefstabbing,orelectric
shocklikepainparoxysmsfeltinoneormoredivisionsofthetrigeminaldistribution,eitherspontaneouslyoron
gentletactilestimulationofatriggerpointonthefaceorintheoralcavity.149ItisunclearwhetherTNisa
neuropathicpainstateofthecentralorperipheralnervoussystem.
BellPalsy
Bellpalsyisalowermotorneuron(LMN)diseaseofthefacialnervecharacterizedbyawiderangeoffacial
musclemovementdysfunctionfrommildparesistototalparalysis.Individualpatientsdisplayaspectrumof
symptoms:somemaintainonlyreducedmovementthroughoutthecourseofthedisorderwhileothersrapidly
becometotallyparalyzedthroughoutthedistributionofthefacialnerveovera24hourperiod.Bellpalsyisthe
mostcommonformoffacialparalysis,withanincidenceof2030per100,000persons.150Thediagnosisis
establishedbytheexclusionofseverallocalizedlesions,suchastemporalbonefracture,acousticneuroma,
suppurationortumorofthemiddleear,anddisordersoftheparotidgland.151
Fundamentaltomanagementissuesofthisdisorderisthequestionofitsetiology,oncethoughttobeidiopathic.
Tworecentindependentstudies152,153stronglysupporttheconceptthatthefacialparalysisassociatedwithBell
palsyistheresultofaviral,inflammatoryresponsethatinducesedemaandischemiaofthefacialnerveasit
passesthroughitsbonycanal.TheinfectiousagentsassociatedwithBellpalsyareherpessimplexvirustype1,
varicellazostervirus,andthespirocheteBorreliaburgdorferi,thecausativeorganismofLymedisease.154
Theinterventionforthisconditionisempiric,varyingfromobservationalonetotheuseofcorticosteroids,
electricstimulation,surgicaldecompression,andantiviralagents.Transcranialmagneticstimulationofthefacial
nervehasalsobeenreportedtobeuseful.155
Healingisoccasionallyincomplete,resultinginresidualnervedysfunction,includingpartialpalsyandmotor
synkinesis(involuntarymovementaccompanyingavoluntaryone)andautonomicsynkinesis(involuntary
lacrimationafteravoluntarymusclemovement).OnthebasisofthestudyofPeitersen,156allpatientsregain
somefunction,and85%ofallpatientswillregainnormalorverynearnormalfunctionwithin68weeks.
SurgicalmanagementofBellpalsyhasbeencontroversialsinceitsinceptionbecauseofthefollowingpoints:
issuesofpatientselectioncriteriabasedonelectrodiagnosticstudies,siteofdecompression,limitednumberof
patientswhorequiredecompressionatanysinglecenter,andtheinabilitytotransferresultsfromstudytostudy
becauseofthecontinueduseofindependentfacialfunctiongradingsystems.157
RamsayHuntSyndrome
RamsayHuntsyndrome,aherpeticinflammationofthegeniculateorfacialnerveganglia,orboth,manifestsas
aperipheralfacialnervepalsyaccompaniedbyanerythematousvesicularrashontheear(zosteroticus)orinthe
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mouth.158Itisthesecondmostcommoncauseofatraumaticperipheralfacialparalysis.Otherfrequent
symptomsandsignscanincludetinnitus,hearingloss,nausea,vomiting,vertigo,andnystagmus.
ComparedwithBellpalsy,patientswithRamsayHuntsyndromeoftenhavemoresevereparalysisatonsetand
arelesslikelytorecovercompletely.TheinterventionforRamsayHuntsyndromecaninvolvemedication.
Prednisoneandacyclovirmayimprovetheoutcomealthoughaprospectiverandomizedtreatmenttrialremains
tobeundertaken.158
ArteriovenousMalformation
Thiscongenitalmalformationmaymanifestwithanabruptonsetofheadandfacialpain.
Meningitis
Thebrainisprotectedfrominfectionbytheskull,pia,arachnoid,andduralmeningescoveringitssurfaceandby
thebloodbrainbarrier(seeChapter3).Whenanyofthesedefensesisbroachedbyapathogen,infectionofthe
meningesandsubarachnoidspacecanoccur,resultinginmeningitis.159
Sincethefifthcenturybc,theseriousnessofinfectiousmeningitishasbeenrecognized.160Inthe20thcentury,
theannualincidenceofbacterialmeningitisrangesfromapproximately3per100,000populationintheUnited
States161to500per100,000inthesocalledmeningitisbeltofAfrica.162
Predisposingfactorsforthedevelopmentofcommunityacquiredmeningitisincludepreexistingdiabetes
mellitus,otitismedia,pneumonia,sinusitis,andalcoholabuse.163
Theclinicalfeaturesofmeningitisreflecttheunderlyingpathophysiologicprocesses.164Oncethebloodbrain
barrierisbreached,aninflammatoryresponsewithinthecerebrospinalfluid(CSF)occurs.Theresultant
meningealinflammationandirritationelicitaprotectivereflextopreventstretchingoftheinflamedand
hypersensitivenerveroots,whichisdetectableclinicallyasneckstiffnessorrigidity(KernigorBrudzinski
signs).165,166
Brudzinskisign:thepatientispositionedinsupine.Theclinicianpassivelyflexesthepatientsneck.A
positivesignistheappearanceofinvoluntaryhipflexion,whichliftsthepatientslegsoffthetable.
Kernigsign:thepatientispositionedinsupine.Theclinicianpassivelyflexesthepatientshipto90
degreesandthenattemptstoextendtheknee.Painwiththekneeextensionisapositivesign.
CLINICALPEARL
Rigidityoftheneckcanoccurwithneuralgiaandotherirritativelesionsofthemeninges,suchasmeningitis.164
Themeningealinflammationmayalsocauseafeverandgeneralizedheadacheandnausea.167Ifthe
inflammatoryprocessprogressestocerebralvasculitis,orcausescerebraledemaandelevatedintracranial
pressure,alterationsinmentalstatus,vomiting,seizures,andcranialnervepalsiesmayensue.159
Despiteclassicdescriptionsofmeningealsignsandsweepingstatementsaboutitsclinicalpresentation,thesigns
andsymptomsofmeningitishavebeeninadequatelystudied.164Basedonthelimitedstudies,thefollowing
pointsshouldberememberedduringtheexamination:164
Theabsenceofallthreesignsoftheclassictriadoffever,neckstiffness,andanalteredmentalstatus
virtuallyeliminatesadiagnosisofmeningitis.Feveristhemostsensitiveoftheclassictriadofsignsand
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occursinamajorityofpatients,withneckstiffnessbeingthenextmostsensitivesign.Alterationsin
mentalstatusalsohavearelativelyhighsensitivity,indicatingthatnormalmentalstatushelpstoexclude
meningitisinlowriskpatients.Changesinmentalstatusaremorecommoninbacterialthaninviral
meningitis.
Amongthesignsofmeningealirritation,theBrudzinskiandKernigsignsappeartohavelowsensitivity
buthighspecificity.
CerebrovascularDisease
Thefrequencyofaheadachewithcerebrovasculardiseaseisdependentonthesizeandlocationofthe
hemorrhage.Smallhemorrhagesmayoccurwithoutanassociatedheadache.Althoughaheadachemaybethe
presentingsymptomofcerebrovasculardisease,associatedneurologicalchangesarealsolikelyandaremore
indicativeofcerebrovasculardisease.Thesecouldinclude,butarenotlimitedto,lossoftheabilitytosit,stand,
andwalkrightorleftsidedweaknessvisualdisturbancesaphasiaapraxiadysphasiaseizuresandmental
statuschanges.
IntracranialBleeding
Dependingontherateofarterialorvenousbleeding,signsofintracranialbleedingmaytakeminutestodays.A
meningealarteryorbranchlacerationwithanassociatedoverlyingskullfractureisafrequentsourceofdelayed
epiduralbleeding.168However,venousbleedingisalsoassociatedwithdelayedandchronichematomasbythe
natureofthelowpressureandslowrateofbleeding.168Othercausesoflowtensionhemorrhagesaresmall
durallesionsordiffusecerebralcontusionsites.
Asubarachnoidhemorrhagecanbethecauseofhead,facial,orbital,orneckpain.Thepain,whichisusually
severe,mayoccurinoneregionoroveralloftheareas.Neckstiffnessandpainonmovementarecommon
findingsandoftenareassociatedwithnauseaandvomiting.Otherpossiblefindingsinclude:
UMNsignsandsymptoms(Babinski,clonus,hyperreflexia,ataxia,andsoon)
photophobia
motororsensorydisturbances
syncope
somnolenceandlethargy
seizures
visualdisturbances
dysphasia.
Patientswithintracranialbleedingusuallyprefertoremainstill,withtheireyesclosed.Theyoftenbecome
disorientedanddemonstratejudgmentandmemoryabnormalities.
Tumors
Acompletediscussionofeachtypeofbraintumorisbeyondthescopeofthistext.Tumorsofthebrainmaybe
classifiedaccordingtotypeasfollows:
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Astrocytomas.Astrocytomasarebenignbraintumors.Glioblastomamultiforme,atypeofastrocytoma,is
themostcommonadultbrainneoplasm.
Oligodendrogliomas.Thesearebenignprimarybraintumorsthatarisefromoligodendrocytes.
Meningiomas.Thesetumorsareslowgrowingandbenignandcompriseabout20%ofallintracranial
tumorsinadults.
Metastatictumors.Thesearetumorsthatoriginatefromtissuesoutsideofthebrain.Theycanoccuras
singleormultipletumors.
Thetermbenignismisleadingwhenreferringtobraintumors.Althoughbenignmaymeancurable,thisisnot
alwaystruewithbraintumors.Tumors,benignorotherwise,arespaceoccupyinglesionsthatmayincreasetoa
sizethatcompressesnearbystructuresorincreasesintracranialpressure.Patientswithtumorsofthebrainmay
presentacutelywiththefollowingsymptoms:
Abruptonsetofasevereheadache
Facialpain
Episodesoflossofconsciousness
Changesinmentalstatus
Nauseaandvomiting
Focalneurologicsignsandsymptoms
Neckstiffnessorpain
Encephalitis
Encephalitisisaninflammationofthebrain.Theinflammationmaybecausedbyanarthropodbornevirus,orit
mayoccurasasequelaofinfluenza,measles,Germanmeasles,chickenpox,herpessimplex,orotherinfectious
diseases.Clinicalfindingsinclude:
signsofmeningealirritation(KernigorBrudzinskisign)
changesinmentalstatus
signsofincreasedintracranialpressure,includingincreasedrestlessness,vomiting,seizures,andpupil
irregularitiesand
behavioralchanges.
SystemicInfections
SystemicinfectionsthatarecapableofprovokingheadorfacialpainincludeRockyMountainspottedfever,
Lymedisease,pneumonia,andpyelonephritis.
RockyMountainSpottedFever
Thisconditionbeginsabruptlywithahighfeverandbilateralfrontalorafrontotemporalheadache.Theclassic
rashbeginsonthedistalaspectsoftheextremitiesandspreadsproximally.Serologictestsarerequiredto
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confirmthediagnosis.
LymeDisease
Lymediseaseisabacterialinfectionthatistransmittedtohumansbyticksthatusuallyliveonmiceordeer.
MostinfectionsareacquiredinthreedistinctsectionsoftheUnitedStates:alongthenortheastcoast,inareasof
WisconsinandMinnesota,and,toalesserextent,innorthernCaliforniaandsouthernOregon.Peoplewhohike,
camp,orliveinornearwoodedareasintheselocationsduringsummermonthsaremostatriskforLyme
disease.Followingabitefromadeertick,aredbumpmayoccuratthesiteofthebite.Ifthetickisinfected,a
largerrashmayformaroundthebite.Theclassicdescriptionoftherashisanenlargingareaofrednesswith
partialcentralclearing.However,itmaytakeseveraldaysbeforethelesionexpandsenoughtohavetheclassic
appearance.
Themostcommonsignsandsymptomsassociatedwiththerasharenonspecificflulikesymptoms,including
myalgia,arthralgias,fever,jointpainandswelling,headache,fatigue,motororsensoryradiculoneuritis,
mononeuritismultiplex,orneckstiffness.169
Cardiacsymptomscanincludefluctuatingdegreesofatrioventricularblock,occasionallyacutemyopericarditis
ormildleftventriculardysfunction,and,rarely,cardiomegalyorfatalpancarditis.169
Theinitialdiagnosisusuallyisbasedontherecognitionofthecharacteristicclinicalfindings.ThecultureofB.
burgdorferifromspecimensinBarbourStoennerKellymediumpermitsadefinitivediagnosis.169
Pneumonia
Pneumoniaisaninflammationofthelungs,usuallycausedbyaninfectionofthelungtissuebyoneofmany
differentmicroorganisms.Thepresentingsymptomsdependonhowmuchofthelungisaffectedandthetypeof
infection.Relatedtothisbodyregion,patientswithpneumoniamaypresentwithafeverandsevereheadache.
Pyelonephritis
Acutepyelonephritisisaninflammationofthekidneyandrenalpelvis.Clinicalsignsandsymptomsofacute
pyelonephritisincludefevershakingchillsthoracolumbar,interscapular,neck,andflankpainnauseaand
vomitingcostovertebralangletendernessand,lesscommonly,symptomsofcystitissuchasdysuriaand
increasedfrequency.170Inaddition,abifrontalorageneralizedheadachemayaccompanytheneckpainand
stiffness.
MultipleSclerosis
Multiplesclerosis(MS)isachronicdemyelinatingdisorderwithawiderangeofclinicalmanifestationsthat
reflectsmultifocalareasofCNSmyelindestruction.Inadults,theclinicalpresentationofMSatonsetis
characterizedbymotorsystem(26.5%),sensorysystem(25%),oropticnerve(21%)involvementora
combinationofallthree.171Cerebellarandsphinctericinvolvementarelessfrequent(14.1%each).171
Patientswithmotorweaknessmaydevelopparalysisaffectingoneormore,orall,limbs.Sensorydysfunction
mayoccurinonemodality(e.g.,tolighttouch,temperature,ordeepsensation)andmaymanifestas
hypoesthesia/anesthesiaorhypersensitivitywithnumbness,burningsensation,paresthesia,anddysesthesiain
variouspartsofthebody).171Othermanifestationsincludefatigue,cognitiveloss,andmooddisturbance.Optic
neuritisisassociatedwithadecreaseinvisualacuity,sometimesresultinginblindness,accompaniedbyorbital
painwhentheinvolvedeyemoves.172
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MostpatientswithMS(85%)havearelapsingremittingcourseofthedisease,witheachrelapsebeing
associatedwithnewneurologicsymptomsorworseningofexistingones.Withadditionalrelapses,the
possibilityofcompleterecoveryisreduced,andpermanentdisabilitymaydevelop.171Intheremaining15%of
patients,thediseasecourseisprimaryprogressive,withcontinuousneurologicdeterioration.171
MSusuallymanifestsbetween20and40years,withapeakonsetataround30yearsandafemaletomaleratio
of2:1.Atpresent,MSisregardedasbeingmodifiable,butincurable.
MiscellaneousCauses
TemporalArteritis
Thiscondition,alsoknownasgiantcellarteritis,isaninflammatoryconditionaffectingthemediumsizedblood
vesselsthatsupplythehead,eyes,andopticnerves.Thediseaseusuallyaffectsthoseover60yearsandis
characterizedbyasevereheadache,whichcanbeginabruptlyorgradually,andisusuallythrobbinginnature.
Associatedsymptomsmayincludeflulikesymptoms,swollenandtendertemporalarteries,jawweakness,scalp
tenderness,andvisualloss.Womenareapproximatelyfourtimesmorelikelytosufferfromthisdiseasethan
men.173
AcuteSinusitis
Sinusitisisaninfectionorinflammationofthesinuses.Sinusesarehollowairspaceslocatedwithintheskullor
bonesoftheheadsurroundingthenose.Eachsinushasanopeningintothenoseforthefreeexchangeofairand
mucus,andeachisjoinedwiththenasalpassagesbyacontinuousmucousmembranelining.Anythingthat
causesaswellinginthenose,suchasaninfection,anallergicreaction,oranimmunereaction,mayaffectthe
sinuses.Sinusitisinvolvesaninfectionorinflammationofoneormoreofthefollowing:
Frontalsinusesovertheeyesinthebrowarea
Maxillarysinusesinsideeachcheekbone
Ethmoidsinusesjustbehindthebridgeofthenoseandbetweentheeyes
Sphenoidsinusesbehindtheethmoidsintheupperregionofthenoseandbehindtheeyes
Airtrappedwithinablockedsinus,alongwithpusorothersecretions,maycausepressureonthesinuswalland
subsequentpain.Similarly,whenairispreventedfromenteringasinusbyaswollenmembraneattheopening,a
vacuummaybecreated,whichalsocausespain.Thelocationofthesinuspaindependsonwhichsinusis
affected.Symptomscaninclude:
aheadacheuponawakeninginthemorningandtendernesstopalpationoverthefrontalsinuses
upperjaw,cheek,andtoothpain(maxillarysinuses)
painandswellingoftearductsinthecorneroftheeyesandpainbetweentheeyesandsidesofthenose
(ethmoidsinuses)and
earaches,neckpain,anddeepachingatthetopofthehead(sphenoidsinuses).
Othersymptomsofsinusitisinclude:
fever
weakness
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tiredness
Acoughthatmaybemoresevereatnightand
Arunnynose(rhinitis)ornasalcongestion.
Onrareoccasions,acutesinusitismayresultinbraininfectionandotherseriouscomplications.
Eclampsia
Eclampsiaisthemostcommonlyoccurringhypertensivediseaseinpregnancy.Worldwide,preeclampsiaand
eclampsiacontributetothedeathofapregnantwomanevery3minutes.174Theclassicclinicalpresentation
consistsofblurredvision,severeheadaches,epilepticseizures,orcomamanifestingduringthethirdtrimesteror
earlypuerperiuminwomenwhoalreadyhavethetriadofpreeclampticsymptoms:edema,proteinuria,and
hypertension.175Thediagnosisofeclampsiarequirestheexclusionofothermedicalorneurologicdisorders
underlyingthesymptomatology.Thedifferentialdiagnosticconsiderationsincludesinusorcerebralvein
thrombosis,subarachnoidhemorrhagefromananeurysm,infectiousorautoimmuneinflammatorydisorders,
andsicklecellcrisis.
CSFHypotension
Thisconditioncommonlyoccursfollowingalumbarpuncture,whichcanproduceleakageofCSFthrougha
duraltear.Alumbarpunctureisaroutineprocedureperformedforavarietyoffunctions:spinalanesthesia,
intrathecaladministrationofcytotoxicandantibioticdrugs,myelography,obtainingCSFsamples,andpressure
measurement.176TheleakofCSFresultsinCSFhypovolemiaanddownwardshiftingofthebrain,causing
pressureonthepainsensitiveduralsinusesthatisamplifiedintheuprightpostureandrelievedwith
recumbence.177TheclinicalmanifestationsofCSFhypotensionareaheadacheandbackache,whichusually
startwithinhourstoaweekfollowingthelumbarpuncture.Moreseriouscomplicationsmayinclude
labyrinthineandocularcranialnervedisturbances,meningitis,subduralhematomas,andfistulas.
TemporomandibularJointDysfunction
SeeChapter26.
PeriodontalDisease
Periodontaldiseasemaybeassociatedwithasmallincreasedriskofcoronaryheartdisease.178Clinically,
periodontitisstartsasanacuteinflammationoftheapicalperiodontalligamentandtheneighboringspongiosa,
accompaniedbywellknownimminentsymptomssuchaspain,tendernesstopercussion,andswelling.
Thyroiditis
Acutebacterialthyroiditis(orpyogenicthyroiditis)isarare,potentiallylifethreateningcomplicationof
bacterialinfectionelsewhereinthebody,especiallyfollowinganupperrespiratorytractinfection.179The
conditionoccursinallagegroups,althoughwomenwithpreexistingthyroiddiseaseconstitutethegroupmost
likelytodevelopthyroidinfection.Inchildhood,itisoftenlinkedtolocalanatomicdefects.Theampleblood
supplyandlymphaticdrainage,highiodinecontent,andprotectivethyroidcapsulecontributetothelow
incidenceofinfection.
CommonpathogensincludeStreptococcuspyogenes,Streptococcuspneumoniae,andStaphylococcus.Less
commonorganismsincludeSalmonella,Bacteroides,Haemophilusinfluenzae,Streptococcusviridans,andother
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streptococcalorganisms.179Clinicalsignsandsymptomsincludefever(92%),anteriorneckpain(100%),
tenderness(94%),warmth(70%),erythema(82%),dysphagia(91%),dysphonia(82%),andpharyngitis
(69%).179
FractureoftheFacialBonesorSkull
Theexaminationofthefaceforafracturerequiresknowledgenotonlyofnormalanatomybutalsoofcommon
fracturepatternsintheface.Computedtomography(CT)iscurrentlytheimagingprocedureofchoiceformost
facialfracturesbecauseithighlightsthecomplexanatomyandfracturesofthefacialbonesandtheirrelatedsoft
tissuecomplicationsextremelywell.Approximately,6070%ofallfacialfracturesinvolvetheorbit.180The
exceptiontothisisalocalnasalbonefractureorazygomaticarchfracture.Themostcommonmechanism
producingfacialfracturesisautoaccidents.Othermechanismsincludefightsorassaults,falls,sports,industrial
accidents,andgunshotwounds.Lessthan10%ofallfacialfracturesoccurinchildren,perhapsbecauseofthe
increasedresiliencyofachildsfacialskeleton.180Thenoseisthemostfrequentlyinjuredfacialstructure,and
themostcommonlymissedfacialfractureofthefaceisafractureofthenasalbone.Patientswithatemporal
bonefracturemaypresentwithaconductivehearinglosscausedbydislocationsintheossicularchain.Facial
nerveparalysismayalsooccursecondarytoeithertransectionoredemaofthefacialnerve.
Trochleitis181
Trochleitisisalocalinflammatoryprocessofthesuperiorobliquetendontrochleacharacterizedbyperiocular
pain.Eyemovementinsupraductiontypicallyaggravatesthepain.Physicalexaminationdemonstratesexquisite
pointtendernessoverthetrochleaofthesuperiorobliquemuscle.Thecauseoftenisunknown,buttrochleitis
canoccurinRA,SLE,psoriasis,orenteropathicarthropathy.Rarecausesincludesinusitis,trauma,and
metastasis.
CAUSESOFCERVICALPAIN
Thecausesofcervicalpainarenumerous,asoutlinedinTable58andFigure52.
TABLE58PotentialCausesofCervicalPain
Thyroiddisease
Subarachnoidhemorrhage
Retropharyngealabscess
Carotodynia
Cardiacdisease
Trauma
Myofascialpainsyndrome
Tumors
Temporomandibularjointdysfunction
Meningitis
Epiduralhematoma
Lymedisease
Cervicaldiskdiseaseorherniation
Vertebralarterydisorders
Torticollis
Rheumatoidarthritis
Ankylosingspondylitis
Gout
Osteoarthritis
Occipitalneuralgia
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FIGURE52
Potentialcausesofcervical,thoracic,lumbar,pelvic,andlowerextremitypain.
ThyroidDisease
Thethyroidglandsynthesizes,stores,andsecretesthyroidhormones,mainlylthyroxine(T4).ltriiodothyronine
(T3)isproducedfromT4bydeiodination,mainlyintheliver,kidney,andmuscle.Thethyroidglandcontrols
themetabolicrateofmanyorgansandtissues.Thethyroidglandcannotfunctionnormallyunlessitisexposed
tothyroidstimulatinghormone(TSH),whichisproducedbythethyrotrophsoftheanteriorpituitary.182Under
activity(hypothyroidism)andoveractivityofthyroidfunction(hyperthyroidism),whichrepresentthemost
commonendocrineproblems,havewidespreadmanifestations,includingcervicalpain,andoftenrequirelong
termtreatment.
Hypothyroidism
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Mostpatientswithhypothyroidismhaveadiseaseofthethyroidgland.Occasionally,hypothyroidismdevelops
inpatientswithnormalthyroidglandsbecauseofinadequatestimulationbyTSH.Suchindividualshave
disordersoftheanteriorpituitaryorhypothalamus.Thyroidhormonedeficiencyaffectspracticallyallbody
functions.Thecomplaintsandphysicalfindingsvarywidelyfrompatienttopatient,dependingontheseverity
ofthedeficiency.Patientsmaypresentwithweakness,fatigue,arthralgiasandmyalgias,musclecramps,cold
intolerance,constipation,lethargy,drynessoftheskin,headache,neckpain,menorrhagia,hoarseness,edema,
andweightgain.182Mostpatientshavevaryingdegreesofbrittlenailsandhair,pallor,delayedrelaxationtime
ofthemusclestretchreflexes,keratinicskincolor,thickeningofthetongue,mentalstatuschanges,anddiastolic
hypertension.182Insomepatients,severehypothermia,edema,andeveneffusionsintothepleura,and
peritonealandpericardialcavitiesmayoccur.182
Hyperthyroidism
HyperthyroidismdenotesclinicaldisordersassociatedwithincreasedserumconcentrationsofthefreeT4
estimateorfreeT3orboth.ThemostcommoncausesofhyperthyroidismareGravesdisease,nodulargoiter,
andthyroiditis.Excessivethyroidhormoneconcentrationsaffectmanybodyfunctions.Suchsymptoms
include:182
nervousness
restlessness
heatintolerance
increasedandinappropriateperspiration
fatigue
musclecramps
paratrachealneckpain
increasedfrequencyofbowelmovements
weightlossinassociationwithunchangedorincreasedfoodingestionand
palpitations.
Theclinicalsignsofhyperthyroidism,whichvarywidelyamongpatients,mayincludeexophthalmus,
tachycardia,finerestingtremors,moistwarmskin,heatradiationfromtheskin,hyperreflexia,onycholysis,an
enlargedthyroidglandwithorwithoutabruit,anddiplopia.182Patientswhoarefoundtohaverelatively
specificsymptomsandsigns(suchasgoiter,nodule,eyefindingsofGravesdisease,ortremor)shouldbe
referredtoanendocrinologistforconsiderationoftreatment.
SubarachnoidHemorrhage
SeethediscussionofintracranialbleedingunderCausesofHead,Face,Eye,andTemporomandibularJoint
Painearlierinthechapter.
RetropharyngealAbscess
Retropharyngealabscess(RPA)isarelativelyuncommoninfectionofthespaceanteriortotheprevertebrallayer
ofthedeepcervicalfascia.Thisinfectionismostcommoninchildrenyoungerthan3or4years,becauseofthe
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richconcentrationoflymphnodesinthisspace.183Theinfectioninchildrenclassicallyresultsfromthe
extensionoforopharyngealinfections,includingpharyngitis,tonsillitis,andadenitis.184Trauma,oftencaused
byafallwhileholdingapencilorstickinthemouth,anddentalinfectionsaretheusualunderlyingcausesof
RPAinolderchildrenandadults.184ThemajorcausativeorganismsareS.pyogenes,Staphylococcusaureus,
andoropharyngealanaerobicbacteria.185Theinfectionprogressesthroughthreestages:cellulitis,phlegmon
(diffuseinflammationofthesoftorconnectivetissue),andabscess.
RPAcanproduceposteriorneckandshoulderpainandstiffness.Thesesymptomsarealsoassociatedwith
hyperextensionoftheneck,torticollis,fever,irritability,muffledvoice,stertor,andothersignsofupperairway
obstruction.184Thepainoftenisworsenedwithswallowing.Swellingofthelateralorposterioraspectofthe
neckcanbepresent.
Thedifferentialdiagnosisincludesacuteepiglottitis,foreignbodyaspiration,vertebralosteomyelitis,hematoma
(particularlyinboyswithhemophilia),andlymphoma.184
Carotidynia
Inadditiontosinusanddentalabnormalitiesandstress,severaldifferentneurologicconditionscancausefacial
pain.Theseincludevariousneuralgias(trigeminal,vagoglossopharyngeal,andcranial),carotidynia(apainful
carotidartery),andopticneuritis.Paincharacteristicsandresultsofspecificneurologictestsestablishthe
diagnosis.Carotidyniaisassociatedwithneckpain,tenderness,andaunilateralheadache.
CardiacDisease
SeethediscussionofmyocardialinfarctionunderCausesofThoracicPainlater.
TraumaorWhiplash
SeeChapter25.
Tumors
Tumorsoftheadultcervicalspinemaybeprimary,arisingfromthebone,orsecondary(i.e.,metastaticfroma
distantprimarysite.)Tumorsofthecervicalcordmaycauseneckpain.Thesetumorsmaybeextramedullary,or
intramedullary.Apainofinsidiousonset,withorwithoutneurologicsignsandsymptoms(e.g.,progressiveleg
weakness,bladderparalysis,andsensoryloss),mayoccur.
TemporomandibularJointDysfunction
SeeChapter26.
Meningitis
SeethediscussionofCausesofHead,Face,Eye,andTemporomandibularJointSymptomsearlier.
EpiduralHematoma
Mostcervicalepiduralhematomasarespontaneous,withprecipitatingfactorsthatincludecoagulopathy,
vascularmalformation,neoplasm,andpregnancy.186Cervicalepiduralhematomacanalsobecausedbytrauma
althoughthisisuncommon.Traumaticcausesofspontaneousepiduralhematomaincludevertebraltrauma,
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epiduralsteroidinjection,lumbarpuncture,penetratinginjuries,birthtrauma,andspinalmanipulation.187
Excessivemovementofthecervicalspine,whichmayoccurwithacervicalmanipulation,caninjurethe
epiduralveins,eitherbydirecttraumaorbyasuddenincreaseinvenouspressure,resultinginacervical
epiduralhematoma.186,188Theclinicianmustthereforebeparticularlymindfuloftheriskfactorsforthe
complicationsofspinalmanualtherapy,suchasmisdiagnosis,unrecognizedneurologicmanifestations,
impropertechnique,presenceofcoagulationdisorderordiskherniation,andmanipulationofthecervical
spine.189
Presentingsignsandsymptomsvary.Theonsetofneckpainisoftenthefirstsymptom,butepiduralhematoma
hasbeendiagnosedinitsabsence.Compressionofthespinalcordcanalsoproducesensorydeficits,motor
deficits,andbowelorbladderincontinence.
LymeDisease
SeethediscussionofsystemicinfectionsunderCausesofHead,Face,Eye,andTemporomandibularJoint
Symptomsearlier.
CervicalDiskDiseaseorHerniation
SeeChapter25.
VertebralArteryDisorders
SeeChapter24.
Torticollis
Asmanyas80differentcausesoftorticollishavebeendocumentedintheliterature.190Torticollisisnota
specificdiagnosisbut,rather,asignofanunderlyingdisorderresultinginthecharacteristictiltingoftheheadto
oneside.Differentialdiagnosisoftorticollisrangesfrominnocuousabnormalitiesthatrequirenospecific
therapyforpotentiallylifethreateningtumorsoftheCNS.Theneuromuscularcausesoftorticollismaybe
classifiedascongenitaloracquired.Congenitalmusculartorticollisisthemostcommontypeoftorticollis.191
Severalcausesareimplicated,includingfetalpositioning,difficultlaboranddelivery,cervicalmuscle
abnormalities,Sprengeldeformity,andKlippelFeilsyndromeInadditiontotorticollis,patientswithKlippel
FeilsyndromehavetheclassicclinicaltriaddescribedbyKlippelandFeilin1912:short,broadnecksrestricted
movementandlowhairlines.192,193Therestrictedneckmobilityistheresultofthefusionofavariablenumber
ofcervicalvertebrae,sometimesreducingtheirnumber,andcervicalspinabifida.194Extraosseouschanges,
hemivertebra,vertebralbodyclefts,andthoracolumbarabnormalitiessometimesarealsoseen.195
Acquiredtorticollis,whichincludesspasmodictorticollis,isclinicallysimilarbuthasdifferentetiologies.196
Acquiredtorticollisinchildrenmayberelatedtotraumaorinfections,asinGriselsyndrome,whichoccursafter
head,neck,andpharyngealinfections.197Inthissyndrome,thesofttissueinflammationassociatedwith
pharyngitis,mastoiditis,ortonsillitisresultsintheaccumulationoffluidinthenearbycervicaljoints.198This
edemamaythenleadtosubluxationoftheatlantoaxialjoint.
Spasmodictorticollisistheinvoluntaryhyperkinesisofneckmusculature,causingturningoftheheadonthe
trunk,sometimeswithadditionalforwardflexion(anterocollis),backwardextension(retrocollis),orlateral
flexion(laterocollis)(seeChapter25).196Itisalsomarkedbyabnormalheadpostures.198The
sternocleidomastoidmuscleisinvolvedin75%ofcasesandthetrapeziusin50%.198Othermusclesthatmight
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becomeinvolvedincludetherectuscapitis,obliquusinferior,andspleniuscapitis.199Insomecases,thespasm
generalizestothemusclesoftheshoulder,girdle,trunk,orlimbs.200
Neckmovementscanvaryfromjerkytosmooth200,201andareaggravatedbystanding,walking,orstressful
situationsbut,usually,donotoccurwithsleep.247
Spontaneousremissions(partialorcomplete)havebeenreportedinupto60%ofpatientsinsomeseries201
othersnotefullremissionin16%,withsustainedremissionfor12monthsof612%.202,203
Varioustreatmentsfortorticollishavebeendescribed.Spenceretal.204describedasinglesubjectstudyusing
behavioraltherapiesthatconsistedofprogressiverelaxation,positivepractice,andvisualfeedback.Theirpatient
hadsignificantimprovementsinallareas,whichweremaintainedata2yearfollowupexamination.
AgrasandMarshall205usedmassednegativepractice(i.e.,repeatingthespasmodicpositioning),200400
repetitionsofthemovementdaily,whichachievedfullresolutionofsymptomsinoneoftwopatients.Results
persistedfor22months.
Anothersinglecasestudyusedpositivepractice(exercisingagainstthespasmodicmusclegroups)inabed
riddenwomanwhohadsymptomsofspasmodictorticollisfor8years.After3monthsofpositivepractice,she
wasabletoambulateunassistedhertherapeuticgainsweremaintainedata1yearfollowupexamination.204
Biofeedbackhasalsobeenusedsuccessfullyasaninterventionfortorticollis.206
RheumatoidArthritis
InvolvementofthecervicalspineiscommoninRA,AS,andjuvenilepolyarthritis.105Fiftypercentormoreof
patientswithRAhaveevidenceofneckinvolvement,especiallyattheatlantoaxialjoint.105Thesepatientsare
pronetoacervicalderangement,ofwhichananteriorsubluxationofC1onC2,duringheadflexion,isthemost
common.207Althoughmostpatientswithanteriorsubluxationhavenoneurologiccomplications,themore
advancedandunstablelesionsmayresultinmyelopathy.105
Patientscanalsoexperienceseverebonyerosionsofoneorbothofthelateralzygapophysealjoints.This
erosioncanresultinoccipitalpainwithcervicalrotationandarotationalheadtiltdeformityifthelesionis
unilateral.207
Thesymptomsofthesespondyloarthropathiestypicallyfallintotwocategories:
1.Painresultingfromtheinflammatoryprocess.RAofthecervicalspinemaycausegeneralizedachingof
theposteriorneckandshoulder,andoccipitalpain.Thispainisoftenworsewithneckflexion.
2.Derangementordeformity.Thisfindingresultsfromjointdamage,typicallywithaconcomitantriskto
thenearbyneuralstructures.Radicularsymptomsmaybepresentinoneorbothupperextremities.With
myelopathy,spasticweakness,hyperreflexia,andotherUMNsignsarepresent.Dependingonthelevelof
involvementofthecervicalspine,signsandsymptomsofvertebralarterycompromisemayalsobe
present(seeChapter24).
AScommonlyaffectstheC12segments,althoughthisisusuallyalatemanifestationofthediseaseprocess.
Followingankylosingofthesacroiliac,lumbar,andthoracicsegments,theatlantoaxialjointbecomespainful
initially,onlytobelesssymptomaticasthejointbeginstolosemotion.105
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NeurologicinjuryassociatedwithASisusuallytheresultofcervicalfractureofthesyndesmophytesand
resultingpseudoarticulation.105,208ASisdescribedfurtherunderCausesofThoracicPain.
Gout
Althoughtheoccurrenceofgoutintheneckisdistinctlyuncommon,themedicationsusedtotreatitcanhave
serioussideeffectsinthisregion.Thesecomplicationsincludeligamentlaxitywithresultantinstabilityandneck
pain.209
Osteoarthritis
DegenerativeOAofthesubaxialcervicalspineiscommoninelderlypatients210andistypicallycharacterized
byposteriorneck,shoulder,andarmpaininaspecificdermatomalpatternratherthanoccipitocervicalpain.211
Diffuseorfocaltriggerpointtendernessmaybepresentintheposteriorneckontheinvolvedside.
OAoftheatlantoaxialjointsmaybeoverlookedwhenthepatienthasoccipitocervicalpainassociatedwith
degenerativechangesinthesubaxialspine.
OccipitalNeuralgia
CAUSESOFTHORACICPAIN
Thoracicpainhasawidedifferentialdiagnosis(Fig.52).Painmayoriginatefromstructureswithinthethorax,
suchastheheart,lungs,oresophagus.However,musculoskeletalcausesofchestpainmustbeconsidered.
Musculoskeletalproblemsofthechestwallcanoccurintheribs,sternum,articulations,ormyofascialstructures
(seeChapter27).Thecauseisusuallyevidentinthecaseofdirecttrauma.
Systemicoriginsofmusculoskeletalpaininthethoracicspine(Table59)areusuallyaccompaniedby
constitutionalsymptomsaffectingthewholebodyandbyotherassociatedsymptomsthatthepatientmaynot
relatetothepainand,therefore,mayfailtomentiontotheclinician.Theseadditionalsymptomsshouldbe
discoveredduringthesubjectiveexaminationbythecarefulinterviewer.Whenthepatient(ortheexamination)
indicatesthepresenceofassociatedfever(ornightsweats),areferraltoaphysicianisindicated.
TABLE59SystemicCausesofThoracicPain
SystemicOrigin Location
Gallbladderdisease Midbackbetweenscapula
Acutecholecystitis Rightsubscapulararea
Pepticulcer:stomach 510ththoracicvertebraeorduodenalulcers
Pleuropulmonarydisorders
Basilarpneumonia Rightupperback
Empyema Scapula
Pleurisy Scapula
Spontaneous Ipsilateralscapula
pneumothorax Middlethoracicorlumbarspine
Pancreaticcarcinoma Costovertebralangle(posteriorly)
Acutepyelonephritis Midbackbetweenscapula
Esophagitis Midthoracicspine
Myocardialinfarction Rightupperback,midbackbetweenscapula,rightinterscapular,orsubscapular
Biliarycolic areas
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DatafromGoodmanCC,SnyderTE.DifferentialDiagnosisinPhysicalTherapy.Philadelphia,PA:WB
Saunders1990.
Thecloseproximityofthethoracicspinetothechestandrespiratoryorgansmayresultinacorrelationbetween
respiratorymovementsandincreasedthoracicsymptoms.Whenscreeningthepatientthroughthesubjective
history,theclinicianshouldrememberthatsymptomsofpleural,intercostalmuscular,costal,andduraloriginall
increaseoncoughingordeepinspirationthus,onlypainofacardiacoriginisruledoutwhensymptoms
increaseinassociationwithrespiratorymovements.
ThecausesofthoracicpainincludethoselistedinTable510.
TABLE510PotentialCausesofThoracicPain
Mediastinaltumors
Pancreaticcarcinoma
Gastrointestinaldisorders
Pleuropulmonaryconditions
Spontaneouspneumothorax
Myocardialinfarction
Herpeszoster
Acutediskherniation
Vertebralfracture
Ribfracture
Stressfracture
Intercostalneuralgia
Costochondritis
Osteoarthritis
Rheumatoidarthritis
Diffuseidiopathicskeletalhyperostosis
Manubriosternaldislocations
GastrointestinalConditions
Thesubjectivehistoryoftenprovidesseveralcluestoagastrointestinalcauseofchestpain.
ColorectalCancer
ColorectalcanceristhethirdmostcommoncancerinbothmenandwomenintheUnitedStates.Riskfactors
includeage,adietrichinfatandcholesterol,inflammatoryboweldisease(especiallyulcerativecolitis),and
geneticpredisposition.212Themostcommonmetastaticpresentationofcoloncancerisinthethoracicspineand
ribcage.3Theoverall5yearsurvivalratefromcoloncancerisapproximately60%,andnearly60,000people
dieofthediseaseeachyearintheUnitedStates.212The5yearsurvivalrateisdifferentforeachstagethe
stagingclassificationforcoloncancercanpredictprognosiswell.TheDukesclassificationwastraditionally
usedtopredictprognosisbuthassincebeenreplacedbytheTNMstaging(Table511):
TABLE511TNMStagingofCancer
RegionalLymphNode RemoteMetastasis
Stage PrimaryTumor(T)
(N) (M)
Stage0 Carcinomainsitu N0 M0
Tumormayinvadesubmucosa(T1)ormuscle
StageI N0 M0
(T2)
Tumorinvadesmuscle(T3)orperirectaltissues
StageII N0 M0
(T4)
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Stage RegionalLymphNode M0
RemoteMetastasis
Stage T14
IIIA PrimaryTumor(T) N1
(N) (M)
Stage
T14 N23 M0
IIIB
StageIV T14 N13 M1
Tumor(primary)
Node(regionallymph)
Metastasis(remote)
Anexcellentcorrelationexistsbetweenthestageandthe5yearsurvivalrateinpatientswithcoloncancer212:
ForstageIorDukesstageA,the5yearsurvivalratefollowingsurgicalresectionexceeds90%.
ForstageIIorDukesstageB,the5yearsurvivalrateis7085%followingresection,withorwithout
adjuvanttherapy.
ForstageIIIorDukesstageC,the5yearsurvivalrateis3060%followingresectionandadjuvant
chemotherapy.
ForstageIVorDukesstageD,the5yearsurvivalrateispoor(approximately5%).
Itisimportantforthephysicaltherapisttoassistotherhealthcareprofessionalsinstressingtheimportanceof
routinescreeningexaminationsforcolorectalcancer(sigmoidoscopyandcolonoscopy)forindividualswitha
familyhistoryofcoloncancer.3,andforthosepatientsover50yearsofage.Theinformationcollectedbya
physicaltherapistduringahistoryorphysicalexaminationthatcouldserveasredflagsforcoloncancerare:
1.agegreaterthan50years
2.historyofcoloncancerinanimmediatefamilymember
3.boweldisturbances(e.g.,rectalbleedingorblackstools)
4.unexplainedweightlossand
5.backorpelvicpainthatisunchangedbypositionsormovement.213
PepticUlcerDisease
Pepticulcerationofthestomachorduodenumisoftenaccompaniedbyabnormalitiesofthegastricmucosa,and
thekeytodeterminingthecauseofulcerdiseaseoftenliesinthehistologicdiagnosisoftheassociatedgastritis
orgastropathy.
Thetermsulcerdiseaseandpepticulcerareusedsynonymouslytorefertoerosionsorulcersofthestomachand
duodenum.
Ulcerdiseasewaslongassumedtobeidiopathic,causedbyacidhypersecretionorpsychologicstress,ora
combination.Helicobacterpyloriarenowwellrecognizedasamajorriskfactorforthedevelopmentofpeptic
ulcerdisease.214
Thepatientusuallydescribesatypicalhistoryofulcerscharacterizedbyperiodicsymptoms,reliefwithantacids,
andtherelationshipofpaintocertainfoodsandthetimingofmeals.Forexample,thepatientmayhaverelief
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frompainaftereatinginitially,butthepainthenreturnsandincreases12hoursaftereatingwhenthestomach
isemptied.Inthepediatricagegroup,abdominalpainisaverycommonreasonforseekingmedicaladvice.Itis
alsothemostcommonpresentingsymptomofpepticulcerdisease.However,pepticandothererosiveor
ulcerativegastritidesandgastropathiesofthestomachandduodenumarerelativelyuncommoninthisage
group.215
Thepainofapepticulceroccasionallyoccursonlyinthebackbetweenthe8thand10ththoracicvertebrae.
Duodenalulcersmayreferpainfromthefifththoracicvertebra,eitheratthemidlineorjustateithersideofthe
spine.Thislocalizationmayaccompanypenetrationthroughtheviscera(organs).Whenquestionedfurther,the
patientmayindicatethatbloodispresentinthefeces.
Thedifferentialdiagnosisofulcerdiseaseincludesesophagitis,gastritis,gastropathy,nonulcerdyspepsia,
gallbladderorliverdisease,pneumonia,andpancreatitisamongothers.215
CLINICALPEARL
Sparkesetal.216developedtwospecificclustersofquestionstobeusedinidentifyingpatientswithabdominal
painthatismusculoskeletalinorigin:
Cluster1
1.Doescoughing,sneezing,ortakingadeepbreathmakeyourpainfeelworse?(Yes)
2.Doactivitiessuchasbending,sitting,lifting,twisting,orturningoverinbedmakeyourpainfeelworse?
(Yes)
3.Hastherebeenanychangeinyourbowelhabitsincethestartofyoursymptoms?(No)
Cluster2
1.Doeseatingcertainfoodsmakeyourpainfeelworse?(No)
2.Hasyourweightchangedsinceyoursymptomsstarted?(No)
ApatientansweringyestoeitherofthefirsttwoandnotothethirdquestionofCluster1suggestsahigh
probabilitythatabdominalpainismusculoskeletalinorigin.
IfthepatientanswersnotobothquestionsinCluster2,inadditiontocorrespondingresponsestothequestions
inCluster1,thereisanevengreaterprobabilitythatabdominalpainismusculoskeletalinorigin.216
AcuteCholecystitis
Acutecholecystitisistheresultofcysticductobstructionbygallstonesorbiliarysludge.Inthiscondition,ductal
obstructionissoonfollowedbychemicalinflammationandasuperimposedinfectionofthegallbladder.Acute
cholecystitismayreferintense,sudden,paroxysmalpaintotherightscapula,midback,orrightshoulder.Pain
intensityoftenincreaseswithmovementorrespirations.Reboundtendernessandabdominalmuscleguarding
areoftenpresent.Alowgradefeveralsomaybepresent.Theremaybereportsofnauseaandvomiting.Finally,
mildjaundice,whichismoreapparentinfairskinnedpatients,maybeobservedinthoseexperiencingacute
cholecystitis.217Thisfindingisattributabletoedemaofthecommonbileduct,whichcausesbilirubintodiffuse
acrosstheinflamedgallbladdermucosa.217
BiliaryColic
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Biliarycolicisacommoninitialpresentationofgallstonedisease.Thepainofbiliarycolicisreferredtothe
rightposteriorupperquadrant,withpainintherightshoulder.Theremaybepainintheinterscapulararea,with
referredpaintotherightside.Occasionally,thepainbeneaththerightcostalmarginmaybeconfusedwiththe
shouldergirdlepainsecondarytointracostalnervecompression.Thepainisinitiallyintermittent.Painusually
recurs,buttheintervaltothenextattackofpainisquitevariable.
SevereEsophagitis
Gastroesophagealrefluxdiseaseisdefinedassymptomsormucosaldamage(esophagitis)resultingfromthe
exposureofthedistalesophagustorefluxedgastriccontents.Esophagealpainhasmanypatterns.Itisoften
describedasburning,sometimesasgripping,anditcanalsobepressing,boring,orstabbing.Itmaybe
associatedwithafoultaste,morningpain,worseningpainafterameal,andepigastrictenderness.Severe
esophagitismayreferpaintotheanteriorchest.Ittendstobefeltmainlyinthethroatorepigastrium.On
occasion,itcanradiatetotheneck,back,orupperarmsallofwhichmayequallyapplytocardiacpain.
PancreaticCarcinoma
Painisthemostfrequentsymptomofapancreaticcarcinoma.Itfirstmaybenotedasaparoxysmal(sudden,
recurrent,orintensifying)orsteady,dullpain,radiatingfromtheepigastriumtotheback.Thepainisusually
slowlyprogressive,isworseatnight,andisunrelatedtodigestiveactivities.Othersignsandsymptomsmay
includejaundice,anorexia,severeweightloss,andgastrointestinaldifficultiesunrelatedtomeals.Thediseaseis
predominantlyfoundinmen(3:1)andoccursinthesixthandseventhdecades.
MediastinalTumors
Mostspinaltumorsoccurinthefirsthalfoflife.Althoughprimarytumorsofthethoracicspinearerare,the
thoracicspineisthemostcommonsiteformetastases.Tumorsoccurinthethoracicspinebecauseofitslength
andproximitytothemediastinum.Thevascularizationofthevertebraeinthemidtolowerthoracicspineis
generallythroughawatershedeffectratherthanbydirectsegmentalarteries,whichleavestheregionsusceptible
toasecondarymetastaticinvasionfromlymphnodesinvolvedwithlymphoma,breast,orlungcancer.218,219
TumorsofT12L2(typically,multiplemyeloma)maycompresstheconusmedullariscontainingtheS35nerve
roots.Thismayleadtoanimpairmentoftheurinaryoranalsphincter,whichissometimesassociatedwith
saddleanesthesia.
MyocardialInfarction
Painofmyocardialorigin,resultingfromasuddenandcompleteocclusionofthecoronaryartery,frequently
radiatesovertheleftpectoralregion,leftshoulder,medialleftarm,rightupperextremity,epigastrium,andjaw
andcan,therefore,mimicmusculoskeletalpain.Thepaintypicallyhasacrushingorgrippingqualityoverthe
substernalregion.Anginapectorispain,whichisasymptomthatrepresentsanimbalancebetweenmyocardial
perfusionanddemand,maybeexertionalorvariant,makingitdifficultforthecliniciantorecognize.The
distributionofsymptomsforanginapectorisincludessubsternalandchestpressure,shoulderpain,andneckor
jawpain,whichworsenswithexertionandimproveswithrest.Thisconditionconstitutesamedicalemergency.
PleuropulmonaryConditions
Pneumothorax
Pneumothoraxisdefinedastheentryofairintothepleuralspacewithsecondarylungcollapse.220Thepleurais
athinserouslayerthatcoversthelungs(visceralpleura).Thepleuralspaceextendsfrom3cmabovethe
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midpointoftheclavicledowntothe12thriboverlyingthekidney.Threetypesofpneumothoraxmaycause
thoracicpain:spontaneous,iatrogenic,andtraumatic.
Spontaneouspneumothorax,incontrasttoiatrogenicandtraumaticpneumothorax,occurswithoutany
precipitatingevent.Primaryspontaneouspneumothorax,seeninotherwisehealthyindividuals,israrelylife
threatening.Secondaryspontaneouspneumothorax,seeninpatientswithunderlyinglungdisease,isamore
seriousconditionandisassociatedwithsubstantialmortality.
Severalfindingsintheexaminationoftherespiratoryandcardiovascularsystemsmayhelpestablishthe
diagnosisofpneumothorax.Patientswithpneumothoraxpresentwithpleuriticpainorbreathlessness.Thepain
islocalizedtothesideofthepneumothorax.Thispainmaybereferredtotheipsilateralscapulaorshoulder,
acrossthechest,orovertheabdomen.Pneumothoraxmayalsobeassociatedwithhemoptysis(bloodin
sputum),tachycardia(increasedheartrate),tachypnea(rapidrespirations),andcyanosis(bluelipsandskin
resultingfromlackofoxygen).12Thepatientmaybemostcomfortablesittinginanuprightposition.
Achestradiographisusuallysufficienttoconfirmthediagnosis.Interventioncanrangefromsimpleaspiration,
tubedrainage,andchemicalsclerosisofthepleuratothoracoscopyandthoracotomy.
PleuralEffusion
Pleuraleffusiondescribesfluid(transudativeorexudative)withinthepleuralspace.Pleuraleffusionusually
resultsfromanunderlyingdisease,suchasheartfailure,orfrommedicaldisordersleadingto
hypoalbuminemia.221Itmayalsobecausedbyinfection(bacterialormycobacterial),malignancy,collagen
vasculardisease,pancreatitis,orpulmonaryembolism.222
Pleuraleffusionsmaybeasymptomaticbut,iflarge,producebreathlessnessorpain,orboth.221Breathsounds
arereducedontheaffectedside,andthepercussionnoteisstonydull.221
Interventionusuallyinvolvesdrainageofthefluid.
AcuteDiskHerniation
Disklesionsaccountforahighpercentageofthecausesofanteriorandposteriorthoracicpainsyndromes(see
Chapter27).223Thoracicdiskherniationsdonothaveacharacteristicclinicalpresentation,andthe
symptomatologymaybeconfusedwithotherdiagnoses.Inareviewoftheliterature,covering280casesof
thoracicdiskherniation,224only23%hadsensorysymptoms,mostcommonlynumbness,paresthesias,or
dysesthesias.Athoracicdiskherniationcanproduceposterior,anterior,orradicular(bilateralorunilateral)pain,
whichcanbesosevereastomimicamyocardialinfarction.Allmovementsareseverelylimitedandextremely
painfulandmayreproduceradicularpain.
VertebralFracture
Ahighpercentageofspinalfracturesinvolvethethoracolumbarspine.Fracturesofthethoracolumbarspinecan
beclassifiedintofourgroupsaccordingtomechanism:
Flexioncompression(awedgeorcompressionfracture).Compressionfracturesarerelativelybenign
becausetheyinvolveonlytheanteriorcolumn,withvaryingdegreesofmiddleandposteriorcolumn
insult.Theyarethoughttooccurbecauseoftherelativestiffnessofthethoracicspinecomparedwiththe
greatermobilityoftheneighboringlumbarspine.225Thesefractures,whichmostcommonlyoccurinthe
midlowthoracicandmidlumbarspine,aretypicallystable,unlesssevere.Diagnosisisconfirmedwitha
lateralradiograph,whichdemonstratesanteriorwedging.Burstfracturesinvolveboththeanteriorandthe
middlecolumnsandalsomayinvolveligamentousorbonyinjuryoftheposteriorcolumn.Althoughthe
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mechanismforthistypeoffractureisthesameasforcompressionfractures,theaxialloadingisofa
greatermagnitudeandtypicallyiscombinedwithflexion.Consequently,theanteriorbodyundergoesa
burstingeffect,withretropulsionofpartoftheposteriorvertebralbodywall(middlecolumn)intothe
canal,decreasingthecanalsize.226
Axialcompression.Thistypeusuallyresultsinaburstfractureinvolvingthefailureofboththeanterior
andthemiddlecolumns.Bothcolumnsarecompressed,andtheresultisalossofheightofthevertebral
body.
Flexiondistraction.ThistyperesultsinaninjurycalledaChance(orseatbelt)fracture,involvingthe
failureoftheposteriorcolumnwithaninjurytotheligamentouscomponents,bonycomponents,orboth.
Rotationalfracturedislocation.Thistyperesultsfromacombinationofsideflexionandrotationwithor
withouttheinvolvementofaposterioranteriorlydirectedforce.Osteoporosiscausesfracturesofthe
vertebrae.
Osteoporoticfracturesaremostcommoninthemidtolowthoracicspineandresultfromtheinabilityofthe
vertebralbodytosustainthecompressionforcesinvolvedwitheverydayactivities.68Theprevalenceratefor
thesefracturesincreasessteadilywithage,rangingfrom20%for50yearoldwomento65%forolder
women.227Mostvertebralfracturesdonothaveahistoryofanidentifiabletrauma(sensitivity,0.30).40Many
patientsremainundiagnosedandpresentwithsymptomssuchasbackpainandincreasedkyphosis.Fractures
thatoccuratthelevelsofT110canhaveassociateddamagetothespinalcord,whereasfracturesatT1112can
manifestasmixedspinalcord,conusmedullaris,orspinalnerverootinjuries.228
RibFracture
Ribfracturesareverycommonintheblunttraumapopulation,withonereviewdemonstratingthat10%of
patientsadmittedtoalevel2traumacenterhadevidenceofribfractures.229However,thetrueincidenceofrib
fracturesisnotknown,becauseupto50%ofribfracturesmaybemissedonastandardchestxrayfilm.230The
primarysymptomofaribfractureisapainoninspiration,resultinginhypoventilation(seeChapter27).228On
physicalexamination,thereislocaltenderness,crepitation,and,onoccasion,apalpabledefect.
StressFractureoftheRib
Therearemorereportsofstressfracturesofthefirstribthananyothersinglerib.231Acontractionofthe
anteriorscalenemuscleproducesbendingforcesatthesubclaviansulcus,whichistheusualsiteofthe
fracture.232Thismechanismusuallyoccursinoverheadactivities,suchaspitching,basketball,tennis,or
weightlifting.233,234
Painoccursintheregionoftheshoulder,anteriorcervicaltriangle,orclavicularregion.234Thepainmayradiate
tothesternumorpectoralregion.Theonsetisusuallyinsidious,althoughitmaystartwithacutepain.Painmay
occurwithdeepbreathing.235
Tendernesstopalpationmaybepresentmedialtothesuperiorangleofthescapula,atthebaseoftheneck,
supraclaviculartriangle,ordeepintheaxilla.231Shouldermovementsmaybepainfulorrestricted.
Therecommendedtreatmentofafirstribstressfractureinvolvesimmobilizationoftheshouldergirdleonthe
affectedsidewithasling.231Painresolveswithin28weeksofimmobilization.234
Stressfracturesoftheotherribsmayalsooccur.Themostcommoncauseisachangeintechniqueortraining
load.Theexaminationmayreveallocaltendernesstopalpation.Ribspringingisusuallypositiveforpain.
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IntercostalNeuralgia
Neurogenicpainofthethoraxcanbetheresultofinfection,suchasvaricellazoster(shingles),mechanical
compressionofthenervebyadiskprotrusion,anosteophyte,aneuroma,afracture,oraconditioncalled
postherpeticneuralgia.Neuralgicpain,whichtypicallyhasaburningquality,isunchangedbyanalgesicsorrest.
EpidemicMyalgia
Epidemicmyalgia,alsoknownasepidemicpleurodyniaorBornholmdisease,ischaracterizedbytheabrupt
onsetofeitherchestorabdominalpain,usuallyaccompaniedbyfever,andwasfirstdescribedinthelate
1800s.236ThisacuteviralillnessiscausedmainlybyCoxsackieBvirus,butotherenterovirusesmaybe
implicated.231Themodeoftransmissionisviaasharedwatersource,237andthereisa35dayincubation
period.PeakincidenceisinthesoccerandAmericanfootballseasons,andoutbreaksinvolvingathleticteams
havebeenreported.237
Thepresentationusuallyfollowsanonspecificprodromalillness(earlysetofsymptoms),withsuddenonsetofa
sharplateralchestorabdominalpain.231Theintercostalandupperabdominalwallmusclesaremostcommonly
involved,withthepleurabeinginvolvedrarely.238Thepainisintermittentandexacerbatedbymovement,
coughing,anddeepinspiration,andistypicallyaccompaniedbyfeverandmalaise.231
Diagnosisismadebyisolationofthevirusfromthefeces,oronthroatswab,intheearlystagesofthedisease.
Theconditionisselflimitingandrarelyrequiresanyspecifictreatment.231Symptomsusuallyresolveaftera
fewdaysbutmayrecur.
Costochondritis
Costochondritisisacommonbutpoorlyunderstoodconditionthatmanifestsaschestwallpain.Itisusually
characterizedbypainandtendernessinthecostochondralorchondrosternaljointsintheabsenceofswelling.
Thesecondtofifthcostalcartilagesarethemostcommonlyaffected.238
Diagnosisisbasedonahistoryofchestpainwithassociatedanteriorchestwalltendernessthatislocalizedto
thecostochondraljunctionofoneormoreribs.Swelling,heat,anderythemausuallyareabsent.Thepainmay
beprovokedbycertainmovements,suchasadductionofthearmontheaffectedside,withaccompanying
rotationoftheheadtothesameside.231
Costochondritisisamostlybenign,selflimitingcondition.Symptomsusuallyresolvewithin1year.239
Osteoarthritis
OAofthethoracicspineaffectsthreesites:theintervertebraldisk,thezygapophysealjoints,andthe
articulationsoftheribwiththevertebralbodyandtransverseprocess.223
OsteoarthriticchangesinthezygapophysealandcostovertebraljointsoccurmostcommonlyatT11andL1,
whichcoincideswiththosejointswhoseorientationismoresagittal,andtheareathatsustainsthepeak
incidenceoftraumaticfracturesinthethoracicspine.225,240OAofthecostovertebralandcostotransversejoints
isafrequentsourceofchronicpainbutisnottypicallyassociatedwithneurologicchanges.223Thisconditionis
associatedwithlocalpainandtendernessatthesiteofdegeneration.Ribjointpaintypicallyisexacerbatedby
exaggeratedrespiratorymovements.241
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Spondylosis,diskdegeneration,andSchmorlnodes(seeChapter27)aremostfrequentlyencounteredwithinthe
T1012vertebrae,240probablyasaresultofreducedresistancetotorsioninthisarea.190
TherelationshipbetweenzygapophysealjointorientationandOAsuggeststhatrepeatedtorsionaltraumamight
wellhaveasignificantroleinthedevelopmentofOAinzygapophysealjointsthataresagittallyoriented.240
RheumatoidArthritis
ThoracicpainrelatedtoRAisassociatedwithpainandstiffnessthatisgreatestinthemorningandusually
improveswithmovement.223,242Inspectionusuallyshowsaflatthoracolumbarspine,andagrosslimitationof
sideflexioninbothdirectionsisdemonstrated.
SeesectionAnkylosingSpondylitisearlierinthechapter.
DiffuseIdiopathicSkeletalHyperostosis
Diffuseidiopathicskeletalhyperostosis,orForestierdisease,isametabolicdiseasethattypicallyaffectsmen
olderthan40yearsanddoesnotusuallyresultinseveredisability.243Thediseaseischaracterizedbyan
ossificationoftheanteriorlongitudinalligamentsandallrelated,anatomicallysimilarligaments,223without
markeddiskdisease,whichresultsinoverallstiffnessofthespine,particularlyinthemorning,andpalpable
tenderness.
ManubriosternalDislocations
Traumaticdisruptionofthemanubriosternaljointmostoftenoccursviaoneoftwomechanisms.244,245Thefirst
andmostcommonmechanismresultsfromadirectcompressioninjurytotheanteriorchest.Thedirectionof
appliedforcedisplacesthefragmentposteriorlyanddownward.Thesecondtypeofmechanismfollows
hyperflexionwithcompressioninjurytotheupperthorax.Theforceistransmittedtothesternumthroughthe
clavicles,chin,oruppertworibs.
CAUSESOFLUMBARPAIN
Lumbarpainismostcommonlycausedbymechanicaldysfunction,whichcanbedefinedassymptomsthatare
relatedtothemusculoskeletalsystemandvarywithmovement.However,seriousnonmechanicalspinal
disorders(e.g.,neoplasm,infection,inflammatoryarthritis,fracture)orvisceraldisease(e.g.,gastrointestinal,
genitourinary,vascular)maybethecauseofLBPinasmallpercentageofpatients(Fig.52andTable512).246
TABLE512PotentialCausesofLumbarPain
Renaldysfunction
Colorectalcancer
Epiduralabscessandepiduralhematoma
Sacroiliitis
Metastasis
Maignesyndrome
Aorticoriliacaneurysm
Prostatitis
Pleuraldysfunction
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Ankylosingspondylitis
Stiffpersonsyndrome
RenalOrigin
Thepainofrenaloriginisassociatedwithpelvic,flank,orLBP.
AcutePyelonephritis
SeethediscussionofpyelonephritisunderCausesofHead,Face,Eye,andTemporomandibularJoint
Symptomsearlier.
RenalCorticalAbscess
Renalabscesshasbeendescribedasanelusivediagnosisinpatientswithvariablesymptomsofinsidiousonset.
Thisconditioncancauseflankpain,chills,andfeverandmaybeassociatedwithahistoryofrecentinfection.
Urologicmanagementofrenalabscessesincludessurgicalexploration,percutaneousdrainage,intravenous
antibiotictherapy,ornephrectomy.247,248
AcuteGlomerulonephritis
Thisconditionoccasionallycanmanifestwithbilateralflankpain,costovertebralangletenderness,andfever.
Malaise,fatigue,anorexia,andnauseafrequentlyaccompanythiscondition.
UreteralColic
Ureteralcoliccausesconstantseverepainintherightlowerabdomen.Thepainiscausedbythepassageofa
calculus(kidneystone),bloodclot,ortissuefragmentinthelowerhalfoftheureter.Thepain,whichmaybe
intermittent,radiatesdownthecourseoftheureterintotheurethraorgroinarea.Accompanyingsignsand
symptomsincludenausea,vomiting,sweating,andtachycardia.
Kidneystonesareassociatedwithconditionsofhypercalcemia(excesscalciumintheblood)suchas
hyperparathyroidism,metastaticcarcinoma,multiplemyeloma,senileosteoporosis,specificrenaltubular
disease,hyperthyroidism,andCushingdisease.12Otherconditionsassociatedwithcalculusformationare
infection,urinarystasis,dehydration,andexcessiveingestionorabsorptionofcalcium.12
UrinaryTractInfection
Aurinarytractinfection(UTI)affectingthelowerurinarytractisrelateddirectlytoanirritationofthebladder
andtheurethra.Theintensityofsymptomsdependsontheseverityoftheinfection,and,althoughLBPmaybe
thepatientschiefcomplaint,furtherquestioningusuallyelicitsadditionalurologicsymptoms,suchasurinary
frequency,urinaryurgency,orhematuria.ThediagnosisofUTIisbasedonsymptomsandthepresenceof
pathogensandwhitebloodcellsintheurine.
EpiduralAbscess
Mostspinalepiduralabscessesorinfectionsarethoughttoresultfromthespreadofbacteria,usuallyfroma
cutaneousormucosalsource.Infectioninthespinalepiduralspaceisanuncommonbutpotentiallyfatal
conditionthatoftenconstitutesasurgicalemergency.Theinfectiousagentmayentertheepiduralspaceby
severalroutes:249
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Insertionofanepiduralneedleandcatheter
Migrationalongtheoutsideofacatheter
Localspreadthroughsofttissueandbone
Hematogenousspread
Injectionorinfusionofcontaminatedfluid
Earlydiagnosisisessentialforsuccessfultreatment.250Thediagnosisofaspinalabscesscanbedifficult
becauseofitsrarityandtheinsidiouspresentation.Thesignsandsymptomsmaydevelopslowlyoverdaysto
severalweeks.Feverisnotalwayspresent.251Localizedbackpainorradicularpainisfrequentlythefirstsign
ofepiduralinfection.251,252Thisinitialfindingisfollowedbyprogressiveradicularandcordcompression
signs.251,252Painisthemostconsistentsymptomandoccursinvirtuallyallpatientsatsometimeduringtheir
illness.250
Interventiondependsonthecauseandrangesfromantibiotictherapytosurgery.
Prostatitis
Prostatitisisaninflammationoftheprostategland.Thecauseoftheinflammationisusuallyinfection,which
canbebacterialornonbacterial.Inacutebacterialprostatitis,patientscomplainofasuddenonsetoffever,
chills,andlowbackorperinealpain.Typically,dysuria,frequency,orhesitancyispresent.Patientswithchronic
bacterialprostatitismayhavenosystemicsymptomsthatis,theymaynothavefeverorchills,although
complaintsofperinealorLBPusuallyarepresent.Patientswithnonbacterialprostatitishaveavariable
presentationandlacksystemicsymptoms.Thesepatientshavemildpainandmayhavevoidingsymptoms.
Differentialdiagnosisincludesprostatodynia,cystitis,urethritis,andbenignprostatichypertrophy.
PleuralDysfunction
Althoughusuallyassociatedwiththoracicpain,pleuriticpaincanproducerightlowerabdomenpain.Thecause
isusuallypneumoniaorpulmonaryembolism.Thesymptomsaccompanyingpneumoniaincludefever,
coughing,rales,wheezes,chills,andpurulentsputum.Pulmonaryembolismisusuallyassociatedwithdyspnea,
fever,cough,rales,andwheezes.Highriskpatientsforpulmonaryembolismincludethosewithrecent:
trauma
surgery
pregnancy
heartfailure
malignancy
previousembolism
prolongedtravelinautomobileorairplaneand
prolongedimmobilization.
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AbdominalAorticAneurysm
Theanatomyoftheaortaissegmentallydescribedinthreesections:ascendingaorta,aorticarch,anddescending
aorta.Theportionoftheaortaabovethediaphragmisdesignatedasthoracic,andtheabdominalaortaisthat
portionbelowthediaphragm.Theabdominalaortagivesrisetolumbarandmusculophrenicarteries,renaland
middlesuprarenalarteries,andvisceralarteries.
Theaortaconsistsofthreelayers:adventitia(theoutermost),media,andintima.Anacuteaorticdissectionis
causedbyatransversedisruptionintheintimaandmedia.253Thisdisruptionresultsintheformationofa
hematomawithinthemedia.Aorticaneurysmscanbedescribedaseitherfusiform(circumferentialdilatation)or
saccular(balloonlike).254
Theunderlyingcausesofaorticdiseasearenotfullyunderstoodandarethereforeassociatedwithmanyfactors,
includingatherosclerosis,hypertension,medialdegenerationandaging,aortitis,congenitalabnormalities,
trauma,smoking,cellularenzymedysfunction,andhyperlipidemia.253Majorriskfactorsincludehypertension,
andagegreaterthan60years,malesex,pasthistoryofsmoking,atherosclerosis,coronaryarterydisease,family
historyofAAA,anduseofstatins.246FactorsthatarenegativelyassociatedwithAAAincludefemalesex,
blackrace,anddiabetes.246
Acuteaorticdissectionischaracterizedbytheonsetofintensepain,describedassharp,tearing,orstabbing.The
painoccursinthechestandspreadstowardthebackandintotheabdomenandisunaffectedbyposition.
However,duringthephysicalexamination,overpressureintohipflexionmayreproducesymptoms.246In
addition,duringabdominalpalpation,averystrong,nontenderabdominalpulsationmaybedetected.246Distal
pulsesfrequentlyaredecreasedorabsent.Byconvention,aninfrarenalaortathatis3cmindiameterorlargeris
consideredaneurysmal.255Thediameteroftheinfrarenalaortaisthestrongestknownpredictorofriskfor
rupture.246Thisisapotentiallylifethreateningcondition,requiringimmediatetransportofthepatienttoan
emergencydepartment.Thepatientisadmittedtotheintensivecareunitforfurtherevaluationandto
temporarilymanagethecrisiswithantihypertensivemedications.253
Metastasis
Malignantneoplasm(primaryormetastatic)isthemostcommonsystemicdiseaseaffectingthespine,although
itaccountsforlessthan1%ofepisodesofLBP.40Metastaticlesionsaffectingthelumbarspineoccurmost
commonlyfromtheovary,breast,kidney,thyroid,lung,orprostategland.AccordingtoastudybyDeyoand
Diehl256thatreviewed1,975consecutivepatientsseekingmedicalcareforLBP,thefourclinicalfindingswith
thehighestpositivelikelihoodratiosfordetectingthepresenceofcancerresultinginLBPwereaprevious
historyofcancer,failuretoimprovewithconservativemedicaltreatmentduringthepastmonth,anageofat
least50yearsorolder,andunexplainedweightlossofmorethan4.5kg(10lb)in6months.256Theabsenceof
allfourofthesefindingsconfidentlyrulesoutmalignancy.256,257
Spondylolisthesis
Thetermspondylolisthesisreferstoananteriorslippageandinabilitytoresistshearforcesofavertebral
segmentinrelationtothevertebralsegmentimmediatelybelowit,whichusuallyoccursinthelumbarspinedue
toadefectinthepars.ThemostcommonsiteforspondylolysisandspondylolisthesisisL5S1(seeChapter28).
DifferentialdiagnosisincludescoexistingOAofthehip,myelopathy,spinaltumors,andinfections.
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SeesectionAnkylosingSpondylitisearlierinthechapter.
StiffPersonSyndrome
Stiffpersonsyndrome(SPS),alsoknownasMoerschWoltmannsyndrome,orstiffmansyndromeisarare,
disablingneurologicaldisordercharacterizedbyrigidityandfluctuatingmusclespasms,whichisoften
underdiagnosedbecauseofalackofawarenessofitsclinicalmanifestations.Theconditionprimarilyimpacts
theactualmusculatureandlowerextremities,althoughvariantsofthesyndromemayinvolveonelimbonly
(stifflegsyndrome)oravarietyofadditionalneurologicalsymptomsandsignssuchaseyemovement
disturbances,ataxia,orBabinskisigns(progressiveencephalomyelitiswithrigidityandmyoclonus)orbe
associatedwithmalignantdisease(paraneoplasticSPS).258TheetiologyofSPSisunknown,butan
autoimmunemediatedchronicencephalomyelitis(elevatedlevelsofantibodiestoglutamicaciddecarboxylase
[GAD])issuggestedduetoitsfrequentassociationwithotherautoimmunedisorderssuchastype1diabetesor
thyroiditis.PatientswithSPShavetoolittlegammaaminobutyricacid(GABA),whichisaninhibitory
neurotransmitterinvolvedinskeletalmusclecontractiontogetherwithitsantagonistnorepinephrine(see
Chapter9).ThelackofGABAresultsindisproportionatelyhighlevelsofnorepinephrineandincreasingpulses
toLMNs,whichinturnresultincontinuouscontractionofantagonistmusculature.259
SPS,whichaffectsbothsexesequally,hasaninsidiousonset,usuallyinthefourthorfifthdecades,withaslow
progressionovermonthsoryears,followedbylonglastingstabilization.SPSischaracterizedbyfluctuating
symmetricalmusclerigidityandbackpainwithsuperimposedpainfulepisodicspasmsoftheaxialandproximal
limbmuscles.260
ThemusclerigidityassociatedwithSPScanleadtocontractures,posturalabnormalities,and
simultaneouscontractionofthethoracolumbarparaspinalandabdominalwallmusclescauseslumbar
hyperlordosis.
Theepisodicspasms,whichareoftenprovokedbynoise,touch,emotionalupset,orsuddenmovement,
maymanifestasanexcessivestartlereaction.Thesespasmscanbeviolentenoughtocauseexcruciating
painand,inrarecases,generateforcescapableoffracturinglongbones.PatientswithSPSmayexhibit
excessivefearandavoidanceofcircumscribedsituationsthatareassumedbypatientstobedifficultto
masterbecauseofanincreaseinstiffness,andparoxysmalspasms.261Suchsituationsincludecrossinga
street,climbingdownstairswithoutbanisters,orwalkingunaided.Thegaitisoftenwidebased,deliberate,
andslow.Therigidityandspasmsgraduallyimpairvoluntarymovementsandposturalreflexes,resulting
inslow,restrictedmovementsandanincreasedriskoffalls.Patientsmaybeincapacitatedbythephobia
tothesamedegreeasthemotorsymptomsthemselves.Ithasbeensuggestedthatthepresenceofthis
particularanxietyisoneofthereasonsforthefrequentmisdiagnosisofpsychogenicmovementdisorderin
thesepatients.261
Intellectisnotaffected,andmotorandsensorynerveexaminationisalsonormal.However,almostallpatients
haveanabnormalelectromyographic(EMG)pattern,whichshowscontinuousmotorunitactivityinaffected
muscles.StiffnessandspasmsresemblingSPSmayoccurasdominantsymptomsinavarietyofrecognized
neurologicaldiseasessuchasMS,brainstemorspinalcordtumors,andparaneoplasticorcirculatorydiseasesof
thespinalcord.258
ThemainstaysoftreatmentforSPSaredrugsthatenhanceGABAmediatedcentralinhibition(diazepam,
baclofen,sodiumvalproate,andvigabatrin).Physicaltherapycanincludegentlelumbarflexionexercisestohelp
reducelumbarhyperlordosis,stretchingoftheAchillesandhamstringtendonstopreventcontractures,
antispasticmeasures,andisometricabdominalexercisestohelpmobilizethetrunk.262264SPSshouldbe
consideredinallpatientswithunexplainedbackpain,stiffness,andmusclespasms,asearlyrecognitionand
therapeuticinterventioncansignificantlydecreasemorbidityandimprovethequalityoflife.
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CAUSESOFBUTTOCKANDUPPERANDLOWERLEGPAIN
ThecausesforbuttockandupperandlowerlegpainincludethoselistedinFigure52andTable513.
TABLE513PotentialCausesofButtockandUpperandLowerLegPain
Femoralnerveneuropathy
Lumbardiskherniation
Piriformissyndrome
Intermittentclaudication
Sacralplexopathy
Conusmedullarissyndrome
Trochantericbursitis
Meralgiaparesthetica
Iliofemoralthrombophlebitis
Sacroiliitis
Mononeuritismultiplex
Ischialapophysisandavulsion
Glutealcompartmentsyndrome
Genitalherpes
Vasculardisorders
LumbarDiskHerniation
SeeChapter28.
FemoralNerveNeuropathy
Femoralneuropathyhasbeendescribedasacomplicationofcompressionresultingfrom:265
hematoma
hemophilia
leukemia
hysterectomyandpelvicsurgery
lithotomyposition
blunttrauma
iliacarteryaneurysm
inguinalherniorrhaphy
malignancyandradiationtherapy
EpsteinBarrvirusinfectionand
diabetesmellitus.
Typicalsignsoffemoralneuropathyareaweaknessofipsilateralhipflexion,kneeextension,andparesthesias
oftheanteromedialthigh.Symptomsmayvarywithbothdegreeandlocationoftheinjury.Themoredistal
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injuriesmayhaveeithersensoryormotorsymptomswhereastheproximalinjuriestendtohaveboth.A
decreasedorabsentkneejerkisusuallypresent.Thedifferentialdiagnosesofupperlumbarnerveroot
symptomsincludespondylolisthesis,diskprolapse,oraninfectivecausesuchasdiskitisoranepiduralabscess.
PiriformisSyndrome
Thepiriformissyndrome,afairlycommonbutoftenundiagnosedcauseofbuttockandlegpain,hasbeen
describedasananatomicabnormalityofthepiriformismuscleandthesciaticnerve,whichcanresultin
irritationofthesciaticnervebythepiriformismusclecausingbuttockandhamstringpain.Piriformissyndrome
mayalsobedescribedasasensationinwhichthehamstringmusclesfeeltightorareabouttotear.266
Multipleetiologieshavebeenproposedtoexplainthecompressionorirritationofthesciaticnervethatoccurs
withthepiriformissyndrome:267
Hypertrophyofthepiriformismuscle.268,269Ithasbeenreportedthatthesciaticnervecoursesdirectly
throughthismusclein14%ofthepopulation.270,271
Overuseofthepiriformismuscle.Althoughthereisdisagreement,overuseseemstobethemostcommon
causeofpiriformissyndrome.272Thissuggeststhatpatientsmustbeeffectivelycautionedaboutreturning
tooquicklytothetypeofactivitythatboughtaboutthepiriformissyndromeoncerecovered.
Trauma.273275Trauma,directorindirect,tothesacroiliacorglutealregioncanleadtopiriformis
syndromeandisaresultofhematomaformationandsubsequentscarringbetweenthesciaticnerveand
theshortexternalrotators.
Hipflexioncontracture.Aflexioncontractureatthehiphasbeenassociatedwithpiriformissyndrome.
Thisflexioncontractureincreasesthelumbarlordosis,whichincreasesthetensioninthepelvicfemoral
muscles,asthesemusclestrytostabilizethepelvisandspineinthenewposition.Thisincreasedtension
causestheinvolvedmusclestohypertrophywithnocorrespondingincreaseinthesizeofthebony
foramina,resultinginneurologicalsignsofsciaticcompression.276
Gender.Femalesaremorecommonlyaffectedbypiriformissyndrome,withasmuchasa6:1femaleto
maleincidence.275,277280
Ischialbursitis.
Pseudoaneurysmoftheinferiorglutealartery.273
Excessiveexercisetothehamstringmuscles.281
Inflammationandspasmofthepiriformismuscle.282Thisisofteninassociationwithtrauma,268,283
infection,andanatomicalvariationsofthemuscle.276,284,285
Anatomicalanomalies.In1938,anomaliesofthepiriformismuscle,withasubsequentalterationinthe
relationshipbetweenthepiriformismuscleandthesciaticnerve,wereimplicatedinsciatica.284Local
anatomicalanomaliesmaycontributetothelikelihoodthatsymptomswilldevelop.Patientswiththis
conditionreportradicularpainthatismuchlikethenerverootpainassociatedwithlumbardiskdisease
withthemovementofthehip.286Thesepatientstypicallypresentwithahistoryofglutealtrauma,
symptomsofpaininthebuttockandintolerancetositting,tendernesstopalpationofthegreatersciatic
notch,andpainwithflexion,adduction,andinternalrotationofthehip.
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Asearlyas1937,twofindingsonphysicalexaminationwereattributedtosciaticpain,withthepiriformisasthe
cause287:
1.Positivestraightlegraise(paininthevicinityofthegreatersciaticnotchontheextensionoftheknee,
withthehipflexedto90degreesandtendernesstopalpationofthegreatersciaticnotch).
2.Freibergsign(painwiththepassiveinternalrotationofthehip,whichplacestensiononthepiriformis
muscle).
Robinson283hasbeencreditedwithintroducingthetermpiriformissyndromeandoutliningitssixclassic
findings:
1.Ahistoryoftraumatothesacroiliacandglutealregions.
2.Painintheregionofthesacroiliacjoint,greatersciaticnotch,andpiriformismusclethatusuallycauses
difficultywithwalking.
3.Acuteexacerbationofpaincausedbystoopingorlifting(andmoderatereliefofpainbytractiononthe
affectedextremitywiththepatientinthesupineposition).
4.Apalpablesausageshapedmass,tendertopalpation,overthepiriformismuscleontheaffectedside.
5.Apositivestraightlegraise.
6.Glutealatrophy,dependingonthedurationofthecondition.
Otherclinicalsignshavesincebeenintroduced.PaceandNagle275describedadiagnosticmaneuverthatisnow
referredtoasthePacesign:painandweaknessinassociationwithresistedabductionandexternalrotationofthe
involvedthigh.
Localmusclespasmusuallyispalpableintheobturatorinternusor,lesscommonly,inthepiriformismuscle.
Theneurologicexaminationisusuallynormal,althoughtheremaybeneurologicsymptomsintheposterior
lowerlimbifthefibularis(peroneal)componentofthesciaticnerveisinvolved.266Anexaminationofthehip
andlowerlegusuallydemonstratesrestrictedhipadductionandinternalrotationofthehip,andlumbosacral
muscletightness.266TheFABER(flexion,abduction,externalrotation)testmaybepositive(seeChapter29).
Typically,piriformissyndromeisadiagnosisofexclusion.
Conservativeinterventionforthisconditionincludesgentle,painfreestaticstretchingofthepiriformismuscle,
straincounterstraintechniques,softtissuetherapies(longitudinalglidingcombinedwithpassiveinternalhip
rotation,aswellastransverseglidingandsustainedlongitudinalrelease,withthepatientlyingononeside),ice
massagetotheglutealregion,andsprayandstretchtechniques.288,289Localcorticosteroidsorbotoxinjections
maybeusefulinmoreacutecases.290Botulinumneurotoxins,injectedintothemyoneuraljunctionsof
intrafusalmusclefibers,havebeensuccessfullyusedinclinicalpracticetoreducethestrengthofidiopathic
muscularspasmandmuscletightnesscausedbyoveruse,trauma,oroccupationinthepiriformismuscle.291293
Onestudyshowedthatthisformofinjectionfollowedbyphysicaltherapysignificantlyshortensrecoverytime,
therebyreducingboththepatientspainandtreatmenttime.293
SacralPlexopathy
Thesciaticnerveisthemostfrequentlyinjuredlowerextremitynerve.Sciaticnervecompressionhasbeen
reportedsecondarytopiriformisentrapment,heterotopicossificationaroundthehip,294arupturedaneurysm,
retroperitonealbleeding,pelvicfracture,dislocationorfractureofthehip,tumor,misplacedintramuscular
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injections,myofascialbandsinthedistalthigh,295andmyositisossificansofthebicepsfemorismuscle.296
Additionalcausesincludeposttraumaticoranticoagulantinducedextraneuralhematomas297andcompartment
syndromeoftheposteriorthigh.298Entrapmentsciaticneuropathycomplicatingtotalhiparthroplastyhasbeen
describedsecondarytoescapedcement,subfascialhematoma,andnerveimpingementduringtrochanteric
wiring.299
Intheusualsituation,thepatientcomplainsofanimmediateonsetofpainfulparesthesia,radiatingdownthe
posteriorandposterolateralthighandcalf,andintothefoot.DifferentialdiagnosisalsoincludesanL5S1
radiculopathycausedbyaherniateddiskorzygapophysealjointdiseasewithlateralrecessorforamenstenosis.
IntermittentClaudication
Thebloodsupplyofthelumbarandsacralplexusesusuallyderivesfrombranchesoftheinternaliliacartery
(iliolumbarartery,superiorandinferiorglutealartery,andlateralsacralartery)andthedeepiliaccircumflex
artery.300Acuteischemicimpairmentsofthelumbosacralplexusarecausedbyhighgradestenosisand
occlusionoftheiliacarteriesorofthedistalabdominalaorta.
Themostfrequentcauseofsuchacuteischemicimpairmentsofthelumbosacralplexusisduringsurgeryofthe
aorticbifurcationandthepelvicarteries,orradiationtherapy.301Finally,intraarterialinjectionsintotheiliac
arteriesorglutealarteriesmayresultinpersistentischemicplexopathy.302
Reducedperfusionoftheareaoftheinternaliliacarterycanresultinatemporaryischemicimpairmentofthe
lumbosacralplexus.Thisimpairmentoccursonlyduringmuscularactivityofthelegs.Inthiscondition,thepain
ismostlylocalizedtothepelvisandisfollowedbyparesthesia,adiminishingofthemusclestretchreflexes,
withpossiblemotorweakness.Thisspecialtypeofintermittentclaudicationisusuallyassociatedwithstenosis
ofthepelvicarteries,includingtheinternaliliacarteries.302
Thediagnosisisconfirmedbychangesinthelumbarmotorevokedpotentialsafterexertion.Thesechanges
excludethediagnosisofischemiaofthelowerspinalcordorconusmedullaris.
Peripheralnerveshaveahightolerancetoischemiabecauseofcollateralcirculation.303However,duringleg
activity,themusclessuppliedbybranchesoftheexternaliliacarteriesexperienceastealphenomenonthat
privilegesthelegmusclesoverthepelvicorgans.302
Althoughtheneurologicexaminationoftheinactivepatientusuallydisclosesnoabnormality,theclinical
diagnosisofthistypeofintermittentclaudicationcausedbyexerciseinducedischemiaofthelumbosacral
plexusisbasedmainlyontwospecificfeatures:302
1.Thesymptomsappearincorrelationwiththedegreeofmuscleactivity.Inearlystagesofthedisease,
complaintsonlyoccurduringwalkinguphillorridingabicycle.Thisallowsadistinctionfromthe
intermittentclaudicationcausedbyspinalstenosis.Inthelatter,symptomspredominantlyappearduring
walkingdownhill.Inaddition,patientswithspinalstenosiscanrideabicycleforalongdistancewithout
complaints(seethebicycletestofvanGeldereninChapter11).
2.Inadditiontopain,progressivesensorimotordeficitsintheareaofthelumbosacralplexusoccurduring
exertion.Thiscannotbeseeninpatientswiththeperipheralarterialocclusivedisease.
ConusMedullarisSyndrome
Conusmedullarissyndromeresultsfromaninjurytothespinalcord.Theinjurycanbecausedbytrauma,such
asboneorbulletfragments.Itmayalsoresultfromcystformation,aorticsurgery,andvasculardisease.
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Thesymptomsincludeseverelowbackandbuttockpain,lowerlimbweakness,andsaddlehyperesthesiaor
anesthesia.Bowelandbladderchangesarealsofrequentlyreported.
MeralgiaParesthetica
ThetermmeralgiaparestheticacomesfromtheGreekwordsmeros(thigh)andalgos(pain).Meralgia
parestheticaisasyndromeofpainand/ordysesthesiacausedbyentrapmentorneurinomaformationofthe
lateralcutaneous(femoral)nerve(LCN)ofthethigh(seeChapter3).304306ItisalsoknownasBernhardtRoth
syndrome.AlthoughmorecommonlyinvolvingtheLCN,meralgiaparestheticacanalsooccurtoothernerves
thattraversethehip,suchastheilioinguinal,genitofemoral,obturator,andanteriorcutaneousnervesofthe
thigh.289
TheLCNisprimarilyasensorynervebutalsoincludesefferentsympatheticfiberscarryingvasomotor,
pilomotor,andsudomotorimpulses.307Itisquitevariableandmaybederivedfromseveraldifferent
combinationsoflumbarnerves,includingL2andL3,L1andL2,L2alone,andL3alone.308TheLCNmaybe
associatedwiththefemoralnerveasitpassesthroughtheinguinalligament,oritmayanastomosewiththe
femoralnervedistaltotheinguinalligament.306
Thecompressionofthenerve,whichismostcommoninmiddleagedmen,maybeattheleveloftheroots,but
itmayalsobecompressedalongtheretroperitonealcourse.
Numerousdirectandindirectcausesofthediseasehavebeensuggestedintheliterature,including:309313
obesity
ascites
directtrauma
abdominaldistention,includingpregnancy
abdominopelvictumorsorinflammationsitmayoccurasthefirstsignofalumbarcordtumor
metastaticcarcinomaintheiliaccrest
anatomicvariationatthesiteofpassage311
retroperitonealtumors
leglengthdiscrepancy
idiopathiccauses
tightclothingaroundthewaist
complicationsafterthoracoabdominalsurgeryand
complicationsafteriliacbonegraftharvesting.
Toxicandmetabolicdisorders,suchasdiabetesmellitus,alcoholism,andleadpoisoning,whichhavebeen
reportedtobecausativeinseveralcases,haveallbeendescribedtoincreasesusceptibilityofindividual
peripheralnerves,includingtheLCN,tomechanicalinsults.314,315
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Neuropathyofthisnervemaycausepain,numbness,anddysesthesiaintheanterolateralaspectofthethigh,
whichismostmarkedinwalking,standing,andsleepingintheproneposition.316Sittingmayrelievethe
symptomsinsomepatientsbutexacerbatetheminothersdependingonthecause.Eventually,noposition
providesrelief.Patientsmayhavesecondaryhip,knee,andcalfpain.Entrapmentofthelateralcutaneousnerve
ofthethighcanalsobethecauseofchronicgroinpain.317319
Differentialdiagnosisincludesback,hip,andgroinpathology.Meralgiaparestheticasymptomsmaybeconfused
withmorefrequentlyseensymptomsproducedbyentrapmentoftheupperlumbarnerveroots.320,321
Interventionisdependentonthecause.
IliofemoralThrombophlebitis
Thrombophlebitisofthesuperficialveinsofthelegisusuallyregardedasamildanduncomplicateddisease.
Althoughthisisgenerallytrueinthecaseofacutethrombosisofthebranchesofthesaphenousvein,thenatural
historyofsuperficialvenousthrombophlebitisinvolvingthemaintrunkmaynotbeasbenign.Therelationship
betweensuperficialvenousthrombophlebitisanddeepvenousthrombosis(DVT)withattendantpulmonary
embolushasbecomethefocusofmorerecentstudies.AnassociationwithDVThasbeenreportedwith
frequenciesof1244%,322andtherehavebeenseveralreportsofpulmonaryembolisminthrombophlebitis.323
Theclinicalsignsandsymptomsofiliofemoralthrombophlebitisincludegeneralizedlegpain,bluish
discoloration,andswellingofthelowerextremities.Thisconditionmayalsobeassociatedwithacutelower
abdominal,groinandflankpain,fever,chills,andlocalizedtenderness.
MononeuritisMultiplex
Mononeuritismultiplexcanoccurinassociationwithanumberofothermedicalconditions,includingRA,
vasculitis,polyarteritisnodosa,diabetesmellitus,sarcoidosis,andamyloidosis.Anischemicmechanismisthe
mostlikelycauseofmononeuritismultiplex.ItisgenerallyacceptedthatmononeuritismultiplexinRAresults
fromischemiacausedbyvasanervorumvasculitis.Involvementofperipheralnervesprecedesinvolvementof
theCNS.Theclassicsymptomsformononeuritismultiplexincludeasuddenonsetofsevereaching,burningor
lancinatinglegpain,paresthesias,sensoryloss,andmotorweakness.324Thesymptomscaninvolveoneormore
nervesineachleg,usuallyinanasymmetricpattern.324
IschialApophysitisandAvulsion
Theischialapophysisconstitutestheinsertionofthehamstringsandtheadductormagnusmuscles(seeChapter
19).Ischialtuberositypainmaybecausedbyseveralclinicalentities,whichincludeacuteandoldbonyor
periostealavulsionsandapophysitis.Theclinicaldiagnosticcriterionforischialapophysitisconsistsofagradual
increaseinfunctionalandpalpatorypainattheischialtuberosity,withoutanymajortraumaatthebeginningof
thesymptoms.Usually,thereisasymmetryonplainradiographsoftheischialtuberositiesinapophysitis.The
radiographdemonstratesascleroticareaandosteoporoticpatchesonthelowermarginoftheischialtuberosity.
Patientswithanavulsionusuallyreportanacutetraumaticincident.Anavulsionfragmentmaybevisibleon
plainradiographimmediatelyafterinjuryorlater.Thepainisusuallylocalbutmayalsoradiatedownthethigh.
Activeorresistedkneeflexionincreasesthepainunlesstheavulsioniscomplete.Completeavulsionscanbe
painless.
Thehealingprocessofanavulsionmayleadtoaheterotrophicboneformation.
Differentialdiagnosisincludesintervertebraldiskdisease,piriformissyndrome,ischialbursitis,andpubicarch
stressfracture.
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Conservativeinterventionforapophysitisconsistsofamodificationofactivities.Avulsionsrequireatleast1
monthofrestfromtraining,dependingonthedisplacement.Urgentsurgicalinterventionisrecommendedin
casesofacompleteornearlycompletesofttissueavulsionofthehamstringmuscle.325
GlutealCompartmentSyndrome
Thecharacteristicfindingofaglutealcompartmentsyndromeisatense,swollenbuttockfollowingamechanism
ofseverecontusion,suchasafallfromaheight.326Theswellinginthebuttockcanresultinnecrosisofthe
glutealmusclesorsciaticneuropathy,orboth.Thepatientshouldbereferredimmediatelytoanorthopaedic
surgeon.Afasciotomyistypicallyperformedifthepressurewithintheglutealcompartmentis30mmHgor
higherforadurationof68hours.327
GenitalHerpes
Genitalherpesisachronic,viral,sexuallytransmitteddiseaseforwhichthereisnocure.Itaffectsover30
millionpeopleintheUnitedStatesandcontinuestoincreaseworldwide.328Themajorityofindividualsare
asymptomatichowever,somepresentwithpainfulandrecurrentgenitallesionsandsystemiccomplications.As
achronicillness,theindividualsresponsetothediseasemayproduceseriouspsychosocialmorbidity.329
Womenaremorelikelytohavegenitalherpesthanmen.330
VascularDisorders
Gradualobstructionoftheaorticbifurcationproduces:12
bilateralbuttockandlegpain
weaknessandfatigueofthelowerextremities
atrophyofthelegmusculature
absentfemoralpulses
colorandtemperaturechangesinthelowerextremities
painthatisoftenaggravatedwithlumbarextension
apulsingsensationintheabdomen.Onoccasion,anabdominalaorticaneurysm(AAA)cancausesevere
backpain.Promptmedicalattentionisimperativebecauserupturecanresultindeath.Thepatientsare
usuallymenintheirsixthorseventhdecade,whopresentwithadeep,boringpaininthemidlumbar
region.Otherhistoricalcluesofcoronarydiseaseorintermittentclaudicationofthelowerextremitiesmay
bepresent.Anexaminationmayrevealapulsingabdominalmassand
peripheralpulsesmaybediminishedorabsent.331
Involvementofthefemoralarteryalongitscourse,oratthefemoralpoplitealjunction,produces:12
thighandcalfpain
absentpulsesbelowthefemoralpulse.
Obstructionofthepoplitealarteryoritsbranchesproducespaininthecalf,ankle,orfoot.
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CAUSESOFPELVICPAIN
ThecausesofpelvicpainincludethoselistedinFigure52andTable514.
TABLE514PotentialCausesofPelvicPain
Sacroiliacarthritis
Acuteappendicitis
Iliopsoasabscess
Iliopsoashematoma
Signofthebuttock
Gynecologicdisorders
Prostatecancer
SacroiliacArthritis
Sacroiliacarthritisischaracterizedbypainintheposterioraspectofthesacrum,orbygroinpain(uncommon),
whichcanradiateintotheposteriorthigh.Thepainisusuallyincreasedwithwalking,eitheratheelstrikeorat
midstance.Frequentlythepainwakesthepatientwhenturninginbed.
Lumbarextensionisthemostpainfulmotion,ipsilateralsidebendingandrotationlessso,andflexionleastof
all.Ifthepainisincreasedwithunilateralweightbearingorhoppingbutisreducedifasacroiliacbeltisworn,
sacroiliacjointarthritismaybepresent.
ThesacroiliacjointstresstestsdescribedinChapter29areusedtohelpwiththeclinicaldiagnosis.Imaging
studiesareusedtoconfirmthediagnosis.
AcuteAppendicitis
Thisconditionfrequentlybeginswithdullandachingpainintherightlowerabdomen.Thepainisintensifiedby
walking,coughing,andtrunkmovements.Thereisusuallyanassociatedlowgradefever.Dysuria,diarrhea,
constipation,orincreasedurinaryfrequencyalsomaybereported.Thepatientisoftenabletolocalizethepain
toMcBurneypoint,whichislocatedbypalpationatthemidpointbetweentheanteriorsuperioriliacspineand
theumbilicus.
Lesscommonsignsincluderectalortesticulartendernessandrightlowerabdominalskinhyperesthesia.
IliopsoasAbscess
Thepainassociatedwithaniliopsoasabscessoccursintherightlowerabdomen.Thepainisusuallymildto
moderateandisincreasedwithhipextensionandpalpationintherightiliacfossa.Theabscessiscausedbyan
infectionofthethoracolumbarspine,suchastuberculosis,orissecondarytoanintestinaldisorder,suchas
Crohndisease.332
IliopsoasHematoma
Hematomasaremorefrequentlyseenintheiliacusmusclethanthepsoas.333Thecausesofthesehematomas
include:
heparinanticoagulationorDVTprophylaxistherapy
hemophilia
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traumafromeitheradirectblowtotheabdomenorahyperextensionmomentatthehip,suchasoccursin
asliporfall.
Nontraumatichematomasoftenmanifestinsidiouslywithnoobviouslesionorecchymosis.Patientsinitially
maycomplainofflankpainbutfrequentlywilldevelopmotorandsensorydeficitsalongthefemoralnerve
distributionoftheaffectedside.Flankpainreferstopaininthesideofthetrunkbetweentherightorleftupper
abdomenandtheback.Apalpablelowerabdominalmassmaybepresent,dependingonthesizeandlocationof
thehematoma.
Iliopsoashematomashavebeensuccessfullymanagedwithconservativetreatment.Thisinterventioninvolves
bedrestfor2448hours,followedbyagentlehiprangeofmotionexercise.Progressivestrengtheningexercises
aretheninitiatedaccordingtopatienttolerance.
Thesurgicalinterventioninvolvestheevacuationoftheclot.
SignoftheButtock
Thesignofthebuttockisnottechnicallyacauseofpainbutis,rather,acollectionofsignsindicatingaserious
pathologypresentposteriortotheaxisofflexionandextensioninthehip.334Amongthecausesofthesyndrome
areosteomyelitis,infectioussacroiliitis,fractureofthesacrumorpelvis,septicbursitis,ischiorectalabscess,
glutealhematoma,glutealtumor,andrheumaticbursitis.
Thesignofthebuttocktypicallyincludesalmostallofthefollowing:
Limitedstraightlegraising
Limitedhipflexion
Limitedtrunkflexion
Noncapsularpatternofrestrictionatthehip
Painfulandweakhipextension
Glutealswelling
Emptyendfeelonhipflexion
Greenwoodetal.335havesuggestedthatanoncapsularpatternofthehipinthepresenceofapositivesignofthe
buttockindicatesthatthepathologyisnotamenabletoaphysicaltherapyintervention.
GynecologicDisorders
Gynecologicdisordershavethepotentialtocausemidpelvicorlowbackdiscomfort.
PelvicInflammatoryDisease
Pelvicinflammatorydisease(PID)isthegeneraltermdescribingendometritis,salpingitis,tuboovarianabscess,
orpelvicperitonitis.ThemicrobialetiologyofPIDisunclearbutisassumedtooccurbytheascendingspreadof
microorganismsfromthevaginaorendocervixintotheuppergenitaltract.336PIDhasbeenconsidered
primarilyasexuallytransmitteddisease,causedinlargepartbythesexuallytransmittedpathogensNeisseria
gonorrhoeaeandChlamydiatrachomatis.336However,endogenousmicroorganismsthatarepartofthelower
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genitaltractfloracanalsoberecoveredfromtheendometrium,fallopiantubes,andperitonealfluidofwomen
withacutePID.336
ThecharacteristicpresentationofPIDisoneofsuprapubicpain.Thepainisusuallyconstantorcrampyandmay
beassociatedwithfever,chills,anddirectabdominaltenderness.332Theuseofanintrauterinedevicedoubles
theriskofendometritis.332
TheonsetofPIDisusuallywithin7daysofthebeginningofamenstrualcycle.Theremaybefeverandvaginal
discharge.
TubalPregnancy
Initsearlystages,thisconditionusuallyproducesmildandcolickylowerabdominalpain.Thepainiscausedby
anectopicpregnancy,inwhichtheembryolocatesitselfinthefallopiantubeinsteadoftheuterus.Atubal
pregnancyisusuallyassociatedwithabnormalmenstruationandirregularspottingorstaining.
Endometriosis
Endometriosisisacommongynecologicaldisorderthataffectsuptooneinsevenwomenandasmanyas30
50%ofallinfertilewomen.337Endometriosiscanbefoundanywhereinthepelvis,includingthebroad
ligaments,uterosacralligaments,andovaries.Theconditionislinkedtoabdominal,midline,andpelvicpain.
Theincidenceandprevalenceofendometriosisarehighestinthesameagerangeasthatofpeoplewith
nonspecificLBP.338Associatedsignsandsymptomsincludepelvicpain,painwithdefecation,diarrhea,
dysmenorrhea,dyspareunia(difficultorpainfulcoitus),anddysuria.339Theseverityofthepainisnotdependent
onthestageofthedisorder.340Thediagnosisofendometriosiscanbeelusivebecauseitsmostcommon
symptomsarealsosymptomsofmultipledisorders.337Althoughendometriosisisnotconsideredamalignant
disorder,ithascharacteristicsincommonwithmalignantcells.Forinstance,endometriosis,likecancer,canbe
bothlocallyanddistantlymetastaticitattachestoothertissues,invades,anddamagesthem.341Giventhe
associatedsymptomswiththisdisorder,itisimperativetoincludeendometriosisasadifferentialdiagnosisin
womenofreproductiveagewithpelvic,lowerback,andlowerextremitypain.338
InterstitialCystitis
Interstitialcystitisisaclinicalsyndromeofurinaryfrequencyorpelvicpain,orboth,inapatientinwhomno
otherpathologycanbeestablished.Interstitialcystitishasnosingle,definablepresentation.Thepainthatoccurs
withthissyndromeisnotlimitedtopainonvoiding(dysuria)itcanrefertolocationsthroughoutthepelvis,
includingtheurethra,vagina,suprapubicarea,lowerabdomen,lowerback,medialaspectofthethigh,and
inguinalarea,inanycombination.342
ProstateCancer
Prostatecanceristhemostcommonnonskincancerandthesecondleadingcauseofmalecancerdeathsamong
U.S.men.Riskfactorsforprostatecancerincludeage,familialhistoryofcancer,andethnicity.Whetherchronic
orrecurrentprostaticinflammationcontributestoprostatecancerdevelopmenthasnotbeenascertained.
Prostatecancerisoftendiagnosedwhenamanseeksmedicalassistancebecauseofurinaryobstructionor
sciatica.Thesciatic(lowback,hip,andleg)painiscausedbymetastasisofcancertothebonesofthepelvis,
lumbarspine,orfemur.
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Prostatecancerscreeningorearlydetectionhasbeenaccomplishedusingdigitalrectalexamination,
measurementofserumprostatespecificantigen(PSA)anditsvariousforms,transrectalultrasonography,and
combinationsofthesetests.
Digitalrectalexamination.Thevastmajorityofprostaticcarcinomasariseintheperipheralzoneofthe
prostate,whichcomprisestheposteriorsurfaceofthegland,includingtheapical,lateral,posterolateral,
andanterolateralportionsoftheprostate.Itisthispartoftheglandthatisaccessiblebydigitalrectal
examination.
PSA.MeasurementofPSAlevelsisregardedwidelyasthemostclinicallyusefultoolfortheearly
diagnosisofprostatecancer,althoughthereisanabundanceofconflictingadviceastoitsuse.Thisis
largelyduetothefactthatPSAlevelscanfluctuateupanddown.Itwaspreviouslythoughtthatahigh
PSAresultindicatedtheneedforabiopsy.However,itisnowbelievedthattheresultsneedtobe
confirmedbyasecondtesttaken46weekslater.Eventhen,approximately70%ofmenwithanelevated
PSAlevelwillnotsubsequentlybediagnosedwithprostatecancer.343
CAUSESOFHIP,TROCHANTERIC,PUBIC,ANDTHIGHPAIN
Potentialcausesoftrochanteric,pubic,andthighpainincludethoselistedinFigure53andTable515.Painfelt
inthehipandpelvismayoriginatefromhipstructuresormaybereferredfromstructuresinthetorsoorviscera.
FIGURE53
Potentialcausesoftrochanteric,pubic,andthighpain.
TABLE515PotentialCausesofTrochanteric,Pubic,andThighPain
Dislocationandfracturedislocationofthehip
Labraltear
Hiporpelvisfracture
Pubicstressfracture
Femoralneckstressfracture
Osteoarthritisofthehip
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Septicarthritisofthehip
Reitersyndrome

Transientsynovitisofhipinchildrenoradolescents
Avascularnecrosisoffemoralhead
Iliopsoasabscess

Iliofemoralvenousthrombosis

Obturator,femoral,oringuinalhernia
Osteomyelitispubis
Compartmentsyndrome
Genitalherpes
DislocationandFractureDislocationoftheHip
Atraumaticposteriordislocationofthehipusuallyoccursinamotorvehicleaccidentorfall.Thereisusually
severegroinandlateralhippain.Thelegisshortened,andheldflexed,adducted,andinternallyrotated.
Posteriordislocationsaremorecommonthananteriordislocations.
Ananteriordislocationusuallyoccursastheresultofforcedabduction.Anteriordislocationscausegroinpain
andtenderness.Inasuperioranterior(pubic)dislocation,thelegisheldextendedandexternallyrotated.Inan
inferioranterior(obturator)dislocation,thethighisabducted,externallyrotated,andheldinflexion.
Theinterventionforahipdislocationisearlyclosedreductionunderspinalorgeneralanesthesia.
Developmentaldysplasiaofthehip,previouslyreferredtoascongenitaldysplasiaofthehip,isdescribedin
Chapter30.
LabralTear
SeeChapter19.
HipFracture
Afractureoftheproximalfemur(femoralneck,intertrochanteric,orsubtrochanteric)usuallyresultsfromafall
butcanoccurspontaneously,especiallyintheelderly.Thecharacteristicfindingsincludeaseveregroin,anterior
thigh,and,sometimes,trochantericpainandtenderness.Fractureofthefemoralnecktypicallyoccursinan
elderlyosteoporoticpatient,withafemaletomaleratioof4:1.344Dependingontheseverityandlocationofthe
fracture,theremaybeashorteningoftheinvolvedleg.
PubicStressFracture
Pubicramifracturesarethemostcommonlyseenpubicfractures,withthesuperiorramusmorecommonly
involvedthantheinferiorramus(seeChapter30).Pubicramiandpubicbonefracturesaccountformorethan
70%ofallpelvicfractures.345Pubicstressfracturesareassociatedwithagradualonsetofgroinpain,whichis
intensifiedbyweightbearing,walking,orabductionofthethigh.
FemoralNeckStressFracture
SeeChapter19.
OsteitisPubis
SeeChapter29.
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AdductorMuscleStrain
SeeChapter19.
ReiterSyndrome
Reitersyndromereferstotheclinicaltriadofnongonococcalurethritis,conjunctivitis,andarthritisfirst
describedbyReiterin1916.346Thisformofarthritisusuallyfollowsaninfectionofthegenitourinaryor
gastrointestinaltract.Itusuallymanifestsatleastoneotherextraarticularfeature,withasymmetricinvolvement
ofthelargeweightbearingjoints.37ThejointsofthemidfootandtheMTPandinterphalangealjointsofthe
toesaremostcommonlyaffected.Onsetisusuallybetweentheagesof20and40,withmalespredominantly
affected.37
TheassociationofReitersyndromewithHLAB27,occurringin7090%ofpatients,hasbeenrecognizedfor
nearlyaslongastheassociationofHLAB27withAS.347
TransientSynovitisoftheHipinChildrenorAdolescents
Transientsynovitisofthehipisoneofthemostcommoncausesofhippainandlimpinyoungchildren.Itis
definedasanacute,selflimitinginflammationofthesynovialliningofthehipjoint(seeChapter30).
OAoftheHip
SeeChapter19.
SepticArthritisoftheHip
Theclinicalpresentationofsepticarthritisofthehipissimilartothatofsynovitisofthehip.However,because
delayeddiagnosisofsepticarthritiscanbelifethreatening,correctandearlydifferentiationofsepticarthritis
andtransientsynovitisisimportant.348Comparedwithpatientswhohavetransientsynovitis,thosewithseptic
arthritisusuallyhavemoreseverepainandspasm.Thelegisrigidandisheldinthestandardflexedand
externallyrotatedpositiontoincreasecapsularcapacity.348
OsteonecrosisoftheFemoralHead
Osteonecrosisofthefemoralheadisalsoknownasasepticnecrosisoravascularnecrosis.Accordingto
Kenzora349andKenzoraetal.,350thetermavascularnecrosisshouldbereservedexclusivelyforposttraumatic
causesbecausetheyoriginateinischemiaasaresultofbloodflowinterruption.Whentheetiologyofthe
necroseshasnotbeenestablishedclearlyorisobscure,itisbesttousethegeneraltermidiopathicosteonecrosis.
Avascularnecrosiscanoccursecondarytotrauma,suchasafractureordislocation.Severaletiologicfactors
havebeenimplicatedinthedevelopmentofidiopathicosteonecrosisofthehip,buttheprecipitatingeventthatis
commontomost,ifnotall,isamechanicalinterruptionofthecirculationofthefemoralhead.Iftheaffected
areaissufficientlylarge,andthecollateralcirculationisinadequate,avascularnecrosiswilldevelop.Thismay
occurbydirectexternalvascularocclusionwithoutdisruptionofthevessels,asinmarrowinfiltrativediseases.
Arterialthrombosisprobablyoccursinthevasculardisorders,andembolihavebeenimplicatedinsicklecell
diseaseandcaissondisease(dysbaricosteonecrosis).Thesystemicadministrationofsteroidsandanexcessive
intakeofalcoholarethetwofactorsmostoftenassociatedwithidiopathicosteonecrosis.351Overall,etiologic
factorscanbeclearlyidentifiedinmostpatientsperhapsonly1020%ofpatientshavetrulyidiopathic
osteonecrosis.
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Thesymptomsofavascularnecrosisandidiopathicosteonecrosisarenonspecificandusuallyinsidiousinonset.
Thepain,whichistypicallyfeltinthegroin,proximalthigh,orbuttockarea,isusuallyexacerbatedbyweight
bearing,butitisoftenpresentatrest.Theclinicalfindingsvary,anditisonlywhenthefemoralheadbecomes
deformedthatlimitationsofmotioninanoncapsularpatternoccur.Thelossofrangeofmotionmostcommonly
affectshipflexion,internalrotation,andabduction.Axialloadingofthejoint,asinthescourtest,may
reproducethesymptoms.Alimporanantalgicgaitistypicallyalatefinding,andthefunctionaldisabilityis
proportionatetothelevelofpain.351Usually,thepainbecomesmoresevereasfragmentationandcollapseof
thefemoralheadtakeplace.Sometimesthepainwilllessenifspontaneousimprovementoccurs,andsmall
lesionsmayremainasymptomaticandresolvespontaneously.351
Radiographicevaluationisthegoldstandardfordiagnosisofosteonecrosis.352MRIorarthrographycanfurther
evaluatetheextentofarticularcartilage.Clinicallydiagnosedavascularnecrosisisprogressivein7080%of
patientswhoaremanagednonoperatively,andthisprogressionusuallyresultsinthecollapseofthefemoral
head.351Althoughconservativeinterventionisaimedatlimitingthestressesthroughthehipjointandutilizinga
support,operativeinterventiongenerallyisrecommended.
Aparallelconditionthatoccursinchildren(mostcommoninboysaged58years)isLeggCalvPerthes
disease(seeChapter30).
IliopsoasAbscess
SeethediscussionofCausesofPelvicPainearlier.
TrochantericBursitis
SeeChapter19.
Obturator,Femoral,orInguinalHernia
Theclinicaldiagnosisofinguinalandfemoralherniasisusuallystraightforward.Afewhernias,however,
presentadiagnosticproblem.Thisdiagnosticdifficultyisusuallyencounteredinobesepatientsorinpatients
withreducibleherniasthatarenotprotrudingatthetimeofphysicalexamination.Falsepositivefindings
includelipomaofthespermaticcordandpreperitoneallipoma.Acordlipomaappearsasasmooth,fingerlike
projectionoffatparalleltothecordvesselsatrest.Duringstraining,longitudinalslidingoccurs.Unlikeindirect
inguinalhernias,theanteroposteriordiameteroftheinguinalcanaldoesnotincreaseduringtheValsalva
maneuver.
OsteomyelitisPubis
Bonyinfectionorinflammationofthepubicareaisrare.Osteomyelitispubisisanentitycharacterizedbypelvic
pain,awidebasedgait,andbonydestructionofthemarginsofthepubicsymphysis.353Delayinitsdiagnosisis
commonbecausethepresentationissimilartothatofosteitispubisandurologic,gynecologic,andabdominal
lesions.Osteomyelitispubisshouldbeconsideredwhenapatientpresentswiththefollowingsigns:painor
pubictenderness,painfulhipabduction,andfever.353
Antibiotictreatmentisessential,withthespecificdrugtherapydependingontheidentificationofthecausative
agent.
CompartmentSyndrome
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Compartmentsyndromeisaconditioninwhichmyoneuralanoxiaresultsfromaprolongedincreaseintissue
pressurewithinaclosedosseofascialspace.Thiscompromiseslocalbloodflowofskeletalmuscle,resultingin
ischemiaandnecrosis.
Localbloodflowmaybeimpairedby:
anincreaseinthepressureofthecompartmentresultingfromtheapplicationofatightbandageorplaster
cast
adecreaseinarterialflow,asinPVD
anincreaseinvenouspressurethatcanreducethegradientforlocalbloodflow.
Falseaneurysmsoftheprofundafemorisarteryareararebutrecognizedcomplicationfollowingorthopaedic
proceduresintheupperthigh.Suchproceduresincludeinternalfixationofintertrochanteric,subtrochanteric,
andintracapsularfemoralneckfracturessubtrochantericosteotomyandintramedullarynailingofthefemur.354
Acompartmentsyndromeofthethighusuallymanifestsasapulsating,expandingswellingoftheupperthigh
withanaudiblebruit.Potentialcomplicationsincludeexpansionandextensivesofttissuedestructionand
pressureofneighboringstructures.354Thiscanresultinneuropathyorvenousoutflowobstructionand
thrombosis.Ruptureandseverehemorrhage,infectionofananeurysm,andsepsisofthenearbyprosthesis,as
wellasfracturenonunion,alsohavebeenreported.354
Earlyrecognitionandrepairofananeurysmareofparamountimportancetoavoidlifeandlimbthreatening
complicationsfromdelayeddiagnosis.354Anyunexplainedthighswellingencounteredfollowingasurgical
procedureontheproximalfemurandshaftshouldalertthecliniciantoapotentialinjurytotheprofundafemoris
artery.354
GenitalHerpes
SeethediscussionunderCausesofButtockandUpperandLowerLegPainearlier.
CAUSESOFSHOULDERANDUPPERARMPAIN
ThecausesofshoulderandupperarmpainincludethoselistedinTables516and517.
TABLE516PotentialCausesofShoulderPain
Tendinousandcapsularlesions
Traumaticsynovitis
Subluxation
Dislocation
Spondyloarthropathy
Acutearthritis
Infections
Tumor
Clayshovelerfracture
Degenerativeconditions
Metabolicconditions
Cerebrovasculardisease
Multiplesclerosis
Cervicalradicularpain
Elbowdysfunction
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Peripheralnerveentrapment
Brachialplexopathy
Herpeszoster

Gallbladderdysfunction
Cardiacdysfunction

Pulmonarydysfunction
Diaphragm
Spleen
TABLE517OriginandLocationofShoulderPain
RightShoulder LeftShoulder
Systemic
SystemicOrigin Location Location
Origin
Ruptured Leftshoulder
spleen Left
Pepticulcer Lateralborderofrightscapula
Myocardial pectoral/shoulder
ischemia area
Myocardialischemia
Rightshoulderanddownarm Pancreas Leftshoulder
Hepatic/biliary
Rightshoulder,betweenscapulae,and
Acutecholecystitis
rightsubscapulararea
Liverabscess Rightshoulder
Gallbladder Rightuppertrapezius
Liverdisease(hepatitis,cirrhosis, Rightshoulderandrightsubscapular
andmetastatictumors) area
DatafromGoodmanCC,SnyderTE.DifferentialDiagnosisinPhysicalTherapy.Philadelphia,PA:WB
SaundersCompany1990.
LocalConditions
TendinousandCapsularLesions
SeeChapter16.
Synovitis
Theshoulderjointiscomposedoftwosynovialcavities:thesubacromialsubdeltoidbursaandthe
glenohumeraljoint.Inrotatorcuffdiseases,subacromialsynovitisisresponsibleforthegenerationofshoulder
pain,anditsseveritymaycorrelatewiththeintensityofpain.Duringinflammation,thesocalledhyperalgesia
occurs,whichischaracterizedbyintensifiedpainwithareducedthresholdtosomaticstimulation.
Pigmentedvillonodular(PVN)synovitisisoneofagroupofbenign,proliferativelesionsarisingfromthe
synoviumofjoints,bursae,andtendonsheaths.355Traditionally,theselesionshavebeenidentifiedasabenign
giantcelltumorofthetendonsheath,hemorrhagicvilloussynovitis,andproliferativesynovitis.356PVN
synovitisinthekneeandhandhasbeendescribedfrequently,butitsoccurrenceattheshoulderisrare.
ThecauseofPVNsynovitisisunclear,butitmayberelatedtoinflammationortrauma.Thelesionsdevelop
slowly,andpatientsusuallypresentwithagradualonsetofpainintheaffectedjoint.355Apalpable,tender,soft
tissuemassmaybepresent.PVNsynovitisisregardedasalocallyaggressivebutbenigntumor.Earlydiagnosis
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andtreatmentareessentialforpreservingjointfunctionandintegrity.Thetreatmentofchoiceiscomplete
synovectomyorbursectomy,orarthroscopicsynovectomy.355
Subluxation
Shouldersubluxationcanbecausedbytrauma,overuse,orhemiplegia.Thetraumaticandoverusecausesof
shouldersubluxation,whichcanoftenbediagnosedonthebasisofhistoryandphysicalexamination,are
describedinChapter16.Themostcommoncomplaintsareofinstability,restrictedactivities,andpain.Strength
andrangeofmotionareusuallynormal.Themostcommonsignificantfindingonphysicalexaminationis
apprehension.
Oneofthemostcommonlycitedcausesofshoulderpaininhemiplegiaisshouldersubluxation.Shoulder
subluxationoccursinhemiplegiabecauseoftheparalysisofactiverestraints,whichplayacriticalrolein
maintainingglenohumeraljointintegrity.Inthispopulation,glenohumeraljointsubluxationmayinhibit
functionalrecoverybylimitingtheglenohumeralrangeofmotion.
Unfortunately,theavailableoptionsforpreventingandtreatingshouldersubluxationinthehemiplegic
populationarelimited.Armboardsandlaptrayshavenotbeenshowntobeeffectiveandmayleadtoan
overcorrectionofinferiorsubluxation.357Thisovercorrectionmaypredisposetheinvolvedshoulderto
impingementsyndromes.Theuseofslingsremainscontroversial.Slingsmaycauselateralsubluxation,
contributetothedeleteriouseffectsofjointimmobilization,orpromoteundesirablesynergisticpatternsof
muscleactivation.357Intramuscularneuromuscularelectricalstimulation(NMES)deliveredviapercutaneously
placedelectrodesmayaddressthelimitationsoftranscutaneoussystemsinthetreatmentofshouldersubluxation
andpain.357
Dislocation
Incontrasttothehip,inwhichtheballandsocketjointisdeepandwellstabilized,thearticularsurfaceofthe
shoulderrestsintheshallowglenoidcavity.Ninetyfivepercentofshoulderdislocationsoccurintheanterior
directionandresultinstretchinganddetachmentoftheanteriorcapsuleandlabrum.358Dislocationofthe
shoulderisacommonandoftendisablinginjury,resultingindamagetonerves,bloodvessels,andtherotator
cuffmuscles(seeChapter16).Mostshoulderdislocationsaretraumaticinorigin.Themostcommon
mechanismsareafallonanoutstretchedhand,ablowagainsttheanteriorarmwhenthelimbisextendedand
externallyrotated,or,rarely,ablowtothebackoftheshoulder.
Traumaticshoulderdislocationsareaccompaniedbyextremepainthatworsensasthesupportingmusculature
goesintospasm.359Generally,patientspresentwiththearmsomewhatabductedandexternallyrotated,often
graspedtightlybytheoppositehandtominimizemovement.359
Theexaminationofapatientwhohasrecentlydislocatedtheshoulderisoftendifficultbecauseofassociated
painandmuscleguarding(seeChapter16).Itisimportanttoattempttoexamineforaxillarynervefunction
(deltoidpowerandoverlyingsensation),supraspinatuspower,andglenohumeralrangeofmotion.360Axillary
nervepalsyandavulsionofthesupraspinatusarecommoncomplicationsofadislocatedshoulder.Associated
fracturesmaybepresent.Vascularcompromiseisuncommoninthisinjury,butwhenitoccurs,rapidsurgical
referralisnecessarytosavethelimb.359
Spondyloarthropathy
RAaffectsthejointsinacharacteristicandsymmetricfashion.Inadditiontothesmallerjoints,RAcanaffect
thelargerjoints,includingtheshoulders.Itresultsinpainandstiffness,whichareusuallygreatestinthe
morning.361363Thisconditionshouldbeconsideredwhenpatientshavesymmetricinvolvementofthe
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shoulder,morningstiffness,constitutionalsigns,andphysicalsignsofjointinflammation.364Synovial
inflammationofthesubacromialsubdeltoidbursaecanoccur,resultinginpainwithabductiontoapproximately
90degreesinbothshoulders.364Chronicinflammationorlongtermcorticosteroiduse,orboth,mayalsoresult
inrotatorcufftearing,anotherviablecauseofpainandfunctionlossinthepatientwithRA.Thisshouldbe
suspectedwhensignificantweaknessisnotedonabductionorexternalrotationoftheshoulder.364Theclinician
shouldalsolookforothersignsofinflammatoryarthritis,whichincludesynovialthickeningoftheMCPjoints
andthickeningat,andlossofrangeofmotionof,thewrists.Therheumatoidfactorisoftennegativeinolder
patientswithRA.364
CLINICALPEARL
Polymyalgiarheumaticaisanothercauseofshoulderpaininolderindividuals.Thesepatientshavepaininthe
shoulderandhipgirdlemuscles,profoundmorningstiffness,andmalaise.364Thisconditioncanbedifficultto
distinguishfromRAinolderpeople.
AcuteArthritis
Septicarthritisoftheshoulderisuncommonbutcanoccurinpatientswhoaredebilitatedfromgeneralized
disease,365inthosetakingimmunosuppressivemedications,orincombinationwithanunderlyingshoulder
diseaseprocess,suchasrotatorcufftearing366orRA.367,368
Diabeticpatientsareathigherriskofdevelopingmonoarticularsteroidsensitivearthritis.369Aconditionof
unknownetiology,itcanaffecttherotatorcuffandtheglenohumeraljointcapsule.370Asthenamesuggests,the
conditionisprovokedbythepatientsreactiontohydrocortisone.
Diagnosisrequiresjointaspirationandbacteriologicaltesting.Monoarticulararthritis,whichusuallyresolves
spontaneouslyin2yearswithmedicalintervention,371isanabsolutecontraindicationtocapsularstretching.372
DegenerativeConditions
Intrinsicglenohumeralarthritisisaninfrequentcauseofshoulderpain,butthelossofglenohumeralmotionis
oftenseeninpatientswithperiarticularsyndromes(seeChapter16).364Althoughtherotatorcuffoftenisintact,
thesubscapularismuscleoftenisshortened,limitingexternalrotation.373Xrayfindingsinclude373
flatteningposteriorerosionoftheglenoidandanenlargedordeformedhumeralhead374,375
inferiorlylocatedosteophytesand
acromioclaviculararthriticchanges.374
Infections
Osteomyelitis
Themostcommonlyinvolvedboneswithacutehematogenousosteomyelitisinorderoffrequencyarethefemur,
tibia,humerus,fibula,radius,phalanges,calcaneus,ulna,ischium,metatarsals,andvertebralbodies.376Patients
withsicklecelldiseaseareatanincreasedriskofbacterialinfections,andosteomyelitisisthesecondmost
commoninfectioninthesepatients.377
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Patientsusuallypresentwithfever,malaise,irritability,pain,andlocalizedtendernessatthesiteofinfection.
Muscleguardingmayalsobeafeature,aswellasdecreasedmovementandpainoftheaffectedlimband
adjacentjoints.Thesesymptomsmaybeaccompaniedbyedemaanderythemaovertheinvolvedarea.
CatScratchDisease
Catscratchdiseaseisgenerallyabenign,selflimitedinfectiousdiseaseinimmunocompetentpatients.Itis
causedbyBartonellahenselae,asmall,gramnegative,argyrophilic,nonacidfast,pleomorphicbacillus.378
Domesticcats,especiallykittens,serveasareservoirforB.henselae.378Ingeneral,patientspresentwitha
historyofascratch,bite,orclosecontactwithakittenorcat.Oftenaredbrownnontenderpapuledevelopsat
theregionoftheinoculationwithin310daysandmaypersistforseveralweeks.Mostpatientsdeveloptender
regionallymphadenopathy,particularlyintheaxilla,andmanydevelopafever.
Tumors
Thedifferentialdiagnosisofallpainfulshouldersincludestumorsofawidevariety.Evaluationofashoulder
tumorhasseveralareasincommonwithothermusculoskeletalneoplasms.Athoroughevaluationofpatients
requiresnotonlyroutineradiographybutalsoradionuclideimaging,CTscanning,magneticresonanceimaging
(MRI),andangiography.Thetypicalclinicalfeaturesofabonetumorincludevariablepain,whichisoften
worseatnightandmarkedlyunresponsivetoNSAIDs.Surgicaltreatmentofshouldertumorsdependsonthe
patientsageandthetype,extent,andaggressivenessofthetumor.
VascularConditions
Nontraumaticosteonecrosisofthehumeralheadmaybeidiopathicorassociatedwiththesystemicuseof
corticosteroids,dysbaricconditions(blockageofthebloodvesselsbyabubbleofnitrogencomingoutof
solution),transplantation,systemicillness,alcoholism,sicklecelldisease,hyperuricemia,pancreatitis,
lymphoma,orGauchersdisease.368,379382
Diagnosisisthroughimaging,particularlyMRI,whichdetectsthepathologyatitsearlieststage.
MetabolicConditions
Goutisametabolicdiseasecharacterizedbyrecurrentepisodesofacutearthritisthatcanmanifestinthe
shoulderjoints.
Fractures
SeeChapter16.
ReferredPain
Referredpainfromthecervicalregionmaybeexperiencedintheshoulderorinterpretedasadistalsensation.383
Referralsourcesforthisregionincludetheheart,384pleura,lungtissue,diaphragmaticpain,385lymphnodesof
theneck,shoulder,chest,andbreasttissue.385
Painintheshoulderareacanbecausedbydirectorreferredpainfromanunderlyingmalignancy,suchasa
Pancoasttumor(seeTumor).385Thescapulaandhumerusarefrequentlysitesofmetastasesintumorsofthe
kidney,breast,lung,andprostate.364Thesepatientshavepersistentpainthatisunaffectedbymovementbutis
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associatedwithfatigue,weightloss,andotherconstitutionalsigns.Ahistoryofgraduallyprogressivepain,
startingasamildachebutdevelopingintopersistentseverepain,shouldinitiateasearchformalignancy.364
Severeshoulderpaininapatientwithanormalphysicalexaminationoftheshoulderandcervicalspineshould
increasethesuspicionofmalignancy.
Intrinsicneckpathologycancausereferredpaintothehead,anteriorandposteriorchestwall,shouldergirdle,
andupperlimb.383Inthecaseofradiculopathy,musclefunctionmightbeaffecteddirectly.Cervicalspine
symptomsareusuallyaffectedbyheadposition,withneckextensioncausinganexacerbationandflexion
producingsomerelief.364
IntracerebralandIntraspinalConditions
CerebrovascularDisease
SubclavianStealSyndrome
Thiscondition(seeChapter24)resultsinsignsandsymptomsofcerebralischemiaandupperarmpain.
Ischemiaistheresultofsubclavianarterystenosisproximaltotheoriginofthevertebralarteryand,
subsequently,stealsofbloodfromthecerebralcirculationoftheCircleofWillisandbasilarvessel(see
Chapter24).
Thesymptomsofsubclavianstealsyndromeareusuallyprecipitatedoraggravatedbyarmexercises.386
MultipleSclerosis
Pain,eitheracuteorchronic,occursinmorethan65%ofpatientswithMS387duringallstagesofthedisease.
Chronicpainmaybecharacterizedbydysestheticextremities,backandshoulderpain,andpainsecondaryto
spasticity.172Complicationsofdisuse,suchasfrozenshoulderandosteoporosis,areotherpainfulsyndromes
thatmaydevelop.172
ExtraspinalConditions
Theextraspinalcausesofshoulderpainincludetumor,clayshovelerfracture,brachialplexopathy,andherpes
zoster.
Tumor
Pancoastsyndromeisaconstellationofcharacteristicsymptomsandsignsthatincludesshoulderandarmpain
alongthedistributionoftheeighthcervicalnervetrunkandfirstandsecondthoracicnervetrunks,Horner
syndrome(seeChapter3),andweaknessandatrophyofthemusclesofthehand,mostcommonlycausedby
localextensionofanapicallungtumoratthesuperiorthoracicinlet.388,389Thesetumorsarecalledsuperior
pulmonarysulcustumorsorPancoasttumors.
ThemostcommoninitialsymptomisshoulderpainduetothelocalizationofthePancoasttumorsinthesuperior
pulmonarysulcus.Paincanradiateuptotheheadandneckordowntothemedialaspectofthescapula,axilla,
anteriorpartofthechest,oripsilateralarm,oftenalongthedistributionoftheulnarnerve.390Thisradicular
causalgicpainisoftendifficulttotreat.Sensorylossandmotordeficitintheupperextremitymayalsooccur.
Weaknessandatrophyoftheintrinsicmusclesofthehandarenotuncommon,alongwithpainandparesthesia
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ofthemedialaspectofthearm,forearm,andfourthandfifthdigitsalongthedistributionoftheulnarnerve,
causedbyextensionofthetumortotheC8andT1nerveroots.390
ThedifferentialdiagnosisofPancoastsyndromeincludesotherprimarythoracicneoplasms,metastaticand
hematologicconditions,infectiousdiseases,thoracicoutletsyndromes,andpulmonaryamyloidnodules.390
ClayShovelerFracture
Clayshovelerfractureisararecondition.TheconditionwasfirstdescribedbyMcKellar391andwasbasedona
fewcasesreported,foundinEnglishmen,whospentlonghoursdiggingheavyclay.Ithassincebeendescribed
inpowerlifters.392Theconditionischaracterizedbyatractionfractureofthelowercervicalorupperthoracic
spineduetoanexcessivepullofthetrapezius,rhomboidmusclesduringheavywork.Typically,thepatient
reportsasuddenonsetofasharpneck,shoulder,andarmpainandexhibitslimitedactivebilateralarmelevation
toaround150degrees.Passiveelevationremainsunaffected.Otherconditionsthatmimicthesesymptoms
includeafractureofthefirstrib,mononeuritisofthelongthoracicnerve,mononeuritisoftheaccessorynerve,a
C5rootpalsy,oratotalruptureofthesupraspinatus.372
BrachialPlexopathy393
Idiopathicbrachialplexopathy(IBP)isasyndromeofshoulderpainandweakness.IBPhasanumberof
pseudonyms,includingneuralgicamyotrophy,ParsonageTurnersyndrome,andidiopathicbrachialneuritis.
TheinitialsymptomtypicallyseenwithIBPissudden,sharp,andthrobbingpainintheshouldergirdle,
followedbyweaknessinthescapularandproximalarmmuscles.Sensorylossisusuallynotprominent.The
painusuallysubsideswithin24hoursto3weeks,andtheweaknessandatrophyarerecognizedasthepain
resolves.Weaknessismaximalwithin23weeksoftheonsetofsymptomsandoftenisaccompaniedbymuscle
wastingandscapularwinging.Slowresolutionoftheweaknessfollowsinnearlyallpatients,butrecoverymay
beincomplete.
HerpesZoster394
Herpeszosterischaracterizedbydeep,boring,orstabbingthoracicandarmpain.Varicellazostervirusinfection
isuniquebecauseofitstwoclinicalmanifestations:varicella(chickenpox)andherpeszoster(shingles).Afteran
individualhaschickenpox,thevirusliesdormantintheposterior(dorsal)rootgangliaandsensorygangliaof
cranialnerves.Herpeszosteroccursifthevirusbecomesreactivated,causinganacute,painfulinfectionofa
sensorynerveanditscorrespondingcutaneousareaofinnervation.Herpeszoster,therefore,occursonlyin
individualspreviouslyinfectedwiththechickenpoxvirus.
Postherpeticneuralgiaisthemostcommoncomplicationofherpeszoster.Itarisesfrominflammatoryinjuryto
sensorynerves,ganglia,andnerverootsandfrommaladaptiveresponsestopainsignalingandthelikely
inabilityofpainreceptorstoreturntonormalaftertheinflammationsubsides.Thenervedysfunctioncanresult
inhyperesthesia,hypoesthesia,dysesthesia,andallodynia(painastheresultofinnocuousstimuli,suchas
clothingtouchingtheaffectedskin).
Thecharacteristicrashbeginsaserythematousmaculesandpapulesthatprogresstovesicleswithin24hours,
thentopustules(34days),andfinallytocrusts(710days).Themostcommondistributionofherpeszosteris
unilateralinvolvementofthethoracicdermatome,followedbythecranial,cervical,andlumbardermatomes.
Involvementofthemaxillarydivisionofthetrigeminalnervecausesvesiclesoftheuvulaandtonsillararea.
Involvementofthemandibularbranchproducesvesiclesonthefloorofthemouth,buccalmembranes,andthe
anteriorpartofthetongue.Herpeszosternearorinvolvingtheeyesisconsideredanemergencybecausethis
potentiallyseriousdevelopmentcanleadtoblindness.
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Ingeneral,thediagnosisofherpeszosterisbasedonthehistoryandtheclinicalexamination,whichshowsthe
characteristicpainful,groupedvesicularrashinadermatomaldistribution.Acuteherpeszosterinfectionisa
selflimitingcondition,andtheprimarytreatmentgoalsaretoreduceandmanagetheacutepainandmodifythe
durationoftherashandinflammation.
CAUSESOFELBOWANDFOREARMPAIN
ThecausesofelbowandforearmpainincludethoselistedinTable518.
TABLE518PotentialCausesofElbowandForearmPain
Fracture
Dislocation
Osteochondritis
Ligamentsprain
Arthrosis
Softtissueinjuryortendinosis(lateralepicondyle,medialepicondyle,triceps,biceps,brachialisandLittle
Leagueelbow)
Infectivearthritis
Polyarthritis
Gout
Bursitis
Vasculardisorders
Referredpain
Fracture
SeeChapter17.
Dislocation
SeeChapter17.
OsteochondritisDissecansCapitellum
SeeChapter17.
LigamentSprain
SeeChapter17.
Arthrosis
Arthrosisoftheelbowisoftentheresultofapreviousmicroormacrotraumaticinjurytotheelbow.Unlessthe
caseissevere,thepatientdoesnotcomplainofmuchpain,exceptperhapswithvigorousactivity.However,
complaintsofearlymorningstiffnessandpainattheendofthedayarecommon.Motiontestingrevealsa
capsularpattern,withabonyendfeel,inbothflexionandextension,andcrepitusisfeltduringbothmotions.
Thereisnospecifictreatmentforthiscondition.Surgerymaybenecessarytoremoveloosebodiesorfor
debridementinseverecases.
PeripheralNerveEntrapment
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SeeChapters3and17.
SoftTissueInjuryorTendinopathy
SeeChapter17.
InfectiveArthritis
Thesourceofinfectivearthritisiscommonlytoothdecayorapelvicdisease.Ahistoryofapuncturewoundof
theskinalsoshouldarousesuspicion.Thepainisdescribedasasevereachingorthrobbing.Theinvolvedjoint
feelshotandappearsswollen.Theinvolvedelbowisusuallyheldstifflyinslightflexion.Associatedfindings
includefeverandjointtenderness.
Polyarthritis
Thepolyarthritisthatcanaffecttheelbowincludesacuterheumaticfever,Reitersyndrome,andLymedisease
arthritis.
Gout
Goutattheelbowischaracterizedbyacutepain,swelling,redness,andtendernessoftheelbowjoint.
Bursitis
SeeChapter17.
VascularDisorders
VolkmannIschemia(AnteriorCompartmentSyndrome)
Thisconditionoccursastheresultofincreasedtissuefluidpressurewithinafascialmusclecompartmentthat
reducescapillarybloodperfusionbelowalevelnecessaryfortissueviability.395Intheupperextremity,acute
compartmentsyndromethatinvolvestheforearmisthemostcommontypeofcompartmentsyndrome.Nerve
injuryresultingfromthecompressionproducesadeformedlimbknownasVolkmannischemiccontracture.396
Acutecompartmentsyndromecanbecausedbyconstrictivecastsordressings,limbplacementduringsurgery,
blunttrauma,hematoma,burns,frostbite,snakebite,strenuousexercise,andfractures.395Clinicalfindings
include395:
aswollenandtense,tendercompartment
severepainexacerbatedwithapassivestretchoftheforearmmuscles
sensibilitydeficits
motorweaknessorparalysisand
noabsenceofradialandulnarpulsesatthewrist.
Theclinicaldiagnosisisconfirmedbymeasuringtheintracompartmentaltissuefluidpressure.
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Conservativeinterventioninvolvestheremovaloftheconstrictingsplint,dressing,orcast.Surgicalintervention,
byperformingafasciotomy,isreservedforpatientswhosesymptomsdonotresolvequickly.395
AcuteAxillaryorBrachialArteryOcclusion
Thecausesofarterialocclusionincludeembolifromtheheartorfromanatheromatousplaqueoraneurysmof
theinnominateorsubclavianaxillaryarteries.397Traumatothechest,shoulder,orupperarmmayalsocause
arterialobstruction.ThefivePsdescribethesignsandsymptomsofthismedicalemergency:
Pain
Paralysis
Paresthesias
Pallor
Pulses(absent)
Thepainisusuallysevereandconstant,involvingtheforearm,hand,andfingers.Paralysisandparesthesia
indicatesevereischemiaofthearm.Gangrenecanbegintodevelop6hoursaftertheonsetofsymptomsinsuch
scenarios.Thepalloroccursbecauseoflackofbloodflowandcutaneousvasoconstriction.Theabsenceof
pulsesconfirmsocclusion.
ReferredPain
Referredpaintotheelbowcanhaveanumberofcauses,includingcoronaryheartdisease,polyarthritis,oran
acuteC8radiculopathy.
CAUSESOFWRIST,HAND,ANDFINGERPAIN
Wrist,hand,andfingerpaincanbecausedby,butarenotlimitedto,thoselistedinTable519andshownin
Figure54.
TABLE519CausesofWrist,Hand,andFingerPain
Fracture
Sprainsanddislocations
Triangularfibrocartilagecomplexlesions
Tenosynovitis
Tendinopathy
Carpalinstability
Goutandpseudogout
Rheumatoidarthritis
Psoriaticarthritis
Osteoarthritis
Carpaltunnelsyndrome
Infection
Kienbckdisease
Ganglia
Tumors
Reflexsympatheticdystrophy/complexregionalpainsyndrome
Vascularocclusion
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Mononeuritismultiplex
Referredpain
FIGURE54
Potentialcausesofwristandhandpain.
Fracture
SeeChapter18.
SprainsandDislocations
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SeeChapter18.
TriangularFibrocartilageComplexLesions
SeeChapter18.
Tenosynovitis
SeeChapter18.
Tendinopathy
SeeChapter18.
CarpalInstability
SeeChapter18.
GoutandPseudogout
Goutyarthritisandpseudogoutaremetabolicjointdiseasescausedbythedepositionofsodiumurateorcalcium
pyrophosphatecrystalsinthejoint,leadingtoarthritis(seealso,earlierdiscussions).Thewristsarethesecond
mostcommonlyaffectedjointinpseudogout,aftertheknees.Radiographsdemonstratecrystaldepositsin
articularfibrocartilageofthewrist.398Septicarthritisofthewristcancausethedestructionofjointcartilageand
bonystructures.Generally,thediagnosisofacuteinfectionisnotproblematic,butdifferentiationbetweenpure
softtissueinfectionandinfectioninvolvingthebonystructurescanbecomplicated.399Furthermore,
identificationofachronicinfectionasthecauseofchronicwristpainmaybedifficult.400,401Ifthereisa
clinicalsuspicion,a(ultrasoundguided)needleaspirationorsynovialbiopsyshouldbetaken.399Thenew
generationofultrasonographyhasproventobeavaluabletechnique,withahighsuccessrate,forobtaining
synovialfluidormembranesamplesforpathologicandbacteriologicexaminations.402
RheumatoidArthritis
Inthehand,manycommondeformitiescanbeseen,suchasulnardeviationoftheMCPjoints,boutonnire
deformity,andswanneckdeformitiesofthedigits(seeChapter18).
PsoriaticArthritis
SeesectionPsoriaticArthritisearlierinthechapter.
Osteoarthritis
SeeChapter18.
CarpalTunnelSyndrome
SeeChapter18.
Infection
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Wrist
Themostcommoninfectionofthewristisinfectioustenosynovitisoftheflexorpollicislongus.
Hand
Theseinfectionsinclude:
bursalinfections
spaceinfections
infectedbites
Cellulitis.Cellulitisisaninfectionoftheskinandunderlyingstructures.Withtreatment,itusuallyfollows
arelativelybenigncourse.However,insomecases,thesamepathogenscancauseotherdiseases,suchas
necrotizingfasciitisortoxicshocksyndrome,andevendeath.Themostcommonpathogensincellulitis
areS.aureusandhemolyticstreptococci.Symptomsincludelocalizedredness,swelling,andpain.
Associatedsymptomsincludefever,chills,andnauseaandvomiting.Cellulitistypicallyistreatedwith
systemicantibioticsviaeithertheoralortheintravenousroute.
Fingers
ParonychiaandEponychia.Paronychiaisanacuteinflammationofthelateralorproximalnailfoldsthatare
usuallycausedbyinfection,producingared,tender,throbbing,andintenselypainfulswellingoftheproximalor
lateralnailfolds.403Itisthemostcommoninfectionofthehand.Iftheinfectioninvolvestheeponychiumas
wellasthelateralfold,itiscalledeponychia.
Mildcasesofparonychiatypicallyaretreatedwithwarmsoakstwotofourtimesdailyandsplintingwithor
withoutsystemicantibiotics.Themoreseverecasesrequireincisionanddrainage.404
Differentialdiagnosisincludesapicalabscess,felon,andsubungualinfection.405Asubungualinfectionmay
resultfromanextensionoftheparonychiaunderthenail.405
Felon
Afelonisanabscessoftheterminalphalanxpulp.Themostcommoncauseisapuncturewound.Initially,the
conditionischaracterizedbymildswelling,erythema,andtenderness.Overaperiodofafewdays,thepulp
becomestense,red,andexquisitelytender.405
Mildcasesaretreatedwithantibioticsandelevation.Mostcases,however,requireacombinationofincisionand
drainage,andsystemicantibiotics.
WebSpaceInfections
Awebspaceabscessusuallyiscausedbyapunctureintheskinbetweenthefingers.Itischaracterizedbyits
collarbuttonordumbbellshape,astheexpandingabscesspenetratesthepalmarfascia.405Swellingand
tendernessarenotedonthepalmarandposterior(dorsal)aspectsofthewebspace.Theadjacentfingersadoptan
abductedposition.Theinterventioninvolvesincisionanddrainage.
HerpeticWhitlow
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Herpeticwhitlowisaviralinfectionofthefingers.Itiscausedbycontactwiththeherpessimplexvirus.405The
conditionusuallymanifestswithintensethrobbinganderythemaoftheinvolvedfinger.Theconditionisself
limitingandtypicallylastsfor23weeks.Theinterventionisconservativeandsymptomatic.405
KienbckDisease
Kienbckdisease,orlunatomalacia,isacomplicationofinjurytothelunate.Itisdefinedasanasepticor
avascularnecrosisofthelunate.Theetiologyofthisdiseaseremainselusive,althoughitisthoughtthattrauma
playsalargepartindisruptingthebloodsupplytothebone.406Thediseaseoccurspredominantlyinmales,with
a2:1prevalence,407andthemajorityofpatientsare2040yearsofage.408
Subjectivecomplaintsincludepainonthecentralposterior(dorsal)aspectofthewrist,especiallyduringand
afteractivities.Handstiffnessisanothercommoncomplaint.409Withtime,thepainbecomessevereand
constant,withaccompanyingweaknessofgripstrengthandlossofwristmotion,especiallywristextension.409
Imagingtechniquesareneededtomakeadefinitivediagnosis.
TheinterventionforKienbckdiseasedependsonthestageofthedisease.Conservativemeasuresinvolve
immobilizationduringtheacutephase.Surgicaloptionsincludejointlevelingbyradialshorteningorulnar
lengthening,intercarpalfusion,arthroplastyandvascularizedbonegrafts.410
Ganglia
Gangliaarethinwalledcystscontainingmucoidhyaluronicacidthatdevelopspontaneouslyoverajointcapsule
ortendonsheath.Ganglia,seenprimarilyin2030yearoldsmayalsooccurinassociationwithsuchsystemic
diseasesasarthritisorwithtrauma.411414Theexactcauseofthegangliaiscontroversial.However,thereis
consensusthataonewayconnectiontothesynovialsheathallowsfluidtoenterthecystbutnottoflowfreely
backintothesheath.411
Uponexamination,aganglionissmooth,round,ormultilobulatedandtenderwithappliedpressure.Thekeyto
distinguishingaganglionfromothersofttissuetumorsisthehistoryofsizevariation(Table520).Suspicious
softtissuemassesrequireevaluationandfurtherdiagnostictestingorexcisionalbiopsy.411
TABLE520DifferentialDiagnosisofWristGanglia
Benigntumor(chondroma,fibroma,giantcelltumoroftendonsheath,
hemangioma,lipoma,andneuroma)
Aneurysm/arteriovenous Malignanttumor(epithelioidsarcoma,malignantfibroushistiocytoma,
malformation metastasis,andsynovialsarcoma)
Anomalousmuscleandother Skeletal
anomalousstructure
Bursa Benigntumor(cyst,chondroma,giantcelltumor,collagen
Displacedtendon osteochondroma,andosteoidosteoma)
Foreignbodygranulomas Malignanttumor(chondrosarcoma,metastasis,andosteosarcoma)
Hypertrophicstructure
Nerveentrapment Infectious
Nerveganglion
Periarticularcalcaneal Fungus,mycobacteria,pyogen,tuberculosis
Repetitiveusefibrosis
Scar
Tendonentrapment Disease/metabolic
Tuberoussclerosis
Skeletal
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Arthriticresiduum Rheumatoidarthritisanddisease,rheumatoidnodule,synovialcyst,

Pigmentedvillonodularsynovitis andtenosynovitis
Posttraumaticresiduum:subluxed
scaphoid Goutandpseudogout
Neuritis(PIN),vasculitis,andamyloidosis
DatafromKozinSH,UrbanMA,BishopAT,etal.Wristganglia:Diagnosisandtreatment.JMusculoMed.
199310:7576.
Tumors
Benigntumorsaccountforthemajorityoftumorsofthewristandhand,althoughmalignanciescanoccur.415
Theclinicalpresentationisvariableanddependsonthecondition,location,size,anddegreeofsofttissue
involvement,althoughthereareanumberofscenariosthatwarrantsuspicionofapossibleoccultlesion:416
Ayoungpatientcomplainingofbonepainthatisnotrelatedtoanyprecedingtrauma.
Thepresenceofswelling,oramass,intheabsenceoftrauma.
Painorswellingthatpersistsdespiteintervention.
Thepainofaneurogenicorigincanbereferredtothewristandhand.ThesecanincludeC5T1nerveroot
lesions,peripheralnervelesions,thoracicoutletsyndrome,andbrachialplexustensionsyndromes(seeChapter
3).Inaddition,neurogeniccausescanbesecondarytoadhesionformationortrauma.
ProximalNerveEntrapment
Proximalcausesofpain,paresthesias,andnumbnessinthelateralhand,thumb,andindexandmiddlefingers
include:
C6orC7radiculopathy(seeChapter25)
thoracicoutletsyndrome(seeChapter25)
pronatorteressyndrome(seeChapter17).
Proximalcausesofthesesymptomsinthemedialhandandthefourthandfifthfingersinclude:
C8radiculopathy
brachialplexuscompressionatthethoracicoutletand
cubitaltunnelsyndrome(seeChapter17).
DistalNerveEntrapment(seeChapter18)
Entrapmentofthefollowingnervesmayoccur:
Mediannerve(carpaltunnelsyndrome)
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Ulnarnerve(Guyoncanalentrapment)
Radialnerve
ComplexRegionalPainSyndrome(ReflexSympatheticDystrophy)
SeeChapter18.
VascularOcclusion
Anembolusortraumamayobstructthebrachial,ulnar,orradialartery.Theamountofpaindistaltothe
obstructionisdependentonthedegreeofcollateralcirculation.Theprolongedrestrictiontothebloodflowmay
resultingangrene.
RaynaudPhenomenon
Raynaudphenomenonisavasculardisorderthatcanaffectonehandorbothhandsandthefeet.Reversible
vasospasmoftheextremitiesoccurseitherasanisolatedsymptomwithoutunderlyingdisorder(primary
Raynaudphenomenon)orinassociationwithanotherdisorderorcondition(secondaryRaynaudphenomenon).
Theclinicalfindingsincludedigitalpallorfollowedbycyanosisandthenrubor.417Throbbingandtingling
sensationsusuallyaccompanytheruborstage.
Raynaudphenomenonisusuallymanagedwithsimplemeasures,suchasusingwarmclothes,mittens(not
gloves),handwarmers,andautomaticcarstarters.418Themostfrequentlyuseddrugsarecalciumchannel
antagonists.
Scleroderma
Sclerodermameanshardskin.Thetermisusedtodescribetwodistinctdiseases:localizedsclerodermaand
systemicscleroderma.Localizedsclerodermaisprimarilyacutaneousdisease.Systemicsclerosisisa
multisystemconnectivetissuedisease.Theetiologyofbothofthesediseasesisnotknown.
Therearetwomainsubsetsofsystemicsclerosis,limitedscleroderma(formerlyreferredtoasCREST
syndrome)anddiffusescleroderma:
Limitedscleroderma.PatientsgenerallyhavealonghistoryofRaynaudphenomenon,insomecases10
15years,andmildlypuffyorswollenfingersbeforetheypresenttotheirphysicianwithadigitalulcer,
heartburn,orshortnessofbreath.
Diffusescleroderma.Patientshaveamuchmoreacuteonsetofdisease.Theyhavearthralgias,carpal
tunnelsyndrome,swollenhands,swollenlegs,andcrepituslikefrictionrubsoverthetendonareasof
hands,wrists,andankles.Thesepatientspotentiallyhavesevereproblemsnotonlyfromskinthickening
andcontracturesbutalsofromotherorgansystems,includinggastrointestinal,pulmonary,cardiovascular,
andrenal.
Raynaudphenomenonispresentinalmostallpatientswithscleroderma.
MononeuritisMultiplex
Thisconditionisassociatedwithasuddenonsetofsevereachingorsharpforearmandhandpain,paresthesias,
anddysesthesiasinthedistributionofthemedian,ulnar,orradialnerves.417Mononeuritismultiplexcanoccur
inassociationwithanumberofothermedicalconditions,includingRA,vasculitis,polyarteritisnodosa,diabetes
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mellitus,sarcoidosis,andamyloidosis.Anischemicmechanismisthemostlikelycauseofmononeuritis
multiplex.ItisgenerallyacceptedthatmononeuritismultiplexinRAresultsfromischemiacausedbyvasa
nervorumvasculitis.
ReferredPain:Viscerogenic
Theheart,apicallung,andbronchusareallcapableofreferringpaintothewristandhand.
CAUSESOFKNEEPAIN
GeneralizedKneePain
Causesofgeneralizedkneepaininclude:
fracture(supracondylar,patellar,andproximaltibia)
acutedislocationofthetibiofemoraljoint
acutedislocationofthepatella
intraarticularligamentinjury(seeChapter20)
monoarthritis
polyarthritis
reactivearthritis
CRPS(RSD)and
referredpain.
AnteriorKneePain
Anteriorkneepainisacommonprobleminactiveadolescentsandyoungadults.Thecausesofanteriorknee
paingenerallyfallunderthreecategories:419
Focalmusculoskeletallesions.Thisgroupconsistsmainlyoflesionsthatcanbeclinicallyand
radiologicallydefined.SuchlesionsincludeOsgoodSchlatterdisease,jumpersknee,bipartitepatella,
tumors,plicalirritation,andligamentousinjuries(seeChapter20).Theselesionsnormallyrespondwellto
locallyappliedinterventions.
Traumaticlesions.Thisgroupincludesall(seeChapter20)theconditionswithaspecificmechanismof
injuryinvolvingdirecttrauma.Theseconditionsincludeosteochondritisdissecansandbonecontusions.
Miscellaneouslesions.Thisgroupincludesthemoreobscurecausesofanteriorkneepainincluding
dynamicproblems,suchasmaltrackingofthepatellaandtheexcessivelateralpressuresyndrome(see
Chapter20),aswellasidiopathicchondromalacia,referredpain,CRPS,andpsychogenicpain.
MusculoskeletalCauses
OsgoodSchlatterDisease
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SeeChapter30.
Bursitis
SeeChapter20.
JumpersKnee
SeeChapter20.
BipartitePatella
Thisconditioniscommoninchildhood.Itisoftenbilateralandusuallyisregardedasavariationofnormal
ossification.Veryrarely,inresponsetooveruseoracuteinjury,thesynchondrosisseparatingthetwocentersof
ossificationmaybecomepainfulandthesiteoflocaltenderness.Therearethreesitesatwhichbipartitepatella
isfound,andeachhasanimportantsofttissueattachment:419
Thedistalpoleofthepatellawithattachmentofthepatellartendon.Thistypemayrepresenttheendstage
ofSindingLarsenJohanssonsyndrome.
Lateralmarginofthepatellawithattachmentofthelateralretinaculum.
Superiorlateralcornerofthepatella,theinsertionofvastuslateralis.Thisisthemostcommonsitefor
symptoms.
TraumaRelatedCauses
OsteochondritisDissecans
Osteochondritisdissecans(OCD)isararecauseofanteriorkneepaininyoungathletes.Itinvolvestheweight
bearingportionsofthemedialandlateralfemoralcondyles.Occasionally,painmaynotbethemostprominent
symptom,butacatchingsensationwithkneeflexionoranextensorweaknessmaybetheprimarycomplaint.
Sometimesthelesionisassociatedwithmaltracking.Ifthelesionissmall,apainfularcisproducedasitpasses
overthearticularsurfaceofthefemurduringmovement.
MRI,CT,andbonescansareoftenusedtocharacterizetheselesions.
Conservativeinterventionwithrestisappropriateforintactlesions,whichusuallywillshownosclerosis,andin
patientsyoungerthan13or14years,inwhomhealingistherule.419
Surgicaltechniquescanbeusedtosecurelyattachthelooseosteochondralfragmentstotheunderlyingbone.
BoneContusion
Bonecontusions(bruises)arerelatedtotraumaandcanoccuratsitesotherthantheknee.Thereisnounique
mechanismofinjury,buttheyseemtoresultfromdirectimpact,axialoverloading,andimpingement.Theypose
apotentialriskforchondrolysisandstressfracture,andmobilizationandweightbearingshouldbeincreased
gradually.
MiscellaneousCauses
Tumors
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Neoplasticinvolvementofthekneeisalesscommoncauseofkneepain.Malignantprimarytumorsarising
fromthepatellaincludehemangioendothelioma,hemangiosarcoma,lymphoma,fibroushistiocytoma,
osteoblastoclastoma,andplasmacytoma.420Softtissuesarcomasarethemostcommonmalignanttumorofthe
knee,andtheseincludeosteosarcomas,Ewingsarcoma,rhabdomyosarcoma,andsynovialsarcomas.421,422
Metastasistothepatellaisrare.423
Benigntumorsaremoreprevalentatthissite.Inapublishedseriesof42patellartumors,42490%werebenign,
withthemostcommondiagnosisbeingchondroblastoma.Otherbenigntumorsofthekneemayinclude
osteochondromas,nonossifyingfibromas,andosteoidosteomas.Veryrarely,softtissuetumorsmayoccur
withinthefatpadinaddition,synoviallesions,suchasPVNsynovitis,cancauseanteriorkneepain,clicking,
andcatching.419
Ahistoryofkneepainworsenedbyactivityandrelievedbyrestsuggestsbenigninvolvement.However,pain
thatisconstant,unrelenting,severe,andthatoccursatnightsuggestsamalignantprocess.425427Inmalignant
tumorsofthepatella,thepathologicfractureisoftenthepresentingcomplaint.
Plicae
SeeChapter20.
HoffaSyndrome
SeeChapter20.
OsteomyelitisofthePatella
Osteomyelitisofthepatellausuallyaffectschildrenbetweentheagesof5and15years.Itisexceedinglyrarein
adultsandinchildrenyoungerthan5years.428
Thepatientmaypresentwithcomplaintsofaninsidiousonsetofpainandswellinginthekneeandcalf.Pain
localizedtothepatellamaybemildorsevere,causingalimpandrestrictionofmotion.Motionislessseverely
affectedthaninpatientswithsepticarthritis.Swellingmaybeminimalinthemoreindolentcases,ormarked
withdistentionoftheprepatellarbursaortheknee,whichmaydivertattentionfromthepatella.Cellulitis
overlyingthepatellamayalsobepresent.Isolatedpinpointtendernessoverthepatellaisprobablythesingle
mostusefulclinicalsign.428
Differentialdiagnosisoftheswollenkneeinanindividualwithsepsisincludessepticarthritisosteomyelitisof
thedistalfemur,proximaltibia,orpatellaandsepticbursitis.429Withmorebenignsymptomsandthepresence
ofalyticlesionofthepatella,neoplasm,andBrodieabscessmustbeconsidered.429
ExcessiveLateralPressureSyndrome
SeeChapter20.
MaltrackingofthePatella
SeeChapter20.
IatrogenicCauses:InfrapatellarContractureSyndrome
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SeeChapter20.
MedialKneePain
Thecausesofmedialkneepainincludethefollowing.
Medialmeniscustear:seeChapter20.
Medialcollateralligamentsprain:seeChapter20.
Medialcollateralligamentbursitis:seeChapter20.
Hoffasdisease:seeChapter20.
Pesanserinebursitis:seeChapter20.
Semimembranosustendinopathy:seeChapter20.
LateralKneePain
Thecausesoflateralkneepainincludethefollowing.
Iliotibialbandfrictionsyndrome:seeChapter20.
Popliteustenosynovitis
Popliteustendonrupture
Lateralmeniscaltear:seeChapter20.
Lateralcollateralligamentsprain:seeChapter20
Tibiofibulardisorder:seeChapter20.
Bicepsfemoristendinopathy:seeChapter20.
Osteochondralfractureofthelateralfemoralcondyle
PosteriorKneePain
Thecausesofposteriorkneepainincludethefollowing.
Gastrocnemiusmusclestrainorrupture
Plantarismusclestrainorrupture
Hamstringmuscleandtendondisorder
Musclespasmorcramp
Posteriorcruciateligamentorposteriorcapsuletear:seeChapter20
Bakercyst:seeChapter20
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CAUSESOFLOWERLEGPAIN
AnterolateralLowerLegPain
ThecausesofanterolaterallowerlegpainincludethoselistedinTable521.
TABLE521PotentialCausesofAnterolateralLegPain
Anteriorcompartmentsyndrome
Lateralcompartmentsyndrome
Irritationofthesuperficialfibular(peroneal)nerve
Musclestrainofoneormoreofthefibularis(peroneal)musclesorofanteriortibialis
AnteriorCompartmentSyndrome
Acompartment,orchronicexertionalcompartment,syndromeisaconditionofpainassociatedwithincreased
tissuepressureintheinvolvedmuscularcompartmentwithsustainedexercise.Duringheavyexercise,fluid
accumulateswithintheinterstitialspaceofskeletalmuscle,increasingmassupto20%asthefluidincreases.430
Thegradualbuildupofinterstitialfluidcombinedwithalimitedexpansionofthefascialcompartments,
especiallyintheanteriorandlaterallegcompartments,mayleadtoelevatedintramuscularpressures,causing
capillaryocclusion,andeventualcellhypoxiaanddeath.431Thus,thisconditionissuggestedbylowerleg
muscularpainwithrunningorotheractivityandisrelieved,veryrapidly,bystoppingtheactivity.Theclinical
signsofcompartmentsyndromecanberememberedusingthemnemonicofthefivePs:pain,paralysis,
paresthesia,pallor,andpulses.Pain,especiallydisproportionatepain,isoftentheearliestsign,butthelossof
normalneurologicsensationisthemostreliablesign.432,433
Palpationofthecompartmentinquestionmaydemonstrateswellingoratensecompartment.434Adecreaseor
lossoftwopointdiscriminationalsocanbeanearlyfindingofcompartmentsyndrome.432,433Clinicalfindings
mayalsoincludeshiny,erythematousskinoverlyingtheinvolvedcompartment(describedaswoody)and
excessiveswelling.Intracompartmentaltissuepressureisusuallylowerthanarterialbloodpressure,making
peripheralpulsesandcapillaryrefillpoorindicatorsofbloodflowwithinthecompartment.434
Compartmentsyndromeisconfirmedbyelevatedcompartmentpressures.Normaltissuepressureranges
between0and10mmHg.434Capillarybloodflowwithinthecompartmentmaybecompromisedatpressures
greaterthan20mmHg.Muscleandnervefibersareatriskofischemicnecrosisatpressuresgreaterthan3040
mmHg.
Differentialdiagnosisincludestibialstressfracture,anteriortibialistendinopathy,andthecatchallgroupof
shinsplints.Acutecompartmentsyndromerequiresemergentsurgicalfasciotomy.
LateralCompartmentSyndrome
Lateralcompartmentsyndromeisveryrare.Itisoftenmisdiagnosedastenosynovitisofthetibialisanteriorand
flexorhallucislongus,fibularstressfracture,oralateralgastrocnemiusstrain.Characteristicfindingsinclude
tendernessalongtheproximalhalfoftheleg,withswellingandtightnessoverthelateralcompartment.On
occasion,theremaybecomplaintsofnumbnessovertheposterioraspectofthefootcausedbycompressionof
thesuperficialfibular(peroneal)nerve.433,434
Interventionisbasedontheseverityofthesymptoms.Inmildcases,treatmentinvolvesrelativerest,education,
andexaminationforunderlyingetiologies.435Theseincludelowerextremitymalalignment,muscleimbalances,
trainingerrors,inadequatefootwear,andpoortechnique.435
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Anacutecompartmentsyndrome,oronethatdoesnotrespondtoconservativeintervention,requiresanopen
fasciotomy.
PoplitealArteryEntrapmentSyndrome
Mostcasesofpoplitealarteryentrapmentsyndrome(PAES)arecausedbyanatomicvariationsinthenormal
courseofthepoplitealartery(seeChapter20),includinganabnormalattachmentofthemedialheadofthe
gastrocnemiuswithintheintercondylarnotch,medialcourseofthepoplitealartery,hypertrophyofsurrounding
musculatureand/oraberrantfibrousbands.436,437Anyoneoftheseanomaliescanresultinafocalcompression
ofthepoplitealarteryagainstthemedialfemoralcondyleduringforcefulplantarflexion.438Sincepopliteal
arteryentrapmentsyndromeisverysimilarinitspresentationtochronicexertionalcompartmentsyndromecare
mustbetakenwiththediagnosis.PAESiscommonlydiagnosedusingtheanklebrachialindex(i.e.,ratioofthe
bloodpressureinthelowerlegstothebloodpressureinthearms).439Sincethisentrapmentistypically
functional,itisrecommendedthattheanklebrachialindexbedonewiththeankleintheneutral,forced
dorsiflexion,andforcedplantarflexionpositions.439Ananklebrachialindexoflessthan0.9isconsidered
abnormal.439
IrritationoftheSuperficialFibularis(Peroneal)Nerve
Compressionofaperipheralnervecausesdeformationofthenervefibers,localischemia,edema,andincreased
endoneurialpressurecausedbyacceleratedvascularpermeability,resultinginthelossofnervefiberfunction
(seeChapter3).
MuscleStrain
SeeChapter20.
CalfPain
ThecausesofcalfpainincludethoselistedinTable522.
TABLE522PotentialCausesofCalfPain
Pyomyositis
Fibularshaftfracture
Deepveinthrombosis
Hematoma
RuptureofAchillestendon
Soleusmusclestrain
Acuteposteriorcompartmentsyndrome
Musclecramps
Pyomyositis
Pyomyositisisatermusedtodenoteaspontaneousmuscleabscessofskeletalmuscle.Itispredominantlya
diseaseoftropicalcountries.Theetiologyofpyomyositisispoorlyunderstood.Localmechanicaltraumaatthe
timeofincidentalbacteremiaisfrequentlypostulatedasamechanism.Underlyingconditions,suchas
immunodeficiency,orchronicillness,suchasdiabetesmellitus,maypredisposetopyomyositis.
Thenaturalhistoryofpyomyositismaybedividedintothreestages:invasive,purulent,andlate.
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1.Invasivestage.Thisstageoccurswhentheorganismentersthemuscle.Itischaracterizedbyaninsidious
onsetofdull,crampingpain,withorwithoutfeverandanorexia.440Thereislocalizededema,sometimes
describedasinduratedorwoody,butusuallylittleornotenderness.Thisstagelastsfrom10to21days.
2.Purulentstage.Thisstageoccurswhenadeepcollectionofpushasdevelopedinthemuscle.Themuscle
usuallybutnotalwaysistender,andfeverandchillsarecommon.Theoverlyingskinmaybenormalor
showmilderythema.
3.Latestage.Thisstageischaracterizedbyexquisitetendernessofthesite,whichisredandfluctuant.The
patienthasahighfeverandoccasionallymaybeinsepticshock.
Theiliopsoasisoneofthemostcommonsitesofpyomyositis(seethediscussionofiliopsoasabscessunder
CausesofPelvicPainearlier),buttheycanalsooccurinotherlegmuscles.
FibularShaftFracture
Directtraumaisthemostcommoncauseofisolatedfibularfractures.441Anothercauseisaforcedmuscle
contractionofthesoleus.442Fibularstressfracturesarecommoninlongdistancerunners.Maximalloadingof
thefibulaoccursduringtheinitialperiodofstanceandforcesuptothreetimesbodyweightaretransmitted
throughtheleg.443Thus,painwiththisconditionistypicallyreportedwithweightbearingduringtheinitial
periodofstance.Therealsomaybetendernessoverthefracturesite.
DeepVenousThrombosis
Muscleveinsdrainintothedeepveinsofthelowerextremity.Solealmuscleveinsdrainintothefibularand
tibialposteriorveins.Theveinsofthegastrocnemiusdrainintothepoplitealvein.Thrombosisusuallydevelops
asaresultofvenousstasisorslowflowingbloodaroundvenousvalvesinuses(seeChapter2).Extensionofthe
primarythrombusoccurswithinorbetweenthedeepandsuperficialveinsoftheleg,andthepropagatingclot
causesvenousobstruction,damagetovalves,andpossiblevenousthromboembolism(VTE).Mostepisodesof
VTEareclinicallysilent.Themostcommoncauseoflegswellingisedema,butexpansionofallorpartofa
limbmayresultfromanincreaseinanytissuecomponent(muscle,fat,blood,etc.).444
Theclinicalfeaturesofadeepveinthrombosis(DVT)include:444
calfpainortenderness,orboth
swellingwithpittingedema
swellingbelowtheknee(distaldeepveinthrombosis)oruptothegroin(proximaldeepveinthrombosis)
increasedskintemperature
superficialvenousdilationand
cyanosis,inpatientswithsevereobstruction.
Theinterventionisaimedatreducingsymptomsandpreventingcomplications.Themaincomplicationsofa
DVTareapulmonaryembolism(seeChapter2),postthromboticsyndrome,andrecurrenceofthrombosis.444
Proximalthrombiareamajorsourceofmorbidityandmortality.Distalthrombiaregenerallysmallerandmore
difficulttodetectnoninvasively,andtheirprognosisandclinicalimportancearelessclear.444
Hematoma
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Astrainofthegastrocnemiusmusclemayfollowatrivialtrauma.Completeorpartialtearsofthe
musculotendinousunitmayresultinahematoma.Clinicalmanifestationsofgastrocnemiushematomamay
includelocalswelling,pain,andtendernessaggravatedbypassivedorsiflexionoftheanklejoint.Thiscondition
canmimicaDVT.Thesubjectivehistorymayhelpwiththediagnosis.AdefinitediagnosisisestablishedbyCT
scanningexamination,whichwillrevealalocalsofttissuemasswithinthegastrocnemiusconsistentwitha
hematoma.
RuptureoftheAchillesTendon
SeeChapter21.
SoleusMuscleStrain
SeeChapter21.
AcutePosteriorCompartmentSyndrome
Acutecalfpaincanoccurasaresultofaposteriorcompartmentsyndrome.CausesincludeaDVT,ruptureofa
Bakercyst,andspontaneousruptureofthemedialheadofthegastrocnemius.Thediagnosisofposterior
compartmentsyndromeismadebymeasuringthepressureintheposteriorcompartment.Theintervention
usuallyinvolvesafasciotomy.
AnteromedialLowerLegPain
ThecausesofanteromediallowerlegpainincludethoselistedinTable523.
TABLE523PotentialCausesofAnteromedialLowerLegPain
Stressfractureoftibia
Medialtibialstresssyndrome
Saphenousneuritis
Osteomyelitisoftibia
Soleussyndrome
Shinsplints
Greatersaphenousveinthrombosis
MedialTibialStressSyndrome
SeeChapter21.
SaphenousNeuritis
Saphenousneuritis,alsoknownasgonalgiaparesthetica,isapainfulconditioncausedbyeitherirritationor
compressionattheadductorcanalorelsewherealongthecourseofthesaphenousnerve.445Theconditionmay
alsobeassociatedwithsurgicalornonsurgicaltraumatothenerve,especiallyatthemedialoranterioraspectof
theknee.
Saphenousneuritiscanimitateotherpathologyaroundthekneeorcalf,particularlyamedialmeniscaltear,
muscleinjury,orOA.Asanisolatedentity,saphenousneuritismayappearinconjunctionwithothercommon
problems,suchasOAandpatellofemoralpainsyndrome.Itsclinicalappearanceischaracterizedbyadullor
achypainalongthecourseofthesaphenousnerveonthemedialsideofthethigh,knee,orcalf.Hyperesthesia
ofthenerveiscommon.Thereisusuallytendernesstolightpalpationalongthecourseofthenerve,especiallyat
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theexitofthenervefromtheadductorcanal,nearthemedialjointline,oralongthenerveintheproximalthird
oftheleg.Thediagnosisisconfirmedbyreliefofsymptomsafterinjectionoftheaffectedareawithlocal
anesthetic.
Initialtreatmentcanincludenonsurgicalsymptomaticcare,treatmentofassociatedpathology,desensitization
therapy,transcutaneouselectricalnervestimulation(TENS),anddiagnosticortherapeuticinjectionsoflocal
anesthetic.Inrecalcitrantcases,surgicaldecompressionandneurectomyarepotentialoptions.Thekeyto
treatmentispromptrecognitionpalpationofthesaphenousnerveshouldbepartofeveryroutineexaminationof
theknee.
OsteomyelitisoftheTibia
Osteomyelitisisasevereinfectionthatcanariseafteroperativetreatmentofboneandfromanacute,penetrating
traumatothebone.Thetibiaisthemostcommonsiteofposttraumaticosteomyelitis.446Posttraumatictibial
osteomyelitisresultsfromtraumaornosocomialinfectionfromthetreatmentoftraumathatallowsorganismsto
enterthebone,proliferateintraumatizedtissue,andcausesubsequentboneinfection.446Theresultinginfection
isusuallypolymicrobial.
Patientswithposttraumaticosteomyelitisofthetibiamaypresentwithlocalizedboneandjointpain,erythema,
swelling,anddrainagearoundtheareaoftrauma,surgery,orwoundinfection.446Signsofbacteremias,suchas
fever,chills,andnightsweats,maybepresentintheacutephaseofosteomyelitis,butnotinthechronic
phase.446
Radiographsareimportantforthediagnosis,staging,andevaluationoftheprogressionofposttraumatic
osteomyelitis.446
CAUSESOFANKLEPAIN
ThecausesofgeneralizedanklepainincludethoseshowninFigure55andlistedinTable524.
FIGURE55
Potentialcausesoffootandanklepain.
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TABLE524PotentialCausesofGeneralizedAnklePain
Crystalinducedarthropathies
Ligamentsprain
Tendinopathy
Fracture
Bursitis
Ostrigonum
Osteochondritisdissecansoftalus
Acutemonarthritis
Transientmigratoryosteoporosis
Polyarthritis
Lymearthritis
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Reitersyndrome
Rheumatoidarthritis
CrystalInducedArthropathies
Twotypesofarthritis,gout,andpseudogoutarequitecommonintheanklejoint.Episodesofacutearthritisin
thisregion,withoutapparentcause,shouldarousethesuspicionofagoutattack,especiallyinamiddleaged
man.
LigamentSprain
SeeChapter21.
Tendinopathy
SeeChapter21.
Fracture
SeeChapter21.
Bursitis
SeeChapter21.
OsTrigonum
Thetermostrigonumreferstoafailureofthelateraltubercleoftheposteriorprocesstounitewiththebodyof
thetalusduringossification,producinganimpingementwithextremeplantarflexion.447Theposterioraspectof
thetalusoftenexhibitsaseparateossificationcenter,appearingat810yearsingirlsand1113yearsinboys.
Fusionusuallyoccurs1yearafteritsappearance.448,449Whenfusiondoesnotoccur,anostrigonumisformed.
Anostrigonumhasbeenreportedtobepresentinapproximately10%ofthegeneralpopulationandisoften
unilateral.448,450452Theoriginofthisossiclemaybecongenitaloracquired.Congenitally,itcanbea
persistentseparationofthesecondarycenterofthelateraltuberclefromtheremainderoftheposteriortalus
secondarytorepeatedmicrotraumaduringdevelopment.448,452Theacquiredformmaybesecondarytoan
actualfracturethathasnotunited.448,452,453Witheitherform,theostrigonumisusuallyasymptomaticinmost
cases.447However,itcanbecomesymptomaticinyoungathleteswhoactivelyplantarflextheankle,suchas
balletdancers,gymnasts,iceskaters,or,onoccasion,soccerplayers.448,450,452,454,455
Symptomsassociatedwithostrigonumincludepainwithmaximumplantarflexionastheposteriortalus
impingesontheposteriortibia.456Thepain,whichistypicallyintheposterolateralankle,resultsfromthe
mechanicalimpingementoftheposteriortalusbetweentheposteriortibiaandthecalcaneus.447Repetitive
impingementofthesofttissuesinthisintervalcanalsoresultinhypertrophiccapsulitis.448,451,457459
Associatedposteromedialpain.Associatedposteromedialpain448,454,458mayindicateaconcurrentflexor
hallucislongustendinopathy.Thediagnosisisconfirmedbyimagingstudies.
Plainradiographsshouldincludealateralviewoftheankleandalateralviewinplantarflexion.Abonescan
maybeusedtodeterminethereactivityoftheostrigonum,448,460butabsenceofuptakedoesnotexclude
impingement.447
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Differentialdiagnosisincludesposteriorankleimpingement,Achillestendinopathy,fibularistendinopathy,and
flexorhallucislongustendinopathy.448
Conservativeinterventionmayincluderest,antiinflammatorymedications,avoidanceofplantarflexioncasting,
andinjection.448,454Onceappropriate,restorationofnormalstrength,ROM,andbiomechanicsareintroduced.
Ifsymptomspersist,surgicalremovalofthebonemayberequiredbutisdelayeduntilskeletalmaturityis
achieved.456
OsteochondritisDissecans
OCDofthetalusmayresultfromaninversionstresstotheankle.Thisisactuallyatranschondralfracture
secondarytotrauma.461Morecommonly,theonsetofpainisinsidious,andsomepriormacrotraumais
evident.447Youngpatientsmaypresentwithpainovertheanterolateralorposteromedialtalusandoftenreport
recurrentankleeffusionsorweakness.Plainradiographsoftheankleusuallyshowthelesion,butsometimesa
bonescanorMRIisnecessaryfordiagnosis.462TheBerndtHarty463classificationoftalusOCDisasfollows:
TypeI.Smallareaofcompressionofsubchondralbone.
TypeII.Partiallydetachedosteochondralfragment.
TypeIII.Completelydetachedosteochondralfragmentbutremaininginitscrater.
TypeIV.Displacedosteochondralfragment.
BerndtandHarty463reportedthat43%ofOCDlesionsinvolvedthemiddlethirdofthelateraltalus,with57%
involvingtheposteriorthirdofthemedialtalus.461Onestudy464reportedthatlateralOCDlesionsrarelyheal
ontheirown,whereasmostmediallesionsdo.461
TheinterventionfortypeIandIIlesionsbeginswithcastingandorthotics.447TheinterventionfortypeIII
mediallesionsstartsoffconservatively,aswell,butmayrequirearthroscopicoropendebridement.TypeIII
laterallesionsandtypeIVlesionsallrequirearthroscopicremovalorpinningforthebestchanceofhealing.465
CAUSESOFFOOTPAIN
GeneralizedFootPain
ThecausesofgeneralizedfootpainincludethoseshowninFigure55andlistedinTable525.
TABLE525PotentialCausesofGeneralizedFootPain
Trauma
Infection
Rheumatoidarthritis
Gout
Pseudogout
Systemiclupuserythematosus
Sicklecelldisease
Reflexsympatheticdystrophy/complexregionalpainsyndrome
Peripheralvasculardisease
Peripheralpolyneuropathy
Systemicdisorders
Nerveandrootcompressionsyndromes
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Footcramps
Coldinjury
Bites

Cutaneousdisorders
Infection
Infectionofthefootincludessuchdiagnosesascellulitis,necrotizingfasciitis,andosteomyelitis.
Cellulitis
Cellulitisiscommonafterfootandanklesurgery.Itisimportanttodistinguishasuperficialinfectionfromone
thatinvolvesthedeepersofttissueenvelopeandpossiblythejointorbone.
Superficial.Withasuperficialinfection,theskiniswarm,tender,anderythematous,butjointmotionis
painless.Occasionally,lymphangitisorlymphadenopathyispresent.Theareaistendertopalpation.The
mostcommoncausativeorganismsinuncompromisedhostsareS.aureusandhemolyticstreptococci.
Deep.Deepinfectionswithabscessformationareaseriouscomplication.Inpatientswithdeepinfections,
theskiniswarm,tender,swollen,andpossiblyfluctuant.Whitebloodcellcountandtemperaturemaybe
increased.Plainradiographs,MRI,andneedleaspirationarehelpfulinmakingthediagnosis.
NecrotizingFasciitis
Necrotizingfasciitisischaracterizedbyrapidlyprogressivenecrosisandedemaofthesubcutaneousfatand
fasciathatcanresultinsepticshock,endorganfailure,andlossoflimborlife.Patientswhoare
immunocompromised,suchasthosewithhumanimmunodeficiencyvirus(HIV)infections,diabetesmellitus,
andalcoholism,areatincreasedriskofnecrotizingfasciitis.Clinicalsignsofnecrotizingfasciitisincludetense
edemaanderythemathatdonotrespondtoantibioticsorelevation.Patientsareusuallyfebrile.
Osteomyelitis
Fever,localpain,edema,exudativedrainage,andelevatedleukocytecountandsedimentationratearetypical
findingswithosteomyelitis.Surgicaltreatmentofpatientswithosteomyelitisconsistsofdebridementofall
necroticandinfectedtissueandappropriateantibiotictherapy.Treatmentmayalsoincludetheuseofantibiotic
impregnatedmethylmethacrylatebeads,localorvascularizedsofttissueflaps,autogenousbonegrafts,or
vascularizedbonegraftsoncetheinfectioniseradicated.
RheumatoidArthritis
RAcharacteristicallyinvolvesthesynovialtissuesofthesmalljointsofthefeet,ratherthanthetalocruralor
subtalarjoint.Threetimesmorewomenthanmenareaffected.In17%ofcases,thediseasefirstmanifestsinthe
foot.466
Theearlystageofthediseaseshouldbesuspectedinyoungwomenpresentingwithbilateralfootpainanda
tendencyformorningstiffnessintheMTPjointsofthefeet.
Gout
About60%ofinitialattacksofgoutinvolvethegreattoe(podagra),whichbecomesswollenandexcruciatingly
painful.466
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Pseudogout
PseudogoutinvolvesjointsinadditiontotheMTPjoint,includingthetalonavicularorsubtalarjoints.466
SystemicLupusErythematosus
SLEisasystemicautoimmunediseasewithclinicalfeaturesthatincludeglomerulonephritis,rashes,serositis,
hemolyticanemia,thrombocytopenia,andCNSinvolvement.467Thisdiseaseoccursmostcommonlyinwomen
ofchildbearingage.
ThevarietyofneurologicpresentationsofSLEcanincludecranialneuropathies,strokesyndromes,movement
disorders,spinalcordlesions,seizuredisorders,dementias,cognitivedisturbances,psychoses,andmood
disorders.Peripheralnervoussystem(PNS)manifestationsincludesymmetricpolyneuropathies,mononeuritis
multiplex,acuteinflammatorydemyelinatingpolyneuropathies,chronicrelapsinginflammatorydemyelinating
polyneuropathies,andautonomicfailure.
SLEisconsideredtobetheprototypicalhumanautoimmunediseasemediatedbypathogenicimmune
complexes.
SickleCellDisease468
SicklecelldiseaseisaninheritedblooddisorderthataffectsmostlyAfricanAmericans.Itleavespatients
vulnerabletorepeatedcrisesthatcancauseseverepain,multisystemorgandamage,andearlydeath.Sicklecell
crisestypicallybeginduringthepreschoolorearlyelementaryschoolyears.Howoftentheyrecurandhowlong
eachattacklastsvaryconsiderably.
Thecrisisbeginswhenatriggersuchasanacuteinfection(especiallyviral),stress,dehydration,orextremely
hotorcoldtemperaturescausestheredbloodcellstoreleaseoxygen.Peoplewiththesicklecelldiseasehave
abnormalhemoglobin,calledhemoglobinS(HbS),whichformslongpolymersupondeoxygenation.Therod
likepolymerschangethenormallyroundandpliableredbloodcellsintostiffcellswithacrescent,orsickle,
shape.
Bundlesofthesedeformedcellsplugupthecapillariesthroughoutthebody,reducingbloodflow.This
vasoocclusioncauseslocalizedtissuehypoxia,which,inturn,promotesfurthersickling.Tissueinfarctionand
necrosissoonfollow.
Painisusuallythemainsymptom.Itmaybelocalizedordiffuse,constantorintermittent.Abouthalfofall
patientsalsohaveafever,swellinginthejointsofthehandsorfeet,longbonepain,tachypnea,hypertension,
nausea,andvomiting.Hospitalizationbecomesnecessarywhenthesecomplicationsaresevere.Acutechest
syndromeandcerebrovascularaccidentsarelifethreateningcomplicationsofsicklecelldisease.Inaddition,the
patientmaydevelopaninfarctinalung,causingacutechestsyndrome,characterizedbyacombinationofchest
pain,dyspnea,fever,andleukocytosis.
ComplexRegionalPainSyndrome
CRPSformerlyknownasRSD,isaregional,posttraumatic,neuropathicpainproblemthatmostoftenaffects
oneormorelimbs(seeChapter18forCRPSoftheupperextremity).469
MostpatientswithCRPShaveanidentifiableincitingorinitiatinginjury,whichmaybetrivial,suchasaminor
limbsprain,orsevere,suchastraumainvolvingamajornerveornerves.AdultscanpresentwithCRPSaftera
fractureortraumawithimmobilization.Withchildren,CRPSoccursmostofteninathleticgirls(1:6,boysto
girls)withanaverageageof12years.470
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MostofthecasesofCRPSinthelowerextremity,includingthefootandankle,haveahistoryofminortrauma.
Thekeyfeaturesarepain,allodynia,andhyperalgesia(seeChapter3),abnormalvasomotoractivity,and
abnormalsudomotoractivitypersistingbeyondtheperiodofnormalhealing.
PatientswithCRPSoftenadoptaprotectiveposturetoprotecttheaffectedextremityfrommechanicaland
thermalstimulation.Theymaywearastockingtoguardtheinvolvedextremity.Allodyniamaybesoseverethat
thepatientwillnotallowthecliniciantoexamineoreventouchtheaffectedlimb.
SuccessfultreatmentofCRPSdependsonanaggressiveandmultidisciplinaryapproach.Becausepainandlimb
dysfunctionarethemajorclinicalproblems,physicalrehabilitation,andpaincontrolarethemaintreatment
objectives.Earlyreferraltoapainclinicforpossiblesympatheticnerveblocksorneurosuppressivemedications
maybeindicated.
PeripheralVascularDisease
PVDiscommoninthewesternworld.PVD,typicallybeginsitsprogressioninmidlife(formen,at
approximately45years,andforwomen,5560years).471Arteriesgenerallyhavesmoothlinings,whichallow
bloodtoflowunimpaired.Arteriosclerosisisadegenerativearterialdiseasethatreferstothesocalledhardening
ofthearteries.Inthiscondition,muscleandelastictissuearereplacedwithfibroustissue,andcalcificationmay
occur.
Atherosclerosisisthemostcommontypeofarteriosclerosis.Itischaracterizedbytheformationofatheromatous
plaques,whicharedepositsoffattymaterialintheliningofmediumandlargesizedarteries.Thesearteries
thenbecomenarrowedandroughasmorefatisdeposited.Bloodclotsformmoreeasilybecauseofthe
roughnessofthevesselwall,furthernarrowingthearteryand,thus,potentiallylimitingbloodflow.Areduction
ofbloodsupplytotheorgansandtissuespreventsthemfromperformingadequately.Inaddition,theplaquesare
liabletobreakdownandformulcers.Thrombosesmaythendevelopasaresultoftherougheningandulceration
oftheinnercoatofthearteries.
Apatientwhoissufferingfromreducedbloodsupplytothelowerlimbs,oftenexperienceseffortrelatedcramp
inthecalves,thighs,andbuttocks,whichdisappearsatrest.Thisconditionisknownasintermittent
claudication.
PVDwithclaudicationcanbeconfusedwithneurogenicclaudicationandspinalstenosis.Themajordifference
istheresponseofthepaintorestortothepositionofthespine.Unlikethepainfromspinalstenosis,thepain
fromPVDisnotrelievedbytrunkflexionoraggravatedwithsustainedtrunkextension(Table526).
TABLE526DifferentiatingCausesofClaudication
VascularClaudication NeurogenicClaudication SpinalStenosis
Painisusuallybilateralbut
Painaisusuallybilateral maybeunilateral
Usuallybilateralpain
Occursinback,buttocks, Occursinback,buttocks,thighs,
Occursincalf(foot,thigh,hip,orbuttocks)
thighs,calves,andfeet calves,andfeet
Painisdecreasedinspinal
Painisdecreasedinspinalflexion
flexionandincreasedin
Painconsistentinallspinalpositions andincreasedinspinalextension
spinalextensionandwith
andwithwalking
walking
Painisbroughtonbyphysicalexertion Painisrelievedwithprolongedrest
Painisdecreasedby
(e.g.,walking),relievedpromptlybyrest (maypersisthoursafterresting)and
recumbency
(15min),andincreasedbywalkinguphill decreasedwhenwalkinguphill
Burninganddysesthesiafrom Burningandnumbnesspresentin
Noburningordysesthesia
backtobuttocksandleg(s) lowerextremities
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VascularClaudication NeurogenicClaudication SpinalStenosis

Decreasedorabsentpulsesinlower
Normalpulses Normalpulses
extremities
Colorandskinchangesinfeetcold,numb,
dry,orscalyskinandpoornailandhair Goodskinnutrition Goodskinnutrition
growth
Peaksintheseventhdecade,affects
Affectsagesof4060+years Affectsagesof4060+years
menprimarily
DatafromGoodmanCC,SnyderTE.Differentia!DiagnosisinPhysicalTherapy.Philadelphia,PA:WB
Saunders1990.
aPainassociatedwithvascularclaudicationalsomaybedescribedasanaching,cramping,ortired
feeling.
Thesiteofclaudicationindicatesthemostlikelysiteofthenarrowingorblockage.Whensevere,claudication
canbecomedebilitating,canlimitmobility,andsometimesisassociatedwithaworsenedqualityoflifeandloss
offunctionalindependence.Painmayoccuratmoreregularintervals,asthediseaseprocesscontinuestoitsend
stagecriticallimbischemiauntilfinallyitoccurswhenthepatientisatrest(restpain).Atthisstage,rest
painisusuallyworsewhenthelegsareelevatedandduringsleep,withthepatientgainingreliefbyhangingthe
footoverthesideofthebed.Thedevelopmentofnonhealingwoundsorgangrene(tissuedeath)mayoccurat
thisstage.
Thisdiseaseprocesscanleadtolossoflimbandlifetherefore,investigationandearlydiagnosisareimportant.
Thepatientwhopresentswithtypical,reproducible,exertionaldiscomfortinthebuttocks,thighs,orcalvesthat
disappearsduringrestislikelytohaveclaudicationandsymptomaticPVD.
PeripheralPolyneuropathy
Polyneuropathyisasyndromewithmanydifferentcauses.Clinicalfeaturesinpainfulneuropathiesinclude
sensoryloss,paresthesia,paradoxhyperalgesia,paroxysms,andincreasedpainwithrepetitivestimulation.
SystemicDisorders
Thesystemicdisordersthatcancausefootpaininclude:
carcinoma
leukemia
lymphoma
myeloma
amyloidosis
connectivetissuediseases(polyarteritisnodosaandSLE)
renalfailure
acquiredimmunodeficiencysyndrome
sarcoidosisand
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cutaneousdisorders.
NerveandRootCompressionSyndromes
SeeChapters3and21.
ForefootPain
ThecausesofforefootpainincludethoseshowninFigure55andlistedinTable527.
TABLE527PotentialCausesofForefootPain
Metatarsalgia
Freibergdisease
Mortonneuroma
Arthritis
Fracture
Forefootsprain
Bursitis
Idiopathicsynovitis
Arterialinsufficiency
Metatarsalgia
Metatarsalgia,initsbroadestdefinition,includesdiscomfortaroundthemetatarsalheadsortheplantaraspects
ofthemetatarsalheads.MetatarsalgiaisdiscussedinChapter21.
FreibergDisease
Freibergdisease,anavascularnecrosisofthesecondmetatarsalepiphysis,isasourceofmetatarsalgia.447The
diseaseisanosteochondrosisofcongenital,traumatic,orvascularetiologythatleadstoeventualcollapseand
deformityofalessermetatarsalhead.ItisunlikelythatanathleticinjuryisthesolecauseofFreibergdisease,
althoughamechanicalstresstotheforefootmayexacerbateapreviouslysubclinicalcondition.Theconditionis
mostcommoninthesecondmetatarsalhead,withapredilectionof6882%.472,473Lesscommonly,itmay
occuratthethird,fourth,orfifthmetatarsalheads.
ThefemaletomaleratioinFreibergdiseaseis5:1andthetypicalpatientisafemaleadolescentaged1117
years.474Theconditionmaybeasymptomaticearlyinitscourseandmanifestinyoungadulthoodtomiddle
age.
Physicalexaminationusuallyrevealsunilateralpainoverthesecondmetatarsalheadthatisworsewithactivity,
limitedrangeofmotion,periarticularswelling,and,occasionally,aplantarcallosityunderthesecondmetatarsal
head.475
Thisconditionisusuallyselflimitingandrequiresonlyconservativetreatmentintheformofrestfromhigh
impactactivities,anorthosistocorrectpronation,476arangeofmotionwalkingboot,orashortlegcastfor
moresevereacutepain.Patientswithsevereantalgiashouldusecrutches.Hoskinson473reportedsuccesswith
conservativetreatmentin11of28patients,althoughallhadarestrictionofjointmotion.
ThesurgicalinterventionforFreibergdiseaseinvolvesdebridementofthejoint,removalofloosebodies,and
removalofmetatarsalheadosteophytes,withreshapingofthehead.477Adorsiflexionosteotomyofthe
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metatarsalheadalsohasbeenadvocatedtorotatethehealthyplantarcartilageupintoarticulationwiththe
proximalphalanx.
MortonNeuroma
Aninterdigitalneuroma,orMortonneuroma,isamechanicalentrapmentneuropathyoftheinterdigitalnerve.
Theentrapmentmayoccurasthenervecoursesontheplantarsideofthedistalaspectofthetransverse
intermetatarsalligament,whereitisvulnerabletotractioninjuryandcompressionduringthetoeoffphaseof
runningorduringrepetitivepositionsoftoerise.478
Themostcommonlyinvolvednerveisthethirdinterdigitalnerve,betweenthethirdandfourthmetatarsalheads,
followedinincidencebythesecondinterdigitalnerveand,rarely,thefirstandfourthinterdigitalnerves.478,479
Theindividualwithaninterdigitalneuromawillcomplainofsymptomsofforefootburning,cramping,tingling,
andnumbnessinthetoesoftheinvolvedinterspace,withoccasionalproximalradiationinthefoot.478
MortonneuromaisdescribedfurtherinChapter21.
Arthritis
SeeChapter21.
Fracture
SeeChapter21.
ForefootSprain
SeeChapter21.
Bursitis
SeeChapter21.
MedialForefootandGreatToePain
ThecausesofmedialforefootandgreattoepainincludethoseshowninFigure55andlistedbelow.
NailLesions
SeeChapter21.
HalluxValgus
SeeChapter21.
HalluxRigidus
SeeChapter21.
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ArthritisoftheFirstMTPJoint
SeeChapter21.
MidfootPain
ThecausesofmidfootpainincludethoseshowninFigure55andlistedbelow.
LongitudinalArchStrain
AsepticNecrosisoftheNavicular
TendinopathyoftheFlexorHallucisLongusorFibularis(Peroneal)
SubtalarOsteochondralFracture
SeeChapter21.
AccessoryNavicular
Theaccessorynavicularisthemostcommonaccessoryboneinthefoot.Itoccursonthemedialplantarborder
ofthenavicularatthesiteofthetibialisposteriortendoninsertion.480Theincidenceinthegeneralpopulation
hasbeenreportedtobebetween4%and14%,480,481butfewpatientsactuallybecomesymptomatic.447A
histologicstudybyGroganetal.in1989482suggestedthattensilefailureinthecartilaginoussynchondrosiswas
thecauseofpain.
Intheadolescentathleticpopulation,symptomsmayarisesecondarytopressureoverthebonyprominence,a
tearintheactualsynchondrosis,ortibialisposteriortendinopathy.481
Thepatientusuallypresentswithpainandaprominenceofthenavicularinapronatedfoot.Thereisusually
localtendernesstopalpationandpainwithresistedfootinversion.480Ithasbeenhypothesizedthatwhenthe
tibialisposteriortendoninsertsintotheaccessorynavicular,aweakerinsertionpoint,itcontributestoadropin
themedialarchofthefootandapesplanus.483However,SullivanandMiller484foundnodifferenceinthe
longitudinalarchesofthosewithanaccessorynavicularandthosewithout.447
Aphysicalexaminationcanbesupplementedbyradiographicassessment.Theanteroposteriorviewora45
degreeeversionobliqueviewisusuallydiagnostic.480
Theinterventionforthisconditionconsistsoforthotics,trialofcasting,rangeofmotionexercises,andeventual
removalifsymptomscontinue.480482,484487
KhlerBoneDisease
Khlerbonediseaseisanasepticnecrosisofunknownetiologythattypicallyaffectsthetarsalnavicular
bone.447Theconditionislikelycausedbyrepetitivemicrotraumatothematuringepiphysis.447Itislargely
foundinactiveboysaged47years.
Khlerbonediseaseistypicallyselflimitingandshouldnotrequireanytypeofsurgery.Theinitialintervention
involvesdecreasedactivityorashortlegcastfor36weeks.488Orthoticsmaybenecessarytomaintainthe
longitudinalarch.
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StressFractureoftheNavicular
SeeChapter21.
AcquiredFlatfoot
SeeChapter21.
Osteoarthritis
SeeChapter21.
PlantarFascialPain
SeeChapter21.
CuboidSubluxationSyndrome
SeeChapter21.
Posterior(Dorsal)FootPain
TendinopathyoftheExtensorHallucisLongus,ExtensorDigitorumLongus,orTibialisAnterior
SeeChapter21.
HindfootPain
ThecausesofgeneralizedhindfootpainincludethoseshowninFigure55andareasfollows.
IntraarticularCalcanealFractures
Thecalcaneusisthemostfrequentlyfracturedtarsalbone,withcalcanealfracturesaccountingfor65%oftarsal
injuriesandapproximately2%ofallfractures.489Acutecomplicationsincludeswelling,fractureblisters,and
compartmentsyndromes.Latecomplicationsincludearthritismalunion,includingcalcaneofibularabutment
andheelpadproblems.Complicationsassociatedwithoperativetreatmentincludewounddehiscence,infection,
andiatrogenicnerveinjury.
FatPadDisorders
CalcaneusStressFracture
SeeChapter21.
PlantarFasciitis
SeeChapter21.
EntrapmentNeuropathyoftheFirstBranchoftheLateralPlantarNerve
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SeeChapter21.
FlexorTendinopathy
SeeChapter21.
SuperficialAchillesBursitis
SeeChapter21.
RetrocalcanealBursitis
SeeChapter21.
HaglundSyndrome
SeeChapter21.
AchillesTendinopathy
SeeChapter21.
AchillesTendonRupture
SeeChapter21.
CalcanealOsteomyelitis
Primaryhematogenousosteomyelitisofthecalcaneusisuncommonandaccountsfor310%ofallacutebone
infectionsinchildren.490Thecalcaneushasasocalledmetaphysealequivalentregionthatbordersthe
apophysisandissusceptibletohematogenousinfection,asinlongbones.491S.aureushasbeenfoundtobethe
mostcommonbacterialagentinhematogenouscalcanealosteomyelitis.
Clinicalfindingsincludefever,pain,andswellinginthefootandankle.Thedifferentialdiagnosismayinclude
septicarthritisoftheankle,cellulitis,stressfracture,calcanealapophysitis,Achillesenthesopathy,and
subcutaneousabscess.
TibialisPosteriorTendinopathy
SeeChapter21.
FlexorHallucisLongusTendinopathy
SeeChapter21.
TarsalTunnelSyndrome
SeeChapter21.
CalcanealFracture
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SeeChapter21.
MedialAnkleSprain
SeeChapter21.
Fibularis(Peroneal)MuscleStrainorTendinopathy
SeeChapter21.
LateralAnkleSprain
SeeChapter21.
OsteochondralFractureoftheTalarDome
SeeChapter21.
StressFractureoftheLateralMalleolus
SeeChapter21.
CASESTUDYNECKPULSINGHISTORY
A37yearoldwomanpresentedtotheofficecomplainingthatherheadwantedtogoback.Hersymptoms
beganapproximately6monthsearlier,withpainlesspulsingontheleftsideofherneckthatbecameworse
withstressfulsituationsandphysicalactivitybutwasrelievedbyrelaxationandsleep.Shecouldbrieflystopthe
pulsingbyplacingherhandontherightposterioraspectoftheneck.Hersymptomshadprogressedtoan
extensionoftheneckwithspasm,whichcausedhertoleanforwardtomaintaineyecontactwithothers.She
alsonotedanoccasionaleyetic,whichseemedtocomeandgospontaneously.Shedeniedanyparesthesias,
weakness,dysphasia,visualchangesorhearingloss,orbowelorbladderchanges.Althoughshehadnofamily
historyofspecificneurologicproblems,thepatientreportedamaternalauntwhohadfacialtics.Thepatient
hadamedicalhistorynotableforanxietyandseveralphobiasforwhichshehadreceivedpsychological
counseling.Vascularstudieshadruledoutvasculardiseaseandthepresenceofananeurysmintheneckand
trunk.Imagingstudieshadruledoutfractureortumor.
Questions
1.Whataspectsofthehistoryshouldalertthecliniciantothepossibilityofaseriouspathology?
2.Whatcouldbethesignificanceofthepulsing?
3.Doesthispresentation/historywarrantfurtherinvestigation?Whyorwhynot?
CASESTUDYGROINPAININAMIDDLEAGEDFEMALEHISTORY
A56yearoldmoderatelyobesewomanpresentswithaprescriptionthatreadshipOA,evaluate,andtreat.
Patientpresentedwithleftgroinpainofaninsidiousonsetthatwasworsening.Thepainstartedapproximately3
monthsago,whenthepatientcommencedawalkingprogramtolosesomeweight.Thesymptomsimprovewith
rest,butworsenwithactivity,especiallywithwalkingandstairnegotiation.Theseriesofradiographstakenat
thephysiciansofficerevealedslightdegenerativechangesatthehipjoint.
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Questions
2.Whatisthesignificanceofaninsidiousonset?
CASESTUDYBACKANDLEGPAINHISTORY
A55yearoldmanpresentedwithcomplaintsofaninsidiousonsetofseverebackandleftlegpain.
Progressivelyworseningsymptomsofpainoverthepastfewmonthswerefollowedbyleftfootdrop.AnMRI
examinationwasinterpretedasmildlumbarspinedegenerativediskdiseasewithoutevidenceofnerveroot
compromise.Thepatientcouldreportnospecificaggravatingorrelievingactivitiesbutdidreportpainatnight,
notrelatedtomovementinbed.Thepatientspastmedicalhistorywassignificantforarenaltransplantation
approximately20yearspreviously.
Questions
2.Whatisthesignificanceofnightpainthatisunrelatedtomovement?
CASESTUDYLEFTSIDEDLOWBACKANDLEGPAINHISTORY
A45yearoldmanpresentedwithcomplaintsofintermittentvariableleftsidedLBPthatextendedintohisleft
posteriorthighandintermittentvariabletinglingalongtheanterolateralaspectofhisleftlowerextremity.249
Thiswasthepatientsfirstvisittoahealthcarefacilityforthisconditiontherefore,medicalrecordswerenot
available.Thesymptomsbeganabout2monthsago,withnospecificmechanismofinjury.Thepatientreported
workingasaqualitycontrolmanagerforapharmaceuticallab.Hisjobrequiredsittingforapproximately50%
ofthedayandoccasionalliftingofboxesweighingbetween4.5and9.1kg.Activitiesorpositionsthatincreased
oraggravatedallofthepatientssymptomsincludedlyingsupine,coughingandsneezing,prolongedwalking,
andsittingforlongerthananhour.Activitiesthatdecreasedthepatientssymptomsincludedapplyingaheating
padtohislowbackregionandtakingoverthecounteribuprofen(200mg)every4hours.Thepatientnotedthat
hissymptomsweremostintenseintheeveningandintothenight,withpainsometimescausinghimdifficulty
withfallingasleep.Thepatientalsoremarkedthathewouldsometimesawakenbecauseofpainbutwasableto
fallasleepafterfindingacomfortableposition.Thepatientspastmedicalhistorywasunremarkableforcancer,
bowelandbladderproblems,hypertension,diabetes,orrecentweightchanges.
Questions
2.Whattypesofconditionshaveaninsidiousonset?
3.Doesthispresentation/historysoundlikeaneuromuscularproblemordoesthisconditionwarrantfurther
investigation?Whyorwhynot?
CASESTUDYRIGHTBUTTOCKPAINHISTORY
A55yearoldwomanpresentedforphysicaltherapywithaphysiciandiagnosisofrightlumbosacral
radiculitis.Thepatienthada10monthhistoryofrightbuttockpainwithradiationtotheposterolateralright
lowerlimb,whichwasassociatedwithintermittentnumbnessandtinglingofthedistallowerlimbandfoot.She
deniedanyLBPoranyradiationofpaindownherleftlowerlimb.Thepainwasexacerbatedbywalkinguphill,
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bylyingonherrightside,andafterexercise.ItwasnotworsewithbendingorwithValsalvamaneuver.Past
medicalhistorywassignificantforchronicLBP,lymphoma(diagnosedatageof23yearsandtreated
successfullywithlocalradiationtotheneckandaxillae),statuspostmeningiomaresection,statuspostbilateral
modifiedradicalmastectomyforcarcinomainsitu,andhypothyroidism.490AnMRIofthelumbosacralspine
revealedmultileveldegenerativediskdiseasefromL3andL4throughL5S1,withmildforaminalnarrowing
bilaterally.Therewasnoevidenceoffocalherniationorcanalstenosis.
Questions
1.Whatstructure(s)couldbethecauseofthesesymptoms?
2.Doesthehistoryofthesymptomsfollowapatternassociatedwithamusculoskeletaldisorder?Ifnot,why
not?
3.Whatinthepatientspastmedicalhistoryneedstobenoted?
4.Whattestsorquestionswouldyouusetohelpruleoutthepotentiallyseriouscausesofthesesymptoms
suchascaudaequinacompression?
5.Whatimpairmentcouldcauseanincreaseinthesesymptomswhenwalkinguphillandlyingontheright
side?
6.Whywouldthepatientssymptomsincreaseafterexercise?
7.Whatisyourworkinghypothesisatthisstagebasedonthevariousdiagnosesthatcouldmanifestwithleg
painandparesthesia,andwhattestsyouwouldusetoruleouteachone?
8.Doesthispresentation/historywarrantascanningexamination?Whyorwhynot?
CASESTUDYINTERMITTENTLEGNUMBNESSHISTORY
A46yearoldmanpresentedtotheclinicwitha10yearhistoryofsensationsthathedescribedasamixture
bothofpinsandneedlesandofcottonwoolaroundthesecondandthirdtoesofhisfeet.Thesymptoms
developedsuddenlywhileatworkandhadprogressedtointermittentnumbnessofbothlegsfromthewaist
down.Overthefollowing10years,thepatientsufferedmomentarilyfromelectrictypesensationsradiating
downintohislegs,moresoontherightthanontheleft.Inaddition,henoticedstiffnessinhisgaitandreduced
sensationonpassingurine,andanachingsensationhaddevelopedinthebuttocks.Hehadahistoryof
infrequentLBPoveranumberofyears.ThepatientsphysicianhadgivenhimaworkupforMS,buttheresults
werenegative.
Questions
2.Whatisthesignificanceofthegaitstiffness?
3.Whatisthesignificanceofthereducedsensationonpassingurine?
4.Doesthispresentation/historywarrantascanningexamination?Whyorwhynot?
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undefined
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CHAPTER6:GaitandPostureAnalysis
CHAPTEROBJECTIVES
1.Summarizethevariouscomponentsofthegaitcycle.
2.Applytheknowledgeofgaitcomponentstogaitanalysis.
3.Performacomprehensivegaitanalysis.
4.Categorizethevariouscompensationsofthebodyandtheirinfluencesongait.
5.Recognizethemanifestationsofabnormalgaitanddevelopstrategiestocounteracttheseabnormalities.
6.Describeanddemonstrateanumberofabnormalgaitsyndromes.
7.Makeanaccuratejudgmentwhenrecommendinganassistivedevicetoimprovegaitandfunction.
8.Describeanddemonstratethevariousgaitpatternsusedwithassistivedevices.
9.Evaluatetheeffectivenessofaninterventionforagaitdysfunction.
10.Summarizethecomponentsofaposturalassessment.
11.Performathoroughpostureassessment.
12.Recognizethemostcommonmanifestationsofabnormalposture.
13.Makeanaccuratejudgmentwhenrecommendingposturaladjustments.
14.Evaluatetheeffectivenessofaposturaladjustment.
OVERVIEW
Theassessmentofsymmetrywithinlocomotionandpostureiscriticalintheevaluationofneuromusculoskeletal
dysfunction.Formostindividuals,gaitorpostureisaninnatecharacteristic,asmuchapartoftheirpersonality
astheirsmile.Indeed,manypeoplecanberecognizedinagroupbytheirgaitorposture.Thepurposeofthis
chapteristodescribethevariouscomponentsofgaitandpostureandtoprovidetheclinicianwiththenecessary
toolsfortheanalysisofeach.
GaitandtheGaitCycle
Thelowerkineticchainhastwomainfunctions:toprovideastablebaseofsupport(BOS)instanding,andto
propelthebodythroughspacewithgait.Duringgait,thebodyfollowstheleastrestrictivepathwayinthemost
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efficientmanner.1Inordertomaintainthisefficiency,thebodyattemptstomaintainalevelcenterofgravity
(COG)inallplanes.1Whilemaintainingastaticequilibriumofforces,theobjectivewithmobilityistocreate
andcontroldynamic,unbalancedforcestoproducemovement.2Gaitisthusanexampleofcontrolledinstability.
Itisnotclearwhethergaitislearnedorispreprogrammedatthespinalcordlevel.However,oncemastered,gait
allowsustomovearoundourenvironmentinanefficientmanner,requiringlittleinthewayofconscious
thought,atleastinfamiliarsurroundings.Theevolutionofbipedalgaithasallowedthearmsandhandstobe
freeforexplorationoftheenvironment.Eventhoughgaitappearstobeasimpleprocess,itisproneto
breakdown.Despiteindividualgaitpatternsbeingcharacterizedbysignificantvariation,onlythreeessential
requirementsarenecessaryforefficientlocomotion:progression,posturalcontrol,andadaptation:3
Progression.Thefallthatoccursattheinitiationofgaitsothatanindividualmusttakethefirststepis
controlledbythecentralnervoussystem(CNS).4TheCNScomputesinadvancetherequiredsizeand
directionofthisfalltowardthesupportingfoot.Progressionofthehead,arms,andthetrunkisinitiated
andterminatedinthebrainstemthatmaintainsacentralpatterngenerator(CPG)throughthespinalcord
(seeChapter3).ThelocomotorCPGproducesselfsustainingpatternsofstereotypemotoroutput
resultingingaitlikemovements.Inaddition,gaitreliesonthecontrolofthelimbmovementsbyreflexes.
Twosuchreflexesincludethestretchreflexandtheextensorthrust.Thestretchreflexisinvolvedinthe
extremesofjointmotion,whereastheextensorthrustmayfacilitatetheextensormusclesofthelower
extremityduringweightbearing.5BoththeCPGandthereflexesthatmediateafferentinputtothespinal
cordareunderthecontrolofthebrainstemandarethereforesubconscious.6Thiswouldtendtoindicate
thatverbalcoaching(i.e.,feedbackthatisprocessedinthecortex)regardinganaberrantgaitpatternmight
belesseffectivethanasensoryinputthatwillelicitabrainstemmediatedposturalresponse.2
Posturalcontrol.Posturalcontrolisdynamicallymaintainedtoappropriatelypositionthebodyfor
efficientgait.
Adaptation.Althoughcentralpatterngenerationoccursindependentofanysensoryinput,afferent
informationfromtheperipherycaninfluencetheCPG.Adaptationisachievedbyadjustingthecentral
patterngeneratedtomeettaskdemandsandenvironmentaldemands.
Gait,therefore,isinitiatedgrosslyinthespinalcordandthenfinetunedbythehigherbraincenters.2Inpatients
whohavedevelopeddysfunctionalgaitpatterns,physicaltherapycanhelptorestorethisexquisiteevolutionary
gift.7Pain,weakness,anddiseasecanallcauseadisturbanceinthenormalrhythmofgait.However,exceptin
obviouscases,abnormalgaitdoesnotalwaysequatewithimpairment.
Inadditiontoneuralinput,normalhumangaitalsoinvolvesacomplexsynchronizationofthecardiopulmonary
andmuscularsystemsinwhichthecardiopulmonarysystemproducestheenergyrequiredforgait.Normalgait
requiresconcentric,eccentric,andisometriccontractionsofthefoot,ankle,knee,hip,andtrunkaswellas
trainingtomaintainanuprightposture.1
Walkinginvolvesthealternatingactionofthetwolowerextremities.Thiswalkingpatternisstudiedasagait
cycle.Agaitcycleisdefinedastheintervaloftimebetweenanyoftherepetitiveeventsofwalking.Suchan
eventcouldincludethepointwhenthefootfirstcontactsthegroundtothepointwhenthesamefootcontactsthe
groundagain.Thesevenintervalsthatoccurduringthegaitcycleinclude:
1.Loadingresponse
2.Midstance
3.Terminalstance
4.Preswing
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5.Initialswing
6.Midswing
7.Terminalswing
Theseintervalsoccurduringtwophases,thestancephaseandtheswingphase(Fig.61).Fouroftheintervals
occurinthestancephase,andtheremainingthreeoccurduringtheswingphase(Fig.62).
FIGURE61
Thetwophasesofgait.
FIGURE62
Theintervalsofgait.
1.Stance.Thestancephase(Fig.61)takesabout0.6secondsduringanaveragewalkingspeed.Thisphase
constitutesapproximately60%ofthegaitcycle(Fig.61)anddescribestheentiretimethefootisin
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contactwiththegroundandthelimbisbearingweight.Thestancephasebeginswhenthefootmakes
contactwiththeground(initialcontact)andconcludeswhentheipsilateralfootleavestheground(toeoff)
(Fig.62).Theinitialcontactintervalaccountsforthefirst10%ofthegaitcycleanddescribesthephase
whenonefootiscomingoffthefloorwhiletheotherfootisacceptingbodyweightandabsorbingthe
shockofinitialcontact(Fig.62).Becausebothfeetareincontactwiththefloor,thisphaseisreferredto
asdoublesupport(Fig.61).Thephaseofdoublesupportoccurstwiceduringasinglegaitcycleand
accountsforapproximately20%ofthegaitcycle(Fig.61).Thefourintervalswhichoccurinthisphase
includetheloadingresponse,midstance,terminalstance,andpreswing(seeFig.62).
a.Loadingresponse.Theloadingresponseintervalbeginsasonelimbbearsweightwhiletheother
legbeginstogothroughitsswingphase.Theextenttowhicheccentricmuscletensioncounteracts
theeffectofgravityonthebodymassduringtheloadingresponsetogroundcontactdetermines
boththevelocityandamplitudeofmotionthatoccursatanygivenjointinthelowerextremity.8
b.Themidstanceinterval,representingthefirsthalfofthesinglelimbsupporttask(Fig.62),begins
asonefootisliftedandcontinuesuntilthebodyweightisalignedovertheforefoot.
c.Theterminalstanceinterval(Fig.62)isthesecondhalfofthesinglelimbsupporttask.Itbegins
whentheheeloftheweightbearingfootliftsoffthegroundandcontinuesuntilthecontralateral
footstrikestheground.
d.Thepreswinginterval(Fig.62)beginswiththeinitialcontactofthecontralaterallimbandends
withtheipsilateraltoeoff.Duringthisphase,thestancelegisunloadingthebodyweighttothe
contralaterallimbandpreparingthelegfortheswingphase.
2.Swing.Gravityandmomentumaretheprimarysourcesofmotionfortheswingphase.5Theswingphase
constitutesapproximately40%ofthegaitcycle(Fig.62)anddescribesthephasewhenthefootisnotin
contactwiththeground.Theswingphasebeginsasthefootisliftedfromthegroundandendswhenthe
ipsilateralfootmakescontactwiththegroundagain.Thethreeintervalswhichoccurinthisphaseinclude
initialswing,midswing,andterminalswing:
a.Initialswing(Fig.62).Thisintervalbeginswiththeliftingofthefootfromthefloorandends
whentheswingingfootisoppositethestancefoot.Itrepresentsthe6073%phaseofthegaitcycle
(Fig.62).
b.Midswing(Fig.62).Thisintervalbeginsastheswinginglimbisoppositethestancelimbandends
whentheswinginglimbisforward,andthetibiaisvertical.Itrepresentsthe7387%phaseofthe
gaitcycle(Fig.62).
c.Terminalswing(Fig.62).Thisintervalbeginswithaverticaltibiaoftheswinglegwithrespectto
thefloorandendsthemomentthefootstrikesthefloor.Itrepresentsthelast87100%ofthegait
cycle(Fig.62).
CLINICALPEARL
Intermsofenergyexpenditure,theswingphaserequiresrelativelylittle,relyingheavilyonpassive,softtissue
tension,gravity,andmomentumtoaccelerateanddecelerateindividualsegments.2Incontrast,stancerequires
moredynamicactivity,withmusclesinthestancelimbsupportandthebodypropellingitforward.
Theprecisedurationofthegaitcycleintervalsdependsonanumberoffactorsincluding,butnotlimitedto,age,
degreeofimpairment,attentiontoanothertask,healthstatus,motorcontrol,muscleperformance,enduranceand
habitualactivitylevels,walkingenvironment,andthepatientswalkingvelocity.9Walkingvelocityisdefinedas
thedistanceabodymovesinagiventimeandisthuscalculatedbydividingthedistancetraveledbythetime
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taken.Normalfreegaitvelocityonasmoothandlevelsurfaceaveragesabout1.21.4m/sforadults,withspeed
varyingbygender,ageandanthropometrics,withmenbeingabout5%fasterthanwomen.10
Runninginvolvesbothastancephase(30%)andaswingphase(70%),withincreasedspeedshowingan
increaseintheswingtostanceratio.Runningalsoinvolvesafloatphase,duringwhichthereisnofootcontact
withtheground,andpotentialenergyisgreatest,andwhichcomprises30%oftherunningcycle.11
CLINICALPEARL
Anincreaseinselfselectedwalkingspeedisassociatedwithclinicallymeaningfulimprovementinqualityof
life.12
GAITPARAMETERS
Anormalgaitpatternisafactorofanumberofparameters.
StepWidth
Thestepwidthisthedistancebetweenbothfeet.Thenormalstepwidth,whichisconsideredtobebetween5
and10cm(24in),formstheBOSduringgait.ThesizeoftheBOSanditsrelationtotheCOGareimportant
factorsinthemaintenanceofbalance(seeChapter1)and,thus,thestabilityofanobject.AstheCOGmoves
forwardwitheachstep,itbrieflypassesbeyondtheanteriormarginoftheBOS,resultinginatemporarylossof
balance.13Thistemporarylossofequilibriumiscounteractedbytheadvancingfootatinitialcontact,which
establishesanewBOS.AlargerthannormalstepwidthorBOSisobservedinindividualswhohavemuscle
imbalancesofthelowerlimbsandtrunk,aswellasthosewhohaveproblemswithoverallstaticanddynamic
balance.14Assistivedevices,suchascrutchesorwalkers,canbeprescribedtoincreasetheBOSand,therefore,
enhancestability.Thestepwidthshouldbeseentodecreasetoaroundzerowithincreasedspeed.Ifthestep
widthdecreasestoapointbelowzero,crossoveroccurs,wherebyonefootlandswheretheothershould,and
viceversa.
CLINICALPEARL
Whenwalking,thebodysCOGiselevatedtoitshighestpositionduringmidstance,andthenitfalls
anteriorly.15Whenrunning,kneeandhipflexionproducedownwarddisplacementoftheCOGthatreachesits
lowestpositionduringmidstance,butwhichsubsequentlybeginstomoveinasuperiorandanteriordirectionas
thekneeandhipextendduringtheterminalportionofthestancephase.8
StepLength
Steplengthismeasuredasthedistancebetweenthepointofinitialcontactofonefootandthepointofinitial
contactoftheoppositefoot.Theaveragesteplengthisabout72cm(28in).Themeasurementshouldbeequal
forbothlegs.
StrideLength
Stridelengthisthedistancebetweensuccessivepointsoffoottofloorcontactofthesamefoot.Astrideisone
fulllowerextremitycycle.Twosteplengthsaddedtogethermakethestridelength.Theaveragestridelengthfor
normaladultsis144m(56in).10
Typically,thestepandstridelengthsdonotvarymorethanafewcentimetersbetweentallandshortindividuals.
Mentypicallyhavelongerstepandstridelengthsthanwomen.Stepandstridelengthsdecreasewithage,pain,
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disease,fatigue,andasthespeedofgaitdecreases.16,17Adecreaseinsteporstridelengthmayalsoresultfrom
aforwardheadposture,astiffhip,oradecreaseintheavailabilityofmotionatthelumbarspine.Thedecrease
instepandstridelengththatoccurswithagingisthoughttobetheresultofanumberoffactorsincludingan
overalldecreaseinjointrangeofmotion(ROM),andtheincreasedlikelihoodoffallingduringtheswingphase
ofambulation,causedbydiminishedcontrolofthehipmusculature.16,17Thislackofcontrolpreventstheaged
personfrombeingabletointermittentlyloseandrecoverthesameamountofbalancethattheyoungeradultcan
loseandrecover.
Cadence
Cadenceisdefinedasthenumberofseparatestepstakeninacertaintime.Normalcadenceisbetween90and
120stepsperminute.10Thecadenceofwomenisusuallysixtoninestepsperminuteslowerthanthatofmen.13
Cadenceisalsoaffectedbyage,decreasingfromtheageof4totheageof7years,andthenagaininadvancing
years.18
CLINICALPEARL
Comparedtomen,womengenerallyhavenarrowershoulders,greatervalgusattheelbow,greatervarusatthe
hip,andgreatervalgusattheknee.19WomenalsohaveasmallerAchillestendon,anarrowerheelin
relationshiptotheforefoot,andafootthatisnarrowerthanamansinlength.Onaverage,womenwalkata
highercadencethanmen(sixtoninestepshigher),butatlowerspeeds.2024Womenalsohaveslightlyshorter
stridelengths,20,21,2327althoughwhennormalizedforheight,womentendtohavethesameorslightlygreater
stridelengths.2426
Velocity
Theprimarydeterminantsofgaitvelocityaretherepetitionrate(cadence),physicalconditioning,andthelength
ofthepersonsstride.10
CLINICALPEARL
Amathematicalrelationshipexistsbetweencadence,stridelength,andvelocity,suchthatiftwoofthemare
directlymeasured,thethirdmaybederivedbycalculation(Table61).28
TABLE61GaitParameters
Cadence(steps/min)=velocity(m/s)120/stridelength(m)
Stridelength(m)=velocity(m/s)120/cadence(steps/min)
Velocity(m/s)=cadence(steps/min)stridelength(m)/120
DatafromLevineD,WhittleM.GaitAnalysis:TheLowerExtremities.LaCrosse,WI:OrthopaedicSection,
APTA,Inc.1992.
Asgaitspeedincreases,itdevelopsintojoggingatapproximately2.02.7m/s,29andthenrunning,withchanges
ineachoftheintervals.Forexample,asspeedincreases,thestancephasedecreasesandtheterminaldouble
stanceintervaldisappearsaltogether,sothattherearealternatingsingleextremitysupportintervalsthatare
separatedbyaperiodofnogroundcontactbyeitherextremity.Thisproducesadoubleunsupportedinterval.30
Initialcontactwiththegroundisnormallymadebytheheelwhenwalking,whichisalsothecaseformorethan
75%ofindividualswhilerunning.31Normalrunninggaitbeginswithlateralheelstrike,followedbyfoot
pronationduringmidstance,andfootsupinationduringpushoff.Therearfootstrikerunningpatternisfacilitated
bytheelevatedandcushionedheelsofmodernrunningshoesduringwhichgroundreactionforces(GRFs)(see
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nextsection)reach1.53timesbodyweight.32Acurrenttrendinrehabilitationhascenteredonmodifying
runningtechniquetoprevent,treat,andreducerunninginjuries.Differentrunningstylesaredefinedbythe
portionofthefootsegmentthemakesinitialcontactwiththeground.Thesepatternsincluderearfootstrike,
midfootstrike,andforefootstrike.33Runnerstendtouseaheelstrikeormidfootstrike,whereassprinters
typicallyuseaforefootstrike.Barefoot,orevolution,running,withitsemphasisonforefootstriking,has
increasedinpopularityduetoitsclaimthatthestyleproducesasignificantreductioninGRFs,stridelength,and
groundcontacttime.Aswithwalking,runningeconomycanbeaffectedbyphysiologicalandbiomechanical
factors.Whileforefootstrikersrelymoreheavilyonmusculaturetoaidincushioningduringstance,traditional
runnersdemonstrateaheelstrikepattern,secondarytoaheavyrelianceonfootwearandskeletalstructuresto
absorbGRFs.34Whileithasbeendemonstratedthatbarefootforefootstrikerunnersgeneratesmallerimpact
forcesthanshorterrearfootstrikers,thereisnoevidencetodatethateitherconfirmsorrefutesimproved
performanceandreducedinjuriesinbarefootrunners,althoughthereissomeevidencethattheformerimproves
runningefficiency.34
Althoughthemotionoccurringateachofthelowerextremityjointsissimilarforwalkingandforrunning,the
requiredROMincreaseswiththespeedoftheactivity.Asthespeedofwalkingorrunningincreases,sodothe
forcesthatactonthevariousjoints,andthejointsthemselveshavetoproducegreaterexcursionswithgreater
muscleactivity.
Humanshavethecapacitytorunatabroadspectrumofspeeds.35Eliteathleteshavetheabilitytoachieve
maximalrunningspeedsgreaterthan10m/s(36km/h).36Gaitspeedcanbeincreasedbypushingontheground
moreforcefully,pushingonthegroundmorefrequently,oracombinationofthetwo.Whenspeedisinitially
increased,thepriorityappearstobepushingonthegroundmoreforcefullyasthisresultsinalongerstride
lengthbecausethebodyspendsmoretimeintheair.37Thelowerlimbmusclesthatareresponsibleforpushing
onthegroundforcefullyduringrunningarethemajorankleplantarflexors(soleusandgastrocnemius).At
speedsbeyondapproximately7.0m/s,thedominantstrategyshiftstowardthegoalofincreasingstride
frequencyandpushingonthegroundmorefrequently,whichresultsintheforcegeneratingcapacityofthese
musclesbecominglesseffective.35Instead,asmorepoweratthehipjointisrequired,theproximallowerlimb
musclessuchastheiliopsoas,gluteusmaximus,rectusfemoris,andhamstringsbecomedominant.35
Duetoitsrepetitivenature,runninghasthepotentialtocreatelowerextremitypathology.Forexample,atthe
hip,theymaybemicroinstabilityduetorepeatedhipextensionandstretchingoftheanteriorcapsule.38
GroundReactionForces
AnanalysisofGRFsisimportanttoquantifythemagnitudeofforcessustainedbybodystructuresduring
movementsandexercise.Newtonsthirdlawstatesthatforeveryactionthereisanequalandoppositereaction.
GRFscanbeinfluencedbyseveralfactors,suchastheenvironmentinwhichthemovementisexecuted(e.g.,on
landorinwater),movementspeed,andtheweightoftheindividualperformingtheexercise.Thecenterof
pressure(COP)isthelocationoftheverticalprojectionoftheGRF,andisequalandoppositetotheweighted
averageofallthedownwardforcesactingontheareaofcontactwiththeground.39TheCOPisconsideredtobe
areflectionofthebodysneuromuscularresponsestoimbalancesoftheCOG.Duringgait,verticalGRFsare
createdbyacombinationofgravity,bodyweight,andthefirmnessoftheground.Forexample,duringrunning,
jointreactiveforcesthroughthehiphavebeendemonstratedatfivetimesbodyweightduringsinglelimb
support.Evenwhenimmersedinwater,stationaryrunningstillinvolvescontactforces(seeChapter8).Under
normalconditions,wearemostlyunawareoftheseforces.However,inthepresenceofjointinflammationor
tissueinjury,thesignificanceoftheseforcesbecomesapparent.TheGRFduringgaitbeginswithanimpact
peakoflessthanbodyweightandthenexceedsbodyweightattheendoftheinitialcontactinterval,dropping
duringmidstanceandrisingagaintoexceedthebodyweight,reachingitshighestpeakduringtheterminal
stanceinterval.Thus,therearetwopeaksofGRFduringthegaitcycle:thefirstatmaximumlimbloading
duringtheloadingresponseandthesecondduringterminalstance.
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TheGRFvectorchangesfromquitefaranteriortothehipjointatinitialcontacttoaprogressivelyposterior
positionatlatestance,whentheGRFisposteriortothehip.10,40,41Peakflexiontorqueoccursatinitialcontact
butgraduallydeclines,changingtoanextensiontorqueinmidstance.Theextensiontorqueremainsuntil
terminalstance.10,40,41Inthefrontalplane,ahipabductionmomentisgeneratedtocounteracttherelativehip
adductionangleatinitialcontact.
Duringthegaitcycle,thetibiofemoraljointreactionforcehastwopeaks:thefirstimmediatelyfollowinginitial
contact(twotothreetimesbodyweight)andthesecondduringpreswing(threetofourtimesbodyweight).42
Tibiofemoraljointreactionforcesincreasetofivetosixtimesbodyweightforrunningandstairclimbing,and
eighttimesbodyweightwithdownhillwalking.42,43
ItiswellestablishedthatjointanglesandGRFcomponentsincreasewithwalkingspeed.44Thisisnot
surprising,becausethedynamicforcecomponentsmustincreaseasthebodyissubjectedtoincreasing
decelerationandaccelerationforceswhenwalkingspeedincreases.
CLINICALPEARL
Becauseleglengthinwomenis51.2%oftotalbodyheightcomparedwith56%inmen,womenmuststrikethe
groundmoreoftentocoverthesamedistance.45Furthermore,becausetheirfeetareshorter,womencomplete
theheeltotoegaitinashortertimethanmendo.Therefore,thecumulativeGRFsmaybegreaterinwomen.19
MediolateralShearForces
Mediolateralshearinwalkinggaitbeginswithaninitialmedialshear(occasionallylateral)forceafterinitial
contact,followedbylateralshearfortheremainderofthestancephase.10Attheendofthestancephase,the
shearshiftstoamedialdirectionbecauseofpropulsionforces.
AnteroposteriorShearForces
Anteroposteriorshearforcesingaitbeginwithananteriorshearforceatinitialcontactandtheloadingresponse
intervals,andaposteriorshearattheendoftheterminalstanceinterval.
CHARACTERISTICSOFNORMALGAIT
Muchhasbeenwrittenaboutthecriteriafornormalandabnormalgait.10,20,28,40,4652Althoughthepresenceof
symmetryingaitappearstobeimportant,asymmetryinitselfdoesnotguaranteeimpairment.Itmustbe
rememberedthatthedefinitionofwhatconstitutesthesocallednormalgaitiselusive.Unlikeposture,whichis
astaticevent,gaitisdynamicandassuchisprotean.
CLINICALPEARL
Goodalignmentoftheweightbearingsegmentsofthebody:
Reducesthelikelihoodofstrainandinjurybyreducingjointfrictionandtensioninthesofttissues.
Improvesthestabilityoftheweightbearinglimbandthebalanceofthetrunk.Thestabilityofthebodyis
directlyrelatedtothesizeoftheBOS.Inordertobestable,theintersectionofthelineofgravitywiththe
BOSshouldbeclosetothegeometriccenterofthebase.53
Reducesexcessenergyexpenditure.
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Gaitinvolvesthedisplacementofbodyweightinadesireddirection,utilizingacoordinatedeffortbetweenthe
jointsofthetrunkandextremitiesandthemusclesthatcontrolorproducethesemotions.Anyinterferencethat
altersthisrelationshipmayresultinadeviationordisturbanceofthenormalgaitpattern.This,inturn,may
resultinincreasedenergyexpenditureorfunctionalimpairment.
PerryandBurnfield10listfourprioritiesofnormalgait:
1.Stabilityoftheweightbearingfootthroughoutthestancephase.
2.ClearanceoftheNWBfootduringtheswingphase.
3.Appropriateprepositioning(duringterminalswing)ofthefootforthenextgaitcycle.
4.Adequatesteplength.
Gageetal.18addedafifthpriority,energyconservation.Thetypicalenergyexpendedinnormalgait(2.5
kcal/min)islessthantwicethatspentwhilesittingorstanding(1.5kcal/min).18Twodimensionalkineticdata
haverevealedthatapproximately85%oftheenergyfornormalwalkingcomesfromtheplantarflexorsofthe
ankle,and15%fromtheflexorsofthehip.54Ithasbeenproposedthatthetypeofgaitselectedisbasedon
metabolicenergyconsiderations.55Currentcommonlyusedparameterstomeasurewalkingefficiencyinclude
oxygenconsumption,heartrate,andcomfortablespeedofwalking.5658Theeconomyofmobilityisa
measurementofsubmaximaloxygenuptake(submaxVO2)foragivenspeed.59,60Adeclineinfunctional
performancemaybeevidencedbyanincreaseinsubmaxVO2forwalking.61Thischangeintheeconomyof
mobilitymaybeindicativeofanabnormalgaitpattern.61Someresearchershavereportednogenderdifferences
foreconomyofmobility,6264whereasotherssuggestthatmenaremoreeconomicalorhavelowerenergycosts
thanwomenatthesamework.6567Agerelateddeclinesintheeconomyofmobilityalsohavebeenreportedin
theliterature,withdifferingresults.Someresearchersreportedthatolderadultswerelesseconomicalthan
youngeradultswhilewalkingatvariousspeeds.59,68,69Conversely,economyofmobilityappearstobe
unaffectedbyagingforindividualswhomaintainhigherlevelsofphysicalactivity.7072
Someauthorshaveclaimedthatalimblengthdiscrepancyleadstomechanicalandfunctionalchangesingait73
andincreasedenergyexpenditure.74Interventionhasbeenadvocatedforlimblengthdiscrepanciesoflessthan
1cmtodiscrepanciesgreaterthan5cm,7375buttherationalefortheserecommendationshasnotbeenwell
defined,andtheliteraturecontainslittlesubstantiveinformationregardingthefunctionalsignificanceofthese
discrepancies.76Forexample,Grossfoundnonoticeablefunctionalorcosmeticproblemsinastudyof74adults
whohadlessthan2cmofdiscrepancyand35marathonrunnerswhohadasmuchas2.5cmofdiscrepancy.75
CLINICALPEARL
Thecardiovascularbenefitsderivedfromincreasesingaitspeedmaybeacceptableforanormalpopulation,or
anadvancedrehabilitationprogram,butshouldbeusedcautiouslywithpostsurgicalpatients.77
Forgaittobeefficientandtoconserveenergy,theCOGmustundergominimaldisplacement:
Anydisplacementthatelevates,depresses,ormovestheCOGbeyondnormalmaximumexcursionlimits
wastesenergy.
Anyabruptorirregularmovementwillwasteenergyevenwhenthatmovementdoesnotexceedthe
normalmaximumdisplacementlimitsoftheCOG.
CLINICALPEARL
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TheCOGinmenisatapointthatcorrespondsto56.18%oftheirheight.Inwomen,theCOGisatapointthat
correspondsto55.44%oftheirheight.78
Tominimizetheenergycostsofwalking,thebodyusesanumberofbiomechanicalmechanisms.In1953,
Saundersetal.79proposedthatsixkinematicfeaturestheSixDeterminantshavethepotentialtoreducethe
energeticcostofhumanwalking.Thesixdeterminantsareasfollows:80
Lateraldisplacementofthepelvis:Toavoidsignificantmuscularandbalancingdemands,thepelvisshifts
sidetoside(approximately2.55cmor12in)duringthegaitcycleinordertocentertheweightofthe
bodyoverthestanceleg.Ifthelowerextremitiesdroppeddirectlyverticalfromthehipjoint,theCOG
wouldberequiredtoshift34intoeachsidetobepositionedeffectivelyoverthesupportingfoot.The
combinationoffemoralvarusandanatomicalvalgumatthekneepermitsaverticaltibialposturewith
bothtibiasincloseproximitytoeachother.Thisnarrowsthestepwidthto510cm(24in)fromheel
centertoheelcenter,therebyreducingthelateralshiftrequiredoftheCOGtowardeitherside.
Pelvicrotation:Therotationofthepelvisnormallyoccursaboutaverticalaxisinthetransverseplane
towardtheweightbearinglimb.Thetotalpelvicrotationisapproximately4degreestoeachside.18
ForwardrotationofthepelvisontheswingsidepreventsanexcessivedropinthebodysCOG.Thepelvic
rotationalsoresultsinarelativelengtheningofthefemurbylesseningtheangleofthefemurwiththe
floor,andthussteplength,duringtheterminationoftheswinginterval.81
Theverticaldisplacementofthepelvis:VerticalpelvicshiftingkeepstheCOGfrommovingsuperiorly
andinferiorlymorethan5cm(2in)duringnormalgait.Duetotheshift,thehighpointoccursduring
midstance,andthelowpointoccursduringinitialcontact.Theamountofverticaldisplacementofthe
pelvismaybeaccentuatedinthepresenceofaleglengthdiscrepancy,fusionoftheknee,orhipabductor
weakness,thelatterofwhichresultsinaTrendelenburgsign.TheTrendelenburgsignissaidtobepositive
if,whenstandingononeleg,thepelvisdropsonthesideoppositetothestanceleg.Theweaknessis
presentonthesideofthestancelegthegluteusmediusisnotabletomaintaintheCOGonthesideof
thestanceleg.
Kneeflexioninstance:Kneemotionisintrinsicallyassociatedwithfootandanklemotion.Atinitial
contactbeforetheanklemovesintoaplantarflexedposition,andthusisrelativelymoreelevated,theknee
isinrelativeextension.Respondingtoaplantarflexedpostureatloadingresponse,thekneeflexes.
MidstancekneeflexionpreventsanexcessiveriseinthebodysCOGduringthatperiodofthegaitcycle.
Ifnotforthemidstancekneeflexion,theCOGsriseduringmidstancewouldbelarger,aswoulditstotal
verticaldisplacement.Passingthroughmidstanceastheankleremainsstationarywiththefootflatonthe
floor,thekneeagainreversesitsdirectiontooneofextension.Astheheelcomesoffthefloorinterminal
stance,theheelbeginstoriseastheankleplantarflexesandthekneeflexes.Inpreswing,astheforefoot
rollsoverthemetatarsalheads,theheelelevatesevenmoreasfurtherplantarflexionoccurs,andflexionof
thekneeincreases.
Anklemechanism:Fornormalfootfunctionandgait,theamountofanklejointmotionrequiredis
approximately10degreesofdorsiflexion(tocompletemidstanceandbeginterminalstance)and20
degreesofplantarflexion(forfullpushoffinpreswing).Atinitialcontact,thefootisinrelative
dorsiflexionduetothemuscleactionofthepretibialmusclesandthetricepssurae.Thismuscleaction
producesarelativelengtheningoftheleg,resultinginasmoothingofthepathwayoftheCOGduring
stancephase.
Footmechanism:Thecontrolledleverarmoftheforefootatpreswingisparticularlyhelpfulasitrounds
outthesharpdownwardreversaloftheCOG.Thus,itdoesnotreduceapeakdisplacementperiodofthe
COGastheearlierdeterminantsdidbutrathersmoothsthepathway.Anadaptivelyshortened
gastrocnemiusmusclemayproducemovementimpairmentbyrestrictingnormaldorsiflexionoftheankle
fromoccurringduringthemidstancetoheelraiseportionofthegaitcycle.Thismotioniscompensated
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forbyincreasedpronationofthesubtalarjoint,increasedinternalrotationofthetibia,andresultant
stressestothekneejointcomplex.
CLINICALPEARL
Adecreaseinflexibilityorjointmotion,orboth,mayresultinanincreaseinbothinternalresistanceandthe
energyexpenditurerequired.
JointMotions
Duringthegaitcycle,theswingofthearmsisoutofphasewiththelegs.Astheupperbodymovesforward,the
trunktwistsaboutaverticalaxis.Thethoracicspineandthepelvisrotateinoppositedirectionstoeachotherto
enhancestabilityandbalance.Incontrast,thelumbarspinetendstorotatewiththepelvis.Inaddition,thepelvis
tiltsanteriorlyandposteriorly(Fig.63).Theshouldersandtrunkrotateoutofphasewitheachotherduringthe
gaitcycle.82Unlesstheyarerestrained,thearmstendtoswinginoppositiontothelegs,theleftarmswinging
forwardastherightlegswingsforward,andviceversa.5Whenthearmswingisprevented,theuppertrunk
tendstorotateinthesamedirectionasthepelvis,producinganawkwardgait.
FIGURE63
Pelvicmotionduringnormalgait.
CLINICALPEARL
Differentpatternsofinterlimbcoordinationbetweenarmsandlegshavebeenobservedwithinthehuman
walkingmode.83,84Atlowerwalkingspeeds,thearmsaresynchronizedtothesteppingfrequency(2:1ratioof
armtoleg),whereasathigherwalkingvelocities,thearmsaresynchronizedtothestridefrequency(1:1ratioof
armtoleg).Theseresultsalsosuggestthatatlowerspeeds,theresonantfrequencyofthearmsdominatesthe
interlimbcoupling,whereasathigherspeeds,theresonantfrequencyofthelegsisdominant.85
Maximumflexionofboththeelbowandtheshoulderjointsoccursattheinitialcontactintervaloftheopposite
foot,andmaximumextensionoccursattheinitialcontactofthefootonthesameside.86
Althoughthemajorityofthearmswingresultsfrommomentum,thependularactionsofthearmsarealso
producedbygravityandmuscleaction.5,87
Theposteriordeltoidandteresmajorappeartobeinvolvedduringthebackwardswing.
Theposteriordeltoidservesasabrakingmechanismattheendoftheforwardswing.
Themiddledeltoidisactiveinboththeforwardandthebackwardswing,perhapstopreventthearms
frombrushingagainstthesidesofthebodyduringtheswing.
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Themotionsthatoccurateachofthelowerextremityjointsduringthestancephaseofthegaitcycleare
outlinedinTable62andFigure64.
TABLE62JointMotionsintheLowerExtremitiesDuringGait
Phase Hip KneeandTibia AnkleandFoot
Kneepositionedinfull
Hipbeginstomovetoward extensionbeforeinitial
extensionfromapositionof2040 contactbutflexesasheel Footpositionedinsupination(rigid)at
degreesofflexionslight makescontact heelcontact,withtheanklemoving
Initial
adductionandexternalrotation Tibiapositionedinslight intoplantarflexion
contact
Reactionforceanteriortohipjoint externalrotation Reactionforcesbehindthejointaxis
creatingflexionmomentmoving Reactionforcebehind plantarflexionmomentatheelstrike
towardextension kneerapidlyincreases
causingflexionmoment
Footpositionedinpronationtoadapt
Kneein20degreesof tosupportsurface,withtheankle
kneeflexion,moving movingfromplantarflexionto
Hipmovesintoextension,
Loading towardextension dorsiflexionoverafixedfoot
adduction,andinternalrotation.
response Tibiaintointernal Maximumplantarflexionmoment
Flexionmoment
rotation reactionforceisbeginningtoshift
Flexionmoment anteriorly,producingadorsiflexion
moment
Hipmovesthroughneutral Kneein15degreesof
positionwiththepelvisrotating flexion,movingtoward
Footinneutralandanklein3degrees
posteriorly extension
Midstance ofdorsiflexion
Reactionforcenowposteriorto Tibiainneutralrotation
Slightdorsiflexionmoment
hipjointcreatingextension Maximumflexion
moment moment
Kneein4degreesof
Hippositionedin1015degrees flexion,movingtoward Footinsupinationbecomingrigidfor
ofhipextension,abduction,and extension pushoff
Terminal
externalrotation Tibiainexternalrotation Anklein15degreesdorsiflexion
stance
Extensionmomentdecreasesafter Reactionforcesmoving towardplantarflexion
doublelimbsupportbegins anteriortothejoint Maximumdorsiflexionmoment
extensionmoment
Kneemovingfromnear
Hipmovingtoward10degreesof fullextensionto40
extension,abduction,andexternal degreesofflexion.Tibia Footinsupinationandanklein20
Preswing rotation inexternalrotation degreesofplantarflexion
Continueddecreaseofextension Reactionforcesmoving Dorsiflexionmoment
moment posteriortokneeasknee
flexesflexionmoment
DatafromGiallonardoLM.Gait.In:MyersRS,ed.SaundersManualPhysicalTherapyPractice.Philadelphia,
FIGURE64
Jointkinematicsinthehorizontalplaneduringgait.
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Hip
Thefunctionofthehipistoextendthelegduringthestancephaseandflexthelegduringtheswingphase
(Table62).Althoughmovementofthehipduringgaitpredominatelyoccursinthesagittalplane,thehipmotion
alsooccursinthefrontalandtransverseplanesduringthegaitcycle.Duringswing,thehipflexestoadvancethe
limb,while,duringstance,thehipextendstomovethetrunkforwarduntiltoeoff.88
Thehipflexesandextendsonceduringthegaitcycle,withthelimitofflexionoccurringatthemiddleof
theswingphase,andthelimitofextensionbeingachievedbeforetheendofthestancephase(Table62).
Thehipgoesthroughatotalexcursionof4050degreesduringstance,withmaximumhipflexionof30
35degreesoccurringjustbeforetheinitialcontact,atabout85%ofthegaitcycle.Aftermaximumhip
flexionhasbeenobtained,thereisoftenasmallmovementtowardextension(i.e.,thehipbecomeslightly
lessflexed)asthelegadjustsforplacementorprepositioningofthefootjustpriortoinitialcontact.88
Maximumextensionofapproximately1020degreesisreachedneartoeoffatapproximately60%ofthe
cycle.10,40,41,89Theligamentsofthehiphelpstostabilizethejointinextension.
Inthecoronalplane,thehipisslightlyabductedatinitialcontactbeforehipadductionoccursthroughout
earlystanceasthelimbisloaded,andthebodyissupportedandreachesamaximumat40%ofthe
cycle.89Muchofthehipadductionisaresultofthepelvicanglesothatadductionduringstanceoccurs,in
part,duetothedroppingofthepelvisonthecontralateralunsupportedlimb.Thehipthenmovesinto
abductionasthepelvislevelsout,andthebodyprogressesoverthestancelimb,reachingmaximum
abductionshortlyaftertoeoff.88ThetotalROMisnear15degrees,withequalamountsofabductionand
adduction.Duringtheswingphase,hipadductiontotaling57degreesoccursinearlyswingphase,which
isfollowedbyslighthipabductionattheendoftheswingphase,especiallyifalongstrideis
taken.10,40,41,89
CLINICALPEARL
WomennaturallyhavealargerQanglethanmen(seeChapter20).Inaddition,womenhaveincreasedhip
adduction,hipinternalrotation,kneevalgus,andtheinternalrotationduringfunctionalactivitiessuchas
runningandwalkingascomparedtomen.90,91
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Thehiprotatesinternallyandexternallyapproximately4045degreesinthetransverseplaneduringa
normalstride,beginninginapproximately10degreesofexternalrotationatinitialcontact.10Thehip
beginstointernallyrotateduringtheloadingresponsetoapproximately5degreesofinternalrotation.
Maximuminternalrotationoccursaroundthetimeofinitialcontactonthecontralateralside.88Thehip
externallyrotatesduringtheswingphase,withmaximalexternalrotationoccurringinterminalswing.40
Thegreatestforceonthehipoccursduringmidstance.Painfulhip,knee,orankleconditionscausethisinterval
tobeshortenedtodecreasethetimespentinthepainfulposition.
CLINICALPEARL
Themovementsofthethighandlowerlegoccurinconjunctionwiththerotationofthepelvis.Thepelvis,thigh,
andlowerlegnormallyrotatetowardtheweightbearinglimbatthebeginningoftheswingphase.82
Knee
Thekneeflexestwiceandextendstwiceduringeachgaitcycle:onceduringweightbearingandonceduring
NWB.
Normalsagittalplaneexcursionofthekneejointduringagaitcycleisapproximately60degreeswiththeknee
nearfullextensionatinitialcontactandmidstance.Atinitialcontactduringnormalgait,theGRFinitiallypasses
anteriortothekneejointandgivesrisetoanexternalkneeextensionmoment,whichiscounterbalancedbyan
internalkneeflexionmomentcreatedbythehamstringsandpassiveposteriorkneestructures.9Immediately
afterinitialcontact,theGRFpassesbehindthekneejointcausinganexternalkneeflexionmomentastheknee
flexestoabout20degreesduringtheloadingresponseinterval,whichactsasashockabsorbingmechanism.
Aftermidstance,theGRFpassesinfrontofthekneeagainasthekneebeginstoextenduntiltoeoffand,asthe
heelrisesduringtheterminalstanceinterval,thekneeisalmostfullyextended,butflexesagainastheswing
phasebegins.TheGRFdoesnotactupontheswinglimb.Theflexionoccurssothatthelowerlimbcanbe
advancedduringtheswingphasewithaminimumverticaldisplacementoftheCOG.Thekneethencontinuesto
flexasthelegmovesintotheswingphase.Duringinitialtomidswing,thekneecontinuestoflextoamaximum
of60degrees,beforeextendingagainpriortoinitialcontact.28Duringterminalswing,thehamstringsactto
slowtheprogressionofthetibiainpreparationforcontactwiththeground.Althoughmovementsinthefrontal
andtransverseplanescanoccuratthekneeduringgait,themagnitudeoftheexcursionismuchsmaller,making
thesemotionshardertoanalyzevisually.Inindividualswithoutjointpathology,thereisverylittlemovementin
thefrontalplane,althoughthereisslightkneevarusexcursionduringtheloadingresponseofapproximately4
degreesoftibialabductionrangerelativetothefemurduringstancephase.92Themotionofthekneeinthe
transverseplanehasbeentermedthescrewhomeorlockingmechanismandisconsideredakeyelementinknee
jointstability(seeChapter20).
Innormalwalking,about60degreesofkneeflexionisrequiredforadequateclearanceofthefootduringthe
swingphase.Thispeakflexionisrequiredimmediatelyaftertoeoffbecauseatthatpointinthegaitcycle,the
toeisstillpointedtowardtheground.18
CLINICALPEARL
Themostcommonproblematthekneeduringthestancephaseisexcessiveflexion.Duringtheswingphase,the
mostcommonerrorresultsfrominadequatemotion.
WhentheGRFactstocollapsethekneejointduringstance,producinganexternaljointmoment,anequal
andoppositeangularforce,orinternaljointmoment,needstobeproducedbytheindividualtomaintain
anuprightposition.9Ifexcessiveflexionatthekneeoccursinmidstance,theGRFmovesposteriorlyto
thekneeandgeneratesaflexionratherthananextensionmoment.Thischangeatthemomentrequiresthe
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hip,knee,andankletomaintainstability.Thesharingoftheseforcesbetweenthehip,knee,andankleare
knownasthetotalsupportmomenttheredistributionofforcesamongthesejointscanresultinvisible
gaitcompensations.9
Excessiveflexionatthekneeresultsinexcessiveflexionoccurringatthehip.This,inturn,increasesthe
magnitudeoftheloadonboththehipandthekneejoints.93
Thearthrokinematicsinvolvedduringtheloadingresponseincludeananteriorglidingofthefemoralcondyles,
whichservestounlocktheknee.Thisforwardglidingiscontrolledbythepassiverestraintoftheposterior
cruciateligament(PCL)andbytheactivecontractionofthequadricepsmuscles.
CLINICALPEARL
BecauseACLreconstructedpatientsmayexperiencepatellofemoralpain,9496especiallythosewithpatella
tendonautografts,itisimportanttoprescribeexercisesthatdecreaseACLstrainthroughincreasedflexion,and
minimizepatellofemoralpainbyexercisingwiththekneenearfullextension.77Thishasbeenrecognizedasa
paradox97,98exercisesperformedbetweenthetwoextremes,approximately3060degreesofkneeflexion,
mayavoidexcessiveACLstrainandlimitpatellofemoralpain.77However,patellofemoralcontactpressurescan
increasedramaticallywithincreasedkneeflexion.99101Asaresult,patellofemoralpainisexacerbatedbutcan
beavoidedandtreatedbystrengtheningthequadricepsinthe030degreeskneeflexionrange.102
Alossofkneeextension,whichcanoccurwithaflexiondeformity,resultsinthehipbeingunabletoextend
fully,whichcanalterthegaitmechanics.Patientswithpatellofemoraldysfunctiondemonstratelesskneeflexion
thannormalduringthestancephaseofgait,combinedwithincreasedexternalrotationofthefemurduringthe
swingphase.49Excessivecompensatoryinternalrotationofthefemuroftheweightbearinglegduringthe
stancephasemayresultinabnormalstressesbeingplacedonthepatellofemoraljoint.49
CLINICALPEARL
Studiesusingaforwarddynamicanalysisshowastrongrelationshipbetweentibialadvancementandthe
movementduringthefirsthalfofthestancephaseofgait.103Bydeceleratingthetibiaaftermidstance,the
gastrocnemiusmusclecontributestokneeextension.
Inlatestance,plantarflexionattheanklecontributestosupport(verticalforcesactingonthetrunk)andforward
progression(horizontalforcesactingonthetrunk).104
AnkleandFoot
Anklejointmotionsduringthegaitcycleoccurprimarilyinthesagittalplaneandareassociatedwithbalance
andforwardprogression.Duringnormalgait,theinitialcontactwiththegroundismadebytheheel,withthe
ankleinarelativelyneutralorslightlydorsiflexedposition,theheelslightlyinverted,andthesubtalarjoint
slightlysupinated.105.Inindividualswithpoorcontrolofdorsiflexion(e.g.,incasesofhemiplegia),theinitial
contactismadewiththelowerpartoftheheelandforefootsimultaneously.Thisisusuallyaccompaniedbya
toedragduringtheswingphase.Akneeflexioncontractureorspasticitymaycausethesamealteration.
Similarly,ifthequadricepsareweak,thepatientmayextendthekneebyusingthehandormayhittheheelhard
onthegroundtowhipthekneeintoextension.Ifheelpainoccursatinitialcontact,thispainmaycause
increasedflexionoftheknee,withearlyplantarflexiontorelievethestressorpressureonthepainfultissues.10
CLINICALPEARL
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Theabilityofthefoottoperformbothasarigidleverforpropulsionandasaflexiblestructureforshock
absorptionduringgaitdependsonanumberofstructuralmechanismswithinthefoot.Midfootlockingis
associatedwiththeaxesofthetalonavicularandcalcaneocuboidjointchangingaccordingtowhetherthefootis
pronatedorsupinated(seeChapter21).Whenthehindfootispronated,theaxesofthesetwojointsareparallel
toeachotherwhichallowsformovement(flexiblefoot).Whenthehindfootisinverted,theaxesarenot
parallel,whichresultsindecreasedmovementandenhancedfunctionofthefootasarigidlever.104
Theimmediateimpactoftheinitialcontactistakenthroughthelateraltubercleofthecalcaneus,astructure
uniquetohumansthatisdesignedtotoleratetheshockviathecalcanealfatpad.Thecalcaneusquicklymoves
intoapproximately5degreesofvalgusasthelimbisloadedtodissipatethehighGRFthatisgeneratedat
impact.Duringtheloadingresponse,theanklemovesfromneutraldorsiflexionatinitialcontacttoabout58
degreesofplantarflexionatmidstance.Duringtheloadingresponseinterval,thevalgusdisplacementofthe
calcaneuswithinthefrontalplaneinducespronationatthesubtalarjoint,whichinturnresultsinexternal
rotationofthecalcaneusandinternalrotationofthetaluswithinthetransverseplane.105
CLINICALPEARL
Tiberio106hasproposedthatprolongedpronationduringgaitcanleadtoincreasedkneeinternalrotationand
subsequentpatellofemoralproblems.
Thesubtalarjointmovesintopronationfrominitialcontacttomidstance,thenrapidlyinvertsandsupinates
duringterminalstance(after50%ofstance)andpeaksnear90%ofstance.Thepronationofthesubtalarjoint
unlocksthefootandallowsmaximalROMofthemidtarsaljoint,whichbringsthearticulatingsurfacesofthe
cuboidandnaviculartoapositionrelativelyparalleltotheweightbearingsurfaceandallowstheforefootto
becomesupple.107,108Thisincreaseinmidtarsaljointmobilityenhancesthefootsabilitytoadapttothe
supportsurface.Abnormalresponsesduringthisintervalincludeexcessive,ornokneemotion,asaresultof
weakquadriceps,plantarflexorcontractures,orspasticity.10
CLINICALPEARL
Therearetwobroadtypesoferrorsatthefootandanklejointsinthestanceandswingphases:
1.Malrotation.Themalrotationinstancerotatestheplaneofthefootoutsideoftheplaneofprogression,
resultingintheCOGprematurelypassingoutsideoftheBOS.Thisalteration,inturn,resultsina
shorteningofthecontralateralsteplength.Inaddition,ifthefootismalrotatedsignificantlyintoexternal
rotation,avalgusmomentandanexternalrotationmomentareintroducedattheknee.
2.Varusorvalgusdeformity.Varusandvalgusdeformitiesproducealossofstabilitythroughoutthestance
phasebecausetheyintroducelargeexternalmomentsinthefrontalplanethatmustbebalancedbylarge
musclemoments,ifstabilityistobemaintained.
Inthestancephase,thesedeviationsmayinterferewiththefirstandfourthofPerrysprioritiesofgait(stability
instanceandadequatesteplength).Intheswingphase,thesedeviationsmayinterferewithpriorities2and3
(clearanceofthefootinswingandprepositioningofthefootinterminalswing).
Attheendofthemidstanceinterval,asthelegsegmentadvancesoverthefixedfoot,theanklemovesinto
dorsiflexion,andthesubtalarjointbeginstosupinate.Thissubtalarjointmovementmayplayakeyrolein
assistingthefoottobecomearigidleverandincreasetheheightofthemediallongitudinalarch.During
preswing,theankleplantarflexesapproximately20degrees,whichservestolengthenthelimbandpreservethe
verticalpositionoftheCOG.Inordertoperformthisfunction,thefootmustbecomearigidlever.However,if
thepainiselicitedduringthisinterval,theheelmayliftoffthefloorearly.Fromthemidstancetotheterminal
stanceinterval,thefootisinsupination.107Supinationatthesubtalarjointlocksthefootintoarigid
lever105,109bypromotingsupinationatthemidtarsaljoint,whichresultsinthearticulatingsurfacesofthe
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cuboidandcalcaneusadoptingapositionthatisperpendiculartooneanother,thusstabilizingtheir
articulation.108Thefixedcuboidactsasafulcrumforthefibularis(peroneus)longusmuscle,facilitating
plantarflexionofthefirstmetatarsalinpushingoff.107
CLINICALPEARL
Anadaptivelyshortenedgastrocnemiusmusclemayproducemovementimpairmentbyrestrictingnormal
dorsiflexionoftheanklefromoccurringduringthemidstancetoheelraiseportionofthegaitcycle.Thismotion
iscompensatedforbyincreasedpronationofthesubtalarjoint,increasedinternalrotationofthetibia,and
resultantstressestothekneejointcomplex.
Oncetheankleisfullyclosepacked,theheelisliftedbyacombinationofpassiveforceandcontractionfrom
thetautgastrocnemiusandthesoleus.Theliftingoftheheelaccentuatestheforceappliedtothemidand
forefoot,reinforcingtheclosepackingofthisareawhilesimultaneouslyreducingtheclosepackingoftheankle
joint.
Thehallux,orfirstMTPjoint,undergoesconsiderableROMwhilewalking(inexcessof40degreesof
extension),110particularlyattheendofstance,astheankleisplantarflexingandthehalluxremainsincontact
withtheground.110Asankleplantarflexionreachesitspeakattheendoftheterminalstanceintervalthefirst
MTPjointispassivelyextended.ThisextensionofthefirstMTPjointplacestensionontheplantarfasciaand
helpstoelevatethemediallongitudinalarchthroughthewindlassmechanismoftheplantarfascia(seeChapter
21).Thiswindlassmechanismcreatesadynamicstablearchand,hence,amorerigidleverforpushoff.107
However,ifthepainiselicitedduringthisinterval,thepatientisunabletopushoffonthemedialaspectofthe
footandinsteadcompensatesbypushingoffonthelateralaspectofthefoot.
Whiletheforefootisontheground,andtheheelisoff,theheelisinverted,andthefootissupinated.105The
plantarflexionactionhelpstosmooththepathwayoftheCOG.Theheelrisecoincideswiththeoppositeleg
swingingbythestanceleg.111Approximately40%ofthebodyweightisbornebythetoesinthefinalstagesof
footcontact.112,113Muscleactivityduringpushoffisdesignedtoinitiatepropulsion.107However,ifthe
plantarflexorsareweak,thepushoffmaybeabsent.
CLINICALPEARL
BojsenMller114describestheheelriseandthepushoffastakingplaceattheMTPjointsaroundtwoprimary
axes:oneobliqueandonetransverse.Theheelriseoccursfirstaroundtheobliqueaxis,whichpassesthrough
theMTPjointsofthesecondthroughthefifthtoes.Thisisfollowedbythepushoffaroundthetransverseaxis
passingthroughtheMTPjointsofthefirstandsecondtoes.Theresistancearmofferedagainsttheforcearmof
thetricepssuraewhilethepushoffvariesandis20%longerwhenthepushoffisbeingperformedalongthe
transverseaxis.BojsenMllercharacterizesthemotionaroundtheobliqueMTPjointaxisasalowgearmotion,
andthemotionaroundthetransverseaxisasahighgearmotion.112,114,115Highgearmotionisusedfor
sprinting,andlowgearmotionisusedforuphillwalkingwithloads,andinthefirststepofasprint.
Frominitialcontacttoearlymidstance,thetibiamovesanteriorly,internallyrotatingwithintheanklemortise,
andproducingtalaradductionandplantarflexion,andcalcanealeversion(weightbearingpronationofthe
subtalarjoint).107Theforwardtibialadvancementrequiresapproximately10degreesofanklejointdorsiflexion
topreventexcessivepronationatthesubtalarandobliquemidtarsaljoints.52,108,116
Duringtheswingphase,theanklemustdorsiflexinorderfortheforefoottocleartheground.Afterthetoes
cleartheground,theanklemovesintoapositionofdorsiflexion,whichismaintainedthroughouttheremainder
oftheswingphase.117However,iftheankledorsiflexormusclesareweak,thepatientmustutilizeasteppage
gait,manifestedbyexcessiveflexionatthehipsothatthetoescancleartheground.Priortothenextinitial
contact,theankleadoptsaneutralpositionintermsofdorsiflexionandplantarflexion.
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MuscleActionsDuringGait
Themusculotendinousunitsthatspanthelowerextremityjointsactastorsionalsprings,whichproducea
forwardtranslationofthebodymassinamannersimilartothatofabouncingball.118Theefficiencyof
locomotion(i.e.,walkingorrunning)isgreatlyenhancedbythestretchshorteningcycleoftheskeletalmuscles
(i.e.,recoilofthestretchedparallelandserieselasticcomponents,combinedwitharapidtransitionfroman
eccentrictoaconcentriccontractionmode).8Duringtheswingphase,thesemispinalis,rotatores,multifidus,and
externalobliquemusclesareactiveonthesidetowardwhichthepelvisrotates.5Theerectorspinaeandinternal
obliqueabdominalmusclesareactiveontheoppositeside.Thepsoasmajorandquadratuslumborumhelpto
supportthepelvisonthesideoftheswinginglimb,withthecontralateralhipabductorsalsoprovidingsupport.
Theankleandhipmusclesareresponsibleforthemajorityofpositiveworkperformedwhilewalking(54%of
thehipand36%oftheankle).119Thekneecontributesthemajorityofthenegativework(56%).119Themuscle
actionsthatoccurduringthestancephaseofgaitaredepictedinTable63.120
TABLE63MuscleActionsintheLowerExtremitiesDuringtheStancePhaseofGait
Phase Hip KneeandTibia AnkleandFoot
Gluteusmaximusand Quadricepsfemoris
Thedorsiflexors(tibialisanterior,extensor
hamstringswork contractseccentricallyto
Initial digitorumlongus,andextensorhallucis
eccentricallytoresistflexion controlrapidknee
contact longus)contracteccentricallytoslow
momentanddeceleratethe flexionandtoprevent
plantarflexion.
leg buckling
Afterthefootisflat,
Gluteusmaximusand Dorsiflexionactivitydecreasestibialis
quadricepsactivity
Loading hamstringscontract posterior,flexorhallucislongus,andflexor
becomesconcentricto
response concentricallytobringthe digitorumlongusworkeccentricallyto
bringthefemuroverthe
hipintoextension controlpronation
tibia
Iliopsoasworkseccentrically Quadricepsactivity Plantarflexormuscles(gastrocsoleusand
toresistextensiongluteus decreasesgastrocnemius fibularis[peroneal]muscles)areactivated
Midstance mediuscontractsinreverse workseccentricallyto tocontroldorsiflexionofthetibiaand
actiontostabilizeopposite controlexcessiveknee fibulaoverafixedfootbycontracting
pelvis extension eccentrically
Gastrocnemiusbeginsto
Terminal Plantarflexormusclesbegintocontract
Iliopsoasactivitycontinues workconcentricallyto
stance concentricallytoprepareforpushoff
startkneeflexion
Adductormagnusworks
Plantarflexormusclesatpeakactivitybut
eccentricallytocontrolor Quadricepsfemoris
Preswing becomeinactiveasthefootleavesthe
stabilizethepelvisiliopsoas contractseccentrically
ground
activitycontinues
DatafromGiallonardoLM.Gait.In:MyersRS,ed.SaundersManualPhysicalTherapyPractice.Philadelphia,
Hip
Thehipisuniqueinthatitcontrolsmotionsofthesagittal,frontal,andtransverseplanesduringthegaitcycle,
withthemajorityoccurringinthesagittalplane.1Duringtheinitialcontact,theglutealmusclesandthe
hamstringscontractisometricallywithmoderateintensity.Thepassivehipextensionmomentatinitialcontact
hasbeencalculatedtobeapproximately60100%ofthetotalmomentoccurringduringthestancephase,
suggestingthatpassiveelasticenergyisstoredandreleasedduringgait.121Theloadingresponseintervalis
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accompaniedbyhamstringandgluteusmaximusactivity,whichaidshipextension.10,41,89,122Theadductor
magnusmusclesupportshipextensionandalsorotatesthepelvisexternallytowardtheforwardleg.In
midstance,frontalplanemuscleactivityisgreatest,astheabductorsstabilizethepelvisbyisometricallyand
eccentricallycontracting.123127Themuscleactivityinitiallyiseccentric,asthepelvisshiftslaterallyoverthe
stanceleg.
Thegluteusmediusandminimusremainactiveinterminalstanceforlateralpelvicstabilization.Theiliacusand
anteriorfibersofthetensorfasciaelatae(TFL)arealsoactiveintheterminalstanceandpreswingintervals.10
Notable,butinconsistent,muscleactivityoftherectusfemorisisdescribedbyseveralauthors.10,41,89,122The
onlymusclesofthehipthatcontractsignificantlyduringthelastpartofthestancephasearetheadductor
magnus,longus,andpossiblybrevis.5
Duringtheearlytomidportionoftheswingphase,theiliopsoasistheprimemover,withassistancefromthe
rectusfemoris,sartorius,gracilis,adductorlongus,andpossiblytheTFL,pectineus,andshortheadofthebiceps
femorisduringtheinitialswinginterval.5Perrynotestheadductorlongusmuscletobethefirstandmost
persistenthipflexor.10Interminalswing,thereisnoappreciableactionofthehipflexorswhenambulatingon
levelground.Instead,thehamstringsandgluteusmaximusarestronglyactivetodeceleratehipflexionandknee
extension.10Boththesesuperficialmusclesandtheirdeepercounterparts,suchasthehipadductors,gemelli,
andshortrotators,certainlycontribute.51Inrapidwalking,thereisincreasedactivityofthesartoriusandthe
rectusfemorisduringtheswingphase.5
CLINICALPEARL
Thehipflexors(primarilytheiliopsoasmuscle)contracttoslowdownhipextension,whereasthehip
extensors(primarilythehamstringmuscles)contracttoslowdownhipflexion.
Thehipabductormusclesprovidestabilityduringsinglelegsupport,acriticaleventforthehip.51
CLINICALPEARL
Themajorproblemsthatoccuratthehipduringgaitareinadequatepower,aninadequateorinappropriateROM,
andmalrotation.
Aweaknessofthehipflexorsisbestseenduringthepreswingandinitialswingintervals.Aweaknessofthehip
abductorsisnotedduringthesinglesupportphaseofstancebecausethehipabductorsarerequiredtoprevent
thecollapseofthepelvistowardtheunsupportedside(Trendelenburgsign).
Aweaknessofthehipextensorsisusuallyseenatinitialcontactandduringloadingresponse.Ifthehamstrings
areweak,theinitialcontactmaybeexcessivelyharshtolockthekneeintoextension.
Astheflexors,adductors,andinternalrotatorsofthehiparedominantovertheirantagonists,flexion,adduction,
andinternalrotationdeformitiestendtobetherule.
Malrotationofthehipusuallyresultsfromconditionssuchasfemoralanteversion.
Knee
Thefunctionsofthekneeduringgaitaretoabsorbshock,reduceverticaldisplacementoftheCOG,maintainthe
stridelength,bearweight,andallowthefoottomovethroughitsswing.Inanormalgaitcycle,theloading
responseintervalbeginswiththekneeslightlyflexedastheheelinitiallycontactstheground.Throughoutthe
loadingresponseinterval,thekneecontinuestoflextoabout20degrees,atwhichtimethekneeisunder
maximumweightbearingload.9Theloadingresponsephaserequireslargeamountsofeccentricquadriceps
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force.Midstancecorrespondswithconcentricloadingofthekneeextensorsasthekneebeginstoextend
followingitsroleinabsorbingthebodysweightduringtheloadingresponse.9Duringtheswingphase,thereis
verylittleactivityfromthekneeflexors.Thekneeextensorscontractslightlyattheendoftheswingphaseprior
toinitialcontact.Duringlevelwalking,thequadricepsachievepeakactivityduringtheloadingresponseinterval
(25%maximumvoluntarycontraction)andarerelativelyinactivebymidstanceasthelegreachesthevertical
positionandlocks,makingquadricepscontractionunnecessary.46,128130Inagradedexercise,Brandell131
examinedtheeffectofspeedandgradeonelectromyographic(EMG)activityofthequadricepsandcalf
musculature.TheauthorconcludedthatincreasesinspeedandgraderesultedinarelativeincreaseinEMG
activityofthequadricepscomparedwiththecalfmusculature.MorerecentlyCiccottietal.132notedsimilar
magnitudesandprofilesofEMGactivityinthequadricepsduringlevelwalking(1.5m/s)andascendingaramp
of10%gradeatthesamespeedaslevelwalking.Althoughminimaldatawerepresentedforcomparison,the
authorsdidnoteadecreaseinvastuslateralisactivityfrom16%tolessthan10%ofmaximummanualmuscle
test,withtheadditionofagrade.Therefore,itremainsquestionablewhethergradedwalkingactuallyfacilitates
quadricepsactivity.77
CLINICALPEARL
Ifthequadricepsmusclesareweak,thetrunkmusclesthrustthepelvisforwardtoprovideforwardmomentum
totheleg.
Hamstringinvolvementisalsoimportanttonormalkneefunction.Thehamstringsprovidedynamicstabilityto
thekneebyresistingbothmediolateralandanteriortranslationalforcesonthetibia.133Thecoactivationofthe
antagonistmusclesaboutthekneeduringtheloadingresponseintervalaidstheligamentsinmaintainingjoint
stabilitybyequalizingthearticularsurfacepressuredistributionandcontrollingtibialtranslation.134,135EMG
activityofthehamstringsduringlevelwalkinghasshownthatthehamstringsdeceleratethelegpriortoheel
contactandthenactsynergisticallywiththequadricepsduringthestancephasetostabilizetheknee.129,136The
hamstringsalsodemonstrateactivityattheendofthestancephase.Hamstringactivityduringgradedwalking
andincreasedspeeddemonstratesincreasedactivityandforalongerduration.5
CLINICALPEARL
Notonlyisquadricepsandhamstringstrainingimportantinkneerehabilitation,butproperROMmustalsobe
considered.77
AnkleandFoot
Theextensorhallucislongus(EHL)andextensordigitorumlongus(EDL),whicharebothinnervatedbythe
deepfibular(peroneal)nervecontainingfibersfromL4S1,eccentricallyassisttheforefootincontrollingthe
decelerationofthefootatheelstrike.Atinitialcontact,thetibialisanteriorisactive.Followinginitialcontact,
thetibialisanteriorworkseccentricallytocontrolthespeedofplantarflexiontolowerthefoottotheground
duringtheloadingresponseinterval.137,138Lossofthisplantarflexioncontrolcanresultinaninabilityto
transferweighttotheanteriorfoot,increasedankledorsiflexion,andincreasedkneeflexion.Eccentrictension
withinthetibialisposteriormusculotendinousunitrestrainsexcessivedistraction(pronation)ofthemedial
articularsurfacesofthesubtalarjointandtransversetarsaljointsduringimpactloading,andsubsequent
isometricandconcentrictensiongeneratedbythetibialisposteriorprovidethemidfootstabilizingeffectthatis
essentialforbodymasspropulsion.139Indeed,thetibialisposteriorisrequiredtoactduringthefullweight
bearingphaseofthegaitcycleandisthusactivefrominitialcontacttoshortlyaftertheheelraisesbeforetoe
off.Theanteriormovementofthetibiaandtalusislimitedbytheeccentricactionofthegastrocnemiusand
soleusmusclegroupsasthefootmovestowardmidstance.120
CLINICALPEARL
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Thetibialisposteriormuscleisactiveduring4580%ofthegaitcycle,andtheinterdependentclosedchain
displacementsofthevariousfoot,andanklejointsareheavilyinfluencedbythismuscle.139Indeed,thetibialis
posteriormusclelikelyplaysanimportantroleincontrollinghindfootpronationandsupinationwhileproviding
secondarycontrolofabductionandadductionofthemidfootduringgait.104Inaddition,thetibialisposterior
playsanintegralroleinmaintainingtheintegrityofthelongitudinalarchofthefoot(seeChapter21).
Eccentriccontractionsdominategastrocnemiusfunctionduringnormalwalkingtherefore,rehabilitationshould
emphasizeeccentricmovement.140
Pronation,whichiseccentricallycontrolledbythetibialisposterioralsooccursinthisphasetoallowforshock
absorption,groundterrainchanges,andequilibrium.108,141Thetricepssuraebecomeactiveagainfrom
midstancetothelatestancephase,contractingeccentricallytocontrolankledorsiflexion,astheCOGcontinues
tomoveforward.Inlatestancephase,theAchillestendonisstretched,astheankledorsiflexes.142Inaddition,
thetibialisposterioristheinitiatorofinversionofthehindfootatthesubtalarjoint.Attheendofthestance
phase,theheelrisesofftheground,andtheactionoftheplantarflexorschangesfromoneofeccentric
contractiontooneofconcentriccontractionastheyprovideanactivepushoff.143,144Thecontributionof
musclesotherthanthetricepssuraemusclestoperformankleplantarflexionisextremelysmall.104Theenergy
storedinthestretchedtendonhelpstoinitiateplantarflexionandtheinitiationofpropulsion.142Atthesame
time,concentriccontractionofthetibialisposteriormuscleinducessupinationofboththerearfootandforefoot
byadductingthetransversetarsaljoint.Thisactionhastwobeneficialeffectsonthegastrocnemiussoleus
complex:itlocksthetransversetarsaljointallowingmaximalplantarflexionattheanklejoint,anditshiftsthe
pulloftheAchillestendonfurthermedially.145Weaknessofthetibialisposteriormusclewilllimittheabilityto
activelysupinatethefootduringthelatterportionofthestancephaseofgait,whichisessentialtoconvertitinto
arigidleverforaforciblepushoff.8Thus,theinterlockingofthesupinatedarticularsurfacesofeachofthe
adjacenthindfoot,midfoot,andforefootjoints,combinedwithpowerfulactionthatthetricepssuraemuscles
exerttotheAchillestendontoelevatetheheel,resultsinaforefootvarusthrustthatfacilitatesgenerationofa
propulsiveGRFbeneaththeforefoot.146
Duringthebeginningoftheswingphase,thetibialisanterior,EDL,EHL,andpossiblythefibularis(peroneus)
tertiuscontractconcentricallywithslighttomoderateintensitytoprovideclearanceforthefootandtoes,
taperingoffduringthemiddleoftheswingphase.5,137,138Astheswingphasebegins,thefibularis(peroneus)
longusalsocontractsconcentricallytoeverttheentirefootandbringthesoleofthefootparalleltothesubstrate.
Atthepointwherethelegisperpendiculartothegroundduringtheswingphase,thetibialisanterior,EDL,and
EHLgroupofmusclescontractconcentricallytodorsiflexandinvertthefootinpreparationfortheinitial
contact.5,137,138Thereisverylittleactivity,ifany,fromtheplantarflexorsduringtheswingphase.Thefibularis
(peroneus)brevisactstoevertthefootandunlockthetransversetarsaljointsinthenonweightbearingswing
phaseofgait.147
CLINICALPEARL
Athreestageprocessoftransferringgroundcontactfromtherearfoottotheforefoot,whichinvolves
interactionbetweentheanatomicstructureandmuscleactions,hasbeendescribedasconsistingofthree
rockermechanisms15:
1.Thefirstrockeroccursbetweentheinitialcontactwiththeconvexundersurfaceoftheheelandwhenthe
footisflatonthefloor.Thisrocker,whichactsinamannersimilartothebaseofarockingchairto
facilitateaforwardrollingoftherearfoot,involvestheankledorsiflexors,workingeccentricallyto
controlplantarflexiontograduallypermitthefoottocomeintofullcontactwiththeground.8
2.Duringthesecondrocker,thefootremainsflatontheground,whilethetibiaanteriorlyrotatesoverthe
talus.Thismotion,whichisacombinationofarticularsurfacerollingandslidingoftheconcaveplafond
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ofthetibiaovertheconvexdomeofthetalus,resultsfromtheplantarflexors,workingeccentricallyto
controltheankledorsiflexiondisplacementthatoccurs.8
3.Thethirdrockerisproducedduringterminalstancebytheconvexcontouroftheundersurfacebeneath
theheadsofthemetatarsals,whichresultsinelevationoftherearfootasthelegandfootsegmentsroll
forward.Thisisthephaseofpowergeneration.Duringrapidwalkingwithalongstride,contractionofthe
ankleplantarflexorscontributestoforwardpropulsionimmediatelypriortotoeoff.8Subsequent
concentriccontraction(seeChapter1)oftheankledorsiflexorspreventsthetoesfromcontactingthe
groundduringtheswingphase.148,149
Thus,thefirsttworockersaredecelerationrockers,inwhichtherespectivemusclesareworkingeccentrically
byundergoingalengtheningcontractionwithenergyabsorption.Thethirdrockerisanaccelerationrockerand
aidsinpropulsion.Abnormalmusclemomentsattheankleduringthestancephasecanmanifestasaweakness
ofthetibialisanterior,resultinginafootslapatinitialcontactduringthefirstrocker.Theweaknessofthe
tricepssuraeallowsthetibiatoprogresstoorapidlyduringthesecondrocker,causingtheGRFtofallbehindthe
knee,andinducingkneeflexion.Abnormalmusclemomentsduringtheswingphaseincludetheexcessive
activityoftheplantarflexorsandinsufficientstrengthofthedorsiflexors,resultinginfootdropandpoorfoot
clearance.
AsthefirstMTPjointisdorsiflexingduringgait,andespeciallyatheelrise,theflexorhallucislongus(FHL)
muscleislengtheningacrossthefirstMTPjointwhileitisshorteningatanklejoint,resultinginanearisometric
contraction.150
CLINICALEXAMINATIONOFGAIT
Theclinicalexaminationofgaitcanbeperformedusingmethodsrangingfromobservationtocomputerized
analysis(Table64).Computerizedgaitanalysismeasuresgaitparametersmorepreciselythanispossiblewith
clinicalobservationalone,151,152andisusedintheevaluationandtreatmentplanningforpatientswithgait
abnormalities.153However,computerizedgaitanalysisisoftencostprohibitiveand,thus,notpracticalformost
clinicians,whomust,therefore,relyontheirpowersofobservation.Manyspatiotemporalvariables,likespeed,
cadence,andsteplength,areeasilyassessedintheclinicalsetting,andprovidesomeusefulinformationongait
deficiencies.Walkingspeedreflectsunderlyingphysiologicprocessesandisadvocatedasavitalsignduetoits
abilitytopredictfuturehealthstatus.154Selfselectedgaitspeedsbelow1.0m/simplyaneedforrehabilitation9
andspeedsbelow0.6m/sareassociatedwithahighriskoffalls.155Thereliabilityandagreementbothbetween
andwithinratersforgaitproblemsdetectedbyobservationalonehasbeenreported.Krebsetal.152found
moderatereliabilitywithinandbetweenphysicaltherapistsobservingchildrensgaitfromvideotape.Eastlacket
al.156foundonlyslighttomoderatereliabilitybetweenratersintheassessmentofdeviationsatasinglejoint
fromavideotape.153
TABLE64StrengthsandLimitationsofGaitAnalysisMethods
Method Strengths Limitations
1.Widelyavailable
2.Canbeenhancedbysimple
1.Subjective
videotaping
Observational
2.Unabletomeasuremoresubtle
analysis 3.Allowsclassificationofgrossgait
phenomena
patterns
4.Inexpensive
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Method Strengths Limitations

1.Providesquantitativeinformation
regardingtimedistanceparameters 1.Doesnotpermitangularkinematicand
kineticanalysis
2.Easyandfast
Strideanalysis 2.Requiresthatpatientshavedistinct
3.Lowspacerequirements swingphaseinvolvingremovaloffloor
contact
4.Relativelyinexpensive
1.Requirestechnicallytrainedpersonnel
formeasurementandinterpretationof
1.Permitsprecisemeasurementofjoint results
Angularkinematic angularexcursions
2.Highspacerequirements
analysis
2.Objectiveandquantitative
3.Limitedportability
4.Expensive
1.Limitedusefulnessinisolation
1.Permitsprecisemeasurementof
externalloads 2.Typicallyrequirespermanent
installation(gaitlab)
Forceplateand 2.Permitsanalysisofinversedynamics
pressureplate 3.Requirestechnicallytrainedpersonnel
analyses 3.Providesinformationregardingload formeasurementandinterpretationof
patternsanddistributionsonstance results
limb
4.Expensive
1.Requirestechnicalexpertisefor
measurementandinterpretation
1.Providesmeasurementofmotor
performanceandfunctionalroleof 2.Subjecttointerferenceandartifact
Electromyographic musculature duringsampling
analysis
2.Enhancesinterpretationofkinematic 3.Invasivenessofintramusculartechnique
andkineticparameters posesrisktopatients
4.Expensive
DatafromSpivakJM,DiCesarePE,FeldmanDS,etal.,eds.Orthopaedics:AComprehensiveStudyGuide.
Perhaps,themostcommonlyusedgaitanalysischartistheonedesignedbytheRanchoLosAmigosMedical
Center(Fig.65),whichallowsthecliniciantodeterminedeviationsandtheireffectongaitinauserfriendly
format.
FIGURE65
RanchoLosAmigosgaitanalysischart.
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Severalotherexaminationtoolsareavailable.Someofthesetoolsarespecifictoaparticularpopulation.For
example,themodifiedversionoftheGaitAbnormalityRatingScale(Table65)canbeusedwithcommunity
dwellingfrailolderpersonstohelppredictindividualswhoareathighriskforfalling.157
TABLE65ModifiedGaitAbnormalityRatingScale
Name____________No._____________Visit__________Date____________
1.Variabilityameasureofinconsistencyandarrhythmicityofsteppingandofarmmovements
0=fluidandpredictablypacedlimbmovements
1=occasionalinterruptions(changesinvelocity),approximately25%oftime
2=unpredictabilityofrhythmapproximately2575%oftime
3=randomtimingoflimbmovements
2.Guardednesshesitancy,slowness,diminishedpropulsion,andlackofcommitmentinsteppingandarm
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swing
0=goodforwardmomentumandlackofapprehensioninpropulsion
1=centerofgravityofhead,arms,andtrunk(HAT)projectsonlyslightlyinfrontofpushoff,butstillgood
armlegcoordination
2=HATheldoveranterioraspectoffoot,andsomemoderatelossofsmoothreciprocation
3=HATheldoverrearaspectofstancephasefoot,andgreattentativityinstepping
3.Staggeringsuddenandunexpectedlaterallydirectedpartiallossesofbalance
0=nolossesofbalancetoside
1=asinglelurchtoside
2=twolurchestoside
3=threeormorelurchestoside
4.Footcontactthedegreetowhichtheheelstrikesthegroundbeforetheforefoot
0=veryobviousangleofimpactofheelonground
1=barelyvisiblecontactofheelbeforeforefoot
2=entirefootlandsflatonground
3=anterioraspectoffootstrikesgroundbeforeheel
5.HipROMthedegreeoflossofhiprangeofmotionseenduringagaitcycle
0=obviousangulationofthighbackwardduringdoublesupport(10degrees)
1=justbarelyvisibleangulationbackwardfromvertical
2=thighinlinewithverticalprojectionfromground
3=thighangledforwardfromverticalatmaximumposteriorexcursion
6.ShoulderextensionameasureofthedecreaseofshoulderROM
0=clearlyseenmovementofupperarmanterior(15degrees)andposterior(20degrees)toverticalaxisof
trunk
1=shoulderflexesslightlyanteriortoverticalaxis
2=shouldercomesonlytoverticalaxis,orslightlyposteriortoitduringflexion
3=shoulderstayswellbehindverticalaxisduringentireexcursion
7.Armheelstrikesynchronytheextenttowhichthecontralateralmovementsofanarmandlegareoutof
phase
0=goodtemporalconjunctionofarmandcontralaterallegatapexofshoulderandhipexcursionsallofthe
time
1=armandlegslightlyoutofphase25%ofthetime
2=armandlegmoderatelyoutofphase2550%oftime
3=littleornotemporalcoherenceofarmandleg
ROM,rangeofmotion.
Dysfunctionofthevestibularsystemmayleadtogaitabnormalities.158,159TheFunctionalGaitAssessment
(Table66)isa10itemtestthatcomprises7ofthe8itemsfromaprevioustestcalledtheDynamicGaitIndex,
whichwasdevelopedtoassessposturalstabilityduringgaittasksintheolderadult(greaterthan60yearsofage)
atriskforfalling.160AccordingtothedesignersoftheFunctionalGaitAssessment,thetooldemonstrates
acceptablereliability,internalconsistency,andconcurrentvaliditywithotherbalancemeasuresusedforpatients
withvestibulardisorders.159InterventionstrategiesforvestibulardysfunctionaredescribedinChapter14.
TABLE66FunctionalGaitAssessmentRequirements:AMarked6m(20ft)WalkwayThatisMarkedwitha
13.48cm(12in)Width
1.Gaitlevelsurface
Instructions:Walkatyournormalspeedfromheretothenextmark(6m/20ft)
Grading:Markthehighestcategorythatapplies
(3)Normal:Walks6m/20ft,inlessthan5.5s,noassistivedevices,goodspeed,noevidenceforimbalance,
normalgaitpattern,deviatesnomorethan15.24cm(6in)outsideofthe30.48cm(12in)walkwaywidth
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(2)Mildimpairment:Walks6m/20ft,inlessthan7sbutgreaterthan5.5s,usesassistivedevice,slower
speed,mildgaitdeviations,ordeviates15.2425.4cm(610in)outsideofthe30.48cm(12in)walkwaywidth
(1)Moderateimpairment:Walks6m/20ft,slowspeed,abnormalgaitpattern,evidenceforimbalance,or
deviates25.438.1cm(1015in)outsideofthe30.48cm(12in)walkwaywidth.Requiresmorethan7sto
ambulate6m(20ft)
(0)Severeimpairment:Cannotwalk6m/20ftwithoutassistance,severegaitdeviationsorimbalance,deviates
greaterthan38.1cm(15in)outsideofthe30.48cm(12in)walkwaywidth,orreachesandtouchesthewall
2.Changeingaitspeed
Instructions:Beginwalkingatyournormalpace(for1.5m/5ft).WhenItellyougo,walkasfastasyoucan
(for1.5m/5ft).WhenItellyouslow,walkasslowlyasyoucan(for1.5m/5ft)
(3)Normal:Abletosmoothlychangewalkingspeedwithoutlossofbalanceorgaitdeviation.Showsa
significantdifferenceinwalkingspeedsbetweennormal,fast,andslowspeeds.Deviatesnomorethan15.24
cm(6in)outsideofthe30.48cm(12in)walkwaywidth
(2)Mildimpairment:Isabletochangespeedbutdemonstratesmildgaitdeviations,deviates15.2425.4cm
(610in)outsideofthe30.48cm(12in)walkwaywidth,ornogaitdeviationsbutunabletoachievea
significantchangeinvelocity,orusesanassistivedevice
(1)Moderateimpairment:Makesonlyminoradjustmentstowalkingspeed,oraccomplishesachangeinspeed
withsignificantgaitdeviations,orchangesspeedbuthassignificantgaitdeviations,deviates25.438.1cm
(1015in)outsideofthe30.48cm(12in)walkwaywidth,orchangesspeedbutlosesbalancebutisableto
recoverandcontinuewalking
(0)Severeimpairment:Cannotchangespeeds,deviatesgreaterthan38.1cm(15in)outsideofthe30.48cm
(12in)walkwaywidth,orlosesbalanceandhastoreachforwallorbecaught
3.Gaitwithhorizontalheadturns
Instructions:Walkfromheretothenextmark(6m/20ft)away.Beginwalkingatyournormalpace.Keep
walkingstraightafterthreesteps,turnyourheadtotherightandkeepwalkingstraightwhilelookingtothe
right.Afterthreemoresteps,turnyourheadtotheleftandkeepwalkingstraightwhilelookingleft.Continue
alternatinglookingrightandlefteverythreestepsuntilyouhavecompletedtworepetitionsineachdirection
(3)Normal:Performsheadturnssmoothlywithnochangeingaitvelocity.Deviatesnomorethan15.24cm(6
in)outsideofthe30.48cm(12in)walkwaywidth
(2)Mildimpairment:Performsheadturnssmoothlywithslightchangeingaitvelocity,i.e.,minordisruptionto
smoothgaitpath,deviates15.2425.4cm(610in)outsideofthe30.48cm(12in)walkwaywidth,oruses
assistivedevice
(1)Moderateimpairment:Performsheadturnswithmoderatechangeingaitvelocity,slowsdown,deviates
25.438.1cm(1015in)outsideofthe30.48cm(12in)walkwaywidthbutrecovers,cancontinuetowalk
(0)Severeimpairment:Performstaskwithseveredisruptionofgait,i.e.,staggersoutsideofthe30.48cm(12
in)walkwaywidth,losesbalance,stops,orreachesforwall
4.Gaitwithverticalheadturns
Instructions:Walkfromheretothenextmark(6m/20ft)away.Beginwalkingatyournormalpace.Keep
walkingstraightafterthreesteps,tipyourheadupandkeepwalkingstraightwhilelookingup.Afterthree
moresteps,tipyourheaddown,keepwalkingstraightwhilelookingdown.Continuealternatinglookingup
anddowneverythreestepsuntilyouhavecompletedtworepetitionsineachdirection
Grading:Markthehighestcategorythatapplies.
(3)Normal:Performsheadmovessmoothlywithnochangeingait.Deviatesnomorethan15.24cm(6in)
outsideofthe30.48cm(12in)walkwaywidth
(2)Mildimpairment:Performstaskwithslightchangeingaitvelocity,i.e.,minordisruptiontosmoothgait
path,deviates15.2425.4cm(610in)outsideofthe30.48cm(12in)walkwaywidth,orusesassistivedevice
(1)Moderateimpairment:Performstaskwithmoderatechangeingaitvelocity,slowsdown,deviates25.438.1
cm(1015in)outsideofthe30.48cm(12in)walkwaywidthbutrecovers,cancontinuetowalk
(0)Severeimpairment:Performstaskwithseveredisruptionofgait,i.e.,staggersoutsideofthe30.48cm(12
in)walkwaywidth,losesbalance,stops,orreachesforwall
5.Gaitandpivotturn
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Instructions:Beginwalkingatyournormalpace.WhenItellyou,turnandstop,turnasquicklyasyoucanto
facetheoppositedirectionandstop
(3)Normal:Pivotturnssafelywithin3sandstopsquicklywithnolossofbalance
(2)Mildimpairment:Pivotturnssafelyin>3sandstopswithnolossofbalance,orpivotturnssafelywithin3
sandstopswithmildimbalance,requiressmallstepstocatchbalance
(1)Moderateimpairment:Turnsslowly,requiresverbalcueing,orrequiresseveralsmallstepstocatchbalance
followingturnandstop
(0)Severeimpairment:Cannotturnsafely,requiresassistancetoturnandstop
6.Stepoverobstacle
Instructions:Beginwalkingatyournormalspeed.Whenyoucometotheshoebox,stepoverit,notaroundit,
andkeepwalking
(3)Normal:Isabletostepovertwostackedshoeboxestapedtogether(22.86cm/9intotalheight)without
changinggaitspeed,noevidenceofimbalance
(2)Mildimpairment:Isabletostepoveroneshoebox(11.43cm/4.5intotalheight)withoutchanginggait
speednoevidenceofimbalance
(1)Moderateimpairment:Isabletostepoveroneshoebox(11.43cm/4.5intotalheight)butmustslowdown
andadjuststepstoclearboxsafely.Mayrequireverbalcueing
(0)Severeimpairment:Cannotperformwithoutassistance
7.Gaitwithnarrowbaseofsupport
Instructions:Walkonthefloorwitharmsfoldedacrossthechest,feetalignedheeltotoeintandemfora
distanceof3.6m(12ft).Thenumberofstepstakeninastraightlinearecountedforamaximumof10steps
(3)Normal:Isabletoambulatefor10stepsheeltotoewithnostaggering
(2)Mildimpairment:Ambulates79steps
(1)Moderateimpairment:Ambulates47steps
(0)Severeimpairment:Ambulateslessthan4stepsheeltotoeorcannotperformwithoutassistance
8.Gaitwitheyesclosed
Instructions:Walkatyournormalspeedfromheretothenextmark(6m/120ft)withyoureyesclosed.
(3)Normal:Walks6m/20ft,noassistivedevices,goodspeed,noevidenceofimbalance,deviatesnomore
than15.24cm(6in)outsideofthe30.48cm(12in)walkwaywidth.Ambulates6m/20ftinlessthan7s
(2)Mildimpairment:Walks6m/20ft,usesassistivedevices,slowerspeed,mildgaitdeviations,deviates
15.2425.4cm(610in)outsideofthe30.48cm(12in)walkwaywidth.Ambulates6m/20ftinlessthan9s
butgreaterthan7s
(1)Moderateimpairment:Walks6m/20ft,slowspeed,abnormalgaitpattern,evidenceforimbalance,deviates
25.438.1cm(1015in)outsideofthe30.48cm(12in)walkwaywidth.Requiresmorethan9stoambulate6
m/20ft
greaterthan38.1cm(15in)outside30.48cm(12in)walkwaywidth,orwillnotattempttask
9.Ambulatingbackward
Instructions:WalkbackwarduntilItellyoutostop
(3)Normal:Walks6m/20ft,noassistivedevices,goodspeed,noevidenceofimbalance,normalgaitand,
deviatesnomorethan15.24cm(6in)outsideofthe30.48cm(12in)walkwaywidth
(2)Mildimpairment:Walks6m/20ft,usesassistivedevices,slowerspeed,mildgaitdeviations,deviates
15.2425.4cm(610in)outsideofthe30.48cm(12in)walkwaywidth
(1)Moderateimpairment:Walks6m/20ft,slowspeed,abnormalgaitpattern,evidenceforimbalance,deviates
25.438.1cm(1015in)outsideofthe30.48cm(12in)walkwaywidth
greaterthan38.1cm(15in)outside30.48cm(12in)walkwaywidth,orwillnotattempttask
10.Steps
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Instructions:Walkupthesestairsasyouwouldathome,i.e.,usingtherailingifnecessary.Atthetop,turn
aroundandwalkdown
(3)Normal:Alternatingfeet,norail
(2)Mildimpairment:Alternatingfeet,mustuserail
(1)Moderateimpairment:Twofeettoastair,mustuserail
(0)Severeimpairment:Cannotdosafely
TOTALSCORE:________________/30
DatafromWrisleyDM,MarchettiGF,KuharskyDK,etal.Reliability,internalconsistency,andvalidityofdata
obtainedwiththefunctionalgaitassessment.PhysTher.200484:906918.
ObservationalAnalysis
Observationalanalysisofgaitshouldfocusononegaitintervalatatime.Forexample,theclinicianshould
observethepatternofinitialcontactwiththefloorattheankle,knee,hip,pelvis,trunk,andupperextremities
andthen,inturn,studythesameactionsthroughouttheloadingresponseinterval.
Apaperwalkway,approximately25ftlong,onwhichthepatientsfootprintscanberecorded,isveryusefulfor
gaitanalysis.48,161Toassessgait,knowledgeofwhatisdeemedabnormalandthereasonsforthose
abnormalitiesareprerequisite(Table67).
TABLE67SomeGaitDeviationsandTheirCauses
GaitDeviations Reasons
Generalizedweakness
Pain
Jointmotionrestrictions
Slowercadencethanexpectedforpersonsage
Poorvoluntarymotor
control/weaknessoflowerlimb
muscles
Shorterstancephaseoninvolvedsideanddecreasedswingphaseon
uninvolvedside
Antalgicgait,resultingfrompainful
Shorterstridelengthonuninvolvedside
injurytolowerlimbandpelvicregion
Decreaselateralswayoverinvolvedstancelimb
Decreaseinvelocity
Pain
Lackoftrunkandpelvicrotation
Stancephaselongerononeside
Restrictionsinlowerlimbjoints
Increasedmuscletone
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Ipsilaterallean(towardthestanceleg)
markedhipabductorweakness
(compensatedgluteus
medius/Trendelenburggait)
Contralateralleandecreasedhip
flexioninswinglimbmildhip
abductorweakness(gluteus
Lateraltrunklean(purposeistobringcenterofgravityoftrunknearer medius/Trendelenburggait)
tohipjoint) Painfulhip
Abnormalhipjoint(congenital
dysplasia,coxavara,etc.)
Widewalkingbase
Unequalleglength
Adaptiveshorteningofquadratus
lumborumonswingside
Contralateralhipadductorspasticity
Weakorparalyzedkneeextensorsor
Anteriortrunkleaningatinitialcontact(occurstomovelineofgravity
gluteusmaximus
infrontofaxisofknee)
Hippain
Anteriortrunkleaningduringmidandterminalstance,asthehipis
Hipflexioncontracture
movedoverthefoot
Pesequinusdeformity
Weakorparalyzedhipextensors,
especiallygluteusmaximus(gluteus
maximusgait)
Posteriortrunkleaningduringinitialcontacttoloadingresponse(occurs
Hippain
tobringlineofexternalforcebehindaxisofhip)
Hipflexioncontracture
Inadequatehipflexioninswing
Decreasedkneerangeofmotion
Inabilitytoextendhip,usuallydueto
Increasedlumbarlordosisinterminalstance
hipflexioncontractureorankylosis
Adaptivelyshortened/spasticityofhip
Excessiveposteriorhorizontalpelvicrotation flexorsonsameside
Limitedhipjointflexion
Functionalleglengthdiscrepancy
Hipcircumductionduringswing(groundcontactcanbeavoidedby (shorteningoftheswingleg
swinginglegifitisswungoutwardfornaturalwalkingtooccurlegthat secondarytoreducedhipflexion,
isinitsstancephaseneedstobelongerthanlegthatisinitsswing reducedkneeflexion,and/orlackof
phasetoallowtoeclearanceofswingfoot) ankledorsiflexion)
Arthrogenicstiffhiporknee
Functionalleglengthdiscrepancy
(shorteningoftheswingleg
secondarytoreducedhipflexion,
reducedkneeflexion,and/orlackof
Hiphiking(pelvisisliftedonsideofswingingleg,bycontractionof
ankledorsiflexion)
spinalmusclesandlateralabdominalwall)
Functionallyoranatomicallyshort
stanceleg
Hamstringweakness
Quadratuslumborumshortening
Vaulting(groundclearanceofswinginglegwillbeincreasedifthe Functionalleglengthdiscrepancy.
patientgoesupontoesofstancephaseleg) Vaultingoccursonshorterlimbside
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Adaptiveshorteningofiliotibialband
Weaknessofhipexternalrotators
Abnormalinternalhiprotation(producestoeingait) Femoralanteversion
Adaptiveshorteningofhipinternal
rotators
Adaptiveshorteningofhipexternal
rotators
Abnormalexternalhiprotation(producestoeoutgait)
Femoralretroversion
Weaknessofhipinternalrotators
Spasticityorcontractureofipsilateral
hipadductors
Increasedhipadduction(scissorsgait),whichresultsinexcessivehip Ipsilateralhipadductorweakness
adductionduringswing(scissoring),decreasedbaseofsupport,and Coxavara
decreasedprogressionofoppositefoot Hipflexioncontracture
Inadequatehipextension/excessivehipflexion,whichresultsinlossof Iliotibialbandcontracture
hipextensioninmidstance(forwardleaningoftrunk,increasedlordosis, Hipflexorspasticity
andincreasedkneeflexionandankledorsiflexion)andlatestance Pain
(anteriorpelvictilt),andincreasedhipflexioninswing Arthrodesis(surgicalorspontaneous
ankylosis)
Lossofankledorsiflexion
Inadequatehipflexion,whichresultsindecreasedlimbadvancementin
Hipflexorweakness
swing,posteriorpelvictilt,circumduction,andexcessivekneeflexionto
Hipjointarthrodesis
clearfoot
Decreasedhipswingthrough(psoaticlimp),whichismanifestedby LeggCalvPerthesdisease
exaggeratedmovementsatpelvisandtrunktoassisthiptomoveinto Weaknessorreflexinhibitionofpsoas
flexion majormuscle
Pain
Anteriortrunkdeviation/bending
Weaknessofquadriceps
hyperextensionisacompensationand
Excessivekneeextension/inadequatekneeflexion,whichresultsin
placesbodyweightvectoranteriorto
decreasedkneeflexionatinitialcontactandloadingresponse,increased
knee
kneeextensionduringstance,anddecreasedkneeflexionduringswing
Spasticityofthequadricepsnoted
moreduringtheloadingresponseand
duringinitialswingintervals
Jointdeformity
Lackofankledorsiflexionofthe
swingleg
Excessivehipandkneeflexionduringswing
Functionallyoranatomicallyshort
contralateralstanceleg
Kneeflexioncontracture,resultingin
decreasedsteplengthanddecreased
kneeextensioninstance
Excessivekneeflexion/inadequatekneeextensionatinitialcontactor Increasedtone/spasticityof
aroundmidstanceresultsinincreasedkneeflexioninearlystance, hamstringsorhipflexors
decreasedkneeextensioninmidstanceandterminalstance,and Decreasedrangeofmotionofankle
decreasedkneeextensionduringswing dorsiflexioninswingphase
Weaknessofplantarflexors,resulting
inincreaseddorsiflexioninstance
Lengthenedlimb
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Inadequatedorsiflexioncontrol(footslap)duringinitialcontactto Weakorparalyzeddorsiflexors
midstance.Steppagegaitduringtheaccelerationthroughdecelerationof Lackoflowerlimbproprioception
theswingphase.Theexaggeratedkneeandhipflexionareusedtolift Weakorparalyzeddorsiflexor
foothigherthanusual,forincreasedgroundclearanceresultingfrom muscles
footdrop Functionalleglengthdiscrepancy
Deformitysuchashipabductor
musclecontracture
Increasedwalkingbase/stepwidth(>20cm) Genuvalgus
Fearoflosingbalance
Leglengthdiscrepancy
Hipadductormusclecontracture
Decreasedwalkingbase/stepwidth(<10cm)
Genuvarum
Excessivetibiavara(referstofrontal
planepositionofthedistalonethird
ofleg,asitrelatestosupporting
surface)
Excessiveeversionofcalcaneusduringinitialcontactthroughmidstance Forefootvarus
Weaknessoftibialisposterior
Excessivelowerextremityinternal
rotation(duetomuscleimbalances
andfemoralanteversion)
Insufficientankledorsiflexion(<10
degrees)
Increasedtibialvarum
Compensatedforefootorrearfoot
varusdeformity
Uncompensatedforefootvalgus
Excessivepronationduringmidstancethroughterminalstance
deformity
Pesplanus
Longlimb
Uncompensatedmedialrotationof
tibiaorfemur
Weaktibialisanterior
Excessiveinversionandplantarflexionofthefootandankleduring Pesequinovarus(spasticityofthe
swingandatinitialcontact plantarflexorsandinvertors)
Limitedcalcanealeversion
Rigidforefootvalgus
Pescavus
Uncompensatedlateralrotationof
Excessivesupinationduringinitialcontactthroughmidstance tibiaorfemur
Shortlimb
Plantarflexedfirstray
Uppermotorneuronmuscle
imbalance
Compensationforkneeflexion
contracture
Inadequateplantarflexorstrength
Excessivedorsiflexionduringinitialcontactthroughtoeoff
Adaptiveshorteningofdorsiflexors
Increasedmuscletoneofdorsiflexors
Pescalcaneusdeformity
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Increasedplantarflexoractivity
Excessiveplantarflexionduringmidstancethroughtoeoff
Plantarflexorcontracture
Contracture
Excessivevarusduringinitialcontactthroughtoeoff Overactivityofmusclesonmedial
aspectoffoot
Weakinvertors
Excessivevalgusduringinitialcontactthroughtoeoff
Foothypermobility
Inabilityofplantarflexorstoperform
Decreasedorabsenceofpropulsion(plantarflexorgait)during
function,resultinginashorterstep
midstancethroughtoeoff
lengthontheinvolvedside
DatafromGiallonardoLM.Clinicalevaluationoffootandankledysfunction.PhysTher.198868:18501856
EplerM.Gait.In:RichardsonJK,IglarshZA,eds.ClinicalOrthopaedicPhysicalTherapy.Philadelphia,PA:
WBSaunders1994:602625HuntGC,BrocatoRS.Gaitandfootpathomechanics.In:HuntGC,ed.Physical
TherapyoftheFootandAnkle.Edinburgh:ChurchillLivingstone1988KrebsDE,RobbinsCE,LavineL,et
al.Hipbiomechanicsduringgait.JOrthopSportsPhysTher.199828:5159LarishDD,MartinPE,Mungiole
M.Characteristicpatternsofgaitinthehealthyold.AnnNYAcadSci.1987515:1832LevineD,WhittleM.
GaitAnalysis:TheLowerExtremities.LaCrosse,WI:OrthopaedicSection,APTA,Inc.1992PerryJ.Gait
Analysis:NormalandPathologicalFunction.Thorofare,NJ:SlackInc.1992SongKM,HallidaySE,Little
DG.Theeffectoflimblengthdiscrepancyongait.JBoneJointSurg.199779A:16901698.
Gaitisassessedbyhavingthepatientwalkbarefootandwithfootwear.Barefootwalkingprovidesinformation
aboutfootfunctionwithoutsupportandcanhighlightpainfulareasonthesole,andcompensations,suchas
excessivepronation,andfootdeformities,suchasclawtoes.162Forexample,metatarsalgiaisindicatedifthe
metatarsalheadsaremademorepainfulwithbarefootwalking.Painatinitialcontactmayindicateaheelspur,
bonecontusion,calcanealfatpadinjury,orbursitis.Thepatientsfootisalsoexaminedforcallusformation,
blisters,corns,andbunions.Callusformationonthesoleofthefootcanbeanindicatorofdysfunctionand
providestheclinicianwithanindextothedegreeofshearstressesappliedtothefoot,andaclearoutlineof
abnormalweightbearingareas.163Adequateamountsofcallusesmayprovideprotection,butinexcessamounts
theymaycausepain.Callusformationunderthesecondandthirdmetatarsalheadscouldindicateexcessive
pronationinaflexiblefoot,orMortonneuroma,ifjustundertheformer.Acallusunderthefifth,andsometimes
thefourth,metatarsalheadmayindicateanabnormallyrigidfoot.
Havingthepatientwalkwithfootwearcanprovideinformationabouttheeffectivenessofthefootwearto
counteractthecompensations.Thepatientsfootwearisexaminedforpatternsofwear.Thegreatestamountof
wearonthesoleoftheshoeshouldoccurbeneaththeballofthefootandintheareacorrespondingtothefirst,
second,andthirdMTPjoints,andslightweartothelateralsideoftheheel.Theupperportionoftheshoeshould
demonstrateatransversecreaseattheleveloftheMTPjoints.AstifffirstMTPjointcanproduceacreaseline
thatrunsobliquely,fromforwardandmedialtobackwardandlateral.164Scuffingofthetopoftheshoeatits
frontmightindicatetibialisanteriorweaknessoradaptivelyshortenedheelcords.162
Thepatientshouldbeaskedtowalkonthetoesandthenontheheels.Aninabilitytoperformeitherofthese
actionscouldbetheresultofpain,weakness,oramotionrestriction,oracombinationofall.
Thepatientisaskedtowalkinhisorherusualmannerandattheusualspeed.Theclinicianbeginsthegait
assessmentwithanoveralllookatthepatientwhiletheywalkandnotingthecadence,stridelength,steplength,
andvelocity.Thearmsswingduringgaitshouldalsobeobserved.Ifanindividualhasaproblemwiththefootor
ankleononeside,theoppositearmswingisoftendecreased.
Thepatientisobservedfromheadtotoeandthenbackagain,fromtheside,fromthefront,andthenfromthe
back.
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Inadditiontoobservingthepatientwalkingathisorhernormalpace,theclinicianshouldalsoobservethe
patientwalkingatvaryingspeeds.Thiscanbeachievedonatreadmillbyadjustingthespeedorbyaskingthe
patienttochangethewalkingspeed.
Onceanoverallassessmenthasbeenmadeofthepatientsgait,thecliniciancanfocusattentiononthevarious
segmentsofthekineticchainofgaitthatappearabnormal.
Attemptsaremadetodeterminetheprimarycauseofanygaitdeviationsorcompensations(seeTable67).
AnteriorView
Whenobservingthepatientfromthefront,thecliniciancannotethefollowing:
Headpositionthesubjectsheadshouldremainfairlystationaryduringthegaitcycleandshouldnot
movetoomuchinalateralorverticaldirection.Abouncinggaitischaracteristicofadaptively
shortenedgastrocnemiiorincreasedtoneofthegastrocnemiusandsoleus.
Theamountoflateraltiltofthepelvis.
Theamountoflateraldisplacementofthetrunkandpelvis.
Whetherthereisexcessiveswayingofthetrunkorpelvis.
Reciprocalarmswingmovementsoftheuppertrunkandlimbsusuallyoccurintheoppositedirectionto
thepelvisandthelowerlimbs.
Whethertheshouldersaredepressed,retracted,orelevated.
Whethertheelbowsareabnormallyflexedorextended.
Theamountofhipadductionorabductionthatoccurs.Causesofexcessiveadductionincludeanexcessive
angleofthecoxavara,hipabductorweakness,hipadductorcontractureorspasticity,andcontralateralhip
abductioncontracture.Excessivehipabductionmaybecausedbyanabductioncontracture,ashortleg,
obesity,impairedbalance,orhipflexorweakness.165
Theamountofvalgusorvarusatthekneeduringgait,theremaybeanobviousvarusextensionthrust.
AccordingtoNoyesetal.,thisgaitpatternischaracteristicofchronicinjuriestotheposterolateral
structuresoftheknee.166
Theamountofkneeeffusion.Kneejointeffusionandkneepainmayleadtoquadricepsmuscle
inhibition.167Inonestudy,whenintraarticulareffusionwasinducedinhealthyindividuals,gaitpatterns
worsenedwithincreasedeffusionlevels.168Thekneeeffusioncausedanincreaseinkneeflexionangle
andadecreaseinexternalkneeflexionmoment,impulse,andjointwork.Whilekneeeffusioncauseda
decreaseinquadricepsactivityduringgait,itresultedinanincreaseinhamstringactivity.168
ThewidthoftheBOS,orstepwidth.
Thedegreeoftoeoutthetermtoeoutreferstotheangleformedbytheintersectionofthelineof
progressionofthefootandthelineextendingfromthecenteroftheheelthroughthesecondmetatarsal.
Thenormaltoeoutangleisapproximately7degrees,andthisangledecreasesasthespeedofgait
increases.
Whetheranycircumductionofthehipoccurs.Hipcircumductioncanindicatealeglengthdiscrepancy,a
decreasedabilityofthekneetoflex,orahipabductorshorteningoroveruse.
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Whetheranyhiphikingoccurs.Hiphikingcanindicatealeglengthdiscrepancy,hamstringweakness,or
shorteningofthequadratuslumborum.
Evidenceofthighatrophy.
Thedegreeofrotationofthewholelowerextremity.Becausepositioningthelowerextremityinexternal
rotationdecreasesthestressonthesubtalarjointcomplex,anindividualwithafootorankleproblem
oftenadoptsthispositionduringgait.111Excessiveinternalorexternalrotationofthefemurcanindicate
adaptiveshorteningofthemedialorlateralhamstrings,respectively,resultinginanteversionor
retroversion,respectively.
LateralView
Whenobservingthepatientfromtheside,thecliniciancannotethefollowing:
Theamountofthoracicandshoulderrotation.Eachshoulderandarmshouldswingreciprocally,with
equalmotion.
Theorientationofthetrunk.Thetrunkshouldremainerectandlevelduringthegaitcycle,asitmovesin
theoppositedirectiontothepelvis.Compensationcanoccurinthelumbarspineforalossofmotionatthe
hip.Abackwardleanofthetrunkmayresultfromweakhipextensorsorinadequatehipflexion.A
forwardleanofthetrunkmayresultfromapathologyofthehip,knee,orankleabdominalmuscle
weaknessdecreasedspinalmobilityorhipflexioncontracture.Forwardleaningduringtheloading
responseandearlymidstanceintervalsmayindicatehipextensorweakness.10
Theorientationofthepelvictilt.Ananteriorpelvictiltof>10degreesisconsiderednormal.Excessive
anteriortiltingcanbecausedbyweakhipextensors,hipflexioncontracture,orhipflexorspasticity.
Excessiveposteriorpelvictiltingduringgaitusuallyoccursinthepresenceofhipflexorweakness.
Thedegreeofhipextension.Causesofaninadequateamountofhipextensionincludehipflexion
contracture,iliotibialbandcontracture,hipflexorspasticity,orpain.10
Thedegreeofhipflexion.Commoncausesofinadequatehipflexionincludehipflexorweaknessorhip
jointarthrodesis.10
Kneeflexionandextension.Thekneeshouldbeextendedduringtheinitialcontactinterval,followedby
slightflexionduringtheloadingresponseinterval.Duringtheswingphase,theremustbesufficientknee
flexion.Stridelengthandcadencehaverecentlybeenshowntoberelatedtoloadrateandriskforinjuryat
theknee.169Byincreasingsteprateandproportionatelydecreasingsteplengthtomaintainaconstant
speed,thereisareductioninimpactloading,withthegreatesteffectoccurringattheknee.170Causesof
excessivekneeflexionandinadequatekneeextensionincludeinappropriatehamstringactivity,knee
flexioncontracture,soleusweakness,andexcessiveankleplantarflexion.Causesofinadequateknee
flexionandexcessiveextensionatthekneeincludequadricepsweakness,pain,quadricepsspasticity,
excessiveankleplantarflexion,hipflexorweakness,andkneeextensioncontractures.10Individualswith
genurecurvatummayhaveafunctionalstrengthdeficitinthequadricepsmuscleorgastrocnemiusthat
allowskneehyperextension.171Itisimportanttoassessspatiotemporalmeasurementsintheelderlywho
havekneeinjuriesbecausethispopulationwalkslowly,havealongerstridetimeandspendmoretimein
doublesupport,whichputsthematagreaterriskoffalls.172
Ankledorsiflexionandplantarflexion.Duringmidstance,theankledorsiflexes,andthebodypivotsonthe
stationaryfoot.Attheendofthestancephase,theankleshouldbeseentoplantarflextoraisetheheel.At
thebeginningoftheswingphase,theankleisplantarflexed,movingintodorsiflexionastheswingphase
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progressesandreachesaneutralpositionatthetimeofheelcontactattheterminationoftheswing.
Excessiveplantarflexioninmidswing,initialcontact,andloadingresponsemaybecausedbypretibial,
especiallytheanteriortibialis,weakness.Excessiveplantarflexionalsomaybecausedbyplantarflexion
contracture,soleusandgastrocnemiusspasticity,orweakquadriceps.10Excessivedorsiflexionmaybe
causedbysoleusweakness,anklefusion,orpersistentkneeflexionduringthemidstancephase.10
Thestridelengthofeachlimb.Eachlegshouldswingreciprocally,withequalmotion.
Cadence.Thecadenceshouldbenormalforthepatientsage(Table67).
Heelrise.AnearlyheelrisecouldindicateanadaptivelyshortenedAchillestendon.Delayedheelrise
mayindicateaweakgastrocnemiussoleuscomplex.
Heelcontact.Alowheelcontactduringinitialcontactmaybecausedbyplantarflexioncontracture,
tibialisanteriorweakness,orprematureactionbythecalfmuscles.10
Preswing.Anexaggeratedpreswingismanifestedbythepatientwalkingonthetoes.Causesincludepes
equinesdeformity,adaptiveshorteningorincreasedtoneofthetricepssurae,weaknessofthedorsiflexors,
andkneeflexionoccurringatmidstance.Adecreasedpreswingisoftencharacterizedbyalackof
plantarflexionatterminalstanceandpreswing.Causesforthiscanincludeankleorfootpainorweakness
oftheplantarflexormuscles.
PosteriorView
Whenobservingthepatientfromtheback,thecliniciancannotethefollowing:
Theamountofsubtalarinversion(varus)oreversion(valgus).Excessiveinversionoreversionusually
relatestoabnormalmuscularcontrol.Generallyspeaking,varustendstobethedominantdysfunctionin
spasticpatients,whereasvalgustendstobemorecommonwithflaccidparalysis.10
BOS/stepwidth.
Pelviclist.
Thedegreeofhiprotationasinstanding,excessivefemoralinternalrotationpastthemidstanceofgait
willaccentuategenurecurvatum.Causesofexcessiveexternalhiprotationmayincludegluteusmaximus
overactivityandexcessiveankleplantarflexion.10Causesofexcessiveinternalhiprotationincludemedial
hamstringoveractivity,hipadductoroveractivity,anteriorabductoroveractivity,andquadriceps
weakness.10
Theamountofhipadductionorabduction.
Theamountofknee/tibialrotation.
ABNORMALGAITSYNDROMES
EachoftheattributesofnormalgaitdescribedearlierunderCharacteristicsofNormalGaitissubjectto
compromise.Ingeneral,gaitdeviationsfallunderfourheadings:thosecausedbyweakness,thosecausedby
abnormaljointpositionorROM,thosecausedbymusclecontracture,andthosecausedbypain.18,173
Weaknessimpliesthatthereisinadequateinternaljointmovement,orlossofthenaturalforcecouple
relationship.
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Neuromuscularconditionsmaybeassociatedwithabnormalitiesofmuscletone,timingofmuscle
contractions,andproprioceptiveandsensorydisturbances,thelatterofwhichcanprofoundlyaffectreflex
posturalbalance.
Theabnormaljointpositioncanbecausedbyanimbalanceofflexibilityandstrengtharoundajointorby
contracture.
Contractures,changesinthelengthoftheconnectivetissueofmuscles,ligaments,andthejointcapsule,
mayproducechangesingait.Ifthecontractureiselastic,thegaitchangesareapparentintheswingphase
only.Ifthecontracturesarerigid,thegaitchangesareapparentduringtheswingandthestancephases.
Paincanaltergait,asthepatientattemptstousethepositionofminimalarticularpressure(seeAntalgic
Gait).Painmayalsoproducemuscleinhibitionandeventualatrophy.
AntalgicGait
Theantalgicgaitischaracterizedbyadecreaseinthestancephaseonthepainfulextremityinanattemptto
minimizetheamountofweightbearingoftheinjuredbodypartasmuchaspossible.Theantalgicgaitpattern
canresultfromnumerouscauses(Table68),includingdisease,jointinflammation(Table69),oraninjuryto
themuscles,tendons,andligamentsofthelowerextremity.Thekneestiffeningstrategy,whichoccursduring
theloadingresponseinterval,includesreducedsagittalplanekneemotion,reducedinternalkneeextensor
moments,andalteredmuscleactivationpatterns,allofwhichservetoavoidpositionsofmaximalintraarticular
pressure,andtoseekthepositionofminimumarticularpressure.9
TABLE68SomeCausesofAntalgicGait
Cause Examples
Fracture
Infection
Bonedisease Tumor
Avascularnecrosis(LeggCalvPerthesdisease,OsgoodSchlatterdisease,andKhlerbone
disease)
Traumaticruptureandcontusion
Muscledisorder Crampsecondarytofatigue,strain,malposition,orclaudication
Inflammatorymyositis
Traumaticarthritis
Infectiousarthritis
Rheumatoidarthritis
Jointdisease
Crystallinearthritis(goutandpseudogout)
Hemarthrosis
Bursitis
Neurologic
Lumbarspinediseasewithnerverootirritationorcompression
disease
Hip,knee,orfoottrauma
Other
Corns,bunions,blisters,oringrowntoenails
DatafromJudgeRD,ZuidemaGD,FitzgeraldFT.Musculoskeletalsystem.In:JudgeRD,ZuidemaGD,
FitzgeraldFT,eds.ClinicalDiagnosis.4thed.Boston,MA:Little,BrownandCompany1982:365403.
TABLE69GaitAbnormalitiesinArthriticDiseaseandAssociatedConditionsandTreatmentExamples
GaitAbnormalities
Time
Disorder Observational Angular KineticandEMG Treatment
Distance
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1.Stance
time,
uninvolved
side
2.Double Hipflexion
Osteoarthritisofthe Assistive
Laterallurch limbsupport extension
hip,unilateral Hipabductormoment device(cane
gaitpattern 3.Steptime, excursion,
involvement orcrutches)
involvedside involvedside
4.Step
length,
involvedside
5.Velocity
1.Kneeflexion
1.Velocity
duringstance
2.Single
2.Dorsiflexion Cane
limbsupport,
1.Antalgic duringstance Tibialisanterior RigidAFO
Rheumatoidarthritis involvedside
gaitpattern 3.Plantarflexion activationduring orhindfoot
withhindfootpain 3.Cadence
2.Flatfoot duringterminal terminalstanceand orthoses
anddeformity 4.Stride
gaitpattern stance preswing Rocker
length
4.Subtalar bottomshoes
5.Delayed
eversionduring
heelrise
terminalstance
1.Single
Totalknee limbsupport,
Kneeflexion Kneeextensor
arthroplasty, involvedside N/A
duringstance moment
unilateral 2.Stride
length
EMG,electromyography.
Minimumarticularpressureoccursattheankleat15degreesofplantarflexion.
Minimumarticularpressureoccursatthekneeat30degreesofflexion.Withapainfulknee,thegaitis
characterizedbyadecreaseinkneeflexionatinitialcontactandtheloadingresponseinterval,andan
increaseinkneeextensionduringtheremainderofthestancephase.
Minimumarticularpressureoccursatthehipat30degreesofflexion.Oneofthemostcommoncausesof
anantalgicgaitatthehipisOA,whichisassociatedwithpain,stiffness,andfunctionallimitation,the
extentofwhichdependsontheamountofstructuraldiseaseprogressionandassociatedsymptoms,aswell
assensorimotoradaptationstothedisease.174Perhapsnotsurprisingly,individualswithhipOAwalkata
slowerspeedandexhibitgreatergaitasymmetrythancontrols.174
Perhapssurprisingly,recentstudieshaveshownthatthegaitpatternisalteredinindividualswithlowback
pain.175Theseindividualsexhibitacautiousgaitexemplifiedbyareductionincycledurationaswellaship
flexionextensionexcursion.176Whencomparedtohealthycontrols,patientswithbackpainexhibitsimilar
patternsofactivationacrossthegaitcycle,butwithprematureactivityinthelumbarspineandhipextensor
muscles,andprolongedactivityofthegluteusmaximusandspineextensors.175Thisraisesthequestionasto
whatroletheCNSplaysinthisalterationofgait.177
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EquinusGait
TheequinusgaitdemonstratesprematurefiringofthecalfmuscleintheswingphaseofgaitwithEMGresulting
inatoewalkinggaitpattern.178Atoewalkinggaitpatterndescribesdynamicankledeviationsthatinclude179:
alossofheelstrikeatinitialcontact,withdisruptionofthefirstanklerocker
disruptionofthesecondrocker,withankleplantarflexion(insteadofdorsiflexion)occurringatmidstance
variabledisruptionofthethirdrockerinterminalstance
variableanklealignmentduringswingphase.
Equinusgait,oneofthemorecommonabnormalpatternsofgaitinpatientswithspasticdiplegia(seealso
SpasticGait),ischaracterizedbyforefootstriketoinitiatethegaitcycle,andprematureplantarflexioninthe
loadingresponseintervaltomidstance.180Inthispatientpopulation,motorimpairmentoccursasaresultofa
numberofdeficits,includingpoormusclecontrol,weakness,impairedbalance,hypertonicity,andspasticity.181
However,reducedjointmotionasaconsequenceofspasticityisperhapsthemostnoticeableandrecorded
impairment.Asaconsequence,muscletendonunitsfrequentlybecomecontractedovertime,contributingto
malalignmentoftheextremityduringgait.
Toewalkingmaybeaprimarygaitdeviation,whichistheconsequenceofexcessivemyostaticcontractureof
thetricepssurae,excessivedynamiccontractionoftheankleplantarflexors,oracombinationofbothfactors.In
addition,toewalkingmaybeacompensatorydeviationformyostaticdeformityordynamicoveractivityofthe
ipsilateralhamstringmuscles,whichdirectlylimitskneealignmentandsecondarilycompromisesfootandankle
positionduringthestancephase.Fortheclinician,thechallengeistodistinguishbetweenchangesthatarethe
directconsequenceofsuchanunderlyingneuromusculardisorderandare,therefore,primary,andthosechanges
thatresultfrombiomechanicalconstraintsoftoewalkingandare,therefore,secondaryorcompensatory.Itis
notunusualfornormalchildrentodisplayintermittenttiptoegaitwhentheyfirstbegintowalkhowever,amore
matureheeltoegaitpatternshouldbecomeconsistentbytheageof2years.182Olderchildrenwithpersistent
tiptoegaitareoftenlabeledidiopathictoewalkers.Toewalkingthatbeginsafteramatureheeltoegaitpattern
hasbeenestablishedmaysignifymusculardystrophy,diastematomyelia,fibularismuscularatrophy,orspinal
cordtumor.Toewalkinghasbeenassociatedwithprematurebirth,developmentaldelay,schizophrenia,autism,
andvariouslearningdisorders.183
Associatedgaitdeviationsarefrequentlyseenintheknees,hips,andpelvisinchildrenwithcerebralpalsywho
arewalkingontheirtoes:179
Deviationsseenatthekneesincludeincreasedflexioninthestancephaseatinitialcontactandin
midstance,anddelayedanddiminishedpeakkneeflexionintheswingphase.
Thehipsoftenshowdiminishedextensioninthesagittalplaneatterminalstance.
Acommondeviationseeninthepelvisinchildrenwithcerebralpalsywhoaretoewalkingisanincreased
anteriortilt.
GluteusMaximusGait
Thegluteusmaximusgait,whichresultsfromweaknessofthegluteusmaximus,ischaracterizedbyaposterior
thrustingofthetrunkatinitialcontactinanattempttomaintainthehipextensionofthestanceleg.Thehip
extensorweaknessalsoresultsinananteriortiltofthepelvis,whicheventuallytranslatesintohyperlordosisof
thespinetomaintainposture.
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QuadricepsGait
Quadricepsweaknesscanresultfromaperipheralnervelesion(femoral),spinalnerverootlesion(L24),
trauma,ordisease(musculardystrophy).Althoughoftenappearingtohaveanormalgaitpatternwhenwalking
onalevelsurface,thepatientwithquadricepsweakness/paralysisoftendemonstratesdifficultywalkingon
roughorinclinedsurfacesandstairs,andisunabletorun.Insuchinstances,forwardmotionispropagatedby
circumductingeachleg.Tocompensate,thepatientleansthebodytowardtheuninvolvedside,tobalancethe
COG,andswingstheinvolvedleglikeapendulum.
HipFlexorGait
Thistypeofgaitiscommonlyseeninpatientswithahipflexioncontracturesecondarytodecreasedmobilityor
diseaseprocessesthatresultinincreasedtone.Hipflexioncontractureshavebeenassociatedwithdecreasedgait
efficiencyandcompensationsincludingincreasedanteriorpelvictilting,increasedlumbarlordosis,excessive
kneeflexion,decreasedhipextension,andreducedcontralateralsteplength.184Whiletheiliopsoasmusclehas
beenidentifiedasthemaincontributortocontractureitrarelyoccurswithouttheinvolvementofotheranterior
hipstructuressuchastherectusfemoris,TFL,orsartorius.185Ahipflexioncontracturereduceshipextension
duringgaitduetodecreasedflexibilityandgreaterpassivetensionoftheiliopsoasandotheranteriorhip
structures.186Thedecreaseindynamichipextensionduringterminalstancecausesadecreaseinsingleleg
supporttimeontheaffectedlimb,whichinturnleadstoashortersteplengthonthecontralateralsideand
overalldecreasedgaitefficiency.88Increasedkneeflexionduringstanceisanothercompensationforreduced
hipextensionexcursionduringstanceasitallowsthefoottoremainflatonthefloorwithouttheneedforan
exaggeratedlumbarlordosis.187
SteppageGait
Thistypeofgaitoccursinpatientswithweaknessorparalysisofthedorsiflexormusclesresultingfroman
injurytothemuscles,theperipheralnervesupply,orthenerverootssupplyingthemuscles(Table610).188The
resultisaninabilitytocontrolthedorsiflexionthatissupposedtooccuratinitialcontact.Instead,thefoot
dropsintoplantarflexion.Tocompensateforthis,thepatientliftstheleghighenoughtocleartheflailfootoff
thefloor,byflexingexcessivelyatthehipandknee,andthenslapsthefoottothefloor.
TABLE610GaitAbnormalitiesAssociatedwithMuscleWeaknessandTreatmentExamples
GaitAbnormalities
Disorder Observational TimeDistance Angular KineticandEMG Treatment
1.Steppage 1.Ankleplantarflexion
Dorsiflexor 1.Timeto
gaitpattern duringswing
paresisor footflat Dorsiflexormoment AFO
2.Footslap 2.Hipandkneeflexion
paralysis 2.Steplength
gaitpattern duringswing
1.Hipadductionduring
1. midstance,with
Trendelenburg 1.Double Trendelenburg
Hipabductor Assistive
Hipabductor gaitpattern limbsupport 2.Lateraltrunktiltwith
momentduringstance device(cane
weakness 2.Lateral 2.Steplength laterallurch
withlaterallurch andcrutches)
lurchgait 3.Velocity 3.Pelvictiltduring
pattern swing,involvedside,
withTrendelenburg
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GaitAbnormalities
Disorder Observational TimeDistance Angular KineticandEMG Treatment
1.Prolonged
midstance 1.Plantarflexor
Plantarflexor 2.Step 1.Stancephaseknee powerduringlate
paresisor Nopattern length, flexion stance.
discernible uninvolvedside 2.Stancephase 2.Prolongedstance AFO
paralysis
3.Single dorsiflexion phasequadriceps
limbsupport, activation
involvedside
EMG,electromyographyAFO,anklefootorthosis.
NewYork:McGrawHill,1999:214.
TrendelenburgGait
Thistypeofgaitresultsfromweaknessofthehipabductors(gluteusmediusandminimus),withalossofthe
normalstabilizingeffectofthesemuscles,suchthatthepatientdemonstratesanexcessivelaterallist,inwhich
thetrunkisthrustlaterallyinanattempttokeeptheCOGoverthestanceleg.ApositiveTrendelenburgsignis
alsopresent(Table610).
SpasticGait
Aspasticgaitmayresultfromeitherunilateralorbilateraluppermotorneuron(UMN)lesions.Anumberof
typesarerecognized.
SpasticHemiplegic(Hemiparetic)Gait
ThistypeofgaitresultsfromaunilateralUMNlesion.Spastichemiplegicgaitisfrequentlyseenfollowinga
completedstroke.Spasticityofallmusclesontheinvolvedsideisnoted,butitismoremarkedinsomemuscle
groups.Duringgait,thelegtendstocircumductinasemicircle,rotatingoutwardorispushedahead,withthe
footdraggingandscrapingthefloor.Theupperlimbtypicallyiscarriedacrossthetrunkforbalance(Table6
11).
TABLE611GaitAbnormalitiesAssociatedwithNeurologicDisordersandTreatmentExamples
GaitAbnormalities
Time
Distance
1.Orthoticstabilization
Variable tocontrolmovement
Ataxicgait Variablestrideto
Ataxia strideto Variablestridetostride variability
pattern stride
stride 2.Walkingaids(e.g.,
crutchesandwalker)
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GaitAbnormalities
Time
Distance
1.
Double
limb
support
2.Step
length,
involved 1.Anklefootorthosis
1.Stiff
side 1.Kneeflexormoment 2.Rectusfemoris
leggedgait 1.Plantar
3.Delayed duringstance release
pattern flexionduring
heelrise 2.Amplitudeofjoint 3.TendoAchilles
Hemiplegia 2.Equinusor swing
4. powers lengthening
fromstroke equinovarus 2.Knee
Velocity 3.Abnormaltimingof 4.Tendontransfer,foot
gaitpattern flexionduring
5.Stride muscleactivation(i.e., andankle
3. stanceandswing
length masssynergypatterns) 5.Functionalelectrical
Circumduction
6. stimulation
Cadence
7.Absent
heelcontact
8.Toedrag
during
swing
1.Stride
length
2.Step
1.Shuffling length
Angular Agonistantagonist
Parkinson gaitpattern 3.Step Pharmaceutical/medical
excursions coactivationwithfrozen
disease 2.Frozen width management
throughout pattern
gaitpattern 4.
Cadence
5.
Velocity
SpasticParapareticGait
ThistypeofgaitresultsfrombilateralUMNlesions(e.g.,cervicalmyelopathyinadultsandcerebralpalsyin
children).Spasticparapareticgaitischaracterizedbyslow,stiff,andjerkymovements.Spasticextensionoccurs
attheknees,withadductionatthehips(scissorsgait).
AtaxicGait
Theataxicgaitisseenintwoprincipaldisorders:cerebellardisease(cerebellarataxicgait)andposteriorcolumn
disease(sensoryataxicgait)(Table611).
CerebellarAtaxicGait
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Thenatureofthegaitabnormalitywithacerebellarlesionisdeterminedbythesiteofthelesion.Invermal
lesions,thegaitisbroadbased,unsteady,andstaggering,withanirregularsway.Thepatientisunabletowalkin
tandem,orinastraightline.Theataxiaofgaitworsenswhenthepatientattemptstostopsuddenlyortoturn
sharply,resultinginatendencytofall.
Inhemispherallesions,theataxiatendstobelesssevere,butthereispersistentlurchingordeviationtowardthe
involvedside.
SensoryAtaxicGait
Withthistypeofataxia,becausethepatientisunawareofthepositionofthelimbs,thegaitisbroadbased,and
thepatienttendstoliftthefeettoohighandslaponthefloorinanuncoordinatedandabruptmanner.Thepatient
tendstowatchthefloorandthefeettomaximizetheopportunitiesforvisualcorrection,andmayhavedifficulty
walkinginthedark.
ParkinsonianGait
TheParkinsoniangaitischaracterizedbyaflexedandstoopedposture,withflexionoftheneck,elbows,
metacarpophalangealjoints,trunk,hips,andknees(Table611).Thepatienthasdifficultyinitiatingmovements
andwalksusingshortsteps,withthefeetbarelyclearingtheground.Thisresultsinashufflingtypeofgaitwith
rapidsteps.Asthepatientgetsgoing,heorshemayleanforwardandwalkprogressivelyfaster,asthough
chasingtheCOG(propulsiveorfestinatinggait).Lesscommonly,deviationoftheCOGbackwardmaycause
retropulsion.Thereisalsoalackofassociatedarmmovementduringthegaitbecausethearmsareheldstiffly.
HystericalGait
Thehystericalgaitisnonspecificandbizarre.Itdoesnotconformtoanyspecificorganicpattern,withthe
abnormalityvaryingfrommomenttomomentandfromoneexaminationtoanother.Theremaybeataxia,
spasticity,inabilitytomove,orothertypesofabnormality.Theabnormalityisoftenminimalorabsentwhenthe
patientisunawareofbeingwatchedorwhendistracted.However,althoughallhystericalgaitsarebizarre,all
bizarregaitsarenothysterical.
Pregnancy
Substantialhormonalandanatomicchangesoccurduringpregnancy,whichdramaticallyalterbodymass,body
massdistribution,andjointlaxity.Duringpregnancy,musculoskeletaldisordersarecommonandmaycause
problemsrangingfrommilddiscomforttoseriousdisability.Itiswidelypresumedthatpregnantwomenexhibit
markedgaitdeviations.Theresultsofarecentstudyappeartorefutethatnotion.189Thestudyconcludedthat
velocity,stridelength,andcadenceduringthethirdtrimesterofpregnancyweresimilartothosemeasured1
yearpostpartumandthatonlysmalldeviationsinpelvictiltandhipflexion,extension,andadductionwere
observedduringpregnancy.189Thestudyfoundsignificantincreases(p<0.05)inhipextensor,hipabductor,and
ankleplantarflexorkineticgaitparameters,whichsuggestsanincreaseduseofhipextensor,hipabductor,and
ankleplantarflexormusclestocompensateforincreasesinbodymassandchangesinbodymassdistribution
duringpregnancy.Theseincreaseskeepspeed,stridelength,cadence,andjointanglesrelativelyunchanged.189
However,thesecompensationsmayresultinoveruseinjuriestothemusclegroupsaboutthepelvis,hip,and
ankle,includinglowback,pelvic,andhippaincalfcrampsandotherpainfullowerextremitymusculoskeletal
conditionsassociatedwithpregnancy.189Itwasunclearfromthisstudywhetherthewomenexaminedhad
gainednormalamountsofweightassociatedwithpregnancy.Itwouldseemobviousthatobesityassociatedwith
pregnancymayhavedifferingeffectsongait.
Obesity
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AsobesityisreachingepidemicproportionsintheUnitedStatesandisagrowingproblemindeveloped
countries,theclinicianneedstobeawareofitseffectsonthenormalgaitpatterntohelpdiscriminate
compensatorypatternsasopposedtopathologicmanifestations.Obesityisassociatedwithanumberof
comorbidities,suchascoronaryarterydisease,type2diabetes,gallbladderdisease,andsleepapnea.Givena
normalbodymassindex(definedastheweightinkilogramsdividedbythesquareoftheheightinmeters)
rangingfrom18.5to24.9,34%oftheadultpopulationintheUnitedStatesisoverweight(bodymassindexof
2529.9)andanother27%isobese(bodymassindexof30ormore).190
Thegaitusedbytheobesepatientisoftendescribedasawaddlinggait.Dependingonthedegreeofobesity,the
waddlinggaitischaracterizedbyincreasedlateraldisplacement,pelvicobliquity,hipcircumduction,increased
kneevalgus,externalfootprogressionangle,overpronation,andincreasesinthenormalizeddynamicBOS.
Nanteletal.191comparedthebiomechanicalparametersbetweenobeseandnonobesechildrenduringselfpaced
walking.KinematicswerecapturedwitheightVICONoptoelectroniccameras(OxfordMetricsLimited,Oxford,
UK)recordingat60Hz.Findingsfromthestudyrevealedthatobesechildrenmodifiedtheirhipmotorpattern
byshiftingfromanextensortoaflexormomentearlierinthegaitcycle.Thisledobesechildrentosignificantly
decreasethemechanicalworkdonebythehipextensorsduringtheloadingresponseintervalandsignificantly
increasethemechanicalworkdonebythehipflexors,comparedwithnonobesechildren.Finally,therewasa
significantdecreaseinthesinglesupportdurationintheobesegroupcomparedwithnonobese.Gushueetal.192
attemptedtoquantifythethreedimensionalkneejointkinematicsandkineticswhilewalkinginchildrenwith
varyingbodymassandtoidentifyeffectsassociatedwithobesity.Thestudyfoundthattheoverweightgroup
walkedwithasignificantlylowerpeakkneeflexionangleduringearlystance,butnosignificantdifferencesin
peakinternalkneeextensionmomentswerefoundbetweengroups.However,theoverweightgroupshoweda
significantlyhigherpeakinternalkneeabductionmomentduringearlystance.Thesedatasuggestthatalthough
overweightchildrenmaydevelopagaitadaptationtomaintainasimilarkneeextensorload,theymaynotbe
abletocompensateforalterationsinthefrontalplane,whichmayleadtoincreasedmedialcompartmentjoint
loads.192Finally,inastudybydeSouzaetal.,193anoutpatientpopulation(age47.212.9years,94.1%
females,BMI40.16.0kg/m2,n=34)hadtheirgaitanalyzedbyanexperiencedphysicaltherapist.Variables
includedspeed,cadence,stridelength,stepwidth,andfootangle,whichwerecomparedtoreferencevalues.All
variablesweresignificantlylowerintheobesepatients,exceptforstepwidth,whichwasincreased.Speedwas
73.316.3versus130cm/s,cadencewas1.40.2versus1.8steps/s,stridelengthwas106.813.1versus
132.0cm,andstepwidthwas12.53.5versus10.0cm(p<0.05).Theauthorsconcludedthatthesefindings
wereconsistentwithpoorskeletalmuscleperformance,highmetabolicexpenditure,andconstantphysical
exhaustion.193
CLINICALPEARL
Obeseadultsdemonstratealongerstancetime,decreasedstridelength,astepwidththatisdoublethatofthe
nonobese,anincreasedsupportperiod(doubleandsingle),alteredhipabductionangles,anddecreasedgait
velocity(1.09m/s).194
Obesityalsoimpactsotherareasofmobilitysuchassittostandtransfers.Inobeseadults,sittostandis
performedbyplacingthefeetfurtherunderthebodyandutilizinglesshipflexionthaninthenonobese.177
Whilethisresultsinadecreasedtorqueatthehip,italsoresultsinanincreasedtorquedemandandjointstressat
theknee.195Perhapsmorealarminglyisthefindingthatobesechildrenhavesignificantdifficultywiththesit
tostandtask.177Inonestudy,69%ofobesechildrenrequiredassistancetoperformasittostandtransfer.196
Althoughthefunctionalcomorbiditiesofexcessbodyweightsuchasgaitproblemsareperhapsclinically
insignificantcomparedtothoseassociatedwithcertainmetabolicsequelae,theymayinterferewiththequality
oflifeandalsoacttoincreasemuscle,bone,andjointstress.Forexample,thechangesinthenaturalalignment
oftheweightbearingsegmentsmayresultinoveruseinjuriessuchastendonitisandbursitisandeventual
osteoarthritisofthehiporknee,orboth.
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JointReplacementSurgery
Individualsundergoingkneereplacementandhipreplacementsurgerydemonstrateimpairedgaitpatterns177:
Kneereplacement.Thegaittendstopresentwithslowerpreoperativeandpostoperativecadencethanage
matchednormals,aswellasshortersteplengthbothpreoperativelyandpostoperatively.197Thesechanges
remainstablefor12yearsaftersurgery.197Individualswithkneereplacementsurgeryalsocontinueto
exhibitreducedkneeexcursionduringgaitbeforeandaftersurgerythroughoutalltimeperiods.197
Muscleactivationalsoremainsalteredwithastiffkneegaitpatternthatinvolvescoactivationduringthe
stancephasepredominatingupto2yearspostoperatively.198
Hipreplacement.Individualsundergoingboththeposterolateralandtheanterolateralsurgicaltotalhip
arthroplasty(THA)approacheshavedemonstratedalteredgaitparametersat618months
postoperative.199TypicalfindingsfollowingaTHAincludesignificantlydecreasedgaitspeed,cadence,
steplength,andstridelength.200Twoseparatestudies201,202havesuggestedthatthedecreasedstride
lengthisduetofailuretofullyextendtheinvolvedhipduringthestancephase,thusdecreasinggaitspeed.
Whetherthislossofhipextensionistheresultofanincreaseinpassiveresistance,orcontractureofthe
anteriorhipstructures,orhipextensorweakness,isnotknown.203,204Theanterolateralapproachtendsto
leadtogreatertrunkforwardinclinationandaTrendelenburggaitpattern.199Theipsilateraltrunkside
bendingassociatedwiththeTrendelenburgisconsideredtobeastrategytodecreasedemandonthehip
abductorstostabilizethepelvisinthefrontalplaneduringsinglelegstancebymovingtheCOGcloserto
theaxisofrotationatthehip.205Earlymaximalstrengthtraining,combinedwithconventional
rehabilitation,mayimprovemusclestrengthandworkefficiencyinpatientsfollowingTHAmore
effectivelythanconventionalrehabilitationprogramsalone.206,207
ASSISTIVEDEVICES
Themostcommoncauseofthebreakdownofthenormalgaitcycleisaninjurytooneorbothofthelower
extremities.Suchaninjuryusuallyresultsinanantalgicgait.Iftheinjuryissevereenough,anassistivedevice
isneeded.Assistivedevicesaredesignedtomakeambulationassafeandaspainlessaspossible.However,it
mustberememberedthatthereisanenergycostassociatedwiththeuseofassistivedevices.Energyexpenditure
duringwalkingwithassistivedevicessuchascrutchesorawalkerhasgenerallybeenexaminedonlyinyounger
peoplewithcontrastingresults.Onestudy208showedthatwalkingwithcrutchesresultedinlowerVO2
comparedwithwalkingwitharollatororastandardwalker.Comparedwithunassistedwalking,walkingwitha
wheeledwalkerresultedinmoreoxygenuse.Anotherstudy209foundthatsubjects75yearsofageorolder,
consumedanaverageof2.8METSwhenwalkingwhileusingawheeledwalkerthiscorrespondstoamoderate
levelofintensityaccordingtotheACSMscalefortheveryold.210212
Inessence,anassistivedeviceisanextensionoftheupperextremity,usedtoprovidesupport,balance,and
weightbearingnormallyprovidedbyanintactfunctioninglowerextremity.213Assistivedevicesfunctionto
reduceGRFs,withthesizeoftheBOSthattheyprovidebeingproportionaltotheamountofreductioninthese
forces.
Assistivedevices,inorderofthestabilitytheyprovide,includeawalker,crutches,walkercane,quadcane,
straightcane,andbentcane,withthewalkerprovidingthemoststability.
Theindicationsforusinganassistivedeviceinclude214
decreasedabilitytobearweightonthelowerextremities
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muscleweaknessorparalysisofthetrunkorlowerextremities
decreasedbalanceandproprioceptionintheuprightposture.
Correctfittingofanassistivedeviceisimportanttoensurethesafetyofthepatientandtoallowforminimal
energyexpenditure.Forcorrectfitting,thepatientispositionedinbilateralsupportstance,wearingthefootwear
thatheorshewilltypicallywearforambulation,withthetoesslightlyout,theankleinneutral,thekneein
neutralextension,andthehipinneutralextension.Theupperextremityshouldbepositionedsothattheelbows
andtheshouldersarerelaxedandlevel.Oncefitted,thepatientshouldbetaughtthecorrectwalkingtechnique
withthedevice.Thefittingdependsonthedevicechosen:
Walkers,hemiwalkingcanes,andquadcanes.Theheightofthedevicehandleshouldbeadjustedtothe
levelofthegreatertrochanterofthepatientship,orattheulnarstyloidoftheupperextremity(Figs.66
and67).
Standardcrutches.Anumberofmethodscanbeusedfordeterminingthecorrectcrutchlengthfor
axillarycrutches:
Askforapatientsheightandthenadjustaccordingtotheheightmarkingsonthecrutch.
Calculate77%ofthepatientsheight
Subtract16infromanadultpatientsheight
Takeameasurementfromthepatientsaxillaryfoldtoapoint68inlateraltothebottomofthe
heel(includingfootwear).
Havethepatientsitwithbotharmsabductedto90degrees.Askthepatienttoflexoneoftheelbows
to90degrees.Themeasurementisthentakenfromtheolecranonprocessofthepatientsflexed
elbowtothetipofthelongfingeroftheoppositehand(Fig.68).
FIGURE66
Measuringforaquadcane.
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FIGURE67
Measuringforawalker.
FIGURE68
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Amethodformeasuringforcrutches.
Whenthecrutchesarefittedcorrectly,thereisa58cm(23in)gapbetweenthetopsoftheaxillarypadsand
thepatientsaxilla(Fig.69)whenthecrutchtipisverticaltothegroundandpositionedapproximately5cm(2
in)lateraland15cm(6in)ata45degreeangleanteriortothepatientsfoot.Thehandgripsofthecrutchare
adjustedtotheheightofthegreatertrochanterofthehipofthepatient,orattheulnarstyloidoftheupper
extremitywiththeelbowflexed2030degrees.
FIGURE69
Checkingtoseethereisa58cm(23in)gapbetweenthetopsoftheaxillarypadsandthepatientsaxilla.
Forearm/lofstrandcrutches.Thecrutchisadjustedsothatthehandgripislevelwiththegreater
trochanterofthepatientshipandthetopoftheforearmcuffjustdistaltotheelbow.
Canes.Usingacanetoaidwalkingisperhapsasoldasthehistoryofhumankind.Inancienttimes,canes
wereusedforsupport,defense,andtheprocurementoffood.215Later,canesbecameasymbolofpower
andaristocracy.216Currently,canesareusedtoprovidesupportandprotection,toreducepaininthelower
extremities,andtoimprovebalanceduringambulation.217Itiscommonpracticetoinstructpatientswith
lowerextremitypaintousethecaneinthehandcontralateraltothesymptomaticside.218Theuseofa
caneinthecontralateralhandhelpspreservereciprocalmotionandamorenormalpathwayforthe
COG.219Useofacaneinthisfashionalsohelpstodecreaseforcesatthehip,asestimatedbyexternal
kinematicsandkinetics.220223Useofacanecantransmit2025%ofbodyweightawayfromthelower
extremities.224,225ThecanealsoallowsthesubjecttoincreasetheeffectiveBOS,therebydecreasingthe
hipabductorforceexerted.Ifmeasuringforastandardcane,thecanetipshouldbeapproximately34in
anteriortothefootata45degreeangle.
GAITTRAININGWITHASSISTIVEDEVICES
Theclinicianmustalwaysprovideadequatephysicalsupportandinstructionwhileworkingwithapatientusing
anassistivegaitdevice.Whenprovidinggaittraining,itisimportantthatthepatientreceiveverbaland
illustratedinstructions.Patientinstructionshouldinitiallybeprovidedinasafeenvironmentandinan
environmentfreefromdistractionsothatthepatientcanconcentrate.Ideally,theclinicianshoulddemonstrate
howtousetheassistivedevicebeforeaskingthepatienttodoso.Thepatientshouldbeencouragedtolook
aheadratherthandowntohelpwithproprioceptivetraining.Thetrainingshouldbeinitiatedonlevelsurfaces
andthenadvancedtoincludenegotiationofcurbs,stairnegotiation,ambulatinginbusycorridors,andsitto
stand/standtosittransfersfromdifferentsurfaces.Theseinstructionsshouldalsoincludeanyweightbearing
precautionspertinenttothepatient,theappropriategaitsequence,andacontactnumberatwhichtoreachthe
clinicianifquestionsarise.Finally,thepatientshouldbeeducatedonhowtocreateasafehomeenvironmentto
preventanyfalls,andoncareandmaintenanceofthedevice(replacingrubbertipsasneeded,andtighteningany
loosefasteners,etc.).
Theclinicianmustalwaysprovideadequatephysicalsupportandinstructionwhileworkingwithapatientusing
anassistivegaitdevice.Guardingistheprocessofprotectingapatientfromexcessiveweightbearing,incorrect
gaitpattern,lossofbalance,orfalling.Properguardingrequirestheuseofagaitbeltfittedaroundthepatients
waisttoenablethecliniciantoassistthepatient.ThekeyistominimizethedistancebetweenthepatientsCOG
andthecliniciansCOG.Typically,theclinicianpositionshimselforherselfontheinvolvedsideofthepatient,
tobeabletoassistthepatientonthesidewherethepatientwillmostlikelyhavedifficulty.Whenambulating
withapatient,theclinicianshouldbejustbehindthepatient,standingtowardtheinvolvedside.Whateverside
ischosen,ifthepatientfallsforward,backward,ortoeitherside,theaimistoreturnthecombinedCOGofthe
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patientandtheclinicianwithintheBOSoftheclinician,withonlyashiftofthecliniciansweight,andwithno
largefootmovementsbytheclinician.Thus,theBOSoftheclinicianmustbelargeenoughtosupportsuch
shiftsintheCOGshouldthepatientstarttofallandtheclosertheclinicianistothepatient,theeasierthisisto
maintain.Althoughfallstypicallyoccurinonedirection,theclinicianmustrememberthatsometimesthe
patientslowerextremitiescangivewayresultinginacollapsingfall.Insuchinstances,theclinicianshould
moveclosertothepatientandliftonthegaitbelttoprovidetimeforthepatienttoregainsupport.
Theselectionofthepropergaitpatterntoinstructthepatientisdependentonthepatientsbalance,strength,
cardiovascularstatus,coordination,functionalneeds,andweightbearingstatus:
NWB.Thepatientisnotpermittedtobearanyweightontheinjuredlimb.
Partialweightbearing(PWB).Thepatientispermittedtobearaportion(25%,50%,etc.)ofhisorher
weightthroughtheinjuredlimb.
Touchdownweightbearing/toetouchweightbearing.Thepatientispermittedminimalcontactofthe
injuredlimbwiththegroundforbalance.Theexpressionasthoughwalkingoneggshellscanbeusedto
helpthepatientunderstand.
Weightbearingastolerated.Thepatientispermittedtobearasmuchweightthroughtheinjuredlimbas
iscomfortable.
Fullweightbearing.Patientnolongermedicallyrequiresanassistivedevice.
Severalgaitpatternsarerecognized(Table612),themostcommonofwhichwillbedescribedhere.
TABLE612GaitPatternswhenUsingAssistiveDevices
Pattern Description
Closelyapproximatesthenormalgaitpattern,butrequirestheuseofanassistivegaitdevice(canes
Two orcrutches)oneachsideofthebody
point Thepatientmovestheassistivegaitdeviceandthecontralaterallowerextremityatthesametime
pattern Requiressomecoordinationandisusedwhentherearenoweightbearingrestrictionsinthe
presenceofbilateralweaknessortoenhancebalance
Isthesameasthetwopointexceptthatitrequiresonlyoneassistivedevice,positionedonthe
oppositesideoftheinvolvedlowerextremity
Two
Thispatterncannotbeusedifthereareanyweightbearingrestrictions,i.e.,PWB,NWB,butis
point
appropriateforapatientwithunilateralweaknessormildbalancedeficits
modified
Thepatientisinstructedtomovethecaneandtheinvolvedlegsimultaneously,andthenthe
uninvolvedleg
Requirestheuseofanassistivegaitdevice(canesorcrutches)oneachsideofthebody,isused
Four whenthepatientrequiresmaximumassistancewithbalanceandstability
point Thepatternisinitiatedwiththeforwardmovementofoneoftheassistivegaitdevices,andthenthe
pattern contralaterallowerextremity,theotherassistivegaitdevice,andfinallytheoppositelowerextremity
(e.g.,rightcrutch,thenleftfootleftcrutch,thenrightfoot)
Isthesameasthefourpointexceptthatitrequiresonlyoneassistivedevice,positionedonthe
Four oppositesideoftheinvolvedlowerextremity
point Thispatterncannotbeusedifthereareanyweightbearingrestrictions,i.e.,PWB,NWB,butare
modified appropriateforapatientwithunilateralweaknessormildbalancedeficits
Thepatientisinstructedtomovethecane,thentheinvolvedleg,andthentheuninvolvedleg
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Pattern Description
Usedfornonweightbearingwhenthepatientispermittedtobearweightthroughonlyonelower
extremity
Involvestheuseoftwocrutchesorawalker(cannotbeusedwithacaneoronecrutch)
Three Requiresgoodupperbodystrength,goodbalance,andgoodcardiovascularendurance
point Thepatternisinitiatedwiththeforwardmovementoftheassistivegaitdevice(s).Next,theinvolved
lowerextremityisadvanced,whilestayingNWBasthepatientthenpressesdownontheassistive
gaitdeviceandadvancestheuninvolvedlowerextremity
Amodificationofthethreepointgaitpatternthatrequirestwocrutchesorawalker
Thispatternisusedwhenthepatientcanbearfullweightwithonelowerextremitybutisonly
Three
allowedtopartiallybearweightontheinvolvedlowerextremity.Inpartialweightbearing,onlypart
point
ofthepatientsweightisallowedtobetransferredthroughtheinvolvedlowerextremity
modified
Thepatternisinitiatedwiththeforwardmovementofoneoftheassistivegaitdevices,andthenthe
or3point
involvedlowerextremityisadvancedforward,allowingonlyPWB.Thepatientpressesdownonthe
1
assistivegaitdeviceandadvancestheuninvolvedlowerextremity,usingeitheraswingtoora
swingthroughpattern
TwoPointPattern
Thetwopointgaitpattern,whichcloselyapproximatesthenormalgaitpattern(VIDEO15),requirestheuseof
anassistivegaitdevice(canesorcrutches)oneachsideofthebody.Thispatternrequiresthepatienttomovethe
assistivegaitdeviceandthecontralaterallowerextremityatthesametime.Thispatternrequirescoordination
andbalance.Theuninvolvedlowerextremitycanbeadvancedtoapointatwhichitisparalleltotheinvolved
lowerextremity(VIDEO1)oritcanbeadvancedaheadoftheuninvolvedlowerextremity.
TwoPointModified
Thetwopointmodifiedpatternisthesameasthetwopointexceptthatitrequiresonlyoneassistivedevice,
positionedontheoppositesideoftheinvolvedlowerextremity(VIDEO2).Thispatterncannotbeusedifthere
areanyweightbearingrestrictions,thatis,PWBorNWBbutareappropriateforapatientwithunilateral
weaknessormildbalancedeficits.Thepatientisinstructedtomovethecaneandtheinvolvedleg
simultaneously,andthentheuninvolvedleg.
ThreePointGaitPattern
Thispatternisusedfornonweightbearingwhenthepatientispermittedtobearweightononlyonelower
extremity.Thethreepointgaitpattern,whichdemandsahighdegreeofenergyfromthepatient,involvesthe
useoftwocrutchesorawalker.Itcannotbeusedwithacaneoronecrutch.Thethreepointgaitpatternrequires
goodupperbodystrength,goodbalance,andgoodcardiovascularendurance.Thepatternisinitiatedbythe
forwardmovementoftheassistivegaitdevice.Next,theinvolvedlowerextremityisadvancedasthepatient
thenpressesdownontheassistivegaitdeviceandadvancestheuninvolvedlowerextremity.Twomethodsof
advancingthelowerextremitycanbeused:
Swingto:theuninvolvedlowerextremityisadvancedtoapointatwhichitisparalleltotheinvolved
lowerextremity(VIDEO3).
Swingthrough:theinvolvedlowerextremityisadvancedaheadoftheuninvolvedlowerextremity
(VIDEO4).
SittoStandTransfers
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Beforethepatientcanbeginambulation,heorshemustfirstlearntosafelytransferfromasittingpositiontoa
standingposition.Thewheelsofthebedorwheelchairarelocked,andthepatientisremindedofanyweight
bearingrestrictions.Thepatientisaskedtoslidetothefrontedgeofthechairorbed,andtheweightbearing
footisplacedunderneaththebodysothattheCOGisclosertotheBOS,whichwillmakeiteasierforthepatient
tostand.
Thepatientistheninstructedtoleanforwardandpushupwiththehandsfromthebedorarmrests.
Ifthepatientisbeinginstructedontheuseofawalker,heorsheshouldgraspthehandgripsofthewalker
onlyafterbecominguprightandshouldnotbepermittedtotrytopulluptoastandingpositionusingthe
walker,becausethiscancausethewalkertotipoverandincreasethepotentialforfalls.
Ifthepatientisusingcrutches,heorsheisinstructedtoholdbothcrutcheswiththehandonthesameside
astheinvolvedlowerextremity.Thepatientthenpressesdownonthehandgripsofthecrutches,the
armrest,orbedandwiththeuninvolvedlowerextremity,tostand.Oncestanding,andwithadequate
balance,thepatientmovesthecrutchesintopositionandbeginstoambulate.
Ifthepatientisusingoneortwocanes,heorsheisinstructedtopushupwiththehandsfromthebedor
armrests.Oncestanding,thepatientshouldgraspthehandgrip(s)ofthecane(s)withtheappropriatehand
andbegintoambulate.
StandtoSitTransfers
Thestandtosittransferisessentiallythereverseofthesittostandtransfer.Inordertositdownusingan
assistivedevice,thepatientmustfirstbackupagainstthefrontedgeofthebedorchair.Ifthepatienthas
difficultybendingthekneeoftheinvolvedlowerextremity,heorsheisinstructedtoslowlyadvancethis
extremityforward.Onceinposition:
thepatientusingawalkerreachesforthebedorarmrestwithbothhandsandslowlysitsdown
thepatientusingcrutchesmovesbothcrutchestothehandonthesideoftheinvolvedlowerextremity.
Withthathandholdingontobothhandgripsofthecrutches,thepatientreachesbackforthebedorarmrest
withtheotherhandbeforeslowlysittingdown
Thepatientusingoneortwocanesplacesthehandgripofthecane(s)againsttheedgeofthechairorbed.
Next,thepatientreachesbackforthebedorarmrestandslowlysitsdown.
StairNegotiation
AscendingStairs
Toascendsteps,thepatientmustfirstmovetothefrontedgeofthestep.Thewalkerwillhavetobeturned
towardtheoppositesideofthehandrailorwall.Ascendingmorethantwotothreestairswithawalkerisnot
recommended.
Toascendstairsusingawalker,thepatientisinstructedtograspthestairhandrailwithonehandandto
turnthewalkersidewayssothatthetwofrontlegsofthewalkerareplacedonthefirststep.Whenready,
thepatientpushesdownonthewalkerhandgripandthehandrailandadvancestheuninvolvedlower
extremityontothefirststep.Thepatientthenadvancestheinvolvedlowerextremitytothefirststepand
movesthelegsofthewalkertothenextstep.Thisprocessisrepeatedasthepatientmovesupthesteps.
Toascendstepsorstairswithcrutches,thepatientshouldgraspthestairhandrailwithonehandandgrasp
bothcrutchesbythehandgripswiththeotherhand.Ifthepatientisunabletograspbothcrutcheswithone
hand,orifthehandrailisnotstable,thenthepatientshouldusebothcrutchesonly,althoughthisisnot
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recommendediftherearemorethantwotothreesteps.Wheninthecorrectpositionatthefrontedgeof
thestep,thepatientpushesdownonthecrutchesandhandrail,ifapplicable,andadvancestheuninvolved
lowerextremitytothefirststep.Thepatientthenadvancestheinvolvedlowerextremityandfinallythe
crutches.Thisprocessisrepeatedfortheremainingsteps.
Toascendstepsorstairswithoneortwocanes,thepatientshouldusethehandrailandthecane(s).Ifthe
handrailisnotstable,thenthepatientshouldusethecane(s)only.Thepatientpushesdownonthecane(s)
orhandrail,ifapplicable,andadvancestheuninvolvedlowerextremitytothefirststep.Thepatientthen
advancestheinvolvedlowerextremity.Thisprocessisrepeatedfortheremainingsteps.
DescendingStairs
Inordertodescendsteps,thepatientmustfirstmovetothefrontedgeofthetopstep.Descendingmorethantwo
tothreestairswithawalkerisnotrecommended.
Todescendstairsusingawalker,thewalkeristurnedsidewayssothatthetwofrontlegsofthewalkerare
placedonthelowerstep.Onehandisplacedontherearhandgrip,andtheotherhandgraspsthestair
handrail.Whenready,thepatientlowerstheinvolvedlowerextremitydowntothefirststep.Thenthe
patientpushesdownonthewalkerandhandrailandadvancestheuninvolvedlowerextremitydownthe
firststep.Thisprocessisrepeatedasthepatientmovesdownthesteps.
Todescendstepsorstairswithcrutches,thepatientshoulduseonehandtograspthestairhandrailandthe
othertograspbothcrutchesandhandrail.Ifthepatientisunabletograspbothcrutcheswithonehand,or
ifthehandrailisnotstable,thenthepatientshouldusebothcrutchesonly,althoughthisisnot
recommendediftherearemorethantwotothreesteps.Whenready,thepatientlowerstheinvolvedlower
extremitydowntothefirststep.Next,thepatientpushesdownonthecrutchesandhandrail,ifapplicable,
andadvancestheuninvolvedlowerextremitydowntothefirststep.Thisprocessisrepeatedforthe
remainingsteps.
Todescendstepsorstairswithoneortwocanes,thepatientshouldusethecane(s)andhandrail.Ifthe
handrailisnotstable,thenthepatientshouldusethecane(s)only.Whenready,thepatientlowersthe
involvedlowerextremitydowntothefirststep.Next,thepatientpushesdownonthecane(s)and
handrail,ifapplicable,andadvancestheuninvolvedlowerextremitydowntothefirststep.Thisprocessis
repeatedfortheremainingsteps.
GAITASSESSMENTSCALES
Anumberofgaitassessmentscaleshavebeendesignedforavarietyofsettingsandpatientpopulations.
ModifiedGaitEfficacyScale(mGES).226Thisisa10itemmeasurethataddressestheperceptionofolder
adultsoftheirlevelofconfidenceinwalkingduringchallengingcircumstances.Theitemsinclude
walkingonalevelsurfaceandongrass,steppingoveranobstacle,steppingupanddownacurb,
ascendinganddescendingstairs(withandwithoutthehandrail),andwalkingoveralongdistance(Fig.6
10).ThemGEShasbeenreportedtobeareliableandvalidmeasureofconfidenceinwalkingamong
communitydwellingolderadults.226
The40mSelfPacedWalkTest.Participantsareaskedtowalkasquicklybutassafelyaspossibletoa
mark10maway,return,andrepeatforatotaldistanceof40m.Subjectsaretimedforthistest,anddata
areexpressedasspeed.227
TheTimedUpandGo(TUG)Test.Participantsareaskedtorisefromastandardarmchair,walkas
quicklybutassafelyaspossibletoamark3maway,turnaround,andreturntotheseatedchairposition.
Subjectsaretimedforthistest.228
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TheFigureofEightWalkTest.Thistestisdesignedtodetermineparticipantscurvedpathwalking
ability,whichisnecessaryfordailylivinginthehomeandcommunity.229Theparticipantswalkina
figureofeightpatternattheirusualpacearoundtwoconesthatare1.5m(5ft)apart,andthetimeto
completethefigureofeightisrecorded.Thistesthasdemonstratedtestretestreliability(ICC=0.84)and
interraterreliability(ICC=0.90).230
SixMinuteWalkTest(6MWT).Thistestmeasuresarewalkingenduranceandexercisecapacityby
havingparticipantswalkasfaraspossiblein6minutes.The6MWThasdemonstratedtestretest
reliability(Pearsonr=0.95)incommunitydwellingolderadults.231
GaitSpeed.Thistestdeterminesparticipantsgaitspeedbywalkingona4mcomputerizedwalkway
(GaitMattII,E.Q.Inc.,Chalfont,Pennsylvania)withadditional2mpanelsateachendtoallowfor
accelerationanddeceleration.Theparticipantsusualwalkgaitspeedisaveragedoverfourpassesand
hasdemonstratedtestretestreliability(ICC=0.98).232
SimpleandComplexWalkingWhileTalking(WWT)Tests.Thesetestsaredesignedtoprovidea
cognitivechallengewhilewalkingtopredictfallsbyimposingtheneedtodivideattention.Duringthe
simpleWWT,participantsareaskedtosaythelettersofthealphabetoutloudwhilewalkingdowna6.2
m(20ft)corridor.ThecomplexWWTisidenticalexceptforthefactthatindividualsareaskedtosay
everyotherletterofthealphabetoutloudwhilewalkingdownthe6.2mcorridor.ThesimpleWWTtest
hasdemonstratedaspecificityof89.4%andsensitivityof46.1%withatimeof20secondsorlonger(ona
12.2m[40ft]corridor)asapredictoroffallsincommunitydwellingolderadults.233ThecomplexWWT
predictsfallsinolderadultswithatimeof33secondsorlonger(ona12.2mcorridor)withaspecificity
of95.6%andsensitivityof38.5%incommunitydwellingolderadults.234
NarrowWalkTest.Thistestrequirestheparticipanttowalk4mathisorherusualpacewithina15cm
corridormarkedonthefloorusingtwolines,andthetimetocompletethewalkandthenumberof
deviationsfromthe15cmwidepatharerecorded.Participantswhocannotcompletethetest
independentlyorwhostepoutsideofthewalkwaymorethan10timesareclassifiedasunable.
ObstacleWalkTest.Thistestdetermineswhetheranindividualcanmodifyhisorhergaitkinematics
whilewalking.Asmall(6cmhigh)obstacleisplacedat2m,andalarge(30cmhigh)obstacleisplaced
at4mwithina7mdistance.Theparticipantisaskedtostepoverbothobstaclesandthetimetocomplete
thewalkisrecorded.
FIGURE610
Themodifiedgaitefficacyscale.
Participantscompletetwotrialsofeachwalk(narrowandobstacle),andthemeantimeiscalculatedforeach
condition.Incommunitydwellingolderadults,thenarrowandobstaclewalktestshavedemonstratedtestretest
reliability(ICC=0.76and0.89,respectively).233
DynamicGaitIndex(DGI).Thistestmeasuresthecapacityoftheparticipanttoadaptgaittocomplex
taskscommonlyencounteredindailylifeusingacombinedscoreofgaitpatternandlevelofassistance.
Item1oftheDGIexaminestheabilitytowalkunderlowchallengeconditions(selfpaced,levelsurface,
gait),whiletheremainingsevenitemsexaminetheparticipantsabilitytoadaptgaitinfourenvironmental
dimensions:temporal(changingspeed,posturaltransition)changingdirectionusingapivotturn,changing
headorientationincludinghorizontalandverticalheadturns,terrain(climbingstairs),anddensity
dimension(steppingoverandaroundobstaclesforcollisionavoidance).235
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POSTURE
Aswiththesocalledgoodmovement,goodpostureisasubjectivetermreflectingwhattheclinicianbelievesto
becorrectbasedonidealmodels.Variousattemptshavebeenmadetodefineandinterpretposture.89,236240
Goodposturemaybedefinedastheoptimalalignmentofthepatientsbodythatallowstheneuromuscular
systemtoperformactionsrequiringtheleastamountofenergytoachievethedesiredeffect.238Posturalor
skeletalalignmenthasimportantconsequencesaseachjointhasadirecteffectonbothitsneighboringjointand
onthejointsfurtheraway.Asyndromeisacharacteristicpatternofsymptomsordysfunctions.Abnormalor
nonneutralalignmentisdefinedaspositioningthatdeviatesfromthemidrangepositionoffunction.241Tobe
classifiedasabnormalordysfunctional,thealignmentmustproducephysicalfunctionallimitationsor
impairments.Theseconfinescanoccuranywherealongthekineticchain,atadjacentordistaljointsthrough
compensatorymotionsorpostures.
Fromthemechanicalpointofview,thespinalsystemishighlycomplexandstaticallyhighlyindeterminate.The
requirementformuscularcontrolofthespinevarieswithintheROM.Theneutralzoneisatermusedby
Panjabi242todefinearegionoflaxityaroundtheneutralrestingpositionofaspinalsegment.Theneutralzone
(seeChapter22)isthepositionofthesegmentinwhichminimalloadingisoccurringinthepassivestructures
(allofthenoncontractileelementsofthespineincludingtheligaments,fascia,jointcapsules,intervertebral
disks[IVDs],andnoncontractilecomponentsofmuscle),andthecontributionoftheactivesystem(themuscles
andtendonsthatsurroundandcontrolspinalmotion)ismostcriticalwithinitsneutralzoneofmotion,the
restraintsandcontrolforbending,rotation,andshearforcearelargelyprovidedbythemusclesthatsurround
andactonthespinalsegment.243,244Thesizeoftheneutralzoneisdeterminedbytheintegrityofthepassive
restraintandactivecontrolsystems,whichinturnarecontrolledbytheneuralsystem.242Studieshave
demonstratedthatalargerthannormalneutralzonecausedbyinjuryordiseaseisrelatedtoalackofsegmental
musclecontrolandisassociatedwithintersegmentalinjuryandIVDdegeneration.242,245248Unfortunately,
thereisasyetnoclinicalmethodtomeasurethesizeoftheneutralzone.
TheresearchofGardnerMorseetal.249andOSullivanetal.250lendssupporttothehypothesisofaneutral
zone.Theyproposedthatthepassivesystemaloneisincapableofprovidingsufficientspinalstabilizationduring
mostactivitiesandwouldbuckleunderitsownweightwithoutsufficientmusculartension.251,252Inaddition,
activitiessuchasacuterepetitiveloadinghavebeenshowntohaveasignificanteffectonreducingthestiffness
ofthepassivesystem,becauseoftheviscoelasticnatureofthestructuresofthepassivesystem(e.g.,ligaments
andIVDs).253,254Thus,inadditiontostructuralintegrity,stabilizationofthespinemustalsorelyonmuscular
support.
Theoverallcontourofthenormalvertebralcolumninthefrontalplaneisstraight.Incontrast,thecontourofthe
sagittalplanechangeswithdevelopment.Atbirth,aseriesofprimarycurvesgiveakyphoticposturetothe
wholespine.Withthedevelopmentoftheerectposture,secondarycurvesdevelop.Forexample,thecervical
spineformsalordoticcurvethatdevelopssecondarytotheresponseofanuprightposture,whichinitiallyoccurs
whenthechildbeginstolifttheheadat34months.Thepresenceofthecurveallowstheheadandeyesto
remainorientedforwardandprovidesashockabsorbingmechanismtocounteracttheaxialcompressiveforce
producedbytheweightofthehead.Thus,thecurvesinthespinalcolumnprovideitwithincreasedflexibility
andshockabsorbingcapabilities.255Acontinualforcethatimpactspostureisgravity.Themusclesandinert
structuresofthebodyfunctiontocounteracttheforcesofgravityduringbothstaticanddynamicactivities.
Thus,posturalalignmentisbothstaticanddynamic.
Theposturalcontrolsystem,themechanismbywhichthebodymaintainsbalanceandequilibrium,hasbeen
dividedintoseveralsubsystems,namely,thevestibular,visual,andsomatosensorysubsystems(seeChapter
3).256,257Inamultisegmentedorganismsuchasthehumanbody,manyposturesareadoptedthroughoutthe
courseofaday.Nonneutralalignment,whethermaintainedstaticallyorperformedrepetitively,appearstobea
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keyprecipitatingfactorinsofttissueandneurologicpain.258Thismaybetheresultofanalterationinjointload
distributionorintheforcetransmissionofthemuscles.Thisalterationcanresultinamuscleimbalance.
Theabilitytomaintaincorrectpostureappearstoberelatedtoanumberoffactors:259
Energycost.259Theincreaseinmetabolicrateoverthebasalratewhenstandingissosmall,compared
withametaboliccostofmoving,astobenegligible.Thetypeofposturethatinvolvesaminimumof
metabolicincreaseoverthebasalrateisoneinwhichthekneesarehyperextended,thehipsarepushed
forwardtothelimitofextension,thethoraciccurveisincreased,theheadisprojectedforward,andthe
uppertrunkisinclinedbackwardinaposteriorlean.
Strengthandflexibility.Pathologicalchangestotheneuromuscularsystem(e.g.,excessivewearingofthe
articularsurfacesofjoints,thedevelopmentofosteophytesandtractionspurs,andmaladaptivechangesin
thelengthtensiondevelopmentandangleofpullofmusclesandtendons)maybetheresultofthe
cumulativeeffectofrepeatedsmallstresses(microtrauma)overalongphaseoftimeorofconstant
abnormalstresses(macrotrauma)overashortphaseoftime(seeChapter2).Strong,flexiblemusclesare
abletoresistthedetrimentaleffectsoffaultyposturesforlongerphasesandprovidetheabilitytounload
thestructuresthroughachangeofposition.However,controlofthesechangesinpositionarenotpossible
ifthejointsarestiff(hypomobile)ortoomobile(hypermobile),orthemusclesareweak,shortened,or
lengthened.
Age.Asthehumanbodydevelopsfrominfancytooldage,severalphysicalandneurologicalfactorsmay
affectposture.Asdiscussed,atbirth,aseriesofprimarycurvescausetheentirevertebralcolumntobe
concaveforward,orflexed,givingakyphoticposturetothewholespine,althoughtheoverallcontourin
thefrontalplaneisstraight.Incontrast,thecontourofthesagittalplanechangeswithdevelopment.Atthe
otherendofthelifespan,theagingadulttendstoalterpostureinseveralways.Acommonfunctionof
aging,atleastinwomen,isthedevelopmentofastoopedpostureassociatedwithosteoporosis.
Psychologicalaspects.259Notallpostureproblemscanbeexplainedintermsofphysicalcauses.Atypical
posturesmaybesymptomsofpersonalityproblemsoremotionaldisturbances.
Evolutionaryandheredityinfluences.259Thetransformationofthehumanracefromarboreal
quadrupedstouprightbipedsislikelyrelatedtotheneedofthemalehominidtohavethehandsandarms
availableforcarryingawidervarietyoffoodsforfairlylongdistances.260Thistransformationwas
responsiblenotonlyforthechangesintheweightbearingpartsofthemusculoskeletalstructurebutalso
forchangesintheupperextremities,whicharenowfreeforthedevelopmentofagreatervarietyof
manipulativeskills.Inattemptingtocorrectanindividualsposture,onemustberealisticandacceptthe
limitsimposedbypossiblehereditaryfactors.
Structuraldeformities.Thenormalfrontalandsagittalalignmentofthespinecanbealteredbymany
conditions,includingleglengthinequality(seeChapter29),congenitalanomalies,developmental
problems,trauma,ordisease(Table613).261263
Disease.Thenormalcoronalalignmentofthespinecanbealteredbymanyconditions,includingjoint
degenerationandscoliosis.Scoliosis,whichisadescriptivetermforlateralcurvature,isusually
accompaniedbyarotationalabnormality.Scoliosiscanbeidiopathic,aresultofcongenitaldeformity,
pain,ordegeneration,orbeassociatedwithnumerousneuromuscularconditions,suchasleglength
inequality(seeChapter29).Sagittalplanealignmentcanalsobealteredbydiseaseandinjury.This
alterationismanifestedclinicallywithareasofexcessivekyphosisorlordosis,oralossofthenormal
curves.Respiratoryconditions(e.g.,emphysema),generalweakness,excessweight,lossof
proprioception,ormusclespasm(asseenincerebralpalsyorwithtrauma)mayalsoleadtopoor
posture.264
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Pregnancy.Althoughneversubstantiated,posturalchangeshaveoftenbeenimplicatedasamajorcause
ofbackpaininpregnantwomen.265,266Therelationshipbetweenpostureandthebackpainexperienced
duringpregnancyisunclear.Thismaybebecausesignificantskeletalalignmentchangesthatarerelatedto
backpainthatareoccurringatthepelvisduringpregnancybutmaynotbedirectlymeasuredbypostural
assessments,suchaslumbarlordosis,sacralbaseangle,andpelvictilt.Mooreetal.267foundasignificant
relationship(r=0.49)betweenchangeinlordosisduring1624and3442weeksofpregnancyandan
increaseinlowbackpain.Ostgaardetal.268foundthatabdominalsagittaldiameter(r=0.15),transverse
diameter(r=0.13),anddepthofthelordosis(r=0.11)wererelatedtothedevelopmentofbackpain
duringpregnancy.Bullocketal.,266intheonlystudythatusedavalidatedandreliablepostureassessment
instrument,foundnorelationshipbetweenspinalposture(thoracickyphosis,lumbarlordosis,andpelvic
tilt)magnitudeorchangesduringpregnancy,andbackpain.TheresultsfromastudybyFranklinand
ConnerKerr269suggestthatfromthefirsttothethirdtrimesterofpregnancy,lumbarlordosis,posterior
headposition,lumbarangle,andpelvictiltincreasehowever,themagnitudesandthechangesofthese
posturevariablesarenotrelatedtobackpain.
Habit.Themostcommonposturalproblemisapoorposturalhabitanditsassociatedadaptivechanges.
Poorposture,and,inparticular,poorsittingposture,isconsideredtobeamajorcontributingfactorinthe
developmentandperpetuationofshoulder,neck,andbackpain.Musclesmaintainedinashortenedor
lengthenedpositioneventuallywilladapttotheirnewpositions.Althoughthesemusclesinitiallyare
incapableofproducingamaximalcontractioninthenewlyacquiredpositions,270changesatthe
sarcomereleveleventuallyallowthemuscletoproducemaximaltensionatthenewlength.271Although
thismayappeartobeasatisfactoryadaptation,thechangesinlengthproducechangesintension
development,aswellaschangesintheangleofpull.272Itistheorizedthat,ifamusclelengthensaspart
ofacompensation,musclespindleactivityincreaseswithinthatmuscle,producingreciprocalinhibitionof
thatmusclesfunctionalantagonistandresultinginanalterationinthenormalforcecoupleand
arthrokinematicrelationship,therebyeffectingtheefficientandidealoperationofthemovement
system.271,273276Forexample,apassivelyinsufficientmuscleisactivatedearlierinamovementthan
normalmuscleandhasatendencytobemorehypertonic,therebyproducingareflexinhibitionofthe
antagonists.273,274,277,278Itisdifficulttodeterminewhyaparticularposturebecomesdysfunctionalin
oneindividual,yetnotinanother.Differingadaptivepotentialsofthetissuesbetweenindividualsmaybe
amongthecausesinadditiontoneurologic,neurodevelopmental,andneurophysiologicfactors.
TABLE613CommonStructuralDeformities
Deformity Description Manifestation
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Causesofincreased
lordosisinclude:
1.Posturaldeformity
2.Laxmuscles,
especiallythe
abdominal
Anexcessiveanteriorcurvatureofthespine.Pathologically,itisan muscles,in
exaggerationofthenormalcurvesfoundinthecervicalandlumbar combinationwith
spines tightmuscles,
Thepelvicangle,normallyapproximately30degrees,isincreasedwith especiallyhip
lordosis flexorsorlumbar
Therearetwotypesofexaggeratedlordosis:pathologicallordosisand extensors
swaybackdeformity
Pathologicallordosis: 3.Aheavyabdomen,
Involvesscapulaeprotraction,internallyrotatedarms,internallyrotated resultingfrom
legs,andforwardhead,accompaniedbyweaknessofthedeeplumbar excessweightor
extensorsandtightnessofthehipflexorsandtensorfasciaelatae, pregnancy
combinedwithweakabdominals
Lordosis 4.Hipflexion
Swaybackdeformity:
Increasedpelvicinclinationtoapproximately40degreesandkyphosisof contractures
thethoracolumbarspine.Aswaybackdeformityresultsinthespine
bendingbackrathersharplyatthelumbosacralangle.Withthispostural 5.Spondylolisthesis
deformity,theentirepelvisshiftsanteriorly,causingthehipstomove
intoextension.Tomaintainthecenterofgravityinitsnormalposition, 6.Congenital
thethoracicspineflexesonthelumbarspine.Theresultisanincreasein problems,suchas
thelumbarandthoraciccurves.Suchadeformitymaybeassociatedwith bilateralcongenital
tightnessofthehipextensors,lowerlumbarextensors,andupper dislocationofthe
abdominals,alongwithweaknessofthehipflexors,lowerabdominals, hip
andlowerthoracicextensors
7.Failureof
segmentationofthe
neuralarch
8.Fashion(e.g.,
wearinghigh
heeledshoes)
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Thereareseveralcauses
Excessiveposteriorcurvatureofthespine ofkyphosis,including
Pathologically,itisanexaggerationofthenormalcurvefoundinthe tuberculosis,vertebral
thoracicspine compressionfractures,
Therearefourtypesofkyphosis: Scheuermanndisease,
ankylosingspondylitis,
1.Roundbackalong,roundedcurvewithdecreasedpelvic senileosteoporosis,
inclination(<30degrees)andthoracolumbarkyphosis.Thepatient tumors,compensationin
oftenpresentswiththetrunkflexedforwardandadecreased conjunctionwithlordosis,
lumbarcurve.Onexamination,therearetighthipextensorsand andcongenitalanomalies
trunkflexors,withweakhipflexorsandlumbarextensors Thecongenitalanomalies
Kyphosis includeapartial
2.Humpbackorgibbusalocalized,sharpposteriorangulationin segmentaldefect,asseen
thethoracicspine inosseousmetaplasia,or
3.Flatbackdecreasedpelvicinclinationto20degreesandamobile centrumhypoplasiaand
lumbarspine aplasia
Inaddition,paralysismay
4.Dowagerhumpoftenseeninolderpatients,especiallywomen. leadtoakyphosis
Thedeformitycommonlyiscausedbyosteoporosis,inwhichthe becauseofthelossof
thoracicvertebralbodiesbegintodegenerateandwedgeinan muscleactionneededto
anteriordirection,resultinginakyphosis maintainthecorrect
posture,combinedwith
theforcesofgravity
DatafromMageeDJ.Assessmentofposture.In:MageeDJ,ed.OrthopaedicPhysicalAssessment.Philadelphia,
PA:WBSaunders2002:873903KendallFP,McCrearyEK,ProvancePG.Muscles:TestingandFunction.
Baltimore,MD:Williams&Wilkins1993.
CLINICALPEARL
Thepainfromanysustainedpositionisthoughttoresultfromischemiaoftheisometricallycontractingmuscles,
localizedfatigue,orexcessivemechanicalstrainonthestructures.Intramuscularpressurecancompressthe
bloodvesselsandpreventtheremovalofmetabolitesandthesupplyofoxygen,eitherofwhichcancause
temporarypain.279,280
Posturaldevelopmentbeginsataveryearlyage.Astheinfantstartstoactivatetheposturalsystem,skeletal
musclesdevelopaccordingtotheirpredeterminedspecificusesinvariousrecurrentfunctionsandmovement
strategies.281JullandJanda278,282developedasystemthatcharacterizedmusclesbasedoncommonpatternsof
kineticchaindysfunction,intotwofunctionaldivisions(seeTable14):
Posturalmuscles.Theserelativelystrongmusclesaredesignedtocountergravitationalforcesand
provideastablebaseforothermusclestoworkfrom,althoughtheyarelikelytobepoorlyrecruited,laxin
appearanceandshowaninabilitytoperforminnerrangecontractionsovertime.
Phasicmuscles.Thesemusclestendtofunctioninadynamicallyantagonisticmannertothepostural
muscles.Phasicmusclestendtobecomerelativelyweakcomparedtotheposturalmuscles,aremore
pronetoatrophyandadaptiveshortening,andshowpreferentialrecruitmentforsynergisticactivities.In
addition,thesemuscleswilltendtodominatemovementsandmayalterposturebyrestrictingmovement.
TheworkofJullandJanda278alsointroducedtheconceptofposturalpatternsanddescribedalowerquadrant
syndromecalledthepelviccrossedsyndrome.Inthissyndrome,theerectorspinaeandiliopsoasareadaptively
shortened(tight),andtheabdominalsandgluteusmaximusareweak.Thissyndromepromotesananteriorpelvic
tilt,anincreasedlumbarlordosis,andaslightflexionofthehip.Thehamstringsfrequentlyareadaptively
shortenedinthissyndrome,andthismaybeacompensatorystrategytolessentheanteriortiltofthepelvis,275
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orbecausethegluteiareweak.Inadditiontoincreasingthelumbarlordosis,anincreasedthoracickyphosisand
acompensatoryincreaseincervicallordosistokeeptheheadandeyesleveloccurs.Jandaalsodescribedan
upperquadrantsyndromecalledtheuppercrossedsyndrome.282Thissyndromeinvolvesadaptiveshorteningof
thelevatorscapulae,uppertrapezius,pectoralismajorandminor,andsternocleidomastoid(SCM),andweakness
ofthedeepneckflexorsandlowerscapularstabilizers.Thesyndromeproduceselevationandprotractionofthe
shoulderandrotationandabductionofthescapula,togetherwithscapularwinging.Italsotheoreticallyproduces
aforwardheadandhypermobilityoftheC4C5andT4segments.
Morerecently,Sahrmann271hasstressedtheimportanceoftherelationshipofneighboringjointsalongboth
directionsofthekineticchaintodeterminethemechanicalcauseofthesymptoms.
CLINICALPEARL
Posturalimbalancesinvolvetheentirebody,asshouldanycorrections.Itisimportanttorememberthatan
appropriateexaminationmusttakeplacepriortoanyintervention.
Manystudieshaveevaluatedtheeffectofinjuryontheneuromuscularsystem.283289Ifmusclecontrolispoor,
jointstrainandpainmayresult.242,290Traumatotissuesthatcontainmechanoreceptorsmayresultinpartial
deafferentation,whichcanleadtoproprioceptivedeficitsandalterjointfunction.291,292Forexample,in
additiontothemechanicalrestraintprovidedbyligaments,ithasbeenobservedthatligamentsprovide
neurologicfeedbackthatdirectlymediatesreflexmusclecontractionsaboutajoint.291,293
Astheneuromuscularsystembeginstodeclineinfunction,certainpredictableandstereotypicalchangestendto
occur.294Theseincludeincreasedlumbarlordosisandthoracickyphosis,decreasedhipextension,decreased
mediallateralstabilityandincreasedhipflexedpostureduetomuscleimbalanceanddecreasedanterior
posteriorstability,decreasedstridelength,greaterweightplacedontheforefoot,increaseddoublefootstance
time,decreasedproprioception,andharderheelstrike.281Asthedeclineprogresses,thelocomotorsystem
becomeslessabletoadapttoitsenvironment,requiringgreaterattentiontorecruitmoresensoryinformationin
ordertomaintainposturalcontrol.Manyofthechangesthatoccurinthedevelopingneuromuscularsystem
interestinglyrecurinsomesortofreverseorderduringthedegradingprocess.281Thesechangesincludea
transitionfromananklestrategyduringgaitbacktoahipstrategy,abroadenedstancetocombatincreased
mediallateralinstability,ashortenedstridelengthtobettermaintainCOG,decreasedintegrationofupperbody
counterrotation,increasedvisualsensoryinput,andrecruitmentofadditionalafferentationforpostural
equilibrium,suchastheuseofacane,theaidofamoreposturallystableperson,orboth.281
Examination
Theassessmentofpostureprimarilyinvolvesinformationgleanedfromthehistoryinadditiontovisualand
palpatoryobservations.Aclearunderstandingoffunctionalanatomyandtopographicallandmarksisvital.281
Aswithgaitanalysis,variousattemptshavebeenmadetoobjectivelymeasureposture,includingradiography,
goniometry,inclinometry,flexiblerulermeasurement,photography,theIowaanatomicalpositionsystem,and
plumblineassessment.Becausethereisanalmostendlessvarietyofactivityposturesandbecausetheseare
extremelydifficulttoassess,aconvenientcustomhasbeentoacceptthestandingpostureastheindividuals
basicposturefromwhichallotherposturesstem.259Underthisconcept,idealposturalalignmentforstanding
(viewedfromtheside)wasdefinedasastraightline(lineofgravity)thatpassesthroughtheearlobe,thebodies
ofthecervicalvertebrae,thetipoftheshoulder,midwaythroughthethorax,throughthebodiesofthelumbar
vertebrae,slightlyposteriortothehipjoint,slightlyanteriortotheaxisofthekneejoint,andjustanteriortothe
lateralmalleolus(Fig.611).
FIGURE611
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Commonposturaldysfunctions.
CLINICALPEARL
Asimpleandcommonlyappliedparameterofglobalbalanceistheplumblineoffsettakenfromafulllength
standingradiograph.ThecenterofC2(orC7)isdrawnverticallydownward,andthedistancefromthecenterof
thesacrumisnotedonthefrontalprojection,whiletheoffsetfromtheanteriorsuperioredgeorposterior
superioredgeofS1isnotedonthelateralprojection.
Althoughthismeasurementissimple,itmaynotaccuratelyreflectthebalanceofthespinetheplumbline
measurementisaradiographicvalueandnotarepresentationoftheappliedforces.
Theoretically,thisposturalalignmentresultsinminimumstressbeingappliedtoeachjoint,withminimal
muscleactivitybeingrequiredtomaintaintheposition.
Toassesspostureaccurately,thepatientmustbeadequatelyundressed.Standardprotocolsforpatientattirevary
withrespectto,amongotherfactors,regional,societal,religious,legal,healthcarespecialty,gender,andage
relatedissues.281Ideally,malepatientsshouldbeinshorts,andfemalepatientsshouldbeinabraandshorts,
andthepatientshouldnotwearshoesorstockings.However,ifthepatientuseswalkingaids,braces,collars,or
orthoses,theyshouldbenotedandmaybeusedafterthepatienthasbeenassessedinthenaturalstateto
determinetheeffectoftheappliances.264Inaddition,theflooronwhichthepatientstandsandisassessed,
shouldbealevel,hardsurface.Aslightdegreeofpaddedcarpetingisacceptable,althoughahardflooris
preferable.281
Thepatientshouldassumeacomfortableandrelaxedposture,lookingstraightahead,withfeetapproximately4
6inapart.Often,ittakessometimeforthepatienttoadopttheusualposturebecauseoftenseness,uneasiness,
oruncertainty.264Forthestaticexamination,theclinicianmustbeorientedtothepatientsothatthedominant
eye(Table614)islocatedinthemidlinebetweenthelandmarksbeingcompared.Thestaticassessmentof
postureisinitiallyperformedinaglobalfashion,withthepatientinthestanding,sitting,andlying(supineand
prone)positions.264Althoughitmayseemcontrary,unassistedstill,uprightposturalstancerequiresgreater
stabilitythanunassistedwalking,whichiswhywalkingoccursfirstinthetoddler.281Duringmaturestill,
uprightstance,thehipjointsaccountforthemajorityofmediallateralstabilitywhiletheanklejointsaccount
foragreatdealofanteriorposteriorstability.295
TABLE614IdentifyingtheDominantEye
Havingmadeacirclewiththefirstfingerandthumband,holdingthearmoutinfrontoftheface,
observeanobjectacrosstheroom,throughthatcircle,withbotheyesopen
Closeoneeye
Iftheobjectisstillinthecircle,thedominanteyeisopen
If,however,theimageshiftsoutofthecirclewhenonlyoneeyeisopen,opentheclosedeyeandclose
theopeneye,andtheimageshouldshiftbackintoclearview,insidethecircle
Theeyethatseesthesameviewwhenbotheyeswereopenistheonetouseincloseobservationofthe
body
Whenattemptingtoassessbyobservation,apositionshouldbeadoptedthatallowsthedominanteyeto
beclosesttothecenterofwhatisbeingviewed
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DatafromMorrisC,ChaitowL,JandaV.Functionalexaminationforlowbacksyndromes.In:MorrisC,ed.
LowBackSyndromes:IntegratedClinicalManagement.NewYork,NY:McGrawHill,2006:333416Dinnar
U,BealMC,GoodridgeJP,etal.Descriptionoffiftydiagnostictestsusedwithosteopathicmanipulation.JAm
OsteopathAssoc.198281:314321DinnarU,BealMC,GoodridgeJP,etal.Classificationofdiagnostictests
usedwithosteopathicmanipulation.JAmOsteopathAssoc.198079:451455.
Whenobservingapatientforabnormalitiesinposture,theclinicianlooksforasymmetry.264Regional
asymmetryshouldtriggerafurtherevaluationofthatarea,butasymmetryalonedoesnotconfirmorruleoutthe
presenceofdysfunction.Assomeasymmetrybetweenleftandrightsidesisnormal,theclinicianmustmakethe
determinationastowhethertheapparentdeviationisnormalorcausedbypathology.Itmustberemembered
thatposturaladaptationscanoccurinanumberofways,includingchangesingait,jointloading,neural
function,musclecoordination,respiratoryfunction,endurance,strength,andbalance.281Afterthepatienthas
beenexaminedintheaforementionedpositions,theexaminermaydecidetoincludeotherhabitual,sustained,or
repetitiveposturesassumedbythepatienttoseewhethertheseposturesincreaseoraltersymptoms.264
StaticExamination
Thestaticposturalexamination,asitrelatestoeachjointandthevariousposturalsyndromesthatexist,is
describedintherelevantchapters.AsummaryofthemostcommonfindingsandfaultsarelistedinTable613.
Commonlowerlimbskeletalmalalignmentsandpossiblecorrelatedandcompensatorymotionsorposturesare
compiledinTable615.
TABLE615SkeletalMalalignmentoftheLowerQuarterandCorrelatedandCompensatoryMotionsor
Postures
PossibleCorrelatedMotionsor PossibleCompensatoryMotionsor
Malalignment
Postures Postures
Ankleandfoot
Hypermobilefirstray
Subtalarormidtarsalexcessivepronation
Ankleequinus
Hiporkneeflexion
Genurecurvatum
Excessiveinternalrotationalongthe
lowerquarterchain
Halluxvalgus
Rearfootvarus Tibialtibialandfemoralortibial,
Functionalforefootvalgus
Excessivesubtalarsupination femoral,andpelvicexternal
Excessiveorprolongedmidtarsal
(calcanealvalgus) rotation
pronation
Excessiveexternalrotationalongthe
lowerquarterchain
Functionalforefootvarus
Halluxvalgus
Tibialtibialandfemoralortibial,
Rearfootvalgus Excessivemidtarsalorsubtalarpronation
femoral,andpelvicinternalrotation
Excessivesubtalarpronation orprolongedpronation
Halluxvalgus
(calcanealvalgus) Excessivetibialtibialandfemoralor
Subtalarsupinationandrelated
Forefootvarus tibial,femoral,andpelvicinternalrotation
rotationalonglowerquarter
orallwithcontralaterallumbarspine
rotation
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Malalignment
Postures Postures
Excessivemidtarsalorsubtalarsupination
Halluxvalgus
Excessivetibialtibialandfemoralor
Forefootvalgus Subtalarpronationandrelated
tibial,femoral,andpelvicexternalrotation
orallwithipsilaterallumbarspinerotation
Halluxvalgus
Internaltibialtorsion
Metatarsusadductus
Flatfoot
Intoeing
Forefootvalgus Excessivetibialtibialandfemoralor
Halluxvalgus Subtalarpronationandrelated tibial,femoral,andpelvicexternalrotation
rotationalongthelowerquarter33 orallwithipsilaterallumbarspinerotation
Kneeandtibia
Pesplanus
Excessivesubtalarpronation Forefootvarus
Externaltibialtorsion Excessivesubtalarsupinationtoallow
Lateralpatellarsubluxation lateralheeltocontactground
Genuvalgus
Excessivehipadduction Intoeingtodecreaselateralpelvicsway
Ipsilateralhipexcessiveinternal duringgait
rotation Ipsilateralpelvicexternalrotation
Lumbarspinecontralateralrotation
Excessivelateralangulationoftibia
infrontalplane(tibialvarumand Forefootvalgus
tibiavara) Excessivesubtalarpronationtoallow
Genuvarus
Internaltibialtorsion medialheeltocontactground
Ipsilateralhipexternalrotation Ipsilateralpelvicinternalrotation
Excessivehipabduction
Posteriorpelvictilt
Ankleplantarflexion
Genurecurvatum Flexedtrunkposture
Excessiveanteriorpelvictilt
Excessivethoracickyphosis
Outtoeing Functionalforefootvarus
Externaltibialtorsion Excessivesubtalarsupinationwith Excessivesubtalarpronationwithrelated
relatedrotationalonglowerquarter rotationalonglowerquarter
Intoeing
Functionalforefootvalgus
Metatarsusadductus
Internaltibialtorsion Excessivesubtalarsupinationwithrelated
Excessivesubtalarpronationwith
relatedrotationalonglowerquarter
Excessivetibialretroversion
(posteriorslantoftibial Genurecurvatum
plateaus)
Inadequatetibialretrotorsion
(posteriordeflectionof
Flexedkneeposture
proximaltibiadueto
hamstringspull)
AlteredalignmentofAchilles
Inadequatetibialretroflexion
tendon,causingalteredassociated
(bowingofthetibia)
jointmotion
Bowlegdeformityoftibia Forefootvalgus
Internaltibialtorsion
(tibiavaraandtibialvarum) Excessivesubtalarpronation
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Malalignment
Postures Postures
Hipandfemur
Excessiveexternaltibialtorsion
Intoeing Excessivekneeexternalrotation
Excessivefemoralanteversion Excessivesubtalarpronation Excessivetibialtibialandfemoralor
Lateralpatellarsubluxation tibial,femoral,andpelvicexternalrotation
orallwithipsilaterallumbarspinerotation
Excessivekneeinternalrotation
Excessivetibialtibialandfemoralor
Outtoeing
Femoralretrotorsion tibial,femoral,andpelvicinternalrotation
Excessivesubtalarsupination
orallwithcontralaterallumbarspine
rotation
Longipsilaterallowerlimband Excessiveipsilateralsubtalarpronation
Excessivefemoralneckto
correlatedmotionsorposturesofa Excessivecontralateralsubtalarsupination
shaftangle(coxavalga)
longlimb Contralateralplantarflexion
Posteriorpelvicrotation Ipsilateralgenurecurvatum
Supinatedsubtalarjointandrelated Ipsilateralhiporkneeflexion
externalrotationalongthelower Ipsilateralforwardpelviswithcontralateral
quarter lumbarspinerotation
Excessiveipsilateralsubtalarsupination
Pronatedsubtalarjointandrelated
Excessivecontralateralsubtalarpronation
internalrotationalonglowerquarter
Ipsilateralplantarflexion
Decreasedfemoralneckto Shortipsilaterallowerlimband
Contralateralgenurecurvatum
shaftangle(coxavara) correlatedmotionsorpostures
Contralateralhiporkneeflexion
alonglowerquarter:anteriorpelvic
Ipsilateralbackwardpelvicrotationwith
rotation
ipsilaterallumbarspinerotation
DatafromRieggerKrughC,KeysorJJ.Skeletalmalalignmentsofthelowerquarter:Correlatedand
compensatorymotionsandpostures.JOrthopSportsPhysTher.199623:164170.
Duetotherelationshipsbetweenhead,neck,thorax,lumbarspine,andpelvis,anydeviationinoneregioncan
affecttheotherareas.Anumberofcommonposturesaredescribedhere.
PelvicandLumbarRegion
Themorecommonfaultyposturesofthepelvicandlumbarregioninclude296:
Lordoticposture(Fig.611).Itischaracterizedbyanincreaseinthelumbosacralangle,anincreasein
lumbarlordosis,andanincreaseintheanteriorpelvictiltandhipflexion.297Thispostureiscommonly
seeninpregnancy,obesity,andthoseindividualswithweakenedabdominalmuscles.Potentialmuscle
impairmentsinclude
decreasedmobilityinthehipflexormuscles(iliopsoas,tensorfascialatae,rectusfemoris)and
lumbarextensormuscles(erectorspinae)
impairedmuscleperformanceduetostretchedandweakenedabdominalmuscles(rectusabdominis,
internalandexternalobliques,andtransversusabdominis).
Thispostureplacesstressthroughoutthelumbarspineontheanteriorlongitudinalligament,thezygapophyseal
(facet)joints,andnarrowstheposteriordiskspaceandtheintervertebralforamen,allofwhicharepotential
sourcesofsymptoms.
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Slouchedposture:Thisposture,alsoreferredtoastheswayback,240ischaracterizedbyashiftingofthe
entirepelvicsegmentanteriorly,resultinginrelativehipextension,andashiftingofthethoracicsegment
posteriorly,resultinginarelativeflexionofthethoraxontheupperlumbarspine(Fig.611).Asaresult,
thereisanincreasedlordosisinthelowerlumbarregion,increasedkyphosisinthethoracicregion,and
usuallyaforward(protracted)head.Thispostureiscommonlyseenthroughoutmostagegroupsandis
typicallytheresultoffatigueormuscleweakness.Potentialmuscleimpairmentsincludethefollowing:
Decreasedmobilityintheupperabdominalmuscles(uppersegmentsoftherectusabdominisand
obliques),internalintercostal,hipextensor,andlowerlumbarextensormusclesandrelatedfascia.
Impairedmuscleperformanceduetostretchedandweakenedlowerabdominalmuscles(lowersegments
oftherectusabdominisandobliques),extensormusclesofthelowerthoracicregion,andhipflexor
muscles.
Thispostureplacesstressontheiliofemoralligaments,theanteriorlongitudinalligamentofthelowerlumbar
spine,andtheposteriorlongitudinalligamentoftheupperlumbarandthoracicspine.Inaddition,thereis
narrowingoftheintervertebralforameninthelowerlumbarspineandapproximationofthezygapophyseal
(facet)jointsinthelowerlumbarspine.
Flatlowbackposture.Thispostureischaracterizedbyadecreasedlumbosacralangle,decreasedlumbar
lordosis/extension,andposteriortiltingofthepelvis(Fig.611).Thispostureiscommonlyseeninthose
individualswhospendlongperiodsslouchingorflexinginthesittingorstandingpositions.Thepotential
muscleimpairmentsinclude
decreasedmobilityinthetrunkflexor(rectusabdominis,intercostals)andhipextensormuscles
impairedmuscleperformanceduetostretchedandweaklumbarextensorandpossiblyhipflexor
muscles.
Thisposturecanapplystressontheposteriorlongitudinalligament,theposteriordiskspace,andonthenormal
physiologicallumbarcurve,whichreducestheshockabsorbingeffectsofthelumbarregionandpredisposesthe
patienttoinjury.
CervicalandThoracicRegion
Themorecommonfaultyposturesofthecervicalandthoracicregioninclude:296
Scoliosis
Twoterms,scoliosis,androtoscoliosis,areusedtodescribethelateralcurvatureofthespine,whichtypically
involvesthelumbarandthoracicregions.Scoliosisistheoldertermandreferstoanabnormalsidebendingof
thespinebutgivesnoreferencetothecoupledrotationthatalsooccurs.Rotoscoliosisisamoredetailed
definition,usedtodescribethecurveofthespinebydetailinghoweachvertebraisrotatedandsideflexedin
relationtothevertebrabelow.Forexample,withaleftlumbarconvexity,theL5vertebrawouldbefoundtobe
sideflexedtotherightandrotatedtotheleftinrelationtothesacrum.Thesamewouldbetruewithregardto
therelationbetweenL4andL5.Thisrotation,towardtheconvexity,continuesinsmallincrementsuntiltheapex
atL3.L2,whichisabovetheapex,isrightrotatedandrightsideflexedinrelationtoL3.Thesmallincrements
ofrightrotationcontinueupuntilthethoracicspine,wherethesidebendingandrotationreturntotheneutral
position.Thecurrentlyaccepteddefinitionofscoliosisisa10degreelateralcurvaturemeasured
radiographically(seeChapter7),withthevertebralrotationofthespinetakenwiththepatientstanding
upright.298Thisdefinitionisbasedonthefactthatagraphoflateralspinalcurvatureofthegeneralpopulationis
asmoothexponentialfunctioninwhichthesharpestchangeinslopeoccursat10degrees.299Despitethis
reasonableapproachtothedefinitionofthediseasestate,itresultsinanextremelyhighprevalenceofthe
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disorderinthegeneralpopulationof23%.300Scoliosiscanbefoundinfourforms:static,sciatic,idiopathic,
andpsychogenic.Thecauseofthelatterisselfexplanatory.Anabnormallateralthoraciccurveisdescribedas
beingstatic(structural)ordynamic(nonstructural):
Static.Thetermstatic,orstructural,scoliosisisusedtodescribeanirreversiblelateralcurvaturewith
fixedrotationofthevertebrae.Withstructuralscoliosis,thevertebralbodiesrotatetowardtheconvexity
ofthecurve,producingaprominence.301Theprominence,whichoccursposteriorlyonthesideofthe
spinalconvexityinthethoracicspineiscalledaribhump.Therotationofthevertebralbodiescausesthe
spinousprocessestodeviatetowardtheconcaveside,whichcausesaprominenceanteriorlyonthesideof
theconcavity.Thecurvatureresultsinanadaptiveshorteningoftheintrinsictrunkmusclesonthe
concavesideandlengtheningoftheintrinsicmusclesontheconvexside.Persistentscoliosisduring
forwardbending(Adamssign)isindicativeofastructuralcurve.Structuralcurvesmaybegenetic,
congenital,oridiopathic,producingastructuralchangetotheboneandalossofspinalflexibility.For
example,structuralscoliosismaybecausedbyahemivertebra,osteoporosis,osteomalacia,or
compressionfractures.
Dynamic
Thetermdynamic,ornonstructural,scoliosisisusedtodescribeareversiblelateralcurvaturethatcanbe
changedwithforwardorsidebendingandwithpositionalchanges.Causesincludepoorposture,nerveroot
irritation(seeSciatic),leglengthdiscrepancy,atrophy,orhipflexorcontracture.Inthecaseofaleglength
discrepancy,ifaplatformundertheheeloftheshorterlimbeasesorevenabolishesthesymptomswhile
standingoronlumbarflexionorextension,ashoeliftisadvised.75,302
Othertypesofscoliosistoconsiderinclude:
Sciatic.Thesightofapatientwithapelvicshiftorlistisrelativelycommoninpatientspresentingwith
LBP.Thesciatic,ornonstructural,lumbarscoliosisresultsfromsciaticpaincausedbyalumbardisk
herniationandunilateralspasmofthebackmuscles.Sciaticscoliosisusuallyoccurswithconvexitytothe
symptomaticsideoftheherniateddisk.303Theshiftisthoughttoresultfromthebodyfindingaposition
ofcomfortandprotection,asaconsequenceofanirritationofaspinalnerveoritsduralsleeve,303
althoughtheneuronalmechanismsofsciaticscoliosishavenotbeenwellclarified.Theseposturalchanges
cannotberelievedbyvoluntaryeffortsbutusuallydisappearafteralleviationofthesciaticpain.303The
extentofscoliosisshouldbenotedifitisthoughttobecontributingtothepatientssymptomsandis
occurringbecauseofpainordysfunction.Anattemptshouldbemadetomanuallycorrecttheshift(see
Chapter28)toascertainwhetherthiscanbedonepainlessly.Acompensatoryshiftorscoliosisisoften
easyandpainlesstocorrect.304,305
Idiopathic.Scoliosisisnevernormal,althoughmostcasesareidiopathic,manifestinginthepreadolescent
years.306,307ThecurveofidiopathicscoliosisdiffersfromthetiltofthespineassociatedwithrecentIVD
problemsinthatitisaccompaniedbyalowerthoracicorlumbarrotationdeformity.302Ifthisdeformityis
notobviousinthestandingposture,itshouldbecomeobviousduringflexion,asitismanifestedbytheso
calledrazorbackeminenceofthethoraciccage.
Thecurvepatternsarenamedaccordingtotheleveloftheapexofthecurve.Forexample,arightthoraciccurve
hasaconvexitytowardtheright,andtheapexofthecurveisinthethoracicspine.Theremaybeanumberof
curvesspanningthethoracicandlumbarregion,andtheclinicianshoulddetermineifthecurvatureis
contributingtothepatientspainas,frequently,thesecurvescanbeasymptomatic.Aslightlateralcurveinthe
frontalplaneisthoughttoresultfromrighthanddominanceorthepresenceoftheaorta.308
RoundBackwithForwardHead
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Thispostureischaracterizedbyincreasedkyphoticthoraciccurve,protractedscapulae(roundshoulders),and
forwardhead(excessiveflexionofthelowercervicalspineandhyperextensionoftheuppercervicalspine)(Fig.
612).Thecausesofthisposturearesimilartothosefoundwiththeflatlowbackposture.Thepotentialmuscle
impairmentsincludethefollowing:
FIGURE612
Forwardheadposture.
Decreasedmobilityinthemusclesoftheanteriorthorax(intercostalmuscles),musclesoftheupper
extremityoriginatingonthethorax(pectoralismajorandminor,latissimusdorsi,serratusanterior),
musclesofthecervicalspineandheadthatattachtothescapularandupperthorax(levatorscapulae,
SCM,scalene,uppertrapezius),andmusclesofthesuboccipitalregion(rectuscapitisposteriormajorand
minor,obliquuscapitisinferiorandsuperior).
Impairedmuscleperformanceduetostretchedandweaklowercervicalandupperthoracicerectorspinae
andscapularretractormuscles(rhomboids,middletrapezius),anteriorthroatmuscles(suprahyoidand
infrahyoid),andcapitalflexors(rectuscapitisanteriorandlateralis,superiorobliquelonguscolli,and
longuscapitis).
Thisposturecanplaceexcessivestressonanyorallofthefollowingstructures:
Theanteriorlongitudinalligamentintheuppercervicalspineandposteriorlongitudinalligamentinthe
lowercervicalandthoracicspine.
Irritationofthezygapophyseal(facet)jointsintheuppercervicalspine.
Impingementontheneurovascularbundlefromanteriorscaleneorpectoralisminormuscletightness
(thoracicoutletsyndrome).
Impingementofthecervicalplexusfromlevatorscapulaemuscletightness.
Temporomandibularjointdysfunction.
Lowercervicaldisklesions.
Flatupperbackandneckposture.Thispostureischaracterizedbyadecreaseinthethoraciccurve,
depressedscapulae,depressedclavicles,anddecreasedcervicallordosiswithincreasedflexionofthe
occiputontheatlas.Althoughnotcommon,thispostureoccursprimarilywithexaggerationofthemilitary
posture(Fig.613).Thepotentialmuscleimpairmentsincludethefollowing:
Decreasedmobilityintheanteriorneckmuscles,thoracicerectorspinae,andscapularretractors,
withpotentiallyrestrictedscapularmovement,whichcaninterferewithshoulderelevation.
Impairedmuscleperformanceinthescapularprotractorandintercostalmusclesoftheanterior
thorax.
FIGURE613
Flatupperbackandneckposture.
Thisposturecanplacestressontheneurovascularbundleinthethoracicoutletbetweentheclavicleandribsand
candecreasetheshockabsorbingfunctionofthekyphoticcurvature,therebypredisposingthenecktoinjury.
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ForwardHead
Forwardheadpostureisdescribed(insittingorstanding)astheexcessiveanteriorpositioningofthehead,in
relationtoaverticalreferenceline,increasedlowercervicalspinelordosis,androundedshoulderswiththoracic
kyphosis(Fig.612).Otherposturaladaptationsassociatedwiththeforwardheadpostureincludeprotracted
scapulaewithtightanteriormusclesandstretchedposteriormusclesandthedevelopmentofacervicothoracic
kyphosisbetweenC4andT4.274,309ForeachinchthattheheadisanteriortotheCOG,theweightoftheheadis
addedtotheloadbornebythecervicalstructures.310Forexample,theaverageheadweighs10lb.Ifthechinis
2inanteriortothemanubrium,20lbisaddedtotheload.Ifnormalmotionisundertakeninthispoorpostural
environment,theresultmaybeabnormalstrainplacedonthejointcapsule,ligaments,IVDs,levatorscapulae,
uppertrapezius,SCM,scalene,andsuboccipitalmuscles.
Sustainedforwardheadposturesmaycauseapainfulfatigueinthelevatorscapulae,rhomboids,andlower
portionofthetrapezius,aconditionreferredtoastirednecksyndrome.311Thetraumatizedmusclesmaycause
pain,whichinturncausesthepatienttorestrictmotion.Patientswiththeseposturalabnormalitiesmay
experiencemyofascialpainthatcancausereferralzonepain.263Thismyofascialpainisthoughttobecausedby
wasteproductsproducedbythemusclesorfromlocalizedischemiaofthosestructures.Anunderlyingcycleof
abnormalrelaxationinsomemuscles,withshortening,stretching,andalossoftoneinothers,occursduringthis
process,withresultantjointstrainanddysfunction.
Astheheadisbroughtforwardbyflexingthecervicalsegments,thescalenemusclesarepermittedtoadaptively
shorten,thuslesseningthesupportoftheupperribs.Thecervicalflexionisfollowedbyanincreaseofthe
thoraciccurvatureandthetensionofthespinalmusculatureincreases.312,313Inthisposition,thecapital
extensionmustnowoccurtokeeptheeyeshorizontalandallowtheindividualtolookahead.236,314,315This
occipitalhyperextensionofthecraniumonthecervicalspinehasbeenrelatedtohead,neck,and
temporomandibularjointpain.AposturalpainrelationshiphasbeendescribedbyWillfordetal.316inpeople
wearingmultifocalcorrectivelenses.
Undernormalcircumstances,theCOGfortheheadfallsslightlyanteriortotheear.Thehabitualplacementof
theheadanteriortotheCOGofthebodyplacesunduestressonthetemporomandibularjoint,thecervicaland
upperthoracicfacetjoints(especiallyatthecervicothoracicjunction),andthesupportingmuscles.237,238
Theabductionofthescapulaeorprotractionoftheshoulderscausesaloweringofthecoracoidprocess,
producingadaptiveshorteningofthepectoralisminor,which,inturn,mayflattentheanteriorchestwalland
alterthemotionofthescapula,producingamechanicalimpairmentoftheshoulder.
Protractionoftheshouldergirdlesalsolimitsextensionoftheupperthoracicspine,which,inturn,limits
elevationandabductionoftheshoulders.Thisalterationcanleadtoahypermobilityorinstabilityofthe
glenohumeraljointandoverusesyndromesoftheshoulderelevatorsorabductors.Shoulderprotractionalso
causesthehumerustorotateinternallywhichstretchestheposteriorglenohumeraljointcapsuleinaddition,it
increasestheanteriorforceatthejointasaresultofgravity.Theformermayleadtoposteriorinstabilityand
rotatoryhypermobility,andthelattertoanteriorinstabilityandabicepstendonitis,asthismusclebecomes
overusedinitsattempttostabilizetheglenohumeraljoint.
Theanteriorlydisplacedlineofgravityinducedbytheforwardheadposturehasaneffectonrespiration.This
changeinpostureispostulatedtohavethefollowingconsequences:317
1.Openmouthbreathing.318Openmouthbreathingisthenormalpatternofbreathingforanewborn.This
patternofbreathingbecomesabnormalifitpersistsintothe57years.Achildwithalongboutofsinus
infectionsandblockagesisforcedtousemouthbreathingastheprimarymethodofbreathing.Withthe
developmentoftheteethandtongue,theoralpassagewayforairisgraduallyreduced,forcingthechildto
openthemouthfurtherinordertobreathe.Itispostulatedthatthiscanresultin243245:
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afailuretofiltertheinspiredairofpathogensandparticles.Theseparticlesgodirectlyintothe
alveoli,producinganinflammatoryreactioninthelungsthatresultsinbronchospasmorasthmaand
stimulatesafuturehypersensitivitytoanynewparticles
afailuretohumidifytheinspiredair,sothattheairenteringthelungsisdry
afailuretowarmtheinspiredair.Coldorcoolairenteringthelungsstimulatesanincreased
presenceofwhitebloodcells,increasingthehypersensitivityofthelungs.Earlyinterventionwith
mouthbreathersisessential,anditisrecommendedthatthechildbeencouragedtokeepthetongue
againsttheroofofthemouthwhilebreathing.
2.Thoracichyperflexion.Althoughonlytheoretical,thethoraciccompensationisnecessarytocounteract
thebackwardtiltingoftheheadandtoreturntheeyestoahorizontalposition.Thiscompensation
producesthefollowing:
3.Areductioninthoracicextension.
4.Areducedabilityoftheribstoelevateduringinspiration,resultingfromareducedabilityofthethoracic
cavitytoexpandduringinspiration.319321
5.Anincreaseintherespiratoryrate.319321
6.Ashorteningofthescalenemuscles.Becauseoftheirnewlyacquiredshortenedposition,themuscles
haveareducedabilitytocontract,resultinginareducedabilitytoelevatethefirstribareducedabilityto
increasetheverticaldimensionofthethoraciccavityduringinspirationanincreaseinapical
breathing.319321
Theforcesfromthecervicalandthoracicregionsofthespinecanbetransmittedtothelumbarspine,increasing
thelordoticcurve.322,323Theexaggerationofthelumbarcurveisaccompaniedbyashiftoftheweighttothe
posteriorpartofthevertebralbodiesandtothearticularprocesses,producingmaximumjointstrainofthe
lumbosacraljunctionandaforwardinclinationofthepelvis.
Theincreasedforwardinclinationofthepelvismayproduceashorteningoftheerectorspinaegroupandflexors
ofthehip,accompaniedbyalengtheningoftheabdominalandhamstringmuscles.Thesemuscleimbalances
servetomaintainthedeformity.324
TheinterventionfortheforwardheadisoutlinedinChapter25.
DYNAMICEXAMINATION
Itshouldbeapparentthatanyposturalexaminationshouldincludeadynamicassessment,asastatic
examinationalonecannotdemonstratetheeffectofaparticularpostureonfunction.Adynamicexaminationthat
assessesfunctionalmovementpatterns,suchastheSelectiveFunctionalMovementAssessment(SFMA),325,326
helpsthecliniciantoascertainwhethertheapparentposturalabnormalityisdysfunctional.TheSEMAassesses
functionalmovementusingfourcategories:
Functionalandnonpainful
Functionalandpainful
Dysfunctionalandnonpainful
Dysfunctionalandpainful
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Withinthesecategories,thetermfunctionaldescribesanyunlimitedorunrestrictedmovement,whereastheterm
dysfunctionalisusedtodescribemovementsthatarelimitedorrestrictedandwhichreproducepainand/or
demonstratealackofmobility,stability,orsymmetrywithinagivenfunctionalmovement.Althoughmost
clinicianscanappreciatethatrepeatedmovementpatternsperformedinatherapeuticmannermaybebeneficial,
itmustalsoberememberedthatrepeatedmotionsperformederroneouslycanproducechangesinmuscle
tension,musclestrength,length,andstiffness.271Itisquitenormalformusclestofrequentlychangetheir
lengthsduringmovements.However,thischangeinrestinglengthmaybecomepathologic,whenitissustained
throughincorrecthabituationorasaresponsetopain.
Thedynamicposturalexaminationcanalsobedesignedtoassesseachjointtoitsextremesofmotion.The
followingshouldserveasaguideline:
Jointsoftheextremities:activemovementsthroughthefullrangeofeachdirectionforeachjoint,with
passiveoverpressureandamaximumisometriccontraction,appliedattheendrange.Combinedmotions
shouldalsobeassessed,forexample,elbowflexionandsupination.
Jointsofthespine:flexion,extension,sidebending,androtationofthecervical,thoracic,andlumbar
spineinsitting,standing,andlyingasappropriate.Combinedmotionshouldalsobeassessed,for
example,cervicalflexionwithrotationsuperimposedontheflexion.
Functionalmovements:deepsquatting(heelsflatandshouldersflexed),Apleyscratchtest(fingertips
touchingbehindtheback).
Duringthesevariousmovements,theclinicianislookingforsymmetry,easeofmovement,andtheprovocation
ofanysymptoms.
SpecialTests
Thespecialtestsusedintheassessmentofpostureincludeallthosethatarerelatedtotheassessmentofmuscle
lengthandstrength.Examplesincludemanualmuscletesting,theThomastest,andtheObertest.Thesetestsare
describedintherelevantchapters.Inaddition,theclinicianshouldexamineneurodynamicmobilityforthe
presenceofadverseneuraltension(seeChapter11).
Intervention
Thefocusoftherapeuticinterventionforpostureandmovementimpairmentsyndromesistoalleviatesymptoms
andtoplayasignificantroleineducatingthepatientagainsthabitualabuse.Interestingly,despitethe
widespreadinclusionofposturalcorrectionintherapeuticinterventions,thereislimitedexperimentaldatato
supportitseffectiveness.Therapeuticexerciseprogramsforthecorrectionofmuscleimbalancestraditionally
focusonregainingthenormallengthofamusclesothatgoodmovementpatternscanbeachieved.The
interventionofanymuscleimbalanceisdividedintothreestages:
1.Restorationofthenormallengthofthemuscles.Ifthemuscleactivityisinhibited,themuscleshouldbe
stretchedintheinhibitoryphase.Ifthemuscleishypertonic,muscleenergytechniquesmaybeusedto
produceminimalfacilitationandaminimalstretch.Withtrueadaptiveshorteningofthemuscle,stronger
resistanceisusedtoactivatethemaximumnumberofmotorunits,followedbyvigorousstretchingofthe
muscle.
2.Strengtheningofthemusclesthathavebecomeinhibitedandweak.Vigorousstrengtheningshouldbe
initiallyavoidedtopreventsubstitutionsandthereinforcementofpoorpatternsofmovement.
3.Establishingoptimalmotorpatternstosecurethebestpossibleprotectiontothejointsandthesurrounding
softtissues.
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Inadditiontousingspecifictechniquestostretchandstrengthenmuscles,muscleenergy(seeChapter10),
proprioceptiveneuromuscularfacilitation,andtheincorporationofamorewholisticapproachcanoftenhave
abeneficialeffectonposturaldysfunctionandmovementimpairment.Thereisagrowinginterestinthefieldof
integrativecaretheblendingofcomplementaryorwholistictherapieswithconventionalmedicalpractice.
Wholisticapproachesprovidewholepersoncareaddressingpeopleratherthandiseases,caringratherthan
curing,usingallpossibletherapeuticmodalitiesratherthanalimitedfew,andempoweringpatientswherever
possibletouseselfcareapproachesandtobeactiveparticipantsindecisionsregardingtheirhealth.
Examplesofthesewholisticapproaches,currentlyusedinassociationwithphysicaltherapy,includethe
Alexandertechnique,Feldenkraismethod,Tragerpsychophysicalintegration(TPI),Pilates,TaiChiChuan
(TCC),andyoga.
AlexanderTechnique
TheAlexandertechnique327iscommonlyviewedasaseriesofbreathingandposturetechniques.However,the
purposeofthetechniqueistomakepatientsmoreawareofstructuralimbalances,differentwaysofmoving,and
theexcessivetensionsthatcanbeproducedinactivitiesofdailyliving.Althoughitisnotwithinthescopeof
thischaptertofullydescribetheAlexandertechnique,someofitsprinciplesareoutlinedhere,andthereaderis
encouragedtolearnmoreaboutthistechniquethroughfurtherreading.
TheAlexandertechniqueusesreeducationtochangethethoughtprocesses,aswellastheposturaland
movementhabits,thataretheorizedtoprovokepain.Accordingtothistheory,themainreflexinthebody
termedtheprimarycontrol,whichissituatedintheareaoftheneck,controlsalloftheotherreflexesofthe
body.Dysfunctionofthismainreflex,resultingfromincreasedtensionintheneck,causesapullingbackofthe
headandchangestherelationshipoftheneckandback,eventuallycausingtensionsinotherpartsofthebody.
Basedontheseassumptions,Alexanderdevisedthreedirections:327
1.Allowthenecktobefree.Thepurposeofthisdirectionistoeliminateanyexcesstensioninthemuscles
oftheneck.
2.Allowtheheadtogoforwardandupward.Whentheneckmusclesarereleased,theheadgoesslightly
forwardandupward.
3.Allowthebacktolengthenandwiden.Astheheadmovesslightlyforwardandupward,thespine
lengthens.Becauseanincreaseinthespinelengthcanalsonarrowthespine,wideningoftheback,
througharetractionoftheshouldersandbroadeningoftheribcage,isencouraged.
FeldenkraisMethod
TheFeldenkraismethodofsomaticeducationisaselfdiscoveryprocessusingmovement.Itwasdevelopedby
Dr.MosheFeldenkrais,aphysicistandelectronicsengineer.TheaimoftheFeldenkraismethodisforan
individualtomovethroughrelaxationandselfawareness,withminimumeffortandmaximumefficiency.The
methodteachesthatmanypainsandmovementrestrictionsaretheresultsnotofanactualphysicaldefectorthe
inevitabledeteriorationsofage,butofhabitualpooruse.328Overtime,thiscausesfatigue,disability,andpain.
Theantidote,accordingtoFeldenkrais,istorelearncertainfunctionalmovementsandposturesusingtheso
calledorganiclearningstyle,basedonthewayhumanslearntoperform,astheydevelopduringearlychildhood.
Duringthisgrowthphase,someofthemovementsarelearnedcorrectly,othersarenot.Incorrectmovement
patternsmayresultininefficientmovementsorrestrictionstomovements.Inhumans,thepremotorcortex
relatestoposturestabilityandtheactofreaching.Itisalsothesupplementarymotorareaforplanning,
programming,andinitiatingmovement.329Theselattercomponentsrequirecorrectsequencingand
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organization.TheFeldenkraismethodisseenasawayofreprogrammingthenervoussystemandreteaching
thebodyhowtoperformthefunctionalmovementpatternscorrectly.
Functionalmovementpatternsinvolvetheintegrationandsequencingofmovementpatternswhilemaintaining
neuromuscularcontrol.ThesepatternsandposturesaredevelopedusingthetwoaspectsoftheFeldenkrais
method:awarenessthroughmovement(ATM)andfunctionalintegration(FI).Althoughcloselyrelated,ATM
andFIhavefundamentaldifferences:
ATMisusuallydoneinagroup,whereasFIinvolvesoneononelearning.
ATMinvolvestheperformanceofgentleexploratorymovementsusingverbalguidance.Incontrast,FI
usesguidanceintononhabitualmovements,withtactilecueingbyatrainedpractitioner.
Bothoftheaspectsworktowardchangingoldmovementpatternsorcreatingnewmovementpatterns.
Individualsareledthroughaseriesofmovementsequences.Allmovementsareperformedslowly,without
pauseandshortoftherangeofdiscomfortandpain.TheproponentsoftheFeldenkraismethodclaimthatthese
movementspromoteimprovedattentionandawareness.330Itisalsoclaimedthatthesemovementsrefinethe
abilitytodetectinformationandmakeperceptualdiscriminations.330Regularuseofsuchattentiveexplorations
andintegrationoftheskillsleadtoanautomaticuseofthesemotorabilities.AnexampleofaFeldenkrais
exerciseistomoveonesheadinonedirectionandonesshoulderandeyesintheother.331Thesemovement
sequencesareusuallyrepeatedanumberoftimes.
FivekeyprinciplesareinvolvedinthedevelopmentoftheFeldenkraismethod:330,332
1.Selforganization:Dynamicsystemstheoristsbelievethatbehaviorsareassembledinthemomentand
contextofthecurrentmovementtask.
2.Behaviorisdynamicandplastic.
3.Perturbationistheinstrumentofchange.
4.Thechoiceisnecessary.
5.Thehumandevelopmentfollowsalogicalsequence.
TheFeldenkraismethodisbotheducationalandexperimental.Itisprocess,notgoal,orientedandisentirely
pragmatic.333Withacuteconditions,thepatientstartsinthepositionofmaximumcomfort.Thelessonthenuses
anymovement,howeversmall,withinthelimitofcomfort.Thepatientisencouragedtobecomeawareofthe
smoothnessandclarityofthemovement.Themovementisrepeatedandpracticed.Furthermovementswithin
thisframeworkareinvestigatedandpracticed.Thesemovementsaresimpleinitially,becomingmorecomplex
asthepatientgainsconfidence.333
TragerPsychophysicalIntegration
TPIisamultifacetedintervention,consistingoflight,gentle,andpainlessmovementstofacilitatethereleaseof
deepseatedphysical(andmental)patterns.334TPIwasdesignedatthebeginningofthe20thcenturybyDr.
MiltonTragerandhasbeenshowntobeeffectiveinpromotingmobilityanddecreasingpainforpatientswitha
widevarietyofdiagnoses,includingcerebralpalsy,335chronicspinalpainanddysfunction,336and
arthritis.334,337
AccordingtoTPIphilosophy,detrimentalphysicalpatternsarethosedevelopedbypoorposture,trauma,stress,
andpoormovementhabits.338Tragertechniquesservetoproduceoverallrelaxationonthepartofthepatient,
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developingasenseofintegrationandeffortlessmovementthroughaseriesofguidedmovementsandmental
gymnastics.339,340
TheTragerapproachisbrokendownintotwocomponents:tableworkandmentastics.
Tablework
Tableworkconsistsofaseriesofgentleandpainlessmovementsthatresemblegeneralmobilizationtechniques.
Thebodyofthepatientispassivelymovedbytheclinicianwholooksandfeelsforinvolvementofthetissue.
Theaimistoprovokeafeelingofsoftnessandfreedomtomotionthroughoutthebody.336Usingthese
movements,theentirebodyismobilized.Rhythmicrockingmotionsareinitiatedduringthesemovementsto
stimulatethevestibularandreticularactivatingsystemsofthepatient.Thisistheorizedtoproduceanoverall
senseofrelaxationandwellbeingthroughaninhibitionofthesympatheticsystemandthefacilitationofthe
parasympatheticsystem.341
Mentastics
Mentasticsisasystemofactivemovements,designedtoenhancethefeelingofwellbeingprovidedbythe
tableworkexercises.Mentasticsencouragethepatientnottocontrolthemovement,asintraditionalexercise,but
toletgoofthecontrol.336Thepatientistaughttolistentosignalsofpainandfatigueandtochangethe
symptomsbyalteringthemovement.Overtime,thepatientlearnshowtomovecomfortablyandtorelease
tension.340
Pilates
ThePilatesmethod(PilatesInc.)isatechniqueandapparatusdevelopedinthe1940sbyJosephPilates,who
waspronetochronicillnessasachild.Describedasauniquemindbodyexerciseprogram,itwasoriginally
calledContrology342anditsoriginalgoalwastofusethemindandbodysothatwithoutthinking,thebody
choosesthegreatestmechanicaladvantagetoachieveoptimalbalance,strength,andhealth.342Thisisachieved
bydevelopingthebodyuniformlyandcorrectingpostures.
CLINICALPEARL
ThePilatesmethodincorporatesmovementprinciplesthatincludebothphysicalandcognitiveelements:whole
bodymovement,attentiontobreath,balancemuscledevelopment,concentration,control,centering,precision,
andrhythm.343
JosephPilatesiscreditedforlabelingthecore,orcenter,asthepowerhouse,andcentering,whereallenergy
beginsandthenradiatesoutwardtotheextremities,whichisthefocalpointofthePilatesmethod.Accordingto
Pilates,hedescribedthecoreasaboxdelineatedbytwohorizontallines:onelinerunningfromshoulderto
shoulder,andthesecondlinerunningfromhipjointtohipjoint.344Thus,accordingtoPilates,core
strengtheningincludedstrengtheningoftheshoulderandhipgirdles.
Although,thePilatesmethodisnotyogaordance,itwasfirstembracedbythedancecommunityanddance
medicine.Itsinherentconceptofcorestabilization,mindbodyawareness,andcontrolofmovementandposture
hassincebeenusedsuccessfullyinrehabilitation,forthedevelopmentofoverallstrengthandfitnessinpatients
withbackpain,balancedeficits,andurinaryincontinenceduetopelvicfloormuscleweakness.
PartoftheappealofthePilatesmethodisthatitincorporatesmanyoftheconceptsandtechniquesthatphysical
therapistscommonlyemploy,withanincreasedemphasisonneuromuscularcontrol.Assuch,thePilatesmethod
focusesonmotortraining,ratherthanonmotorstrength,usingpreciseandcontrolledexercises.ThePilates
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methodstressestheimportanceofthesocalledpowerhousemusclesofthebodydeep,coordinatedbreathing
posturalsymmetryandcontrolledmovement.AccordingtothePilatesmethod,thepowerhousemusclesinclude
thetransversusabdominis,thelumbarmultifidus,thepelvicfloormuscles,andthediaphragmmuscle.
Approximately10repetitionsareneededforeachexercise.
ThePilatesexercisesemphasizethemaintenanceofaneutralpelvis,spine,andscapulaethroughoutmachine
andmatexercises.Thejointsarealwaysstacked:shouldersoverthehips,hipsovertheknees,andkneesover
theankles.344Pilatesbasedexerciseisprogressedfrombasicgravityeliminatedmovementstocomplexand
functionalmovementsrequiringcoordinationandbalanceagainstgravity.345ManyofthePilatesexercises
involvesqueezingtheinnerthighstogetherinthePilatesstance,whilesimultaneouslyengagingthepelvicfloor
muscles,inanefforttoincreasetrunkstability.Unlikespecificstabilizationexercisetherapy,Pilatesdoesnot
attempttofacilitateconsciousactivationofanyisolatedmuscleormusclegroup.However,somehave
incorporatedconsciousmuscleactivationtechniquesintoaPilatesbasedexerciseprogramforacombined
therapeuticintervention.346Forexample,thePilatesstanceinvolvesslightexternalrotationinbothhipsand
lowerextremities,whilemaintainingthethighsinfirmcontact.OtherPilatesexercisesincludeinstructionson
howtoisolateatransversusabdominiscontractionfromtherestoftheabdominalmuscles.Thisiscommonly
achievedusingtheverbalcueingofpullyourbellybuttontowardyourspine.Thiscontractionisthen
practicedinavarietyofpositionsandtechniques,inordertoenhancespinal,orcore,stability.Pelvicstabilityis
encouragedwithsuchverbalcueingaspullyoursittingbonestogether,therebyproducingacontractionofthe
ischiococcygealmusclethatprovidessupportforthepelviccontents,inadditiontocontributingtosacroiliac
jointstability.
AlthoughmanyofthePilatesexercisescanbeperformedonmats,12speciallydesignedpiecesofequipment
mayalsobeused.FourbasicmachinescomprisethePilatesequipmentline:
1.Reformer.ThisisthebasicmachineofthePilatesmethod.Itresemblesatwinbedinsizeandframeand
isequippedwithhandholds,pulleys,andcablesthatexerciserspushorpullwiththeirhandsorfeet.The
reformerisanapparatusforprovidinganassistedenvironmentthroughitspulleysystemandsprings,
gradedmovementfromassistedtoresistive,andallowingnonpainfulmovementtobeginearlyinthe
rehabilitationphase.345Gradedmovementmaybehelpfulinthetreatmentoffearavoidance,whichcan
causefaultymotorpatternsandhasbeenlinkedtoanumberofconditionsincludinglowback
injuries.345,347Thereformercanalsobeusedintherehabilitationofhamstringtears,andstressfractures.
2.Cadillacortrapezetable.Thispieceofequipmentisequippedwithmultiplebarsandstrapsandfeaturesa
pulldownbar.Itisusedforoverallconditioning.
3.Pedipull.Thepedipullistheequipmentofchoiceforfootworkandforanklerehabilitation.Itcanbe
adaptedforsuchactivitiesasonearmpushes,lunges,anddips.
4.Ladderbarrel.Thispieceofequipmentconsistsofaslidingbaseandfiverungsandisusedforavariety
ofstrengtheningandflexibilityexercises.
TheuseofPilatesapparatustotrainstabilizationstrategiesduringmovementmayenhancetheeffectofthemore
relativelystaticmatexercises.
TaiChiChuan
TCCisaChineselowspeedandlowimpactconditioningexerciseandiswellknownforitsslowandgraceful
movements.Duringthepractice,diaphragmaticbreathingiscoordinatedwithgracefulmotionstoachievemind
tranquility.
ClassicalYangTCCincludes108postures,withsomerepeatedsequences.Eachtrainingsessionincludes20
minutesofwarmup,24minutesofTCCpractice,and10minutesofcooldown.348Warmupexerciseisvery
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importantbecauseitmayenhanceTCCperformanceandpreventinjury.Itusuallyincludes10movements
(ROMexercises,stretching,andbalancetraining),with1020repetitions.
TheexerciseintensityofTCCdependsontrainingstyle,posture,andduration.349,350Ahighsquatpostureand
shorttrainingdurationaresuitedtothosewithlowlevelsoffitnessorelderlyparticipantsalowsquatposture
andlongerdurationsaresuitedtohealthyoryoungerparticipants.348
RecentinvestigationshavefoundthatTCCisbeneficialtocardiorespiratoryfunction,351strength,352
balance,352,353flexibility,353microcirculation,354andpsychologicalprofile.349Hartmanetal.355alsoreported
thatTCCcouldcontrolfatigueandregulatepainduringactivitiesandcouldimprovewalkingspeedandself
careactivitiesinpatientswithosteoarthritis.
Yoga
Yoga,aliteraltranslationfromtheSanskritwordforunion,isa5,000yearoldIndianpractice.Thereare40
mainschoolsofyogaphilosophy,ofwhichHatha(pronouncedhahtha)yogaisthemostpopularintheUnited
States.AccordingtoIndiantradition,HathayogaisoneofthefourmaintraditionsofTantrayoga,aholistic
approachtothestudyoftheuniversefromthepointoftheindividual.Hathayogaisbasedonthepracticeof
physicalpostures(asanas),breathcontrol(pranayama),andmeditationinordertoenergizesubtlechannelsof
themindcallednadis.
Asanas.Physicalposturesthatareperformedusingisometriccontractionsandheldfirmlyfromatime
thatrangesfromsecondstominutes.Thereare84basicasanasinHathayoga,whicharecategorizedin
accordancewiththemovementtheycreateinthebody.
Pranayama.Yogabreathingisperformedslowlyandwithoutstrainthroughouttheroutine,withabrief
pauseof12secondsaftereachinhalationandexhalation.
Thetheoreticalbenefitsassociatedwithyogaencompassphysiological,psychological,psychomotor,cognitive,
andbiochemicalaspects.Thephysiological,psychological,psychomotor,andcognitivebenefitsincludereduced
stressimprovedattention,memory,andlearningefficiencydecreasedpulserate,respiratoryrate,andblood
pressureandincreasedmuscularstrengthandaerobicandmuscularendurance.356363Thebiochemical
benefitsincludeanincreaseinhighdensitylipoproteincholesterol,adecreaseinlowdensitylipoprotein
cholesterol,andanincreaseinhematocritlevels.356
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CHAPTER7:ImagingStudiesinOrthopaedics
CHAPTEROBJECTIVES
1.Listthevariousimagingstudiesavailableandgiveabriefdiscussionofeach.
2.Describehowthevariousmusculoskeletaltissuesaredepictedinimagingstudies.
3.Understandthestrengthsandweaknessesofeachoftheimagingstudies.
4.Outlinetherationaleforthechoiceofoneimagingtechniqueversusanother.
5.Describehowtheresultsofimagingstudiesmayhelpintheclinicaldecisionmakingprocess.
OVERVIEW
Forhealthcareprofessionalsinvolvedintheprimarymanagementofneuromusculoskeletaldisorders,diagnostic
imagingisanessentialtool.Theavailabilityofdiagnosticimagestophysicaltherapistsgreatlydependsonthe
practicesetting.Forexample,physicaltherapistsintheUnitedStatesarmyhavehadprivilegesforordering
diagnosticimagingproceduressincetheearly1970s.1OutsideoftheUnitedStatesmilitaryhealthsystem,few
publishedexamplesdescribeciviliansectorpracticemodelsthatincludephysicaltherapistsreferringpatients
directlyforimagingtests.2TheroleofimagingbasedonthePhysicalTherapyPracticeActlanguageforthe50
statesandtheDistrictofColumbiarevealstremendousvariability,rangingfromprohibitingtheuseofroentgen
raysforanypurposetotheprohibitionofphysicaltherapistsfromreferringpatientsfordiagnosticimaging,to
beingsilentontheissue.2Thisissomewhatsurprisinggiventhedrivetopasspatientdirectaccesstophysical
therapyservices,astheabilitytodirectlyreferpatientstootherproviders,includingaradiologist,wouldseem
paramount.3Attheheartoftheissueiswhetherphysicaltherapistsareadequatelyeducatedregarding
appropriateimagingreferral.AlthoughSpringeretal.4demonstratedthatmilitaryphysicaltherapistswereas
competentasorthopedistsintheutilizationofthemodifiedOttawaanklerules(determiningwhetheranklefoot
radiographsareindicatedforpatientspostankleinjury),theparticipatingphysicaltherapistshadcompletedan
advancedtrainingprogram.3Withregardtothosephysicaltherapiststrainedintheciviliansector,theadventof
DoctorofPhysicalTherapy(DPT)degreeprogramshasresultedinincreasedemphasisonimagingasacontent
areainthesedegreeprograms,althoughitisdifficulttofindpublicationsthatdescribecurrentimaging
curricularwithintheseprograms.3Boissonnaultetal.3performedadescriptivesurveytodescribethestatusof
diagnosticandproceduralimagingcurriculawithintheUnitedStatesphysicaltherapistprofessionaldegree
programsandfoundthat,whilethemajorityofprogramsreportedincludingimagingcurricula,variabilitywas
notedinallcurricularaspects.
Althoughtheorderingofimagingstudiesisnotcurrentlywithinthescopeofmanyphysicaltherapypractices,
cliniciansfrequentlyrequestorreceiveimagingstudyreports.Althoughtheinterpretationofdiagnosticimages
isalwaystheresponsibilityoftheradiologist,itisimportantforthecliniciantoknowwhatimportancetoattach
tothesereports,andthestrengthsandweaknessesofthevarioustechniquesthatimageboneandsofttissues,
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suchasmuscle,fat,tendon,cartilage,andligament.Ingeneral,imagingtestshaveahighsensitivity(fewfalse
negatives)butlowspecificity(highfalsepositiverate),soarethususedintheclinicaldecisionmakingprocess
totestahypothesisbutshouldnotbeusedinisolation.Inaddition,imagingstudiesareexpensiveandsomewhat
moreinvasivecomparedtoaphysicalexamination,sotheclinicianmustweightherelativevalueof
recommendinganimagingstudyinrelationtotheworkinghypothesis.Forexample,whenthereislittle
likelihoodthatimagingwillrevealanythingthatwillchangethecourseoftreatment,thetestsshouldbe
consideredunnecessary.1Inaddition,theclinicianneedstounderstandthattheresultsofanimagingstudymay
notcorrelatewiththeresultsofthephysicalexamination.Althoughimagingmayprovideevidenceofpathology,
themerepresenceoftheabnormalitymayormaynotberelevanttothepresentingsignsandsymptoms.Insuch
situations,theclinicianshouldplacenomoreorlessweightontheimagingresultsthanonotheraspectsofthe
decisionmakingprocess.
Radiography
In1895,WilhelmConradRntgenwasexperimentingwithatypeofelectricaltubethatproducedanelectrical
dischargewhenahighvoltagecurrentwaspassedthroughit.5WhenRntgenshieldedthetubewithheavyblack
cardboard,henoticedthatafluorescentscreenafewfeetawaylitupandglowedindicatingthatsomeformof
energywaspassingthroughthetube.FurtherexperimentsledRntgentodiscoverthattheseenergywavescould
reliablyreproduceimagesofthehumanskeletononaglassphotographicplate.5Rntgennamedtheseenergy
wavesxraysbecausexwastheunknownquantityinamathematicalequation,andhewasunsureofwhatthe
rayswerecomposedof.5In1896,HenriBecquereldiscoveredthebasicnatureofradiationandalmost
immediatelyanarticleappearedintheJournaloftheAmericanMedicalAssociationtheorizingonthepossible
diagnosticandtherapeuticusesofthisnewdiscovery.5Xraysweresoondeterminedtobepartofthe
electromagneticspectrumwiththeabilitytopenetratethroughbodytissuesofvaryingdensities.Itwasalso
discoveredthattheamountofbeamabsorbedasitpassedthroughthebodydependedonthedensityofthe
tissue.Thisallowedphysicianstousetheimagestoviewanumberofanatomicalstructures.Initially,onlysmall
segmentsofthebodycouldberadiographedinasingleexposurestudiesoflarge,thickbodypartssuchasthe
abdomen,andhipcouldnotbeadequatelycovered.Then,in1912,Dr.GustavBuckypublishedhisfindings
describingastationary,crosshatchedorhoneycombedleadgrid,whichhelpedabsorbscatterradiationand
thusenhancedimagequality.Thegridconsistedofwidestripsofleadarrangedintwoparallelseriesthat
intersectedatrightangles.Onedisadvantageofthestationarygridisthattheleadstripsleftblankorwhite
linesonthefilm(gridlines).Afewyearslater,Dr.HollisPotterintroducedamultileafedfocusedgrid,which
movedthegridsidewaysacrossthefilmduringtheexposure,therebyblurringouttheshadowsofthegridstrips,
andfurtherenhancingtheimagequality.Overtheyears,variousmechanismshavebeenutilizedtoachievethis
movement.Twophysicalfactorsresponsibleforgridefficiencyarethegridratioandthegridfrequency.
Gridratio:Theheightoftheleadstripinrelationshiptothedistancebetweenthem.Example:A10:1grid
hasleadstrips10mmhigh,andthesestripsare1mmapart.Thestripsaretentimesastallasthedistance
betweenthem.
Gridfrequency:Definedasthenumberofleadstripspercentimeter(orperinch).Thegreaterthe
frequency,thethinnerthestrips,andthegreaterthelikelihoodofscatteredphotonspassingthrough.
Gridselectioninvolvesacompromisebetweenfilmqualityandpatientexposure.Highratiogridsproducefilms
withbettercontrastatthecostofincreasedpatientexposurehowever,properalignmentismorecritical.
CLINICALPEARL
AnumberofpiecesofradiologyequipmentarenamedafterDoctorGustavBucky:
Buckyfactor:sometimesreferredtoasgridfactororgridconversionfactor(GCF)aratioofpatientdose
withandwithoutagrid.Itmeasuresthepenetrationofprimaryandsecondaryradiationwithandwithouta
grid.
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Buckytray:housestheimagereceptor.
Buckyslotcover:acoverthatshieldstheopeningundertheradiologyexaminationtablethathousesthe
Buckytray.ThiscoverisengagedwhentheBuckytrayismovedtothefootoftheexaminationtableand
isusedduringfluoroscopy.
Conventional(plainfilm)radiographyisgenerallyconsideredtobethefirstorderdiagnosticimagingmodality.6
Thebasicprocessisfairlysimple.Thepatientsbodypartofinterestisorientedinaprescribedpositionandthe
filmplate,receptoror,detectorispositionedtocapturetheparticlesofthexraybeamthatarenotabsorbedby
thetissuesofthebody.Bothsidesofthefilmarethinlycoatedwithafluorescentgel,andthenthefilmisplaced
withinatwolayeredhardplasticshell,whichprotectsthefilmandallowseasyportability.Anxraymachine
thendirectselectromagneticradiationuponthespecifiedregionofthebody.
CLINICALPEARL
Thetermradiographreferstotheimageproducedontheradiographicfilm.Xrayfilm,likeanyphotographic
film,initiallyproducesanegativeimage.Oncethebriefexposureofthepatienttoxrayshasoccurred,thexray
filmisplacedintoamechanicalorelectronicfilmdeveloperandthefinalimageisproduced.
Exposuretothexrayparticlescausesthefilmtodarken,whereasareasofabsorptionappearlighteronthefilm.
Tissuesofgreaterdensityallowlesspenetrationofthexraysand,therefore,appearlighteronthefilm.A
differenceinradiodensityisnecessaryfortwostructurestoappeardifferentonresultantradiographs.The
followingstructuresarelistedinorderofdescendingdensity:metal,bone,softtissue,waterorbodyfluid,fat,
andair.Becauseairistheleastdensematerialinthebody,itabsorbstheleastamountofxrayparticles,
resultinginthedarkestportionofthefilm.Bonescanhavevaryingdensitieswithinthebody.Forexample,
cancellousboneislessdensethancorticalboneandthusappearslighterthanthecorticalboneonthe
radiograph.Softtissuesoftencannotbeseparatedbecausetheyhavesimilarradiodensities.
CLINICALPEARL
Aninfectionofthelungtissues,likepneumonia,hasagreatdealofwaterandcellularmatterinit.Thismaterial
absorbsagreatdealofradiation,andthuslittleofthefilmisexposed.Therefore,ifpneumoniaispresent,itis
easilydiagnosedbytheappearanceofalargewhiteshadow(orinfiltrate)inthemiddleofthenormally
homogeneousblacklung.
Numeroustechnicalfactorsaremanipulatedandequilibratedinordertoproduceahighqualitydiagnosticimage
whilekeepingtheradiationdoseaslowaspossible.Longfocalfilmdistances,shortobjectfilmdistances,small
focalspots,shortexposuretime,tightcollimation(theprocessofrestrictingandconfininganxraybeamtoa
givenarea),andoptimalfilm/screencombinationscanallbeusedtoenhancetheimage.7Reducingradiation
exposuretothelowestlevelsmaybeaddressedbyattentiontodetailsofpatientcentering,shielding,and
collimation,reducingrepeatfilms,andthetimelycalibrationofxrayequipment.7
Digitalradiographyexistsintheformofcomputedradiographyordirectradiography.Imageprocessingand
distributionisachievedthroughapicturearchivingandcommunicationsystem.However,thespatialresolution
ofdigitalradiographysystemsisnotyetasgreatasthatwithfilmscreenradiography.8
Plainfilm,orconventional,radiographsarerelativelyinexpensiveandgiveanexcellentviewofcorticalbone
(Figs.71to77).RadiographsmaybemorespecificthanMRIindifferentiatingpotentialcausesofbony
lesionsbecauseoftheprovenabilitytocharacterizespecificcalcificationpatternsandperiostealreactions.1
Plainradiographsarenotconsideredsensitivetotheearlychangesassociatedwithtumors,infections,andsome
fractures.9However,theycanbeveryhelpfulindetectingfracturesandsubluxationsinpatientswithahistoryof
trauma.10Radiographsmayalsobeusedtohighlightthepresenceofdegenerativejointdisease,whichis
characterizedbyanapproximationofthejointsurfacesontheradiograph.However,radiographsdonotprovide
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themostaccurateimageofsofttissuestructures,suchasmuscles,tendons,ligaments,andintervertebraldisks
(IVDs).
FIGURE71
Radiographshowingabnormalbonegrowthoffemur.
FIGURE72
RadiographshowinganextensivehistoryofACLreconstructions
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FIGURE73
RadiographshowinggradeISalterHarrisfractureofthefibula.
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FIGURE74
Radiographfollowingmedialwedgeosteotomyoftherightknee.
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FIGURE75
RadiographfollowingACLreconstruction(allograft)oftherightknee.
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FIGURE76
Radiographshowingendstagemedialcompartmentdegeneration(Varusmalalignment)oftherightknee.
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FIGURE77
Radiographshowingrightankleavulsionfracture/deltoidsprain.
Radiographsarea2Drepresentationofa3Dstructure.Duringtheinitialexposuretoreadingradiographs,itis
importantthattheclinicianexaminesasmanynormalradiographsaspossible.Thereisagreatdealof
variationsinthehumanbodyandagreatdealofvariationsinwhatisconsideredtobenormal.Whenevaluating
radiographs,asystematicapproachsuchasthemnemonicABCSisrecommended11:
A:Architectureoralignment.Theentireradiographisscannedfromtoptobottom,sidetoside,andin
eachcornertocheckforthenormalshapeandalignmentofeachbone.Theoutlineofeachboneshouldbe
smoothandcontinuous.Breaksincontinuityusuallyrepresentfractures.Malalignmentsmayindicate
subluxationsordislocations,orinthecaseofthespine,scoliosis.Malalignmentinasettingoftrauma
mustbeconsideredtraumaticratherthandegenerativeuntilprovenotherwise.7
B:Bonedensity.Theclinicianshouldassessbothgeneralbonedensityandlocalbonedensity.Thecortex
oftheboneshouldappeardenserthantheremainderofthebone.Subchondralbonebecomessclerosedin
thepresenceofstressinaccordancewithWolffslaw12andincreasesitsdensity.Thisisaradiographic
hallmarkofosteoarthritis.
C:Cartilagespaces.Eachjointshouldhaveawellpreservedjointspacebetweenthearticulating
surfaces.Adecreasedjointspacetypicallyindicatesthatthearticularcartilageisthinnedfromatraumatic
processoradegenerativeprocesssuchasosteoarthritis.
S:Softtissueevaluation.Traumatosofttissuesproducesabnormalimagesresultingfromeffusion,
bleeding,anddistension.
Foralljointsandregions,thereareanumberofstandard,orroutine,radiographicseriesthataretypically
obtained.13Aradiographicseriesisagroupofxraysfilms,takenfromoneareaofthebody,fromdifferent
angles.Thesegroupsoffilmshavebeenstandardizedbylongyearsofexperienceandstandardsofcareto
providealltheneededinformationaboutanareaofinterest.Forexample,astandardchestxrayusescertain
establishedanglesandamountsofradiationtoenhancetheviewofthesofttissuesoftheheartandlungs,
whereasaribseriesusesanentirelydifferentsetofanglesandradiationtobringoutthebonydetailwithmore
clarity.Inadditiontothestandardseries,therearealsoadditionalorspecialviewsthatcanbeorderedto
visualizeaparticularstructuremoreeffectively(Table71).13Forexample,apatientpresentingwithpaininthe
anatomicsnuffboxareaofthewristmayhaveafractureofthescaphoidbone,requiringaspecialviewofthe
arearatherthanastandardwristseries.Itisimportantthattheclinicianhasanappreciationofvariousviewsand
whateachrepresents.
TABLE71StandardandSpecialRadiographicViews
Common
Region Views/Special PatientPosition PurposeandStructuresImaged
Views
Thepatientissupineorerect, Anatomicpositionoftheshoulder
preferablyerect,andslightlyoblique, girdlewiththegreatertuberosity
sothescapulaisnearparalleltothe seeninprofile,laterally.The
AP,external film.Theforearmissupinatedwitha glenohumeraland
Shouldercomplex
rotation slightabductionoftheshoulderfor acromioclavicularjoints,proximal
externalrotation,andtheelbowis humerus,clavicle,andportionsof
slightlyflexed.Centralray scapulacanallbeviewedinthis
perpendiculartothecoracoidprocess position
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Common
Views
Providesapproximately90degree
Thepatientispositionedasfor opposingviewtoanteroposterior,
externalrotationexceptthattheback externalrotationincludingatrue
AP,internal
ofthehandrestsonthehip.Central lateralofthehumeruswiththe
rotation
rayisperpendiculartothecoracoid lessertuberosityseeninprofile,
process medially
Hasmanyvariationsbutessentially
Theglenohumeraljoint,coracoid
consistsofthexraybeampassing
process,andtheacromionprocess
throughtheaxillafrominferiorto
canbeseeninadditiontothe
superior.TheWestPointaxillary
humeralheadpositionwithrespect
viewisobtainedwiththepatient
toglenoidfossa
proneandthetubeangled25degrees
WestPointviewmaximizes
Axillary craniallyandmedialtothemidlineof
visualizationoftheanteriorinferior
theglenohumeraljoint.TheStryker
glenoidrim,enhancingthe
notchviewistakenwiththepatient
detectionofbonyBankartlesions
supineandthearmflexed(without
Strykernotchview:maximizesthe
abduction),andthecassettebeneath
visualizationofthehumeralhead
theshoulder.Thecentralrayis
andHillSachslesions
directed10degreescranially
Usefulinidentifyingfracturesof
AP,lateral
scapula
scapula
Entirescapulabestviewfor
Transscapularor
comminutedanddisplaced
Yview
fracturesofthescapula
Thepatientiserectwiththearms
Acromioclavicular hangingatthesides.Thecentralray Abilateralfrontalprojectionofthe
AP
joints is15degreescraniallyatthelevelof ACjoint
thecoracoidprocess.
Asaboveexceptwith1020lb
weightstrapped(ifthepatientholds
Helpsdifferentiateincomplete
Stress theweight,theresultingmuscle
fromcompleteinjuries
contractionmayproduceafalse
negative)tothepatientswrist
Thepatientispositionedinprone.
Afrontalviewofthe
Thecentralrayisperpendicularto
Sternoclavicular PA sternoclavicularjointsandmedial
themidpointofthebodyatthelevel
aspectsoftheclavicles.
ofthesternoclavicularjoints
Thepatientissupineorerect,facing
Allowsforevaluationofanterior
Serendipity thetube.A40degreecranialtiltof
andposteriordislocation
thecentralray
Theelbowisextendedwiththe
forearmsupinatedandthepatient AnAPprojectionoftheelbow
leaninglaterallyuntiltheanterior jointincludingthedistalendofthe
Elbow AP surfaceoftheelbowisparallelwith humerus,thehumeroulnarand
theplainxraycassetteofthefilm. humeroradialjoints,andthe
Centralrayisperpendiculartothe proximalendoftheforearm
elbowjoint
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Common
Views
Theelbowisflexed90degreesand
Integrityofolecranonarticulation
thehandisinalateralposition.
Lateral witholecranonfossalookforfat
Centralrayisperpendiculartothe
padsigns
elbowjoint
Usedtodeterminewhetherthereis
Epicondylar Thisviewisanaxialview,modified bonyencroachmentonthecubital
groove(cubital by15degreesofexternalrotation tunnel,contributingtoulnarnerve
tunnel) entrapment
Obtainedinthesamepositionasa
lateralviewwiththeprimarybeam
Radialhead Bestviewofradialhead,
angled45degreestowardthe
capitellum capitellum,andcoronoidprocess
shoulderandcenteredontheradial
head
Bothviewsincludetheelbowandthe
Forearm AP,lateral wrist,andbothviewsarecenteredon Entireradiusandulna,wrist,elbow
themidshaftoftheforearmbones
Forearmandhandonxraycassette
PAprojectionofallcarpals,the
withpalmarsurfacedownthehand
distalendoftheradiusandulna,
Wrist PA isslightlyarched,placingthewristin
andtheproximalendsofthe
closecontactwiththefilm.Central
metacarpals,carpalalignment
rayperpendiculartothemidcarpus
Lateralviewofthecarpus,the
Elbowflexed90degrees,theforearm
proximalendofthemetacarpals
andarmonthexraycassetteare
Lateral andthedistalendoftheradiusand
ulnarsidedown.Centralray
ulnahighlightingposterior
perpendiculartothecarpus
(dorsal)/volarrelationships
Fromthelateralposition,theforearm Demonstratesthecarpalboneson
ispronateduntilthewristformsan thelateralsideofthewrist,in
angleofapproximately45degrees particularthescaphoid.Inaddition
Posterioroblique
withtheplaneofthefilm.The thefirstmetacarpal,thumb
centralrayisperpendiculartothe carpometacarpaljoint,and
scaphoid trapeziumcanbeviewed
PAviewofthecarpals,
metacarpalsandphalanges(except
thethumb),andthedistalendsof
theradiusandulna.Thisposition
yieldsanobliqueviewofthe
Forearmandhandonxraycassette
thumb.Atrueanteriorposterior
withpalmarsurfacedown.Central
Hand PA projectionofthethumbisobtained
rayperpendiculartothethird
byturningthehandintoaposition
metacarpophalangealjoint
ofextremeinternalrotationand
holdingtheextendedfingersback
withtheoppositehand,withthe
posterior(dorsal)surfaceofthe
thumbrestingonthexraycassette
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Common
Views
Lateralviewofthebonyandsoft
Forearmandhandonxraycassette, tissuestructureshighlightingthe
ulnarsidedownwithfingers posterior(dorsal)/volar
Lateral
superimposed.Centralray relationshipssothatanteriorand
perpendiculartotheMCPjoints posteriordisplacementoffracture
fragmentscanbeseen
Forearmandhandonxraycassette,
ulnarsidedownwiththeforearm
Obliqueviewoftheboneandsoft
pronatedsothatthefingers,which
tissueofthehand.Withaslight
areslightlyflexed,touchthecassette
Posterioroblique adjustmentofthisposition,atrue
andtheMCPjointsformanangleof
lateralofthethumbcanbe
approximately45degrees.Central
obtained
rayperpendiculartothethirdMCP
joint
Patientsupinewiththefeetinternally
rotated15degrees(toeliminate Frontalprojectionoftheentire
Hip APpelvis overlayofthegreatertrochanter). pelvis,bothhipsandproximal
Centralrayperpendiculartothe femurs
midpointofthefilm
Extremelyvaluableforexamining
Thepatientisturnedtoanearlateral
thefemoralheadandneck,
positionandtowardtheaffectedside
Lateraloblique especiallytoexcludefracturesand
withthehipandkneeflexed.A
(frogleg) toassesstheapophysisandfemoral
straighttubeiscenteredonthe
capitalepiphysisintheimmature
femoralhead
patient
Patientsupinewiththeknee Frontalviewofthetibiofemoral
Knee AP extended.Centralray57degrees jointspaceandarticularsurfaces
cranialtothekneejoint distalfemurproximaltibia
Lateralwiththeaffectedsidedown
Lateralviewofthepatellar
andthekneeflexedapproximately
Lateral position,distalfemurproximal
30degrees.Thecentralrayis5
tibiaandfibula
degreescranial
Thepatientispositionedinprone
Patellofemoraljointand
andthekneeisflexedmorethan90
Sunriseaxial medial/lateralpositioningof
degrees.Thebeamisangled
patellarintercondylargroove
perpendiculartothexraycassette
Intercondylarfossa,notchof
Thepatientispositionedkneelingon poplitealtendon,tibialspines,
thetablewiththekneeflexedto70 intercondylareminence,posterior
Intercondylar
degreesandthebeamcenteredonthe aspectsofthedistalfemurand
inferiorpoleofthepatella proximaltibia,intercondylar
eminenceoftibia
Thepatientissupineandtheknees
areflexedovertheendofthexray Patellar,femoralcondyles.
Merchant cassette.Thebeamisdirectedtoward Preferredviewofarticularsurface
thefeetandthefilmcassetteisheld ofthepatellar,subtledissertations
ontheshins
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Common
Views
Frontalprojectionoftheankle
joint,thedistalendofthetibiaand
Thepatientispositionedinsupine
fibula,andtheproximalportionof
withthefootvertical.Thecentralray
Ankle AP thetalus.Neitherthesyndesmosis
perpendiculartoapointmidway
northeinferiorportionofthe
betweenthemalleoli
lateralmalleoliiswell
demonstratedinthisprojection
Thesyndesmosisiswellseen
Supinewiththelegandfootrotated
withoutoverlapoftheanterior
internallyapproximately15degrees.
Mortise processofthedistaltibiabest
Thecentralrayperpendiculartothe
viewofmortiseanddistalaspectof
anklejoint
thelateralmalleolus
Lateralsideoftheankledownthe
Alateralviewofthedistalthirdof
patientissupineandturnedtoward
Lateral thetibiaandfibula,theanklejoint,
theaffectedside.Thecentralrayis
talus,calcaneus,andthehindfoot
perpendiculartothelateralmalleolus
Theankleispositionedinextreme
plantarflexiontodetectposterior Toassessbonycontributionto
Impingement impingement,andweightbearing posteriororanteriorimpingement
andmaximumdorsiflexiontodetect
anteriorimpingement
Bestviewtodetectafractureofthe
Theankleispositionedtoprovidean anteriorprocessofthecalcaneus,
Obliquetarsal
obliqueviewofthefoot butcanalsodemonstratefractures
ofthebaseofthefifthmetatarsal
Bestperformedwithacalibrated
Inversionstress standardizeddeviceneededto Checkforlateralinstability
positionandstresstheankle
Bestperformedwithacalibrated
Eversionstress standardizeddeviceneededto Checkformedialinstability
positionandstresstheankle
Patientsupinewiththekneeflexed Afrontalprojectionofthetarsals,
andthesoleofthefootrestingonthe metatarsals,andphalanges
Foot Dorsoplantar xraycassette.Centralrayis tarsometatarsal,
perpendiculartothebaseofthethird metatarsophalangeal,and
metatarsal interphalangealjoints
Atruelateralprojectionofthe
Lateralsidedownwiththepatient
talocrural,subtalar,transverse,and
Lateral supine.Thecentralrayis
tarsometatarsaljointhindfoot,
perpendiculartothemidfoot
midfoot,andforefootrelationships
Thecalcaneocuboid,cuboidfourth
Supinewiththekneeflexedandthe andfifthmetatarsal,cuboid
legrotatedmediallyuntilthesoleof cuneiform,andtalonavicular
Medialoblique thefootformsanangleof30degrees articulations
totheplaneofthefilm.Thecentral Lessoverlapoftarsalsthan
rayisperpendiculartothemidfoot anteroposterior
Goodviewofsinustarsi
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Common
Views
Thepatientispositionedinsittingon
thexraytable,legextended,andthe
heelrestingonthecassette.The
Bestshowsthearticularsurfacesof
ankleisextendedandheldinthis
boththeposteriorandmedial
HarrisBeath positionbythepatientapplying
subtalarjoints,coalitionatthe
(axial)viewof tractiontotheforefootwitha
medialfacet,andavulsions
thehindfoot bandageorstrap.A45degreecranial
fracturesatthemedialorlateral
tubeangleisusedwiththeprimary
aspectsofthecalcanealtuberosity
beamenteringthesoleofthefootat
thelevelofthebaseofthefifth
metatarsal
AfrontalviewoftheC3C7
vertebralbodies,andtheuppertwo
Thepatientisplacedeithersupineor orthreethoracicbodies,the
erect.Thecentralrayis1520 interpedicularspaces,the
Cervicalspine AP
degreescranialatthemostprominent superimposedtransverseand
pointofthethyroidcartilage articularprocesses,theuncinate
processes,andtheintervertebral
diskspaces
AlateralviewoftheC1C7
vertebralbodies,diskspaces,the
articularpillars,spinousprocesses,
andthelowerfivefacetjoints.
Thepatientislateraltothexray Dependingonhowwellthe
cassette,eitherseatedorstanding. shoulderscanbedepressed,the
Lateral Thecentralrayisperpendicularto sevencervicalvertebraeand
themidneck sometimestheupperoneortwo
thoracicvertebraecanbeseenall
sevencervicalvertebrae,
particularlyintraumacases,must
beseen
Providesinformationontheneural
Obtainedbyrotatingtheentire foramenandposteriorelementsof
patient45degreesonewayandthen thecervicalspine.Bestviewfor
APobliques
theother,obtainingimagesineach detectingosteoarthritic
position encroachmentoftheintervertebral
foramina
Thepatientsheadispositionedin AnteroposteriorviewofC1C2
slightextensiontopreventthefront articulation.FracturesofC1and
APopenmouth
teethfrombeingsuperimposedover arthriticchangesattheC1C2
theodontoid facetsmayalsobeidentified
Obtainedbyaskingthepatienttoflex Stressfilmstocheckforinstability
Flexion/extension
andthenextendtheneck,obtaining thatmaynotbedetectedonroutine
laterals
imagesineachposition neutralviews
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Common
Views
Showsthearticularpillarsorlateral
AnAPviewtakenwith2030 massestoadvantageasthecentral
degreesofcaudaltubeangulation, beamisangulatedparalleltotheir
Pillar withapadundertheupperthoracic slopingcourse,caudadintheAP
spinetoelevatetheshouldersandto projection,andcranialinthePA
allowextensionofthecervicalspine projection.Occultfracturesmaybe
detectedwiththisview
BestviewofC7T2,prevents
Obtainedbypositioningthepatient
obstructionbyshoulders.Proximal
sothatonearmisraisedabovetheir
Swimmersview humerus,lateralclavicle,ACjoint,
headandtheotherisbytheirside
superiorlateralaspectofthe
likeafreestyleswimmer
scapula
Obtainedwiththepatientinthe
T1T12vertebralendplates,
supineposition,armsbythesideand
pedicles,andspinousprocesses
shouldersatthesamelevel.The
Thoracicspine AP intervertebraldiskspaces
kneesareslightlyflexedtoreduce
costovertebraljointsmedialaspect
thedorsalkyphosisandthebeamis
posteriorribs
sentto10cmbelowthesternalnotch
Thepatientispositionedstanding
sideon,withtheshoulderjust T1T12vertebralendplates,
touchingtheBuckyforsupport.The pedicles,spinousprocesses
Lateral
armsareextendedandthepatients intervertebraldiskspacesand
balanceisstabilized.Thefilmis foramina
centeredonT7
Thepatientispositionedwiththeir
backagainstthebucky,andthen
rotatedposteriorlysotheyareangled
45degreeswiththeaffectedside
Facetjoints,pedicles,andthepars
Posterioroblique touchingthebucky.Thearmonthe
interarticularis
affectedsideispositionedsothatitis
awayfromtheareaofinterest(either
outtotheside,oroverthepatients
head)
Thepatientispositionedwiththeir
backagainstthebucky,andthen
rotatedanteriorlysotheyareangled
45degreeswiththeaffectedside
Sternum,axillaryportionofthe
Anterioroblique touchingthebucky.Thearmonthe
ribs
affectedsideispositionedsothatitis
awayfromtheareaofinterest(either
outtotheside,oroverthepatients
head)
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Common
Views
AfrontalviewoftheL1L5
vertebralbodies,pedicles,disk
Eitherfrontalprojectionisadequate
spaces,thelamina,andthespinous
andcanbetakenwiththepatient
andtransverseprocesses.The
supineorerectwithpatientcomfort
APor FergusonviewisanAPviewwith
Lumbarspine dictatingtheposition.Ifthepatientis
posteroanterior acranialangulation,which
supine,thekneesandhipsshouldbe
essentiallycompensatesforthe
flexed.Thecentralrayis
normallordosisofthelumbosacral
perpendiculartoL3
region,andallowsonetoseethe
junctionclearly
Alateralviewofthelumbar
Supineorerect.Ifsupine,theleft vertebralbodiesandtheirdisk
sideisdownwiththehipsandknees spaces,thespinousprocesses,the
Lateral
flexedtoacomfortableposition.The lumbosacraljunction,sacrumand
centralrayisperpendiculartoL3 coccyx,theintervertebralforamina,
andthepedicles
Notonlyshowstheneural
Thepatientispositionedinsupine foraminabutalsodemonstratesthe
Obliques withtheirbodyangled3045 parsinterarticularistoaidinthe
degrees detectionofspondylolysisbest
viewoffacetjoints
Thepatientispositionedstandingin
L5S1(coned alateralpositionwiththearms LateralofL4S1vertebralbodies
downlateral) acrossthechest anddiskspaces
spotview Thepatientispositionedstanding Mayenhancespondylolisthesisor
Flexion sideonandisaskedtoflexand retrolisthesisordemonstrate
extension extendthelumbarspine.Animageis pivotalmotionatagivendisk
takenateachposition
Thepatientispositionedinstanding, APimagesbilateralsacroiliac
APaxial,
Sacroiliacjoint withtheaffectedsiderotated2030 jointsobliquesimageunilateral
obliques
degreesawayfromthefilm. sacroiliacjoint
Supinewiththefeetinternally
rotatedapproximately15degrees. Afrontalviewofthepelvicgirdle
Pelvis AP
Centralrayperpendiculartothe andproximalthirdofbothfemora
midpointofthepubicsymphysis
Alsocalledthebilateralfrogleg
Detectionofacetabularandpubic
Oblique position,andthepatientispositioned
ramifractures
accordinglyforabilateralview
Patientsupineandthebeamangled
Inlet
10degreescranially
Patientsupineandthebeamangled
Outlet
15degreescaudad
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Common
Views
Internallyrotated:ananterior
obliquevieworobturatoroblique
viewisobtainedwhich
demonstratestheiliopubic
Patientpositionedsothattheinjured (anterior)columnandtheposterior
Judet sideisrotated45degreesinternally lipoftheacetabulum
andexternally Externallyrotated:aposterior
obliquevieworiliacobliqueview
isobtainedwhichshowsthe
ilioischial(posterior)andthe
anterioracetabularrim
AP,anteroposteriorPA,posteroanterior.
DatafromShankmanS.Conventionalradiographyandtomography.In:SpivakJM,DiCesarePE,FeldmanDS,
etal.,eds.Orthopaedics:AStudyGuide.NewYork,NY:McGrawHill,1999:173178BarrJB.Medical
screeningforthephysicaltherapist:Imagingprinciples.In:WilmarthMA,ed.MedicalScreeningforthe
PhysicalTherapist.OrthopaedicSectionIndependentStudyCourse14.1.1.LaCrosse,WI:OrthopaedicSection,
APTA,Inc.,2003:115DeyleG.Diagnosticimaginginprimarycarephysicaltherapy.In:BoissonnaultWG,
ed.PrimaryCareforthePhysicalTherapist:ExaminationandTriage.StLouis,MD:ElsevierSaunders,
2005:323347.
Radiographs,likeallmedicalprocedures,haverisksandbenefits.Ionizingradiationcanincreasetheriskof
cancer,andinsufficientdosescancausedeath.14Inadditiontothehealthrisks,theoverutilizationofradiologic
studieshasbecomeasignificanteconomicproblemintheUnitedStates.15Forthesereasons,therehasbeenan
increasedneedforclinicalpredictionordecisionrulesindicatinganeedforradiographyforspecifictypesof
injuryincertainareasofthebody.Aclinicaldecisionrule(CDR)isatoolthatcanquantifyindividual
contributionsfromthecomponentsoftheexaminationtodeterminethediagnosis,prognosis,ortreatmentfora
givenpatient.1
ClinicalApplications
CervicalSpine
CDRsforreevaluationofcervicalspineinjuriesremaincontroversial,althoughconsensusexiststhatcervical
radiographicstudiesareoverutilizedintheemergencydepartment(ED).16Inadditiontotheroutineprojections
ofthecervicalspine,theanteroposterior(AP)andlateralviews,anumberofotherviewscanbeusedtoaidin
theevaluationoftraumaandarthritis(Table71).TheAPviewprovidesinformationabouttheshapeofthe
vertebra,thepresenceofanylateralwedgingorosteophytes,andthediskspace.Inthelowercervicalspine,the
APviewcanalsoprovideinformationaboutthepresenceofacervicalrib.Thelateralviewprovides
informationaboutthelordosisandgeneralshapeofthecervicalcurveandcervicalvertebrae.Thisviewalso
providesinformationaboutanyanteriororposteriordisplacementofthevertebrae,thesizeofthediskspace,the
integrityofthevertebraledges(lipping),facetsubluxation,softtissueabnormalities,andthepresenceofany
osteophytes.BymeasuringtheprevertebralsofttissuewidthattheanteroinferiorborderoftheC3vertebra,a
determinationismadeastotheexistenceofedemaorhemorrhageifthewidthiswiderthanthenormal7mm.17
CLINICALPEARL
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Thenormalratioofspinalcanaldiametertovertebralbodydiameter(Torgratio)is1.ATorgratiothatisless
than0.8indicatespossiblecervicalstenosis.18
Radiographicimagesarelimitedintheirabilitytodetectinstabilityofthecraniovertebralregionbecauseofan
incompleteimagedefinitionofsofttissues,butthedisruptionofnormalskeletalrelationshipsmayindicatea
lossofintegrityoftheinterposedtissues.Tomeasurethedegreeofatlantoaxialsubluxation,theanterior
atlantodensinterval(AADI),whichmeasuresthespatialrelationshipbetweentheodontoidprocessandthe
anteriorarchoftheatlashasbeenused.Beforeskeletalmaturityoccurs,thisvaluemaybeupto45mm.In
adultsandolderchildren,avalueof3mmisgenerallyconsideredtobetheupperlimitofnormal.19Rocheet
al.20haveproposedthat36mmsuggeststransverseligamentdamageandgreaterthan6mmimpliesalar
ligamentinjury.However,AADIinterpretationsmustbeusedwithcaution.Theposterioratlantodensinterval
(PADI),whichisthedistancebetweentheanteriormarginoftheposteriorringoftheatlasandtheposterior
surfaceoftheodontoid,maybeamorevaluablemeasurement,asitresultsinamoreaccuratereflectionofcanal
sizeandpotentialforneurologiccompromise.APADIof40mmisconsideredthelowerlimittoavoid
encroachmentontothespinalcord.20
ThoracicSpine
StandardviewsofthethoracicspineincludetheAPviewandlateralview(Table71).
APview.Thisviewisusedtohelpthecliniciandetermineifthereisanywedgingofthevertebrae(suggestive
ofstructuralkyphosisresultingfromconditionssuchasScheuermannsdiseaseorawedgefracture),whether
thediskspacesappearnormal,whetherthereisnormalsymmetryoftheribs,whetherthereisanymalpositionof
theheartandlungs,whetheranyscoliosisispresent,andwhethertheringepiphysis,ifpresent,isnormal.From
adiseaseperspective,inpatientswithsuspectedankylosingspondylitis,theclinicianisobservingforabamboo
spine.TheCobbmethodisatechniqueusedtomeasurespinalcurvatureincasesofsuspectedscoliosis.Alineis
drawnparalleltothesuperiorcorticalplateoftheproximalendvertebraandtotheinferiorcorticalplateofthe
distalendvertebra.Aperpendicularlineisthenusedtojoineachoftheselines,andtheangleofintersectionof
theperpendicularlinesistheangleofspinalcurvatureresultingfromscoliosis.
Lateralview.Thisviewistohelpthecliniciandetermineifthereisanormalkyphosis,whetherthediskspaces
appearnormal,theangleoftheribs,thepresenceofanyosteophytes,whetherthereisanywedgingofthe
vertebrae,andwhetherthereareanySchmorlsnodesindicatingherniationoftheIVDintothevertebralbody.
LumbarSpine
Routineprojectionsforthelumbarspinearetheposteroanterior(PA)orAP,andlateralviews(Table71).
Lowerbackradiographshavebeendescribedasthesinglemostoverprescribeddiagnosticimaging
procedure.21,22SpecificguidelineshavebeendevelopedbytheAgencyforHealthCarePolicyandResearchto
helpreducetheorderingoflumbarplainfilmsthatareofminimaldiagnosticvalue.21Imagingintheeventof
spinaltraumamustbefullyevaluatedregardingtheforcesinvolvedaswellasthemetabolicbonehealthofthe
patient.1Symptomsthatarenotrelievedbyrestorchangesinposition,symptomsthatsharplyincreasewith
movement,unremittingparaspinalmusculaturespasm,andanunwillingnesstomovethespineallsuggesta
spinalfracture.1
Pelvis
RoutineprojectionsforthepelvisareoutlinedinTable71.Additionalviewsincludethefollowing:
Proneviewofthesymphysispubis.Thisviewimprovesthedetailofthesymphysisinpatientswithagroin
strain,aswellasdemonstratingthepubicrami.Theviewistakenwiththepatientlyingpronetobringthe
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symphysisclosetothefilmandwith2030degreesofcranialtubeangulation.
Obturatorview.Thisview,whichcanbeobtainedsupineorprone,providestheclinicianwithmoredetailofthe
pubicramiandischialtuberosities.Inthesupineposition,thecranialangulationofthetubeis2530degrees
and,ifthepronepositionisused,theangulationiscaudal.Theprimarybeamiscenteredjustbelowtheinferior
marginofthesymphysis.
Flamingoviews.Theseviewsofthesymphysisareusedinthediagnosisofpelvicinstabilitybydemonstrating
movementofthesymphysisunderweightbearingstress.TwoPAviewsofthesymphysisareobtainedwith
weightbearingoneachleginturn.Anymovementatthesymphysisinexcessof2mmisconsideredabnormal.
ConePA/APview.Theseviewsofthesacroiliacjoints(SIJs)areusedwhenanabnormalityoftheSIJis
suspectedonaroutineviewofthepelvis.Atubeangulationofabout30degreesisusedalthoughthiswillvary
dependinguponthelumbarcurve.
Shoulder
Radiographicexaminationoftheshouldergirdlemaybetailoredtoanygivenclinicalsituation.Atraumaseries
consistsofanAP,axillary,andscapularlateralviews(Table71).
APview
AtrueAPoftheshouldergirdleisoneinwhichthexraybeamisperpendiculartothescapula.Thisrequires
obliquingthepatient45degreessuchthatthescapulaitselfisparalleltothexraycassette.Inthisway,the
glenohumeral(GH)jointisseenwithoutoverlapofthehumeralheadandglenoidfossa.Oneviewthatishelpful
intheevaluationofimpingementsyndromeistheoutletview,whichcentersthebeamatthecoracoacromial
arch.AstandingbilateralAPimageisusedtoassesstheclavicleandacromioclavicular(AC)joint.
Axillary
Thisviewshowstherelationofthehumeralheadtotheglenoidandisusedtodiagnoseanteriorandposterior
dislocationsattheGHjoint,ACjointdysfunctions,andtolookforavulsionfracturesoftheglenoidoraHill
Sachslesion(seeChapter16).Thetechniquerequiresthatthepatientbeabletoabductthearm7090degrees.
ScapularY
ThescapularYview,obtainedbytiltingthexraybeamapproximately60degreesrelativetotheAPview,
providesgoodvisualizationofthehumerusrelativetotheglenoidandtheacromionandcoracoidprocess.23
Strykernotchview
Thepatientispositionedinsupinewiththearmforwardflexedandthehandontopofthehead.Thebeamis
centeredonthecoracoidprocess.ThisviewisusedtoassessaHillSachslesionoraBankartlesion(see
Chapter16).
Westpointview
Thepatientispositionedinprone.Thisprojectiongivesagoodviewoftheglenoidtodelineateglenoid
fractures.
Archview
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Thearchviewisusedtodeterminethewidthandheightofthesubacromialarchandhelpstodeterminethetype
ofacromialarch(seeChapter16).
Elbow
ThestandardxrayseriesoftheelbowincludesAPandlateralviews(Table71).24
APview.TheAPviewistakenwiththeelbowextended,andtheforearmsupinated,withthexraybeam
directedperpendiculartotheanterioraspectoftheelbow.TheAPviewdemonstratesthehumeroradial
andhumeroulnarjoints,aswellasthemedialandlateralepicondyles.Thecarryingangleoftheelbowcan
alsobemeasuredfromtheAPview.
Lateralview.Thelateralviewistakenwiththeelbowflexedat90degreesandforearminaneutral
position,withthexraybeamdirectedperpendiculartothelateralaspectoftheelbow.Thelateralview
bestdemonstratesthecoronoidprocessoftheulnaandthetipoftheolecranon.Fatpadsarealsobest
identifiedonthelateralview.
Specialviewscanbeorderedtohelpdefinespecificsymptomaticareasandincludeoblique,axial,radialhead,
andstressviews.
Medialobliqueviews.Thisviewistakenwiththearminternallyrotated,theelbowextended,andtheforearm
pronated.Thisviewallowsbettervisualizationofthetrochlea,olecranon,andcoronoidprocessoftheulna.
Lateralobliqueviews.Thisviewistakenwiththearmexternallyrotated,theelbowextended,andtheforearm
supinated.Thelateralobliqueviewprovidesgoodvisualizationoftheradiocapitellarjoint,proximalradioulnar
joint,andmedialepicondyle.Oftennondisplacedorminimallydisplacedfracturesandloosebodiesnotseenon
theAPorlateralviewswillbedemonstratedontheobliqueviews.
Axialview.Theaxialviewisobtainedwiththearmonthecassettetheelbowflexedto110degrees,andthex
raybeamdirectedperpendiculartothearm.Thereverseaxialviewisobtainedwiththeforearmonthecassette,
theelbowcompletelyflexed,andthebeamprojectedperpendiculartotheforearm.Theaxialandreverseaxial
viewsbestdemonstratetheolecranonfossaandtheolecranon,respectively.
Radialheadview.Theradialheadviewwillhelpidentifyoccultradialheadfractures.Thisviewisobtained
withtheelbowflexedto90degreesandthebeamangledat45degreestothelateralelbow.APstressviews
demonstratesubtlechangesinjointspaceandcongruencywithvarusorvalgusstressontheelbow.These
changesarethencomparedtothenonstressedAPview,ortoastressviewoftheoppositeside.Wideningofthe
radiocapitellarjointwithvarusstressreflectsinjurytothelateralligaments.Wideningofthehumeroulnarjoint
withvalgusstressreflectsinjurytothemedialligaments.
Theradiocapitellarviewisespeciallyhelpfulindemonstratingradialheadandcapitellumfractures.Onthe
lateralviewoftheelbow,alineisdrawnthroughthemidportionoftheradiusthatnormallypassesthroughthe
centerofthecapitellum.Thelateralprojectionanglesthecentralbeamcranially,projectingtheradiocapitellar
jointfreeoftheulnartrochleararticulation.Viewsofthecubitaltunnelcanbeobtainedwiththeelbowflexed
approximately45degrees,andtheforearmsupinatedwithitsposterior(dorsal)surfaceagainstthexray
cassette.Thecentralrayisangledapproximately20degreeswithrespecttotheolecranonprocess.Thisis
mostlyusefulforinspectingthebonyaspectofthecubitaltunnelwheretheulnarnerveliesandcanshow
osteophytesandloosebodies.
Wrist
InadditiontothestandardandspecialradiographicviewsdepictedinTable71,ananteriorobliquepositionor
semisupinatedobliqueviewmaybeobtainedfortheevaluationofarthritis.Fromthelateralposition,the
forearmissupinateduntilthewristformsanangleofapproximately45degreeswiththeplaneofthefilm.The
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pisiformtriquetraljointcompartmentisonlyseenwithsuchaview.Earlyerosionsthatareassociatedwith
inflammatoryarthritis,especiallyrheumatoidarthritis,mayoccuratthisjoint.Stressviewsofthefirst
carpometacarpaljointscanbeobtainedbyaskingthepatienttopressthetipsofthethumbtogetherwiththe
handsinanearlylateralposition.Radialsubluxationofthefirstcarpometacarpaljointismostcommonlyseenin
basaljointosteoarthritis.
Thecarpaltunnelviewistakenwiththewristhyperextended.Thexraybeamisangledalong(parallelto)the
anterioraspectofthewristshowingthebonyanatomyofthecarpaltunnel.Thisviewishelpfulindetecting
erosionsinthecarpaltunnelandmaydetectoccultfracturesofthehookofthehamate,whichmaybedifficultto
seeonroutineradiographs.
Motionseriesofthewristmayaidinthedetectionofligamentousinjuriesthatresultininstability.Thisincludes
PAradialandulnardeviationviewsandlateralanterioranddorsiflexionviews.Suchstaticviewsmaybe
normalinthesettingofligamentousinjury,anddynamicvideofluoroscopyofthewristmayberequired.The
clenchedfistanteriorposteriorviewmaydemonstrateascapholunatedissociationbydrivingthecapitate
proximallybetweenthelunateandscaphoid.Specializedviewsofthescaphoiditselfhavebeendesignedforthe
detectionofoccultfractures.
Hand
Allsignificanthandinjuries,includingthosewithanydegreeofswelling,shouldbeevaluatedradiographically
evenifthelikelihoodofafractureseemsremote.25Chiporavulsionfracturescannotbesuspectedbasedonthe
clinicalexaminationaloneandyetifundetected,anduntreatedmayresultinasignificantdisability.25Rotational
deformityinvolvingthemetacarpalorproximalphalanxcanresultinapoorlyfunctioningpartiallydisabled
hand.Witharotationalalignmentofthedistalinterphalangealjoint,theplanesofthefingernailsarenotparallel
whenonecomparestheplanesoftheinjurednailtothenormalfingernailoftheoppositehand.
InadditiontothestandardandspecialradiographicviewsdepictedinTable71,stressviewsofthefirst
metacarpophalangealjointmayberequiredforevaluationoftheligamentousinjuries.Specifically,abduction
stressviewsoftheinjuredandnormalformmaydemonstratewideningoftheulnaraspectofthejointwith
radialsubluxationoftheproximalphalanxwhentheulnarcollateralligamentisdisrupted,aswiththegame
keeperthumb(seeChapter18).Fracturesofthefourthandfifthmetacarpalsarefrequentlyundetecteduntila
lateralviewwith10degreesofsupinationisobtained.25Secondandthirdmetacarpalinjuriesareoftendetected
onalateralviewwith10degreesofpronation.25Fingerinjuriesrequireatruelateralviewwithout
superimpositionoftheotherdigits.25
Hip
Therearetwoprojectionsintheroutinehipseries(Table71):
APview.Thisviewallowstheclinicianto
comparethetwohipsforsymmetry.
notetheneckshaftangle(coxavaraorcoxavalga),andtheshapeofthefemoralhead.
viewthejointspaces(presenceofosteophytesorarthritis),pelviclines,andotherlandmarks.
notethepresenceofanybonedisease(e.g.,LeggCalvePerthesdisease).
noteanyevidenceoffracture,dislocation,orpelvicdistortion.
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Lateralobliqueview.Thisviewallowsthecliniciantolookforanypelvicdistortionoranyslippingofthe
femoralhead.
Inadditiontothestandardandspecialradiographicviews,crosstablelateralfilmingisthebestapproximation
ofatruelateralfilmofthehipandisparticularlyusefulinassessingsubtlesubcapitalfracturesandasa
postoperativeevaluationofhiparthroplasty.Thepatientispositionedinsupinewiththefilmcassettecenteredat
thegreatertrochanter.Thekneeandhipoftheunaffectedsideareflexed.Thecentralrayisperpendiculartothe
longaxisofthefemoralneckandthefilmcassette.TheJudetviewisusedifthereisasuspicionofafracturein
theregionoftheacetabulum.Thisviewistakenbyrollingthepatient40degreesonewayandthentheother,
acquiringimagesinbothpositionsbyusingastraighttubecenteredonthefemoralhead.
CLINICALPEARL
Pistolgripdeformity:abnormalheadneckoffset(i.e.,flatteningofthesuperiorfemoralhead).
Saggingropesign:occurswithLeggCalvePerthesdiseaseasaresultofosteonecrosisofadeveloping
femoralhead,andindicatesdamagetothegrowthplate.
Teardropsign:resultsfromsuperiormigrationofthefemoralheadinrelationtothepelvisduetojoint
degeneration.Theteardropsignisvisibleatthebaseofthepubicbone,extendingverticallyinferiorlyto
terminateinaroundteardroporhead.
TibiofemoralJoint
InadditiontothestandardandspecialradiographicviewsdepictedinTable71,weightbearingviewsofthe
kneeswithandwithoutflexionareparticularlyhelpfulintheevaluationofarthritisandthedetectionofjoint
spacenarrowingwhichmaynotbeasobviouswithnonweightbearingornonstandingviews.Weightbearing
withflexionisparticularlyhelpfulinthedetectionofosteoarthritiswhenfocalcartilagelosscanbeseen
posteriorly.TheOttawakneeCDRsandthePittsburghCDRsareguidelinesfortheselectiveuseofradiographs
inkneetrauma.Applicationoftheserulesmayleadtoamoreefficientevaluationofkneeinjuriesanda
reductioninhealthcostswithoutanincreaseinadverseoutcomes.15TheOttawakneeCDRs,whichhavebeen
demonstratedtohavenear100%sensitivityforkneefracturesandreducetheneedforkneeradiographsby20%
whenusedbyemergencyphysicians,6issummarizedinTable72.ThePittsburghCDRofthekneeindicating
theneedforradiographicstudiesissummarizedinTable73.
TABLE72OttawaKneeRulesforRadiography
IndicationsforRadiography,ifAny ExclusionCriteria
Patientsolderthan55years Ageyoungerthan18years
Tendernessattheheadofthefibula Isolatedsuperficialskininjuries
Isolatedtendernessofthepatella Injuriesmorethan7daysold
Inabilitytoflexto90degrees Recentinjuriesbeingreevaluated
Patientswithalteredlevelsof
Inabilitytoweightbearfourstepsbothimmediatelyaftertheinjuryandin
consciousness
theemergencydepartment
Paraplegiaormultipleinjuries
DatafromSeabergDC,YealyDM,LukensT,etal.Multicentercomparisonoftwoclinicaldecisionrulesforthe
useofradiographyinacute,highriskkneeinjuries.AnnEmergMed.199832:813.
TABLE73PittsburghDecisionRulesforRadiography
IndicationsforRadiographyiftheMechanismofInjuryisBlunt
ExclusionCriteria
TraumaorFallandEither
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Kneeinjuriessustainedmorethan6days
Thepatientisyoungerthan12orolderthan50years beforepresentation
Patientswithonlysuperficiallacerations
andabrasions
Theinjurycausesaninabilitytowalkmorethanfourweightbearing Historyofprevioussurgeriesorfractures
stepsintheemergencydepartment ontheaffectedknee
Patientsbeingreassessedforthesame
injury
DatafromSeabergDC,YealyDM,LukensT,etal.Multicentercomparisonoftwoclinicaldecisionrulesforthe
useofradiographyinacute,highriskkneeinjuries.AnnEmergMed.199832:813.
PatellofemoralJoint
Standardworkupforpatellarinstabilityincludeanteroposterior(AP),lateral,andoneofseveralpatellofemoral
views(sunrise/skylineviewat20degreesofkneeflexion,oraMerchantviewata30degreedownwardangle
onakneeflexedat45degrees).26ForpatellaheighttheInsallSalvatiratioistheverticallengthofthepatella
overthelengthofthepatellatendon(fromtheinferiorpoleofthepatellatothetendonscorrespondinginsertion
onthetopofthetibialtubercle).27Alternatively,theBlackburnPeelratioisthelengthofapatellararticular
surfacedividedbythedistancefromthedistalpatellatoalinecrossingthroughthelowestpoleofthetibial
plateau.27Trochleadysplasiaisevaluatedonlateralradiographsbythecrossingsigntheintersectionofthe
trochleafloorandthemostanterioredgeofthelateralfemoralcondyle.28
Lateralradiographs.29Radiographsshouldincludealateralviewwithposteriorcondylesapproximated
ascloselyaspossible.Thedistancebetweenthelateralfemoralcondylesandthetrochleaisameasureof
trochleardepth.Theabsenceofthegrooveatanypointalongthetrochleararcispathologic.
Axialradiographs.29TheaxialviewshouldbeobtainedinthemannerdescribedbyMerchantetal.,26but
withthekneeflexed50degreesratherthan45degreestobetterdetectabnormaltiltandlateral
displacement.Lateraldisplacement,inparticular,ismostpronouncedintheearlydegreesofflexion,
beforethepatellaengagesthetrochleargroove.
Ankle
TheOttawaankleCDRwasdevelopedtohelppredictfracturesinpatientswithankleinjuriesandhasbeen
showntobe100%sensitiveand40%specificandtoreducetheneedforEDankleradiographsby36%.6,30
UsingthisCDR,radiographyisindicatedifanyofthefollowingarepresent:
Bonetendernessattheposterioredgeortipofthelateralmalleolus.
Bonetendernessattheposterioredgeortipofthemedialmalleolus.
InabilitytobearweightbothimmediatelyandintheED.
StandardviewsoftheankleincludetheAP,mortise,andlateralviews(Table71):
APview.Thisviewprovidestheclinicianwithinformationabouttheshape,position,andtextureofthebones,
andhelpsdeterminewhetherthereisanyfracturedornewsubperiostealbone.
Mortiseview.Thisviewprovidesinformationabouttheanklemortiseandthedistaltibiofibularjoint.
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Lateralview.Thisviewprovidestheclinicianwithinformationabouttheshape,position,andtextureofbones,
includingthetibialtubercle,talus,andcalcaneus.
Othernonroutineviewsincludethefollowing:
Dorsoplantarviewofthefoot.Thisviewprovidesinformationwithregardtotheforefoot.
Medialobliqueviewofthefoot.Thisviewprovidesinformationaboutthetarsalbonesandjointsandthe
metatarsalshaftsandbases.Inaddition,thisviewcanhighlightanypathologyinthecalcaneocuboidjoint.
Stressviewsoftheanklesareroutinelyutilizedforassessmentofinstabilityandinjurytothelateralcollateral
ligamentofstructures(Table71).Boththeaffectedandnormalsidesareexaminedforcomparison.Complete
tearsofthedeltoidligamentmaybedemonstratedwitheversionstress.However,thevalueofstress
roentgenogramsoftheankleisacontroversialtopic.31,32Thestressviewsincludeinversiontoassesstalartilt
andtheanteriordrawerstress.Theaccuracyofthesetestsincreaseswiththeuseoflocalanesthesiaanda
comparisonwiththeuninvolvedankle.
Theanteriordrawertestisperformedwithalateralviewoftheankleinaneutralpositionwhileattemptingto
manuallytranslatethefootanteriorlywithrespecttotheleg.31,32Thesagittalplanetranslationofthetaluswith
respecttothetibiaismeasured.Whencomparedwiththesamefootunstressed,anteriorsubluxationofmore
than3mmisconsideredtoindicateananteriortalofibularligament(ATFL)injury.33
Thetalartilttestisusedmoreoftenandisfelttobemorereliable.Inthisexamination,amortiseorAPviewof
theankleheldinneutralpositiontoslightplantarflexionwithaninversionstressappliedtothefootis
obtained.31,32Theangletobemeasuredisthatformedbyalineparalleltosubchondralboneofthedistaltibia
andproximaltalus.Itistheconsensusthatatalartilttestispositivewhentheinjuredanklehasastressed
tibiotalarangleof515degrees34,35greaterthantheuninjuredside.However,theabsolutenumberofdegreesis
notasimportantasthefunctionalinstabilityofthepatient,aslaxitydoesnotalwaysmeaninstability.31,32
StressRadiograph
Astressradiographisaprocedureusingradiographstakenwhileastressisappliedtoajoint.Anunstablejoint
demonstrateswideningofthejointspacewhenthestressisapplied.Forexample,spineflexionandextension
viewscanbehelpfulinassessingspinalmobilityandstabilityandaretypicallyorderedintheacutelyinjured
athletewhenthereisahighdegreeofsuspicionofspineinjury.Greaterthan2mmofmotionbeyondnormalat
anysegmentallevelinthespinewouldsuggestinstabilityandwarrantfurtherexamination.
VideoFluoroscopy
Fluoroscopicproceduresinvolvetheuseofxraystoevaluatethequalityandquantityofjointmotion.Because
oftherelativelyhighexposuretoradiationwiththistechnique,itisusedmainlyinthedetectionofjoint
instability.
ContrastEnhancedRadiography
Contrastenhancedradiographyproceduresinvolvetheuseofacontrastingagenttohighlightdifferent
structures.Theseagentsmaybeadministeredorally,rectally,orbyinjection.Differentcontrastmediamaybe
usedandincluderadiopaqueorganiciodidesandradiotranslucentgases.Contrastenhancedradiography
proceduresincludethefollowing:
Arthrography.Arthrographyisthestudyofstructureswithinanencapsulatedjointusingacontrast
mediumwithorwithoutairthatisinjectedintothejointspace.Thecontrastmediumdistendsthejoint
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capsule.Thistypeofradiographiscalledanarthrogram.Anarthrogramoutlinesthesofttissuestructures
ofajointthatwouldotherwisenotbevisiblewithaplainfilmradiograph.Thisprocedureiscommonly
performedonpatientswithinjuriesinvolvingtheshoulderortheknee.Theprimarygeneralindications
forperformingaconventionalarthrogramare36
toconfirmintracapsularpositioningofaneedleorcatheterfollowingajointaspirationorpriortoan
anestheticjointinjection
inplaceofanMRscan(seelater)ifitisnotavailable,contraindicated,orifthepatientistooobese
forthegantryorisclaustrophobic
forthediagnosisandtreatmentofadhesivecapsulitis
Arthrographycanalsobeperformedinconjunctionwithmagneticresonanceimaging(MRI)orcomputed
tomography(CT)(seelater).
Myelography.Myelographyistheradiographicstudyofthespinalcord,nerveroots,duramater,and
spinalcanal.Thecontrastmediumisinjectedintothesubarachnoidspace,andaradiographistaken.This
typeofradiographiscalledamyelogram.MyelographyisusedfrequentlytodiagnoseIVDherniations,
spinalcordcompression,stenosis,nerverootinjury,ortumors.Thenerverootanditssleevecanbe
observedclearlyondirectmyelograms.WhenmyelographyisenhancedwithCTscanning,theimageis
calledaCTmyelogram(CTM)(seelater).
Diskography.DiskographyistheradiographicstudyoftheIVD.Aradiopaquedyeisinjectedintothe
diskspacebetweentwovertebrae.Aradiographisthentaken.Thistypeofradiographiscalleda
diskogram.AnabnormaldyepatternbetweentheIVDsindicatesaruptureofthedisk.Theindicationsfor
lumbarorcervicaldiskogramare36
severeorunremittinglowbackorneckpainwithorwithoutradicularsymptomsinapatientwith
negativestandardimagingstudiesordegenerativediskdisease
foruseinpreoperativeplanningpriortospinalfusiontoincludeonlythosepainfuldisklevels
intheevaluationofneuralforaminamasses,whichmayrepresentanextrudeddiskherniationor
nervesheathtumor
todetermineaccurateneedleplacementpriortochymopapaininjection
persistentpaininthepostoperativeperiod
Angiography.Angiographyistheradiographicstudyofthevascularsystem.Awatersolubleradiopaque
dyeisinjectedeitherintraarterially(arteriogram)orintravenously(venogram).Arapidseriesof
radiographsisthentakentofollowthecourseofthecontrastmediumasittravelsthroughtheblood
vessels.Angiographyisusedtohelpdetectinjurytoorpartialblockageofbloodvessels.Theindications
forangiographyare36
asadiagnosticstudy,followingpossiblevascularinjuryfromtrauma
embolizationofactivebleedingsitesnotamenabletosurgicalcontrol,suchaswithinthepelvis
evaluationofboneandsofttissuetumors(thefindingswillassessneovascularityofthelesion,the
extentofthetumor,andinvasionorimpingementofmajorvessels)
preoperativeorpalliativeintraarterialembolizationorchemotherapy
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diagnosisandtreatmentofarteriovenousmalformations
evaluationofthearterialanatomypriortoboneorsofttissuegrafts
diagnosisofarteritisthatisfurthercomplicatingcollagenvasculardisease
ComputedTomography
ThewordtomographyisderivedfromtheGreektomos(slice)andgraphia(towrite).CTimagesareusefulto
evaluateinjuredareaswherethe3Dconfigurationofthestructuremakestheplainradiographsdifficultto
interpret.25TheCTimageisnotrecordedinaconventionalradiographicmanner.ACTscannersystem,also
knownascomputerizedaxialtomography(CAT)andcomputerizedtransaxialtomography(CTI),consistsofa
scanninggantry,whichholdsthexraytubeanddetectors(movingparts),amovingtableorcouchforthe
patient,anxraygenerator,acomputerprocessingunit,andadisplayconsoleorworkstation.37Imagesare
obtainedinthetransverse(axial)planeofthepatientsbodybyrotatingthexraytube360degrees.
Theimagesareproducedbyrotatingathincollimatedxraybeamthrougha180degreearcaroundthepatient
suchthatstructuresofacertaindepthwillbestationaryinthebeamandappearwithenhancedclarity,whereas
tissuessuperficialanddeeptothislevelwillberelativelyobscuredbymotion.Thebasicprincipleofany
tomographicsystemisthatallpartsoftheobjectthatareperpendiculartothedirectionofthetubemotionare
maximallyblurred,whereasthosepartsthatareparalleltothedirectionofmotionarenotblurredbutmerely
elongated.
Likeconventionalradiography,CTalsousesradiation,butinsteadofaunidirectionalbeam,boththeradiation
sourceanddetectorsystematicallyencirclethebody.Thexraysareabsorbedinpartbythepatientsbody.The
numberofxraystransmittedthroughthebodyisdetectedontheoppositesideofthegantrybyanarrayof
detectors.Eacharraydetectorrespondstotheamountofraysdetectedbydownloadingdatatothesystems
computer,whichassignsanumericvaluebasedontheattenuationpropertyofthevarioustissuesofthebody,
andthenformsanimagebasedonthedifferentialabsorptionofthexrays.Theseattenuationvalues,orrelative
attenuationcoefficient(),areexpressedinHounsfieldunits(HU)andarenormalizedtowater.7Hence,water
measures0HU,bone(thehighestabsorptionvalues)measures>400HU,musclemeasures40HU,fatmeasures
120HU,andair(thelowestabsorptionvalues)measures1,000HU.37Inessence,theCTimageisamapof
thelinearattenuationvalueofthetissue.ByadjustingthelevelandthewidthofthedisplayedrangesofHU
(window),theoperatorcanstudydifferenttissuesoptimally.Softwarehasbeenintroducedovertheyearsto
allowforfastimagereconstructioninanydesiredplane(2D)orsurfacereconstruction(3D).37CTdependsupon
multiplethinslicesofradiationthatarebackplottedthroughFouriertransformers.Thecontinuousmovement
offeredbyspiralCT,referredtoasmultisliceormultidetectorCTscanners,greatlyreducescantime.These
newermultisliceCTscannersrepresentamajorimprovementinhelicalCTscantechnology,wherein
simultaneousactivationofmultipledetectorrowspositionedalongthelongitudinalorzaxis(directionoftable
organtry)allowsacquisitionofinterweavinghelicalsections.38Withthisdesign,sectionthicknessis
determinedbydetectorsizeandnotbythecollimator(adevicethatfiltersrayssothatonlythosemoving
paralleltoaspecifieddirectionareallowedtopass)itself.38
ImagequalityinCTimagingdependsonavarietyoffactors,whicharemostlyselectedbytheoperator.Two
parametersareusedtodefinetheimagequalityofagivensystem:spatialresolutionandcontrastresolution:37
Spatialresolution:Spatialresolutionisdefinedastheabilityofthesystemtodistinguishbetweentwo
closelyspacedobjects.Forimprovementofspatialresolution,theoperatorselectsasmallmatrixsize(256
256),smallfieldofview,andthinslices.Specialreconstructionalgorithmscanalsobechosento
improvespatialresolutions.
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Contrastresolution:Contrastresolutionisdefinedastheabilityofthesystemtodiscriminatebetweentwo
adjacentareaswithdifferentattenuationvalues.Theoperatorhasseveralchoicestoimprovecontrast
resolution:appropriateselectionofreconstructionalgorithm,tubecurrent(measuredinmilliamperes),
scanningtime(measuredinseconds),pixelsize(matrix),andslicethickness.Itmustberememberedthat
increasingtubecurrentorscanningtimeincreasestheradiationdose.Anotherstrategytoincreasecontrast
resolutionistousecontrastmaterial,eitherintraarticularorintravenous.ThecontrastresolutionofCTis
dramaticallybetterthanconventionalradiography(approximately100times),andtheimagesprovide
greatersofttissuedetailthandoplainfilms.7
Providedthepatientremainsmotionlessforthestudy,theCTscanprovidesgoodvisualizationoftheshape,
symmetry,andpositionofstructuresbydelineatingspecificareas(Fig.78).Thisinformationcanbehelpfulin
theexaminationofacutetrauma,aneurysms,infections,hematomas,cysts,andtumors.
FIGURE78
CTimageofalumbarspineshowingbilateralspondylolysisattheL5S1level.
CervicalSpine
CTismostoftenutilizedinthecervicalspineexaminationintheassessmentofpotentialfractures,butmaynot
bethemodalityofchoicewhenusedinisolationforsofttissueimaging.Forexample,theaccuracyofCT
imagingrangesfrom72%to91%inthediagnosisofdiskherniation,butapproaches96%whencombiningCT
withmyelography.39,40ACTMisadiagnostictoolthatusesradiographiccontrastmedia(dye)thatisinjected
intothesubarachnoidspace(cerebrospinalfluid[CSF]).Afterthedyeisinjected,thecontrastmediumservesto
illuminatethespinalcanal,cord,andnerverootsduringimaging.Thelowviscosityofthewatersolublecontrast
permitsfillingofthenerverootsandbettervisualization.7
CLINICALPEARL
MultiplestudieshaveindicatedCTtobesuperiortoradiographyindetectingfracturesofthecervicalspine,
evensmallfractures.41
Shoulder
CTistypicallyusedforsuspectedfractures,particularlyoftheglenoidrim.
Elbow,Forearm,Wrist,andHand
CTispreferredoverradiographyincasesofsuspectedligamentousinstability.Inaddition,fracturelinesand
fragmentlocationscanbestbedelineatedwiththehelpofCT.CThasalsobeenusedtoprovideaccurate
assessmentofthereorientationofthedistalradiusarticularsurfacefollowingfracture,whichiscriticalin
determiningwhetherclosedoropenreductionisthepreferredcourseofaction.42
PelvisandHip
CTofthehipandpelvisishelpfulwithidentifyingthespatialrelationshipsoffracturesofthefemoralheadand
acetabulumandanyassociatedfragments,particularlyincasesofcomplicatedfractures.43CTisalso
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recommendedwhenconsideringcongenitalhipdysplasia,preoperativeprosthesisplanning,andthedetectionof
neoplasms.44
Knee
CTscansareoftenusedtoviewsofttissuesaswellasthebonesofthekneejointcomplex.
AnkleandFoot
CToftenenablesdelineationofcorticalandtrabecularorientationsofbone,andthearticularsurfacesofthe
jointsbetterthanplainfilms.Thisisparticularlytrueincasessuchasatalardomeinjury.
MAGNETICRESONANCEIMAGING
Unlikeanxray,orCT,MRIdoesnotuseionizingradiationbut,rather,utilizesanapparentlysafeinteraction
betweenstaticmagneticfields,radiofrequency(RF)waves,atomicnuclei,andcompleximagereconstruction
techniques.45Theabilitytomanipulatetheseinteractionsallowsfordifferenttissuecontrastfromthesame
anatomy,andthedelineationofpathology.46AnMRIcanalsoaidindiagnosis,staging,andtreatment
monitoring.MRIhasbeenaviableimagingtechniquesincetheearly1980s,andhasnowbecomethestandard
modalityfordifferentiatingamongsofttissuesintheneuromusculoskeletalsystem.37Certainnuclei(themost
commonbeinghydrogen,carbon13,fluorine,sodium,andphosphorus)generatetheirownmagneticmoment
andsohaveaninherentinteractionwithexternalmagneticfields,whichmeanstheyareabletoabandontheir
normalrandomspatialorientationsandalignparallelorantiparallelwhenexposedtoalargemagneticfield.46
ClinicalMRIprimarilyutilizestheabundanthydrogennuclei,whicharepresentasboundorfreewaterinthe
body.46Protonsalsohaveanaturalspinningmotionataspecificfrequency(Lamorfrequency).WhenanRF
pulseofthesamefrequencyasthatofthespinningprotonswithinthemagneticfieldisapplied,theprotonsare
deflectedfromtheirnewlyalignedaxisbyaspecificangle,withthedegreeofdeflectionbeingdependentonthe
strengthoftheappliedRFwavepulse.Theanglebywhichthemagnetizationistipped(alsoknownastheflip
angle)isalsodependentonthelengthoftimetheRFpulseisapplied.46Theprotons,nowspinning
synchronously,orcoherently,atananglewiththemagneticfield,induceacurrentinanearbytransmitter
receivercoilorantenna.Arangeofreceivercoilsisavailabletosuitdifferentanatomicalareasofinterest,and
providethebestsignaltonoiseratio.Thissmallnuclearsignalisthenrecorded,amplified,measured,and
localized(linkedtotheexactlocationinthebodywheretheMRIsignaliscomingfrom),producingahigh
contrast,clinicallyusefulMRimage.Thesignalstartstodecayorrelax,assoonastheRFpulseisdiscontinued,
andtheprotonsbegintoreturnbacktoastateofequilibrium.Thedecayingofthesignalisintimatelyrelatedto
tworelaxationprocesses:
Therealignmentoftheprotonswithinthemagneticfield(longitudinalrelaxation).Thisisanexponential
processthatdependsontheinteractionofthenucleuswithitssurroundings.
Thetimeconstantthatdescribestheprocesswherebythenucleusspinsgooutofphasewitheachother
(dephasing),losingtheirinitialcoherenceandsynchronizationastheycontinuespinningatanangletothe
magneticfield(transverserelaxation).
Thesetwophenomena,calledT1(longitudinal)andT2(transverse)relaxationtimes,arebiologicalparameters
withtissuespecificrelaxationconstantsfordifferenttypesoftissueandtheirmolecularcomposition.Bothof
theseprocessesoccurtogetherandcannotbeseparatedbutpulsesequences(seelater)canbechosentoincrease
thecontributionofeitherT1orT2,tooptimizetherequiredcontrast.45T1referstothetimeittakesforthe
tissuetorecover63%ofitsoriginallongitudinalmagnetization,whereasT2referstothetimeittakesfor63%of
theoriginalexcitedtransversemagnetizationtoremain.46Eachbiologicaltissuetypehasdifferentcharacteristic
T1andT2rates,whichareaffectedbythenatureofthetissue.46Forexample,tissuessuchaswaterhavevery
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mobileprotonsthatreturnveryquicklytoalignmentinthemagneticfield,whereasboneprotonsarelargely
immobile.Achangeinrelaxationtimesmayindicatepathology.46Forexample,anincreaseinfatassociated
withmuscleatrophywillshortenT1andT2timeswhereastheelevatedwaterassociatedwithmuscleedema,
andmuscledenervation,willbothlengthenrelaxationtimes.46T1andT2canbemeasuredindependentlyto
createimagesthataredependentondifferentT1valuesofthetissues(T1weightedimages[T1WI])oron
differentT2values(T2weightedimages[T2WI]).ImagescontainingT1andT2informationarecalledbalanced
imagesorprotondensityweightedimages(PDWI).Tissuecontrastdevelopsasaresultoftheratesatwhich
nucleirealignwiththemainmagneticfieldandisdependentonthedifferencesbetweenT1,T2,andtheproton
densityvaluesonT1WI,T2WI,orPDWI.Forexample,fat(includingmarrowfat)isbrightonT1WI,while
CSFisdark,andstructureswithhighfibroustissuecontentsuchastendons,ligaments,andcorticalboneare
alsodark.WithT2WI,fluidsincludingCSF,synovialfluid,andedemaarebright,whilethefatsignalvaries,and
fibrousstructuressuchastendons,ligaments,andcorticalboneareagaindark.
CLINICALPEARL
ContrastagentscanbeusedinMRItochangetheT1andT2relaxationproperties.Forexample,agadolinium
basedcontrastagentisusedtoshortenbothT1andT2relaxationtimes.46
ThespecifictechniquesforobtainingtheMRIarecalledpulsedsequences.MostMRIusesaspinecho(SE)
techniquetoproducehighqualityimages,butatthecostoflongscantimesandhighenergydepositionin
tissue.45Gradientrecalledecho(GRE)sequencesreducethescantimeandenergydepositionatthecostofsome
quality,particularlywheretissuesofdifferenttypesinterface.45Anotherechotypeisthestimulatedecho,which
requiresthree90degreeRFpulsesinarow,whichhashalfthesignaltonoiseratioofanequivalentSE
sequence.Imagecontrastcanbeenhancedbymanipulatingtwosequencefactors:therepetitiontime(TR),echo
time(TE):
Repetitiontime.ThisistheamountoftimebetweensuccessiveRFpulsesappliedtothesameslice.
Echotime.Thisrepresentsthetimeinmillisecondsbetweentheapplicationofthe90degreepulseandthe
peakoftheechosignal.Bychangingtheseparameters,theoperatorcancontroltherateofrepetitionof
theRFpulses(TR),thetimeelapsedbetweenanRFpulseandtheproductionofthesignalorecho(TE),
andtheintensityoftheappliedRFpulsewhichdeterminestheFA.
ImagesobtainedusingshortTRandshortTEwillproduceT1weightedcontrast.
ImagesobtainedwithlongTRandlongTEwillproduceT2weightedcontrast
ImagesobtainedwithlongTRandshortTEwillproducePDweightedcontrast.
Table74itemizesthedifferencesinsignalintensitiesonT1weightedandT2weightedMRimages.
TABLE74DifferencesinSignalIntensityonT1Weighted(T1W)VersusT2Weighted(T2W)Images
Tissue T1W T2W
Corticalbone Low Low
Tendonsandligaments Low Low
Fibrocartilage Low Low
Muscle Intermediate Intermediate
Nonneoplastictumor Lowintermediate Low/intermediate/possiblehigh
Neoplastictumor Lowintermediate Intermediatehigh/possiblelow
Water,CSF Low High
Inflammation Low High
Proteinaceousfluid,abscess Intermediate High
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Fat Tissue High T1W High(slightlylowerthanonT1W)

T2W
Hemorrhage,acute High High
Hemorrhage,chronic Low High
DatafromMorrisC,ed.LowBackSyndromes:IntegratedClinicalManagement.NewYork,NY:McGrawHill,
2006:495.
Becauseoftheuniquepropertiesofmagneticimaging,MRIissubjecttoanumberofartifacts.Themost
importantofthesearemetallicartifacts,specificallythoseproducedbyferromagneticobjects,whichdistortthe
alignmentofprotonsinthescannersmainmagneticfield.7Suchspatialdistortionmayproducegrossly
erroneousmeasurements.Somewhatlesscommonartifactsincludebandingartifacts,wraparound(anadjacent
areawrappingintotheareaofinterest,seenonverysmallfieldsofview)andchemicalshiftartifact(seenwhen
tissuesandmarkedlydifferentchemicalstructuresliedirectlyadjacenttooneanother,forinstance,atthe
discovertebralinterface).7
MagneticResonanceSpectroscopy
Magneticresonance(MR)spectroscopyisanadvancedMRItechniqueinvolvingtheadditionofaseriesoftests
toatraditionalMRIscanthatcomparethechemicalcompositionofnormaltissuewithabnormaltissue,and
makesanassessmentofthechemicalmetabolismofthetissues.MRspectroscopycananalyzemoleculessuchas
aminoacids,lipids,creatine,andhydrogenionsorprotons.Thus,MRspectroscopycanprovidedetailed
informationaboutthestructure,dynamics,reactionstate,andchemicalenvironmentofavarietyoftissues.For
example,MRspectroscopyhasbeenusedtoexploreandquantifythemetabolicenvironmentofthespinalcord
andbraininpatientswithvaryingspinalconditionswithneurologicalcompromise,suchasmyelopathy,chronic
whiplashrelatedpainanddisability,andfibromyalgia.47
TheadvantagesofMRIincludeitsexcellenttissuecontrast,abilitytoprovidecrosssectionalimages,
noninvasivenature,andcompletelackofionizingradiation.MRIprovidesanexcellentviewofanatomicand
physiologictissues(Figs.79and710).ItiscommonlyusedtoassesstheCNSandsofttissueinjuries.For
example,itisidealforexaminingstriatalmusclevolume,shape,andarchitecture.Inaddition,MRIhasbeen
showntobesensitiveinthedetectionofoccultbonelesions,anditcanalsodetectandhelpassessbothoccult
andtraumaticbonelesions,especiallyoccultstressandposttraumaticfracture.25Generalcontraindicationsfor
MRIinclude:7
FIGURE79
MRIshowingACLdeficientleftknee.
FIGURE710
MRIshowingACLdeficientleftkneedifferentview.
intracranialaneurysmclips
cardiacpacemakers
someprostheticheartvalves
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implantedcardiacdefibrillators
carotidarteryvascularclamp
spinalcordstimulators(neurostimulators)
insulininfusionpump(implanteddruginfusiondevice)
bonegrowthstimulator
metallichardware,devices,fragments
hearingaidsanddentures(mustberemoved)
cochlearimplants,ocularimplants,penileimplants
someshrapnelandbullets
intraocularforeignbodies
tattooedeyeliner
sometypesofmakeup
Spine
ThecombinationofmultiplanarcapabilitiesandhighcontrastresolutionthatMRimagesprovideareidealfor
spinalimaging.ComparedtoCTandradiography,MRIprovidesforthebestassessmentofsofttissuepathology
whilealsoprovidingtheonlydirectevaluationofthespinalcord.47MRIhasdemonstratedexcellentsensitivity
inthediagnosisoflumbardiskherniation,andisconsideredtheimagingstudyofchoicefordetectionand
stagingofdemyelinatingdisordersinvolvingthespine(e.g.,multiplesclerosis),syringomyelia,andfordetecting
nerverootimpingement,althoughthelatteruseistemperedbytheprevalenceofabnormalfindingsin
asymptomaticsubjects.48Itcan,however,detectligamentanddiskdisruption,whichcannotbedemonstratedby
otherimagingstudies.49,50
Shoulder
ItisimportanttoimagetheGHjointwithadedicatedshouldercoil.47ChallengesthataffectshoulderMRI
includeinherentoffcentermagnetplacementofthisjoint,withreductionofthesignaltonoiseratioandless
homogeneousfatsuppression.47ThemainindicationsforMRIoftheshoulderincluderotatorcuffpathology,
proximalhumerusfracture,bicepstendinopathy,GHjointinstability,andshoulderpainofunknownetiology.
Thepatientispositionedinsupinewiththearminaneutralpositionasinternalrotationoftheshouldercreates
structureoverlapping.Theshoulderjointistypicallyimagedinthreeplanes:51
Axial.Thesecanbeusedtoassessthesubscapularistendon,theextraarticularportionofthelongheadof
thebicepstendon,thearticularcartilage,thelabrum(particulartheanteriorandposteriorlabrum)the
jointcapsule(includingthesuperior,middle,andinferiorGHligaments),theACjoint,andallthe
osseousstructures,particularlythehumeralhead.
Obliquecoronal.Thesecanbeusedtoassessthesupraspinatusandinfraspinatustendons,thebiceps
tendonanchor,thesuperiorandinferiorlabrum,thearticularcartilage,theaxillaryrecessoftheinferior
GHligament,theACjoint,theosseousstructures,andthedeltoidmuscle.51
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Obliquesagittal.Thesecanbeusedtoassesstherotatorcuffintervalwiththecoracohumeralligamentand
thejointcapsule,theintraarticularcourseofthelongheadofthebicepstendon,glenoidmorphology,the
ACjoint,andthemorphologyoftheacromion.
Elbow
ThemainindicationsforMRIattheelbowjointaretodifferentiateboneandsofttissues,studymasslesions,
tendonandligamentouslesions,osteochondrallesions(includingloosebodies),pediatricelbowfractures,
compressiveneuropathies,rheumatoidarthritis,bicepstendoninjury,andmiscellaneousconditions.37Itis
importanttopositionthejointascloseaspossibletothecenterofthemagnet,whichusuallyinvolvesplacing
thepatientinaproneposition.45Axialscansarebestforevaluatingtheneurovascularstructures,whereas
sagittalscansbestdemonstratethearticularanatomyoftheelbowjoint.45
HandandWrist
ThemostfrequentindicationsforMRIofthehandandwristinclude:theevaluationofpalpablemasslesions,
ligamentoustears,triangularfibrocartilagecomplextears,posttraumaticavascularnecrosisofthescaphoid,
Kienbcksdisease(avascularnecrosisofthelunate),tendontears,andcompressiveneuropathies.37
Hip
MRIismostcommonlyusedinthehiptoevaluateforthepresenceofavascularnecrosisorosteonecrosisofthe
femoralhead.37OtherindicationsforMRIofthehipincludetransientosteoporosisofthehip,osteochondral
lesions,tumors,synovialchondromatosis,andpigmentedvillonodularsynovitis(PVNS).37
Knee
ThekneeisoneofthemostcommonlyimagedareasofthemusculoskeletalsystembyMRI.52Ligaments,
tendons,andmenisciallhavehighlyorderedcollagenultrastructure,interferingwiththemovementofhydrogen
moleculesbymagnetizationbyconventionalsequencessothattheyareuniformlylowinsignalontraditional
MRIpulsesequences.53Meniscalandligamentousinjuries(Figs.79and710)canbediagnosedwithan
accuracyofalmost95%.37
AnkleandFoot
ThemostcommonindicationsforMRIoftheankleincludetendonlesions,osteochondritisdissecans,chronic
ankleinstability,andpainofunknownetiology.37
DIAGNOSTICULTRASOUND(ULTRASONOGRAPHY)
Ultrasonographyevolvedwiththedevelopmentofmilitarysonar,thesendingandrecordingofacertain
frequencyofasoundwaveasitistransmittedandthenreflectedoffvariousobjects.Althoughinitiallyused
primarilyforabdominalimaging,ultrasoundimagingisrapidlybecomingappreciatedforitsmusculoskeletal
applications.Continuousorpulsedtherapeuticultrasoundproduces1MHzor3MHzthermalandnonthermal
energy,whereasdiagnosticultrasoundproducespulsedwavesat7.520MHzthatareprocessedtoproduce
pulsedechoimages.Adiagnosticultrasoundsystemiscomposedofasetoftransducers,apowersystem,anda
computerunitwithadisplayscreen.Thetransducer,whichisthedevicethatsendsandreceivestheultrasound
waves,iscomposedofanarrayofquartzcrystalsthatgeneratethesewaves.Asultrasoundwavesaretransmitted
throughthebody,theyarereflectedattissueinterfaces,andthetimeittakesforthewavestobereflectedbackto
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thetransducingprobeallowsthecomputertoproduceanimage.Thereflectivityofthesoundwaveisinfluenced
bytwofactorsasfollows:54
Theacousticimpedanceofthetwotissuescomposingtheinterface.Acousticimpedanceistheproductof
thespeedofsoundtransmissionwithinthesubstanceandthedensityofthematerial.Thereflectivityis
greatestattheinterfacesbetweentissuesofdissimilaracousticimpedance.
Theangleofincidenceofthesoundbeam.Whentheangleofincidenceofthesoundbeamisat90
degreesorperpendiculartothetissueinterface,thereflectivityishighestanddecreaseswithincreasing
angle.
Athighlyreflectiveinterfaces,almostalloftheenergyofthesoundbeamisreflected,producingasoundvoid
areabeneaththeinterface.Thisoccursbetweensofttissuesandairorcalcium.Thesoundbeamappearstobe
enhancedwhenitpassesthroughtissuesuchaswaterorotherfluidsthatdonotabsorbultrasound,therefore,
showingassoundvoidareas.Thus,differenttissuestransmitsoundwavesatdifferentvelocitiesand,therefore,
createdifferentimages.Moredensetissuesuchasboneandcollagenreflectsmorewavesthanlessdensetissue
suchaswaterorfat.
Ultrasonographyisperhapsmoreoperatordependentthananyotherimagingmodality.54Theultrasound
transducermustbeheldata90degreeangletothescanningtargettissuetopreventartifactssothatthemaximal
numberofwaveswillbeprocessedintoanaccurateimage.Technicalconsiderationsarealsoimportantbecause
itisnecessarytooperatewithhighresolutiontransducerstoobtainimageswithsufficientdiagnostic
information.Despiteitsdisadvantages,ultrasonographyisareadilyavailabletechnique,islessexpensivethan
mostotherimagingmodalities(withtheexceptionofplainfilms),doesnotinvolveionizingradiation,andis
noninvasive.54Inaddition,itallowsrealtimeimaging,afeaturethatisveryusefulforsomeconditions,suchas
snappingtendonsyndromeordevelopmentaldysplastichip,wheredynamicimagingprovidesadditional
information.54Someofthedisadvantagesofultrasonography,includingthosealreadymentioned,areasmall
fieldofviewandthepresenceofartifacts.Cometfailartifactiscausedbydeepechogenicitybandsthatcross
tissueboundariesandisusuallyassociatedwithmetalorglassforeignbodies.Otherartifactsarerefractionand
reverberation.Refractionoccurswhentheultrasonographyprobeisnotmaintainedata90degreeangle
(perpendicular)totheexaminedtissueswhichcancauseanincorrectdepictionofstructureorlesion.
Reverberationoccursathighlyreflectiveinterfacescausingtheappearanceofphantomstructures.
Ultrasonographycanbeusedtodiagnoseanypathologicalconditionthatislocatedsuperficiallyenoughtobe
detectedbythetransducer,andiscurrentlyusedinorthopaedicstohelpdetectsofttissueinjuries,tumors,bone
infections,andarthropathyandtoevaluatebonemineraldensity.Tendonsarewellsuitedbecauseoftheparallel
fasciclesofcollagenandthegroundsubstancewhichprovidedifferentreceptivity,attenuation,andbackscatter.
Ultrasonographyisparticularlyusefulinstagingmuscleinjuries,allowingforamoreaccurateestimateofwhen
anathletecanreturntosport.Ultrasoundimagingmayalsobeusedtoassessthedegreeandqualityoffracture
healingandinthedetectionofsynovitisandwoodandplasticforeignbodies.Finally,ultrasonographycanbe
usedtoconfirmproperplacementofaninjectionandprovidediagnosticinformationaswellastoprovide
treatmentforinflammatoryconditionssuchasbursitis,intraarticularloosebodies,cysts,andnervethickening.
Futureusesforultrasoundimagingwilllikelyincludetheplacementoftissuegrafts(stemcells,platelets,
matrixes)toaidinthehealingofinjuriesbecauseofitsrealtimeimagingcapabilities.
RADIONUCLEOTIDEBONESCANNING
Radionucleotidescanningstudiesinvolvetheintroductionofboneseekingisotopes,whichareadministeredto
thepatientorallyorintravenouslyandallowedtolocalizetotheskeleton.Thephotonenergyemittedbythe
isotopesisthenrecordedusingagammacamera24hourslater.Thepathophysiologicbasisofthetechniqueis
complexbutdependsonlocalizeddifferencesinbloodflow,capillarypermeability,andmetabolicactivitythat
accompanyanyinjury,infection,repairprocess,orgrowthofbonetissue.25Themostcommonradionuclide
scanningtestisthebonescan(Fig.711).Thistestisusedtodetectparticularareasofabnormalmetabolic
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activitywithinabone.Theabnormalityshowsupasasocalledhotspot,whichisdarkerinappearancethan
normaltissue.Thebonescanisanextremelysensitivebutfairlynonspecifictoolfordetectingabroadrangeof
skeletalandsofttissueabnormalities.Anabnormalbonescanmayindicatetumor,osteonecrosis,abone
infection(osteomyelitis),Pagetsdisease,orrecentfracture.Comparisonoftheaffectedandunaffectedsideis
generallyusedtodetectdifferencesinuptake.Wholebodyorspotviews,patientpositioning,andthenumberof
viewsemployeddependontheindicationfortheexamination.
FIGURE711
Bonescanshowingstressfractureoftherighttibia.
ThreePhaseBoneScan
Thethreephasebonescanconsistsofthefollowingimagephases:55
1.Flowstudy.Theinjectionisthesameasforaroutinebonescan,butimagingisbegunimmediatelyafter
theinjection.Sequentialimagesareobtainedevery23secondsfor60seconds.
2.Bloodpool.Immediatelyfollowingtheflowstudy,abloodpoolimageisobtainedovertheareaof
interest.Thisimageservesasamarkerofextravasculartissueactivity.
3.Delayedstaticimages.Afteraminimumof2hours,imagesareobtainedovertheareaofinterest.These
imagesdemonstrateradioisotopeuptakeintheosseousstructures.
SPECTScan
Singlephotonemissioncomputedtomography(SPECT)scanningimprovesboththedetectionandlocalization
ofanabnormalitybypermittingspatialseparationofbonestructuresthatoverlaponstandardplanarimages.55
Aftertheacquisitionofthestudy,acomputerisusedtoreconstructimagesinaxial,sagittal,andcoronalplanes.
Todate,boneSPECThasbeenfoundtobeofparticularclinicalvalueinstudiesofthevertebralcolumnandhas
beenshowntobemoresensitivethanplainfilmradiology,withthemajorityofSPECTlesionscorrespondingto
identifiablediseaseonCT.55SPECTscanningisahighlysensitivemeansofdetectingspondylolysis,afracture
oftheparsinterarticularis.55
Radionucleotidebonescansareusedthroughoutthebody.Applicationsoftheradionuclidebonescancanbe
dividedintotraumaticandnontraumaticcategoriesasfollows:25
Traumatic.
Fractures.
Anatomicallydifficultlocations.Theseincludethescapula,sternum,sacrum,andportionsofthepelvis.
Occultfractures(nondisplacedorstressfractures).Bonescanscanrevealmetabolicdisturbanceata
fracturesitewithin24hoursoftheinjury,longbeforeaconventionalradiographshowsanyabnormality
andoftenbeforetheyaresymptomatic.25Suchfracturesincludethetibia(Fig.711),scaphoid,radial
head,andthefemoralneck.Stressfracturesofthemetatarsalsandotherbonesareseenonbonescanupto
2weeksbeforebecomingvisibleonplainradiographs.
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Traumaticosteonecrosiswithoutfracture.
Nontraumatic
Osteomyelitis.Thisconditioncauseslocalizedincreaseduptakeoftheisotopewhichisvisibleonbone
scanwithin48hoursofthebeginningofinfection.
Atumor,primaryormetastatic.Theseareusuallydetectablebybonescanbythetimetheycause
symptoms.Theabilityofthescantocoverthewholeskeletonisparticularlyusefulfordeterminingthe
presenceandextentofmetastaticdisease.
Occultfractures.
Tendinopathyandtenosynovitis.
Hippain.
Adults:asepticnecrosis,arthritis,transientosteoporosis,occultfemoralneckfracture.Asepticnecrosis
appearseitherasahotspotoverlyingthefemoralheadorasacoldcentralareasurroundedbyaringof
increaseduptake.Transientosteoporosis,anentitymainlyaffectingyoungmen,alsodemonstrates
increaseduptakeofthefemoralheadwhenviewedunderabonescan.However,transientosteoporosis
displaysadecreasedbonedensitywhenviewedonplainfilms.Arthritiscausesincreaseduptakeof
isotopeintheperiarticularboneonbothsidesofthejoint.Occultfemoralneckfracturesresultingfrom
thenormalstressplacedonbonesweakenedbyosteoporosisareseenonthebonescanasbandsof
increaseduptakelocalizedtotheneckofthefemur.
Children:arthritis,LeggPerthesdisease.ThebonescaninLeggPerthesdiseaserevealsdecreaseduptake
atthefemoralheadearlyinthedisease.Later,aringofincreaseduptakemaysurroundthecoldspot.
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undefined
McGrawHill
Allrightsreserved.
Silverchair
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CHAPTER8:TheIntervention
CHAPTEROBJECTIVES
1.Understandanddescribetheprinciplesofacomprehensiverehabilitationprogramduringthevarious
phasesofhealing.
2.Discussthevariouscomponentsoftheinterventionandtheirrespectiveimportance.
3.Listtheclinicaltoolsthatcanbeusedtodecreasepainandinflammationandpromotehealing.
4.Discusstheintrinsicandextrinsicstimulithatcanbeusedtopromoteandprogresshealing.
5.Describethebenefitsofeachoftheelectrotherapeuticmodalities.
6.Describethebenefitsofeachofthephysicalagentsandmechanicalmodalities.
7.Understandtherationaleforthetherapeutictechniquesusedineachofthethreestagesofhealing.
8.Understandtheimportanceofpatienteducation.
OVERVIEW
Interventionisorganizedintothreecategories1:
1.Remediation.Consistsofenhancingskillsandresourcesorreversingimpairmentsandassumesthatthe
potentialforchangeexistsinthesystemandtheperson.
2.Compensationoradaptation.Referstothealterationoftheenvironmentorthetaskandistheapproach
takenwhenitisdeterminedthatremediationisnotpossible.
3.Prevention.Referstothemanagementofanticipatedproblems.
Thepurposeofthephysicaltherapyinterventionistopreventanyanticipatedproblemswheneverpossible,and
tosafelyreturnapatienttohisorherpreinjurystate,withaslittleriskofreinjuryaspossibleandwiththe
minimumamountofpatientinconvenience.Thelatterisnormallyachievedbyreducinginflammationfollowed
byagradualprogressionofstrengtheningandflexibilityexerciseswhileavoidingdamagetoanalready
compromisedstructure.2Formusclesandtendons,thisisgenerallyaccomplishedthroughmeasuredrest,
physicaltherapyproceduresandtechniquesincluding,manualtherapy,highvoltageelectricalstimulation,
central(cardiovascular)aerobics,resistanceexercisesandgeneralconditioning,whileavoidingcompromiseto
thehealingstructures.Fortheinertstructures,suchasligamentsandmenisci,moreemphasisisplacedon
controllingtheleveloftensionandforceplacedonthemtostimulatethefibroblaststoproducefiberand
glycosaminoglycans.3Beyondthehealingphase,theprogressionmayincludeadvancingtohighfunctional
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demandsorsportsspecificexercises,dependingonthepatientsrequirements.Fortheathlete,thecriteriafor
returntoplayshouldincludenopain,fullpainfreerangeofmotion(ROM),normalflexibility/strength/balance,
goodgeneralfitness,normalsportsmechanics,anddemonstrationofsportsspecificskills.4
AccordingtotheGuidetoPhysicalTherapistPractice,5aninterventionisthepurposefulandskilled
interactionofthephysicaltherapistandthepatient/clientand,whenappropriate,withotherindividualsinvolved
inthepatient/clientcare,usingvariousphysicaltherapyproceduresandtechniquestoproducechangesinthe
conditionconsistentwiththediagnosisandprognosis.
Threecomponentscomprisethephysicaltherapyintervention:coordination,communication,and
documentationpatient/clientrelatedinstructionanddirectinterventions(Box81).5
Box81ComponentsofanInterventionCoordination,Communication,andDocumentation
Theseinterventionsmayincludecasemanagement,communicationwithotherhealthcareprovidersorinsurers,
andthecoordinationofcarewiththepatient/clientorsignificantothersinvolvedinthecareofthepatient/client.
Thisistoensureacontinuumofcareamonghealthcareproviders.Otherinterventionsmayinclude
documentationofcare,dischargeplanning,educationplans,patientcareconferences,recordreviews,and
referralstootherprofessionalsorresources.
PatientRelatedInstruction
Patienteducationcaninclude,butisnotlimitedto,verbal,written,orpictorialinstructions,whichmaybepart
ofahomeprogram.Computerassistedinstructionanddemonstrationsbythepatient/clientorcaregiversarealso
examplesofinstructionsthatmaybegiven.Audiovisualaidesanddemonstrationsofexercisesorfunctional
activitiesmaybeused.Thisenablesthepatient/clienttocontinuewiththeprogramwhenoutoftheclinic,either
independentlyorwithassistance.
DirectInterventions
Directinterventionsareselectedonthebasisofthefindingsintheevaluationandexaminationofthe
patient/client,diagnosis,prognosis,andanticipatedoutcomesandgoalsfortheindividual.Thedirect
interventionsareperformedwithoronthepatient.Thissectionencompassesthelargestcomponentofpatient
care.Examplesofdirectinterventionsinclude,butarenotlimitedto,therapeuticexercise,aerobicexercise,
functionaltraining,manualtherapy,anduseofassistivedevicesandmodalities.
Aninterventionismosteffectivelyaddressedthroughaproblemorientedapproachandisbasedonthepatients
functionalneedsandonmutuallyagreedupongoals.5Decisionsabouttheinterventionaremadetoimprovethe
patientsabilitytoperformbasictasksandtorestorefunctionalhomeostasis.Themostsuccessfulintervention
programsarethosethatarecustomdesignedfromablendofclinicalexperienceandscientificdata,withthe
levelofimprovementachievedbeingrelatedtogoalsettingandtheattainmentofthosegoals(Table81).The
necessaryknowledgetoperformaninterventionincludes:6
TABLE81KeyQuestionsforInterventionPlanning
Whatisthestageofhealing:acute,subacute,orchronic?
Howlongdoyouhavetotreatthepatient?
Whatdoesthepatientdoforactivities?
Howcompliantisthepatient?
Howmuchskilledphysicaltherapyisneeded?
Whatneedstobetaughttopreventrecurrence?
Areanyreferralsneeded?
Whathasworkedforotherpatientswithsimilarproblems?
Arethereanyprecautions?
Whatisyourskilllevel?
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DatafromGuidetophysicaltherapistpractice.PhysTher.200181:S13S95.
thetemporalphasesoftissuehealing(seeChapter2),commonproblemsassociatedwitheachphase,and
stressesthattissuescansafelytolerateduringeachphase
movementcharacteristicsincludingtheamountofrange,control,andcapacityrequiredforvarious
functionalactivities
therangeofavailableinterventionstrategiesandprocedurestopromotehealingandcorresponding
outcomesinvariedpatientpopulations
sequencingofvariousinterventionstochallengeappropriatelyinvolvedtissuesandthewholepatient.For
example,beingabletorecognizetheunderlyingtissuehealingandbalancedisordersinapatientstatus
posthipfracturewithdiabetesmellitus,theneedforaerobicconditioninginassessingpatientswithlow
backdysfunction,andtheimportanceofbodymechanicseducationinprenatalandpostnatalexercise
classesand
interventionstrategiestopromoteoverallhealthandwellbeing,andtopreventsecondarydysfunction.
CLINICALPEARL
Thegoaloftheinterventionprocessistoachievethedesiredfunctionaloutcomesbyreducingexisting
impairments,preventingsecondaryimpairments,enhancingfunctionalability,promotingoptimalhealth,and
reducingenvironmentalchallenges.6,7
Whethertheidentificationofthespecificstructureorstructurescausingthedysfunctionisnecessaryinorderto
proceedwithanintervention,remainscontroversial.Cyriax8designedhisexaminationprocesstoselectively
stressspecifictissuesinordertoidentifythestructureinvolvedanditsstageofpathology.Incontrast,
McKenzie9andMaitland10,11seldomidentifiedtheinvolvedstructure,believingthatitisnotalwayspossible,
orevennecessary,fortheprescriptionofappropriatetherapeuticinterventions.Indeed,basedontheMaitland
andMcKenziephilosophy,thetherapeuticstrategyisdeterminedsolelyfromtheresponsesobtainedfromtissue
loadingandtheeffectthatloadinghasonsymptoms.9Oncetheseresponseshavebeendetermined,thefocusof
theinterventionistoprovidesoundandeffectiveselfmanagementstrategiesforpatients,whichavoidharmful
tissueloading.9However,althoughselfmanagementmustbeencouragedwheneverfeasible,thesestrategies
havetheirlimitations.Onecannotrealisticallyexpectthemajorityofpatientstofullyrehabilitatethemselves
withaconditionthatrequirestheintegrationofamultitudeofdecisionmakingprocessessuchasoccurswitha
jointreplacement,orananteriorcruciateligamentreconstruction.
ThefocusoftherehabilitationshouldbetoimproveanindividualsROM,flexibility,strength,andcoordination
toalevelthatapproximatesthedemandsofthedesiredactivity(speed,agility,strength,power,endurance,etc.).
Thus,ingeneral,therehabilitationprogramshouldfollowthefollowing10basicprinciples:12
respectthetissueinjurycycleregardingtheinvolvedstructure(s)
minimizeswelling,pain,andaddressmuscularinhibitionandatrophy
maintainandrestorenormalROM
establishanormalizedgaitpatternwithinweightbearinglimitations(lowerextremity)
restoreneuromuscularcontrol
restorecervicothoracicand/orlumbopelvicstability,asappropriate
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developupperand/orlowerextremitystrength,asappropriate
improvebalanceandproprioception
increasecardiovascularconditionand
integratesportsspecific/functionaltraining.
CLINICALPREDICTIONRULES
Manyinterventionsformusculoskeletaldisordershaveshownsmalleffectswhentestedinrandomized
controlledtrials.Identifyingpatientswhorespondbesttocertaintreatmentshasreceivedincreasedinterestin
researchactivity.Withaclinicalpredictionrule(CPR),acombinationorclusterofpatientcharacteristicsisused
todeterminethediagnosis,prognosis,orlikelyresponsetoaspecifictreatmentofthatindividual.13The
developmentofaCPRinvolvesthefollowingstages:derivation(analyzingadatasettoestablisharulewith
predictivepower),narrowvalidation(evaluatingtheruleinasimilarclinicalsettingandpopulation),broad
validation(evaluatingtheruleinmultipleclinicalsettings),andimpactanalysis(determiningwhethertherule
changescliniciansbehavior,improvespatientoutcomes,orreducescosts).13Thusfar,however,thevast
majorityoftheCPRshavebeenderivedusingsinglearmstudydesignsand,therefore,theresultsofthese
studiesmustbeinterpretedwithcaution,astheseCPRsrunagreaterriskofidentifyingprognosticfactorsrather
thanfactorsthatmodifytheeffectofatreatment.14OtherimportantlimitationsofmanyofthecurrentCPRsare
theuseofshorttermoutcomesonly,arguablytrivialfindings,andlimitedruleapplicationpotential.Todate,
onlyoneCPRonspinalmanipulationforlowbackpain15underwentvalidationinacontrolledtrialandcanbe
consideredforclinicalapplication(andonlyinapopulationsimilartothattested).14
INTERVENTIONBASEDONSTAGEOFHEALING
Theinterventionistypicallyguidedbyshortandlongtermgoals,whicharedynamicinnature,beingalteredas
thepatientsconditionchanges,andstrategieswithwhichtoachievethosegoalsbasedonthestagesofhealing
(Table81).Interventionstrategiescanbesubdividedintoactive(direct)orpassive(indirect),withthegoal
beingtomaketheinterventionasactiveaspossibleattheearliestopportunity.Theonlyinterventionthat
consistentlyappearsbeneficialacrossawidespectrumofspinalandnonspinalmusculoskeletalproblemsisthe
continuedapplicationofcontrolledstresses.
Manyfactorscancontributetothepatientsresistancetoimprovement.Insomecases,itmaybeanindividual
factorthat,wheneliminated,willallowthepatienttorespondwell.Inthemajorityofcases,theresistanceto
improvementisbasedontheinteractionofmultiplefactors,whichmustberecognizedandcorrected.
Misjudgmentsaresometimesmadewiththeintervention.Ingeneral,thepatientspainshouldnotlastmorethan
acoupleofhoursafteranintervention.Painthatlastslongerthan2hoursisusuallyanindicationthatthe
intensityoftheintervention,ratherthantheinterventionitself,hasbeeninappropriate.Theclinicianhasto
removethenotionthatallpainisbad.Inmanyrespects,aslightincreaseinpainfollowinganinterventionisa
moredesirablefindingthannochangeinpain,becauseitindicatesthatthecorrectstructureisbeingstressed,
albeittooaggressively.
AcutePhase
Theacutephasecorrelateswiththehemostasis,inflammatory,andcoagulationphasesofhealing(seeChapter
2).Clinicalfindingsduringtheacutestageareassociatedwithinflammationandincludepain,edema,redness,
heat,andimpairmentorlossoffunction.Althoughtherednessandheatarenotnecessarilyproblemsthatrequire
aspecifictreatmentgoal,pain,edema,andlossoffunctioncertainlyare.Giventhenumberofpathologicentities
thatcanbeevokedbytherepairprocess,suchascomplexregionalpainsyndrome(CRPS,previouslyreferredto
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asreflexsympatheticdystrophy)andmyositisossificans,itisclearthatneurophysiologicprocessesareatwork.
Usually,duringtheacutephase,thereisapainatrestorwithactivemotion,orwhenspecificstressisappliedto
theinjuredstructure.Thepain,ifsevereenough,canresultinmuscleguardingandlossoffunction.With
passivemobilitytesting,painisreportedbeforetissueresistanceisfeltbytheclinician.Thegoalsofthe
interventionduringthisphasearetocontrolinflammation,avoidpainfulpositions,minimizepainandedema,
restorefull,passiveROM,maintainsofttissuejointintegrity,reducemuscleatrophythroughgentleisometric
musclesetting,maintainaerobicfitnessandtoenhancefunction.Duringtheinflammatorystage,itisalso
importantforthepatienttofunctionasindependentlyaspossible.
Pain
Amajorfocusofphysicaltherapyintheacutephaseisthecontrolofpain.Atthesimplestlevel,the
transmissionofinformationrelatingtopainfromtheperipherytothecortexiscriticallydependenton
integrationatthreelevelswithinthecentralnervoussystem:thespinalcord,brainstem,andforebrain(see
Chapter3).Althoughpainservesasaprotectivemechanism,allowinganindividualtobeawareofasituations
potentialforproducingtissuedamageandtominimizefurtherdamage,itcanpersistbeyonditsusefulness.In
addition,thepresenceofpaincanstimulatemusclespasm,whichinturncanleadtocirculatorydeficiency,
muscleatrophy,andlossoffunction.Thechallengefortheclinicianduringthevariousphasesofhealingisto
controlthepainwhilesimultaneouslyprogressingthepatient.Severaldifferentapproachescanbeusedto
providepainreliefasfollows:16
Encouragethebodyscentralbiasingmechanisms(seeChapter3)throughtheuseofcognitiveprocesses
(motivation,relaxationtechniques,positivethinking,andmentalfocus).
Minimizefurthertissuedamage.Therapeuticmodalitiesareprobablythemostfrequentlyusedtoolinall
ofmusculoskeletalrehabilitation.Physicalagents,includingtherapeuticcold,electricalcurrent,and
compressioncanbeusedthroughouttheacutephase.Clearly,anunderstandingofthephysiologicalbasis
forusingtheseagentsiscriticalifcliniciansaretousetheseagentseffectively.
Educatethepatientastotherationaleofthetreatment,andwhatheorshecanexpect.
Recognizethatallpain,evenpsychosomaticpain,feelsveryrealtothepatient.
InflammationandEdema
Inflammationandedemaoccuraspartofthehealingprocess(seeChapter2).Inadditiontocontrollingpain,the
goalsduringtheinitialphaseofinterventionforanacutelesionaretocontroltheinflammationandedema,and
toprotectthedamagedstructuresfromfurtherdamage,whileattemptingtopromoteandprogresstissuehealing
andincreasefunction.
CLINICALPEARL
Severaltoolsareatthecliniciansdisposaltohelpcontrolinflammation,andedema.Theseincludeelevationof
theinjuredpartasappropriate,compression,theapplicationofelectrotherapeuticandphysicalmodalities
(cryotherapy,andhighvoltageelectricalstimulation),gentle(ROM)exercisesandgradedmanualtechniques.
LossofFunction
Neuromuscularinhibitioncanresultfrompainandjointeffusionandshouldbeaddressedasearlyaspossible.
Thefunctioncanbeenhancedthroughtheuseofassistiveandsupportivedevices(crutches,cane,sling,
immobilizer,etc.).
Twoacronymshavebeenusedforyearstohelpremembertheprotocolsduringtheacutestageofhealing:
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1.R.I.C.E.Rest,ice,compression,andelevation.Theseshouldbeused.
2.H.A.R.M.Heat,alcohol,running,andmassage.Theseshouldbeavoided,largelyduetothefactthat
theycreateheat/bloodflowor,inthecaseofrunning(forlowerextremityinjuries),heatandphysical
stress.
Morerecently,RICEhasbeenexpandedtoPRICEMEM:
Protection.Excessivetissueloadingmustbeavoided.Forexample,inthelowerextremitywhen
ambulationispainful,crutchesorotherassistivedevicesareadvocateduntilthepatientcanbearweight
painlessly,orwithinareasonabletolerance.
Rest.Restisgenerallyconsideredtobeabsencefromabuse,ratherthanacompleteabsencefromactivity
asprolongedimmobilizationcanhaveadetrimentaleffectonmuscles,ligaments,bones,collagen,and
jointsurfaces.Inresponsetothetrainingstimulus,thehealingtissuesmayundergosomebreakdownat
thesubcellular,cellular,ortissuelevel,whichwilltemporarilylowerthefunctionalabilityofeach.Arest
periodallowsthebodytoadaptbyresynthesizingtheproteininthesestructurestoahigherlevelthan
beforetheoverload.1719Thisprocessofsynthesizingtakesbetween12and48hoursdependingonthe
intensity(quality)oftheexerciseandthevolume(totalamount)oftheload.20However,itisimportantto
rememberthatifthetrainingstimulusisstopped,reduced,oralteredtoomuch,thetrainingeffectwill
decline.
Ice.Thetherapeuticapplicationofcoldorcryotherapy(seePhysicalAgents)hasbeenusedasahealing
modalitysincethedaysoftheancientGreeks.Inmostcases,iceshouldbeuseduntiltheswellinghas
ceased.Limitingtheeffusionservestohastenthehealingprocessbyminimizingtheamountof
extracellularfluidandhematomatobereabsorbed.21
Compression.Themostcommonmethodofapplyingcompressionisviaanelasticbandage.21The
compressionprovidedbyapneumaticdevice,22,23orbyafeltpadincorporatedintoanelasticwrapor
taping,24hasalsobeendemonstratedtobeeffectiveindecreasingeffusion.
Elevation.Elevationofanextremityaidsinvenousreturnandhelpsminimizeswelling.Ingeneral,
elevationandcompressionshouldbecontinueduntiltheswellinghascompletelydissipated.25
ManualTherapy.Thecontrolledapplicationofvariousmanualtechniquescanhaveseveraltherapeutic
benefits(seeChapter10).Thesebenefitsaretheoreticallyachievedthrough26,27
stimulationofthelargefiberjointafferentsofthejointcapsule,softtissue,andjointcartilage,
whichaidsinpainreduction
stimulationofendorphins,whichaidsinpainreduction
thedecreaseofintraarticularpressure,whichaidsinpainreduction
themechanicaleffect,whichincreasesjointmobility
remodelingoflocalconnectivetissue
theincreaseoftheglidingoftendonswithintheirsheathsand
anincreaseinjointlubrication.
Manualtechniques,whicharediscussedinChapter10,allowthecliniciantochoosethedegreeofspecificityof
anintervention.Manualtherapytechniquesincludinglowdosagejointmobilization(gradeIorgradeII)canbe
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usedtoimprovefluiddynamicsandtoreflexivelyinhibittheperceptionofpain(seeChapter10).Althoughthe
goalistobeasspecificaspossible,therearemanytimeswhenageneraltechniqueisappropriate.General
techniquesaretypicallylessaggressive,areappliedtothelargermusclegroupsorregions,andoftencanbe
performedbythepatientaspartofthehomeexerciseprogram.Generalmanualtherapytechniquesthatcanbe
usedduringthisstageincludegentlemassagetoincreasebloodflow.Specificmanualtechniquesthatcanbe
usedduringthisstageincludepassivejointdistractionsandglides(gradeIorII).
EarlyMotion.Earlymotionisadvocatedto28
reducethemuscleatrophythatoccursprimarilyintypeIfibers2931
maintainjointfunction
preventligamentouscreeping
reducethechanceofarthrofibrosisorexcessivescarring3236and
enhancecartilagenutritionandvascularization,therebypermittinganearlyrecoveryandenhanced
comfort.31,37,38
CLINICALPEARL
Thebenefitsofearlymobilizationaretopreventthedetrimentalphysiologiceffectsofimmobilization,including
lossofmuscle,ligament,andbonestrength39,40formationofadhesions41andlossofproprioception.42
Therapeuticexerciseisthefoundationofphysicaltherapyandafundamentalcomponentofthevastmajorityof
interventions.Prescribedaccurately,therapeuticexercisecanbeusedtorestore,maintain,andimprovea
patientsfunctionalstatusbyincreasingstrength,endurance,andflexibility.Tissuespecificmovementshouldbe
directedtothestructureinvolvedtopreventabnormaladherenceofthehealingfibrilsandfuturedisruptionof
thescar.Initially,ifthemotioniscontraindicated,gentlemusclesettingexercisescanbeprescribed.Theseare
performedintheshortenedorrelaxedpositiontopreventnewscarformationbeingpulledfromthehealingsite
beforeprogressingtoavarietyofjointangles.PassiveROMwithinthelimitsofpainisintroducedasearlyas
feasiblewhilebeingverycarefulnottoimpartanysignificantstretchtothehealingtissues.Researchhas
demonstratedthatjointmotionstimulatesthehealingoftornligamentsaroundajoint43,44andthatearlyjoint
motionstimulatescollagenbundleorientationalongthelinesofforce,akindofWolffslawofligaments.43,45
Whendesigninganexerciseprogram,theclinicianshouldcreateexercisesthataresafeyetchallenging,
progressive,systematic,proprioceptivelyenriched,activityspecific,andbasedonevidencebasedscience.46A
typicalexercisecontinuumincludesanumberofprogressions,whichincludesthefollowing:46
Activitiesinitiallyperformedslowlybeforebeingprogressedtoafasterpace.
Theperformanceoffamiliaractivitiesandthenunfamiliaractivities.
Activitiesareinitiallyperformedonastablebaseofsupportandarethenmadeprogressivelymore
challengingbyincreasingtheamountofcontrolrequired,andwiththeintroductionofactivitiesthat
requiredynamiccontrol.
Theintroductionofresistanceduringthemovements.Theinitialresistanceusedisoflowforceandthen
incrementallyincreased.
Correctperformanceoftheactivitywithincreasinglevelsofcomplexity.
CLINICALPEARL
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Thegoalofthefunctionalexerciseprogressionistoidentifythemotion,ormotions,thatthepatientisableto
exerciseinto,withoutelicitingsymptomsotherthanpostexercisesoreness.47
Medications.Pharmacologicintervention,whichcanplayanimportantroleinthemanagementofthe
painandinflammationassociatedwithorthopaedicconditionsisdescribedinChapter9.
Tissuerepaircanbeviewedasanadaptivelifeprocessinresponsetobothintrinsicandextrinsicstimuli.48
Physicaltherapycannotacceleratethehealingprocess,butwithcorrecteducationandsupervision,itcanensure
thatthehealingprocessisnotdelayedordisruptedandthatitoccursinanoptimalenvironment.9
CLINICALPEARL
Thepromotionandprogressionoftissuerepairinvolvesadelicatebalancebetweenprotectionandapplicationof
controlledfunctionalstressestothedamagedstructure.
Therehabilitationproceduresusedtoassistwiththisrepairprocessdiffer,dependingonthetypeoftissue
involved,theextentofthedamage,andthestageofhealing.Healingisrelatedtothesignsandsymptoms
presentratherthantheactualdiagnosis.Thesesignsandsymptomsinformtheclinicianastothestageofrepair
thatthetissueisundergoing.Awarenessofthevariousstagesofhealingisessentialfordeterminingtheintensity
ofaparticularinterventioniftheclinicianistoavoiddoinganyharm.Decisionstoadvanceorchangethe
rehabilitativeprocessneedtobebasedontherecognitionofthesesignsandsymptoms,andonanawarenessof
thetimeframesassociatedwitheachofthephases.49,50
Janda51introducedtheconceptofthedirectandindirecteffectsofneuralinputonmuscleactivationandnoted
theinfluencethatpainandswellingcanhaveondirectmuscleinhibition.
CLINICALPEARL
AccordingtoJanda,51musculardevelopmentcannotproceedinthepresenceofpain,becausepainhasthe
potentialtocreateahighdegreeofmuscleinhibitionthatcanaltermusclefiringpatterns.
Duringthisstage,usingtheprinciplesofPRICEMEM,resultsindecreasedearlybleedingandfacilitationofthe
removaloftheinflammatoryexudates,whichcanpreventfurtherdamageandinflammationtothearea.Limiting
theeffusionservestohastenthehealingprocessbyminimizingtheamountofextracellularfluidandhematoma
tobereabsorbed.52,53
Thecriteriaforadvancementfromthisphaseincludeadequatepaincontrolandtissuehealing,nearnormal
ROM,andtoleranceforstrengthening.4
SubacuteorIntermediatePhase
Thevariouswaysinwhichthemusculoskeletaltissueshealatthecellularlevelduringthisphasearedescribed
inChapter2.Clinically,thisstageischaracterizedbyadecreaseinpainandswellingandanincreaseinpain
freeactiveandpassiveROM(seeChapter2).DuringpassiveROM,theoccurrenceofpainissynchronouswith
tissueresistance.
AlthoughtheamountofpainfreeROMmaybeincreasedinthisphase,itisstillnotwithinnormallimits,and
stressappliedtotheinjuredstructuresstillproducespain,althoughthepainexperiencedislessened.54,55Itis
criticalduringthisphasethatthepatientbeeducatedtorecognizethesignsandsymptomsofoverstressed
healingtissues.Duringthisphase,thereislessemphasisontheuseofpassivetechniquesandmodalitiesand
moreemphasisonprogressivelystressingthehealingstructures.Thetreatmentgoalsforthisphasearetomodify
faultyjointmechanics,toprotecttheformingcollagenanddirectitsorientationtobeparalleltothelinesof
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forceitmustwithstand,andpreventcrosslinkingandscarcontracture.Ifthesegoalsareachieved,thescarwill
bestrongandextensible.
TherapeuticExercise
ThevarioustypesoftherapeuticexercisearedescribedinChapters1215.Theroleofexerciseduringthe
healingphasesisdiscussedinthischapter.AsoutlinedinChapter12,thevariouscharacteristicsofanexercise
loadinclude:20
Intensity(i.e.,speed,resistance).
Duration(amountoftimeoftheexercisesession).
Frequency(numberofsessionsperweek).
Volumeoftraining.
Length(numberofweeksormonths).
Pattern(continuousversusinterval).
Mode(e.g.,running,cycling,swimming).
Progressionsinthetotalloadofexercisecanbeachievedbyincreasingtheintensity,duration,orfrequency,ora
combinationofthethree(seeChapters1215).20Duringrecoveryfrominjury,itseemsthatthefibroblastsneed
tobeguidedsothatthereplacedcollagenfibersarelaidalongthelinesofstress.
Gentlemovementstotheareaprovidenaturaltensionsforthehealingtissuesandhelpproduceastronger
repair,56soaprogressiveincreaseinmovementshouldbeencouraged.Eachindividualrespondsuniquelyto
exercisedependingonanumberofvariables,including:20
Geneticendowment.Eachindividualhasagivengeneticpotentialthatwilllimittheextenttowhichthe
effectsofphysicaltrainingcanbemanifested.Thefartheranindividualisfromthegeneticlimit,the
largerwillbetheimprovement,butastheindividualgetsclosertothelimit,lessimprovementwillbe
elicited.Genderalsoplaysanimportantrole,aswomentendtohavelessmusclemassandmorebodyfat
atagiventraininglevel.20
Biologicalage.Anindividualsbiologicalagehasagreaterimpactthanchronologicalage.Youngeradults
haveagreaterresponsetotrainingthandoolderadults.57
Trainingstate.Individualsatlowerlevelsoffitnesswillrespondwithahigherrateandmagnitudeof
adaptationthanwhentheypossesshigherlevelsoffitness.58
Healthstatus.Duringeithersicknessorinjury,theamountofadaptiveenergyisreduced,alongwiththe
abilitytoperformatoptimalintensitiesandvolumesofwork.Thisnecessitatesareduction(or
elimination)intheprescriptionofexerciseduringsuchtimes.
Fatiguestate.Fatiguelimitsonesabilitytoworkatoptimalintensitiesordurations.
Earlymotionexercisesfollowapredictablepath:thepassiveROMusedintheacutephaseisprogressedto
activeassistiveandthentoactiveROM,basedontissueandpatientresponses.Ifsignsofinflammationincrease
ortheROMprogressivelydecreases,theintensityoftheexerciseandactivitymustdecrease.Exerciseoractivity
sorenessshoulddecreaseafter24hours.Strengtheningexercisesduringthisstageareinitiallyrestrictedto
submaximalisometrics(seeChapter12)andprotectedweightbearingexercises.Thesubmaximalisometricsare
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initiallyperformedintheearlypartoftherange,beforebeingperformedatmultipleanglesofthepainfree
ROM.AsROMandjointplayimprove,concentricexercises(seeChapter12)areinitiated,withtheresistance
beingincreasedastolerated.
ManualTherapy
Aswiththerapeuticexercise,manualtherapy(seeChapter10)playsanintegralroleinthehealingprocessby
providingcontrolledstressestothehealingtissues.Manualtherapiesduringthisstageincludejoint
mobilizations(gradeII)tohelprestorenormaljointplay,transversefrictionmassage,andgentlecontractrelax
techniques.Itisimportanttoemphasizetothepatientthatanoverlyaggressiveapproachduringthisstagecan
resultinadelayordisruptionintherepairprocessthroughanincreaseinthestimulationoftheinflammatory
chemicalirritantsandexudates.
Thecriteriaforadvancementtothechronicoradvancedstageofrehabilitationincludesnocomplaintsofpain
full,painfreeROMgoodflexibilityandbalanceandstrengthof7580%,orgreater,comparedwiththe
uninvolvedside.4
ChronicorReturntoFunctionPhase
Thevariouswaysinwhichthemusculoskeletaltissueshealatthecellularlevelduringthisphasearedescribed
inChapter2.Duringthisstage,paintypicallyisfeltattheendoftherangewithpassiveROM,afterthetissue
resistancehasbeenencountered.Thegoalsduringtheearlypartofthisphaseincludeagradualreturntoafull
andpainfreeROM,toprogressivelyincreasemovementspeed,andcontinuetodevelopneuromuscularcontrol.
Bytheendofthisphase,afullandunrestrictedROMshouldbepresent,andmoreaggressiveworkrelatedand
sportsspecificmovementsandactivitiesareincorporatedasappropriate.
ManualTherapy
Manualtechniquesmayberequiredatthisstagetoemphasizetherestorationofaccessoryjointmotionandto
increasetheextensibilityofsofttissues.Techniquestoincreaseaccessoryjointmotion(seeChapter1)may
includejointmobilizations(gradesIIIV).Techniquestoincreasesofttissueextensibilityincludeavarietyof
techniquesincludingpassivestretchingandmyofascialrelease(seeChapter10).
Taping
Similartomanualtherapy,tapingtechniquescanbeanintegralpartofacomprehensiveinterventiontoimprove
thequalityofmovement.Tapingmayattempttoreinforcethenormalprotectivesupportstructures,improve
proprioception,enhanceneuromuscularactivation,and/oralteredbiomechanics.59Theinherentpropertiesofthe
differenttypesoftapeavailablevarysignificantlysuchthatthedifferingcharacteristicsofeachcanbeusedfor
differentpurposes:59
Zonas(Johnson&Johnson,Skillman,NJ)andLeukotape(BSN,JOBST,Toledo,OH)haveapproximately
thesamenumberofprimaryfibersthatareparalleltothedirectionalloading.However,Leukotapehas
secondaryfibersorientedat45degreestotheloadingdirection,whichcanhelpdissipatemultidirectional
loading,increasethetensilestrength,andincreasethestiffnessofthetape.
Jaylastic(Jaybird&Mais,Westboro,MA)hasconsiderablyfewerfibersinthedirectionalloadingand
subsequentlylowertensilestrengthbutgreaterextensibility.
Occlusivetapinghaslessadhesiveforcethanpermeabletape(Coban)duetofluidaccumulationunderthe
tape.
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TherapeuticExercise
Themusculoskeletaltissuesrespondtothecontrolledstressesappliedtothembyadaptation.Thisresponsehas
beendescribedasaspecificadaptationtoimposeddemand(SAID)(seeChapter12).60
CLINICALPEARL
TheSAIDprincipleacknowledgesthatthehumanbodyrespondstoexplicitdemandsplaceduponitwitha
specificandpredictableadaptation.Sinceeachloaddemandsaspecificadaptation,avarietyofloads(cross
training)willstimulateavarietyofadaptations.20
Theapplicationofinappropriatestressescanleadtovariousformsoftissuedysfunction,suchascontracture,
laxity,fibrosis,adhesion,diminishedfunction,repeatedstructuralfailure,andanalterationinneurophysiologic
feedback.61,62
CLINICALPEARL
IftheROMandjointplayarerestricted,thepatientcontinueswithisometricsatvariousanglesintherange.
Otherwise,thepatientisprogressedthroughacontinuumofresistiveexercises.
Thehierarchyoftheresistiveexerciseprogressionisbasedonpatienttoleranceandresponsetoensurethatany
progressmadeisdoneinasafeandcontrolledfashion.Thetypicalsequenceoccursinthefollowingorder:63
Smallarcsubmaximalconcentric/eccentric
FullROMsubmaximalconcentric/eccentric
FullROMsubmaximaleccentric
Functional/activityspecificplanesubmaximalconcentric
FunctionalROMsubmaximaleccentric
Openandclosedkineticchainexercisesperformedconcentricallyandtheneccentrically
FullROMsubmaximalconcentricisokinetic
FullROMsubmaximaleccentricisokinetic
FunctionalROMsubmaximaleccentricisokinetic
Intheinstanceofchronicconditions,aslightincreaseorworseningofsymptomsissometimespermissiblewith
exercise,becausethedesensitizationofsomeofthestructuresmayrequireamechanicalinputviastimulationof
thelargeAfibers(seeChapter3).However,theincreaseinsymptomsmayalsosignalaretriggeringofthe
inflammatoryprocess.64Tohelppreventthesepathologicchanges,Liebenson65recommendsthefollowing:
Patienteducationabouthowtoidentifyandcontrolexternalsourcesofbiomechanicaloverload.
Earlyidentificationofpsychosocialfactorsofabnormalillnessbehavior.
Identificationandrehabilitationofthefunctionalpathology.
Whatisconsideredtobenormalflexibility,strength,speed,andaerobicoranaerobicenduranceformost
patientsinrehabilitationisinadequateforthosepatientsreturningtosport.66Asskillisassociatedwith
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enhancedmechanicalefficiencyandreducedriskofinjury,skillinexercisespecificactionshouldbeestablished
beforethetrainingloadisincreased.20
Inthemodern,costconscioushealthcareenvironment,thestageatwhichthepatientisreadytoreturntofull
functionisnotoftenplayedoutintheclinic.Althoughpatienteducationemphasizingaslowandgradualreturn
toactivitycan,tosomeextent,preparethesubjectforthisphase,reinjury,orinsufficientrecovery,isareal
possibility.
Thetermsfunctionandfunctionalhavebeenusedextensivelywithinthefieldofrehabilitation.Inthecontextof
physicaltherapy,functionhasbeendefinedasthoseactivitiesidentifiedbyanindividualasessentialtosupport
physical,social,andpsychologicalwellbeingandtocreateapersonalsenseofmeaningfulliving.67Functional
limitationshavebeendescribedasthelimitationofperformanceatthelevelofthewholeorganismorperson
andshouldnotbeconfusedwithdiseases,disorders,conditions,orimpairmentsinvolvingspecifictissue,organ,
orsystemabnormalitiesthatresultinsignsorsymptoms.67
Therefore,inordertorestorefunction,theclinicianmustthinkbeyondthelevelofimpairmentsofspecific
tissuesandstructuresresultingfrominjury,butinsteadfocusonthefunctionallimitationsofthepatient.Such
focusrequiresknowledgeoffunctionaltestingratherthanthetraditionalclinicaltesting(e.g.,ROM,strength).
Functionaltaskscanbedesignedtoassessthebalance,balancereach,excursion,speedandagility,endurance,
strength,andpowerofthepatient,whichcanthenbeequatedwithfunction.68Similarly,functionalprogression
trainingshouldinvolvenotmerelythereproductionofanactivityortaskbyanexercise.Instead,theultimate
goaloffunctionaltrainingistherestorationofthepatientsconfidence,whichimpliesareturntonormalofthe
neurovascular,neurosensory,andkinestheticsystemsofthebody,sothatthereflexperformanceofamovement
isnotdeliberate,hesitant,ordyskinetic.6971
Itshouldbeobviousthatthespeedandextentbywhichtheinjuredtissueshealdeterminesboththespeedand
theextentoftheprogressiontowardanoptimumfunctionaloutcome.Whileitisvirtuallyimpossibletohasten
thehealingprocess,itispossibletoprescribeacontrolledandsafecontinuum,inwhichthepatientcanimprove
hisorherfunctionalstatus,withoutharmingthehealingstructures.
Functionalprogressiontraining,aswithexerciseprogressions,mustbedesignedinasequential,stepbystep
manner,beginningwithsimpletasksandprogressingtohighlycoordinatedtasks,witheachstepintheprocess
requiringgreaterskillthanthelast.Theoverridingprincipleoffunctionalrehabilitationistoreturnpatientsto
thefunctionalleveltheydesire,oratwhichtheywerepreviouslyfunctioning.70
Ataskorientedapproachrequiresthecliniciantounderstandthespecificrequirementsofanoccupation,
activity,orsport.Theclinicianshouldassumethatthetasksinvolvemotionsorstressesinallthreeplanes
multiplejoints,segments,orlimbscontributionsfromuniarticularandmultiarticularmusclesandthe
simultaneousneedforthebodytomoveandbestable.72Importantspecificconsiderationsincludethe:72
commonposturesandmovementpatterns
theamountofmotion
thespeedofmovement
natureandmagnitudeofforces/resistances
dominantdirections/planesofmotion
muscularactivationpatterns
jointspecificdemands
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symmetryorasymmetryofmotion
unilateralorbilaterallimbdemandsand
environmentaldemands.
Functionalprogressionsthatarespecifictothelowerorupperextremityareincludedinvariouschaptersofthis
book.Functionalprogressionsandtheirgradingforthenonathletearealsoincluded.Anumberoffunctional
progressionsforathleteshavebeendevisedtoguidetheclinician.Mostoftheseprogressionsoriginatedfrom
postsurgicalprotocols,inparticular,fromanteriorcruciateligamentreconstructionsandrotatorcuffsurgery,
whichdealwithvariousfunctionallevels.
ChronicInflammation
Mostinjuries,whentreatedappropriately,resolveontheirown,providedthattheinjuredtissueisallowedto
progressthroughthenaturalstagesofhealing.Ifthisnaturalprogressiondoesnotoccur,chronicinflammation
canresult(Table82)(seeChapter2).Whilesimilarinterventionprinciplescanbeappliedinthepresenceof
chronicinflammationsuchascryotherapy,controlledrest,therapeuticexercise,andmanualtherapy,additional
focusmustbeplacedondeterminingthecauseofthechronicirritation.Forexample,anassessmentofflexibility
andstrength,posture,footwear,technique,runningstyle,repetitiveactivities,ormotionsmustbeperformed.A
moresubtlecauseofchronicinflammationcanbethepresenceofahypermobilejoint,whichallowsthe
excessivemotiontooccurthatmustbecompensatedforalongthekinematicchain.Thishypermobilityshould
beaddressedusingjointstabilizationtechniques(seeChapter14).Themorecommonoveruseinjuriesare
describedintherelevantchapters.
TABLE82CausesandContributingFactorsofChronicInflammation
Causesand
Contributing Description
Factors
Overuse,
repetitivestrain, Repetitivemicrotraumaovertimeresultsinstructuralweakening,orbreakdownofconnective
andcumulative tissue
trauma
Traumawith
Resultsinaconditionthatnevercompletelyhealsandtheinvolvedregionbecomesmore
subsequent
susceptibletoinjury
microtrauma
Sincescartissueisnotascompliantasundamagedtissue,itisunabletosustainthestresses
Scarring
thatnormal,healthytissuecansustain
Adaptive
shorteningof
Connectivetissuecontracturescanbecomestressedwithrepeatedorvigorousactivity
connective
tissues
Imbalance
betweenlength
Thiscanleadtofaultymechanicsofjointmotionand/orabnormalforcesthroughthemuscles
andstrengthof
muscles
Improperperformanceandequipmentcoupledwiththeconditionoftheparticipantandan
inappropriateintensityoftheexercisecanleadtoabnormalstresses.Inaddition,asudden
Trainingerrors
increaseorchangeinanexerciseortrainingroutinemaynotbetoleratedbytheconnective
tissues
Agerelated Thereisadeclineintheoverallcomplianceoftissueswithagingwhichreducestheirability
factors towithstandsustainedstress
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Causesand
Contributing Description
Factors
Excessive
Thereisamarkedincreaseintheproportionofdisruptedmusclefibersaftereccentricas
repeated
comparedwithconcentricexercise.Eccentricexerciseisalsolinkedtomorphologicand
eccentric
metabolicsignsofmusclealteration:myofibrillardamagealongtheZband
demand
Muscle
Musclefatigueresultsinadecreaseincontractilityandshockabsorbingcapabilities
weakness
Faulty
biomechanics Anybiomechanicaloranatomicalasymmetries,particularlyinthelowerextremitiescanlead
andanatomical tostructuralbreakdownthroughcompensation
malalignment
RehabilitationModalities
Clinicianshaveattheirdisposalabatteryofphysicalagentsandelectrotherapeuticmodalitiesforuseinthe
acutephaseandoncetheacutestageofhealinghassubsided.Themodalitiesusedduringtheacutephase
involvetheapplicationofcryotherapy,electricalstimulation,pulsedultrasound,andiontophoresis.Modalities
usedduringthelaterstagesofhealingincludethermotherapy,phonophoresis,electricalstimulation,ultrasound,
iontophoresis,anddiathermy(Tables83and84).
TABLE83ClinicalDecisionMakingontheUseofVariousTherapeuticModalitiesinTreatmentofAcute
Injury
Possible
Approximate Rationalefor
Phase ClinicalPicture Modalities
TimeFrame Use
Used
CRYO Swelling,
ESC pain
Initialacute Injuryday3 Swelling,paintotouch,andpainonmotion IC Pain
LPL Swelling
Rest Pain
CRYO
Swelling,
ESC
Swellingsubsides,warmtotouch, pain
Inflammatory IC
Days16 discoloration,paintotouch,andpainon Pain
response LPL
motion Swelling
Rangeof
Pain
motion
THERMO Mildly
ESC circulation
LPL Painmuscle
Fibroblastic
Days410 Paintotouch,painonmotion,andswollen IC pumping
repair
Rangeof Pain
motion Facilitate
Strengthening lymphaticflow
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Possible
Approximate Rationalefor
Phase ClinicalPicture Modalities
TimeFrame Use
Used
ULTRA Deepheatingto
ESC circulation
LPL Rangeof
SWD motion,
Maturation Day7 Swollen,nomorepaintotouch,and MWD strength
remodeling recovery decreasingpainonmotion Rangeof Pain
motion Pain
Strengthening Deepheatingto
Functional circulation
activities
CRYO,cryotherapyESC,electricalstimulatingcurrentsIC,intermittentcompressionLPL,lowpowerlaser
MWD,microwavediathermySWD,shortwavediathermyTHERMO,thermotherapyULTRA,ultrasound,
decrease,increase.
DatafromPrenticeWE.Usingtherapeuticmodalitiesinrehabilitation.In:PrenticeWE,VoightML,eds.
TechniquesinMusculoskeletalRehabilitation.NewYork,NY:McGrawHill2001:299.
TABLE84IndicationsandContraindicationsforTherapeuticModalities
PhysiologicResponses Contraindicationsand
TherapeuticModality
(IndicationsforUse) Precautions
Electricalstimulatingcurrents Painmodulation Pacemakers
Musclereeducation
Musclepumpingcontractions
Retardatrophy
Thrombophlebitis
Highvoltage Musclestrengthening
Superficialskinlesions
IncreaseROM
Fracturehealing
Acuteinjury
Woundhealing Malignancy
Lowvoltage Fracturehealing Skinhypersensitivities
Iontophoresis Allergiestocertaindrugs
Painmodulation
Musclereeducation
Interferential Musclepumpingcontractions Sameashighvoltage
Fracturehealing
IncreaseROM
Russian Musclestrengthening Pacemakers
Fracturehealing Malignancy
Microelectricnervestimulation
Woundhealing Infections
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PhysiologicResponses Contraindicationsand
TherapeuticModality
(IndicationsforUse) Precautions
Metalimplants
Increasedeepcirculation Pacemakers
Increasemetabolicactivity Malignancy
Reducemuscleguardingand Wetdressings
spasm Anesthetizedareas
Reduceinflammation Pregnancy
Shortwavediathermyandmicrowavediathermy Acuteinjuryand
Facilitatewoundhealing
Analgesia inflammation
Increasetissuetemperatures Neareyes
overalargearea Areasofreducedblood
flow
Anesthetizedareas
Acuteinjury
Vasoconstrictionanddecreased Allergytocold
bloodflow Circulatoryimpairments
Cryotherapy(coldpacksandicemassage)
Analgesia Woundhealing
Reduceinflammation Hypertension
Reducemuscleguarding/spasm
Vasodilationandincreased
bloodflow
Acuteandpostacute
Analgesia
trauma
Thermotherapy(hotwhirlpool,paraffin, Reducemuscleguardingand
Poorcirculation
hydrocollator,andinfraredlamps) spasm
Circulatoryimpairments
Reduceinflammation
Malignancy
Increasemetabolicactivity
Facilitatetissuehealing
Painmodulation(triggerpoints) Pregnancy
Lowpowerlaser
Facilitatewoundhealing Neareyes
Acne Psoriasis
Asepticwounds Eczema
Ultraviolet Folliculitis Herpes
Pityriasisrosea Diabetes
Tinea Pellagra
Lupuserythematosus
Hyperthyroidism
Septicwounds
Renalandhepatic
Sinusitis
insufficiency
Increasecalciummetabolism
Generalizeddermatitis
Advancedatherosclerosis
Increaseconnectivetissue Infection
extensibility Acuteandpostacute
Deepheat injury
Increasedcirculation Epiphysealareas
Ultrasound
Treatmentofmostsofttissue Pregnancy
injuries Thrombophlebitis
Reduceinflammation Impairedsensation
Reducemusclespasm Neareyes
Decreaseacutebleeding
Intermittentcompression Circulatoryimpairment
Decreaseedema
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ROM,rangeofmotion.
DatafromPrenticeWE.Usingtherapeuticmodalitiesinrehabilitation.In:PrenticeWE,VoightML,eds.
TechniquesinMusculoskeletalRehabilitation.NewYork,NY:McGrawHill2001:301.
Atpresent,withtheexceptionofcryotherapy,thereisinsufficientevidencetosupportorrejecttheuseof
modalities.7375However,theabsenceofevidencedoesnotalwaysmeanthatthereisevidenceofabsence(of
effect),andthereisalwaystheriskofrejectingtherapeuticapproachesthatarevalid.76
CLINICALPEARL
Itisimportantthattheclinicianhaveanunderstandingoftheprinciplesthatrelatetoaparticularmodalityso
thatthemodalityisusedwhenindicated,andthemaximumtherapeuticbenefitmaybederivedfromitsuse.
Ifmodalitieshaveaplaceintheclinic,itisduringtheacutephaseofhealing,whenthereislittletheclinician
candointheformofmanualtechniquesortherapeuticexercise.Intheremodelingorfunctionalphase,thermal
modalitiesmaybeusedtopromotebloodflowtothehealingtissuesandtopreparethetissuesforexerciseor
manualtechniques.However,attheearliestopportunity,thepatientshouldbeweanedawayfromthese
modalities,andthefocusoftheinterventionshouldshifttotheapplicationofmovementandtherepeatedand
prolongedfunctionalrestorationoftheinvolvedstructures.
Twocategoriesofmodalitiesarerecognized:
1.Physicalagentsandmechanicalmodalities
2.Electrotherapeuticmodalities
PhysicalAgents
Physicalagentsaresourcesofenergythatareusedtherapeutically.
Cryotherapy.Cryotherapy,whichremovesheatfromthebody,therebydecreasingthetemperatureofthebody
tissues,isthemostcommonlyusedmodalityfortheinterventionofacutemusculoskeletalinjuries.Theuseof
icebyitselforinconjunctionwithcompressionhasbeendemonstratedtobeeffectiveinminimizingtheamount
ofexudate.7782Cryotherapycanbeappliedinvariousforms,butcrushedicebags(CIB),coldpacks(Fig.81),
andcoldwaterimmersion(CWI)arefrequentlyused.Amoreexpensiveformofcryotherapycanbesuppliedby
apneumaticcoldcompressionunitsuchasGameReady(Fig.82)thatsimultaneouslydeliversactive
pneumaticcompressionandadjustablecoldtherapiestospecificareasofthebody.
FIGURE81
Coldpack.
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FIGURE82
Pneumaticcoldcompressionunit.
Thephysiologiceffectsoflocalcoldapplicationareprincipallytheresultofvasoconstriction,reducedmetabolic
function,andreducedmotorandsensoryconductionvelocities.Theseeffectsincludethefollowing:
Adecreaseinmuscleandintraarticulartemperature.Thedecreaseinmuscletemperatureand
intraarticularstructuresoccursbecauseofadeclineinlocalbloodflow55,57,60,68,69andappearstobe
mostnoticeablebetweenthetemperaturesof40Cand25C.70Temperaturesbelow25C,whichtypically
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occurafter30minutesofcryotherapy,actuallyresultinanincreaseinbloodflow(Huntingeffect),70with
aconsequentunfavorableincreaseinhemorrhageandanexaggeratedacuteinflammatoryresponse.63The
reductioninmuscleandintraarticulartemperatureismaintainedforseveralhoursafterremovalofthe
coolingagent.71Aprolongedapplicationofcold,however,canresultinasympatheticallymediatedreflex
vasodilationinanattempttorewarmthearea,whichmayactuallyworsentheswelling.71,72
Localanalgesia.75,8388ThestagesofanalgesiaachievedbycryotherapyareoutlinedinTable85.89Itis
worthrememberingthatthetimingofthestagesdependsonthedepthofpenetrationandthedepthofthe
overlyingadiposetissue.90Thepatientshouldbeadvisedastothesevariousstages,especiallyinlightof
thefactthattheburningorachingphaseoccursbeforethetherapeuticphases.
Decreasedmusclespasm.23,75,9193
Adecreaseinedema.75,94,95
Adecreaseinnerveconductionvelocity(NCV).96
TABLE85StagesofAnalgesiaInducedbyCryotherapy
Stage Response TimeafterInitiationofCryotherapy(min)
1 Coldsensation 03
2 Burningoraching 27
3 Localnumbnessoranalgesia 512
4 Deeptissuevasodilationwithoutincreaseinmetabolism 1215
DatafromHocuttJE,JaffeeR,RylanderR,etal.Cryotherapyinanklesprains.AmJSportsMed.198210:316
319.
Severalmethodsofapplyingcryotherapyhavebeenexaminedindifferentstudies.Theuseoficechipsin
towelinghasbeenshowntobemoreeffectiveindecreasingskintemperaturethanicechipsinplasticbags,or
coldgelpacks.97,98Findingsfromanotherstudy99indicatedthaticemassageandicebagsareequallyeffective
indecreasingintramusculartemperatureandinmaintainingthedurationoftemperaturedepression.Thatstudy
alsofoundthaticemassageachievesmaximalintramusculartemperaturedecreasesoonerthantheicebag.99A
studybyaRuppetal.100usingCIBandCWIfoundtherewasnodifferenceintimerequiredtoreduce
intramusculartemperature8C1cmbelowadiposetissuebutthatintramusculartemperatureremained
significantlycolder90minutesfollowingCWI.
Cryotherapyisrecommendedinallofthephaseswhenanyinflammationispresent,butparticularlyintheacute
phase,becauseofitseffectivenessinreducingbothpainandedema.80,99,101Icethathasbeenfrozeninapaper
cupisappliedtotheareainsmall,circularmotionsfor1015minutesbeforeandafteractivity,uptosixtimesa
day.
Coldpacksapplieddirectlytothejointareaareusefulindecreasingpain.87Currentrecommendationsareto
applyicefor2030minutesevery2hours.102
Theapplicationofcoldtoanareaiscontraindicatedoversuperficialnervesorhealingwoundsinpatientswith
Raynauddiseaseorcoldsensitivityandinareaswithpoorcirculationorsensation.103
Thermotherapy.Thermotherapyinvolvesthetherapeuticapplicationofheat,whichinvolvesthetransfer
ofthermalenergy.Fivetypesofheattransferexist:
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1.Convectionoccurswhenaliquidorgasmovespastabodypart.Anexampleofthistypeofheat
transferisthewhirlpoolorfluidotherapy(Fig.83)
2.Evaporationoccurswhenthereisachangeinthestateofaliquidtoagas,andaresultantcooling
takesplace.Anexampleofthistypeofheattransferoccursduringsprayandstretchtechniques.
3.Conversionoccurswhenoneformofenergyisconvertedintoanotherform.Examplesofthistype
ofheattransferincludeultrasound(Fig.84),shortwavediathermy,andmicrowavediathermy.
4.Radiationoccurswhenthereareatransmissionandabsorptionofelectromagneticwaves.
5.Conductionoccurswhenheatistransferredbetweentwoobjectsthatareincontactwitheachother.
Anexampleofthistypeofheattransferoccurswithaparaffinbath(Fig.85),andhydrocollator
heatingpacks(Fig.86).
FIGURE83
Fluidotherapyunit.
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FIGURE84
Ultrasoundunit.
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FIGURE85
Paraffinbath.
FIGURE86
Hydrocollatorhotpack.
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Thermotherapyisusedinthesubacuteandchronicstagesofhealing,becausethedeepheatingofstructures
duringtheacuteinflammatorystagehasthepotentialtodestroycollagenfibersandacceleratetheinflammatory
process,104whereasinthelaterstagesofhealing,anincreaseinbloodflowtotheinjuredareaisbeneficial.
Thephysiologiceffectsoflocalheatapplicationincludethefollowing:105109
1.Dissipationofbodyheatthroughselectivevasodilationandshuntingofbloodviareflexesinthe
microcirculation,andregionalbloodflow.110
2.Decreasedmusclespasm.85,110112Themusclerelaxationprobablyresultsfromadecreaseinneural
excitabilityofthesensorynerves.
3.Increasedcapillarypermeability,cellmetabolism,andcellularactivity,allofwhichhavethepotentialto
increasethedeliveryofoxygenandchemicalnutrientstothearea,whiledecreasingvenous
stagnation.106,113
4.Increasedanalgesiathroughhyperstimulationofthecutaneousnervereceptors.
5.Increasedtissueextensibility110whichhasobviousimplicationsfortheapplicationofstretching
techniques.Thebestresultsareobtainedifheatisappliedduringthestretchandifthestretchis
maintaineduntilcoolingoccursaftertheheathasbeenremoved.
CLINICALPEARL
Foraheatapplicationtohaveatherapeuticeffect,theamountofthermalenergytransferredtothetissuemustbe
sufficienttostimulatenormalfunction,withoutcausingdamagetothetissue.114
Althoughthehumanbodyfunctionsoptimallybetween36Cand38C,anappliedtemperatureof40C,and
45Cisconsideredeffectiveforaheatintervention.Commercialhotpacks,orelectricheatingpads,area
conductivetypeofsuperficialmoistheat,andthetemperatureoftheunitissetanywherebetween65Cand
90C.Themoistheatpackcausesanincreaseinthelocaltissuetemperature,reachingitshighestpointabout8
minutesaftertheapplication.115Thedepthofpenetrationfortraditionalheatingpads(andcoldpacks)isabout1
cm,whichresultsinchangesinthecutaneousbloodvesselsandthecutaneousnervereceptors.98
Wetheatproducesagreaterriseinlocaltissuetemperaturecomparedwithdryheatatasimilartemperature.116
However,athighertemperatures,wetheatisnottoleratedaswellasdryheat.
Itisimportanttoassessthepatientssensitivitytotemperature,pain,andcirculationstatuspriortotheuseof
thermotherapy.Moistheatshouldnotbeappliedtoanareawithdecreasedsensation,poorcirculation,anopen
wound,oranacuteinjury.103Theapplicationofmoistheattoanareaofmalignancyisalsocontraindicated
becauseitcanincreasethetemperatureofthetumorandincreasetherateofgrowth.103Hemophiliacsarealsoat
riskwiththermotherapybecauseoftheincreasedbloodflow.
Ultrasound
Thetypeofultrasoundinphysicaltherapyisprimarilyusedforitsabilitytodeliverheattodeepmusculoskeletal
tissuessuchastendon,muscle,andjointstructuresusingultrasonicwaves.Thesesoundwavesaredelivered
throughatransducer,whichhasapiezoelectriccrystal,thelatterofwhichvibratesveryrapidly,converting
electricalenergyintoacousticalenergy.Astheenergy,whichleavesthetransducerinastraightline,travels
furtherfromthetransducer,thewavesbegintodiverge.Thedepthofpenetrationofthesoundwavesdependson
anumberoffactorsincludingtheabsorptionandscatteringofthebeam,themediumbeingused(gelorlotion),
thecontactqualityofthetransducer,thetreatmentsurface,andthetissuetype(muscle,skin,fat,etc.).117,118
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Scartissue,tendon,andligamentdemonstratethehighestabsorption.Tissuesthatdemonstratepoorabsorption
includebone,tendinous,andaponeuroticattachmentsofskeletalmuscle,cartilaginouscoveringofjoint
surfaces,andperipheralnerveslyingclosetothebone.119Theportionofthesoundheadthatproducesthe
soundwaveisreferredtoastheeffectiveradiatingarea(ERA).TheERAisalwayssmallerthanthetransducer.
Clinicalunitstypicallydeliverultrasoundof0.753MHz,withdutycyclesrangingfrom20%to100%.The
depthofpenetrationoftheultrasoundisroughlyinverselyrelatedtoitsfrequency.120,121Afrequencyof3MHz
ismoresuperficial,reachingadepthofapproximately2cm,whereas1MHziseffectivetoadepthof4or5
cm.122Dutycycleslessthan100%areusuallytermedpulsedultrasound,whereasa100%dutycycleisreferred
toascontinuousultrasound.Continuousmodeultrasoundproducesathermaleffect.Pulsedultrasounddoesnot.
Thethermaleffectsofultrasoundaresimilartothosepreviouslydescribedforthermotherapy.Thenonthermalor
mechanicalpropertiesofultrasoundarelesswelldefinedbutarebelievedtoaltercellularpermeabilityand
metabolismandmaybeimportantinthepromotionofwoundhealingbyreducingedema,pain,andmuscle
spasms.123126
Thebeamnonuniformityratioofultrasoundisthemaximal/averageintensity(W/cm2)foundintheultrasound
field.Eachtransducerproducessoundwavesinresponsetothevibrationofthecrystal.Thisvibrationhas
differentintensitiesatpointsonthetransducerhead,havingpeaksandvalleysofintensity.Thegreatertheratio
differenceinthebeamnonuniformityratio,themorelikelythetransducerwillhavehotspots.Hotspotsare
areasofhighintensity.Highintensitieshavebeenshowntocauseunstablecavitationaleffectsandtoretard
tissuerepair.126,127Intensitiesof0.10.3W/cm2arerecommendedforacutelesions,whereas0.40.8W/cm2
arerecommendedforchroniclesions.128
Treatmenttimesforultrasoundarebasedontheprincipleof1minuteofultrasoundpertreatmentheadarea,
althoughaccountmustbetakenofthepulseratioemployed.Thepulserationeedstobehigherformoreacute
lesions(1:4)andlowerformorechronicones(1:1orcontinuous).
Onestudy129demonstratedthattoachieveatissuetemperatureof4C,usingcontinuousultrasound,the
followingparametersandapplicationtimesarenecessary:
1MHzat1.5W/cm2for13minutes
3MHzat1.5W/cm2for4.5minutes
Itmustberememberedthattheeffectsofultrasoundarepredominantlyempiricalandarebasedonreported
biophysicaleffectswithintissue130,131andonanecdotalexperienceinclinicalpractice.132134Despitethe
paucityofdocumentedevidenceintermsofrandomizedcontrolstudies,135manybenefitshavebeenascribedto
ultrasound.Theseincludethefollowing:
Productionofcellularexcitation,enhancingcellularactivityratherthandampeningit,andenhancingthe
inflammatorycascade,therebyencouragingthetissuestomoveintotheirnextphase.119,136138
Decreasedswellingwhenappliedinapulsedformatduringtheinflammatorystageof
healing.128,130,131,139144
Stimulationoftheactivecellsandamaximizationofscarproductionactivityandquality,ifappliedduring
theneurovascularphase.144146Duringthelatterphase,ultrasoundappearstoenhancetheremodelingof
tissue.127,142,145
Analterationoftheparametersofultrasound,whichchangestheintentoftheintervention.54
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Phonophoresis
Phonophoresisisaspecifictypeofultrasoundapplicationinwhichpharmacologicagentsare
introduced.140,147153Phonophoresishasbeenusedclinicallysincetheearly1960s,inanattempttodrivethese
drugstransdermallyintosubcutaneoustissues.Theoretically,increasesincellpermeabilityandlocal
vasodilationmayresultinincreaseddiffusionofthetopicalagent.140,148,149
Theefficacyofphonophoresishasnotbeenconclusivelyestablished.Someearlystudieshaveshowndrug
penetrationasdeepas10cm,153155butamorerecentstudyhascastdoubtonthesefindings.156Otherstudies
haveexaminedtheeffectsofphonophoresiswithdifferentcorticosteroidconcentrations,comparedwith
ultrasoundalone,intheinterventionofvariousmusculoskeletalconditions.Recentpapershavearguedthat
manyofthecommonlyusedcreambasedpreparationsdonotallowadequatetransmissionoftheacoustic
wave.117,118,143Gelbasedpreparationsappeartobesuperiorwithrespecttothetransmissivityofultrasound.
Consequently,gelbasedcorticosteroidcompoundsmightbeexpectedtobesuperiorforphonophoresis
applications.
MechanicalModalities
Traction
Mechanicalormanualtractionhasbeenadvocatedthroughoutthespinedespitethelackofevidenceforits
effectiveness.Tractionhasbeenpromotedtodistractthezygapophysealjoint,toincreasethespacebetweenthe
vertebrae,toenlargetheintervertebralforamina,tostretchthejointcapsuleandligaments,toimproveblood
supply(intermittenttraction),andtoreducemusclespasmsandpain.157Manualtractionisusuallythefirstform
appliedasitprovidestheclinicianwithinformationaboutthepatientsreactiontotractionandallowsthe
cliniciantoquantifytheamountofforcebeingused.Ideally,themanualtractionshouldbeappliedspecifically
byapplyinglongitudinaltractiontoasegmentwhilestabilizingthebelowsegmentsusingvariouslocking
techniques.Thetwomostcommonmodesemployedwithmechanicaltractionincludethefollowing:
Sustainedorstatic.Thistypeoftractionisappliedcontinuouslyforanumberofminutesandis
recommendedforpatientswithjointand/ornerverootirritability,thosepatientswithreasonable
developingneurologicalsignsthathavebeenassociatedwithirritability,andthosepatientswithsevere
armpaincombinedwithreducedneckmovementtowardthepainfulside.
Intermittent.Thistypeoftractionisappliedforshortperiods,witharestperiodinbetween,andis
indicatedforpatientswithanacutejointderangement,thoserequiringgeneralizedjointmobilization,and
thosewithpaincomingfrommusclespasm.
Contraindicationstomechanicaltractionincludeimpairedcognitivefunction,rheumatoidarthritis,osteoporosis,
evidenceofinstability,claustrophobia,spinaltumors,spinalinfections,spondylolisthesis,vascularcompromise,
andveryoldoryoungpatients.
Twotypesofmechanicaltractionaredescribed,cervicalandlumbar.
Cervical
Cervicaltractionisappliedwiththepatientinsittingorsupineposition(Fig.87),althoughthesupineposition
isgenerallypreferredasitremovestheweightofthepatientsheadandallowsthepatienttorelaxbetter.With
intermittenttraction,adutycycleofeither1:1or3:1isused,andthetreatmenttimevariesaccordingtothe
conditionbeingtreated510minutesisrecommendedforacuteconditionsanddiskprotrusionand1530
minutesisrecommendedforotherconditions.158160Weightsof2545lbappearnecessarytoproducevertebral
separationwithcervicaltraction.161Twentytotwentyfivepoundsisnecessarytostraightenthelordotic
curvatureofthecervicalspine.Approximately810lbor710%ofthepatientsbodyweightisrecommended
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initiallytotreatdiskprotrusions,musclespasm,andtoelongatesofttissueinacuteconditions.158160Less
forceappearstobenecessarywhentreatmentisdirectedtotheuppercervicalarea.161Itispossibletoapply
tractionmorespecificallybyvaryingtheangleofneckflexion:158160
FIGURE87
Cervicaltraction.
ToincreasetheintervertebralspaceattheC15levels,approximately05degreesshouldbeused.
ToincreasetheintervertebralspaceattheC57levels,2530degreesofflexionisrecommended.
Twentyfourtothirtyfivedegreesofflexionisrecommendedforzygapophysealjointseparation.
Zerodegreesofflexionisrecommendedfordiskdysfunction.
Lumbar
Thetotaltreatmenttimestobeusedinlumbartractionareonlypartiallyresearchbasedandcanrangefrom5to
30minutes.162164Thetractionforcenecessarytocauseeffectivevertebralseparationvaries(approximately
50%ofthepatientsbodyweight).162164
CLINICALPEARL
Thereisconflictingevidencefortheefficacyofintermittentlumbartractionforpatientswithlowbackpain.
Severalrandomizedcontrolledtrialshavecomparedtractiontoashamtractionintervention,withnosignificant
differencesfoundbetweengroups.Clarketal.,165inasystematicreview,investigatedtheuseoftraction
comparedtoreferencetreatments,placebo/shamtraction,ornotreatment,forpatientswithlowbackpain.They
concludedtherewasmoderateevidenceshowingnostatisticallysignificantdifferencesinshortorlongterm
outcomesbetweentractionasasingletreatmentandaplacebo,sham,ornotreatment.Thereispreliminary
evidencethatasubgroupofpatientswithsignsofnerverootcompressionalongwithperipheralizationof
symptomsorapositivecrossedstraightlegraisewillbenefitfromintermittentlumbartractionintheprone
position.166Inaddition,thereismoderateevidencethatintermittentorstaticlumbartractionshouldnotbeused
forreducingsymptomsinpatientswithacuteorsubacute,nonradicularlowbackpain,orinpatientswith
chroniclowbackpain.167
Hydrotherapy
Hydrotherapyistheuseofwateranditsmechanicalandthermaleffectsinthetreatmentofmusculoskeletal
dysfunction.
Whirlpool.Awhirlpoolmaybeusedinanattempttofacilitatetheresorptionofeffusion.Acold
whirlpoolisindicatedinacuteandearlysubacuteconditions,inwhichgentleexerciseoftheinjuredpart
ispermitted.Thetemperatureforacoldwhirlpoolisintherangeof5060F(1016C).Awarm
whirlpoolisindicatedinchronicconditions.Duringthetreatment,thebodypartmaybeexercised.The
temperatureofawarmwhirlpoolisintherangeof100110F(3945C).
Contrastbath.Acontrastbathisamethodoftreatmentthatusesanalternatingcycleofwarmandcold
whirlpoolstocreateacycleofalternatingvasoconstrictionandvasodilation.Contrastbathsareusedmost
ofteninthemanagementofextremityinjuries.168,169InastudybyMyreretal.,170acontrastbaththerapy
of20minuteshadnoimpactontheintramusculartemperatureofthegastrocnemiusoftheirsubjects1cm
belowthesubcutaneousfat,asmeasuredbyamicroprobe.
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Prolotherapy.Althoughprolotherapyisnotadministeredbyphysicaltherapists,patientsseenintheclinic
mayhavereceivedacourseofprolotherapyfromtheirphysician,anditisthusincludedforcompleteness.
Prolotherapy,alsoknownasproliferationtherapy,isarelativelycontroversialinjectionbasedpain
managementtechniquethatmaybeusedasaninterventionfordegenerativeorchronicinjuryto
ligaments,tendons,fascia,andjointcapsulartissue.Prolotherapyinvolvestheinjectionofasmallvolume
ofanirritantsolution(e.g.,dextrose10%,sodiummorrhuate,andphenolglycerineglucose)atmultiple
sitesonpainfulligamentandtendoninsertionsandinadjacentjointspaces.
Prolotherapyispurportedtoallowrapidproductionofnewcollagenandcartilagethroughstimulationofthe
immunesystemshealingmechanism.Thenumberofinjectionsrequiredperinterventionisbasedonthetypeof
injury.Rabagoetal.171revieweddatafrom34casereportsandcaseseriesandtwononrandomizedcontroltrials
andsuggestedthatprolotherapywasefficaciousformanymusculoskeletalconditions.However,theyconcluded
thatfurtherinvestigationwithhighqualityrandomizedcontrolledtrialswasrequiredbeforeitwouldbepossible
todeterminewhetherornotprolotherapywaseffective.
Sclerosingtherapy.Likeprolotherapy,sclerosingtherapyisnotadministeredbyphysicaltherapists,but
patientsseenintheclinicmayhavereceivedacourseofprolotherapyfromtheirphysician,anditisthus
includedforcompleteness.Sclerosinginjectionshavebeenusedinpatientswithvariousconditions,
includingchroniclowbackpain,172174shoulderimpingement,175tenniselbow,176Achilles
tendinosis,177,178andpatellatendinosis179withgoodresults.Sclerosingtherapyinvolvestheinjectingof
abnormalvesselsthatareassociatedwithpainfultendonswithasclerosingagenttodecreasepain.High
resolutioncolorDopplerultrasoundshowsintratendinousDoppleractivityinpatientswithchronic
tendinopathy.Theaffectedareaissclerosedwithvascularingrowth.Theinjectedchemical(e.g.,
Polidocanol)irritatesthevascularintimatocauseavesselthrombosis.Inaddition,itmayalsosclerosethe
nervesadjacenttothenewvessels,eitherdirectly(bydestruction)orindirectly(byischemia),whichcould
explainthereductioninpainfollowingtheprocedure.
ElectrotherapeuticModalities
Electricalstimulation.Historically,manyclinicianshaveadvocatedelectricalstimulation(Fig.88)to
assistwithstrengthrecovery,musclereeducation,preventionofatrophy,andreductionoffunctional
limitation.180Electricalstimulationistraditionallyusedto181
produceamusclecontraction
stimulatesensorynervestohelptreatpain.Forexample,transcutaneouselectricalnervestimulation
(TENS)and
createanelectricalfieldwithinthetissuestostimulateoralterthehealingprocess.
FIGURE88
Electricalstimulationunit.
Inadditiontoitsuseintheacutephase,electricalstimulationcanbeusedintheotherstagesofhealingforthe
reductionofpainandforneuromuscularreeducation.
Electricalcurrentthatpassesthroughtissueforcesnervestodepolarize.Thetypeofnerveinfluencedinthis
way,andtherateatwhichthefiberisdepolarized,determinesthephysiologicand,therefore,therapeuticeffect
achieved.182,183
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Thelimitedstudiesonpostsurgicaloracutelyinjuredpatientsseemtoindicatethatneuromuscularelectrical
musclestimulation(NMES)iseitheraseffectiveas,ormoreeffectivethan,isometricexercisesatincreasing
musclestrengthandbulkinbothatrophiedandnormalmuscles.184,185
Severalauthorshavedemonstratedtheinfluenceofstimulationparameters,suchaselectrodepositioning,186
currentfrequency,187currentamplitude(intensity),188stimuluspulseduration,189andburstdutycycleof
mediumfrequencyalternatingcurrent,190onelectricallyinducedtorque.180
CLINICALPEARL
AburstdutycycleisanimportantparameterofNMES,asitcandirectlyaffecttorqueproductionandsensory
discomfortinhealthy,untrainedindividuals.191InastudybyaLiebanoetal.aburstdutycycleof20%of
mediumfrequencyalternatingcurrent,comparedtoburstdutycyclesof35%and50%,producedhigherpeak
torqueofthequadricepsfemorisinprofessionalsoccerplayerswhileproducingnodifferenceindiscomfort.
Transdermaliontophoresis.Transdermaliontophoresisisamethodbywhichionictherapeuticagentsare
administeredthroughtheskinbytheapplicationofalowlevelelectricalcurrent.Iontophoresishasproved
tobevaluableintheinterventionofmusculoskeletaldisorders.Iontophoresiscausesanincreased
penetrationofdrugsandothercompoundsintotissuesbytheuseofanappliedcurrentthroughthetissue.
Theprinciplebehindiontophoresisisthatanelectricalpotentialdifferenceactivelycausesionsinsolution
totransferaccordingtotheirelectricalcharge.Ionizedmedicationsdonotordinarilypenetratetissues,
and,iftheydo,itisnotnormallyataraterapidenoughtoachievetherapeuticlevels.192Thisproblemis
overcomebyprovidingadirectcurrentenergysource.192,193
CLINICALPEARL
Negativelychargedionsarerepelledfromanegativeelectrodeandattractedtowardthepositiveelectrode.In
contrast,thepositiveionsarerepelledfromthepositiveelectrodeandattractedtowardthenegative
electrode.192,193
Iontophoresishas,therefore,beenusedforthetransdermaldeliveryofsystemicdrugsinacontrolledfashion.194
ThefactorsaffectingthequalityofthetransdermaliontophoretictransportincludepHtheintensityofthe
current,orcurrentdensity,attheactiveelectrodeionicstrengthconcentrationofdrugmolecularsizeandthe
durationofthecurrentflow(continuousorpulsecurrent).
Iontophoresiscanbeperformedusingawiderangeofchemicals(Table86).Iftheionicsourceisinanaqueous
solution,itisrecommendedthatalowconcentrationbeused(24%)toaidinthedissociation.195Although
electronsflowfromnegativetopositive,regardlessofelectrodesize,havingalargernegativepadthana
positiveonewillhelpshapethedirectionofflow.
TABLE86VariousIonsUsedinIontophoresis
Ion Polarity Solution Purpose/Condition
Acetate 25%aceticacid Calciumdeposits171
Atropinesulfate + 0.0010.01% Hyperhidrosis
Calcium + 2%calciumchloride Myopathyandmusclespasm
Chlorine 2%sodiumchloride Scartissueandadhesions
Copper + 2%coppersulfate Fungusinfection
Dexamethasone + 4mg/mLdexamethasoneNaP Tendonitisandbursitis172
Lidocaine + 4%lidocaine Trigeminalneuralgia173
Hyaluronidase + Wydase Edema174
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Ion Polarity Solution Purpose/Condition

Iodine Iodexointment Adhesionsandscartissue175
Magnesium + 2%magnesiumsulfate(Epsomsalts) Musclerelaxant176andbursitis
Mecholyl + 0.25% Musclerelaxant
Potassiumiodide 10% Scartissue
Salicylate 2%sodiumsalicylate Myalgiaandscartissue
Tapwater Hyperhidrosis
+,positive,negative.
Currentintensityisrecommendedtobeat5mAorless.Thedurationofthetreatmentcanvaryfrom10to20
minutes.Longerdurationshavebeenshowntoproduceadecreaseintheskinimpedance,thusincreasingthe
likelihoodofburnsfromanaccumulationofionsundertheelectrodes.196Anaccumulationofnegativeions
underthepositiveelectrodeproduceshydrochloricacid.Anaccumulationofpositiveionsunderthenegative
electrodeproducessodiumhydroxide.
Othercomplicationshaveincludedprolongederythemathatresolvedin24hours,tingling,burning,andpulling
sensationsthatwereespeciallyapparentatthestartofthecurrentoriftheamperagewasturneduptoorapidly.
Thevisibleerythemademonstratestheclearincreaseinbloodflowandtheinfluenceoftheiontophoresis.
Currently,researchhasbeenfocusedonthedevelopmentofiontophoreticpatchesforthesystemicdeliveryof
drugsas(1)theyprovidetheoptiontomonitorandcontrolthepowersuppliedduringuse,(2)candetectthe
numberoftimesthepatchhasbeenused,and(3)thecontrollercanberenderedunusabletoavoidabuse,once
thedrugisexhausted.
ExtracorporalShockWaveTherapy
Highenergyextracorporealshockwaveshavebeenusedinurologyforthedisintegrationofstoneconcretionfor
almost15years.Forthepast10years,thistechnologyhasemergedasatreatmentmodalityformanagingpain
causedbyabroadrangeofmusculoskeletalconditions.Theseconditionsincludetendinopathiesandnonunion
anddelayedunionoffractures.197199Currently,thetherapeuticmechanismsofshockwavesin
musculoskeletalproblemsortheirspecificbiologiceffectsonthevariousmusculoskeletaltissues(bone,
cartilage,tendon,andligament)arenotfullyunderstood.200Theextracorporealshockwaveisanacousticwave
characterizedbyhighpositivepressuresofmorethan1,000bar(100MPa),whichcanbedevelopedwithinan
extremelyshortrisetime(109seconds)andfollowedbyalowpressurephaseoftensilestressequivalentto
100bar(10Mpa).201Aclinicallyapplicableshockwaverepresentsnothingmorethanacontrolledexplosion,
producingasonicpulseinmuchthesamewayasafastflyingaircraftmayproduceasonicboom.200Whenthe
shockwaveentersthetissue,itmaybedissipatedandreflectedsothatthekineticenergyisabsorbedaccording
totheintegralstructureofthetissuesorstructuresthatareexposedtotheshockwaves.200However,becausethe
durationoftheshockwaveissoshort(35microseconds)andisgeneratedatlowfrequencies,nothermaleffect
isgenerated.Forshockwavestobeeffectiveintheclinicalsituation,themaximallybeneficialpulseenergy
mustbeconcentratedatthepointatwhichtreatmentistobeprovided.Therearethreemechanismsbywhich
extracorporealshockwavetherapy(ESWT)unitsgeneratetheshockwaves:electromagnetic,electrohydraulic,
andpiezoelectric.Theelectromagneticandpiezoelectricunitstendtogeneratelowerenergyshockwavesthan
theelectrohydraulicunits.202Medicallyusefulshockwavesusuallyaregeneratedthroughafluidmedium
(water)andacouplinggeltofacilitatetransmissionintobiologictissues.Theenergyfluxdensity(ED)refersto
theshockwaveenergyflowthroughanareaperpendiculartothedirectionofpropagation2021,0002,000
shockwavesofanEDfrom0.01to0.4mJ/mm2areusuallyappliedtwotothreetimesatweeklyintervals.201
Pulsedurationisusuallyfixedat35microsecondsandthecalculationofdose(totalenergydelivered)depends
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onthechoiceofenergylevelandthetotalnumberofshockwaveimpulsesdelivered.202Mostpatientsreporta
sharppainsensationduringtheapplicationofESWT,necessitatingaskinsensationtestpriortoitsuse.
AmetaanalysisbyOgdenetal.203reportedthat,ofvariousapplicationsofESWTonmusculoskeletal
conditions,theuseofESWTfortreatingchronic,recalcitrantheelpainsyndromewasthemostcredible.
ESWTiscontraindicatedforuseinpatientssufferingfromhemophilia(becauseitmaycausemicrovascular
disruption)andmalignancy,andESWTshouldnotbeappliedtogrowthplatesorwhereexposuretolungtissue
mayoccur(clavicleorfirstrib).200,202
TranscutaneousElectricalNerveStimulation
TENSwasfirstintroducedintheearly1950stodeterminethesuitabilityofpatientswithpainascandidatesfor
theimplantationofposterior(dorsal)columnelectrodes.TENShassincebeenshowntobeaneffective,
inexpensive,andnoninvasiveinterventioninprovidingpainreliefintheearlystagesofhealingfollowing
surgery204209andintheremodelingphase.210213
ThepercentageofpatientswhobenefitfromshorttermTENSpaininterventionhasbeenreportedtorangefrom
50%to80%,andgoodlongtermresultswithTENShavebeenobservedin644%ofpatients.210,212,214,215
However,mostoftheTENSstudiesrelysolelyonsubjectspainreportstoestablishefficacyandrarelyonother
outcomemeasuressuchasactivity,socialization,ormedicationuse.
TENSunitstypicallydeliversymmetricorbalancedasymmetricbiphasicwavesof100to500millisecond
pulseduration,withzeronetcurrentstominimizeskinirritation,216andmaybeappliedforextendedperiods.
Threemodesofactionaretheorizedfortheefficacyofthismodality(seeChapter3):
1.Gatecontrolmechanism.Spinalgatingcontrolthroughstimulationofthelarge,myelinatedAalpha
fibersinhibitstransmissionofthesmallerpaintransmittingunmyelinatedCfibersandmyelinatedAdelta
fibers.207,217
2.Endogenousopiatecontrol.Whensubjectedtocertaintypesofelectricalstimulationofthesensory
nerves,theremaybeareleaseofenkephalinfromlocalsiteswithinthecentralnervoussystemandthe
releaseofendorphinfromthepituitaryglandintothecerebrospinalfluid.216,218,219Asuccessful
applicationcanproduceananalgesiceffectthatlastsforseveralhours.
3.Centralbiasing.Intenseelectricalstimulation,approachinganoxiouslevel,ofthesmallerCorpain
fibers,producesastimulationofthedescendingneurons.
Diathermy
Diathermyisatherapeuticmodalitythatgeneratesaformofanelectromagneticwave(acombinationofboth
electricalandmagneticfields)thathasfrequencyrangesthatcanbecategorizedaseithermicrowaveor
shortwave.Diathermyisgenerallyusedtodecreasepain,increasemetabolicfunctions,increasedeeptissue
temperature,andincreaseROM.Contraindicationstodiathermyincludeapplicationovermetal,metabolic
conditions,andpacemakers.
Shortwavediathermy.Thisisalsodescribedaseithercontinuousshortwavediathermyorpulsed
shortwavediathermy.
Microwavediathermy.Microwavediathermydeliversshorterwavesofhigherfrequencyelectromagnetic
wavesthanshortwavediathermy.
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Variationinthestrengthoftheelectromagneticwaveisdependentuponseveralfactorsincludingthefrequency
oftheunit,andcharacteristicsoftheapplicator.Althoughthereissomeevidencetosupporttheclinicaluseof
diathermy,220225thereisalsoevidencethatdoesnotsupportitsuse.
HyperbaricOxygenTherapy
Hyperbaricoxygentherapy(HBOT)isthemedicaluseofoxygenatalevelhigherthanatmosphericpressure,
whichproducesanexcessofoxygeninthebody.Thisincreaseddissolvedoxygenintheplasmahasbeenshown
tomoreeffectivelyreachinjuredtissuesthanoxygenboundhemoglobin.226Thecurrentliteratureincludes
studiesoftreatmentofnumerousdifferentorthopaedicconditionsusingHBOT,includingdelayedonsetmuscle
soreness,chronicwounds,fibromyalgia,complexregionalpainsyndrome,migraineandclusterheadaches,and
edema.226TheonlyabsolutecontraindicationtoHBOTisuntreatedpneumothorax.
AquaticTherapy
Currentresearchshowsaquatictherapytobebeneficialinthetreatmentofeverythingfromorthopaedicinjuries
tospinalcorddamage,chronicpain,cerebralpalsy,multiplesclerosis,andmanyotherconditions.Amongthe
psychologicalaspects,watermotivatesmovementbecausepainfuljointsandmusclescanbemovedmoreeasily
andpainlesslyinwater.
Theindicationsforaquatictherapyincludeinstanceswhenpartialweightbearingambulationisnecessary,to
increaseROM,whenstandingbalanceneedstobeimproved,whenendurance/aerobiccapacityneedstobe
improved,orwhenthegoalistoincreasemusclestrengthviaactiveassisted,gravityassisted,activeorresisted
exercise.
Contraindicationstoaquatictherapyincludeuncontrolledincontinence,urinarytractinfections,waterand
airborneinfectionsordiseases(e.g.,influenza,andgastrointestinalinfections),unprotectedopenwounds,
menstruationwithoutinternalprotection,heatintolerance,severeepilepsy/seizuresdisorder,uncontrolled
diabetes,unstablebloodpressure,orseverecardiacand/orpulmonarydysfunction(e.g.,incipientcardiacfailure,
unstableangina,andavitalcapacityoflessthan1L).Ingeneral,pregnantwomenarequitesensitivetocore
temperatureelevationsandshould,therefore,exerciseincooltoneutraltemperatures.Thesamecanbesaidfor
patientswithheatintolerantmultiplesclerosis.However,afewstudieshavereportedbenefitsforthispatient
populationifthewatertemperatureiscontrolled.227229
PhysicalPropertiesandResistedForces
Thereareseveralphysicalpropertiesofwater,whichmakeexercisinginwaterdifferfromthatonland:
Density.Althoughthehumanbodyismostlywater,thebodysdensityisslightlylessthanthatofwater,
whichhasaspecificdensityof1.0kg/m3,andaveragesaspecificgravityof0.974kg/m3,withmen
averaginghigherdensitythanwomen.Anyobjectwithaspecificgravitylessthanthatofwaterwillfloat.
Thebuoyantvaluesofdifferentbodypartsvaryaccordingtoanumberoffactors:
Bonetomuscleweight.Leanbodymass,whichincludesbone,muscle,connectivetissue,and
organs,hasatypicaldensitynear1.1kg/m3.
Theamountanddistributionoffat.Fatmass,whichincludesbothessentialbodyfatplusfatin
excessofessentialneeds,hasadensityofabout0.9kg/m3.
Hydrostaticpressure:hydrostaticpressureisthepressureexertedbythewateronimmersedobjectswith
thepressurebeingdirectlyproportionaltoboththeliquiddensityandtotheimmersiondepthwhenthe
fluidisincompressible.Waterexertsapressureof22.4mmHg/ftofwaterdepth,whichtranslatesto1
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mmHg/1.36cm(0.54in)ofwaterdepth.Thus,ahumanbodyemergedtoadepthof48inissubjectedto
aforceequalto88.9mmHg,slightlygreaterthannormaldiastolicbloodpressure.230Theeffectsof
hydrostaticpressure,whichistheforcethataidsresolutionofedemainaninjuredbodypart,begin
immediatelyonimmersion,causingplasticdeformationofthebodyoverashortperiod.Thisresultsina
superiordisplacementofblood,ariseinrightatrialpressure,anincreaseinpleuralsurfacepressure,
compressionofthechestwall,andasuperiordisplacementofthediaphragm.
Surfacetension:Surfacetensionisaresultofthecohesiveforcesamongliquidmoleculesthatcausesfluid
toactasamembraneundertension.Fromaclinicalperspective,usingequipmentatthesurfaceofthe
waterincreasestheresistance.Inaddition,anditismoredifficultforapatienttomoveanextremity
throughthesurfacethanmovingtheextremityunderwater.
Buoyancy:thehumanbodydisplacesavolumeofwaterweighingslightlymorethanthebody,forcingthe
bodyupwardbyaforceequaltothevolumeofthewaterdisplaced,asdiscoveredbyArchimedes.This
buoyancyforceisresponsibleforthemainadvantageofexercisinginwater.Asthebodyisgradually
immersed,waterisdisplaced,creatingtheforceofbuoyancy.Buoyancycanprovideafeelingofrelative
weightlessness.Ahumanwithaspecificgravityof0.974kg/m3reachesfloatingequilibriumwhen97%
ofhisorhertotalbodyvolumeissubmerged.230Adjustingthedepthofimmersionhasbeendescribedas
aneffectivewayofcontrollingtheloadsactingonbodystructures.231
Withneckdepthimmersion,onlyabout15lbofcompressiveforceisexertedonthespine,hips,and
knees.
Withimmersionuptothesymphysispubis,40%ofthebodyweightiseffectivelyoffloaded.
Withimmersionuptotheumbilicus,50%ofthebodyweightiseffectivelyoffloaded.
Withimmersionuptothexiphoid,60%ormore(dependingonwhetherthearmsareoverheador
besidethetrunk)ofthebodyweightiseffectivelyoffloaded.
Comparedtostationaryrunningonland,runninginwaterthatishipleveldecreasesforcesapplied
tothebodybynearly40%,whilerunninginwaterthatischestleveldecreasestheforcesbyalmost
50%.232
Viscosityreferstothemagnitudeofinternalfrictionspecifictoafluidinmotion.Alimbmovingrelative
towaterissubjectedtothevariousresistiveeffectsofthefluid:230
Dragforce:Itisafactoroftheshapeofanobjectanditsspeedofmovement.Objectsthataremore
streamlined(minimizingthesurfaceareaatthefrontoftheobject)producelessdragforce.Moving
waterpastthepatient,orusingaquaticequipmentsuchasapaddleorboard,requiresthepatientto
workharder.
Laminarflow:movementinwhichallmoleculesmoveparalleltoeachother.
Turbulence:movementinwhichmoleculesdonotmoveparalleltoeachother.Underturbulentflow
conditions,resistanceincreasesasalogfunctionofvelocity.
Viscousresistanceincreasesasmoreforcesareexertedagainstit,butthatresistancedropstozeroalmost
immediatelyonthecessationofforce.
Thermodynamics
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Specificheatistheamountofheatrequiredtoraisethetemperatureof1gofasubstanceby1C.Theheat
capacityofwateris1,000timesgreaterthantheequivalentvolumeofair.Thetherapeuticutilityofwater
dependsgreatlyonbothitsabilitytoretainheatanditsabilitytotransferheatenergy.Heattransferbegins
immediatelyonimmersion,andastheheatcapacityofthehumanbodyislessthanthatofwater(0.83vs.1.00),
thebodyequilibratesfasterthanthewaterdoes.
CLINICALPEARL
Waterisanefficientconductor,transferringheat25timesfasterthanair.Thisthermalconductiveproperty,in
combinationwiththehighspecificheatofwater,makestheuseofwaterinrehabilitationveryversatilebecause
waterretainsheatorcoldwhiledeliveringeasilytotheimmersedbodypart.230
DesignandSpecialEquipment
Certaincharacteristicsofthepoolshouldbetakenintoconsiderationifitistobeusedforrehabilitation
purposes:
Thepool(Fig.89)shouldnotbesmallerthan1012.
Thepoolshouldhavebothashallow(1.25m/2.5ft)andadeep(2.5m/5ftplus)area(Fig.89)toallow
forstandingexercisesandswimmingornonstandingexercise.
Thepoolbottomshouldbeflatandthedepthgradationsclearlymarked.
Apneumaticchairlift(Fig.810)canbeusedtohelpapatientaccessthewater.
FIGURE89
Anaquatherapypool.
FIGURE810
Apneumaticchairlifttoaidapatient.
Variabletemperaturecontrolforthewatershouldbeavailable(waterthatistoowarmcanleadtofatigue,or
evenheatexhaustionbecauseevaporationofperspirationisnotpossibleinwater,whereaswaterthatistoocool
cancauseshivering,increasemusculartension,orproducehypothermia):
Coldplungetanksareoftenusedattemperaturesof1015Ctoproduceadecreaseinmusclepainand
speedrecoveryfromanoveruseinjury.
Mostpublicandcompetitivepoolsoperateintherangeof2729C.
Typicaltherapypoolsoperateintherangeof33.535.5C.
Hottubsareusuallymaintainedat37.541C.
Rescuetubes,innertubes,andwetvestsshouldbepurchasedtoassistinfloatationactivities.Handpaddlesand
pullbuoyscanbeusedforstrengtheningtheupperextremity.Kickboardsandfinsareusefulforstrengthening
thelowerextremity.
Advantages
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Aquatictherapyoffersanumberofadvantagesovertraditionallandborneexercises:
Thebuoyancyofthewaterallowsactiveexercisewhileprovidingasenseofsecurityandcausinglittle
discomfort.Deepwaterrunningdrills,usingabuoyancyvest,canbeusedtomaintainfitnessduring
recoveryfromlowerlimbinjuryandasaformofcrosstrainingtoreduceimpactwiththeaimofreducing
overuseinjuries.
Earlyintherehabilitationprocess,aquatictherapyisusefulinrestoringROMandflexibilityusinga
combinationofthewatersbuoyancy,resistance,andwarmth.
Thebuoyancyprovidessupport.Anaquaticexerciseprogramcanbedesignedtovarytheamountof
gravityloadingbyusingbuoyancyasacounterforce.Shallowwaterverticalexercisesgenerally
approximateclosedchainexercises,albeitwithreducedjointloadingbecauseofthecounterforce
producedbybuoyancy.Deepwaterexercisesmoregenerallyapproximatetheopenkineticchainsystem,
asdohorizontalexercises.Paddlesandotherresistiveequipment(Fig.811)tendtoclosethekinetic
chain.
Theslowmotioneffectofmovinginwaterprovidesextratimetocontrolmovementandtoreact.Aquatic
exerciseprotocolshavebeensuccessfullyusedtoimprovebalanceandcoordinationinolderindividuals,
whofaceanincreasedriskoffalling.233
Thewaterprovidestactilestimulationandfeedback.
Thebuoyancyofthewatercanbeusedtoprovideagradualtransitionfromnonweightbearingtofull
weightbearingexercisesbyadjustingtheamountthebodyissubmerged.Forexample,acuteinjury
programstypicallystartatnonweightbearingdepths,limitingactivitybelowpainonset,andthen
progresstoweightbearinglevelsassymptomspermit.
Theintensityofexercisecanbecontrolledbymanipulatingthebodyspositionorthroughtheadditionof
exerciseequipment.Duringaquatictreadmillrunning,oxygenconsumptionisthreetimesgreaterata
givenspeedofambulationthanonland.Thus,thetrainingeffectmaybeachievedatasignificantlyslower
speedthanonland.234
FIGURE811
Examplesofexerciseequipmentforuseinaquatherapy.
Disadvantages
Thedisadvantagesofaquatictherapyinclude:
Thecostofbuildingandmaintenance.
Difficultyintreatingpatientswithaninherentfearofwater.
Potentialadverseeffectsonthecardiovascularsystem.Becauseanindividualimmersedinwaterissubject
toexternalwaterpressureinagradient,whichwithinarelativelysmalldepthexceedsvenouspressure,
bloodisdisplacedupwardtothevenousandlymphaticsystems,firstintothethighs,thenintothe
abdominalcavityvessels,andfinallyintothegreatvesselsofthechestcavityandintotheheart.230The
followingcardiovascularchangescanoccurwithimmersionofthebody:
Anincreaseincentralvenouspressure.
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Anincreaseinpulsepressureasaresultoftheincreasedcardiacfillinganddecreasedheartrate
duringthermoneutralorcoolimmersion.
Anincreaseincentralbloodvolume.
Anincreaseincardiacvolume,cardiacoutput,andstrokevolume.
Adecreaseinsympatheticvasoconstriction,resultinginareductioninbothperipheralvenoustone
andsystemicvascularresistance.
Potentialadverseeffectsonthepulmonarysystem.Immersionofthebodytothelevelofthethoraxcauses
ashiftingofbloodintothechestcavityandincreasedcompressionofthechest.230Thecombinedeffectis
toalterpulmonaryfunction,increasetheworkofbreathing,andchangerespiratorydynamics.However,
whilecaremustbetakenwithpatientswhohaveinspiratorymuscleweaknessduetoconditionssuchas
congestiveheartfailureandchronicobstructivelungdisease,respiratorystrengtheningcanalsobean
importantaspectofhighlevelathleticperformance.
AquaticTherapyProtocols
Manyofthetherapeuticactivitiesthataretraditionallylandbasedcanbeperformedinwater.Theseinclude
manualstretching,extremitystrengtheningexercises,corestabilization,andaerobicconditioning.Incontrastto
gravity,buoyancyworksintheoppositedirectionbut,likegravity,canbemanipulatedbychangingthedirection
inwhichanexerciseisperformed,orhowmuchsupportthepatientisgiven.Forexample,mostROMand
stretchingexercisescanbeperformedwiththepatientsupportedinsupineusingavarietyofbuoyancyaids.
Strengtheningexercisescanbeprogressedbyworkingparalleltothebuoyancyforcetoworkingperpendicular
tothebuoyancyforcemovingthesegmenttowardthebottomofthepool.
PostsurgicalRehabilitation
Traditionalinterventionsforpostsurgicalpatientshaveinvolvedadheringtoexerciseprotocolsdesignedbythe
surgeonperformingtheoperationinordertolimitpostsurgicalstresstothehealingtissues.Thishasledtoan
emphasisoninterventionsbasedsolelyonexerciseslinkedtotimeframes,asortofcookbookapproach,rather
thanacomprehensiveapproachdesignedinconjunctionwiththephysicaltherapistbasedonclinicalfindings
andindividualconsideration.
Amongthekeyfactorsthatmustbeconsideredinthepostsurgicalrehabilitationare:235
typeofsurgery
patientsage
patientsphysicalstatus,includingweight,andothermedicalconditions,suchasanyhistoryof
cardiovascularorperipheralvasculardisease(PVD),ordiabetes
thesociallifestyleofthepatient
preoperativejointcontractureormuscleatrophy
themethodofsurgicalfixation
surroundingsofttissuesinvolved
thedegreeofcorrectionofbiomechanicalalignment
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functionalandrecreationalgoalsofthepatientand
frequencyofvisitsduringtheepisodeofcare.
Thesefactorsmayinfluencetherateatwhichthepatientprogressesthroughtherehabilitationprocess,aswellas
determinetheextentoffunctionalreturnthatcanbeexpectedinthelongterm.
ThestagesofhealingdescribedinChapter2shouldnotbeviewedasdistinctentitiesorasrigidtemplatesbutas
acontinuumthatmustbemodifiedonthebasisofclinicalfindingsandsubjectiveresponses.Forexample,
responsestoaninterventionthatindicateanoverlyaggressiveapproachinclude:
increasedareaofpain
painatrestthatlastslongerthan2hoursafterexercising236
painthatalterstheperformanceofanactivityorexerciseinadetrimentalmanner.236
Eachsurgicalprocedureisdifferent,asisthehealingcapacityofeachindividual.Inaddition,eachsurgeonhas
hisorheropinionastotheintensityofthepostsurgicalintervention.Theseopinionsmustalwaysberespected.
Althoughestimatedtimetablesaretypicallyprovidedwitheachprotocol,thepointatwhichthevarioustoolsof
interventioncanbeusedfollowingsurgerymayvary.
Realisticgoalsettingisimportantfollowingsurgery.Postsurgicalrehabilitationgoalsshouldbebasedonthe
statusoftheuninvolvedbodyparts,andthepatientshouldbeinvolvedinthegoalsettingprocesswhenever
possible.
Patient/ClientRelatedInstruction
Patient/clientrelatedinstructionformsthecornerstoneofeveryintervention.Duringthephysicaltherapyvisits,
theclinicianandthepatientworktoalterthepatientsperceptionofthefunctionalcapabilities.Together,the
patientandcliniciandiscussthepartsofthepatientslifethatheorshecanandcannotcontrolandthenconsider
howtoimprovethosepartsthatcanbechanged.Itisimperativethattheclinicianspendstimeeducatingthe
patientabouthisorhercondition,sothatthepatientcanfullyunderstandtheimportanceofhisorherroleinthe
rehabilitationprocessandbecomeaneducatedconsumer.Educatingthepatientaboutstrategiestoadoptinorder
topreventrecurrencesandtoselfmanagehisorherconditionisalsoveryimportant.Discussionsabout
interventiongoalsmustcontinuethroughouttherehabilitativeprocessandmustbemutuallyacceptable.
Oftentimes,thephysicianreliesonthephysicaltherapisttogiveabroaderexplanationabouttheconditionand
toanswerquestionsandconcernsrelatedtotherehabilitativeprocess.Theaimofpatientinstructionistocreate
independence,notdependence,andtofosteranatmosphereoflearningintheclinic.Adetailedexplanation
shouldbegiventothepatientinalanguagethatheorshecanunderstand.Thisexplanationshouldinclude:
thenameofthestructure(s)involved,thecauseoftheproblem,andtheeffectofthebiomechanicsonthe
area.Wheneverpossible,anillustrationoranatomicalmodeloftheinvolvedstructureshouldbeshownto
thepatient.Anatomicmodelscanalsobeusedtoexplainbiomechanicalprinciplesinlaypersonsterms.
informationabouttests,diagnosis,andanyinterventionsthatareplanned.
theprognosisoftheproblemandadiscussionaboutthepatientsfunctionalgoals.Anestimationof
healingtimeisusefulforthepatientsothatheorshedoesnotbecomefrustratedataperceivedlackof
progress.
whatpatientscandotohelpthemselves.Thisincludesthepermitteduseofthejointorarea,abrief
descriptionoftherelevantstageofhealing,andthevulnerabilityofthevariousstructuresduringthe
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pertinenthealingphase.Thisinformationmakesthepatientawareandmorecautiouswhenperforming
activitiesofdailyliving,recreationalactivities,andthehomeexerciseprogram.Emphasisshouldbe
placedondispellingthemythofnopain,nogain,andpatientsshouldbeencouragedtorespectpain.
Patientsoftenhavemisconceptionsaboutwhentouseheatandice,anditistheroleoftheclinicianto
clarifysuchissues.
homeexerciseprogram.Beforeprescribingahomeexerciseprogram,theclinicianshouldtakeinto
considerationthetimethatwillbeneededtoperformtheprogram.Inaddition,theleveloftoleranceand
motivationforexercisevaryamongindividualsandarebasedontheirdiagnosisandstageofhealing.A
shortseriesofexercises,performedmorefrequentlyduringtheday,shouldbeprescribedforpatientswith
poorenduranceorwhentheemphasisisonfunctionalreeducation.Longerprograms,performedless
frequently,areaimedatbuildingstrengthorendurance.Eachhomeexerciseprogramneedstobe
individualizedtomeetthepatientsspecificneeds.Althoughtwopatientsmayhavethesamediagnosis,
theexaminationmayrevealdifferentpositivefindingsandstagesofhealing,bothofwhichmayalterthe
intervention.
Thereareprobablyasmanywaystoteachastherearetolearn.Itisnotwithinthescopeofthistexttodiscuss
allofthetheoriesonlearning,butanoverviewofthemajorconceptsismerited.Motorlearningandskill
acquisitionisdescribedinChapter3.
LitzingerandOsif237organizedindividualsintofourmaintypesoflearners,basedoninstructionalstrategies:
1.Accommodators.Thistypelooksforthesignificanceofthelearningexperience.Theselearnersenjoy
beingactiveparticipantsintheirlearningandwillaskmanyquestions,suchas,Whatif?andWhy
not?
2.Divergers.Thistypeismotivatedtodiscovertherelevancyofagivensituationandpreferstohave
informationpresentedinadetailed,systematic,andreasonedmanner.
3.Assimilators.Thistypeismotivatedtoanswerthequestion,Whatistheretoknow?Theselearnerslike
accurate,organizeddeliveryofinformation,andtheytendtorespecttheknowledgeoftheexpert.They
areperhapslessinstructorintensivethansomeothertypesoflearnersandwillcarefullyfollowprescribed
exercises,providedaresourcepersonisclearlyavailableandabletoanswerquestions.
4.Convergers.Thistypeismotivatedtodiscovertherelevancy,orhow,ofasituation.Theinstructions
giventothistypeoflearnershouldbeinteractive,notpassive.
Apatientslearningstylecanbeidentifiedbyaskinghowheorshepreferstolearn.Somepatientswillprefera
simplehandoutwithpicturesandinstructionsotherswillprefertoseetheexercisesdemonstratedandthenbe
supervisedwhiletheyperformtheexercises.Somemaywanttoknowwhytheyaredoingtheexercises,which
musclesareinvolved,whytheyaredoingthreesetsofaparticularexercise,andsoon.Otherswillrequireless
explanation.
Iftheclinicianisunsureaboutthepatientslearningstyle,itisrecommendedthateachexercisefirstbe
demonstratedbytheclinicianandthenbythepatient.Therationaleandpurposebehindeachoftheexercises
mustbegiven,aswellasthefrequencyandintensityexpected.
Compliance
Complianceisvitallyimportantinthehealingprocess.Compliancecanbedefinedasengaginginbehavioras
instructedorprescribed.238Anothertermadherence,whichcanbedefinedascontinuingtoengagein
behaviors,issimilarinthatbothvaryfrompatienttopatient,andbotharerelatedtomotivation.Motivation,a
psychologicalfeaturethatdrivesanorganismtowardadesiredgoal,isconsideredvitaltomaintainingbehavior.
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Motivationhasbeenclassifiedaseitherintrinsic(internal)orextrinsic(external).Anumberofmotivational
theorieshavebeenproposed(Table87).
TABLE87MotivationalTheories
Theory Proponents Description
Individualsactascontributorstotheirownmotivation,behavior,and
development.
Socialcognitive Banduraa Behaviorandcharacteristicsaremodifiedbyenvironment.
Primarymediatorsincludeselfefficacyandtheabilitytoselfregulate.
Masteryisthebestwaytocreateastrongsenseofefficacy.
Choicesmadearebasedonexperiences,thoughts,contemplations,and
interactionswithothers.
Essentialpsychologicalneedsincludecompetence,relatedness,andautonomy.
Comprisedoffiveminitheoriesc:
CognitiveEvaluationTheory(CET):intrinsicmotivationisalifelong
creativewellspring.CEThighlightsthecriticalrolesplayedby
competenceandautonomyinfosteringintrinsicmotivation.
OrganismicIntegrationTheory:extrinsicmotivationisbehaviorthataims
towardoutcomesextrinsictothebehavioritself.Highlightssupportsfor
Self Lepperet autonomyandrelatednessascriticaltointernalization.
determination al.b
CausalityOrientationsTheory:describesindividualdifferencesinpeoples
tendenciestoorienttowardenvironmentsandregulatebehaviorinvarious
waysbasedonrewards,gains,andapproval.
BasicPsychologicalNeedsTheory:psychologicalwellbeingandoptimal
functioningispredicatedonmeetingtheneedsofautonomy,competence,
andrelatedness.
GoalContentsTheory:Goalsareseenasdifferentiallyaffordingbasic
needsatisfactionsandarethusdifferentiallyassociatedwithwellbeing.
Anindividualsattitude,socialnorms,andperceivedcontrolareaccurate
predictorsofbehavioralintentions.
InvolvestheTRAandtheTPB:
Healthbelief Ajzendand TRAismostsuccessfulwhenappliedtobehaviorunderanindividuals

model voluntarycontrol.
Fishbeine
TPBtheorizesthatifanindividualsperceivedcontrol,selfefficacy,or
selfesteemislow,theperceptionandbeliefthatheorshecaninfluence
behaviorinapositivemannerisundermined.
Basedontheconceptthatthereisahierarchyofbiogenicandpsychogenicneeds
thathumansmustprogressthrough.
Humanistic Maslowf Hypothesizesthatthehigherneedsinthishierarchyonlycomeintofocusonce
alltheneedsthatarelowerdownaremainlyorentirelysatisfied.
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Theory Proponents Description

Describesfivestagesofchange:
Precontemplation:definedbyalackofintentiontotakeaction.
Contemplation:definedbytheindividualthinkingaboutengagingina
behaviororactivityinthenearfuture.
Prochaska Preparation:definedbytheindividualintendingtotakeactioninthe
Transtheoretical and immediatefuture.
model
DiClementeg
Action:definedbytheindividualactivelyengagedinthebehavioror
change.
Maintenance:definedbyanindividualwhohasengagedinabehavioror
changeforlongerthan6months.
TPB,theoryofplannedbehaviorTRA,theoryofreasonedaction.
aBanduraA.Socialfoundationsofthoughtandaction:asocialcognitivetheory.UpperSaddleRiver,NJ:
PrenticeHall1986.
bLepperMK,GreeneD,NisbettR.Underminingchildrensintrinsicinterestwithextrinsicreward:Atestofthe
overjustificationhypothesis.JPersonalitySocialPsychol.197328:129137.
cUniversityofRochester:Selfdeterminationtheory:approachtohumanmotivationandpersonality.Available
at:http://www.psych.rochester.edu/SDT/theory.php.
dAjzenI.Fromintentionstoactions:atheoryofplannedbehavior.In:KuhlJ,BeckmannJ,eds.ActionControl:
FromCognitiontoBehavior.Heidelberg:Springer1985:1139.
eAjzenI,FishbeinM.UnderstandingAttitudesandPredictingSocialBehavior.EnglewoodCliffs,NJ:Prentice
Hall1980.
fMaslowA:TheFartherReachesofHumanNature.NewYork:VikingPress1971.
gProchaskaJO,DiClementeCC.Stagesandprocessesofselfchangeofsmoking:towardanintegrativemodel
ofchange.JConsultClinPsychol.198351:390395.
Anecdotally,unmotivatedpatientsmayprogressmoreslowly.Muchliteraturehasconceptualizedorreported
poormotivationinrehabilitationassecondarytopatientrelatedfactors,includingdepression,apathy,cognitive
impairment,lowselfefficacy(e.g.,lowconfidenceinonesabilitytosuccessfullyrehabilitate),fatigue,and
personalityfactors.239Variousstudieshavefoundthataveragecompliancewithmedicationregimensoccurs
onlyin5060%ofpatients,andcompliancewithphysicaltherapyprogramsisapproximately40%.240Other
reportshavefoundthatcompliancewasdecreasedifthephysicaltherapistsdidnotprovidetheirpatientswith
positivefeedback.241
Severalconsiderationsshouldbemadetoincreasecompliance:
Thepatientsageolderindividualstendtoadheretoexerciseprogramsmorethanyounger
individuals242
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Thepatientsmaritalstatussinglestendtohavelowerratesofadherencetophysicalactivity/exercise
thanmarriedcouples243
Thepatientseducationindividualswithhighlevelsofeducationshowmorecompliancetoexercise
programsthanthosewhoareuneducated243
Thepatientsgendermalesreportgreaterlevelsoftotalandvigorousactivitythanfemales243
Thepatientsbiomedicalstatuspoorerhealthtendstoleadtodecreasedadherence244
Thepatientssocioeconomicstatusanindividualsincomebrackettendstoinfluencetheabilityto
accessmedicalcare,aswellasexerciseequipmentandvenues245247
ThepatientsethnicityCaucasiansappeartoparticipateinmorephysicalactivitiesthanotherracialor
ethnicgroups,regardlessofage.243
Finally,anumberoffactorshavebeenoutlinedtoimprovecomplianceincluding:248250
involvingthepatientintheinterventionplanningandgoalsetting
realisticgoalsettingforbothshortandlongtermgoals
promotinghighexpectationsregardingfinaloutcome
promotingperceivedbenefits
projectingapositiveattitude
providingclearinstructionsanddemonstrationswithappropriatefeedback
keepingtheexercisespainfreeorwithalowlevelofpainand
encouragingpatientproblemsolving.
ProgressandReexamine
Theselectionofinterventionprocedures,andtheinterventionprogression,mustbeguidedbycontinuous
reexaminationofthepatientsresponsetoagivenprocedure,makingthereexaminationofpatientdysfunction
before,during,andaftereachinterventionessential.251
Ateachvisit,theclinicianmustreexaminethepatientsstatus.Toevaluateprogress,comparisonsaremade
betweenthefindingsfromtheinitialexaminationandsubsequentvisits.Therearethreepossiblescenarios
followingareexamination:
1.Thepatientsfunctionhasimproved.Inthisscenario,theintensityoftheinterventionmaybe
incrementallyincreased.
2.Thepatientsfunctionhasdiminished.Inthisscenario,theintensityandthefocusoftheinterventionmust
bechanged.Furtherreviewofdiagnosisandworkinghypothesismaybeneeded.Thepatientmayrequire
furthereducationonactivitymodificationandtheuseofheatandiceathome.
3.Thereisnochangeinthepatientsfunction.Dependingonthetimethathaselapsedsincethelastvisit,
theremaybeareasonforthelackofchange.Thisfindingmayalsoindicatetheneedforachangeinthe
intensityoftheintervention.Ifthepatientisintheacuteorsubacutestageofhealing,adecreaseinthe
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intensitymaybewarrantedtoallowthetissuesmoreofanopportunitytoheal.Inthechronicstage,an
increaseinintensitymaybewarranted.
Thedevelopinghealthcaresystemofthelastdecadehasdramaticallylimitedpatientsaccesstorehabilitation
servicesandhasincreasedtheaccountabilityofthehealthcareprovider.252Thisdevelopmenthasplaceda
burdenonthephysicaltherapyprofessiontomakethenecessarychangestodealeffectivelywithhealthcare
reform,sothatphysicaltherapistsbecomemoreaccountablefortheirprofessionalperformanceandmorecost
effectiveintheirprovisionofpatientcare.252Itisimportantthatexaminationandinterventiontechniques
continuetobeverifiedthroughpeerreviewedresearch,patientoutcomedatabases,andanincreasedefficiency
andeffectiveness.253,254
HealthPromotion,Wellness,andPhysicalFitness
In1996,theSurgeonGeneralsreportonphysicalactivityandhealthhighlightedtheimportanceofengagingin
anactivelifestyletopreventtheinsidiousonsetofchronicdiseaseandillness.255Morerecently,theofficeof
diseasepreventionandhealthpromotionintheDepartmentofHealthandHumanServicesintroducedanagenda
throughHealthyPeople2020thatestablishedgoalsforpromotingahealthylifestyleforindividualsinthe
UnitedStates.256
TheWorldHealthOrganizationhasdefinedhealthpromotionastheprocessofenablingpeopletoincrease
controlovertheirhealthanditsdeterminants,andtherebyimprovetheirhealth.*
TheNationalWellnessInstitutehasdelineatedsixcomponentsofwellness:
Social.Thisincludescontributingtoonesenvironmentandcommunityandemphasizingthe
interdependencebetweenothersandnature.
Occupational.Thisincludessatisfactionandenrichinglifethroughwork.
Spiritual.Thisincludesanappreciationofthedepthofanexpansivelifeandhavingmeaninginoneslife.
Physical.Thisincludesawarenessoftheneedforregularphysicalactivity,gooddiet,andnutritionand
avoidinghabitsthatareharmfultowellness.
Intellectual.Thisincludesbeingabletosolveproblems,expandknowledgeandskills,andhavean
opennesstonewideas.
Emotional.Thisincludesawarenessandacceptanceofonesfeelingsandthinkingofoneselfpositively.
Physicaltherapistsserveasmajorprovidersofhealthpromotion,wellness,andfitnessbymakingpatientsand
clientsmoreawareoflifestylechanges,particularlyintheareasofphysicalactivity,lifelonghealthpromotion,
andcreatinganenvironmentthatsupportshealthpracticesleadingtoahealthylifestyle.257Evidenceexiststhat
whenhealthcareprofessionalscounselpatientsaboutriskreduction,thosepatientsaremorelikelytochange
poorhealthhabits,thusenhancingahealthierlifestyle.
Theeffectsofphysicalactivityandexerciseonvariousphysiologicalandpsychologicalparametersacrossthe
lifespansupporttheuseofexerciseprescriptionsandtheirroleinpreventingdiseaseandimprovingfunctionand
health.Thisisparticularlyrelevantinpromotingmobilityanddependenceoftheelderly,theolderold,andthe
frailelderly.257
*Availableathttp://w3.whosea.org/EN/Section1174/Section1458/Section2057.htm,accessedSeptember2005.
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Availableatwww.nationalwellness.org/index.php?id=166&id_tier=81,accessedSeptember2005.
Availableatwww.healthwellness.org/archive/research/study5.htm,accessedNovember2004.
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Allrightsreserved.
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Silverchair
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CHAPTER9:PharmacologyfortheOrthopaedic
PhysicalTherapist
FIGURE91
CHAPTEROBJECTIVES
1.Differentiatebetweenpharmacokineticsandpharmacodynamics.
2.Describetheprocessofdrugdevelopment,regulation,anddistribution.
3.Describecontrolledsubstancesandtheirpotentialforabuse.
4.Recognizethethreedifferentnamesusedfordrugs.
5.Describethevariousmodesofactionofdrugs.
6.Describethevariousdrugreceptorsiteswithinthebody.
7.Outlinethedifferentadministrationroutesusedfordrugdelivery.
8.Understandthepotentialeffectsofphysicalagentsandexerciseondrugdelivery.
OVERVIEW
Pharmacologyisthebroadareaofstudythatdealswithhowchemicalsubstancesaffectlivingtissueona
molecularlevelandhowdrugsaffectspecificpatientpopulations(Table91).Drugtherapyisoneofthe
mainstaysofmoderntreatments,andphysicaltherapistsoftenencounterpatientswhoaretakingvarious
medications.TheGuidetoPhysicalTherapistPractice1identifiesclinicalpharmacologyasanessential
componentofappropriatepatientmonitoring,modalitydelivery,andcommunicationamongmedical
professionals.Itisthereforeimportantforthephysicaltherapisttohaveaworkingknowledgeofpharmacology
becauseofthenumberofdrugscurrentlyonthemarketandthenumberofphysicaltherapypatientsthatare
likelytohavebeenprescribedmedications.Asphysicaltherapistsattempttoaccountfortheeffectsoftheir
interventions,itbecomesapparentthattheymustalsounderstandtheeffectandpotentialinteractionsofall
availableandreasonableresources,includingpharmacologicalinterventions,offeredbyothermembersofthe
healthcareteam.2Theprescriptiondrugwritingprivilegesexercisedbyselectmilitarytherapistsandthe
evolutionofthephysicaltherapyprofessionpromoteconsiderationofanexpandedpharmacologicalrolein
physicaltherapypractice.3Althoughthedispensingofmedicationsiscurrentlyoutofthescopeofpracticefor
thevastmajorityofphysicaltherapists,questioningthepatientaboutprescribedmedicationusecanreveal
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medicalconditionsthatthepatientmightnotconsiderrelatedtohisorherpresentproblem,astheprescribed
medicationsmaybeforpreexistingconditionsthatarenotdirectlyrelatedtotheconditionbeingtreatedwith
physicaltherapy.Inaddition,thisinformationcanalsoprovidetheclinicianwithpossiblereactionsthatthe
patientmayhavetoexerciseorothertreatmentprocedures,andtheimpactonclinicalfindings.Forexample:
TABLE91PharmacologyTermsandDefinitions
Term Definition
Anysubstancethatcanbeusedtomodifyachemicalprocessorprocessesinthebody,
e.g.,totreatanillness,relieveasymptom,enhanceaperformanceorability,ortoalter
Drug statesofmind.
TheworddrugisetymologicallyderivedfromtheDutch/LowGermanworddroog,
whichmeansdry,sinceinthepast,mostdrugsweredriedplantparts.
Thescienceofstudyingboththemechanismsandtheactionsofdrugs,usuallyinanimal
Pharmacology
modelsofdisease,toevaluatetheirpotentialtherapeuticvalue.
Themixinganddispensingofdrugs.
Pharmacy Themonitoringofdrugprescriptionsforappropriatenessandthemonitoringofpatients
foradversedruginteractions.
Pharmacotherapeutics Theuseofchemicalagentstoprevent,diagnose,andcuredisease.
Pharmacokinetics Thestudyofhowthebodyabsorbs,distributes,metabolizes,andeliminatesadrug.
Thestudyofthebiochemicalandphysiologiceffectsofdrugsandtheirmechanismsof
Pharmacodynamics
actionatthecellularororganlevel.
Pharmacotherapy Thetreatmentofadiseaseorconditionwithdrugs.
Thestudyofhowvariationinhumangenesleadstovariationsinourresponsetodrugs
Pharmacogenetics
andhelpsdirecttherapeuticsaccordingtoapersonsgenotype.
Astudyofthenegativeeffectsofchemicalsonlivingthings,includingcells,plants,
Toxicology
animals,andhumans.
Painmedications,musclerelaxants,andnonsteroidalantiinflammatorydrugs(NSAIDs)canmasksigns
andsymptoms,therebyaffectingexaminationfindingsandincreasingthepotentialforinjuryduringthe
performanceofprescribedexercises.4However,ifthepatienthasasignificantamountofpain,appropriate
useofthesemedicationsmayenhancetreatment,allowingamorerapidprogressionthanwouldotherwise
bepossible.However,asthepatientimproves,theneedforthismedicationshouldlessen.
Certainmedicationscanproducechangesinmusculoskeletalstructures.Forexample,prolongeduseof
corticosteroidsmayproduceosteoporosisandweakeningofconnectivetissues.5
Apatientundergoinganticoagulanttherapyhasareducedclottingabilityandismoresusceptibleto
bruisingorhemarthrosis.Itisworthrememberingthataspirinandaspirinbasedproductshavean
anticoagulanteffect.
CLINICALPEARL
Whiletheimportanceofapharmacologicallyintegratedapproachtocomprehensivepatientmanagementcannot
beoveremphasized,itisworthrememberingthatwhilesomedrugscanenhancephysicaltherapyinterventions,
manycanhavenegativeconsequences.
PHARMACOKINETICS
Pharmacokineticsisthestudyofthephysicochemicalfactorsinvolvedasthebodyabsorbs,distributes,
metabolizes,andeliminatesadrug.Tohaveadesirableeffect,adrugmusthaveanappropriateconcentrationat
thesiteofaction.Thephysicochemicalpropertiesofdrugs,theirdosageformulations,androutesof
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administrationdeterminethelevelofdrugabsorptionandtheresponsethatoccurs.Absorptionistheprocessby
whichadrugismadeavailabletothebodyfluidsthatdistributethedrugtotheorgansystems.Theprimary
routesofadministrationincludeoral,buccal,sublingual,rectal,parenteral,topical,andinhalational(Table92).
Asthetargetcellsbecomeexposedtoincreasingconcentrationsofthedrug,increasingnumbersofreceptors
becomeactivated,andthemagnitudeoftheresponseincreasesuntilthereisamaximalresponse.In
pharmacology,thetermbioavailabilityisusedtodescribetherateandextentofatherapeuticallyactivedrug
thatreachesthesystemiccirculationandisavailableatthesiteofaction.Bioavailabilityisoneoftheessential
toolsinpharmacokinetics,asbioavailabilitymustbeconsideredwhencalculatingdosages.Theconceptof
equivalenceamongdrugproductsisalsoimportantinmakingclinicaldecisions:
TABLE92MethodsforDrugAdministration
Method Description
Enteral
Oral Chewed,sucked,orswallowed
Sublingualorbuccal Placedunderthetongueorinthecheek
Rectal Placedintherectumasasuppositoryorenema
Parenteral
Intravenous Directplacementofadrugintothebloodstream
Intramuscular Injectedintothemuscle
Intraarticular Administereddirectlyintothesynovialfluidofajoint
Subcutaneous Administeredbelowthedermis
Intrathecal Injectedintothesubarachnoidorsubduralspacestobypassthebloodbrainbarrier
Epidural Administeredintotheepiduralspace
Other
Inhalational
Topical
Transdermal
Chemicalequivalencereferstodrugproductsthatcontainthesamecompoundinthesameamount.
Bioequivalencereferstochemicalequivalentsthat,whenadministeredtothesamepersoninthesame
dosageregimen,resultinequivalentconcentrationsofdruginthebloodandtissues.
Therapeuticequivalencereferstodrugproductsthat,whenadministeredtothesamepersoninthesame
dosageregimen,provideessentiallythesametherapeuticeffectortoxicity.Bioequivalentproductsare
expectedtobetherapeuticallyequivalent.
Thus,thephysicochemicalpropertiesofadruggovernitsabsorptivepotential,butthepropertiesofthedosage
form(whichpartlydependonitsdesignandmanufacture)andthemodeofadministrationcanlargelydetermine
drugbioavailability.
Thevolumeofdistributionisusedtoindicatehowasystemicdoseofthemedicationisultimatelydispersed
throughoutthebody.Thevolumeofthedistributionrepresentshowmuchofthedrugappearsintheplasma
relativetothetotalamountofdrugadministered,thushavingimportantimplicationsastotheamountofdrug
thatreachesthetargettissue.Becauseofhighlevelsofbloodflow,wellperfusedorganssuchastheheart,liver,
kidney,andbrainrapidlyreceivemostofthedrugduringthefirstfewminutesafterabsorption.6Tissueswith
lessvascularperfusionsuchasmuscle,skin,andfatrequireseveralminuteslongertoachieveasteadystate.The
processofabsorption,distribution,biotransformation,andexcretionofadrugasrelatedtopassageacrosscell
membranesisdependentuponthecharacteristicsofthedrugsmolecularsize,shape,solubility,siteof
absorption,degreeofionization,andrelativelipidsolubilityofitsionizedandnonionizedforms.6Clearanceis
therateatwhichtheactiveformofthedrugisremovedoreliminatedfromthebody.Itisthetimethatittakesto
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clearthedrugfrombloodplasma.Therateoftheprocesstoinactivateadrugoreliminateitfromthecirculation
isreferredtoastheeliminationhalflife(seelater).
TRANSPORTACROSSCELLMEMBRANES
Whenadministeredbymostroutes(excludingintravenously),adrugmusttraversesemipermeablecell
membranesatseverallocationsbeforereachingthesystemiccirculation(Fig.91).Thesemembranesare
biologicbarriersthatselectivelyinhibitthepassageofdrugmoleculesandarecomposedprimarilyofa
bimolecularlipidmatrix,containingmostlycholesterolandphospholipids.Thelipidsprovidestabilitytothe
membraneanddetermineitspermeabilitycharacteristics.Globularproteinsofvarioussizesandcompositionare
embeddedinthematrixtheyareinvolvedintransportandfunctionasreceptorsforcellularregulation.Drugs
maycrossabiologicbarrierbyanumberofmethods:(1)diffusionthroughthewaterfilledchannelsor
specializedionchannels,(2)passivediffusionthroughthelipidmembrane,(3)facilitateddiffusion,(4)active
transport,or(5)pinocytosis.
FIGURE91
Drugtransferacrossacellmembrane.
Diffusion
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Mostdrugsareweakorganicacidsorbases,existinginnonionizedandionizedformsinanaqueous
environment.Thenonionizedformisusuallylipidsolubleanddiffusesreadilyacrosscellmembranes.However,
theionizedformcannotpenetratethecellmembraneeasilybecauseofitslowlipidsolubilityandthehigh
electricalresistanceprovidedbythelipidportionofthemembrane.Steroidsarenonionized(lipidsoluble),the
receptorsforwhicharelocatedinsidethecellratherthanontheexternalsurfaceofthecell.Distributionofan
ionizabledrugacrossamembraneatequilibriumisdeterminedbythedrugspKa(thepHatwhich
concentrationsofnonionizedandionizedformsofthedrugareequal)andthepHgradient,whenpresent.Fora
weakacid,thehigherthepH,thelowertheratioofnonionizedtoionizedforms.Inplasma(pH,7.4),theratioof
nonionizedtoionizedformsforaweakacid(e.g.,withapKaof4.4)is1:1,000ingastricfluid(pH,1.4),the
ratioisreversed(1,000:1).Whentheweakacidisgivenorally,theconcentrationgradientforanonionizeddrug
betweenstomachandplasmatendstobelarge,favoringdiffusionthroughthegastricmucosa.Atequilibrium,
theconcentrationsofanonionizeddruginthestomachandintheplasmaareequalbecauseonlythenonionized
drugcanpenetratethemembranestheconcentrationofanionizeddrugintheplasmawouldthenbeabout1,000
timesgreaterthanthatinthestomach.ForaweakbasewithapKaof4.4,theoutcomeisreversed.Thus
theoretically,weaklyacidicdrugs(e.g.,aspirin)aremorereadilyabsorbedfromanacidmedium(stomach)than
areweakbases(e.g.,quinidine).
PassiveDiffusion
Inthisprocess,transportacrossacellmembranedependsontheconcentrationgradientofthesolute.Mostdrug
moleculesaretransportedacrossamembranebysimplediffusionfromaregionofhighconcentration(e.g.,
gastrointestinal[GI]fluids)tooneoflowconcentration(e.g.,blood).Becausedrugmoleculesarerapidly
removedbythesystemiccirculationanddistributedintoalargevolumeofbodyfluidsandtissues,drug
concentrationinbloodisinitiallylowcomparedwiththatattheadministrationsite,producingalargegradient.
Thediffusionrateisnotonlydirectlyproportionaltothegradientbutalsodependsonthemoleculeslipid
solubility,thedegreeofionization,andthesizeandareaoftheabsorptivesurface.Becausethecellmembraneis
composedoflipids,lipidsolubledrugsdiffuseacrossthemembranemorerapidlythanrelativelylipidinsoluble
drugs.Smallmoleculestendtopenetratemembranesmorerapidlythanlargeones.
FacilitatedPassiveDiffusion
Forcertainmolecules(e.g.,glucose),therateofmembranepenetrationisgreaterthanpredictedduetotheirlow
lipidsolubility.Onetheoryisthatacarriercomponentcombinesreversiblywiththesubstratemoleculeatthe
cellmembraneexterior,andthecarriersubstratecomplexdiffusesrapidlyacrossthemembrane,releasingthe
substrateattheinteriorsurface.Carriermediateddiffusionischaracterizedbyselectivityandsaturability:The
carriertransportsonlythosesubstrateswitharelativelyspecificmolecularconfiguration,andtheprocessis
limitedbytheavailabilityofcarriers.Theprocessdoesnotrequireenergyexpenditure,andtransportagainsta
concentrationgradientdoesnotoccur.
ActiveTransport
Thisprocessrequiresenergyexpenditurebythecell.Substratesmayaccumulateintracellularlyagainsta
concentrationgradient.Activetransportappearstobelimitedtodrugsstructurallysimilartoendogenous
substances.Thesedrugsareusuallyabsorbedfromsitesinthesmallintestine.Activetransportprocesseshave
beenidentifiedforvariousions,vitamins,sugars,andaminoacids.
Pinocytosis
Thisprocessoccurswhenacellengulfsfluidorparticles.Thecellmembraneinvaginates(encloses)thefluidor
particles,thenfusesagain,formingavesiclethatlaterdetachesandmovestothecellinterior.Thismechanism
requiresenergyexpenditureandprobablyplaysonlyaminorroleindrugtransport,exceptinthecaseofprotein
drugs.
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DISTRIBUTIONOFDRUGS
Thedistributionofadrugreferstothemovementortransportofadrugtothesiteofaction.Onceadrugenters
thesystemiccirculation,itisdistributedtodifferentpartsofthebodyincludingtheinterstitialandintracellular
fluid,andextravasculartissues.Therateatwhichthisoccursdependsonavarietyoffactorsincludingthe
following:7
Therateoforganbloodflow.
Thedegreeofdrugionizationindifferentcompartments.
Thebindingofapercentageofthedrugmoleculestoserumprotein.Theprimaryproteinthatbindsdrug
moleculesisserumalbumin.Bindingpreventsthedrugfromexertinganypharmacologicaction.The
unboundmoleculesaretheportionsofthedrugthatcanpenetratecapillarywallstoreachthesiteof
action.
Thenumberofcompetingdrugswithinthesystem.Somedrugscompeteforthesamebindingsites.This
competitionmayresultinhigherlevelsoftheunbounddrugactingonthebody.
Molecularweight.
Bloodbrainbarrier.Manydrugsthateasilypenetrateotherbodyorgansdonotappreciablyenterthebrain
becauseofthesievelikeactionofthebloodbrainbarrier.
Lipidsolubility.
Lipidsolubledrugsaremorelikelytopenetratethebloodbrainbarrierthanotherdrugsbecause
theypassthroughthecellmembrane.
Lipidsolubledrugsmaybestoredinadiposetissue,whichactsasadrugrepository.
Anylocalmetabolismthatoccursinanytissueotherthanthetargetorgan.
METABOLISMOFDRUGS
Metabolismreferstotheprocessoftransformingadrugintoacompoundthatcanbeexcreted.Metabolism
occursprimarilyintheliver,whichreducesthedrugspharmacologicalactivityandlipidsolubility.Drug
metabolisminvolvestwoprocessesorphases:
PhaseI.Thesereactionsarecatabolicandinvolveoxidation,reduction,fullhydrolysisreactions,with
oxidationoccurringmostfrequently.
PhaseII.Duringthisphase,thedrugundergoesconjugationreactions.
DRUGELIMINATION
Drugsareeliminatedfromthebodybyavarietyofroutesincludingeliminationinfluids(urine,breastmilk,
saliva,tears,andsweat),throughtheGItractinthefeces,andexpelledinexhaledairthroughthelungs.The
kidneyistheprimaryorganfortheexcretionofdrugsthathavebeeninactivatedbytheliverintowatersoluble
metabolites.8Excretionofadrugbythekidneysoccursbytwoprocesses7:
Glomerularfiltration,inwhichdrugsarefilteredthroughtheglomerulusandthencarriedthroughthe
tubuleintotheurine.Therateofdrugexcretiondependsuponrenalbloodflow.Renalbloodflowmaybe
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diminishedwithkidneypathologyandtheagingprocess.9
Activesecretionofthedrugbythetubuleintotheurine.
DRUGHALFLIFE
Therateatwhichadrugdisappearsfromthebody,throughmetabolism,excretion,oracombinationiscalledthe
halflife.Itistheamountoftimerequiredforhalfofthedrugthatisinthebodytobeeliminated.Twotermsare
usedtodescribehalflife:
Eliminationhalflife.
Thetimeinwhichtheconcentrationofthedrugintheplasmafallstoonehalfofitsoriginal
amount.
Adrugsrateofdisappearancefromthebody,whetherbymetabolism,excretion,oracombination
ofboth.
Biologicalhalflife.
Thetimeinwhichthedurationofactionfallstoonehalfofitsoriginalduration.
Thetimeofthedrugsresponseratherthanitsplasmaconcentration.
CLINICALPEARL
Thehalflifeistheamountoftimerequiredforhalfofthedrugthatisinthebodytobeeliminated.
Knowingthehalflifeofadrugiscriticalindetermininghowoftenandinwhatdosageadrugmustbe
administeredtoachieveandmaintaintherapeuticlevelsofconcentration.Thedosageinterval(timebetween
administrationsofthedrug)isequaltothehalflifeofaparticulardrug.Theshorterthehalflife,themoreoften
thepatientmusttakethemedication.Theoreticallyasteadystatewillbereachedwhentheamountofthedrug
takenwillequaltheamountthatisexcreted.Asteadystateisusuallyreachedafterfivehalflivesofthedrug
haveoccurred.Thus,adrugwithalonghalflifemaytakeseveraldaystoweekstoreachasteadystate.
DRUGALLERGYANDDRUGINDUCEDILLNESSES
Drugallergiesorhypersensitivitiesrangefrommildpresentationstoveryseverelifethreateningevents.Fora
drugtoproduceareaction,itmusthaveantigeniceffectsandstimulateantibodyformationortheformationof
sensitizedTlymphocytes,whichisimmunerelated.Drugallergiesaregenerallyclassifiedintofourtypes:
TypeI(anaphylacticreactions).Anaphylaxisisthemostsevereallergicreactionandinvolvestheskin
andpulmonaryandcardiovascularsystems,producingcardiovascularandrespiratorycollapse.Thesigns
andsymptomsassociatedwithanaphylacticshock,whichusuallyoccurwithinminutesafterantigen
exposure,butmaystilloccurupto1hourlater,include:
Neurological:dizziness,weakness,andseizures.
Ocular:pruritus,lacrimation,edemaaroundtheeyes.
Respiratory:nasalcongestion,hoarseness,stridor,cough,dyspnea,tachypnea,bronchospasm,and
respiratoryarrest.
Cardiac:tachycardia,hypotension,arrhythmias,myocardialinfarction.
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Integumentary:flushing,erythema,urticaria.
GI:nausea,vomiting,anddiarrhea.
CLINICALPEARL
Anaphylaxisisthemostsevereformofallergicreactionandcanoftenbelifethreatening.
TypeII(cytotoxicreaction).Theantigensadheretothetargetcellandbegintodestroythetargettissue.
Theclinicalmanifestationsinclude:
Fever
Arthralgia
Rash
Splenomegaly
Lymphnodeenlargement
TypeIII(autoimmunereaction).Acomplexmediatedhypersensitivityreactioninwhichthebodyhas
difficultyineliminatingantigenantibodycomplexes.Manifestationsincludeserumsickness,
glomerulonephritis,vasculitis,andpulmonarydisorders.
TypeIV(cellmediatedhypersensitivity).ThistypeofreactionismediatedthroughTlymphocytesas
opposedtoantibodies.Manifestationsincludelocalortissuereaction.
THEEFFECTSOFEXERCISEONPHARMACOKINETICS
Theeffectsofexerciseondrugdistributionarecomplexandaredependentonfactorsthatpertaintothe
characteristicsofeachdrugaswellasexerciserelatedfactorssuchasexerciseintensity,mode,andduration.10
Exerciseincreasesmuscularbloodflowandtemperatureandthesubsequentenhancementofabsorptionthrough
moleculardiffusionacrossbiologicalmembranes.Thebioavailabilityofdrugscanbealteredwithexercise
primarilybecauseofitsinfluenceonthedrugsabsorptionsite.11Forexample,thereisanincreasedbindingof
digoxin(aheartmedicationthatreducestheventricularrate)intheskeletalmuscle.11Ontheotherhand,
exercisemaysequestersomedrugssuchaspropranolol(amedicationusedtotreathypertension)inmuscleand
reducetheavailabilityofthedrugforelimination.Inaddition,exercisedecreasestheclearanceofhighly
extracteddrugsandincreasestheirplasmaconcentration.Hepaticbloodflowhasbeenfoundtobereducedas
muchas50%withanexerciseintensitylevelof70%ofmaximaloxygenuptake.12Decreasinghepaticblood
flowcouldpotentiallydecreasetheclearanceofdrugsthataremetabolizedasafunctionofbloodthroughthe
liver.Inasimilarfashion,sinceexercisereducesrenalbloodflow,theplasmaconcentrationsofthosedrugsthat
areprimarilyeliminatedbythekidneysmayincrease.12
Exercisedoesappeartoenhanceabsorptionfromintramuscular,subcutaneous,transdermal(iontophoresis,
phonophoresis),andinhalationsites.However,exerciseatthesiteofadministrationalsoincreasescutaneous
bloodflowwhich,inthecaseofiontophoresisandphonophoresis,couldbetherapeuticallyunfavorableasthe
targetsiteofdrugadministrationcouldbecomedilutedbelowtherapeuticlevels.9
THEEFFECTSOFPHYSICALAGENTSON
PHARMACOKINETICS
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Similartoexercise,physicaltherapymodalitieshavethepotentialtoalterthepharmacokineticsoflocallyand
systemicallyadministereddrugs,primarilybyaffectingbloodflowandtissuekineticandmetabolicactivity.9,13
Thermalagentsthatincreaseregionalbloodflowcantheoreticallyincreasedeliveryofadrugtoaspecifictissue
sitealthoughthereareafewstudiesthathavedocumentedwhetherthesechangeshaveanyclinicalrelevance.
However,applicationoflocalheattothesiteofthedrugadministrationwillalmostcertainlyincreasedispersion
ofthedrugawayfromthedeliverysite.10Incontrast,coldcantheoreticallyrestrictdrugdeliverybycausing
vasoconstrictionatthecryotherapysite.10
THEEFFECTSOFMANUALTECHNIQUESON
PHARMACOKINETICS
Manualtechniquesthatincreasebloodflowtoanarea,suchasmassage,increasedrugabsorptionfromlocal
subcutaneousinjectionsites.Whethermanualtechniqueshaveaneffectonthedeliveryofsystemically
administereddrugsisnotknownatpresent.
Inconclusion,becausesomephysicaltherapyinterventionsarecapableofproducingcomplexchangesinthe
pharmacokineticsofcertaindrugs,anyvariationintheclinicalresponsethatisobservedduringoraftera
physicaltherapysession,shouldraisethesuspicionaboutthepotentialpharmacokineticeffectofadrug.9In
addition,ifmaintainingtheplasmaconcentrationofadrugatacertainlevelisimportant,considerationshould
begiventoalternativedrugsifthepatientistoreceivetreatmentthatmayaffecttheabsorption,distribution,and
metabolismofadrug.13
PHARMACOTHERAPY
Anunderstandingofthepotentialeffectsofcertaintypesofdrugscommonlyencounteredduringthe
rehabilitationprocessisessential.
MUSCULOSKELETALPHARMACOLOGY
Drugsarewidelyusedinthemanagementofbothacuteandchronicpainandinflammation.Byfarthemost
frequentlyencounteredand/orprescribeddrugagentsinphysicaltherapypracticearethosethatareprescribedto
controlpainand/orinflammation.
OpioidAnalgesics
Mostofthenarcoticsusedinmedicinearereferredtoasopioids,astheyarederiveddirectlyfromopiumorare
syntheticopiates.14Examplesoftheseopioidsincludecodeine,Darvon(propoxyphenehydrochloride),
morphine,andDemerol(meperidine)(seeNarcoticAnalgesics).Opioidanalgesicsaremoreeffectivein
controllingpainofaconstantdurationversussharpintermittentpain.15
NonopioidAnalgesics
Nonopioidanalgesicscompriseaheterogeneousclassofdrugsincludingthesalicylates(aspirinanddiflunisal),
paraaminophenolderivatives(primarilyacetaminophen),andtheNSAIDs,suchasibuprofen,Motrin,and
manyothers.Despitetheirdiversestructures,nonopioidanalgesicshavesimilartherapeuticeffects,oralefficacy,
andsimilarsideeffectprofiles.Nonopioidanalgesicsarebettertoleratedcomparedtoopioidsbyambulatory
patients,havelesssedativeeffects,andaremuchlesslikelytoproducetoleranceordependence.Conversely,the
hazardsoflongtermadministrationofthesedrugsarerecognized.
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ParaAminophenolDerivatives
Oftheparaaminophenolderivatives,onlyacetaminophen(Tylenol)iswidelyused.Acetaminophenisnot
typicallyclassifiedasanNSAIDbecauseofitslackofanantiinflammatoryeffect(itdoesnotinhibit
prostaglandinsynthesisinperipheraltissues).Acetaminophenisprimarilycentrallyactingyetexertsits
analgesicandantipyreticeffectsperipherallybyweakinhibitionofbothisoformsofcyclooxygenasethroughan
unknownmechanism.16
NonsteroidalAntiinflammatoryDrugs
NSAIDsaredistinguishedfromtruesteroidagentssuchascortisone(cortisol),prednisone(seelater),andfrom
theopiatederivedanalgesics.NSAIDshaveantipyretic,anticlotting(nonselectiveNSAIDsonly),analgesic,and
antiinflammatoryeffectsandarebyfarthemostfrequentlyencounteredformofdruginphysicaltherapy
practice.NSAIDsarethefirstlinedrugchoiceforthetreatmentofmildtomoderatepain,softtissueinjury,
osteoarthritis,gout,andinflammatoryrheumaticdisorders.3Ofthosepatientsseeingphysicaltherapists,25
40%aretakingprescriptionantiinflammatoryagents,withabout40%ofthoseusingmultipleNSAIDs
concomitantly.3,17,18Aspirin,anacetylsalicylicacid,hasbeenrecognizedforitspharmaceuticalpropertiesfor
centuries.ThepharmacologyofaspirinisquiteconsistentwiththatofotherNSAIDs,anditremainsthe
prototypeforcomparisonsoftheefficacyandsafetyofnewmedicationsinitsclass.Aspirincontinuestobethe
firstlinedrugforavarietyofconditions,includingmildpain,fever,osteoarthritis,rheumatoidarthritis,stroke
preventiontherapy,andpotentialreductioninprostatecancerincidence.19OtherNSAIDsdifferfromaspirinin
kinetics,durationofaction,andpatienttolerance,buttheoverallefficacyisverysimilar.
CLINICALPEARL
WhileithasbeenshownthatNSAIDsmaybeofbenefitinmuscleandtendonhealing,thereisgrowing
evidenceofimpairmentofboneandcartilagehealingduetoNSAIDs.3
TheanalgesicandantiinflammatoryactivityofNSAIDsisprimarilyduetotheinhibitionofarachidonicacid
metabolism.20Arachidonicacidispresentoncellmembranesthroughoutthebodyandactsasasubstratefor
prostaglandin,prostacyclin,andthromboxanesynthesis.3Arachidonicacidisreleasedfromcellmembranesin
responsetophysical,chemical,hormonal,andbacterialorotherstimuli.3
NSAIDsalsoseemtopromotetheinhibitionofthereleaseofcyclooxygenase1(COX1)andcyclooxygenase2
(COX2)andthesynthesisofprostaglandinsataninjurysite.20
COX1inhibitors.COX1isconstitutivelypresentinvirtuallyalltissuesundernormalconditions.3The
inhibitionofCOX1byNSAIDshasatendencytoproduceanumberofadverseeffectsonmultipleorgan
systems,includingGIinflammation,ulceration,bleeding,andincreasedpotentialforperforation.21Other
possiblesideeffectsincludeanalterationofnormalfunctionintheGImucosaandkidneybloodflow,
delayedwoundhealing,edema,nausea,dyspepsia,andfluidretention.NSAIDsmayalsoalterkidney
bloodflowbyinterferingwiththesynthesisofprostaglandinsinthekidneyinvolvedintheautoregulation
ofbloodflowandglomerularfiltration.22
COX2inhibitors.MuchattentionhasbeengiventotheselectiveCOX2inhibitors,suchascelecoxib
(Celebrex),whichweredevelopedtoprovideNSAIDbenefitswithoutaffectingtheGImucosa,renal
tissue,orplateletaggregation.3COX2istypicallynotfoundoncellmembranesunderbaseline
conditionsbutisinducedandupregulatedbycytokines,suchasinterleukin1inthepresenceofcellstress
orinjury.3BecauseCOX2inhibitorsdonotproducethesameGIeffectsasCOX1inhibitors,theyare
safertouseinpatientswhoarepredisposedtogastricorkidneymalfunctions.COX2drugsblockonly
theCOX2enzyme,whichisresponsiblefortriggeringpainandinflammation.20BecauseCOX1isnot
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affected,thepatientsstomachliningisprotected,andbleedingtendenciesareavoided.However,the
enthusiasmforthecoxibshavebeensomewhattemperedbydatasuggestingtheyareassociatedwitha
higherriskofcardiovasculareventsthanthenonselectiveNSAIDs,whichledtothewithdrawalfromthe
marketoftwowidelydistributeddrugs:VioxxandBextra.23
ThepharmacokineticsofNSAIDshavebeenstudiedextensively:3
Absorption.NSAIDsaretypicallylipidsolubleweakacidsandareideallysuitedforrapidabsorption
fromtheacidicstomachandduodenum.Afteringestion,mostNSAIDswillexhibitaneffectwithin1530
minutes.Thetimeintervaltoperceivesymptomreliefvarieswiththerateofenzymaticbreakdownof
previouslysynthesizedprostaglandinsandthetimerequiredfortheingesteddrugagenttoinhibit
replacement.OnceinthebloodstreamNSAIDs,exceptforaspirin,areheavilyboundtoplasmaproteins.
DespitethehighlevelofNSAIDproteinbinding,atherapeuticeffectisexertedbytheconstant
dissociationofthedrugfromitsbindingproteinandreleaseasfreeoractivefractionwithintheserum.
BecauseofNSAIDshighproteinaffinitytheymaydisplaceothermoreweaklyproteinbounddrugs
unintentionally,suchaswarfarin(Coumadin),sulfonylureahypoglycemicagents,andmethotrexate.
Distribution.NSAIDsarewidelydistributedthroughoutmostbodytissues.
Metabolism.TheliverisresponsibleforthemetabolismandbioconversionofNSAIDs.Integrationofthe
NSAIDhalflifedataintotheclinicianstherapeuticmodalityselectionallowsformaximaldrugbenefit
andaminimizationinanyadverseimpactontherapy.Itisworthnotingthatdrugswithlongerhalflives
areassociatedwiththehighestriskforadverseeffect.TheeffectofagivenNSAIDwillvaryamong
individualpatients,sometimesleadingtoatrialofseveraldifferentagentsinanefforttoobtainthebest
therapeuticeffect.Inclinicalpractice,710daysaregenerallylongenoughtoascertaintheeffectofa
givendrug.
Elimination.NSAIDsareeliminatedbyrenalexcretion.AlterationsinurinepHcanaffectthelevelof
ionizedornonionizeddrugresidueand,therefore,ratesofelimination.
CLINICALPEARL
Excessingestionofsalicylate,includingtopicalproductscontainingsalicylates(e.g.,BenGay,andoilof
wintergreen),isacommoncauseofpoisoning.Symptomscanincluderespiratoryfailure,sepsislike
syndrome,apotentiallylethalcomplicationofsalicylatetoxicity,alteredmentalstatus,andsignsandsymptoms
ofrespiratoryalkalosisandmetabolicacidosis.
LocalAnesthetics
Localanestheticsdecreasesensationinabodypartwithoutalossofconsciousnessorimpairmentsofvital
functionsthatareassociatedwiththeuseofageneralanesthetic.15Alllocalanestheticsaremembrane
stabilizingdrugsthatactbyreversiblydecreasingtherateofdepolarizationandrepolarizationofnociceptor
membranesbyinhibitingsodiuminfluxthroughsodiumspecificionchannelsintheneuronalcellmembrane.
Whentheinfluxofsodiumisinterrupted,anactionpotentialcannotarise,andsignalconductionisinhibited.
Thelocaladverseeffectsofanestheticagentsincludeneurovascularmanifestationssuchasprolongedanesthesia
andparesthesia,whicharesymptomsoflocalizednerveimpairment.Dependingonthelocaltissue
concentrationsoflocalanesthetics,theremaybeexcitatoryordepressanteffectsonthecentralnervoussystem
(CNS),whichcanincludegeneralizedconvulsions,coma,respiratoryarrest,anddeath.
Corticosteroids
Corticosteroidscanbeclassifiedasnaturalorsynthetic.Thenaturalform(mineralocorticoids)isproducedby
theadrenalglands,underthecontrolofthehypothalamus,andisinvolvedinmaintainingfluidandelectrolyte
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balance.Glucocorticoids(cortisol,anddrugssuchasprednisone),areusedprimarilyforthetreatmentofarange
ofimmunologicalandinflammatorymusculoskeletalconditions.Althoughglucocorticoidsaffectnearlyevery
majororgansysteminthebody,theirprimaryroleistoregulatebloodglucose.Corticosteroidsexerttheiranti
inflammatoryeffectsbybindingtoahighaffinityintracellularcytoplasmicreceptorpresentinallhumancells,24
whichinturninteractwithdiscretenucleotidesequencestoaltergeneexpression.Becausemoststeroid
receptorsintargetcellsarelocatedinthecytoplasm,theyneedtogetintothenucleustoaltergeneexpression.
Thesideeffectsfromexcesscorticosteroidsareassociatedwithanumberofnegativesideeffects,includinga
cataboliceffectonalltypesofsupportivejointtissue.ExogenoussteroiduseleadstoCushingssyndrome:25
Cutaneousmanifestations.Cutaneousmanifestationsofhypercortisolismincludedelayedwoundhealing,
acanthosisnigricans(avelvety,thickened,hyperpigmentedplaquethatusuallyoccursontheneckorin
theaxillaryregion),acne,ecchymosisafterminortrauma,hyperpigmentation,hirsutism,petechia,and
striae.
Hypokalemia.Hypokalemia(apotentiallyfatalconditioninwhichthebodyfailstoretainsufficient
potassiumtomaintainhealth)isawellrecognizedsideeffectofcorticosteroidtherapyandisprobably
relatedtothemineralocorticoideffectofhydrocortisone,prednisone,andprednisolone.Dexamethasone
hasnomineralocorticoideffect.
Myopathy.Therearetworecognizedformsofcorticosteroidinducedmyopathy:acuteandchronic.Acute
myopathymayinpartbecausedbyhypokalemia,althoughcorticosteroids(especiallymassivedosages)
mayhaveadirecteffectonskeletalmuscle.Bothproximalanddistalmuscleweaknessoccuracutely,
usuallywithanassociatedandsignificantelevationinserumcreatininephosphokinase,whichis
indicativeoffocalanddiffusemusclenecrosis.Inthemorechronicformofmyopathy,weaknessismore
insidiousinonsetandprimarilyinvolvestheproximalmusclegroups.
Hyperglycemia.Hyperglycemiaisaconditioninwhichanexcessiveamountofglucosecirculatesinthe
bloodplasma.Whenhyperglycemiaiscombinedwiththeimmunosuppressiveeffectofcorticosteroids,
thereisasignificantincreaseintheriskforinfection.
Neurologicalimpairments.Thesecanincludevertigo,headache,convulsions,andbenignintracranial
hypertension.
Osteoporosis.Corticosteroidsinhibitboneformationdirectlyviainhibitionofosteoblastdifferentiation
andtypeIcollagensynthesisandindirectlybyinhibitionofcalciumabsorptionandenhancementof
urinarycalciumexcretion.
Ophthalmologicsideeffects.Corticosteroidsincreasetheriskofglaucomabyincreasingintraocular
pressure,regardlessofwhetheradministeredintranasally,topically,periocularly,orsystemically.
Growthsuppression.Corticosteroidsinterferewithboneformation,nitrogenretention,andcollagen
formation,allofwhicharenecessaryforanabolismandgrowth.
DiseaseModifyingAntirheumaticDrugs
Diseasemodifyingantirheumaticdrugs(DMARDs),sometimesreferredtoasslowactingantirheumaticdrugs
(SAARDs),areagroupofdrugsthatappeartodecreaseinflammation,thoughtheyarenotcategorizedasanti
inflammatorydrugs.DMARDsdifferfromNSAIDsastheydonotdecreaseprostaglandinproduction,donot
directlyrelievepain,norreducefever.Ineffect,DMARDsslowthediseaseprocessbymodifyingtheimmune
system.DMARDsaremostcommonlyusedinthetreatmentofrheumatoidarthritiswhencombinedwithanti
inflammatoryagents,andcorticosteroids,butsomearealsousedforankylosingspondylitis,psoriaticarthritis,
andlupus.StudiesthroughouttheyearshaveshownDMARDstobeveryeffectivedrugs,withuncommonly
observedserioussideeffects.ThenewestDMARDsarebiologicalagentsthatspecificallytargetandblock
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interleukin1ortumornecrosisfactor,bothofwhicharecytokinesthatplayaroleintheinflammatoryprocess
indiseasessuchasrheumatoidarthritis.
SkeletalMuscleRelaxants
Skeletalmusclerelaxantsarethoughttoactbydecreasingmuscletonewithoutcausingimpairmentinmotor
function,andbyactingcentrallytodepresspolysynapticreflexes.Asmuscleguardingandspasmaccompany
manymusculoskeletalinjuries,itwasoriginallythoughtthatthesedrugs,byeliminatingthespasmand
guarding,wouldfacilitatetheprogressionofarehabilitationprogram.However,otherdrugswithsedative
properties,suchasbarbiturates,alsodepresspolysynapticreflexes,makingitdifficulttoassessifcentrally
actingskeletalmusclerelaxantsareactuallymusclerelaxantsasopposedtononspecificsedatives.26There
presentlyexistsadiscrepancybetweenthecommonclinicaluseofskeletalmusclerelaxantsandtheresultsof
controlledclinicaltrialsevaluatingtheirefficacyincomparisonwithplacebo.Supportingevidencedoesnot
existfortheirefficacyinthepainofmyogenicoriginnorisitcleariftheyprovideanadditiveeffectwith
exercisesaimedatmusclerelaxation.
Becausenearlyalloftheoralskeletalmusclerelaxantshavethepotentialtoproducedrowsiness,sedation,or
muscleweakness,theseagentscanhaveaneffectonthepatientsabilitytoperformmotorrelatedtasksor
participateintherapyprograms.15
EXAMPLESOFDISEASESPECIFICDRUGS
MusculoskeletalSystemPharmacology
Osteoporosis
Whileestrogentherapyisstillusedinthetreatmentofosteoporosis,thereareanumberofmedicationoptions
presentlybeingused.Thecurrentdrugoptionsforosteoporosisfallintofourcategories:15
1.Bisphosphonates.Theseareantiresorptiveagentsthatdecreaseosteoclasticboneresorption.Theresults
aredecreasedboneremodeling,indirectlyincreasedbonemassandareducedriskoffractures.
2.Calcitonin.Thisisacalciumloweringhormonesecretedbythethyroidglandthatexertsitseffectsby
directinhibitionofosteoclastactivity,andpromotionofrenalexcretionofcalciumandotherminerals.
3.Selectedreceptormolecules.Thistypeofnonhormonalmedicationactsasanestrogenagonistinthebone
tosuppressboneremodelingwithoutunfavorablestimulationoftheestrogenreceptorslocatedinthe
breasttissueortheuterus.
4.StrontiumRanelate.Adrugthatoffersthedualmechanismsofactionofcombiningtheantiresorptive
effectwiththeanaboliceffectofnewboneformation.
Gout
Themedicationsprescribedtotreatgoutusuallydependonwhetherthepatientproducestoomuchuricacidor
doesnotexcreteuricacidproperly.Ifthebodyproducestoomuchuricacid,adrugsuchasallopurinolisusedto
slowuricacidproduction.Inthecasewherethebodydoesnotexcreteuricacidwell,anotherdrugsuchas
probenecidcanbeused.
NeurologicSystemPharmacology
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AntianxietyMedications
SelectiveSerotoninReuptakeInhibitors
Selectiveserotoninreuptakeinhibitors(SSRIs)arecommonlyprescribedpsychotherapeuticagents.Serotoninis
aneurotransmittersynthesizedfromtheaminoacidLtryptophan.Synthesisisnecessaryforboththecentraland
peripheralnervoussystems(PNSs)becauseserotonincannotcrossthebloodbrainbarrier.Oncesynthesized,
serotoniniseitherstoredinneuronalvesiclesormetabolizedbymonoamineoxidase(MAO)to5
hydroxyindoleaceticacid.ThemostseriousdrugrelatedadverseeffectofSSRIsisthepotentialtoproduce
serotoninsyndrome(SS).SS,characterizedbymentalstatuschanges,neuromusculardysfunction,and
autonomicinstability,isthoughttobesecondarytoexcessiveserotoninactivityinthespinalcordandbrain.
Symptomsattributedtoserotoninexcessmayinclude:
restlessness
hallucinations
shivering
diaphoresis
nausea
diarrhea
headache
MonoamineOxidaseInhibitors(MAOIs) 27
Neurotransmittersaregenerallymonoamines.Whenreleasedintothesynapticspace,neurotransmittersare
eitherreabsorbedintotheproximalnerveordestroyedbyMAOinthesynapticcleft.ThetwotypesofMAOare
MAOAandMAOB.MAOAisfoundprimarilyintheliverandGItractwithsomefoundinthe
monoaminergicneurons.MAOApresentintheliverisinvolvedintheeliminationofingestedmonoamines,
suchasdietarytyramine.Circulatingmonoaminessuchasepinephrine,norepinephrine,anddopamineare
inactivatedwhentheypassthroughaliverrichinMAOA.MAOB,ontheotherhand,isfoundprimarilyinthe
brainandinplatelets.
MAOIsactbyinhibitingtheactivityofMAOpreventingthebreakdownofmonoamineneurotransmitters
(norepinephrine,serotonin,anddopamine)therebyincreasingtheavailablemonoaminesavailablewithinthe
CNS.
Benzodiazepines.28
Benzodiazepines(BZDs)aresedative/hypnoticagentsthatareusedforavarietyofsituations,includingseizure
control,anxiety,alcoholwithdrawal,insomnia,controlofdrugassociatedagitation,asmusclerelaxants
(antispasticityagents),andaspreanestheticagents.Theyalsoarecombinedfrequentlywithothermedications
forconscioussedationbeforeproceduresorinterventions.
Aminobutyricacid(GABA)isthemajorinhibitoryneurotransmitterintheCNS.TwotypesofGABA
receptorscalledAandBtypes,arefoundinthebrainandspinalcordneurons.BZDsexerttheiractionby
potentiatingtheactivityofGABA.TheybindtoaspecificreceptorontheGABAAreceptorcomplex,which
facilitatesthebindingofGABAtoitsspecificreceptorsite.BZDbindingcausesincreasedfrequencyofopening
ofthechloridechannelcomplexeswiththeGABAAreceptor.ThereversalpotentialforGABAA/chloride
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complexesisnegativetothethresholdforgeneratinganactionpotential.Inthisway,activationoftheGABAA
receptor/chlorideporeisinhibitory.
CLINICALPEARL
GABAhastwotypesofreceptors:
GABAA.GABAAreceptorisstimulatedandchloridechannelsopentoallowtheinfluxofnegativeions
(i.e.,chloride).TheGABAAreceptorshavemultiplebindingsitesforBZDs,barbiturates,andothers
substancessuchaspicrotoxins,bicuculline,andneurosteroids.
GABAB.TheGABABreceptorislinkedtoapotassiumchannel.
EnhancedGABAneurotransmissionresultsinsedation,striatedmusclerelaxation,anxiolysis,and
anticonvulsanteffects.StimulationofPNSGABAreceptorsmaycausedecreasedcardiaccontractility,
vasodilation,andenhancedperfusion.
blockers
blockersareaclassofdrugsusedforvariousindications,includingthemanagementofcardiacarrhythmias,
hypertension,cardioprotectionaftermyocardialinfarction,andtoblocktheautonomicresponseinpersonswith
socialphobia.
Sedatives/Hypnotics
Sedative/hypnoticsareagroupofdrugsthatcauseCNSdepressionandaremainlyusedinthetreatmentof
insomnia,butcanalsobeusedtotreatanxiety,depression,andpsychosis.BZDs,whicharenonbarbiturates(see
above),arethemostcommonlyusedagentsinthisclass.29Althoughbarbituratesproduceasedativehypnotic
effect,theassociatedrapiddevelopmentoftolerancecarrieswithitahighriskofphysicalandpsychological
dependence,withdrawalsyndromes,andfatalitiesbyoverdose.Forthesereasons,barbituratesarenotroutinely
prescribed.BZDsinducesleepbydecreasingthenumberofarousalsbetweenthedifferentstagesofsleep
therebyallowingformorecontinuoustotalsleeptime.Mostsedative/hypnoticsstimulatetheactivityofGABA,
theprincipalinhibitoryneurotransmitterintheCNS.Hydroxybutyricacid(GHB)isasedative/hypnotic
recentlybannedforsaletothepublicbecauseoffrequentabuseandseriousadversetoxiceffects.GHBisa
neuroinhibitoryneurotransmitterorneuromodulatorintheCNS.ItalsoappearstoincreaseGABABreceptor
activityanddopaminelevelsintheCNS.
Mildtoxicityofsedative/hypnoticsresemblesethanolintoxicationandcanincludeexcessivedrowsiness,
impairedpsychomotorcoordination,decreasedconcentration,andcognitivedeficits.29Moderatepoisoning
leadstorespiratorydepressionandhyporeflexia.Severepoisoningleadstoflaccidareflexiccoma,apnea,and
hypotension.
Occasionally,hyperreflexia,rigidity,clonus,andBabinskisignsarepresent.Miosisiscommon,butmydriasis
maybepresentwithcertainagents.Thenonbarbiturates,suchasmethyprylonandglutethimide,more
commonlypresentwithmydriasis.Hypotensionisusuallysecondarytovasodilationandnegativecardiac
inotropiceffects.
NarcoticAnalgesics
Thetermnarcoticspecificallyreferstoanysubstancethatinducessleep.Incurrentpractice,narcoticrefersto
anyofthemanyopioidsoropioidderivatives.
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ActivationoftheopiatereceptorsresultsintheinhibitionofsynapticneurotransmissionintheCNSandPNS.
Opioidsbindtoopiatereceptorstherebyinducingapostsynapticresponse.Thephysiologicaleffectsofopioids
aremediatedprincipallythroughandreceptorsintheCNSandperiphery.receptoreffectsinclude
analgesia,euphoria,respiratorydepression,andmiosis.receptoreffectsincludeanalgesia,miosis,respiratory
depression,andsedation.Twootheropiatereceptorsthatmediatetheeffectsofcertainopiatesincludeand
sites.receptorsmediatedysphoria,hallucinations,andpsychosisreceptoragonismresultsineuphoria,
analgesia,andseizures.
Commonclassificationsdividetheopioidsintoagonist,partialagonist,oragonistantagonistagentsandnatural,
semisynthetic,orsynthetic.Opioidsdecreasetheperceptionofpain,ratherthaneliminateorreducethepainful
stimulus.Inducingslighteuphoria,opioidagonistsreducethesensitivitytoexogenousstimuli.TheGItractand
therespiratorymucosaprovideeasyabsorptionformostopioids.
Peakeffectsaregenerallyreachedin10minuteswiththeIVroute,1015minutesafternasalinsufflation,3045
minuteswiththeIM(intramuscular)route,90minuteswiththePO(bymouth)route,and24hoursafterdermal
application.Followingtherapeuticdoses,mostabsorptionoccursinthesmallintestine.Toxicdosesmaydelay
absorptionbecauseofdelayedgastricemptyingandslowedgutmotility.
Mostopioidsaremetabolizedbyhepaticconjugationtoinactivecompoundsthatareexcretedreadilyinthe
urine.Certainopiatesaremorelipidsolubleandcanbestoredinthefattytissuesofthebody.Allopioidshavea
prolongeddurationofactioninpatientswithliverdisease(e.g.,cirrhosis)becauseofimpairedhepatic
metabolism.Thismayleadtodrugaccumulationandopioidtoxicity.Renalfailurealsoleadstotoxiceffects
fromaccumulateddrugoractivemetabolites.
Opioidtoxicitycharacteristicallypresentswithadepressedlevelofconsciousness.Opiatetoxicityshouldbe
suspectedwhentheclinicaltriadofCNSdepression,respiratorydepression,andpupillarymiosisispresent.
Drowsiness,conjunctivalinjection(rednessofthewhitescleraoftheeye),andeuphoriaareseenfrequently.
Otherimportantpresentingsignsareventriculararrhythmias,acutementalstatuschanges,andseizures.
Antidepressants
TricyclicAntidepressants.30
Tricyclicantidepressants(TCAs)areusedinthetreatmentofdepression,chronicpain,andenuresis(involuntary
dischargeofurine,especiallywhileasleep).Patientswithdepressionandthosewithchronicpainareathighrisk
forabuse,misuse,andoverdosingofthesedrugs.
TCAsaffectthecardiovascular,pulmonary,andGIsystems,andtheCNS.Thetoxiceffectsonthemyocardium
arerelatedtotheblockingoffastsodiumchannels,whichinvolvesthesamemechanismastypeIA
antiarrhythmics(e.g.,quinidine).Theresultisaslowingmyocardiumdepolarizationthatleadstoarrhythmia,
myocardialdepression,andhypotension.Hypotensionalsoresultsfromtheperipheraladrenergicblockade,
whichcausesvasculardilatation.Inhibitionofnorepinephrinereuptakeandsubsequentdepletioncausesfurther
hypotension.Theeffectsonthepulmonarysystemincludepulmonaryedema,adultrespiratorydistress
syndrome,andaspirationpneumonitis.Theetiologiesofthefirsttworemainunclear,butthethird,aspiration
pneumonitis,issecondarytoanalteredmentalstatus.
TheanticholinergiceffectsofTCAscauseaslowingoftheGIsystem,whichresultsindelayedgastric
emptying,decreasedmotility,andprolongedtransittime.
CNStoxicityresultsfromtheanticholinergiceffectsanddirectinhibitionofbiogenicaminereuptake.An
excitationsyndromeistheinitialresultandmanifestsasconfusion,hallucinations,ataxia,seizures,andcoma.
ParkinsonDiseaseandParkinsonianSyndrome
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Parkinsondisease(PD)isaprogressiveneurodegenerativediseaseaffectingevery100150perhundred
thousandindividuals,orabout1%ofthoseover60yearsofage,intheU.S.population.3133PDis
characterizedclinicallybytremor,bradykinesia,rigidity,andposturalinstability.Thebasalgangliamotorcircuit
modulatescorticaloutputnecessaryfornormalmovement.
Levodopa,coupledwithaperipheraldecarboxylaseinhibitor(PDI),remainsthecriterionstandardfor
symptomatictreatmentforPD,asitprovidesthegreatestantiparkinsonianbenefitwiththefewestadverse
effects.30
Dopamineagonistsprovidesymptomaticbenefitcomparabletolevodopa/PDIinearlydiseasebutlacksufficient
efficacytocontrolsignsandsymptomsbythemselvesinlaterdisease.
MedicationsforPDusuallyprovidegoodsymptomaticcontrolfor46years.Whetherlevodopahasatoxicor
protectiveeffectinthebrainwithPDisunknown.AsPDprogresses,fewerdopamineneuronsareavailableto
storeandreleaselevodopaderiveddopamine.Thepatientsclinicalstatusbeginstofluctuatemoreandmore
closelyinconcertwithplasmalevodopalevels.Fluctuatinglevodopaderiveddopamineconcentrationsin
associationwithadvancingdisease,therefore,mayberesponsibleforthedevelopmentofmotorfluctuationsand
dyskinesia.30
Incontrasttolevodopa,thelongactingdopamineagonistsproviderelativelysmoothandsustainedreceptor
stimulation.30
Theselectionofmedicationdependsinpartonthenatureandcauseofthedisability.Ifthedisabilityisdue
solelytotremor,atremorspecificmedication,suchasananticholinergicagent,isoftenused.Anticholinergic
medicationsprovidegoodtremorreliefinapproximately50%ofpatients,butdonotimprovebradykinesiaor
rigidity.30Becausetremormayrespondtooneanticholinergicmedicationandnotanother,asecond
anticholinergicusuallyistriedifthefirstisnotsuccessful.Thesemedicationsareusuallyintroducedatalow
doseandescalatedslowlytominimizeadverseeffects,whichincludememorydifficulty,confusion,and
hallucinations.Adversecognitiveeffectsarerelativelycommon,especiallyintheelderly.
Ifthedisabilityisduetoadopamineresponsivesymptomsuchasbradykinesia,rigidity,decreaseddexterity,
slowspeech,orshufflinggait,adopaminergicmedication(dopamineagonistorlevodopa/PDI)aretypically
introduced.30Symptomaticmedicationsarestartedatalowdose,escalatedslowly,andtitratedtocontrol
symptoms.Mostpatientsrequiresymptomaticdopaminergictherapytoamelioratebradykinesiaandrigidity
within12yearsafterdiagnosis.
Forpatientsyoungerthan65years,symptomatictherapyisnormallyinitiatedwithadopamineagonistandthen
addlevodopa/PDIwhenthedopamineagonistalonenolongercontrolssymptomsadequately.30Dopamine
agonistsprovideantiparkinsonianefficacycomparabletolevodopa/PDIfor618monthsorlongerandmay
controlsymptomsadequatelyforseveralyears.
Forpatientswhoaredementedorthoseolderthan70years,whomaybepronetoadverseeffectsfrom
dopamineagonists,andforthoselikelytorequiretreatmentforonlyafewyears,physiciansmayelectnottouse
adopamineagonistbutdependonlevodopa/PDIastheprimarysymptomatictherapy.30Forpatientsaged6570
years,ajudgmentismadebasedongeneralhealthandcognitivestatus.
MedicationsforCerebrovascularAccidents
Theischemiccascadeisaseriesofbiochemicalreactionsthattakeplaceinthebrainandotheraerobictissues
aftersecondstominutesofischemia(inadequatebloodsupplyTable93).34Sincetheischemiccascadeisa
dynamicprocess,theefficacyofinterventionstoprotecttheischemiccascadealsomayprovetobetime
dependent.
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TABLE93TheIschemicCascade
LackofoxygencausestheneuronsnormalprocessformakingATPforenergytofail.
Thecellswitchestoanaerobicmetabolism,producinglacticacid.
ATPreliantiontransportpumpsfail,causingthecelltobecomedepolarized,allowingions,includingcalcium
(Ca++ ),toflowintothecell.
Theionpumpscannolongertransportcalciumoutofthecell,andintracellularcalciumlevelsgettoohigh.
Thepresenceofcalciumtriggersthereleaseoftheexcitatoryaminoacidneurotransmitterglutamate.
GlutamatestimulatesAMPAreceptorsandCa++ permeableNMDAreceptors,whichopentoallowmore
calciumintocells.
Excesscalciumoverexcitescellsandcausesthegenerationofharmfulchemicalslikefreeradicals,reactive
oxygenspecies,andcalciumdependentenzymessuchascalpain,endonucleases,ATPases,andphospholipases.
Calciumcanalsocausethereleaseofmoreglutamate.
Asthecellsmembraneisbrokendownbyphospholipases,itbecomesmorepermeable,andmoreionsand
harmfulchemicalsflowintothecell.
Mitochondriabreakdown,releasingtoxins,andapoptoticfactorsintothecell.
Thecaspasedependentapoptosiscascadeisinitiated,causingcellstocommitsuicide.
Ifthecelldiesthroughnecrosis,itreleasesglutamateandtoxicchemicalsintotheenvironmentaroundit.
Toxinspoisonnearbyneurons,andglutamatecanoverexcitethem.
Ifandwhenthebrainisreperfused,anumberoffactorsleadtoreperfusioninjury.
Aninflammatoryresponseismounted,andphagocyticcellsengulfdamagedbutstillviabletissue.
Harmfulchemicalsdamagethebloodbrainbarrier.
Cerebraledemaoccursbecauseofleakageoflargemoleculeslikealbuminfrombloodvesselsthroughthe
damagedbloodbrainbarrier.Theselargemoleculespullwaterintothebraintissueafterthembyosmosis.This
vasogenicedemacausescompressionofanddamagetobraintissue.
AMPA,amino5hydroxy3methyl4isoxazolepropionicacidNMDA,Nmethyldaspartate.
Theoretically,calciumchannelblockersshouldhavethenarrowestwindowoftherapeuticopportunitysince
calciuminfluxisoneoftheearliesteventsintheischemiccascade.
Neuroprotectantsaffectinglatereventsintheischemiccascadeincludefreeradicalscavengersandneuronal
membranestabilizers.Monoclonalantibodiesagainstleukocyteadhesionmoleculesalsoarebeingevaluatedas
lateneuroprotectants.
Anticoagulantsareconsideredaspotentialtreatmentsforcerebrovascularaccidents(CVA).However,although
heparinpreventsrecurrentcardioembolicstrokesandmayhelpinhibitongoingcerebrovascularthrombosis,no
definitiveevidenceexiststoshowthatinitiatinganticoagulationreducesbraininjuryinacuteischemicstroke.
Anticoagulationdrugtreatmentisnotwithoutrisk.Overall,intracranialhemorrhageoccursin14%ofpatients
whoreceiveananticoagulantforTIAoracutestroke.Accordingly,uncontrolledhypertension,intracranial
hemorrhage,anduncontrolledbleedingatanothersitearecontraindicationstoanticoagulation.
Severalneworalanticoagulantmedicationsareinthefinalstagesofclinicaltrialsforuseintheprophylaxisof
ischemicthromboembolicstroke.Onceapprovedforuse,thepotentialofsuchdrugsinthearenaofstroke
treatmentmaybesignificant.
AntiepilepticDrugs
Manystructuresandprocessesareinvolvedinthedevelopmentofaseizure,includingneurons,ionchannels,
receptors,glia,andinhibitoryandexcitatorysynapses.35Theantiepilepticdrugs(AEDs)aredesignedtomodify
theseprocessestofavorinhibitionoverexcitationinordertostoporpreventseizureactivity.TheAEDscanbe
groupedaccordingtotheirmainmechanismofaction,althoughmanyofthemhaveseveralactionsandothers
haveunknownmechanismsofaction.Themaingroupsareasfollows.
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Sodiumchannelblockers
Thesodiumchannelblockadeisthemostcommonandthemostwellcharacterizedmechanismofcurrently
availableAEDs.AEDsthattargetthesesodiumchannelspreventthereturnofthechannelstotheactivestateby
stabilizingtheirinactiveform.Indoingso,repetitivefiringoftheaxonsisprevented.Thepresynapticand
postsynapticblockadesofsodiumchannelsoftheaxonscausestabilizationoftheneuronalmembranes,block
andpreventposttetanicpotentiation,limitthedevelopmentofmaximalseizureactivity,andreducethespreadof
seizures.
CLINICALPEARL
Anticonvulsantsinmooddisordershavefourmajoreffects:
Increasingoftheseizurethreshold
Decreasingtheseizureduration
Decreasingtheneurometabolicresponsetoanepisode
Decreasingthephenomenaofamygdaloidkindling
Essentially,theymakeitmoredifficultforthepostsynapticneurontoreachitsexcitationthresholdeither
electricallyorneurochemically,andonceithasbeenreached,decreasethewidespreadeffects.
Sideeffectsandtoxicity
AEDscanproducedoserelatedadverseeffects,whichincludedizziness,diplopia,nausea,ataxia,andblurred
vision.Rareidiosyncraticadverseeffectsincludeaplasticanemia,agranulocytosis,thrombocytopenia,and
StevensJohnsonsyndrome.Asymptomaticelevationofliverenzymesisobservedcommonlyduringthecourse
oftherapyin510%ofpatients.Rarely,severehepatotoxiceffectscanoccur.
GABAreceptoragonists
DirectbindingtoGABAAreceptorscanenhancetheGABAsystembyblockingpresynapticGABAuptake,by
inhibitingthemetabolismofGABAbyGABAtransaminase,andbyincreasingthesynthesisofGABA.
Themostcommoneffectissedation.Otheradverseeffectsincludedizziness,ataxia,blurredvision,diplopia,
irritability,depression,musclefatigue,andweakness.
ABAreuptakeinhibitors
AtleastfourspecificGABAtransportingcompoundshelpinthereuptakeofGABAthesecarryGABAfrom
thesynapticspaceintotheneuronsandglialcells,whereitismetabolized.Nipecoticacidandtiagabine(TGB)
areinhibitorsofthesetransportersthisinhibitionmakesincreasedamountsofGABAavailableinthesynaptic
cleft,whichservestoprolongGABAmediatedinhibitorypostsynapticpotentials(IPSPs).
Themostcommonadverseeffectsincludedizziness,asthenia,nervousness,tremor,depressedmood,and
emotionallability.DiarrheaalsowassignificantlymorefrequentamongTGBtreatedpatientsthanplacebo
treatedpatients.Otheradverseeffectsincludedsomnolence,headaches,abnormalthinking,abdominalpain,
pharyngitis,ataxia,confusion,psychosis,andskinrash.
GABAtransaminaseinhibitor
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GABAismetabolizedbytransaminationintheextracellularcompartmentbyGABAtransaminase(GABAT).
InhibitionofthisenzymaticprocessleadstoanincreaseintheextracellularconcentrationofGABA.Vigabatrin
(VGB)inhibitstheenzymeGABAT.
Themostcommonadverseeffectisdrowsiness.Otherimportantadverseeffectsincludeneuropsychiatric
symptoms,suchasdepression(5%),agitation(7%),confusion,and,rarely,psychosis.Minoradverseeffects,
usuallyattheonsetoftherapy,includefatigue,headache,dizziness,increaseinweight,tremor,doublevision,
andabnormalvision.
Glutamateblockers
Glutamateandaspartatearethemosttwoimportantexcitatoryneurotransmittersinthebrain.Theglutamate
systemisacomplexsystemwithmacromolecularreceptorswithdifferentbindingsites(i.e.,AMPA,kainate,
NMDA,glycine,metabotropicsite).
Commonadverseeffectsincludeinsomnia,weightloss,nausea,decreasedappetite,dizziness,fatigue,ataxia,
andlethargy.Polytherapyisassociatedwithincreasesinadverseeffects.
Neuroleptics(Antipsychotics)
Thetermneurolepticreferstotheeffectsoncognitionandbehaviorofantipsychoticdrugsthatreduce
confusion,delusions,hallucinations,andpsychomotoragitationinpatientswithpsychoses.36Alsoknownas
majortranquilizersandantipsychoticdrugs,neurolepticagentscompriseagroupofthefollowingclassesof
drugs:
Phenothiazines
Aliphatics
Piperidines
Piperazines
Thioxanthenes
Butyrophenones
Dibenzoxazepines
Dihydroindolone
Diphenylbutylpiperidine
Benzisoxazole
Theadverseeffectsofneurolepticsarenotconfinedtopsychiatricpatients.Neurolepticsalsoareusedas
sedatives,fortheirantiemeticproperties,tocontrolhiccups,totreatmigraineheadaches,asantidotesfordrug
inducedpsychosis,andinconjunctionwithopioidanalgesia.
ThemajortranquilizershavecomplexCNSactionsthatareincompletelydefined.Theirtherapeuticactionis
thoughttobeprimarilyanantagonismofcentraldopaminergic(D2receptor)neurotransmission,althoughthey
alsohaveantagonisteffectsatmuscarinic,serotonergic,1adrenergic,andH1histaminergicreceptors.
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Althoughallantipsychoticpreparationssharesometoxiccharacteristics,therelativeintensityoftheseeffects
variesgreatly,dependingontheindividualdrug.Generally,allneurolepticmedicationsarecapableofcausing
thefollowingsymptoms:
Hypotension:Phenothiazinesarepotentadrenergicblockersthatresultinsignificantorthostatic
hypotension,evenintherapeuticdosesforsomepatients.Inoverdose,thehypotensionmaybesevere.
Anticholinergiceffects:Neurolepticagenttoxicitycanresultintachycardia,hyperthermia,urinary
retention,toxicpsychosis,andhot,dryflushedskin.
Extrapyramidalsymptoms:Alterationinthenormalbalancebetweencentralacetylcholineanddopamine
transmissioncanproducedystonia,oculogyriccrisis,torticollis,acuteparkinsonism,akathisia,andother
movementdisorders.Chronicuseofmajortranquilizersisassociatedwithbuccolingualdysplasia(tardive
dyskinesia,TD),parkinsonism,andakathisia.
Neurolepticmalignantsyndrome:Allofthemajortranquilizershavebeenimplicatedinthedevelopment
ofneurolepticmalignantsyndrome(NMS)alifethreateningderangementthataffectsmultipleorgan
systemsandresultsinsignificantmortality.
Seizures:Mostmajortranquilizerslowertheseizurethresholdandcanresultinseizuresathighdosesand
insusceptibleindividuals.
Hypothermia:Certainmajortranquilizerspreventshivering,limitingthebodysabilitytogenerateheat.
Cardiaceffects:ProlongationoftheQTintervalandQRScanresultinarrhythmias.
Respiratorydepression:Hypoxiaandaspirationofgastriccontentscanoccurinchildrenandinmixed
overdose.
Spasticity
Spasticityisamotordisordercharacterizedbyavelocitydependentincreaseintonicstretchreflexeswith
exaggeratedtendonjerks,resultingfromhyperexcitabilityofthestretchreflex,asonecomponentoftheupper
motorneuronsyndrome(seeChapter3).37,38Thedrugsusedtoreducespasticityworkasagonistsor
antagonistsatbothoftheGABAreceptors.
BZDsdiazepamandclonazepam
TheBZDsbindGABAAreceptorcomplexesinneuronslocatedinthebrainstemandatthespinalcordleveland
increasetheaffinityofGABAfortheGABAAreceptorcomplex.Thisresultsinanincreaseinpresynaptic
inhibitionandthereductionofmonosynapticandpolysynapticreflexes.Thesedrugsmayimprovepassiverange
ofmotionandreducehyperreflexia,painfulspasms,andanxiety.Diazepamhasahalflifeof2080hoursand
formsactivemetabolitesthatprolongitseffectiveness.Thehalflifeofclonazepamrangesfrom18to28hours.
Sedation,weakness,hypotension,adverseGIeffects,memoryimpairment,incoordination,confusion,
depression,andataxiamayoccur.Toleranceanddependencycanoccur,andwithdrawalphenomena,notably
seizures,havebeenassociatedwithabruptcessationoftherapy.
Baclofenoralandintrathecalpump
BaclofenisaGABAagonist,anditsprimarysiteofactionisthespinalcord,whereitreducesthereleaseof
excitatoryneurotransmittersandsubstancePbybindingtotheGABABreceptor.Studiesshowthatbaclofen
improvesclonus,flexorspasmfrequency,andjointrangeofmotion,resultinginimprovedfunctionalstatus.
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Adverseeffectsincludesedation,ataxia,weakness,andfatigue.
IntrathecalbaclofenisapprovedintheUnitedStatesforthetreatmentofspasticityofspinalorcerebralorigin.
Inchildren,intrathecalbaclofenisparticularlyeffectiveforthetreatmentofspasticityofthelowerextremities.
Complicationsoftheprocedurearerelativelyfewandusuallyarelimitedtomechanicalfailuresofthepumpor
thecatheter.Adversedrugeffectsareusuallytemporaryandcanbemanagedbyreducingtherateofinfusion.
CARDIOVASCULARSYSTEMPHARMACOLOGY
Manycardiovascularmedicationshavethepotentialtoalterresponsestobothacuteandchronicexerciseina
predictablemanner.Knowledgeofhowcommondrugsaltertheseresponsescanassisttheclinicianinassessing
thesafetyandappropriatenessofexerciseandindeterminingtheeffectivenessofexercisetraining.39Most
medicationsthatareprescribedforcardiovasculardiseasehaveeitheradirectorindirecteffectontheheartor
vascularsystem,includingalterationofthemyocardialoxygenconsumption,peripheralbloodflow,andcardiac
preloadorafterload.39Medicationsmayeitherincreaseordecreaseexercisecapacity,oraltertheexpected
changesinheartrateandbloodpressurethatnormallyoccurwithanincreaseinactivityoratrest(Table94).39
TABLE94EffectsofMedicationsontheCardiovascularandMetabolicResponsestoExercise
MedicationsThatCouldAlter
PhysiologicalResponse SpecificExample
Response
Contractility
Increasedbydigitalis
Cardiacoutput Initiation/conductionofcardiacaction
Decreasedbyblockers
potential
Venodilationorconstriction:preload Decreasedbynitrates
Effectsonperipheral Arterialvasoconstrictionordilation: Decreasedby1antagonists
circulation afterload
Bloodvolume Decreasedbydiuretics
Heartrate
Myocardialoxygen Decreasedbyblockers
Bloodpressure
consumption Decreasedbynitrates
Systolicwalltension
Distributionofcardiac Bloodflowtoactiveskeletalmuscles Decreasedby1antagonists
output Bloodflowtocutaneousvessels Decreasedby1antagonists
Fattyacidmobilizationandoxidation Decreasedbyblockers
Metabolism
Glycogenolysis Decreasedbyblockers
DatafromPeelC,MossbergKA.Effectsofcardiovascularmedicationsonexerciseresponses.PhysTher.
199575:387396.
AdrenergicBlockingDrugs(1Antagonists/Blockers)
Thesedrugsworkthroughtheautonomicnervoussystem(ANS)byblockingreceptors.receptorsnormally
promoteconstrictionofthearterioles.Blockingconstrictionpromotesdilationofvesselsandlowersblood
pressureaswellasreducingtheworkoftheheartinsomesituations.blockingdrugsalsoinhibittheactionsof
norepinephrinethatraisesbloodpressureaspartofthefightorflightresponse.blockersareusuallyprescribed
alongwithotherbloodpressureloweringdrugs,suchasablockingdrugand/oradiuretic.Therearenow
severalmedicationsavailablethatcombinetheeffectsofblockingboththeandreceptors.
Possibleadversesideeffects
Nauseaandindigestiontheseusuallysubsidewithlongtermuse.Lessfrequenteffectsarecoldhandsandfeet,
temporaryimpotence,andnightmares.Dizzinessmayoccurinitiallyorasthedosageisincreased.
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AngiotensinConvertingEnzymeInhibitors
Thesedrugsacttopreventproductionofahormone,angiotensinII,whichconstrictsbloodvessels.Theybelong
totheclassofdrugscalledvasodilatorsdrugsthatdilatebloodvessels,aneffectivewaytolowerblood
pressureandincreasethesupplyofbloodandoxygentotheheartandvariousotherorgans.Inadditionto
dilatingbloodvessels,angiotensinconvertingenzyme(ACE)inhibitingmedicationsmayproducesome
beneficialeffectsindirectlybypreventingtheabnormalriseinhormonesassociatedwithheartdisease,suchas
aldosterone.ACEinhibitorsarewidelyusedtotreathighbloodpressure,orhypertension,amajorriskfactorfor
cardiovasculardisease.Usedaloneorincombinationwithotherdrugs,ACEinhibitorshavealsoproved
effectiveinthetreatmentofcongestiveheartfailure.
PossibleAdverseSideEffects
Commonsideeffectsaredizzinessorweakness,lossofappetite,arash,itching,ahacking,unpredictablecough,
andswelling.
AntiarrhythmicDrugs
Thesedrugs,whicharepotentmedications,correctanirregularheartbeat(arrhythmia)andslowaheartthatis
beatingtoofast(tachycardia).
Possiblesideeffects
Themostsignificantcommonsideeffectsareweakeningofheartcontractions,worseningofsomearrhythmias,
weightloss,nausea,andtremors.Otherlesscommoneffectsarefever,rash,drymouth,depressedwhiteblood
cellcount,liverinflammation,confusion,lossofconcentration,dizziness,anddisturbancesinvision.About
0.10.2%ofpatientssufferlunginflammation,apotentiallyserioussideeffect.
Anticoagulants,Antiplatelets,andThrombolytics
Thesedrugsaresometimesreferredtoasbloodthinners,butthistermisnottrulyaccurate,astheyinhibitthe
abilityofthebloodtoclotpreventingclotsfromforminginbloodvesselsandfromgettingbigger.
Anticoagulants,antiplateletagents,andthrombolyticseachhavespecificindicationsanduses.Anypatientwho
hashadaheartvalvereplacedwithamechanicalvalverequireslifelongoralanticoagulantsinordertoprevent
clotsfromformingonthevalve.Patientswhodevelopatrialfibrillationmayrequireanticoagulantsclot
formationintheleftatriumisapotentialhazardofthisrhythmicdisturbance.Oralanticoagulantsareprescribed
forpatientswhodevelopthrombophlebitis,aninflammationoftheveinsinthelegsorpelvis.Oneofthedangers
ofthisconditionisthedevelopmentofbloodclotsthatmaytraveltothelungsandcausepulmonaryemboli.
Finally,somepatientswhohaveaseriousheartattackinvolvingtheanteriorsurfaceoftheheartareprescribed
ananticoagulanttopreventclotsfromformingontheinnerliningofthescar.
Heparinisananticoagulantthatisadministeredintravenouslywhenrapidanticoagulationisnecessary.All
patientsundergoingopenheartsurgeryaretreatedwithheparinwhiletheirbloodisbeingoxygenatedbythe
heartlungmachine.Attheendoftheoperation,medicationisgiventoreversetheeffectsofheparin.
Aspirinisnotananticoagulantbuthasaprofoundeffectonplateletsbloodcellsthatsticktogetherandcause
clotstoform.Becauseofaspirinsabilitytoinhibittheclottingactionofplatelets,itisdesignatedasan
antiplateletandisfrequentlyprescribedinpatientswhohaverecoveredfromaheartattack,inordertoprevent
clotsfromformingintheveinsusedforcoronarybypasssurgery.
Themostrecentandexcitingclassesofdrugsthatareusefulforpeoplewithheartattacksarethethrombolytic
drugs.Theseagentsaregivenintravenouslyassoonaspossiblewiththegoalofdissolvingtheoffendingclot
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withinacoronaryarterybeforeitcausespermanent,debilitatingdamage.Thethreemostcommonlyused
thrombolyticsaretPA,streptokinase,andAPSAC.
Possiblesideeffects
Adverseeffectsarerare,butmayincludenausea,headache,flushing,dizzinessorfaintness,orrash.
AdrenergicBlockers
Thesedrugsprobablyreducebloodpressurebyreducingcardiacoutput(orperhapsbyblockingtheproduction
ofangiotensin).blockersarealsousedtotreathypertension.Specifically,theyblockresponsesfromthe
nervereceptors.Thisservestoslowdowntheheartrateandtolowerbloodpressure.blockersalsoblockthe
effectsofsomeofthehormonesthatregulatebloodpressure.Duringexerciseoremotionalstress,adrenalineand
norepinephrinearereleasedandnormallystimulatethereceptorssensorsthattransmitmessagestotheheart
tospeedupandpumpharder.Byblockingthereceptors,blockersacttoreduceheartmuscleoxygendemands
duringphysicalactivityorexcitement,thusreducingthepossibilityofanginacausedbyoxygendeprivation.
Possiblesideeffects
Lethargyandcoldhandsandfeetbecauseofreducedcirculationmayoccur.Thesedrugsmayalsocausenausea,
nightmaresorvividdreams,andimpotence.
CalciumChannelBlockers.Calciumplaysacentralroleintheelectricalstimulationofcardiaccellsandinthe
mechanicalcontractionofsmoothmusclecellsinthewallsofarteries.Calciumchannelblockersarerelatively
newsyntheticdrugsthatworkbyblockingthepassageofcalciumintothemusclecellsthatcontrolthesizeof
bloodvessels.Allmusclesneedcalciuminordertocontractbypreventingthemusclesofthearteriesfrom
contracting,bloodvesselsdilate,allowingbloodtoflowthroughthemmoreeasily,andreducingbloodpressure.
Possiblesideeffects
Excessivelyslowheartrate,lowbloodpressure,headache,swellingofankle/feet,constipation,nausea,
tiredness,dizziness,rednessoffaceandneck,palpitations,andrash.
DigitalisDrugs
Likemanydrugs,digitaliswasoriginallyderivedfromaplant,inthiscase,thefoxglove.Digitalishasthe
primaryeffectofstrengtheningtheforceofcontractionsinweakenedheartsandisalsousedinthecontrolof
atrialfibrillation.Themostcommonlyuseddigitalisproductsaredigoxinanddigitoxin.Thedrugpenetratesall
bodytissuesandreachesahighconcentrationinthemuscleoftheheart.Itsmoleculesbindwithcellreceptors
thatregulatetheconcentrationofsodiumandpotassiuminthespacesbetweentissuecellsandinthe
bloodstream.Thesetwomineralsdeterminethelevelofcalcium.Digitalispreparationsactbyincreasingthe
amountofcalciumsuppliedtotheheartmuscleandthusenhancingitscontractions.Digitalisdrugsalsoaffect
electricalactivityincardiactissues.Theycontroltherateatwhichelectricimpulsesarereleasedandthespeed
oftheirconductionthroughthechamberwalls.Thesetwoactionsdeterminethetwomajorusesofdigitalis
drugsinheartdiseasetreatmentofheartfailureandcontrolofabnormalheartrhythms.Digitalismaybegiven
onashorttermbasisinacuteheartfailureoroveralongperiodoftimetotreatchronicheartfailure.Digitalis
drugscanbeusedtotreatdisturbancesoftheheartbeat,particularlytheabnormallyrapidcontractionsofthe
atriareferredtoasatrialorsupraventriculararrhythmias(especiallyatrialfibrillation).Thedrugsrestorethe
normalheartbeateitherbyinterruptingtheabnormalrhythmorbyslowingdowntherapidbeats,sothat
effectiveandcoordinatedheartcontractionsarepossible.
Possiblesideeffects
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Somesideeffectsincludetiredness,nausea,lossofappetite,anddisturbancesinvision.
Diuretics
Diuretics,commonlyreferredtoaswaterpills,lowerbloodpressurebyincreasingthekidneysexcretionof
sodiumandwater,whichinturnreducesthevolumeofblood.Thereareseveraltypesofdiuretics,whichare
classifiedaccordingtotheirsiteofactioninthekidney.
Thiazidediureticsworkinthetubules(thestructuresthattransporturineinthekidneys).
Loopdiureticsaremorepotentthanthethiazidediuretics.Theyaresonamedbecausetheyworkinthe
areaofthekidneycalledtheloopofHenle.Theyareusuallyprescribedwhenathiazidediureticproves
insufficientorforpatientswithheartfailureorcompromisedkidneyfunction.
Potassiumsparingdiureticsworkintheareaofthekidneyordistaltubuleofthenephronsinthekidney
wherepotassiumisexcreted.Theypreventtheexcessivelossofpotassiumthatsometimesoccurswiththe
thiazides.Theyaremostoftengiveninconjunctionwithathiazideorloopdiuretics.
Possiblesideeffects
Althoughuncommon,lethargy,cramps,rash,orimpotencemayoccur.Someoftheseeffectsmaybecausedbya
lossofpotassiumandmaybeavoidedbyincludingapotassiumsupplementorpotassiumsparingagentinthe
regimen.
Nitrates
Theoldestandmostfrequentlyusedcoronaryarterymedicationsarethenitrates.Nitratesarepotentveinand
arterydilators,causingbloodtopoolintheveinsandthearteriestoopenup,thusreducingtheamountofblood
returningtotheheart.Thisdecreasestheworkoftheleftventricleandlowersthebloodpressure.Nitratesmay
alsoincreasethesupplyofoxygenatedbloodbycausingthecoronaryarteriestoopenmorefully,thus
improvingcoronarybloodflow.Nitrateseffectivelyrelievecoronaryarteryspasm.Theydonot,however,
appeartoaffecttheheartscontractions.
Possiblesideeffects
Headaches,flushing,anddizzinessmayoccur.
PULMONARYSYSTEMPHARMACOLOGY
Thedeliveryofadrugtothelungsallowsthemedicationtointeractdirectlywiththediseasedtissueandreduce
theriskofadverseeffects,specificallysystemicreactions,whilealsoallowingforthereductionofdose
comparedtooraladministration.Theprescriptionofanypulmonarymedicationisfoundedonfourbasic
goals:40
Promotionofbronchodilationorreliefofbronchoconstriction.
Facilitationoftheremovalofsecretionsfromthelungs.
Improvementofalveolarventilationoroxygenation.
Optimizationofthebreathingpattern.
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Therelativeimportanceofeachofthesegoalsdependsonthespecificdiseaseprocessandtheresultant
respiratoryproblem.40
Mostinhaleddrugsareadministeredthroughapressurizedmetereddoseinhaler.Drypowderinhalersorbreath
activateddevicesaredeliverydevicesthatscatterafinepowderintothelungsbymeansofabriskinhalation.
Theothermajordrugdeliverysystemforpulmonaryproblemsisthenebulizer,adevicethatdispensesliquid
medicationsasamistofextremelyfineparticlesinoxygenorroomair,sothatisinhaled.
BronchodilatorAgents
Bronchodilatoragentsareagroupofmedicationsthatproduceanexpansionoftheluminaoftheairway
passagesofthelungs.TheprimarygoalofbronchodilatortherapyistoinfluencetheANSviatwoopposing
nucleotides:cyclicadenosinemonophosphate(cAMP)andcyclicguanosinemonophosphate(cGMP).40cAMP
facilitatessmoothmusclerelaxationandinhibitsmastcelldegranulation,resultinginbronchodilation.40cGMP
facilitatessmoothmusclecontractionandmayenhancemastcellreleaseofhistamineandothermediators,
resultinginbronchoconstriction.40Bronchodilatoragents,whicheitherstimulate(sympathomimetics)orinhibit
(sympatholytics)adrenergicreceptors,arecentraltothesymptomaticmanagementofchronicobstructive
pulmonarydisease(COPD)andasthma(Table95).
TABLE95DrugsThatHaveaPositiveInfluenceonBronchialIntralumenalDiameter
Group Action MechanismofAction SideEffects
IncreasescyclicAMP,decreases
Tremor,palpitations,tachycardia,
intracellularcalcium
Bronchodilation headache,nervousness,dizziness,
sympathomimetics concentrations,thusrelaxing
nausea,hypertension
smoothmuscle
Blocksthedegradationofcyclic
Methylxanthines(a AMP Agitation,tachycardia,headache,
substancefoundin Usedforpatientswhodonot palpitations,dizziness,
Bronchodilation
coffee,tea,and respondtothestandardasthma hypotension,chestpain,nausea,
chocolate) agents,andisoccasionallyusedin possiblydiuresis
thetreatmentofspinalcordinjury
Agitation,tachycardia,headache,
palpitations,dizziness,
sympatholytics Bronchodilation BlocksthedecreaseofcyclicAMP
hypotension,chestpain,nausea,
possiblydiuresis
Blocksparasympathetic
stimulation,whichpreventsan Centralnervoussystem
increaseincyclicGMP,allowing stimulationwithlowdoses,
Prevents
Parasympatholytics cyclicAMPtoincreaseblocksthe depressionwithhighdoses
bronchoconstriction
activityoftheenzyme delirium,hallucinations,decreased
phosphodiesterase,whichprevents gastrointestinalactivity
thedegradationofcyclicAMP
Administeredsystemicallyor Cushingoidappearanceobesity
topically growthsuppression
Blocksthereleaseofarachidonic hyperglycemiaanddiabetes,mood
Glucocorticoids Bronchodilation acidfromairwayepithelialcells, changes,irritability,ordepression
whichinturnblocksproductionof thinningofskinmusclewasting
prostaglandinsandleukotrienes osteoporosishypertensionand
Decreasesinflammatoryresponse immunosuppression
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Group Action MechanismofAction SideEffects

Preventsinfluxofcalciumions
intothemastcell,thusblocking
thereleaseofmediators
Cromolynsodium responsiblefor Throatirritation,hoarseness,dry
(extractofa bronchoconstriction
Bronchodilation mouth,cough,chesttightness,
Mediterranean Usedprophylacticallytoprevent bronchospasm
plant) exerciseinducedbronchospasm
andseverebronchialasthmavia
oralinhalation
AMP,adenosinemonophosphateGMP,guanosinemonophosphate.
DatafromCahalinLP,SadowskyHS.Pulmonarymedications.PhysTher.199575:397414.
AncillaryPulmonaryMedications
Inadditiontobronchodilators,severalotherdruggroupsarefrequentlyusedinthetreatmentofrespiratory
disorders,includingdecongestants,antihistamines,antitussives,mucokinetics,respiratorystimulantsand
depressants,andparalyzingandantimicrobialagents.40
Antitussives
Antitussivesaredrugsthatsuppressanineffective,dry,hackingcoughbydecreasingtheactivityoftheafferent
nervesordecreasingthesensitivityofthecoughcenter.Thestimulusforacoughisrelayedtothecoughcenter
inthemedullaandthentotherespiratorymusclesviathephrenicnerve.Theprimaryadverseeffectof
antitussiveagentsissedation,althoughGIdistressanddizzinessmayalsooccur.40
Decongestants
Decongestantsareusedtotreatupperairwaymucosaledemaanddischargebybindingwiththe1receptorsin
thebloodvesselsofthemucosalliningoftheupperairwaystherebystimulatingvasoconstriction.40Primary
sideeffectsincludeaheadache,dizziness,nausea,nervousness,hypertension,andcardiacirregularities.40
Antihistamines
HistaminesplayaroleinthemodulationofneuralactivitywithintheCNSandtheregulationofgastricsecretion
bymeansoftwotypesofreceptors:
H1receptors.Theseareprimarilylocatedinvascular,respiratory,andGIsmoothmusclesandare
specificallytargetedforblockadebyantihistaminesinthetreatmentofasthma.H1antagonistdrugs
decreasethemucosalcongestion,irritation,anddischargecausedbyinhaledallergens.Theadverseeffects
mostoftenattributabletoantihistaminesincludesedation,fatigue,dizziness,blurredvision,lossof
coordination,andGIdistress.
H2receptors.TheseactviaGproteins(guaninenucleotidebindingproteins)tostimulateadenylate
cyclase,theenzymethatsynthesizescAMPfromadenosinetriphosphate(ATP).Amongthemany
responsesmediatedbythesereceptorsaregastricacidsecretion,smoothmusclerelaxation,inotropicand
chronotropiceffectsontheheartmuscle,andinhibitionoflymphocytefunction.
Mucokinetics
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Thisclassofdrugsisresponsibleforpromotingthemobilizationandremovalofsecretionsfromtherespiratory
tract.40Therearefourbasictypesofmucokineticsagents:40
Mucolyticsactbydisruptingthechemicalbondsinmucoidandpurulentsecretions,decreasingthe
viscosityofthemucusandpromotingexpectoration.Theprimaryadverseeffectsofthesedrugsinclude
mucosalirritation,coughing,bronchospasm,andnausea.
Expectorantsincreasetheproductionofrespiratorysecretions,thusfacilitatingtheirejectionfromthe
respiratorytract.
Wettingagentsmakeexpectorationeasierforthepatientandaredeliveredbyeithercontinuousaerosolor
intermittentultrasonicnebulization.
Surfaceactiveagents(surfactant)lowerthesurfacetensionofthemediuminwhichthesearedissolved.
Theyareprimarilyusedtostabilizeaerosoldropletstherebyenhancingtheirefficacyascarriervehicles
fornebulizeddrugs.
AntimicrobialAgents/Antibiotics
Penicillinsarethemainstayinthetreatmentofrespiratoryinfections.40First,secondandthirdgeneration
cephalosporinsaregenerallyconsideredasalternativestothepenicillins,whenpenicillinsarenottoleratedby
thepatientorwhentheyareineffective.40
Oxygen
Oxygenshouldbeconsideredadrugwhenitisbreathedinconcentrationshigherthanthosefoundinthe
atmosphericair.Thetherapeuticadministrationofoxygencanelevatethearterialoxygentensionandincrease
thearterialoxygencontent,improvingperipheraltissueoxygenation.40Whenusedjudiciously,oxygentherapy
hasfewsideeffects.
MetabolicandEndocrineSystem
Physicaltherapistsroutinelytreatpatientswhoarediagnosedwithdiabetesmellitus(DM).PeoplewithDMare
atincreasedriskofdevelopingchroniccomplicationsrelatedtoophthalmic,renal,neurological,cerebrovascular,
cardiovascular,andperipheralvasculardisease.41,42ThemajorclassesofDMareinsulindependentdiabetes
mellitus(IDDM),alsoknownastype1DM,andnoninsulindependentdiabetesmellitus(NIDDM),alsoknown
astype2DM,andsubclassedasobeseornonobese.43Type1DMresultsfromautoimmunebetacell
destruction,whereastype2DMisrelatedtodeficiencyininsulinproductionoraconditionofinsulinresistance.
MalnutritionrelatedDM,gestationalDM,andothertypesofDMassociatedwithspecificconditionscomplete
theclassification.Byitsactiononcarbohydrate,protein,andlipidmetabolism,insulinexertsadominanteffect
ontheregulationofglucosehomeostasis.43Throughvariousactions,insulin,ahormonewhichissecretedby
thebetacellsofthepancreas,lowersbloodglucosebyeithersuppressingglucosereleasefromtheliver,orby
promotinguptakeofglucoseintoperipheraltissues,especiallymuscle.Insulinalsoaffectsadiposetissueby
activatinglipogenesis(conversionofglucoseintotriglyceride).43Glucagon,catecholamines,glucocorticoids,
andgrowthhormoneactinoppositiontoinsulinbyincreasingbloodglucose.
TheclassicinterventionapproachtoDMisthetriadofdiet(weightmanagement),exercise,anddrugtherapy.43
PatientswithIDDMrequireinsulinreplacement,withdietandexercisecompletingthetreatmentplan,whereas
patientswithNIDDMareoftenmanagedbydietandexercisepriortoanyuseofpharmacologicalagents.
DrugsforDiabetes
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Becausepatientswithtype2(NIDDM)diabeteshavebothinsulinresistanceandbetacelldysfunction,oral
medicationtoincreaseinsulinsensitivityisoftengivenwithanintermediateactinginsulinatbedtimeoralong
actinginsulingiveninthemorningorevening.ThemedicationsprescribedforDMhaveavarietyofactions.
Exercisehastheeffectofincreasingglucoseuptakebyinsulinsensitivetissuesbytwomechanisms:43
Increasingbloodflowandthusenhancingglucoseandinsulindeliverytomuscle.
Stimulationofglucosetransportbymusclecontraction.
Inanondiabeticperson,insulinlevelsfallduringacuteexercise,andhepaticglucoseproductionrisestomeet
thedemandsoftheexercisingmuscle.Inadiabeticpatient,exerciselowersbloodglucoseconcentrationand
transientlyimprovesglucosetoleranceduringacuteexercise.Themetabolicresponsetoexerciseisbasedonthe
fitnessleveloftheindividual,theintensityanddurationoftheexercise,andtimingofexerciseinrelationto
insulinadministrationandmeals.43
Additionalbenefitsofexerciseinadiabeticpopulationincludeimprovedwholebodyinsulinsensitivity,
improvedglycemiccontrol,reductionofcertaincardiovascularriskfactors,andanincreaseinpsychological
wellbeing.
ERGOGENICAID
Ergogenicaidisatermusedtodescribeabroadcategoryoftopicsincludingphysiologic,pharmacologic,
psychologic,andnutritionalenhancement.44Themostcommonpharmacologicenhancementusedbyathletes
areanabolicandrogenicsteroids,asyntheticderivativeofthemalehormonetestosterone.Themoreappropriate
termanabolicandrogenicsteroidsisfrequentlyshortenedtoanabolicsteroids.
AnabolicAndrogenicSteroids
Theuseofanabolicsteroidsfornonmedicalpurposeshasbeeninexistenceforover50years.Thesesynthetic
agentshaveacoresteroidstructurethatgivesthembothanabolic(tissuebuilding)andandrogenic
(masculinizing)effects,althoughphysiologicallytheseeffectsareinseparable.45Anabolicsteroidsmaybetaken
orallyorparenterally.Orallyingestedsteroidsarewellabsorbedfromthestomach,excretedfairlyrapidlyfrom
thebodybecauseoftheirshorthalflives,aremoretoxictotheliverthaninjectablesteroids,andarehighly
potent.44,4648Injectablesteroidsarecharacterizedbydelayeduptakefromthebody,slowerexcretion,
increaseddetectabilityindrugtestsforlongerperiodsoftime,reducedlivertoxicity,andhavelesspotencythan
oralsteroids.44,4648
Studiesontheeffectsofanabolicsteroidsonmusclestrengthprovideinconsistentresults.44Muscularstrength
increaseswillresultfromanabolicsteroiduseonlyifthefollowingcriteriaaremet:44,49
Theathletemusthavebeenintensivelytrainedinweightliftingimmediatelypriortothesteroidregimen
andmustcontinuewithintenseweightliftingduringthesteroidregimen.
Theathletemustmaintainahighprotein,highcaloriediet.
Strengthmustbeassessedwithasinglerepetition,amaximalweighttechniqueusingthespecific
exerciseswithwhichtheathletetrains,asopposedtosinglejoint,isolationtestingtechniques.
Weightgainiscommonlyassociatedwithanabolicsteroiduse.Whetherthesegainsarereflectedinmusclemass
increasesorfluidretentionremainsunclear.44
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Althoughthepotentialbenefitsassociatedwithanabolicsteroiduseremainquestionable,theimmediateand
longtermsideeffectsarewellestablishedandinclude:44
increasedriskofmyocardialinfarctionandstroke
livertoxicity
significantdecreasesinplasmatestosterone,testicularatrophy,impotence,prostateenlargement,
decreasedspermcounts,andadecreaseintestosteroneproductionfromthetestes
gynecomastia,characterizedbyasubareolar,buttonlikeunilateralorbilateralplaqueoftissue,and/orthe
developmentofbreasttissue
increasedmusculotendinousinjury
prematureclosureoftheepiphysisinchildren,resultingindecreasedadultheight
alterationsinlipidprofilesasignificantriseintotalserumcholesterollevelandadecreaseinhigh
densitylipoprotein(HDL)and
alterationsinmentalstatusincluding,euphoria,aggressiveness,irritability,nervoustension,changesin
libido,mania,depression(withwithdrawalfromsteroids),andpsychosis.
Amphetamines
Thephenylethylaminestructureofamphetaminesissimilartocatecholaminergic,dopaminergic,and
serotonergicagonists(biogenicamines),whichmayexplaintheiractions,withtheclinicalpresentationbeing
dependentonthetypeofamphetamineused.Forexample,methamphetaminelacksmuchoftheperipheral
stimulantpropertiesofamphetaminewhilestillofferingeuphoricandhallucinogenicproperties.Theseactions
aresimilartothoseofcocainehowever,whileeffectsofcocainelastfor1020minutes,durationof
amphetamineactionismuchlonger,lastingaslongas1012hours.
Theroutesofamphetamineadministrationmaybeoral(ingestion),inhalation(smoke),orinjection(IV).Oral
useisassociatedwithanapproximate1hourlagtimebeforetheonsetofsymptoms,whereasinhaledandIV
methodsyieldeffectswithinafewminutes.Peakplasmaconcentrationsoccurwithin5minuteswithIVuse,30
minuteswithnasalorIMuse,and23hourspostingestion.
CentralNervousSystem
Amphetaminecompoundscauseageneraleffluxofbiogenicaminesfromneuronalsynapticterminals(indirect
sympathomimetics).Theyinhibitspecifictransportersresponsibleforthereuptakeofbiogenicaminesfromthe
synapticnerveendingandpresynapticvesicles.AmphetaminesalsoinhibitMAO,whichdegradesbiogenic
amineneurotransmittersintracellularly.Theneteffectisanincreaseofmonoamineneurotransmitterreleaseinto
thesynapse.Physiologicaladaptationoccursthroughreceptororcouplingdownregulationthistoleranceandan
accompanyingpsychologicaltolerancecanleadtoescalatinguseofthedrugandincreasedtoxicity.Chronicuse
canleadtoadepletionofbiogenicaminestoresandaparadoxicalreverseeffectofthedrugawashout.
Elevatedcatecholaminelevelsusuallyleadtoastateofincreasedarousalanddecreasedfatigue.Increased
dopaminelevelsatsynapsesintheCNSmayberesponsibleformovementdisorders,schizophrenia,and
euphoria.Serotonergicsignalsmayplayaroleinthehallucinogenicandanorexicaspectsofthesedrugs.
Otherserotonergicanddopaminergiceffectsmayincluderesettingthethermalregulatorycircuitsupwardinthe
hypothalamusandcausinghyperthermia.Thehyperthermiaproducedbyamphetaminesissimilartothatofthe
SS.
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PeripheralNervousSystem
Catecholaminergic(sympathomimetic)effectsofamphetaminesincludeinotropicandchronotropiceffectson
theheart,whichcanleadtotachycardiaandotherdysrhythmias.Thevasoconstrictivepropertiesofthedrugs
canleadtohypertensionand/orcoronaryvasospasm.
Theserotonergicactionofamphetaminesonperipheralvasculaturecanleadtovasoconstriction,whichis
especiallyproblematicinplacentalvessels.Animalstudieshaveshownthatserotonergicactionsof
amphetamineseffectchangesinplasmalevelsofoxytocin,somatostatin,gastrin,andcholecystokinin.
Patientswithamphetamineintoxicationoftenareidentifiedbyachangeinmentalstatusaloneorassociatedwith
anotherinjuryand/orillness.Thesechangesincludedisorientation,headache,dyskinesias,agitation,symptoms
ofstroke,cardiovascularsignsandsymptoms(chestpain,palpitations),GIproblems(drymouth,nauseaand
vomiting,diarrhea),genitourinarydysfunction(difficultmicturition),andskinchanges(diaphoresis,
erythematouspainfulrashes,needlemarks,infecteddeepulcerations[ecthyma]).
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undefined
McGrawHill
Allrightsreserved.
Silverchair
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CHAPTER10:ManualTechniques
CHAPTEROBJECTIVES
1.Givedefinitionsforcommonlyusedbiomechanicaltermsusedinmanualtherapy(MT).
2.Listthecriteriathatareimportantforthecorrectapplicationofamanualtechnique.
3.SummarizethevarioustypesofMT.
4.Describetheimportanceofknowingtheshapesofthevariousarticularsurfacesandhowthatdetermines
thedirectionoftheapplicationofatechnique.
5.ApplytheknowledgeofthevariousMTsintheplanningofacomprehensiverehabilitationprogram.
6.Recognizethemanifestationsofabnormaltissueanddevelopstrategiesusingmanualtechniquestotreat
theseabnormalities.
7.CategorizethevariouseffectsofMTonthesofttissues.
8.MakeanaccuratejudgmentwhenrecommendinganMTtechniquetoimprovejointormusclefunction.
OVERVIEW
Touchhasalwaysbeenandcontinuestobeaprimaryhealingmodality.Thefirstwrittenrecordsofmassagego
backtoAncientChina,andwallpaintingsinEgyptdepicthandsonhealingtechniquesthatgoback15,000
years.1Fromthisearlylayingonofhandsevolvedmanyofthetechniquesusedtoday.
ThetechniquesofMTfallundertheumbrellaoftherapeutictouch.MThasbecomesuchanimportant
componentoftheinterventionfororthopaedicandneurologicdisordersthatitisconsideredbymanyasanarea
ofspecializationwithinphysicaltherapy.
Oftheapproachescommonlyapplied,theCyriax,2Mennell,3andosteopathictechniques4,5(Table101)
originatedfromphysicians,whereastheMaitland,6,7Kaltenborn,8andMcKenzieandMay9approaches(Table
102)werederivedbyphysicaltherapists.1012
TABLE101ManualTherapyApproachPhysicianGenerated
Cyriax
(Orthopaedic Mennell
OsteopathicAssertions
Medicine) Assertions
Assertions
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Dysfunction
indicatesa
serious
pathologic
Allpainhasan
processorjoint
anatomicsourceand, disease Neuromusculoskeletalsystemisconnectedwithother
therefore,all systemstherefore,diseaseprocessescanbeevidentin
Lossofnormal
treatmentmustreach musculoskeletalsystem
jointmovement
Philosophy thatanatomicsource Anabnormalityinstructure(somaticdysfunction)can
orjointplaycan
Ifthediagnosisis leadtoabnormalfunctionofrelatedcomponents
leadto
correct,thetreatment dysfunction Manipulativetherapycanrestoreandmaintainnormal
willbeofbenefitto structureandfunctionrelationships
Joint
thesource
manipulationcan
restorenormal
jointplay
movements
Diagnosisofsoft
tissuelesions Diagnosisofsomaticdysfunction
Categorizationof Examinationfocusesonpresenceofasymmetry,
referredpain Assessmentof restrictionofmovement,andpalpationofsofttissue
Keyconcepts
Differentiation jointplay texturechanges(i.e.,palpationofskin,muscle,and
betweencontractile otherconnectivetissueforfeelingofthickness,
andnoncontractile swelling,tightness,ortemperaturechange)
lesions
Present
Observationand complaint
history Onset
Ageandoccupation Natureofpain History
Symptoms(siteand Localizationof Knowledgeofphysicaltrauma,pasthistoryofvisceral,
spread,onsetand pain andsofttissueproblems
History
duration,and Lossof Presentcomplaint
behavior) movement Establishrelationshipfrompatientshistorybetween
Medical Pasthistory timeandmechanismtoadaptation,anddecompensation
considerations Familyhistory
Inspection Medicalsystems
review
Inspection
Palpation
Examinationof
Activemovements voluntary Posturalanalysis
Passivemovements movements Regionalscreeningfunctionalunits
Resistedmovements Muscle Pelvicgirdle
Physical
Neurologic examination Foot
examination
examination Specialtests Vertebralcolumn
Palpation (e.g., Shouldergirdle
Inspection roentgenography) Hand
Examinationof
jointplay
movements
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Determinationofdysfunction:
Positionalfault
Identificationof
Interpretation
anatomicstructure Jointdysfunction Restrictionfault
ofevaluation
associatedwithlesion
Segmentalormultisegmental
Injection
Manipulation
Frictionmassage Manipulation
Mobilization
Manipulation Mobilization
Muscleenergy
Treatment Mobilization Physicaltherapy
Myofascialtechniques
strategies Physicaltherapy (e.g.,exercise
Counterstrain
(e.g.,exerciseand andmodalities)
Exercisetherapy
modalities) Patienteducation
Patienteducation
Patienteducation
DatafromDiFabioRP.Efficacyofmanualtherapy.PhysTher.199272:853864.
TABLE102ManualTherapyApproachPhysicalTherapistGenerated
Maitland(Australian) Kaltenborn(Norwegian)
McKenzieAssertions
Assertions Assertions
Personalcommitmentto
understandpatient
Predisposingfactorsofsitting
Considerationandapplication Biomechanicalassessmentofjoint
posture,lossofextension
oftheoretical(e.g.,pathology movements
range,andfrequencyofflexion
Philosophy andanatomy)andclinical Pain,jointdysfunction,andsoft
contributetospinalpain
thinking(e.g.,signsand tissuechangesarefoundin
Patientsshouldbeinvolvedin
symptoms) combination
selftreatment
Continualassessmentand
reassessmentofdata
Examination,technique,and
assessmentareinterrelatedand Duringmovementsofspine,
interdependent positionalchangetonucleus
Applicationofprinciplesfrom
Gradesofmovement(IV) pulposustakesplace
arthrokinematics(e.g.,concave
Strongemphasisonuseof Strongemphasisonuseof
Key convexruleandcloseandopen
passivemovementtesting activemotions
concepts packedpositions)todetermine
(testingaccessoryand Flexedlifestyleleadstoamore
existenceofsomaticdysfunction
physiologicjointmovements) posteriorpositionofnucleus
Gradesofmovement(IIII)
Differentialassessmentto Intervertebraldiskiscommon
proveordisproveclinical sourceofbackpain
workinghypothesis
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McKenzieAssertions
Subjectiveexamination(as
definedbyMaitland)14,15 History(fivebyfivescheme)
Establishkindofdisorder Immediatecasehistory(e.g.,
Areaofsymptoms assesssymptomsforlocalization,
Behaviorofsymptoms time,character,etc.) History
Irritability Previoushistory(e.g.,assessfor Interrogation(e.g.,wheredid
Nature kindoftreatment,reliefof painbegin,how,constantor
Specialquestions symptoms,presenceofsimilar intermittent,whatmakesit
Planningobjective symptomsorrelatedsymptoms) betterorworse,previous
examination(asdefinedby Socialbackground episodes,andfurther
Maitland)14,15 Medicalhistory questions)
Familyhistory Posture(sittingandstanding)
Evaluation Physicalexamination
Patient'sassessmentofcauseof Examinationofmovement
framework Observation
Functionaltests complaint (flexion,extension,andside
Activemovements Physicalexamination gliding)
Isometrictests Inspection Movementsinrelationtopain
Otherstructuresinplan Function(activeandpassive Repeatedmovements
Passivemovements(e.g., movementstestingwithtraction, Testmovements
specialtests,physiologicand compression,andglidingand Othertests(e.g.,neurologic
accessoryjointmovements, resistedtests) andotherjoints)
andrelevantadverseneural Palpation
tissuetensiontests) Neurologictests
Palpation Additionaltests
Neurologicexamination
Highlightmainfindings
Initialassessmentrelates
examinationfindings Diagnosisaccordingto
Behaviorofpatient's syndrome,asopposedto
symptomspainorstiffness specificstructure
(somewhatanalogousto Posturalsyndrome(endrange
McKenzie'sderangementand Biomechanicalassessment(i.e., strainonnormaltissues)
Evaluation dysfunctionsyndrome, restrictionofjointmobility)and Dysfunctionsyndrome
respectively) assessmentofsofttissuechanges (adaptiveshorteningof
Diagnosis,althoughno structure)
specificstructuredesignated Derangementsyndrome
Stageofdisorder (disturbanceofnormal
Stabilityofdisorder anatomicrelationship)
Irritabilityofdisorder
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McKenzieAssertions
Basedoncontinualassessment
ofsubjectiveandobjective
findings
Patientselftreatmentusing
Focusontreatingpainor Mobilization
repeatedactivemovements
stiffness Exercise(emphasison
Exerciseusingmovementsthat
Mobilization proprioceptiveneuromuscular
havepositiveinfluenceon
Intervention Manipulation facilitation)
symptoms
strategies Adverseneuraltissue Traction/distraction
Mobilizationormanipulation
mobilization Softtissuemobilization
(ifneeded)
Traction Manipulation
Strongemphasisonpatient
Exerciseusingmovements Patienteducation
educationandselftreatment
thathavepositiveinfluenceon
symptoms
Patienteducation
DatafromDiFabioRP.Efficacyofmanualtherapy.PhysTher.199272:853864.
Withinthesemajorphilosophies,anumberofsubsetshavealsoemerged,includingmyofascialrelease(MFR),
positionalreleasetechniques,neurodynamicmobilizationtechniques(seeChapter11),manuallyresisted
exercise,proprioceptiveneuromuscularfacilitation(PNF),jointmobilization,andhighvelocitythrust
(manipulation)techniques.
MTtechniqueshavetraditionallybeenusedtoproduceanumberoftherapeuticalterationsinpainandsoft
tissueextensibilitythroughtheapplicationofspecificexternalforcestodecreasepainandimprovemotion
qualityinanareawithrestriction.13Someofthesetherapeuticalterationsmaybeneurophysiologicandare
thereforedifficulttoclinicallyassess.Unfortunately,thetherapeuticefficacyofmanyMTtechniquesremains
undetermined.Thus,manyofthesetechniqueshavenotbeendevelopedwiththesamescientificrigorasfields
suchasanatomyandphysiology,andmuchoftheiruseisbasedonclinicaloutcomes,ratherthanevidence
basedproof.Therearenumerousconcernswithdeterminingthevalidityofstudiesaddressingtheefficacyof
manualtechniques:
Theselectionofaparticulartechniqueistypicallymadeonanadhocbasis.
Thestrongplaceboeffectassociatedwiththelayingonofhands.Complicatingthemeasurementof
outcomeandtheeffectivenessofanMTistheplaceboeffect(aresponseresultingfromthesuggestion
thatsomethingisbeneficial,eventhoughitmaybeinert).AlthoughMTisnotaloneinitsuseofthe
placeboeffect,itisincreasinglyimportantthatcliniciansdeterminethespecificeffectsofeverythingthey
do.14
Manymusculoskeletalconditionsareselflimitingsothatpatientsmayimprovewithtimeregardlessof
theintervention.
Thedifficultyofblindingcliniciansandsubjectstotheinterventionthesubjectsarereceiving.
Clearcutdefinitionsastowhenonetechniqueismoreefficaciousthananotherarelacking.
OverrelianceonMTtechniquestoimproveapatientsstatusisapassiveapproachinanerawhenpatient
independenceisstressed.
Althoughitisgenerallyagreedthatmanualtechniquesarebeneficialforspecificimpairments,suchasa
restrictedjointglideandadaptivelyshortenedconnectivetissue,thereislessagreementonwhichtechniqueis
themosteffective.Thedecisionaboutwhichapproachortechniquetousehastraditionallybeenbasedonthe
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cliniciansbelief,training,thelevelofexpertise,anddecisionmakingprocesses.Thishasledtowidespread
opinionsonwhichtoolstousetomeasureoutcomehowtoapplyaparticulartechniqueintermsofpatient
setup,intensity,anddurationandhowtogaugeanindividualsresponsetoatechnique.Indeed,researchstudies
seemtoagreethatthemostefficaciousapproachisacombinationofmanualtechniqueswithotherinterventions,
suchasprogressiveexercises,theuseoftherapeuticmodalities,andpatienteducationaboutproperbody
mechanics,positions,andpostures.1517RegardlessofwhichMTtechniqueisused,allpatientsshouldundergo
afullexamination/evaluationbeforeanytechniqueisperformed.
CLINICALPEARL
Anabsenceofevidencedoesnotalwaysmeanthatthereisevidenceofabsence(ofeffect),andthereisalways
theriskofrejectingtherapeuticapproachesthatarevalid.18
CORRECTAPPLICATIONOFMANUALTECHNIQUES
Despitethevariedapproachesandrationales,thereisgeneralagreementconcerningthecriteriaforthecorrect
applicationofamanualtechnique.Theseinclude:19
Knowledgeoftherelativeshapesofthejointsurfaces(concaveorconvex).Theconcaveconvexpattern
ofarthrokinematics,basedonarthrologystudiesbyMaitland,7Kaltenborn,8,20andMacConailland
Basmajian,21havebeentaughtinphysicaltherapyschoolsintheUnitedStatesforabout30years.22
Thesepatternsdescribetherollandsliderelationshipsthatnaturallyoccurbetweentwomovingarticular
surfaces,whichdependsonwhethertheconvexorconcavearticularsurfaceofthejointisconsideredthe
movingsegment.Forexample,ifthemovingarticularsurfaceisconvexrelativetotheothersurface,the
jointglideoccursinthedirectionoppositetotheosteokinematicmovement(angularmotion).If,onthe
otherhand,themovingarticularsurfaceisconcave,thejointglideoccursinthesamedirectionasthe
osteokinematicmovement.Itisimportanttorememberthattheconcaveconvexrulewasnotintendedto
establishthedirectionofthemanualglideappliedtothejoint,butmerelytodescribethearthrokinematic
patternthatminimizestheinherentmigrationofthecenteroftheconvexmemberinthedirectionofthe
roll.22Forexample,anumberofkinematicstudiesoftheglenohumeraljointappeartoconflictwiththe
expectedarthrokinematicforconcaveconvexsurfacemovementbymaintainingthatthehumeralhead
actuallyremainsnearlystationaryor,infact,translatessuperiorlywhenperforming90120degreesof
shoulderabduction.23,24However,thenetsuperiortranslationofthehumeralheadisonlyafew
millimetersandisoffsetbyaconcurrentinferiorslideofthehumeralhead.22
Duration,type,andirritabilityofsymptoms6,7(Table103).Thisinformationcanprovidetheclinician
withsomegeneralguidelinesfordeterminingtheintensityoftheapplicationofaselectedtechnique(see
IndicationsforMTlaterinthischapter).
Patientandclinicianposition.Correctpositioningofthepatientisessentialbothtohelpthepatientrelax
andtoensuresafebodymechanicsfromtheclinician.Whenpatientsfeelrelaxed,theirmuscleactivityis
decreased,reducingtheamountofresistanceencounteredduringthetechnique.Ifappropriate,
thermotherapycanbeusedpriortothetreatmenttowarmthetissuesaroundthejoint,improvecirculation,
andrelaxthemuscles.
Positionofstructuretobetreated.Thepositionofthestructuretobetreatedmustbeappropriateforthe
stageofhealing,thetechniquetobeapplied,andtheskilloftheclinician.Itisrecommendedthatthe
restingpositionofthejointbeusedwhenthepatienthasanacutecondition,ortheclinicianis
inexperienced.Therestingposition,inthiscase,referstothepositionthattheinjuredjointadopts,rather
thantheclassicresting(openpacked)positionforanormaljoint.Otherpositionsforstartingthe
mobilizationmaybeusedbyaskilledclinicianinpatientswithnonacuteconditions.Asthetreatment
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progresses,thejointispositionedatorneartheendoftheavailablerangepriortotheapplicationofthe
mobilizationforcesoastoplacetherestrictingtissueinitsmoststretchedposition.
Handplacement.Accuratehandplacementisessentialforefficientstabilizationandfortheaccurate
transmissionofforce.Thehandshouldconformtotheareabeingtreatedsothattheforcesarespreadover
alargerarea.Thislargercontactsurfaceismorecomfortableforthepatient.Typically,theproximalbone
isstabilizedusingtheclinicianshands,abelt,oranassistant,andthedistalboneismoved.
TABLE103IndicationsforSelectionofManualTechniqueBasedonDurationofSymptoms
Acute Subacute Chronic
Muscle Strongly Usedtopreparetissueforjointmanipulation
Stronglyindicated
energy indicated andpreventrecurrenceofdysfunction
Joint GradesI
GradesIIandIII GradesIIIandIV
mobilization andII
Joint Rarely Moderatetostrongindicationif Strongindicationifmuscleenergytechnique
manipulation indicated muscleenergytechniqueunsuccessful ineffective
DatafromEllisJJ,JohnsonGS.Myofascialconsiderationsinsomaticdysfunctionofthethorax.In:FlynnTW,
ed.TheThoracicSpineandRibCage:MusculoskeletalEvaluationandTreatment.Boston,MA:Butterworth
CLINICALPEARL
Agentleandconfidenttouchinspiresconfidenceinthepatient.
Specificity.Specificityreferstotheexactnessoftheprocedureandisbasedonitsintent.Whenever
possible,theforcesimpartedbyatechniqueshouldoccuratthepointwheretheyareneeded.Theclinician
shouldcheckonejointatatime,onemovementatatime.
Directionandtypeofforce.Thetreatmentforceisappliedasclosetotheopposingjointsurfaceas
possible.Thisnecessitatesthattheclinicianbeabletoidentifyanatomicallandmarksasguides.
Distractiontechniquesareperpendiculartothetreatmentplane,whereasglidingtechniquesareapplied
paralleltothetreatmentplane.Whenpossibletheclinicianshouldworkwiththeforceofgravityrather
thanagainstit.Thedirectionoftheforcecanbeeitherdirect,whichistowardthemotionbarrieror
restriction,25orindirect,whichisawayfromthemotionbarrierorrestriction.26,27Althoughtherationale
foradirecttechniqueiseasytounderstand,therationaleforusinganindirecttechniqueismore
confusing.Agoodanalogyisastuckdrawerthatcannotbeopened.Oftenthemovementthateventually
freesthedrawerisaninwardmotion,followedbyapull.19
Theamountofforce.Theamountofforceuseddependsontheintentofthemanualprocedureanda
numberofotherfactors,includingbutnotlimitedto
theage,sex,andgeneralhealthstatusofthepatient
thebarriertomotionandendfeel(stageofhealing)(Table104)and
thetypeandseverityofthemovementdisorder.
Reinforcementofanygainsmade.Ithasbeendemonstratedthatmovementgainedbyaspecificmanual
techniqueperformedinisolationwillbelostwithin48hours,ifthemotionsgainedarenotreinforced.28
Thus,themotionsgainedbyamanualtechniquemustbereinforcedbyboththemechanicalandthe
neurophysiologicbenefitsofactivemovement,selfstretching,automobilization,andfunctionalactivities
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usingthenewrange.29Theseactivemovementsmustbeaspreciseaspossibletotheinvolvedsegmentor
myofascialstructure.
TABLE104AppropriateTechniqueBasedonBarriertoMotionandEndFeel
Barrier EndFeel Technique
Pain Empty None
Pain Spasm None
Pain Capsular Oscillations
Jointadhesions Earlycapsular Passivearticularmotionstretch
Muscleadhesions Earlyelastic Passivephysiologicmotionstretch
Hypertonicity Facilitation Holdrelax
Bone Bony None
Reassessmentisanintegralpartofanyintervention.Theclinicianmustbeabletogaugehoweffectivea
techniquehasbeensothatnecessarymodificationscanbemade.Measurementproceduresusedbytheclinician
todeterminetheeffectivenessofmanualinterventionmustadequatelyreflectchangesinpainlevel,
impairments,andfunctionalability.Althoughmeasurementsofrangeofmotion(ROM),pain,andstrengthare
validandreliable,3032thefunctionalmeasurementselectedshouldberelatedtotheparticularfunctional
limitationthattheclinicianisexpectingtochangewiththeintervention.33
INDICATIONSFORMT
MTisindicatedinthefollowingcases:
Mildmusculoskeletalpain
Anonirritablemusculoskeletalconditiondemonstratedbypainthatisprovokedbymotion,butthat
disappearsveryquickly
Intermittentmusculoskeletalpain
Painreportedbythepatientthatisrelievedbyrest
Painreportedbythepatientthatisrelievedorprovokedbyparticularmotionsorpositions
Painthatisalteredbychangesrelatedtosittingorstandingposture
CONTRAINDICATIONSTOMT
ContraindicationstoMTincludethosethatareabsolutecontraindicationsandthosethatarerelative.34,35
Absolute
Systemicorlocalizedinfection(e.g.,osteomyelitis),febrilestate
Acutecirculatorycondition
Malignancy
Anopenwoundatthetreatmentsite,orsuturesoverthetreatmentsite
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Recentfracture
Hematoma
Hypersensitivityoftheskin
Inappropriateendfeel(spasm,empty,andbony),orevidenceofjointankylosis,orjointhypermobility
Advanceddiabetes
Rheumatoidarthritis(inastateofanexacerbation)
Cellulitis
Constant,severepain,includingpainatrestorthatdisturbssleep,indicatingthattheconditionislikelyto
beveryirritableorintheacutestageofhealing
Extensiveradiationofpain
Anyconditionthathasnotbeenfullyevaluated
Relative
Jointeffusionorinflammation
Rheumatoidarthritis(notinastateofanexacerbation)
Presenceofneurologicsigns
Osteoporosis
Pregnancy,ifatechniqueistobeappliedtothespine
Dizziness
Steroidoranticoagulanttherapy
SOFTTISSUETECHNIQUES
Softtissuetechniquescanaddressmultiplestructuressimultaneouslytoinclude,butarenotlimitedtomuscles,
tendons,ligaments,fascia,and/orvenouslymphaticstructures.13Increasingthelengthoftissue,breakingup
fibrousscartissue,breakingupadhesions,remodelingofcollagenfibers,increasingcirculation,andimproving
venousfunctionand/orlymphaticfunction,decreasingpain,canallbeincludedasgoalsforsofttissue
mobilization.13
TransverseFrictionMassage
Transversefrictionmassage(TFM)isatechniquedevisedbyCyriax,wherebyrepeatedcrossgrainmassageis
appliedtoamuscle,tendon,tendonsheath,orligament.TFMhaslongbeenusedbyphysicaltherapiststo
increasethemobilityandextensibilityofindividualmusculoskeletaltissues,andtohelppreventandtreat
inflammatoryscartissue.2,3641
CLINICALPEARL
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TFMisindicatedforacuteorsubacuteligament,tendon,ormuscleinjurieschronicallyinflamedbursaeand
adhesionsinligamentormuscle,orbetweentissues.TFMalsocanbeappliedbeforeperformingamanipulation
orastrongstretchtodesensitizeandsoftenthetissues.
TFMiscontraindicatedforacuteinflammation,hematomas,debilitatedoropenskin,andperipheralnerves,and
inpatientswhohavediminishedsensationinthearea.
TFMispurportedtohavethefollowingtherapeuticeffects:
Traumatichyperemia.2AccordingtoCyriax,longitudinalfrictiontoanareaincreasestheflowofblood
andlymph,which,inturn,removesthechemicalirritantbyproductsofinflammation.Inaddition,the
increasedbloodflowreducesvenouscongestion,therebydecreasingedemaandhydrostaticpressureon
painsensitivestructures.
Painrelief.TheapplicationofTFMstimulatestypeIandIImechanoreceptors,producingpresynaptic
anesthesia.Thispresynapticanesthesiaisbasedonthegatetheoryofpaincontrol(seeChapters3and8).
However,ifthefrictionsaretoovigorousintheacutestage,thestimulationofnociceptorswilloverride
theeffectofthemechanoreceptors,causingthepaintoincrease.Occasionally,thepatientmayfeelan
exacerbationofsymptomsfollowingthefirsttwoorthreesessionsofthemassage,especiallyinthecase
ofachronicallyinflamedbursa.42Inthesecases,itisimportanttoforewarnthepatient.
Decreasingscartissue.Thetransversenatureofthefrictionassistswiththeorientationofthecollagenin
theappropriatelinesofstressandalsohelpsproducehypertrophyofthenewcollagen.Giventhestagesof
healingforsofttissue(seeChapter2),lightTFMshouldonlybeappliedintheearlystagesofasubacute
lesion,soasnottodamagethegranulationtissue.Thesegentlemovementstheoreticallyservetominimize
crosslinkingandsoenhancetheextensibilityofthenewtissue.Followingaligamentsprain,Cyriax
recommendsimmediateuseofgentleTFMtopreventadhesionformationbetweenthetissueandits
neighbors,bymovingtheligamentoustissueovertheunderlyingbone.2
Theapplicationofthecorrectamountoftensiontoahealingstructureisveryimportant.Thetissueundergoing
TFMshould,wheneverpossible,bepositionedinamoderatebutnotpainfulstretch.Theexceptiontothisruleis
whenapplyingTFMtoamusclebelly,whichisusuallypositionedinitsrelaxedposition.2,43Lubricantisnot
typicallyusedwiththeapplicationofTFM.However,ultrasoundcanbeappliedtoatissuebeforeTFM.
Beginningwithlightpressure,andusingareinforcedfinger(i.e.,middlefingerovertheindexfinger),orthumb,
theclinicianmovestheskinoverthesiteoftheidentifiedlesionbackandforth,inadirectionperpendicularto
thenormalorientationofitsfibers(Fig.101).Itisimportantthatthepatientsskinmovewiththeclinicians
fingertopreventblistering.
FIGURE101
Transversefrictiontothesupraspinatustendon.Thetendonisbroughtintoamoresagittalpositionjustbelow
theanterioracromionbyplacingthepatientshandbehindtheback.Theforefingeroftheclinicianisreinforced
bythemiddlefingerwhileapplyingthemassageperpendiculartothetendonfibers,inananteriorposterior
direction.
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CLINICALPEARL
TheapplicationofTFMisconditionandpatientdependent.Theintensityoftheapplicationisbasedonthestage
ofhealing.ThepaininducedbyTFMshouldbekeptwithinthepatientstolerance.Lightpressureshouldbe
usedintheearlystages,beforebuildingupthepressureforafewminutestoallowforaccommodation.
Theamplitudeofthemassageshouldbesufficienttocoveralloftheaffectedtissue,andtherateshouldbeat
twotothreecyclespersecond,appliedinarhythmicalmanner.
Thedurationofthefrictionmassageisusuallygaugedbywhendesensitizationoccurs(normallywithin35
minutes).Tissuesthatdonotdesensitizewithin35minutesshouldbetreatedusingsomeotherformof
intervention.Iftheconditionischronicorintheremodelingstageofhealing,thenthefrictionsarecontinuedfor
afurther5minutesafterthedesensitization,inanefforttoenhancethemechanicaleffectonthecrosslinksand
adhesions.FollowingtheapplicationofTFM,theinvolvedtissueiseitherpassivelystretchedoractively
exercised,takingcarenottocausepain.
MostconditionsamenabletoTFMshouldresolvein610sessionsover28weeks.Whenpossible,patients
shouldbetaughthowtoapplyTFMonthemselvessothattreatmentscanbecontinuedathome.Tissuesthatdo
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notshowsignsofimprovementafterthreetreatmentsessionsshouldbetreatedusingsomeotherformof
intervention.
MyofascialRelease
MFRisaseriesoftechniquesdesignedtoreleaserestrictionsinthemyofascialtissueandisusedforthe
treatmentofsofttissuedysfunction.Thedevelopmentofaholisticandcomprehensiveapproachtothe
evaluationandtreatmentofthemyofascialsystemofthebodyiscreditedtoJohnBarnes,whowasstrongly
influencedbytheteachingsofMennell44andUpledgerandVredevoogd.45
CLINICALPEARL
Fasciaisatoughconnectivetissue,composedofcollagen,elastin,andaviscousgel,thatexistsinthebodyin
theformofacontinuousthreedimensionalweborganizedalongthelinesoftensionimposedonthebody(see
Chapter1).46
Accordingtomyofascialtheory,thecollagenprovidesstrengthtothefascia,theelastingivesititselastic
properties,andthegelfunctionstoabsorbthecompressiveforcesofmovement.Threetypesoffasciaare
consideredtoexist(seeChapter1):35,46
1.Superficial,lyingdirectlybelowthedermis.
2.Deep,surroundingandinfusingwithmuscle,bone,nerve,bloodvessels,andorganstothecellularlevel.
3.Visceral,whichisthedeepestlayercomprisingtheduraofthecraniosacralsystem,whichencasesthe
centralnervoussystemandbrain(seeChapter3).
ThetheoryofMFRisbasedontheprinciplethattraumaorstructuralabnormalitiesmaycreateinappropriate
fascialstrain,becauseofaninabilityofthedeepfasciatoabsorbordistributetheforces.46Thesestrainstothe
deepfasciacanresultinaslowtighteningofthefascia,causingthebodytoloseitsphysiologicadaptive
capacity.46Overtime,thedeepfascialrestrictionsbegintopullthebodyoutofitsthreedimensionalalignment,
causingbiomechanicallyinefficientmovementandposture.46Inaddition,becauseoftheassociationofthedeep
fasciaatthecellularlevel,itistheorizedthattraumatoormalfunctionofthefasciacanleadtopoorcellular
efficiency,disease,andpainthroughoutthebody.35,46Threetheoreticalmodelsforthemanifestationof
myofascialdysfunctionareacontraction,contracture,andcohesioncongestion(Table105).
TABLE105TheoreticalModelsfortheManifestationofMyofascialDisorders
Model Manifestation EndFeel
Contraction Musclehypertonicityorspasm Reactive,firm,andpainfulendfeel
Inertornoncontractiletissuesthathaveundergone
Contracture Abrupt,firm,stiff,orhardendfeel
fibroticalteration
Cohesion Fluidochemicalchangesinmicrocellulartransport Boggy,stiff,orreactiveendfeellymphatic
congestion systems,resultinginimpairment flow,vascularstasis,orischemia
DatafromEllisJJ,JohnsonGS.Myofascialconsiderationsinsomaticdysfunctionofthethorax.In:FlynnTW,
ed.TheThoracicSpineandRibCage:MusculoskeletalEvaluationandTreatment.Boston,MA:Butterworth
Thus,thepurposeofMFRtechniquesistoapplyagentlesustainedpressuretothedeepfascia,inorderto
releasefascialrestrictions,therebyrestoringnormalpainfreefunction.35Cliniciansusetheelbow,knuckle,or
fingertipscreatinglocalizedhyperemiathroughdeepfriction.MFRreliesentirelyonthefeedbackreceivedfrom
thepatientstissues,withtheclinicianinterpretingandrespondingtothefeedback.Thisfeedbackisbasedonthe
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Upledgerconceptofthenaturalbodyrhythm,calledthecraniosacralrhythm.45Itisthisrhythmthatistheorized
toguidetheclinicianastothedirection,force,andthedurationofthetechnique.
ItisnotunusualforapatienttoexperiencemusclesorenessfollowingMFRtechniques.Thissorenessisthought
toresultfromposturalandalignmentchangesorfromthetechniquesthemselves.
MyofascialStroking
ThesofttissuetechniquesusedinMFRarepurportedtobreakupcrossrestrictionsofthecollagenofthefascia.
Threeofthemorecommonlyusedtechniquesinvolvestrokingmaneuvers:35
Jstroke.Thistechniqueisusedtoincreaseskinmobility.Counterpressureisappliedwiththeheelofthe
hand,whileastrokeintheshapeoftheletterJisappliedinthedirectionoftherestriction,withtwoor
threefingers,whichcreatessometorqueattheendofthestroke.
Verticalstroke.Thepurposeofverticalstrokingistoopenupthelengthofverticallyorientedfascia.As
intheJstroke,counterpressureisappliedwithonehand,whilethestrokingisperformedwiththeother.
Transversestroke.Asitsnamesuggests,thetransversestrokeisappliedinatransversedirectiontothe
body.Forceisapplieddownwardintothemusclewiththefingertipsofbothhands,andtheforceis
appliedslowlyandperpendiculartothemusclefibers.
Crosshandstechnique.Thecrosshandstechniqueisusedforthereleaseofdeepfascialtissues.The
clinicianplacescrossedhandsoverthesiteofrestriction.Theelasticcomponentofthefasciaisthen
stretcheduntilthebarrierismet.Atthispoint,theclinicianmaintainsaconsistent,gentlepressureatthe
barrierforapproximately90120seconds.Oncethereleaseisfelt,theclinicianreducesthepressure.
ItisimportanttorememberthattheclaimedbenefitsandeffectivenessofMFRtechniquesarelargelyanecdotal
becauseatthetimeofwritingthereisnoscientificexperimentalresearchtovalidatetheseclaims.
SoftTissueMobilization
Softtissuemobilizations(STMs)areusedinmanyofthemanualtechniquesdescribedwithinthischapter,
includingMFR,muscleenergy(ME),andPNF.ThetechniquesofSTMarebasedontheconceptthattissue
restrictionsoccuratdifferentlayers,rangingfromsuperficialtodeep.
ThegeneralprinciplesbehindSTMarethatthesuperficiallayersaretreatedbeforedeeplayers,withtheforce
usedappliedinthedirectionofthemaximumrestriction,andwherethechoiceoftechniqueisdependentonthe
extentoftherestriction,amountofdiscomfort,anddegreeofirritability.Deeptissuemassageisrecommended
toreducespasm47andpromotepainreduction.48SeveralwellrecognizedSTMtechniquesaredescribednext.49
SustainedPressure
Thistechniqueisappliedtothecenteroftherestrictedtissueattheexactdepth,direction,andangleofthe
maximalrestriction.Thesustainedpressuretechniquecanbemodifiedbyapplyingaforceineitheraclockwise
oracounterclockwisedirectionwhilemaintainingthesustainedpressure.Thisspiralmotionincreasesthetissue
tensioninonedirectionwhileeasingitintheother.Sustainedpressurecanalsobeappliedperpendicularor
paralleltotherestriction.
IschemicCompression
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Ischemiccompression,asimilartechniquetosustainedpressure,canbeusedonbothactiveandinactivetrigger
points.Itisbelievedthattheischemiccompressiondeprivesthetriggerpointsofoxygen,renderingthem
inactiveandbreakingthecycleofpainspasmpain.Usually,thepressureisappliedfor812seconds.Ifthe
patientreportsalesseningoflocalandreferredpain,thecliniciancanrepeatthetreatment.However,ifthepain
doesnotlessen,theclinicianmayneedtoadjustthepressureorchooseanalternativetechnique.
GeneralMassage
Massagecanbedefinedasthesystematic,therapeutic,andfunctionalstrokingandkneadingofthebody.50The
Frencharecreditedwiththeintroductionofmassage,andmanyofthetermsassociatedwithmassagestillbear
Frenchnames.Massagehaslongbeenacentralpartofthephysicaltherapycurriculum.Studieshave
demonstratedthatdeepmassageincreasesthecirculationandskintemperatureofthemassagedarea,asaresult
ofdilationofthecapillaries.5154Anumberoftraditionalmassagetechniquesareused,including:
Effleurage.Thisisageneralstrokingtechniqueappliedtothemusclesandsofttissuesinacentripetal
direction(fromdistaltoproximal),toenhancerelaxationandincreasevenousandlymphaticdrainage.
Theclinicianappliesafirmcontactwiththepatientusingthepalmsofthehandand,attheendofthe
stroke,liftsthehandsfromthepatientsskinandreplacesthematthestartingposition.55Oilorcreamcan
beusedtoaidthestroking.
Stroking.Strokingtechniquesareappliedsuperficiallyalongthewholelengthofasurface.These
techniquesaretypicallyappliedprevioustothedeepertechniquesofmassagetoenhancerelaxation.54
Petrissage.Thistermisusedtodescribeagroupoftechniquesthatinvolvethecompressionofsofttissue
structuresandincludekneading,wringing,rolling,andpickinguptechniques,toreleaseareasofmuscle
fibrosisandtomilkthemusclesofwasteproductsthatcollectfromtraumaorabnormalinactivity.56
Strumming.Thetechniqueofperpendicularstrumminginvolvestheapplicationofrepeated,rhythmic
deformationsofamusclebellyinastrummingfashion.
Acupressure
Acupressureisbasedontheancientartsofshiatsuandacupuncture,involvingmanualpressureoverthe
acupuncturepointsofthebody,toimprovetheflowofthebodysenergy,knownasQi.Thisenergyisthoughtto
circulatethroughoutthebodyalongaseriesofchannels,calledmeridians.TraditionalEasternmedicineisbased
ontheconceptthatalldisordersarereflectedatspecificpoints,eitherontheskinsurfaceorjustbeneathit,
alongthesechannels.Bycarefulmanipulationofthesepoints,thecliniciancantheoreticallystrengthen,
disperse,orcalmtheQi,enablingittoflowsmoothly.57Modernacupressuristsusetraditionalmeridian
acupuncturepointsnonmeridianorextrameridianacupuncturepoints,whicharefixedpointsnotnecessarily
associatedwithmeridiansandtriggerpoints,whichhavenofixedlocationsandarefoundbyeliciting
tendernessatthesiteofmostpain.58Whenacupressureisappliedsuccessfully,thepatientissupposedto
experienceasensationknownastehchi,definedasasubjectivefeelingoffullness,numbness,tingling,and
warmthwithsomelocalsorenessandafeelingofdistentionaroundtheacupuncturepoint.58Westernscientific
researchhasproposedanumberofmechanismsfortheeffectofacupressureonrelievingpain,asfollows:
Thegatecontroltheoryofpain(seeChapter3).
Diffusenoxiousinhibitorycontrol.Thistheoryimpliesthatnoxiousstimulationofheterotopicbodyareas
modulatesthepainsensationoriginatinginareaswhereasubjectfeelspain.58
Stimulationoftheproductionofendorphins,serotonin,andacetylcholineinthecentralnervoussystem,
whichenhancesanalgesia.5967
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MuscleEnergy
TheoriginofMEtechniquesiscreditedtoFredMitchell,Sr.68MEtechniquescombinetheprecisionofpassive
mobilization,withtheeffectiveness,safety,andspecificityofreeducationtherapiesandtherapeuticexercise.69
CLINICALPEARL
Muscleenergytechniquesrequiretheactiveparticipationofthepatientandarethusviewedasmobilization
techniques,whichutilizemuscularfacilitationandinhibition.70
MEtechniques,whichinvolvepositioningarestrictedmusclejointcomplexatitsrestrictedbarrier,canbeused
tomobilizejoints,strengthenweakenedmuscles,andstretchadaptivelyshortenedmusclesandfascia.Optimal
successwiththesetechniquesismorelikelyintheacuteorsubacutestagesofhealingbeforeprolongedjoint
changeshavehadtheopportunitytooccur.
AccordingtotheteachingsofME,musclesfunctionasflexors,extensors,rotators,andsidebendersofjoints,as
wellasbeingrestrictorsorbarrierstomovement.Inotherwords,musclesbothproduceandcontrolmotion.
Althoughitisobviousthatmusclesproducemotion,itiseasytoforgetthattheyalsoresistmotion.This
resistancetomotionisrelatedtomuscletone,acomplexneurophysiologicstategovernedbybothcorticaland
spinalreflexesandbytheafferentactivityfromthearticularandmusclesystems.AfferentinputfromtypesI
andIImechanoreceptorslocatedinthesuperficialanddeepaspectsofthejointcapsuleisprojectedtothemotor
neurons(seeChapter3).Exaggeratedspindleresponsesareprovokedbyanymotionsthatattempttolengthen
themuscle,creatinganincreaseinresistancetothosemotions.Stretchingorlengtheningofthemusclealso
stimulatestheGolgitendonorgans,whichhaveaninhibitoryinfluenceonmuscletension,leadingtomuscle
relaxation.Inaddition,ithasbeendemonstratedthatcutaneousstimulationofcertainareasofthebodycan
produceinhibitionorexcitationofspecificmotorneuronpools.71
Itistheorizedthattheneuromuscularsystemisscarredbypainandimpairment,producingasymmetryinthe
musculoskeletalsystemandresultinginadisruptionoftheharmonyandrhythmofthebody,referredtoas
somaticdysfunction.69Somaticdysfunctionscanbedescribedornamedinoneofthreeways:25
1.Thedirectionofincreasedfreedomofmotion.
2.Thepositionofthelesion.
3.Thedirectionoflimitationofmotion.
Inthepresenceofasomaticdysfunction,thereisusuallyanasymmetricpatternofmotion,withrestrictionin
onedirectionandincreasedfreedomintheoppositedirection.25ThetriadofART(asymmetry,rangeofmotion
restrictionorbarrier,andtissuetexture)27helpstodescribethecharacteristicsofsomaticdysfunction.Primary
somaticdysfunctions,whichmayresultfromtrauma,arereversible,aslongastheyaretreatedcorrectlyanddo
notbecomechronicintermsofabnormalfibrosisoradhesions.Secondarysomaticdysfunctionsresultfromthe
consequencesofvisceralpathology,orfromtheadaptationsmadebysomaticstructuresinresponsetoforcesor
stressesimposedonthem.
Theconsequenceofasomaticdysfunctioncanbeachangeinthelengthofthetissuesthatsurroundajoint.
Someofthesetissuesadaptivelyshorten,whereasothersadaptivelylengthen.Thesechangesinlengthare
theorizedtoproducechangesintheneurophysiologicmakeupofthemuscle,affectingtensiondevelopment,as
wellaschangesintheangleofpull.
ThereissomecommonalitybetweenMEandseveralproceduresusedinorthopaedicMT,suchasPNF.72
Greenman27summarizestherequirementsforthecorrectapplicationofMEtechniquestobecontrol,balance,
andlocalization.
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Thetechnique,whichinvolvesacontrolledeffortinacontrolleddirection,commencesfromacontrolled
position.Eccentric,concentric,andisometriccontractions,atvaryinglevelsofeffort,areusedinME,
withinarangeofmovementcontrolledbytheclinician.
Theclinicianbalancesthedegreeofforceused,dependingontheintention.
Theforceusedislocalizedasmuchaspossibletothejointinquestion.Thelocalizationofforceismore
importantthantheintensityoftheforce.
TheintentofMEistotreatsomaticdysfunctionsbyrestoringthemusclesaroundajointtotheirnormal
neurophysiologicstate,througheitherstretchingorstrengtheningtheagonistandantagonist.Somatic
dysfunctionsincludethoseinwhichthemotionbarrierisencounteredbeforethephysiologicbarrieris
reached.69Thetypeofmotionbarrierisdeterminedbytheendfeel(seeChapter4).
Anormalendfeelwouldindicatenormalrange,whereasanabnormalendfeelwouldsuggestabnormalrange,
eitherhypomobileorhypermobile,withthelattercharacterizedbyalossofendfeelresiliencyandanabrupt
approachtotheanatomicbarrier.AllMEtechniquesareclassedasdirecttechniquesbecausetheyengagethe
barrier.26Indirecttechniquesformthebasisforthestraincounterstrain(positionalrelease)techniques,73and
thefunctionaltechniques,7476bothofwhicharediscussedlater.
Thepositionoftheclinicianduringtheperformanceofthetechniquemustalloweasyaccesstothestructures
involvedwhilemaintainingproperbodymechanics.IneachoftherecognizedmethodsofME,thesetupis
identical.Theclinicianpositionstheboneorjointsothatthemusclegrouptobeusedisatitsrestinglength.The
patientisthengivenspecificinstructionsaboutthedirectioninwhichtomove,theintensityofthecontraction,
andthedurationofthecontraction.72,7779Theamountsofforceandcounterforcearegovernedbythelength
andstrengthofthemusclegroupinvolved,aswellasbythepatientssymptoms.77Thecliniciansforcecan
matchtheeffortofthepatient,thusproducinganisometriccontractionandallowingnomovementtooccur,orit
mayovercomethepatientseffort,thusmovingtheareaorjointinthedirectionoppositetothatinwhichthe
patientisattemptingtomoveit,therebyincorporatinganeccentricorisolyticcontraction.72Thereappearstobe
noconsensusastowhethertousetherelaxationoftheagonistortheantagonisttogainmotion.27,70,8082
StrainCounterstrain(PositionalRelease)
Straincounterstrainisapassivepositionaltechniqueusedinthetreatmentofmusculoskeletalpainandrelated
somaticdysfunction.Accordingtostraincounterstraintheory,myofascialtenderpoints(Fig.102)arelocated
andthenmonitoredduringwhichapositionofcomfort,orease,isestablishedtoevokeatherapeutic
effect.73,83,84Itisworthnotingthattodatenoexperimentalstudieshavebeenpublishedtoconfirmthe
existenceofthesetenderpointsortheeffectivenessofstraincounterstrain.
FIGURE102
Straincounterstraintenderpointsofthebody.AC,anteriorcervicalPC,posteriorcervicalLH,lateral
hamstringMH,medialhamstringGX,gastrocnemiusLA,lateralankleLC,lateralcalcanealNA,navicular
LT,lateraltrochanterSP,spinousprocessTP,transverseprocessPS,paraspinalLE,lateralepicondyleME,
medialepicondyleLM,lateralmeniscusMM,medialmeniscusPAT,patellaTAL,talusMA,medialankle
DC,posterior(dorsal)cuboidDM,posterior(dorsal)metatarsalIS,interspinalPSIS,posteriorsuperioriliac
spinePLT,posterolateraltrochantericPMT,posteromedialtrochanteric.
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ApossibleneurophysiologicexplanationofhowandwhythesetechniquesworkwasfirstsuggestedbyKorr,85
whopostulatedthataninjuredjointanditsrelatedtissuesbehaveddifferentlyfromthoseofanuninjuredjointin
thatthemotorneuronactivityintheformerbecameincreased.Bailey86laterrefinedthetheorybysuggesting
thataninappropriatehighgainsetofthemusclespindle(seeChapter3)resultedinchangescharacteristicof
somaticdysfunction.87Thus,thetechniquesofstraincounterstrainappeartoservetoeffectthemusclespindle
loop,byallowingtheextrafusalmusclefiberstolengthentotheirnormalrelaxedstate,therebydecreasing
spindleoutputandinterruptingthepainspasmcycle.8789Straincounterstrainisalsothoughttoimproveblood
flowtotheareathroughacirculatoryflushingofpreviouslyischemictissues.88,90
CLINICALPEARL
Theskillandsuccessofstraincounterstraintechniquesreliesontheabilityofthecliniciantofindthetender
pointandthentoposition,ormove,thepatientinsuchawayastoreleasemusculartensionaswellasrelieve
pain.88
Whentreatingthespine,thefirststepintheexaminationprocedureisamodificationofthesagittalpostureof
thepatienttoproduceaflatteningofthelordosiskyphosisintheregiontobeexamined.87Intheextremities,
thebodypartisplacedinapositionofrelaxation.Thispositionofease(mobilepoint),whichinvolvesa
shorteningorfoldingofthetissuesaroundthemyofascialtenderpoint,usuallycorrespondstothepointof
maximumrelaxation.Anymovementfromthispositionproducesanincreaseintissuetensionunderthe
monitoringhandattheselectedtenderpointsite.73,83,84Tissuetextureabnormalitiesandareasoftendernessare
thensought.Thepositionofgreatestresistanceandpainisusuallythepositionthatisdirectlyrelatedtothatof
theoriginalmechanismofinjurythus,thepositionofeaseisusuallyoppositetothatdirection.Forexample,if
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ananklesustainedaninversioninjury,thepositionofcomfortislikelytobeineversion.Inmostcases,the
tenderpointwillbein,ornear,theareaofdiscomfort.Oncethecorrectpositionisachieved,itisthen
maintainedfor90120secondsbeforethepatientreturnsslowlytothenormalposition.73Forexample,ifthe
bicepsarebeingtreated,thetenderpointismonitored,whiletheelbowisflexed,andtheforearmis
simultaneouslypronated.Ifthemuscleisbeingmovedinthecorrectdirection,thetendernessshouldlessen.
Slightadjustmentsfromtherecommendedpositionsinthistextmaybeneeded.Ifthereismorethanonetender
point,thecliniciantreatseachoneatatime,untilthedominantoneisfound.
Oncethetenderpointhasbeensuccessfullyremoved,theclinicianshouldfocusonlengtheningand/or
strengtheningtheinvolvedmuscle.
FunctionalTechniques
Functionaltechniquesareindirecttechniquesthatusepositionalplacementawayfromtherestrictivebarrier,
similartothetechniquespreviouslydescribedforstraincounterstrain.Thefunctionaltechniqueswere
developedintheosteopathicprofessioninthe1950s,andmuchcreditisgiventoDr.AndrewTaylorStill91for
identifyingthedysfunctionsthataretreatedwiththesetechniques.74,92Stillconsideredthesomaticlesiontobe
amechanicalinvolvementofthestructure,andhisteachingsplacedprimaryemphasisonpertinentanatomy,
withpalpationusedtoidentifythepositionandarrangementofaparticularstructure.75
Althoughthetermfunctionaltechniqueisitselfsomewhatofamisnomer,thecriterionthatdistinguishes
functionaltechniquesfrommostmanualtechniquesistheemphasisonmovingthejointbeingtreatedaway
from,ratherthantoward,therestrictivebarrier.Asinthecaseofstraincounterstraintechniques,thejointin
questionismovedtowardthenormalphysiologicbarrier,attheoppositeendoftheROMtothatofthe
restriction.
Accordingtofunctionaltechniquetheory,thereisadynamicbalancepointlocatedbetweentherestrictive
barrierandtheoppositephysiologicbarrier,whichisthejointpositioninwhichthetensionsinthesofttissues
aroundthejointbecomebalancedequallyinallthreeplanes.Ifthisbalanceisachieved,thecliniciancandetect
asenseofeaseunderhisorherpalpatingfingers.Itisthedeepsegmentaltissues,whichsupportandposition
thebonesofasegment,andtheirreactiontonormalmotiondemands,thatareattheheartoffunctional
techniquespecificity.93Ifmotioninanyplaneisinitiatedawayfromthedynamicbalancepoint,thesofttissue
tensionaroundthetreatedsegmentincreases,andtherewillbeanincreasedsenseofpalpatorytension,or
bind.94
Twotheorieshavebeenproposedtoexplainthebeneficialeffectsofthesetechniques94:
1.Theafferentinputfromtheproprioceptorsisinhibited,which,inturn,suppressesthelocalprotectivecord
reflexes.
2.Thetechniquesstimulatethemechanoreceptorssufficientlytoinhibitthepainreceptors,allowingthe
tissuestorelax.
Oncethepatienthasbeenpositionedcorrectly,thecliniciancanuseoneoftwointerventionoptions:
1.Active.Inthismethod,theclinicianinitiatesmovementalongthepathofleastresistancethroughthe
sequentialreleaseofanysofttissuetensionthatoccurs,untiltherestrictivebarrierisnolongerdetectable,
andnormalmotionisregained.
2.Passive.Inthismethod,theclinicianfollowsthearticularunwindingthroughsequentialreleasesofthe
treatedjointtothepointoffullsofttissuerelease,untiltherestrictivebarrierisnolongerdetectable,and
normalmotionisregained.
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CraniosacralTherapy
Craniosacraltherapy(CST)isanalternative,complementaryMTpracticedthroughouttheUnitedStatesand
aroundtheworldbyosteopathicandchiropracticphysiciansphysical,occupational,andmassagetherapistsand
dentists.95CSTisbasedontheassumptionthatcranialbonemovementoccursthrougharespiratorymechanism
comprisingthebrain,cerebrospinalfluid(CSF),intracranialandintraspinalmembranes,cranialbones,spinal
cord,andsacrum.96CSTpractitionersareoftheopinionthatrestrictions,misalignments,immobilityofthe
cranialsutures,andtensionoftheintracranialmeningesdirectlyimpactthehealthofanindividual.Inaddition,
practitionersofCSTclaimthattheycanidentifyalterationsinthemovementpatternsofthesacrumandthe
cranialsuturesthroughmanualpalpation.Palpationofthecraniumtheoreticallyallowsthecliniciantoperceive
therhythmicimpulseresultingfromthewideningandnarrowingoftheskull.95However,thereliabilityreports
ofidentifyingtherhythmicmovementofthesuturesusingpalpationhaverangedfromworsethanachanceto
fair.95,97CSTisalsobasedontheexistenceofarticularmobilityatthecranialbones.AccordingtoCST
practitioners,510gofforceisrecommendedtomanipulatehumansutures.Despitethenumberofstudiesand
thestrongclaimsmadebyresearchersfromavarietyoffieldsregardingthemobilityofthecranialbonesthe
researchoncranialbonemotiondonetodateisfarfromconclusive.95InastudybyDowneyetal.,95arabbit
modelunderwentincrementallyincreasingforcesthroughtheskull.Movementwithinthecoronalsuturedidnot
occuruntil500gofforcewasapplied.Furthermore,forcesupto22kgwererequiredtocause1mmof
movement.95
Ithasbeensuggestedthatbasedonthelackofcredibleevidence,CSTshouldbeabandonedasaviable
rehabilitativetheory(i.e.,thatcranialsuturesmove),untilsuchtimethattheadvocatesofCSTcontributewell
designedstudiesevaluatingtheefficacyofthesetechniquestothepeerreviewedliterature.97
JOINTMOBILIZATIONS
Jointmobilizationtechniquesincludeabroadspectrum,fromthegeneralosteokinematicpassivemotions(see
Chapter1)performedinthephysiologiccardinalplanesatanypointinthejointrangetothesemispecificand
specificaccessory(arthrokinematic)jointglides(seeChapter1),orjointdistractions,initiatedfromtheopen
packedpositionofthejoint.
Thesetechniquesformthecornerstoneofmostrehabilitativeprogramsandinvolvelowhighvelocitypassive
movementswithinoratthelimitofjointROM,torestoreanylossofaccessoryjointmotion(roll,slide,orspin
seeChapter1)astheconsequenceofjointinjury.98
TheindicationsforjointmobilizationsincludethosealreadymentionedforMTtechniques,buttheevidence
basedindicationsincludethefollowing:
IncreasingjointextensibilityandjointROM.Although,theoretically,thejointcapsuleandarticular
surfacesarethestructuresaffectedbyjointmobilizations,otherperiarticulartissues,suchastendons,
muscles,andfasciaarealsolikelyaffected.However,therearestillnostudiesthatidentifyhistological
jointchangesresultingfromjointmobilizations.Thereisalsonoconclusiveresearchproviding
informationregardingtheoptimaltypeofmobilization,theamountoftimeajointshouldbemobilized,or
theoptimalamountofforcerequiredtotreatanyofthesocalledjointimpairments.
IncreasingjointROM.AnumberofstudiesaddressingtheeffectofjointmobilizationsonROMprovide
evidenceofanassociation.99,100
Decreasepain.Anumberofstudieshaveshownthathypoalgesiaoccursasaresultofjoint
mobilizations,101103althoughtheeffectseemstooccurregardlessofthetechniquebeingused,thejoint
beingtreated,ortheimpairmentbeingaddressed.
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Promotemusclerelaxation.Althoughthereissomeevidencethatjointmobilizationscanreducemuscle
activityinmuscles,thespecificmechanismisunknown.101
Improvemuscleperformance.Evidencesuggeststhatjointmobilizationcanimprovemuscleperformance,
regardlessofthepresenceornatureofthemuscleimpairment.104
CLINICALPEARL
Mobilizationtechniquesthatutilizeaccessorymovementsanddistractionsareusedprimarilyoninerttissues,
andphysiologicmovementsareusedtomobilizebothcontractileandnoncontractiletissues.105
ThecontraindicationsandprecautionsforjointmobilizationsincludethosealreadymentionedforMT
techniquesincludingthepresenceofjointhypermobility,acuteinflammation,andacutejointeffusion.
Jointmobilizationsareappliedinadirectionthatiseitherparallel(slideorroll)orperpendicular(compression
ordistraction)tothetreatmentplane(seeChapter1),torestorethephysiologicarticularrelationshipwithina
joint,therebyreducinghypomobility,andtodecreasepain.106Additionalbenefitsattributedtojoint
mobilizationsincludedecreasingmuscleguarding,lengtheningthetissuearoundajoint,neuromuscular
influencesonmuscletone,andincreasedproprioceptiveawareness.107,108
Threetypesofmobilizationsarerecognized,basedonthelevelofparticipationbytheclinicianandpatient:
1.Active,inwhichthepatientexertstheforce
2.Passive,inwhichtheclinicianexertstheforce
3.Combined,inwhichtheclinicianandpatientworktogether
Toapplyjointmobilizations,thecomponentscanbeutilizedinavarietyofways,dependingonthemethod
employed:
Directmethod.Anengagementismadeagainstabarrierinseveralplanes.
Indirectmethod.Maigne109postulatedtheconceptofpainlessandoppositemotion,inwhich
disengagementfromthebarrieroccurs,andabalanceofligamentoustensionissought.
Combinedmethod.Disengagementisfollowedbydirectretracingofthemotion.
SeveralotherschoolsofthoughthavebeenputforwardtoaddresstheconceptsofincreasingjointROM.
Kaltenborn8introducedtheNordicprogramofMT,whichutilizesCyriaxs2methodtoevaluate,andthespecific
osteopathictechniquesofMennell3forintervention.FurtherinfluencefromStoddard,4anosteopath,cemented
thefoundationsoftheNordicsystemofMT.Evjenth,110whojoinedKaltenbornsgroup,broughtagreater
emphasisonmusclestretching,strengthening,andcoordinationtraining.
KaltenbornTechniques
Kaltenbornreferstotheamountofjointplayatajointasslack.Eachjointinterfacehasaplaneofmotion,an
imaginarylinelyingacrossthejointsurfaces.AccordingtoKaltenborn,alljointmobilizations,whenperformed
correctly,shouldbemadeparalleloratrightanglestothisplaneofmotion,andarebasedonthe
arthrokinematicsofthejoint(seeChapter1),specificallytheconcaveconvexrule(Figs.18and19)(Table10
6).8Forexample,ifextensionofthetibiofemoraljointisrestricted,eitherthefemur(convex)canbestabilized
andthetibia(concave)glidedanteriorlyorthetibiacanbestabilizedandthefemurglidedposteriorly.The
concaveconvexrulecannotbeappliedtoeverysituation.Exceptionsincludemovementsatplanejoints,
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movementsforwhichtheaxisofrotationpassesthroughthearticulatingsurfaces,andmovementsatjointsin
whichtheconcavesideofthejointformsadeepsocket.111
TABLE106Shape,RestingPosition,andTreatmentPlanesoftheJoints
TreatmentPlaneand
Relationshipofthe
Concave
Joint ConvexSurface RestingPosition OsteokinematicMotion(OM)
Surface
andArthrokinematicGlide
(AG)
For
elevation/depression,
Forelevation/depressionthe
thesternumis
OMandAGareinopposite
concave,theclavicle
directions
Sternoclavicular isconvex Armrestingbyside
Forprotraction/retractionthe
For
OMandAGareinthesame
protraction/retraction,
directions
thesternumisconvex,
theclavicleisconcave
OMandAGareinopposite
Acromioclavicular Clavicle Acromion Armrestingbyside
directions
55degreesof
abduction,30
Inscapularplane:OMandAG
Glenohumeral Humerus Glenoid degreesof
areinoppositedirections
horizontal
adduction
Perpendiculartolongaxisof
Elbowextended,
Humeroradial Humerus Radius radius:OMandAGareinthe
forearmsupinated
samedirections
70degreesof
45degreestolongaxisofulna:
elbowflexion,10
Humeroulnar Humerus Ulna OMandAGareinthesame
degreesofforearm
directions
supination
70degreesof
Paralleltolongaxisofulna:
Radioulnar elbowflexion,35
Radius Ulna OMandAGareintheopposite
(proximal) degreesofforearm
directions
supination
Paralleltolongaxisofradius:
Supinated10
Radioulnar(distal) Ulnar Radius OMandAGareinthesame
degrees
directions
Linethroughradius Perpendiculartolongaxisof
Radiocarpal Proximalcarpalbones Radius andthird radius:OMandAGarein
metacarpal oppositedirections
Trapezium Paralleltojointsurfaces:OM
Intercarpal Scaphoid and Midposition andAGareinthesame
trapezoid directions
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TreatmentPlaneand
Relationshipofthe
Concave
Joint ConvexSurface RestingPosition OsteokinematicMotion(OM)
Surface
andArthrokinematicGlide
(AG)
Forflexion/extension,
thecarpalisconvex,
Forflexion/extension:OMand
themetacarpalis
AGareinthesamedirections.
concave
Carpometacarpal Forabduction/adduction:OM
For Midposition
jointofthethumb andAGareinopposite
abduction/adduction
directions
thecarpalisconcave,
themetacarpalis
convex
Metacarpophalangeal Proximal Paralleltojoint:OMandAG
Metacarpal Slightflexion
(25) phalanx areinthesamedirections
Distal Paralleltojoint:OMandAG
Interphalangeal Proximalphalanx Slightflexion
phalanx areinthesamedirections
Hipflexed30
degrees,abducted OMandAGareinopposite
Hip Femur Acetabulum
30degrees,slight directions
externalrotation
Onsurfaceoftibialplateau:OM
Tibiofemoral Femur Tibia Flexed25degrees andAGareinthesame
directions
Kneeinfull Alongfemoralgroove:OMand
Patellofemoral Patella Femur
extension AGareinoppositedirections
Inthemortisein
Plantarflexed10 anterior/posteriordirection:OM
Talocrural Talus Mortise
degrees andAGareinopposite
directions
Intalus,paralleltofootsurface:
Subtalarneutral
OMandAGareinthesame
Subtalar Calcaneus Talus between
directions
inversion/eversion
AGareinthesamedirections
OMandAGareinthesame
Talonavicular Talus Navicular Midposition
directions
Forflexion/extension
thecalcaneusis
convex,thecuboidis Forflexion/extension:OMand
concave. AGareinthesamedirections.
Calcaneocuboid For Forabduction/adduction:OM
abduction/adduction, andAGareinopposite
thecalcaneusis directions
concave,thecuboidis
convex
Proximal Paralleltojoint:OMandAG
Metatarsophalangeal Tarsalbone Slightextension
Distal Paralleltojoint:OMandAG
Interphalangeal Proximalphalanx Slightflexion
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Kaltenbornstechniquesuseacombinationofdistractionandmobilizationtoreducepainandmobilize
hypomobilejoints.Thechoiceofwhethertouseaparticulargradedependsonthepatientsresponse.Three
gradesofdistractionaredefined:
GradeIpiccolo(loosen).Thisgradeinvolvesadistractionforcethatneutralizespressureinthejoint,
withoutproducinganyactualseparationofthejointsurfaces.GradeItractionisusedwithallgliding
motionstoreducethecompressiveforcesonthearticularsurfacesandtherebypain,bothintheinitial
interventionsessionandwithallofthemobilizationgrades.Theintermittentdistractionsareappliedfor
710secondswithafewsecondsrestbetweenforseveralcycles.
GradeIIslack(takeuptheslack).Thisgradeofdistractionseparatesthearticulatingsurfacesand
eliminatestheplayinthejointcapsule.Itistypicallyusedfortheinitialtreatmenttodeterminethe
sensitivityofthejoint.
GradeIIIstretch.Thisgradeofdistractionisdesignedtostretchthejointcapsuleandthesofttissues
surroundingthejointtoincreasemobility.GradeIIIdistractionisusedinconjunctionwithmobilization
glidesaccordingtotheconvexconcaverulestotreatjointhypomobilityintheremodelingstageof
healing.8Forrestrictedjoints,theclinicianappliesaminimumofa6secondstretchforcefollowedbya
partialrelease(togradeIorII),beforerepeatingwithslow,intermittentstretchesat34secondintervals.
AustralianTechniques
TheAustralianapproachwasintroducedprimarilybyMaitland,7whosegradingsystemisusedthroughoutthis
text.Underthissystem,theROMisdefinedastheavailablerange,notthefullrange,andisusuallyinone
directiononly(Fig.103).Eachjointhasananatomiclimit,whichisdeterminedbytheconfigurationofthejoint
surfacesandthesurroundingsofttissues.Thepointoflimitationisthatpointintherangethatisshortofthe
anatomiclimitandisreducedbyeitherpainortissueresistance.
FIGURE103
Maitlandsfivegradesofmotion.
Maitlandadvocatedfivegradesofjointmobilizationoroscillations,eachofwhichfallswithintheavailable
ROMthatexistsatthejointapointsomewherebetweenthebeginningpointandtheanatomiclimit(seeFig.
103).AlthoughtherelationshipthatexistsbetweenthefivegradesintermsoftheirpositionswithintheROMis
alwaysconstant,thepointoflimitationshiftsfurthertotheleft,astheseverityofthemotionlimitation
increases6:
GradeI:asmallamplitudetechnique(about25%)performedatthebeginningoftheavailableROM.
GradeII:alargeamplitudemovementinthemiddleoftheROM(i.e.,themiddle50%).
GradeIII:alargeamplitudemovementattheendoftheROM(i.e.,thelast50%).
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GradeIV:asmallamplitudemovementattheendofROM(thelast25%).
GradeV:amovementthatexceedstheresistancebarrier,commonlyreferredtoasahighvelocitythrust
techniqueormanipulation.
AswiththeKaltenbornphilosophy,thedirectionoftheglideincorporatedisdeterminedbytheconcaveconvex
rule,andthejointtobemobilizedisinitiallyplacedinitsopenpackedposition.Byvaryingthespeedof
oscillations,differenteffectscanbeproduced.Forexample,manycliniciansuseacombinationofKaltenborns
gradeIIIdistractionwithMaitlandsgradeIVoscillationstodecreasepainandincreasejointmobility.The
differencebetweenoscillationsandsustainedtechniquesisrelatedtotherhythmorspeedofrepetitionofthe
stretchforce.Whilebothtechniquesareappliedwithastretchingforceatthelimitofmotion,oscillation
techniquesarevibratoryinnature.
MaitlandsgradesIandIIareusedsolelyforpainreliefandmuscleguardingandhavenodirectmechanical
effectontherestrictingbarrier,althoughtheytheoreticallyhaveahydrodynamiceffect.Mobilizationinduced
analgesiahasbeendemonstratedinanumberofstudiesinhumans,112114andischaracterizedbyarapidonset
andspecificinfluenceonmechanicalnociception.GradeIandIIjointmobilizationsaretheoreticallyeffectivein
painreductionandmuscleguarding,byimprovingjointlubricationandcirculationintissuesrelatedtothe
joint.105,115Rhythmicjointoscillationsalsopossiblyactivatethearticularandskinmechanoreceptorsthatplay
aroleinpainreduction.116,117
MaitlandsgradesIIIandIV,whichareusedprimarilyasstretchingmaneuvers,haveamechanical,aswellasa
neurophysiologic,effect.GradeIIIandIVjointdistractionsandstretchingmobilizationsmay,inadditiontothe
abovestatedeffects,activateinhibitoryjointandmusclespindlereceptors,whichaidinreducingrestrictionto
movement.105,115117
Theselectionofthemobilizationtechniquewilldependonthebarriertomovementfeltbytheclinician(the
endfeel)andtheacutenessofthecondition(seeTable104).Thejointispositionedinitsrestingpositionorthe
positionofgreatestcomfort.Muscleisusuallythefirstbarrierandistreatedwithlightholdrelaxtechniquesor
asustainedgradeIIdistraction.Oftensomepainfollowsthisinitialmobilization,whichistreatedwithgradeIII
orIVoscillations.118Atthenextsession,ifthereisincreasedpainandsensitivity,theclinicianshouldreduce
theamplitudetoagradeIoscillation.Asthepainisreduced,therealbarriertomovementisapproached.Ifthis
barrierisperiarticulartissue,thengradeIV+rhythmicaloscillationsareusedtostretchthetissueifthejointis
subluxed,erratic,jerkygradeIII+areapplied.118
Whenjointmotionislessthan50%butjointresistancetomovementisthedominantdysfunction,aprogression
fromtheuseofphysiologicmovements(gradeIVseeFig.103)tostretchthejointlimitation,andtheuseof
accessorymovementsatthelimitofthejoint,isadvocated.7,105GradesIIIandIVhavebeenfurthersubdivided
intoIII+(++)andIV+(++),indicatingthatoncetheendoftherangehasbeenreached,afurtherstretchto
impartamechanicalforcetothemovementrestrictionisgiven.118AgradeVmobilization,definedasthe
skilledpassivemovementofajoint,isashortduration,smallamplitude,highvelocitythrustthatisappliedat
thephysiologiclimitofjointrange(seeFig.103).
CLINICALPEARL
Ifthejointsurfaceisconvexrelativetotheothersurface,theslideoccursintheoppositedirectiontothebone
movement(angularmotion).If,ontheotherhand,thejointsurfaceisconcave,theslideoccursinthesame
directionasthebonemovement(angularmotion).
Inthespine,theconvexruleappliesattheoccipitoatlantaljoint,butbelowthesecondvertebra,theconcave
rulesapply.
Thisruleisveryimportanttorememberforjointmobilitytestingandforjointmobilizations.
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If,duringmobilitytesting,thereisalimitedglide:
Ifthelimitationoccurswhentheconcavesurfaceismoving,therestrictionislikelyduetoacontractureof
thetrailingportionofthecapsule.
Ifthelimitationoccurswhentheconvexsurfaceismoving,therestrictionislikelyduetoaninabilityof
themovingsurfacetomoveintothecontractedportionofthecapsule(maybeduetoadhesionsbetween
redundantfoldsofthecapsule).
Itisworthrememberingthatadhesionsbetweencollateralligamentsandtheunderlyingtissueplanemaylimit
movementinmorethanonedirection.
Ifmobilizingintheappropriatedirectionaccordingtotheconvexconcaveruleappearstoexacerbatethe
patientssymptoms,theclinicianshouldapplythetechniqueintheoppositedirectionuntilthepatientcan
toleratetheappropriatedirection.119
CLINICALPEARL
Althoughsellarsurfacesfollowthesamerulesasovoidsurfaces,becauseofthenatureofthecurvatureoftheir
jointsurfaces,thedirectionoftheswingandtheglidevaries.Forexample,atthefirstcarpometacarpaljoint,the
followingbiomechanicsareinvolved:
Flexion/extensionofmetacarpal:themovingsurfaceisconcave.
1.Theswingoftheboneoccursinananteromedial/posterolateraldirection.
2.Thebaseglidesandrollsinananteromedial/posterolateraldirection.
Abduction/adductionofmetacarpal:themovingsurfaceisconvex.
1.Theswingoftheboneoccursinananterolateral/posteromedialdirection.
2.Thebaseglidesintheoppositedirectiontotheswingandrollsinthesamedirectionastheswing.
Physiologicmovementmobilizationsandaccessoryanddistractionmobilizationsmaybeperformedatany
gradeindicated.Themobilizationsareperformedbothatthesiteofpainandtojointsproximaltothesiteofpain
toproduceanalgesia.120
Whichevertechniqueorgradeisemployed,anumberoffurtherconsiderationshelpguidetheclinicianin
additiontothosementionedunderCorrectApplicationofManualTechniques:
Thepositionofthejointtobetreatedmustbeappropriateforthestageofhealingandtheskillofthe
clinician:
Therestingoropenpackedpositionisusedfortheacutestageand/orinexperiencedclinician.
Otherstartingpositionsmaybeemployedbyaskilledclinicianinthenonacutestages.
Onehalfofthejointshouldbestabilized,whiletheotherhalfismobilized.Boththestabilizingand
mobilizinghandsshouldbeplacedascloseaspossibletothejointline.Theotherpartsoftheclinician
involvedinthemobilizationshouldmakemaximumcontactwiththepatientsbody,tospreadtheforces
overalargerareaandreducepainfromcontactofbonyprominences.Themaximumcontactalsoresults
inmorestabilityandincreasedconfidencefromthepatient.Analternativetechnique,whichproducesthe
desiredresults,mustbesoughtifthecontactbetweenoppositesexesisuncomfortabletoeitherthepatient
ortheclinician.
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Thedirectionofthemobilizationisalmostalwaysparallelorperpendiculartoatangentacrossadjoining
jointsurfacesandisappropriateforthearthrokinematicsofthejointbeingtreated.
Themobilizationshouldnotmoveintoorthroughthepointofpainthroughoutthedurationofthe
technique.
Thevelocityandamplitudeofmovementarecarefullyconsideredandisbasedonthegoalofthe
intervention,torestorethejointmotionortoalleviatethepain,orboth.
Slowstretchesareusedforlargecapsularrestrictions.
Fastoscillationsareusedforminorrestrictions.
Onemovementisperformedatatime,atonejointatatime.
Thepatientisreassessedafterafewmovementsifthejointisintheacutestageofhealing,lessfrequently
forotherstagesofhealing.
Theinterventionshouldbediscontinuedforthedaywhenalargeimprovementhasbeenobtainedorwhen
theimprovementceases.
Musclereeducationisessentialaftermobilizationorhighvelocitythrusttechniquesandoftenproducesa
noticeablereductioninposttreatmentsoreness.Whilethejointismaintainedinthenewrange,fivetosixgentle
isometriccontractionsareaskedforfromtheagonistsandantagonistsofthemotionmobilized.118Recently,the
emphasishasshiftedfrommobilizationofthejointinstraightplanestomobilizationsthatincorporatethe
combinedorcongruentrotationsthatoccurwithnormalmotion,inordertotakeupalloftheslackinthe
capsule.
Thejointmobilizationtechniquesspecifictoeachjointaredescribedanddepictedintherelevantchapters.
MobilizationswithMovements
Theconceptofmobilizationswithmovements(MWMs)wasintroducedbyBrianMulligan.121,122MWMsare
basedontheprinciplesofjointmobilizationoriginatedbyKaltenbornusedinconjunctionwithactiveand/or
passivephysiologicalmovement.
CLINICALPEARL
ThetechniquesofMWMcombineasustainedmanualglidingforcetoajointwithconcurrentphysiologic
motionofthejoint,eitheractivelyperformedbythepatientorpassivelyperformedbytheclinician,withthe
intentofcausingarepositioningofthesocalledbonypositionalfaults.121,122
Withfewexceptions,Mulligansmobilizationtechniquesareappliedparalleltotheplaneofmotionandare
sustainedthroughoutthemovementuntilthejointreturnstoitsstartingposition,withtheintentionofproducing
nopainandimprovingfunctionwhenapplied.122Indeed,thegoldenruleofMWMsisthatifthepainis
producedwithanMWM,thetechniquesarecontraindicated.Themostcommoncauseofpainwiththese
techniquesoccurswhenthemobilizationisnotsustainedthroughoutthewholemotion.122
ThemovementsusedwithMWMsarepatientdependentandcanincludeactive,passive,andresisted
movements.Theirsuccessisbasedonthetheorythatbonypositionalfaultscancontributesubstantiallyto
painfuljointrestrictions,whichissimilartothetheorybehindthesuccessofjointmanipulations.122
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MulligansMWMtechniqueswereoriginallydesignedforthecervicalspinebuthavesincebeenexpandedto
includevirtuallyeveryjointinthebody.Severalstudies121,123126thatlookedattheeffectsofMWM
concludedthatMWMisapromisingintervention.
Mulliganhasdevisedanumberofguidelineswhenapplyingthesetechniques:121,122
Thepatientisplacedinaweightbearingposition.
Otherinterventionsshouldbeusedinconjunctionwiththesetechniques.
Whentreatinghingejoints,thesustainedglideormobilizationshouldbeatrightanglestotheglidethat
usuallyoccurswiththedesiredmovement.Forexample,inthecaseoffingerflexion,theglide
mobilizationofthedistaljointsurfaceisappliedinamedialorlateraldirection.
Whenjointmovementsinvolveadjacentlongbones,asinthecaseatthewristorankle,itisoften
necessaryforthecliniciantoadjusttherelativepositionsofthelongbonestoenablepainfreejoint
movementtooccur.
Theglidemobilizationisalwayssuccessfulinonedirectiononly.Thesuccessfulglidemobilizationis
applied10timesbeforereassessingthejointmotion.
Overpressureshouldbeappliedattheendrangeoftheavailableactiverangeofmotion(AROM).
Mulligantechniquesaredescribedindetailintherelevantchaptersofthistext.
HIGHVELOCITYTHRUSTTECHNIQUES
Theearliestphysicianstousehighvelocitythrusttechniques(jointmanipulations)wereEnglish,andbookson
thesubjectwerepublishedintheearly1900s.44,127129
Comparedwiththefourgradesofjointmobilization(gradesIIV),highvelocitythrusttechniquesaregiventhe
designationgradeV.Recently,manipulativetherapyhasbeenbroadlydefinedtoincludeallprocedures,in
whichthehandsareusedtomassage,stretch,mobilize,adjust,ormanipulatemusculoskeletaltissuesfor
therapeuticreasons.130However,inthistext,highvelocitythrusttechniquesrefertogradeVtechniques.
AlthoughthegradeVtechniquesharessimilaritieswiththegradeIVmobilizationintermsofamplitudeand
positioninthejointrange,gradeVdiffersinthevelocityofdelivery.Appliedatthebarrierorpointofjoint
restriction,agradeVtechniqueinvolvestheapplicationofafastimpulseofsmallamplitudetorestorejoint
play.Thetermsvelocityandamplitudeareusedtodescribethenatureofthefinalactivatingforceorthrustused.
MostgradesIIVjointmobilizationsusevaryingdegreesofvelocityandamplitude,whereasgradeV
techniquesgenerallyemployahighvelocity(quick)andlowamplitude(shortdistance)thrust.Unlike
mobilizations,whichareappliedsingularlyorrepetitivelywithinoratthephysiologicrangeofjointmotion,131
jointmanipulationsinvolveathrusttoajointsothatthejointisbrieflyforcedbeyondtherestrictedROM.98
Thespeed,force,andcorrectapplicationofahighvelocitythrusttechniquearecriticalifseriousinjuryistobe
avoided.Thisisparticularlytrueinthecraniovertebralregion,whereanoverzealoustechniquecanresultin
seriousconsequences.Atthetimeofwriting,thereismuchdiscussionastowhetherornotapatientshouldbe
requiredtosignaninformedconsentpriortoreceivingahighvelocitythrusttechnique.Attheveryleast,the
clinicianhasanethicaldutytoobtainatleastverbalconsentoragreementafterexplainingtherationaleforthe
techniqueandthepossiblesideeffects.132
CLINICALPEARL
Whenperformedcorrectly,ahighvelocitythrustmayactuallybesaferthanmanyotherrepetitive,lowvelocity
orprolongedstretchtechniques.Theoretically,ahighvelocitythrusttechniqueminimizestheriskofcreepand
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fatiguefailureinnormalcollagentissues.Ifdamagedoesoccurtotissues,itismorelikelyduetoexcessive
amplitudeofthethrust,excessivemagnitudeofforceused,orthefactthatthethrustingforceispassingthrough
amechanicallyunsoundjoint.132
Highvelocitythrusttechniquesmayconsistoflonglevertechniquesthatexertforcesonapointonthebody
somedistancefromthetreatmentarea,orshortlevertechniquesthatcompriseforcesdirectedspecificallyatan
isolatedjoint.133Alesionthatmightbenefitfromahighvelocitythrusttechniquemaybedefinedbymovement
restrictionandpain,especiallyajointrestrictionthatelicitspainonprovocation.Thedecisiontouseahigh
velocitythrusttechniqueismadeafterfirstidentifyingtherestrictionthroughtheendfeel.Forexample,when
significantexcessivecollagendensity(e.g.,chroniccapsularfibrosis)isthoughttobethecauseofthemotion
barrier,theuseofahighvelocitythrusttechniqueisdeemedinappropriate.132Insuchcases,thetechnique
utilizingaslow,prolongedstretchwouldbemoreappropriate.Theplaneordirectionofjointrestriction
determinesthetypeanddirectionofthehighvelocitythrusttechniquetobeused.Thedirectionofthetechnique
canbedeliveredeitherperpendiculartoorparalleltothejointsurfaceinquestion132:
Perpendicular:Thesetechniques,morecommonlyknownasdistraction(gapping)techniques,aimto
separatethejointsurfacesandareusuallydeliveredwithinthejointspathologicalpositionofease.This
typeoftechniqueisonlyappropriateifthebiomechanicalassessmentsuggestsanintraarticularinclusion
orunstablejointwhichhasbecomelockeduporfixatedbeyonditsneutralzone.
Parallel:Thesetechniques,aimedatimprovingthejointglide,areperformedattheendofavailablerange
Engagingthebarrier,whichrequiresahighlevelofskill,localizestheforce,ensuringitwillbeappliedtothe
restriction,therebyminimizingthemagnitudeandamplitudeoftheforce.Tosuccessfullyengagethebarrier,a
seriesofmaneuverscalledjointlockingtechniquesareutilized.Excessiveforceorfailuretolocalizethe
techniqueforceresultsinadissipationofthoseforcesand,unlessthepatientisabletoabsorbtheseforces,they
mayprovetobeharmful,especiallyinthespinalregions.25Theseharmfuleffectscanincludefracture,spinal
cordcompression,vertebralarterycompromise(seeChapter24),cerebralischemia,andevendeath.134
CLINICALPEARL
Cervicalmanipulationshavebeenlinkedtovertebrobasilarcomplications.Inareviewofthe58casesinthe
Englishlanguageliteratureofvertebrobasilarcomplicationsfollowingcervicalmanipulation,Grantfoundthe
averageagetobe37.3yearswitharangeof73years.135ItwasestimatedfromastudybyHoseketal.136that
oneinonemillioncervicalmanipulationswillresultinaseriousvertebrobasilareffectwhereasDvorakandvon
Orelli137estimatedamuchhigherincidenceofonein400,000.Thislatterfigurewouldindicatethataclinician
performingcervicalmanipulationson15patientseachdayfor30years(allowingforvacations)standsalittle
betterthanoneinfourchanceofcausingaseriousstrokeinthecourseofacareer.Putanotherway,oneinfour
clinicians,manipulatingatthesamerate,willrunintoaseriousproblemfromthevertebralartery.
LOCKINGTECHNIQUES
Thefollowingtwomethodsoflockingarecommonlycitedforthelumbarspine(seeChapter28)136:
1.Lockingfromabove.Thistechniqueplacesthelumbarspineinrotationandsidebendingtotightenthe
ligamentsandcapsule,thusstabilizingthejoint,andcanbeperformedinflexion,neutral,orextensionof
thelumbarspine.Becausethecliniciancanonlyadequatelycontrolrotationmotionwhenthisisaway
fromtheedgeofthebed,whicheversidethepatientislyingonthedictatestherotationthatcanbeused
intheoppositedirectionfromthepatientsidelyingposition(e.g.,leftsidelyingwillpermitright
rotation).Thesidebendingmotionisachievedbyusingthepatientslowerarmtopulltheshouldergirdle
ineitheraninferiororasuperiordirection.Forexample,ifthepatientislyingontheleftside,pullingthe
leftshouldergirdlesuperiorlywillproducerightsidebendingofthetrunk,whereaspullingthepatients
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leftshouldergirdleinferiorlywillproduceleftsidebending.Flexionandextensioncanonlybeproduced
unilaterallyincombinationwiththerotation.Forexample,withthepatientinrightsidelying,flexioncan
beproducedwithleftrotationbyaskingthepatienttoholdontotheedgeofthetablewiththeirlefthand
(keepingtheleftshouldergirdlestationary),whiletheclinicianpullsthepatientsrightarmhorizontally
forward.Extensioncanbeproducedwithleftrotationbyplacingthepatientslefthandontotheirwaistso
thattheweightofthepatientsarmcreatesaleftrotationwithabackwarddisplacement.Thiscanbe
furtherenhancedbypullingthepatientsrightarmasverticalaspossiblewhilemaintainingtheright
shoulderinarelativelystationaryposition.Neutralrotation(i.e.,involvingeitherflexionorextension)can
beachievedbypullingthepatientsrightarmforwardata45degreeangle.Thesepatientpositionsenable
thecliniciantocombineuptothreecomponentsinthelockingtechniquessimultaneously.
2.Lockingfrombelow.Aswithlockingfromabove,thedirectionoftherotationisdictatedbywhichever
sidethepatientlieson(e.g.,thespineisrotatedtotherightifthepatientisinleftsidelying).Therotation
canbeenhancedbybringingthenonweightbearingsideofthepelvisanteriorly.Flexionandextension
ofthelumbarsegmentsareproducedbymotionsofthehipandpelvisasisperformedwithpassive
intervertebraljointmotion(PIVM)testing.Thefollowingsequenceisrecommended:
Producethenecessaryflexionorextensionmotiontotheappropriatelevel:
Flexionisfacilitatedbykeepingthekneesawayfromfullflexion,thusutilizingtensioninthe
hamstringstorotatethepelvisposteriorly.
Extensionisfacilitatedbykeepingthepatientskneesasflexedaspossible,therebyutilizing
thetensionintherectusfemoristorotatethepelvisanteriorly.
Introducethenecessarysidebendingusingthelegs.Sidebendingisachievedbyaskingthepatient
toactivelysidetiltthepelvisbyusingcommandssuchasPushyourlowerlegdown,orMake
yourlowerleglonger.
Theclinicianthencarefullyadjuststhepositionofthehipsandkneeswithoutmovingthepelvisuntiltheupper
kneeisinfrontofthelowertouserotationforamoresecurelock.Aswiththelockingtechniquesfromabove,
theclinicianhassevenpossiblecombinations:
Neutralrotation,flexion,orextension.
Ipsilateralextension(lowerlegextending)orcontralateralextension(upperlegextending)
Ipsilateralflexion(lowerlegextending),orcontralateralflexion(upperlegextending)
Withbothlockingtechniques,theadjacentjointsarepositionedattheendoftheavailableROMfor
flexion/extension,sidebending,orrotation.Thispositioningpreventsfurthermovementatthesejointsbecause
eithertheligamentsaretautorthearticularsurfacesarecontactingoneanothersothatanyfurthermotion
inducedbyamanualtechniqueislikelytooccuratthemotionsegmentthatisnotimmobilizedbythelockthe
motionsegmenttargetedfortreatment.
Inthecervicalspine,twotypesoflockingtechniquesarealsocommonlyadvocated(seeChapter25):
craniovertebrallockingandlockingthroughsegmentaltranslation.Becauseofthepotentialforvertebralartery
compromiseinthecraniovertebralregion,thecraniovertebraljointsareoftenlockedfirstbeforecontinuing
motionintothemiddleand/orlowercervicalspinejoints.Inthefollowingexample,aleftsidebending
techniqueisused.Althoughthislockingtechniquemaybeusedwiththepatientpositionedinsittingorsupine,
ifitisusedinsupineitisimportanttoapplyasmallamountofcompressiontocompensateforthelossofthe
spinalloadingduetotheweightofthehead.
WhilepalpatingtheC2spinousprocess,theclinicianslowlysidebendsthepatientsheadtotheleft.Iftheside
bendingisperformedaroundasagittalcraniovertebralaxis,theC2spinousprocessshouldbefelttomovetothe
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right,indicatingleftrotationoftheC2ontheC3.Maintainingtheleftsidebentposition,theheadisnowrotated
totherightuntiltheC2spinousprocessregainsacentralposition.Theheadisagainsidebentslightlytotheleft,
andtheC2spinousprocessderotatedbacktothemidline.Thesemotionsarecontinueduntilafirmendfeelis
reached.Atthispoint,motioninthecraniovertebraljointshasnowbeenexhausted,whiletherestofthecervical
jointsremaininneutral.Beingcarefultomaintainthepositionofthehead,especiallytherightrotation,theside
bendingiscontinuedlefttothemiddleorthelowercervicallevelrequired.Asthecervicaljointsareprevented
fromrotatingtotheleft,themiddlecervicalsidebendingmotionisexhaustedveryquickly.
Whenaspecificforceisappliedtothebodilyjoints,clickingorpoppingsounds,calledcavitations,maybe
heard.Distractiontechniquesareundoubtedlytheeasiestwaytogetthejointsound,especiallyfromanormal
joint.Theactualcausesofthesecavitationsorclicksareunknownbutarethoughttoresultfromasudden
releaseofsynovialgasduringthetechniques.Thegasisthenreabsorbedbythejointoveraperiodofabout30
minutes,whichmayexplainwhyjointscanonlyberecrackedevery2030minutes.Itisquitepossiblethat
thesecavitationsmightproduceaneuromuscularorneurochemicaleffectthatwillleadtotemporarygeneralized
changes,includingthereliefofpain.Themechanismbehindthepainreliefprovidedbyahighvelocitythrust
techniqueisnotyetunderstood,althoughattemptshavebeenmadetoexplainthepossibleeffects,includingthe
freeingofanentrappedmeniscoidordiskalelement,138analterationinmuscletone,139andamechanical
disruptionofintraarticularadhesions.140142Certainly,itisknownthatrestrictionofmotionatajointproduces
jointadhesions,softtissuecontracture,anddegenerativejointdisease.143145Therefore,byincreasingthe
motionatajoint,amanipulationisthoughttoreversetheaforementioneddetrimentaleffects.Itisalsopossible
thatahighvelocitythrusttechniquemayproduceoutcomesdirectlyassociatedwithavarietyofpsychological
influences.146Theonlytruetestofasuccessfultechniqueisbythedeterminationofobjectivechangeinthe
patientsarticularfunction,asconfirmedbyactiveandpassivemotiontests.132
Priortoperformingahighvelocitythrusttechnique,theclinicianmustattempttodeterminethenaturalhistory
ofthejointthroughasubjectiveassessmentorreactiontoprevioustreatments.Ideally,theclinicianshould
initiallyattempttoregainthelostmotionutilizingothertechniquessuchasjointmobilizations,ME,andROM
exercisespriortogivingconsiderationtoahighvelocitythrusttechnique.Unfortunately,ahighvelocitythrust
techniqueoftenbecomestheprocedureofchoicebecauseitcarriesacertainauraandis,therefore,often
erroneouslythoughtofasapanacea.147Theindicationsandcontraindicationsforhighvelocitythrust
techniquesarethesameasthoseoutlinedatthebeginningofthechapter.Additionalcontraindicationsinclude
thefollowing132:
Theinabilityofthepatienttorelax.
Apastmedicalhistorythatincludesanyconditionthatcanweakenboneorcollagen(e.g.,rheumatoid
arthritis,osteoporosis),anyconditionthatmaycreateabnormalhypomobility(e.g.,Marfansyndrome,
EhlersDanlossyndrome),anyconditioninvolvingajointfusion(surgicalorotherwise),oranycondition
involvingchemotherapyorradiotherapyforthetreatmentofcancer.
Pediatricpatient.Theriskofdamagetodevelopinggrowthepiphysesandthequestionofwhetherthe
pretreatmentexplanationisunderstoodmakechildrenveryprecariouscandidatesformanipulation.
Oncethedeterminationismadetoperformahighvelocitythrusttechnique,theclinicianshouldplacethejoint
intoapremanipulativepositionforapproximately10secondsandassessanychangeinthesymptoms,the
patientsreaction,andanylocalizedordistalvascularorneurologicalsignsorsymptoms.Theseinclude
vertebrobasilararteryorspinalcordsignsorsymptoms.Theoretically,thepremanipulativepositiontakesthe
targetjointanditssurroundingsofttissuesslightlybeyondtherangethroughwhichahighvelocitythrust
techniqueistobeperformed.Attheendofthishold,thepatientisquestionedastothecontinuedwillingnessof
thetechniquetobeperformed,andwhetherthispositioniscomfortableandnonirritating.Underno
circumstanceshouldathrusttechniqueberepeated,ifthepatientssymptomsarereportedtoworsenorifthe
firsttechniquedidnotsucceedwithlittleforce.
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Theevaluationoftheeffectivenessofhighvelocitythrustinterventionsisdifficultbecausethenumberof
scientificstudiesonthesubjectisextremelylimited.148Itappearsevidentthatthesetechniquescancausean
immediatereliefoflowbackpaininpatientswithacutelowbackpain,149althoughthedegreeofimprovement
variesamongindividuals.Somepatientsrespondimmediatelytoahighvelocitythrusttechniquehowever,this
populationcannotbeidentifiedinadvance,andtherearenostrongreasonsforrecommendinghighvelocity
thrusttechniquesinsteadofmobilizations.148
NEUROPHYSIOLOGICTECHNIQUES
ProprioceptiveNeuromuscularFacilitation
PNF,amanualtechniquethatpromotestheresponseoftheneuromuscularmechanismthroughstimulationofthe
proprioceptor,wasdevelopedattheKabatKaiserInstitutebyHermanKabatandMargaretKnottduringthelate
1940sandearly1950s.150Initially,theapproachwasdevelopedasamethodoftreatmentforneurologically
weakmusclesduetoanteriorpoliomyelitis.Thetechniqueswerelaterexpandedforuseingeneralmuscle
strengthening,jointmobilizations,andthestretchingofadaptivelyshortenedmuscles.151ThePNFstretching
techniquesaredescribedinChapter13.
PNFtechniquesprovidetheclinicianwithanefficientmeansforexaminingandtreatingstructuraland
neuromusculardysfunctions.152154Structuraldysfunctions(myofascialandarticularhypermobilitiesand
hypomobilities)affectthebodyscapacitytoassumeandperformoptimalposturesandmotions.155
Neuromusculardysfunctions(aninabilitytocoordinateandefficientlyperformpurposefulmovements)cause
repetitive,abnormal,andstressfulusageofthearticularandmyofascialsystems,oftenprecipitatingstructural
dysfunctionsandsymptoms.155157ThetheorybehindPNFisthatthehumanmuscularsystemconsistsof
musclegroupsthatareclassifiedasagonists,antagonists,neutralizers,supporters,andfixators158:
Agonists:worktoproduceamovement
Antagonists:relaxtoallowmovement
Neutralizers:inhibitamusclefromperformingmorethanoneaction
Supporters:stabilizethetrunkandproximalextremities
Fixators:holdbonessteady
Withinspecificmovementpatterns,thesemusclegroupsmustcontractinthepropersequenceforoptimal
effectiveness.Musclecontractionsareclassifiedasstaticordynamic.Staticcontractionsarethoseinwhichno
motionoccurs.Dynamiccontractionsareconcentric,eccentric,ormaintainedisotonic(aPNFterm),thelatterof
whichinvolvestheintentiontomove,butnomotionoccurs.Theoretically,thefacilitationoftotalpatternsof
movementwillpromotemotorlearninginsynergisticmusclepatterns,andthesetotalpatternsofmovementand
postureareimportantpreparatorypatternsforadvancedfunctionalskills.Thesepatternsaredesignedto
encouragethestrongersynergisticmusclegroupstoassisttheweakeronesduringfunctionalmovementsandare
concernedwithgrossmotionsasopposedtospecificmotions.
AccordingtoPNFtheory,musclefunctionoccursthreedimensionallyaroundthreeplanesofmovement,with
eachmovementassociatedwithanantagonisticmotion:
Flexionorextension
Adductionorabductionintheextremitiesandlateralmovementinthetrunk
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Internalorexternalrotation.
Combinationsofthesemovementsworktogetherinspiralanddiagonalpatterns.Thepatterns,whichintegrate
themotionsofsportanddailyliving,arebasedontheinfantdevelopmentalsequencessuchasrolling,crawling,
andwalking.Therearetwodiagonalpatternsforthelowerextremity(Table107),andtwodiagonalpatternsfor
theupperextremityandscapula(Table108),whicharereferredtoasthediagonal1(D1)anddiagonal2(D2)
patterns.TheseD1andD2patternsaresubdividedintothosethatmoveintoflexionandthosethatmoveinto
extension.Inadditiontotheupperandlowerextremitypatterns,patternsexistfortheuppertrunk,lowertrunk,
andcervicalspine.
TABLE107LowerExtremityProprioceptiveNeuromuscularFacilitationPatterns
StartPositionforD1Pattern
D1Extension D1Flexion
Hipflexed,adducted,andexternallyrotated Hipextended,abducted,andinternallyrotated
Kneeflexed Kneeextended
Tibiainternallyrotated Tibiaexternallyrotated
Ankleandfootdorsiflexedandinverted Ankleandfootplantarflexedandeverted
Toesextended Toesflexed
Movementintohipextension,abductionandinternal Movementintohipflexion,adductionandexternal
rotationankleplantarflexionfooteversiontoe rotationankledorsiflexionfootinversiontoe
flexion extension
StartPositionforD2Pattern
D2Flexion D2Extension
Hipextended,adducted,andexternallyrotated Hipflexed,abducted,andinternallyrotated
Kneeextended Kneeflexed
Tibiaexternallyrotated Tibiainternallyrotated
Ankleandfootplantarflexedandinverted Ankleandfootdorsiflexedandeverted
Toesflexed Toesextended
Movementintohipflexion,abductionandinternal Movementintohipextension,adductionandexternal
rotationankledorsiflexionfooteversiontoe rotationankleplantarflexionfootinversiontoe
extension flexion
D1,diagonal1D2,diagonal2.
TABLE108UpperExtremityandScapularProprioceptiveNeuromuscularFacilitationPatterns
D1Flexion
StartPositionforD1Pattern D1Extension
Scapuladepressedandadducted Scapulaelevatedandabducted
Shoulderextended,abducted,andinternallyrotated Shoulderflexed,adducted,andexternallyrotated
Elbowextended Elbowextended
Forearmpronated Forearmsupinated
Wristextendedandulnarlydeviated Wristflexedandradiallydeviated
Fingersabductedandextended Fingersadductedandflexed
Thumbextendedandabducted Thumbflexedandadducted
Movementintoshoulderflexion,adductionand Movementintoshoulderextension,abductionand
internalrotationscapularelevationandabduction internalrotationscapulardepressionandadduction
forearmsupinationwristflexionandradialdeviation forearmpronationwristextensionandulnardeviation
fingerflexion fingerextension
D2Extension
StartPositionforD2Pattern D2Flexion
Scapulaelevatedandadducted Scapuladepressedandabducted
Shoulderflexed,abducted,andexternallyrotated Shoulderextended,adducted,andinternallyrotated
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Elbowextended Elbowextended
Forearmsupinated Forearmpronated
Wristextendedandradiallydeviated Wristflexedandulnarlydeviated
Fingersextendedandabducted Fingersadductedandflexed
Thumbextendedandadducted Thumbflexedandabducted
Movementintoshoulderextension,adductionand Movementintoshoulderflexion,abductionandexternal
internalrotationscapulardepressionandabduction rotationscapularelevationandadductionforearm
forearmpronationwristflexionandulnardeviation supinationwristextensionandradialdeviationfinger
fingerflexion extension
D1,diagonal1D2,diagonal2.
CLINICALPEARL
PNFpatternscanbeperformedunilaterallyorbilaterally.Forexample,thechopandliftpatternsusedfrequently
inrecruitingthestabilizingmusculatureofthetrunk(seeChapter28),areapplicationsoftheupperextremity
diagonalthatinvolvetheuseofbilateralupperextremityinwhichoneupperextremityisperformingtheD1
patternwhiletheotherupperextremityisperformingtheD2pattern(Figs.104and105)witheitherboth
movingintoflexion,orextensionwhileusingspiralanddiagonalmovementsthatcrossthemidline.
FIGURE104
ChopPNFpattern.
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FIGURE105
LiftPNFpattern.
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PNFsimplifiesfunctionalmovementsintothesecomponentpartsfordiagnosisandtreatment.Knowledgeofthe
normalfunctionalmovementpatternsofthebodyallowsthecliniciantoidentifyalteredpatternsofmotion.
Oncetheclinicianhasdiagnosedimpairmentsorfunctionallimitation,theclinicianmakesadecisionasto
whichpatternwillbeusedandthegoalofthetechnique.Basicproceduresoffacilitationincludebody
positioningthemechanics,manualcontacts,manualandmaximalresistance,irradiation,verbalandvisual
cueing,tractionandapproximation,stretch,andtiming.159Thepositionofthepatient,whichoftenuses
developmentalpositions,allowsforconsistencyofmeasurementandplaysamajorroleininfluencingpostural
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tone.Theexercisepatternisinitiatedafterpositioningthepatientinsuchawayastoplacethemusclegroupsin
theirlengthenedposition.Themusclegroupsarethenmovedthroughtheirfullrangetotheirshortenedposition.
ThekeytothesuccessofPNFistheabilityofthecliniciantoapplymanualcontactwithappropriatepressure
andexactpositioning,whichallowsforasmooth,coordinatedmotionthroughoutthepattern.Manualcontacts
areusedtoisolatemusclegroups,providetactilecues,andinfluencethestrengthofthecontraction.Appropriate
pressureisdescribedastheamountofresistancethatfacilitatesthedesiredmotorresponseofasmooth,
coordinated,andoptimalmusclecontraction.153,158Forexample,thecliniciancanapplymaximalresistanceat
specificpointsintherangetopromoteoverflowtotheweakercomponentsofthemovementpattern.
ThepatientisfirsttaughtthediagonalPNFpatternfromthestartingpositiontotheterminalposition,usingbrief
andsimpleverbalcues,suchaspush,pull,andhold,aswellasvisualandtactileinputwhilebeingcareful
toavoidexceedingtheextensibilitylimitsofthemusculotendinousunit.
Ifadysfunctionalmovementisidentifiedinanyofthediagonalsofmotion,thecliniciancanapplyappropriate
resistanceinconjunctionwithvariousPNFtechniques(Table109)tofacilitatetherelearningandrehabilitative
process.152155,158Forexample,aquickstretchappliedtoamusclebeforecontractionfacilitatesamuscular
responsetoproduceagreaterforce.
TABLE109PNFTechniquesofFacilitation
Designedtoimprovetheabilityofthetargetagonisttodirectandbeginmovement.
Techniques
Rhythmic Techniquestartswithpassivemovementinachosendirectionorpatternthat
of
initiation encouragesgradualpatientparticipationbeforeresistingthepatientasperformance
facilitation
improves.
Designedtorepeatedlyelongatetheagonistmusclegroupstoreintroducereflex
Repeated outputandinitiatemovement.Iftheclinicianstretchoccursinthefullylengthened
contractions range,thetechniqueiscalledrepeatedstretch.Iftherestretchoccurswithintheactive
rangeofmotion,itiscalledrepeatedcontractions.
Reversalsof Designedtofacilitatecontractionoftheagonistaftercontractionoftheantagonist
antagonists therebyimprovingstaticanddynamicposterolateral,andreciprocalmovements.
Designedtofacilitatedynamiccontractionsoftheantagonisticmovements
Dynamic
reciprocallyinarangeappropriatetothegoaloftheexercise.Thistechniquecanbe
reversalsof
usedtoincreaseactiverangeofmotion,strengthintheavailablerangeofmotion,and
antagonists
improvebalanceandcoordinationoftheantagonists.
Stabilizing Designedtoenhancebalanceandstabilitybyapplyingalternatingresistanceto
reversals agonistantagonistmusclepairs.
Rhythmic Designedtoenhancecocontractionoftheantagonistsatanypointinagivenrangeof
stabilization motion.
Combination Designedtointegratemovementbyvaryingthetypeofagonistcontraction
ofisotonics (concentric,eccentric,andmaintaineddynamic)requiredforthefunction.
ThefollowingPNFtechniquescanbeusedforthedevelopmentofmuscularstrength,endurance,and
coordination.
RhythmicInitiation
Therhythmicinitiationtechniqueisusedtoteachapatientaspecificmovementpattern,orwithpatientswhoare
unabletoinitiateamovement,orthosewhohavealimitedROMbecauseofincreasedmuscletone.
Theapplicationofthetechniqueinvolvesaprogressionthroughtheagonistpatternofpassive,thenactiveand
assistive,thenactivemovement.ThistechniqueisappliedslowlyagainstresistancethroughtheavailableROM
whileavoidingactivationofaquickstretch.
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RepeatedContraction
Repeatedcontractionisausefultechniqueforpatientswhohaveaweakness,eitherataspecificpointor
throughouttheentirerangeandtocorrectimbalancesthatoccurwithintherange.Thepatientisaskedtopush
repeatedlybyusingtheagonistconcentricallyandeccentricallyagainstamaximalresistanceuntilfatigueoccurs
intheweakerrangesofthemotion.Theamountofresistancetothemotiongivenbytheclinicianismodifiedto
accommodatethestrengthofthemusclegroup.Astretchcanbeappliedattheweakestpointintherangeto
facilitatetheweakermusclesandpromoteasmoother,morecoordinatedmotion.
StabilizingReversal
Thistechnique,alsoknownasanisotonicreversal,canbeusedfordevelopingAROMoftheagonistswhilealso
developingthenormalreciprocaltimingbetweentheantagonistsandagoniststhatoccursduringfunctional
movements.Thetechniqueinvolvesaconcentriccontractionoftheagonistfollowedimmediatelybya
concentriccontractionoftheantagonist,withtheinitialagonistpushcontractionfacilitatingthepullcontraction
oftheantagonistsmuscles.
RhythmicStabilization
Thetechniquesofrhythmicstabilization,alsocalledstabilizingreversals,emphasizethecocontractionof
agonistsandantagonists,whichresultsinanincreaseintheholdingpowertoapointwherethepositioncannot
bebroken.Thiseffectisachievedbyalternatingisometriccontractionsoftheagonistwithisometric
contractionsoftheantagonist,toproducecocontractionofthetwoopposingmusclegroups.Thecommand
holdisalwaysgivenbeforemovementisresistedineachdirection.Thegoalsofthistechniquearetoimprove
stabilityaroundajoint,increasepositionalneuromuscularawareness,improvepostureandbalance,andenhance
strengthorstretchsensitivityofthetonicmusclesintheirfunctionalrange.155
Thefinalstepistointegratethegainsfromthetechniqueintoafunctionalactivity.
MyofascialTriggerPointTherapy
Thetermmyofascialtriggerpointisabitofamisnomerbecausetriggerpointscanalsobecutaneous,
ligamentous,periosteal,andfascial.160
AnMTrPisahyperirritablelocation,approximately25cmindiameter,161withinatautbandofmusclefibers
thatispainfulwhencompressedandthatcangiverisetocharacteristicreferredpain,autonomicphenomena,
tenderness,andtightness.MTrPsareclassifiedaseitheractiveorlatent(Box101).162Thepatientsreactionto
firmpalpationoftheMTrPisadistinguishingcharacteristicofmyofascialpainsyndrome(MPS)(givenlater)
andistermedapositivejumpsign.163Thisreactionmayincludewithdrawal,wrinklingoftheface,orverbal
response.Thishyperirritabilityappearstobearesultofsensitizationofthechemonociceptorsand
mechanonociceptorslocatedwithinthemuscle.
Box101ClassificationofTriggerPoints
Activetriggerpointsarethosethataresymptomaticwithrespecttopainandreferapatternofpainatrest
orduringmotion(orboth)thatisspecificforthatmuscle.Anactivetriggerpointusuallyproduces
restrictedrangeofmotionandavisibleorpalpablelocaltwitchresponseduringmechanicalstimulationof
theMTrP,butfailuretoelicitthisresponsedoesnotexcludeMPS.MTrPsarealwaystenderandcause
muscleweakness.
Latenttriggerpoints,whichrepresentthemajorityoftriggerpoints,areusuallyasymptomaticbutmay
havealltheotherclinicalcharacteristicsofactivetriggerpoints.Latenttriggerpointscanpersistforyears
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afterapatientrecoversfromaninjuryandmaybecomeactiveandcreateacutepaininresponsetominor
overstretching,overuse,orchillingofthemuscle.
Associatedtriggerpointsdevelopinresponsetocompensatoryoverload,shortenedrangeofmotion,or
referredphenomenacausedbytriggerpointactivityinanothermuscle.Therearetwokindsofsuchtrigger
points:
Satellitetriggerpointsareinthezoneofreferralofanothermuscle.
Secondarytriggerpointsareactivatedbecausethemusclewasoverloadedasasynergistoranantagonist
ofamuscleharboringaprimarytriggerpoint.
CLINICALPEARL
Someconfusionexistsastothedifferencebetweentriggerpointsandtenderpoints.AlthoughMTrPscanoccur
atthesamesitesasthetenderpointsofFM,MTrPscancausereferralofpaininadistinctandcharacteristic
area,remotefromthetriggerpointsite,notnecessarilyinadermatomaldistribution.164Referredpainis,by
definition,absentinthetenderpointsofFM.65,165
Healthytissuesdonotcontaintriggerpoints,arenottendertofirmpalpation,anddonotreferpain.Several
possiblemechanismscanleadtodevelopmentofMTrPs,includinglowlevelmusclecontractions,anuneven
intramuscularpressuredistribution,directtrauma,unaccustomedeccentriccontractions,eccentriccontractions
inanunconditionedmuscle,andmaximalorsubmaximalconcentriccontractions.166Thus,MTrPsaretypically
locatedinareasthatarepronetoincreasedmechanicalstrainorimpairedcirculation(e.g.,uppertrapezius,
levatorscapulae,infraspinatus,quadratuslumborum,andgluteusminimus).Aswithallchronicpainconditions,
concomitantsocial,behavioral,andpsychologicaldisturbancesoftenprecedeorfollowtheir
development.167,168
Whatevertheetiologicfactors,itwouldappearthatthedevelopmentofMTrPsmaybeaprogressiveprocess,
withastageofneuromusculardysfunctionofmusclehyperactivityandirritabilitythatissustainedbynumerous
perpetuatingfactorsandthenfollowedbyastageoforganicdystrophicchangesinthemusclebandswith
MTrPs.163
AccordingtoSimons,169thediagnosisofMPScanbemadeiffivemajorcriteriaandatleastoneoutofthree
minorcriteriaaremet.Themajorcriteriaare
1.localizedspontaneouspain
2.spontaneouspainoralteredsensationsintheexpectedreferredpainareaforagiventriggerpoint
3.presenceofatautpalpablebandinanaccessiblemuscle
4.exquisitelocalizedtendernessinaprecisepointalongthetautband
5.somedegreeofreducedrangeofmovementwhenmeasurable.
Minorcriteriainclude
1.reproductionofspontaneouslyperceivedpainandalteredsensationsbypressureonthetriggerpoint
2.elicitationofalocaltwitchresponseofmuscularfibersbytransversesnappingpalpationorbyneedle
insertionintothetriggerpoint
3.painrelievedbymusclestretchingorinjectionofthetriggerpoint.
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ThemajorgoalsofMTrPtherapyaretorelievepainandtightnessoftheinvolvedmuscles,improvejoint
motion,improvecirculation,andeliminateperpetuatingfactors.Whentreatingapatientforaspecificmuscle
syndrome,itisimportanttoexplainthefunctionoftheinvolvedmuscleandtodescribeordemonstrateafewof
theactivitiesorposturesthatmightoverstressit,sothatthepatientcanavoidsuchactivitiesorpostures.
AnumberofmanualinterventionsforMTrPsareavailabletheseincludethefollowing.64,170172
StretchandSprayorStretchandIce
Althoughnottechnicallyamanualtechnique,thesprayandstretchtechniqueinvolvesamanualstretchduring
itsapplication.67,160
Thepatientisplacedinapositionofmaximumcomforttoenhancemusclerelaxation.Thepartofthebody
affectedisthenpositionedsothatamildstretchisexertedspecificallyonthetautband.Parallelsweepsofthe
vapocoolantsprayoriceareappliedunidirectionallythen,whileoneoftheclinicianshandsanchorsthebaseof
themuscle,theotherstretchesthemuscletoitsfulllength.169Thesprayisheldapproximately18inawayfrom
theskin,toallowforsufficientcoolingofthespray.Oneortwosweepsofcoolantaresprayedovertheareaof
theinvolvedmuscletoreduceanypain.Asthemuscleispassivelystretched,successiveparallelsweepsofthe
sprayareappliedtotheskinfromtheMTrPtotheareaofreferredpain,coveringasmuchofthereferredpain
patternaspossible.Aftereachapplicationofthesprayandstretchtechnique,themuscleisselectivelymoved
throughasfullanROMaspossibletonormalizeproprioceptiveinputtothecentralnervoussystem.160Intense
coldstimulatescoldreceptorsintheskin,whichtendstoinhibitpain.Thistechniqueissupposedtohelpblock
reflexspasmandpain,allowingforagradualpassivestretchofthemuscle,whichdecreasesmuscletension.
Severaltreatmentsmaybeneededtoeliminatethepainsyndromeresultsshouldbeseenafterfourtosix
treatments.160Ifvaporizedcoolantsarenotavailable,icemaybeusedintheirplace,takingcaretoprevent
chillingoftheunderlyingmuscles,whichislesslikelywiththeuseofvaporizedcoolants.160
MuscleStripping
Musclestrippingisusedafterfirstapplyingalubricanttotheskin.Thetechniqueinvolvestheslowslidingof
thethumb,knuckle,orelbowalongtheedgeofatautbandwithfirmpressurewhileatthesametimeattempting
tobowitout.160Thistechniquehastheeffectofapplyingbriefischemiccompression,asthethumbslowly
slidesovertheMTrPs,andofpassivelylengtheningthetautband.Musclestrippingisaseffectiveasthespray
andstretchtechnique,althoughitissomewhatmorepainful.160
MassageTherapy
DeepmassagemechanicallyhelpsbreakupthefibrousbandsofMTrPs.Theapplicationofdeeppressure
produceslocalischemia.Whenthepressureisreleased,areactivehyperemiaoccurs,improvingcirculationand
releasingenergytothearea.173
MyofascialRelease
Thesetechniques,discussedinaprevioussection,combinemassagewithdeepstretchtechniquestorelaxthe
muscleandbreakuptheMTrPs.46,67
IschemicCompression160
Compressioncanbeappliedwithathumb,knuckle,orelbow.Thecompressionservesasthehyperstimulant,
andthepainisusuallyrelievedwithin2060seconds.Thetechniqueinvolvestheapplicationofpressure
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directlytothetriggerpoint,withinthepatientstolerance.Asthepainsubsides,theclinicianslowlyincreases
thepressureuntil,ideally,thepainfulstimulusiseliminated,andasofteningoftheareaisfelt.
Stretching
Lengtheningofthetautbandisaneffectiveformofintervention.Itistheorizedtodisengagetheactinand
myosinfilamentsoftheskeletalmuscle(seeChapter1),allowingmorenormalmusclelengthandincreased
ROM,andresultsinnormal,patternedproprioceptiveinputtothecentralnervoussystem,whichmayprevent
theresumptionofpain.160Lengtheningcanbeaccomplishedwithgentlestretchingoftheinvolvedmuscles.
JointMobilizations
Typically,treatmentofadysfunctionaljointleadstospontaneousresolutionofsofttissuetensionandthe
restorationofnormalmusclelengthsaroundthejoint,therebyallowingthehypertonicmusclesto
relax.44,78,82,174
NonmanualInterventions
ThenonmanualinterventionsforMTrPsareincludedhereforcompleteness.64,170172
Thermotherapy.Moistheat,ultrasound,orahottubsessionof515minutesdurationhelpsrelax
underlyingmusclesandincreasecirculation,therebyimprovingthesupplyofnutrientsanddecreasing
tensionontheMTrPs.67Painreliefistheorizedtoberelatedtoawashoutofpainmediatorsbyincreased
bloodflow,changesinnerveconduction,oralterationsincellmembranepermeabilitythatdecrease
inflammation.162,175
Cryotherapy.Brief,intensecoldstimulationoftheskinoverlyingthetriggerpointanditspainreferral
area,iseffectiveinreleasingtautbandsandinactivatingtriggerpoints,particularlywhendonein
combinationwithapassivestretch.160
Triggerpointinjections.Triggerpointinjectionsusingvarioustechniqueshavebeenwidelyusedto
inactivateMTrPsbydisruptingthefibrousbanding,althoughtheinjectedlocalanestheticagentseemsless
importantforinactivationofthetriggerpointthantheneedlingitself.62,176,177Triggerpointinjections
shouldbefollowedbystretchingandtheapplicationofheat.67Theeffectivenessofultrasoundtherapyis
comparabletotriggerpointinjectionsandshouldbeofferedasanoninvasivetreatmentofchoiceforthose
patientswhowanttoavoidinjections.162
Eliminationofcausativeorperpetuatingfactors,ifany.Mechanicalandmetabolicdisordersneedtobe
correctedtopreventfurtherstressandstrainonthemuscles.Althoughmanypeoplehavesomedegreeof
imbalancedbodystructure,thestructuralimbalanceisanextremelycommoncontributingfactorto
myofascialconstrictionsandtriggerpoints.61,170,171,178,179Inaddition,patientsshouldbeencouragedto
limitcaffeineintaketolessthantwocaffeinatedbeveragesperdayandavoidsmoking,bothofwhich
directlyandindirectlyaggravateMTrPs.67Nutritiondeficienciesmayrequirecorrection,andsupplements
ofvitaminsC,B1,B6,B12,andfolicacidhavebeenadvocatedbecauseoftheiressentialroleinnormal
musclemetabolism.160
Biofeedbackandmusclerelaxation.Biofeedbackandmusclerelaxationtechniquescanbeusedtoavoid
chronicmuscletension.
Exercise.ExerciseisimportantinlimitingrecurrencesofMTrPs.179
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Counterirritation.Thisveryoldmethodofcontrollingpainhasbeenusedforcenturies.Itssuccessrelates
tothefactthatitbreaksthepainspasmpaincyclethatsooftenperpetuatesapainfulconditionthrough
thegatecontrolmechanismofpaincontrol(seeChapter3).
Combinationtherapy.Onestudy,162whichlookedatthecombinedinterventionofultrasound,trigger
pointinjections,andstretching,foundthatthecombinationofthesethreeinterventionswereeffectivein
thereductionofpain,andimprovingROM,independentoftheseverityordurationofpainpresentbefore
thetreatment.Anotherstudy,whichexaminedacombinedinterventionofultrasound,massage,and
exercise,foundthatpatientswhohadmassageandexercisehadareductioninthenumberandintensityof
MTrPs,whereasultrasoundalonegavenopainreduction.180
Electrotherapy.Electrotherapyhasalsobeenfoundtobeaneffectivetherapeuticmodalitytorelievepain
fromMTrPs,60,171,181althoughelectrotherapyaloneisreportednotaseffectiveasthermotherapyor
intermittentcoldwithstretching.171Electrotherapyisthoughttoworkbyproducingmusclecontractions,
whichsqueezeouttheedemafromneedling,increasebloodflowtothearea,andrelaxthemuscles.61Two
majortypesofelectricalstimulationtherapyusedforsofttissuelesionsareelectricalnervestimulation
(ENS)andelectricalmusclestimulation(EMS).
ENSistheapplicationofalowintensityelectricalcurrenttotheperipheralnerve.Ingeneral,ENS,such
astranscutaneousnervestimulation,isusedinreducingpainintensityandincreasingthepainthresholdof
MTrPs(nomatterhowseveretheinitialpain).182,183
EMSistheapplicationofelectricalcurrentwithstrongerintensitydirectlytotheinvolvedmuscle.EMS
canbeusedtoenhancemusclecirculation,reducemusclespasm,eliminatemusclepain,andincrease
musclestrength.178,181,183
Accordingtoonestudy,ENSwasfoundtobemoreeffectivethanEMSforimmediatepainrelief,whereasEMS
wasmoreeffectivethanENSforimprovingROM.183
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CHAPTER11:NeurodynamicMobilityand
Mobilizations
CHAPTEROBJECTIVES
1.Summarizethevarioustypesofneurodynamicexaminationandmobilizationtechniques.
2.Describetheproposedmechanismsbehindtheneurodynamicexaminationandmobilizationtechniques.
3.Applyknowledgeofthevariousneurodynamicmobilizationtechniquesintheplanningofa
comprehensiverehabilitationprogram.
4.Recognizethemanifestationsofabnormalnervoustissuetensionanddevelopstrategiesusing
neurodynamicmobilizationtechniquestotreattheseabnormalities.
5.Evaluatetheeffectivenessofaneurodynamicmobilizationtechniquewhenusedasanintervention.
OVERVIEW
Neurodynamicsisthestudyofthemechanicsandphysiologyofthenervoussystem.Thenervoussystemisan
electrical,chemical,andmechanicalstructurewithcontinuitybetweenitstwosubdivisions:thecentraland
peripheralnervoussystems(seeChapter3).Inadditiontopermittinginterandintraneuralcommunication
throughouttheentirenetwork,thenervoussystemiscapableofwithstandingmechanicalstressasaresultofits
uniquemechanicalcharacteristics.Nervoustissue,aformofconnectivetissue,isviscoelastic.This
viscoelasticityallowsforthetransferofmechanicalstressthroughoutthenervoussystemduringtrunkorlimb
movements.Thisadaptationresultsfromchangesinthelengthofthespinalcordduringmovementandthe
capacityoftheperipheralnervestoadapttodifferentpositions.Theperipheralnervesadaptthroughaprocessof
passivemovementrelativetothesurroundingtissueviaaglidingapparatusaroundthenervetrunk.1,2Three
mechanismsappeartoplayanimportantroleinthisadaptability:2
Elongationofthenerveagainstelasticforces.Innormaldailymovement,nervesmayslideupto2cmin
relationtosurroundingtissuesandcontendwithastrainof10%.3
Longitudinalmovementofthenervetrunk.
Anincreaseanddecreaseoftissuerelaxationatthelevelofthenervetrunk.
Theefficiencyofthismechanismpartiallydependsonthecapacityofthelooseconnectivetissuearoundthe
nerve(adventitia,conjunctivanervorum,perineurium)toallowanytractionforcestobedistributedoverthe
wholelengthofthenerve.Ifthisdistributionofforcesiscompromised,anunfavorableriseintractionforcescan
occuratcertainsegments,dependingontheanatomicsite(seenextsection).3
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Therolethattensionontheneuraltissueplaysinpainanddysfunctionhasbeenstudiedforoveracentury.
Duringthistime,anumberofspecifictestshavebeendesignedtoexaminetheneurologicalstructuresforthe
presenceofadaptiveshorteningandinflammation.36Themorecommonoftheseneurodynamicmobilitytests
aredescribedinthischapter.
Oncedetected,anylackofneuralmobilitythatappearstobecontributingtoapatientssignsand/orsymptoms
canbeaddressedusinganumberofneuralmobilizationtechniques.Neurodynamicmobilizations,whichuse
specificcombinationsofactiveorpassivemovementsthataimtoreducemechanosensitivityandrestore
symptomfreefunction,havebeenadvocatedforcertainnerverelateddysfunctions.7,8
PROPOSEDMECHANISMSFORNEURODYNAMIC
DYSFUNCTION
Untilrecently,theproposedeffectsofneuralmobilizationwerebasedontheoryratherthanresearch
evidence.911Mostofthestudieshaveexaminedtheinfluenceofneuralmobilizationexercisesonnerve
mechanicsincadaversandsubsequentlyinvivo.12Thespinaldura(seeChapter3)formsaloosesheatharound
thespinalcordfromtheforamenmagnumtothelevelofthesecondsacraltubercle.Fromthereitcontinuesas
thefilumterminaletotheendatthecoccyx.Laterally,thedurasurroundstheexitingspinalnerverootsatthe
leveloftheintervertebralforamen.Therearethreeareascalledtensionsites,inwhichtheduraistetheredtothe
bonycanal,providingstabilitytothespinalcord.ThesetensionsitesarefoundatthesegmentallevelsofC6,T6,
andL4theelbowtheshoulderandthekneehavesimilarsites.3,4,13Asaresultofthesesitesoftension,the
neurologictissuesmoveindifferentdirections,dependingonwherethestressisapplied,andinwhichorderitis
applied.3
Ithasbeensuggestedthatthenervoussystemisloadeddifferentlydependingonthesequenceofjoint
movement.ThissuggestionhasbeenquestionedinastudybyBoydetal.14whichfoundthatvaryingthe
movementsequencedidnotsubstantiallyimpactexcursionandstrainintheendpositionofoneofthemost
commonneurodynamicteststhestraightlegraise(SLR).Theoretically,duringmovement,neuraltissuetakes
itsleadfromthemovementofjointsandmuscles,withthephysicalloadingofthenervedependentonthe
locationofthenerveinrelationtothejointaxis.3Variousstudieshavedemonstratedexcursionofthenerve
complexduringmovementsoftheextremity.12,1518Undernormalcircumstances,thetensionsitesarenot
adverselyaffectedbythemotionoftheextremities.Despitetheirapparentmobility,nerves,andtheir
microcirculationarevulnerabletotension,friction,andcompressiveforcesatmultiplesitesalongtheirroutes.19
Ifthedurabecomesadherent,excessivestressmaybeproducedintheareasofadhesion,increasingthelengthof
thedurabeyonditsnormallimitoftension(Table111).3Theoretically,increasedduraltensionmaybefelt
throughouttheneuromeningealsystemand,potentially,itmayaffecttherangeofmotionavailabletothetrunk
andtoanextremity.Pathomechanically,adecreaseinthemobilityofanervealongitsentirelengthmaymake
thenervemorevulnerabletoadditionalinjuriesduringrepetitivemovements.3,19,20Onestudy12examinedthe
differenceinmediannerveexcursionbetweendifferenttypesofnerveglidingexercises(includingslidersand
tensioners).Slidersutilizecombinationsofjointmovementstoencourageperipheralnerveexcursionby
increasingelongationatoneendofthenervebed,therebycreatingtensiononthenervefromthatend,while
simultaneouslyreleasingtensionfromtheotherendofthenerve.11Incontrast,tensionersutilizecombinations
ofjointmovementsthatelongatethenervebedfrombothendsinanattempttostretchthenormalconnective
tissues.Ofthetwo,itwasdeterminedthatslidersproducegreateramountsofnerveexcursioncomparedto
tensioners.12
TABLE111SitesofPeripheralNerveandNerveRootVulnerability
Site Description
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Hardsidedtunnels,suchasthecarpaltunnel,increasetheprobabilityofspatialcompromiseofthe
nerve.Withinatunnel,thecontainednervoussystemalwayshasthepotentialtorubonthetunnel
Tunnels structure,creatingfriction,andanytraumaoralterationtothetunnelstructurecanmechanicallyor
chemicallycompromisetheneuralstructures
Itismoredifficultforthenervetomoveawayfromforcesatthosepointswhereanervebranches
Branches
(e.g.,radialnerveattheelbow)
Hard Anerveismorereadilycompressedifitliesonaboneorpassesthroughfascia(e.g.,radialnervein
interfaces thespiralgrooveofthehumerus)
Proximity
Superficialnerves,suchasthesensoryradialnerveintheforearm,aremorevulnerabletoexternal
tothe
compression
surface
Adherence
to Someareasofnervearemorefirmlyadherenttointerfacingtissuesthanothers(e.g.,thecommon
interfacing fibular(peroneal)nerveattheheadofthefibula)
structures
DatafromButlerDS,TomberlinJP.Peripheralnerve:structure,function,andphysiology.In:MageeD,
ZachazewskiJE,QuillenWS,eds.ScientificFoundationsandPrinciplesofPracticeinMusculoskeletal
Rehabilitation.St.Louis,MO:WBSaunders,2007:175189.
CLINICALPEARL
Neuraltissuerespondstotraumainthesamewaythataligamentortendondoes,byevokingthecascadeofthe
inflammatoryprocess,resultinginpainwhenstressed.21,22Inadditiontotheeffectthattheinflammatory
processcanhaveonthenervetissue,fibroustissueformationcandevelopwithinthenerverootsheathcausing
adhesionsbetweenthesheathandthenerveroot.3
Anumberofmechanisms(excludingdiseasessuchasdiabetesmellitus,hypothyroidism,immunedeficiency
syndromes,rheumatoidarthritis,andalcoholism)arehypothesizedtocontributetoaninjuryoftheperipheral
nervetrunk.Theseincludethefollowing:23
Posture.Sustainedposturesthatproducechangesinthenaturalcurvesofthespinecanresultina
shorteningofthedistancetraveledbytheperipheralnervetrunkandeventualadaptiveshorteningofthese
structures.Correctionofthisposture,aftersufficienttimehaselapsedforittohavetakenplace,may
produceastretchingoftheneuraltissues.
Directtrauma.Orthopaedicinjuriesaccountforsomeoftheinjuriestoperipheralnerves.Forexample,
theradialnerveisinjuredthroughorthopaedictraumamorethananyothermajornerve.24Nerveinjuries
canoccurastheresultofadirectblowtothenerveorsecondarytodamageofanadjacentstructuresuch
asafracture,25,26jointdislocation,27ortendonrupture.28Othercausesofdirectnervetraumahave
includedinjections,29jointmanipulations,30andsurgicalprocedures.31Aneurologicalinjuryisoneof
themostseriouscomplicationsoffractureanddislocation,bothintheshortandlongterm.Forexample,
theprevalenceofinjurytothesciaticnerveafteracetabularfractureorfracturedislocationofthehiphas
beenreportedtobebetween10%and25%.32
Extremesofmotion.Giventhecourseofmanyoftheperipheralnervetrunks,itisnotdifficulttoenvision
movementsoftheextremitiesthatcouldplaceatractionforceonthesetrunks.Indeed,thoseverysame
movementsareexploitedinsomeoftheneurodynamicmobilitytests.
Electricalinjury.Ina17yearreviewofburnunitadmissions,permanentnerveinjurieswerefoundin
22%ofelectrocutedpatients.33Theupperlimbwasmostcommonlyinvolvedwiththemedianandulnar
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nervesmostcommonlyinjured.33Postneurologicsymptomsinsuchcasescanvaryfromneuropathyto
complexregionalpainsyndrome(CRPS).
Compression.Compressiontoanervecanoccurduringmusclecontractionandasaresultoftightfascia,
osteochondroma,ganglia,lipomasandotherbenignneoplasms,andbonyprotuberances.
CLINICALPEARL
Thesympatheticnervoussystemispartoftheperipheralnervoussystem,andsympatheticneuronsinperipheral
nervesaresubjecttothesamedeformationandinjurypotentialduringmovementassomaticneurons.3
Theunderlyingmechanismsassociatedwithclinicalimprovementsfollowingneuralmobilizationremain
unclear.9
DoubleCrushInjuries
Thedoublecrushsyndrome(DCS)isageneraltermreferringtothecoexistenceofdualneuropathiesalongthe
courseofaperipheralnerve.TheconceptwasproposedbyUptonandMcComasin197334whosuggestedthat
proximalcompressionofanervemaydecreasetheabilityofthenervetowithstandamoredistalcompression.35
Fromthepathophysiologicalviewpoint,impairmentofneuralexcursion,lossofelasticity,underlying
abnormalityoftheconnectivetissueaswellasdirectpressureonthenervemayleadtodisruptionofaxons,
impairmentofaxonaltransport,endoneuraledema,orischemicchangesinnerves.35Forexample,accordingto
thistheory,acervicalradiculopathy,manifestingaslittlemorethanneckpainandstiffness,couldprecipitatea
distalfocalentrapmentneuropathy.34Thetermdoublecrushsyndromeisusedtodescribethismechanismof
nerveinjury:theserialcompromiseofaxonaltransportalongthesamenervefibercausingasubclinicallesionat
thedistalsitetobecomesymptomatic.
Atleasteightetiologicmechanismshavebeenproposedtoexplaintherelationshipbetweentheproximaland
distalnervefiberlesions:34,3639
1.Aproximalnervelesionrendersthedistalnervesegmentmorevulnerabletocompressionbecauseof
serialconstraintsofaxoplasmicflow.
2.Theperipheralnervespossessanunderlyingsusceptibilitytopressure.
3.Interruptionoflymphaticandvenousdrainageattheproximalnervelesionsiterendersthedistalnerve
segmentmorevulnerable.
4.Endoneurialedemaatonelesionsitecompromisesneuralcirculation,renderingnervefibersattheother
sitemorevulnerable.
5.Aconnectivetissueabnormalitycommontobothsitesalongthenervefibers.
6.Tetheringofthenerveatonesitecausesinjuriousshearforcesattheothersite.
7.Entrapmentofthenerveatonesitecancauseadecreaseinthefunctionofthemusclepump,which
createsaslight,generalizededemaofthelimb.Thisincreasestissuepressureincertainanatomic
passages,whichcausesanadditionalentrapmentnervelesion.
8.Theinitialnervelesiondischargesametabolitethattravelsthroughtheintraneuralcirculation,increasing
thevulnerabilityofothersegmentsofthenerve.
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Sinceitsintroduction,thedoublecrushhypothesishasbeeninvokedtoexplainagreatnumberofcoexisting
proximalanddistalnerveimpairments.Infact,ithasbeenexpandedinvariousways(i.e.,totriplecrush,
quadruplecrush,andmultiplecrushsyndromes,aswellasthereversedDCS).37,40,41Despiteitsacceptance,
therearesomeclinicalsituationswherethedoublecrushhypothesishasanatomicandpathophysiologic
restrictionsthatrenderitinapplicable.42FortheDCStooccur,theremustbeanatomiccontinuityofnervefibers
betweenthetwo(ormore)lesionssites.Ifthisislacking,thenasequentialimpairmentofaxoplasmicflow
obviouslycannotoccur.Consequently,twofocalnervedisordersalongthesameneuralpathway(e.g.,cervical
rootlesionsandcarpaltunnelsyndrome)donotautomaticallyfulfilthisanatomiccriterionofDCSunlessthe
sameaxonsarecompromisedatbothsites.42
Although,experimentalstudiesofthedoublecrushhypothesishaveshownthatsuccessivelesionsalonga
peripheralnervecansummate,38,43,44studiesthathaveattemptedtodemonstratetheexistenceofDCShaveas
yetprovedinconclusive.4547
Aneurophysiologicalexaminationiscriticalindistinguishingbetweenasingleoradoublelesionaswellas
determiningthecomparativeseverityofthetwolesions.35
NEURODYNAMICMOBILITYEXAMINATIONS
BothElvey48andButler20havebeencreditedwiththeinitialdevelopmentoftheexaminationtechniquesfor
neurodynamicmobility.Elvey48developedwhathenamedthebrachioplexustensiontest,whichwaslater
calledtheupperlimbtensiontest(ULTT).Similartests,suchastheSLRandpronekneeflexiontests,have
sincebeendesignedforthelowerextremity.Theslumptest,popularizedbyMaitland,49,isconsideredtobea
generaltestofneurodynamicmobility.Thetensiontestsaredesignedtoapplyacontrolledsequentialand
progressivemechanicalandcompressivestresstotheduraandotherneurologictissues,bothcentrallyand
peripherally,therebyassessingthecontributionofthespinalnerverootsandperipheralnervestoextremitypain.
Thetestsplacetensilestressesontheduraofspinalnerverootsandperipheralnervesusingalongitudinal
tractionforceofthenerveuntilthepatientssymptomsarereproduced.3
Theexaminationofneuraladhesionsisbynomeansanexactscience,buttheprinciplesarebasedonsound
anatomictheory.Knowledgeofthecourseofeachoftheperipheralnervesisthusessentialinordertoputa
sequentialandadequatetensionthrougheachofthem(seeChapter3).
Breigstissueborrowingphenomenonoffersaplausibleexplanationfortheneurodynamictests.50Breig
observedthattensionproducedinalumbosacralnerverootresultedinthedisplacementoftheneighboringdura,
nerveroots,andlumbosacralplexustowardthesiteoftension.Ineffect,aborrowingoftherestingslackin
neighboringmeningealtissuesoccursasneuralstructuresarepulledtowardthesiteofincreasedtension.51This
displacementofthenerverootsplexiresultsinadecreaseintheavailableslackandpotentialmobilityofthe
neuraltissuesthroughouttheregion.51
Positivesymptomsforthepresenceofneuropathicdysfunctionincludepain,paresthesia,andspasm.23
Unfortunately,thesesignsandsymptomsarealsoassociatedwithahostofmusculoskeletalinjuries.Asburyand
Fields52hypothesizedthatthetypeofpainthatresultsfromaninjurytoaperipheralnerveischaracteristicand
hastwovarieties:
1.Dysestheticpain.Thistypeofpainisfeltintheperipheralsensorydistributionofasensoryormixed
nerveandresultsfromnociceptiveafferentfibers.
2.Nervetrunkpain.Thistypeofpainresultsfromthenociceptorswithinthenervesheathsandexhibitsa
paindistributionfollowingthecourseofthenervetrunk.
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However,relyingonthereproductionofatypeofpain(asubjectiveissueatthebestoftimes)isnotsufficientto
makethediagnosisofneuraltissuedysfunction.
Becausethesubjectofneuralprovocationtestsandtheinterventionofneurodynamicmobilizationremain
controversial,theclinicianshouldensurethattheresultsofthesetestsarealwaysusedinconjunctionwith
findingsfromacompleteneuromusculoskeletalexamination,includingthefollowing:3,23,5355
Observation.Aninjurytoaperipheralnervetrunkmayresultinvisibleatrophywithinitsmotor
distribution.
Palpation.Theclinicianshouldcarefullypalpatealongeachofthenervetrunksintheregionwherethey
aresuperficial.Physicaldeformationofanirritatednerveshouldreproducepainwithpalpation.
Therangeofmotion.Inareasofdecreasedneuralmobility,bothactiveandpassiverangeofmotionmay
bediminishedinthesamedirection.However,alesiontothemusculotendinousunitwouldalsoreproduce
painwiththesamemaneuver,particularlyinmusclesthatcrosstwojoints.
Resistivetesting.Resistivetestscanbeusedtoexamineforthepresenceofweaknessinthedistributionof
aperipheralnerveandtohelpdifferentiatebetweenpainreproducedwithactiveorpassiverangeof
motionthatindicatesdamagetothemusculotendinousunit,andpainthatresultsfromneuraltension.For
example,painreproducedintheposteriorthighwiththeSLRmayindicatealesionofthehamstring
musclebellyoralesiontothesciaticnerve.Ifresistedkneeflexiondoesnotreproducepain,the
musculotendinousunitisunlikelytobeatfault,leavingthesciaticnerveasthelikelycause.
Thepurposeofthephysicalexaminationistodeterminewhichtissueisatfault.Thisisaccomplishedby
isolating(wherepossible)eachtissuethathasthepotentialtoproducethosesymptomsandselectivelystressing
thattissue.Partoftheproblemwiththisapproachliesinthefactthatapositivefindingformanyofthe
assessmenttechniquesmayjustproduceasensitivemovement,ratherthanastretchofthedura.3Forexample,
whenwristextensionisperformedwiththeelbowinextensionandtheshoulderabducted,inadditiontoplacing
stressontheelbowandwristjoints,wristflexors,andelbowflexors,theloadingofthenervoussystemis
continuedproximally,atleastuptotheleveloftheaxilla.56
Someofthesocalledduralsymptomscouldalsoresultfromtheimpartedstretchontheduraduringthevarious
maneuvers,producingchangesintheaxoplasmicflowinsidethenerves,provokingthefiringofabnormal
impulses,anddecreasingthevascularsupplytothenerve.5759
SLUMPTEST
Aneuraltensiontestperformedinasittingpositionisnecessarytosimulatetheextremesofspinalmotion
associatedwithsymptomprovokingactivitiessuchasslouchedsittingorenteringandexitingacar.49,60,61
Theslumptest,introducedbyMaitland,49isacombinationofotherneuromeningealtests,namely,theseated
SLR,neckflexion,andlumbarslumping.Intheslumptest,thepatientisseatedinfullflexionofthethoracic
andlumbarregionsofthespine.62Sensitizingmaneuversarethensystematicallyappliedandreleasedtothe
cervicalspineandlowerextremitieswhiletheclinicianmaintainsthepatientstrunkposition.51Theslumptest
assessestheexcursionofneuraltissueswithinthevertebralcanalandintervertebralforamen61anddetects
impairmentstoneuraltissuemobilityfromanumberofsourcesasidentifiedbyMacnab63andFahrni.64
Maitlandassertedthattheslumptestenablesthetestertodetectadversenerveroottensioncausedbyspinal
stenosis,extraforaminallateraldiskherniation,disksequestration,nerverootadhesions,andvertebral
impingement.60,61
CLINICALPEARL
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Theslumptesthasbeenshowntoinducesympatheticresponsesinhumans,socliniciansareurgedtoconsider
thepossibilitythatthestructureandfunctionofsympatheticneurons,eitherinthetrunkorintheperipheral
nerve,maybeadverselyaffected,particularlywheninjuriesarelongstandingorrecurrentinnature.3
Overtheyears,severalstudies50,6567havedemonstratedtheeffectsofthetrunkandheadpositiononneural
structureswithinthevertebralcanalandintervertebralforamenduringslumptesting.Thesestudiesreportedthat
fullspinalflexionorflexionofthecervical,thoracic,andlumbarregionsofthespineresultsinalengtheningof
thevertebralcanalandtransmitstensiontothespinalcord,lumbosacralnerverootsleeves,andnerve
roots.50,6568AmorerecentstudybyDavisetal.69foundtheslumptesthadahighfalsepositiveratein
asymptomaticindividualsandrecommendedthatthecurrentcriteriafordeterminingapositivetestshouldbe
examinedusingnewrangeofmotioncutoffscores.Thestudyalsorecommendedthatthetestshouldbe
consideredpositiveonlywhenperipheralsymptomsarereproducedbefore22degreesofkneeextension.69A
2011pilotstudybyTrainorandPinnington70indicatedgoodintertesterreliabilityandsuggestedthattheslump
kneebendtesthasthepotentialtobeausefulclinicaltestforidentifyingpatientswithmidlumbarnerveroot
compression.
CLINICALPEARL
Onestudy71foundthatapositiveslumptestwasrecordedin57%ofsubjectswithapparentrepetitivegradeI
hamstringstrainsreinforcingtherelationshipbetweenthehamstringsandthesciaticnerve.
Dependingonwhichtextisread,thereisawidevarietyofprogressivestepstotheslumptest,particularlywhen
thelumbarkyphosisstageisintroduced.Althoughthespecificorderofimplementationremainscontroversial,it
isimportantthattheclinicianconsistentlyusethesamesequencewitheachpatient.Forexample,whenthe
extensionofthecervicalspineisintroduced,theduraandthenerverootsslacken.Extendingthethoracicand
lumbarspinesincreasestheslackintheneuraltissues.
Becausetheslumptestisacombinationofothertests,achoiceastoitsuseneedstobemade.Eithertheclassic
SLRtestoritsvariationsshouldbeperformed,ortheslumptestshouldbeused.72
CLINICALPEARL
Bechterewstest.Bechterewstestisanabbreviatedslumptest,performedbyaskingtheseatedpatientto
activelyextendhisorheruninvolvedlegattheknee,tolowerthatlegandthensubsequentlyextendthe
involvedleg.Ifsymptomsarenotproduced,thepatientisaskedtoextendbothlegsattheknee
simultaneously.Apositivefindingincludesthereproductionofradicularpainbelowtheknee,inabilityto
attainfullkneeextension,leaningbackwardandbracingoneselfonthetable(tripodsign),orany
combinationthereof.
Sittingroottest.Thisisanothertestsimilartotheslumptest.Withthepatientseatedandhisorherneck
flexedtothechest,theclinicianplacesonehandonthedistalthighofthetestedlegtopreventhipflexion
andusestheotherhandtoextendthelowerlegattheknee.AnyofthetypicalSLRresponsesis
consideredapositivefinding.Ifthetestisnegative,theclinicianmayincreasetensionplacedonneural
elementsbyaddingtrunkflexion.
Femoralslumptest.Thisisasidelyingversionoftheslumptestthatissometimespreferredtoremovethe
effectsofgravityontheresults.Thepatientispositionedinsidelying,withthelegclosesttothebed
graspedsothatthekneeisheldatapproximately90degreesofhipflexion,andwiththecervicaland
thoracicspinesflexed(Fig.111).Theclinicianstandsbehindthepatientandsupportstheuppermostleg
tomaintainaneutralhippositionandthekneeflexed.Theclinicianthenslowlyextendsthehipofthe
uppermostlegtothepointwhensymptomsareevoked.Oncethesymptomsareevoked,thepatientis
askedtoextendtheneckwhiletheclinicianmonitorsachangeinsymptoms.
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FIGURE111
Thefemoralslumptest.
Assoonassymptomsarereproducedduringthesetests,thetestshouldbeterminated.Itisworthremembering
thatduringaduraltensiontest,theduraitselfdoesnotmove.Itismerelystressedhence,thenameforthetests.
Onesuchmethodofsequencingfortheslumptestisdescribednext.
Thepatientispositionedsittingwiththehandsbehindtheback,thepoplitealcreasesjustofftheedgeofthebed
andaslightarchintheback(Fig.112),andtheheadflexedandthenplacedinneutral.Thisinitialpositionis
thenfollowedbyaslumpofthelumbarandthoracicspinewithaposteriorpelvictiltastheclinicianmaintains
thepatientsneckinneutral(Fig.113).Thismaneuverhastheeffectoftighteningtheentireduraincludingthe
thoracicdura.Ifthetestisstillnegative,thepatientisaskedtoflextheneckbyfirstapplyingachintuckand
placingthechinonthechestandthentostraightenthekneeasmuchaspossible.Overpressureisthengently
appliedtotheupperthoracicandthelowercervicalspineandmaintainedthroughouttheexamination(Fig.11
4).Thesubjectsankleisthenpassivelydorsiflexedtothepointofslightresistance,whilethekneeisslowly
passivelyextendedtofullextensionortothepointwhenthesubjectreportsanonsetofneuralmediated
symptoms(Fig.115).Ifthepatientisunabletostraightenthekneebecauseofareproductionofsymptoms,he
orsheisaskedtoactivelyextendtheneck.Followingtheextensionoftheneck,ifthepatientcannotstraighten
thekneefurther,thetestcanbeconsideredpositive.
FIGURE112
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Theslumptest1.
FIGURE113
Theslumptest2.
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FIGURE114
Theslumptest3.
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FIGURE115
Theslumptest4.
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Thetestcanalsobeperformedinreversebecauseapositiveresponsemayoccurinonedirectionbutnotthe
other.
LOWEREXTREMITYTENSIONTESTS
Sciaticaisdefinedaspainalongthecourseofthesciaticnerveoritsbranchesandismostcommonlycausedby
aherniateddiskorbylateralrecessspinalstenosis.73Characteristically,patientswithsciaticareportglutealpain
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radiatingdowntheposteriorthighandleg,paresthesiainthecalforfoot,andvaryingdegreesofmotor
weakness.Extraspinalentrapmentofthesciaticnerve(i.e.,alongitscoursewithinthepelvisorthelower
extremity),althoughinfrequent,isdifficulttodiagnosebecauseitssymptomsaresimilartothoseofthemore
frequentcausesofsciatica.
StraightLegRaise
TheSLRtestisrecognizedasthefirstneuraltissuetensiontesttoappearintheliterature.Itwasfirstdescribed
byLasguewellover100yearsago.74
CLINICALPEARL
TheSLRtestshouldbearoutinetestduringtheexaminationofthelumbarspineinpatientswithsciaticaor
pseudoclaudication.However,thetestisoftennegativeinpatientswithspinalstenosis.75
Thepatientispositionedsupinewithnopillowunderthehead.Thepatientstrunkandhipshouldremain
neutral,avoidinginternalorexternalrotation,andexcessiveadductionorabduction.Eachlegisraised
individually(uninvolvedsidefirst).Toensurethatthereisnounduestressonthedura,thetestedlegisplacedin
slightinternalrotationandadductionofthehipandextensionoftheknee.Theclinicianholdsthepatientsheel,
maintainingtheextensionandneutraldorsiflexionattheankle,andraisesthestraightleg(Fig.116)until
complaintsofpainortightnessintheposteriorthighareelicited.Atthispoint,therangeofmotionisnoted,and
theclinicianthenlowersthestraightlegslightlyuntilthepatientreportsadecreaseinsymptoms.
FIGURE116
Thestraightlegraise.
TheevaluationofthefindingsfromtheSLRtestrequiresthattherangeofmotionmeasuredandthesymptoms
producedarecomparedwiththecontralateralsideandwithexpectednorms.3Becausesittingkneeextension
andtheSLRculminateinessentiallyidenticalpositions,symptomaticresponsestothetwotypesofmaneuvers
shouldbesimilaralthoughtheangleatwhichpainiselicitedmayvary.76
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CLINICALPEARL
ConfoundingtheresultsfromtheSLRtestarethenonneuralstructuressuchasthesacroiliacjoint,lumbar
zygapophysialjoints,hipjoint,muscles(hamstrings),andconnectivetissue.Thesestructuresmaylimitleg
elevationandprovokepatientdiscomfortduringtesting.3
Itisgenerallyagreedthatthefirst30degreesoftheSLRservestotakeuptheslackorcrimpinthesciaticnerve
anditscontinuations.Usingsymptomreproductionbelow40degreesasacriterionforapositiveSLRtestresult
hasbeenfoundtoincreasethesensitivityto72%.77
Paininthe0to30degreerangemayindicatethepresenceof:
acutespondylolisthesis
tumorofthebuttock
glutealabscess
verylargediskprotrusionorextrusion78
acuteinflammationofthedura
malingeringpatient
thesignofthebuttock
Between30and70degrees,thespinalnerves,theirduralsleeves,andtherootsoftheL4,L5,S1,andS2
segmentsarestretchedwithanexcursionof26mm.79After70degrees,althoughthesestructuresundergo
furthertension,otherstructuresalsobecomeinvolved.Theseadditionalstructuresincludethehamstrings,
gluteusmaximus,hip,lumbar,andsacroiliacjoints.AnSLRtestispositiveif:
therangeislimitedbyspasmtolessthan70degrees,suggestingcompressionorirritationofthenerve
roots.Apositivetestreproducesthesymptomsofsciatica,withpainthatradiatesbelowtheknee,not
merelybackorhamstringpain.75WhentheSLRisseverelylimited,itisconsidereddiagnosticforadisk
herniation.80
thepainreproducedisneurologicinnature.Thispainshouldbeaccompaniedbyothersignsand
symptomssuchaspainwithcoughing,tyingshoelaces,andsoonbutnotnecessarilybymuscle
weakness.
CLINICALPEARL
TheSLRtestplacesatensilestressonthesciaticnerveandexertsacaudaltractiononthelumbosacralnerve
rootsfromL4toS2.3DuringtheSLR,theL4L5andS1S2nerverootsaretrackedinferiorlyandanteriorly,
pullingtheduramatercaudally,laterally,andanteriorly.Tensioninthesciaticnerve,anditscontinuations,
occursinasequentialmannerdevelopingfirstinthegreatersciaticforamen,andthenoverthealaofthesacrum,
nextintheareawherethenervecrossesoverthepedicle,andfinallyintheintervertebralforamen.
Theinferiorandanteriorpullonthenerverootandtherelativefixationoftheduralinvestmentattheanterior
wallproducesadisplacementthatpullstherootagainsttheposterolateralaspectofthediskandvertebra.In
addition,anyspaceoccupyinglesionssituatedattheanteriorwallofthevertebralcanalinthefourthandfifth
lumbarandfirstandsecondsacralsegmentsmayinterferewiththeduramaterornerverootstructures.
ThefollowingcaveatsareimportantforaccurateassessmentoftheSLR:
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Thepatientmusthavethenecessarilyavailablerangeofhipflexion(3070degrees).
TheSLRproducesaposteriorshearandsomedegreeofrotationinthelumbarspine(aregionnotwell
suitedtoshearingorrotationalforces).Thus,backpainalonewiththeSLRisnotapositivetest.76
CLINICALPEARL
IpsilateralSLRhassensitivitybutnotspecificityforaherniatedIVD.Forexample,Deyoetal.81noteda
sensitivityof80%andaspecificityof40%fortheSLRinthediagnosisoflowlumbardiskherniationandvan
derHoogenetal.82reportedasensitivityof88100%andaspecificityof1144%fortheSLRinthediagnosis
oflumbardiskherniation.
Sensitizers
Passivedorsiflexionoftheankle(Braggardstest)(Fig.117)and/orpassivecervicalflexion(SotoHalltest)
maybeusedassensitizersfortheSLRtest.Thecervicalflexioncanalsobeperformedactively(Fig.118).In
addition,furtherinternalrotationorextremeadductionofthehipmayalsobeaddedtotheSLR.These
additionalmaneuversincreasethetensionexertedonthespinalcord,spinaldura,andlumbosacralnerve
roots.6,20,50,65,8385Researchstudies50,66,8386havedemonstratedthatcervicalflexionlengthensthespinal
cordanddura.Thisactionmayprovokeradicularsymptomswithoutstressingnonneuraltissuesinthelower
extremity.
FIGURE117
Thestraightlegraisewithankledorsiflexion.
FIGURE118
Thestraightlegraisewithactivecervicalflexion.
Thus,theduracanbepulledfrombelow,usingdorsiflexion,orfromabove,usingcervicalflexion.Further
modificationscanbeincorporatedtoplacestressondifferentbranchesofthesciaticandcommonfibular
(peroneal)nervesbyadjustingtheankleandfootposition.Coppietersetal.87evaluatedtheclinicalhypothesis
thatstraininthenervesaroundtheankleandfootcausedbyankledorsiflexioncanbefurtherincreasedwithhip
flexion.Intheirversionofthetest,ankledorsiflexionisperformedfirsttoloadtheneuralandlocalnonneural
structuresaroundtheankleandfootbeforeaddinghipflexionasthesensitizingmaneuver.Lineardisplacement
transducerswereinsertedintothesciatic,tibial,andplantarnervesandplantarfasciaofeightembalmed
cadaverstomeasurestrainduringthemodifiedSLR.87Nerveexcursionwasmeasuredwithadigitalcaliper.
Ankledorsiflexionresultedinasignificantstrainanddistalexcursionofthetibialnerve.87Withtheanklein
dorsiflexion,theproximalexcursionandtensionincreasesinthesciaticnerveassociatedwithhipflexionwere
transmitteddistallyalongthenervefromthehiptobeyondtheankle.87Ashipflexionhasanimpactonthe
nervesaroundtheankleandfootbutnotontheplantarfascia,themodifiedSLRmaybeausefultestto
differentiallydiagnoseplantarheelpain.87AlthoughthemodifiedSLRcausedthegreatestincreaseinnerve
strainnearesttothemovingjoint,mechanicalforcesactingonperipheralnervesaretransmittedwellbeyondthe
movingjoint.87Basedonthesefindings,thefollowingankleandfootadjustmentscanbemade:
Dorsiflexion,footeversion,andtoeextensionstressthetibialbranch.
Dorsiflexionandinversionstressthesuralnerve.
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Plantarflexionandinversionstressthecommonfibular(peroneal)nerve(deepandsuperficial).
IfsymptomsarenotreproducedwiththeSLR,buttheslumptestispositive,numerousreasonshavebeen
proposed,andthefollowingarefewamongthem:72
Thepresenceofasoftdiskprotrusion,particularlyacentralsoftprotrusion.Softcentralprotrusionsneed
loadingthroughweightbearingandareoftennegativeinanonweightbearingposition.
Acutespondylolisthesis.
Posteriorinstability.
Malingeringpatient/nonorganicsymptoms.
CLINICALPEARL
Kempstestusesthepatientstrunkasbothalevertoinducetensionandasacompressiveforce.Thetestmay
beperformedwiththepatientineithertheseatedorstandingposition.
Seated.Withthepatientseatedandarmscrossedoverthechest,theclinicianusesonehandtostabilizethe
patientslumbosacralregiononthesidetobetestedandtheotherarmtocontrolthepatientsupperbody
movement.Thepatientispassivelydirectedintotrunkflexion,rotation,sidebending,andfinally
extension.Dependingonthepatientsresponse,axialcompressionisappliedinthefullyextendedand
rotatedpositionsoastoincreasestressontheposteriorjoints.Radiatingpaindownthelegprovoked
anywherealongthearcofmovementshouldbenoted,andthetestshouldbediscontinuedatthatpoint.
Oftenpatientswillreportdullorachypainstemmingfromthelumbarspinethatmaybeduetoafacetor
extraspinalsofttissueirritation.
Standing.ThestandingversionofKempstestisperformedbyaskingthepatienttoplacethebackofhis
orherhandontheipsilateralglutealregionandthenslidethehanddistallydowntheposteriorthigh.Axial
compressionmaybeappliedbypressingdownwardonthepatientsshoulders.Forcliniciansdesiring
eithermorecontroloverpatientpositioningorlessmuscleactivation,theseatedversionofKempstest
maybepreferable.
CrossedStraightLegRaiseSign
ThecrossedSLRsign,orWelllegraisingtestofFajersztajn,88isassociatedwiththeSLRtest.Therearethree
recognizedtypes:
1.SLRthatproducespaininthecontralaterallegbutnotwhenthecontralaterallegisraised.
2.SLRthatproducespaininbothlegs.
3.SLRofeitherlegthatproducespaininthecontralaterallimb.Forexample,SLRoftherightlegproduces
painintheleftleg,andSLRoftheleftlegproducespainintherightleg.
Therearemanytheoriesastothecauseandsignificanceofthecrossoversign.Onetheorysuggeststhatthe
neuromeningesarepulledcaudally,resultingincompressionoftheduralsleeveagainstalargeormedially
displaceddiskherniation.ThecrossedSLRisconsideredrelativelyinsensitivebuthighlyspecificandisthought
tobemoresignificantthantheSLRtestintermsofitsdiagnosticpowerstoindicatethepresenceofalargedisk
protrusion.89Forexample,Kosteljanetzetal.90foundthetesttohave24%sensitivityand100%specificity,and
Kerretal.91foundthetesttohaveasensitivityof25%andaspecificityof95%.Onestudygoessofarasto
recommendusingthecombinedresultsfromtheSLRandcrossedSLRforamoreaccuratediagnosis.82
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Thefollowingfindingsarestronglypredictiveofdiskherniation78,89,92:
SeverelylimitedSLR.
PositivecrossoverSLR.
Severelyrestrictedandpainfultrunkmovements.
BilateralStraightLegRaise
OncetheunilateralSLRtestiscompleted,theclinicianshouldtestbothlegssimultaneously(Fig.119).A
limitationoftheunilateralSLRisthatitmaynothighlightthepresenceofacentraldiskprotrusion,particularly
asoftdiskprotrusion.93ByperformingabilateralSLRandincorporatingbothneckflexionanddorsiflexion,
centralprotrusionsmaybedetected.72
FIGURE119
Thebilateralstraightlegraise.
Becauseacentralprotrusionmaymimicalateralrecessstenosis,adifferentiationtestisneeded.Thebicycletest
ofvanGelderen94isadvocated.Thepatientisappropriatelypositionedonabicycleandaskedtopedalagainst
resistance.
Apatientwithlateralspinalstenosistoleratesthispositionwell.
Apatientwithintermittentclaudicationofthelowerextremitiestypicallyexperiencesanincreasein
symptomswithcontinuedexercise,regardlessofthepositionofthespine.
Apatientwithintermittentcaudaequinacompressiontypicallyhasanincreaseofsymptomswithan
increaseinlumbarlordosis.
Apatientwithadiskherniationusuallyfairswellifthelumbarspineremainsextended.
BowstringTests
Thebowstringtestsarenamedafterthetechniqueappliedtothenerveunderexamination.Boththetibialandthe
commonfibular(peroneal)nervescanbetestedandalthoughthetestsimpartaninsufficientstretchofthedura
todetectchronicadhesions,theycanbeusedtohelpmakeaprognosisaboutacutediskherniations.Astrong
indicatorforsurgeryisapositivebowstringtest,butthistestneedonlybeperformediftheSLRispositivewith
theadditionofdorsiflexion.72
TibialNerveTest
Thetibialnervetravelsdownthemiddleoftheposteriorthighbetweenthefemoralcondylesanddowntheback
andmiddleofthecalfenteringthefootunderthemedialmalleolusoftheankle(seeChapter3).Theinvolved
extremityisextendedatthekneetothepointofpainandthenloweredslightlytodecreasepain.Theclinician
supportsthepatientslegonhisorhershoulderandthenappliesfingerpressuretothepoplitealfossainan
attempttotensionthesciaticnerve(Fig.1110).Ifthesymptomsreturnwiththismaneuver,thetestis
consideredpositive.
FIGURE1110
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SLRbowstring(poplitealspacepressure).
CommonFibular(Peroneal)Test
Typically,thecommonfibular(peroneal)nervetravelswiththetibialbranchtotheposteriordistalthighregion
(seeChapter3).Itthenwrapsitselfaroundthefibularheadandhasstrongattachmentstothetendonofthe
bicepsfemoris.Theprocedureforthistestissimilartothatofthetibialversionofthetestexceptthatafterthe
kneeisslightlyflexed,theclinicianpullsthebicepsfemoristendonatthefibularheadmediallyandlaterally
(Fig.1111).Ifthismaneuverreproducesthesymptoms,itisconsideredapositivetest.
FIGURE1111
SLRbowstring(fibularhead).
CLINICALPEARL
Thesciatictensiontest,alsoreferredtoastheDeyerleandMaytest,reproducesthemechanicsoftheBowstring
testsinaseatedposition.
ProneKneeBendingTest
Thepronekneebending(PKB)teststretchesthefemoralnerveusinghipextensionandkneeflexiontostretch
thenerveterminationinthequadricepsmuscle.72Someclinicianspreferusingthefemoralslumptestinplaceof
thePKBtoremovetheeffectofgravity(seeSlumpTestearlier).Bothtestshavebeenusedtoindicatethe
presenceofupperlumbardiskherniations,95particularlywhenthehipextensionisadded.96Thefemoralnerve
travelsanteriorlytoboththehipandtheknee(asdoestherectusfemoris).Therefore,thenerverootsandthe
rectusfemorisarestretchedwithacombinationofkneeflexionandhipextension.Thelateralcutaneousnerve
ofthethighandthehipflexorstravelanteriortothethighandmaybestressedwiththehipextensioncomponent
ofthismaneuver.
SomecliniciansrecommendperformingaPKBtestbeforeexecutingasacroiliacupslipcorrectionbecause
thereisasmallpotentialtoavulsetheL23nerverootswiththismaneuver.
ThePKBtestisperformedasfollows:thepatientispositionedprone,andtheclinicianstabilizestheischiumto
preventananteriorrotationofthepelvis.Theclinicianthengentlymovesthelowerextremityintokneeflexion,
bendingthekneeuntiltheonsetofsymptoms(Fig.1112).Thismaneuverislikelytoproduceastretching
sensationontheanterioraspectofthepatientsthigh.Thezoneatwhichtheduraisstretchedis80100degrees
ofkneeflexion.Kneeflexiongreaterthan100%introducesbotharectusfemorisstretchandlumbarspine
motionintothefindings.Anumberofsensitizingmaneuverscanbeusedincludinghipextension,plantar
flexion,dorsiflexion,orheadmovements.
FIGURE1112
Pronekneebend.
Thetestispositiveifthereisareproductionofunilateralpaininthelumbararea,buttock,posteriorthigh,ora
combinationinthe80100degreerangeofkneeflexionwhichcouldindicateanL2,L3,orL4nerveroot
impairmentalthoughanacuteL4S1diskprotrusionmayalsoproducepositivefindings.97
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ThereliabilityandvalidityofthePKBarenotknown.81Porchetetal.98foundthetesttohaveasensitivityof
84%,butthepositivefindingswereassociatedwithseverelateraldiskherniations.
CrossedProneKneeBendingTest
ThisisavariationofthePKBtestexceptthattheuninvolvedlowerextremityismovedintokneeflexion.A
positivetestisthereproductionofthepatientssymptomsintheuntested(opposite)leg.Nodiagnosticaccuracy
studieshavebeenperformedtodeterminethesensitivityandspecificityofthistest.
UPPERLIMBTENSIONTESTS
Theroleofadverseneuromechanicsintheupperlimbandtrunkhasreceivedmuchattentionsincethe
1970s,48,99,100andhasbeenlinkedtochronicneckandarmpainandupperlimbdisorders.101,102
UptonandMcComas34demonstratedthattheperipheralnerveanditscervicalrootsmightmanifestirritationat
simultaneoussites.Afurtherstudy,whichinvestigatedadversetensionintheneuralsystemin20subjects
sufferingfromunilateralsymptomsoftenniselbow,appearedtosuggestthattheadversetensioncouldbea
factor.103
Therelativemobilityofthenerverootanditsinvestingsheath,whichoccursinthelumbarspine,alsohasbeen
demonstratedinthecervicalspine.104Thismobilityisproducedwithcertainmovementsofthearmandoccurs
maximallyatC5andC6,toalesserdegreeatC7,andtoanevenlesserdegreeatC8andT1.22
TheULTTs,orbrachialplexustensiontests,involveanorderedsequenceofmovementoftheshouldergirdle,
arm,elbow,forearm,wrist,andhand.Becausethereareanumberoftissuesinthecervicobrachialregionthat
couldbestressedbythesemaneuvers,cervicalsidebendingorcervicalflexion,whicharethoughttobemore
selectivetothenervoussystem,areadded.104
TheprinciplesbehindtheULTTarethesameasthosedescribedforthelowerextremitytensiontests.Therefore,
onlytheproceduresthemselvesaredescribedhere.Duringtheseprocedures,caremustbetakentomaintainthe
cervicalspineinneutralflexionextension,sidebending,androtation.
ULTT1(MEDIANNERVEDOMINANT)
Thepatientispositionedsupine.Thecliniciandepressestheshouldergirdle,abductsthehumerusto
approximately110degrees,supinatestheforearm,andextendstheelbow,wrist,andfingers(Fig.1113).The
sensitizersforthistestarecervicalspinesideflexionseithertowardorawayfromtheinvolvedside.Thetestis
repeatedonthecontralateralextremity,andtheresultsarecompared.
FIGURE1113
ULTT1(mediannerve).
Severalstudieshaveshownthatthelongitudinalmotionofthemediannerveisaffectedbymotionofthefingers
andwrist,withdigitalflexionresultinginaproximalslideintotheforearm,andwristandfingerextensionboth
producingadistalslideofthenervetowardthehand.104106Hyperextensionofthewristhasbeenshownto
causethemediannervetoslide1015mmdistallyrelativetoafixedbonylandmarkinthecarpaltunnel
whereasflexionofthewristandfingersmovesthenerve4mmproximally.105
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ULTT2(RADIALNERVEDOMINANT)
Thepatientispositionedsupine.Thecliniciandepresses,abducts,andinternallyrotatestheshoulder,pronates
theforearm,extendstheelbow,andflexesthewristandthumb(Fig.1114).Thesensitizersforthistestare
cervicalspinesideflexionseithertowardorawayfromtheinvolvedside.Thetestisrepeatedonthe
contralateralextremity,andtheresultsarecompared.
FIGURE1114
ULTT2(radialnerve).
ULTT3(ULNARNERVEDOMINANT)
Thepatientispositionedsupine.Theclinicianextendsthewrist,supinatestheforearm,fullyflexestheelbow,
anddepressesandabductstheshoulder.Thesensitizersforthistestaresideflexionoftheheadandneck,both
towardandawayfromthetestside.Thetestisrepeatedonthecontralateralextremity,andtheresultsare
compared.
Evans107describedamodificationofthebasicULTT3.Thepatientactivelyabductsthehumeruswiththe
elbowstraight,stoppingjustshortoftheonsetofsymptoms.Thepatientthenexternallyrotatestheshoulderjust
shortofsymptoms,andtheclinicianholdsthisposition.Finally,thepatientflexestheelbowssothatthehandis
placedbehindthehead.Reproductionofthesymptomswithelbowflexionisconsideredapositivetest.
MusculocutaneousNerve
Thepatientispositionedsupinewiththeheadunsupportedbyapillow.Theclinician,facingthepatientsfeet,
supportsthepatientsarminabout80degreesofelbowflexion.Theshoulderisplacedinfullexternalrotation
andapproximately10degreesofabduction.Shoulderdepressionisthenappliedfollowedbyglenohumeral
extension(thesensitizer),elbowextension,andwristulnardeviation.
AxillaryNerve
Thepatientispositionedsupinewiththeheadunsupportedbyapillow.Theclinicianplacesonehandontopof
thepatientsshoulderanddepressestheshoulder.Theglenohumeraljointisthenexternallyrotated,andthe
patientsideflexestheheadawayfromthetestedside.Theshoulderisthenabductedtoapproximately40
degrees.
SuprascapularNerve
Thepatientispositionedsupinewiththeheadunsupportedbyapillow.Theclinicianplacesahandontopofthe
patientsshoulder.Thepatientsarmisplacedininternalrotationandshouldergirdleprotraction.Thearmis
thenmovedintohorizontaladductionfollowedbythepatientsidebendingtheheadawayfromthetestside.The
cliniciannowdepressestheshoulder.
NEURODYNAMICMOBILITYINTERVENTIONS
Adverseneuraltensionisanabnormalresponsetomechanicalstimuliofneuraltissue.Thegenesisofthis
abnormaltissueresponsecanbefromavarietyoffactorstoincludeinjuries(compression,vibration,and
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postsurgical),intraneural,extraneural,andanatomic.108Afactorthatreceivesasignificantamountofattention
involvesthatofrepetitivestraininjuriesspecificallywiththeupperextremities.
Thedetrimentaleffectsofimmobilizationonmusculoskeletalstructuresarewelldocumentedasarethebenefits
ofearlymobilizationprotocols.Therationalebehindtheuseofneuralmobilizationtechniquesistoattemptto
restorethedynamicbalancebetweentherelativemovementofneuraltissuesandsurroundingmechanical
interfaces,therebyallowingreducedintrinsicpressuresontheneuraltissueandimprovingnerveconduction
velocity.109Byapplyingearlymobilizationtotheneuralsystem,itseemspossiblethatsimilarbenefitsshould
occur.Thebenefitsfromsuchtechniquesarethoughtoincludefacilitationofnervegliding,areductioninnerve
adherence,thedispersionofnoxiousfluids,increasedneuralvascularity,andimprovementsintheaxoplasmic
flow.55,109,110However,animportantdistinctionneedstobemadebetweentechniquesthatlengthenorstretch
theduraandtechniquesthatstretchtheanatomicstructuresthatsurroundtheinvolvedneuraltissue.Thereis
limitedevidencereportingfavorableoutcomeswhenusingneuralmobilizationtotreatspecificpatient
populations,buttheappropriateparametersofdosage(i.e.,duration,frequency,andamplitude)remaintobe
confirmed.111
ElveyandHall23recommendaninitialinterventionofpassive,gentle,andcontrolledoscillatorymovementsto
theanatomicstructuresthatsurroundtheneuraltissuebeforeprogressingtothetechniquesthatstretchboththe
surroundingtissuesandtheneuraltissuestogether.Usingthisapproach,thetreatmentbarrierisrepresentedby
theonsetofmuscleactivity.100Forexample,inthecervicalspine,thesequenceofneurodynamicmobilizations
isinitiatedwithshoulderdepressionwiththeneckinneutralandthearmbythesidefollowedbyshoulder
depressionwithfixationofthecervicalspine,thenshoulderdepression,cervicalfixation,andarmtractionwith
thearmbytheside.Oncethisprogressionhasbeenperformedwithoutanyadverseeffects,themorespecific
movementsusedtoisolatethenerveareemployed.
Evidencefortheefficacyofthisgradualapproachhasbeendemonstratedinsubjectswithlowbackpainand
radiculopathy,49,61,112lateralepicondylalgia,113andchroniccervicobrachialpain.23,114Clelandetal.115
performedapilotclinicaltrialtodetermineifslumpstretchingresultedinimprovementsinpain,centralization
ofsymptoms,anddisabilityin30patientswithnonradicularlowbackpainwithsuspectedmildtomoderate
neuralmechanosensitivity.Patientswererandomizedtoreceivelumbarspinemobilizationandexercise(n=14)
orlumbarspinemobilization,exercise,andslumpstretching(n=16).Allpatientsweretreatedwithphysical
therapytwiceweeklyfor3weeksforatotalofsixvisits.Upondischarge,outcomemeasureswerereassessed.
Independentttestswereusedtoassessdifferencesbetweengroupsatbaselineanddischarge.Nobaseline
differencesexistedbetweenthegroups(p>0.05).Atdischarge,patientswhoreceivedslumpstretching
demonstratedsignificantlygreaterimprovementsindisability(9.7pointsontheOswestryDisabilityIndex,p>
0.01),pain(0.93pointsonthenumericpainratingscale,p>0.001),andcentralizationofsymptoms(p>0.01)
thanpatientswhodidnot.Theauthorssuggestedthatslumpstretchingisbeneficialforimprovingshortterm
disability,pain,andcentralizationofsymptomsandalsorecommendedthatfuturestudiesshouldexamine
whetherthesebenefitsaremaintainedatalongtermfollowup.115
Arecentsystematicreviewofrandomizedcontrolledtrialswithananalysisofthetherapeuticefficacyofneural
mobilizationsfoundonlylimitedevidencetosupportitsuse.109However,choosingtherighttechniqueforthe
rightpatientbasedoncausalmechanismisfraughtwithdifficultywhenitcomestoheterogeneousgroups.116
StretchingProgramfortheSciaticNerve
Thehomestretchingexercisestoimprovetissuemobility,andneuralextensibilityareperformedinthreephases
orpositionsasfollows:117
1.Thepatientispositionedsupinewiththehipsandkneesareflexedatacomfortablerange.Usingthe
uninvolvedleg,thepatientliftstheheeloftheinvolvedsideupuntilheorsheexperiencesastretch(Fig.
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1115).Thispositionismaintainedforapproximately1minute(canbeperformedupawalltoprovide
additionalsupport).
2.Fromthepositioninstep1,thepatientslidestheheelfurtherup.Ifthismaneuverprovokesany
paresthesias,thepatientallowstheheelbackdown.Progressismeasuredbytimingtheperiodduring
whichthepatientisabletokeepthekneestraight.
3.Thepatientperformsthesamemaneuverasinstep2butwithapillowunderthehead.Thisstretchis
performed35timesadayfor35minutesatatime.
FIGURE1115
Sciaticnervestretch.
StretchesfortheUpperExtremityNerves
Therecommendedhomestretchingexercisetoimprovetissuemobilityandneuralextensibilityoftheperipheral
nervesthroughouttheupperextremityisperformedinfourphasesorpositionsasfollows:117
1.Thepatientisseatedwiththecervicalspineinneutralsidebendingandthearmabductedto90degrees.
Thepatientisaskedtoextendthefingersandtobeginflexingtheelbowwhilesidebendingtowardthe
elevatedarm(Fig.1116A).
2.Keepingtheupperextremityinthesameposition,thepatientisaskedtobendtheheadawayfromthe
elevatedarm(Fig.1116B).Whenagentlestretchisfelt,thepositionisheldfor1015seconds.
3.Whenthepatientisabletomaintainthepreviousstretchfor3060seconds,trunkrotationawayfromthe
involvedsideisadded.
4.Oncefulltrunkrotationisachieved,variouspositionsofcervicalsidebendingandelbow
flexion/extensioncanbeattempted(Fig.1116C).Forexample,elbowextensioncombinedwith
contralateralcervicalsidebending.Toincreasetension,forearmsupinationorpronationcanbe
superimposedontheelbowmotions.
FIGURE1116
Upperextremitynervestretches.
Eachpositionisheldfor7secondsandisrepeatedfivetimespersession.
Aseriesofhomestretchingexercisetoimprovetissuemobilityandneuralextensibilityofthemediannervein
casesofcarpaltunnelsyndromehavebeenadvocated.Theoretically,stretchingexercisesofthemediannerve
affectsymptomresolutioninacarpaltunnelsyndromeby:118
stretchingtheadhesions
broadeningthelongitudinalareaofcontactbetweenthemediannerveandthetransversecarpalligament
reducingtenosynovialedemabyamilkingaction
improvingvenousreturnfromthenervebundles
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reducingpressureinsidethecarpaltunnel
Sixpositionsareusedformobilizationofthemediannerveatthewrist:
1.Thewristinneutral,withthefingersandthumbinflexion(Fig.1117)
2.Thewristinneutral,withthefingersandthumbextended(Fig.1118)
3.Thewristandfingersextended,withthethumbinneutral(Fig.1119)
4.Thewrist,fingers,andthumbextended(Fig.1120)
5.Thewrist,fingers,andthumbextended,withtheforearmsupinated(Fig.1121)
6.Thewrist,fingers,andthumbextended,withtheforearmsupinatedandtheotherhandgentlystretching
thethumb(Fig.1122)
FIGURE1117
Thewristinneutral,withthefingersandthumbinflexion.
FIGURE1118
Thewristinneutral,withthefingersandthumb,extended.
FIGURE1119
Thewristandfingersextended,withthethumbinneutral.
FIGURE1120
Thewrist,fingers,andthumbextended.
FIGURE1121
Thewrist,fingers,andthumbextended,withtheforearmsupinated
FIGURE1122
Thewrist,fingers,andthumbextended,withtheforearmsupinatedandtheotherhandgentlystretchingthe
thumb.
Eachpositionisheldfor7secondsandisrepeatedfivetimespersession.118Alloftheexercisesperformedin
theclinicshouldbeperformedbythepatientathomewheneverpossible.
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undefined
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Silverchair
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CHAPTER12:ImprovingMusclePerformance
CHAPTEROBJECTIVES
1.Outlinethevariousrolesofhumanskeletalmuscle.
2.Listthevariousrolesofmuscleinthehumanbody.
3.Differentiateamongmusclestrength,endurance,andpower.
4.Understandtheimportanceofmanualmuscletesting
5.Performagrossmusclescreeningofapatientsstrength
6.Performspecificmanualmuscleteststothevariousmusclesofthebody
7.Definedelayedonsetmusclesoreness(DOMS)andexplainwhyitoccurs.
8.Describetheconceptofspecificityoftraining.
9.Describestrategiestoincreasemusclestrength,endurance,andpower.
10.Listthedifferenttypesofresistancethatcanbeusedtoimprovemuscleperformance.
11.Outlinethevarioustypesofexerciseprogressionandthecomponentsofeach.
12.Explainthebasicprinciplesbehindplyometrics.
OVERVIEW
Movementofthebodyoranyofitspartsinvolvesconsiderableactivityfromthosemusclesdirectlyresponsible.
Muscleistheonlybiologicaltissuecapableofactivelygeneratingtension.Thischaracteristicenablesthehuman
skeletalmuscletoperformtheimportantfunctionsofmaintaininguprightbodyposture,movingbodyparts,and
absorbingshock.Forfunctionalbodymotionstotakeplace,themusclesproducingmovementmusthavea
stablebasefromwhichtoworkfrom.Ifafunctionallimitationishighlightedduringthephysicalexaminationof
thepatient,theclinicianmustdeterminethecauseofthefunctionaland/orparticipationrestrictions.Ifthecause
isfoundtobepoormuscleperformance,aprogressionofexercisestoenhancemuscleperformancemustbe
initiated.Oneofthemostcommonwaysofimprovingmuscleperformanceisthroughtheuseofgraded
resistanceexercises,whichcanbeappliedgloballyorlocally.Theclinicianmustrememberthattherearea
numberoffactorsthatinfluenceapatientsabilitytoexercise.Thesefactorscanincludefearofpainorreinjury,
poormotivation,lowcompliance,depression,thesideeffectsofmedication,andimpairedattentionormemory.
MusclePerformance
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Theabilityofamuscletocarryoutitsvariousrolesisameasureofmuscleperformance.Thethreemaintypes
ofmusclecontractionareisometric,concentric(Fig.121AandB),andeccentric(Fig.122AandB)(see
Chapter1).Muscleperformancecanbeassessedbymeasuringanumberofparameters.Theseincludestrength,
endurance,andpower.
FIGURE121
Concentriccontraction.A:Startposition.B:Endposition.
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FIGURE122
Eccentriccontraction.A:Startposition.B:Endposition.
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Strength.Theimprovementofmusclestrengthisanintegralcomponentofmostrehabilitationprograms.
Strengthmaybedefinedastheamountofforcethatmaybeexertedbyanindividualinasinglemaximum
muscularcontractionagainstaspecificresistance,ortheabilitytoproducetorqueatajoint.Strengthcan
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bemeasuredinoneofthreeways:asamaximalforceexertedinanisometriccontraction,themaximal
loadthatcanbeliftedonce,orthepeaktorqueduringisokineticmeasurement.Inaclinicalsetting,muscle
strengthcanbemeasuredasfollows:
Manualmuscletesting(MMT):MMTisanacceptablestandardizedprocessutilizedtofindgross
strengthdeficitsandtoisolatemusclegroupsandactions(seelater).
Usingadynamometer:Dynamometryistheprocessofmeasuringforcesthataredoingwork.A
dynamometerisadevicethatmeasuresstrengthbyusingaloadcellorspringloadedgauge.These
measurementsaremoreobjectivethanMMT.Examplesofadynamometerincludethefollowing:
Handheld:Thisisusedtoassessthegripstrengthofapatient,ortomeasuremusclegroup
strengthbyhavingthepatientexertmaximalforceagainstthedynamometer.
Isometric:Thismeasuresthestaticstrengthofthemusclegroupbystabilizingtheextremityusing
stabilizationstrapsorverbalinstruction.
Isokinetic:Thismeasuresthestrengthofamusclegroupduringamovementwithconstant,
predeterminedspeed.
Power.Mechanicalpoweristheproductofstrengthandspeed.Morespecifically,powerisworkperunit
oftime(forcedistance/time)orforcevelocity(distancetime).Thus,timeisanessentialelement
whentrainingforpower.Muscularpower,themaximumamountofworkanindividualcanperformina
givenunitoftime,istheproductofmuscularforceandvelocityofmuscleshortening.Muscleswitha
predominanceoffasttwitchfibersgeneratemorepoweratagivenloadthanthosewithahigh
compositionofslowtwitchfibers.1TheratioformeanpeakpowerproductionbytypeIIb,typeIIa,and
typeIfibersinskeletaltissue(seeChapter1)is10:5:1.2Greaterforcedevelopmentistherateatwhich
strengthincreasesandisthemostimportantnormaladaptationforthemajorityofathletes,asmuscular
powerisanimportantcontributortoactivitiesrequiringbothstrengthandspeed.Theassessmentofpower
involvesincreasingtheworkamusclemustperformduringaspecificperiodoftime,orreducingthe
amountoftimerequiredtoproduceagivenforce.
Endurance.Skeletalmuscleendurancerequirestheabilityofamuscle,orgroupofmuscles,tocontinue
toperformlowintensitysustainedactivitieswithoutfatiguewhilemaintainingproperalignmentofthe
bodysegmentsoveranextendedperiodoftimewithbalanceandcontrol.Therearetwotypesof
endurance:generalendurance,whichisabaselevelofcardiorespiratoryability,andspecialendurance,
whichisrelatedtospecificactivities(metaboliccapacity).3Endurancecanbeassessedbyhavingthe
patientperformmanyrepetitionsusinglowresistanceorsustainingamusclecontractionforanextended
periodoftime.
Theaboveparametersareusedinrehabilitationtoenhancebalance,jointstabilization,coordination,the
performanceofactivitiesofdailyliving,andtoimproveathleticperformance.Thesethreecomponentsof
muscleperformanceareimportantinfunctionalactivitiesastheycanallowthepatienttointeractwiththeir
environmentinamoreefficientandpainfreewaythroughincreasedmovementcontrolandcapacity.Itis
importanttorememberthatmuscleperformancechangesthroughoutthelifespanbutthatimprovementsin
strengthandendurancearepossiblewithonlyamodestincreaseinphysicalactivity.Thechangesthatoccurin
earlychildhoodthroughadolescencearedescribedinChapter30.Thechangesthatoccurthroughoutadulthood
aresummarizedinBox121.
Box121ChangesinMusclePerformanceBasedonAgeDuringAdulthoodYoungandMiddleAdulthood
Musclemassinmenandwomenpeaksbetween18and25yearsofage.
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Adecreaseinmusclemassbeginstooccurasearlyas25yearsofagealthoughmusclemassconstitutes
approximately40%oftotalbodyweight.
Musclestrengthandendurancereachapeakduringtheseconddecadeoflife,earlierforwomenthanmen.
However,bysometimeinthethirddecade,strengthdeclinesbetween8%and10%perdecadethroughthefifth
orsixthdecade.Thisdeclineoccurslessrapidlyinphysicallyactiveversussedentaryindividuals.
LateAdulthood
Therateofdeclineofmusclestrengthacceleratesto1520%perdecadeduringthesixthandseventhdecades
andincreasesto30%perdecadethereaftersothatbytheeighthdecademusclemasshasdecreasedby50%
comparedtopeakmusclemassduringyoungadulthood.
WhilebothtypeIandtypeIIfibernumbersdecreasewithage,thereispreferentialatrophyoftypeIImuscle
fibers.
Thereisasignificantdeteriorationinfunctionalabilitiesbytheeighthdecadebutthisdeteriorationoccursless
rapidlyinphysicallyactiveversussedentaryindividuals.
DatafromKisnerC,ColbyLA,eds.Resistanceexerciseforimpairedmuscleperformance.In:Therapeutic
Exercise:FoundationsandTechniques.6thed.Philadelphia,PA:F.A.Davis2012:157240.
CLINICALPEARL
Theultimatesourceofenergyformuscularcontractionistheadenosinetriphosphate(ATP)molecule.The
catabolicbreakdownofthechemicalbondsoftheATPmoleculeprovidestheenergynecessarytoallowmyosin
crossbridgestopulltheactinfilamentsacrossthemyosinfilaments,whichresultsinmusclecontraction(see
Chapter1).
Tomeasureimprovementinmuscleperformance,itisnecessarytohaveabaselinemeasurementfromwhichto
demonstrategains.Typicallythebaselinemeasureusedismusclestrengththroughanassessmentofthepatients
abilitytoperformanisometriccontraction.Muscletestingrequiresthatthepatientbeabletovoluntarilycontrol
thetensiondevelopedinthemuscles.Musclestrengthcanbeassessedgrosslyorspecifically.Normally,gross
strengthisassessedfirst,andspecifictestingisusedwhenthegrossmusclescreeninghighlightsanareaof
muscleweakness.
GrossMuscleScreening
Agrossmusclescreeningisperformedonapatientwhenaquickassessmentofthepatientsgenerallevelof
musclestrengthisrequired.Ifanyweaknessisfoundduringthegrossmusclescreeningtest,aspecificmuscle
testisthenperformed.Itisimportanttorememberthatthegrossmusclescreeningdoesnotdetailthe
determinationofstrengthitonlyprovidestheclinicianwithinformationastowhetheraregionofthebodyis
eithernormalorweak.Regardlessofthetypeofmuscletestingused,theprocedureisinnatelysubjectiveand
dependsonthesubjectsabilitytoexertamaximalcontraction.Thisabilitycanbenegativelyaffectedbysuch
factorsaspain,poorcomprehension,motivation,cooperation,fatigue,andfear.
ThegrossmuscletestingproceduresforeachofthemainregionsofthebodyaredescribedinTable121.One
ofthemorecommongrossmuscletestingproceduresistheoneperformedbytheclinicianbeforegaittraining
withanassisteddevicewhentheclinicianisnotsureofthepatientscapabilities.Inthisscenario,theclinician
mustefficientlyassessthestrengthofthemajormusclegroupsthatareusedwhenusinganassistivedevice.The
musclegroupstestedincludetheshoulderabductors(Fig.123),theshoulderflexors(Fig.124),theshoulder
extensors(Fig.125),theelbowflexors(Fig.126),theelbowextensors(Fig.127),thewristextensors(Fig.12
8),thewristflexors(Fig.129),thehipflexors(Fig.1210),thekneeextensors(Fig.1211),thekneeflexors
andhipextensors(thehamstrings)(Fig.1212),thehipabductors(Fig.1213),theankledorsiflexors(Fig.12
14),andtheankleplantarflexors(Fig.1215).
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TABLE121GrossMuscleScreening
Patient TestedMuscle
Procedure
Position Group
Thepatientisinstructedtoraisebothlegsoffthesupportingsurface
Hipflexors simultaneouslywhilekeepingbothlegsstraight.Thepositionisheldfor10
seconds.Thehipflexorscanalsobetestedinthesittingposition.
Thepatientisinstructedtoabductthelegstoeachsidethentoholdtheposition
Hipabductors
whiletheclinicianattemptstobringthelegstogether.
Thepatientisinstructedtokeepthelegstogetherwhiletheclinicianattempts
Hipadductors
toseparatethelegs
Thepatientisinstructedtoflexthehipsandthekneeskeepingthesolesofthe
Hipextensors feetonthesupportingsurfaceandtoraisethepelvisfromthesupporting
surface.Thispositionisheldfor10seconds.
Shoulderflexorsand Thepatientisinstructedtoflextheshoulderto90degreeswiththeelbow
scapularupward straightandtoholdthepositionwhiletheclinicianattemptstopushthearms
Supine rotators intoextension
Shoulderextensors Thepatientisinstructedtoflextheshoulderto90degreeswiththeelbow
andscapula straightandtoholdthepositionwhiletheclinicianattemptstopushthearms
downwardrotators intoflexion
Thepatientisinstructedtoflextheshoulderto90degreeswiththeelbow
Shoulderhorizontal
straightandtoholdthepositionwhiletheclinicianattemptstopushthearms
abductors
togetherintohorizontaladduction
Thepatientisinstructedtobringthehandstogetherinfrontofthechest,
Shoulderadductors keepingtheelbowstraightandtoholdthisposition.Theclinicianattemptsto
separatethearmsintohorizontalabduction.
Thepatientisinstructedtoholdbotharmsstraightinfrontofthebodyandthen
Neckandtrunk
toraisetheheadandshouldersoffthesupportingsurface,andtoholdthis
flexors
position
Thepatientisinstructedtoabducttheshouldertothesideuptoshoulderlevel
Shoulderabductors withtheelbowsstraight.Theclinicianattemptstopushthearmsdowntothe
patientssidesintoshoulderadduction.
Thepatientisinstructedtoabducttheshouldertothesideuptoshoulderlevel
Shoulderadductors withtheelbowsstraight.Theclinicianattemptstopushthearmsoverthe
patientsheadintoshoulderabduction.
Thepatientisinstructedtoholdthearmsatthesides,flextheelbowsto
Shoulderinternal
approximately90degreesandtoplacetheforearmsinneutral.Theclinician
rotators
attemptstopushthearmsoutwardintoexternalrotationoftheshoulder
Shoulderexternal
rotators
attemptstopushthearmsinwardintointernalrotationoftheshoulder
Elbowflexors
attemptstopushtheforearmstowardthesupportingsurfaceintoelbow
extension
Elbowextensors approximately90degreesandtoplacetheforearmsinneutral.Theclinician
attemptstopushtheforearmstowardtheshouldersintoelbowflexion
Forearmsupinators approximately90degreesandtoplacetheforearmsinneutral.Theclinician
attemptstoturnthepalmsdownintopronation
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Forearmpronators approximately90degreesandtoplacetheforearmsinneutral.Theclinician
Supine attemptstoturnthepalmsupwardintosupination
or Thepatientisinstructedtoholdthearmsatthesides,flextheelbowsto
sitting Wristflexors approximately90degreesandtoplacetheforearmsinneutral.Theclinician
attemptstopushthepalmsawayfromthebodyintowristextension
Wristextensors approximately90degreesandtoplacetheforearmsinneutral.Theclinician
attemptstopushthepalmstowardthebodyintowristflexion
Fingerflexors placeshisorherindexandmiddlefingersintothepatientshandandthe
patientisaskedtosqueezethefingers.Theclinicianthenattemptstopullthe
fingersout.
approximately90degreesandtoplacetheforearmsinneutral.Thepatientis
Fingerextensors
askedtostraightenthefingersandthentheclinicianattemptstopushthe
fingersintoflexion
Anteriorinterossei
askedtoadductthefingersandthentheclinicianattemptstopullthefingers
intoabduction
Posteriorinterossei
askedtoabductthefingersandthentheclinicianattemptstopushthefingers
intoadduction
Opponenspollicis
placeshisorherindexfingerbetweenthepatient'sthumbandeachfingerone
atatimewhileaskingthepatienttopinchthefinger
Thepatientisinstructedtoplacebothhandsonthesupportingsurfacenextto
Latissimusdorsiand thehips,keepingtheelbowsstraightandtheshouldershrugged.Thepatientis
triceps thenaskedtodepressthescapularbyliftingthebuttocksoffthesupporting
surface.
Uppertrapeziusand Thepatientisinstructedtoshrugtheshoulderstowardtheearsandtoholdthe
levatorscapulae position.Theclinicianattemptstopushtheshouldersdownintodepression
Sitting
Internalrotatorsof Thepatientisinstructedtoevertthefootandtoholdthepositionwhilethe
thehipandevertors clinicianpushesonthelateralborderofeachfoot,intoinversionandexternal
ofthefeet rotationofthehip
Externalrotatorsof Thepatientisinstructedtoinvertthefootandtoholdthepositionwhilethe
thehipandinvertors clinicianpushesonthemedialborderofeachfoot,intoeversionandinternal
ofthefeet rotationofthehip
Thepatientisinstructedtoflextheelbowslevelwiththeshoulders,pinchor
Rhomboids,middle
adductthescapulaetogetherandraisethearmsfromthesupportingsurface.
trapezius,and
Theclinicianattemptstopushthearmsdownward
posteriordeltoid
Thepatientisinstructedtoraisethearmoffthesupportingsurfacewhile
Elbowandshoulder
Prone keepingthearmsatthesidesandtheelbowsstraight.Theclinicianattemptsto
extensors
pushthearmsdownward
Extensorsofthehips, Thepatientisinstructedtokeepthearmsatthesidesandtoraisetheheadand
back,neck,and shouldersandarmsandlegsofthesupportingsurfacesimultaneouslyby
shoulders archingtheback.Thepositionisheldfor10seconds
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Hamstrings Thepatientisinstructedtoflexthekneestoabout90degrees.Theclinician
Proneor
attemptstopullthekneesintoextension
sitting
Thepatientisinstructedtoflexthekneestoabout90degrees.Theclinician
Quadriceps
attemptstopushthekneesintoflexion
Thepatientisinstructedtostandononelegwithonefingeronthesupporting
Gastrocnemius/soleus surfaceforbalance.Thepatientisthenaskedtoriseupontiptoesandtorepeat
10times.Theotherlegisthentested
Standing
Dorsiflexors Thepatientisinstructedtowalkontheheelfor10steps
Hipandknee
Thepatientisinstructedtodofivepartialdeepkneebends
extensors
FIGURE123
Grossmuscletestingoftheshoulderabductors.
FIGURE124
Grossmuscletestingoftheshoulderflexors.
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FIGURE125
Grossmuscletestingoftheshoulderextensors.
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FIGURE126
Grossmuscletestingoftheelbowflexors.
FIGURE127
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Grossmuscletestingoftheelbowextensors.
FIGURE128
Grossmuscletestingofthewristextensors.
FIGURE129
Grossmuscletestingofthewristflexors.
FIGURE1210
Grossmuscletestingofthehipflexors.
FIGURE1211
Grossmuscletestingofthekneeextensors.
FIGURE1212
Grossmuscletestingofthekneeflexorsandhipextensors.
FIGURE1213
Grossmuscletestingofthehipabductors.
FIGURE1214
Grossmuscletestingoftheankledorsiflexors.
FIGURE1215
Grossmuscletestingoftheankleplantarflexors.
SpecificMuscleTesting
Specificmuscletesting,alsocalledMMTisaprocedurefortheevaluationofthevoluntaryfunctionand
strengthofindividualmusclesandmusclegroupsbasedoneffectiveperformanceoflimbmovementinrelation
totheforcesofgravityandmanualresistance.ThetheoreticalconceptsandgradingmethodsofMMTare
outlinedinChapter4.
CLINICALPEARL
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Maximummuscularstrengthisthemaximumamountoftensionorforcethatamuscleormusclegroupcan
voluntarilyexertinonemaximaleffort,whenthetypeofmusclecontraction,limbvelocity,andjointangleis
specified.
Toaccuratelyperformaspecificmuscletest,theclinicianmusthaveknowledgeofthefollowing:
Theoriginandinsertionofthemusclebeingtested.
Thefunctionofthemusclebeingtested.Musclesrarelyperformonesingleactioninsteadtheyform
groupsofactionsthatoverlapwiththefunctionsofothermuscles.Forthatreason,ifacomponentofa
musclesfunctionislost,othermusclesthathaveduplicatefunctionscancompensateforthatloss.
Howtoeliminatesubstituteortrickmotions.Thisisbestaccomplishedbyusingstandardizedtesting
positions.Whereappropriate,thesemotionsareincludedineachofthetestproceduressothatthe
clinicianisawareofwhattoavoid.
Howtoskillfullyapplyresistance.Pressureshouldbeappliedslowly,verygently,andgraduallybefore
progressingtothemaximumresistancetolerable.
Thestandardpositionsforeachmuscletestbasedontheeffectsofgravity.Typicallythepatientis
positionedineitheranantigravityoragravityeliminatedposition(seelater).
Themainpurposesofspecificmuscletestingareasfollows:
Tohelpdetermineadiagnosis.Forexample,specificmuscletestingcanaidinpreciselylocalizingalesion
intheperipheralnervoussystem.
Toestablishabaselineformusclereeducationandexercise.
Todetermineapatientsneedforsupportiveapparatus(orthosis,assistivedeviceofambulation,or
splints).
Tohelpdetermineapatientsprogress.
Thepatientispositionedinanantigravitypositionforgrades35andinagravityeliminatedpositionforgrades
02.Ifthemusclestrengthislessthangrade3,thenthemethodsadvocatedinmuscletestingmanualsmustbe
used.Forthetestingmethodsandpositionsdescribedinthischapter,itisassumedthatthepatienthasagradeof
35.Alternative,gravityeliminated/minimizedpositionswillalsobeprovided.
CLINICALPEARL
Iftheclinicianishavingdifficultydifferentiatingbetweenagrade4andagrade5,theeccentricbreakmethod
ofmuscletestingmaybeused.Thisprocedurestartswithanisometriccontraction,butthentheclinicianapplies
sufficientforcetocauseaneccentriccontractionorabreakinthepatientsisometriccontraction.
MuscleTestingoftheShoulderComplex
Anumberofsignificantmusclescontrolmotionattheshoulderandprovidedynamicstabilization(seeChapter
16).
UpperTrapeziusandLevatorScapulae
Itisworthrememberingthatitisdifficulttodifferentiatethestrengthofthelevatorscapulaefromthatofthe
uppertrapezius.Forthisreason,thelevatorscapulaestrengthisoftenassessedtogetherwiththerhomboids,or
withtheuppertrapezius.Thepatientisseatedwiththearmrelaxedatthesides.Thepatientisaskedtoraisethe
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shoulderashighaspossible,andtoextendandrotatetheocciputtowardtheelevatedshoulder(Fig.1216).The
clinicianstabilizesthetopoftheshoulderswithonehandandappliesresistanceagainsttheheadinthedirection
ofcervicalflexionanterolaterally(seeFig.1216).ThecommandgiventothepatientisDontletmeseparate
yourheadandshoulder.Substitutionortrickmotionscanincludeabductionandupwardrotationofthescapula
(serratusanterior),elevationanddownwardrotationofthescapula(rhomboidmajorandminor),anteriortilting
ofthescapula(pectoralisminor),andelevationofthefirstandsecondribs(scalenusmusclegroup).Thegravity
minimized/eliminatedpositionforthismuscleiswiththepatientpositionedinasupineorpronepositionwith
theupperlimbandshouldersupported.
FIGURE1216
Testpositionfortheupperportionofthetrapezius(andlevatorscapulae).
MiddleTrapezius
Tospecificallytestthismuscle,thepatientispositionedinpronewiththeshoulderabductedto90degrees,the
elbowextended,andtheupperextremityexternallyrotatedsothatthethumbpointstowardtheceiling(Fig.12
17).Theclinicianappliespressureagainsttheforearminadownwarddirectiontowardthetable.Thecommand
giventothepatientisDontletmepushyourarmdownwhilekeepingyourelbowstraightandyourthumb
pointingupward.Substitutionortrickmotionscanincludetrunkrotation,horizontalabductionoftheshoulder
(posteriordeltoid)elevationanddownwardrotationofthescapula(rhomboidmajorandminor),depressionand
downwardrotationofthescapula(lowertrapezius),synergisticcontractionoftheupperandlowerfibersofthe
trapeziusmuscle,andsynergisticcontractionofthelowertrapeziusandtherhomboids.Thegravity
minimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsittingwiththeupperlimb
supportedonafrictionfreesurfaceinapositionof90degreesofabductionand90degreesofelbowflexion.
FIGURE1217
Testpositionforthemiddletrapezius.
LowerTrapezius
Tospecificallytestthismuscle,thepatientispositionedinpronewiththearmplaceddiagonallyoverhead,and
theshoulderisexternallyrotated(Fig.1218).Theclinicianappliespressureagainsttheforearmdownward
towardthetable.ThecommandgiventothepatientisDontletmepushyourarmdownwhilekeepingyour
armdiagonallyupwardandyourthumbfacingupward.Substitutionortrickmotionscanincludeassistance
fromtheposteriordeltoid,latissimusdorsi,orpectoralismajor.Thegravityminimized/eliminatedpositionfor
thismuscleiswiththepatientpositionedinpronewiththearmsbythesidesandtheupperextremitysupported
bytheclinician.Thepatientisaskedtodepressandadductthescapulathroughthefullrangeofmotion.
FIGURE1218
Testpositionforthelowertrapezius.
SerratusAnterior
Tospecificallytestthismuscle,thepatientispositionedinsupine,standing,orsitting.
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Supine:thepatientisaskedtoflextheshoulderto90degreeswithslightabductionandwiththeelbowin
extension.Fromthisposition,thepatientmovesthearmupwardtowardtheceilingbyabductingthe
scapula.Theclinicianappliesresistancebygraspingaroundtheforearmandelbowandapplyinga
downwardandinwardpressuretowardthetable(Fig.1219).ThecommandgiventothepatientisTryto
liftyourarmhigherbymovingyourshoulderforwardwhileIpushdownonit.
Standing:thepatientplacesahandagainstthewallwiththeshoulderinforwardflexionto8090degrees
andtheelbowslockedinextension.Whilemonitoringtheinferiorangleofthescapulaforanywinging,
thecommandgiventothepatientisPushagainstthewall.
Sitting:thistestfocusesontheupwardrotationactionoftheserratusintheabductedposition.Thepatient
isaskedtomovethehumerusintoapproximately120130degreesofflexion.Usingonehand,the
clinicianstabilizestheinferioraspectofthescapula,andtheotherhandisplacedontheanterioraspectof
thearm(Fig.1220).ThecommandgiventothepatientisKeepyourarmstillwhileItryandpushit
down,astheclinicianpushesdownwardlyonthearmwhileapplyingaresistiveforcewiththeother
handintomedialrotationoftheinferiorangleofthescapula.
FIGURE1219
Testpositionfortheserratusanteriorpatientsupine.
FIGURE1220
Testpositionfortheserratusanteriorpatientsitting.
Substitutionortrickmotionstypicallyoccurinsittingandcanincludeflexionofthevertebrae,orrotationofthe
vertebrae.
Thegravityminimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsittingwiththeupper
limbrestingonatable,withtheshoulderpositionedin90degreesofflexion,andtheelbowextended.
RhomboidMajor,Minor,andLevatorScapulae
Thepatientispositionedinpronewiththeheadturnedtowardthetestedside,theelbowflexed,andthe
ipsilateralhumerusabducted,slightlyextended,andexternallyrotated(Fig.1221A).Theclinicianapplies
pressurewithonehandagainstthepatientsarminthedirectionofabductingthescapulaandexternallyrotating
theinferiorangle,whiletheotherhandisplacedonthepatientsshoulderinthedirectionofdepression(seeFig.
1221A).ThecommandgiventothepatientisDontletmepushyourarmdown.Substitutionortrickmotions
canincludeassistancefromthewristextensors,middletrapezius,posteriordeltoid,latissimusdorsi,teresmajor,
andlevatorscapulae.Analternativetestcanbeperformedwiththepatientpositionedinpronewiththeupper
extremitypositionedin90degreesofabductionandinternallyrotatedsothatthethumbispointingdown(Fig.
1221B).Thepatientisaskedtoraisethearmtowardtheceilingandtoholdthepositionwhiletheclinician
appliesadownwardforcetothepatientsforearm.Thegravityminimized/eliminatedpositionforthismuscleis
withthepatientpositionedinsittingwiththehandrestingonthelumbarspine.
FIGURE1221
A:Testpositionfortherhomboids(andlevatorscapulae).B:Alternatetestpositionfortherhomboids.
FIGURE1222
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Testpositionforthelatissimusdorsi.
LatissimusDorsi
Tospecificallytestthismuscle,thepatientispositionedinpronewiththeshoulderinternallyrotatedand
adductedandthepalmfacingupward(Fig.1222).Thepatientisaskedtoextendtheshoulderwhilekeepingthe
elbowstraight.ThecommandgiventothepatientisWhilekeepingyourpalmfacingtheceiling,dontletme
pushyourarmdown.Theclinicianstabilizesthethorax,andresistanceisgivenproximaltotheelbowjoint
usingaforcethatisacombinationofshoulderabductionandminimalflexion(seeFig.1222).Substitutionor
trickmotionscanincludescapularadductionwithnoshouldermotion,anteriortippingandabductionofthe
scapula,assistancefromtheteresmajor,posteriordeltoid,orpectoralismajor(sternalhead).Thegravity
minimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsidelying,withtheupperlimb
supportedin90degreesofshoulderflexionandinternalrotation,andwiththeelbowflexed.
TeresMajor
Tospecificallytestthismuscle,thepatientispositionedinpronewiththeupperextremityextended,abducted,
andmediallyrotatedandwiththebackofthehandrestingonthesmalloftheback.Theclinicianplacesahand
againstthearmproximaltotheelbow(Fig.1223),andthecommandgiventothepatientisKeepingyourhand
onyourback,dontletmemoveyourarmtowardthetable,whilethecliniciangeneratesaforceintoflexion
andabductionoftheupperextremity.Substitutionortrickmotionscanincludescapularadductionwithout
shouldermotion,externalrotationoftheglenohumeraljoint,andassistancefromthelatissimusdorsi,pectoralis
major,andteresminor.Ingeneral,theteresmajormuscleisnottestedinagravityeliminatedposition,because
itwillonlycontractagainstresistance.
FIGURE1223
Testpositionfortheteresmajor.
PectoralisMajor
Tospecificallytestthismuscle,thepatientispositionedinsupine.Thepatientsarmpositiondependsonwhich
portionofthemuscleisbeingtested:
Theclavicularportion(upperfibers):thepatientarmispositionedin6090degreesofshoulderabduction
andtheelbowisslightlyflexed.Thepatientisthenaskedtohorizontallyadducttheshoulderasthe
clinicianappliesresistanceproximaltothewrist(orproximaltotheelbowiftheelbowflexorsareweak)
inadownwardandoutwarddirection(Fig.1224A).Thecoracobrachialis,asynergistoftheupperfibers,
canalsobeassessed(Fig.1224B).
Thesternalportion(lowerfibers):thepatientarmispositionedin120degreesofshoulderabductionwith
theelbowslightlyflexed.Thepatientisaskedtomovethearmdownandinacrossthebodyasthe
clinicianappliesresistanceproximaltotheelbowinanupandoutwarddirection(Fig.1225).
FIGURE1224
A:Testpositionforthepectoralismajorupperfibers.B:Testpositionforthecoracobrachialis.
FIGURE1225
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Testpositionforthepectoralismajorlowerfibers.
Substitutionortrickmotionscanincludetrunkrotation,assistancefromtheanteriordeltoid,coracobrachialis,
andbicepsbrachii.Thegravityminimized/eliminatedpositionforthismuscleiswiththepatientpositionedin
sittingwiththeshoulderpositionedinneutralrotationandin90degreesofabduction,theelbowflexedto90
degrees,andtheupperlimbsupported.
PectoralisMinor
Tospecificallytestthismuscle,thepatientispositionedinsupinewiththearmsatthesidesandthepatientis
askedtolifttheshouldergirdlefromthetable(withoutusingforcefromtheelboworhand)andtoholdthe
positionwhiletheclinicianappliesresistanceagainsttheanterioraspectoftheshoulder(Fig.1226)ina
downwarddirectiontowardthetable.Substitutionortrickmotionscanincludeflexionofthewristorfingers,
whichcangivetheappearanceofanteriortippingofthescapula.Thegravityminimized/eliminatedpositionfor
thismuscleiswiththepatientpositionedinsittingwiththehandrestingonthesmalloftheback.
FIGURE1226
Testpositionforpectoralisminor.
Deltoid
Tospecificallytestthevariousportionsofthismuscle,thepatientsarmpositionuseddependsonwhichportion
ofthemuscleisbeingtested:
Anteriordeltoid.Thepatientispositionedinsittingorsupinewiththeshoulderabductedinminimal
flexion.ThecommandgiventothepatientisMoveyourarmdiagonallyforwardandtowardyourbody,
andholditagainstmyresistance.Whilestabilizingthepatientsshoulderwithonehand,theclinician
usestheotherhandtoapplyresistancetotheanteriorandmedialaspectofthearmproximaltotheelbow
inthedirectionofabductionandminimalextension(Fig.1227).Substitutionortrickmotionscaninclude
elevatingtheshoulderandleaningbackward,assistancefromthebicepsbrachii,coracobrachialis,or
pectoralismajor(clavicularhead),orbymovingthescapula.Thegravityminimized/eliminatedposition
forthismuscleiswiththepatientpositionedinsidelyingwiththeupperextremitysupported,andthe
shoulderpositionedinneutral,andtheelbowflexed.
Middledeltoid.Thepatientispositionedinsittingwiththearmabductedto90degreesandtheelbow
flexedtoapproximately90degrees.Thepatientisaskedtoholdthispositionwhiletheclinicianapplies
resistancejustproximaltotheelbowinadownwarddirection(Fig.1228).Substitutionortrickmotions
canincludetrunkflexiontothesameside,orassistancefromthebicepsbrachii,supraspinatusorserratus
anterior.Thegravityminimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsupine
withtheupperextremitysupportedandtheelbowflexedto90degrees.
Posteriordeltoid.Thepatientpositionedinsittingwiththeshoulderabductedtoapproximately90degrees
andpositionedinminimalshoulderextensionandinternalrotation.Thepatientisaskedtopushthearms
backtowardtheclinicianastheclinicianusesonehandtostabilizethescapulaandtheotherhandtoapply
resistancetotheposterolateralaspectofthearm,proximaltotheelbow,inthedirectionofshoulder
abductionandslightflexion(Fig.1229).Substitutionortrickmotionscanincludeassistancefromthe
longheadofthetricepsoradductionofthescapulawithouthorizontallyabductingtheshoulder.The
gravityminimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsittingwiththe
upperextremitysupportedonatable,andtheshoulderandelbowflexedto90degrees.
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FIGURE1227
Testpositionfortheanteriordeltoid.
FIGURE1228
Testpositionforthemiddledeltoid.
FIGURE1229
Testpositionfortheposteriordeltoid.
RotatorCuff
Therotatorcuff(RC)musclesconsistofthesupraspinatus,infraspinatus,teresminor,andthesubscapularis.
EachofthemusclesoftheRCcanbespecificallytested,withthepatientsetupdependentonwhichmuscleis
beingtested:
Teresminor.Thepatientispositionedinpronewiththeshoulderabductedto90degreesandthearm
supportedbythetablesothattheforearmispermittedtomovefreely(Fig.1230).Thepatientisaskedto
externallyrotatetheshouldersothattheforearmmovestowardtheceiling.Thepatientisaskedtohold
thispositionwhiletheclinicianappliesresistancetothepatientswristinadownwarddirectionwithone
hand,whileusingtheotherhandtosupportthepatientsarm(seeFig.1230).Theteresminorcanalsobe
testedwiththepatientinsupinewiththehumerusinexternalrotationandtheelbowheldatarightangle.
Usingonehand,theclinicianstabilizestheupperarm,whileusingtheotherarmtoapplypressureinthe
directionofinternalrotationofthehumerus(Fig.1231).
Subscapularis.Thepatientispositionedinpronewiththeshoulderabductedto90degreesandthearm
restingonthetablesothattheforearmispermittedtomovefreely(Fig.1232).Thepatientisaskedto
internallyrotatetheshouldersothattheforearmmovestowardtheceiling.Thepatientisaskedtoholdthe
positionwhiletheclinicianappliesresistanceatthewristinadownwarddirectionwithonehand,while
usingtheotherhandtosupportthepatientsarm(seeFig.1232).Thesubscapulariscanalsobetested
withthepatientinsupinewiththeupperarmatthesideandtheelbowheldattherightangle(Fig.1233).
Usingonehandtostabilizethepatientsupperarm,theclinicianusestheotherhandtoapplyforcetothe
inneraspectofthepatientswristandforearminadirectionofexternalrotation.Substitutionortrick
motionscanincludescapularabduction,pronationoftheforearm,andassistancefromthepectoralis
major,teresmajor,andlatissimusdorsi.Thegravityminimized/eliminatedpositionforthismuscleiswith
thepatientpositionedinpronewiththeshoulderflexedovertheedgeofthetable.
Supraspinatus.Thepatientispositionedinsittingwiththearmbytheside,andtheheadrotated
ipsilaterallyandextended.Usingonehand,theclinicianpalpatesthesupraspinatustheotherhandapplies
resistanceattheelbowintoshoulderadductionwhilethepatientisaskedtoraisethearmupintoshoulder
abduction.Thisisadifficultmuscletoisolateasitworksinconjunctionwiththemiddledeltoid.
Infraspinatus.Thepatientispositionedinpronewiththeshoulderabductedto90degreesandthearm
supportedbythetablesothattheforearmispermittedtomovefreely(seeFig.1230).Thepatientis
askedtoexternallyrotatetheshouldersothattheforearmmovestowardtheceilingandtoholdthat
position.Usingonehand,theclinicianstabilizesthepatientsarmwhileusingtheotherhandtoapply
resistanceinadownwarddirectionatthepatientswrist(seeFig.1230).Theinfraspinatuscanalsobe
testedwiththepatientinsupinewiththehumerusinexternalrotationandtheelbowheldatarightangle.
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Usingonehand,theclinicianstabilizestheupperarm,whileusingtheotherarmtoapplypressureinthe
directionofinternalrotationofthehumerus(seeFig.1231).
FIGURE1230
Testpositionfortheshoulderexternalrotatorsteresminorandinfraspinatuspatientprone.
FIGURE1231
Testpositionfortheshoulderexternalrotatorsteresminorandinfraspinatuspatientsupine.
FIGURE1232
Testpositionfortheshoulderinternalrotatorssubscapularispatientprone.
FIGURE1233
Alternatetestpositionfortheinternalrotatorssubscapularispatientsupine.
LongHeadoftheBicepsBrachii
Thestrengthofthelongheadofthebicepsisassessedincombinationwiththeshortheadofthebiceps(see
ElbowFlexorslater).
MuscleTestingoftheElbow
BicepsBrachii
Tospecificallytestthismusclethepatientispositionedinsittingwiththeelbowflexedtoapproximately90
degreesandtheforearminsupination.Usingonehandtostabilizethepatientsshoulder,theclinicianusesthe
otherhandtoapplyresistanceovertheanterioraspectofthepatientsforearmwhileaskingthepatienttohold
thepositionofelbowflexionagainsttheresistance(Fig.1234).Aswithalloftheelbowflexors,thegravity
minimized/eliminatedpositioniswiththepatientpositionedinsittingwiththearmsupportedonatableat90
degreesofabduction,theshoulderinneutralrotation,andtheelbowextended.Substitutionortrickmotions
whentestinganyoftheelbowflexorscanincludeshoulderextension,assistancefromthepronatorteres,orthe
wristandfingerextensorsandflexors.
FIGURE1234
Testpositionforthebicepsbrachii.
Brachialis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeelbowflexedandthe
forearmpronated(Fig.1235).Usingonehandtostabilizethepatientsarm,theclinicianplacestheotherhand
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overtheposteriorsurfaceofthepatientsforearmproximaltothewristandappliesaforceinthedirectionof
elbowextensionwhileaskingthepatienttotryandpreventthemotion(seeFig.1235).
FIGURE1235
Testpositionforthebrachialis.
Brachioradialis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeelbowflexedandthe
forearmplacedinaneutralpositionhalfwaybetweensupinationandpronation(Fig.1236).Usingonehandto
stabilizethepatientselbow,theclinicianplacestheotherhandproximaltothepatientswristandappliesa
forcetowardelbowextensionwhileaskingthepatienttoresistthemovement.
FIGURE1236
Testpositionforthebrachioradialis.
PronatorTeres
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeelbowflexedto
approximately8090degreesandtheforearmfullypronated(Fig.1237).Usingonehand,theclinician
stabilizesthepatientselbowagainstthepatientsthoraxwhileplacingtheotherhandproximaltothepatients
wrist(seeFig.1237).Thepatientisaskedtomaintainthepositionwhilethecliniciangeneratesaforceinto
forearmsupination.Substitutionortrickmotionscanincludetrunkflexiontothecontralateralside,and
abductionandinternalrotationoftheshoulder.Thegravityminimized/eliminatedpositionforthismuscleis
withthepatientpositionedinsittingwiththeshouldersupportedonatableat90degreesofflexion,theelbow
flexedto90degreesandtheforearmperpendiculartothetable.
FIGURE1237
Testpositionforthepronatorteres.
ExtensorCarpiRadialisLongus
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeelbowextendedandthe
forearmjustshortoffullpronation.Usingonehand,thecliniciansupportsthepatientsforearm,andthepatient
isaskedtoextendthewristinaradialdirection(Fig.1238).Usingtheotherhand,theclinicianappliespressure
totheposterioraspectofthepatientshandalongthesecondmetacarpalboneinanulnardirectionwhileasking
thepatienttopreventthemovement(Fig.1238).
FIGURE1238
Testpositionfortheextensorcarpiradialislongusandbrevis.
FlexorCarpiRadialis
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Tospecificallytestthismuscle,thepatientispositionedinsittingorsupine,withthewristflexedandulnarly
deviatedandtheforearminsupination.Usingonehand,thecliniciansupportsthepatientforearm,whileusing
theindexandmiddlefingeroftheotherhandtoapplypressureonthethenareminenceinanulnarandextension
direction(Fig.1239).Thepatientisaskedtopreventthismotion.
FIGURE1239
Testpositionfortheflexorcarpiradialis.
FlexorCarpiUlnaris
Tospecificallytestthismuscle,thepatientispositionedinsupineorsittingwiththeforearmssupported,the
wristflexed,andthefingersrelaxed.Thepatientisaskedtoflexandulnarlydeviatethewrist.Whilestabilizing
thewristwithonehand,thecliniciangeneratesaradialandextensionforcewiththeotheronthemedialaspect
ofthepatientshand(Fig.1240).
FIGURE1240
Testpositionfortheflexorcarpiulnaris.
PronatorQuadratus
Althoughlocatedproximaltothewrist,thismuscleistestedwiththeotherforearmpronators.Tospecifically
testthismusclethepatientispositionedinsittingorsupinewiththeelbowcompletelyflexed,andtheforearm
pronated.Usingonehandtostabilizethepatientselbow,theclinicianplacestheotherhandproximaltothe
patientswristandappliesaforceintosupinationwhileaskingthepatienttopreventthemovement(Fig.1241).
FIGURE1241
Testpositionforthepronatorquadratus.
Supinator
Tospecificallytestthismuscle,thepatientispositionedinstandingorsitting.Thepatientsarmcanbe
positionedinoneoftwoways:
Theshoulderflexedto90degrees,theelbowfullyflexed,andtheforearmfullysupinated(Fig.1242).
Theshoulderandelbowextendedbehindthepatientandtheforearmsupinated(Fig.1243).
FIGURE1242
Testpositionforthesupinator.
FIGURE1243
Alternatetestpositionforthesupinator.
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Usingonehandtostabilizethepatientsupperarmattheelbow,theclinicianplacestheotherhandjustproximal
tothepatientswristandappliesaforceintopronationwhileaskingthepatienttopreventthemotion.
TricepsBrachiiandAnconeus
Tospecificallytestthetricepsbrachiiandanconeus,threedifferentpositionscanbeused:
Patientprone.Thepatientabductstheshoulderto90degrees,extendstheelbowfully,andthenunlocksit
slightly(Fig.1244).
Patientsupine.Thepatientflexestheshoulderto90degrees,extendstheelbowfully,andthenunlocksit
slightly(Fig.1245).
Patientissitting.Thepatientabductstheshoulderto160degrees,extendstheelbowfully,andthen
unlocksitslightly(Fig.1246).Thispositionistheoneusedmostcommonly.
FIGURE1244
Testpositionforthetricepsbrachiipatientprone.
FIGURE1245
Testpositionforthetricepsbrachiipatientsupine.
FIGURE1246
Testpositionforthetricepsbrachiipatientsitting.
Witheachoftheforegoingpositions,theclinicianusesonehandtostabilizetheupperarmandplacestheother
handproximaltothepatientswrist.Thepatientisaskedtoholdthearmpositionwhiletheclinicianappliesa
forceintoelbowflexion.
Substitutionortrickmotionscanincludeflexionoftheshoulder.Thegravityminimized/eliminatedpositionfor
thismuscleiswiththepatientpositionedinsittingwiththeshouldersupportedin90degreesofabductionand
internalrotationandwiththeelbowflexedandtheforearminneutral.
MuscleTestingoftheWristandForearm
Themusclesoftheforearmarecontainedwithinthreemajorfascialcompartments,theanteriorforearm,the
posteriorforearm,andthecompartmentreferredtoasthemobilewad,andcanbesubdividedintothe19
intrinsicmusclesthatariseandinsertwithinthehandandthe24extrinsicmusclesthatoriginateintheforearm
andinsertwithinthehand(seeChapter18).
PalmarisLongus
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeforearmsupinatedandis
askedtoflexthewristandcupthepalm(Fig.1247).Whilesupportingthepatientsforearmwithonehand,the
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clinicianusestheotherhandtoapplyanuncuppingandwristextensionforcetothethenarandhypothenar
eminencesofthepatientshand(seeFig.1247).
FIGURE1247
Testpositionforthepalmarislongus.
FlexorDigitorumSuperficialis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeforearmsupportedin
supinationandthemetacarpophalangeal(MCP)jointstabilizedbytheclinician.Thepatientisaskedtobendthe
middlephalanxofthefinger(Fig.1248).Ifnecessary,thecliniciancanstabilizethethreefingersthatarenot
beingtestedinextensionandpreventthewristfromflexing.Thecliniciantestseachfingerindividuallyby
applyinganextensionforcetotheanterioraspectofthemiddlephalanxwhileaskingthepatienttopreventthe
movement.
FIGURE1248
Testpositionfortheflexordigitorumsuperficialis.
FlexorPollicisLongus
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththehandsupportedandthe
forearminsupination.Usingonehand,theclinicianstabilizestheMCPjointofthethumbintoextension(Fig.
1249)andusestheotherhandtogenerateanextensionforcetotheanterioraspectofthedistalphalanxofthe
thumb(seeFig.1249).
FIGURE1249
Testpositionforflexorpollicislongus.
FlexorDigitorumProfundus
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththewristinaneutralpositionor
slightlyextended.Usingonehand,theclinicianstabilizestheproximalandmiddlephalangesofthefingertobe
tested.ThepatientisaskedtoflextheDIPjointofthefingerwhiletheclinicianappliesanextensionforcetothe
anterioraspectoftheDIP(Fig.1250).
FIGURE1250
Testpositionforflexordigitorumprofundusmuscle.
ExtensorCarpiRadialisBrevis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththeelbowfullyflexed(toplace
theECRLinapositionofmechanicalinsufficiency),andtheforearmjustshortoffullpronationsupportedby
theexaminerorthetable(Fig.1251).Thepatientisaskedtoextendthewristinaradialdirectionandtohold
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thatpositionwhiletheclinicianappliespressuretotheposterioraspectofthehandalongthesecondandthird
metacarpalbones.
FIGURE1251
Testpositionfortheextensorcarpiradialisbrevis.
ExtensorDigitorumCommunis
Tospecificallytestthismusclethepatientispositionedsupineorsittingwiththeforearmpronated,thewrist
positionedinneutralhalfwaybetweenflexionandextensionandtheMCPandproximalinterphalangeal
(PIP)jointsslightlyflexed.ThepatientisaskedtoextendtheMCPofthefingertobetestedandtoholdthat
position.Theclinicianusesonehandtostabilizethewristand,usingtwofingersoftheotherhand,applies
pressureagainsttheposteriorsurfacesofthepatientsproximalphalanges(Fig.1252).
FIGURE1252
Testpositionfortheextensordigitorumcommunis.
ExtensorDigitiMinimi
Tospecificallytestthismusclethepatientispositionedsupineorsittingwiththeforearmpronated,thewrist
positionedinneutralhalfwaybetweenflexionandextensionandtheMCPandPIPjointsslightlyflexed.The
patientisaskedtoextendtheMCPofthefifthdigitandtoholdthatposition.Theclinicianusesonehandto
stabilizethewristand,usingtwofingersoftheotherhand,appliespressureagainsttheposteriorsurfaceofthe
patientsproximalphalange(Fig.1253).
FIGURE1253
Testpositionfortheextensordigitiminimi.
ExtensorCarpiUlnaris
Tospecificallytestthismuscle,thepatientispositionedsittingorsupinewiththeforearmpositionedin
completepronation.Thepatientisaskedtoextendthewristinanulnardirectionandtoholdthisposition.Using
onehandtostabilizethepatientsforearm,theclinicianusestheotherhandtoapplypressuretotheposterior
aspectofthepatientshandalongthefifthmetacarpalboneinaradialdirection(Fig.1254).
FIGURE1254
Testpositionfortheextensorcarpiulnaris.
AbductorPollicisLongus
Tospecificallytestthismuscle,thepatientispositionedsittingorsupine.Thepatientisaskedtoabductand
slightlyextendthethumbandtoholdthatposition.Usingonehand,theclinicianstabilizesthepatientswrist
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andusestheotherhandtoapplyanadductionandflexionforceagainstthelateralaspectofthedistalfirst
metacarpal(Fig.1255).
FIGURE1255
Testpositionfortheabductorpollicislongus.
ExtensorPollicisBrevis
Tospecificallytestthismuscle,thepatientispositionedsittingorsupinewiththeMCPjointofthethumb
extended.Usingonehand,theclinicianstabilizesthepatientswrist,whileusingafingerfromtheotherhandto
applyaflexionforceagainsttheproximalphalanxofthethumb(Fig.1256).
FIGURE1256
Testpositionfortheextensorpollicisbrevis.
ExtensorPollicisLongus
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupinewiththethumbextended.The
clinicianusesonehandtostabilizethepatientshandandusestheothertoapplyaflexionforcetothedistal
phalanxoftheposteriorsurfaceofthepatientsthumb(Fig.1257).
FIGURE1257
Testpositionfortheextensorpollicislongus.
ExtensorIndicis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupineandisaskedtoextendtheindex
finger.Theclinicianusesonehandtostabilizethepatientswristandusestheotherhandtogenerateaflexion
forcetotheposterioraspectoftheproximalphalanxoftheindexfinger(seeFig.1258).
FIGURE1258
Testpositionfortheextensorindicis.
MuscleTestingoftheHand
Themusclesofthehandarethosethatoriginateandinsertwithinthehandandareresponsibleforthefinefinger
movements(seeChapter18).
AbductorPollicisBrevis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupineandisaskedtoabductthethumb.
Usingonehand,theclinicianstabilizesthepatientswristandhandandusestheotherhandtogeneratea
downwardforceagainsttheproximalphalanxofthepatientsthumb(Fig.1259).
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FIGURE1259
Testpositionfortheabductorpollicisbrevis.
FlexorPollicisBrevis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupineandisaskedtoflexthethumb.
Usingonehand,theclinicianstabilizesthepatientswristandhandandusestheotherhandtoapplyan
extensionforcetotheanteriorsurfaceoftheproximalphalanxofthepatientsthumb(Fig.1260).
FIGURE1260
Testpositionfortheflexorpollicisbrevis.
OpponensPollicis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupineandisaskedtotouchhisorher
thumbtothelittlefinger(acombinationofflexion,abduction,andslightinternalrotation).Theclinicianuses
onehandtostabilizethepatientswristandhand,andtheotherhandtogeneratepressuretothemetacarpalbone
ofthethumbinanadductionandexternalrotationandextensiondirection(Fig.1261).
FIGURE1261
Testpositionfortheopponenspollicis.
AdductorPollicis
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupineandisaskedtomovethethumb
towardthepalm.Usingonehand,theclinicianstabilizesthepatientswristandhand,whileusingtheotherto
applyanabductionforcetotheinneraspectofthethumb(Fig.1262).
FIGURE1262
Testpositionfortheadductorpollicis.
AbductorDigitiMinimi
Tospecificallytestthismuscle,thepatientispositionedsittingorsupineandisaskedtoabductthelittlefinger.
Theclinicianusesonehandtostabilizethepatientswristandhand,andtheothertoapplyanadductionforce
againsttheulnaraspectofthemiddlephalanxofthepatientsfifthdigit(Fig.1263).
FIGURE1263
Testpositionfortheabductordigitiminimi.
FlexorDigitiMinimi
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Tospecificallytestthismuscle,thepatientispositionedsittingorsupineandisaskedtoflexthelittlefingerat
theMCPjointwhilemaintainingtheinterphalangealjointinextension.Usingonehand,theclinicianstabilizes
thepatientswristandhand,whileusingtheothertoapplyanextensionforceagainsttheflexedproximal
phalanxofthepatientsfifthdigit(Fig.1264).
FIGURE1264
Testpositionfortheflexordigitiminimi.
OpponensDigitiMinimi
Tospecificallytestthismuscle,thepatientispositionedinsittingorsupineandisaskedtotrytocupthefifth
metacarpaltowardthethumb.Usingonehand,theclinicianstabilizesthepatientswristandhand,whileusing
theotherhandtograspthefirstmetacarpalofthefifthdigitandapplyadownwardforce(Fig.1265).
FIGURE1265
Testpositionfortheopponensdigitminimi.
AnteriorInterossei
Tospecificallytestthismusclegroup,thepatientispositionedsittingorsupinewiththedigitsnotbeingtested
stabilized,andthefingerbeingtestedbroughttowardthemidline.Onebyone,theclinicianappliespressurein
anabductiondirectionagainsttheappropriatesideofthedistalphalanxofthethumb,index,ring,andlittle
finger(Fig.1266).
FIGURE1266
Testpositionfortheanteriorinterossei.
PosteriorInterossei
Tospecificallytestthismusclegroup,thepatientispositionedsittingorsupinewiththedigitsnotbeingtested
stabilized,andthefingerbeingtestedmovedawayfromthemidline.Onebyone,theclinicianappliespressure
inthedirectionofadductionagainsttheappropriatesideofthedistalphalanxofthethumb,index,ring,andlittle
finger(Fig.1267).
FIGURE1267
Testpositionfortheposteriorinterossei.
Lumbricals
Tospecificallytestthismusclegroup,thepatientispositionedinsittingorsupineandisaskedtoplacethehand
intoanintrinsicplusposition(Fig.1268)andtoholdtheposition.Usingonehand,theclinicianstabilizesthe
patientswristinminimalextension,andpressureisthenappliedintwodistinctphases:
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FIGURE1268
Testpositionforthelumbricals.
1.Aflexionforceisappliedtotheposteriorsurfacesofthedistalandmiddlephalanges.
2.Anextensionforceisappliedtotheanteriorsurfacesoftheproximalphalanges.
MuscleTestingoftheHip
Thehipjointissurroundedbyalargenumberofmusclesthataccelerate,decelerate,andstabilizethehipjoint.
Indeed,21musclescrossthehip,providingbothtriplanarmovementandstabilitybetweenthefemurand
acetabulum(seeChapter19).
Iliopsoas
Tospecificallytestthismuscle,thepatientispositionedinsupineorsitting:
Supine.Thepatientslowerextremityispositionedinkneeextension,slighthipabduction,andflexionof
thehip(Fig.1269).
Sitting.Withthekneeflexed,thepatientflexesthehip(Fig.1270).
FIGURE1269
Testpositionforiliopsoaspatientsupine.
FIGURE1270
Testpositionforiliopsoaspatientsitting.
Withbothpositions,theclinicianappliespressureonthedistalfemurinthedirectionofhipextensionwhilethe
patientattemptstopreventthemotion.Cautionshouldbetakentoensurethatthepatientdoesnotexternally
rotatethefemur,asthiswillcausethehipadductorstocontract.Substitutionortrickmotionscanincludehip
abductionandexternalrotation,hipabduction,andinternalrotation,orassistancefromtherectusfemoris.The
gravityminimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsidelyingwiththe
extremitysupportedonafrictionfreesurfaceandthehippositionedinneutralrotationwiththekneeflexedto
90degrees.
GluteusMaximus
Tospecificallytestthismuscle,thepatientispositionedinpronewiththekneeflexedtoatleast90degrees(to
eliminatehamstringactivation)andthehipextended(Fig.1271).Theclinicianappliesaforceoverthedistal
femurinadirectionofhipflexionwhilethepatientattemptstopreventthemotion.Substitutionortrickmotions
canincludeassistancefromthehamstringsoranincreaseinthelumbarlordosis.Thegravity
minimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsidelyingwiththeextremity
supportedthehipflexedto90degrees,andthekneeflexed.
FIGURE1271
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Testpositionforgluteusmaximus.
GluteusMedius
Tospecificallytestthismuscle,thepatientispositionedinsidelyingwiththetestedleguppermost.Thepatient
hipispositionedinabduction,slightextension,andexternalrotation(Fig.1272).Whilestabilizingthepelvis
withonehand,theclinicianappliesaforceofabductionandminimalflexiontothehipatthedistalfemurwhile
thepatientattemptstopreventthemotion.Substitutionortrickmotionscanincludeassistancefromthe
quadratuslumborumandthelateralabdominalswhichcantiltthepelvislaterallygivingtheappearanceof
abduction,assistancefromthegluteusmaximus(superiorfibers),orallowingthepatienttorollslightlytoward
thesupineposition,whichplacesthetensorfasciaelatae(TFL)inamorefavorablepositionforhipabduction.
Thegravityminimized/eliminatedpositionforthismuscleiswiththepatientpositionedinsupinewiththe
extremityonafrictionfreesurface.
FIGURE1272
Testpositionforgluteusmedius.
GluteusMinimus
Tospecificallytestthismuscle,thepatientispositionedinsidelyingwiththetestedsideuppermost.Thepatient
isaskedtoabductthehipwhileavoidinganyrotation,flexion,orextensionofthehip(Fig.1273).While
stabilizingthepelviswithonehand,theclinicianappliesanadductionandminimalextensionforcetothehipat
thedistalfemurwhilethepatientattemptstopreventthemotionfromoccurring.
FIGURE1273
Testpositionforgluteusminimus.
TensorFasciaeLatae
Tospecificallytestthismuscle,thepatientispositionedinsupinewiththekneeextended.Thepatientisasked
toabduct,flex,andinternallyrotatethehipandtoholdtheposition(Fig.1274)whiletheclinicianapplies
resistanceinadirectionofhipextensionandhipabduction(therotationalcomponentisnotresisted)onthe
distaltibia.Substitutionortrickmotionscanincludeassistancefromthehipflexors.Thegravity
minimized/eliminatedpositionforthismuscleiswiththepatientpositionedinlongsittingwiththehips
supportedonthetable,flexedto45degreesandinneutralrotation,andtheupperextremitiessupportingthe
trunk.
FIGURE1274
Testpositionfortensorfasciaelatae.
RectusFemoris
ThespecifictestforthismuscleisdescribedinthesectionMuscleTestingoftheKnee.
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HipExternalRotators
Thehipexternalrotatorsincludethepiriformis,quadratusfemoris,obturatorinternus,obturatorexternus,
gemellussuperior,andgemellusinferior.Theexternalrotatorsofthehiparetestedasagroup.Thepatientis
positionedinsittingwiththethighsupportedonthetableandthelowerlegovertheendofthetable.Thepatient
rotatesthehipexternallysuchthatthefootmovestowardthecontralateralside(Fig.1275).Usingonehand,the
clinicianstabilizesthepatientsthighwhilewiththeotherhandgeneratingaforceofinternalrotationofthehip
byapplyingpressuretotheinneraspectoftheleg(seeFig.1275).
FIGURE1275
Testpositionforexternalrotatorsofthehip.
HipInternalRotators
TheinternalrotatorsofthehipconsistoftheTFL,gluteusminimus,andgluteusmedius(anteriorfibers).These
musclesaretestedasagroup.Thepatientispositionedinsittingwiththethighsupportedonthetableandthe
lowerlegovertheendofthetable.Thepatientrotatesthehipinternallysuchthatthefootmovesawayfromthe
contralateralside.Usingonehand,theclinicianstabilizesthepatientsthighwhilewiththeotherhand
generatingaforceofexternalrotationofthehipbyapplyingpressuretotheouteraspectoftheleg(Fig.1276).
FIGURE1276
Testpositionforinternalrotatorsofthehip.
HipAdductors
Thehipadductorsaretestedasagroup.Thepatientispositionedinsidelyingwiththetestedsideclosesttothe
table.Thecliniciansupportstheuppermostleginhipabduction,andthepatientisaskedtoadductthelowerleg
offthetable(Fig.1277).Thegravityminimized/eliminatedpositionforthismusclegroupiswiththepatient
positionedinsupine.
FIGURE1277
Testpositionforhipadductormusclegroup.
Sartorius
Tospecificallytestthismuscle,thepatientispositionedinsupine.Thepatientisaskedtoexternallyrotate,
abduct,andflexthehipwhilealsoflexingtheknee.Theclinicianplacesonehandontheouteraspectofthe
patientskneeandusestheotherhandtocupthepatientsheel.Thepatientisaskedtopreventanymotionasthe
clinicianappliesanextension,internalrotation,andadductionforcetothehipwhilealsoapplyinganextension
forcetotheknee(Fig.1278).
FIGURE1278
Testpositionforsartorius.
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Hamstrings
Thehamstringsmusclegroupconsistsofthebicepsfemoris,thesemimembranosus,andthesemitendinosus.
ThespecifictestsforthesemusclesaredescribedinthesectionMuscleTestingoftheKnee.
MuscleTestingoftheKnee
Themajormusclesthatactonthekneejointcomplexarethequadriceps,thehamstrings(semimembranosus,
semitendinosus,andbicepsfemoris),thegastrocnemius,thepopliteus,andthehipadductors(seeChapter20).
Quadriceps
Tospecificallytestthismusclegroup,thepatientispositionedsittingattheedgeofthetablewiththethigh
supportedandtheleghangingovertheedge(Fig.1279).Thepatientisaskedtoleanbackwardtorelaxthe
hamstringsandthentostraightenthekneetojustshortoffullextension.Usingonehand,theclinicianstabilizes
thepatientsthighandplacestheotherhandovertheanteriorsurfaceofthedistallegjustproximaltotheankle.
Theclinicianappliesaforceintokneeflexionwiththehandjustproximaltotheanklewhileaskingthepatient
toresistthemovement.
FIGURE1279
Testpositionforthequadricepsfemorisgroup.
Hamstrings
Thehamstringsarespecificallytestedbasedontheiranatomythesemimembranosusandsemitendinosusare
testedtogether,andthebicepsfemorisistestedseparately.Thegravityminimized/eliminatedpositionforthis
musclegroupiswiththepatientpositionedinsidelyingwiththetestedlegonafrictionfreesurface.
Tospecificallytestthesemimembranosusandsemitendinosus,thepatientispositionedinpronewiththe
kneeflexedtoapproximate45degreesandthetibiainternallyrotatedsothatthetoesarepointinginward
(Fig.1280).Usingonehandtostabilizethepatientsthigh,theclinicianplacestheotherhandjust
proximaltotheankleontheposterioraspectofthepatientslegandappliesaforcetowardkneeextension
whileaskingthepatienttopreventthemotion(seeFig.1280).
Tospecificallytestthebicepsfemoris,thepatientispositionedinpronewiththekneeflexedto
approximately45degreesandthetibiainslightexternalrotationsothatthetoesarepointingoutward
(Fig.1281).Usingonehandtostabilizethepatientsthigh,theclinicianplacestheotherhandjust
proximaltotheankleontheposterioraspectofthepatientslegandappliesaforcetowardkneeextension
whileaskingthepatienttopreventthemotion(seeFig.1281).
FIGURE1280
Testpositionforthebicepsfemoris.
FIGURE1281
Testpositionforthesemitendinosusandsemimembranosus.
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Gastrocnemius
ThespecifictestforthismuscleisdescribedintheMusclesoftheLegandFootsectionlater.
Popliteus
Tospecificallytestthismuscle,thepatientispositionedinsittingwiththekneeflexedto90degrees.Thepatient
isaskedtointernallyrotatethetibia(Fig.1282).Thereisnoresistanceappliedforthistestthetestisusedto
determinewhetherthemuscleisactiveandcapableofinternallyrotatingthetibia.
FIGURE1282
Testingthefunctionofthepopliteus.
MuscleTestingoftheLegandFoot
Twentythreemusclesareinvolvedwithmotionatthefootandankle,12ofwhichoriginateonthetibiaor
fibula,and11onthefootitself(seeChapter21).
TibialisAnterior
Tospecificallytestthismuscle,thepatientispositionedinsupineorsitting,andthepatientsfootispositioned
indorsiflexionandinversion,withthegreattoepointingdownward(tominimizeactivationoftheextensor
hallucislongus).Thekneemustremainflexedduringthetesttoallowcompletedorsiflexion.Usingonehand,
thelegisstabilizedbytheclinician,whileresistanceisappliedtothemedialposterioraspectoftheforefootin
aninferior/lateraldirectionintoplantarflexionandeversion(Fig.1283).
FIGURE1283
Testingpositionfortibialisanterior.
ExtensorDigitorumLongus
Tospecificallytestthismuscle,thepatientispositionedsittingorsupine,andthepatientisaskedtoextendthe
toes.Usingonehandtostabilizetheankleandkeepingthefootinslightplantarflexion,theclinicianusesthe
otherhandtoapplyforceagainsttheproximalphalangesoftoes2through5inthedirectionoftoeflexion(Fig.
1284).
FIGURE1284
Testpositionforextensordigitorumlongus.
ExtensorHallucisLongus
Tospecificallytestthismuscle,thepatientispositionedinsupineorsitting,andtheankleispositionedina
neutralposition.ThepatientisaskedtoextendtheMTPandinterphalangealjointsofthegreattoeandtoholda
positionwhiletheclinicianappliespressureonthedistalphalanxinaplantarflexiondirection(Fig.1285).
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FIGURE1285
Testpositionfortheextensorhallucislongus.
Fibularis(Peroneus)Tertius
Tospecificallytestthismuscle,thepatientispositionedsitting,orsupineandthepatientisaskedtodorsiflex
andthenevertthefoot(Fig.1286).Whileusingonehandtostabilizethepatientslowerleg,theclinicianuses
theotherhandtoapplypressureonthedorsalandlateralaspectsofthefootintoaplantarflexionandinversion
directionwhileaskingthepatienttopreventthemotion.
FIGURE1286
Testpositionfortheperoneustertius.
Gastrocnemius
Tospecificallytestthegastrocnemius,thepatientispositionedinstandingononelegholdingontosomething
forbalance.Keepingthekneestraight,thepatientisaskedtoraiseuponthetoes(Fig.1287).Foranormal
grading,thepatientshouldbeabletorepeatthis10times.
FIGURE1287
Testpositionforthegastrocnemius.
Soleus
Tospecificallytestthismuscle,thepatientispositionedinpronewiththekneeflexedto90degrees.Usingone
hand,theclinicianstabilizesthedistallegofthepatientbyholdingtheproximalankle.Thepatientisaskedto
plantarflextheanklewithoutinversionoreversionofthefoot,andtheclinicianappliesadorsiflexionforceto
theposteriorcalcaneus(Fig.1288).
FIGURE1288
Testpositionforthesoleus.
Plantaris
Theplantarismuscleistestedusingthespecifictestofthegastrocnemius.
TibialisPosterior
Tospecificallytestthismuscle,thepatientispositionedsupineorsittingwiththefootandankleplantarflexed
andinverted.Thepatientisaskedtosustainthispositionthroughoutthetest.Usingonehand,theclinician
stabilizestheproximaltothepatientsankle,whileusingtheotherhandtoapplyaneversionanddorsiflexion
forcetothepatientsfootandankle(Fig.1289).
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FIGURE1289
Testpositionforthetibialisposterior.
FlexorDigitorumLongus
Tospecificallytestthismuscle,thepatientispositionedsupineorsitting.Thepatientisaskedtoflexthetoes
andtosustainthepositionthroughoutthetest.Usingonehandtostabilizethemidfoot,theclinicianappliesan
extensionforcetothetoes(Fig.1290).
FIGURE1290
Testpositionfortheflexordigitorumlongus.
FlexorHallucisLongus
Tospecificallytestthismuscle,thepatientispositionedinsupineorsittingandisaskedtoflexthegreattoe.It
isimportanttonotethatthepatientmayhavedifficultyisolatingthemotionofthistoefromtheothertoes.
Usingonehandtostabilizethepatientsankle,theclinicianusestheotherhandtostabilizethemetatarsalswhile
applyinganextensionforceofthegreattoe(Fig.1291).
FIGURE1291
Testpositionfortheflexorhallucislongus.
Fibularis(Peroneus)LongusandBrevis
Bothofthesemusclesaretestedtogether.Thepatientispositionedinsittingorsupineandisaskedtoplantarflex
andevertthefoot(Fig.1292).Usingonehand,theclinicianstabilizesthedistallegand,usingtheotherhand,
appliesaforceonthelateralaspectofthefootintoinversionanddorsiflexion.
FIGURE1292
Testpositionfortheperoneuslongusandbrevis.
AbductorHallucis
Tospecificallytestthismuscle,thepatientispositionedinsupineorsitting.Usingonehand,theclinician
stabilizesthepatientsfootwhileusingtheotherhandtoapplyadductionforcetothegreattoeandwhileasking
thepatienttopreventthemotion(Fig.1293).Itisimportanttorememberthatthismuscleisdifficultformany
peopletoisolate.
FIGURE1293
Testpositionfortheabductorhallucis.
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Abductordigitiminimi.Thismusclearisesfromthelateralprocessofthecalcanealtuberosityaswellas
theplantaraponeurosisandinsertsintothelateralsideofthebaseoftheproximalphalanxofthelittletoe.
Themusclefunctionstoassistinflexionoftheinterphalangealjointofthefifthdigitandtostabilizethe
forefoot.Thesynergistsofthismuscleincludetheflexordigitorumlongusandthefourthlumbrical.The
antagonisttothismuscleisthefifthanteriorinterossei.Thereisnospecifictestforthismuscle.
Flexordigitorumbrevis.Tospecificallytestthismuscle,thepatientispositionedinsittingorsupine.
Usingonehandtostabilizethepatientsmidfoot,theclinicianusestheotherhandtoapplypressure
againsttheplantarsurfaceofthePIPjointsofthesecondthroughfifthdigits(Fig.1294).
Flexordigitorumaccessories.Thereisnospecifictestforthismuscle.
Lumbricals.Tospecificallytestthesemuscles,thepatientispositionedsupineorsittingandisaskedto
flextheMTPjointsofthefeet.Whileusingonehandtostabilizethepatientsfoot,theclinicianusesthe
otherhandtoapplyanextensionforceundertheMTPjointsoftoes2through4(Fig.1295).
Flexorhallucisbrevis.Tospecificallytestthismuscle,thepatientispositionedinsupineorsitting.Using
onehandtostabilizethefootproximaltotheMTPjointandmaintaininganeutralpositionofthefootand
ankle,theclinicianusestheotherhandtoapplyanextensionforceattheMTPjointsofthegreattoe(Fig.
1296).
Adductorhallucis.Thereisnospecifictestforthismuscle.
Posterior(dorsal)andanterior(plantar)interossei.Tospecificallytestthesemusclegroups,thepatient
ispositionedinsupineorsittingandisaskedtoextendtheinterphalangealjointsofthefourlateraltoes.
TheclinicianstabilizestheMTPjointsandplacesafingerontheposteriorsurfaceofthedistalphalanges
ofeachtoeinthedirectionofflexion(Fig.1297).
FIGURE1294
Testpositionfortheflexordigitorumbrevis.
FIGURE1295
Testpositionforthelumbricals.
FIGURE1296
Testpositionfortheflexorhallucisbrevis.
FIGURE1297
Testpositionfortheinterosseimuscles.
ContraindicationstoStrengthening,Endurance,andPowerExercises
Absolutecontraindicationsincludeunstableangina,uncontrolledhypertension,uncontrolleddysrhythmias,
hypertrophiccardiomyopathy,andcertainstagesofretinopathy.Patientswithcongestiveheartfailure,
myocardialischemia,poorleftventricularfunction,orautonomicneuropathiesmustbecarefullyevaluated
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beforeinitiatinganexerciseprogram.Typically,thepresenceofpainandinflammationarecontraindicationsto
resistanceexercisesuntilbotharecontrolled.
Anumberofprecautionsneedtobetakenwhenexercisingpatientswhohaveacompromisedcardiovascularor
pulmonarysystem(seeChapter15):
Anappropriatelevelofintensitymustbechosen.Toohighalevelcanoverloadthecardiorespiratory
systemcausingittoworkanaerobically,notaerobically.Toohighanintensitycanoverstressthemuscular
system,whichcanpotentiallycauseinjuries.
Asufficientperiodoftimeshouldbeallowedforwarmupandcooldowntopermitadequate
cardiorespiratoryandmuscularadaptation.
CLINICALPEARL
Contraindicationstomuscleperformancetraining:
Inflammation.Exercisecanincreaseswellingandcausedamagetomusclesorjoints.
Pain.Severejointormusclepainduringexercise,orformorethan24hoursafterexercise,requiresan
eliminationorreductionoftheexercise.
Overtraining
Whilethegoalofanyrehabilitationprogramistogetthepatientbetterasquicklyaspossible,safetymustnever
besacrificedforefficiency.Overtrainingoccursbecauseofaninsufficientamountofrest,recovery,and
unloading.Overtrainingresultsinalossofthebodysadaptivecapabilityafterchronichighvolumeloading,or
inresponsetoanexcessiveincreaseineitherdurationorintensityoftraining.Twotypesoffatigueare
recognized:musclefatigue(seeChapter1),andcardiopulmonaryfatigue(seeChapter15).Thesignsand
symptomsofovertrainingincludeaninabilitytorecoverfromexercise,aloweredresistancetoinjury,adecline
inperformance,chronicfatigueorexhaustion,lossofappetite,inabilitytosleep,lethargy,musclesoreness,and
analteredmetabolism.46Overtrainingshouldnotbeconfusedwithoverloadingwhichisdiscussedinthe
SpecificityofTrainingsection.
Otherpotentialindicatorsofovertrainingincludedelayedonsetmusclesoreness(DOMS),stressfracture(see
Chapter2),pathologicalfracture,andaprolongedincreaseinsymptoms.
DelayedOnsetMuscleSoreness
Familiartomostindividualsatsometime,muscularsorenessisoneofthedrawbackstoparticipatinginan
exerciseprograminvolvingactivitybeyondwhatoneusuallyexperiences.Thepurposeoftherecoveryphaseis
torestorethemusclesinthebodytopreexerciselevelsthroughpromotionofvenousturnandremovalof
metabolitesfrommuscle,reestablishmentoffluidbalance,replacementofdepletedfuelenergyreserves,and
relaxationinmusclesthatwereactive.7Therecoveryperiodisalsonecessarytoreplenishmuscleglycogen
followingprolongedexerciseofthecontinuousorintegralnature.Iftherecoveryperiodisinsufficient,DOMS
canresult.Acutesorenessisapparentduringthelaterstagesofanexerciseboutandduringtheimmediate
recoveryperiod.8Thisresultsfromanaccumulationofendproductsthatoccurswithexercise,specificallyH+
ions,andlactate,butgenerallydisappearsinbetween2minutesand1houraftercessationofexercise.8DOMS,
ontheotherhand,appears2456hoursaftertheexercisebout,9andcanexhibitasanything,fromminormuscle
sorenesstodebilitatingpainandswelling,butismostcommonlydescribedascausingareductioninjointrange
ofmotion,shockattenuation,andpeaktorque.10ArecentreviewofDOMSconfirmsthatthemechanisms,
treatmentstrategies,andimpactonathleticperformanceremainuncertain.11Recognizedmechanismsinclude
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lacticacidandpotassiumaccumulation,musclespasms,mechanicaldamagetotheconnectivetissues,
inflammation,enzymeeffluxsecondarytomusclecelldamage,andedema.11DOMSisalsoassociatedwith
structuraldamagetothesubcellularcomponentsofmusclefibers,includingthesarcolemma,membranesinthe
sarcoplasmicreticulum,theTtubule,andthemyofibrils.12Thisdamagecanresultinmuscleweaknessupto
46%immediatelyafterexercise,andforupto72hoursafterexercise.12
Thereisamarkedincreaseintheproportionofdisruptedmusclefibersaftereccentricexerciseascomparedwith
concentricexercise,whichhasbeenroughlycorrelatedtothedegreeofDOMS.13Eccentricexerciseisalso
linkedtomorphologicandmetabolicsignsofmusclealteration:myofibrillardamagealongtheZband,14,15
mitochondrialswelling,14,15increasedintramuscularpressure,14,15andimpairedglycogenresynthesis.
GiventheroleofeccentricexerciseinDOMS,preventionofDOMSinvolvesthecarefuldesignofanyeccentric
program,whichshouldincludepreparatorytechniques,accuratetrainingvariables,andappropriateaftercare,
includingacooldownperiodoflowintensityexercisetofacilitatethereturnofoxygentothemuscle.Itisa
widelyheldbeliefamongathletesandcoachesthatmassageisaneffectivetherapeuticmodalitythatcan
enhancemusclerecoveryandreducesorenessfollowingintensephysicalactivity.16However,theactual
scientificliteraturedoesnottendtosupportthepositiveefficacyofmanualmassageasapostexercise
therapeuticmodalityintheathleticsetting.1618
TohelppreventDOMS,thereissomecontroversyastowhetheracooldownorwarmupshouldbeused.A
numberofstudiesadvocateashort(510minutes)lowintensitywarmup(3065%ofVO2max)toassistin
maintainingvenousreturnandremovalofmetabolitesabovelevelsduringpassiverest.19,20However,one
randomizedcontrolledtrialfoundthatwhereasa10minutewarmupreducedperceivedmusclesoreness
(measuredona100mmvisualanaloguescale)48hoursafterexercise(meaneffectof13mm,95%CI224
mm),a10minutecooldownhadnoapparenteffect(meaneffectof0mm,95%CI111mm).21
IfthepreventionofDOMSisunsuccessful,theinterventionshouldinclude,asappropriate,rest,localmeasures
toreduceedema(e.g.,cryotherapy,elevationoftheinvolvedlimb(s)),drugtherapy(typicallynonsteroidalanti
inflammatoryagents),orfurtherexercise(aerobicsubmaximalexercisewithnoeccentriccomponent,e.g.,
swimming,biking,orsteppermachine,painfreeflexibilityexercises,andhighspeed[300degreespersecond]
concentriconlyisokinetictraining).22,23
PathologicalFracture
Apathologicfractureoccurswhenabonebreaksinanareathatisweakenedbyanotherdiseaseprocess.Causes
ofweakenedboneincludetumors,infection,osteoporosisorosteopenia,andcertaininheritedbonedisorders
(seeChapter5).Ifthereisnoknownhistoryofosteoporosis,theclinicianmustrecognizethosefactorsthat
placeapatientatriskforosteoporosis.Forexample,postmenopausalwomenareathighriskasarethosewho
areassociatedwithprolongedimmobilizationordisuse,restrictedweightbearing,orextendeduseofcertain
medications,suchassystemiccorticosteroidsorimmunosuppressants.Somewhatironically,weightbearingand
resistanceexercisesareanessentialelementoftherehabilitationforindividualswith,oratriskfor,osteoporosis.
However,highimpactactivitiessuchasjumpingorhopping,excessivetrunkflexionwithrotation,andactivities
thatcausetorsionalmovementsofthehipsshouldbeavoided.
PhysiologicalChangeswithResistanceExercise
Toincreasemusclestrengthmosteffectively,amusclemustworkwithincreasingeffortagainstprogressively
increasingresistance.24Inastrengthtrainingprogram,thetermloadreferstotheamountofweightusedina
specificexercise.Moststrengthandconditioningprogramsdescribetheloadasapercentageofarepetition
maximum(RM).TheRMcanbeexpressedasthegreatestamountofloadliftedonetime(1RM).Astheload
becomesheavier,thenumberoftimesanindividualcanlifttheload(performarep)decreases,whereasifthe
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loadbecomeslighter,morerepscanbeaccomplished.Ifresistanceisappliedtoamuscleasitcontractssothat
themetaboliccapabilitiesofthemuscleareprogressivelyoverloaded,adaptivechangesoccurwithinthemuscle,
whichmakeitstrongerovertime.25,26Theseadaptivechangesincludethefollowing2733:
Anincreaseintheefficiencyoftheneuromuscularsystem.Neuraladaptationsareattributedtomotor
learningandimprovedcoordination.Innormalindividuals,anincreaseinstrengthafteraresistedexercise
programisthoughttoinitiallyoccurasaresultofneuraladaptation.Thisincreasedefficiencyresultsin
anincreaseinthenumberofmotorunitsrecruited,withanincreaseinthefiringrateofeachmotor
unit,
anincreaseinthesynchronizationofmotorunitfiring,and
animprovementintheenduranceofthemuscle.
Anincreaseinthesizeofthemuscle(hypertrophy).Iftheexerciseiscontinuedforalongerperiod,the
initialadaptationoftheneuromuscularsystemisfollowedbyhypertrophy(andpossiblehyperplasia)34,35
ofmusclefibers.Hypertrophyisanincreaseinthebulkofanindividualmusclefibercausedbyan
increaseinmyofibrillarvolume(seeChapter1).ThegreatestamountofhypertrophyoccursinthetypeIIb
fibers.Mitochondriaarethemainsubcellularstructuresthatdeterminetheoxygendemandofmuscle.
Thereisaconsensusthatthereisadilutionofmitochondrialvolumedensitythroughanincreasein
myofibrillar(i.e.,contractileprotein)volumedensityasaconsequenceofstrengthtypeexercise
training.36,37Thisincreaseinmyofibrillarvolumedensity,orhypertrophythatoccurswithstrength
trainingisregardedasthemaincauseoftheoverallincreaseintheanatomicalcrosssectionalarea(CSA)
ofanentiremusclegroup.Thefiberhypertrophyistypicallygreaterforfastthanforslowtwitchmuscle
fibers,38althoughthereisremodelingoftypeIIbtotypeIIa,thereisnochangeinthedistribution/ratioof
typeIandtypeIIfibers.
Changesinthemetabolicsystemandenzymaticactivity(seeChapter1).Overallthereisanincreasein
ATP,andphosphocreatine(PCr)andmyoglobinstorage,andrisesincreatinephosphokinaseand
myokinase.
Anincreaseintheforceperunitarea.Strengthtraininghasalsobeenshowntoleadtoanincreaseinthe
forceperunitCSAofthemuscle.Thiseffecthasbeenattributedeithertoanincreaseinneuraldrive39or
toanactualincreaseinmusclespecifictensionduetoadenserpackingofmusclefilaments.40Adenser
packingofcontractiletissuealongthetendoncouldtheoreticallyincreasetheangleofpennationof
musclefibers.41
Areductioninthetimetopeakforce.42Thiscanbedefinedasthetimefromtheonsetofmuscle
activationuntilpeakforceisattained.
Stimulationofslowtwitchfibers(whenperformingworkloadsoflowintensity)andstimulationoffast
twitchIIafibers(whenperformingworkloadsofhighintensityandshortduration).
Rhythmicactivitiesincreasebloodflowtotheexercisingmusclesviacontractionandrelaxation.
Thepowerofthemuscleimproves.
Improvedbonemass(Wolffslaw).
Anincreaseinmetabolism/calorieburning/weightcontrol.
Increasedintramuscularpressureresultsfromamusclecontractionofabout60%ofitsforce
generatingcapacity.
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Cardiovascularbenefitswhenusinglargemusclegroups.Strengthtrainingofspecificmuscleshasa
briefactivationperiodandusesarelativelysmallmusclemass,producinglesscardiovascularmetabolic
demandsthanvigorouswalking,swimming,etc.
Changesinbodycomposition.Overaperiodoftime,thereisanincreaseinlean(fatfree)bodymassand
adecreaseinthepercentageofbodyfat.
Adaptivechangesintheconnectivetissue.Thetensilestrengthofligaments,tendons,andtheconnective
tissueinmuscleincreases.Thereisalsoanincreaseinbonemineraldensity(BMD).
Anincreaseintherateofforcedevelopment.42
Conversely,amusclecanbecomeweakoratrophiedthrough:
Disease.
Neurologiccompromise.
Immobilization.Continuousimmobilizationofskeletalmuscletissuescancausesomeundesirable
consequences(seeChapter2).Theseincludeweaknessoratrophyofmuscles.TypeI(slowtwitch)muscle
fibersatrophyatafasterratethantypeII(fasttwitch)fibers.43Muscleatrophyisanimbalancebetween
proteinsynthesisanddegradation.Aftermodesttrauma,thereisadecreaseinwholebodyprotein
synthesisratherthanincreasedbreakdown.Withmoreseveretrauma,majorsurgery,ormultipleorgan
failures,bothsynthesisanddegradationincrease,thelatterbeingmoreenhanced.
Disuse.
SpecificityofTraining
Itappearsthatthemuscleresponsetoresistancetrainingforpeoplewhohaveabroadrangeofconditionsand
whomightconsultaphysicaltherapistissimilartomuscleresponsesreportedinyoungpeoplewithout
impairment.44Resistancetrainingcanhaveabeneficialeffectinpopulationswherepainisaparticularproblem,
suchaspeoplewithlowbackpainandpeoplewithosteoarthritis.Inaddition,resistancetrainingcanhavea
beneficialeffectonconditionssuchashighbloodpressure,fracturerehabilitation,andcardiovasculardisease.
Theeffectofresistancetrainingonotherimpairmentparameters,suchasBMD,fatmass,andaerobiccapacity,
remainsinconclusive.44Thereisalsoevidencetosuggestthatimprovementsintheabilitytogeneratemuscle
forcecancarryoverintoanimprovedabilitytodoeverydaytasks.Thisphenomena,referredtoastransferof
trainingorcrosstraining,canprovideimprovementsinvariousparametersofstrengthinnotonlythemuscles
used,buteveninanonexercised,contralaterallimb4547However,theeffectsaregenerallyquitemodest,and
thereareanumberofexamplesintheliteraturewheresignificantimprovementsinactivitywerenot
demonstratedafterresistancetraining.44Partoftheproblemwithdrawingconclusionsfromtheliteratureisthe
lackofdetailsprovidedastothespecificsoftheexercisesprescribed.Specificityoftrainingisanaccepted
conceptinphysicaltherapyrehabilitation.Thisconceptinvolvestheprincipleofthespecificadaptationto
imposeddemand(SAID).Thus,thefocusoftheexerciseprescriptionshouldbetoimprovethestrengthand
coordinationoffunctionalorsportsspecificmovementswithexercisesthatapproximatethedemandsofthe
desiredactivity(speed,agility,strength,power,endurance,etc.).Inaddition,exerciseprotocolsshouldmimic
thework:restratiosofaparticularsport.48Forexample,asawrestlercompetesin3minuteperiodsofvarying
intensity,theexerciseprogressionsshouldbemadebyincreasingtheintensityorthenumberof3minute
intervals.
CLINICALPEARL
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Theprincipleofoverloadstatesthatagreaterthannormalstressorloadonthebodyisrequiredfortraining
adaptationtotakeplace.Toincreasestrength,themusclemustbechallengedatagreaterlevelthanitis
accustomedto.Highlevelsoftensionwillproduceadaptationsintheformofhypertrophyandrecruitmentof
moremusclefibers.
ThreeimportantconceptsarerelatedtotheSAIDprinciple7:
Overload.Whencells,tissues,andorgansareloadedbeyondwhattheynormallyarerequiredtodo,they
willadapttopermitthemtodealwiththesenewloadsmoreeffectively.Thesetrainingeffectsarespecific
totheenergysupplysystemsthathavebeenutilized,thelocaleofthestimulus,thespecificmuscle
groups,thejointaction(s),thetypeofcontraction,andthespeedofcontraction.Whenloadsareapplied,
theyshouldbespecifictothedesiredeffect(SAID),andbeappropriatetotheindividualintermsof
frequency,intensity,andduration.Itisimportanttorememberthatonceanadaptationhastakenplacetoa
specificload,thisloadisnolongeranoverload,andtheloadmustbeprogressivelyincreasedtoget
furtherimprovements.
Underload.Whencells,tissues,andorgansareloadedatalevelbelowwhatisnormallyperformed,the
bodywilladaptbydecreasingitsabilityintheunderloadedcomponent(detraining).Detraining,or
reversibility,occursquicklyafterthecessationoftrainingareductionintheVO2maxcanbedetected
withinaweekortwoofdetrainingandcontinuesuntiltrainingeffectsarelost.Therefore,itisimportant
thatpatientsareprescribedmaintenanceprogramstocontinueexercisingoncetheirphysicaltherapy
sessionshaveended.
CLINICALPEARL
Anoverprescriptionofresistancetrainingexercisemayresultinoverstressinjuries,whereasunderprescription
willresultinafailuretoachievethenecessaryordesiredstrengthimprovement.
TheSAIDprinciplecanbeappliedbyexercisingthemusclesalongeachextremityandwithinthetrunkin
functionalpatterns.49Theexercisecomponentoftheinterventionshouldbeasspecificasthemanualtechnique
usedintheclinic.Musclescanbeclassifiedintotonicandphasicgroupsaccordingtohowmusclesdevelop
fromthemyotomes50(Table122)(seeChapter1).
TABLE122TheVariousMuscleTypesandTheirPrimaryInnervation
MuscleType Characteristics PrimaryInnervation Examples
Extensors
TypeI Tonic Type1aphasicnerveendings Externalrotators
Abductors
Slowtwitch
Smallneuron
Flexors
TypesIIaandIIb Phasic Anteriordivisionsofthenerveplexus Adductors
Twojointmuscles
Fasttwitch
Largeneuron
DatafromWilkKE,VoightML,KeirnsMA,etal.Stretchshorteningdrillsfortheupperextremities:theoryand
clinicalapplication.JOrthopSportsPhysTher.199317:225239.
CLINICALPEARL
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Ingeneral,tonicmusclesfunctionasendurance(postural)muscles,whereasphasicmusclesfunctionasthe
powermuscles.51,52
Speedstrengthtrainingappliestheprinciplesofspecificityoftrainingandistypicallyusedwithhighly
conditionedathleteswhowanttotaketheirperformancetothenextlevel.Speedstrengthtraininginvolves
takingsomeofthebasicmovementsofataskandincreasingtheresistance.Forsports,suchasbaseballand
golf,athletescanusedevices,suchasanoversizedballorweightedgolfclub,totrainthearmsandtrunkto
workagainstagreaterresistance.Sprintershavelongbenefitedfromtheuseofasmallparachutetoincrease
windresistance,orbydraggingatirefastenedbyarope.Sincethetwocomponentsofspeedproductionare
stridelengthandstridefrequency,exerciseprotocolscanbedesignedtoincreasebothofthesecomponents:48
Stridelengthcanbeimprovedbyrunninguphill,boundingdrills,orpowerskips.53,54
Stridefrequencycanbeimprovedwithfastlegdrillsintoflexionandextension(Fig.1298)andadduction
andabduction(Fig.1299)wherethepatientattemptstoswingthelegasfastaspossiblewhileusinga
supportforbalance.Otherwaystoincreasestridefrequencyincluderesistedsprints(pullingaweighted
sled,orparachute),orassistedsprints(theindividualisattachedtoanathletewhopullstheindividual,
forcingtheindividualtomovehisorherlegsfaster).54
FIGURE1298
Fastlegdrillsinto(A)flexionand(B)extension.
FIGURE1299
Fastlegdrillsintoabductionandadduction.
Thetheorybehindspeedstrengthtrainingisthatoncethehigherresistanceisremovedtheathletesspeedis
improvedwhentheyperformtheactivityundernormalresistance.Whereverpossible,strengthtestingbythe
clinicianshouldassessthefunctionofmuscle.Ifapowermuscleisassessed,itsabilitytoproducepowershould
beassessed.Incontrast,anendurancemuscleshouldbetestedforitsabilitytosustainacontractionfora
prolongedperiod,suchasoccurswithsustainedpostures.
Inadditiontospeedstrengthtraining,agilitydrills,rapidreflex,andspecificskilltrainingshouldformthecore
ofmanysportsspecificexerciseprograms.
CLINICALPEARL
TheprinciplesofresistancetrainingcanbeeasilyrememberedbytheacronymPROSprogression,regularity,
overload,andspecificity.
ModeofExercise
Thetypeofexerciseperformedisreferredtoasthemode.Thistypicallydescribesthemannerinwhichthe
exerciseiscarriedout,thetypeofresistanceused,andthetypeofmusclecontractionthatisused.Thevarious
mannersinwhichexercisecanbecarriedout,includingweightbearingornonweightbearing,andclosedchain
versusopenchainexercises,arecoveredlaterinthechapter.AsoutlinedinChapter1,amusclecancontractina
varietyofways.Eachtypeofcontractionhasitsadvantagesanddisadvantages.
TypeofContractionUsed
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IsometricExercises
Studieshavedemonstratedthata6secondholdof75%ofmaximalresistanceissufficienttoincreasestrength
whenperformedrepetitively.55,56Isometricexerciseshaveanobviousrolewhenjointmovementisrestricted,
eitherbypainorbybracingandcasting.Theprimaryroleinthisregardistopreventatrophyandasubsequent
decreaseoftheligament,bone,andmusclestrength.Isometricexerciseshavethefollowingdisadvantages:
Strengthgainsarenotincreasedthroughouttherange(unlessperformedatmultipleangles).
Theydonotactivateallofthemusclefibers(primaryactivationisofslowtwitchfibers).
Therearenoflexibilityorcardiovascularfitnessbenefits.
Peakeffortcanbeinjurioustothetissuesbecauseofvasoconstrictionandjointcompressionforces.
Thereislimitedfunctionalcarryover.57
Considerableinternalpressurecanbegenerated,especiallyifthebreathisheldduringcontraction.During
exertionaleffort,adeepinspirationisfollowedbyclosureoftheglottisandcontractionoftheabdominal
muscles,whichinturnincreasesintraabdominalandintrathoracicpressures,andcauseanabrupt,
temporaryincreaseinarterialbloodpressure.58Thiscanproveinjurioustopatientswithweaknessinthe
abdominalwall(hernia)orcardiovascularimpairment(increaseinbloodpressure)throughthe
maneuver/phenomenon,evenifperformedcorrectly.5962
CLINICALPEARL
TheValsalvaphenomenonhastraditionallybeenassociatedasoccurringwithhigheffortisometricexercises.
However,theclinicianmustrememberthatthisphenomenoncanalsooccurduringhigheffortdynamicmuscle
contractions.
ConcentricExercises
Thesecontractionsarecommonlyusedintherehabilitationprocessandinactivitiesofdailyliving.Thebiceps
curlandtheliftingofacuptothemouthareexamples,respectively.Concentricexercisesaredynamicandallow
thecliniciantovarytheloadfromconstant,usingfreeweights,tovariable,usinganexercisemachine.The
speedofcontractioncanalsobemanipulateddependingonthegoaloftheintervention.AsoutlinedinChapter
1,amaximumconcentriccontractionproduceslessforcethanamaximumeccentriccontractionunderthesame
conditions.
Anumberofprogramshavebeendesignedfortheprogressionofconcentricexerciseprograms.Someofthese
PREprogramsaresummarizedinTables123and124.AnRMisthemaximumnumberofrepetitionsan
individualcanperformthroughthefull,availablerangeofmotionwithcontrolatagivenweight.Forexample,a
1RMistheweightthepatientcanliftamaximumofonetime.DeterminingtheRMisdependentuponthe
goalsoftheindividualandhisorherfunctionaldemands.Sincedetermininga1RMtouseasabaseline
measurementofdynamicstrengthisnotappropriateformanypatients,a510RMtestingloadisoften
recommendedtoestimatethe1RM.Usingthismethod,theclinicianselectsaspecificamountofresistance
(weight)andthennoteshowmanyrepetitionscanbecompletedtothefullrangebeforethemusclebeginsto
fatigue.Forexample,ifthepatientwasabletoperformeightrepetitionsbeforebecomingfatigued,the1RM
canbecalculatedbasedonthe8RM.TherehabilitationprogramdesignedbyDeLormeisbasedonanRMof
10(10RM).29TheOxfordtechnique63reversesthepercentageofthemaximuminthethreesets(Table123).
Bothoftheseprogramsshouldonlybeusedwithhealthyyoungadults,athletes,andactiveolderadults.The
MacQueentechnique64,65differentiatesbetweenbeginning,intermediate,andadvancedlevels.Incontrast,the
programdesignedbySandersisbasedonaformulathatusesapercentageofbodyweighttodeterminestarting
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weights.66Thedailyadjustedprogressiveresistiveexercise(DAPRE)program,designedbyKnight,allowsfor
individualdifferencesintheratesatwhichpatientsprogressintheirrehabilitationprograms67(Table124).
Finally,theBergertechnique68selectsanamountofweightthatissufficienttoallow68RMineachofthe
threesets(theinitialselectionofastartingweighttypicallyrequiressometrialanderror),witharecoveryperiod
of6090secondsbetweensets.Ifatleastthreesetsof6RMcannotbecompleted,theweightisconsideredtoo
heavyandisreduced.Conversely,ifitispossibletodomorethanthreesetsof8RM,theweightisconsidered
toolightandisincreased.Toachievetraininginducedadaptationsinstrengthatthebeginningofanexercise
programislow(3040%oftheRM)forsedentary,untrainedindividualsorveryhigh(>80%ofRM)forthose
alreadyhighlytrained.69Forhealthybutuntrainedadults,atypicaltrainingzoneusuallyfallsbetween40%and
70%ofthebaselineRM.69
TABLE123ExerciseProgressions
Set(s)of10 AmountofWeight Repetitions
1 50%of10RM 10
DeLormeprogram 2 75%of10RM 10
3 100%of10RM 10
1 100%of10RM 10
Oxfordtechnique 2 75%of10RM 10
3 50%of10RM 10
3(beginning/intermediate) 100%of10RM 10
MacQueentechnique
45(advanced) 100%of23RM 23
Totalof4sets(3timesperweek) 100%of5RM 5
Day1:4sets 100%of5RM 5
Day2:4sets 100%of3RM 5
Sanderprogram
Day3:1set 100%of5RM 5
2sets 100%of3RM 5
2sets 100%of2RM 5
1 50%ofRM 10
2 75%ofRM 6
KnightDAPREprogram
3 100%ofRM Maximum
4 Adjustedworkingweight Maximum
Bergersadjustmenttechnique 3 100%of10RM 68
DAPRE,dailyadjustableprogressiveresistiveexerciseRM,repetitionmaximum.
TABLE124AdjustmentSequenceforDAPREProgram
NumberofRepetitionsPerformed AdjustedWorkingWeightforFourth NextExerciseSession
DuringSet Set(lb) (lb)
02 510 510
34 05 Sameweight
56 Sameweight +510
710 +510 +515
11 +1020 +1020
DAPRE,dailyadjustableprogressiveresistiveexercise.
CLINICALPEARL
The1RMequivalentisaformulathattakesintoaccounttheweightliftedandrepsmultipliedbyanumeric
equivalent.
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1RM=(weightliftednumberofreps0.03)+weightlifted.
Forexample,apatientwhohaslifted100lbforabenchpressatotalof12reps,hisorherRMequivalentwillbe
equalto(100120.03)+100=136.
Atypicalexerciseprescriptionforhighschool,collegiate,andprofessionalathletesincludesthreeormoresets
ofa612RMperexerciseperformed3days/week.70Forothers,a1015RMisgenerallyrecommended.71For
childrenandtheelderly,alowtomoderatepercentageoftheestablishedRMisrecommended.69Initially,the
strengtheningexercisesareperformedonadailybasis,withthevariablesdependentonthepatientsresponseto
theexercise.Thisisprogressedtoeveryotherday,andthentoatleastthreetimesperweek,butnomorethan
fourtimesperweek.
CLINICALPEARL
Todeterminehowmuchweightshouldbeincreasedforaparticularexercisethe2for2rulemethodis
recommendedasitisrelativelyconservative.Therulestatesthattheloadshouldincreaseiftheindividualcan
performtwoormorerepsovertheassignedrepsforthatparticularexerciseovertwoconsecutiveworkouts.
EccentricExercises
Theclinicalindicationsfortheuseofeccentricexercisearenumerous22(Table125).Eccentrictraining
producesmoreforcethanconcentrictraining.A1987metaanalysiscomparingeccentrictoconcentrictraining
foundthateccentrictrainingismoreeffectiveatincreasingtotalandeccentricstrength,aswellasmusclemass,
andthatitissuperiortoconcentrictrainingforrateofforcedevelopment.72Sincetheforcevelocity
relationshipisdifferentduringconcentricandeccentricmusclecontractions(seeChapter1),aneccentric
contractiongeneratesgreatertensionthanaconcentriccontractionatslowvelocitieswithamaximumload.
Clinicallythismeansagreaterloadorweightcanbeloweredwithcontrolthancanbelifted.Contrarytopopular
beliefHowever,asloweccentriccontractionusingaconstantloaddoesnotalwaysgenerategreatertensionthan
aconcentricone.Infact,lesstensionisoftengenerated,sotoincreasethetensionduringaneccentricexercisea
greaterloadhastobeused.Sincegreaterloadscanbeusedforeccentrictraining,thereisgreaterstressonthe
cardiovascularsystemduringeccentricexercisethanduringconcentricexercise.73Somewhatparadoxically,
usingsimilarexerciseloads,eccentricexercisesaremoreefficientatthemetaboliclevelthanconcentricexercise
eccentricmusclecontractionsconsumelessoxygenandenergystoresthanconcentriccontractions.74The
clinicalrelevanceofthisisthatmuscularendurancecanbeimprovedmoreefficientlyusingeccentricactivities
thansimilarconcentricactivitiesbecausemusclefatigueoccurslessquicklywitheccentricexercise.73Eccentric
exercisecanbeappliedbycompletingtheconcentricportionoftheliftwithbothextremities(i.e.,legpress)and
byusingonlytheinvolvedlimbfortheeccentricportion.
TABLE125ClinicalIndicationsforEccentricBiasedExercise
Mechanical,reproduciblejointpain
Jointpainresistanttomodalityintervention
Unidirectionaljointcrepitusorpainarc
Deconditionedorlowendurancepatients
Plateausinstrengthgains
Tendonitispresentations
Latestagerehabilitationandperformancetraining
DatafromAlbertM.Conceptsofmuscletraining.In:WadsworthC,ed.OrthopaedicPhysicalTherapy.Topic
StrengthandConditioningApplicationsinOrthopaedics:HomeStudyCourse98a.LaCrosse,WI:Orthopaedic
Section,APTA,Inc.,1998AlbertMS.Principlesofexerciseprogression.In:GreenfieldB,ed.Rehabilitationof
theKnee:AProblemSolvingApproach.Philadelphia,PA:FADavis1993AlbertMS.EccentricMuscle
TraininginSportsandOrthopaedics.2nded.NewYork,NY:ChurchillLivingstone1995.
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CLINICALPEARL
Functionalstrengthistheabilityoftheneuromuscularsystemtoperformcombinationsofconcentricand
eccentriccontractionsintheperformanceofactivitiesthatrelatetoapatientsneedsandrequirementsina
multiplanarenvironment(seesectionSpecificityofTraining).75Thereissomeevidencetosuggestthat
exercisingeccentricallyorconcentricallycanleadtostrengthgainsintheother(eccentrictrainingcanimprove
concentricstrengthandviceversa).76Effectiverehabilitationtargetsspecificmuscleswithregardtofunctional
muscleactivitypatternsandoverallconditioningandusesaprogressionofincreasedactivitywhilepreventing
furthertrauma.77Incrementalgainsinfunctionshouldbeseenasstrengthincreases.
IsokineticExercises
Anisokineticexercise,whichcanbeusedthroughoutallstagesofrehabilitationforexerciseandtesting,isone
inwhichthelengthofthemuscleischangingwhilethecontractionisperformedataconstantvelocity.78Thus,
isokineticexerciseisalsoreferredtoasaccommodatingresistanceexercise.Earlyphasesofrehabilitationare
especiallyamenabletotheaccommodativeresistanceofferedsincetheresistanceisnevermorethanthemuscle
cangenerate.79Themainprinciplebehindisokineticexerciseisthatpeaktorque(themaximumforcegenerated
throughtherangeofmotion)isinverselyrelatedtoangularvelocity,thespeedthatabodysegmentmoves
throughitsrangeofmotion.Putmoresimply,theresistanceprovidedbyanisokineticmachinemovesatsome
presetspeed,regardlessofthetorqueappliedtoitbytheindividual,thus,thekeytoisokineticexerciseisnot
theresistancebutthespeedatwhichtheresistancecanbemoved.80Fundamentaltotheconceptofisokinetic
exerciseisthatthevelocityofmusclelengtheningorshorteningisbothpresetandcontrolledbytheunitand
remainsconstantthroughouttherangeofmotionoftheexercise.
Advantagesforthistypeofexerciseinclude:
Bothhighspeed/lowresistanceandlowspeed/highresistanceregimensresultinexcellentstrength
gains.8184Highspeedsareconsideredtobebetween240and360degreespersecond,mediumspeeds
areconsideredtobebetween60and240degreespersecond,andslowspeedsbetween30and60degrees
persecond.
Bothconcentricandeccentricresistanceexercisescanbeperformedonthemachines.
Accommodationtofatigue.Asthecontractingmusclefatigues,apatientisstillabletoperformrepetitions
becausetheresistanceencounteredisdirectlyproportionaltotheforceapplied.
Providesobjectiveandquantifiablemeasurementsofmuscularstrength.
Allowsforreciprocaltrainingofagonistandantagonistmuscles.
Themachinesprovidemaximumresistanceatallpointsintherangeofmotion.Inaddition,therangecan
besetsothattheexerciseisonlyperformedinaspecificrange.Thiscanbeadvantageousifthepatient
hasapainfularcofmotion.
Thegravityproducedtorquecreatedbythemachineaddstotheforcegeneratedbythemusclewhenit
contractsresultinginahighertorqueoutputthanitactuallycreatedbythemuscle.
Disadvantagesofthistypeofexercise:
Expense.Isokineticmachines,whichrelyonhydraulic,pneumatic,andmechanicalpressuresystems,are
veryexpensive,withpurchasepricesrangingbetween$45,000and$80,000.
Requiresmaximalefforttoworkeffectively.
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Theincreasedpotentialforimpactloadingandincorrectjointaxisalignment.85Duringconcentric
exercise,astheforceoutputdecreases,thecompressiveforcesacrossthemovingjointarelessatfaster
angularvelocitiesthanatslowvelocities.
Questionablefunctionalcarryover.
TypesofResistanceUsed
Resistancetrainingprogramshavethepotentialformanypositivebenefitsprovidedthetrainingisappropriately
progressedtomeettheneedsofapersonashisorherstrengthincreases.Resistancecanbeappliedtoamuscle
byanyexternalforceormass,includinganyofthefollowing.
Gravity
Gravityalonecansupplysufficientresistanceforaweakenedmuscle.Withrespecttogravity,muscleactions
mayoccur
inthesamedirectionasgravity(downward)
intheoppositedirectiontogravity(upward)
inadirectionperpendiculartogravity(horizontal)and
inthesameoroppositedirectionofgravity,butatanangle.
Thedirectioninwhichthemuscleisworkingdeterminestherolethatgravityplaysandtherolethatthemuscle
mustplayinordertocounteracttheforcesofgravity.Forexample,ifanarmmuscleisworkingtolowerabook
toatable,thebicepsmuscleworkseccentricallyagainsttheforceofgravitytocontrolthespeedofthelowering.
Ifthemuscleworkstoliftthebookfromthetable,thebicepsmusclemustworkconcentricallyagainsttheforce
ofgravity.
CLINICALPEARL
Anactiverangeofmotionexerciseisdesignedtoworkagainstgravity,whereasanactiveassistedexerciseis
typicallyperformedperpendiculartogravity.
ConstantversusVariableLoad
Thisreferstohowconsistenttheresistanceisapplied.Forexample,performingabicepscurlwhileholdinga
dumbbellprovidesaconstantload.However,thecontractingmuscleischallengedmaximallyatonlyonepoint
intherangeofmotioninwhichthemaximumtorqueoftheresistancematchesthemaximumtorqueoutputof
themuscle.Thetrainingpremiseforavariableloadistwofold:86
1.Theloadincreaseswherethemusclehasmoreleverageintheearlyphasesofthelift.
2.Theloaddecreaseswherethemusclehaslittleleverageinthelaterphasesofthelift.
Theloadcanbemadevariablebyusingaspeciallydesignedpieceofresistanceequipmentthatmanipulatesthe
loadusingaweightcablesystemthatmovesoveranasymmetricallyshapedcam(seeExerciseMachines).In
addition,variableresistancetrainingusingelasticbandsorheavychainshasgainedpopularity.Forexample,
whenusingelasticbandsduringaseatedoverheaddumbbellpress,theelasticbandisattachedtothedumbbell
andtothechair.Asthepatientliftsthedumbbellfromtheshoulderheightpositiontowardtheelbowextended
position(Fig.12100),aconcentriccontractionisusedwhereasasthepatientlowersthedumbbells(Fig.12
101),theeccentriccontractioncanbeenhancedbythepulloftheelasticband.Theuseofchainsworksbya
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slightlydifferentmechanism.Forexample,whenaheavychainisattachedtotheendsofabarduringasquat,
theeccentricloadincreasesearlyintheliftbecausethechainlinksareaddedatthebeginningofthedescent,and
itdecreasesasthelinksaccumulateonthegroundasthepatientmovesfromthestandpositionintothesquat
position.48Conversely,theconcentricloadincreasesasthechainlinksliftoffofthefloor.
FIGURE12100
Seateddumbellpresswithelasticbandconcentriccontraction.
FIGURE12101
Seateddumbellpresswithelasticbandeccentriccontraction.
BodyWeight
Awidevarietyofexerciseshavebeendevelopedthatdonotrequireanyequipmentbutrelysolelyonthe
patientsbodyweightfortheresistance(e.g.,pushup).Theseexercisesarecommonlyreferredtoasclosed
chainexercises,whereasinanonweightbearingpositionwherethedistalsegmentmovesfreelyarecommonly
referredtoasanopenchainexercise.Bothofthesetypesofexercisearediscussedlater.
AccommodatingResistance
Isokineticmachinesareabletocontrolthevelocityofanactivemovementduringexercise.
SmallWeights
Cuffweights,dumbbells,andsurgicaltubing(elasticresistance)areeconomicalwaysofapplyingresistance.
Smallweightsaretypicallyusedtostrengthenthesmallermusclesortoincreasetheenduranceoflargermuscles
byincreasingthenumberofreps.Freeweightsalsoprovidemoreversatilitythanexercisemachines,especially
forthreedimensionalexercises,asthemovementsdonotoccurinastraightlineorplane.Thedisadvantageof
freeweightsisthattheyoffernovariableresistancethroughouttherangeofmotionandsotheweakestpoint
alongthelengthtensioncurveofeachmusclelimitstheamountofweightlifted.Accordingtoarecentstudy,
96%ofrehabilitationprofessionalsuseelasticresistancewiththeirpatients,and85%ofhomeexercise
programsprescribedbyrehabilitationprofessionalsrequireelasticresistancebandsortubing.83,8792Elastic
resistanceoffersauniquetypeofresistancethatcannotbeclassifiedintothetraditionalsubcategoriesof
strengthening.Theamountofvariableresistanceofferedbyelasticbandsortubingisafactoroftheinternal
tensionproducedbythematerial.Thisinternaltensionisafactoroftheelasticmaterialscoefficientof
elasticity,thesurfaceareaoftheelasticmaterial,andhowmuchtheelasticmaterialisstretched.92Itis
commonlybelievedthattheresistanceprovidedbythesebandsortubingincreasesexponentiallyattheend
rangeofmotion.However,theforcesproducedbytheelasticresistancearelinearuntilapproximately500%
elongation,atwhichpointtheforcesincreaseexponentially.92Astheelasticresistanceisnotstretchedmore
than300%inprescribedexercises,thisexponentialincreaseshouldnotbeattained.Inaddition,thetorque
productionofelasticresistanceexercisesissimilartothatproducedbyaconcentric/eccentricdumbbellexercise:
abellshapedcurve.93
MedicineBalls
Medicineballsprovidetheopportunitiestoimprovestrength,balance,andcoordinationthroughdynamic
movementsbytrainingthebodyasafunctionalunitandstrengtheningthecoreandtrunkmusculature.Both
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upperandlowerbodymedicineballexercisescanbeperformedusingavarietyofspeeds,andmedicineball
weightsandsizes.
ExerciseMachines
Insituationswherethelargermusclegroupsrequirestrengthening,andwhereexercisesneedtobeperformedin
straightandsupportedlines,amultitudeofspecificexercisemachinescanbeused.Thesemachinesaremost
oftenusedinthemoreadvancedstagesofarehabilitationprogramwhenmoreresistancecanbetolerated,but
canalsobeusedintheearlierstagesdependingonthesizeofthemuscleundergoingrehabilitation.Examplesof
thesemachinesincludethemultihip,thelatpulldown,thelegextension,andthelegcurlmachine.Exercise
machinesareoftenfittedwithanovalshapedcamorwheelthatmimicsthelengthoftensioncurveofthe
muscle(Nautilus,Cybex).Althoughthesemachinesareamoreexpensivealternativetodumbbellorelastic
resistance,theydooffersomeadvantages:
Theyprovideadequateresistanceforthelargemusclegroupsthatcannotbeachievedwithfree
weights/cuffweights,ormanualresistance.
Theyaretypicallysaferthanfreeweightsascontrol/supportthroughouttherangeisprovided.
Theyprovidetheclinicianwiththeabilitytoquantifyandmeasuretheamountofresistancethatthe
patientcantolerateovertime(ascomparedwithelasticresistance).
Thedisadvantagesofexercisemachinesareasfollows:
theinabilitytomodifytheexercisetobemorefunctionalorthreedimensional
theinabilitytomodifytheamountofresistanceatparticularpointsoftherange
ManualResistance
Manualresistanceisatypeofactiveexerciseinwhichanotherpersonprovidesresistancemanually.Anexample
ofmanualresistanceisproprioceptiveneuromuscularfacilitation(PNF)(seeChapter10).Theadvantagesof
manualresistance,whenappliedbyaskilledclinician,areasfollows:94
Controloftheextremitypositionandforceapplied.Thisisespeciallyusefulintheearlystagesofan
exerciseprogramwhenthemuscleisweak.
Moreeffectivereeducationofthemuscleorextremity,usingdiagonalorfunctionalpatternsofmovement.
Thecriticalsensoryinputtothepatientthroughtactilestimulationandappropriatefacilitationtechniques
(e.g.,quickstretch).
Accurateaccommodationandalterationsintheresistanceappliedthroughouttherange.Forexample,the
resistancecanbemodifiedtoavoidapainfularcintherange.
Abilitytolimittherange.Thisisparticularlyimportantwhentheamountofrangeofmotionneedstobe
carefullycontrolled(postsurgicalrestrictions).
Thedisadvantagesofmanualresistanceincludethefollowing:
Theamountofresistanceappliedcannotbemeasuredquantitatively.
Theamountofresistanceislimitedbythestrengthoftheclinician/caregiverorfamilymember.
Adifficultywiththeconsistencyoftheappliedforcethroughouttherange,andwitheachrep.
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ExercisePrescriptions
Beforeinitiatinganexerciseprogram,itisnecessarytoconductaneedsanalysistoevaluatethephysical
requirementsandphysicalattributesofthepatient.Determiningtheselectionofexerciseisdependentuponthe
goalsandobjectivesandtheneedsanalysis.Progressionisdefinedastheactofmovingforwardoradvancing
towardaspecificgoalovertimeuntilthetargetgoalhasbeenachieved.71Aprogressiveexerciseprogramis
recommendedtoconditionthepatientforareturntoactivityandtopreventoverloadinjuries.Suchaprogram
shouldaddressthefollowingareas:9599
Flexibility.Attemptsshouldbemadetoimprovegeneralbodyflexibility,withanemphasisonthespecific
activityorexercise.Thegeneralflexibilityexercisesshouldaddresstheentirekinematicchainandnotjust
thejointinquestion(e.g.,shoulderrotationandelbowmotioninthearm,lowback,hiprotation,and
hamstringsinthelegs).
Strengthening.Theexercisestoimprovestrengthshouldbeappliedinappropriateamountsandlocations
toaddresssportsorfunctionalspecificactivities.
Power.Powerisincorporatedthroughtheuseofrapidmovementsinappropriateplaneswithweightsand
ballisticactivities.
Endurance.Endurancecanbebuiltupwithaerobicexercises.
Optimalresistancetrainingprogressionsshouldalwaysbebasedonsoundrationaleandshouldalwaysbe
individualizedtomeetspecifictraininggoals.Eachprogressionismademorechallengingbyalteringoneofthe
parametersofexercise,includingtheintensity,duration,andfrequencywhicharemodifiedaccordingtopatient
response.
Aswithprescriptionsformedications,asuccessfulexerciseprescriptionrequiresthecorrectbalancebetween
thedose(exercisevariables)andtheresponse(specifichealthorfitnessadaptations).100Thedosageofan
exercisereferstoeachparticularpatientsexercisecapabilityandisdeterminedbyanumberofvariables(Table
126).22Forthesevariablestobeeffective,thepatientmustbecompliantandbeabletotrainwithout
exacerbatingthecondition.101
TABLE126ResistiveExerciseVariables
Resistance(loadorweight)
Duration
Trainingfrequency(weekly,daily)
Pointofapplication
Bouts(timedsessionsofexercise)
Setsandrepetitions
Trainingvolume
Mode(typeofcontraction)
Rests
CLINICALPEARL
Thetrainingvolumedescribesthetotalamountofresistanceliftedduringastrengthtrainingsessionandis,
therefore,dependentupontheweightlifted,thereps,andsets.Thetrainingvolumeiscalculatedbymultiplying
theresistance(forcedistance)bythetotalnumberofrepetitionsperformedinaspecifiedperiodoftime
(Trainingvolume=numberofsetsnumberofrepsweightliftedperrep).Thevolumemayalsobe
calculatedbyaddingthefrequencyanddurationofrehabilitationortrainingsessions.
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Dependingonthespecificprogramdesign,resistancetrainingisknowntoenhancemuscularstrength,power,or
enduranceandcanprovideapotentstimulustotheneuromuscularsystem.Othervariablessuchasspeed,
balance,coordination,jumpingability,flexibility,andothermeasuresofmotorperformancehavealsobeen
positivelyenhancedbyresistancetraining.71
CLINICALPEARL
Ifthepainispresentbeforeresistanceortheendfeel,thepatientssymptomsareconsideredirritable.The
interventioninthepresenceofirritabilityshouldnotbeaggressive,particularlyinclusiveofexercise.102
Ifpainoccursafterresistance,thenthepatientssymptomsarenotconsideredirritableandexercise,
particularlystretching,canbemoreaggressive.
Itisworthrememberingthatwhentheindividualtrainsfortwodifferenttypesofadaptations(e.g.,aerobic
fitnessversusstrength),thetrainingstimulicaninterferewithoneanotherandresultinlessimprovementinone
orbothoftheeffects.Forexample,whenstrengthloadsarecombinedwithaerobictraining,theaerobic
adaptationisnotdetrimentallyaffected,butthereisanegativeimpactonstrengthdevelopment.7,103
Eachexercisesessionshouldincludea515minutewarmupanda515minutecooldownperiod.
Warmup
includeslowintensitycardiorespiratoryactivities.
preventstheheartandcirculatorysystemfrombeingsuddenlyoverloaded.
Cooldown
includeslowintensitycardiorespiratoryactivitiesandflexibilityexercises.
helpspreventabruptphysiologicalalterationsthatcanoccurwithsuddencessationofstrenuous
exercise.
Thelengthofthewarmupandcooldownsessionsmayneedtobelongerfordeconditionedorolder
individuals.Thetypeofexerciseprescribeddeterminesthetypeofwarmup.104Thepossiblebenefitsofa
warmuppriortophysicalactivityarelistedinTable127.Themosteffectivewarmupconsistsofbothgeneral
(walking,biking,jogging,andgentleresistiveexercises)andspecific(movementsthatareappropriateforthe
particularactivitytobeundertaken)exercises.104
TABLE127PossibleBenefitsofaWarmUpPriortoPhysicalActivity
Increasedbloodflowtomuscles.
Increasedoxyhemoglobinbreakdown,withincreasedoxygendeliverytomuscles.
Increasedcirculationleadingtodecreasedvascularresistance.
Increasedreleaseofoxygenfrommyoglobin.
Enhancedcellularmetabolism.
Reducedmuscleviscosityleadingtosmoothermusclecontractionandincreasedmechanicalefficiency.
Increasedspeedofnerveimpulses.
Increasedsensitivityofnervereceptors.
Decreasedactivityofalphafibersandsensitivityofmusclestostretch.
Decreasednumberofinjuriesduetoincreasedrangeofmotion.
Decreasedstiffnessofconnectivetissueleadingtodecreasedlikelihoodoftears.
Increasedcardiovascularresponsetosuddenstrenuousexercise.
Increasedrelaxationandconcentration.
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DatafromBahrR.Principlesofinjuryprevention.In:BruknerP,KhanK,eds.ClinicalSportsMedicine.3rded.
Sydney:McGrawHill2007:78101StewartIB,SleivertGG.Theeffectofwarmupintensityonrangeof
motionandanaerobicperformance.JOrthopSportsPhysTher.199827:154161RosenbaumD,HennigEM.
TheinfluenceofstretchingandwarmupexercisesonAchillestendonreflexactivity.JSportsSci.199513:481
490GreenJP,GrenierSG,McGillSM.Lowbackstiffnessisalteredwithwarmupandbenchrest:Implications
forathletes.MedSciSportsExerc.200234:10761081.
Oncethewarmupiscompleted,itisrecommendedthataflexibilityprogrambeincorporatedtoincreasejoint
movementandmuscleextensibility(seeChapter13).
Theinitialexerciseisprescribedatalevelthatthepatientcanperform,beforeprogressingindifficulty.Thiswill
bedeterminedbyanumberoffactors,includingthegoalsofthetreatment,theextentofimpairment,the
patientsage,generalhealthandfitnesslevel,andthestageofhealingoftheinjuredtissues.Aswithany
treatment,theprescribedexercisesmustbeperformedcorrectlysothatthemovementreplicatestheactionofthe
muscleormusclegroups,andpreventsanysubstitutemotions(seeChapter4).Theearlygoalsofexerciseare
concernedwithincreasingcirculation,preventingatrophy,increasingproteinsynthesis,andreducingthelevelof
metabolites.101
CLINICALPEARL
Resistancetraining,particularlywhenincorporatedintoacomprehensivefitnessprogram,reducestherisk
factorsassociatedwithcoronaryheartdisease,noninsulindependentdiabetes,andcoloncancerprevents
osteoporosispromotesweightlossandmaintenanceimprovesdynamicstabilityandpreservesfunctional
capacityandfosterspsychologicalwellbeing.71
IncreasingMuscleStrength
Strengtheningofamuscleoccurswhenthemuscleisforcedtoworkatahigherlevelthanthattowhichitis
accustomed.Amusclebecomesstrongerfromaresistancetrainingprogramviahypertrophyoranincreasein
CSAofthemuscle.Functionalstrengthrelatestotheabilityoftheneuromuscularsystemtoperformfunctional
activitiesinasmooth,andcoordinatedmanner.Sinceallmusclesfunctioneccentrically,isometrically,and
concentricallyinthesagittal,frontal,andtransverseplanes,anintegratedtrainingprogramshouldutilizea
multiplanartrainingapproachusingtheentiremuscleandvelocitycontractionspectrum.48Thefollowing
factorsshouldbeconsideredwhendesigninganexerciseprogramtoincreasestrength.
RepetitionsandSets
Theinitialselectionofastartingweightmayrequiresometrialanderrortofindthecorrectnumberofreps.
Despitemanystudies,nooptimalnumberofrepetitionsorsetshavebeenestablished.However,foranygiven
exercise,therecommendationsarethattheamountofweightselectedshouldbesufficienttoallow812repsper
exercisefor35setswitharecoveryperiodbetweensetsof6090secondstoelicitimprovementsinmuscular
strengthandenduranceaswellasmusclehypertrophy.69
Exerciseorder.Resistanceexercisescanbeperformedindifferentorderstoallowforthemostefficientsession.
Typically,ifseveralmusclegroupsareexercisedinasinglesession,afewguidelinesarerecommended105:
Largemusclegroupsareexercisedbeforesmallmusclegroups
Multijointexercisesareperformedbeforesinglejointexercises
Highintensityexercisesshouldbeperformedbeforelowintensityexercises.
CLINICALPEARL
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Threetermsarecommonlyusedwithresistancetrainingprescriptions:
Repetitions.Thenumberoftimesaspecificmovementorexerciseisrepeated.
Repetitionmaximum(RM).TheRMisthemaximumnumberofrepetitionsanindividualcanperformat
agivenweight.Forexample,a10RMistheweightthepatientcanliftamaximumof10times(seeType
ofContractionUsed).
Set.Aparticularnumberofrepetitions.Whateverexerciseprogressionisusedtoachieveanincreasein
thetotalnumberofrepetitionswhilemaintainingasufficienteffort,thenumberofsetsmustalsobe
increased.Thisincreaseinsetsmustoccurinconjunctionwithareductioninthenumberofrepetitionsper
setby1020%101orareductionintheamountofresistance.Generallyspeaking,nomorethanthreeto
fivesetsareused.Aftereachset,thereisabriefintervalofrest.
Intensity
Intensityistherateofperformingwork,ortheloadorresistanceunderwhichthepatientexercises.Intensity
referstothepoweroutputorhowmucheffortisrequiredtoperformtheexercise.Inclinicalterms,intensity
referstotheweightorresistanceliftedbythepatient,orexerciseload.Inaddition,theintensityofexerciseis
alsodependentonthefrequency,volume,lengthofrestperiods,andorderofexercises.Theamountofintensity
willvarybasedontheintenthighintensityusingtheoverloadprincipletoincreasemusclestrengthandpower,
andlowintensitytoincreaseendurance.Lowintensitylevelsarealsousedintheearlystagesofsofttissue
healing,afterprolongedimmobilization,andwhenthepatientisinitiallylearninganexercisetoemphasizethe
correctform.Itisnowrecognizedthatanindividualsperceptionofeffort(ratedperceivedexertion,orRPE)is
closelyrelatedtothelevelofphysiologicaleffort.106,107TheBorgScaleiscommonlyusedtohelpdeterminea
patientsRPE,asanindividualsperceptionofeffortiscloselyrelatedtothelevelofphysiologicalefforta
highcorrelationexistsbetweenapersonsRPEmultipliedby10,andtheiractualheartrate.106,107Forexample,
ifapersonsRPEis15,then1510=150sotheheartrateshouldbeapproximately150beatsperminute.A
cardiorespiratorytrainingeffectcanbeachievedataratingofsomewhathardorhard(1316).Notethatthis
calculationisonlyanapproximationofheartrate,andtheactualheartratecanvaryquiteabitdependingonage
andphysicalcondition.TheoriginalscaleintroducedbyBorg107ratedexertiononascaleof620,butamore
recentonedesignedbyBorgincludedacategory(C)ratio(R)scale,theBorgCR10Scale(Table128).To
determinehowmuchresistancethepatientshoulduseduringtheexerciseprogram,theRMcanbecalculated.
TABLE128RatingofPerceivedExertiona
TraditionalScale VerbalRating Revised10GradeScale VerbalRating
6 0 Nothingatall
7 Very,verylight 0.5 Very,veryweak
8 1.0 Veryweak
9 Verylight 2.0 Weak(light)
10 3.0 Moderate
11 Fairlylight 4.0 Somewhatstrong
12 5.0 Strong(heavy)
13 Somewhathard 6.0
14 7.0 Verystrong
15 Hard 8.0
16 9.0
17 Veryhard 10.0 Very,verystrong(almostmaximum)maximal
18
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TraditionalScale VerbalRating Revised10GradeScale VerbalRating

19 Very,veryhard
aDatafromBorgGAV.Psychophysicalbasisofperceivedexertion.MedSciSportsExerc.199214:377381.
Patientresponsesthatcanmodifytheintensityincludeanincreaseinpainlevel,musclefatigue,thetimetaken
torecoverfromfatigue,cardiovascularresponse,compensatorymovements,thelevelofmotivation,anddegree
ofcomprehension.Theclinicianmustbeawarethatiftheloadusedistoohigh,thepatientmayattempttocarry
outthedesiredmovementbyusingsubstitutemotions.Thisisobviouslycounterproductiveandmustbeavoided
byusinganappropriateamountofresistance.
Frequency
Trainingfrequencyreferstothenumberoftimesstrengthtrainingsessionsarecompletedinagivenperiod(e.g.,
thenumberofworkoutsperweek).Optimaltrainingfrequencydependsonseveralfactorssuchasexperience,
trainingvolumeandstatus,intensity,exerciseselection,thelevelofconditioning,recoveryability,andthe
numberofmusclegroupstrainedperworkoutsession.Thoseexercisesthatrequiregreaterrecoverytimeshould
beperformedlessfrequentlythanothers.Basedonthestudiesofisokineticandeccentric/concentricexercise,
musclestrengthrecoveryfollowsasteady,nonlinear,andpredictableincreaseovertime.22,108,109Theoptimal
frequencyperweekhasnotbeenestablished,althoughafrequencyoftwotothreetimesperweek,everyother
day,oruptofiveexercisesessionsperweekarecommonlycitedforhealthyindividuals.105Inrehabilitation,it
isrecommendedthatshortsessionsofexercisesbeperformedonadailybasisseveraltimesadaywhilekeeping
boththeintensityandrepetitionslow.Ashealingprogresses,evidencedbyadecreaseinpainandswellingand
anincreaseintherangeofmotion,theexercisesshouldbeperformedeveryotherday.Ifthetrainingloadisnear
themaximumcapacity,moretimeforrecoverywillberequiredtominimizesorenessandprovidetheadequate
rest.Oncesufficientstrengthisattained,evenifthepatientonlyperformsthestrengthtrainingataminimumof
onceperweek,thestrengthcanbefairlywellmaintainedovera3monthperiod.110
Strengthismosteffectivelyenhancedbyaprogramfeaturinghighresistanceandfewreps.Moretraining
sessionscanbeaccomplishedandprovideadequaterestifasplitroutineisused.Asplitroutinedividesthe
trainingsessionintogroupings,splitbetweentheupperbodyandlowerbodyexercisesusingarestintervalof
48hours.Anotheralternativeistoperformapushandpullexerciseprogram,inwhichthestrengthtrainingis
dividedintoexercisesinwhichtheindividualpushesaweight(e.g.,tricepsextension,benchpress),thenpullsa
weight(e.g.,bicepscurl,latissimusdorsipulldown).
Duration
Durationreferstothelengthoftheexercisesession.Itcanalsorefertothetotalnumberofweeksormonths
duringwhichanexerciseprogramiscarriedout.Withinaparticularexercisesession,physicalconditioning
occursoveraperiodof1560minutesdependingonthelevelofintensity.Averageconditioningtimeis2030
minutesformoderateintensityexercise.However,individualswhoareseverelycompromisedaremorelikelyto
benefitfromaseriesofshortexercisesessions(310minutes)spacedthroughouttheday.
RestPeriods
Inmostexercisesprescriptions,fatigueofthemusclebeingexercisedisthegoal.However,fatiguemayalso
occurduetolackofcoordination,insufficientbalance,poormotivation,ortheadditionofcompensatory
movements.Inaddition,fatiguemayalsobeassociatedwithspecificclinicaldiseases,forexample,multiple
sclerosis,cardiacdisease,peripheralvasculardysfunction,andpulmonarydiseases.Becausefatigueis
detrimentaltoperformance,restisanimportantcomponentofanyexerciseprogression.Therestperiodmustbe
sufficienttoallowformuscularrecuperationanddevelopmentwhilealleviatingthepotentialforovertraining.92
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Ingeneral,theheavierloadslifted,thelongertherestperiodbetweensets.Therestperiodbetweensetscanbe
determinedbythetimethebreathingrate,orpulseofthepatientreturnstothesteadystate,orbyusingthe
followingguidelines:
muscularendurance:lessthan30secondsrest
muscularhypertrophy:6090seconds
muscularstrength:25minutes
musclepower:25minutes
A48hourrestperiodbetweenconcurrenttrainingsessionsisgenerallyrecommended.71
CLINICALPEARL
Intherehabilitationpopulation,fatigueshouldbeachievedwithoutexceedingthepatientstoleranceandwhile
protectingtheinjurysite.Itisnowclearthatthedevelopmentoffatigueprobablyinvolvesseveralfactorsthat
influenceforceproductioninamannerdependentonmusclefibertypeandactivationpattern,andthatoneof
thesefactorsmaybetheregulationofCa2+ bythesarcoplasmicreticulum.111Characteristicsofmusclefatigue
includereductioninmuscleforceproductioncapabilityandshorteningvelocity,areductioninthereleaseand
uptakeofintracellularcalciumbythesarcoplasmicreticulum,aswellasprolongedrelaxationofmotorunits
betweenrecruitment.111,112
Oneofthebiggestchallengesforaclinicianistofindabalancebetweenachievingamaximumtrainingeffect
whilealleviatingfatigue.Fortunately,fatiguehasamuchfasterdecaytimethanthetrainingeffect.Thus,to
removethefatigue,thevolumeoftrainingshouldbereducedwhilemaintainingthetrainingeffectbyholding
theintensityofthetrainingloadconstant.113
TheSpeedofExercise
Thespeedoftheexerciseshoulddependontheimposeddemandsofanindividual.Sincemanyfunctional
activitiesinvolvereasonablyfastvelocitiesoflimbmovement,increasingthespeedofanexercisefollowingthe
initialphaseoflearningaparticularexerciseanddevelopingproficiencyintheperformanceoftheexerciseis
beneficial.8Inaddition,highervelocitytrainingappearstoimprovepeakpowermeasures.71Thespeedofan
exercisecanbecontrolledmorespecificallyusinganisokineticdynamometerormachine.
Variation
Ithasbeenshownthatsystematicallyvaryingvolumeandintensityismosteffectiveforlongterm
progression.71,114Variationintraining,orperiodization,isafundamentalprinciplethatsupportstheneedfor
alterationsinoneormoreprogramvariablesovertimetoallowforthetrainingstimulustoremainoptimal
(Table129).71Theconceptofperiodizationhasbeenrootedinprogramdesignuniversallyformanyyears.
Periodizationisthesystematicprocessofplannedvariationsinaresistancetrainingprogramoveraspecified
trainingcycletopreventovertrainingandtoperformatpeakoroptimumlevelsattherighttime.114Twomodels
ofperiodizationaretheclassic(linear)andtheundulating(nonlinear)protocols:71
TABLE129TypesofTrainingThatIncorporateVariation
Circuittrainingorcrosstrainingincorporatesawidevarietyofmodesoftraininganduseshigh
Circuit
repetitionsandlowweighttoprovideamoregeneralconditioningprogramaimedatimprovingbody
training
composition,muscularstrength,andsomecardiovascularfitness.
Intervaltrainingincludesanexerciseperiodfollowedbyaprescribedrestinterval.Itisperceivedtobe
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lessdemandingthancontinuoustrainingandtendstoimprovestrengthandpowermorethan
endurance.

Interval Withappropriatespacingofworkandrestintervals,asignificantamountofhighintensityworkcanbe
training achievedandisgreaterthantheamountofworkaccomplishedwithcontinuoustraining.

Thelongertheworkinterval,themoretheanaerobicsystemisstressedandthedurationoftherest
periodisnotmoreimportant.

Inashortworkinterval,aworkrecoveryratioof1:1or1:5isappropriatetostresstheaerobicsystem.
Classic.Thismodelischaracterizedbyhighinitialtrainingvolumeandlowintensity.Astraining
progresses,volumedecreasesandintensityincreasesinordertomaximizestrength,power,orboth.
Undulating.Thenonlinearprogramenablesvariationinintensityandvolumewithineach7to10day
cyclebyrotatingdifferentprotocolsoverthecourseofthetrainingprogram.Nonlinearmethodsattempt
totrainthevariouscomponentsoftheneuromuscularsystemwithinthesame7to10daycycle.Duringa
singleworkout,onlyonecharacteristicistrainedonagivenday(e.g.,strength,power,ormuscular
endurance).
Periodizationconsistsofseveralphases,includingthemacrocycle,mesocycle,andmicrocycle.Themacrocycle
foranathletecan,forexample,lastfor1yearendingwiththeendofacompetitiveseason.Themacrocycleis
dividedintoseveralmesocycles.Amesocycledefinesdistinctvariationsintheresistanceandexerciseprogram.
Forexample,amesocycleforanathletecanbedividedintothreedistinctphases:104
Conditioning.Thisphaseemphasizesdevelopingaerobicandanaerobicfitness,strength,andpower.
Precompetition.Thisphaseemphasizescorrecttechnique.
Competition.Duringthisphase,theemphasisisoncompetitiveperformancewhilemaintainingbasic
conditioning.
Thefinalbreakdownofperiodizationisthemicrocycle,whichinvolveschangesintrainingparameterssuchas
intensity,workrestratios,sets,reps,exerciseorder,andspecificexercises,andgenerallylastsfor12weeks.A
commonformatisa4weekmesocyclethatconsistsofthreemicrocyclesof1weekeach,inwhichtheloadis
progressivelyincreased,followedbya1weekmicrocycleofreducedvolumeandintensity.
IncreasingMuscleEndurance
Itiswellestablishedthatendurancetrainingresultsinenhancedperformanceandadelayedonsetoffatigue
duringenduranceexercise.Morespecifically,endurancesportsimprovementisaccomplishedbyincreasing
aerobicsourcesofenergybydelayingtheonsetthebloodlactateaccumulation.3Enduranceexercisetraining
alsoleadstoashiftofskeletalmusclemitochondriatowardanincreaseduseoflipidsasasubstratesourceboth
atthesameabsoluteandatthesamerelativeexerciseintensity.37,115Thenatureofenduranceexercise
encouragesthebodytoworkaerobically,whichisreferredtoascardiopulmonaryendurance.Thisphenomenon,
calledsteadystate,occursaftersome56minutesofexerciseataconstantintensitylevel.37Duringsteadystate,
therateofmitochondrialATPproductioniscloselymatchedtotherateofATPhydrolysisanddemonstratesthe
existenceofefficientcellularmechanismstocontrolmitochondrialATPsynthesisinawidedynamicrange.116
Enduranceexercisetrainingproducesanincreaseinmitochondrialvolumedensityinallthreemusclefiber
types117andthusmuscleaerobicpower.Withahighermitochondrialdensityintrainedmuscle,therateof
substratefluxperindividualmitochondrionwillbelessatanygivenrateofATPhydrolysis.116Therefore,the
requiredactivationofmitochondrialrespirationbyadenosinediphosphate(ADP)toachieveagivenrateofATP
formationwillbeless,resultinginincreasedADPsensitivityofmuscleoxidativephosphorylation.116To
developendurance,musclesmustoxidizelactateduringworkanddecreasedependenceonglycolysistosupply
energy.48
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Muscularendurancetrainingistypicallyprescribedduringthegeneralpreparationphaseoftrainingtoprepare
thebodyfortheincreasedworkdemandsthatwillberequired,andtoprogramthebodysneuromuscular
coordinationsystems.
Toincreasemuscleendurance,exercisesareperformedagainstlightresistanceformanyreps(nofewerthan20
perset)sothattheamountofenergyexpendedisequaltotheamountofenergysupplied.Theamountofweight
usedduringmuscularendurancetrainingcanbedeterminedbyusinganRPEscale,inwhich1isverylight
exertion,and10isintenseexertion.Generalenduranceistrainedbyusinglowloads(30%of1RM),shortrest
periods(1030seconds),andrepetitionsbetween20and150.3
Specializedendurancetrainingmayincludespeedendurancegeneratingtensionoveralongperiodoftime
withoutadecreaseinefficiency.3Strengthenduranceisdevelopedwith2550%of1RM,withamoderate
tempoofrepetitionperformance(60120repetitionsperminute).Usingtheexampleofabenchpress,ifan
athletesmaximumweightforthebenchpressis220lb,heorshecouldreducetheworkoutweightby50%(110
lb)andincreasethenumberofrepstoapproximately90perminute.
Thenumberofrepsusedisafactorofthespeedofonerep,andhowmanyrepstheathletecancompletein60
seconds.Forexample,ifundernormaltrainingconditionstheathletetakes3secondstoraisetheweightduring
abicepscurland3secondstolowerit,themuscleisundertensionfor6secondsandtheathleteisworkingata
speedof10repsperminute.Byincreasingthespeedoftherepto4seconds(thetimethemuscleisunder
tension),theathletemustachieveatleast15repsinordertobuildmuscularendurance.Amixedintensity
intervaltrainingprogramcanbeusedtofacilitatesportsspecificenduranceusing30to90secondintervalsof
varyingintensityoverthecourseof6minutes,withprogressioninvolvingincreasingthenumberof6minute
intervals.118
Themajordrawbackofmuscularendurancetrainingistheincreasedpotentialforoveruseinjuries.Thiscanbe
offsetbymanipulatingoneormoreofthetrainingvariables,suchassets,loads,tempo,restperiodsbetween
sets,thenumberofexercises,handposition,andgripwidth.Itisalsoworthrememberingthatworkingatalevel
towhichthemuscleisaccustomedimprovestheenduranceofthatmusclebutdoesnotincreaseitsstrength.
IncreasingMusclePower
Powerisincreasedbyhavingamuscleworkdynamicallyagainstresistancewithinaspecifiedperiod.Olympic
weightliftingisanexcellentmeanstodeveloppowerfortheathleticpopulation.However,theselifting
techniques,whichinvolveasteeplearningcurve,requiretotalbodycoordination,strength,andbalance.48
Alternatively,twosimplertechniques,usingdumbbells,maybemoreappropriateforrehabilitation48:
1.Doublelegdumbbellsnatch.Thepatientstandswiththefeetshoulderwidthapart,holdingadumbbellin
onehand(Fig.12102A).Usingasmoothmovement,thepatientmovesintothesquatposition(Fig.12
102B)whileraisingthedumbbelloverthehead(Fig.12102C).
2.Singlelegdumbbellsnatch.Thepatientstandsononeleg,withtheotherlegraiseslightlybehind,and
holdingadumbbellinthesameupperextremity(Fig.12103A).Usingasmoothmovement,thepatient
movesintoalungepositionwhileraisingthedumbbelloverthehead(Fig.12103B).
FIGURE12102
Doublelegdumbbellsnatch.
FIGURE12103
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Singlelegdumbbellsnatch.
Plyometrics
Inthecontextofrehabilitation,plyometrictrainingcanbeviewedasthebridgebetweenpurestrengthand
sportsrelatedexercises.119Ithasbeendemonstratedthatwhenaconcentriccontractionisprecededbyaphase
ofactiveorpassivestretching,elasticenergyisstoredinthemuscle.Thisstoredenergyisthenusedinthe
subsequentcontractilephase.Forexample,duringsomefunctionalactivities,suchasjumping,themovement
involvesaneccentricloadingofamuscleormusclegroup,followedimmediatelybyaconcentricmuscleaction,
aspartofastretchshorteningcycle.31Theeccentric/concentricactionsutilizethestretchreflexorstretch
shorteningcycleinwhichthemuscleispreloadedwithenergyduringtheeccentricphase(muchlikestretchinga
rubberbandapart)andthereleaseofthatstoredenergyforsubsequentmuscularactions(releasingtherubber
band).120Thestoredelasticenergywithinthemuscleisusedtoproducemoreforcethancanbeprovidedbya
concentriccontractionalone.121123
Thegoalofplyometrictrainingistodecreasetheamountoftimebetweentheyieldingeccentricmuscle
contractionandtheinitiationoftheovercomingconcentriccontraction.124
ThetrainingsystemofplyometricsiscreditedtoYuriVerhoshanski,125therenownedSovietjumpcoachofthe
late1960s,althoughtheactualtermplyometricswasfirstintroducedinthemid1970sbyanAmericantrack
coachFredWilt.126Thetermplyometrics,whenbrokendowntotherootsofthewords,isalittleconfusing.
PlyocomesfromtheGreekwordpleythein,whichmeanstoincrease,andmetric,whichmeanstomeasure.
Plyometricsisassociatedwithanenhancementoftheabilityofthemuscletendonunittoproducemaximal
forceintheshortestamountoftimethroughactivationofthemyotaticreflex.127130Thetendonportionofthe
muscletendonunithasbeenfoundtobethemaincontributortomuscletendonunitlengthchangesandthe
storageofelasticpotentialenergy.131Theamountofavailableelasticenergyisaffectedbytime,themagnitude
ofthestretch,andthevelocityofthestretch.50
Movementpatternsinbothathleticsandactivitiesofdailylivinginvolverepeatedstretchshorteningcycles,in
whichaneccentricmovementmustbestoppedandconvertedintoaconcentricmovementintheopposite
direction.Whenamusclecontractsinaconcentricfashion,mostoftheforceproducedcomesfromthemuscle
fiberfilamentsslidingpastoneanother.Forceisregisteredexternallybybeingtransferredthroughtheseries
elasticcomponentofthemuscle,andasthemusclelengthenslikeaspringduringtheeccentriccontraction,the
serieselasticcomponentisalsostretchedandcontributestotheoverallforceproduction.124
Accelerationanddecelerationarethemostimportantcomponentsofalltaskspecificactivities.101These
activitiesusevariablespeedandresistancethroughouttherangeofcontraction,stimulatingneurologicreceptors
andincreasingtheirexcitability.Thenervereceptorsinvolvedinplyometricsarethemusclespindle,theGolgi
tendonorgan,andthejointcapsule/ligamentousreceptors(seeChapter3).Theseneurologicreceptorsplayan
importantroleinfiberrecruitmentandphysiologiccoordination.Plyometricactivitiesservetoimprovethe
reactivityofthesereceptors.Twootherreflexmechanisms,whichresultfromneuralsignalsgeneratedby
musclereceptorsthatprojectbacktothemuscleoforiginaswellasothermuscles,canbeinitiatedby
plyometricexerciseandmayassistwithmotorcoordinationandjointstability:132
Lengthfeedback.Thesesignals,generatedbymusclestretch,occuraroundthesametimeframeasthe
stretchreflex,andservetolinkmusclesthataresynergiststhroughexcitatoryfeedbackandthosewith
oppositeactionsbyreciprocalinhibition.133Lengthfeedbackalsolinksmonoarticularmuscleswith
excitatoryfeedbackandcontributestojointstiffness.133
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Forcefeedback.Thesearesignalsgeneratedbymuscleforce,whichareprovidedbystimulationofthe
Golgitendonorgan,andwhichconnectmusclesthatcrossdifferentjointsandexerttorqueindifferent
directionsthroughinhibitoryfeedback.Forcefeedbackregulatescouplingbetweenjoints.133
Together,lengthandforcefeedbackinducedduringtheloadingphaseofaplyometricactivityhavethepotential
toimproveneuromuscularcontrol.132
Thephysiologyofplyometricscanbebrokendownintoanumberofphases:
1.Aloadingphase(eccentric,deceleration,setting,yielding,orcockingphase),inwhichthemuscletendon
unitsoftheprimemoversandsynergistsarestretchedasaresultofkineticenergyorloadingappliedto
thejointandbegintoperformnegativework.132Stretchingofthemuscletendonunitduringthisphase
elicitsthestretchshorteningcycle,whichresultsinenhancedforceproductionandperformancewhen
comparedtotheabsenceofstretch.50Thestretchofactivemuscleduringtheloadingphaseelicitstwo
mechanismsassociatedwiththestretchshorteningcycle:musclepotentiationandactivationofthe
musclespindle:132
Musclepotentiation.Analterationofthemusclecontractilepropertiesthatleadstohigherforce
productionthroughanincreaseintheproportionofcrossbridgesattachedtoactin,andadecrease
inthecrossbridgedetachmentrate.
Musclespindleactivation.Sensoryinformationfromthemusclespindleispassedthrougha
monosynapticreflexlooptoprovideexcitatoryfeedbacktothesamemuscle(seeChapter3).This
resultsinshortlatencyreflexmuscleactivity(myotaticorstretchreflex).However,thestretch
reflexmaynotbeelicitedinallmusclesthatarestretchedduringaplyometricactivity.
Monoarticularmusclesareconsistentlyactivated,butbiarticularmusclesarenot.Differencesin
reflexmuscleactivitybetweenmonoarticularandbiarticularmusclesmaybeexplainedby
differencesinmusclelengthchangesduringloading.Incertainactivities,someofthefasciclesof
biarticularmusclesundergolengthening(eccentricaction),whiletheothermusclefasciclesact
nearlyisometrically.Thissuggeststhatmonoarticularmusclesmaybenefitmorethanbiarticular
musclesfromstretchreflexforceaugmentationforenhancedworkoutput.
2.Acoupling(amortization,transmission,payoff,orreversal)phase:Thisphasemarksthetransition
betweentheloadingphaseandtheunloadingphase.50Thecouplingphase,thedefinitivephaseofthe
plyometricexercise,isgenerallyaperiodofquasiisometricmuscleaction.132Ifthistransitionphaseis
notcontinuous,theactivitywillnolongerbeconsideredplyometricbecausethebenefitsofthestretch
shorteningcyclewillbelost.132
3.Anunloadingphase:Theunloading(rebound,shortening,pushoff,orpropulsion)phaseofaplyometric
exerciseoccursimmediatelyafterthecouplingphaseandinvolvesshorteningofthemuscletendonunit.
Inthebiphasicanalysisofplyometricjumps,theunloadingphasebeginsatthestartofupwardmovement
ofthecenterofmassandendswhengroundcontactceases.134Mostplyometricactivitiesterminateina
momentumphase,duringwhichbodysegmentscontinuetomoveasaresultoftheforcesgeneratedinthe
unloadingphase.132
Byreproducingthesestretchshorteningcyclesatpositionsofphysiologicfunction,plyometricactivities
stimulateproprioceptivefeedbacktofinetunemuscleactivitypatterns.Stretchshorteningexercisetrainsthe
neuromuscularsystembyexposingittoincreasedstrengthloadsandimprovingthestretchreflex(seeChapter
3)50Thedegreeofperformanceenhancementduringthemomentumphaseisdependentonthemagnitudeofthe
forcesandquicknessofmovementduringtheplyometricactivity.132Inparticular,higherforcesareassociated
withashortercouplingphase135andgreaterenergystorageintheserieselasticcomponent.136Performanceis
alsoaconsequenceofthetotalcontactduration(loadingthroughunloadingphases),becauseasthecontact
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durationbecomesshorter,higherforcesandjointmomentsaregenerated,137andthetendoncontributionto
workisincreased.132,138
Themechanismsbywhichperformanceisenhancedduringplyometricexercisedependonanumberoffactors:
Theactivitymustimparthigherforcesandfasterspeedsofmovement.
Prolongedcontacttimesshouldbeavoided.Prolongedcontacttimesmayresultwhentheintensityistoo
highduringtheloadingphaseorwhenthetransitionbetweentheloadingandunloadingphasesisnot
continuous.132
Plyometricexercisesmustbeinitiatedatalowerintensityandprogressedtomoredifficult,higher
intensitylevelsaccordingtotolerance.Beforeinitiatingplyometricexercises,theclinicianmustensure
thatthepatienthasanadequatestrengthandphysicalconditionbase.50Initially,thepatientisinstructedto
performfewersetsandreps.Later,thepatientispermittedtodomoresets,butnotmorereps.
Plyometricexercisesweretraditionallydesignedtoenablelowerextremitymusclesprimarilythethighs,
quadriceps,hamstrings,andcalvestoattainmaximalpowerusinghighintensityworkoutsinshortspurtsof
hops,leaps,orbounds.Therefore,careshouldbetakenwhenapplyingthephysiologicalprinciplesderivedfrom
lowerextremityinvestigationstoupperbodyandtrunkapplications,asitisunknownwhethertheupper
extremityandtrunkwillrespondinasimilarmanner.132Plyometricexerciseistypicallyintroducedintothe
rehabilitationprograminthelaterstagesasmanyplyometricexercises,evenatlowintensities,exposejointsto
substantialforcesandmovementspeeds.Plyometricexerciseisindicatedforthosepatientswhodesiretoreturn
toactivitiesthatincludeexplosivemovements.Contraindicationsforinitiatingplyometricexerciseareacute
inflammationorpain,immediatepostoperativestatus,andjointinstability.50Jointpathologiessuchasarthritis,
bonecontusion,orchondralinjuryarerelativecontraindications,dependingontheabilityofthetissueto
toleratethehighforcesandjointloadingrequiredinmanyplyometricactivities.132Musculotendinousinjuryis
alsoarelativecontraindicationuntilthetissueisabletohandletherapidandhighforcesofaplyometric
exercise.132
Guidelinesforinitiatingplyometricexerciseinrehabilitationarepoorlydeveloped.Mostofthecriteriahave
beenestablishedforhighintensityexerciseinuninjuredathletesandaregroundedinopinionratherthan
research.132Forexample,ithasbeensuggestedthatplyometricexerciseshouldbeinitiatedonlyafterachieving
theabilitytoperformonerepofaparallelsquatwithaloadof1.52.5timesbodymassonthebackand/orsquat
60%ofbodymass5timeswithin5seconds(lowerextremity),andabenchpresswithonethirdofbodyweight
and/orperformfivehandclappushups(upperextremity).119Inaddition,successinthestaticstabilitytests
(Table1210)anddynamicstabilitytests(verticaljumpforthelowerextremitiesandmedicineballthrowforthe
upperextremities)havealsobeenusedasameasureofpreparation.22
TABLE1210StaticStabilityTestsforPerformanceofPlyometrics
1.Singlelegstance:30seconds
Eyesopen
Eyesclosed
2.Singlelegquartersquat:30seconds
Eyesopen
Eyesclosed
3.Singleleghalfsquat:30seconds
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Eyesopen
Eyesclosed
DatafromVoightML,TippertSR.Plyometricexerciseinrehabilitation.In:VoightML,HoogenboomBJ,
PrenticeWE,eds.MusculoskeletalInterventions:TechniquesforTherapeuticExercise.NewYork,NY:
Manydifferentactivitiesanddevicescanbeusedinplyometricexercises.Plyometricexercisesmayinclude
diagonalandmultiplanarmotionswithtubingorisokineticmachines.Theseexercisesmaybeusedtomimicany
oftheneededmotionsandcanbeperformedinthestanding,sitting,orsupinepositions.Generally,4872hours
ofrestisrecommendedforrecoverybetweenplyometrictrainingsessions.139
LowerExtremityPlyometricExercises
Lowerextremityplyometricexercisesinvolvethemanipulationoftheroleofgravitytovarytheintensityofthe
exercise(Table1211).Thus,plyometricexercisescanbeperformedhorizontallyorvertically.
TABLE1211LowerExtremityPlyometricDrills
Warmupdrills
Doublelegsquats
Doubleleglegpress
Doublelegsquatjumps
Jumpingjacks
Entryleveldrillstwolegged
Twoleggeddrills
Sidetoside(floor/line)
Diagonaljumps(floor/4corners)
Diagonaljumps(4spots)
Diagonalzigzag(6spots)
Plyometriclegpress
Plyometriclegpress(4corners)
Intermediateleveldrills
Twoleggedboxjumps
Oneboxsidejump
Twoboxsidejumps
Twoboxsidejumpswithfoam
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Fourboxdiagonaljumps
Twoboxwithrotation
One/twoboxwithcatch
One/twoboxwithcatch(foam)
Singlelegmovements
Singlelegplyometriclegpress
Singlelegsidejumps(floor)
Singlelegsidetosidejumps(floor/4corners)
Singlelegdiagonaljumps(floor/4corners)
Advancedleveldrills
Singlelegboxjumps
Oneboxsidejumps
Twoboxsidejumps
Singlelegplyometriclegpress(4corners)
Twoboxsidejumpswithfoam
Fourboxdiagonaljumps
Oneboxsidejumpswithrotation
Twoboxsidejumpswithrotation
Oneboxsidejumpwithcatch
Oneboxsidejumprotationwithcatch
Twoboxsidejumpwithcatch
Twoboxsidejumprotationwithcatch
Endurance/agilityplyometrics
Sidetosidebounding(20ft)
Sidejumplunges(cone)
Sidejumplunges(conewithfoam)
Alteringrapidstepup(forward)
Lateralstepovers
Highstepping(forward)
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Highstepping(backward)
Depthjumpwithreboundjump
Depthjumpwithcatch
Jumpandcatch(plyoball)
DatafromVoightML,DraovitchP,TippettSR.Plyometrics.In:AlbertMS,ed.EccentricMuscleTrainingin
SportsandOrthopaedics.NewYork,NY:ChurchillLivingstone1995.
Horizontalplyometricexercisesareperformedperpendiculartothelineofgravity.Theseexercisesare
preferableformostinitialclinicalrehabilitationplansbecausetheconcentricforceisreduced,andthe
eccentricphaseisnotfacilitated.22Examplesofthesetypesofexercisesincludepushingasledagainst
resistance,andamodifiedlegpressthatallowsthesubjecttopushoffandlandonthefootplate.
Verticalplyometricexercises(againstorwithgravitationalforces)aremoreadvanced.Theseexercises
requireagreaterlevelofcontrol.22Thedropjumpisanexamplethesubjectstepsoffabox,landsand
immediatelyexecutesaverticaljump.
Thefootwearandlandingsurfacesusedinplyometricdrillsmusthaveshockabsorbingqualities,andthe
protocolshouldallowsufficientrecoverytimebetweensetstopreventfatigueofthemusclegroupsbeing
trained.140
UpperExtremityPlyometricExercises
Plyometricexercisesfortheupperextremityinvolverelativelyrapidmovementsinplanesthatapproximate
normaljointfunction.Forexample,attheshoulderthiswouldincludeflexionorabductionattheshoulder,trunk
rotation,anddiagonalarmmotions,andrapidexternalandinternalrotationexercises.
Plyometricsshouldbeperformedforallbodysegmentsinvolvedintheactivity.Hiprotation,kneeflexionand
extension,andtrunkrotationarepoweractivitiesthatrequireplyometricactivation.Plyometricexercisesforthe
upperextremityincludepushoffsfromatable(Fig.12104),cornerpushupsandweightedballthrows(Fig.
12105).Medicineandotherweightedballsareveryeffectiveplyometricdevices.Theweightoftheballcreates
aprestretchandaneccentricloadwhenitiscaught.Thiscombinationcreatesresistanceanddemandsa
powerfulagonistcontractiontopropelitforwardagain.Theexercisescanbeperformedusingonearmorboth
armsatthesametime.Theformeremphasizestrunkrotationandthelatteremphasizestrunkextensionand
flexion,aswellasshouldermotion.
FIGURE12104
Pushofffromtable.
FIGURE12105
Medicineballtoss.
Avarietyofpositivechangesinathleticperformanceandneuromuscularfunctionhavebeenattributedto
plyometrictraining,predominantlyinthelowerextremity:132
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Increasedmaximalverticaljumpheight.141
Increasedlegstrength,especiallywhencombinedwithweighttraining.141
Afasterrateofforcedevelopmentduringjumping.142
Delayedonsetofmusclefatigueduringjumping.143
Correctionofneuromuscularimbalances.144
Duetothescarcityofresearchonupperextremityperformanceplyometrictraining,theimprovementsinupper
extremityperformanceremainlargelyanecdotal.Itisalsounknownwhetherpatientsrecoveringfrominjurywill
respondtoplyometricexerciseinamannersimilartouninjuredsubjects.132
Basedontheconceptofpostactivationpotentiation,complextrainingmaybeusedtodeveloppowerinthe
athletebyalternatingbiomechanicallysimilarhighloadweighttrainingwithplyometricexercises,setforset,in
thesameworkout.145Basedonthisconcept,themuscleforceexertedisincreasedduetotheprevious
contraction,becausethecontractilehistoryofamuscleinfluencesthemechanicalperformanceofsubsequent
musclecontractions.146Clinically,thismeansthatwhilefatiguingmusclecontractionsimpairmuscle
performance,briefnonfatiguingcontractionsathighloadsenhancemuscleperformance.147Therearetwo
proposedmechanismsofpostactivationpotentiation:48
1.Strengthtrainingbeforeplyometricexercisescausesincreasedexcitationatthespinalcord,resultingin
increasedpostsynapticpotentialsandenhancedforcegeneratingcapacity.148,149
2.Thephosphorylationofmyosinregulatorylightchainsrendersactinmyosinmoresensitivetocalcium
releasefromthesarcoplasmicreticulum(seeChapter1)duringsubsequentmusclecontractions.
Anexampleofusingcomplextrainingwithalowerextremityplyometricexercisewouldbetohavethepatient
performasquatfollowedbyaplyometricsquatjump.Fortheupperextremity,thepatientcanperformabench
pressfollowedbyaplyometricpushup.
Inadditiontocomplextraining,contrasttrainingisanothermethodtoenhancepowertraining.Contrasttraining
useshighandlowloadsinthesametrainingsession.48Theeffectislikesomeoneliftinghalfagallonofmilk
whenheorshethinksthecontainerisafull.Forexample,apatientmayperform13repetitionswithaload
between80%and90%of1RM,alternatingwith36repetitionswithaloadbetween30%and50%1RM
performedatmaximumspeed.145Thecellularmechanismsbehindcontrasttrainingarethesameasthosefor
complextraining.
FunctionalMusclePerformance
Theultimategoalofanyrehabilitationprogramistoimprovefunctionorperformance.Intheathletic
community,safeexecutionrequiresmultiplecomponentsofphysicalperformance,includingmuscularstrength,
power,endurance,flexibility,balance,proprioception,speed,agility,andfunctionalmovementpatterns.The
besttestedabilitytoreturntosportisonethatcloselymimicsthatactivity.Inthegeneralpopulation,exerciseor
activitiesthatincreasemusclestrengthorendurancehavetobeprescribedwithfunctionalmobilityandstability
inmind.
IntegrationoftheEntireKinematicChain
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Attheearliestopportunity,exercisesmustbeintroducedthatincorporatetheentirekinematicchainratherthan
focusingonanisolatedjoint.Althoughforcedependentmotorfiringpatternsshouldbereestablished,special
caremustbetakentocompletelyintegrateallofthecomponentsofthekineticchaintogenerateandfunnelthe
properforcestotheappropriatejoint.Itshouldbeclearthatforakinematicchaintooperateefficiently,there
mustbeanoptimalsequentialactivationofthelimbsegmentsinvolved.Thisthenallowsforefficientgeneration
andtransferofforcealongthekinematicchain.150Whenchoosingamodeofkinematicexercise,thevariables
ofeachtypeofexercisemustbeconsidered.Theclinicianshouldunderstandtheprinciplesofexercise
applicationandthedifferencesbetweenopenkinematicchain(OKC)andclosedkinematicchain(CKC)
movements(seeChapter1)(Table15),inordertoaccomplishaspecificinterventiongoal(Table1212).
AlthoughitiscommonlybelievedthatallweightbearingexercisesinvolvesomeelementsofaCKCactivity,
notallCKCexercisesareperformedinweightbearingpositions.151
TABLE1212DifferentialFeaturesofOKCandCKCExercises
Exercise
Characteristics Advantages Disadvantages
Mode
1.Isolated
recruitment 1.Limitedfunction
1.Singlemusclegroup
2.Simplemovement 2.Limitedfunction
2.Singleaxisandplane
Open pattern
3.Limitedeccentrics
kinematic 3.Emphasizesconcentric
3.Isolated
chain contraction 4.Lessproprioceptionandjoint
recruitment
stabilitywithincreasedjointshear
4.Nonweightbearing
4.Minimaljoint forces
compression
1.Multiplemuscle 1.Functional
groups recruitment
1.Difficulttoisolate
2.Multipleaxesand 2.Functional
planes movementpatterns 2.Morecomplex
Closed
3.Balanceofconcentric 3.Functional 3.Lossofcontroloftargetjoint
kinematic
andeccentric contractions
contractions 4.Compressiveforcesonarticular
4.Increase surfaces
4.Weightbearing proprioceptionand
exercise jointstability
DatafromGreenfieldBH,TovinBJ.Theapplicationofopenandclosedkinematicchainexercisesin
rehabilitationofthelowerextremity.JBackMusculoskelRehabil.19922:3851.
Anumberofstudieshaveillustratedtheimportanceofthesequentialactivationofthesekineticlinks.152,153
Thebenefitofclosedkinematicchainexercises(CKCEs)overopenkinematicchainexercises(OKCEs)isbased
onthepremisethatCKCEs,particularlyinthelowerextremities,appeartoreplicatefunctionaltasksbetterthan
OKCEs.ThisisbecausetheCKCEsappeartoallowtheentirelinkagesystemofthekinematicchaintobe
exercisedtogether.49,99,154160Inaddition,CKCEshavebeenshowntoenhancejointcongruency,decreasethe
shearingforces,andstimulatethearticularmechanoreceptorsusingaxialloadingandincreasedcompressive
forces.157,161165Thus,CKCactivitiesarepurportedtohelpreinforcethesynchronizationofthenecessary
musclefiringpatternsforbothantagonistandagonistmusclegroupsusedduringstabilizationandambulation.49
However,therealsoappearstobemuchintheliteraturetosuggestthatOKCEshaveabeneficialeffecton
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function,82,166,167especiallywhencombinedwithspecificclosedchainexercisesorwhenusedtostrengthen
individualmuscles.154
Acomprehensiverehabilitationprogramthusshouldintegratetheentirekinematicchain,usingablendof
OKCEsandCKCEs.Thisintegrationmustoccurduringfunctionalexercises,withtheemphasisdeterminedby
theactivitytoberestored.Typically,OKCEsareusedinitiallyinnonweightbearingpositionswheretheforces
ofgravitycanbecontrolledbetter.CKCEscanbeintroducedgraduallybycontrollingthepercentageofbody
weightthatisusedduringtheexercise,usingawiderbaseofsupport(BOS),usingastablesupportsurface,and
performingexercisesinauniplanardirection.Astheprogramprogresses,morebodyweightcanbeused,the
BOSbecomesnarrowed,thesupportsurfacebecomesmoreunstable,andexercisesareperformedinmultiplanar
directions.
CLINICALPEARL
Therehabilitationofthekinematicchainshouldaddressthestrengthandflexibilityoftheentirekinematic
chain,usingtheprincipleofspecificity,withthespecificelementsoftherehabilitationprogrambeing
determinedbyboththeexistingpathologyandthefunctionalgoalsofthepatient.154,168
Inaddition,undertheconceptofspecificity,ratherthanisolatingOKCEsorCKCEs,itmaybewiseto
emphasizefunctionalpositioningduringtheexercisetraining,whilestrikingabalancebetweenmobilityand
stability.154,169
Severalobjectivesmustbemetiftherehabilitationofthefunctionalkinematicchainistobecomprehensive:154
1.Thefirstobjectiveoftherehabilitationprogram,thehealingphase,istherestorationoffunctional
stability,whichistheabilitytocontrolthetranslationofthejointduringdynamicfunctionalactivities,
throughtheintegrationofboththeprimaryandthesecondarystabilizers.170
2.Thesecondobjective,thefunctionalphase,istorestoresportsorfunctionalspecificmovementpatterns.
Thefunctionalphasebeginsoncethepatienthasnearfull,painfreerangeofmotion.
3.Thefinalobjectiveisassessingthereadinessofthepatienttoreturntohisorherpriorleveloffunctionor
levelofathleticperformance.
IncreasingDynamicStabilization
Akeycomponentoffunctionalactivityandathleticperformanceiscontrolledstability,ablendofpowerand
balance.Balanceandstabilitycanimprovewithstrengthandpower,andbalancetrainingwithoutresistancecan
improveproprioception.171,172Instabilityresistancetraining(IRT)isusedtoimprovebothstaticanddynamic
stabilization.SincemostCKCEsareperformedinweightbearingpositions,theyhelptofacilitatecoactivation
ofagonistsandantagoniststherebypromotingdynamicstability.Thus,stabilizationandbalanceexercises
shouldbeintroducedtotherehabilitationprogramasearlyasfeasible(seeChapter14).Therearetwo
componentstoIRT:171
1.Progressivechallengestobalance
2.Theadditionofloadorresistance
AccordingtoVoight,173,174oncethepatienthasmasteredtheprogressionsoutlinedinChapter14,thefollowing
progressionsoperaticanddynamicexercisescanbeusedasappropriate:
Staticstabilizationexerciseswithclosedchainloadingandunloading(weightshifting).Thisphase
initiallyemploysisometricexercisesaroundtheinvolvedjointonsolidandevensurfaces,before
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progressingtounstablesurfaces.Theearlytraininginvolvesbalancetrainingandjointrepositioning
exercises,andisusuallyinitiated(inthelowerextremitiesaccordingtoweightbearingrestrictions)by
havingthepatientplacingtheinvolvedextremityona68instool,sothattheamountofweightbearing
canbecontrolledmoreeasily.Theproprioceptiveawarenessofajointcanalsobeenhancedbyusingan
elasticbandage,orthotic,orthroughtaping.175180Asfullweightbearingthroughtheextremityis
restored,anumberofdevicessuchasaminitrampoline,balanceboard,stabilityball,andwobbleboard
canbeintroduced.Exercisesonthesedevicesareprogressedfromdoublelimbsupport,tosingleleg
support,tosupportwhileperformingsportsspecificskills.
CLINICALPEARL
Oneoftheadvantagesofusingthestabilityballisthatitcreatesanunstablebase,whichchallengesthepostural
stabilizermusclesmorethanusingastablebase.Itisimportanttochoosethecorrectandappropriatesizeof
stabilityball,whichisdependentuponpatientsize.
45cmball:shorterthan5
55cmball:5to58
65cmball:59to63
75cmball:tallerthan63
Withthepatientsittingontheballwithbothfeetfirmlyplantedontheground,thepatientsthighshouldbe
paralleltothefloor(thekneemaybeslightlyabovethehips).
Pumpinguptheballtoincreasefirmnessincreasesthelevelofdifficultyinanygivenexercise.
Thefurtherawaytheballisfromthesupportpoints,thegreaterthedemandforcorestability.
Decreasingthenumberofsupportpointsincreasesthedifficultyoftheexercise.
Transitionalstabilizationexercises.Theexercisesduringthisphaseinvolveconsciouscontrolofmotion
withoutimpactandreplaceisometricactivitywithcontrolledconcentricandeccentricexercises
throughoutaprogressivelylargerrangeoffunctionalmotion.Thephysiologicalrationalebehindthe
exercisesinthisphaseistostimulatedynamicposturalresponsesandtoincreasemusclestiffness.Muscle
stiffness(seeChapter2)hasasignificantroleinimprovingdynamicstabilizationaroundthejoint,by
resistingandabsorbingjointloads.181
Dynamicstabilizationexercises.Adelicatebalancebetweenstabilityandmobilityisachievedby
coordinationbetweenmusclestrength,endurance,flexibility,andneuromuscularcontrol.182Such
exercisesinvolvetheunconsciouscontrolandloadingofthejointandintroducebothballisticandimpact
exercisestotheappropriatepatient.Theexercisescaninvolveunstableconditionswithbodymassor
externalloads(e.g.,dumbbells,waterexercises)asresistance,unstablesurfaces(e.g.,Swiss/stabilityball,
foamrollers,wobbleboards,andsuspendedchains),unevennaturalsurfaces(e.g.,sandandgravel),and
reducingtheBOSusingunilateralstance(e.g.,oneleggedsquats).Inaddition,theuseofunilateral
resistanceexercises,whereonesideofthebodyexerciseswhiletheotherhalfstabilizes,canprovidea
disruptivetorquetherebyenhancingtheinstabilitychallenge.Forexample,greatererectorspinae
activationoccursduringaunilateralshoulderpressandincreasedabdominalactivitywiththeunilateral
chestpress.183Inaddition,crossoverfatiguecanoccurfromaunilateralexerciseinthecontralaterallimb,
andbytrainingunilaterally,theipsilateralandcontralaterallimbsreceivednormalstimulationwhile
activatingthecoremuscles.184,185
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Mostofthefollowingexercisesrequireadvancedstrengthandpowerandshouldthereforeonlybeusedwiththe
veryathleticpatient.
Seatedpushupsonanunstablesurface.
Weightshiftingonanunstablesurfacewhileinakneelingposition(Fig.12106).
WeightshiftingonaSwissballwiththefeetonthefloor,andthepatientreachinginvariousdirections
(Fig.12107).Theexercisecanbemademoredifficultbyraisingtheheightofelevationofthefeet,such
asplacingthefeetonachair.
Pronepushupwithlegselevated.
Armstepupswithapushup.
Pronepushuponunstablebases.
Handwalkingonatreadmill.
Climbingwiththehandsonasteppingmachine.
Bridgingusingunstablesurfaces.
Unilaterallegsquat.
Resistancebandwalkingandrunning.
Plyometricexercises.Thesecanincludesquatjumps,bounding,fourquadrantjumps,tuckjumps,lunge
jumps,zigzaghopping,andmultipleplatformjumpingandhopping.
FIGURE12106
Weightshiftingonanunstablesurfacewhileinakneelingposition.
FIGURE12107
WeightshiftingonaSwissballwiththefeetelevatedonasupport.
FunctionalPerformanceTests
Functionalperformancetestingcanprovidequantitativeandqualitativeinformationonspecializedmovements
insport,exercise,andoccupations.186Thetestchosenmustbeappropriatefortheindividualscondition,stage
ofinjury,andabilities.Ingeneral,approximately12to16weeksisneededtofollowingsofttissuerepairsbefore
aggressiveloadingcanbeattemptedtoinjuredshouldersorknees.187Inaddition,themostfatiguing(aerobic)
portionofthetestshouldbeperformedlast,withthemostexplosivetestsbeingperformedfirst,asaerobic,or
enduranceexercisesdecreaseisotonicandisokineticmuscleperformance.186,188Functionalperformancetests
havebeendevisedbasedonbodyareasasfollows:189
Trunk.Abalancebetweentheanterior,posterior,andlaterallocalandglobaltrunkmusclesisnecessary
tomaintainneutralspinealignmentnecessaryfordynamicstability(seeChapter28).190Thefollowing
twotestsarerecommended:
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Backwardmedicineballthrow.Thepatientispositionedholdingamedicineballwiththearmsin
frontofthebody(Fig.12108A).Followingacountermovement,thepatientextendsforcefully
backwardtothrowtheballovertheshoulder(Fig.12108B).
Sidearmmedicineballthrow.Thepatientispositionedsidewaystothethrowingdirectionina
crouchedposition,withthehipsandkneesflexedwhileholdingamedicineballwiththearms
straight.Themedicineballisheldonthelateralaspectofthekneewhichisfurthestawayfromthe
throwingline(Fig.12109).Thepatientistheninstructedtoswingthemedicineballacrossthe
bodyandtothrowitasfaraspossible(Fig.12110).
Lowerextremity.Thesetestsaredesignedtoassesstheabilityofthelowerextremitiestoproduce
velocity.
Verticaljump.Theverticaljumptestcanassessoveralllowerextremitypower,bilaterallyor
unilaterally.Thetestcanbedonewithapieceofchalkandawall,orusingtheVertecVerticalJump
System(Senoh,Columbus,Ohio).Thepatientispositionedinstandingwithequalweightplacedon
bothlowerextremitiesandreachingashighaspossiblewithasinglearm.Thepatientisthenasked
tojumpashighaspossible,andtheheightachievedbythereachinghandisrecorded.
Standinglongjump.Thepatientstandsinfrontofalineandisaskedtojumpandlandonbothfeet
asfarforwardaspossible(Fig.12111).
Singleleghop.Thepatientstandsinfrontofalineononelegandisaskedtohopforwardasfaras
possible(Fig.12112).Thescoreisthedistancefromthestartlinetothelocationoftheposterior
heelonthelandingleg.
Upperextremity.Thistestisdesignedtoisolatetheupperextremitiestherebypreventingany
contributionsfromthetrunkorlowerextremities.
Seatedshotputthrow.Thepatientispositionedinsitting,holdingamedicineball,withhisorherback
againstthewall(Fig.12113).Thepatientisthenaskedtothrowthemedicineball,usingbotharms,asfar
aspossible.
FIGURE12108
Backwardmedicineballthrow.
FIGURE12109
Sidearmmedicineballthrowstartposition.
FIGURE12110
Sidearmmedicineballthrowendposition.
FIGURE12111
Standinglongjump.
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FIGURE12112
Singleleghop.
FIGURE12113
Seatedshotputthrow.
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undefined
McGrawHill
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Allrightsreserved.
Silverchair
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CHAPTER13:ImprovingMobility
CHAPTEROBJECTIVES
1.Describethethreecomponentsofmobilityandtheirdifferences.
2.Describethetwodifferenttypesofflexibility.
3.Performagoniometricassessmentofeachjoint.
4.Describestrategiestoincreaserangeofmotion(ROM)usingdifferenttechniques.
5.DescribetheindicationsandcontraindicationsforthevarioustypesofROMexercises.
6.Defineactiveinsufficiencyandpassiveinsufficiencyofamuscle.
7.Outlinetheindicationsandcontraindicationsforcontinuouspassivemotion(CPM).
8.Defineflexibilityanddescribeitsimportanceinrehabilitation.
9.Explainthedifferencesbetweenthevariousstretchingtechniques.
10.Describestrategiestoincreaseflexibilityusingdifferenttechniques.
OVERVIEW
Normalmobilityisnecessaryforefficientmovement.Thetermsrangeofmotion(ROM),flexibility,and
accessoryjointmotionareoftenlistedascomponentsofmobility.
ROMreferstothedistanceanddirectionajointcanmove.Thedirectioninwhichajointmovesis
describedusingtermslikeflexion,extension,abduction,adduction,internalrotation,andexternal
rotation.EachspecificjointhasanormalROMthatisexpressedindegrees.Withinthefieldofphysical
therapy,goniometryiscommonlyusedtomeasurethetotalamountofavailablemotionataspecificjoint.
ROMofajointmaybelimitedbytheshapeofthearticulatingsurfaces,adaptiveshorteningofthe
muscles,andcapsularandligamentousstructuressurroundingthatjoint.Undernormalcircumstances,itis
themusclesthatmovethejoints.Thefullrangeofextensibilityofamuscleiscalleditsfunctional
excursion.Theamountofexcursiondependsonthearrangementofthemusclefibersandwhetherthe
muscleisaonejointoramultijointmuscle(seelater).
Flexibilityreferstothepassiveextensibilityofconnectivetissuethatprovidestheabilityforajointor
seriesofjointstomovethroughafull,nonrestricted,injuryfree,andpainfreeROM.Flexibilityisalso
dependentuponpainlevelsandneuromuscularcontrol.Magnusson1identifiedthreefactorsthatmight
contributetoimprovingflexibility:passivetissueproperties,segmentalreflexexcitability,andtolerance
ofdiscomfort.Whenaninjuryoccurs,thereisalmostalwayssomeassociatedlossoftheabilitytomove
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normallyduetothepain,swelling,muscleguarding,orspasm.Thesubsequentinactivityresultsina
shorteningofconnectivetissueandmuscle,lossofneuromuscularcontrol,oracombinationofthese
factors.2
Accessoryjointmotion.Accessoryjointmotionistheamountofthearthrokinematicglidethatoccursat
thejointsurfaces,termedjointplay(seeChapter1).Anumberofanatomicfactorscanlimittheabilityof
ajointtomovethroughafull,unrestrictedROM,includingtheintegrityofthejointsurfaces,increasing
age,andthemobilityandpliabilityofthesofttissuesthatsurroundajoint.Beforeattemptingtoimprove
thearthrokinematicglideataparticularjoint,theclinicianmustalwaysconsiderthestatusofthe
neighboringjointsintermsoftheirhypermobilityorhypomobility(seeChapter2).Jointmobilizationisa
techniquethatpreservesorincreasesarthrokinematicmotion.Techniquestoenhancejointmotionare
describedinChapter10.
Adecreaseinaccessoryjointmotion,ROMand/orintheflexibilityofonejointcanaffectthemobilityofthe
kineticchain.Forexample,adecreasedROMorflexibilityintheshouldercanimpactthemobilityoftheentire
arm.Inordertoprovidetreatmentforalossofmobility,theclinicianmustmakethedeterminationastothe
specificcause,thatis,lossofjointmotion,ROM,ordecreasedflexibility.Forexample,isthespecificcausedue
tojointeffusion,adaptiveshorteningofconnectivetissuestructures,achangeinbonyarchitecture,or
malalignmentofthearticularsurfaces?AttemptingtoperformROMandflexibilitytechniquesintheabsenceof
normalarthrokinematicmotionatthejointsurfacewillnotresultinanimprovementintheimpairedmobility,
butmayinsteadincreasethepatientssymptoms.
Flexibility
FlexibilityistheabilitytomoveasinglejointorseriesofjointsthroughanunrestrictedandpainfreeROM.
Flexibilitydependsonsoundjointarthrokinematics,fullROM(normalosteokinematics),andsofttissue
extensibility.Italsodependsonthemechanicalandneurophysiologicalpropertiesofthetissuesinvolvedand
howthosetissuesreacttophysicalloading(seeChapters1and2).Stretchingtechniquesaredesignedto
improvetheextensibilityofbothcontractileandnoncontractiletissues,includingneuraltissues(seeChapter11).
IndicationsforstretchingincludethosescenarioswhenROMislimitedduetoalossofextensibilityinthesoft
tissuesbecauseofscartissueformation,adhesions,andcontracturesthathaveresultedinfunctionallimitations
orparticipationrestrictions.Contraindicationsforstretchingincludeabonyendfeel,anincompletebonyunion,
recentfracture,acuteinflammatoryorinfectiousprocess,sharppainwithjointmovement,orinthepresenceof
hypermobility.
CLINICALPEARL
Itiswidelybelievedthatstretchingenhancesathleticperformance.However,anumberofstudies3,4have
indicatedthatacutestretchingeitherhasnoeffectordecreases,ratherthanenhances,muscleperformance
immediatelyfollowingthestretchingsession.Inaddition,acutestretchinghasbeenshowntohavenobenefiton
theperformanceofactivitiesthatrequirestrength,suchasjumpingorsprinting.5Incontrast,whenstretchingis
performedaspartofaregularandcomprehensiveconditioningprogramforanumberofweeks,beneficial
effectsonphysicalperformancehavebeenreported.3,6
Whenreferringtoflexibility,twotypesarerecognized,staticanddynamic.
Staticflexibility.Staticflexibility,alsoreferredtoaspassivemobility,isdefinedastherangeormotion
availabletoajointorseriesofjoints.7,8Increasedstaticflexibilityshouldnotbeconfusedwithjoint
hypermobility,orlaxity,whichisafunctionofthejointcapsuleandligaments.Decreasedstaticflexibility
indicatesalossofmotion.Theendfeelencounteredmayhelpthecliniciandifferentiatethecauseamong
adaptiveshorteningofthemuscle(musclestretch),atightjointcapsule(capsular),andanarthriticjoint
(hard).Staticflexibilitycanbemeasuredbyanumberoftests,suchasthetoetouchandthesitandreach,
bothofwhichhavebeenfoundtobevalidandreliable.9,10
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Dynamicflexibility.Dynamicflexibilityalsoreferredtoasactivemobility,referstotheeaseofmovement
withintheobtainableROM.Dynamicflexibilityismeasuredactively.Theimportantmeasurementin
dynamicflexibilityisstiffness,amechanicaltermdefinedastheresistanceofastructureto
deformation.11,12AnincreaseinROMaroundajointdoesnotnecessarilyequatetoadecreaseinthe
passivestiffnessofamuscle.1315However,strengthtraining,immobilization,andaginghavebeen
showntoincreasestiffness.1619Theconverseofstiffnessispliability.Whensofttissuedemonstratesa
decreaseinpliability,ithasusuallyundergoneanadaptiveshortening,oranincreaseintone,termed
hypertonus.ThereisgrowingresearchtosuggestthatthelimitingfactorsinpreventingincreasesinROM
arenotonlytheconnectivetissuesbutarealsotheresultofneurophysiologicalphenomenacontrolledby
thehighercentersoftheCNS.20
Inadditiontothosealreadymentioned,anumberofotherfactorsinfluenceconnectivetissuedeformation:
Sensoryreceptors.Twosensoryreceptorsthatmonitormuscleactivity,themusclespindle,andGolgi
tendonorgans(GTOs)(seeChapter3),playanimportantrolewhenattemptingtoincreaseflexibility
throughstretching.Thesetworeceptorscanactivatebothspinalreflexesandlonglooppathways
involvingsupraspinalcenters.Whenamuscleisstretched,boththemusclespindlesandtheGTOs
immediatelybeginsendingastreamofsensoryimpulsestothespinalcord.Initially,impulsescoming
fromthemusclespindlesnotifytheCNSthatthemuscleisbeingstretched.Impulsesreturntothemuscle
fromthespinalcord,causingthemuscletoreflexivelycontract,thusresistingthestretch.2TheGTOs
respondtothechangeinlengthandtheincreasingtensionbyfiringoffsensoryimpulsesoftheirownto
thespinalcordand,ifthestretchofthemusclecontinuesforanextendedperiodoftime(atleast6
seconds),impulsesfromtheGTOsbegintooverridemusclespindleimpulsesandcauseareflex
relaxationoftheantagonistmuscle(autogenicinhibition).2
CLINICALPEARL
Inanysynergisticmusclegroup,acontractionoftheagonistcausesareflexrelaxationoftheantagonistmuscle,
allowingittostretchandprotectingitfrominjurythisphenomenonisreferredtoasautogenicinhibition.2
Tissuetemperature.Attemperaturesabove37C(98.6F),thecrosslinksbetweencollagenfibrilsare
brokenmoreeasilyandmorerapidly,withthemostprofoundchangesoccurringbetween40and45C
(104113F).21,22Anumberofkeypointsmustberememberedbytheclinicianinordertoeffectively
manipulatetemperature:23
Theamountofforcerequiredtoattain/maintainadesireddeformationdecreasesastemperature
increases.
Thetimerequiredtodeformcollagentothepointoffailureisinverselyrelatedtotemperature.
Thehigherthetemperature,thegreatertheloadcollagenisabletotoleratebeforefailure.
Thehigherthetemperature,thegreatertheamountofdeformationpossiblebeforefailure.
Itisimportanttomakeadistinctionbetweenstretchingandwarmupasthetwoarenotsynonymousbutare
oftenconfusedbythelayman.Whilestretchingplacesneuromusculotendinousunitsandtheirfasciaunder
tension,awarmuprequirestheperformanceofanactivitythatraisestotalbodyandmuscletemperaturesto
preparethebodyforexercise.24Researchhasshownthatwarmuppriortostretchingresultsinsignificant
changesinjointROM.25Anecdotally,itwouldmakesensenottoperformstretchingatthebeginningofthe
warmuproutinebecausethetissuetemperaturesaretoolowforoptimalmuscletendonfunction,andareless
compliantandlesspreparedforactivity.Someadvocatestretchingafteranexercisesession,citingthatthe
increasedmusculotendinousextensibilityleadstothepotentialforimprovedjointflexibility.26Inonestudy,
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staticstretchingwasdonebefore,after,andbothbeforeandaftereachworkout.Allproducedsignificant
increasesinROM.27
Theamountofforceused.Viscoelasticchangesarenotpermanent,whereasplasticitychanges,whichare
moredifficulttoachieve,resultinaresidualorpermanentchangeinlength.Thekeyfactorforanychange
inconnectivetissuelengthisthedeformingforce,inparticular,themagnitudeandvelocityapplied.The
applicationoflowload,longdurationforcesisrecommended,althoughamusclemayrequireagreater
stretchingforceinitially,possiblytobreakupadhesionsorcrosslinkages,andtoallowforviscoelastic
andplasticchangestooccurinthecollagenandelastinfibers.28
Thedirectionofthestretch.Tostretchamuscleappropriately,thestretchmustbeappliedparalleltothe
musclefibers.Theorientationofthefiberscanbedeterminedbypalpation.Typically,intheextremities,
themusclefibersrunparalleltothebone.
Thedurationandfrequencyofthestretch.Thedurationreferstohowlongtheclinicianappliesthe
stretchingforce.Thefrequencyreferstothenumberoftimesorrepetitionsthestretchisperformed.There
continuestoremainalackofagreementontheidealcombinationofeitherthedurationofasinglestretch
orthenumberofrepetitionsofastretchinasinglesessionthatisnecessarytoachievethebestresults.
Researchershavereportedthattechniquesutilizingcyclicandsustainedstretchingfor15minuteson5
consecutivedaysincreasedhamstringmusclelengthandthatasignificantpercentageoftheincreased
lengthwasretained1weekposttreatment.29Otherresearchershavereportedthatafterusingfour
consecutivekneeflexorstaticstretchesof30seconds,thenewkneeROMwasmaintainedfor3minutes
buthadreturnedtoprestretchlevelsafter6minutes.30Asimilarstudyusingasequenceoffivemodified
holdrelaxstretchesreportedproducingsignificantlyincreasedhamstringflexibilitythatlasted6minutes
afterthestretchingprotocolended.31Frequentstretchingensuresthatthelengtheningismaintained
beforethemusclehastheopportunitytorecoiltoitsshortenedstate.32Frequencyofstretchingneedsto
occurataminimumoftwotimesperweek.33,34Incontrast,ithasbeendeterminedthat80%ofthelength
changesoccurinthefirstfourstretchesof30secondseach.26Itisimportantforthecliniciantoremember
thatanygainsinflexibilityandROMachievedfromastretchingprogramareonlytemporary.35Thus,itis
importanttointegratefunctionalactivitiessuchasreaching,bending,squatting,twisting,andpushinginto
thepatientsexerciseprogramthatutilizetheregainedrangeonaregularbasis.
Thespeedofthestretch.Twocommonstretchingtechniques,staticandballistic,usedifferentspeed
parameters.Thestaticstretchallowsforasteadyspeedtoallowlengtheningoftheentiremyotendinous
unit,andaholdordelayattheendoftheavailablemotion.36Theballisticstretchusesvariousspeedsof
singularorrepetitivebouncingattheendofmotiontostretchaparticularmuscle.Themuscleisstretched
bythemomentumcreatedfromthebouncingmovementssupplyingthetensileforceusedforthe
stretch.26ThepatientquicklyrelaxesthemusclewhenreachingtheendofROM.Thisisperformedina
cyclicalbouncingmotionandrepeatedseveraltimes,thusengaginganeurologicalcomponentcalled
activeresistancethecontractionofmusclesthatresistelongationintheformofmusclereflex
activity.26,37Incomparisonsoftheballisticandstaticmethods,twostudies38,39havefoundthatboth
producesimilarimprovementsinflexibility.However,theballisticmethodappearstocausemoreresidual
musclesorenessormusclestrain,thanthosetechniquesthatincorporaterelaxationintothetechniqueand
arethereforenotappropriateforelderlyorsedentaryindividuals.39,40Instead,theapplicationofany
stretchshouldbeappliedandreleasedgraduallytominimizemuscleactivationandinjurytotissues.
Positioningandstabilizationofthestructurebeingstretched.AsdescribedinChapter10,when
performinganymanualtechnique,correctpositioningofthepatientisessentialbothtohelpthepatient
relaxandtoensuresafebodymechanicsfromtheclinician.Forexample,whenstretchingthehip
musculature,itisimportanttoprotectthelumbarspinebymaintainingitinaneutralposition.When
patientsfeelrelaxed,theirmuscleactivityisdecreased,reducingtheamountofresistanceencountered
duringthetechnique.Accuratehandplacementisessentialforefficientstabilizationandfortheaccurate
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transmissionofforce.Thecliniciancanstabilizeeithertheproximalordistalattachmentsiteofthemuscle
tendonunitbeingstretched,althoughitismorecommontostabilizetheproximalattachmentandmove
thedistalsegment.
Thetypeofstretch.Thetypeofstretchreferstothemethodbywhichthestretchisimparted.Stretching
canbeappliedmanuallyormechanically.
Avarietyofstretchingtechniquescanbeusedtoincreasetheextensibilityofthesofttissues.
StaticStretching
Staticstretchinginvolvestheapplicationofasteadyforceforasustainedperiod.Thestretchshouldbe
performedatthepointjustshyofthepain,althoughsomediscomfortmaybenecessarytoachieveresults.28
Smallloadsappliedforlongperiodsproducegreaterresiduallengtheningthanheavyloadsappliedforshort
periods.41Restorationofthenormallengthofthemusclesmaybeaccomplishedusingtheguidelinesoutlinedin
Table131.Weightedtractionorpulleysystemsmaybeusedforthistypeofstretching.Itisimportantforthe
patienttorealizethattheinitialsessionofstretchingmayincreasesymptoms.42However,thisincreasein
symptomsshouldbetemporary,lastingforacoupleofhours,atmost.32,43
TABLE131StaticStretchingGuidelines
Heatshouldbeappliedtoincreaseintramusculartemperaturepriorto,andduring,stretching.adThis
heatcanbeachievedwitheitherthroughlowintensitywarmupexercise,orthroughtheuseofthermal
modalities.Theapplicationofacoldpackfollowingthestretchisusedtotakeadvantageofthethermal
characteristicsofconnectivetissue,byloweringitstemperatureandtherebytheoreticallyprolongingthe
lengthchangestheelasticityofamusclediminisheswithcooling.ad
Effectivestretching,intheearlyphase,shouldbeperformedeveryhour,butwitheachsessionlasting
onlyafewminutes.
Withtruemuscleshortness,strongerresistanceisusedtoactivatethemaximumnumberofmotorunits,
followedbyvigorousstretchingofthemuscle.
Stretchingshouldbeperformedatleasttwotimesaweekusing:
Lowforce,avoidingpain
Prolongedduration
Rapidcoolingofthemusclewhileitismaintainedinthestretchedposition
Datafrom:
aAssmussenE,BondePetersonF.Storageofelasticenergyinskeletalmuscleinman.ActaPhysiolScand.
197491:385392.
bBoscoC,KomiPV.Potentiationofthemechanicalbehaviorofthehumanskeletalmusclethrough
prestretching.ActaPhysiolScand.1979106:467472.
cCavagnaGA,SaibeneFP,MargariaR.Effectofnegativeworkontheamountofpositiveworkperformedbyan
isolatedmuscle.JApplPhysiol.196520:157158.
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dCavagnaGA,DismanB,MargaraiR.Positiveworkdonebyapreviouslystretchedmuscle.JApplPhysiol.
196824:2132.
DynamicStretching
Dynamicstretchinginvolvesstretchingbyamuscularcontractiontoincreaseordecreasethejointanglewhere
themusclecrosses,therebyelongatingthemusculotendinousunitastheendROMisobtained26Dynamic
stretchingisaspecificwarmupusingactivityspecificmovementstopreparethemusclesbytakingthem
throughthemovementsusedinaparticularsport.26Dynamicstretchingdoesnotincorporateendrangeballistic
movements,asinballisticstretching,butrathertheuseofcontrolledmovementsthroughanormalROM.26
Thereissomedebateastowhetherthestaticordynamicmethodisbettertostretchamuscle.Staticstretchingis
consideredthegoldstandardinflexibilitytraining.44However,recentstudieshavefoundthatstaticstretchingis
notaneffectivewaytoreduceinjuryrates,45,46andmayactuallyinhibitathleticperformance.6Thisislikely
becausethenatureofstaticstretchingispassiveanddoesnothingtowarmamuscle.47Moredynamicmethods
ofstretchinginvolveeitheracontractionoftheantagonistmusclegroup,thusallowingtheagonisttoelongate
naturallyinarelaxedstate,oreccentricallytrainingamusclethroughitsfullROM.44Thelattermethodwould
appeartoaddresstheproblemthatmostinjuriesoccurduringtheeccentricphaseofactivity.45Astudyby
Nelson44thatcomparedtheimmediateeffectofstaticstretching,eccentrictraining,andnostretching/training
onhamstringflexibilityinhighschoolandcollegeathletes(75subjects)foundtheflexibilitygainsinthe
eccentrictraininggrouptobesignificantlygreaterthanthestaticstretchgroup.
NeurophysiologicStretching
Thistypeofstretchingreferstotheuseoftechniquesthatrelyontheneurophysiologicalchangesthatoccurin
contractiletissues.Thegoalofthesetechniquesistoreducethesensorymotorfeedbackandtherebyincrease
relaxation.Suchtechniquesincludeproprioceptiveneuromuscularfacilitation(PNF)andmuscleenergy(see
Chapter10).ThemajorityofstudieshaveshownthePNFtechniquestobethemosteffectiveforincreasing
ROMthroughmusclelengtheningwhencomparedtothestaticorslowsustained,andtheballisticorbounce
techniques,4858althoughonestudyfoundittobenotnecessarilybetter.59
ThePNFtechniquesofcontractrelax(CR),holdrelax(HR),anagonistcontraction(AC),oraholdrelax
agonistcontractionsequence(HRAC)canbeusedtoactivelystretchthesofttissues:2
CRandHR.HRandCRstretchingtechniquesbeginasperthestaticstretchingtechniquesinthatthe
cliniciansupportsthepatientandbringsalimb(andthetargetedmuscletobestretched)totheendof
ROMuntilgentlestretchingisfelt.Atthatpoint,theclinicianasksthepatienttoprovideaprestretch,end
range,isometriccontractionofthemusclebeingstretchedforapproximately5secondsafterwhichthe
patientisaskedtorelaxthemuscle.Theclinicianthenmovesthelimbpassivelyintothenewrangeuntila
limitationisagainfeltandrepeatstheproceduretwotofourtimes.TheonlydifferencebetweentheHR
techniqueandtheCRtechniqueisthatintheformertechniquetheprestretchisometriccontractionoccurs
inallmusclesofthediagonalpattern,whereasinthelattertechniquetherotatorsofthelimbcontract
concentricallywhileallofthemusclegroupsofthediagonalpatterncontractsisometricallyduringthe
prestretchphaseoftheprocedure.60
AC.ACstretchingusestheprincipleofreciprocalinhibition,andthetermagonistreferstothemuscles
oppositetherangelimitingtargetmuscle,whichcanbeconfusing.Theclinicianmovesthelimbtothe
positionofgentlestretchandasksthepatientforacontractionofthemuscleoppositethemusclebeing
stretched(theantagonist)forabout5seconds,andforthepatienttoholdtheendrangepositionfor
another5seconds.Forexample,whenstretchingthehamstringmuscles,asimultaneouscontractionofthe
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quadricepsmusclescanfacilitatethestretchofthehamstrings.Thetechniqueisrepeatedtwotofour
times.
HRAC.Thistechnique,alsoreferredtoastheCRACorslowreversalHRtechnique,combinestheHR
andACprocedures.ThecliniciantakesthelimbtothepointofgentlestretchandperformsaCRsequence
(i.e.,resistanceappliedagainstthemusclebeingstretched).Aftercontractingthemusclebeingstretched,
thepatientisaskedtorelaxthismusclewhilecontractingtheopposingmusclegroup(antagonist),thus
facilitatingthestretch.Forexample,whenstretchingthehamstringmuscles,thehamstringsarebroughtto
astretchedposition,thehamstringsarethencontractedagainstresistance,andthenrelaxed,andthenthe
quadricepsarecontracted.Eachcontractionisheldforapproximately5seconds,andthetechniqueis
repeatedtwotofourtimes.
Othertechniquesthatcanassistinlengtheningofcontractiletissuethroughrelaxationincludethefollowing:
Theapplicationofheat,whichincreasestheextensibilityoftheshortenedtissues,willallowthemuscles
torelaxinlengthandmoreeasily,reducingthediscomfortofstretching.Heatwithoutstretchinghaslittle
ornoeffectonlongtermimprovementinmuscleflexibility,whereasthecombinationofheatand
stretchingproducesgreaterlongtermgainsintissuelengththanstretchingalone.
Massageandothersofttissuetechniques(seeChapter10),whichincreaselocalcirculationtothemuscle
andreducemusclespasmandstiffness.
Biofeedback,whichteachesthepatienttoreducetheamountoftensioninamuscle.
Relaxationtraining.
Followingeachstretchingsession,thestretchedtissuesmustbeallowedtocoolinalengthenedposition.This
canbefacilitatedbyusingcoldpacks.Oncegainsinmotionhavebeenachieved,itisimportantforthepatientto
gainneuromuscularcontroloftheagonistsinthenewrange.Thiscanbeaccomplishedwithlowloadresistance
exercisesthroughoutthenewlyacquiredrange.Forexample,afterhavingstretchedthehamstringstoreducea
kneeflexioncontracture,thepatientisencouragedtoactivatethequadricepsinthenewrange.OncetheROM
approacheswhatisnormalforthepatient,themusclesthatwereshortenedandthenstretchedmustalsobe
strengthened.
RangeofMotion
Anygivenmuscle,crossingasinglejoint,isnormallycapableofshorteningsufficientlytopermitafullROMat
thatjoint.ThefunctionalexcursionofaonejointmuscleislimitedbytheROMatthejointitcrosses.For
example,thehipabductorsarelimitedbytherangeavailableatthehipjoint.Fortwojointormultijoint
muscles,thefunctionalexcursiongoesbeyondthelimitsofanyonejointthattheycross.Forexample,the
sartoriusmusclecanflex,abduct,andexternallyrotatethehipaswellasbeingabletoflextheknee.The
absoluteamountbywhichanymusclecanshortendependson:
1.Thelengthof,andarrangementof,thefibers
2.Structureanddesignofthejoint.
3.Thenumberofjointstraversed.
4.Resistanceofantagonistmuscleormuscles
5.Thepresenceofanyloadthatopposesthemuscle.
Ifamusclethatcrossestwoormorejointsproducessimultaneousmovementatallofthejointsthatitcrosses,it
soonreachesalengthatwhichitcannolongergenerateafunctionalamountoftension.Thisisreferredtoas
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activeinsufficiency(e.g.,attemptingtoachievemaximalhipflexionwiththekneefullyextended).Incontrast,
whenthefullROMatanyjoint,orjoints,thatthemusclecrossesislimitedbythemusclesownlength,itis
referredtoaspassiveinsufficiency(e.g.,attemptingtofullyextendtheelbow,whilesimultaneouslypronating
theforearmandextendingtheshoulderplacesthebrachialismuscleinapositionofpassiveinsufficiency).
Fromarehabilitationviewpoint,tomaintainorimprovetheamountofROMatajointorkinematicchain,each
jointmustbemovedthroughitsavailableROMatregularintervals.Continuousimmobilizationofskeletal
muscletissuescancausesomeundesirableconsequences,includingweaknessoratrophyofthemuscles.61
Muscleatrophyisanimbalancebetweenproteinsynthesisanddegradation.Aftermodesttrauma,thereisa
decreaseinwholebodyproteinsynthesis62ratherthanincreasedbreakdown.Withmoreseveretrauma,major
surgery,ormultipleorganfailures,bothsynthesisanddegradationincrease,thelatterbeingmoreenhanced.63,64
WhenreferringtoROMtechniquesusedinrehabilitation,threemajormovementsarerecognized:2
Passiverangeofmotion(PROM).PROMreferstothedegreetowhichajointcanbepassivelymovedto
theendpointintheROM.PROMexercisesareperformedbytheclinician,familymember,caregiver
withoutanymuscularactivationbythepatient.Insomecases,thepatientisabletoperformPROMonone
partoftheirbodyusinganotherpart(usingtheleftarmtoflextherightelbow).Inaddition,pulleys,
continuouspassivemotion(CPM)devices,orvarioushouseholdobjects,suchasacounterorchair,canbe
usedtoassistintheperformanceofPROM.PROMisindicatedwhenthepatientsownmuscleforceis
inadequatetoproducesufficientmotionatajoint,whenactivecontractionofthemusclewouldbe
harmful,orasameansofeducatingapatientaboutaparticularmovement.PROMiscontraindicated
duringanystageoftissuehealinginwhichmotioncouldpreventorinhibittissuerepair,inthepresenceof
muscleguarding,orinthepresenceofincreasingpain.FactorsthatcanlimitPROMaboutajointinclude
thejointcapsule,periarticularconnectivetissue,adaptiveshorteningofthemusculotendinousunit,bone
onboneapproximation,loosebodies,pain,andscarringoftheoverlyingskin.Ifoverpressureisappliedat
theendoftheavailablePROM,astretchingforceisimparted,andthecliniciancandeterminetheend
feel.Patienthandlingandpositioningarecriticaltoallowthepatienttorelaxduringtreatmentby
decreasingapprehension.Forexample,adequatestabilizationandtheuseofasmoothandsteadypace.
AlthoughPROMisimportanttoenhancevasculardynamicandsynovialdiffusion,maintainjointmotion,
ROM,andflexibility,itdoesnotpreventmuscleatrophy,increasestrengthorendurance,orassist
circulationtothesameextentthatactive,voluntarymusclecontractiondoes.
CLINICALPEARL
TheuseofaCPMdevicehasbeenpromotedasameanstofacilitateamorerapidrecoverybyimprovingROM,
decreasingthelengthofhospitalstay,andloweringtheamountofnarcoticuse.However,studieshaveshown
thattheeffectofCPMdevicesonanalgesiaconsumption,ROM,hospitalstay,andcomplicationshasbeen
variable:
DatasupporttheuseofCPMtodecreasetherateofmanipulationforpoorROMaftertotalknee
arthroplasty(TKA).AlthoughitappearsthattheuseofaCPMdevicedoeshelpregainkneeflexion
quickerpostTKA,itisnotaseffectiveintheenhancementofkneeextension.
KneeimpairmentordisabilityisnotreducedwiththeuseofaCPMatdischargefromthehospital.
Becauseofstandardizedinpatienthospitalclinicalpathways,thelengthofhospitalstayisnotdecreased
bytheuseofaCPMdevicebut,dependingonthehospitalinvolved,theoverallcostisnotincreased.
WoundcomplicationsprobablyarenotincreasedwiththeuseofCPM,providedgoodtechniqueisusedin
woundclosure.
Activeassistedrangeofmotion(AAROM).AAROMoccurswhenROMofthejointoccursactivelybut
wheretheeffectofgravityhasbeenremovedorwhenmanualassistanceisnecessarytocompletethe
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motionduetoweaknessresultingfromtrauma,pain,neurologicinjury,orpostsurgicalrecovery.AAROM
involvessomemuscleactivationandisadvocatedwhensomemuscleactivationthroughtheROMis
permittedordesired.Forexample,performingshoulderabductionwhilelyingsupine,whichusesthebed
surfaceforsupport.Theamountofassistanceneededvariesfromminimalornoassistanceinsomeranges
tomaximalassistanceinotherpartsoftherange.AAROMisimportanttoenhancevasculardynamicand
synovialdiffusion,maintainjointmotion,ROM,andflexibility,andmayhelppreventmuscleatrophy.
Activerangeofmotion(AROM).AROMreferstothedegreetowhichajointcanbemovedbyamuscle
contraction,usuallythroughthemidrangeofmovement.AROMexercisesaretypicallyusedfollowing
anypassivetechniquetoreinforcepropermovementoraspartofawarmuproutine.AROMisindicated
whenthepatientisabletoperformamovementsafely,effectively,andwithminimumpain.AROMis
contraindicatedintheacutestageofhealing(1248hoursafterthetrauma)orinthepresenceofany
adverseresponsetothemotion(painthatpersistsmorethan2hoursaftertheactivity,anundesired
cardiopulmonaryresponse,oranincreaseineffusion/information).AROMdoesnotmaintainorincrease
strengthordevelopskillorcoordinationexceptinthemovementpatternsused.
CLINICALPEARL
Intheearlystagesoftherehabilitationprocess,ROMexercisesareperformedinthefollowingsequence:
PassiveROMAAROMAROM.ItisimportanttorememberwhenmakingthetransitionfromPROMto
AAROMorAROM,thatgravityhasasignificantimpactespeciallyinindividualswithweakmusculature.
Theseindividualsmayrequireassistancewhenthesegmentmovesupagainstgravity,ormovesdownward,with
gravity.
Goniometry
ThetermgoniometryisderivedfromtwoGreekwords,goniameaningangleandmetron,meaningmeasure.
Thus,agoniometerisaninstrumentusedtomeasureangles.Withinthefieldofphysicaltherapy,agoniometeris
usedtomeasurethetotalamountofavailablemotionataspecificjoint.Goniometrycanbeusedtomeasure
bothactiveandpassiveROM,PROM,AAROM,andAROM.
Goniometersareproducedinavarietyofsizesandshapesandareusuallyconstructedofeitherplasticormetal
(Fig.131).Thetwomostcommontypesofinstrumentsusedtomeasurejointanglesarethebubble
inclinometerandthetraditionalgoniometer.
FIGURE131
Thevarioustypesofgoniometers.
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Bubblegoniometer(Fig.132).Thebubblegoniometer,whichhasa360degreerotatingdialandscale
withfluidindicatorcanbeusedforflexionandextensionabductionandadductionandrotationofthe
neck,shoulder,elbow,wrist,hip,knee,ankle,andthespine.
Traditionalgoniometer.Thetraditionalgoniometer,whichcanbeusedforflexionandextension
abductionandadductionandrotationoftheshoulder,elbow,wrist,hip,knee,andankle,consistsofthree
parts:
Abody.Thebodyofthegoniometerisdesignedlikeaprotractorandmayformafullorhalfcircle.
Ameasuringscaleislocatedonthebody.Thescalecanextendeitherfrom0to180degreesand
180to0degreesforthehalfcirclemodelsorfrom0to360degreesandfrom360to0degreeson
thefullcirclemodels.Theintervalsonthescalescanvaryfrom1to10degrees.
Astationaryarm.Thestationaryarmisstructurallyapartofthebodyand,therefore,cannotmove
independentlyofthebody.
Amovingarm.Themovingarmisattachedtothefulcruminthecenterofthebodybyarivetor
screwlikedevicethatallowsthemovingarmtomovefreelyonthebodyofthedevice.Insome
instruments,thescrewlikedevicecanbetightenedtofixthemovingarminacertainpositionor
loosenedtopermitfreemovement.Thelengthofthestationaryandmovingarmsvariesamong
instruments(Fig.131).Extendablegoniometers(Fig.133)allowvaryingrangesinarmlength
from9to26in.
FIGURE132
Bubblegoniometer.
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FIGURE133
Extendablegoniometer.
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Thecorrectselectionofwhichgoniometerdevicetousedependsonthejointangletobemeasured.Thelonger
armedgoniometer,orthebubbleinclinometer,arerecommendedwhenthelandmarksarefurtherapart,suchas
whenmeasuringspine,hip,knee,elbow,andshouldermovements.Inthesmallerjoints,suchasthewristand
handandfootandankle,atraditionalgoniometerwithashorterarmisused.
ThegeneralprocedureformeasuringROMinvolvesthefollowing:
1.Thepatientispositionedintherecommendedtestpositionandshouldbecorrectlydraped.While
stabilizingtheproximaljointcomponent,thecliniciangentlymovesthedistaljointcomponentthrough
theavailableROMuntiltheendfeelisdetermined(seeChapter4).Anestimateismadeoftheavailable
ROM,andthedistaljointcomponentisreturnedtothestartingposition.
2.Theclinicianpalpatestherelevantbonylandmarksandalignsthegoniometer.
3.Arecordismadeofthestartingmeasurement.Thegoniometeristhenremoved,andthejointismoved
throughtheavailableROM.OncethejointhasbeenmovedthroughtheavailableROM,thegoniometeris
replacedandrealigned,andameasurementisreadandrecorded.
ThestandardtestingproceduresforeachoftheupperandlowerextremityjointsareoutlinedinTables132and
133.
TABLE132GoniometricTechniquesfortheUpperExtremity
Tested
Patient Stationary
Joint Motion/Range Fulcrum/Axis MovingArm
Position Arm
(degrees)
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Lateral
midlineofthe
humerus
Midaxillary usingthe
Flexion/0170to180 Supine Acromionprocess lineofthe lateral
thorax epicondyleof
thehumerus
forreference
Lateral
midlineofthe
humerus
Prone/supine Midaxillary
usingthe
Extension/050to60 witharm Acromionprocess lineofthe
lateral
overedge thorax
epicondyleof
thehumerus
forreference
Paralleltothe
Medial
Abduction/0170to Anterioraspectof midlineofthe
Supine midlineofthe
180 theacromionprocess anterioraspect
humerus
ofthesternum
Paralleltothe
Adduction(return Medial
Anterioraspectof midlineofthe
from Supine midlineofthe
theacromionprocess anterioraspect
abduction)/1800 humerus
ofthesternum
Shoulder Alongthe
midshaftof
Superiorlyonthe Alongthe
thehumerus,
acromionprocessof midlineofthe
Horizontal inlinewith
Seated thescapulathrough shoulder
adduction/0120 thelateral
theheadofthe towardthe
epicondyles
humerus neck
ofthe
humerus
Alongthe
Superiorlyonthe Alignedon midshaftof
acromionprocessof themidlineof thehumerus,
Horizontal
Seated thescapulathrough theshoulder inlinewith
abduction/0120
theheadofthe towardthe thelateral
humerus neck epicondyleof
thehumerus
Ulnausing
Parallelor theolecranon
Internalrotation/0
Supine Olecranonprocess perpendicular processand
60to100
tothefloor ulnarstyloid
forreference
Ulnausing
Parallelor theolecranon
Externalrotation/0
Supine Olecranonprocess perpendicular processand
80to90
tothefloor ulnarstyloid
forreference
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Lateral
midlineofthe
Lateralmidlineof
radiususing
Lateral thehumerususing
theradial
Flexion/0145 epicondyleof thecenterofthe
headand
thehumerus acromionprocessfor
radialstyloid
reference
processfor
reference
Elbow Lateral
Lateral
midlineof
midlineofthe
theradius
humerus
Lateral usingthe
usingthe
Extension/1450 Supine/seated Supine/seated epicondyleof radialhead
centerofthe
thehumerus andradial
acromion
styloid
processfor
processfor
reference
reference
Dorsalaspect
ofthe
Paralleltothe forearm,just
Lateraltotheulnar anterior proximalto
Pronation/090 Supine/seated
styloidprocess midlineofthe thestyloid
humerus processofthe
radiusand
ulna
Radioulnar
Ventral
aspectofthe
Paralleltothe forearm,just
Medialtotheulnar anterior proximalto
Supination/090 Supine/seated
styloidprocess midlineofthe thestyloid
humerus processofthe
radiusand
ulna
Lateral
midlineofthe
Lateral
Lateralaspectofthe ulnausingthe
midlineofthe
Flexion/090 Seated wristsoverthe olecranonand
fifth
triquetrum ulnarstyloid
metacarpal
processfor
reference
Lateral
midlineofthe
Lateral
Lateralaspectofthe ulnausingthe
midlineofthe
Extension/070 Seated wristsoverthe olecranonand
fifth
triquetrum ulnarstyloid
metacarpal
processfor
reference
Wrist
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Dorsal
midlineofthe
Overthemiddleof Dorsal
forearmusing
Radialdeviation/0 thedorsalaspectof midlineofthe
Seated thelateral
25 thewristoverthe third
epicondyleof
capitate metacarpal
thehumerus
forreference
Dorsal
Overthemiddleof midlineofthe Dorsal
thedorsalaspectof forearmusing midlineofthe
Ulnardeviation/035 Seated thewristoverthe thelateral third
capitate epicondyleof metacarpal
thehumerus
forreference
Ventral
midlineofthe
radiususing
Overthepalmar theventral Ventral
Carpometacarpal aspectofthefirst surfaceofthe midlineofthe
Seated
flexion/015 carpometacarpal radialhead first
joint andradial metacarpal
styloid
processfor
reference
Ventral
midlineofthe
radiususing
Overthepalmar theventral Ventral
Carpometacarpal aspectofthefirst surfaceofthe midlineofthe
Seated
extension/070 carpometacarpal radialhead first
joint andradial metacarpal
styloid
processfor
reference
Lateral Lateral
midlineofthe midlineofthe
second first
metacarpal metacarpal
Overthelateral usingthe usingthe
Carpometacarpal
Seated aspectoftheradial centerofthe centerofthe
abduction/060
styloidprocess second first
metacarpalor metacarpalor
phalangeal phalangeal
jointfor jointfor
reference reference
Thumb
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Lateral Lateral
midlineofthe midlineofthe
second first
metacarpal metacarpal
Overthelateral usingthe usingthe
Carpometacarpal
Seated aspectoftheradial centerofthe centerofthe
adduction/600
styloidprocess second first
metacarpalor metacarpalor
phalangeal phalangeal
jointfor jointfor
reference reference
Overthe
Overthe
Overthedorsal dorsal
dorsalmidline
Metacarpophalangeal aspectofthe midlineshaft
Seated shaftofthe
flexion/050 metacarpo ofthe
firstmetal
phalangealjoint proximal
bone
phalanx
Alignedwith Alongthe
Overthepalmar
theshaftof palmar
aspectofthe
Metacarpophalangeal thefirst midlineofthe
Seated metacarpophalangeal
extension/010 metacarpalon proximal
joint
thepalmar phalanxof
side thethumb
Alongthe Alongthe
Overthedorsal dorsalmidline dorsal
Interphalangeal
Seated surfaceofthe surfaceofthe midline
flexion/080to90
interphalangealjoint proximal surfaceofthe
phalanx distalphalanx
Alongthe
Onthe
Overthe midline
palmar
Interphalangeal interphalangealjoint palmar
Seated midline
extension/05 onthepalmar surfaceofthe
surfaceofthe
surface proximal
distalphalanx
phalanx
Overthe
Overthedorsal Overthe
dorsal
Metacarpophalangeal aspectofthe dorsalmidline
Seated midlineofthe
flexion/090 metacarpophalangeal ofthe
proximal
joint metacarpal
phalanx
Overthe
dorsal
Seated midlineofthe
extension/030 metacarpophalangeal ofthe
proximal
joint metacarpal
phalanx
Overthe
dorsal
Seated midlineofthe
abduction/020 metacarpophalangeal ofthe
proximal
joint metacarpal
phalanx
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Overthe
dorsal
Fingers Seated midlineofthe
adduction/020 metacarpophalangeal ofthe
proximal
joint metacarpal
phalanx
Overthe Overthe
Overthedorsal
Proximal dorsalmidline dorsal
aspectofthe
interphalangeal Seated ofthe midlineofthe
proximal
flexion/0120 proximal middle
interphalangealjoint
phalanx phalanx
Overthe Overthe
Overthedorsal
Proximal dorsalmidline dorsal
aspectofthe
interphalangeal Seated ofthe midlineofthe
proximal
extension/010 proximal middle
interphalangealjoint
phalanx phalanx
Overthedorsal Overthe Overthe
Distal
aspectofthe dorsalmidline dorsal
interphalangeal Seated
proximal ofthemiddle midlineofthe
flexion/080
interphalangealjoint phalanx distalphalanx
Overthedorsal Overthe Overthe
Distal
aspectofthe dorsalmidline dorsal
interphalangeal Seated
proximal ofthemiddle midlineofthe
extension/010
interphalangealjoint phalanx distalphalanx
TABLE133GoniometricTechniquesfortheLowerExtremity
Tested
Stationary
Joint Motion/Range PatientPosition Fulcrum/Axis MovingArm
Arm
(degrees)
Overthelateral
Lateralmidline
aspectofthehip
Lateral ofthefemur
Flexion/0115to jointusingthe
Supine midlineof usingthelateral
120 greatertrochanterof
thepelvis epicondylefor
thefemurfor
reference
reference
Overthelateral
Lateralmidline
aspectofthehip
Lateral ofthefemur
Extension/010to jointusingthe
Prone/sideline midlineof usingthelateral
15 greatertrochanterof
thepelvis epicondylefor
thefemurfor
reference
reference
Alignedwith
imaginary Anterior
Overtheanterior
horizontal midlineofthe
superioriliacspine
line femurusingthe
Abduction/045 Supine (ASIS)ofthe
extending midlineofthe
extremitybeing
fromone patellafor
measured
ASIStothe reference
otherASIS
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Tested
Stationary
Hip Arm
(degrees)
Alignedwith
imaginary Anterior
OvertheASISof horizontal midlineofthe
Adduction/020to theextremitybeing line femurusingthe
30 Supine extending midlineofthe
measured
fromone patellafor
ASIStothe reference
otherASIS
Anterior
midlineofthe
Perpendicular lowerlegusing
Internal totheflooror thecrestofthe
Anterioraspectof
rotation/030to Seated paralleltothe tibiaandapoint
thepatella
45 supporting midway
surface betweenthetwo
malleolifor
reference
Anterior
midlineofthe
Perpendicular lowerlegusing
External totheflooror thecrestofthe
Anterioraspectof
rotation/030to Seated paralleltothe tibiaandapoint
thepatella
45 supporting midway
surface betweenthetwo
malleolifor
reference
Lateral
Lateralmidline
midlineof
ofthefibula
thefemur
Flexion/0120to Lateralepicondyle usingthelateral
Prone/supine/sidelying usingthe
130 ofthefemur malleolusand
greater
fibularheadfor
trochanterfor
reference
reference
Knee
Lateral
Lateralmidline
midlineof
ofthefibula
thefemur
Lateralepicondyle usingthelateral
Extension/015 Supine usingthe
ofthefemur malleolusand
greater
fibularheadfor
trochanterfor
reference
reference
Lateral
midlineof
Paralleltothe
thefibular
Lateralaspectofthe lateralaspectof
Dorsiflexion/020 Prone usingthe
lateralmalleolus thefifth
headofthe
metatarsal
fibulafor
reference
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Talocrural Tested
Stationary
Arm
(degrees)
Lateral
midlineof
Paralleltothe
thefibular
Plantarflexion/0 Lateralaspectofthe lateralaspectof
Prone usingthe
50 lateralmalleolus thefifth
headofthe
metatarsal
fibulafor
reference
Posterioraspectof
Posterior Posterior
theanklemidway
Inversion/020 Prone midlineof midlineofthe
betweenthe
thelowerleg calcaneus
malleoli
Hindfoot
Posterioraspectof
Posterior Posterior
theanklemidway
Eversion/010 Prone midlineof midlineofthe
betweenthe
thelowerleg calcaneus
malleoli
Anterior
midlineof
Anterioraspectof Anterior
thelowerleg
theanklemidway midlineofthe
Inversion Shortsitting usingthe
betweenthe second
tibial
malleoli metatarsal
tuberosityfor
Transverse reference
tarsal Anterior
midlineof
Anterioraspectof Anterior
thelowerleg
theanklemidway midlineofthe
Eversion Shortsitting usingthe
betweenthe second
tibial
malleoli metatarsal
tuberosityfor
reference
Overthe
Alongthedorsal
Overthedorsal dorsalaspect
surfaceofthe
aspectofthe oftheshaft
Flexion/045 Seated shaftofthe
metatarso ofthefirst
proximal
phalangeal metatarsal
phalanx
1stMetatarso bone
phalangeal Overthe
Overtheplantar plantar Alongthe
Extension/070to surfaceofthefirst midlineshaft plantarshaftof
Seated
90 metatarso ofthefirst theproximal
phalangealjoint metatarsal phalanx
bone
Alongthe
Alongthedorsal
dorsal
Overthedorsal midline
midline
aspectofthe longitudinal
Flexion/040 Seated longitudinal
metatarsophalangeal shaftofeach
shaftofeach
joints proximal
metatarsal
phalanx
bone
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2nd5th Tested
Metatarso Stationary
phalangeal Arm
(degrees)
Alongthe Alongthe
plantar plantarmidline
Overtheplantar
midline aspectofthe
aspectofthe
Extension/040 Seated longitudinal shaftofthe
metatarso
shaftofeach proximal
phalangealjoints
metatarsal phalanxofeach
bone digit
Alongthe
Alongthedorsal
midlineshaftof
Flexion/090 Seated aspectofthedistal midlineshaft
thedistal
interphalangealjoint ofthemiddle
phalange
phalange
1st Overthe
Interphalangeal Overtheplantar
Overtheplantar plantar
midlineshaftof
aspectofthe midlineshaft
Extension/minimal Seated thedistal
interphalangealjoint ofthe phalanx
proximal
phalange
Overthe
Overtheplantar
2nd5th Overtheplantar plantar
midlineshaftof
Proximal Flexion/035 Seated aspectofthe midlineshaft
themiddle
interphalangeal Extension/minimal Seated interphalangeal ofthe
phalangesofthe
joint joints proximal
othertoes
phalanges
Alongthe
Overthedorsal Alongthedorsal
dorsal
aspectofthedistal midlineshaftof
Flexion/060 Seated midlineshaft
interphalangeal thedistal
ofthemiddle
2nd5thDistal joints phalanges
phalanges
interphalangeal
joint Alongthe
Alongthedorsal
midlineshaftof
Extension/030 Seated aspectofthedistal midlineshaft
thedistal
interphalangealjoint ofthemiddle
phalanges
phalanges
GoniometryoftheUpperExtremity
Thefollowingsectionsdescribeindetailhowtoperformagoniometricmeasurementofthemajorjointsofthe
upperextremity.
ShoulderComplex
Shouldermotionoccursattheglenohumeral,scapulothoracic,acromioclavicular,andsternoclavicularjoints.In
addition,forfullshouldermotiontooccur,theymustalsobeavailablemotioninthecervicalandupperthoracic
spine.Forthefollowingmeasurements,thepatientispositionedinsupinewithbothhipsandkneesflexedand
thefeetplacedonthebedtoflattenthelumbarspineunlessotherwisestated.
ShoulderFlexion
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Whenmeasuringglenohumeralflexion,allowingthemotiontooccurattheotherjointsprovidesamore
functionalreading.However,iftheclinicianrequiresameasurementofpureglenohumeralmotion,theother
jointsmustbemanuallyblocked.Thisisbestachievedbystabilizingthescapulatopreventitfromelevating,
upwardlyrotating,andposteriorlytilting.Inthefollowingdescription,thescapularisnotstabilizedinsteadthe
thoraxisstabilizedtopreventextensionofthespine.
UpperExtremityPosition
Theglenohumeraljointisinitiallypositionedat0degreesofabduction,adduction,androtation,andtheforearm
ispositionedin0degreesofsupinationandpronationsothatthepalmofthehandfacesthebody.
GoniometerPlacement
Thefulcrumiscenteredclosetotheacromionprocess,theproximalarmisalignedwiththemidaxillarylineof
thethorax,andthedistalarmisalignedwiththelateralmidlineofthehumerus,usingthelateralepicondyleof
thehumerusasalandmark.
Technique
Theshoulderismovedpassivelyoractivelytotheendrangeofavailableshoulderflexion(Fig.134),anda
measurementismade(Fig.135).
FIGURE134
Passiveshoulderflexion.
FIGURE135
Goniometricmeasurementofshoulderflexion.
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ShoulderExtension
Thepatientispositionedinprone.
Theglenohumeraljointispositionedat0degreesofabductionandrotation,theelbowispositionedinslight
flexion,andtheforearmispositionedin0degreesofsupinationandpronation.Ifameasurementofpure
glenohumeralextensionisrequired,thescapulamustbestabilizedtopreventelevationandanteriortilting.
GoniometerPlacement
Thefulcrumiscenteredclosetotheacromionprocess,theproximalarmisalignedwiththemidaxillarylineof
thethorax,andthedistalarmisalignedwiththelateralmidlineofthehumerus,usingthelateralepicondyleof
thehumerusasalandmark.
Technique
Theshoulderismovedpassivelyoractivelytotheendrangeofavailableshoulderextension(Fig.136).The
cliniciancantakeameasurementofAROM(Fig.137)orPROM,orbothifacomparisonistobemade.
FIGURE136
Passiveshoulderextension.
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FIGURE137
Goniometricmeasurementofshoulderextension.
ShoulderAbduction
Althoughmeasuredherewiththepatientpositionedinsupine,shoulderabductioncanbemeasuredwiththe
patientinsittingorprone,whichhastheadvantageofallowingfreemotionofthescapula.
Theglenohumeraljointispositionedat0degreesofflexionandextension,andfullexternalrotationsothatthe
palmofthehandfacesanteriorlytopreventthegreatertubercleofthehumerusimpactingontheupperportion
oftheglenoidfossaoracromionprocess.Pureglenohumeralabductioncanbemeasuredbystabilizingthe
scapulatopreventitsupwardrotationandelevation.
GoniometerPlacement
Thefulcrumiscenteredclosetotheanterioraspectoftheacromionprocess,theproximalarmisalignedsothat
itisparalleltothemidlineoftheanterioraspectofthesternum,andthedistalarmisalignedwiththemedial
midlineofthehumerususingthemedialepicondyleasalandmark.Ifshoulderabductionismeasuredwiththe
patientintheseatedposition,thefulcrumiscenteredclosetotheposterioraspectoftheacromionprocess,the
proximalarmisalignedparalleltothespinousprocessesofthevertebralcolumn,andthedistalarmisaligned
withthelateralmidlineofthehumerus,usingthelateralepicondyleasalandmark.
Technique
Theshoulderismovedpassivelyoractivelytotheendrangeofavailableshoulderabduction(Fig.138),anda
goniometricmeasurementismade(Fig.139).
FIGURE138
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Passiveshoulderabduction.
FIGURE139
Goniometricmeasurementofshoulderabduction.
CLINICALPEARL
Shoulderadductionisnottypicallymeasuredasitrepresentsthepatientsarmbytheside.Furthermotion
towardthepatientsmidlineisconsideredhorizontaladduction.
ShoulderInternalRotation
Thepatientispositionedinprone.Theglenohumeraljointispositionedat90degreesofshoulderabductionwith
theforearmperpendiculartothesupportingsurfaceandin0degreesofsupination/pronationsothatthepalmof
thehandfacesthefeet.Ifnecessary,arolleduptowelcanbeplacedunderthehumerussothatthehumerusis
positionedlevelwiththeacromionprocess.
GoniometerPlacement
Thefulcrumiscenteredovertheolecranonprocess,theproximalarmisalignedsothatitiseitherparallelto,or
perpendicularto,thefloor,andthedistalarmisalignedwiththeulnar,usingtheolecranonprocessandulnar
styloidaslandmarks.
Technique
Theshoulderismovedpassivelyoractivelytotheendrangeofshoulderinternalrotation(Fig.1310),anda
measurementistaken(Fig.1311).
FIGURE1310
Passiveshoulderinternalrotation.
FIGURE1311
Goniometricmeasurementofshoulderinternalrotation.
ShoulderExternalRotation
Thepatientpositionisthesameasforinternalrotationoftheshoulder.
GoniometerPlacement
Thegoniometeralignmentisthesameasforshoulderinternalrotation.
Technique
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Theshoulderismovedpassivelyoractivelytotheendrangeofshoulderexternalrotation(Fig.1312),anda
FIGURE1312
Passiveshoulderexternalrotation.
FIGURE1313
Goniometricmeasurementofshoulderexternalrotation.
Alternatively,shoulderinternalrotationcanbemeasuredwiththepatientinsupine(Fig.1314),ascanshoulder
externalrotation(Fig.1315),usingthestartpositionforthegoniometerasdepictedinFigure1316.
FIGURE1314
Goniometricmeasurementofshoulderinternalrotationwiththepatientinsupine.
FIGURE1315
Goniometricmeasurementofshoulderexternalrotationwiththepatientinsupine.
FIGURE1316
Startpositionforthegoniometertomeasureinternalandexternalrotationwiththepatientinsupine.
Elbow/ForearmComplex
Forthefollowingmeasurements,thepatientispositionedinsupinewithbothhipsandkneesflexedandthefeet
placedonthebedtoflattenthelumbarspineunlessotherwisestated.
Flexion/Extension
Apadcanbeplacedunderthedistalendofthehumerustoallowforelbowextension.
Theglenohumeraljointispositionedat0degreesofflexion,extension,andabductionsothatthearmiscloseto
thesideofthebody.
GoniometerPlacement
Thegoniometerplacementisthesameforflexionandextension.Thefulcrumiscenteredoverthelateral
epicondyleofthehumerus,theproximalarmisalignedwiththelateralmidlineofthehumerus(usingthe
acromionprocessasalandmark),andthedistalarmisalignedwiththelateralmidlineoftheradius,usingthe
styloidprocessasalandmark.
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Technique
Theelbowispassivelyoractivelyflexedtotheendoftheavailablerange,andameasurementistaken(Fig.13
17).Tomeasureelbowextension,theupperextremityispositionedcorrectly,andameasurementistaken(Fig.
1318).
FIGURE1317
Goniometricmeasurementofelbowflexion.
FIGURE1318
Goniometricmeasurementofelbowextension.
ForearmPronation
Thismeasurementcanalsobeperformedwiththepatientinsitting.
Theglenohumeraljointispositionedat0degreesofflexion,extension,abduction,androtationsothattheupper
armisclosetothesideofthebody,andtheelbowisflexedto90degreeswiththeforearmmidwaybetween
supinationandpronation.
GoniometerPlacement
Thefulcrumiscenteredlaterallytotheulnarstyloidprocess,theproximalarmisalignedparalleltotheanterior
midlineofthehumerus,andthedistalarmisalignedacrosstheposterioraspectoftheforearm,justproximalto
thestyloidprocessesoftheradiusandulna(Fig.1319).
FIGURE1319
Startpositionforgoniometricmeasurementofforearmsupination/pronation.
Technique
TheforearmismovedpassivelyoractivelytotheendoftheavailableROM(Fig.1320),andameasurementis
taken(Fig.1321).
FIGURE1320
Passiveforearmpronation.
FIGURE1321
Goniometricmeasurementofforearmpronation.
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ForearmSupination
Thepatientpositionisthesameasforforearmpronation.
GoniometerPlacement
Thefulcrumisalignedmedialtotheulnarstyloidprocess,theproximalarmisalignedparalleltotheanterior
midlineofthehumerus,andthedistalarmisalignedacrosstheanterioraspectoftheforearm,justproximalto
thestyloidprocess(Fig.1319).
Technique
TheforearmismovedpassivelyoractivelytotheendoftheavailableROM(Fig.1322),andameasurementis
taken(Fig.1323).
FIGURE1322
Passiveforearmsupination.
FIGURE1323
Goniometricmeasurementofforearmsupination.
Analternativetechniquetomeasureforearmsupinationandpronationinvolveshavingthepatientholdingapen
orpencilinaclosefistedhand.Thegoniometercanthenbealignedusingtheendofthepenasalandmark(Fig.
1324).
FIGURE1324
Alternativemethodformeasuringforearmsupination/pronation.
WristJoints
Forthefollowingmeasurements,thepatientispositionedinsittingnexttoasupportingsurfacesothatthe
forearmissupported,butthehandisfreetomove.
WristFlexionandExtension
Theclinicianshouldstabilizetheforearmtopreventsupinationorpronation.
GoniometerPlacement
Thegoniometerplacementisthesameforwristflexionandwristextension.Thefulcrumiscenteredoverthe
lateralaspectofthewristclosetothetriquetrum,theproximalarmisalignedwiththelateralmidlineofthe
ulnar,usingtheolecranonprocessasalandmark,andthedistalarmisalignedwiththelateralmidlineofthe
fifthmetacarpal.Thepalmofthepatientismoveddownwardforwristflexion,andupwardforwristextension
whileavoidinganyextensionofthefingers.
Technique
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Tomeasurewristflexion,thewristisactivelyorpassivelyflexedtotheendoftheavailableROM(Fig.1325),
andameasurementistaken(Fig.1326).Tomeasurewristextension,thewristisactivelyorpassivelyextended
totheendoftheavailableROM(Fig.1327),andameasurementistaken(Fig.1328).
FIGURE1325
Passivewristflexion.
FIGURE1326
Goniometricmeasurementofwristflexion.
FIGURE1327
Passivewristextension.
FIGURE1328
Goniometricmeasurementofwristextension.
RadialDeviationandUlnarDeviation
Thepatientpositionisthesameasforwristflexion/extension.
GoniometerPlacement
Thegoniometerplacementisthesameforradialdeviationandulnardeviation.Thefulcrumiscenteredoverthe
middleoftheposterioraspectofthewristclosetothecapitate,theproximalarmisalignedwiththeposterior
midlineoftheforearm,usingthelateralepicondylesasalandmark,andthedistalarmisalignedwiththe
posteriormidlineofthethirdmetacarpal.Forradialdeviation,thepatientshandmovestowardthepatients
body,while,forulnardeviation,thepatientshandmovesawayfromthepatientsbody.
Technique
Tomeasureradialdeviation,thewristispassivelyoractivelymovedtotheendoftheavailableROMforradial
deviation(Fig.1329),andameasurementistaken(Fig.1330).Tomeasureulnardeviation,thewristis
passivelyoractivelymovedtotheendoftheavailableROMforulnardeviation(Fig.1331),anda
FIGURE1329
Passiveradialdeviation.
FIGURE1330
Goniometricmeasurementofradialdeviation.
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FIGURE1331
Passiveulnardeviation.
FIGURE1332
Goniometricmeasurementofulnardeviation.
FingerJoints
Thepatientpositionforthesejointsistypicallyinsitting,withtheforearmsupportedandmidwaybetween
pronationandsupination,thewristpositionedin0degreesofflexionandextension,andinneutralradialand
ulnardeviation.
MetacarpophalangealJointFlexion/Extension
Whileperformingthesemeasurements,theclinicianmustensurethatthemetacarpophalangeal(MCP)jointis
maintainedinaneutralpositionrelativetoabductionandadductionandtoavoidtoomuchmotionoccurringat
theproximalinterphalangeal(PIP)anddistalinterphalangeal(DIP)joints.Thesametechniqueisusedforallof
theMCPjointsofthefingers.
GoniometerPlacement
ThegoniometerplacementisthesameforMCPflexionandMCPextension.Thefulcrumiscenteredoverthe
posterioraspectoftheMCPjoint,theproximalarmisalignedwiththeposteriormidlineofthemetacarpal,and
thedistalarmisalignedwiththeposteriormidlineoftheproximalphalanx.Fortheindexfinger,thefulcrumis
centeredoverthethumbsideoftheMCPjoint,theproximalarmisalignedwiththeradialstyloid,andthedistal
armisalignedonthethumbsideofthephalanx(Fig.1333).
FIGURE1333
GoniometerplacementforMCPflexion/extension.
Technique
AmeasurementistakenforMCPflexion(Fig.1334),andMCPextension(Fig.1335).
FIGURE1334
GoniometricmeasurementforMCPflexionoftheindexfinger.
FIGURE1335
GoniometricmeasurementforMCPextensionoftheindexfinger.
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MCPJointAbduction/Adduction
ThesametechniqueisusedforalloftheMCPjointsofthefingers.
GoniometerPlacement
ThegoniometerplacementisthesameforMCPjointabductionandMCPjointadduction.Thefulcrumis
centeredovertheposterioraspectoftheMCPjoint,theproximalarmisalignedwiththeposteriormidlineofthe
metacarpal,andthedistalarmisalignedwiththeposteriormidlineoftheproximalphalanx(Fig.1336).
FIGURE1336
GoniometerplacementforMCPabduction/adduction.
Technique
AmeasurementistakenforMCPabduction(Fig.1337),andforMCPabduction(Fig.1338).
FIGURE1337
GoniometricmeasurementforMCPabduction.
FIGURE1338
GoniometricmeasurementforMCPadduction.
ProximalInterphalangealJointFlexion/Extension
TheclinicianattemptstostabilizetheproximalphalanxtopreventmotionatthewristandMCPjoint.
GoniometerPlacement
ThegoniometerplacementisthesameforPIPjointflexionandPIPjointextension.Thefulcrumiscentered
overtheposterioraspectofthePIPjoint,theproximalarmisalignedwiththeposteriormidlineoftheproximal
phalanx,andthedistalarmisalignedwiththeposteriormidlineofthemiddlephalanx.Thesametechniqueis
usedforeachofthePIPjointsofthefingers.ItisquestionablewhetherameasurementofPIPjointextensionis
possibleasanylossofPIPextensionistechnicallyameasurementofPIPflexion.
Technique
AmeasurementistakenforPIPjointflexion(Fig.1339).
FIGURE1339
GoniometricmeasurementforPIPjointflexion.
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DistalInterphalangealJointFlexion/Extension
TheMCPjointispositionedin0degreesofflexion,extension,abduction,andadduction,withthePIPjoint
positionedinapproximately70to90degreesofflexion.Theclinicianattemptstostabilizethemiddlephalanxto
preventfurtherflexionorextensionofthewrist,MCPjoints,andPIPjoints.
GoniometerPlacement
ThegoniometerplacementisthesameforDIPjointflexionandDIPjointextension.Thefulcrumiscentered
overtheposterioraspectofthePIPjoint,theproximalarmisalignedwiththeposteriormidlineofthemiddle
phalanx,andthedistalarmisalignedwiththeposteriormidlineofthedistalphalanx.Thesametechniqueis
usedforeachoftheDIPjointsofthefingers.AswithPIPjointextension,itisquestionablewhethera
measurementofDIPjointextensionispossibleasanylossofDIPextensionistechnicallyameasurementof
DIPflexion.
Technique
AmeasurementistakenforDIPjointflexion(Fig.1340).
FIGURE1340
GoniometricmeasurementforDIPjointflexion.
ThumbJoints
Thepatientpositionforthesejointsistypicallyinsitting,withtheforearmsupportedinsupination,thewrist
positionedat0degreesofflexionandextension,andinneutralradialandulnardeviation.TheMCPand
interphalangeal(IP)jointsofthethumbarepositionedat0degreesofflexionandextension.
CarpometacarpalFlexionandExtension
GoniometerPlacement
Thegoniometerplacementisthesameforcarpometacarpal(CMC)flexionandCMCextension.Thefulcrumis
centeredovertheanterioraspectofthefirstCMCjoint,theproximalarmisalignedparalleltotheanterior
midlineoftheradius,andthedistalarmisalignedwiththeanteriormidlineofthefirstmetacarpal.CMCflexion
occurswhenthethumbmovestowardthepalmofthehand,andCMCextensionoccurswhenthethumbmoves
awayfromthepalmofthehand.
Technique
TheCMCjointispassivelyoractivelymovedintotheavailableROMforflexion(Fig.1341),anda
measurementistaken(Fig.1342).TheCMCjointispassivelyoractivelymovedintotheavailableROMfor
extension(Fig.1343),andameasurementistaken(Fig.1344).
FIGURE1341
PassivethumbCMCjointflexion.
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FIGURE1342
GoniometricmeasurementofthumbCMCjointflexion.
FIGURE1343
PassivethumbCMCjointextension.
FIGURE1344
GoniometricmeasurementofthumbCMCjointextension.
CMCAbductionandAdduction
ThepatientpositioningisthesameasforCMCflexionandextension.
GoniometerPlacement
ThegoniometerplacementisthesameforCMCabductionandCMCadduction.Thefulcrumiscentered
midwaybetweentheposterioraspectofthefirstandsecondCMCjoints,theproximalarmisalignedwiththe
lateralmidlineofthesecondmetacarpal,andthedistalarmisalignedwiththelateralmidlineofthefirst
metacarpal.CMCabductionoccurswhenthethumbmovesawayfromthehandwhileCMCadductionoccurs
whenthethumbmovestowardthehand.
Technique
TheCMCjointispassivelyoractivelymovedintotheavailableROMforabduction(Fig.1345),anda
FIGURE1345
PassivethumbCMCjointabduction.
FIGURE1346
GoniometricmeasurementofthumbCMCjointabduction.
ThumbOpposition
GoniometerPlacement
Therulercomponentofagoniometeristypicallyusedtomeasuretheamountofthumboppositionby
calculatingthedistancebetweenthetipofthethumbandthetipofthefifthdigit.
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Technique
Thethumbandlittlefingerareactivelyorpassivelymovetogetherinthedirectionofopposition(Fig.1347),
andameasurementistaken(Fig.1348).
FIGURE1347
Passiveoppositionofthumbandlittlefinger.
FIGURE1348
Goniometricmeasurementofactivethumbopposition.
MCPJointoftheThumbFlexionandExtension
GoniometerPlacement
ThegoniometerplacementisthesameforMCPjointflexionandMCPjointextension.Thefulcrumiscentered
overtheposterioraspectoftheMCPjoint,theproximalarmisalignedwiththeposteriormidlineofthe
metacarpal,andthedistalarmisalignedwiththeposteriormidlineoftheproximalphalanx.
Technique
TheMCPjointofthethumbisactivelyorpassivelyflexedtotheendoftheavailableROM,andameasurement
istaken(Fig.1349).
FIGURE1349
GoniometricmeasurementofthumbMCPflexion.
IPJointoftheThumbFlexionandExtension
GoniometerPlacement
ThegoniometerplacementisthesameforIPflexionandIPextension.Thefulcrumiscenteredoverthe
posteriorsurfaceoftheIPjoint,theproximalarmisalignedwiththeposterioraspectoftheproximalphalanx,
andthedistalarmisalignedwiththeposteriormidlineofthedistalphalanx.
Technique
TheIPjointofthethumbisactivelyorpassivelyflexedtotheendoftheavailableROM,andameasurementis
taken.
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LowerExtremity
ThefollowingsectionsdescribeindetailhowtomeasurejointROMforthemajorjointsoftheupperextremity
usingagoniometer.
HipJoint
Thepatientispositionedinsupinetomeasurehipflexion,hipabduction,andhipabduction,seatedtomeasure
hipinternalrotationandexternalrotation,andpronetomeasurehipextension.
HipFlexion
Hipflexioncanbemeasuredinoneoftwoways,withthekneeallowedtoflex,orwiththekneeextended.
Measuringhipflexionwiththekneeextendedismerelyanindicationofthelengthofthepatientshamstrings
ratherthanatruemeasurementofhipjointmotion.Hipflexionwiththekneeflexedisdescribedhere.
LowerExtremityPosition
Thehipispositionedat0degreesofabduction,abduction,androtation,withthekneemotionunrestricted.
GoniometerPlacement
Thefulcrumiscenteredoverthelateralaspectofthehipjointusingthegreatertrochanterofthefemurasa
landmark,theproximalarmisalignedwiththelateralmidlineofthepelvis,andthedistalarmisalignedwith
thelateralmidlineofthefemur,usingthelateralepicondyleofthefemurasalandmark(Fig.1350).
FIGURE1350
Goniometerpositionforhipflexion.
Technique
ThehipisactivelyorpassivelyflexedtotheendoftheavailableROM,andameasurementistaken(Fig.13
51).
FIGURE1351
Goniometricmeasurementofhipflexion.
HipExtension
Thepatientispositionedinprone.Aswithhipflexion,hipextensioncanbemeasuredinoneoftwoways,with
thekneeallowedtoflex,orwiththekneeextended.Measuringhipextensionwiththekneeflexedcanbe
misleadingduetotensionfromtherectusfemorismusclewhichcanrestrictmotion.
Thehipispositionedat0degreesofabduction,adduction,androtation,withthekneemotionunrestricted.
GoniometerPlacement
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Thegoniometerplacementandalignmentarethesameasforhipflexion,exceptthatthepatientispositionedin
prone(Fig.1352).
FIGURE1352
Goniometerpositionforhipextension.
Technique
ThehipisactivelyorpassivelyextendedtotheendoftheavailableROM,andameasurementistaken(Fig.13
53).
FIGURE1353
Goniometricmeasurementofhipextension.
HipAbduction/Adduction
Thelowerextremityiskeptasstraightaspossible.Itisworthrememberingthat,inorderforfullhipadduction
totakeplace,thecontralateralhipmustbeabductedtoallowthehipbeingmeasuredtocompleteitsfullROM.
GoniometerPlacement
Thegoniometerplacementforhipabductionandhipadductionisthesame.Thefulcrumiscenteredoverthe
anteriorsuperioriliacspine(ASIS)oftheextremitybeingmeasured,theproximalarmisalignedwithan
imaginaryhorizontallineextendingfromoneASIStotheotherASIS,andthedistalarmisalignedwiththe
anteriormidlineofthefemurusingthemidlineofthepatellaasalandmark.
Technique
ThehipisactivelyorpassivelyabductedtotheendoftheavailableROM(Fig.1354),andameasurementis
taken(Fig.1355).Tomeasurehipadduction,thehipisactivelyorpassivelyadductedtotheendofthe
availableROM(Fig.1356),andameasurementistaken(Fig.1357).
FIGURE1354
PassivehipabductionwhilemonitoringcontralateralASIS.
FIGURE1355
Goniometricmeasurementofhipabduction.
FIGURE1356
PassivehipadductionwhilemonitoringthecontralateralASIS.
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FIGURE1357
Goniometricmeasurementofhipadduction.
HipInternalRotation/ExternalRotation
Thepatientispositionedinsittingonthesupportingsurface,withthekneeflexedovertheedgeofthetable
surface.
Thehipisin0degreesofabductionandadductionand90degreesofflexion.Ifnecessary,atowelrollisplaced
underthedistalendofthefemurtomaintainthefemurinahorizontalplane.
GoniometerPlacement
Thegoniometerplacementforhipinternalrotationandhipexternalrotationisthesame.Thefulcrumiscentered
overtheanterioraspectofthepatella,theproximalarmisalignedsothatitisperpendiculartothefloorall
paralleltothesupportingsurface,andthedistalarmisalignedwiththeanteriormidlineofthelowerleg,using
thetibialcrestandapointmidwaybetweenthetwomalleoliasreferencepoints.
Technique
ThehipisactivelyorpassivelyinternallyrotatedtotheendoftheavailableROM(Fig.1358),anda
measurementistaken(Fig.1359).Tomeasureexternalrotationofthehip,thehipisactivelyorpassively
externallyrotatedtotheendoftheavailableROM(Fig.1360),andameasurementistaken(Fig.1361).
FIGURE1358
Passivehipinternalrotation.
FIGURE1359
Goniometricmeasurementofhipinternalrotation.
FIGURE1360
Passivehipexternalrotation.
FIGURE1361
Goniometricmeasurementofhipexternalrotation.
TibiofemoralJoint
Toassesstibiofemoraljointflexionandextension,thepatientistypicallypositionedinprone.However,inthe
presenceofsignificantadaptiveshorteningoftherectusfemorismuscle,kneeflexioncanbemeasuredwiththe
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patientinsupine.
TibiofemoralJointFlexion/Extension
Duringthesemeasurements,itisimportanttostabilizethefemurtopreventrotation,flexion,orextensionofthe
hip.
Thehipispositionedat0degreesofabduction,adduction,flexion,extension,androtation.
GoniometerPlacement
Thegoniometerplacementfortibiofemoralflexionandtibiofemoralextensionisthesame.Thefulcrumis
centeredoverthelateralepicondyleofthefemur,theproximalarmisalignedwiththelateralmidlineofthe
femur,usingthegreatertrochanteratalandmark,andthedistalarmisalignedwiththelateralmidlineofthe
fibula,usingthelateralmalleolusasalandmark.
Technique
ThekneeisactivelyorpassivelyflexedtotheendoftheavailableROM(Fig.1362),andameasurementis
taken(Fig.1363).
FIGURE1362
Passivekneeflexion.
FIGURE1363
Goniometricmeasurementofkneeflexionwiththepatientprone.
AnkleJoint
Theanklejointcanbeassessedwiththepatientinsitting,proneorsupine.Foramoreaccuratemeasurementof
anklemotion,thepatientskneeshouldbeflexedtoatleast30degreestoremoveanyinfluencefromthe
gastrocnemiuscomplex.
DorsiflexionandPlantarflexion
Thepatientispositionedinsittingorsupine.
GoniometerPlacement
Thegoniometerplacementisthesamefordorsiflexionandplantarflexion.Thefulcrumiscenteredoverthe
lateralaspectofthelateralmalleolus,theproximalarmisalignedwiththelateralmidlineofthefibula,usingthe
headofthefibulaasalandmark,andthedistalarmisalignedparalleltothelateralaspectofthefifthmetatarsal,
orparalleltotheinferioraspectofthecalcaneus.
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Technique
TheankleisactivelyorpassivelydorsiflexiontotheendoftheavailableROM(Fig.1364),andameasurement
istaken(Fig.1365).Tomeasureankleplantarflexion,theankleisactivelyorpassivelyplantarflexedtotheend
oftheavailableROM(Fig.1366),andameasurementistaken(Fig.1367).
FIGURE1364
Passiveankledorsiflexion.
FIGURE1365
Goniometricmeasurementofankledorsiflexion.
FIGURE1366
Passiveankleplantarflexion.
FIGURE1367
Goniometricmeasurementofankleplantarflexion.
SubtalarJointInversionandEversion
Thepatientispositionedinsittingorprone.
GoniometerPlacement
Thegoniometerplacementisthesameforinversionandeversion.Thefulcrumiscenteredovertheposterior
aspectoftheankle,midwaybetweenthemalleoli,theproximalarmisalignedwiththeposteriormidlineofthe
lowerleg,andthedistalarmisalignedwiththeposteriormidlineofthecalcaneus.
Technique
TheankleisactivelyorpassivelyinvertedtotheendoftheavailableROM(Fig.1368),andameasurementis
taken(Fig.1369).Forankleeversion,theankleisactivelyorpassivelyevertedtotheendoftheavailableROM
(Fig.1370),andameasurementistaken(Fig.1371).
FIGURE1368
Passivesubtalarjointinversion.
FIGURE1369
Goniometricmeasurementofsubtalarjointinversion.
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FIGURE1370
Passivesubtalarjointeversion.
FIGURE1371
Goniometricmeasurementofsubtalarjointeversion.
TarsalJointInversionandEversion
Thepatientispositionedinsitting.
GoniometerPlacement
Thegoniometerplacementisthesameforinversionandeversion.Thefulcrumiscenteredovertheanterior
aspectoftheanklemidwaybetweenthemalleoli,theproximalarmisalignedwiththeanteriormidlineofthe
lowerleg,usingthetibialcrestforreference,andthedistalarmisalignedwiththeanteriormidlineofthe
secondmetatarsal.
Technique
ThetarsaljointsareactivelyorpassivelyinvertedtotheendoftheavailableROM(Fig.1372),anda
measurementistaken(Fig.1373).Fortarsaljointeversion,thetarsaljointsareactivelyorpassivelyevertedto
theendoftheavailableROM(Fig.1374),andameasurementistaken(Fig.1375).
FIGURE1372
Passivetarsaljointinversion.
FIGURE1373
Goniometricmeasurementoftarsaljointinversion.
FIGURE1374
Passivetarsaljointeversion.
FIGURE1375
Goniometricmeasurementoftarsaljointeversion.
ToeJoints
MetatarsophalangealJointFlexionandExtension
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Thepatientispositionedinsittingorsupinewiththemetatarsophalangeal(MTP)andIPjointspositionedat0
degreesofflexionandextension.
GoniometerPlacement
ThegoniometerplacementisthesameforMTPjointflexionandMTPjointextension.Thefulcrumisaligned
overtheposterioraspectoftheMTPjoint,theproximalarmisalignedwiththeposteriormidlineofthe
metatarsal,andthedistalarmisalignedwiththeposteriormidlineoftheproximalphalanx.
Technique
TheMTPjointisactivelyorpassivelyflexedtotheendoftheavailableROM(Fig.1376),andameasurement
istaken(Fig.1377).TomeasureMTPjointextension,theMTPjointisactivelyorpassivelyextendedtothe
endoftheavailableROM(Fig.1378),andameasurementistaken(Fig.1379).
FIGURE1376
PassiveMTPjointflexionofthegreattoe.
FIGURE1377
Goniometricmeasurementofflexionofthegreattoe.
FIGURE1378
PassiveMTPjointextensionofthegreattoe.
FIGURE1379
Goniometricmeasurementofextensionofthegreattoe.
CLINICALPEARL
Althoughmotions,suchasabductionofthegreattoe(Fig.1380),flexion/extensionoftheindividualPIPjoints,
andflexion/extensionoftheindividualDIPjoint,cantheoreticallybemeasured,onehastoquestionthe
usefulnessofthesemeasurements.AmorepracticalapproachistoperformavisualassessmentofcombinedPIP
andDIPjointflexion/extension,andgreattoeabduction(ifthepatientisabletoperformsuchanaction).
FIGURE1380
Goniometricmeasurementofgreattoeabduction.
TheSpine
Goniometricmeasurementofspinalmotionbringsitsownsetofchallenges.Overtheyears,variousmethods
havebeenputforwardthathaveincorporatedtheuseofatapemeasure,theuseofstandardgoniometers,andthe
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useofspecializedgoniometers,suchasthebubblegoniometer(Fig.132).Mostoftheproblemshavestemmed
fromdeterminingthebestappropriatelandmarks,thewidevariationsinbodytypes,andwhethersuch
measurementshavesufficientinterandintraraterreliability.
Whichevermethodischosen,itisimportanttorememberthat,aswithotherjointsinthebody,theROMinthe
spinemayvaryaccordingtoanumberoffactorsincludingstructuralalterations,theindividualsage,neckgirth
andlength,bodyhabitus,diurnalchanges,65neurologicdisease,orotherfactorsunrelatedtothedisabilityfor
whichtheexaminationisbeingperformed.Withouttakingbodysizeintoaccount,measurementsmay
underestimateoroverestimateROM.66
CervicalSpine
CervicalRotation
TraditionalGoniometerMethod
Thefulcrumiscenteredoverthecenterofthesuperioraspectofthehead,theproximalarmisalignedparallelto
animaginarylinebetweenthetwoacromionprocesses,andthedistalarmisalignedwiththetipofthenose.
TapeMeasureMethod
Atapemeasurecanbeusedtomeasurethedistancebetweenthetipofthechinandtheacromionprocess.
BubbleGoniometerMethod
Theinclinometermethod,using12bubblegoniometers,istheapproachrecommendedintheAmerican
MedicalAssociationsGuidestotheEvaluationofPermanentImpairment67andisoftenconsideredtheclinical
standardforassessingcervicalROMintheclinic.68,69Thismethodrequiresaccurateidentificationofanatomic
landmarks.Bothinterandintraraterreliabilitystudieshaveshowntheinclinometrymethodtobereliable.7073
Othersdisputethisconclusionandcontendthattheinclinometermethodisflawedandshouldnotbeusedin
clinicalsettings.74,75ThenormalROMusingthismethodis80degreesorgreaterfromtheneutralpositionfor
activemotion.Tomeasurecervicalrotationusingabubblegoniometer,thepatientispositionedinprone,and
thegoniometerisalignedoverthecrownoftheheadinthetransverseplane(Fig.1381).Thegoniometeris
zeroedout,andthepatientisaskedtorotatetheheadtotheright(Fig.1382),andthentotheleft(Fig.1383).
FIGURE1381
Bubblegoniometerplacementforcervicalrotation.
FIGURE1382
Goniometricmeasurementforrightcervicalrotation.
FIGURE1383
Goniometricmeasurementforleftcervicalrotation.
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CLINICALPEARL
Usingthebubblegoniometermethod,thefullarcofpassivecervicalrotationrangedependsontheageofthe
patient76:
2029:183degrees11
3049:172degrees13
>50:155degrees15
CervicalFlexionandExtension
Thefulcrumiscenteredovertheexternalauditorymeatus,theproximalarmisalignedsothatitiseither
perpendicularorparalleltotheground,andthedistalarmisalignedwiththebaseofthenares(Fig.1384).The
patientisthenaskedtoflexthecervicalspine(Fig.1385),andtoextendthecervicalspine(Fig.1386).
FIGURE1384
Goniometerplacementforthestartpositionforcervicalflexion.
FIGURE1385
Goniometricmeasurementofcervicalflexion.
FIGURE1386
Goniometricmeasurementofcervicalextension.
TapeMeasureMethod
Atapemeasurecanbeusedtomeasurethedistancebetweenthetipofthechinandthesternalnotchwhile
makingsurethatthepatientsmouthremainsclosed.
ThenormalROMforcervicalflexionusingthistechniqueis60degreesorgreaterfromtheneutralposition,and
75degreesorgreaterfromtheneutralpositionforactivemotion.76Fromthestartposition(Fig.1387),the
patientisaskedtoflexthecervicalspine(Fig.1388),andthentoextendthecervicalspine(Fig.1389).
FIGURE1387
Bubblegoniometerplacementforthestartpositionforcervicalflexion.
FIGURE1388
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Goniometricmeasurementofcervicalflexion.
FIGURE1389
Goniometricmeasurementofcervicalextension.
CLINICALPEARL
Usingthebubblegoniometermethod,thefullarcofpassiveflexion/extensionrangedependsontheageofthe
patient76:
2029:151degrees17
3049:141degrees35
>50:129degrees14
CervicalSideBending
Whenmeasuringcervicalsidebending,theclinicianshouldstabilizetheshouldergirdletopreventlateral
flexionofthethoracicandlumbarspine.
ThefulcrumiscenteredoverthespinousprocessoftheC7vertebra,theproximalarmisalignedwiththe
spinousprocessesofthethoracicvertebrasothatthearmisperpendiculartotheground,andthedistalarmis
alignedwiththeposteriormidlineofthehead,usingtheoccipitalprotuberanceasalandmark.
TapeMeasureMethod
Atapemeasurecanbeusedtomeasurethedistancebetweenthemastoidprocessandtheacromionprocess.
Thenormalrangeofcervicalsidebendingusingthismethodis45degreesorgreaterfromtheneutralposition
foractivemotion.Fromthestartposition(Fig.1390),thepatientisaskedtosidebendthecervicalspinetothe
left(Fig.1391),andthentotheright(Fig.1392).
FIGURE1390
Bubblegoniometerplacementforthestartpositionforcervicalsidebending.
FIGURE1391
Goniometricmeasurementofcervicalsidebendingtotheleft.
FIGURE1392
Goniometricmeasurementofcervicalsidebendingtotheright.
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CLINICALPEARL
Usingthebubblegoniometermethod,thefullarcofpassiveright/leftcervicalsidebendingrangedependson
theageofthepatient76:
2029:101degrees11
3049:93degrees13
>50:80degrees17
ThoracicSpine
Oftentimes,thoracicspinemotionismeasuredsimultaneouslywithlumbarspinemotionusingavarietyof
methods,noneofwhichisreallysatisfactory.Toobjectivelymeasurethoracicmotionanddifferentiatethoracic
spinemotionfromlumbarspinemotion,thebubblegoniometertechniquesoftheAmericanMedicalAssociation
arerecommended.67
Flexion
Tomeasurethoracicflexion,twoinclinometersareusedandarealignedinthesagittalplane.Thecenterofthe
firstinclinometerisplacedovertheT1spinousprocess.ThecenterofthesecondoneisplacedovertheT12or
L1spinousprocess(Fig.1393).Thepatientisaskedtoslumpforwardasthoughtryingtoplacetheforeheadon
theknees(Fig.1394),andbothinclinometeranglesarerecorded.Thethoracicflexionangleiscalculatedby
subtractingtheT12fromtheT1inclinometerangle.Thepatientshouldbeabletoflexapproximately50degrees
fromtheneutralposition.77,78Theclinicianobservesforanyparavertebralfullnessduringflexion,whichmight
alterthemeasurement.Thethoracicspineduringflexionshouldcurveforwardinasmoothandevenmanner,
andthereshouldbenoevidenceofsegmentalrotationorsidebending.Todecreasepelvicandhipmovements,
McKenzieadvocatesexaminingthoracicflexionwiththepatientseated.79
FIGURE1393
Bubblegoniometerplacementforthestartpositionofthoracicflexionandextension.
FIGURE1394
Goniometricmeasurementofthoracicflexion.
Extension
ClinicalguidelinesformeasurementsofthoracicextensionrecommendthatROMbedefinedwithreferenceto
themagnitudeofthekyphosismeasuredinstanding.However,todate,therelationshipbetweenthemagnitude
ofthethoracickyphosisandtheamountofthoracicextensionmovementhasnotbeenreported.80Thoracic
extensionmaybemeasuredusingthesametechniqueandinclinometerpositionsasdescribedforflexion(Fig.
1395).ThethoracicextensionangleiscalculatedbysubtractingtheT12orL1fromtheT1inclinometerangle.
Thepatientshouldbeabletoextendapproximately1520degreesfromtheneutralposition.78Alternatively,the
thoracicextensioncanbemeasuredusingatapemeasure.Thedistancebetweentwopoints(theC7andT12
spinousprocesses)ismeasured.A2.5cmdifferencebetweenneutralandextensionmeasurementsisconsidered
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normal.81,82Duringthoracicextension,thethoraciccurveshouldcurvebackwardorstraighten.Aswithflexion,
thereshouldbenoevidenceofsegmentalrotationorsidebending.
FIGURE1395
Goniometricmeasurementofthoracicextension.
Rotation
Rotationisaprimarymovementofthethoracicspineandakeycomponentoffunctionalactivities.Thoracic
rotationcanbemeasuredobjectivelyusingatapemeasureortwobubblegoniometers.
TapeMeasureMethod
Pavelka83devisedasimpleobjectiveclinicalmethodtomeasurethoracolumbarrotationusingatapemeasure
thatcanbeusedtodetectasymmetriesintherotation.ThetapeisplacedovertheL5spinousprocessandover
thejugularnotchonthesuperioraspectofthemanubrium.Ameasurementistakenbeforeandafterfulltrunk
rotation.Themeasurementsfromeachsidearethencompared.
Thepatientispositionedinsitting,andisthenaskedtoflexforwardashorizontalaspossible.Onebubble
goniometerispositionedattheT1levelandtheotherattheT12level,bothinthecoronalplane.Both
goniometersarezeroedoutandthenthepatientisinstructedtorotatethetrunktooneside.Theclinicianrecords
boththeT1andtheT12inclinationsandsubtractstheT12fromtheT1inclinationtoarriveatthethoracic
rotationangle.Thetechniqueisthenrepeatedtotheoppositeside.Thepatientshouldbeabletorotate30
degreesorgreaterfromtheneutralposition.84,85Activethoracicrotationoffewerthan20degreescanresultin
animpairmentoffunctionduringactivitiesofdailylivinginvolvingthethoracicspine.81
SideBending
Sidebendingcanbemeasuredobjectivelyusingatapemeasure,86orusingtwobubblegoniometers.
TapeMeasureMethod
Twoinkmarksareplacedontheskinofthelateraltrunk.Theuppermarkismadeatapointwhereahorizontal
linethroughthexiphisternumcrossesthecoronalline.Thelowermarkismadeatthehighestpointontheiliac
crest.Thedistancebetweenthetwomarksismeasuredincentimeters,withthepatientstandingerect,andagain
afterfullipsilateralsidebending.Thesecondmeasurementissubtractedfromthefirst,andtheremainderis
takenasanindexoflateralspinalmobility.
Thepatientispositionedinsitting,andonegoniometerisplacedflatagainsttheT1spinousprocessandthe
otherflatagainsttheT12/L1spinousprocess(Fig.1396).Bothgoniometersarezeroedoutandthenthepatient
isaskedtosidebendthethoracicspinetotheleftside(Fig.1397)andthentotherightside(Fig.1398).The
T1inclinationangleissubtractedfromtheT12/L1inclinationangletoarriveatthethoracicsidebendingangle.
Thepatientshouldbeabletosidebend2040degreesfromtheneutralposition.
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FIGURE1396
Bubblegoniometerplacementforthestartpositionofthoracicsidebending.
FIGURE1397
Goniometricmeasurementofthoracicsidebendingtotheleft.
FIGURE1398
Goniometricmeasurementofthoracicsidebendingtotheright.
LumbarSpine
Lumbarspinemotioncanbemeasuredusingavarietyofmethods.
FlexionandExtension
Flexionandextensioncanbemeasuredusingtwobubblegoniometersoratapemeasure.
TapeMeasureMethod
UsingthemodifiedSchobertechnique,thepatientispositionedinrelaxedstanding.Apointisdrawnwiththe
skinmarkeratthespinalintersectionofalinejoiningS1.Additionalmarksaremade10cmaboveand5cm
belowS1(Fig.1399).Thepatientisthenaskedtobendforward,andthedistancebetweenthemarks10cm
aboveand5cmbelowS1ismeasured(Fig.13100).Despitethismethodssimplicity,Reynolds87foundthis
measurementofmotiontohavegoodreliability,withPearsoncorrelationcoefficientsof0.59forlumbarflexion
and0.75forlumbarextension.InanotherstudybyFitzgerald,88thePearsoncorrelationcoefficientwasfoundto
be1.0forlumbarflexionand0.88forlumbarextensioninastudyofyoung,healthysubjects.
FIGURE1399
StartpositionforthemodifiedSchobertechnique.
FIGURE13100
EndpositionforthemodifiedSchobertechnique.
Thepatientispositionedinstandingwiththelumbarspineinaneutralposition.Theclinicianplacesonebubble
goniometerovertheT12/L1spinousprocessinthesagittalplane,andtheothergoniometeratthelevelofthe
sacrum,alsointhesagittalplane(Fig.13101).Bothgoniometersarezeroedout,andthepatientisthenaskedto
flexthetrunkforward(Fig.13102).Thecliniciannotestheinclinationsofbothgoniometersandsubtractsthe
sacralinclinationfromtheT12/L1inclinationtoobtainthelumbarflexionangle.Thepatientisthenaskedto
extendthetrunk(Fig.13103).ThecliniciansubtractsthesacralinclinationfromtheT12/L1inclinationto
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obtainthelumbarextensionangle.ThenormalROMforflexionandextensionvaryaccordingtopatientageand
gender.89
FIGURE13101
Bubblegoniometerplacementforthestartpositionoflumbarspineflexionandextension.
FIGURE13102
Goniometricmeasurementforlumbarspineflexion.
FIGURE13103
Goniometricmeasurementforlumbarspineextension.
SideBending
Sidebendingcanbemeasuredwiththepatientstandingwiththefeettogetherusingastandardgoniometer,a
tapemeasure,ortwobubblegoniometers.
StandardGoniometerMethod
ThefulcrumiscenteredovertheposterioraspectofthespinousprocessofS1,theproximalarmisalignedso
thatitisperpendiculartotheground,andthedistalarmisalignedwiththeposterioraspectofthespinous
processofC7.
TapeMeasureMethod
Atapemeasureisusedtomeasurethedistancebetweenthetipofthemiddlefingerandthefloor.
TheclinicianplacesoneagoniometerflatattheT12/L1spinousprocessinthecoronalplaneandtheother
goniometeratthesuperioraspectofthesacrum,alsointhecoronalplane(Fig.13104).Bothgoniometersare
zeroedoutandthenthepatientisaskedtosidebendthetrunktotherightside(Fig.13105),andtheinclination
isrecordedfrombothgoniometers.ThecliniciansubtractsthesacralinclinationfromtheT12/L1inclinationto
obtainthelumbarsidebendingangle.Thetechniqueisthenrepeatedtotheleftside(Fig.13106).Thenormal
ROMforflexionandextensionvaryaccordingtopatientageandgender.88,90
FIGURE13104
Bubblegoniometerplacementforthestartpositionoflumbarspinesidebending.
FIGURE13105
Goniometricmeasurementoflumbarspinesidebendingtotheright.
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FIGURE13106
Goniometricmeasurementoflumbarspinesidebendingtotheleft.
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CHAPTER14:ImprovingNeuromuscularControl
CHAPTEROBJECTIVES
1.Definethecomponentsofneuromuscularcontrol.
2.Describewaysinwhichneuromuscularcontrolcanbeimproved.
3.Describeanumberofexercisesthatcanbeusedtoimproveproprioceptivecontrol.
4.Provideexamplestoenhancebalanceretraining.
5.Explaintheconceptsrelatedtostabilizationretraining.
OVERVIEW
Theentirerehabilitationprocessisfocusedonrestoringfunctionasquicklyandassafelyaspossible.An
importantcomponentoffunctionisneuromuscularcontrol.Neuromuscularcontrolinvolvesthedetection,
perception,andutilizationofrelevantsensoryinformationinordertoperformspecifictasks(seeChapter3).Itis
nowwellacceptedthataneuromuscularcontrolimpairmentcanchangenormalmovementpatternsandincrease
theriskofmusculoskeletalinjury.Successfulperformanceofataskrequirestheintricatecoordinationofvarious
bodypartsusingtheinformationprovidedbyperipheralreceptorslocatedinandaroundthearticularstructures.
Thisfeedbackprovidesinformationthatassistswithproprioception,balance,andkinesthesia(seeChapter3).In
termsofsegmentaljointcontrolandspinalpostureandorientation,eachjointinthekineticchainmusthavethe
abilitytomaintaintheoptimalalignment,biomechanics,and/orcontrolrequiredforthetaskbeingperformed.If
thereisalossofoptimalalignment,biomechanics,and/orcontrol,thisisdefinedasfailedloadtransfer(FLT)at
thatjoint.1Whileasinglesegmentallossofcontroloftencorrelateswithchangesinpostureorientation,
multisegmentallossofcontrolresultsinaninabilitytomaintaintherequiredspinalpostureororientation
requiredforthetasktobeperformed.Thepresenceofalossofsegmentalormultisegmentalcontrolinvolvesan
assessmentof:
whetherthereisadequaterangeofmotion
whetherthereissufficientstrengthoutput
whetherthereistheabilityforautomaticcontrolofthejointsinthekineticchainthatexhibitFLT
whetherpainnegativelyimpactstheperformanceofthetask.
Neuromuscularrehabilitation(NMR)isamethodoftrainingusedtoenhancetheseunconsciousmotor
responses,bystimulatingboththeafferentsignalsandthecentralmechanismsresponsiblefordynamicjoint
control.2TheaimsofNMRaretoimprovetheabilityofthenervoussystemtogenerateafastandoptimal
musclefiringpattern,toincreasejointstability,todecreasejointforces,andtorelearnmovementpatternsand
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skills.2Electromechanicaldelay(EMD)isdefinedasthetimeintervalbetweentheonsetofelectricalactivityof
themuscleandthemechanicalresponseofthemuscle.3Itcorrespondstothetimeneededforthecontractile
componentinthemuscletendoncomplextoinitiatestretchingoftheelasticcomponentseries,4anditsduration
isrelatedtothemechanicalpropertiesoftheelasticcomponentseries(seeChapter1).5TheshortertheEMD
duration,thefasterthemuscleforcetransmissionandthebettertheperformanceandprotectivereflex.
SignificantlylongerEMDsinthevastuslateralis,vastusmedialisobliquus,andfibularis(peroneous)longus
havebeenreportedinpatientswithanteriorcruciateligamentreconstruction,6patellofemoralpainsyndrome,5
andunstableankles,7respectively,comparedtohealthyindividuals.Inaddition,anumberofstudieshaveshown
adecreaseinEMDfollowingneuromuscularreeducationtraining.811
BeforedevelopinganNMRprogram,thefaultymovementpatternorabsentmotorskillmustbeidentified.12In
addition,individualsmusthavetheadequatemusclestrengthtoperformtrainingexercisescorrectly.If
weaknessesarepresent,trainingactivitiesmustbeginatamorebaselinelevelthatincludesweighttraining,
techniqueinstruction,andperformingsingleplaneversusmultiplanarmovements.12Thethreemajor
componentsofNMRareproprioceptiveretraining,balanceretraining,andstabilizationretraining.
PROPRIOCEPTIVERETRAINING
Becausetheafferentinputisalteredafterjointinjury,proprioceptivetrainingmustfocusontherestorationof
proprioceptivesensibilitytoretrainthesealteredafferentpathwaysandenhancethesensationofjoint
movement.13Indesigningexercisestoimprovethreedimensionaldynamicupperandlowerextremitypostural
stability,theclinicianshouldconsiderthefollowing:4
Posturaldifferencesbetweenpatients
Upperandlowerextremityloadingpathomechanics
Thejointpositionsforoptimalmusclemomentarmlengths
Theinterplaybetweenglobalandlocalproprioceptivemechanisms
Theconceptofrehabilitatingmovementsthatfacilitatethedevelopmentofsynergisticupperandlower
extremitymusclefunction14
AlthoughROMandprogressiveresistanceexercises(PREs)helpreestablishjointproprioception,theyarenotas
effectiveinrestoringfunctionasexercisesthatinvolveatechniqueortasktraining.Techniqueortasktraining
involvestheperformanceofspecificmovementswithanemphasisonpropertechnique,withaprogressionto
weightshifting,andchangingdirections,andthenmoreadvancedtechniques,suchasperformingacut
maneuver,asappropriate.12AccordingtoVoightandBlackburn,13,15thestandardprogressionfor
proprioceptiveretraininginvolves:
1.Staticstabilizationexerciseswithclosedchainloadingandunloading(weightshifting).Thisphase
initiallyemploysisometricexercisesaroundtheinvolvedjointonsolidandevensurfaces,before
progressingtounstablesurfaces.Theearlytraininginvolvesbalancetrainingandjointrepositioning
exercisesandusuallyisinitiated(inthelowerextremities)byhavingthepatientplacetheinvolved
extremityona68inchhighstool,sothattheamountofweightbearingcanbecontrolledmoreeasily.
Theproprioceptiveawarenessofajointcanalsobeenhancedbyusinganelasticbandageororthotic,or
throughtaping.1621Asfullweightbearingthroughtheupperorlowerextremityisrestored,anumberof
devices,suchasaminitrampoline,balanceboard,Swissball,andwobbleboard,canbeintroducedto
increasethelevelofdifficulty.
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2.Transitionalstabilizationexercises.Theexercisesduringthisphaseinvolveconsciouscontrolofmotion
withoutimpactandreplaceisometricactivitywithcontrolledconcentricandeccentricexercises
throughoutaprogressivelylargerrangeoffunctionalmotion.Thephysiologicrationalebehindthe
exercisesinthisphaseistostimulatedynamicposturalresponsesandincreasemusclestiffness.Muscle
stiffnesshasasignificantroleinimprovingdynamicstabilizationaroundthejoint,byresistingand
absorbingjointloads.22
3.Dynamicstabilizationexercises.Theseexercisesinvolvetheunconsciouscontrolandloadingofthejoint
andintroducebothballisticandimpactexercisestothepatient.
Adelicatebalancebetweenstabilityandmobilityisachievedbycoordinationamongmusclestrength,
endurance,flexibility,andneuromuscularcontrol.23Theneuromuscularmechanismthatcontributestojoint
stabilityismediatedbythearticularmechanoreceptors(seeChapter3).Thesereceptorsprovideinformation
aboutjointpositionsenseandkinesthesia.20,21,24,25TheobjectiveinNMRistorestoreproximalstability,
musclecontrol,andflexibilitythroughabalanceofproprioceptiveretrainingandstrengthening.
Initially,closedkineticchainexercises(CKCEs)areperformedwithinthepainfreerangesorpositions.Open
kineticchainexercises(OKCEs),includinglowlevelplyometricexercises,maybebuiltuponthebaseofthe
closedchainstabilizationtoallownormalcontrolofjointmobility(seeChapter12).
Theneuromuscularemphasisduringtheseexercisesisonfunctionalpositioningduringexerciseratherthan
isolatingopenandclosedchainactivities.23Theactivitiesshouldeventuallyinvolvesuddenalterationsinjoint
positioningthatnecessitatereflexmuscularstabilizationcoupledwithanaxialload.21,23Suchactivitiesinclude
rhythmicstabilizationperformedinbothaclosedandanopenchainposition26andinthefunctionalpositionof
thejoint(seeChapter12).23Theuseofastable,andthenanunstable,baseduringCKCEsencourages
cocontractionoftheagonistsandantagonists.26
Followingtreatmentofanyjoint,retrainingofthemusclesmustbecarriedouttoreestablishcoordination.
Proprioceptiveneuromuscularfacilitation(PNF)techniquesareespeciallyusefulinthisregard.PNFtechniques
requiremotionsoftheextremitiesinallthreeplanes.27PNFtechniquesthatusecombinationsofspiraland
diagonalpatternsaredesignedtoenhancecoordinationandstrength.28Thediagonalpatterns1and2(see
Chapter10)areappropriate,withresistancebeingaddedifneeded.
BALANCERETRAINING
NeuromuscularcontrolandbalancetestingaredescribedinChapter3.Deficitsinthemotorcomponentsof
balancecontrolcanbecausedbysensorimotorintegrationimpairments,neuromuscularimpairments,and
deficitsduetoaging(seeChapter3).AsoutlinedinChapter3,impairedbalancecanbecausedbyinjuryor
diseasetoanystructuresinvolvedinthestagesofinformationprocessing:somatosensoryinput,visualand
vestibularinput,sensorymotorintegration,andmotoroutputgeneration.29Agerelatedbalancedysfunctions
canoccurthroughalossofsensoryelements(degenerativechangesintheotoconiaoftheutricleandsaccule
lossofvestibularhaircellreceptors),theabilitytointegrateinformationandissuemotorcommands(decreased
numberofvestibularneurons),andmuscleweakness.Diseasescommoninagingpopulationscanleadtofurther
deteriorationinbalancefunctioninsomepatients(Mniresdisease,benignparoxysmalpositionalvertigo
[BPPV],cerebrovasculardisease,vertebrobasilararteryinsufficiency,cerebellardysfunction,andcardiac
disease).Fallscanbemarkersofpoorhealthanddecliningfunction,andtheyareoftenassociatedwith
significantmorbidity.30Morethan90%ofhipfracturesoccurasaresultoffalls,withmostofthesefractures
occurringinpersonsolderthan70yearsofage.30,31Onethirdofcommunitydwellingelderlypersonsand60%
ofnursinghomeresidentsfalleachyear.32Riskfactorsforfallsintheelderlyincludeincreasingage,medication
use,cognitiveimpairment,andsensorydeficits.30,33Elderlypersonswhosurviveafallexperiencesignificant
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morbidity.34Hospitalstaysarealmosttwiceaslonginelderlypatientswhoarehospitalizedafterafallthanin
elderlypatientswhoareadmittedforanotherreason.30,35
Balanceretrainingfocusesontheabilitytomaintainapositionthroughbothconsciousandsubconsciousmotor
control.Therearemanyfactorstoconsiderwhendevelopinganinterventionprogramforbalanceimpairment.
Theclinicianneedstoconsiderthepatientsimpairmentsacrossallsystemsanddecidewhichimpairmentscan
berehabilitatedandwhichrequirecompensationorsubstitution.
Itisalsoimportanttodeterminethecauseoftheimpairmentwhethertheproblemresultsfrom
musculoskeletal,neuromuscular,sensory,orcognitive(e.g.,fearoffalling)impairment.36Thekeyelementsofa
comprehensiveevaluationofindividualswithbalanceproblemsincludethefollowing:37
Athoroughhistoryoffalls,includingwhethertheonsetoffallsaresuddenversusgradualthefrequency
anddirectionofthefallstheenvironmentalconditions,activities,presenceofdizziness,vertigo,and
lightheadednessattimeoffallscurrentandpastmedications,andthepresenceofafearoffalling.
Assessmentstoidentifysensoryinputand/orsensoryprocessingdeficits,abnormalbiomechanicaland
motoralignment,poormusclestrengthand/orendurance,anddecreasedrangeofmotionand/orflexibility.
Ofparticularimportanceiscorestrength.36
Assessmentofcoordination,andawarenessofpostureandthepositionofthebodyinspace.
Testsandobservationstodeterminetheimpactofbalancecontrolsystemdeficitsonfunctional
performance.
Environmentalassessmentstodeterminefullriskhazardsinapersonshome.
Studieshaveshownthatproprioceptionandkinesthesiadoimprovefollowingrehabilitation.20,38Forexample,
habituationexerciseshaveprovenbeneficialforpatientswithacuteunilateralvestibularloss,andadaptationand
balanceexerciseshaveproducedpositiveoutcomesinpatientswithchronicbilateralvestibulardeficits.39The
typeofinterventionwilldependonthedeficitsfoundduringtheclinicalexaminationandtypicallyinvolves
improvingoneormoreofthefollowingcategories:37
Staticbalancecontrol
Dynamicbalancecontrol
Anticipatorybalancecontrol
Reactivebalancecontrol
Sensoryreorganization
Vestibularrehabilitation
Becausebalancetrainingofteninvolvesactivitiesthatchallengethepatientslimitsofstability,itisimportant
thatthecliniciantakesstepstoensurethepatientssafety.Thismaynecessitatetheuseofagaitbelt,performing
theexercisesneararailing,andcloselyguardingthepatient.Examplesofagilityandperturbationsactivitiesare
outlinedinTable141.Balancetrainingtopromotestaticbalancecontrolduringtheearlyphaseinvolves
changingthebaseofsupport(BOS)ofthepatientwhileperformingvarioustasks,firstwiththeireyesopenand
thenwiththeeyesclosed.Thelowerthecenterofgravity(COG),themorestablethepatientfeels.Thus,the
proneorsupinepositionsprovidethelowestCOGandthemostsupport,sittingthenext,withstanding
providingthehighestCOGandtheleastsupport.Theusualprogressionemployedinbalanceretraininginvolves
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anarrowingoftheBOSwhileincreasingtheperturbationandchangingtheweightbearingsurfacefromhardto
softorfromflattouneven.
TABLE141AgilityandPerturbationTrainingExamples
Activity Progression
Thewidthofstepsandthespeedofsteps
areprogressedevery12sessions.The
Sidestepping:thepatientstepssideways,movingrighttoleftand activityisinitiatedonalevelsurfaceand
thenlefttoright,approximately1020ft,repeatingtwotimesin progressedtosidesteppingoverlow
eachdirectionforatotaloffourtimes. obstacleswhenthepatientisableto
sidesteponlevelsurfaceswithout
difficulty.
Braidingactivities:thepatientcombinesfrontandbackcrossover
stepswhilemovinglaterally(walkingcarioca).Duringeach Theactivityisprogressedbyincreasing
activity,thepatientmovesrighttoleftandthenlefttoright, thewidthofstepsandthespeedofsteps
approximately1020ft,repeatingtwotimesineachdirectionfora every12sessions.
totaloffourtimes.
Tworepetitionsareperformed,beginning
Frontandbackcrossoverstepsduringforwardambulation:the
withpartialcrossoverstepsand
patientcrossesoneleginfrontoftheother,alternatinglegswith
progressingtofullcrossoverstepswhen
eachstep,whilewalkingforwardapproximately1020ft.The
thepatient'sperformanceimproves.The
patientthenwalksbackwardtothestartpositionwhilecrossingone
widthofstepsandthespeedofstepscan
legbehindtheother,alternatinglegswitheachstep.
beprogressedevery12sessions.
Shuttlewalking:plasticpylonmarkersareplacedatdistancesof5,
10,and15ft.Thepatientwalksforwardtothefirstmarker,then
returnstothestartbywalkingbackward.Thepatientthenwalks Theactivityisprogressedbyincreasing
forwardtothe10ftmarker,thenreturnstothe5ftmarkerwalking thewidthofstepsandthespeedofsteps
backward.Thepatientthenwalkstothe15ftmarker,returnstothe every12sessions.
10footmarkerwalkingbackward,thenfinishesbywalkingtothe
15ftmarker.
Multiplechangesindirectiononcommandduringwalking:the
cliniciandirectsthepatienttoeitherwalkforward,backward, Thedurationoftheexerciseboutis
sideways,oronadiagonalbycueingthepatientrandomlywith approximately30seconds.
handsignals.
Thedurationoftheactivityis
approximately30seconds.Thedifficultyis
Doublelegfoambalanceactivity:thepatientstandsonasoftfirm progressedasthepatientimprovesby
surfacewithbothfeetonthegroundandtheclinicianattemptsto progressingtoballcatchingwiththe
perturbthepatient'sbalanceinarandomfashion. clinicianperturbingthepatient'sbalance
whilestandingonfoamandprogressingto
singlelegsupportiftolerated.
Thedifficultyoftheactivityisprogressed
Tiltboardbalancetraining:thepatientstandsonatiltboardwith
byaddingballcatchingduringthe
bothfeetontheboard.Theclinicianperturbsthetiltboardin
perturbationsandprogressingtosingle
forwardandbackwardandsidetosidedirectionsfor
limbsupportperturbationsbasedonpatient
approximately30secondseach.
tolerance.
Rollerboardandplatformperturbations:thepatientstandswithone Ifthepatienthasdifficultydoingthe
limbonastationaryplatformandtheotherlimbonarollerboard. activityinfullstanding,theactivitymay
Theclinicianperturbstherollerboardinmultipledirections,at beginwiththepatientinasemiseated
random,andthepatientattemptstoresisttheperturbations.The position,withthehipsrestingonthebed.
activitylastsapproximately30secondsandisthenrepeatedby Theactivityisprogressedtothefull
changingthelimbsontheplatformandtherollerboard. standingpositionastolerated.
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DatafromFitzgeraldGK,PivaSR,GilAB,etal.Agilityandperturbationtrainingtechniquesinexercise
therapyforreducingpainandimprovingfunctioninpeoplewithkneeosteoarthritis:arandomizedclinicaltrial.
PhysTher.201191(4):452469.
CLINICALPEARL
Itisimportantforthecliniciantobeawareofanumberoffactorsthatcanaffectbalanceandincreasetheriskof
fall:
Medications:theriskoffallingcanbeincreasedwhenthepatientisprescribedsedativesand
antidepressants.
Lowvision:patientswithbalanceissuesshouldbeadvisedtohaveregulareyeexaminationsandtoavoid
areaswithpoorlighting.
Sensoryloss:sensorylossinthelowerextremities,whichcanoccurinconditionssuchasdiabetes
mellitus,canresultindifficultieswhenwalkingonsoftorunevensurfaces.
Balancetrainingforadultsusuallybeginsintheshortsittingposition,whichallowsthefeettoprovide
anteriorsupport.ThispositioncanbemademorechallengingbyplacingawobbleboardorSwissball
underthepatientsbuttocks.Thepatientisthenprogressedtoaquadrupedposition,throughtallkneeling,
andfinallytothestandingposition.Balancetrainingforthepediatricpopulationusuallybeginsinthe
Wsittingposition,thentoIndianstylesitting,thentoaquadrupedposition,throughtallkneeling,and
finallytothestandingposition.
Theemphasisduringtheseexercisesistoconcentrateonfunctionalpositioningduringexerciseratherthan
isolatingopenandclosedchainactivities.23Theactivitiesshouldinvolvealterationsinjointpositioningthat
necessitatereflexmuscularstabilizationcoupledwithanaxialload.21,23Suchactivitiesincluderhythmic
stabilization(anisometriccontractionoftheagonistfollowedbyanisometriccontractionoftheantagonist)
performedinbothaclosedandanopenchainposition,26andinthefunctionalpositionofthejoint.23Theuse
ofastable,andthenunstable,baseduringclosedchainexercisesencouragescocontractionoftheagonistsand
antagonists.26
Weightshiftingexercisesareidealforthis.Forexample,thefollowingweightshiftingexercisesmaybeused
fortheupperextremity:
Standingandleaningagainstatreatmenttableorobject.
Inthequadrupedposition,rockingforwardandbackwardwiththehandsonthefloororonanunstable
object.
Slideboardexercisesinthequadrupedposition,movingthehandsforwardandbackward,inopposite
diagonalsandinoppositedirections.
Oncethepatientisabletostand,astructuredsequence,suchastheonethatfollows,isrecommended.
Staticcontrolofthetrunkwithoutextremitymovement.Theseexercisesinvolveclosedchain
loading/unloading.Thepatientispositionedinstanding,withthefeetpositionedapproximatelyshoulder
widthapart.Thepurposeofthestartingpositionistoprovideastablebasefortheproximalsegmentsand
trunkontowhichchallengescanbesuperimposed.Forexample:
Manualperturbationstoastabletrunk.Theclinicianappliesgentleperturbationstothepatientstrunkin
differentdirections.
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Weightshiftingwhilemaintainingposturalequilibrium.Initially,thepatient,withthefeetpositioned
approximatelyshoulderwidthapart,isinstructedtoalternatetransferringweightthroughonelower
extremitythentheother.Thenthepatientisaskedtoputonefootinfrontoftheotherandtotransferthe
weightfromtherearfoottothefrontfootandbackagain.
Dynamiccontroloftrunkwithoutextremitymovement.Forexample,maintainingbothfeetontheground
whilebendingatthewaist.Asindicated,therangeofmotionisincreasedfromasmallrangetoalarger
range.
Oncethisismastered,theprogressionmovestoexercisesthatincorporatestaticcontrolofthetrunkwith
extremitymovement(s)superimposedusingthefollowingprogression:
Standingwiththefeetpositionedapproximatelyshoulderwidthapart,thepatientisaskedtoflexthehip
andkneesothatthefootisapproximately68inoffthefloor.Theexerciseisrepeatedusingtheotherleg.
Toaddachallengetotheexercise,thepatientcanbetrainedwiththeeyesclosed,orthepatientcanstand
onanunstablesurface.
Standingwiththefeetpositionedapproximatelyshoulderwidthapart,thepatientgraspsresistivetubing
withonehandandpullsthetubingtowardthebodyusingasmooth,comfortablemotion(Fig.141).This
producesaforwardweightshiftthatisstabilizedwithanisometriccounterforceconsistingofhip
extension,kneeextension,andankleplantarflexion.40
Thepatientstandssidewaystotheresistivetubing.Thetubingispulledbyonehandinfrontofthebody
andtheotherhandbehindthebodytoequalizetheforceandminimizetherotation(Fig.142).This
causesalateralweightshift,whichisstabilizedwithanisometriccounterforceconsistingofhip
abduction,kneecocontraction,andankleeversion.40
Thepatientstandswithhis/herbacktothetubinginthefrontalplane(Fig.143).Thetubingispulledto
thebodyfrombehind,causingaposteriorweightshift,whichisstabilizedbyanisometriccounterforce
consistingofhipflexion,kneeflexion,andankledorsiflexion.40
FIGURE141
Forwardweightshiftexercise.
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FIGURE142
Lateralweightshiftexercise.
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FIGURE143
Posteriorweightshiftexercise.
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Theaforementionedsingleplaneexercisesareprogressedtomultiplanarexercisesinthefollowingmanner:
PNFmovementpatternsareinitiatedusingresistivetubing.Initiallythepatientstandswithbothfeet
shoulderwidthapart,andthentheexercisesareprogressedsothatthepatientisstandingononeleg.In
additiontousingresistivetubing,medicineballscanbeused.
Ballisticextremitymovementswhilemaintainingtrunkstabilityareintroduced,firstinsittingandthenin
standing.Forexample,maintainthesittingpositionwhilethrowingamedicineball(Fig.144).
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FIGURE144
Medicineballthrowinsitting.
Attheearliestopportunity,functionaltasksmustbeincorporated.Atypicalfunctionalactivityprogression
includes:
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Closedchainactivities(squats,lunges)initially,thenopenchainactivitiessuperimposedontheclosed
chainbyaddingextremitymotionstothesquatsandlunges(Fig.145).
SitstandsitactivitiesfocusingonmovingthebodymassforwardovertheBOS,extendingthelower
extremitiesandraisingthebodymassoverthefeet,andthenreversingtheprocedure.
Standtosittransitionsfocusingonbalancecontrolwhilepivotingandchangingdirection.
Floortostandingraisesusingaprogressionofsidesittoquadrupedtokneelingtohalfkneelingto
standing.
Gaitactivities:ambulatingforward,backward,sidewardatvaryingspeedsandBOSwidths(narrowto
wide).Resistedwalkingand/orrunningcanalsobeused.
Asappropriate,multidirectionaldrills,includingjumping(twofoottakeofffollowedbytwofootlanding),
hopping(onefoottakeofffollowedbylandingonthesamefoot)(Fig.146),andbounding(onefoot
takeofffollowedbyanoppositefootlanding).40
FIGURE145
Lungewitharmsraisedouttosides.
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FIGURE146
Hoppingononeleg.
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CLINICALPEARL
Variousclinicaldeviceshavebeendesignedtoassistwithproprioceptivetrainingfortheupperandlower
extremities.Theseinclude,butarenotlimitedto:
Minitrampoline(Fig.147)
Biomechanicalankleplatformsystem(BAPS)
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Foamrollers
Wobbleboard
Kinestheticabilitytrainingdevice(KAT)
Fitter,Rockerboards,orfoambalancemats
FIGURE147
Minitrampolinestandingononeleg.
STABILIZATIONRETRAINING
Stabilitynormallyinvolvestheinteractionofthreesystemstheneurologicalorcentralcontrolsystem,the
passiveorinerttissues(e.g.,ligaments,capsule),andthecontractile(muscular)oractivesystem(seeChapter
3).41Theneuromuscularmechanismthatcontributestojointstabilityismediatedbythearticular
mechanoreceptors(seeChapter3).Thesereceptorsprovideinformationaboutjointpositionsenseand
kinesthesia.20,21,24,25
Theneutralzoneisatermusedtodefinearegionoflaxityaroundtheneutralrestingpositionofajoint(see
Chapter2).42Theneutralzonereferstothepositionofajointinwhichminimalloadingisoccurringinthe
passivestructures(allofthenoncontractileelementsofthejoint,includingtheligaments,fascia,jointcapsules,
andnoncontractilecomponentsofmuscle),andthecontributionoftheactivesystem(themusclesandtendons
whichsurroundandcontroljointmotion)ismostcritical.43,44
CLINICALPEARL
Thesizeoftheneutralzoneisdeterminedbytheintegrityofthepassiverestraintandactivecontrolsystems,
whichinturnarecontrolledbytheneuralsystem.42Studieshavedemonstratedthatalargerthannormalneutral
zonecausedbyinjuryormicrotraumaisrelatedtoalackofsegmentalmusclecontrolandisassociatedwith
injury.42,4548Unfortunately,thereisasyetnoclinicalmethodtomeasurethesizeoftheneutralzone.
Inboththespineandtheextremities,certainmusclesworkaseithermobilizersorstabilizers.Theperipheral
stabilizersrelyonstabilizationofthetwoprimarydynamicbasesorcorestructuresthepelvisandthescapula.
Thepelvisactsasabaseforthewholebody,especiallyforthespineandthelowerlimbs,whereaseachscapula
actsasabaseforitsrespectiveupperlimb.41Duringperipheraljointmovement,theperipheralstabilizer
musclesnormallycontractfirsttostabilizethecorestructuresfromwhichthemobilizerswork.41,49The
mobilizersthencontract,resultinginacontrolledmovementpattern.Forexample,duringupperextremity
activity,thescapularstabilizerscontractfirsttostabilizethescapulabeforetheothershouldermusclesmovethe
upperextremityintoafunctionalposition.However,withaninjury,apathologicprocess,orotherabnormality,
anabnormalstabilizerrecruitmentpatterncandevelop,resultinginadominanceofthemobilizermusclesand
eventualweakeningofthelocalstabilizers.41,49
Forstabilizationretrainingtobeeffective,theclinicianmust,therefore,ensurethatastablebaseispresentfrom
whichthemobilizerscanact.Oncethestabilizermusclesarefunctioningefficiently,trainingofthemobilizer
musclescanbeginusingthefollowingsequence:isometrictoconcentric,toeccentric,andecocentric(pseudo
isometric)contractions,andfinallytofunctionalmovement(seeChapter12).41
CLINICALPEARL
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Anecocentriccontractionoccurswhenatwojointmuscleshortensatoneendwhilelengtheningattheother
end.Anexampleinvolvesthehamstringswhenmovingfromstandingtosit.
Thebodyhasseveralnaturalstabilizationmethods,includingmusclecontraction,musclespasm,osteophyte
formation,scartissueformation,andadaptiveshorteningofinerttissueormuscle.41Whilethecliniciancannot
impactsomeofthesenaturalstabilizationmethodssuchasmusclespasm,osteophyte,andscartissueformation,
thecliniciancanusemusclecontractionandadaptiveshorteningtothepatientsadvantage.
Initially,closedchainexercisesareperformedwithinthepainfreerangesorpositions.Openchainexercises
maybebuiltuponthebaseoftheclosedchainstabilizationtoallownormalcontrolofjointmobility.
Stabilizationretraininginvolvesapproximately6stageswith12steps:41,49,50
Stage1.Thisstagetypicallyoccursintheacutephaseofhealing.
Step1:Decreasepain.Thiscanbeaccomplishedthroughmusclerelaxationtechniques,patient
educationonjointrestingpositionsandproperbodymechanics,theuseofelectrophysicalagents,
workinginthepainfreerange,andtheuseofmedication.51
Step2:Allowfreedomofmovementandproperarthrokinematicmovementofthejoint.Thiscanbe
accomplishedthroughjointmobilization(jointcapsule),prolongedpassivestretch(inerttissueand
muscle),muscleenergytechniques(muscle),activereleasetechniques(muscle),highvelocity
thrusttechniques(joint),andneurodynamictechniques(nerve),dependingonthetissuecausingthe
restriction.41
Stage2.Thisstageisinitiatedoncethepainisundercontrol,andnormalarthrokinematicsarerestored.
Step1:Ensurethattheindividualmusclescontractwhenandhowtheyshould,startingwithan
isometriccontractionoftheisolatedmuscle(stabilizersfirst).Theinitialemphasisisdirected
towardstrengtheninganyweakstabilizermusclesusingtheinnerrangeormuscletestposition.
Step2:Ensurepropermusclerecruitmentandreeducationsothatthemusclescontractinthecorrect
orderstabilizersfirst,thenmobilizers.Oncethepatientcancontractthemuscleisometrically,
concentricmovementwithintherangethatthepatienthascontrolusingthemobilizerscanbe
initiated,butonlyifthestabilizermusclesfunctionproperly.41Finally,trainingprogressestothe
useofeccentriccontractionswhichallowthepatienttomaintaincontrolofthebasewhile
lengtheningduringfunctionalmovementsorslowingdownaparticularmotion.41
Step3:Ensuremuscleimbalancebetweenmusclegroupstoensurethatthevariousforcecouples
worktogethercorrectlyandfunctiontoenablecontrolandeliminateincoordination.Ingeneral,to
correctmusclelength,oneshouldexerciselengthenedmusclesintheinnerrangetoshortenthem,
andstretchshortmusclestolengthenthem.41
Stage3.Thisstageshouldonlybeinitiatedwhenthepatienthaslearnedtostaticallycontrolthecore
structures.
Step1:Correctenduranceandstrengthdiscrepancies.Exercisesforstabilizermusclesmayinvolve
highload,lowrepetitiontraining,althoughthefocusshouldbeonlowerloadsandhighrepetitions
tobuildupresistancetofatigue.
Stage4.ThisstageistypicallyinitiatedatthesametimeasStage3,providedthepatienthassuccessfully
completedStages1and2andcandemonstratecontrolofthecore.
Step1:Retrainproprioception.Proprioceptiveretrainingisoutlinedatthebeginningofthechapter.
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Stage5.Thisstageinvolvestheintegrationoffivedifferentstepsintotheprogram.52
Step1:Reeducatethestabilizingmusclestatically.Thisisachievedbyensuringproximal
stabilizationofthecorewhileallowingdistalmovementthroughtheextremities.Shortarc
movementsareperformedinitiallywhiletheclinicianobservesfortheexpectedpropersequenceof
musclecontractions(stabilizersthenmobilizers),correctforcecoupleaction,andgoodmuscle
cocontraction(staticstabilization).
Step2:Teachadvancedstaticstabilizationexercises.Thisinvolvestakingthepatientintothe
mechanismofinjurypositionandaskinghimorhertoholdthepositionstaticallyagainstresistance.
Step3:Teachdynamicstabilizationexercises.Thisinvolvestheuseofcontrolledmovement
patternstoensurethedevelopmentofpropermovementpatterns(engramsseeChapter3)and
voluntarycontrol.Exercisesduringthisstepinvolvemovementofthecore,withthecontrol
musclesactingeccentricallywhiledistaljointsaremovedconcentricallythroughthefullrangeof
movement.
Step4:Teachadvanceddynamicstabilizationexercises.Exercisesduringthisstepinclude
multidirectionalstabilitytrainingthatrequirecontroloffunctionalspeeds,progressiveeccentric
exercisesatfunctionalspeeds,andstressingoffunctionaldiagonalpatternsusedintheactivitiesto
whichthepersonplanstoreturn.
Step5:Teachfunctionalstabilization.Functionalactivitiesareinitiallybrokendownintotheir
componentpartsbeforeperformingthewholemovement.
Stage6
Step1:Maintainorrestorefitnessthroughout.Dependingonthelocationoftheinjury,endurance
exercisesareprescribedfortheupperextremitiesorlowerextremitiestoimproveormaintain
cardiovascularfitness(seeChapter15).
Step2:Returntosportsorheavymanuallaborasappropriate.Inordertoreturntosportorheavy
manuallabor,thereshouldbe:41
Completeresolutionofacutesignsandsymptoms
Sufficientdynamic,functionalrangeofmotionofalljointsinvolvedintheactivity
Adequatestrength,endurance,andproprioceptive/kinestheticsensetoperformtheexpected
skills/taskssuccessfully
Noalterationofthepatientsnormalmechanicsthatcouldpredisposehimorhertoreinjury
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undefined
McGrawHill
Allrightsreserved.
Silverchair
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CHAPTER15:ImprovingCardiovascular
Endurance
CHAPTEROBJECTIVES
1.Explaintheimportanceofcardiovascularenduranceintheoverallhealthofanindividual.
2.Describethephysiologyofthecardiovascularsystem.
3.ExplainhowtheFITTprinciplecanbeappliedtocardiovasculartraining.
4.Explainhowthevariousmuscletypesareinvolvedwithenduranceandaerobicactivities.
5.Outlinetheprecautionswithaerobicconditioning.
6.Discussthevariousmethodsbywhichaerobicconditioningcanbeenhancedthrougharehabilitation
program.
OVERVIEW
Physicalactivityhasbeendefinedasanybodilymovementproducedbythecontractionofskeletalmusclesthat
resultsinasubstantialincreaseinrestingenergyexpenditure.1Whenapersonundertakesworkorexercise,a
numberofbodysystemsadapttothedemandsoftherequiredtasks,particularlythecardiorespiratoryand
neuromuscularsystems.2Themaximumworkcapacityofthecardiorespiratorysystemisafactorofthe
maximalamountofoxygenthatcanbetakeninandusedbythebody,orVO2max,whereasthecapacityofthe
neuromuscularsystemisafactorofthemaximumtensionthatcanbedevelopedbytheworkingmuscle,or
musclesthemaximalvoluntarycontraction.Assessmentofthecardiovascularsystemprovidestheclinician
withthejustificationformonitoringornotmonitoringactivitiesduringapatientsrehabilitation,orproviding
modificationsintheexerciseprescription.3
Ifoursedentarysocietyistochangetoonethatismorephysicallyactive,cliniciansmustplaytheirrolein
communicatingwiththeirpatientstheamountsandtypesofphysicalactivitythatareneededtopreventdisease
andpromotehealth,becausepatientsrespecttheiradvice.4,5Wheneverpossible,theclinicianshouldaddressthe
impactonthepatientresultingfromthelossofphysicalactivity.Thislossofactivityaffectsboththe
cardiovascularandthemusculoskeletalsystemsandcanoccurveryrapidly.Thus,itisimportantthatthe
rehabilitationprogramincludesexercisesthatmaintain,orimprove,thepatientscardiovascularendurancewhile
monitoringsafetyconcerns.Patientsshouldberoutinelycounseledtoadoptandmaintainregularphysical
activity.Whilepolicymakersworktoimprovereimbursementforpreventiveservices,cliniciansshoulddevelop
effectivewaystoteachphysicalactivitycounseling.5Thepersonalphysicalactivitypracticesofhealth
professionalsshouldnotbeoverlooked.Healthprofessionalsshouldbephysicallyactive,notonlytobenefit
theirownhealthbutalsotomakemorecredibletheirendorsementofanactivelifestyle.5
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PHYSICALFITNESS
AccordingtotheDepartmentofHealthandHumanServices,physicalfitnessisasetofattributesapersonhasin
regardtohis/herabilitytoperformphysicalactivitiesthatrequireaerobicfitness,endurance,strength,or
flexibilityandisdeterminedbyacombinationofregularactivityandgeneticallyinheritedability.6Although
commonlyassociatedwiththestateofthecardiorespiratorysystem,whichincludestheabilitytoperformwork
orparticipateinactivityovertimeusingthebodysoxygenuptake,delivery,andenergyreleasemechanisms,7
physicalfitnessalsoencompassesanumberofattributes,including:8
Musclestrength,whichistheabilityofmusclestoexertorresistforce(seeChapter12).
Muscleendurance,whichistheabilityofthemuscletoperformwork(seeChapter12).
Musclepower,whichistheabilityofamuscletoexerthighforceathighspeed(seeChapter12).
Balance,whichistheabilitytomaintainequilibriumwhenthebodyisstaticormoving(seeChapter14).
Agility,whichistheabilitytoperformfunctionalorpowerfulmovementsinoppositedirections(see
Chapter14).
Flexibility,whichistheabilitytostretch,easilybend,orbepliable(seeChapter13).
PHYSICALACTIVITY
Physicalactivityiscloselyrelatedto,butdistinctfrom,thesubsetsofexerciseandphysicalfitness.Exerciseis
definedasplanned,structured,andrepetitivebodilymovementdonetoimproveormaintainoneormore
componentsofphysicalfitness.1Thisdiffersfromthedefinitionofphysicalfitness,whichisasetofattributes
thatpeoplehaveorachievethatrelatestotheabilitytoperformphysicalactivity.1Regularphysicalactivityhas
longbeenregardedasanimportantcomponentofahealthylifestyle,anditiswellestablishedfromcontrolled
experimentaltrialsthatactiveindividualshavehighlevelsofcardiorespiratoryfitness.Intermittentactivity
provideditiscontinuedalsoconferssubstantialbenefits.911Studieshavedemonstratedthatwithinafewweeks
ofdiscontinuinganendurancetrainingprogram,thepositiveeffectsofexercisearealmostcompletelylost,with
approximatelyhalfofthatlossoccurringwithinthefirst2weeks.12,13
Clinicalexperienceandlimitedstudiessuggestthatpeoplewhomaintainorimprovetheirlevelsofphysical
activitymaybebetterabletoperformdailyactivities,maybelesslikelytodeveloppain,andmaybebetterable
toavoiddisability,especiallyastheyadvanceintoolderage.5Regularphysicalactivitymayalsocontributeto
betterbalance,coordination,andagility,whichinturnmayhelppreventfallsintheelderly.14Epidemiologic
researchhasdemonstratedprotectiveeffectsofphysicalactivityandriskofseveralchronicdiseases,including
coronaryheartdisease,9,15,16hypertension,17,18noninsulindependentdiabetesmellitus,19,20
osteoporosis,21,22coloncancer,23andanxietyanddepression.24Patternsofphysicalactivityappeartovary
withdemographiccharacteristics.Menaremorelikelythanwomentoengageinregularactivity,1vigorous
exercise,andsports.25Thetotalamountoftimespentengaginginaphysicalactivitynormallydeclineswith
age.1,26Adultsatretirementage(65years)showsomeincreasedparticipationinactivitiesoflighttomoderate
intensity,but,overall,physicalactivitydeclinescontinuouslyasageincreases.1,27ElderlyAfricanAmericans,
andotherethnicminoritypopulations,arelessactivethanwhiteAmericans,2830andthisdisparityismore
pronouncedforwomen.30Peoplewithhigherlevelsofeducationparticipateinmoreleisuretimephysical
activitythandopeoplewithlesseducation.1Differencesineducationandsocioeconomicstatusaccountfor
most,ifnotall,ofthedifferencesinleisuretimephysicalactivityassociatedwithraceandethnicity.31
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CARDIOVASCULARPHYSIOLOGY
Oxygenisavitalcomponentoflife,andthecardiovascularsystemprovidesameansbywhichoxygenis
suppliedtothevarioustissuesofthebodyviatheheart,bloodvessels,blood,andlungs.
CLINICALPEARL
Thebasalmetabolicrate(BMR)istheamountofenergyrequiredtosustainthebodyatrestinasupineposition.
Akilocalorie(kcal)isameasureofexpressingtheenergyvalueoffood.Fivekilocalorieequalapproximately1
Lofoxygenconsumed.1Thus,physicalactivityismeasuredasaratiobetweentheBMRandthefuelrequiredto
performaparticulartask.Thisratioismeasuredasametabolicequivalentofthetask(MET).AMETisdefined
astheoxygenconsumed(milliliters)perkilogramofbodyweightperminute(mL/kg/min).Lightworkforthe
averagemale(65kg)requires2.04.9kcalperminuteor1.63.9METs.Moderateworkfortheaveragemaleis
anactivityperformedatanintensityof46METsandistheequivalentofbriskwalkingat34mphformost
healthyadults.5Heavyworkfortheaveragemalerequires7.59.9kcalperminute,or6.07.9METs.
Bydefinition,cardiorespiratoryenduranceistheabilitytoperformwholebodyactivities(walking,jogging,
rowing,swimming,etc.)forextendedperiodsoftimewithoutunwarrantedfatigue.Themaximalamountof
oxygenthatcanbeusedduringexerciseisreferredtoasmaximalaerobiccapacity(VO2max).Itisalsocommon
toseeaerobiccapacityexpressedinMETs.
Anumberofadaptationsoccurwithinthecirculatorysysteminresponsetoexercise:
Heartrate(HR).Asthebodybeginstoexercise,theworkingtissuesrequireanincreasedsupplyof
oxygentomeetincreaseddemand.MonitoringHRisanindirectmethodofestimatingoxygen
consumptionas,normally,thesetwofactorshavealinearrelationship(thisrelationshipisconsistentwith
verylowandveryhighintensityexercise).Ifaphysicaltherapyinterventionrequiresanincreasein
systemicoxygenconsumptionexpressedaseitheranincreaseinMETlevels,kcal,orVO2max,thenHR
shouldalsobeseentoincrease.32IncreasesinHRproducedbyexercisearemetbyadecreaseindiastolic
fillingtime.TheextentatwhichtheHRincreaseswithescalatingworkloadsisinfluencedbymany
factors,includingage,fitnesslevel,typeofactivitybeingperformed,bodyposition,presenceofdisease,
medications,bloodvolume,andenvironmentalfactorssuchastemperature,humidity,andaltitude.Failure
oftheHRtoincreasewithincreasingworkloads,referredtoaschronotropicincompetence,shouldbeof
concern,evenifthepatientistakingbetablockersbetablockersslowtheHR,whichcanpreventthe
increaseinHRthattypicallyoccurswithexercise.32
Strokevolume(SV).SVistheamountofbloodpumpedoutbytheleftventricleoftheheartwitheach
beat(thedifferencebetweenenddiastolicvolumeandendsystolicvolume).Thevolumeofbloodbeing
pumpedoutwitheachbeatincreaseswithexercise,butonlytothepointwhenthereisenoughtime
betweenbeatsforthehearttofillup(approximately110120beatsperminute).Inthenormalheart,as
workloadincreases,SVincreaseslinearlyupto4050%ofaerobiccapacity,afterwhichitincreasesonly
slightly.FactorsthatinfluencethemagnitudeofchangeinSVincludeexerciseintensity,bodyposition,
andventricularfunction.
Cardiacoutput(CO).COistheamountofblood(approximately5L)dischargedbyeachventricle(not
bothventriclescombined)perminute,usuallyexpressedaslitersperminute.CO,theproductofHRand
SV,increaseslinearlywithworkloadbecauseoftheincreasesinHRandSVinresponsetoincreasing
exerciseintensity.Duringexercise,COincreasestoapproximatelyfourtimesthanthatexperiencedduring
rest.FactorsthatinfluencethemagnitudeofchangeinCOincludeage,posture,bodysize,thepresenceof
disease,andlevelofphysicalconditioning.Alongtermbeneficialtrainingeffectthatoccurswithregard
toHRisareducedrestingHRandreducedHRatastandardexerciseload.Thisoccursbecausetheheart
becomesmoreefficienttheSVincreases,broughtaboutbyincreasedvenousreturn,andincreased
contractileconditionsinthemyocardium.
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Bloodflow.Theamountofbloodflowingtothevariousorgansincreasesduringexercise,butthereisa
changeintheoveralldistributionoftheCOitisincreasedtoactiveskeletalmuscle,butdecreasedto
nonessentialorgans.Totalperipheralresistance,thesumofallforcesthatresistbloodflowwithinthe
circulatorysystem,decreasesduringexerciseprimarilybecauseofthevesselvasodilationintheactive
skeletalmuscles.33
Bloodpressure(BP).BPisdefinedasthepressureexertedbythebloodonthewallsofthebloodvessels,
specificallyarterialbloodpressure(thepressureinthelargearteries).SystolicBPnormallyincreasesin
proportiontooxygenconsumptionandCO,whilediastolicBPnormallyshowslittleornoincrease,or
maydecrease.LongtermaerobictrainingcanresultinreducedsystolicanddiastolicBP.Failureofthe
systolicBPtorisewithanincreaseinintensity,referredtoasexertionalhypotension,isconsidered
abnormal,andmayoccurinapatientwithacardiovascularproblem.TheminimalchangeindiastolicBP
isdueprimarilytothevasodilationofthearteriesfromtheexercisebout.Thus,theexpansioninartery
sizemaylowerBPduringthediastolicphase.32
Oxygenconsumptionrisesrapidlyduringthefirstminutesofexerciseandlevelsoffastheaerobic
metabolismsuppliestheenergyrequiredbytheworkingmuscles.Myocardialoxygenconsumptionisa
measureoftheoxygenconsumedbythemyocardialmuscle.1
CLINICALPEARL
Thebodysdemandforoxygenisdeterminedbytheheartrate,myocardialcontractilitysystemicbloodpressure,
andafterload,thelatterofwhichisdeterminedbythecentralaorticpressureandleftventricularwalltension.
Mitochondria:Anincreaseinsizeandnumberofthemitochondria.
Hemoglobinconcentration.Oxygenistransportedthroughoutthesystemattachedtohemoglobin,aniron
containingproteinthathasthecapabilityofeasilyacceptingorgivingupmoleculesofoxygenas
needed.33Theconcentrationofhemoglobinincirculatingblooddoesnotchangewithtrainingitmay
actuallydecreaseslightly.33However,becausetrainingforimprovingcardiovascularenduranceproduces
anincreaseintotalbloodvolume,thereisacorrespondingincreaseintheamountofhemoglobin.
Myoglobin:Increasedmyoglobincontent.
Theuseoffatandcarbohydrates:Improvedmobilizationanduseoffatandcarbohydrates.
Lungchangesthatoccurduetoexercise.
Anincreaseinthevolumeofairthatcanbeinspiredinasinglemaximalventilation.Ventilationis
theprocessofairexchangeinthelungs.
Anincreaseinthediffusingcapacityofthelungs.
Incontrast,deconditioning,whichoccurswithanyextendedillnessorprolongedinactivityresults
inanumberofnegativechangestothecardiovascularsystem:
Adecreaseinmaximumoxygenconsumption.
AdecreaseinCO/SV.
Adecreaseintotalbloodandplasmavolume.
Duringphysicalexercise,energyturnoverinskeletalmusclemayincreaseby400timescomparedwithmuscle
atrestandmuscleoxygenconsumptionmayincreasebymorethan100times.34Theenergyrequiredtopower
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thismuscularactivitycomesfromanumberofenergysystems(seeChapter1).
RECOVERY
Theperformanceofanyactivityrequiresacertainrateofoxygenconsumption,sothatanindividualsabilityto
performanactivityislimitedbythemaximalamountofoxygenthepersoniscapableofdeliveringintothe
lungs.33Fatigueandrecoveryfromfatiguearecomplexprocessesthatdependonenvironmental(room
temperature,airquality,andaltitude),physical,physiologicandpsychologicalfactors,includingthepatients
healthstatus,diet,andlifestyle(sedentaryoractive).Thephysiologicfactorsincludetheadequacyoftheblood
supplytotheworkingmuscleandthemaintenanceofaviablechemicalenvironment,whereasthepsychological
factorsincludemotivationandincentive.2Certaindiseaseprocessescanalsoaffectfatigue.Forexample,
multiplesclerosistypicallyallowsapatienttofunctionwellduringtheearlymorning,butbymidafternoonthe
patientcanoftenbecomenotablyweak.Cardiopulmonaryfatigueislikelytobecausedadecreaseinblood
sugar(glucose)levels,adecreaseinglycogenstoresinthemuscleandliver,andadepletionofpotassium.The
thresholdforfatigueisthelevelofexercisethatcannotbesustainedforindefinitely.Afteranintenseexercise
session,anaerobicenergysourcesmustbereplenishedbeforetheycanbecalledonagaintoprovideenergyfor
muscularcontraction.TheanaerobicenergysourcesofATPPCrandlacticacidareultimatelyreplenishedby
theoxidativeenergysystem(seeChapter1).Theextraoxygenthatistakenandusedtoreplenishtheanaerobic
energysourcesaftercessationoftheexerciseeffortwaspreviouslyreferredtoastheoxygendebt,butisnow
moreaccuratelyreferredtoasexcesspostexerciseoxygenconsumption(EPOC).
Adequatetimeforrecoveryfromfatiguemustbebuiltintoeveryintrasessionandintersessionexercise
progression.Inaddition,thebodyneedstobepreparedforaresumptionofthestressesanddemandsthatthe
activityorexercisewillplaceuponit.Ifnot,whenthepatientreturnstocompetitivesportsorfunctionaland
workactivities,fatiguemayresultinalterationsinefficientmovementsmakingtheindividualsusceptibleto
injury.
PRECAUTIONSWITHAEROBICCONDITIONING
Aspartoftheinitialassessmenttoidentifyindividualswhoshouldconsultaphysicianbeforeinitiatingan
exerciseprogram,theclinicianshouldperformahealthscreeningcheckorriskfactorassessment.Thefollowing
areconsideredriskfactorsforcardiovasculardisease35:
HighBP:>140mmHgsystolic,or>90mmHgdiastolic
Smoking
Elevatedserumcholesterol:atotalserumlevel>200,LDL>160(individualswithoutheartdisease,>100
inindividualswithheartdisease),orHDL<40inmenor<50inwomen
Lackofregularexercise(threeormoretimesperweekofregularexerciseormoderatephysicalactivity)
Familyhistory(motherorfatherwithheartdiseaseorstrokebeforetheageof60years)
Stress(particularlypersonalityfactorsofangerandhostility)
Diabetes
Obesity
Sex:menareatgreaterriskthanwomenuntilwomenreachmenopause,thenequalrisk
Age:increasingageincreasesrisk
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CLINICALPEARL
Inthecaseofaseverepulmonarydisease,thecostofbreathingcanreach40%ofthetotalexerciseoxygen
consumption,therebydecreasingtheamountofoxygenavailablefortheexercisingmuscles.
Obeseindividualsshouldexerciseatlongerdurationsandlowerintensitiestheyshouldbeabletoexercise
whilemaintainingaconversation(talktest).
Allpatientsshouldbemonitored(i.e.,HR,BP,andsymptoms)duringtheinitialassessmentiftheyhavebeen
determinedprecarioustoexercisebasedonanyriskfactororhealthylifestyleassessment.
Duringexercise,theclinicianshouldnotenormalclinicalresponsestoprogressivelyincreasingaerobicexercise
foreverypatient.Themagnitudeofthechangeincardiovascularresponsesduringaerobicexerciseisrelatedto
thephysicalactivitystatusofthepatient.Forexample,apatientwhoseHRtakeslongerthan5minutestoreturn
torestinglevelsafter2minutesofexercisehaspoorcardiovascularfunction.36Oncetheindividualhas
demonstratednormalvitalsignsandlackofsymptomswiththeactivities,itmaynotbenecessarytomonitor
furtheractivities.
Anumberofprecautionsneedtobetakenwhenexercisingpatientswhohavebeendeterminedprecariousto
exercise.Theseinclude:
Anappropriatelevelofintensitymustbechosen:
Toohighalevelcanoverloadthecardiorespiratoryandmuscularsystemsandpotentiallycauseinjuriesor
severecomplications.
Exercisingatalevelwhichistoohighcausesthecardiorespiratorysystemtoworkanaerobically,not
aerobically.Initially,thepatientshouldbeexercisingatalevelwiththeHRat60%ofhisorher
maximum.IfthepatientisexercisingwithintheirtargetHR,theyshouldbeabletocarryona
conversation.
Asufficientperiodoftimeshouldbeallowedforwarmupandcooldowntopermitadequate
cardiorespiratoryandmuscularadaptation.
CLINICALPEARL
Conditionedindividualshaveacardiovascularandpulmonarysystemthatismorecapableofdeliveringoxygen
tosustainaerobicenergyproductionatincreasinglyhigherlevelsofintensity.
Arapiddeclineincardiorespiratoryfitnessoccursduringthefirstfewweeksofdeconditioning,forexample,
onestudyreportedthat20daysofbedrestwasassociatedwitha28%decreaseinaerobiccapacity.37The
aforementioneddeclineinaerobiccapacityafter20daysofbedrestwasgreaterthanthatfoundafterthree
decadesofaginginthesamesubjects.38
Signsandsymptomsofexerciseintoleranceinclude,butarenotlimitedto:
BP:
SystolicBP>200210mmHg
DropinsystolicBP>20mmHg
DiastolicBP>110mmHg
HR:
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IncreaseinHR>50bpmwithlowlevelactivity
Significantarrhythmias
Chestpain
Nausea,vomiting
Unusualorseverefatigue
Syncopeormoderatedizziness
Markeddyspnea(2+/4+)
Severeclaudication(gradeIII/IV)
Cyanosisorseverepallor
CLINICALPEARL
Currently,onlyafewstudieshaveexaminedtheacuteeffectofresistanceexerciseoncardiovascular
function.39,40Fromthesestudiesithasbeenfoundthatthemagnitudeanddirectionalchangeincardiacvolume
andfunctionduringresistanceexerciseare,forthemostpart,oppositetothosethatoccurduringaerobic
exercise.
TECHNIQUESFORIMPROVING,MAINTAINING,AND
MONITORINGCARDIORESPIRATORYENDURANCE
Aerobicconditioningisespeciallyvaluableforthosewhoparticipateinsportsthatinvolveendurance.41
Nirschl42,43recommendsgeneralbodyconditioningforpatients,whichprovidesthefollowingbenefits:
Increasedregionalperfusion
Neurophysiologicsynergyandoverflow
Neurologicstimulation
Minimizationofthedominoeffectofweaknessofadjacentstructures
Minimizationofnegativepsychologicaleffects
Obesitycontrol
ContinuousTrainingTheFITT(Frequency,Intensity,Time,andType)Principle
Thedeterminantsofanyexerciseprogramcontainanumberofdifferenttrainingfactorsthatmustbeconsidered
whenattemptingtomaintainorimprovecardiorespiratoryendurance.TheAmericanCollegeofSportsMedicine
(ACSM)recommendusingthecomponentsoftheFITTprincipleastheparametersforanendurancetraining
program.1
Frequency:althoughtherearenoclearcutguidelinesprovidedonthemosteffectivefrequencyofexercise
foradaptationtooccur,toseeatleastminimalimprovementincardiorespiratoryendurance,itisnecessary
fortheaveragepersontoengageinnolessthanthreesessionsperweek,butthisisdependentonthe
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healthandageoftheindividual.Thefrequencymaybealessimportantfactorthandurationorintensityof
exercisetraining.
Iftheintensityiskeptconstant,thereappearstobenoadditionalbenefitfromtwiceaweekversus
fourtimesorthreetimesaweekversusfivetimesperweek.
Ifthegoalisweightloss,57daysperweekincreasesthecaloricexpendituremorethan2daysper
week.
Intensity:therecommendationsregardingtrainingintensity,whichcanbedeterminedbasedonthe
overloadprincipleandthespecificityoftrainingprinciple(seeChapter12)vary.Sinceaerobiccapacity
andHRarelinearlyrelated,therelativeexerciseintensityforanindividualcanbecalculatedasa
percentageofthemaximumfunction,usingVO2maxormaximumHR(HRmax).Itisnowrecognized
thatanindividualsperceptionofeffort(relativeperceivedexertionorRPE)iscloselyrelatedtothelevel
ofphysiologicaleffort(seeChapter12).44,45Foraerobicactivities,theexerciseintensityshouldbeata
levelthatis4085%maximalaerobicpower(VO2max)or5590%ofmaximalHR.1SeventypercentHR
maxisaminimallevelstimulusforelicitingaconditioningresponseinhealthyyoungindividuals.It
wouldappearthatexercisingathighintensityforashorterperiodoftimeresultsinagreaterimprovement
intheVO2maxthanexercisingatamoderateintensityforalongerperiodoftime.Thismustbeweighed
againstthefactthatasexerciseapproachesthemaximumlimit,thereisanincreaseintherelativeriskof
musculoskeletalinjuryandcardiovascularcomplications.
CLINICALPEARL
Ifanindividualistakingmedicationsthatmayaffectheartrateandbloodpressureresponses(e.g.,beta
blockers),theBorgratingofperceivedexertionistheonlyrecommendedmethodforprescribingexercise
intensity.
Twoothercommonmethodsofmonitoringintensityareemployed:
MonitoringHRtwoformulasarecommonlyused:
Maximumheartrate(MHR)reserve:thismethodusesthedifferencebetweentheMHRandthe
restingheartrate(RHR),referredtoasthemaximumheartratereserve(MHRR).Whenusingthis
formula,therecommendedintensitylevelrangeis5085%ofVO2max.Forexample,fora40year
oldwithanRHRof65bpmwhowantstotrainatanintensityof70%:
22040=180bpm(MHR)
18065=115bpm(MHRR)
(1150.7)+65=145bpm
Theageadjustedmaximumheartrate(AAMHR)46:MHR=220patientsage.Forexample,fora
40yearold,theMHRis22040=180.Therecommendedlevelofintensitywhenusingthis
formulaisarangebetween60%and90%ofanindividualsMHR.Therefore,thetargetheartrange
(6090%)foranMHRof180isbetween18060%and18090%=108162bpm.
CLINICALPEARL
TanakaandcolleaguesrecentlyrevealedthattheAAMHRequationunderestimatestheactualmaximalheartrate
by615bpminthoseindividualsbetween60and90yearsofage.47Basedonthesefindingsanewformulahas
beenderivedtoestimatetheagepredictedmaximalheartrate:208(0.7age).48
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CalculatingtheVO2maxorHRdirectlyorindirectly:
3minutesteptest.
12minuterun.
1milewalktest.
Regardlessofwhichformulaisused,theclinicianshouldkeepinmindthatformulasaremerelyestimations
(andhighlyinaccuratewhenusedwithpatientstakingprescribedmedicationsthatmayaffectHRandBP
responses),andtherefore,itismoreimportanttomonitorsignsandsymptomsandtobeconservativein
prescribingexerciseintensityforanysedentaryindividual,elderlyindividual,orsomeoneatmoderatetohigh
riskforcardiovasculardisease.3
Time(duration):thegreatertheintensityoftheexercise,theshorterthedurationneededforadaptation.
Theconverseisalsotrue,thelowertheintensityoftheexercise,thelongerthedurationneeded.For
minimalimprovementtooccur,thepatientmustparticipateinacontinuousactivityforatleast20minutes
withanHRelevatedtoitsworkinglevel.Threetofiveminutesperdayproducesatrainingeffectin
poorlyconditionedindividuals,whereas2060minutes,threetofivetimesaweekisoptimalfor
conditionedpeople.Generally,thegreaterthedurationoftheworkout,thegreatertheimprovementin
cardiovascularendurance.33
Typeofexercise:thetypeofactivitychosenincontinuoustrainingmustbeaerobicinvolvinglarge
musclegroupsactivatedinarepetitiveandrhythmicmanner.Wheneverpossible,thetypeofexercise
mustcloselymatchtheactivitytowhichthepatientisreturning.Forexample,runningandjumping
activitiesaremoreappropriateforasoccerplayerthanswimmingandcycling.Aerobicexercisesallow
theindividualtospeeduporslowdownthepacetomaintaintheHRataspecifiedortargetlevel.33
Examplesofaerobicactivitiesarerunning,cycling,swimming,andcrosscountryskiing.Crosstraining
exercises,includingcycling,upperbodyergometer(UBE),andwaterrunning,increasecardiovascular
endurance.However,itmustberememberedthatalthoughcrosstrainingcanproduceasimilar
cardiovasculareffortastheoriginalsport,itdoesnotnecessarilyproducethesamemusculoskeletaleffects
(Table151).
CLINICALPEARL
Discontinuoustraining,alsoknownasintervaltraining,involvestheuseofrepeatedhighintensityexercise
boutsthatareinterspersedwithrestintervals.Althoughendurancelevelscanbeimprovedwiththismethod,
morebenefitsareseeninthedevelopmentofstrengthandpower.
TABLE151ComparisonofPhysiologicAdaptationstoResistanceTrainingandAerobicTraining
ResultFollowingResistance ResultFollowingEndurance
Variable
Training Training
Performance
Musclestrength Increases Nochange
Muscleendurance Increasesforhighpoweroutput Increasesforlowpoweroutput
Aerobicpower Nochangeorincreasesslightly Increases
Maximalrateofforce
Increases Nochangeordecreases
production
Verticaljump Abilityincreases Abilityunchanged
Anaerobicpower Increases Nochange
Sprintspeed Improves Nochangeorimprovesslightly
Musclefibers
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ResultFollowingResistance ResultFollowingEndurance
Variable
Training Training
Fibersize Increases Nochangeorincreasesslightly
Capillarydensity Nochangeordecreases Increases
Mitochondrialdensity Decreases Increases
Fastheavychainmyosin Increasesinamount Nochangeordecreasesinamount
Enzymeactivity
Creatinephosphokinase Increases Increases
Myokinase Increases Increases
Phosphofructokinase Increases Variable
Lactatedehydrogenase Nochangeorvariable Variable
Metabolicenergystores
StoredATP Increases Increases
Storedcreatinephosphate Increases Increases
Storedglycogen Increases Increases
Storedtriglycerides Mayincrease Increases
Connectivetissue
Ligamentstrength Mayincrease Increases
Tendonstrength Mayincrease Increases
Collagencontent Mayincrease Variable
Bonedensity Nochangeorincrease Increases
Bonecomposition
Percentagebodyfat Decreases Decreases
Fatfreemass Decreases Nochange
ATP,adenosinetriphosphate.
DatafromClancyWG.Specificrehabilitationfortheinjuredrecreationalrunner.InstrCourseLect.
198938:483486.
AerobicTrainingMethods
AtypicalexercisesessionisoutlinedinChapter12.Usingthevariousexerciseparametersoutlinedinthis
chapterthatfocusonimprovingcardiovascularendurance,thecliniciancanemployanyofthefollowing
differentaerobicconditioningtrainingprograms.
ContinuousTraining
Continuoustraining,orsteadystate,exerciseisperformedfor2060minuteswithnorestintervalata
submaximalenergyrequirement,andlittlevariationinHR.Anumberofpiecesofexerciseequipmentcanbe
usedwithcontinuoustraining:
Treadmill:progressingfromslowtofastwalkingandshortdistancestolongerdistanceswithorwithout
anincline.Treadmillsarealsoavailableinpoolsandcombinedwithverticaltractiontobettercontrolthe
forcesofgravity.
UBE:AUBE,alsocalledanarmbike,orarmergometerisanexcellentwayofmaintainingorimproving
aerobicfitness,orasawaytowarmuptheupperextremitiespriortoresistancetraining.UBEsworklike
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abicycleforthearms.Somemodelsofferdualpassivemovementforthelegs,whichiscontrolledbythe
arms.Oneofthemanybenefitsofergometersistheiravailabilitytoprovideexerciseforindividualswho
cannotusethelowerextremitiesforphysicalactivity(e.g.,recoveringfromfootorleginjury/surgery,
spinalcordinjury,ormultiplesclerosis).Thereareanumberoftrainingprogramsavailablewhenusing
theUBEdependingontheintent.Forexample,steadystateandhighintensityintervaltrainingcanbe
used.Inaddition,timetrialtrainingcanbeusedbysettingadistancetobeachieved(e.g.,1,000,2,000,or
5,000m)togetherwithaspeedandintensitylevel.
Rowing:Rowing,whetherperformedonoroffwater,involvesacontinuousrepetitivemotionstressing
variousanatomicareasdependingonthestrokephase(Table152).SimilartotrainingwiththeUBE,
trainingprograms,includingsteadystate,timetrial,andhighintensityintervaltrainingcanbeused.
However,unliketheUBE,rowingrequiresboththeupperandlowerextremitiestobeinjuryfree.In
addition,duetothefactthatrowingisthoughttoberesponsibleforahighincidenceofdiskogenicback
pain,49caremustbeusedinitsprescription.Theinitialwarmupshouldbelongandslowpriortotraining
withintensity,distance,andfrequencyadjustments
Indoorstationarycycling:Asitsnamesuggests,indoorstationarycyclinginvolvescyclingonamachine
againstsomeformofmechanicalresistance.InthesamewaytheUBEcanbeusedtowarmuptheupper
extremitiespriortoresistancetraining,stationarycyclingcanbeusedtowarmupthelowerextremitiesfor
thesamepurpose.Stationarycyclingalsoallowsindividualstomaintainorimprovetheircardiovascular
endurancewhentheycannotusetheupperextremitiesforphysicalactivity.
Freeweightsandelasticresistance:theuseoflowresistanceandhighrepetitionscanproduceanaerobic
effect.
TABLE152RowingPhasesandMuscleActivity
Stroke
Description MuscleActivity
Phase
Therowingstrokebeginsatthe
finishwiththekneesfully
The extended,thebackinalaidback Therectusandexternalobliquemusclesfiretostabilizethe
finish positionfromvertical,withits trunkwhichisintheextendedposition
relativelyextendedandtheelbows
flexedintothebodyatwaistheight
Withthebodyinaforwardpositionandthekneesandhips
flexingandcompressing,thereislittletonoactivityfromthe
Early Beginswithmovementofthehands
paraspinalmuscles.Thehamstringsfiresubmaximallytoflex
recovery awayfromthebodytowardthefeet
thekneesandtoinitiatethemovementbackuptheslidetothe
catchposition
Late Forwardflexionatthehipand
recovery forwardmovementofthespine
Beginswhenthebodyandshoulders
areforwardofthehips,thehandsare
pasttheknees,andthelegslowly
Thebackactsasabracecantileverandprovidesanadditional
The begintoflexuntilthecatchposition
sourceofpowerbyextendingfrom30degreesofflexionatthe
catch isreachedwiththekneesflexed
catchtoapproximately30degreesofextensionatthefinish
approximately110120degrees,the
hipismaximallyflexed,andthe
elbowsarefullyextended
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Stroke
Description MuscleActivity
Phase
Theback,shoulder,andarmsfunctionasabracecantileverso
thattheforcegeneratedbythelegscanbeappliedtothe
oar/machinehandle.Therectusfemorisandlumbar/thoracic
Early Thelegsbegintodrivethebody paraspinalmusclesinitiatethedrivephase,withtheformer
drive back providingthepower,andthelatterstabilizingthespineto
enablethetransferoftheforce.Asthekneesandhipsextend
duringthedrivephase,thegluteusmaximusandhamstrings
fire,controllingthedriveandstabilizingthepelvis.
Thelegscontinuetodrivethebody
Late
backuntilthefinishpositionis
drive
reached
Datafrom:
1.HoseaTM,HannafinJA.Rowinginjuries.SportsHealth.20124:236245.
2.KarlsonKA.Rowinginjuries:identifyingandtreatingmusculoskeletalandnonmusculoskeletalconditions.
PhysSportsMed.200028:4050.
3.PerrinAE.Rowinginjuries.ConnMed.201074:481484.
4.RumballJS,LebrunCM,DiCiaccaSR,etal.Rowinginjuries.SportsMed.200535:537555.
IntervalTraining
Intervaltraining,ordiscontinuoustraining,involvestheuseofrepeatedhighintensityexerciseboutsthatare
interspersedwithrestintervals,whichisperceivedtoimprovestrengthandpowermorethanendurance.With
appropriatespacingofworkandrestintervals,asignificantamountofhighintensityworkcanbeachievedand
isgreaterthantheamountofworkaccomplishedwithcontinuoustraining.Thelongertheworkinterval,the
moretheanaerobicsystemisstressedandthedurationoftherestperiodismoreimportant.Inashortwork
interval,aworkrecoveryratioof1:1or1:5isappropriatetostresstheaerobicsystem.
CircuitTraining
Thefundamentalfeatureofcircuittrainingistheuseofaseriesofdifferentexerciseactivities.Circuittraining
incorporatesawidevarietyofmodesoftraininganduseshighrepetitionsandlowweighttoprovideamore
generalconditioningprogramaimedatimprovingbodycomposition,muscularstrength,andsome
cardiovascularfitness.
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undefined
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Allrightsreserved.
Silverchair
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CHAPTER16:TheShoulder
CHAPTEROBJECTIVES
1.Describetheanatomyofthejoints,ligaments,muscles,blood,andnervesupplythatcomprisetheshouldercomplex.
2.Describethebiomechanicsoftheshouldercomplex,includingtheopenandclosepackedpositions,muscleforcecouples,andthestaticanddynamic
stabilizers.
3.Describetherelationshipbetweenmuscleimbalanceandfunctionalperformanceoftheshoulder.
4.Describethepurposeandcomponentsofthetestsandmeasuresfortheshouldercomplex.
5.Performacomprehensiveexaminationoftheshouldercomplex,includinghistory,systemsreview,palpationofthearticularandsofttissuestructures,
specificpassivemobilitytests,passivearticularmobilitytests,andspecialtests.
6.Evaluatethekeyfindingsfromtheexaminationdatatoestablishaphysicaltherapydiagnosisandprognosis.
7.Summarizethevariouscausesofshoulderdysfunction.
8.Describeanddemonstrateinterventionstrategiesandtechniquesbasedontheclinicalfindingsandanyestablishedgoals.
9.Evaluatetheinterventioneffectivenesstodetermineprogressandmodifyaninterventionasneeded.
10.Plananeffectivehomeprogramandinstructthepatientinitsuse.
OVERVIEW
Theshoulderisthemostrewardingjointinthebodybecausewhenalimitedorpainfulmovementisfound,thefindingisseldomambiguousandoften
implicatestheoffendingstructure.
JamesCyriax,MD(19041985)
Theprimaryfunctionoftheshouldercomplexistopositionthehandinspace,therebyallowinganindividualtointeractwithhisorherenvironmentandto
performfinemotorfunctions.Aninabilitytopositionthehandresultsinprofoundimpairmentoftheentireupperextremity.1
Secondaryfunctionsoftheshouldercomplexincludethefollowing:
Suspendingtheupperlimb.
Providingsufficientfixationsothatmotionoftheupperextremityortrunkcanoccur.
Servingasafulcrumforarmelevation.Threetypesofarmelevationarerecognized:anupwardmotionoftheupperextremityinthescapularplane
(scaption)andthemotionsineitherthecoronalplane(abduction)orinthesagittalplane(flexion).
Theshoulderisendowedwithauniqueblendofmobilityandstability.Optimalfunctioningoftheshoulderandarmcanonlytakeplaceifadelicatebalance
betweenthemobilityandstabilityismaintained.Thedegreeofmobilityiscontingentonahealthyarticularsurface,intactmuscletendonunits,andsupple
capsuloligamentousrestraints.Thedegreeofstabilityisdependentonintactcapsuloligamentousstructures,properfunctionofthemuscles,andtheintegrityof
theosseousarticularstructures.1
ANATOMY
Theshouldercomplexfunctionsasanintegratedunit,involvingacomplexrelationshipbetweenitsvariouscomponents.Thecomponentsoftheshoulderjoint
complexconsistof(Fig.161):
FIGURE161
Bonyanatomyoftheshoulder.(Reproduced,withpermission,fromChapter29.OverviewoftheUpperLimb.In:MortonDA,ForemanK,AlbertineKH.eds.
TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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threebones(thehumerus,theclavicle,andthescapula)
threejoints(thesternoclavicular[SC],theacromioclavicular[AC],andtheglenohumeral[GH]joints)
onepseudojoint(thearticulationbetweenthescapulaandthethorax)
onephysiologicalarea(thesuprahumeralorsubacromialspace).
Foroptimalshoulderfunction,cervicothoracicjunctionmotions,andmotionsattheconnectionsbetweenthefirstthreeribsandthesternumandspinemustbe
available.
GLENOHUMERALJOINT
TheGHjointisatruesynovialjointthatconnectstheupperextremitytothetrunk,aspartoftheupperkineticchain.TheGHjointisdescribedasaballand
socketjointthehumeralheadformsroughlyhalfaballorsphere(Fig.161),whereastheglenoidfossaformsthesocket.
Theheadofthehumerusfacesmedially,posteriorly,andsuperiorlywiththeaxisoftheheadforminganangleof130150degreeswiththelongaxisofthe
humerus(Fig.162).2Inthefrontalplane,theheadofthehumerusisangledposteriorly(retroverted)by3040degrees.3,4ThejointcapsuleoftheGHjointis
laxinferiorlytopermitfullelevationofthearm.
FIGURE162
Superioraspectofshouldershowingangleofscapula.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,
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Theglenoidfossaofthescapulafaceslaterally,superiorly,andanteriorlyatrestandinferiorlyandposteriorlywhenthearmisinthedependentposition(Fig.
163).5Theglenoidfossaisflatandcoversonlyonethirdtoonefourthofthesurfaceareaofthehumeralhead.Thisarrangementallowsforagreatdealof
mobilitybutlittleinthewayofarticularstability.However,theglenoidfossaismadeapproximately50%deeper(doublingthedepthoftheglenoidfossa
acrossitsequatorialline)6andmoreconcavebyaringoffibrouscartilage7anddensefibrouscollagen8calledalabrum.Thelabrumformsapartofthe
articularsurfaceandisattachedtothemarginoftheglenoidcavityandthejointcapsule.9Itisalsoattachedtothelateralportionofthebicepsanchor
superiorly.10Inaddition,approximately50%ofthefibersofthelongheadofthebiceps(LHB)brachiioriginatefromthesuperiorlabrum(theremainder
originatesfromthesuperiorglenoidtubercle),8withfourdifferentvariationsidentified,11andcontinueposteriorlytobecomeaperiarticularfiberbundle,
makingupthebulkofthelabrum.10,12Thelabrumenhancesjointstabilitybyincreasingthehumeralheadcontactareasto75%verticallyand56%
transversely.5,9Thehumeralglenoidcontactareaprovidestwoprimaryfunctions:13itspreadsthejointloadingoverabroadarea,anditpermitsmovementof
opposingjointsurfaceswithminimalfrictionandwear.14However,becausethehumeralheadislargerthantheglenoid(Fig.163),atanypointduring
elevation,only2530%ofthehumeralheadisincontactwiththeglenoid,withthegreatestcontactoccurringduringelevationratherthanattheextremes.
Contactbetweenthehumeralheadandglenoidfossaissignificantlyreducedwhenthehumerusispositionedin1517:
FIGURE163
Glenohumeraljoint.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:
GrossAnatomy.NewYork,NY:McGrawHill2011.)
adduction,flexion,andinternalrotation(IR)
abductionandelevation
adductedattheside,withthescapularotateddownward.
AlthoughthelabrumprovidessomestabilityfortheGHjoint,additionalsupportisprovidedbybothdynamicandstaticmechanisms.Thedynamic
mechanismsincludethemusclesoftherotatorcuff(supraspinatus,infraspinatus,teresminor,andsubscapularismuscles)(Fig.164)andanumberofmuscle
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forcecouplesdescribedlater.Thestaticmechanisms,whichincludereinforcementsofthejointcapsule,jointcohesionandgeometry,andligamentoussupport,
arealsodescribedlater.
FIGURE164
Rotatorcuffmuscles.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:
Thescapula(Fig.161)functionsasastablebasefromwhichGHmobilitycanoccur.Thescapulaisaflatbladeofbonethatisorientedtocontributeto
stability:itliesalongthethoraciccageat30degreestothefrontalplane(Fig.162),3degreessuperiorlyrelativetothetransverseplanetoaugmentfunctional
reachingmotionsaboveshoulderheight,18and20degreesforwardinthesagittalplane.1921Thisorientationresultsinarmelevationoccurringinaplanethat
is3045degreesanteriortothefrontalplane.Whenelevationofthearmoccursinthisplane,themotionisreferredtoasscapularplaneabductionorscaption.
CLINICALPEARL
Ithasbeenrecommendedthatmanystrengtheningexercisesfortheshoulderjointcomplexbeperformedinthescapularplane.Reasonsforthisinclude:
Whenthelimbispositionedintheplaneofthescapula,themechanicalaxisoftheglenohumeraljointisinlinewiththemechanicalaxisofthescapula,
andmovementofthehumerusinthisplaneislesslimitingthaninthefrontalorsagittalplanesbecausetheglenohumeralcapsuleisnottwisted.22,23
Becausetherotatorcuffmusclesoriginateonthescapulaandattachtothehumerus,thelengthtensionrelationshipofthesemusclesisimprovedinthis
position.
Thescapulaswideandthinconfigurationallowsforitssmoothglidingalongthethoracicwallandprovidesalargesurfaceareaformuscleattachmentsboth
distallyandproximally.24Inall,16musclesgainattachmenttothescapula(Table161).Sixofthesemuscles,includingthetrapezius,rhomboids,levator
scapulae,andserratusanterior,supportandmovethescapula,whilenineoftheotherten(theomohyoidisnotincluded)areconcernedwithGHmotion.2527
TABLE161MusclesoftheScapula
Trapezius Subscapularis
Levatorscapulae Coracobrachialis
Longandshortheadofthebiceps Pectoralisminor
Rhomboidmajor Serratusanterior
Rhomboidminor Longheadoftriceps
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Supraspinatus Teresmajor
Infraspinatus Teresminor
Deltoid Omohyoid
Posteriorly,thescapulaisdividedbytheelevatedscapulaspineintotwounequallysizedmusclecompartments.Thesupraspinousfossaissmallandservesas
thesiteoforiginforthesupraspinatusmuscle(seeFig.164).Theinfraspinousfossagivesattachmentforthedownwardactinginfraspinatusandteresminor
muscles(seeFig.164),importantmusclesforthestabilizationofthehumeralhead(seeMusclesoftheShoulderComplexsection).Thespineofthescapula
(seeFig.161)providesacontinuouslineofattachmentsforthesupportingtrapeziusmusclealongitsupperborder,whereasthedeltoidmuscle,which
suspendsthehumerus,gainsoriginfromitslowerborder.Theundersurfaceofthescapulaiscoveredbythesubscapularismuscle(seeFig.164),whichalso
assistsinstabilizingthehumeralheadagainsttheglenoidfossa.
Aprominentfeatureofthescapulaisthelargeoverhangingacromion(seeFig.163),which,alongwiththecoracoacromialligamentandthepreviously
mentionedlabrum,functionallyenlargestheGHsocket.Thepositionoftheacromionalsoplacesthedeltoidmuscleinadominantpositiontoprovide
muscularsupportduringelevationofthearm.Biglianietal.21,28introducedthefollowingacromiontypes:
TypeIhasarelativelyflatundersurface
TypeIIisslightlyconvex
TypeIIIishooked
Thedistance,orangle,betweenthescapulaandtheclavicleisvariableanddependsonfunction.Whiletheshoulderisprotracted,theangleis50degrees.At
rest,theangleisapproximately60degrees,andwithretractiontheangleincreasesto70degrees.3
Alongthemedialborderofthescapulaarisethreemuscles:thetworhomboidmusclesandtheserratusanterior(Fig.165),allofwhichaidwithscapular
stabilityduringarmelevation(seelater).Thecoracoidprocess(seeFig.163)projectsforwardlikeacrowsbeak,forwhichitisnamed.Thisforwardposition
providesanefficientleverwherebythesmallpectoralismusclecanhelptostabilizethescapula.Inaddition,theprocessservesasapointoforiginforthe
coracobrachialisandtheshortheadofthebicepsmuscle.
FIGURE165
Rhomboidmusclesandserratusanterior.(Reproduced,withpermission,fromChapter1.Back.In:MortonDA,ForemanK,AlbertineKH.eds.TheBig
Picture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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ThelateralattachmentofthevoluminousjointcapsuleoftheGHjointattachestotheanatomicalneckofthehumerus(Fig.166).6Medially,thecapsuleis
attachedtotheperipheryoftheglenoidanditslabrum.Theoverallstrengthofthejointcapsulebearsaninverserelationshipwiththepatientsagetheolder
thepatient,theweakerthejointcapsule.Thefibrousportionofthecapsuleisverylaxandhasseveralrecesses,dependingonthepositionofthearm.Atits
inferioraspect,thecapsuleformsanaxillaryrecess,whichisbothlooseandredundant.Therecesspermitsnormalelevationofthearm,althoughitcanalsobe
thesiteofadhesionswhentheshoulderisimmobilizedinadduction.Theanterioraspectofthejointcapsuleisreinforcedbythreeligaments(Zligaments),
whicharedescribedinthenextsection.Thetendonsoftherotatorcuff(supraspinatus,infraspinatus,teresminor,andsubscapularis)reinforcethesuperior,
posterior,andanterioraspectsofthecapsule,asdoestheLHBtendon.
FIGURE166
Glenohumeraljointandligaments.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,AlbertineKH.eds.The
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Aninnersynovialmembranelinesthefibrouscapsuleandsecretessynovialfluidintothejointcavity.Thesynoviumtypicallylinesthejointcapsuleand
extendsfromtheglenoidlabrumdowntotheneckofthehumerus.Italsoformsvariouslysizedbursae,thelargestofwhich,thesubacromialorsubdeltoid
bursa,liesonthesuperioraspectofthejoint(seelater).
Thegreaterandlessertuberosities(seeFig.161),whichserveasattachmentsitesforthetendonsoftherotatorcuffmuscles,arelocatedonthelateralaspectof
theanatomicalneckofthehumerus,animaginarylinethatseparatesthehumeralheadfromtherestofthehumerus.Thelessertuberosityservesasthe
attachmentforthesubscapularis.Thegreatertuberosityservesastheattachmentforthesupraspinatus,infraspinatus,andteresminor.Thegreaterandlesser
tuberositiesareseparatedbytheintertuberculargroove(seeFig.161),throughwhichpassesthetendonoftheLHBonitsroutetoattachtothesuperiorrimof
theglenoidfossa.Thisgroovehaswidevarianceintheangleofitswalls,but70%fallwithina6075degreerange.29Certainshoulderdisorders,including
rotatorcuffandbicipitaltendinopathy,havebeenassociatedwithanomaliesofthisgroove.30AsthetendonoftheLHB(Fig.167)passesoverthehumeral
headfromitsorigin,itmakesarightangleturntolieintheanterioraspectofthehumerus.Thisabruptturnmaypermitabnormalwearingofthetendonatthis
point.Theroofofthisgrooveisformedbythetransverseligament.Thetransversehumeralligament(Fig.167),whichrunsperpendicularoverthebiceps
tendon,wasoncethoughttofunctionasarestrainttothebicepstendonwithintheintertuberculargroove.However,thisappearstobetheroleofthe
coracohumeralligament.30
FIGURE167
Softtissuestructuresoftheshoulder.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,AlbertineKH.eds.
TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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Theregionbelowthegreaterandlessertuberosities,wheretheuppermarginofthehumerusjoinstheshaftofthehumerus,isreferredtoasthesurgicalneck
(Fig.161).Theaxillarynerveandposteriorhumeralcircumflexarterylieincloseproximitytothemedialaspectofthesurgicalneck.
CLINICALPEARL
Fracturesofthesurgicalneckofthehumerusoccurmorefrequentlythanfracturesoftheanatomicalneck,andaremostlikelytocausedamagetotheaxillary
nerve.
Ligaments
Anumberofstructuresfunctionasstaticstabilizersduringmotionofthearmtoreciprocallytightenandloosen,therebylimitingtranslationandrotationofthe
GHjointsurfacesinaloadsharingfashion.31TheseincludetheGHligamentsandtheposteriorcapsule.Furtherstaticstabilizationisprovidedbytheglenoid
labrum.Theposteriorcapsuleisundertensionwhentheshoulderisinflexion,abduction,IR(inparticular,thesuperiorandmiddlesegments),orinany
combinationofthese.
Attheanteriorportionoftheouterfibersofthejointcapsule,threelocalreinforcementsarepresent:thesuperior,middle,andinferiorGHligaments.Together
withthecoracohumeralligament,theseligamentsformaZpatternontheanterioraspectoftheshoulder.32Inthemidrangeofrotation,theGHligamentsare
relativelylaxandstabilityismaintainedprimarilybytheactionoftherotatorcuffmusclegroupcompressingthehumeralheadintotheconformingglenoid
articulation.31TheGHligamentsappeartoproduceamajorrestraintduringshoulderflexion,extension,androtation33:
TheanteriorGHligamentisundertensionwhentheshoulderisinextension,abduction,and/orexternalrotation(ER).
TheposteriorGHligamentisundertensioninflexionandER.
TheinferiorGHligamentisthemostimportantoftheGHligaments.Itisundertensionwhentheshoulderisabducted,extended,and/orexternally
rotated.Inaddition,thisligamentisaprimaryrestraintagainstbothanteriorandposteriordislocationsofthehumeralhead,andisthemostimportant
stabilizingstructureoftheshoulderintheoverheadathlete.34At0degreeabduction,thesubscapularismuscle,thelabrum,andthesuperiorGH
ligamentaretheprimaryrestraintsagainstanteriortranslation.At45degreeabduction,thesubscapularismuscleandthemiddleandinferiorGH
ligaments,alongwithlabrum,preventanteriortranslation.Whenthearmisabductedmorethan90degrees,whichisthemostcommonpositionof
anteriordislocation,theanteriorfibersoftheinferiorGHligamentaretheprimaryrestraintagainstanteriormovement.9,35
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ThemiddleGHligamentisundertensionwhentheshoulderisflexedandexternallyrotated.Inaddition,themiddleGHligamentandthesubscapularis
tendonlimitERfrom4575degreesofabduction,andareimportantanteriorstabilizers.
OtherligamentshelpprovidestabilitytotheGHjoint.Theseincludethefollowing:
Thecoracohumeralligament.Thecoracohumeralligament(seeFig.166)arisesfromthelateralendofthecoracoidprocessandrunslaterally,whereit
issplitintotwobandsbythepresenceofthebicepstendon.Theposteriorbandblendswiththesupraspinatustendontoinsertnearthegreatertuberosity,
andtheanteriorbandblendswiththesubscapularistendontoinsertnearthelessertuberosity.ThecoracohumeralligamentcoversthesuperiorGH
ligamentanterosuperiorlyandfillsthespacebetweenthetendonsofthesupraspinatusandsubscapularismuscles,unitingthesetendonstocompletethe
rotatorcuffinthisarea.Tearsofthecuffusuallyextendlongitudinallybetweenthesupraspinatusandcoracohumeralligamentsothatthehoodactionof
thecuffislost.Itisgenerallyagreedthattheposteriorbandofthecoracohumeralligamentlimitsflexion,whereastheanteriorbandlimitsextensionof
theGHjoint.36Boththebandsalsolimitinferiorandposteriortranslationofthehumeralhead,strengtheningthesuperoanterioraspectofthe
capsule.36,37
Thecoracoacromialligament.Thecoracoacromialligament(seeFig.166)isoftendescribedastheroofoftheshoulder.Itisaverythickstructurethat
runsfromthecoracoidprocesstotheanteroinferioraspectoftheacromion,withsomeofitsfibersextendingtotheACjoint.Theligamentconsistsof
twobandsthatjoinneartheacromion,anditisideallysuited,bothanatomicallyandmorphologically,topreventseparationoftheACjointsurfaces.
ThecoracoclavicularligamentsandthecostoclavicularligamentsaredescribedintheACjointsectionandtheSCjointsection,respectively.
CoracoacromialArch
Thecoracoacromialarch(Fig.166)isformedbytheanteroinferioraspectoftheacromionprocess,andthecoracoacromialligament,whichconnectsthe
coracoidtotheacromionandtheinferiorsurfaceoftheACjoint.3840Anumberofstructuresarelocatedinthesubacromialorsuprahumeral,space(Fig.16
7)betweenthecoracoacromialarchsuperiorlyandthehumeralheadinferiorly,andthecoracoidprocess,anteromedially.Theseinclude(frominferiorto
superior)thefollowing:
theheadofthehumerus,
thelongheadofbicepstendon(intraarticularportion),
thesuperioraspectofthejointcapsule,
thesupraspinatusanduppermarginsofsubscapularisandinfraspinatus,
thesubdeltoidsubacromialbursae,
theinferiorsurfaceofcoracoacromialarch.
Innormalindividuals,thesubacromialspaceaverages1011mminheightwiththearmadductedtotheside.41,42Elevatingthearmintheplaneofthescapula
decreasesthisspace,andthespaceisatitsnarrowestbetween60and120degreesofscaption.43Duringoverheadmotionintheplaneofthescapula,the
supraspinatustendon,theregionofthecuffmostinvolvedinoverusesyndromesoftheshoulder,canpassdirectlyunderneaththecoracoacromialarch.Ifthe
armiselevatedwhileinternallyrotated,thesupraspinatustendonpassesunderthecoracoacromialligament,whereasifthearmisexternallyrotated,thetendon
passesundertheacromionitself.44
Muscleimbalancesorcapsularcontracturescancauseanincreaseinsuperiortranslationofthehumeralhead,narrowingthesubacromialspace.Forexample,if
therotatorcuffmusclesareweakorinjured,increasedtranslationoccursbetweenthehumeralheadandtheglenoidlabrum.45Thisincreaseintranslationmay
leadtoincreasedwearonthelabrum,increasedrelianceonthestaticrestraints(e.g.,ligaments,capsule),andeccentricoverloadingofthedynamic(muscle)
restraints,whichinturncanresultininstabilityand/oraconditiontermedsubacromialimpingementsyndrome(SIS).46,47
Bursae
Approximatelyeightbursaearedistributedthroughouttheshouldercomplex.Thesubdeltoidsubacromialbursae(seeFig.167)areusuallycollectively
referredtoasthesubdeltoidbursabecausetheyareoftencontinuousinnature.Thesubdeltoidbursaisoneofthelargestbursaeinthebodyandprovidestwo
smoothserosallayers,oneofwhichadherestotheoverlyingdeltoidmuscleandtheothertotherotatorcufflyingbeneath.Thisbursaisalsoconnectedtothe
acromion,greatertuberosity,andcoracoacromialligament.Asthehumeruselevates,itpermitstherotatorcufftoslideeasilybeneaththedeltoidmuscle.There
arealsosmallerbursaeinterposedbetweenmostofthemusclesincontactwiththejointcapsule:
Thesubcoracoidbursa.Thisbursaislocatedunderthecoracoidprocess.
Thesubscapularbursa.Thisbursaislocatedbetweenthesubscapularmuscletendonandtheanteriorneckofthescapulaandprotectsthetendonasit
passesunderthecoracoidprocess.
Neurology
TheshouldercomplexisembryologicallyderivedfromC5toC8,excepttheACjoint,whichisderivedfromC4(Fig.168).Thesympatheticnervesupplyto
theshoulderoriginatesprimarilyinthethoracicregionfromT2downasfarasT8.48
FIGURE168
Neurologicalandvascularstructuresoftheshoulder.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,
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Onestudy49attemptedtodeterminethevariabilityofthecourseandthepatternofthesenervesandfoundthattheperipheralnervescontributingtotheanterior
shoulderjointincludedtheaxillary(C56),subscapular(C56),andlateralpectoral(C56).Thesamestudyfoundthatthenervescontributingarticular
branchestotheposteriorjointstructuresarethesuprascapularnerve(C56)andsmallbranchesoftheaxillarynerve.49Thepathwaysofthesenervesare
describedinChapter3.
Othernervesinnervatethemusclesthatactupontheshoulder.Theseincludethelongthoracicnerve(C57)(Fig.168),whichinnervatestheserratusanterior,
thespinalaccessorynerve(cranialnerveXIandC34),whichinnervatesthesternocleidomastoid(SCM)andtrapeziusmuscles,andthemusculocutaneous
nerve(C57)(Fig.168),whichinnervatesthecoracobrachialis,bicepsbrachii,andbrachialis,beforedividingintoitscutaneousbranches.
CLINICALPEARL
Shoulderpainthatpersistsdespiteextensiveconservativeapproachescouldbeofneuralorigin,astheperipheralnervesthatinnervatetheligaments,capsule,
andbursaeoftheshoulderjointmayhavebeensubjecttodamage,eitheratthetimeofinitialtraumaorthroughsubsequentsurgicalintervention.4951
Vascularization
Thevascularsupplytotheshouldercomplexisprimarilyprovidedbybranchesofftheaxillaryartery(Fig.169A),whichbeginsattheouterborderofthefirst
ribasacontinuationofthesubclavianartery.Theaxillaryarteryiscommonlydividedintothreeparts:above,behind,andbelowthepectoralisminormuscle.
Theaxillaryarterymeetsthemoredeeplyplacedbrachialplexusintheneck,andheretheyareencasedintheaxillarysheath,togetherwiththeaxillaryvein.52
Thelateral,posterior,andmedialcordsofthebrachialplexusdescendbehindthefirstportionofthearteryandthentakeuptheirrespectivelocationsatthe
secondportionoftheartery(behindthepectoralisminormuscle).Thebranchesofthesecordsalsomaintaintheirrespectivepositions.Compressionofthe
axillaryartery(or,toalesserdegree,theaxillaryvein)canresultinshoulderdysfunctionandmostcommonlyoccursintheposteriorfossaaroundtheshoulder
andagainstthehumeruswithshoulderelevation.52TheGHjointreceivesitsbloodsupplyfromtheanteriorandposteriorcircumflexhumeralaswellasthe
suprascapularandcircumflexscapularvessels(Fig.169BC).53Thevascularsupplytothelabrumarisesmostlyfromitsperipheralattachmenttothecapsule
andisfromacombinationofthesuprascapularcircumflexscapularbranchofthesubscapularandposteriorhumeralcircumflexarteries(Fig.169C).8
FIGURE169
Vascularizationoftheshoulder.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,AlbertineKH.eds.TheBig
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Thebrachialartery(Fig.169A)providesthedominantarterialsupplytoeachofthetwoheadsofthebicepsbrachii.Thearterytravelsinthemedial
intermuscularseptumandisborderedbythebicepsmuscleanteriorly,thebrachialismusclemedially,andthemedialheadofthetricepsmuscleposteriorly.54
Themicrovasculatureoftherotatorcuffhasbeenthesubjectofmuchdiscussionandconsistsofthreemainsources:thethoracoacromial,suprahumeral,and
subscapulararteries.53Thesupraspinatusreceivesitsprimarysupplyfromthethoracoacromialarteries.Thesubscapularisreceivesitssupplyfromtheanterior
humeralcircumflex(Fig.169A)andthethoracoacromialarteries(Fig.169A).Theposteriorrotatorcuffmuscles,theinfraspinatusandteresminor,receive
theirbloodsupplyfromtheposteriorhumeralcircumflexandsuprascapularartery(Fig.169C).Thecirculationoftherotatorcuffisunidirectionalwithno
flowtraversingthetidemarkattheinsertionofthesupraspinatus.55Thesupraspinatusandbicepstendonsappeartobeparticularlyvulnerabletoareasof
relativeavascularity,referredtoascriticalzones.Thevascularcompromiseofthesupraspinatusisthoughttobeduetoanumberoffactors:
Itcanbedirectlycompressedbythesubacromialstructures.Withthearmadductedtotheside,thevesselswithinthesupraspinatustendonarepoorly
perfused.56Otherarmpositions,suchasraisingthearmabove30degrees,havebeenshowntoincreaseintramuscularpressureinthesupraspinatus
muscletoanextentthatmayimpairnormalbloodperfusion.56,57
Itsbloodvesselstravelparalleltothetendonfibers,whichmakethemvulnerabletostretch.58Avascularityappearstoincreasewithagebeginningas
earlyas20years.59
Thepresenceofacriticalzonejustproximaltothesupraspinatusinsertionpoint.56Twoearlystudiesnotedacriticalzonethatliesslightlyproximalto
thesupraspinatusinsertionpoint.60,61Sincethen,ithasbeendeterminedthatthecriticalzoneismorelikelyazoneofanastomosesbetweenthevessels
supplyingtheboneandthetendonandisnotlessvascularexceptincertainpositions.56,62,63
Althoughitispossiblethatsustainedisometriccontractions,prolongedadductionofthearmorincreasesinsubacromialpressure64mayreducethe
microcirculation,itisunlikelythatfrequentabductionorelevationofthearmwouldproduceselectiveavascularityofthesupraspinatusorbicepstendon.
ClosePackedPosition
TheclosepackedpositionfortheGHjointis90degreesofGHabductionandfullERorfullabductionandER,dependingonthesource.
OpenPackedPosition
WithoutIRorERoccurring,theopenpackedpositionoftheGHjointhastraditionallybeencitedas55degreesofsemiabductionand30degreesof
horizontaladduction.65Morerecently,acadaverstudy,whichexaminedthepointintherangeatwhichmaximalcapsularlaxityoccurredinsevensubjects,
determinedtheopenpackedpositiontobe39degreesofabductioninthescapularplaneoratthepointwhichis45%ofthemaximalavailableabductionrange
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ofmotion(ROM).66Thisfindingsuggeststhattheopenpackedpositionmaybeclosertoneutralandthatjointmobilitytestingandjointmobilizationsofthe
GHjointshouldbeinitiatedaccordingtoasmallerangleofabductionthanthetraditionallycitedopenpackedposition.66
ThezeropositionfortheGHjointisthearmrelaxedbytheside,which,relativetothescapula,averagesapproximately0degreesofabduction,12degreesof
flexion,and10degreesofER.67
CapsularPattern
AccordingtoCyriax,68thecapsularpatternfortheGHjointisthatERisthemostlimited,abductionthenextmostlimited,andIRtheleastlimitedina3:2:1
ratio,respectively.However,thispatternonlyappearstobeconsistentwithadhesivecapsulitisoftheshoulder.IR,ratherthanERorabduction,appearstobe
themostlimitedmotioninconditionswithselectedcapsularhypomobility.69
THEACROMIOCLAVICULARJOINT
TheACjointisasynovialjoint,formedbythemedialmarginoftheacromionandthelateralendoftheclavicle.TheACjointismostoftendescribedasa
glidingorplanejoint,butthejointsurfacescanvaryfromflattoslightlyconvexorconcave,correspondingwiththearticulatingsurfaceoftheacromion.Inthe
earlystagesofdevelopment,thearticularsurfacesoftheACjointarelinedwithhyalinecartilage,whichchangestofibrocartilageatapproximately17yearsof
ageontheacromialsideofthejoint,anduntilapproximately24yearsofageontheclavicularside.70WithintheACjoint,thereisvariablepresenceofa
thumbtackshapedintraarticularfibrousdiskthatprojectssuperiorlyinto,andincompletelydivides,theACjoint.Thisdiskissubjecttotearing.70When
viewedfromabove,theclavicleisconvexanteriorlyinthemedialtwothirdsandconvexposteriorlyinthelateralonethird(seeFig.161).Variabilityinthe
inclinationofthejointiscommonandcanbeanywherefrom10to50degrees,buttheanteromedialborderoftheacromionusuallyfacesanteriorly,medially,
andsuperiorly.71Thisvariabilitymayaccountforthedifferencesinvulnerabilitytoseparationseenamongpeople.72
TheACjointservesasthemainarticulationthatsuspendstheupperextremityfromthetrunk,anditisatthisjointaboutwhichthescapulamoves.
Specifically,theACjointprovidesthescapulawithadditionalrangeofrotationonthethorax,whichallowsthescapulatoadjustoutsideofitsinitialplane
(posteriortippingandIR)tofollowthechangingshapeofthethoraxasmovementoccurs.73,74Theclavicleservesastheleverbywhichtheupperextremity
actsonthetorsoandasanattachmentsiteformanysofttissues.70,75Thethinjointcapsuleislinedwithsynovium,whichisstrengthenedanteriorly,
posteriorly,inferiorly,andsuperiorlybyACligaments(seeFig.166).ThesuperiorACligament(seeFig.166)givessupporttothecapsuleandservesasthe
primaryrestrainttoposteriortranslationandposterioraxialrotationatthejoint.70Othersupportstructuresforthejointincludethecostoclavicular,
coracoclavicular(conoidandtrapezoid)ligament,thepectoralismajor,SCM,deltoid,andtrapeziusmuscles(seeFig.1610).75,76
FIGURE1610
Musclesoftheshoulder.(Reproduced,withpermission,fromChapter1.Back.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:Gross
Anatomy.NewYork,NY:McGrawHill2011.)
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CLINICALPEARL
DegenerativechangesoftheACjoint,includingnarrowingofthejointspaceandtheformationofinferiorosteophytes,canpredisposeanindividualto
SIS.40,77,78
Ligaments
Thecoracoclavicularligament(seeFig.166),whichistypicallydescribedashavingconoidandtrapezoidportions,istheprimarysupportfortheACjoint
andrunsfromthecoracoidprocesstotheinferiorsurfaceoftheclavicle.Theconoidligamentisthemorefanshapedwithitsapexpointinginferiorly.Itliesin
thefrontalplaneandisthemoremedialofthetwoligaments.Thisligamentfunctionstoblockcoracoidmovementawayfromtheclavicleinferiorly.79The
trapezoidligamentarisesfromthemedialborderoftheuppersurfaceofthecoracoidprocessandrunssuperiorlyandlaterallytoinsertintotheinferiorsurface
oftheclavicle.Itislarger,longer,andstrongerthantheconoidandformsaquadrilateralsheetthatliesinaplanethatisatrightanglestotheplaneformedby
theconoidligament.Thefunctionofthisligamentisunclear,althoughitsorientationsuggeststhatitmayblockmedialmovementofthecoracoid,79oractasa
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restrainttosuperiororposteriordisplacementoftheclavicle.80Inaddition,astheclaviclerotatesupward,thecoracoclavicularligamentdictates
scapulothoracicrotationbyvirtueofitsattachmenttothescapula.81
CLINICALPEARL
Theconoidandtrapezoidligamentsprovidemainlyverticalstability,withcontrolofsuperiorandanteriortranslationaswellasanterioraxialrotation.70,79,82
Neurology
Innervationtothisjointisprovidedbythesuprascapular,lateralpectoral,andaxillarynerves(Fig.168).83
Vascularization
TheACjointreceivesitsbloodsupplyfrombranchesofthesuprascapularandthoracoacromialarteries(Fig.169).
CapsularPattern
JointssuchastheACjoint,whicharenotcontrolledbymuscles,lacktruecapsularpatterns.However,anecdotalclinicalevidencesuggeststhatthecapsular
patternfortheACjointispainattheextremesofROM,especiallyhorizontaladductionandfullelevation.
ClosePackedPosition
Theclosepackedpositionforthisjointseemstocorrespondto90degreesofGHjointabduction.
OpenPackedPosition
Theopenpackedpositionforthisjointisundetermined,althoughitislikelytobewhenthearmisbytheside.Thispositionstheclavicleinapproximately15
20degreesofretractionrelativetothecoronalplaneandelevatedapproximately2degreesfromthehorizontalplane.84
STERNOCLAVICULARJOINT
TheSCjoint,whichistheonlyjointthatconnectstheshouldergirdletotheaxialskeleton,representsthearticulationbetweentheenlargedmedialendofthe
clavicle,theclavicularnotchofthemanubriumofthesternum,andthecartilageofthefirstrib,whichformsthefloorofthejoint.Thearticulatingsurfacesof
theSCjointarecoveredwithfibrocartilage.TheSCjointisangulatedslightlyupwardapproximately20degreesinaposteriorandlateraldirection.Ifheld
vertically,theproximalendoftheclavicleisconvexwhereasthemanubriumsurfaceisconcave(seeFig.161).Ifheldanteroposteriorly,theproximalendof
theclavicleisconcaveandthemanubriumisconvex.Averythickmeniscusordiskisthekeytothejointcurvature.Theclaviclepresentswithanirregularly
shapedsurfacetothedisk,andthislateralpartofthejointactsasanovoid.Thediskisattachedtotheupperandposteriormarginoftheclavicle,andtothe
cartilageofthefirstribbyanintraarticulardiskligament,whichfunctionstohelppreventmedialdisplacementoftheclavicle,andcompletelydividesthejoint
intotwocavities:alargeronethatisaboveandlateraltothedisk,andasmalleronethatismedialandbelowthedisk.Greatermovementoccursbetweenthe
clavicleandthediskthanbetweenthediskandthemanubrium.TheSCjointhasverylittlebonystabilityandreliesheavilyonsupportfromthesurrounding
capsuleandligaments.
SomeconfusionseemstoexistaboutclassificationoftheSCjointithasbeenclassifiedasaballandsocketjoint,83aplanejoint,andasasaddlejoint.83
Theseclassificationsdependonwhetheranatomyorfunctionisbeingconsidered.Forexample,whenitsfunctionisconsidered,theSCjointactssimilartoa
ballandsocketjoint,allowingformotioninalmostallplanes,includingrotation.
CLINICALPEARL
Duringnormalshouldermotion,theSCjointpermits3035degreesofupwardelevation,35degreesofcombinedforwardandbackwardmovement,and45
50degreesofrotationaboutthelongaxisoftheclavicle.3,85
Ligaments
Becauseofitsbonyarrangement,theSCjointitselfisextremelyweak,butisheldsecurelybystrongligamentsthatholdthesternalendoftheclavicle
downwardandtowardthesternum.Theseligamentsincludethefollowing:
CapsularLigamentousStructures
CapsularLigament
Thisligamentrepresentstheinneraspectofthejointcapsule.Theanteriorportionisheavierandstronger,anditcoverstheanterioraspectofthejointrunning
obliquelyfromtheproximalendoftheclavicletothesternuminaninferiorandmedialdirection.Theposteriorcomponent,whichcoverstheposterioraspect
ofthejoint,alsorunsobliquelyfromtheproximalendoftheclavicletothesternuminaninferiorandmedialdirection.Thecapsularligamentisconsideredthe
mostimportantandstrongestligamentsoftheSCjointandismostresponsibleforpreventingupwarddisplacementofthemedialclavicleinthepresenceofa
downwardforceonthedistalendoftheshoulder.86
Interclavicular
Thisligamentconnectsthesuperomedialsternalendsofeachclaviclewiththecapsularligamentsandtheuppersternum.Together,thesestructureshelptohold
uptheshoulderwhentheupperextremitiesarerestingbytheside.Thisfunctioncanbedemonstratedbyplacingafingerinthesuperiorsternalnotchthe
ligamentislaxwithelevationofthearmbutbecomestautwhenbotharmsarehangingbythesides.
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Costoclavicular(RhomboidLigament)
Thisshortandstrongligament,whichrunsfromtheupperborderofthefirstribtotheinferiorsurfaceoftheclavicle,consistsoftwolaminae:fibersofthe
anteriorlaminarunsuperiorlyandlaterallyandcheckelevationandlateralmovement(upwardrotation)oftheclavicle.86Theposteriorlaminafibersrun
superiorlyandmediallyandcheckdownwardrotationoftheclavicle.86
Duetothesupportprovidedbytheligaments,theSCjointisverystableandtraumatotheclavicleusuallyresultsinafractureratherthanajointdislocation.87
GrossmotionsoccurhereaswiththeACjoint.TheSCM,whichcanbeseenclearlywithrotationofthehead,hasatendinoussternalandclavicularinsertion.
Thesubclavius(C56)hasaquestionablefunctionbutmayfunctionasadynamicligament,whichcontractsandpullstheclavicletowardthemanubrium.
ClosePackedPosition
TheclosepackedpositionfortheSCjointismaximumarmelevationandprotraction.
OpenPackedPosition
TheopenpackedpositionfortheSCjointhasyettobedetermined,butislikelytobewhenthearmisbytheside.
CapsularPattern
SimilartotheACjoint,theSCjointisnotcontrolledbymusclesandthereforelacksaspecificcapsularpattern.Onepossibility,seenclinically,ispainatthe
extremerangesofmotion,especiallyfullarmelevationandhorizontaladduction.
Neurology
Paincanbereferredfromthisjointtothethroat,anteriorchest,andaxillae.Theneuralsupplytothisjointisprimarilyfromthefollowing:
Theanteriorsupraclavicularnerve
Thenervetothesubclavius(medialaccessoryphrenic)C56
TheT1spinalnerveroot
Vascularization
TheSCjointreceivesitsbloodsupplyfromtheinternalthoracicandsuprascapulararteries.88
SCAPULOTHORACICJOINT
Thisarticulationisfunctionallyajoint,butitlackstheanatomiccharacteristicsofatruesynovialjoint.However,themovementofthescapulaonthewallof
thethoraciccageiscriticaltoshoulderjointmotion.Alackofligamentoussupportatthisjointdelegatesthefunctionofstabilityfullytothemusclesthat
attachthescapulatothethorax.
Analteredpositionofthescapula,oranabnormalmotionatthisjointduetomuscleimbalances,havebothbeenlinkedwithshouldercomplex
dysfunction.24,89,90Motionsatthisjointaredescribedaccordingtothemovementofthescapularelativetothethorax.Availablemotionconsistsof
approximately60degreesofupwardrotationofthescapula,4060degreesofIR/ER,and3040degreesofanteriorandposteriortippingofthescapula.91
Othermotionsoccurringhereincludeelevationanddepressionandretraction(adduction)andprotraction(abduction)ofthescapula(Fig.1611).
FIGURE1611
Movementsofthescapulaandupperextremity.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,Albertine
KH.eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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ClosePackedandCapsularPattern
Sincethescapulothoracicjointisnotatruejoint,itisdifficulttodetermineitsclosepackedpositionorcapsularpattern.
OpenPackedPosition
Relativetothethorax,whenthearmisbytheside,thescapulaisinanaverageof3045degreesofIR,andslightupwardrotation,andapproximately520
degreesofanteriortipping.67,91
Bursae
Thereareanumberofbursaelocatedinandaroundthescapulothoracicarticulation.Thescapulothoracicbursaislocatedbetweenthethoraciccageandthe
deepsurfaceoftheserratusanterior.92Thesubscapularbursaismostoftenlocatedbetweenthesuperficialsurfaceoftheserratusanteriorandthe
subscapularis.92
Thescapulotrapezialbursaliesbetweenthemiddleandlowertrapeziusfibersandthesuperomedialscapula.92Thepurposeandclinicalsignificanceofthe
scapulotrapezialbursaarenotknown.Itmayencouragesmoothglidingofthesuperomedialangleofthescapulaagainsttheundersurfaceofthetrapezius
duringscapularrotationinthesamemannerthatthescapulothoracicbursa(betweentheserratusattachmentattheanteromedialsurfaceofthesuperiorangle)
encouragessmoothglidingagainsttheunderlyingribs.92Itispossiblethatinflammationofeitherofthesebursae,directlyorasaconsequenceofinjury,may
resultinpainfulclickingatthesuperomedialangleofthescapula.92
Therelationshipofthespinalaccessorynervetothescapulotrapezialbursamayalsohaveclinicalimportance,especiallyasitiscloselyappliedtothe
superficialwallofthescapulotrapezialbursa.92ThespinalaccessorynervereceivesafferentfibersfromC3andC4,whicharethoughttobeproprioceptive,
beforereachingthedeepsurfaceofthetrapezius.92,93Asaconsequenceoftheirproximity,inflammationandfibrosiswithinthebursamaycauseirritationand
painofthenerve,orinterferencewiththenormalproprioceptivefeedbackmechanismprovidedbythenerve.92
MUSCLESOFTHESHOULDERCOMPLEX
Anumberofsignificantmusclescontrolmotionattheshoulderandprovidedynamicstabilization.Rarelydoesasinglemuscleactinisolationattheshoulder.
Forsimplicity,themusclesactingattheshouldermaybedescribedintermsoftheirfunctionalroles:scapularpivoters,humeralpropellers,humeralpositioners,
andshoulderprotectors(Table162).94
TABLE162MusclesoftheShoulderComplex
Scapularpivoters
Trapezius
Serratusanterior
Levatorscapulae
Rhomboidmajor
Rhomboidminor
Humeralpropellers
Latissimusdorsi
Teresmajor
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Pectoralismajor
Pectoralisminor
Humeralpositioners
Deltoid
Shoulderprotectors
Rotatorcuff(supraspinatus,infraspinatus,teresminor,andsubscapularis)
Longheadofthebicepsbrachii
ScapularPivoters
Thescapularpivoterscomprisethetrapezius,serratusanterior,levatorscapulae,rhomboidmajor,andrhomboidminor.94Asagroup,thesemusclesare
involvedwithmotionsatthescapulothoracicarticulation,andtheirproperfunctionisvitaltothenormalbiomechanicsofthewholeshouldercomplex.The
scapularmusclescancontractisometrically,concentrically,oreccentrically,dependingonthedesiredactionandwhethertheactioninvolvesstabilization,
acceleration,ordeceleration.Tovaryingdegrees,theserratusanteriorandallpartsofthetrapeziuscooperateduringtheupwardrotationofthescapula.
Trapezius
Thetrapeziusmuscle(Fig.1610)originatesfromthemedialthirdofthesuperiornuchalline,theexternaloccipitalprotuberance,theligamentumnuchae,the
apicesoftheseventhcervicalvertebra,allthethoracicspinousprocesses,andthesupraspinousligamentsofthecervicalandthoracicvertebrae.Theupper
fibersdescendtoattachtothelateralthirdoftheposteriorborderoftheclavicle.Themiddlefibersofthetrapeziusrunhorizontallytothemedialacromial
marginandsuperiorlipofthespineofthescapula.Theinferiorfibersascendtoattachtoanaponeurosisglidingoverasmoothtriangularsurfaceatthemedial
endofthespineofthescapulatoatubercleatthescapularlateralapex.
Ithasbeensuggestedthattheupperfibersofthismusclehaveadifferentmotorsupplythanthattothemiddleandlowerportions.95,96Recentclinicaland
anatomicalevidenceseemstosuggestthatthespinalaccessorynerveprovidesthemostimportantandconsistentmotorsupplytoallportionsofthetrapezius
muscle,andalthoughtheC24branchesofthecervicalplexusarepresent,noparticularelementsofinnervationwithinthetrapeziushavebeendetermined.97
Oneofthefunctionsofthetrapeziusistoproduceshouldergirdleelevationonafixedcervicalspine.Forthetrapeziustoperformitsactions,thecervicalspine
mustfirstbestabilizedbytheanteriorneckflexorstopreventsimultaneousoccipitalextensionfromoccurring.Failuretopreventthisoccipitalextensionwould
allowtheheadtotranslateanteriorly,resultinginadecreaseinthelength,andthereforetheefficiency,ofthetrapezius,98andanincreaseinthecervical
lordosis.
CLINICALPEARL
Completeparalysisofthetrapeziususuallycausesmoderatetomarkeddifficultyinelevatingthearmoverthehead.Thetask,however,canusuallybe
completedthroughfullrangeaslongastheserratusanteriorremainstotallyinnervated.99
SerratusAnterior
Themusculardigitationsoftheserratusanterior(seeFig.165)originatefromtheuppereighttotenribsandfasciaovertheintercostals.Themuscleis
composedofthreefunctionalcomponents:100,101
Theuppercomponentoriginatesfromthefirstandsecondribsandinsertsintothesuperiorangleofthescapula.
Themiddlecomponentarisesfromthesecond,third,andfourthribsandinsertsintotheanterioraspectofthemedialscapularborder.
Thelowercomponentisthelargestandmostpowerful,originatingfromthefifththroughninthribs.Itrunsanteriortothescapulaandinsertsintothe
medialborderofthescapula.
Theserratusanteriorisactivatedwithallshouldermovements,butespeciallyduringshoulderflexionandabduction.101Workinginsynergywiththetrapezius,
aspartofaforcecouple(seelater),themainfunctionoftheserratusanterioristoprotractandupwardlyrotatethescapula,102,103whileprovidingastrong,
mobilebaseofsupporttopositiontheglenoidoptimallyformaximumefficiencyoftheupperextremity.104Itslowerfibersdrawthelowerangleofthescapula
forwardtorotatethescapulaupwardwhilemaintainingthescapulaonthethoraxduringarmelevation.105Thismovesthecoracoacromialarchoutofthepath
oftheadvancinggreatertuberosityandopposestheexcessiveelevationofthescapulabythelevatorscapulaeandtrapeziusmuscles.106Withoutupward
rotationandprotractionofthescapulabytheserratusanterior,fullGHelevationisnotpossible.Infact,inpatientswithcompleteparalysisoftheserratus
anterior,Greggetal.104reportedthatabductionislimitedto110degrees.
Dysfunctionoftheserratusanteriormusclecauseswingingofthescapulaasthepatientattemptstoelevatethearm.4,107Scapulothoracicdysfunctioncanalso
contributetoGHinstability,asthenormalstablebaseofthescapulaisdestabilizedduringabductionorflexion.4,108,109
Theserratusanteriormuscleisinnervatedbythelongthoracicnerve(C57).
CLINICALPEARL
Paralysisorweaknessoftheserratusanteriormuscleresultsindisruptionofnormalshoulderkinesiology.Thedisabilitymaybeslightwithpartialparalysis,or
profoundwithcompleteparalysis.Asarule,personswithcompleteormarkedparalysisoftheserratusanteriorcannotelevatethearmsabove110degreesof
abduction.99
LevatorScapulae
Thelevatorscapulaemuscle(seeFig.1610)originatesbytendinousstripsfromthetransverseprocessesoftheatlas,axis,andC3andC4vertebrae,and
descendsdiagonallytoinsertintothemedialsuperiorangleofthescapula.
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Thelevatorscapulaecanactonthecervicalspine(seeChapter23)andonthescapula.Ifitactsonthecervicalspine,itcanproduceextension,sideflexion,and
rotationofthecervicalspinetothesameside.110Whenactingonthescapuladuringupperextremityflexionorabduction,thelevatorscapulamuscleactsasan
antagonisttothetrapeziusmuscle,andprovideseccentriccontrolofscapularupwardrotationinthehigherrangesofmotion(seelater).111
Boththetrapeziusandlevatorscapulaemusclesareactivatedwithincreasedupperextremityloads.98,101,112
Thelevatorscapulaemuscleisinnervatedbytheposterior(dorsal)scapularnerve(C35).
Rhomboids
Therhomboidmajormuscle(Fig.1610)originatesfromthesecondtofifththoracicspinousprocessesandtheoverlyingsupraspinousligaments.Thefibers
descendtoinsertintothemedialscapularborderbetweentherootofthescapularspineandtheinferiorangleofthescapula.
Therhomboidminormuscle(seeFig.1610)originatesfromtheloweraspectoftheligamentumnuchae,andtheseventhcervicalandfirstthoracicspinous
processes,andattachestothemedialborderofthescapulaattherootofthespineofthescapula.
Therhomboidmuscleshelpcontrolscapularpositioning,particularlywithhorizontalflexionandextensionoftheshouldercomplex.111
Therhomboidmusclesareinnervatedbytheposterior(dorsal)scapularnerve(C45).
HumeralPropellers
Thetotalmusclemassoftheshouldersinternalrotators(subscapularis,anteriordeltoid,pectoralismajor,latissimusdorsi,andteresmajor)ismuchgreater
thanthatoftheexternalrotators(infraspinatus,teresminor,andposteriordeltoid).99Thisfactexplainswhytheshoulderinternalrotatorsproduce
approximately1.75timesgreaterisometrictorquethantheexternalrotators.113Peaktorquesoftheinternalrotatorsalsoexceedtheexternalrotatorswhen
measuredisokinetically,underbothconcentricandeccentricconditions.99,114
LatissimusDorsi
Thelatissimusdorsimuscle(seeFig.1612)originatesfromthespinousprocessesofthelastsixthoracicvertebrae,thelowerthreeorfourribs,thelumbarand
sacralspinousprocessesthroughthethoracolumbarfascia,theposteriorthirdoftheexternallipoftheiliaccrest,andaslipfromtheinferiorscapularangle.
Thescapularslipallowsthelatissimusdorsitoactatthescapulothoracicarticulation.Thelatissimusdorsiinsertsintotheintertubercularsulcusofthehumerus.
Themusclefunctionsasanextensor,adductor,andpowerfulinternalrotatorofthehumerus,andalsoassistsinscapulardepression,retraction,anddownward
rotation.115Itisinnervatedbythethoracodorsalnerve(C68).
FIGURE1612
Latissimusdorsi.(Reproduced,withpermission,fromChapter30.ShoulderandAxilla.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:Gross
TeresMajor
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Theteresmajor(seeFig.1612)originatesfromtheinferiorthirdofthelateralborderofthescapulaandjustsuperiortotheinferiorangle.Theteresmajor
tendoninsertsintothemediallipoftheintertuberculargrooveofthehumerus.Theteresmajorfunctionstocomplementtheactionsofthelatissimusdorsiin
thatitextends,adducts,andinternallyrotatestheGHjoint.Itisinnervatedbythelowersubscapularnerve(C5,C6).
PectoralisMajor
Thepectoralismajor(seeFig.1613)originatesfromthesternalhalfoftheclavicle,halfoftheanteriorsurfaceofthesternumtothelevelofthesixthor
seventhcostalcartilage,thesternalendofthesixthrib,andtheaponeurosisoftheobliquusexternusabdominis.Thefibersofthepectoralismajorconvergeto
formatendonthatinsertsintothelaterallipoftheintertubercularsulcusofthehumerus.Althoughthismuscledoesnotinsertintothescapula,itdoesactupon
thescapulothoracicarticulationthroughitsinsertiononthehumerus.Thefunctionofthepectoralismuscledependsonwhichfibersareactivated:
FIGURE1613
Pectoralismajormuscle.
Upperfibers(clavicularhead)IR,horizontaladduction,flexion,abduction(oncethehumerusisabducted90degrees,theupperfibersassistinfurther
abduction),andadduction(withthehumerusbelow90degreesofabduction)oftheGHjoint.
Lowerfibers(sternalhead)IR,horizontaladduction,extension,andadductionoftheGHjoint.
Thepectoralismajorisinnervatedbythemedial(lowerfibers)andlateral(upperfibers)pectoralnerves(C8T1andC57,respectively).
CLINICALPEARL
Thepectoralismajorandlatissimusdorsimusclesarereferredtoashumeralpropellermusclesastheyhavebeenshowntobetheonlymusclesintheupper
extremitytohaveapositivecorrelationbetweenpeaktorqueandpitchingvelocity,andduringthepropulsivephaseoftheswimstroke.
PectoralisMinor
Thepectoralisminor(seeFig.169)originatesfromtheoutersurfaceoftheuppermarginsofthethirdtofifthribsneartheircartilage.Thefibersofthe
pectoralisminorascendlaterally,convergingtoatendonthatinsertsintothecoracoidprocessofthescapula.
Thepectoralisminormuscleisinnervatedbythemedialpectoralnerve(C68).
HumeralPositioners
Deltoid
Thedeltoidmuscleoriginatesfromthelateralthirdoftheclavicle,thesuperiorsurfaceoftheacromion,andthespineofthescapula(Fig.1613).Itinsertsinto
thedeltoidtuberosityofthehumerus.Thedeltoidcanbedescribedasthreeseparatemusclesanterior,middle,andposteriorallofwhichfunctionas
humeralpositioners,positioningthehumerusinspace.94
Thedeltoidmuscleisinnervatedbytheaxillarynerve(C56).
ShoulderProtectors
RotatorCuff
Therotatorcuffmuscles(Fig.164),whichconsistofthesupraspinatus,infraspinatus,teresminor,andsubscapularis,arecommonlyimplicatedwithshoulder
pathology.Theanatomyofthesemuscleswasdescribedpreviously(seeGlenohumeralJointsection).Thesemusclesarereferredtoastheprotectorsofthe
shouldersince,inadditiontoactivelymovingthehumerus,theyfinetunethehumeralheadpositionduringarmelevation.94Comparedwithmostjointsthat
haveasingleaxisonwhichtorquesaregenerated,theshoulderisverydifferent,becauseithasnofixedaxis.Asaresult,eachmuscleactivationcreatesa
uniquesetofrotationalmoments,whichnecessitatesprecisecoordinationinthetimingandmagnitudeofmusclecontractions.72Jenpetal.116used
electromyography(EMG)todetectthemostspecificpositionsofthehighestactivationfortheindividualrotatorcuffmuscles.Thegreatestactivationofthe
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subscapulariswaswiththearminthescapularplaneat90degreesofelevationandneutralhumeralrotation.Thesubscapularishasalsobeenshowntobean
effectivehumeralheaddepressorinER,whereasitproducesalmostnoAPtranslationinabductionandER.Theinfraspinatusteresminormusclesarevery
effectivehumeralheaddepressorswiththearminthesagittalplaneandthehumeruselevatedto90degreesinthemidrangeofexternal/IR(thesocalled
hornblowersposition).Thesupraspinatushasyettobeeffectivelyisolated.
Therotatorcuffmuscleshaveanimportantroleinthefunctionoftheshoulderandservethefollowing:
Assistintherotationoftheshoulderandarm.AttheGHjoint,elevationthroughabductionofthearm(Table163)requiresthatthegreatertuberosityof
thehumeruspassunderthecoracoacromialarch.Forthistooccur,thehumerusmustexternallyrotate,andtheacromionmustelevate.117ERofthe
humerusisproducedactivelybyacontractionoftheinfraspinatusandteresminor,andbyatwistingofthejointcapsule.Aforcecoupleexistsinthe
transverseplanebetweenthesubscapularisanteriorlyandtheinfraspinatusandteresminorposteriorlyinwhichcocontractionoftheinfraspinatus,teres
minor,andsubscapularismusclesbothdepressesandcompressesthehumeralheadduringoverheadmovements.
TABLE163ContributorstoGlenohumeralAbduction
Degreeof
BiomechanicsInvolved
Abduction
Theconcertedactionoftheactivestabilizers(deltoid,biceps,androtatorcuffmuscles)andthepassiverestraints(articularsurfaces,osseous
structures,andligaments)isnecessaryforpurposefulfunction.Thesupraspinatuscontractstoinitiateabductionoftheglenohumeraljoint.aThe
remainingrotatorcuffmusclesalsocontracttopullthehumeralheadintotheglenoidfossa.Atapproximately20degreesofhumeralabduction,
090 scapularupwardrotationbeginswithconcurrentclavicularelevationandaxialrotation.b,cAtapproximately90degrees,oralittlemoreinfemales,
theupperextremeofGHabductionisreached,andclavicularelevationceasesduetotensionofthecostoclavicularligament.dContinued
abductionofthehumerusrequirescontinuedupwardrotationofthescapula,whichbythispointhasrotatedthrougharangeofapproximately30
degrees.e
Asthescapulacontinuestoupwardlyrotate,theglenoidfossafacessuperiorlyandlaterally,anditsinferioranglemoveslaterallythrough
approximately60degrees.Thescapularcontributionpeaksbetween90and140degrees:fThescapularupwardrotationisaccommodatedatboth
90150 theSCandACjointsbyaposterioraxialrotationoftheclavicleof3040degreesandaclavicularelevationofapproximately3036degrees.c
Themusclesproducingthismovementaretheserratusanteriorandtrapezius,actingasaforcecoupleonthescapulothoracicjoint.Themovement
islimitedbytheacromionandSCjoint,andbythescapularandhumeraladductors(notablythelatissimusdorsiandpectoralismajor).
150180 Abductionbeyond150degreesrequiresadequatemotionatthevertebraljointsoftheupperthoraxandcervicalspine.gBilateralabduction
demandsthatthethoracicspineextendsandthelumbarlordosisincreases.
aDatafromPoppenNK,WalkerPS.Forcesattheglenohumeraljointinabduction.ClinOrthopRelatRes.1978135:165170.
bDatafromPoppenNK,WalkerPS.Normalandabnormalmotionoftheshoulder.JBoneJointSurg.197658A:195201.
cDatafromSahaAK.Theclassic.MechanismsofshouldermovementsandapleafortherecognitionofZeroPositionoftheglenohumeraljoint.ClinOrthop
RelatRes.1983173:310.
dDatafromFreedmanL,MunroRR.Abductionofthearminthescapularplane:Scapularandglenohumeralmovements.JBoneJointSurgAm.
196648:15031510.
eDatafromAbelewT.Kinesiologyoftheshoulder.In:TovinBJ,GreenfieldB,eds.EvaluationandTreatmentoftheShoulderAnIntegrationoftheGuideto
PhysicalTherapistPractice.Philadelphia,PA:F.A.Davis2001:2544.
fDatafromDoodySG,FreedmanL,WaterlandJC:Shouldermovementsduringabductioninthescapularplane.ArchPhysMedRehabil.197051:595604.
gDatafromKapandjiIA.ThePhysiologyoftheJoints,UpperLimb.NewYork,NY:ChurchillLivingstone1991.
CLINICALPEARL
Theimportanceoftheexternalrotationduringhumeralelevationcanbedemonstratedclinically.IfthehumerusisheldinfullIR,onlyabout60degreesofGH
abductionispassivelypossiblebeforethegreatertuberosityimpingesagainstthecoracoacromialarchandblocksfurtherabduction.Thishelpsexplainwhy
individualswithmarkedIRcontracturescannotabductfully,butcanelevatethearminthesagittalplane.
However,inclinicalpractice,shouldershavinglargerotatorcufftearsandgoodfunctionarefrequentlyencountered.Inthecoronalplane,thereisanotherforce
couplebetweenthedeltoidandtheinferiorrotatorcuffmuscles(infraspinatus,subscapularis,andteresminor).Withthearmfullyadducted,contractionofthe
deltoidproducesaverticalforceinasuperiordirection,resultinginanupwardtranslationofthehumeralheadrelativetotheglenoid.Cocontractionofthe
inferiorrotatorcuffmusclesproducesbothacompressiveforceandadownwardtranslationofthehumerusthatcounterbalancestheforceofthedeltoid,
therebystabilizingthehumeralhead.
EMGstudieshaveshownthatduringcasualelevationofthearminnormalshoulders,thedeltoidandtherotatorcuffactcontinuouslythroughoutthemotionof
abduction,eachreachingapeakofactivitybetween120and140degreesofabduction.13,118However,duringmorerapidandprecisemovements,suchas
thoseinvolvedwiththrowing,amoreselectivepatternemergeswithspecificperiodsofgreatintensity.119Weakeningoftherotatorcuffappearstoallowthe
deltoidtoelevatetheproximalpartofthehumerusintheabsenceofanadequatedepressorandcompressioneffectfromtherotatorcuff,resultinginadecrease
inthesubacromialspaceandimpingementoftherotatorcuffontheanterioraspectoftheacromion.120,121
ReinforcetheGHcapsule.Therotatorcuffmuscles,togetherwiththecoracohumeralligament,andtheLHB(oftenreferredtoasthefifthrotatorcuff
muscle)functionascontractileligaments.Forexample,firingoftherotatorcuffmusclesincreasesthetensionofthemiddleGHligamentwhenthearm
isabductedto45degreesandexternallyrotated.36
ControlmuchoftheactivearthrokinematicsoftheGHjoint.Contractionofthehorizontallyorientedsupraspinatusproducesacompressionforce
directlyintotheglenoidfossa.120Thiscompressionforceholdsthehumeralheadsecurelyintheglenoidcavityduringitssuperiorroll,whichprovides
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stabilitytothejointandalsomaintainsamechanicallyefficientfulcrumforelevationofthearm.120Intheshouldermidrangeposition,whenallofthe
passiverestraintsarelax,jointstabilityisachievedalmostentirelybytherotatorcuff.Inaddition,aspreviouslymentioned,withoutadequate
supraspinatusforce,thenearverticallineofforceofacontractingdeltoidtendstojamorimpingethehumeralheadsuperiorlyagainstthecoracoacromial
arch.99
LongHeadoftheBicepsBrachii
Thebicepsbrachiimuscleisalargefusiformmuscleintheanteriorcompartmentoftheupperextremity,whichhastwotendinousoriginsfromthescapula
(Fig.167).ThemedialheadandLHBnormallyoriginatefromthecoracoidprocessandsupraglenoidtubercleofthescapula,respectively.However,agreat
dealofresearchhasnotedthattheoriginofthebicepstendonvaries,notonlyinitstypeofinsertion(single,bifurcated,ortrifurcated),butalsointhespecific
anatomicallocationofwhereitinserts.11,72TheproximalLHBtendonreceivesanarterialsupplyfromlabralbranchesofthesuprascapularartery.122Asit
leavesitsorigin,theLHBtendonissurroundedbyasynovialsheath,whichendsatthedistalendofthebicipitalgroove,makingthetendonanintraarticular
butextrasynovialstructure.72AstheLHBtendonmovesbetweenthegreaterandlessertuberosities,itisstabilizedinpositionbythetendoligamentoussling
comprisingthecoracohumeralligament,superiorGHligament,andfibersfromthesupraspinatusandthesubscapularis.72,123Onceinthebicipitalgroove,the
LHBtendonpassesunderthetransversehumeralligament,whichbridgesthegroove.124Aftercoursingthroughthegroove,thetwoheadsjointoformthe
bicepsmusclebellyatthelevelofthedeltoidinsertion.125Themedialtendonisinterarticular,lyinginsidetheGHcapsule.126Thistendonisnotascommona
sourceofshoulderpainasthelongtendon,anditrarelyruptures.3840
Thefunctionofthebicepsasaforearmsupinatorandsecondarilyasanelbowflexoriswellknown.127Attheshoulderjoint,however,thefunctionoftheLHB
tendonislessclear,withmostreferencesregardingitasaweekflexoroftheshoulder.128CadavericstudieshavesuggestedthattheLHBtendonfunctionsasa
humeralheaddepressor(infullER),ananteriorstabilizer,aposteriorstabilizer,alimiterofER,alifteroftheglenoidlabrum,andahumeralheadcompressor
attheGHjoint.129132Themusclehasalsobeendescribedashavinganimportantroleindeceleratingtherapidlymovingarmduringactivitiessuchas
forcefuloverhandthrowing.72Intheanatomicalposition,thebicepshasnoabilitytoelevatethehumerus.Ifthearmisrotated90degreesexternally,thetendon
ofthelongheadlinesupwiththemusclebellytoformastraightlineacrossthehumeralhead.Asthebicepscontractsinthisposition,thehumeralheadrotates
beneaththetendon,resistingERofthehumeralheadandincreasingtheanteriorstabilityoftheGHjoint.133,134ContractionoftheLHBinthispositionfixes
thehumeralheadsnuglyagainsttheglenoidcavity,astheresultantforcepassesobliquelythroughthecenterofrotationofthehumeralheadandatrightangles
totheglenoid.133Thehumeralheadispreventedfrommovingupwardbythehoodlikeactionofthebicepstendon(Fig.167),whichexertsadownwardforce
andassiststhedepressorfunctionofthecuff.135137Interestingly,thebicepstendonwasfoundtobewiderincuffdeficientshouldersinonestudy.138
Thebicepsbrachiimuscleisinnervatedbythemusculocutaneousnerve.
CLINICALPEARL
AnumberofpathologicalconditionshavebeenassociatedwiththeLHBtendonincludingLHBtendondegeneration,SLAPlesions,LHBtendonanchor
abnormalities,andLHBtendoninstability.124
BIOMECHANICS
TheGHjointaccountsforapproximatelytwothirdsofmostshouldermotions,withtheremainderprovidedbythescapulothoracicjoint.85Forfullmotionto
occur,acomplexinteractionbetweenthedeltoidmuscle,rotatorcuffmuscles,LHB,GHcapsule,glenoidarticulatingcartilage,andscapularpivoters
(trapezius,serratusanterior,levatorscapulae,andrhomboids)isrequired.139Completemovementattheshouldergirdlealsoinvolvesacomplexinteraction
betweentheGH,AC,SC,scapulothoracic,upperthoracic,costal,andsternomanubrialjoints,theupperthorax,andthelowercervicalspine.Withinthe
jointsoftheshouldercomplex,thereappeartobenowelldefinedpointswithintherangewhereonejointsmotionendsandanotherbegins.Rather,theyall
blendintoasmoothharmoniousmovementduringnormalarmraising(seeTables163and164).
TABLE164ContributorstoGlenohumeralElevation
Degreeof
Elevationand
BiomechanicsInvolved
Main
Contributor
060degrees: Acombinedmotionofflexion,abduction,andexternalrotationoccursattheglenohumeraljoint,producedbytheanteriordeltoid,
glenohumeral coracobrachialis,andtheclavicularfibersofpectoralismajor.Motionislimitedbytheincreasingtensionintheposteriorcoracohumeral
elevation ligamentandthestretchingoftheshoulderextensors,adductors,andexternalrotators.a
60120degrees: Thescapuladepresses,protracts,andabductsontheposteriorthoracicwall,suchthattheglenoidfossafacesanteriorlyandsuperiorlyand
sternoclavicular itsinferioranglefaceslaterallyandanteriorly.ThismotionisaccommodatedbytheSCandACjoints.Thescapulothoracicmotionis
and producedinthesamemanneraswithabduction,bytheserratusanteriorandtrapezius,andislimitedbytheligamentsofthetwojoints,and
acromioclavicular
elevation thetensionintheshoulderextensorandadductormusculature.a
b
120180degrees Kapandji statesthattheextremeofflexionisthesameastheextremeofabduction.Thatis,duringunilateralelevation,thelateral
costospinal displacementisproducedbythecontralateralspinalmuscleswhilebilateralabductionrequiresanexaggerationofthelumbarlordosisto
elevation bringthearmsvertical.Inaddition,themedialattachmentsofthefirstandsecondribsdescendwhilethoseofthefourthtosixthascendand
thethirdactsastheaxis.Bilateralabductiondemandsthatthethoracicspineextends.
aDatafromPettmanE.LevelIIIcoursenotes.BerrienSprings,MI:NorthAmericanInstituteofManualTherapy,Inc.2003.
bDatafromKapandjiIA:ThePhysiologyoftheJoints,UpperLimb.NewYork,NY:ChurchillLivingstone1991.
Themajorityoffunctionalshouldermotionsinvolveaseriesofsequentiallyactivatedlinksinakineticchainofbodysegments.140,141Forthosemotions
requiringmoreforce,thenumberoflinksinthekineticchainincreasesthesequenceofactivationstartsasagroundreactionforce(GRF)andmovesup
throughtheankles,kneesandhipstothetrunk,andintotheshoulder.Approximately50%ofthetotalkineticenergyandforceoccurringattheGHjoint
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originatefromacombinationoftheGRFandtheforcesfromthelegsandhips.140142Attheshoulder,GH,AC,SC,andscapulothoracicjoints,motion
occurssimultaneouslyasaresultofmuscleactionandligamentoustensioninthesejoints.Thespecificsequenceofmuscleactivationintheupperextremity
dependsontheactivity,althoughthedirectionofactivationisusuallyfromproximaltodistalasthisisthemostefficientmethodforproducinglargeforcesand
accelerationstothearm.Aspartofthisactivationsequence,specificjointpositionsaredevelopeddependingontheactivity.Anychangestothissequenceof
activationcanproduceanabnormalmovementpattern,involvingsubstitutionorcompensationfromthemoredistallinks.46,143Forexample,athrowing
athletewithdecreasedtrunkrotationduetostiffnesshastorelymoreontheshouldertoprovidetheforceforthethrow.Theseadaptivepatternseventually
resultineitherdecreasedperformanceorincreasedinjuryrisk.
Duringshoulderrotationandarmactivities,thescapulainvariablyactsasaplatformuponwhichtheactivitiesarebased.Itisworthnotingthatthesupporting
structuresoftheGHjointareonlyeffectiveifthescapulacanmaintainitscorrectrelationshipwiththehumerus(seeTheDynamicScapulasection).
GlenohumeralJoint
TheGHjointhasthreedegreesoffreedom(DOF):flexion/extension,abduction/adduction,andinternal/ER.AvailablerangesofmotionattheGHjointare
approximatelyasfollows:
Flexionandabduction.Approximately100120degreesareavailable(approximately180degreesifscapularmotionisincluded),withfemales
demonstratingslightlymoremotionthanmales.
Externalrotation.Approximately6080degreesareavailable,withfemalesdemonstratingslightlymoremotionthanmales.
Internalrotation.Approximately8090degreesareavailable,withfemalesdemonstratingslightlymoremotionthanmales.
Extension.Greatvariabilityexistswithextension,withrangesexistingfrom10to90degrees.
GHmotionsconsistofacombinationofglidesandrollsbasedontheconcaveconvexrule(seeChapter10).AttheGHjoint,theconcaveconvexrule
dictatesthatthearticulatingsurfacemovesintheoppositedirectionoftheshouldermotion(Table165).Motionsatthisjointdonotoccurinisolation,but
ratherascoupledmotions.144Forexample,ERandabductionoccurwithflexion,andERandadductionaccompanyextension.76
TABLE165GlenohumeralJointMotionsandTheirAppropriateAxisandAccessoryMotions
Plane/AxisofMotion PhysiologicMotion AccessoryMotion
Sagittal/mediolateral Flexion/extension Spin(minimalrollandslide)
Coronal/anteroposterior Abduction Superiorroll,inferiorslide
Transverse/longitudinal Horizontaladduction Posteriorroll,anteriorslide
Internalrotationat0degreesabduction Anteriorroll,posteriorglide
Externalrotationat0degreesabduction Posteriorroll,anteriorslide
TheGHjointhasbeendescribedasbeingsimilartoagolfballonateeduetothesizerelationships.AmoreaccuratebiomechanicaldescriptionisthattheG
Hjointislikeaballonasealsnose.145Astheballorhumeralsocketmoves,thesealsnose,orthescapula,needstomovetomaintainthepositionoftheball
ontheglenoid.TheorientationoftheGHjointcausesmotionsatthisjointtooccurinthescapularplane.TheshoulderhasthegreatestROMofanyjoint,with
avastarrayofmusclesproducingthosemotions.1Thecorrectfunctionofthesemusclesisdependentonappropriatelengthtensionrelationshipsand
coordinatedactivation.47Over1,600differentpositionsinthreedimensionalspacecanbeassumedbytheshoulder.141,146DuetothiswideROM,theGH
jointisfacedwiththetaskofmaintainingequilibriumbetweenthefunctionalmobilityandadequatestabilityduringnormalactivitiesofdailyliving(ADL).147
Whensportisaddedtotheequation,extremelyhighforcescanbegeneratedattheshoulder.Forexample,theangularvelocityofanoverheadthrowreaches
over7,000degreespersecond,whichisthefastestrecordedhumanmovement.148
CLINICALPEARL
Ithasbeenestimatedthattheanteriortranslationforcesgeneratedwithpitchingareequaltoonehalfbodyweightduringthelatecockingphase,andthereisa
distractionforceequaltobodyweightduringthedecelerationphase.149
Thecomplexkinematicsofthisregionprobablyaccountforthefactthatstrainsandsprainsmayremainsymptomaticformuchlongerthaninotherjoints.1
Fullelevationofthearmoccursthroughanarcofapproximately180degreesandcanoccurinaninfinitenumberofbodyplanes.150Locally,thismotionisa
resultofabductionoftheGHjointandupwardrotationofthescapulothoracicjoint.Duringabductionoftheshoulder,theGHjointisreportedtocontribute
upto120degreesofthetotalarcofmotion,withtheremaining60degreesoccurringatthescapulothoracicjoint.Armelevationbeyond90degreesrequires
motioninother,moredistaljointssuchastheACandSCjoints(seeTheDynamicScapulasection)andthevertebraljointsoftheupperthoraxandlower
cervicalspine,inadditiontovariousstaticrestraints(Tables166and167).
TABLE166StaticRestraintstoInferiorTranslation(DependentonthePositionoftheArm)
DegreesofGlenohumeralAbduction RestrainingStructures
0 SuperiorGHandcoracohumeralligaments
90 InferiorGHligament(posteriorbandinexternalrotation,anteriorbandinIR)
DatafromWarnerJJP,DengXH,WarrenRF,etal.Staticcapsuloligamentousrestraintstosuperiorinferiortranslationoftheglenohumeraljoint.AmJSports
Med.199220:675685.TurkelSJ,PanioMW,MarshallJL,etal.Stabilizingmechanismspreventinganteriordislocationoftheglenohumeraljoint.JBone
JointSurgAm.198163:12081217.
TABLE167StaticRestraintstoInternalRotation(DependentonthePositionoftheArm)
0 PosteriorbandofinferiorGHligament,teresminor,posteriorcapsule(superior)
45 AnteriorandposteriorbandsoftheinferiorGHligament
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90 PosteriorbandoftheinferiorGHligament,posteriorcapsule(inferior)
DatafromWarnerJJP,DengXH,WarrenRF,etal.Staticcapsuloligamentousrestraintstosuperiorinferiortranslationoftheglenohumeraljoint.AmJSports
Med.199220:675685TurkelSJ,PanioMW,MarshallJL,etal.Stabilizingmechanismspreventinganteriordislocationoftheglenohumeraljoint.JBone
JointSurgAm.198163:12081217.
FlexionattheGHjointinvolvesapurespinifitoccursstrictlyinthesagittalplanenorollorslideisnecessary.Tensionwithinthesurroundingcapsular
structures,particularlytheposteriorstructures,maycauseaslightanteriortranslationofthehumerusattheextremesofflexion.45However,althoughflexionin
thesagittalplaneinvolvesapurespin,elevationofthearminthescapularplaneinvolvesacombinationofflexion,abduction,andER.Thus,atthejoint
surfaceoftheGHjointduringarmelevationinthescapularplane,theheadofthehumerusspins(flexioncomponent),glidesinferiorly(abduction
component),andglidesanteriorly(ERcomponent)(Table165).
Thesynchronizedmotionsthatoccurbetweenthescapulaandthehumerusduringelevationareacombinationofscapulothoracicmotionandscapulohumeral
motion.Duringarmelevation,thescapulagenerallyupwardlyrotates,tiltsposteriorly,andeithermovestowardinternalorexternalrotation.Theanglebetween
theglenoidandthemovinghumeralheadhastobemaintainedwithinasafezoneof30degreesofangulationduringactivitiestodecreaseshearandtranslatory
forces.151Forthistooccur,thescapulamustbepositionedmuscularlyinrelationtothemovinghumerusandmustalsoactasastablebaseofmuscleoriginfor
therotatorcuffmuscles.Ifthescapulacannotbecontrolled,theglenoidcannotbepositionedcorrectlytoallowfortheoptimallengthtensionrelationships
withintheshouldercomplex.106,152Thesynchronizedmotionbetweentheglenoidcavityandthehumerusisreferredtoasscapulohumeralrhythm(Fig.16
14).Properrhythminvolvesarotationofthescapuladuringarmelevation.Byallowingtheglenoidtostaycenteredunderthehumeralhead,thestrong
tendencyforadownwarddislocationofthehumerusisresistedandtheglenoidismaintainedwithinaphysiologicallytolerablerange(Fig.1614).Atfull
abduction,theglenoidcompletelysupportsthehumerus.
FIGURE1614
Thescapulohumeralrhythm.
Severalstudieshaveexaminedthescapulohumeralrhythmthreedimensionally.25,26,85,153,154AnearlystudybyInmanetal.85determinedthata2:1ratio
existedbetweenthemotionoccurringattheGHjointandscapula,respectively.However,morerecentstudieshaveshownthatthisratioisnotconsistent
throughouttheROM.21,107,153Asthehumeruselevatesto30degrees(settingphase),thereisminimalmovementofthescapula.Inthisinitialportionof
abduction,GHmotionpredominatesandtheratiohasbeenfoundtobe4.4degreesofGHmotionforeverydegreeofscapularmotion(4.4:1ratio).From30
to90degrees,thescapulaabductsandupwardlyrotates,andtheratiobecomes5degreesofGHmotionto4degreesofscapularmotion(5:4ratio).Asthe
shouldermovesabove90degreesofabductiontofullabduction,thescapulaabductsandupwardlyrotates1degreeforevery1degreeofhumeralelevation
(1:1ratio).25,111,153However,itmustbekeptinmindthattheseratiosarebasedontwodimensionalradiographicprojectionsofangularrotationstakenat
discretepositionsofelevation,whereasinreality,thearmmovesinthreedimensions,andthatthescapulohumeralrhythmhasalsobeenfoundtochangewith
externalloadingofthearm.154
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CLINICALPEARL
Areversescapulohumeralrhythm,inwhichthescapulamovesmorethanthehumerus,occursinconditionssuchasadhesivecapsulitis.
ScapulothoracicJoint
Scapulothoracicmotionisavitalcomponentofshoulderfunctionandconsistsofrotationandtranslationaroundapproximatelythreeaxesofmotion.These
axesareconsideredtobeembeddedinthescapula.155
Anteriorandposteriortippingoccursaroundanaxisparalleltothescapula.
ProtractionandretractionofthescapulaoccurthroughprotractionandretractionoftheclavicleattheSCjoint.
IRandERoccuraroundanaxisrunningthroughthescapulafromsuperiortoinferior.
ElevationanddepressionofthescapulaoccursthroughelevationanddepressionoftheclavicleattheSCjoint.Throughoutthe180degreesofarm
elevation,atotalof3035degreesofclavicleelevationoccurs,inadditiontorotationoftheclavicle(3855degrees)arounditslongitudinalaxis.73This
clavicularelevationandrotationoccurintwomainphasesofshoulderabduction.Assuminga2:1scapulohumeralrhythm,shoulderabductionupto90
degreesoccursasasummationof60degreesofGHabduction,and30degreesofscapulothoracicupwardrotation.The30degreesofupwardrotation
occurspredominantlythroughasynchronous2025degreesofclavicularelevationattheSCjointand510degreesofupwardrotationattheAC
joint.99Theelevationoftheclavicleraisestheacromionduringarmelevationallowingforthesubacromialstructurestopassunderthecoracoacromial
arch.24Shoulderabductionfrom90to180degreesoccursasasummationofanadditional60degreesofGHjointabductionandanadditional30
degreesofscapulothoracicupwardrotation.99Duringthislatephase,theclavicleelevatesonlyanadditional5degreesattheSCjoint,whereas,atthe
ACjoint,thescapulaupwardlyrotates2025degrees.Thus,bytheendof180degreesofabduction,the60degreesofscapulothoracicupwardrotation
canbeaccountedforby30degreesofelevationattheSCjointand30degreesofupwardrotationattheACjoint.99ThemotionattheACjointis
controlledbytensioninthecoracoclavicularligaments.Finally,theclaviclehasbeendemonstratedinvivotoposteriorlyrotatearounditslongaxis
duringthelatephaseofshoulderabduction.24Itis,asyet,unclearwhetherthisposteriorrotationoccursattheSCorattheACjoint.Therotationofthe
clavicle,though,iscontrolledbytensioninthecoracoclavicularligamentsandtheclavipectoralfascia.
Elevationofthearminthescapularplaneinhealthysubjectsisaccompaniedbyposteriortippingandupwardrotationofthescapula.155Theupwardrotation
ofthescapulaoccursaboutanaxisthatpassesthroughthebaseofthespineofthescapulaandoccursinvariousphases(seeTables163and164).Rotationof
thescapulaabouttheverticalaxisshowsasomewhatmorevariablepattern,155withsomestudiesshowingERoccurringpredominantlyathigherelevation
angles,67,156,157whileothersdemonstrateIR.158160
UpwardanddownwardrotationoccursaroundanaxisperpendiculartotheplaneofthescapulathattravelsthroughtheACjointandSCjoint.70The
upwardrotationofthescapuladuringshoulderabductionhelpstomaintainaneffectivelengthtensionrelationshipbetweenthethreegroups(force
couples)ofmusclesthatattachtothescapula.Aforcecouplecanbedefinedastwoforcesthatactinoppositedirectionstorotateasegmentaroundits
axisofmotion.
Duringthefirst30degreesofupwardrotationofthescapula,theserratusanteriormuscleandtheupperandlowerdivisionsofthetrapeziusmuscleare
consideredtheprincipalupwardrotatorsofthescapula.Togetherthesemusclesformtwoforcecouplesoneformedbytheuppertrapeziusandtheupper
serratusanteriormuscles(Fig.1614)andtheotherbythelowertrapeziusandlowerserratusanteriormuscles.6,85,161
TheprimemusclesthatabducttheGHjointarethemiddledeltoidandthesupraspinatusmuscles.99Elevationofthearmthroughflexionisperformed
primarilybytheanteriordeltoid,coracobrachialis,andLHBbrachii.99Thetrapeziusappearstobemorecriticalforcontrollingthescapuladuringtheinitial
phasesofabduction,whereastheserratushasbeenfoundtobethemosteffectiveupwardrotatorofthescapula.85,162Thelowertrapeziuscontributesduring
thelaterphaseofshoulderabductionbypreventingtippingofthescapulaandassistinginthestabilizationofthescapulathrougheccentriccontrolofthe
scapuladuringscapularupwardrotation.111,153
CLINICALPEARL
Duringapproximatelythefirst150degreesofarmelevationthroughflexion
theupperandlowerfibersofthetrapeziuscontractconcentrically,
thefibersofthelowerserratusanteriorcontractconcentrically,
thelevatorscapulaecontractseccentrically,
therhomboidscontracteccentrically.
Fromapproximately150180degrees
thelowerfibersoftheserratusanteriorcontractisometrically,
thelowerfibersofthetrapeziuscontractconcentrically,
thepectoralisminorcontractseccentrically,
theupperfibersoftheserratusanteriorcontracteccentrically.
Themiddletrapeziusandrhomboidsmayalsocontributetothescapularmotionsinvolvedduringarmelevation.163Theantagonistsarethepectoralismajor,
teresmajor,latissimusdorsi,andcoracobrachialis,allworkingeccentrically.Normalmotionofthescapulaonthethoraxisbelievedtoincludeconsistent
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contactbetweenthethoracicwall,themedialborder,andinferiorangleofthescapula.161,163Lossofthiscontacthasbeenclinicallyimplicatedasevidenceof
abnormalscapularkinematics.Theseabnormalscapularkinematicsmayresultinadditionalstressontheanteriorshoulderstabilizers.164166
TheappropriateforcecouplesfortheacromialelevationthatoccursduringGHabductionarethelowertrapeziusandserratusmusclesworkingtogether,
pairedwiththeuppertrapeziusandrhomboidmuscles(Fig.1614).24
TheEMGactivityofthelevatorscapulamuscle,upperandlowertrapeziusmuscles,andserratusanteriormuscleduringarmelevationincreasesprogressively
asthehumeralangleincreases.67Activitiesthatmaintainanupwardlyrotatedscapulawhileaccentuatingscapularprotraction,suchasapushupplus,elicitthe
greatestserratusanteriorEMGactivity.76
CLINICALPEARL
Anumberofinvestigationshaveaimedtodetermineifadaptationsinscapularmovementoccurinindividualswithimpingementorrotatorcuff
disease.156,167169Specificallynotedareadecreasedscapularmovementtowardupwardrotation,posteriortilt,andexternalrotationduringhumeral
elevation.67,170,171
ThelastfewdegreesofshoulderelevationconsistofupperthoracicmovementoncefullGHjointandshouldergirdlemotionhavebeencompleted.Movement
ofthethoracicspineduringunilateralandbilateralarmelevationhasbeenexaminedinanumberofstudies.172,173Inyoung,asymptomaticindividuals,the
totalrangeofthoracicspineextensionmotionhasbeenreportedtobebetween2and19degrees,withslightlygreatermobilityinmen.174Thefactthata
decreaseinthoracicspineextensionmobilityhasbeenreportedinasymptomaticindividualsolderthan60years,175wouldtendtoindicatethatthesagittal
curvatureofthespineintheregion(kyphosis)mustinfluencetheamountofavailablethoracicspineextension.
Thescapulaalsofunctionsduringretractionandprotractionalongthethoracicwall(seeFig.1611).24Protractionoccursastheserratusanterioratthescapula
andthepectoralismajoratthehumeruscontractsimultaneously.Retractionisproducedbythecombinedactionofthetrapeziusandrhomboids.176A1518
cmtranslationofthescapulaaroundthethoracicwalloccursduringretractionandprotraction,dependingonthesizeoftheindividualandthevigorousnessof
theactivity.24,142Thisretractionandprotractionisusedduringactivitiessuchasreachingandpulling,respectively.24
Finally,thescapulafunctionstotransferthelargeforcesandenergyfromthelegs,hips,back,andtrunktotheactualdeliverymechanism,thearmand
hand.24,140,177,178
AcromioclavicularJoint
ThemotionsavailableattheACjointoccuraroundthreeaxes:
Rotationinananteroposterior(AP)directionaroundalongitudinalaxisthatprojectsthroughtheACandSCjoints,androtationinasuperoinferior
(vertical)direction.TheAProtationoccursduringarmelevation.Thesuperoinferiorrotation,whichoccursaroundthecostoclavicularligament,is
involvedduringprotraction(anteriormovementoftheacromialendoftheclavicle)andretraction(posteriormotionoftheacromialend).TheAP
rotationoftheclavicleonthescapulaisthreetimesgreaterthanthatofthesuperoinferiorrotation.TheclaviclecanrotateintheAPdirectionwith
contributionsfromthemobileSCjoint.179Thetypeofglideandrotationthatoccurswithclavicularmotiondependsontheshouldermotionandthe
shapeofthearticularsurfaces.Ifthelateralendoftheclaviclepresentsaconcavesurface,ananteriorglideiscombinedwithananteriorrotation.Ifthe
lateralendpresentsaconvexsurface,ananteriorglideiscombinedwithaposteriorrotation.
CLINICALPEARL
Theclaviclemustbeabletofullyrotateforfullelevationtooccurotherwiseelevationwouldbelimitedtoapproximately110degrees.179
Purespin/rotation.Apurespinoccursduringabduction/adduction(lateralandmedialrotationofinferiorscapulaangle)motions.
Glides.GlidesoftheclaviclecanoccurinanAPandsuperoinferiordirection.
TheACjointispredisposedtochronicstressinjury,especiallyinthesituationsinwhichitissubjectedtorepetitivehighdemand.70,180Thejointcan
alsobeaffectedbydirecttraumaandbynontraumaticfactorssuchasdegenerativearthritisandinflammatoryarthropathies.75Table168containsthe
pathologiesanddysfunctionsthatmayaffecttheACjoint.
TABLE168PathologiesandDysfunctionsthatMayAffecttheACJoint
Traumaticconditions Separation/dislocation(typesIVI),andfracture
Infectiousconditions Septicarthritis
Rheumatoidarthritis
Systemiclupuserythematosus
Inflammatoryconditions Ankylosingspondylitis
Subacromialbursitis
Rotatorcuffpathology
Osteoarthritis
Degenerativejointdisease
Osteolysis
Metabolicconditions Gout
DatafromPowellJW,HuijbregtsPA.Concurrentcriterionrelatedvalidityofacromioclavicularjointphysicalexaminationtests:Asystematicreview.JMan
ManipTher.200614:E19E29.
SternoclavicularJoint
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TwotypesoftranslationalsooccurattheSCjoint:anteriortoposteriorandsuperiortoinferior,withtheformerexceedingthelattermotionby2:1.181These
translationsallowforthreeDOF:themovementsofelevation,depressionprotraction,retractionandupward(backward)anddownward(forward)motion.
Protraction/retraction.Approximately1520degreesofprotractionandretractionoftheclavicleareavailable.Withprotraction,theconcavesurfaceof
themedialclaviclemovesontheconvexsternum,producingananteriorglideoftheclavicle,andananteriorrotationofthelateralclavicle.181With
retractiontotheneutralposition,themedialclaviclearticulateswithaflatsurfaceandtilts/swings,causingananterolateralgapping,andaposterior
rotationatthelateralend.181
Elevation/depressionoftheclavicle.Thereare3540degreesofelevationandapproximately15degreesofdepressionavailable,3,85,181involvingthe
convexclavicleglidingontheconcavesternum.
Astheclavicleelevatesandrollsupwardonthemanubrium,aninferiorglideisproduced,withthereverseoccurringwithdepression.Elevationanddepression
movementsattheSCjointareassociatedwithreciprocalmotionsofthescapulabecauseofthelateralattachmentoftheclavicletothescapulaattheAC
joint.76
Rotationaroundthelongaxisproducesaspinoftheclavicleonthemanubrium.Approximately40degreesofupwardrotationand5degreesofdownward
rotationareavailableandarenecessarytoallowupwardscapularrotation.3,85
CLINICALPEARL
Forthescapulartoabductandupwardlyrotatethroughout180degreesofhumeralabduction,clavicularmovementmustoccuratboththeSCandACjoints.
StabilizationoftheStaticShoulder
Theglenohumeraljointatrestrequiresverylittlemuscularsupport.Itsverticalstabilityisaresultoftheinferiorlateralprojectionandupwardinclinationofthe
glenoidfossa,whichismaintainedbyamildcontractionofthefibersofthetrapezius.Itwastraditionallytheorizedthatthehumeralheadwaspreventedfrom
rollingoffofthislateralprojectionbyamoderatecontractionofthesupraspinatusandthedeltoid.131,182Morerecentstudieshavedemonstratedthatthe
muscletoneoftherotatorcuffisnotasignificantcontributortothestaticinferiorstabilityofthedependentshoulderwithlightloads,butthatmaintenanceof
theintraarticularpressureandtheadhesionandcohesionpropertiesofthearticularsurfacesarefarmoresignificant.183,184However,therotatorcuffdoes
provideapassiverestrainttotranslation,especiallytoposteriortranslation,duringtheearlytomidrangesofelevation.185
Duringthemidandendrangesofmotion,acombinationofseveraldifferentstaticrestraintscreateavectorthatkeepsthehumeralheadsecurelyseatedinthe
glenoid,throughconcavitycompressionnegativearticularpressure.139,146,183,186188Staticrestraintisalsoprovidedbytheanatomiccurvatureofthe
humerusandglenoid,theextradepthofthelabrum,andligamentousrestraints.189(seeTables166,16.7and169).161Theligamentousrestraintscontribute
especiallyattheendrangesofmotion190andareassistedwithconcomitantmuscleactivity(seeTable169).
TABLE169DynamicandStaticRestraintstoExternalRotation(DependentonthePositionoftheArm)
0 Subscapularis,superiorGH,andcoracohumeralligaments
45 Subscapularis,middleGHligament,superiorfibersoftheinferiorGHligament
90 InferiorGHligament
DatafromWarnerJJP,CabornDN,BergerRA,etal.Dynamiccapsuloligamentousanatomyoftheglenohumeraljoint.JShoulderElbowSurg.19932:115
133TurkelSJ,PanioMW,MarshallJL,etal.Stabilizingmechanismspreventinganteriordislocationoftheglenohumeraljoint.JBoneJointSurgAm.
198163:12081217.
StabilizationoftheDynamicShoulder
Dynamicstabilityoftheshouldercomplexisdependentonavarietyofmechanismsincludingtheoptimalalignmentofthescapula,correctGHorientation,
andthequalityofthelengthtensionrelationshipoftheinvolvedmuscles,andcorrectfunctioningofthestaticrestraints.
Thedeltoid,pectoralismajor,latissimusdorsi,andteresmajormusclesareprimemoversoftheGHjoint.EMGstudieshaveshownthatthesemuscles
functionalongthelineofpull,creatingthepotentialforinfinitelinesofpullthatmayallowanalmost360degreesarcofmotion.13,26Indeed,likethe
temporomandibularjoint,theGHjointenjoysthebenefitthatallofitsprimemoverscompressthejointsurface,thusoptimizingjointstability.Thesecondary
moversoftheGHjointaretheLHB,andthetriceps.
CLINICALPEARL
ThelongheadofthebicepsandthetricepsmusclesaremajordynamicstabilizersoftheGHjoint,predominatelyfunctioningasshuntmuscles(musclesthat
produceacompressionatthejointsurfacesofthejointstheycross)duringhighvelocityactivities.
AsmotionoccursattheGHjoint,theglenoidcavityofthescapulaadoptsadiversenumberofreciprocalpositions.Itislikelythatthesescapularpositionsare
basedonboththefunctionaltaskandtheplacementofthehand.Dysfunctionorinhibitionofanyofthescapularstabilizers(serratusanterior,latissimusdorsi,
trapezius,rhomboids,levatorscapulae,andthepectoralisminor)canalterthepositionoftheglenoidsignificantly,resultinginabnormalcenteringofthe
humeralheadwithintheglenoid.24,191,192
Untilrecently,EMGorcadaverstudieshavebeentheprimarymethodofevaluatingthecontributionofeachrotatorcuffandshouldermuscletoaparticular
motionorexercise.Forexample,usingcadavers,Kibleretal.146determinedthatthesubscapulariscontributes53%ofthecuffmomentandbelievedittobe
themostimportantmuscleinhumeralheadstabilization.
Magneticresonanceimaging(MRI)isnowbeingusedtoshowincreasesinmusclesignalintensitydetectedimmediatelyfollowingexercise.147149Onthe
basisofthelevelofsignalintensity,thissocalledexerciseinducedenhancementseenonMRIcandeterminewhichmusclesareusedforagiven
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exercise.140,147,148,150152Forexample,onestudyoftheshoulder149demonstratedthatsidelyingabductionproducedthegreatestsignalintensityinthe
supraspinatus,infraspinatus,andsubscapularismuscles.Surprisingly,scaptionwithinternalrotation(SIR),previouslyassociatedwithisolationofthe
supraspinatusmuscle,didnotprovidethehighestincreaseinanymuscleoftherotatorcuff.149However,cautionmustbeusedindrawingconclusionsfrom
singlestudies,andfurtherresearchiscertainlywarrantedinthisarea.
Aspreviouslymentioned,theroleofthecapsuloligamentouscomplexinstabilizingtheGHjointduringdynamicactivitiesiscomplexandvarieswithboth
shoulderpositionandthedirectionofthetranslationforce.193Theposteriorcapsuleisthemainrestraintagainstposteriortranslationofthehumerusonthe
glenoidfossawiththearmbelow90degreesofabduction.194Withthearmat90degreesofabduction,theinferiorGHligamentandtheposteroinferior
capsulebecomethemainrestraint.194TheposteriorbandoftheinferiorGHligamentresistsinferiortranslationwhenthearmisat90degreesofabduction.
EXAMINATION
Theinterventionstrategiesforthecommonpathologiesoftheshouldercomplexaredetailedaftertheexaminationsection.Anunderstandingofbothis
necessary.Asmentionofthevariouspathologiesoccurswithreferencetotheexaminationandviceversa,thereaderisencouragedtoalternatebetweenthe
two.Shouldercomplexconditionsareoftenmultifaceted,andpatientswiththesameshoulderconditionoftenpresentwithdiversephysicalfindings.Itis
criticalthattheclinicianconsidertheshouldergirdleasawhole,ratherthanasaseriesofisolatedarticulations,andasapartofthewholekineticchain.Inthe
presenceofshouldercomplexdysfunction(assumingsystemicorseriouscauseshavebeenruledout)therearethreelikelycauses:
Compromiseofthepassiverestraintcomponentsoftheshouldergirdle.
Compromiseoftheneuromuscularsystemsproductionorcontrolofshouldergirdlemotion.
Compromisetooneormoreoftheneighboringjointsthatcontributetoshouldergirdlemotion,including
theACjoint,
theSCjoint,
thejointsoftheupperthoracicspineandribs,
thejointsofthelowercervicalspine.
Duetothiscomplexity,alloftheabovementionedjointsmustbeselectivelytestedinaspecificsequencebeforeproceedingwithamoredetailedexamination
ofthesuspectedjointorjoints.
HISTORY
Agoodhistoryisthecornerstoneofproperdiagnosis,especiallysinceshoulderpainhasabroadspectrumofpatternsandcharacteristics.Abodychartcanbe
usedtorecordthepatientssymptomdistribution(seeChapter4).Thebodychartisasymptomaticrepresentationofapatientscomplaintsandcanbean
importantelementinguidingboththehistoryandthetestsandmeasures.
Thehistoryshouldbeginwithabriefoutlineofthepatientsprofileincludingage,occupation,handdominance,recreationalpursuits,workrequirements,and
ADL.195Ageisoccasionallysignificant:196
Childrenandadolescentsmayhaveanepiphysitisofthehumerus,oranosteogenicsarcoma.
Calcificdepositsintheshoulderaremorecommonbetween20and40yearsofage.
Chondrosarcomasusuallyoccuraftertheageof30years.
Rotatorcuffdegenerationusuallyoccursinthe40sand50s.
Afrozenshoulderismorecommoninthoseaged4560yearsandisoftenassociatedwithmedicalconditionssuchasdiabetesmellitusandischemic
heartdisease.195
Theexactmechanismofinjuryshouldbedeterminedasitcanhelpwithapreliminarydiagnosis:197
Overheadexertioninvolvingrepetitivemotionsisacommonmechanismforsubacromialpathology,encompassingsubacromialbursitis,60SIS,39rotator
cufftendinopathy,39,198androtatorcufftear.199Itisalsoacommoncauseofbicipitaltendinopathy.
Afallonanoutstretchedhand(FOOSHinjury)canresultinasprainorstraininjurytothewrist,elbow,andshoulder.Moreseriousinjuriesfromsuch
afallincludefracturesofthewristandelbow,ACseparations,clavicularfractures,andGHfracturesanddislocations.
AfallonthetipoftheshoulderisacommonmechanismforACseparation.Inaddition,thismechanismcanresultinacompressionperiostitis(bone
contusion)oracervicalspineinjury,bothofwhichappearremarkablysimilartoanACseparationespeciallyintheearlystages.
Forcedhorizontalextensionoftheabducted,externallyrotatedarmisacommonmechanismforanteriordislocation.
Shoulderpainisthemostfrequentorthopedicinjuryinswimmers(seeChapter30),withareportedprevalencebetween40%and91%.200Thisisduein
parttothefactthat,unlikemostothersportswherethelegsinitiatethepropulsiveforce,swimmingathletesprimarilyusetheirarmstogenerateforward
thrust.201Itisthoughtthatmusclefatigueoftheupperback,rotatorcuff,andpectoralmusclescausedbytherepetitivemovementsinvolvedin
swimmingcanresultinmicrotraumaduetodecreaseddynamicstabilizationofthehumeralhead.202,203
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Itisimportanttoestablishthepatientschiefpresentingcomplaint(whichisnotalwayspain)aswellasdefiningtheirothersymptoms.Themostcommon
complaintsassociatedwithshoulderpathologyincludepain,instability,stiffness,deformity,locking,andswelling.195However,patientssometimescomplain
ofcatching,clunking,grinding,orpoppingoftheshoulderwithvariousmovements.Thesesoundsandsensationsmaybeasymptomaticandnonpathologicbut
theymayalsoindicatepathologyincludinglabraldisorders,rotatorcufftears,snappingscapular,subacromialbursitis,orbicepstendondisorders,especiallyif
thesoundorsensationisassociatedwithpainorinstability.195Periscapularpainisoftenassociatedwithlocalmusclestrainbutmaybereferred.1
Thequalityofthepainisalsoimportant.Radicularpaintendstobesharp,burning,andradiating.Bonepainisdeep,boring,andlocalized.Musclepaincanbe
dull,aching,andhardtolocalize.Tendonpaintendstobehotandburning.Vascularpaincanbediffused,aching,andpoorlylocalizedandmaybereferredto
otherareasofthebody.Theintensityofpainmaywaxandwanewithparticularmotionsassociatedwithspecificactivities.Forexample,commoncomplaints
witharotatorcufftearincludedifficultywithelevationofthearminabduction,aswellasER,andwhenthepatientattemptstoputhisorherhandbehindthe
headorback(combingthehair,orreachingintoabackpocketrespectively).204PatientswhoreportdifficultytuckingintheirshirtsmayhavelimitedIRfrom
posteriorcapsularstiffness.205ThehallmarkofposteriorcapsularcontractureissymmetriclossofactiveandpassiveIR.Posteriorcapsularstiffnessmayoccur
independentofrotatorcuffdisease.Stiffnessorlossofmotionattheshouldermaybethechiefcomplaintinconditionssuchasadhesivecapsulitis.195AC
jointpaintendstooccurwitharmmotionabove90degreesofabductionandwithhorizontalabduction.Painassociatedwithanidiopathicfrozenshoulder
tendstobeconstant,butisparticularlybadatnightandfrequentlyawakensthepatient.52
Weaknessmaybethechiefcomplaint,leadingtosomediagnosticconfusion.Itisimportanttodistinguishtrueweaknessfromweaknesssecondarytopain,
bothintermsofhistoryandexaminationfindings.206Painlessweaknessisusuallyduetoneurologicalproblemsormyopathies,althoughperipheralnerve
injuriescanbepainful(Table1610).Shoulderweaknessmaybecausedbyarotatorcufftearornerveinjury(suprascapular,axillary,longthoracic,or
thoracodorsalnerves,orcervicalnerverootinjury)(seeTable1610).107
TABLE1610PeripheralNerveLesions
Inabilitytoabductthearmbeyond90degrees
Spinalaccessorynerve
Painintheshoulderwithabduction
Musculocutaneousnerve Weakelbowflexionwithforearmsupinated
Painonflexingafullyextendedarm
Longthoracicnerve Inabilitytofullyflexanextendedarm
Wingingofthescapulaat90degreesofforwardshoulderflexion
Increasedpainonforwardshoulderflexion
Suprascapularnerve Painincreasedwithscapularabduction
Painincreasedwithcervicalrotationtotheoppositeside
Axillarynerve Inabilitytoabductthearmwithneutralrotation
Markeddifficultytoresistshoulderextension
Thoracodorsalnerve
Markeddifficultytoresistshoulderinternalrotation
Cervicalspinalnerveroot Variesaccordingtothelevelinvolved,socanincludevariouscombinationsoftheabove
Symptomsthatarenotassociatedwithmovementshouldalertthecliniciantoamoreseriouscondition(seeSystemsReviewsection).Painthatisworseat
night,butincreasedwhenrollingontotheshoulder,pointstoaperiarticularmechanicalproblem.204
Determiningthelocationofpainisimportant.Painthatradiatesbeyondtheelbowisfarlesslikelytobeduetoshoulderpathology,particularlyifitis
associatedwithanysensorydisturbanceinthelimbsuchasdistalradiationofpain,numbness,orparesthesias.195Insuchcasestheclinicianshouldruleout
thoracicoutletsyndrome(TOS),cervicalradiculopathy,orreferredpainfromneighboringareas.Anteriorshoulderpainsuggestsbicipitaltendinopathy,
whereasposteriorshoulderpainmightbeduetoaposteriorlabraltear.52
CLINICALPEARL
Painduetorotatorcuffpathologyandimpingement,whichisusuallyfeltovertheanteriororlateralpartoftheshoulder,canbecharacterizedbyradiation
downtheupperarm,andisaggravatedwithoverheadactivities.195,207
PainduetoACjointpathologyisusuallylocatedatthesuperiorregionoftheshoulderorwelllocalizedattheACjointitself,andthereisoftenaclearhistory
ofinjurytothisregion.SeverepainontopoftheshoulderwithanassociateddeformitycouldindicateanACjointsprain.Posteriorneckpainmaybe
indicativeofacervicalradiculopathy,asneithertheACjointnorasubacromialirritationreferspaintothisarea.75,208
Theclinicianshoulddeterminewhichpositionsormovementsrelievethepain,asthesecanprovidehelpfulinformation:197
Painrelievedwitharmelevationoverheadcouldindicateacervicogeniccause.209
PainrelievedwiththeelbowsupportedissuggestiveofACseparationandrotatorcufftears.
Painrelievedbycircumductionoftheshoulderwithanaccompanyingclickorclunkcouldindicateaninternalderangementorsubluxation.
Painrelievedwitharmdistractionissuggestiveofbursitisorrotatorcufftendinopathy.
PainrelievedwhenthearmsareheldinadependentpositionsuggestsTOS.
Aninquiryaboutgeneralhealth,anyexistingmedicalconditions,medications,andallergiesshouldbemade.Corticosteroidusecancauseosteoporosisand
tendonatrophyandaffectswoundhealingthereforeahistoryofitsusemayalterthedifferentialdiagnosis.195,204Theuseofanticoagulantmedicationshould
benoted.Patientswhoareundergoingrenaldialysisareatincreasedriskfortendontears,asarepatientswhoare80yearsofageorolder.204Bilateralshoulder
involvementisnotuncommoninthesegroups.
Pastphysicaltherapyinterventions,previousinjections,andprevioussurgeryareimportanttodocument,asarepreviousshoulderinjuriesandwhat
relationship,ifany,theyhavewiththepresentsymptomatology.195
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SystemsReview
Theclinicianshouldbeabletodeterminethesuitabilityofthepatientforphysicaltherapy(PT).Iftheclinicianisconcernedwithanysignsorsymptomsofa
visceral,vascular,neurogenic,psychogenic,spondylogenic,orasystemicdisorder(seeChapter5)thatisoutofthescopeofPT,thepatientshouldbereferred
backtohisorherphysicianoranotherappropriatehealthcareprovider.
Scenariosrelatedtotheshoulderthatmaywarrantfurtherinvestigationbytheclinicianincludeaninsidiousonsetofsymptomsandcomplaintsofnumbnessor
paresthesiaintheupperextremity.
Themostcommoncausesofnumbnessintheshoulderandarmareduetocervicalorupperthoracicinvolvement,witheitherthesegmentalrootsinvolvedor
thebrachialplexus.Thepatientshouldbequestionedaboutrecentchangesinworkrequirementsorenvironment,andthepresenceofneckpain.3840,210In
studieswherenormalcervicalligamentsandmuscles,211cervicalzygapophysealjoints,212anddisks213havebeenstimulated,subjectshavereportedpainin
thehead,anteriorandposteriorchestwall,shouldergirdle,andupperlimbdependingonthecervicallevelstimulated.111
TheCyriaxscanningexamination(seeChapters4and5)maydemonstratesubtleweaknessofthecervicalrootinnervatedmuscles.Depressedorabsentupper
extremityreflexesarealsofrequentlynoted.Finally,reproductionofthepatientspainwithcervicalmotionandnotwithshouldermovementisastrong
indicatorofcervicalorigin.
Inadditiontothecervicalandupperthoracicspine,therelatedjointsreferringsymptomstotheshoulderrequireclearing.Theseincludethetemporomandibular
joint,costosternaljoint,costovertebralandcostotransversejoint,thoracicspine,andtheelbowandforearm.69,207
Systemiccausesofinsidiousshoulderpainincluderheumatoidarthritis.Rheumatoidarthritisoftenaffectstheshouldersandhipsinolderindividualsandcan
bedifficulttodistinguishfrompolymyalgiarheumatica.Morningstiffnesslastingformorethan1hour,constitutionalsigns,andphysicalsignsofjoint
inflammationareallindicativeofaninflammatorydisease.204Othersystemicsourcesofshoulderpainincludelupuserythematosusandgallbladderandliver
disease.69Theselatterconditionsareassociatedwithothersignsandsymptomsthatarenotrelatedtomovementandaresystemicinnature.Chronic
respiratoryandcardiovascularconditionsmustalsocomeintoconsideration.195Theshoulderisveryclosetothechestanditsviscerathereforereferenceof
symptomstotheshoulderfromthesestructuresiscommon(seeChapter5).Itisvitalthatquestionsbeaskedthatwouldrevealarelationshipbetweentheonset
ofsymptomsandlocalmovementsversusgeneralexercise,thelatterofwhichcouldimplicatethelung,heart,ordiaphragm.
CLINICALPEARL
Severeprogressivepainnotaffectedbymovement,persistentthroughoutthedayandnight,andassociatedwithsystemicsigns,mayindicatereferredpainfrom
amalignancy.Theexceptiontothismaybeadhesivecapsulitis(frozenshoulder),whichisoftencharacterizedbyboring,unrelenting,achingpain,evenat
rest.214
Finally,avascularexaminationshouldbeperformedandshouldincludeanassessmentofgeneralskintexture,color,temperature,hairgrowth,andalterationof
sensationaboutanddistaltotheshoulder.52Autonomicsignsandsymptomsaresuggestiveofcomplexregionalpainsyndrome(CRPS)(refertoChapter18).
NeurovascularcompressionorTOStestsaredescribedinSpecialTestsectioninChapter25.
TESTSANDMEASURES
Thephysicalexaminationoftheshouldercomplexshouldbefocusedandthorough,usingtheclinicalimpressiongleanedfromthehistoryandsystemsreview
asaguide.
Observation
Observationofthepatientbeginswhenthepatiententerstheclinic.Theclinicianobserveshowthepatientholdsthearm,theoverallpositionoftheupper
extremity,andthewillingnessofthepatienttomovethearm.Duringgait,anupperextremityshouldswingintandemwithitsoppositelowerextremity.Once
intheexaminationroom,thepatientisappropriatelydisrobedandtheshoulderissystematicallyinspectedfromanterior,lateral,andposteriorpositions.Total
bodyalignmentisexaminedforoverallposture,therelativerotationofthehumerus,structuralmalalignmentsuchaskyphosis,thepresenceofscars,color
changes,andswelling.195Observableswellingintheshouldermayindicateaseriousproblemordamage.Anteriorprominenceofthehumeralheadorahigh
ridingouterclaviclesuggestGHdislocationorACseparation,respectively.52Therelativeheightsoftheshouldergirdlesshouldbeassessed.Theheightof
theshouldermayormaynotbesignificant.Iftheshouldersareelevated,theneckappearsshort.Iftheyaredepressed,theACjointisseentobelowerthanthe
SCjoint.215Elevationoftheclaviclecanbeduetoshortnessoftheuppertrapeziussuchthatthelateralendoftheclavicleappearsappreciablyhigherthanits
medialaspect.215Alowshouldercanresultfrom197
adaptivelaxityoftheshoulder,
leglengthdiscrepancy,
scoliosis,
softtissuehypertonicity,
mechanicaldysfunctionofthepelvis,
handdominancetheshoulderonthedominantsidemaybeslightlylowerandmoremuscularthanthenondominantsidethisisanormalfinding.
DeformityisacommoncomplaintwithinjuriesoftheACjointandfracturesoftheclavicle.Forexample,aseconddegreesprainorseverefirstdegreesprain
oftheACjointcanbeseenasahighridinglateralclavicle(elevationofthedistalend)causingastepofftoformbetweentheclavicleandacromion.17,216It
isfrequentlyreferredtoasatentpoledeformity.ThefountainsigndescribesswellingthatisanteriortotheACjointthatisindicativeofdegenerationthathas
causedcommunicationbetweentheACjointandaswollensubacromialbursaunderneath.
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Observationofmusclesymmetryshouldbenoted.Specificatrophycanimplycertaindiagnoses.Forexample,muscleweaknessoratrophy,especially
posttraumatic,mightindicateperipheralnervedamage:217
Aballedupmusclemayindicateamusclerupture,themostcommonofwhichareofthebicepsandinfraspinatus.RuptureoftheLHBcanbenoticedby
thechangeincontouroftheanteriorarmwithbunchingofthemuscle(thePopeyeappearance).195
Atrophyofthedeltoidfromaxillarynerveneuropathycanresultinasquaredappearanceofthelateralshoulder,216,217whichisbestobservedfromthe
front.17Othercausesofasquaringoftheshoulderincludeananteriordislocationoftheshoulderasthedeltoidisnolongerroundedoutoverthehumeral
head.
Atrophyoftheposteriordeltoidcanoccurinpatientswithmultidirectionalinstability.217
Atrophyattheinfraspinatusorsupraspinatusfossaisahallmarkofarotatorcufftear,16orsuprascapularnerveentrapment.Wastingofthesupraspinati
andinfraspinaticanbedeterminedbypushingtheexaminingfingerintotherespectivemusclebellies.
Atrophyofthetrapeziusmayindicatecompromiseofthespinalaccessorynerve.Atrophyofthetrapeziusischaracterizedbytheappearanceofa
shouldergirdlethatdroopsinassociationwithaprotractedinferiorborderofthescapulaandanelevatedacromion.24,106,218
Atrophyoftheserratusanteriormusclecancreateaprominentmedialborderofthescapula(scapularwinging)(Fig.1615)andadepressedacromion.
FIGURE1615
Scapularwinging.
Thepositionandattitudeofthescapula,bothstaticallyanddynamically,shouldbenoted(seelater).Instanding,withtheirarmsbythesides,thepatients
medial(vertebral)borderofthescapulashouldbe58cmlateraltothethoracicspinousprocesses,196,219themedialendofthespineofthescapulashouldbe
levelwiththeT3spinousprocess,andtheinferiorangleofthescapulashouldbelevelwiththeT7spinousprocess.Thesuperioraspectofthemedialborderof
thescapulabeginsatthelevelofthespinousprocessofT2andextendstothelevelofthespinousprocessofT7.Excessiveprominenceofthescapularspine
mayindicateatrophyoftheinfraspinatusandsupraspinatus.217Twoconditions,whichmaypresentwithdeformityofthescapulaastheirmainsymptom,are
Sprengelsdeformityandwingingofthescapula.195
Sprengelsdeformityisthemostcommoncongenitalabnormalityaffectingtheshoulder.Itischaracterizedbythepresenceofahypoplastic,incorrectlyrotated
scapula,whichsitsabnormallyhighontheposteriorchestwall.Theconditionresultsfromafailureofthenormaldescentofthescapula,whichoccursinutero,
andiscommonlyassociatedwithothersignificantmusculoskeletalandvisceralcongenitalabnormalities.195
Wingingofthescapula(Fig.1615)isduetoalossofthenormalscapularstability.Subtleformsofscapularwinging,usuallyevidentattheinferiorborder,
occurcommonlywithmanyshoulderdisorderssuchasGHjointstiffnessandshoulderinstability.108IncasesofGHjointstiffness,thereispassivelimitation
ofGHmotion,whilewithinstabilitythereisevidenceofexcessivemovementsorpositiveapprehensionsigns.Scapularwingingmayoccurastheresultof
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serratusanteriorweakness,trapeziuspalsy,218excessiveshorteningofthepectoralisminormuscle,2ormyopathies.195,220222Scapularwingingmayalsobe
causedbyGHjointstiffness,shoulderinstability,androtatorcuffdisease(seeAnalysisoftheStaticShouldersection).
Gait
Gaitisevaluatedtoobservefreedomofthearmswing,reciprocalupperextremitymovement,positionofthearmsandscapulae,andmotionofthetrunkand
lowerextremities(seeChapter6).69,207
Posture
Ananalysisofposturecanprompttheclinicianastotheareaofmovementdisturbanceorexcessivestresses(seeChapter6).Awidevarietyofstructuraland
posturalchangesoftheupperquartercanbeacommoncauseofshoulderpain.164,223,224Forexample,thoracickyphosis,scoliosis,ornecklordosiscanresult
inexcessiveprotractionofthescapula,producinginterscapularpain.24,225Intheolderpatient(agedover50years),anincreasedthoracickyphosismaybe
relatedtoadecreaseinshoulderelevation.226
Therelationshipofthehumeralheadtotheacromionshouldbeobserved.Onethirdofthehumeralheadshouldbeanteriortotheacromion.Afindingofless
thanonethirdmayindicateatightposteriorcapsuleoradaptiveshorteningoftheexternalrotators.227
Thepatientshandsandarmsshouldalsobeobservedinstanding.Normally,thethumbfacesanteriororslightlymedial.Iftheposterioraspectofthehand
facesanteriorly,theremaybeexcessiveadaptiveshorteningoftheinternalrotators.227
Musclebalancesintheupperquadrantcancauseacharacteristicposturalpatternoftheforwardheadposition.228Themostcommonmuscleimbalancesare
outlinedinTable1611.Theclinicianshouldobservethetrunkandneckpositionsinsittingandstanding,aswellastherelationshipofthescapulaerelativeto
thetrunkandthehumerusrelativetotheacromion.AnychangeinthescapularpositionhasanimpactontheACandSCjointandcanalsoalterthelength
tensionrelationshipofthescapularmuscles.
TABLE1611CommonMuscleImbalancesoftheShoulderComplex
MusclesPronetoTightness MusclesPronetoInactivityorLengthening
Uppertrapezius Middleandlowertrapezius
Levatorscapulae Rhomboids
Pectoralismajorandminor Serratusanterior
Uppercervicalextensors Deepneckflexors
Sternocleidomastoid Supraspinatus
Scalenes Infraspinatus
Teresmajorandminor
Subscapularis
Theforwardheadandroundedshoulderpostureincludeanabductedandelevatedpositionofthescapulaandaninternallyrotatedhumerus,24,98,229,230andis
morecommoninpatientspresentingwithshoulderpain231andinterscapularpain.231Forwardheadposture(FHP)inthepresenceofabductedscapulaeand
protractedshouldersresultsinadecreaseinthesizeofthesubacromialspace,whichmaypredisposethepatienttorotatorcuffdisorders.232Thisposture
resultsinanadaptiveshorteningoftheuppertrapezius,levatorscapulae,andpectoralis,withweakeningandlengtheningofthedeepneckflexorsandlower
scapularstabilizers.98,231,233
Ifthepectoralismajorisadaptivelyshortenedorstrong,themusclewillbeprominent.Ifthereisanimbalancepresent,itwillleadtoroundedandprotracted
shouldersandaslightIRofthehumerus.234,235Thealteredpositionofthescapulaecandistortthecourseofthesuprascapularnerve,placingitatriskfora
tractioninjuryduringupperextremitymovements.236238
Normally,theinsertionoftheSCMisbarelyvisible.Iftheclavicularinsertionisprominent,itmayindicateadaptiveshorteningoftheSCM.234Agroove
alongtheSCMisanearlysignofweaknessofthedeepneckflexors.Aweakeningandatrophyofthedeepneckflexorshasbeenproposedasasigntoestimate
biologicalage.239Thechangeintheanatomicalrelationshipoftheclavicleassociatedwiththisweaknessandatrophy,decreasesthewidthofthethoracicinlet,
renderingthebrachialplexusvulnerabletocompression(refertoChapter25).236,240,241
Alossofbulkintheinterscapularmusclesmayindicatetightnessinthetrapeziusandlevatorscapula.
AnalysisoftheStaticScapula
Anabnormalpositionofthescapulaatrestiscommoninpatientswithshoulderoveruseinjuries.98,215,231,233Thescapularpositionisinitiallyexaminedwith
thearmsbytheside.Thecliniciannotesanysignsofwinging,elevation,depression,adduction,abduction,androtationofthescapula.Abnormalitiesin
alignmentincludeaflatteningoftheinterscapularareaandanincreaseinthedistancebetweenthethoracicspinousprocessesandthemedialborderofthe
scapula.Whenthescapulaisabducted(morethan8cmfromthemidlineofthethorax),itisalsorotatedmorethan30degreesanteriortothefrontalplaneand
producesamedialrotationofthehumerus.215
Tippingofthescapula,inwhichtheinferiorangleprotrudesawayfromtheribcage,oftenresultsfromaweaknessofthelowertrapeziusandpositionsthe
glenoidfossasothatitfacesamoreinferiordirection.111Thisalignmentisoftenassociatedwithshortnessofthepectoralisminormuscleorbicepsbrachii
muscle.215
Adaptiveshorteningoftherhomboidsandlevatorscapulaemuscles,inthepresenceofalengtheneduppertrapeziusandserratusanterior,resultsinanelevation
ofthescapulaeatthesuperiorangle,andadownwardrotationofthescapula.ThiscausestheGHjointtomoveintoapositionofabduction.215,242Inaddition,
ifthelevatorscapulaadaptivelyshortens,bothcervicalandshouldermotionsoccursoonerthannormalbecausethestartingpositionofthescapulaischanged.
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Thismodificationtothestartingpositionofthescapulaforshoulderelevatedtaskspresumablyhasaneffectonthetimingofthescapularmusclesresponsible
forupwardrotation.Thisresultsinanendpositionofarmelevationthatislowerthanusual(seeExaminationoftheDynamicScapulasection).111
Extremitydominancecanaffecttheorientationofthescapula,withthegreaterdegreeofunilateralactivityproducingthegreaterchanges.Abilateral
comparisonshouldbemadeandallowancesmadeforthedominance.Bilateralcomparisonsdonotalwayshighlightdysfunctions.Forexample,the
symmetricaleffectsofanadaptiveshorteningoftheanteriorchestandshouldermusculature,andlengtheningoftheposteriormusculaturethatoccursinthe
forwardheadandroundedshoulderposture,willnotbeconfirmeduntilduringthemobilitytests.
Anumberofstatictestsforthescapularpositionexist.Theamountofscapularprotractionavailablecanbemeasuredclinicallyusingthemethoddescribedby
Divetaetal.,243whoadvocatetwolinearmeasurementswithapieceofstring.Thedistanceincentimetersbetweentherootofthescapularspineandthe
inferiorangleoftheacromion(scapularwidth)isdividedintothedistancefromthethirdthoracicspinousprocesstotheinferiorangleoftheacromion
(scapularprotraction).Theresultingratioprovidesameasurementofscapularprotractioncorrectedforscapularsize(normalizedscapularprotraction).This
methodofmeasurementofscapularprotractionhasbeenfoundtobebothreliableandvalidwhencomparedwithradiographicmeasurements.231,243,244
Palpation
Palpationmustbeperformedinasystematicmannerandmustfocusonspecificanatomicalstructures(refertoFigs.161to1613).Thedegreeandlocationof
tendernessisoftenareliablephysicalsignleadingtoanaccuratediagnosis.52Forexample,tendernessovertheanterioracromionandgreatertuberosityis
suggestiveofimpingement,whereastendernessovertheposteriorjointlinecouldindicatejointpathologysuchasGHarthritisoratornposteriorlabrum.52
Traditionally,palpationhasbeenviewedasastaticprocess.However,palpationisadynamicprocessandshouldbeperformedalongwithotheraspectsofthe
examination.Theoptimalmethodsofpalpatingtheshouldertendonsoccurinregionswherethereistheleastamountofoverlyingsofttissue.245
Itisbesttodividetheshouldercomplexintocompartmentsforpalpationassymptomsreproducedbypalpationinthesecompartmentsarefrequentlyassociated
withaspecificunderlyingpathology.
AnteriorandSuperiorCompartment
Theclinicianshouldbeginanteriorly,withpalpationofthecontoursoftheclavicle.Theanteriorandsuperioraspectsoftheclaviclearecoveredbythe
platysmamuscle.Thesternalendoftheclavicle,whichprojectscraniallyovertheborderofthemanubrium,iscoveredbytheSCM.Thefollowingareas
relatedtotheclavicleshouldbepalpatedfortenderness,swelling,orsymptomreproduction:
Thesupraclavicularfossa,borderedmediallybytheSCMandlaterallybytheomohyoid.
Theinfraclavicularfossa,betweenthepectoralismajor,deltoid,andclavicle.Thecoracoidprocessislocatedintheinfraclavicularfossa,especiallyifthe
armisplacedinextension.Severalpalpableligamentsandmusclesattachhereincludingthecoracoclavicular,ontheconoidtubercle,thecoracoacromial
ligament,thepectoralisminor,thecoracobrachialis,andtheshortheadofthebiceps.Aprominentcoracoidcouldindicateaposteriordislocationofthe
shoulder.
Thesubclaviusandcostoclavicularligament.
Thesuprasternal(jugular)notchthisindentationonthesuperiorborderofthesternalmanubriumisanimportantreferencepoint.Threecentimeters
abovethenotchistheinferiorborderofthelarynx,whilethesternalbelliesoftheSCMformthesidesofthenotch.Theinterclavicularligamentis
locatedwithinthenotch.DisruptionofthenormalcontoursofthenotchisassociatedwithSCdislocations.
TheSCjointandjointlinearthroticchangesoftheSCjointareevidencedbycrepitusatthejointduringIR/ERofthehumeruswiththearmabducted
to90degrees.ThecontoursoftheSCjointarepalpatedandacomparisonshouldbemadewiththecontralateralside.ThickeningoftheSC,oranSC
dislocation,producesaninabilitytoabductthearm.
TheACjointinjuriesandarthritisofthisjointarecommon,andfocaltendernessisanimportantsignofACpathology.195Changesinthesizeand
shapeofthejointmayindicatepastorpresentseparation,fracture,orosteoarthritis.
Withthearmhangingbythesideandthepalmfacingthebody,thegreatertuberositylieslaterally,andthelessertuberosityliesanteriorlywithrespecttoeach
other.Theyareseparatedbyabicipitalgroove.ThebicipitalgrooveismademoreaccessibleforpalpationwithIRofthearmto1520degrees(Fig.16
16).245,246Withinthisgrooveliesthebicepstendon,whichshouldbepalpatedfortenderness.Ifthearmatrestappearsslightlyabductedandexternally
rotated,ananteriordislocationmightbepresent.Anadductedandinternallyrotatedarmsuggestsmanyshoulderconditions,includingaposteriordislocation.
Thelessertuberosity(shapedlikeaninvertedteardrop)ispalpatedduringpassiveIRandERofthehumerusatapointlateraltothecoracoidprocess.The
subscapulariscanbepalpateddeepinthedeltopectoraltriangleatitsinsertionintothelessertuberosity.Thisisaccomplishedbypositioningthearmbytheside
inneutralrotation,andpalpatingjustlateraltothecoracoid.245
Thegreatertuberosityislocateddirectlyanteriortotheacromion.Itisbestlocatedwiththepatientinsidelying,facingtheclinician,withtheupperarminfront
inapproximately60degreesofshoulderflexion.Theclinicianpalpateslaterallyalongthespineofthescapulauntilcontactismadewiththesuperiorfacetof
thegreatertuberosity.Thesupraspinatusandposteriorcoracohumeralligamentinsertintothesuperiorfacet,theinfraspinatusonitsmiddlefacet,andtheteres
minoronitsinferiorfacet.Thesupraspinatus,locatedjustdistaltotheanterolateralcorneroftheacromion,canbemademorediscerniblebypositioningthe
patientsarmbehindthebackinslightextension.245,247
Thesubacromialsubdeltoidbursacanbepalpatedbyputtingthepatientintheproneposition,andpassivelystretchingthearmintoextensionbeforepalpating
anteriortotheACjoint.Tendernessreportedwithshoulderextensionandrelievedwithshoulderflexionisindicativeofaninflammationofthisbursa.
Theanteriorjointcapsulecanbelocatedbypalpatingonefingerbreadthlateraltothecoracoidprocesswiththearmbytheside.Persistenttendernessatthis
pointwithIRandERofthearmsuggestscapsularinvolvement.248
Themusclebellies,origins,andinsertionsoftheuppertrapezius,supraspinatus,andlevatorscapulashouldbepalpatedfortendernessorasymmetries.
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LateralCompartment
Thedeltoidmusclebellyandinsertionshouldbepalpatedfortendernessoratrophy.
PosteriorCompartment
Thespineofthescapulashouldbelocated.Theclinicianshouldbeabletolocatetheinferiorpoleofthescapula,themedialborderofthescapula,andthe
posteriorangleoftheacromion.Thesuperiorangleofthescapulashouldbelevelwiththesecondrib,thespineofthescapulawiththelevelofT3,andthe
inferiorborderwiththelevelofT7.
Theinfraspinatuscanbepalpatedjustdistaltotheposterolateralacromionwiththearmat90degreeflexionand10degreeadduction.245Theteresminoris
isolatedandpalpatedusingthesamepatientposition.245Tohelplocatetheteresminor,thelongheadofthetricepsispalpatedbyplacingthepatientsarmat
90degreesofabductionfollowedbyextension.Oncethelongheadofthetricepsislocated,thepatientisrepositionedandtheteresminor,nowsuperiortothe
longheadofthetriceps,canbepalpated.Tendernessoftheposteriorcapsulesuggestscapsularlaxity.
InferiorCompartment
Thelymphnodesintheaxillaarepalpatedforswellingortenderness.Alsolocatedintheinferiorcompartmentaretheanteriorcoracohumeralligament,GH
ligament,transversehumeralligament,andpectoralismajor.Thelatissimusdorsitendoncanbepalpateddeepintheaxilla.
Theteresmajortendonispalpatedmedialtothesuperiorpartofthelatissimusdorsitendoninsertion.Itcanbedifferentiatedfromthelatissimusdorsibyusing
acombinationofisometricIRandadductionwiththepatientsshoulderpositionedat90degreesofabductionandmaximumER.
Thesubscapularistendonispalpablebetweentheserratusanteriorandthelatissimusdorsiwhilethepatientsarmiselevated.
ActiveandPassiveRangeofMotion
Duetothecomplexnatureofthearthrokinematics,osteokinematics,andmyokineticsofthisregion,theresultsfromtheactiveandpassivemovementscanbe
misleadingthereforecaremustbetakenwithanyinterpretationofthefindings.Goniometricmeasuringtechniquesfortheshoulderjointcomplexare
describedandillustratedinChapter13.PROMtestingshouldbeperformedwhenactivemotionisincomplete.PROMisperformedifthereisadeficiencyin
activemotiontodeterminetheendfeel.249
Activemotiontestingprovidestheclinicianwithinformationregardingthefollowing:
Willingnessofthepatienttomovetheextremity.Painfulorhesitantinitiationorterminationofmovement.Suchahesitationmaybeasubtlesignof
instabilityorrotatorcuffdysfunction.250
Overallfunctionalcapacityoftheshoulder.
Quantityofmovement(Table1612).EstimationoftrueGHmotionisperformedbyfixingthescapulaatitsinferiorborder.
Developedtrickmovementsormodificationstothemovement,suchasanalteredplane,theuseoftrunkmovements,orabnormalrecruitmentof
muscles.
Associatedsignsandsymptomsnotreproducedwithnonfunctionalmotiontesting.
Presenceofacapsularpattern(Table1613).
Detectionofapainfularc.
Endfeels(seeTable1612),ifpassiveoverpressureisapplied.Painwithendrangestressisanimportantclinicalfinding.Crepituscanbesoftwith
rotatorcuffpathologyorharshwithGHarthritis.
TABLE1612NormalRangesforMovementsoftheShoulderComplexandPotentialCausesofPain
Motion RangeNorms(Degrees) EndFeel PotentialSourceofPain
Suprahumeralimpingement
Elevationflexion 170180 Tissuestretch StretchingofGH,AC,SCjointcapsule
Tricepstendonifelbowflexed
StretchingofGHjointcapsule
Severesuprahumeralimpingement
Extension 5060 Tissuestretch
Bicepstendonifelbowextended
Elevationabduction 170180 Tissuestretch
ACjointarthritisatterminalabduction
AnteriorGHinstability
Externalrotation 8090 Tissuestretch
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Motion RangeNorms(Degrees) EndFeel PotentialSourceofPain
Internalrotation 60100 Tissuestretch
PosteriorGHinstability
DatafromWarnerJJP,CabornDNM,BergerRA,etal.Dynamiccapsuloligamentousanatomyoftheglenohumeraljoint.JShoulderElbowSurg.19932:115
133TurkelSJ,PanioMW,MarshallJL,etal.Stabilizingmechanismspreventinganteriordislocationoftheglenohumeraljoint.JBoneJointSurgAm.
198163:12081217DatafromPagnaniMJ,WarrenRF.Stabilizersoftheglenohumeraljoint.JShoulderElbowSurg.19943:173190OConnellPW,Nuber
GW,MileskiRA,etal.Thecontributionoftheglenohumeralligamentstoanteriorstabilityoftheshoulderjoint.AmJSportsMed.199018:579584Karduna
AR,WilliamsGR,WilliamsJL,etal.Kinematicsoftheglenohumeraljoint:Influencesofmuscleforces,ligamentousconstraints,andarticulargeometry.J
OrthopRes.199614:986993DaviesGJ,DeCarloMS.Examinationoftheshouldercomplex.In:BandyWD,ed.CurrentConceptsintheRehabilitationof
theShoulder,SportsPhysicalTherapySectionHomeStudyCourse.1995.
TABLE1613ClosePacked,OpenPacked,andCapsularPatternsoftheShoulderComplex
ClosePacked OpenPacked CapsularPattern
90degreesofGHabductionandfull 55degreeabduction,30degreehorizontal
Glenohumeral Externalrotation,abduction,internalrotation
externalrotationorfullabduction adductionexternalrotation
Painatextremesofrange,especiallyhorizontal
Acromioclavicular 90degreeabduction Armrestingbyside
adductionandfullelevation
Painatextremesofrange,especiallyhorizontal
Sternoclavicular Fullarmelevationandshoulderprotraction Armrestingbyside
adductionandfullelevation
McClureandFlowers251classifylimitedshouldermotionintotwocategories:
DecreasedROMsecondarytochangesintheperiarticularstructures,includingshorteningofthecapsule,ligaments,ormuscles,aswellasadhesion
formation.Clinicalfindingsforthiscategoryincludeahistoryoftrauma,252254immobilization,252254presenceofacapsularpattern,249capsularend
feel,249andnopainwiththeisometrictesting.249
DecreasedROMduetononstructuralproblems,includingthepresenceofpain,protectivemusclespasm,oraloosebodywithinthejointspace.255
Clinicalfindingsforthispatientincludeahistoryoftraumaoroveruse,andthepresenceofanoncapsularpatternofmotionrestriction.
Riddleetal.256examinedtheintratesterandintertesterreliabilitiesforclinicalgoniometricmeasurementsofshoulderpassiveROM(PROM)usingtwo
differentsizesofuniversalgoniometers.Patientsweremeasuredwithoutcontrollingtherapistgoniometricplacementtechniqueorpatientpositionduring
measurements.RepeatedPROMmeasurementsofshoulderflexionVIDEO,extensionVIDEO,abductionVIDEO,shoulderhorizontalabduction,horizontal
adduction,externalrotationVIDEO,andinternalrotationVIDEOweretakenfortwogroupsof50subjectseach.Theintratesterintraclasscorrelation
coefficients(ICCs)forallmotionsrangedfrom0.87to0.99.TheICCsfortheintertesterreliabilityofPROMmeasurementsofhorizontalabduction,horizontal
adduction,extension,andinternalrotationrangedfrom0.26to0.55.TheintertesterICCsforPROMmeasurementsofflexion,abduction,andexternalrotation
rangedfrom0.84to0.90.GoniometricPROMmeasurementsfortheshoulderappeartobehighlyreliablewhentakenbythesamephysicaltherapist,regardless
ofthesizeofthegoniometerused.
Thepatientisaskedtobringthearmactivelythroughtherangesofmotion.Thesemotionsincludeflexion,extension,abduction,IR,ER,horizontaladduction,
andshruggingoftheshoulders.
ArmElevation
Theclinicianshouldviewthepatientcarefullyasheorsheattemptsarmelevation.Elevationinthefrontalplane(Fig.1617)andscapularplaneisassessed.
Typically,170180degreesofelevationispossibleinbothoftheseplanes,withtheupperportionofthearmbeingabletobeplacedadjacenttothehead.Ifthe
patientisunabletoachieve170180degrees,theclinicianmustdeterminewhereandwhymovementisnotoccurring.Thepresenceofpainwitharmelevation
canprovidetheclinicianwithvaluableinformation(Fig.1618).Acommoncauseofpainwitharmelevationisrotatorcufftendinopathy.Ifthereisanarcof
pain,thepointintherangewherethearcofpainoccurscanbediagnosticinimplicatingthecause.
FIGURE1616
Palpationofthebicipitalgroove.
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FIGURE1617
Elevationinthefrontalplane.
FIGURE1618
Causesofpainfularmelevation.
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Painthatoccursbetween70and110degreesofabductionisdeemedapainfularcandmayindicaterotatorcuffimpingement,ortearing,or
subacromialbursitis.77
Painwhichoccursinthe120160/160180degreerangemayindicateinvolvementoftheACjoint.77
CLINICALPEARL
Onestudy77attemptedtodifferentiatevarioustypesofpainfularcsandproposedthataddingexternalrotationtothepainfulrangeindicatedsubscapularis
involvement,orpossiblysupraspinatusand/orinfraspinatusinvolvementwhenthepainwasincreased.AddingIRtothepainfulrange,thesupraspinatusand/or
infraspinatuswasmorelikelythesourceofinvolvement.77
Kibler24advocatestheuseofthemuscleassistanceorscapularassistancetest(SAT)toassessscapularmotionandpositionduringelevationandlowering
ofthearmtoseeiftheimpingementmaybeduetoalackofacromialelevation(Fig.1619).Asthepatientelevatesthearm,theclinicianpusheslaterallyand
superiorlyontheinferiormedialborderofthescapulatosimulatetheserratusanterior/lowertrapeziusforcecouple.Thetestisconsideredpositiveifthe
manualassistancediminishesorabolishestheimpingementsymptoms.24TheSATispresumedtoindirectlymeasurethefunctionofthescapularotators
however,otherfactors,suchasthoracicpostureandpectoralisminorlength,havealsobeenhypothesizedtoaffectscapularrotation,anditispossiblethatthese
couldbeaffectedbythemanualpressureprovidedduringtheSAT.155,257,258Moreimportantly,theSATisusedtodirectlyassesstheinfluenceofscapular
motiononshoulderpain.InastudybyRabinetal.155amodifiedversionoftheSAT,whichincludedassistingposteriortippingofthescapulainadditionto
assistingupwardrotationofthescapula,wasfoundtopossessacceptableinterraterreliabilityforclinicalusetoassessthecontributionofscapularmotionto
shoulderpain.Thecoefficientandpercentagreementwere0.53and77%,respectively,whenthetestwasperformedinthescapularplane,and0.62and91%,
respectively,whenthetestwasperformedinthesagittalplane.Inthemodifiedversion,theclinicianplacesonehandonthesuperioraspectoftheinvolved
scapula,withthefingersovertheclavicle.Theotherhandisplacedovertheinferiorangleofthescapularsothattheheelofthehandisjustovertheinferior
angleandthefingersarewrappedaroundthelateralaspectofthethorax.Thepatientisaskedtoactivelyelevatehisorherarminthescapularplane,andduring
themovementtheclinicianfacilitatesupwardrotationofthescapulabypushingupwardandlaterallyontheinferiorangle,aswellastiltingthescapula
posteriorlybypullingbackwardonthesuperioraspectofthescapula.24
FIGURE1619
Scapularassist.
Weaknessoftheserratusanteriormuscle,duetopalsyordisuse,produceswingingofthescapula(Fig.1615)asthepatientattemptstoelevatethe
arm.4,107,109Inadditiontowinging,serratusanteriordysfunctionpresentswithlossofscapularprotractionduringattemptedshoulderelevationandthe
inferiortipofthescapulabecomesprominent.106
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Abductionoftheshoulderrequiresagreateruseoftheupperandlowertrapeziusmuscles,whereasshoulderflexionismorelikelytorecruittheserratus
anteriormuscle.85,162
Althoughlesionstothedeltoidarerare,imbalancesofthedeltoidandtherotatorcuffarecommon.Whenthedeltoidbecomesdominant,thehumeralheadis
seentoglidesuperiorlyduringarmelevationbecausethedownwardpulloftherotatorcuffmusclesisinsufficienttocounterbalancetheupwardpullofthe
deltoid(humeralsuperiorglidesyndrome).215ThisalterationintheGHforcecoupleusuallyoccursduringthemiddlephaseofelevation153(between80and
140degrees),becausetheupwardtranslationforceofthedeltoidpeaksduringthisphase,requiringmorecompressiveanddepressiveforcesfromtherotator
cuffmuscles.259,260
Ananteriorglideofthehumeralhead,whichoccursduringarmelevation(humeralanteriorglidesyndrome)215suggeststhattheposteriordeltoidhasbecome
thedominantexternalrotator.215Thissyndromeshouldbesuspectedifthepainislocatedintheanteriororanteriormedialaspectoftheshoulderandis
increasedbyGHIR,shoulderhyperextension,andhorizontalabduction,andisdecreasedwhenthehumeralheadispreventedfrommovinganteriorlyduring
shoulderrotationandflexionmovements.215
Whencompared,therangeachievedforunilateralelevationshouldbegreaterthanthatachievedwhenbilateralarmelevationisattempted.Thisisbecausethe
jointsofthecervicothoracicjunctionhavetobepermittedtorotatetowardtheelevatingarm.Theclinicianshouldobservethesmoothnessofthe
scapulohumeralrhythmduringelevationandtheratiobetweenthescapularupwardrotationandGHelevation(seeExaminationoftheDynamicScapula
section).
CompressiveforcesacrosstheACjointoccurmainlyintheterminal60degreesofabduction.Thisoftencausespainduringthisrangeifpathologyexistsat
thisjoint.195
Extension
Activeextension(Fig.1620)isnormally5060degrees.Caremustbetakenwhenmeasuringthismotion(seeChapter13)assubstitutionscanoccurto
seeminglyincreaseextensionbybendingforwardatthewaistorbyretractingthescapula.Asymmetryofshoulderextensioncanindicateweaknessofthe
posteriordeltoidinonearm(swallowtailsign).
FIGURE1620
ShoulderextensionAROM.
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Rotation
ThefollowingarmpositionscanbeusedtoassessIRandER:
Thearmatshoulderlevel(at90degreesofshoulderabduction,90degreesofelbowflexion,andwiththepalmparalleltothefloor).NormalER(Fig.16
21),whichisperformedbyrotatingthehandtowardthefloor,is90degreesorbeyond.AssessingERinthispositionishelpfulindeterminingthe
presenceofafractureofthegreatertuberosity,oradecrementintheperformanceofathrowingathlete.IRisthencarriedout(Fig.1622),rotatingthe
handtowardthehip,asifpositioningitbehindthebody.NormalIRcanapproach90degrees.However,thistestpositionisoftenuncomfortableandnot
veryfunctional,exceptforpitchers.
Thearmtothesideandtheelbowflexedto90degrees.ERisperformedbymovingthehandawayfrommidline(Fig.1623),andIRisperformedby
movingthehandtowardtheabdomen(Fig.1624).Again,itisimportanttoassessactiveandpassiverange,becausealossofactivemotionalonemay
indicatemuscularweakness.
Thearmatthesideandtheforearmbehindtheback(Apleyscratchtest).ThismeasurementforIRisassessedbythepositionreachedwiththeextended
thumbuptheposterior(dorsal)aspectofthespineusingthespinousprocessesaslandmarks(Fig.1625).253Thisismoreofafunctionaltest,andthe
thumbtipofnormalsubjectswillreachtheT5T10level.195Lossofmotionwiththistestaffectsthepatientsabilitytoperformtoiletingduties,hook
brasbehindtheback,reachintoabackpocket,andtuckinshirts.261Theexaminationismaderelativetotheoppositeside,asthereisquitealarge
variationinrangeamongnormalsubjects.InastudybyHovingetal.,262whichassessedtheintraraterandinterraterreliabilityamongrheumatologistsof
astandardizedprotocolformeasurementofshouldermovements,themovementofthehandbehindtheback(andtotalshoulderflexion)yieldedthe
highestICCscoresforbothintraraterreliability(0.91and0.83,respectively)andinterraterreliability(0.80and0.72,respectively).However,inastudy
byEdwardsetal.,263measurementofIRbyvertebrallevelwasnotreadilyreproduciblebetweenobservers.
Thearmat45degreeabductioninthescapularplane(Fig.1626).ThispositionisusedtoassessERforoverheadathletes.
FIGURE1621
Shoulderexternalrotationinsupine.
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FIGURE1622
ShoulderIRinsupine.
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FIGURE1623
Shoulderexternalrotationintheuprightposition.
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FIGURE1624
ShoulderIRinsitting.
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FIGURE1625
Apleyscratchtest.
FIGURE1626
ShoulderERat45degreesabduction.
MostoverheadathletesexhibitexcessiveERanddecreasedIR.Thecauseofthisadaptationhasnotbeenestablished,withsomeauthors264267documenting
humeralosseousretroversionasthecause,whereasothershavetheorizedthatexcessiveERandlimitedIRareduetoanteriorcapsularlaxityandposterior
capsuletightness,268althoughnoclinicalstudieshaveconfirmedthesefindingstodate.GHIRdeficit(GIRD)andposteriorshouldertightness(PST)have
beenlinkedtoshoulderdysfunctionbasedonastudyseriesbyBurkhartetal.268270Incadavericstudies,tighteningtheposteriorcapsulebyplicationhasbeen
showntoincreaseanteriorGHtranslationduringflexionandcrossbodyadduction,causesuperiorGHtranslationwithflexionandERoftheGHjoint,and
markedlydecreaseIR.45,271,272Similarly,GIRDandPSThavebeendemonstratedinthrowingathleteswithinternalimpingement273andinpatientswith
secondaryimpingement.274However,thetheoryofposteriorcapsuletightnesshascomeintoquestionfromotherresearcherswhohavedeterminedthatROM
inbaseballpitchersspecifically,alossofIRdoesnotcorrelatewithanalterationinanteriorGHtranslation.275,276
CLINICALPEARL
Threetermscanbeusedtodescribetherelationshipbetweeninternalandexternalrotationoftheglenohumeraljoint268:
Glenohumeralinternalrotationdeficit(GIRD):definedasthelossinIRbetweenthethrowingshoulderandthenonthrowingshoulder.Normallythedifference
shouldbewithin1820degrees.ThelossofshoulderIRthatoccurswithGIRDresultsfromposteriorcapsuleshorteningandhasbeenshowntopredispose
baseballpitcherstoahigherpotentialforshoulderinjury.
Glenohumeralexternalrotationgain(GERG):definedasthedifferenceinexternalrotationbetweentwoshoulders.
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IftheGIRD/GERGratioisgreaterthanone,thepatientwilllikelydevelopshoulderproblems.269
Totalrotationalmotion(TRM):determinedbyaddingtheamountofERandIRat90degreesofabductiontodeterminetheTRMarc.Anasymmetryof5
degreesispredictiveofanincreasedinjuryrate.277,278
Itisimportantnottodisregardtheeffectofmuscleforcesonthesebiomechanicalchanges.Reinoldetal.279recentlyexaminedthePROMoftheshoulderin31
professionalbaseballpitchers,beforeandimmediatelyafterpitching.TheresearchersreportedthatrotationalrangeofGHmotionwasimmediatelyaffected
byoverheadthrowingandthatmeanIRROMafterpitchingsignificantlydecreased(7316degreesbefore,6511degreesafter)andTRMdecreased
(average,9degrees).MeanERbeforethrowing(13311degrees)didnotsignificantlychangeafterthrowing(13110degrees).Theresearchers
hypothesizedthatthisdecreaseinIRROMwasduetolargeeccentricforcesbeinggeneratedintheexternalrotatorsduringthefollowthroughphaseof
throwingthatcausedmicroscopicmuscledamageintheposteriorshouldermusculature.Previousstudiesexaminingtheeffectofrepetitiveeccentric
contractionshaveshownasubsequentlossofjointROMintheupperandlowerextremitiesfollowingtesting.280282
Wilketal.277proposedtheTRMconcept,wheretheamountofERandIRat90degreesofabductionareaddedandaTRMarcisdetermined.Theauthors
reportedthattheTRMinthethrowingshouldersofprofessionalbaseballpitchersiswithin5degreesofthenonthrowingshoulder277andthataTRMarc
outsidethe5degreerangemaybeacontributingfactortoshoulderinjuriesandsubsequentsurgery.278Thus,althoughthedominantshoulderhasgreaterER
andlessIR,thecombinedtotalmotionshouldbeequalbilaterally.279
CLINICALPEARL
ItislikelythatbilateralcomparisonsofERandIRareusefulintheassessmentoftheoverheadathlete.
HorizontalAdduction
Horizontaladductionisperformedbybringingthearmacrossinfrontofthebody(Fig.1627).PainwithhorizontaladductionmayindicateACjoint
pathology(seeCrossoverImpingement/HorizontalAdductionTestsection).Horizontaladductionisnormally130degreescomparedwith5075degreesif
thearmisbroughtinfrontofthebody.ThelossofhorizontaladductionROMhasbeenidentifiedasapredictorofincreasedinjuryratesinthethrowing
athlete.273,283Tyleretal.283reportedanaveragelossinhorizontaladductionof35degreesinsubjectswithpathologicalinternalimpingement,andanother
studythatassessedchangesinhorizontaladductionmotionbycalculatingthedifferenceinhorizontaladductionbetweenthethrowinginnonthrowingarm,
reportedadecreaseof4.2cminthrowingathleteswithinternalimpingement.273
FIGURE1627
Horizontaladduction.
Movementcombinationsareassessed.
Ifpainisreproducedwheninternalrotationandextensionarecombinedfromapositionof90degreesofabduction,theACjoint,subcoracoidbursa,or
subscapularistendonmaybeimplicated.
Ifthepainisreproducedwithhorizontalabductionwiththehumerusin90degreesofflexion,theshoulderabductors,externalrotators,andsuprascapular
nervemaybeimplicated.Ajammedendfeelwiththismaneuvermayindicateathoracicdysfunction.
Anisolatedlimitationofpassiveexternalrotationmayindicatesubcoracoidbursitis,whichisaggravatedbythepectoralismajormusclebeingstretched
overit.259
Traditionally,PROMhasbeenperformedwiththepatientpositionedinsupine.Giventheimportanceofscapularmotionduringhumeralelevation,caremust
betakentonotpreventthescapulafromrotatingduringthesetests.
Adiscrepancybetweenactiveandpassivemotionmayindicateapainfulperiarticularcondition.227Lossofactivemotionwithpreservationofpassivemotion
islikelycausedbyarotatorcufftear,60orrarely,suprascapularnerveinjury.210,284Aseverelyrestrictedactiveabductionpatternwithnopainissuggestiveof
aruptureofthesupraspinatusordeltoid.Lossofbothactiveandpassivemotionisusuallycausedbyadhesivecapsulitis.214
AlossofPROMoractiveROM(AROM)maybeassociatedwithalossofflexibilityinthepassiverestraintstomotion.Thiscanoccurwithbothsingleplane
motionsandcombinedmotions.36,285288Forexample,ifbothIRandERarerestrictedandmuscletightnesshasbeenruledoutasacause,anadhesionofthe
middleGHligamentisimplicated.288
ExaminationoftheDynamicScapula
Giventheimportanceofthescapulothoracicjointtooverallshoulderfunction,itisimportanttoexaminethescapulothoracicjointarthrokinematicsandmuscle
power.289Observationofthescapulohumeralrhythmandscapulothoracicmotionshouldrevealthatthescapulastopsitsrotationwhenthearmhasbeen
elevatedtoapproximately140degrees.Uponcompletionoftheelevation,theinferiorangleofthescapulashouldbeincloseproximitytothemidlineofthe
thorax,andthevertebralborderofthescapularshouldberotated60degrees.Movementbeyondthesepointsmayindicateexcessivescapularabduction.215At
theendrangeofelevation,thescapulashouldslightlydepress,posteriorlytilt,andadduct.215Themotionofthescapulashouldbeassessedcarefullyinpatients
withsuspectedmultidirectionalinstability.
Ascapulothoracicdyskinesia(decreaseinscapularabductionandERwithprogressivearmabduction)isoftenobservedinpatientswithanteroinferior
instability.290
Posteroinferiorinstabilityischaracterizedbyexcessivescapularretraction.246
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Aninferiorinstabilityischaracterizedbyadroopingofthelateralscapulaorscapulardumping.246
Afterpositioningthepatientinpronewithhisorherarmabductedto90degrees,ERiscarriedouttotesttheabilityofthescapulatoremaininitscorrect
positionratherthanabductingduetoexcessivelengtheningofthethoracoscapularmuscles(trapeziusandrhomboids)andshorteningofthescapulohumeral
muscles.215
Anumberofmusclesplayanimportantroleinthekinematicsofthescapula,includingthetrapeziusandserratusanterior.Increasedactivityoftheupper
trapeziusmuscle,orimbalancesbetweentheupperandthelowertrapeziusmuscle,duringshoulderelevationmayhaveadverseeffectsonthekinematicsofthe
scapula.89,111,164,291
AccordingtoSahrmann,215fourabnormalclinicalfindingsexistforthescapula:
Thescapularalignmentiscorrectbutitsmovementisimpaired.
Thescapularalignmentisimpairedanditsmovementisimpaired.
Thescapularalignmentisimpairedanditsmovementisofnormalrange,butdoesnotcorrectorcompensatefortheimpairedstartposition.
Thescapularalignmentisimpairedbutitsmovementissufficienttocompensatefortheimpairedstartposition.
Kibler24recommendstheuseoftheisometricscapularpinchtesttoexaminethestrengthofthemedialscapularmuscles.Thisinvolvesthepatientsqueezing
hisorhershoulderbladestogether(Fig.1628).Normally,thescapulacanbeheldinthispositionfor1520secondswithoutdifficulty.Ifaburningpainoccurs
inlessthan15seconds,Kiblersuggeststhatscapularmuscleweaknessmaybethecause.24
FIGURE1628
Scapularpinch.
ResistiveTests
Inadditiontopain,shoulderdysfunctionisoftencausedorexacerbatedbyalossofmotionorweakness.Theresistivetestsassessfunctionintheimportant
musclegroupsoftheupperkineticchain(Tables1614and1615).
TABLE1614MuscleGroupsTestedintheShoulderExamination
Trunkflexors,extensors,andobliques
Scapulothoracicelevators
Scapulothoracicdepressors
Scapulothoracicprotractors
Scapulothoracicretractors
Scapulothoracicupwardrotators
Scapulothoracicdownwardrotators
Glenohumeralflexors
Glenohumeralextensors
Glenohumeralabductors
Glenohumeraladductors
Glenohumeralinternalrotators
Glenohumeralexternalrotators
Glenohumeralhorizontalflexors
Glenohumeralhorizontalextensors
Elbowflexors
Elbowextensors
Forearmsupinators
Forearmpronators
Wristflexors
Wristextensors
Handintrinsics
DatafromDaviesGJ,DeCarloMS.Examinationoftheshouldercomplex.In:BandyWD,ed.CurrentConceptsintheRehabilitationoftheShoulder,Sports
PhysicalTherapySectionHomeStudyCourse1995.
TABLE1615ShoulderGirdleMuscleFunctionandInnervation
Muscles PeripheralNerve NerveRoot Motions
Adduction,horizontaladduction,andinternalrotation
Pectoralismajor Pectoral C58 Clavicularfibers:forwardflexion
Sternocostalfibers:extension
Latissimusdorsi Thoracodorsal C7(C6,C8) Adduction,extension,andinternalrotation
Teresmajor Subscapular C58 Adduction,extension,horizontalabduction,andinternalrotation
Teresminor Axillary C5(C6) Horizontalabduction(alsoaweakexternalrotator)
Anterior:forwardflexion,horizontaladduction
Deltoid Axillary C5(C6) Middle:abduction
Posterior:extension,horizontalabduction
Supraspinatus Suprascapular C5(C6) Abduction
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Muscles PeripheralNerve NerveRoot Motions
Subscapularis Subscapular C58 Adduction,andinternalrotation
Infraspinatus Suprascapular C5(C6) Abduction,horizontalabduction,andexternalrotation
Localized,individualisometricmuscletestsaroundtheshouldergirdlecangivetheclinicianinformationaboutpatternsofpainandweaknessandwith
informationregardingweaknessresultingfromaspinalnerverootorperipheralnervepalsy.Ageneralassessmentofshoulderstrengthisinitiallyperformed,
testingflexion,extension,abduction,adduction,IR,andER.Weaknessonisometrictestingneedstobeanalyzedforthetypeincreasingweaknesswith
repeatedcontractionsofthesameresistanceindicatingapalsy,versusconsistentweaknesswithrepeatedcontractions,whichcouldsuggestadeconditioned
muscleorasignificantmuscletearandthepattern(spinalnerveroot,nervetrunk,orperipheralnerve).Apainfulweakness(seeChapters4and5)is
invariablyasignofseriouspathologyand,dependingonthepattern,couldindicateafractureoratumor.However,ifasinglemotionispainfullyweak,this
couldindicatemuscleinhibitionduetopain.Thevariousmotionsofshouldercanbeassessedthroughtheirarcsofmotionbothconcentricallyandeccentrically
againstresistance,asappropriate.
CLINICALPEARL
Painwithisometricmuscletestingisgenerallyconsideredasignoffirstorseconddegreemusculotendinouslesion(seeChapter4).AccordingtoCyriax,249
painthatoccursduringamusclecontractionismorelikelytoindicatealesionwithinamusclebelly,whereaspainthatoccursuponreleaseofthecontractionis
morelikelytoindicatealesionwithinatendon.259However,becauseofthelargeamountofaccessoryjointglidingthatoccursinthegirdlejointswith
isometriccontraction,thetestsforinerttissueinvolvementmustbenegativebeforecomingtotheconclusionthatthemusculotendinousstructureisatfault.
Anumberofresistivetestshavebeendesignedtoisolatethemusclesoftheshouldercomplex.Cyriax275believedthatsupraspinatustendinopathyisthemost
commoncauseofapainfularc.ThesupraspinatuscanbetestedusingtheJobetestoremptycanposition(Fig.1629)VIDEO.Thepatientsarmispositioned
inIRwithinthescaptionplane,atapproximately90degreesofshoulderflexion.Manualresistanceisthenappliedbytheclinicianinadirectiontowardthe
floor.TheJobetestcanbeperformedsimilarlywiththehumerusexternallyrotated(fullcantest)(Fig.1630)VIDEO.Onestudy292foundtheemptycantest
tohaveahighsensitivityof86%andalowspecificityof50%indiagnosingsupraspinatustendontearsinaseriesof55patients.However,inanotherstudy,293
thefullcantesthadhigherspecificity(74%vs.68%)andanequalsensitivityof77%whencomparedwiththeemptycantestinaseriesof136patients.
FIGURE1629
Jobeoremptycantestforsupraspinatus.
FIGURE1630
Fullcantest.
Apartialruptureofthesupraspinatustendonwillresultinabductionthatisbothweakandpainful.68Apainlessweaknesswithabductioncouldindicatea
completeruptureofthesupraspinatustendon,althoughthedeltoidcannotberuledout.Thetendonofthesupraspinatuscanbepassivelystretchedby
positioningthehumerusinadductionandIRtoseeifthisincreasesthepain.294
Ithasbeendocumentedthatifcoracohumeralpaindecreaseswiththeadditionofarmtractionduringresistedabduction,subacromialsubdeltoidbursitisoran
ACjointlesionshouldbesuspected.295However,thiswasnotfoundtobethecasewithultrasonography.296
Thetestpositionfortheinfraspinatusandteresminormusclesis90degreesofGHflexionandonehalffullER(Fig.1631).116IfthepainisisolatedtoER,
thentheinfraspinatusisatfault.IfERandresistedadductionarepainful,theteresminorisatfault,althoughisolatedinvolvementoftheteresminorisnot
common.Totesttheteresminorfurther,themuscleisplacedonstretchbyputtingthepatientinthepronepositionwithhisorherupperarmsvertical,
adducted,andexternallyrotatedtoapproximately20degrees.Thepatientisaskedtoleantowardthetestedsidetoincreasetheadduction.
FIGURE1631
Resistedtestforinfraspinatusandteresminor.
Theteresmajormusclecanbetestedbyputtingthepatientinthepronepositionwithhisorherhandrestingonhisorherlowerback(Fig.1632)VIDEO.The
patientisaskedtoadductandextendthehumeruswhiletheclinicianappliesresistanceattheelbowintoshoulderabduction.
FIGURE1632
Resistedtestforteresmajor.
CLINICALPEARL
Aproperbalancebetweenagonistandantagonistmusclegroupsarenecessarytoprovidedynamicstabilizationtotheshoulderjoint.297Forexampletoprovide
propermusclebalance,theglenohumeraljointexternalrotatormusclesshouldbeatthe65%ofthestrengthoftheinternalrotatormuscles.298Ultimatelythe
externalinternalrotationmusclestrengthratioshouldbe6675%.298
Toassessforrhomboiddominance,thepatientpositionstheirarmsbytheirsidewiththeirelbowflexedtoapproximately90degrees.ResistedERinthis
positionshouldnotresultinanyscapularadduction,unlessthereisrhomboiddominanceandpoorcontrolofGHER.215Thereshouldalsobenosuperioror
anteriorglidingofthehumerusduringthistest,unlessdeltoiddominanceisoccurring.215
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ConditionstoberuledoutifthereisapainlessweaknessofERinclude,butarenotlimitedto,thefollowing:
Acompleteruptureoftheinfraspinatustendon
AC5nerverootpalsy
Asuprascapularnervepalsy
Neuralgicamyotrophy
ThesubscapularisisbestassessedusingtheliftofftestasdescribedbyGerberandKrushell.Theliftofftestisperformedwiththearminternallyrotatedso
thattheposteriorsurfaceofthehandrestsonthelowerback.Activelyliftingthehandawayfromtheback(Fig.1633)againstaresistingforcesuggest
integrityofthesubscapularis.Failuretodosoindicatesasubscapularistear.Thetesthasbeenfoundtohaveasensitivityof80%andaspecificityof100%for
atearofthesubscapularis.299AsimilartestistheIRlagsigntest(seeSpecialTestssection).
FIGURE1633
Liftofftest.
Resistedadductionistestedwiththearmat0degreesofabductionsothatthesubscapularisisnotfacilitated.299Painwithresistedadductiontendstobefairly
rare,butcouldimplicatethepectoralismajor,latissimusdorsi,teresmajor,orteresminor.
CLINICALPEARL
Apatientwithsubacromialsubdeltoidbursitis,intheabsenceofarotatorcufftear,willoftendemonstrateweaknessoftherotatorcuffsecondarytopainif
testedwiththearmpositionedinthearcofimpingement.Itwill,however,showgoodstrengthiftestedwiththearmoutofabduction.Apatientwitha
significantcufftearusuallydemonstratesprofoundweaknessoftherotatorcuffinvariousarmpositions.
Testingofdeltoidfunctionisbestdonewithresistedabductionwiththearmat90degreesofabductionandneutralrotation(Fig.1634)VIDEO.195Apainful
arccannotbeproducedbyalesiontothedeltoidmuscleduetoitsanatomicalposition.
FIGURE1634
Resisteddeltoid.
Differentialdiagnosiswillbeneededtoruleoutseveralneurologicaldisorders,whichmayprovokepainlessweaknessonresistedabduction.Theseincludean
axillarynervepalsy,asuprascapularnervepalsy,orafifthcervicalrootpalsy.
Thethreecomponentsofthetrapeziusareassessedasfollows:
Uppertrapezius(andlevatorscapulae).Usuallybothsidesaretestedsimultaneously.Thepatientisaskedtoshrugtheshoulderstotheears.Ifthe
patientisunabletoperformthisaction,heorsheliesinthesupinepositiontoeliminatetheeffectofgravityandaskedtorepeatthetest.Resistanceis
appliedbytheclinicianinanattempttodepresstheshouldersVIDEO.Unilateralresistancecanbeappliedtotheposteriorlateralaspectofthehead
whilestabilizingtheshoulder.
Middletrapezius.Thepatientliesinthepronepositionwiththeshoulderjointabductedto90degrees,elbowextended,andtheforearminmaximum
supinationsothatthethumbispointingtotheceiling(Fig.1635)VIDEO.Theclinicianappliespressureonthehumerusbypushingtowardthefloor.
Lowertrapezius.Thepatientliesintheproneposition,withtheupperlimbsupportedintheelevatedpositionandalignedinthedirectionofthelower
trapeziusmusclefibers(Fig.1636)VIDEO.Grades02aredeterminedbythefirmnessofthemusclecontraction.Grades2+and3arebasedonhow
farthelimbisliftedfromthetable.Grades35requiretheapplicationofresistancebytheclinician.
FIGURE1635
Middletrapeziustest.
FIGURE1636
Lowertrapeziustest.
Asdiscussedinthebiomechanicssection,properscapularmovementandstabilityareimperativeforasymptomaticshoulderfunction.24Theserratusanterior
canbeassessedinanumberofwaysVIDEO,includingusingthewallpushup.Amoresensitivetestinvolvesputtingthepatientinthesupinepositionwith
hisorhershoulderflexedto90degreesandtheirelbowflexed.Thepatientisaskedtoprotracttheshoulderbyliftingthestraightarmtowardtheceiling.
Resistanceisappliedbytheclinicianatthehand,pushingdownward(Fig.1637).Giventhattheserratusanteriorfunctionstocontrolupwardrotationofthe
scapuladuringarmelevation,thisabilityshouldalsobeassessed.
FIGURE1637
Serratusanteriortest.
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Finally,resistedelbowflexionandextension,aswellasforearmsupination(seeChapter17),areexaminedtoassessthebicepsVIDEO,brachialisVIDEO,
andtricepsfunctionVIDEO.Isometricelbowextensionandflexionwiththemusclesinastretchedpositionwillhelpexcludethebicepsandtricepsmuscles.
Painreproducedwithresistedelbowflexioncouldindicatealesiontooneormoreoftheelbowflexors,suchasanintraarticularlesionoftheLHBoralesion
inthesulcusoftheLHB.Thesulcuslesioncanbetestedwiththepatientsidelying,facingawayfromtheclinician,andtheirarmhangingbehindthem.The
clinicianstabilizesthescapulaandappliesalongitudinalforcealongthehumerusinasuperiordirectiontodrivethehumerussuperiorly.Apositivesignispain
reproducedwiththismaneuver.
Apainlessweaknessofelbowflexioncanresultfromafifthcervicalrootpalsy,orasixthcervicalrootpalsy(acompleteruptureofalloftheelbowflexorsis
anextremelyunlikelyevent.)
Thewristandhandarealsoevaluatedformotorfunctionasappropriate(seeChapter18).
ExaminationofMovementPatterns
Thesetestsareconcernedwiththecoordination,timing,orsequenceofactivationofthemusclesduringmovement.215
SerratusAnterior
Thepatientliesinthepronepositionandisaskedtoperformapushupandthenreturntothestartpositionextremelyslowly.Theclinicianchecksforthe
qualityofscapulastabilization.Ifthestabilizersareweak,thescapulaonthesideofimpairmentwillshiftoutwardandupwardwitharesultantwingingofthe
scapula.
ShoulderAbduction
Thepatientsitswithhisorherelbowflexedtocontrolthehumeralrotation.Thepatientisaskedtoslowlyabductthearm.Threecomponentsareevaluated:
AbductionattheGHjoint
Rotationofthescapula
Elevationofthewholeshouldergirdletheabductionmovementisstoppedatthepointatwhichtheshoulderbeginstoelevatethistypicallyoccursat
approximately60degreesofGHabduction
FunctionalTesting
Theassessmentofshoulderfunctionisanintegralpartoftheexaminationoftheshouldercomplex.Functionaltestingoftheshouldercomplexcanincludetests
designedtodetectabiomechanicaldysfunctionortestsdesignedtoassessthepatientsabilitytoperformthebasicfunctionsofADL.Giventhenumberof
differentshoulderconditionsthatexist,itisimportanttorememberthateachofthefollowingfunctionaltestsmayhavespecificlimitedapplications.
BiomechanicalFunction
Thereareonlytwofunctionalmotionswithintheshouldergirdle:armelevationusingacombinationofflexionandabduction,andarmextensionwith
adduction.Allothermotionsoftheshoulderarepartsorcompositesofthesetwobasicfunctionalsets.
BasicFunctionTesting
ByreferringtoTable1616,thecliniciancandeterminethefunctionalstatusoftheshoulderforbasicfunctionssimplybymeasuringtheamountofavailable
ROM.Forexample,humeralmotionsnecessaryforeatinganddrinkinghavebeenreportedat545degreesofflexion,535degreesofabduction,and525
degreesofIRrelativetothetrunk.300Combinghairhasbeenfoundtorequire112degreesofarmelevation.190
TABLE1616RangeofMotionNecessaryattheShoulderforFunctionalActivities
Activity NecessaryRangeofMotion
70100degreehorizontaladduction
Eating
4560degreeabduction
Combinghair 105120degreeabduction
90degreeexternalrotation
7590degreehorizontalabduction
Reachperineum 3045degreeabduction
90degreeorgreaterinternalrotation
5060degreehorizontalabduction
Tuckinshirt 5565degreeabduction
90degreeinternalrotation
Positionhandbehindhead 110125degreeforwardflexion
Putanitemonashelf 7080degreeforwardflexion
6090degreeforwardflexion
Washoppositeshoulder
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DatafromMatsenFHIII,LippittSB,SidlesJA,etal.PracticalEvaluationofManagementoftheShoulder.Philadelphia,PA:WBSaunders1994:19150
MageeDJ.Shoulder,OrthopaedicPhysicalAssessment.Philadelphia,PA:WBSaunders1992:90142.
Mannerkorpi301usedthreefunctionaltests(handtoneck,handtoscapula,andhandtooppositescapula)toassessshoulderdysfunctioninpatientswith
fibromyalgia(Table1617).YangandLin302assessedtheintertesterandintratesterreliabilityofthesefunctionaltestsandfoundthemtobereliablefor
documentingreducedfunctionoftheshoulder.
TABLE1617FunctionRelatedTests
Thefingersreachtheposteriormedianlineoftheneckwiththeshoulderinfullabductionandexternal
0 rotationwithoutwristextension
Handtobackofneck(shoulderflexionand 1 Thefingersreachthemedianlineoftheneckbutdonothavefullabductionand/orexternalrotation
2 Thefingersreachthemedianlineoftheneck,butwithcompensationbyadductioninthehorizontalplane
externalrotation)a 3 orbyshoulderelevation
4 Thefingerstouchtheneck
Thefingersdonotreachtheneck
Thehandreachesbehindthetrunktotheoppositescapulaor5cmbeneathitinfullinternalrotation.The
0
wristisnotlaterallydeviated
Handtoscapula(shoulderextensionandinternal 1 Thehandalmostreachestheoppositescapula,615cmbeneathit
2
rotation)b 3
Thehandreachestheoppositeiliaccrest
Thehandreachesthebuttock
4
Subjectcannotmovethehandbehindthetrunk
0 Thehandreachestothespineofoppositescapulainfulladductionwithoutwristflexion
Handtooppositescapula(shoulderhorizontal 1 Thehandreachestothespineoftheoppositescapulainfulladduction
adduction)c 2 Thehandpassesthemidlineofthetrunk
3 Thehandcannotpassthemidlineofthetrunk
aThistestmeasuresanactionessentialfordailyactivities,suchasusingthearmtoreach,pull,orhanganobjectoverheadorusingthearmtopickupanddrink
acupofwater.
bThistestmeasuresanactionessentialfordailyactivities,suchasusingthearmtopullanobjectoutofabackpocketortasksrelatedtopersonalcare.
cThistestmeasuresanactionimportantfordailyactivities,suchasusingthearmtoreachacrossthebodytogetacarsseatbeltorusingthearmtoturna
steeringwheel.
DatafromMannerkorpiK,SvantessonU,CarlssonJ,etal.Testsoffunctionallimitationsinfibromyalgiasyndrome:Areliabilitystudy.ArthritisCoreRes.
199912:193199.
TheassessmenttooloutlinedinTable1618canalsobeusedasafunctionaltestoftheshoulder.Lowerhigherindicatelesspainandgreaterfunction.
TABLE1618FunctionalTestingoftheShoulder
StartingPosition Action FunctionalTest
Raise13lbweight:functionallyfair
Sitting,cuffweightattachedtowrist Forwardflexarmto90degrees,elbowextended Raisearmwithoutweight:functionallypoor
Cannotraisearm:nonfunctional
Raise45lbweight:functional
Raise34lbweight:functionalfair
Sitting,cuffweightattachedtowrist Extendshoulder,elbowextended
Raisearmwithoutweight:functionallypoor
Cannotextendarm:nonfunctional
Sittingwithhandbehindlowback Shoulderinternalrotation
Sidelying,cuffweightattachedtowrist Shoulderexternalrotation
Sitting,cuffweightattachedtowrist Shoulderabductionto90degrees
Pull5lbweight:functional
Pull34lbweight:functionalfair
Sitting,armabductedto145degrees Shoulderadduction
Pull12lbweight:functionallypoor
Cannotpull1lb:nonfunctional
Fiverepetitions:functional
Threetofourrepetitions:functionalfair
Sitting Shoulderelevation(shouldershrug) Onetotworepetitions:functionallypoor
Zerorepetitions:nonfunctional
Fiverepetitions:functional
Threetofourrepetitions:functionalfair
Sitting Scapulardepression
Onetotworepetitions:functionallypoor
Zerorepetitions:nonfunctional
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DatafromMatsenFHIII,LippittSB,SidlesJA,etal.PracticalEvaluationofManagementoftheShoulder.Philadelphia,PA:WBSaunders1994:19150
MageeDJ:Shoulder,OrthopaedicPhysicalAssessment.Philadelphia,PA:WBSaunders1992:90142PalmerML,EplerM.ClinicalAssessmentProcedures
inPhysicalTherapy.Philadelphia,PA:JBLippincott1990.
OneArmHopTest
Theonearmhoptestisafunctionalperformancetestforathletes,whichcanbeusedinpreseasonscreensortoassistinreturntoplaydecisions.Thetest
requiresthepatienttobeinaonearmpushuppositiononthefloor(Fig.1638).Thepatientuseshisarmtohopontoa10.2cm(4in)stepandbacktothe
floor.Thetimerequiredtoperformfiverepetitionsofthismovementasquicklyaspossibleisrecordedandcomparedwiththeuninvolvedarm.Withsufficient
training,atimeofunder10secondsisconsiderednormal.303
FIGURE1638
Onearmpushupposition.
Theonearmhoptestrequiresconcentricandeccentricmusclestrengthandcoordinationwhilethedistalportionoftheupperextremityhasasignificantload
placeduponit.303
ShoulderOutcomeScales
Severalgenericandregionspecificoutcometoolshavebeendevelopedandusedtodocumentoutcomesofpatientswithshoulderpathologies.Anumberof
shoulderoutcomescaleshavebeendeveloped.FiveofthemostcommonlyusedshoulderoutcomescalesaretheUniversityofCaliforniaLosAngeles(UCLA)
shoulderscale,thesimpleshouldertest(SST),theShoulderPainandDisabilityIndex(SPADI),theDisabilitiesoftheArm,Shoulder,andHand(DASH),and
thePennShoulderScore(PSS).
UniversityofCaliforniaLosAngeles(UCLA)ShoulderScale
TheselfreportsectionoftheUCLAShoulderScaleconsistsoftwosingleitemsubscales,oneforpainandtheotherforfunctionallevel(Table1619).The
itemsareLikerttype(apsychometricscale)andscoredfrom1to10,withhigherscoresindicatinglesspainandgreaterfunction.304
TABLE1619UCLAShoulderRatingScale
Pain Rating
Always/unbearable/strongmedication 1
Always/bearable/occasionalmedication 2
Littleatrest/presentwithlightactivity 4
Presentwithheavyactivity 6
Occasionalandslight 8
None 10
Function
Unabletouse 1
Lightactivities 2
ADLs/lighthousework 4
Housework/shopping/driving 6
Slightrestriction/overshoulderlevelOK 8
Normal 10
Activeforwardflexion
>150 5
150 4
120 3
90 2
45 1
<30 0
Strengthofforwardflexion
Normalgrade 5
Goodgrade 4
Fairgrade 3
Poorgrade 2
Contractiongrade 1
Nothing/grade 0
Patientsatisfaction
Satisfied
5
Notsatisfied
0
TOTAL________
TheSimpleShoulderTest
Lippittetal.305advocatetheuseoftheSST(Table1620).TheSSTisastandardizedselfassessmentofshoulderfunctionconsistingof12yes/noquestions.
TheSSThashightestandretestreproducibilityandissensitivetoawidevarietyofshoulderdisorders.305Inaddition,theSSThasbeenshowntobea
practicaltoolfordocumentingtheefficacyoftreatmentforshoulderconditions.Patientswithoutrotatorcuffdiseaseorothershoulderdisordersareunableto
doall12functionsoftheSST.205,306308
TABLE1620TheSimpleShoulderTest
1.Isyourshouldercomfortablewithyourarmatrestbyyourside?
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1.Isyourshouldercomfortablewithyourarmatrestbyyourside?
2.Doesyourshoulderallowyoutosleepcomfortably?
3.Canyoureachthesmallofyourbacktotuckinyourshirtwithyourhand?
4.Canyouplaceyourhandbehindyourheadwiththeelbowstraightouttotheside?
5.Canyouplaceacoinonashelfatthelevelofyourshoulderwithoutbendingyourelbow?
6.Canyoulift1lb(afullpintcontainer)tothelevelofyourshoulderwithoutbendingyourelbow?
7.Canyoulift8lb(afullgalloncontainer)tothelevelofthetopofyourheadwithoutbendingyourelbow?
8.Canyoucarry20lbatyoursidewiththeaffectedextremity?
9.Doyouthinkyoucantossasoftballunderhand10yardswiththeaffectedextremity?
10.Doyouthinkyoucanthrowasoftballoverhand20yardswiththeaffectedextremity?
11.Canyouwashthebackofyouroppositeshoulderwiththeaffectedextremity?
12.Wouldyourshoulderallowyoutoworkfulltimeatyourusualjob?
DatafromMatsenFA,LippittSB,SidlesJA,etal.Evaluatingtheshoulder.In:MatsenFA,LippittSB,SidlesJA,etal.,eds.PracticalEvaluationand
ManagementoftheShoulder.Philadelphia,PA:WBSaunders1994:117.
Whencomparedwithotheravailableshoulderselfassessmentquestionnaires,theSSThasthehighesttest/retestreliability,takestheshortestamountoftime
forapatienttocomplete,istheeasiesttoscore,andhassatisfactoryresponsiveness.309,310Thequestionscanbeaskedattheinitialvisitandthenatsubsequent
visitstotrackprogress.
ShoulderPainandDisabilityIndex.311
TheSPADIconsistsoftwoselfreportsubscalesofpainanddisability.Theitemsofboththesubscalesarevisualanalogscales(VASs).Thefiveitempain
subscaleaskspeopleabouttheirpainduringADL,andeachitemisanchoredbythedescriptorsnopain(leftanchor)andworstpainimaginable(right
anchor).TheeightdisabilityitemsaskpeopleabouttheirdifficultyperformingADL.Theseitemsareanchoredwiththedescriptorsnodifficulty(leftanchor)
andsodifficultitrequiredhelp(rightanchor).Eachitemisscoredbymeasuringthedistancefromtheleftanchortothemarkmadebytheperson.Subscales
arescoredinathreepartprocess.First,itemscoreswithinthesubscalearesummed.Second,thissumisdividedbythesummeddistancepossibleacrossall
itemsofthesubscaletowhichthepersonresponded.Third,thisratioismultipliedby100toobtainapercentage.Higherscoresonthesubscaleindicategreater
painandgreaterdisability.ToobtaintheSPADItotalscore,thepainanddisabilitysubscalesscoresareaveraged.311
DisabilitiesoftheArm,Shoulder,andHand
TheacronymDASHwaschosentodescribeanoutcomemeasurethatreflectstheimpactonfunctionofavarietyofmusculoskeletaldiseasesandinjuriesinthe
upperextremity.312ItemscoveredbytheDASHquestionnairearesymptomsandfunctionalstatus.Thecomponentsincludedundertheconceptofsymptoms
arepain,weakness,stiffness,andtingling/numbness.312Therearethreedimensionsunderfunctionalstatus:physical,social,andpsychologicalstatus.Two
versionsoftheDASHareavailable:a30itemquestionnairethathasoptionalthreequestionmodulesforsport/musicandheavyworkactivities(Table1621),
anda1520itemquestionnairesuitableforofficeuse.
TABLE1621TheDASHQuestionnaire
Pleaserateyourabilitytodothefollowingactivitiesinthelastweekbycirclingthenumberbelowtheappropriateresponse
No Mild Moderate Severe
Unable
Difficulty Difficulty Difficulty Difficulty
1.Openatightornewjar
2.Write
3.Turnakey
4.Prepareameal
5.Pushopenaheavydoor
6.Placeanobjectonashelfaboveyourhead
1 2 3 4 5
7.Doheavyhouseholdchores(e.g.,washwalls,washfloors) 1 2 3 4 5
1 2 3 4 5
8.Gardenordoyardwork 1 2 3 4 5
1 2 3 4 5
9.Makeabed
1 2 3 4 5
10.Carryashoppingbagorbriefcase 1 2 3 4 5
1 2 3 4 5
11.Carryaheavyobject(over10lb) 1 2 3 4 5
1 2 3 4 5
12.Changealightbulboverhead 1 2 3 4 5
1 2 3 4 5
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13.Washorblowdryyourhair 1 2 3 4 5
1 2 3 4 5
14.Washyourback 1 2 3 4 5
1 2 3 4 5
15.Putonapulloversweater 1 2 3 4 5
1 2 3 4 5
16.Useaknifetocutfood 1 2 3 4 5
1 2 3 4 5
17.Recreationalactivitieswhichrequirelittleeffort(e.g.,cardplaying,knitting,etc.) 1 2 3 4 5
18.Recreationalactivitiesinwhichyoutakesomeforceorimpactthroughyourarm,shoulder,
orhand(e.g.,golf,hammering,tennis,etc.)
19.Recreationalactivitiesinwhichyoumoveyourarmfreely(e.g.,playingfrisbee,badminton,
etc.)
20.Managetransportationneeds(gettingfromoneplacetoanother)
21.Sexualactivities
Disabilitiesofthearm,shoulder,andhand
Quitea
Notatall Slightly Moderately Extremely
Bit
22.Duringthepastweek,towhatextenthasyourarm,shoulder,orhandprobleminterferedwith
1 2 3 4 5
yournormalsocialactivitieswithfamily,friends,neighbors,orgroups?(circlenumber)
Not
Slightly Moderately Very
Limited Unable
Limited Limited Limited
atAll
23.Duringthepastweek,wereyoulimitedinyourworkorotherregulardailyactivitiesasa
1 2 3 4 5
resultofyourarm,shoulder,orhandproblem?(circlenumber)
Pleaseratetheseverityofthefollowingsymptomsinthelastweek(circlenumber)
None Mild Moderate Severe Extreme
24.Arm,shoulder,orhandpain 1 2 3 4 5
25.Arm,shoulder,orhandpainwhenyouperformedanyspecificactivity 1 2 3 4 5
26.Tingling(pinsandneedles)inyourarm,shoulder,orhand
27.Weaknessinyourarm,shoulder,orhand 1 2 3 4 5
28.Stiffnessinyourarm,shoulder,orhand 1 2 3 4 5
29.Duringthepastweek,howmuchdifficultyhaveyouhadsleepingbecauseofthepaininyour 1 2 3 4 5
arm,shoulderorhand?(circlenumber) 1 2 3 4 5
Strongly NeitherAgree Strongly
Disagree Agree
Disagree norDisagree Agree
30.Ifeellesscapable,lessconfident,orlessusefulbecauseofmyarm,shoulder,orhandproblem
1 2 3 4 5
(circlenumber)
ScoringDASHfunction/symptoms:Addupcircledresponses(items130)subtract30divideby1.20=DASHscore.
Sports/performingartsmodule(optional)
Thefollowingquestionsrelatetotheimpactofyourarm,shoulder,orhandproblemonplayingyourmusicalinstrumentorsport.Ifyouplaymorethanone
sportorinstrument(orplayboth),pleaseanswerwithrespecttothatactivitywhichismostimportant.
Pleaseindicatethesportorinstrumentwhichismostimportanttoyou:__________________________
Idonotplayasportoraninstrument.(Youmayskipthissection.)
Pleasecirclethenumberthatbestdescribesyourphysicalabilityinthepastweek.Didyouhaveanydifficulty
Unable
1.Usingyourusualtechniqueforplayingyourinstrumentorsport? 1 2 3 4 5
2.Playingyourmusicalinstrumentorsportbecauseofarm,shoulder,orhandpain? 1 2 3 4 5
3.Playingyourmusicalinstrumentorsportaswellasyouwouldlike? 1 2 3 4 5
4.Spendingyourusualamountoftimepracticingorplayingyourinstrumentorsport? 1 2 3 4 5
Workmodule(optional)
Thefollowingquestionsaskabouttheimpactofyourarm,shoulder,orhandproblemonyourabilitytowork(includinghomemakersifthatisyourmainwork
role).
Idonotwork.(Youmayskipthissection.)
Pleasecirclethenumberthatbestdescribesyourphysicalabilityinthepastweek.Didyouhaveanydifficulty
Unable
1.Usingyourusualtechniqueforyourwork? 1 2 3 4 5
2.Doingyourusualworkbecauseofarm,shoulder,orhandpain? 1 2 3 4 5
3.Doingyourworkaswellasyouwouldlike? 1 2 3 4 5
4.Spendingyourusualamountoftimedoingyourwork? 1 2 3 4 5
PennShoulderScore
PSSisaconditionspecificselfreportmeasurethatusesa100pointscaleconsistingofthreesubscales,includingpain,satisfaction,andfunction.Thepain
subscaleconsistsofthreepainitemsthataddresspainatrest,withnoactivities,andwithstrenuousactivities(Table1622).313Allarebasedona10point
numericratingscalewithendpointsofnopainandworstpossiblepain.Pointsareawardedforeachitembysubtractingthenumbercircledfromthe
maximumof10.Thereforeapatientisawarded30pointsforcompleteabsenceofpain.Ifapatientisnotabletousethearmfornormalorstrenuousactivities,
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zeropointsareawardedforthatitem.Patientsatisfactionwithshoulderfunctionisalsoassessedwitha10pointnumericratingscale(Table1623).Theend
pointsarenotsatisfiedandverysatisfied.Amaximumof10pointsforthissectionindicatesthatthepatientisverysatisfiedwiththecurrentlevelof
functionofhisorhershoulder.ThetotalPSSmaximumscoreof100indicateshighfunctionlowpainandhighsatisfactionwiththefunctionoftheshoulder.
ThePSShasbeenfoundtobeareliableandvalidmeasureforreportingoutcomeofpatientswithvariousshoulderdisorders.313
TABLE1622ThePennShoulderScore,Part1:PainandSatisfactionSubscales
PleaseCircletheNumberClosesttoYourLevelofPainorSatisfaction OfficeUseOnly
Painatrestwithyourarmbyyourside: (10#circled)
0 1 2 3 4 5 6 7 8 9 10
Nopain Worstpainpossible
Painwithnormalactivities(eating,dressing,bathing): (10#circled)(Score0ifnotapplicable)
0 1 2 3 4 5 6 7 8 9 10
Painwithstrenuousactivities(reaching,lifting,pushing,pulling,throwing): (10#circled)(Score0ifnotapplicable)
0 1 2 3 4 5 6 7 8 9 10
Painscore: =30
Howsatisfiedareyouwiththecurrentleveloffunctionofyourshoulder? /10(#circled)
0 1 2 3 4 5 6 7 8 9 10
DatafromLegginBG,MichenerLA,ShafferMA,etal.ThePennshoulderscore:Reliabilityandvalidity.JOrthopSportsPhysTher.200636:138151.
TABLE1623ThePennShoulderScore:FunctionSubscale
PleaseCircletheNumberthatBestDescribestheLevelofDifficultyYouMight No Some Much CantDo DidNotDoBefore
HavePerformingEachActivity Difficulty Difficulty Difficulty AtAll Injury
1.Reachthesmallofyourbacktotuckinyourshirtwithyourhand
2.Washthemiddleofyourback/hookbra
3.Performnecessarytoiletingactivities
4.Washthebackofoppositeshoulder
5.Combhair
6.Placehandbehindheadwithelbowheldstraightouttotheside
3 2 1 0 X
7.Dressself(includingputoncoatandpullshirtoffoverhead) 3 2 1 0 X
3 2 1 0 X
8.Sleeponaffectedside 3 2 1 0 X
3 2 1 0 X
9.Openadoorwithaffectedarm 3 2 1 0 X
3 2 1 0 X
10.Carryabagofgrocerieswithaffectedarm 3 2 1 0 X
3 2 1 0 X
11.Carryabriefcase/smallsuitcasewithaffectedarm 3 2 1 0 X
3 2 1 0 X
12.Placeasoupcan(12lb)onashelfatshoulderlevelwithoutbendingelbow 3 2 1 0 X
3 2 1 0 X
13.Placeaonegalloncontainer(810lb)onashelfatshoulderlevelwithout 3 2 1 0 X
bendingelbow 3 2 1 0 X
3 2 1 0 X
14.Reachashelfaboveyourheadwithoutbendingyourelbow 3 2 1 0 X
3 2 1 0 X
15.Placeasoupcan(12lb)onashelfoverheadwithoutbendingyourelbow 3 2 1 0 X
3 2 1 0 X
16.Placeaonegalloncontainer(810lb)onashelfoverheadwithoutbendingyour
elbow
17.Performusualsport/hobby
18.Performhouseholdchores(cleaning,laundry,cooking)
19.Throwoverhand/swim/overheadracquetsports(circleallthatapplytoyou)
20.Workfulltimeatyourregularjob
SCORING
Totalofcolumns=___(a)
NumberofXs3=___(b),60__(b)=___(c)(ifnoXsarecircled,functionscore=totalofcolumns)
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Functionscore=__(a)__(c)=__60__/60
PatientSpecificFunctionalScale
Althoughnotspecifictotheshoulder,thePSFS,inwhichpatientsareaskedtochooseactivitiesthataredifficulttoperformand,subsequently,toratethelevel
ofdisabilityforeachactivityonaratingscale(seeChapter4),Koehorstetal.314reportedthatthePSFSisareliable,valid,andresponsiveinstrumentthatcan
beusedasanevaluatedinstrumentinpatientswithaprimaryshouldercomplaint.
MuscleLengthTests
PectoralisMajor
Thepatientliesinthesupinepositionwiththetrunkstabilized.Theclinicianpassivelyabductsthepatientsarmanddifferentiatesbetweenthedifferentbands
ofthepectoralismajor.
ClavicularPortion
Thepatientsarmhangslooselydownovertheedgeofthetable.Theclinicianmovesthepatientsshoulderdowntowardthefloor.Aslightbarriertothe
motionisnormal,whereasahardbarrierisabnormal.
SternalPortion
Withthepatientsupineonamattable,theyactivelyabducttheirarmfully.Theirarmshouldmaintaincontactwiththetablethroughouttherange.
PectoralisMinor
Thepatientliesinthesupinepositionwiththetrunkstabilized.Adaptiveshorteningofthepectoralisminorisdemonstratedifthelateralborderofthespineof
thescapulaismorethan1inoffthetable.215
LatissimusDorsi
Thepatientliesinthesupinepositionwiththetrunkstabilized.Thepatientisaskedtoperformbilateralshoulderflexion.Undernormalcircumstances,the
patientshouldbeabletoperformcompleteshoulderflexionwithoutanyincreaseinlumbarlordosisoccurring.215Shoulderflexionthatrequiresanincreasein
lumbarlordosistocompleteisindicativeofanadaptivelyshortenedlatissimusdorsi.
ExternalRotators
Thepatientliesinthesupinepositionwiththetrunkstabilized.Theshoulderispositionedat90degreesofabductionwiththeelbowflexedtoapproximately
90degrees.Thepatientisthenaskedtoallowtheshouldertopassivelyinternallyrotate.IRaccompaniedbyananteriortiltofthescapula,ratherthantherange
ofIRincreasing,isindicativeofadaptiveshortnessoftheexternalrotators.215Thisisconfirmedbyhavingthepatientperformthemaneuveragainwhilethe
clinicianpreventstheanteriortiltofthescapulafromoccurring.Withthesecondtest,thereshouldbeadecreaseintheamountofpassiveIRavailable.
PassiveAccessoryMotionTests
Thepassiveaccessorymotiontestsareperformedattheendofthepatientsavailablerangetodetermineifthejointitselfisresponsibleforthelossofmotion.
Forallofthesetests,thejointisinitiallypositionedintherestingoropenpackedposition,thepatientliesinthesupinepositionwiththeirheadsupportedona
pillowifrequired,whiletheclinicianstandsfacingthepatient.
DistractionoftheGHJoint
Theclinicianpalpatesandstabilizestheshouldergirdleandtheanteriorthorax.Withonehand,thecliniciangentlygraspstheproximalthirdofthehumerus.
ThecliniciandistractstheGHjointperpendiculartotheplaneoftheglenoidfossainalateral,anterior,andinferiordirection(30degreesoffthesagittalplane)
(Fig.1639).Thequantityofmotionisnotedandcomparedwiththeotherside.Alternatively,ifthearmispositionedsothatthelongaxisofthehumerusis
perpendiculartotheflattenedconcavesurfaceoftheglenoid,thetechniquecanbeperformedbypullingontheupperarm(Fig.1640).
FIGURE1639
Glenohumeraldistraction.
FIGURE1640
Glenohumeraldistractionusingarmpull.
InferiorGlideoftheGHJoint
Theclinicianpalpatesandstabilizesthecoracoidprocessofthescapulaandthelateralclavicle.Withtheotherhand,thecliniciangentlygraspsproximaltothe
patientselbow.ThehumerusisglidedinferiorlyattheGHjoint,paralleltothesuperoinferiorplaneoftheglenoidfossa(Fig.1641).Thequantityofmotion
isnotedandcomparedwiththeotherside.
FIGURE1641
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Inferiorglide.
PosteriorGlideoftheGHJoint
Theclinicianpalpatesandstabilizesthecoracoidprocessandthelateralthirdoftheclavicle.Withthethenareminenceofthesamehand,theclinicianpalpates
theanterioraspectofthehumeralhead(Fig.1642).Withtheotherhand,thecliniciangentlygraspsthedistalendofthehumerus.Fromthisposition,the
clinicianglidesthehumerusposteriorlyattheGHjoint,paralleltotheAPplaneoftheglenoidfossa.Thequantityofmotionisnotedandcomparedwiththe
otherside.
FIGURE1642
Posteriorglide.
AnteriorGlideoftheGHJoint
Therearetwocommonvariationsforthistechnique,onewiththepatientinthesupineposition,andtheotherwherethepatientliesintheproneposition:
Patientsupine.Theclinicianpalpatestheposterioraspectofthehumeralheadwithonehand(Fig.1643).Withtheotherhand,thecliniciangently
graspsthedistalendofthehumerus.Fromthisposition,theclinicianglidesthehumerusanteriorlyattheGHjoint,paralleltotheAPplaneofthe
glenoidfossa.Thequantityofmotionisnotedandcomparedwiththeotherside.
Patientprone.Theclinicianpalpatestheposterioraspectofthehumeralheadwithonehand(Fig.1644).Withtheotherhand,thecliniciangentlygrasps
thedistalendofthehumerus.Fromthisposition,theclinicianglidesthehumerustowardthefloorinananteriordirection,paralleltotheAPplaneofthe
glenoidfossa.Thequantityofmotionisnotedandcomparedwiththeotherside.
FIGURE1643
Anteriorglidewithpatientsupine.
FIGURE1644
Anteriorglidewithpatientprone.
Theinterventionforjointgliderestrictionsusessimilartechniquesandpositioningasfortheassessmentexceptforthefollowing:
GradeIandIIoscillationsareusedforpainandgradeddependingonthestageofhealing.
GradeIIIVtechniquesareusedtoincreaserange.
PassiveAccessoryMotionTestingoftheScapulothoracicJoint
Distraction
Thepatientliesinthesidelyingposition.ThepatientsuppermostarmisplacedinIRsothattheposteriorsurfaceofthehandispositionedonthesacrum,if
shoulderROMallows.Theclinicianstandsinfrontofthepatient.Theclinicianplacesonehandovertheacromionandthemobilizinghandispositioned
adjacenttotheinferiorangleofthescapula.Theclinicianmovesthescapulamediallyandinferiorlyandthenliftsthescapulaawayfromtheribs(Fig.1645).
Thequantityandqualityofmotionisnoted.
FIGURE1645
Distractionofscapulothoracicjoint.
SuperiorGlide
Thepatientispositionedasforthescapulothoracicjointdistractiontechnique,excepttheuppermostarmispositionedinneutral.Usingthemobilizinghand,
theclinicianglidesthescapulainasuperiordirection(Fig.1646).
FIGURE1646
Superiorglideofscapulothoracicjoint.
InferiorGlide
Thepatientispositionedasforthescapulothoracicjointsuperiorglide.Usingthemobilizinghand,theclinicianglidesthescapulainaninferiordirection(Fig.
1647).
FIGURE1647
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Inferiorglideofscapulothoracicjoint.
MedialGlide
Thepatientispositionedasforthesuperiorglideofthescapulothoracicjoint.Theclinicianpositionsbothhandsoverthelateralsurfaceofthescapula,with
onehandovertheaxillaryborderandtheotherhandovertheacromion.Usingbothhandstheclinicianglidesthescapulainamedialdirection(Fig.1648).
FIGURE1648
Medialglideofscapulothoracicjoint.
LateralGlide
Thepatientispositionedasforthemedialglideofthescapulothoracicjoint.Theclinicianplacesbothhandsandthefingertipsoverthevertebralborderofthe
scapulaandthescapulaisglidedinalateraldirection(Fig.1649).
FIGURE1649
Lateralglideofscapulothoracicjoint.
PassiveAccessoryMotionTestingoftheAcromioclavicularJoint
AnteriorandPosteriorRotationoftheClavicle
DuringGHabduction,orshoulderelevation,thelateralendoftheclaviclemovessuperiorly,themedialendslidesandrollsinferiorly,andtheclaviclerotates
anteriorly.DuringGHadduction,orshoulderdepression,thelateralendoftheclaviclemovesinferiorly,whilethemedialendrollsandslidessuperiorly.
Duringthismotion,theclaviclerotatesposteriorly(seeTable1624).
TABLE1624ClavicleMotionsinRelationtoOtherMotions
MovingBone Motion Rotation
Inspiration Posterior
Ribs
Expiration Anterior
Protraction Anterior
Retraction Posterior
Scapula
Elevation Anterior
Depression Posterior
Ipsilateralrotation Posterior
Contralateralrotation Anterior
Ipsilateralflexion Posterior
Head/neck
Contralateralflexion Anterior
Flexion Anterior
Extension Posterior
Thepatientliesinthesidelyingorsupineposition.Theclinicianstabilizesthehumeruswithonehandandgraspstheanteriorandposterioraspectsofthe
claviclewiththeotherhand,usingthethumb,index,andmiddlefingerssothatthefingersarehookedaroundthelateralaspectoftheclavicle(Fig.1650).The
clinicianpassivelypullstheclavicleintothelimitofanteriorrotationandassessestheendfeel(seeFig.1650).Theclinicianthenpassivelypushestheclavicle
intothelimitofposteriorrotationandassessestheendfeel(seeFig.1650).
FIGURE1650
AnteriorandPosteriorRotationoftheClavicle.
PassiveAccessoryMotionTestingoftheSternoclavicularJoint
Thepatientliesinthesupineposition.Itisassumedthatthetechniquesareperformedonthepatientsrightside.
InferiorGlide
Usingonethumb,theclinicianpalpatesthesuperioraspectofthemedialendoftheclavicleandtheSCjointandappliesaninferiorglidetotheSCjoint(Fig.
1651).Thequantityandqualityofmotionisnoted.
FIGURE1651
InferiorglideofSCjoint.
SuperiorGlide
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Usingthethumbandfingersofonehand,theclinicianpalpatestheinferioraspectofthemedialendoftheclavicleandtheSCjointandappliesa
posterosuperiorglidetotheSCjoint(Fig.1652).Thequantityandqualityofmotionisnoted.
FIGURE1652
SuperiorglideofSCjoint.
Althoughsometextsadvocateassessingtheanteriorandposteriorglidesofthisjoint,bothofthesetechniquescanbeuncomfortableforthepatient,and
providelittleinformationfortheclinician.
SpecialTests
Thespecialtestsfortheshoulderaredividedintodiagnosticcategories.Selectionfortheiruseisatthediscretionoftheclinicianandisbasedonacomplete
patienthistoryandthefindingsfromthephysicalexamination.Itisimportanttorememberthatrarelyisadiagnostictestsensitiveandspecificenoughtobe
usedasthesoledeterminant,althoughmultipletestsmayprovidemorediagnosticconfidence.
RotatorCuffIntegrityandSubacromialImpingementTests
ThefollowingtestshavebeendescribedintheliteraturetoassessrotatorcuffintegrityandthepresenceofSIS(Tables1625and1626).PatientswithSIS
usuallyperceivepainwhenacompressingforceisappliedonthegreatertuberosityandrotatorcuffregion.315Painmayalsobeelicitedwithshoulder
abductioninIRorER.315Itisimportanttorememberthatimpingementisabroaddiagnosisthatencompassesabroadrangeofpathologies,makingits
diagnosticvaluequestionable.
TABLE1625DiagnosticTestPropertiesforImpingementandRotatorCuffTears
Positive Negative
DiagnosticTestorManeuver StudyPopulation Sensitivity Specificity Likelihood Likelihood
Ratio Ratio
54patientsaged4780yr,meanageof66yr,operatedonforcombined
Hornblowerssign 1.0 0.93 14.29 0.00
supraspinatusandinfraspinatustearsa
143shoulderswithvarioussymptoms,patientsage1380yr,meanage43 Pain0.63 0.55 1.40 0.67
Emptycantestfor
Weak0.77 0.68 2.41 0.34
supraspinatustendontears yrb Both0.89 0.50 1.78 0.22
Pain0.66 0.64 1.83 0.53
Fullcantestforsupraspinatus 143shoulderswithvarioussymptoms,patientsage1380yr,meanage43
Weak0.77 0.74 2.96 0.31
tendontears yrb Both0.86 0.57 2.00 0.25
Droppingsignforinfraspinatus 54patientsaged4780yr,operatedonforcombinedsupraspinatusand Not
1.00 1.00 0.00
degeneration infraspinatustearsa applicable
Palmuptest(Speed'stest)for
bicepstendontear 55patientswithimpingement,meanage51yr,range2477yrc 0.63 0.35 0.97 1.06
Combinedtests:supraspinatus (3)48.00 (3)0.76
Not
andexternalrotatorweakness, 400patientswithshoulderinjurythatwarrantedarthroscopy,agerangetestsd 0.00 (2)7.60 (2)0.42
applicable
andimpingementsign (1)1.90 (1)0.01
Transdeltoidpalpation(Rent
test) 109patientsforarthroscopy,aged2966yr,meanage51yre 0.957 0.968 29.91 0.04
Not
Liftofftestforsubscapularis 16patients,aged3966yr,meanage51yrf 0.89 1.00 0.11
applicable
tendon 45patientswithshouldersymptomatology,aged1764yr,meanage41.5yrg 0.89 0.36 0.31
1.39
Aprospectivestudyof100consecutivepainfulshoulderswithimpingement
Internalrotationlagsign syndrome,stages13.LagsignswerecomparedwiththeJobeandliftoff 0.97 0.96 24.25 0.03
(subscapularistear)
signs.h
Aprospectivestudyof100consecutivepainfulshoulderswithimpingement
Externalrotationlagsign syndrome,stages13.LagsignswerecomparedwiththeJobeandliftoff 0.70 1.00 NA NA
(subscapularistear)
signs.h
Supraspinatustest 45patientswithshouldersymptomatology,aged1764yr,meanage41.5yrg 1.00 0.53 2.13 0.00
Combinedtests:supraspinatus
andinfraspinatusmanual 42patientswithrotatorcufftearsseenforsurgery,noagereportedi 0.91 0.75 3.64 0.12
muscletest,andpalpation
Neerimpingementsignfor 85surgicalpatientsaged1672yr,meanage40yrj 0.84 0.51 1.71 0.31
rotatorcufftear 45patientswithshouldersymptomatology,aged1764yr,meanage41.5yrg 0.33 0.61 0.85 1.10
Hawkinsimpingementsignfor 85surgicalpatientsages1672yr,meanageof40yrj 0.88 0.43 1.54 0.28
rotatorcufftear 45patientswithshouldersymptomatology,aged1764yr,meanage41.5yrg 0.44 0.53 0.94 1.06
Liftofftestfordetermining
locationofrotatorcufftear 55patientswithimpingement,aged2477yr,meanage51yrc 0.00 0.61 0.00 1.64
Supineimpingementtest(RC 448consecutivepatientswithsuspectedRCTreferredforarthrographyovera
0.97 0.09 1.07 0.33
tear) 4yearperiodk
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Positive Negative
Ratio Ratio
Theposteriorimpingement 69athletespresentedwithposteriorshoulderpainthatdevelopedduring
sign(RCtearorposteriorlabral 0.76 0.85 5.06 0.28
tear) overhandathleticsl
8physicalexaminationtestswereevaluatedtodeterminetheirdiagnostic
Infraspinatustest(RCdisease) valuesforthreedegreesofseverityinrotatorcuffdisease:bursitis,partial 0.42 0.90 4.20 0.65
thicknessrotatorcufftears,andfullthicknessrotatorcufftears.m
aDatafromWalchG,BoulahiaA,CalderoneS,etal.Thedroppingandhornblowerssignsinevaluationofrotatorcufftears.JBoneJointSurgBr.
199880:624628.
bDatafromItoiE,TadatoK,SanoA,etal.Whichismoreuseful,thefullcantestortheemptycantestindetectingthetornsupraspinatustendon?AmJ
SportsMed.199927:6568.
cDatafromLerouxJL,ThomasE,BonnelF,etal.Diagnosticvalueofclinicaltestsforshoulderimpingement.RevRheum.199562:423428.
dDatafromMurrellGA,WaltonJR.Diagnosisofrotatorcufftears.Lancet.2001357:769770.
eDatafromWolfEM,AgrawalV.Transdeltoidpalpation(therenttest)inthediagnosisofrotatorcufftears.JShoulderElbowSurg.200110:470473.
fDatafromGerberC,KrushellRJ.Isolatedruptureofthetendonofthesubscapularismuscle:Clinicalfeaturesin16cases.JBoneJointSurgBr.199173:389
394.
gDatafromUreBM,TilingT,KirschnerR,etal.Thevalueofclinicalshoulderexaminationincomparisonwitharthroscopy.Aprospectivestudy.
Unfollchirurg.199396:382386.
hDatafromHertelR,BallmerFT,LombertSM,etal.Lagsignsinthediagnosisofrotatorcuffrupture.JElbowShoulderSurgAm.19965:307313.
iDatafromLyonsAR,TomlinsonJE.Clinicaldiagnosisoftearsoftherotatorcuff.JBoneJointSurgBr.199274:414415.
jDatafromMacDonaldPB,ClarkP,SutherlandK.AnanalysisofthediagnosticaccuracyoftheHawkinsandNeersubacromialimpingementsigns.JShoulder
ElbowSurg.20009:299301.
kDatafromLitakerD,PioroM,ElBilbeisiH,etal.Returningtothebedside:Usingthehistoryandphysicalexaminationtoidentifyrotatorcufftears.JAm
GeriatrSoc.200048:16331637.
lDatafromMeisterK,BuckleyB,BattsJ.Theposteriorimpingementsign:Diagnosisofrotatorcuffandposteriorlabraltearssecondarytointernal
impingementinoverhandathletes.AmJOrthop.200433:412415.
mDatafromParkHB,YokotaA,GillHS,etal.Diagnosticaccuracyofclinicaltestsforthedifferentdegreesofsubacromialimpingementsyndrome.JBone
JointSurgAm.200587:14461455.
NeerImpingementTest
Whilescapularrotationispreventedbyonehandoftheclinician,thearmofthepatientispassivelyforcedintoelevationatananglebetweenflexionand
abductionbythecliniciansotherhand.OverpressureisappliedwiththeGHjointinneutral,IR,andthenER(Fig.1653).ApositiveNeerimpingementtest
resultisthoughttorepresentimpingementoftherotatorcuffontheanterosuperiorglenoidrimorcoracoacromialligament.316PostandCohen317foundthe
Neertesttohaveasensitivityof93%intheconfirmationofsubacromialimpingement.
FIGURE1653
Neerimpingementtest.
HawkinsKennedyImpingementTest.318
Thearmofthepatientispassivelyflexedupto90degreesintheplaneofthescapula.ThearmisstabilizedandtheforearmisforcedintoIR(Fig.1654).Ina
cadaverstudy,PinkandJobe316foundthatrotatorcufftendonswereimpingedundertheacromionwiththeHawkinsKennedytest.
FIGURE1654
HawkinsKennedyImpingementtest.
Ureetal.319foundthatthesensitivityoftheHawkinsKennedytestwas62%andthesensitivityoftheNeertestwas46%in45patientswithstageIISIS,as
determinedusingarthroscopy.
McDonaldetal.320assessedthediagnosticaccuracyoftheNeerandHawkinsimpingementsignsforthediagnosisofsubacromialbursitisorrotatorcuff
pathologyin85consecutivepatientsundergoingshoulderarthroscopybyasinglesurgeon.TheNeersignwasfoundtohaveasensitivityof75%forthe
appearancesuggestiveofsubacromialbursitisthiscomparedwith92%fortheHawkinssign.320Forrotatorcufftearing,thesensitivityoftheNeersignwas
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85%andthatoftheHawkinssignwas88%.Specificityandpositivepredictivevaluesforthetwotestswerelow,beingnotmuchhigherthanpretest
probability.Thetwotestshadahighnegativepredictivevalue(96%forbursitis,90%forrotatorcufftearing)whentheywerecombined.320
Anotherstudy321foundthattheHawkinsKennedytestwasmoreaccuratethantheNeertestinaseriesof44shoulders,withtheformerhavingasensitivityof
78%andthelattera0%.
SupineImpingementTest
Thepatientliesinthesupinepositionwiththeclinicianstandingtothesideofthepatientsinvolvedshoulder.Thecliniciangraspsthepatientswristanddistal
humerusandelevatesthepatientsarmtoendrange(170degreesorgreater).TheclinicianthenmovesthepatientsarmintoERandthenadductsthearm
towardthepatientsear(Fig.1655).Thecliniciannowinternallyrotatesthepatientsarm(Fig.1656).Thetestisconsideredpositiveifthepatientreportsa
significantincreaseinshoulderpain.Thistestdoesnotappeartobediagnosticbutmayhavevalueasascreeningtestsinceanegativefindingmayruleouta
rotatorcufftear(Table1625).
FIGURE1655
Supineimpingementtestfirstposition.
FIGURE1656
Supineimpingementtestsecondposition.
InternalRotationLagSign(subscapularistear)
Thepatientsitsorstandswiththeinvolvedarmbehindthebackandthepalmfacingoutward.Thecliniciangraspsthepatientsshoulderwithonehandandthe
wristwiththeotherandthenliftsthepatientsarmofftheback(Fig.1657).Theclinicianthenasksthepatienttomaintainthispositionasthewristisreleased
(Fig.1658).Apositivetest,whichismanifestedwithaninabilityofthepatienttomaintainhisorherarmoffoftheback,indicatesasubscapularistear.A
studybyHerteletal.322reportedhighsensitivity(97%)andspecificity(96%)withthistest(Table1625),butthestudyhadapotentialforbias.
FIGURE1657
IRlagsign(subscapularistear)Firstposition.
FIGURE1658
IRlagsign(subscapularistear)Secondpositiondemonstratingapositivefinding.
ExternalRotationLagSign(subscapularistear)
Thepatientsitswiththeclinicianstandingbehind.Thecliniciangraspsthepatientswristandthenplacestheelbowat90degreesofflexionandtheshoulderat
20degreesofelevationinthescapularplane.Theclinicianpassivelyexternallyrotatestheshoulderand,attheendrange,asksthepatienttomaintainthis
position(Fig.1659)asthepatientswristisreleased.Apositivetest,whichisindicatedbylagthatoccurswiththeinabilityofthepatienttomaintainhisorher
armnearfullER(Fig.1660),indicatesasupraspinatus/infraspinatustear.AstudybyHerteletal.322reported70%sensitivityand100%specificitywiththis
test(Table1625),butthestudyhadapotentialforbias.
FIGURE1659
Externalrotationlagsign(subscapularistear)Firstposition.
FIGURE1660
Externalrotationlagsign(subscapularistear)Secondpositiondemonstratingapositivefinding.
BellyPressTest.299
Thepatientsitsorstandswiththeelbowflexedto90degrees.Thepatientisaskedtointernallyrotatetheshoulder,causingthepalmofthehandtobepressed
intothestomach(Fig.1661).Apositivetest,whichresultsintheelbowdroppingbehindthebodyintoextension,indicatesasubscapularistear.Thediagnostic
valueofthistest,whichwasoriginallydescribedasanalternativetotheliftofftestinthosepatientswithoutadequateIRoftheshoulderisasyetunknown.
FIGURE1661
Bellypresstest.
ThePosteriorImpingementSign
Thepatientliesinthesupinepositionwiththeshoulderplacedat90110degreesofabductionandmaximumER(Fig.1662).Apositivetestisindicatedby
complaintsofpaininthedeepposteriorshoulderandisindicativeofarotatorcufftearand/oraposteriorlabraltear(Table1625).
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FIGURE1662
Theposteriorimpingementsign.
InternalRotationResistedStrengthTest.323
Thepatientliesinthesupinepositionwiththeclinicianstandingbehindthepatient.Theclinicianplacesthepatientsshoulderat90degreesofabductionand
80degreesofER,withtheelbowat90degreesofflexion.TheclinicianfirstappliesamanualresistancetothewristtoassessisometricER,andthenapplies
manualresistancetothewristtoassessisometricIR.Acomparisonismadeofthetworesults.TheIRresistedstrengthtestcanbeusedtodifferentiatebetween
outletimpingement(Fig.1663)andnonoutletorinternalimpingementbasedontheapparentweaknessofIRversusERofthearm:iftheIRstrengthisweaker
thantheER,thetestisconsideredpositiveandthepatienthasinternalimpingement,whereasanegativetest(moreweaknessinER)wouldsuggestclassic
outletimpingement.AstudybyZaslav323reported88%sensitivityand96%specificitywiththistest(Table1626),butthestudyhadapotentialforbias.
(Table1626).323
FIGURE1663
Supraspinatusoutlet.
TABLE1626DiagnosticTestPropertiesforSubacromialImpingement
DiagnosticTestor PositiveLikelihood NegativeLikelihood
StudyPopulation Sensitivity Specificity
Maneuver Ratio Ratio
Eightphysicalexaminationtestswereevaluatedtodetermine
Infraspinatustest(RC theirdiagnosticvaluesforthreedegreesofseverityinrotator
cuffdisease:bursitis,partialthicknessrotatorcufftears,and 0.42 0.90 4.20 0.65
disease)
fullthicknessrotatorcufftears.a
49painfulshoulders,36wereswimmersaged1223yr,mean
age17yrb 0.80 0.76 3.33 0.26
44subjects,22wereswimmersaged1426,meanage17.7yrc 0.78 1.00 Notapplicable 0.21
HawkinsKennedy 45patientswithshouldersymptomatologyaged1764yr,mean 0.62 0.69 2.00 0.55
test
age41.5yrd 0.87
55patientswithimpingementmeanage51yr,range2477yre 0.92 0.25 1.20 0.32
125painfulshouldersaged1870yr,meanage51.6yrf
49painfulshoulders,36wereswimmersaged1223yr,mean
age17yrb 0.39 1.0 Notapplicable 0.61
45patientswithshouldersymptomatologyaged1764yr,mean 0.46 0.66 1.35 0.82
age41.5yrd 0.93
Neertest
72patientsaged2361yr,meanage42yrg 0.00
44subjects,22wereswimmersaged1426,meanage17.7yrc 0.89
0.89 0.31 1.30 0.37
55patientswithimpingementmeanage51yr,range2477yre
125painfulshouldersaged1870yr,meanage51.6yrf
Neerimpingement
signforsubacromial 85surgicalpatientsaged1672yr,meanage40yrh 0.75 0.48 1.44 0.52
bursitis
Hawkinsimpingement
signforsubacromial 85surgicalpatientsaged1672yr,meanage40yrh 0.92 0.44 1.64 0.18
bursitis
Horizontaladduction 125painfulshouldersaged1870yr,meanage51.6yrf 0.82 0.28 1.10 0.65
Speedstest 125painfulshouldersaged1870yr,meanage51.6yrf 0.69 0.56 1.50 0.57
Speedstestforbiceps
orsuperiorlabrum 45patientswithshoulderpainagerange1680yri 0.90 0.14 1.05 0.11
anteriorandposterior
Yergasontest 125painfulshouldersaged1870yr,meanage51.6yrf 0.37 0.86 2.70 0.73
Painfularc 125painfulshouldersaged1870yr,meanage51.6yrf 0.33 0.81 1.70 0.84
Internalrotation 115surgicalpatientswitha(+)Neerimpingementsignaged
0.88 0.96 22.00 0.13
resistedstrengthtest 1776yr,meanage44yr
Gilcreesttest:Palmup
testforbicepslong 55patientswithimpingementmeanage51yr,range2477yre 0.63 0.35 0.97 1.06
head
45patientswithshouldersymptomatologyaged1764yr,mean
Liftofftest 0.92 0.59 2.24 0.14
age41.5yrd
Yocumtest 55patientswithimpingementmeanage51yr,range2477yre 0.78
55patientswithimpingementmeanage51yr,range2477yre
Jobetestfor 0.86 0.50 1.72 0.28
45patientswithshouldersymptomatologyaged1764yr,mean
supraspinatus d
0.85 0.72 3.04 0.21
age41.5yr
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DiagnosticTestor PositiveLikelihood NegativeLikelihood

StudyPopulation Sensitivity Specificity
Maneuver Ratio Ratio
Pattetestfor
infraspinatus 55patientswithimpingementmeanage51yr,range2477yre 0.92 0.3 1.31 0.27
Droparmtest 125painfulshouldersaged1870yr,meanage51.6yrf 0.08 0.972.80 0.95

Modifiedrelocation 100%hardarticularsurfacedamage11hadfrayedundersurfaceof
testat90,110,and 14overhandthrowingathletesfailing3moofrehabilitation rotatorcuff10hadfrayedposteriorsuperiorlabrumat90degrees
120degreesfor aged2131yr,meanage24yrj onlyeightpatientshadrotatorcuffcontactwithlabrum,allat110
internalimpingement degrees,12at120degrees
aDatafromParkHB,YokotaA,GillHS,etal.Diagnosticaccuracyofclinicaltestsforthedifferentdegreesofsubacromialimpingementsyndrome.JBone
JointSurgAm.200587:14461455.
bDatafromBakK,FaunlP.Clinicalfindingsincompetitiveswimmerswithshoulderpain.AmJSportsMed.199725:254260.
cDatafromRuppS,BerningerK,HopfT.Shoulderproblemsinhighlevelswimmersimpingement,anteriorinstability,muscularimbalance.IntJSports
Med.199516:557562.
dDatafromUreBM,TilingT,KirschnerR,etal.Thevalueofclinicalshoulderexaminationincomparisonwitharthroscopy.Aprospectivestudy.
Unfallchirurg.199396:382386.
eDatafromLerouxJL,ThomasE,BonnelF,etal.Diagnosticvalueofclinicaltestsforshoulderimpingement.RevRheum.199562:423428.
fDatafromCalisM,AkgunK,BirtaneM,etal.Diagnosticvaluesofclinicaldiagnostictestsinsubacromialimpingementsyndrome.AnnRheumDis.
200059:4447.
gDatafromPostM,CohenJ:Impingementsyndrome:AreviewoflatestageIandearlystageIIIlesions.ClinOrthRelRes.1986207:127132.
hDatafromMacDonaldPB,ClarkP,SutherlandK.AnanalysisofthediagnosticaccuracyoftheHawkinsandNeersubacromialimpingementsigns.J
ShoulderElbowSurg.20009:299301.
iDatafromBennettWF.SpecificityoftheSpeedstest:Arthroscopictechniqueforevaluatingthebicepstendonatthelevelofthebicipitalgroove.
Arthroscopy.199814:789796.
jDatafromHamnerDL,PinkMM,JobeFW.Amodificationoftherelocationtest:Arthroscopicfindingsassociatedwithapositivetest.JShoulderElbow
Surg.20009:263267.
InfraspinatusTest
Thepatientsitswiththeelbowat90degreesofflexion,neutralforearmrotation,theelbowadductedagainstthebody,andtheshoulderatendrangeER.The
clinicianstandstothesideofthepatientandprovidesanIRforceagainstthepatientsisometricresistance.AstudybyParketal.324reportedthatapositive
test,whichindicatessubacromialimpingement(allstages),occursifthepatientgiveswayduetoeitherpainorweakness,orifthereisapositiveERlagsign.
However,evenwhencombiningtheresultsoftwotests,thestudydemonstratedonlyasmalleffectonposttestprobability(Table1625).
CrossbodyAdductionTest.325
Thepatientsitsandtheclinicianstandstotheinvolvedsideofthepatient.Thepatientisaskedtoelevatethearmto90degreesofshoulderflexion.The
clinicianthenhorizontallyadductsthepatientsarmtoendrange.ApositivetestforsubacromialimpingementoranACjointinjuryisindicatedifshoulder
painispresent(Table1626).
PainfulArcTest.77
Thepatientstandsand,whilebeingobservedbytheclinician,isaskedtoactivelyabducttheinvolvedshoulder.Apositivetestforsubacromialimpingementis
indicatedifthepatientreportsshoulderpaininthe60120degreerange.Painoutsidethisrangeisconsideredanegativetest,andpainthatincreasesinseverity
asthearmreaches180degreesisindicativeofadisorderoftheACjoint.HermannandRose326foundthatthepainfularctestwaspositivein48.9%of50
patientswithdegenerativeimpingement.Akgnetal.327observed57.5%positiveresultswiththetestinstageIISISpatients.Althoughthistestisgoodat
detectingsubacromialimpingement,apositivefindingisunlikelytoaidtheclinicianindeterminingaspecificdiagnosisasthereareanumberofconditions
thatcanbeprovokedwitharmelevation(Table1626).
TransdeltoidPalpation(RentTest).328
Thepatientsitsorstandswiththeinvolvedarmrelaxedandhangingontheside.Theclinicianstandsbehindthepatientandholdsthepatientsdistalarmwith
thepatientselbowflexedto90degrees(Fig.1664).TheclinicianthenpassivelymovesthepatientsGHjointintofullextension,whichallowsgreater
palpationofthehumeralheadandtendonsinsertingintothegreatertuberosity.328Palpationisperformedattheanteriormarginoftheacromion.While
palpatingthisareawiththeshoulderinthefullyrelaxedandextendedposition,theclinicianmovesthepatientsarmintointernalandexternalshoulderrotation
toallowfurtherpalpationoftherotatorcufftendons(Fig.1665).Inthepresenceofacompleterotatorcufftear,theeminenceofthegreatertuberosityappears
quiteprominenttopalpation,andthetornareafeelslikeasulcus,rent,orsofttissuedefect(depressionofapproximately1fingerwidth)thathasavulsed
fromthetuberosity.328Palpatingtheanteriorandposteriormarginsofthecufftearmayelicitanavulsededge.328Itisrecommendedthatthistestbeusedto
determinetheabsenceorpresenceofarotatorcufftearratherthanthesizeofthetear(Table1625).
FIGURE1664
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Transdeltoidpalpation(Renttest)Firstposition.
FIGURE1665
Transdeltoidpalpation(Renttest)Secondposition.
YocumTest
TheYocumtestisperformedbyhavingthepatientlifttheelbowtoshoulderheightwhilerestingthehandontheoppositeshoulder(Fig.1666).Astudy292
comparingtheNeer,HawkinsKennedy,andYocumtestsfoundallthreetodemonstrateahighsensitivityfordiagnosingsubacromialimpingement.
FIGURE1666
Yocumtest.
PatteTest.329,330
ThePattetest,alsoknownasthehornblowerssign(Fig.1631),isperformedwiththepatientinthesittingorstandingposition.Thepatientsarmis
supportedat90degreesofabductioninthescapularplane,withtheelbowflexedto90degrees.Thepatientisthenaskedtorotatetheforearmexternally
againsttheresistanceoftheclinicianshand.Ifthepatientisunabletoexternallyrotatetheshoulderinthisposition,thehornblowerssignissaidtobe
present.
Thistestwasfoundtohave100%sensitivityand93%specificityinthediagnosisofirreparabledegenerationoftheteresminormusclewhencomparedwith
CTarthrographyfindingsinaseriesof54shouldersscheduledforrotatorcuffrepair(Table1625).331Thelossofintegrityoftheteresminorwasconfirmedat
thetimeofsurgery.
Onestudy292attemptedtodeterminethediagnosticvalueofthreeimpingementtests(Yocum,Neer,andHawkinsKennedy),andfourtestswereusedto
determinethelocationofthespecificrotatorcufflesion(Jobeemptycan[seeResistiveTests],Gerberliftoff[seeresistedtests],Pattetest,andSpeedstest
[seelater])bycomparingtheclinicalfindingsfromthetestswiththeoperativefindingsinaseriesof55patientswithchronicshoulderpainandfunctional
impairment.332TheNeertest(89%),theHawkinsKennedytest(87%),andtheYocumtest(78%),alldemonstratedahighsensitivityfordiagnosing
subacromialimpingement.BoththeJobeemptycantest(86%)andthePattetest(92%)demonstratedhighsensitivity,butpoorspecificity(50%and30%,
respectively).BoththeGerberliftoffandtheSpeedstestdemonstratedpoorsensitivity(0%and63%,respectively)andpoorspecificity(61%and35%,
respectively).332
LockTest.333,334
TheLocktestisusedtohelpdifferentiatethecauseofsymptomswhenthepatientcomplainsoflocalizedcatchingshoulderpain,andpainorrestricted
movement,whenattemptingtoplacethehandbehindtheback.Sincethecliniciancontrolsthemotion,thistestcanbeaverysensitivetesttohelpconfirmthe
presenceofanimpingementofthesupraspinatustendon.Itisassumedthatthetechniquesareperformedonthepatientsrightside.
Thepatientliesinthesupinepositionwiththerightshoulderattheedgeofthetable,andtheelbowpositioned10degreesposteriortothefrontalplane(Fig.
1667).Theclinicianuseshisorherrighthandtomonitorthescapula.Theclinicianslefthandisplacedonthepatientsforearm.
FIGURE1667
Locktest.
Afterassessingtherestingsymptoms,theclinicianslowlyglidesthepatientselbowanteriorly,notingthelocationofonsetofresistanceand/orpaininthe
availablerange.Theendpositionforthetestisachievedwhenthepatientsrightshoulderisinmaximalhumeralflexionwithoverpressure,andneitherthe
patientnorthecliniciancanexternallyrotatethearmfurtherwhileatthisendrange.
Inthelockingposition,thegreatertuberosityanditsrotatorcuffattachmentsarecaughtwithinthesubacromialspace.FurthermotionintoER,flexion,or
abductionisnotpossible,unlessthearmisallowedtomoveintolessflexion.Positivefindingsforthistestincludereproductionofthepatientssymptomsand
adecreaseinROMcomparedwiththeuninvolvedshoulder.
DroppingSign.335
Thedroppingsignisperformedwiththepatientsittingorstanding.Theclinicianplacesthepatientselbowandshoulderat90degreesofflexion.The
shoulderisthenexternallyrotatedtonearendrangeandthepatientisthenaskedtomaintainthispositionasthewristisreleased.Apositivetestforan
infraspinatustearisindicatedbyalagthatoccurswithaninabilitytomaintaintheposition,andthearmdropstoaneutralpositionofshoulderrotation.Thisis
calledthedroppingsign.Thistestwasfoundtohavea100%sensitivityanda100%specificityforirreparabledegenerationoftheinfraspinatusmuscle
(confirmedatthetimeofsurgery),althoughthetestwasperformedwiththearmatthepatientsside,whichisnottheoriginaldescription(Table1625).331
RotatorCuffRuptureTests
Droparm(Codmans)Test
Theclinicianpassivelyraisesthepatientsarmto90degreesofabduction.Thepatientisaskedtolowertheirarmwiththeirpalmdown(Fig.1668).Ifatany
pointinthedescent,thepatientsarmdrops,itisindicativeofarotatorcuffinjury(Table1627).
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FIGURE1668
Droparm(Codman)test.
TABLE1627DiagnosticTestPropertiesforDropArmTest
Testfor Reliability Sensitivity Specificity LR+ LR DOR QUADASScore
Supraspinatusteara NT 15 100 NA NA NA 8
RCtearb NT 10 98 5.00 0.92 5.43 5
ImpingementorRCdiseasec NT 27 88 2.25 0.83 2.71 10
Supraspinatusteard 0.280.66kappa NT NT NA NA NA NA
aDatafromCalisM,AkgunK,BirtaneM,etal.Diagnosticvaluesofclinicaldiagnostictestsinsubacromialimpingementsyndrome.AnnRheumDis.
200059:4447.
bDatafromMurrellGA,WaltonJR:Diagnosisofrotatorcufftears.Lancet.2001357:769770.
cDatafromParkHB,YokotaA,GillHS,etal:Diagnosticaccuracyofclinicaltestsforthedifferentdegreesofsubacromialimpingementsyndrome.JBone
JointSurgAm.200587:14461455.
dDatafromOstorAJ,RichardsCA,PrevostAT,etal.Interraterreproducibilityofclinicaltestsforrotatorcufflesions.AnnRheumDis.200463:12881292.
SupraspinatusTests
Twotechniquesdescribedintheliteraturecanbeusedtotestthesupraspinatusmuscle.Ina1982report,JobeandMoynes336suggestedthatthebestposition
forisolatingthesupraspinatuswastheemptycanpositiontheelbowextended,theshoulderinfullIR,andthearminthescapularplane(thumbsdown
position)(Fig.1629)(Table1625).Ina1990article,Blackburnetal118recommendedtestingintheproneposition,inthefullcanpositiontheelbow
extendedandtheshoulderabductedto100degreesandexternallyrotatedwhilethepatientliftsthearmintoabduction(thumbsupposition)(Fig.1630)(Table
1625).Malangaetal.337notedthatalthoughbothtechniquessignificantlyactivatethesupraspinatusmuscle,neithertrulyisolatesthismusclefortesting
becauseothermusclesareactiveinbothpositions.However,droppingofthearmineitherpositionusuallyindicatesasignificantsupraspinatusmuscletear.
Moresubtleweaknessmayrepresentearlydegenerationoftherotatorcuff.
BicepsandSuperiorLabralTears
Thebicepstendonandsuperiorlabrumcanbeinvolvedinvariouspathologicalprocessesincludingbicipitaltendinopathy,bicepsrupture,bicepstendon
subluxationordislocation,andtearsofthesuperiorlabrum(Table1628).195
TABLE1628DiagnosticTestPropertiesforLabralInjuriesa
Positive Negative
Ratio Ratio
66consecutivearthroscopicallyconfirmedSLAPlesions(noages
SLAPprehensiontest 0.88
given)b
MRIvs.clinicaltest/physical
examination(PE)(apprehension, 54patientswithshoulderpainthatwasrefractoryto6moconservative MRI0.59 MRI0.85 MRI3.93 MRI0.48
relocation,loadandshift,sulcus, managementaged1757yr,meanage34yrc PE0.90 PE0.85 PE6.00 PE0.12
crank)
62patientswithshoulderpainthatwasrefractoryto3moconservative
Cranktest 0.91 0.93 13.00 0.10
managementaged1857,meanage28yrd
BicepsloadtestforSLAPlesionsin 75patientswithhistoryofanteriordislocationaged1641yr,mean
0.91 0.97 30.00 0.09
dislocators age24.8yre
BicepsloadtestII 127patientswithshoulderpainaged1552,meanage30.6yrf 0.90 0.97 30.00 0.10
Athleteswithisolatedsuperiorlabeltest,rotatorcufftearsand
Anteriorslidetest instabilities,aswellasasymptomaticathleteswithrotationaldeficits 0.78 0.92 9.75 0.24
aged1832yr,meanage24.6yrg
Activecompressiontest 318patients,50controlsnoagesreportedh 1.00 0.985 66.70 0.00
Newprovocationtestforsuperior
labrum 32patientswiththrowinginjuriesages1729yr,meanage20.9yri 1.00 0.90 10.00 0.00
Speed'stestforbicepsorSLAP 45patientswithshoulderpainagerange1680yrj 0.90 0.14 1.05 0.11

102typeIISLAPlesions(53throwers,aged1536yr,meanage24yr
JobetestforanteriorSLAP 49nonthrowerswithsingleeventtrauma,aged2772yr,meanage40 0.04 0.27 0.05 3.56
yrtotalgroupagerangefrom15to72yr,meanage33yrk
JobetestforposteriorSLAP 0.85 0.68 2.66 0.22
JobetestforcombinedSLAPlesions 0.59 0.54 1.28 0.76
SpeedstestforanteriorSLAP 1.00 0.70 3.33 0.00
SpeedstestforposteriorSLAP 0.29 0.11 0.33 6.45
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Positive Negative
Ratio Ratio
SpeedstestforcombinedSLAP
0.78 0.37 1.24 0.59
lesions
OBrientestforanteriorSLAP 0.88 0.42 1.52 0.29
OBrientestforposteriorSLAP 0.32 0.13 0.37 5.23
OBrientestforcombinedSLAP
0.85 0.41 1.44 0.37
lesions
Bicipitalgroovepainforanterior
1.00 0.47 1.89 0.00
SLAP
Bicipitalgroovepainforposterior
0.32 0.13 0.37 5.23
SLAP
Bicipitalgroovepainforcombined
0.74 0.35 1.14 0.74
SLAPlesions
Aseriesof132consecutivepatientsscheduledfordiagnostic
Hawkinstest 0.68 0.30 0.97 1.07
arthroscopy,examinedpreoperativelyl
Activecompression 0.63 0.50 1.26 0.74
Neertest 0.50 0.52 1.04 0.96
Relocation 0.50 0.53 1.06 0.94
Speed'stest 0.40 0.67 1.21 0.90
Anteriorslide 0.10 0.82 0.56 1.10
Cranktest 0.13 0.83 0.76 1.05
Painprovocation 0.15 0.90 1.50 0.94
Yergasontest 0.13 0.94 2.17 0.93
In172painfulshoulders,theKimtestwascomparedwiththejerktest
Jerktest 0.73 0.98 36.5 0.27
andwasverifiedbyarthroscopicexamination.m
In172painfulshoulders,theKimtestwascomparedwiththejerktest
Kimtest 0.80 0.94 13.33 0.21
andwasverifiedbyarthroscopicexamination.m
aDatafromDeyleGD,BangMD,KaneE.Evidencebasedpracticefortheshoulder.In:WilmarthMA,ed.EvidenceBasedPracticefortheUpperandLower
Quarter.LaCrosse,WI:OrthopaedicPhysicalTherapyHomeStudyCourse13.2.1,OrthopaedicSection,APTA,Inc.2003:14.
bDatafromBergEE,CiulloJV.AclinicaltestforsuperiorglenoidlabralorSLAPlesions.ClinJSportMed.19988:121123.
cDatafromLiuSH,HenryMH,NuccionS,etal.Diagnosisofglenoidlabraltears:Acomparisonbetweenmagneticresonanceimagingandclinical
examinations.AmJSportsMed.199624:149154.
dDatafromLiuSH,HenryMH,NuccionSL.Aprospectiveevaluationofanewphysicalexaminationinpredictingglenoidlabraltears.AmJSportsMed.
199624:721725.
eDatafromKimSH,HaKI,HanKY.Bicepsloadtest:Aclinicaltestforsuperiorlabrumanteriorandposteriorlesions(SLAP)inshoulderswithrecurrent
anteriordislocations.AmJSportsMed.199927:300303.
fDatafromKimSH,HaKI,AhnJH,etal.BicepsloadtestII:Aclinicaltestforslaplesionsoftheshoulder.Arthroscopy.200117:160164
gDatafromKiblerWB.Specificityandsensitivityoftheanteriorslidetestinthrowingathleteswithsuperiorglenoidlabraltears.Arthroscopy.199511:296
300
hDatafromOBrienSJ,PagnaniMJ,FealyS,etal.Theactivecompressiontestanewandeffectivetestfordiagnosinglabraltearsandacromioclavicular
abnormality.AmJSportsMed.199826:610613
iDatafromMimoriK,MunetaT,NakagawaT,etal.Anewpainprovocationtestforsuperiorlabraltearsoftheshoulder.AmJSportsMed.199927:137142.
jDatafromBennettWF.Specificityofthespeedstest:Arthroscopictechniqueforevaluatingthebicepstendonatthelevelofthebicipitalgroove.Arthroscopy.
199814:789796.
kDatafromMorganCD,BurkhartSS,PalmeriM,etal.TypeIISLAPlesions:Threesubtypesandtheirrelationshiptosuperiorinstabilityandrotatorcufftears.
Arthroscopy.199814:553565.
lDatafromParentisMA,MohrKJ,ElAttracheNS.Disordersofthesuperiorlabrum:Reviewandtreatmentguidelines.ClinOrthopRelatRes.20027787.
mDatafromKimSH,ParkJS,JeongWK,etal.TheKimtest:Anoveltestforposteroinferiorlabrallesionoftheshoulderacomparisontothejerktest.AmJ
SportsMed.200533:11881192.
ClunkTest
TheClunktestisthetraditionaltestfordiagnosinglabraltears.Thepatientliesinthesupineposition.Onehandoftheclinicianisplacedontheposterior
aspectoftheshoulderoverthehumeralheadwhiletheotherhandgraspsthehumerusabovetheelbow(Fig.1669).Theclinicianfullyabductsthearmover
thepatientshead.Byplacingthehandposteriortothehumeralhead,theclinicianpushesanteriorlywhiletheotherhandexternallyrotatesthehumerus.A
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clunklikesensationmaybefeltifafreelabralfragmentiscaughtinthejoint.195ClinicalstudieshavefoundthataclickonmanipulationoftheGHjointwas
acommonfindinginpatientswithlabraltears,evenintheabsenceofjointinstability.338,339
FIGURE1669
Clunktest.
Thesensitivityofthistestwasfoundtobelow(15%)inonestudy340whenitwasusedtodetectlabraltearsinaseriesof96arthroscopicsurgerypatients.
CrankTest
Thecranktest341isperformedwiththepatientinthesupineposition.Theirarmiselevatedto160degreesinthescapularplaneofthebodyandispositionedin
maximalinternalorER.Theclinicianthenappliesanaxialloadalongthehumerus(Fig.1670).Apositivetestisindicatedbythereproductionofapainful
clickintheshoulderduringthemaneuver.Thistestwasfoundtohaveahighsensitivity(91%)andspecificity(93%)fordiagnosinglabraltearsinaseriesof
62patientswhopresentedwithshoulderpainthatwasrefractoryto3monthsofconservativemanagement.341
FIGURE1670
CrankTest.
Thecranktesthasbeenfoundtohaveahighersensitivity(90%)thanMRI(59%)andequalspecificity(85%)toMRIindiagnosinglabraltears(Table16
28).339
JerkTest
Thistestisusedtodetectaposteroinferiorlabrallesion.342Thepatientsits,withtheclinicianstandingtothesideandslightlybehindthepatient.Theclinician
graspsthepatientselbowwithonehandandthescapulawiththeother,andthenpositionsthepatientsarmat8590degreesofabductionandIR(Fig.1671).
Theclinicianthenprovidesanaxialcompressionbasedloadtothehumerusthroughtheelbowwhilemaintainingthehorizontallyabductedarm.Theaxial
compressionismaintainedasthepatientsarmismovedintohorizontaladduction.Apositivetestisindicatedbysharpshoulderpainwithorwithoutaclunkor
click(Table1628).
FIGURE1671
Jerktest.
KimTest
Thistestisusedtodetectaposteroinferiorlabrallesion.Thepatientsits,withtheclinicianstandingontheinvolvedside.Thecliniciangraspstheelbowwith
onehandandthemidhumeralregionwiththeotherhand,thenelevatesthepatientsarmto8590degreesofabduction(Fig.1672).Simultaneously,the
clinicianprovidesanaxialloadtothehumerusanda45degreediagonalelevationtothedistalhumerusconcurrentwithaposteroinferiorglidetotheproximal
humerus(Fig.1673).Apositivetestisindicatedbyasuddenonsetofposteriorshoulderpain.AstudybyKimetal.342foundthistesttohaveasensitivityof
80%andaspecificityof94%,butmorestrictmethodologyneedstobefollowedtocorroboratethesestatistics(Table1628).
FIGURE1672
KimtestFirstposition.
FIGURE1673
KimtestSecondposition.
SpeedsTest
Thepatientsarmispositionedinshoulderflexion,fullER,fullelbowextension,andfullforearmsupination(Fig.1674).Manualresistanceisappliedbythe
clinician.Thetestispositiveiflocalizedpainatthebicipitalgrooveisreproduced.Wilketal.10haveintroducedadynamicversionoftheSpeedstest.During
thismaneuver,theexaminerprovidesresistanceagainstbothshoulderelevationandelbowflexionsimultaneouslyasthepatientelevatesthearmoverhead.
FIGURE1674
Speedstest.
ApositiveSpeedstestsuggestsasuperiorlabraltearwhenresistedforwardflexionoftheshouldercausesbicipitalgroovepainordeeppainwithinthe
shoulder.1,343Speedstestisalsousedtodetectbicipitaltendinopathy(Table1628)(seeYergasonsTest).326,344
YergasonsTest.345
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Thepatientsitsorstands,andtheupperarmispositionedwiththeelbowat90degreesofflexionandtheforearmpronated.Thepatientisaskedtosupinatehis
orherforearmagainstthemanualresistanceoftheclinician(Fig.1675).
FIGURE1675
Yergasonstest.
SpeedsandYergasonstestsprobablydiscriminatebicipitaltendondisorders.300However,irritationandedemamayalsooccurinthelongheadofbicepsin
anystageofSIS.BicepstendonsmaybethickenedbyfibrinoiddegenerationintheSIS.327,346Thismayleadtoaninappropriatediagnosisofprimarybicipital
tendinopathyandsubsequenttenodesis.315Inanumberofstudies,thesensitivityoftheSpeedstestinbicepstendondisorderswasfoundtobehigherthanthat
oftheYergasonstest.315,344,347
OBrien(ActiveCompression)Test
TheOBrientest(seealsoAcromioclavicularTestssection)isatwoparttest.Thepatientstandswithhisorherinvolvedshoulderat90degreesofflexion,
10degreesofhorizontaladduction,andmaximumIRwiththeelbowinextension.Inthisposition,thepatientthenresistsadownwardforceappliedbythe
cliniciantothedistalarm(Fig.1676).Thepatientisaskedtoreportanypainaseitherontopoftheshoulder(ACjoint)orinsidetheshoulder(superior
labrumanteriorandposterior[SLAP]lesion).ThetestisthenrepeatedinthesamemannerexceptthatthearmispositionedinmaximumER.Thetestis
positiveforaglenoidlabraltearifthepatientreportspainforclickingorpaininsidetheshoulderwithresistedforwardflexioninIRoftheshoulderthatis
relievedbyERoftheshoulder(Table1628).1OBrienetal.348reportedasensitivityof100%andaspecificityof98.5%fordetectingalabralabnormalityfor
thistestalthoughthetestdemonstratedpoorstudydesign.Forexample,theauthorsprovidednodataontheamountofforceusedforthetest.
FIGURE1676
OBrien(activecompression)test.
AnteriorSlideTest
Theanteriorslidetest349isanotherclinicaltestdesignedtostressthesuperiorlabrum.195Thepatientstandsorsitswithonehandonthehipsuchthatthe
thumbispositionedposteriorly.Oneoftheclinicianshandsisplacedoverthepatientsshoulderandtheotherhandbehindtheelbow(Fig.1677).Aforceis
thenappliedanteriorlyandsuperiorlyatthepatientselbow,andthepatientisaskedtopushbackagainsttheforce.Thetestisconsideredpositiveifpainis
localizedtotheanterosuperioraspectoftheshoulder,ifthereisapoporaclickintheanterosuperiorregion,orifthemaneuverreproducesthesymptoms.195
FIGURE1677
Anteriorslidetest.
Theanteriorslidetesthasdemonstratedgoodsensitivity(78%)andhighspecificity(92%)whenusedtodetectglenoidlabrumtears.349However,other
tests350352foundthetesttohaveverylowsensitivity,indicatingthatthereislittleuseforthistestintheclinictodetectSLAPlesions.
CompressionRotationTest
Thistestisperformedwiththepatientinthesupinepositionandtheclinicianstandingontheinvolvedsideofthepatient.Theclinicianpassivelypositionsthe
patientsshoulderat90degreesofabductionandtheelbowat90degreesofflexion.Theclinicianfirstappliesacompressionforcetothehumerusandrotates
thehumerusbackandforthfromIRtoERinanattempttotrapthelabrumwithinthejoint(Fig.1678).Whenperformingthismaneuver,itisrecommended
thatavarietyofsmallandlargecirclesareused,whileprovidingjointcompression,inanattempttogrindthelabrumbetweentheglenoidandthehumeral
head.ApositivetestisindicatedbytheproductionofacatchingorsnappingintheshoulderandMcFarlandetal.350foundthetesttohaveasensitivityof24%
andspecificityof76%.However,anotherstudybySnyderetal.353concludedthatSLAPlesionscanonlybediagnosedarthroscopically.
FIGURE1678
CompressionrotationTest.
BicepsLoadTest
ThebicepsloadtestwasoriginallydescribedbyKimetal.354Duringthistest,theshoulderisplacedat90degreesofabductionandmaximallyexternally
rotated(Fig.1679).AtmaximalERandwiththeforearminasupinatedposition,thepatientisinstructedtoperformabicepscontractionagainstresistance.10
DeeppainwithintheshoulderduringhiscontractionmayindicateaSLAPlesion.Duetomanydesignfaultsintheoriginalstudy,thistesthassincebeen
refined(bicepsloadII)withtheshoulderbeingplacedinthepositionof120degreesofabductionratherthantheoriginallydescribed90degrees,asthis
positionwasfoundtoaddgreatersensitivitytothetest(Table1628).355
FIGURE1679
Bicepsloadtest.
PronatedLoadTest
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Thepronatedloadtest10isperformedwiththepatientinasupineorseatedpositionwiththeshoulderabductedto90degreesandexternallyrotated,andthe
forearminafullypronatedposition(toincreasetensiononthebicepsandsubsequentlythelabralattachment).10WhenmaximalERisachieved,thepatientis
instructedtoperformaresistedisometriccontractionofthebicepagainstthecliniciansresistance(Fig.1680).Thistestcombinestheactivebicipital
contractionofthebicepsloadtestwiththepassiveERinthepronatedpositionsimilartothepainprovocationtest(seenext).
FIGURE1680
Pronatedloadtest.
PainProvocationTest.356
Thepatientisseatedandtheclinicianstandsbehindtheinvolvedshoulder.Theclinicianplacesthepatientsshoulderat90degreesofabductionandtoward
endrangeER,theelbowat90degreesofflexionandtheforearminmaximumsupination(Fig.1681).Thepatientisaskedtoratehisorherpaininthis
position.Theclinicianthenfullypronatesthepatientsforearmandasksthepatienttoagainratehisorherpain.ApositivetestforaSLAPlesionisindicatedif
painisproducedwithshoulderERwiththeforearminthepronatedpositionoriftheseverityofthesymptomsisgreaterinthepronatedposition.Astudyby
Mimorietal.356foundthistesttohavehighsensitivity(100%)andhighspecificity(90%),althoughthestudyhadmanydesignfaults.
FIGURE1681
Painprovocationtest.
ResistedSupinationExternalRotationTest.357
Duringthistest,thepatientliesinthesupinepositionwiththeclinicianstandingonthesideoftheinvolvedshoulder.Supportingthepatientselbowwithone
hand,theclinicianplacesthepatientsshoulderat90degreesofshoulderabduction,8090degreesofelbowflexion,andtheforearminneutral
pronation/supination(Fig.1682).Thepatientisaskedtoattempttosupinatehisorherarm.Theclinicianresistsagainstamaximalsupinationeffortwhile
graduallypassivelyexternallyrotatingtheshoulder.Apositivetestforatornlabrum/instabilityisindicatedbytheproductionofpainintheanteriorordeep
shoulder,clickingorcatchingintheshoulder,orbyreproductionofthepatientssymptoms.Apreliminarystudyof40patientsrevealedthatthistesthadbetter
sensitivity(82.8%),specificity(81.8%),positivepredictivevalue(92.3%),negativepredictivevalue(64.3%),anddiagnosticaccuracy(82.5%),comparedwith
thecranktestandOBrientest.357
FIGURE1682
Resistedsupinationexternalrotationtest.
ForcedShoulderAbductionandElbowFlexionTest
Thepatientsits,withtheclinicianstandingbehindandtothesideoftheinvolvedshoulder.Theclinicianpositionsthepatientsshoulderinmaximum
abductionwithfullelbowextensionandnotesanyreportsofpainintheposteriorsuperioraspectoftheshoulder(Fig.1683).Theclinicianthenflexesthe
patientselbow.Apositivetestforasuperiorlabraltearisindicatedbytheproductionofpainintheposteriorsuperioraspectoftheshoulderduringshoulder
abductionwithelbowextensionthatisdiminishedorrelievedbytheelbowflexion.InastudybyNakagawaetal.,352thistestwasfoundtohaveasensitivity
of67%andaspecificityof67%.However,thereweresomedesignflawswiththisstudy.Forexample,allofthesubjectswereyoungthrowingathletes,and
onlytwoofthe54subjectswerefemale,leadingtospectrumbias.
FIGURE1683
Forcedshoulderabductionandelbowflexiontest.
Wilketal.10recommendthattheselectionofspecificSLAPteststoperformshouldbebasedonthesymptomaticcomplaintsaswellasthemechanismof
injurydescribedbythepatient(Table1629).
TABLE1629SelectionofSLAPTestsBasedonMechanismofInjury
Mechanism Test
Activecompression(O'Brien)
Compressionrotation
Compressiveinjury
Clunk
Anteriorslide
Speed's
Tractioninjury Dynamicspeed's
Activecompression
Pronatedload
Resistedsupinationexternalrotation
Overheadinjury BicepsloadIandII
Painprovocation
Crank
DatafromWilkKE,ReinoldMM,DugasJR,etal.Currentconceptsintherecognitionandtreatmentofsuperiorlabral(SLAP)lesions.JOrthopSportsPhys
Ther.200535:273291.
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AcromioclavicularTests
OBrienTest
ThisisthesametestdescribedinthesectionBicepsandSuperiorLabralTears.Thetesthasbeenfoundtobebothhighlysensitiveandspecificfor
diagnosingACjointabnormalities.348ThetestisconsideredpositiveforACjointdysfunctionifthepainislocalizedtotheACjointonthefirstpositionand
relievedoreliminatedonthesecondposition.348,358
AcromioclavicularResistedExtensionTest
Thistestisperformedwiththepatientsshoulderpositionedat90degreesofelevationcombinedwithIRand90degreesofelbowflexion.Thepatientisthen
askedtohorizontallyabductthearmagainstresistance(Fig.1684).ThistestisconsideredpositiveifitcausespainattheACjoint.Chronopoulosetal.359
reportedsensitivityof72%andspecificityof85%withthistest,butthisstudyhadsomedesignflawssuchaslackofblindingandnotreportingpatient
inclusion/exclusioncriteria.
FIGURE1684
Acromioclavicularresistedextensiontest.
CrossoverImpingement/HorizontalAdductionTest
Thepatientsarmispositionedat90degreesofGHflexion.Theclinicianpassivelymovesthepatientsarmintohorizontaladductionandappliesoverpressure
(Fig.1685).Althoughthecrossoverimpingement/horizontaladductiontestprovokescompressiveforcesontherotatorcufftendonsthatarelocalizedunder
theACjoint,itisatestmorelikelytobeusedtoinvestigateACjointdysfunction.327,346Chronopoulosetal.359evaluatedthecrossoverimpingementtest,
theactivecompressiontest,andtheACresistedextensiontestfortheisolatedandcombineddiagnosticutilitywithregardtochronicisolatedACjoint
lesions.Thestudywasaretrospectivecasecontrolstudythatused35patientsdiagnosedwithchronicisolatedACjointlesionsand580controlsubjectswho
hadundergonesurgicalproceduresforothershoulderconditions.Theauthorsconcludedthatthethreetestsstudiedhadisolatedclinicalutility.Theyalso
analyzedthediagnosticutilityofmultitestregimensbasedonthesethreetests(Table1630)andsuggestedthattheclinicianshoulduseacriterionofone
positivetestwhenhighsensitivityisrequired,whereasacriterionofthreepositivetestsisappropriatewhenhighspecificityisnecessary.358,359
FIGURE1685
Crossoverimpingement/horizontaladductiontest.
TABLE1630DiagnosticUtilityMultitestRegimensConsistingofCrossBodyAdductionStress,ActiveCompression,andAcromioclavicularResisted
ExtensionTest
PredictivePredictive NegativePredictive PositiveLikelihood NegativeLikelihood
Accuracy Sensitivity Specificity
Value Value Ratio Ratio
0.75 0.00 0.74 0.17 1.00
1Positivetest 0.00 1.4
(237/315) (16/16) (221/299) (16/94) (221/221)
2Positive 0.89 0.81 0.89 0.28 0.99
7.4 0.2
tests (279/315) (13/16) (266/299) (13/46) (266/269)
93 0.25 0.97 0.31 0.96
3Positivetests 8.3 0.8
(294/315) (4/16) (290/299) (4/13) (290/302)
DatafromChronopoulosE,KimTK,ParkHB,etal.Diagnosticvalueofphysicaltestsforisolatedchronicacromioclavicularlesions.AmJSportsMed.
200432:655661PowellJW,HuijbregtsPA.Concurrentcriterionrelatedvalidityofacromioclavicularjointphysicalexaminationtests:Asystematicreview.J
ManManipTher.200614:E19E29.
ExaminationofthePassiveRestraintSystem
IffollowingtheROM,strength,andfunctionalmovementtests,theclinicianisunabletodetermineaworkinghypothesisfromwhichtotreatthepatient,
furtherexaminationisrequired.Thismoredetailedexaminationinvolvestheassessmentofthemobilityandstabilityofthepassiverestraintsystemsofthe
shouldergirdle(Table1631).
TABLE1631DiagnosticTestPropertiesforShoulderLaxitya
Negative
PositiveLikelihood
DiagnosticTestorManeuver StudyPopulation Sensitivity Specificity Likelihood
Ratio
Ratio
100surgicalpatientages 0.30forpain 0.58forpain
Shoulderrelocationtest(noforceonhumerusatstart 0.71 1.21
0.57for 1.0for
position) notreportedb apprehension apprehension
Notapplicable 0.43
0.54forpain 0.44forpain
Shoulderrelocationtest(anteriordirectedforceonhumerus 100surgicalpatientsages 0.96 1.05
0.68for 1.0for
atstartposition) notreportedb apprehension apprehension
Notapplicable 0.32
Relocationtestforposterosuperiorglenoidrotatorcuff 20throwingathletesaged
0.95forpain
lesions 1935yr,meanage24.9yrc
100athletesaged1561,
Anteriorreleasetestforanteriorinstability 0.92 0.89 8.36 0.09
meanage37yrd
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Negative
PositiveLikelihood
DiagnosticTestorManeuver StudyPopulation Sensitivity Specificity Likelihood
Ratio
Ratio
Anterior 0.5 1.00 Notapplicable 0.50
Loadandshifte Posterior 0.14 1.00 Notapplicable 0.86
Inferior 0.08 1.00 Notapplicable 0.92
Intraobserverreproducibility46%,but
43asymptomaticcollegeathletemean 73%whengrades0and1were
Gradingtranslationanterior,posterior,andinferior equalized
age19.2yrf Interobserver47%and73%when
equalized
Hyperabductiontestforstabilityinferiorglenohumeral 100normalsaged2438yr,
ligament>105degreesindicatelaxitynormal8590 0.84 0.95 16.89 0.16
degrees meanage28yrg
90patientswithshoulderinstabilityaged1840yr,meanage24.3yr
100cadaversaged6182yr,meanage76yr
aDatafromDeyleGD,BangMD,KaneE.Evidencebasedpracticefortheshoulder.In:WilmarthMA,ed.EvidenceBasedPracticefortheUpperandLower
Quarter.LaCrosse,WI:OrthopaedicPhysicalTherapyHomeStudyCourse13.2.1,OrthopaedicSection,APTA,Inc.2003:15,Table6.Permissionfrom
OrthopaedicSection,APTA.
bDatafromSpeerKP,HannafinJA,AltchekDW,etal.Anevaluationoftheshoulderrelocationtest.AmJSportsMed.199422:177183.
cDatafromRiandN,LevigneC,RenaudE,etal.Resultsofderotationalhumeralosteotomyinposterosuperiorglenoidimpingement.AmJSportsMed.
199826:453459.
dDatafromGrossML,DistefanoMC.Anteriorreleasetest:Anewtestforoccultshoulderinstability.ClinOrthRelRes.1997339:105108.
eDatafromTzannesA,MurrellGA.Clinicalexaminationoftheunstableshoulder.SportsMed.200232:447457.
fDatafromLevyAS,LintnerS,KenterK,etal.Intraandinterobserverreproducibilityoftheshoulderlaxityexamination.AmJSportsMed.199927:460
463.
gDatafromGageyOJ,GageyN.TheHyperabductiontest.JBoneJointSurgBr.200183:6974.
StabilityTesting
Itisimportanttorememberthatthereisnocorrelationbetweentheamountofjointlaxity/mobilityandjointinstabilityattheshoulder.360Jointstabilityismore
likelyafunctionofconnectivetissuesupportandanintactneuromuscularsystem.242
Manyprovocativemaneuversfortheshouldercomplex,includingtheanteriorandposteriorapprehensiontests,thesulcustest,361363andtheloadandshift
test,havebeendescribedpreviously.Thereproductionofsymptomsisimportantbecauselaxityalonedoesnotindicateinstability.Sidetosidetranslational
asymmetryoftenhasbeentakenasbeingrepresentativeofdisease,buthealthyshouldersmayalsohaveasymmetryuptogradeIIlaxity.364,365
Painandmusclespasmcanmaketheexaminationchallenging.Rarelyisexaminationwiththepatientunderanesthesiausefulforanythingotherthanfine
tuningtheamountofcapsularshiftrequiredatsurgery.366
Glenohumeral:LoadandShiftTest
Thepatientliesinthesupineposition.Theclinicianisbesidethepatientwiththeinsideofthehandoverthepatientsshoulderandforearm,stabilizingthe
scapulatothethorax.TheclinicianplaceshisorherhandacrosstheGHjointlineandhumeralheadsothatclinicianslittlefingerispositionedacrossthe
anteriorGHjointlineandhumeralhead(Fig.1686).Theclinicianthenappliesaloadandshiftofthehumeralheadacrossthestabilizedscapulainan
anteromedialdirectiontoassessanteriorstability,andinaposterolateraldirection,toassessposteriorinstability.Thenormalmotionanteriorlyishalfofthe
distanceofthehumeralhead.Althoughattemptshavebeenmadetogradeorquantifythedegreeofinstabilitymorespecifically,theliteraturesupportsno
consistencyinthegradingtodate.151,367370Thistesthasbeenreportedtobe100%sensitiveforthedetectionofinstabilityinpatientswithrecurrent
dislocation,butnotincasesofrecurrentsubluxation.368
FIGURE1686
Loadandshifttest.
ApprehensionTest
Thepatientliesinthesupinepositionwiththearmat90degreesofabductionandfullER.Theclinicianholdsthepatientswristwithonehandwhiletheother
handstabilizesthepatientselbow(Fig.1687).TheclinicianappliesoverpressureintoER.Patientsapprehensionfromthismaneuver,ratherthanhis/herpain,
isconsideredapositivetestforanteriorinstability.Painwiththismaneuver,butwithoutapprehension,mayindicatepathologyotherthaninstability,suchas
posteriorimpingementoftherotatorcuff.76InastudybyMoketal.,371thistestdemonstratedaspecificityof61%andasensitivityof63%.
FIGURE1687
Apprehensiontest.
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SulcusSignforInferiorInstability
ThesulcussignwasdescribedbyNeerandFoster362andisusedtodetectinferiorinstabilityduetoalaxityofthesuperiorGHandcoracohumeralligaments.
Thepatientsarmispositionedat2050degreesofabductionandneutralrotation.150,372Apositivetestresultsinthepresenceofasulcussign(adepression
greaterthanafingerbreadthbetweenthelateralacromionandtheheadofthehumerus)(Fig.1688)whenlongitudinaltractionisappliedtothedependentarm
inmorethanoneposition.373
FIGURE1688
Sulcussign.
Thesulcussigncanbegradedbymeasuringthedistancefromtheinferiormarginoftheacromiontothehumeralhead.Adistanceoflessthan1cmisgraded
as1+sulcus,12cmasa2+sulcus,andgreaterthan2cmasagrade3+sulcus.362AstudybyLevyetal.374evaluatedtheinterandintraobserver
reproducibilityoftheclinicalexaminationofGHlaxityintheunanesthetizedshoulder.FortythreeasymptomaticdivisionIcollegiateathletesunderwent
bilateralshoulderlaxityexaminationinitiallyandagainafter3months.Overallintraobserverreproducibilityofexaminationwas46%.Whengrades0and1
wereequalized,overallintraobserverreproducibilityimprovedto74%.Forboththeequalizedandnonequalizedreproducibilityvaluesreportedbyall
examiners,thekvaluesforintraobservercorrelationwerelessthan0.5,whichsuggeststhatcorrelationswerenotbetterthanthoseachievedbychancealone.
Overallinterobserverreproducibilitywas47%.Whengrades0and1wereequalized,interobserverreproducibilityimprovedto78%.
JobeSubluxation/RelocationTest
Thistestissimilartotheloadandshifttest,exceptthatmanualpressureisappliedanteriorlybytheclinicianinanattempttoprovokeasubluxation,before
usingmanualpressureintheoppositedirectiontorelocatethesubluxation.Thepatientliesinthesupinepositionwiththeirarmat90degreesofabductionand
fullER.Thecliniciangraspsthepatientselbowwithonehandtomaintainthetestingpositionandgraspsthehumeralheadwiththeotherhand(Fig.1689).
Thecliniciangentlyappliesananteriorpullonthehumerus.Painandapprehensionfromthepatientindicateapositivetestforasuperiorlabraltearoranterior
instability.1Afterpullingthehumeralheadanteriorlyanddemonstratingpainandapprehension,theclinicianshouldthenpushthehumeralheadposteriorly
whilemaintainingtheshoulderinthesameposition(therelocationpartofthetest).Reductionofpainandapprehensionfurthersubstantiatestheclinical
findingofanteriorinstability.Thesensitivityandspecificityoftherelocationtestisreportedtobelowwhenassessingpainresponseonly,butveryhighwhen
assessingtheapprehensionresponseonly.375
FIGURE1689
Subluxation/relocationtest.
Theperformanceoftherelocationpartofthetest(basedonoperativefindingsandmanualexaminationunderanesthesia)wascomparedbetweentwogroupsof
patients:thosewithanteriorinstabilityandwithrotatorcuffdisease.375Thestudyfoundthatitisnotpossibletodiscriminatebetweenanteriorinstabilityand
rotatorcuffdiseasebyusingtherelocationtestforassessingpainresponseonly.
ModifiedJobeRelocationTest
Thepatientliesinthesupineposition,andtheclinicianstandsontheinvolvedsideofthepatient.Theclinicianprepositionstheshoulderat120degreesof
abductionandthengraspsthepatientsforearmandmaximallyexternallyrotatesthehumerus.Theclinicianthenappliesaposteriortoanteriorforcetothe
posterioraspectofthehumeralhead.Ifthepatientreportspainwiththismaneuver,ananteriortoposteriorforceisthenappliedtotheproximalhumerus.A
positivetestforlabralpathologyisindicatedbyareportofpainwiththeanteriordirectedforceandreleaseofpainwiththeposteriordirectedforce.Inasmall
studyof14overheadthrowingathletes,aged2131years,Hamneretal.376foundthetesttohavehighsensitivity(92%)andhighspecificity(100%).However,
therewereanumberofdesignfaultsinthestudythatledtopotentialbias,andfurtherresearchisrequired.
RockwoodTestforAnteriorInstability
Thepatientisseatedwiththeclinicianstanding.377Withthearmbythepatientsside,theclinicianpassivelyexternallyrotatestheshoulder.Thepatientthen
abductsthearmtoapproximately45degrees,andthetestisrepeated.Thesamemaneuverisagainrepeatedwiththearmabductedto90degrees,andthen120
degrees(Fig.1690)toassessthedifferentstabilizingstructures.Apositivetestisindicatedwhenapprehensionisnotedinthelatterthreepositions(45,90,and
120degrees).
FIGURE1690
Rockwoodtestforanteriorinstability.
AnteriorReleaseTest/SurpriseTest
Thepatientliesinthesupinepositionwiththeshoulderat90degreesofabductionandtheelbowflexedto90degrees.378Theclinicianpassivelymovesthe
patientsshoulderintoERwhileapplyingaposteriorlydirectedforcetotheheadofthehumerus.AtthepointofendrangeER,theclinicianquicklyreleases
theposteriorforce(Fig.1691)andnoteswhetherthepatientdisplaysanysignofapprehension.InastudybyLoetal.,379whichassessedthevalidityofthe
apprehension,relocation,andsurprisetestsaspredictorsofanteriorshoulderinstability,forthosesubjectswhohadafeelingofapprehensiononallthreetests,
themeanpositiveandnegativepredictivevalueswere93.6%and71.9%,respectively.Thesurprisetestwasthesinglemostaccuratetest(sensitivity63.89%
specificity98.91%).Animprovementinthefeelingofapprehensionorpainwiththerelocationtestaddedlittletothevalueofthetests.Theresultsofthis
studywouldsuggestthatapositiveinstabilityexaminationonallthreetestsishighlyspecificandpredictiveoftraumaticanteriorGHinstability.379
FIGURE1691
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Anteriorreleasetest.
AnteriorFulcrumTest
Thepatientliesinthesupinepositionwiththeshoulderpositionedatapproximately90degreesofabductionandER.380Theclinicianmovesthearminto
horizontalabductionwhileapplyingananteriorforcetotheGHjointinafulcrummaneuver(Fig.1692).Thecliniciannotestheamountoftranslationand
endfeelincomparisonwiththeoppositeextremity.Thetestcanberepeatedat45degreesofabduction(totestthemiddleGHligament)andinadduction(to
assessthesuperiorGHligament).
FIGURE1692
Anteriorfulcrumtest.
LachmanTestoftheShoulder
Thepatientliesinthesupinepositionandtheshoulderisabductedoverheadtoapproximately120135degreesofabductionandfullER(Fig.1693).381The
clinicianthentranslatestheGHjointanteriorlyandnotestheamountofhumeraltranslationaswellastheendpointoftranslation,incomparisonwiththe
uninvolvedshoulder.Theoreticallyinthisposition,theintegrityoftheinferiorGHligamentandtheanteriorinferiorcapsuleistested.
FIGURE1693
Lachmantestoftheshoulder.
ThoracicOutletSyndromeTests
ThesetestsaredescribedinSpecialTestssectioninChapter25.
DiagnosticStudies
Theconclusionsontheradiologyreportsconcerningsingleplaneviews,whichincludeanAPviewwiththehumerusinIR,andasecondAPviewwiththe
humerusinER(seeChapter7),shouldbetreatedwithcautionastheyhavebeenwelldocumentedtoresultinmisdiagnosis.382
IfACseparationissuspected,aweightedviewisperformedwithaweightsuspendedfromthewristontheinvolvedside.Alternativeorspecializedviewsare
sometimesusedinanattempttobetterdefinespecificstructures.Forexample,withasuspectedshoulderdislocation,theWestPointorLawrenceview
(inferiorsuperioraxialprojection)isusedtohelpdisplaytheinferiorglenoidfossaanditsrelationshiptothehumeralhead,inadditiontothelateral
perspectiveoftheproximalhumerus.
Arthrographyaidsinthediagnosisoffullthicknessrotatorcufftears.383Bonescansarerarelyusedinthediagnosisofshoulderpain,butaCTscanreportcan
beusefulinconfirmingtheclinicalfindingsinsomecases.1TheMRIisveryreliableindetectinglesionsofthecapsuleandlabrum,aswellasassociated
rotatorcufftears.Itcangenerallyindicatetheapproximatesizeofarotatorcufftearandmayalsoindicatewhetherthecriticallyimportantsubscapularistendon
istorn.1,384,385
Inalimitednumberofstudies,acomparisonhasbeenmadeastotheaccuracyofphysicaldiagnostictestsversusarthroscopicexamination.Onesuchstudy
foundthatthephysicaltherapistswereunabletodifferentiatebetweenapartialandcompletetearoftherotatorcufftendons.386However,alaterstudyshowed
thatphysicaltherapistswereabletodiscernsubacromialdisordersandpassiverestraintdisorderswithanagreementof85%and67%,respectively.387
Evaluation
Followingtheexamination,andoncetheclinicalfindingshavebeenrecorded,theclinicianmustattempttodetermineaspecificdiagnosisoraworking
hypothesis,basedonasummaryofallofthefindings.Thisdiagnosiscanbestructurerelated(medicaldiagnosis)(Table1632),oradiagnosisbasedonthe
preferredpracticepatternsasdescribedintheGuidetoPhysicalTherapistPractice.FurtherdetailsonthespecificconditionslistedinTable1630isprovided
inthefollowingsections.
ABLE1632DifferentialDiagnosisforCommonCausesofShoulderPain
Symptoms
Approximate Areaof Painwith Tenderness
Condition MechanismofInjury Aggravated Observation AROM PROM
Patient'sAge Symptoms Resisted Palpation
by
Rotatorcufftendinitis
Swelling Painbelow
Anteriorand Overhead Limited Limited
Acute 2040 Microtrauma/macrotrauma anterior Abduction anterior
lateralshoulder motions abduction abduction
shoulder acromialrim
Overhead Painon Abduction
motions Limited IRand Painbelow
Anteriorand Atrophyof Anterior
Chronic 3070 Microtrauma/macrotrauma Atrophyof abductionand ERat90
anterior
lateralshoulder scapulararea shoulder
shoulder flexion degree acromial
area abduction
rim
Overhead Elbow
motions Possible LimitedER Painon flexion
swelling whenarmat90 combined Speedstest Ofbiceps
anterior degreeabduction extension
Maysee painful, 70/135
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Bicipital 2045 Microtrauma Anteriorshoulder Maysee shoulder Bicepsstability of painful, tendonover
tendinitis signsof
Painonfull testmaybe shoulder Yergason bicipital
concomitant flexionfrom abnormal(if and test groove
rotatorcuff fullextension tendonunstable) elbow occasionally
pathology painful
Limited
abduction Painbelow
Rotatorcuff Posterior/superior Arm Atrophyof Fulland
40+ Macrotrauma Painwithor Abduction anterolateral
rupture shoulder elevation scapulararea painfree
without acromialrim
restriction
All
Allmotions motions
Shoulderand
Adhesive Atrophyof limited limited
3570 Microtrauma/macrotrauma upperarm Allmotions Most/all Varies
capsulitis shoulderarea especiallyER especially
poorlylocalized
andabduction ERand
abduction
Limited Limited ER
Step/bumpat abduction abduction Softtissue
ACjoint Horizontal Pointof
Varies Macrotrauma Pointofshoulder pointof Limited Painwith thickening
sprain adduction shoulder
shoulder horizontal horizontal atpointof
adduction adduction shoulder
Painon
IRat90
Limited degree
abductionandIR abduction
Painbelow
Subacromial Anteriorand Overhead Often Mayhavefull Painonly
Varies Microtrauma Most/all anterolateral
bursitis lateralshoulder motions unremarkable rangebutpainin in
acromialrim
midrangeof midrange
flexion/abduction abduction
and
flexion
Possible
Weakness
posterior Capsularpattern
Glenohumeral Gradualonset,butcanbe Arm ofrotator Poorly
50+ Poorlylocalized positioning (ER>abduction Pain
arthritis traumatic activity cuff,rather localized
ofhumeral >IR)
thanpain
head
Scapular Decreased
malposition forwardflexion
Anterior/superior
Inferior whichdiminishes Medial
shoulder
medial whenclinician Weakness coracoid
Posterosuperior Overhead
SICKScapula 2040 Microtrauma border manually Normal ratherthan Superomedial
scapular activities
prominence repositionsthe pain angleof
Arm,forearm,
Dyskinesia scapulainto scapula
hand
ofScapular retractionand
movement posteriortilt
Cervical
Decreased Painful
extension,
cervicalflexion, into
cervical Mayhave Weakness Variesmay
Cervicalside restricted
side lateral ratherthan have
bendingand active
Cervical Typicallynonebutcanbe Upperback, bendingand deviationof pain numbness
Varies rotationto rangeof
radiculopathy traumatic belowshoulder rotationto headaway Other over
ipsilateralside motions
ipsilateral frompainful neurological dermatomal
decreasedarm Positive
side,full side changes area
elevationon Spurlings
arm
involvedside test
elevation
INTERVENTIONSTRATEGIES
Withthepossibleexceptionsofacutetraumaticshoulderdislocationandacutetraumaticinabilitytoraisethearm(acutemassiverotatorcufftear),aminimum
6weekperiodofconservativeempiricinterventionistypicallyindicatedforshoulderinjuries.Anumberofguidingprinciplescanbeusedintheconservative
rehabilitationoftheshoulder:388
Theshouldermustberehabilitatedaccordingtothestageofhealinganddegreeofirritability.Thedegreeofirritabilitycanbedeterminedbyinquiring
aboutthevigor,duration,andintensityofthesymptoms.Greaterirritabilityisassociatedwithveryacutelyinflamedconditions.Thecharacteristicsign
foranacuteinflammationoftheshoulderispainatrest,whichisdiffuseinitsdistributionandoftenreferredfromthesiteoftheprimarycondition.333
Painabovetheelbowindicateslessseveritythanpainbelowtheelbow.Chronicconditionsusuallyhavealowirritability,butcanhaveanassociatedloss
ofAROMandPROM.Thedegreeofmovementandthespeedofprogressionarebothguidedbythesignsandsymptoms.
Rehabilitatetheshoulderusingscapularplanesratherthanthestraightplanesofflexion,extension,andabductionasthescapularplanesaremore
functional.
Shortleverarmsshouldinitiallybeusedwithexercisesastheydecreasethetorqueattheshoulder.Shortleverscanbeachievedbyflexingtheelbowor
byexercisingwiththearmclosertothebody.
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Obtainastablescapularplatformasearlyaspossible.
AchievetheclosedpackpositionoftheGHjointattheearliestopportunity.AllROMexercisesfortheshoulderhavetraditionallybeeninitiatedinthe
earlyrangesofflexionwiththegoalofachievingfullelevation.Giventheprotectionaffordedthejointbythepassiverestraintsystem,thoughtshouldbe
giventoprovidingROMexercisesinitiatedattheendrangesofelevationaccordingtopatienttolerance.Exceptionstothiswouldbethepatientwhose
conditionprecludedsuchexercises,thatis,followingshouldersurgery,adhesivecapsulitis,orinstability.
Reproducetheforcesandloadingratesthatwillmimicthepatientsfunctionaldemandsastherehabilitationprogresses.
ThemanualtechniquestoincreasejointmobilityandthetechniquestoincreasesofttissueextensibilityaredescribedinTherapeuticTechniquessection.
ACUTEPHASE
Thegoalsoftheacutephaseincludethefollowing:
Protectionofthehealingsite.
RestorationofpainfreeROMthroughouttheremainderofthekineticchain.
Enhancepatientcomfortbydecreasingpainandinflammation.
Retardmuscleatrophy.
Minimizethedetrimentaleffectsofimmobilizationandactivityrestriction.252,253,389392
Maintaingeneralcardiovascularfitnessusinglowerextremityaerobicexercisessuchaswalking.
Independencewithahomeexerciseprogram.
TheprinciplesofPRICEMEM(protection,rest,ice,compression,elevation,manualtherapy,earlymotion,andmedication)areappliedasappropriateduring
theearlystagesoftheacutephase.Icingfor2030minutesthreetofourtimesaday,concurrentwithnonsteroidalantiinflammatorydrugs(NSAIDs)or
aspirin,canassistinreducingpainandswelling.
Earlyactiveassistedandpassiveexercisesareperformedtonourishthearticularcartilageandassistincollagentissuesynthesisandorganization.393397These
exercisesareinitiatedinpainfreearcs,below90degreesofabduction/flexion.RecommendedROMexercisesfortheacutephaseincludethefollowing:
Codmansorotherpendulumexercises(Fig.1694)VIDEO.Codmanspendulumexerciseiscommonlyprescribedaftershouldersurgeryorinjuryto
providegradeIandgradeIIdistractionandoscillationsresultingindecreasedpainandearlyjointmobilization.398Astudy398whichmeasuredEMG
activityoftheshouldermusclesfoundthatthependulumexercisedidnothaveasignificanteffectonshoulderEMGactivity.Generally,the
supraspinatus/uppertrapeziusmuscleactivitywassignificantlyhigherthanthedeltoidandinfraspinatusactivityespeciallyinpatientswithshoulder
pathology.Manyshoulderprotocolssuggestholdingaweightwhileperformingthependulumexercisesasrehabilitationprogresses.Ellsworthetal.398
foundthatperformingthependulumexercisewithaddedweightdidnotresultinsignificantincreasedshoulderEMGactivityforthedeltoidand
infraspinatusmusclesinsubjectswithorwithoutshoulderpathology.However,patientswithshoulderpathologyhadmoredifficultyrelaxingtheir
supraspinatus/uppertrapeziusmusclesthandidthehealthysubjects.398OtherPROMexercisescanalsobeintroduced.Theseincludepassiveshoulder
flexion(Fig.1695)VIDEO,abductionVIDEO,ER(Fig.1696)VIDEO,andIR(Fig.1697)andelbowflexionandextensionVIDEO.
ActiveassistedROM(AAROM)exercises.AAROMmayincludewandorcaneexercisesthatmovethearmintofunctionalplaneswhileincorporating
combinationsofforwardflexion(Fig.1698)VIDEO,extension,abduction(Fig.1699),IR,andER(Fig.16100).Overthedoorpulleyexercisesare
performedlaterintheacutephaseastolerated.However,caremustbetakenwiththeseexercisesinthepresenceofimpingementoradhesivecapsulitisas
theseexercisescanreinforcepoorscapulohumeralmotion.
Activeexercises.Thesecanbeperformedinavarietyofpositionsincludingstanding,sitting,orlying(Figs.1617and1620).
FIGURE1694
Codmanspendulum.
FIGURE1695
Passiveshoulderflexion.
FIGURE1696
Passiveshoulderexternalrotation.
FIGURE1697
PassiveshoulderIR.
FIGURE1698
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Activeassistedshoulderflexion.
FIGURE1699
Activeassistedshoulderabduction.
FIGURE16100
Activeassistedshoulderexternalrotation.
Strengtheningexercisesfortheshoulderareintroducedasearlyastolerated,initiallyusingisometricexercises,withthearmpositionedbelow90degreesof
abductionand90degreesofflexionbeforeadvancingtoprogressiveresistiveexercises(PREs)(Figs.16101to16105).Elbowflexion(Fig.16106)and
extensionPREsarealsointroducedasappropriateVIDEO.SpecificscapularrehabilitationPREsaretypicallyinitiatedwiththeisometricexercises,suchasthe
scapularsettingexerciseVIDEO.Patternsofscapularretractionandprotractionareinitiatedinsingleplanesandthenprogressedtoelevationanddepressionof
theentirescapula.Toimprovebackwardreaching,thepatientmustfirstlearncorrectretractionprocedures.
FIGURE16101
Resistedshoulderexternalrotation.
FIGURE16102
Resistedshoulderhorizontalabduction.
FIGURE16103
Resistedshoulderflexion.
FIGURE16104
ResistedeccentricshoulderIR.
FIGURE16105
Resistedeccentricshoulderexternalrotation.
FIGURE16106
ElbowflexionPRE.
JobeandPink98believethattheorderofstrengtheningintherehabilitationprocessshouldfollowaprogressionbasedonmusclefunction.Theyadvocate
strengtheningtheGHprotectors(rotatorcuffmuscles)andscapularpivoters(levatorscapulae,serratusanterior,middletrapezius,andrhomboidsVIDEO)
initiallybecauseoftheroletheyplayinprovidingstability.Incontrast,exercisesforthehumeralpositioners(deltoid)andthehumeralpropellers
(latissimusdorsiandpectoralismajor)areintroducedintheFunctionalPhasesection.ExercisesfortheGHprotectorsincludetheAAROMwandexercises,
progressingtoAROMinthepainfreerangesthroughoutthefunctionalplanes.Inaddition,theincorporationofscapularretractionandscapularelevation
exerciseswithGHmovementshelpstimulateacocontractionoftheGHprotectorsandallowforamorenormalphysiologicsequencetoredevelop.Scapular
pivoterexercisesincludethescapularpinch,whichisanisometricactivityinvolvingscapularetractiontowardthemidline(Fig.1628),andtheYTWL
exercise(thelettersdescribetheshapethearmsadopt)VIDEO.139,143Otherresistedexercisesforthescapulacanbeintroducedatthisstagetopromote
proximalstability.Examplesincludewallpushupsandisometricchairpushupsatvaryingdegreesofelbowflexion(Fig.16107).
FIGURE16107
Isometricchairpushups.
Oncethearmcanbesafelyelevatedandheldinthepositionof90degreeabductionwhilestandingorsitting,thepatientliesinthesupinepositionandthearm
isactivelyraisedashighasthepainfreerangewillallow(from90to180degrees,dependingontolerance),firstwithoutresistanceandthenwithresistance
VIDEO.Fromthisposition,thepatientperformsaserratuspunchwithaplus.Ifapplicable,thepatientisprogressedfrommodifiedpushups(Fig.16108)
tofullpushups(Fig.16109)VIDEO.Attheendofeachpushupasthearmisfullystraightened,anextrapushisapplied.Thisextrapushwiththepushupis
termedaspushupplus(Fig.16110).Thisexercisestrengthensthepectoralisminor,andthelowerandmiddleserratusanterior.13,118
FIGURE16108
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Modifiedpushup.
FIGURE16109
Fullpushup.
FIGURE16110
Pushupplus.
Theapplicationofjointcompressionwithcontractionthroughtheapplicationofclosedchainexercisesisimportant,asclosedchainactivitieshelptobalance
compressionandshearforcesattheshoulder.Theseactivitiesalsoencouragethecorrectsequencingofmusclecontractionaroundtheshouldergirdleand
emphasizethecocontractionofforcecouplesatthescapulothoracicandGHjoints.85Thisresultsinacorrectscapularpositionandstabilization.139Closed
chainexercisesmaybedoneearlyintherehabilitationphaseastheydonotputshearonthejoint.Theyalsoallowtherotatorcuffmusclestobeactivated
withoutbeinginhibitedbypainordeltoidoveractivity.Theclosedchainexercisescanbeinitiatedinthelowerrangesusingatable(Fig.16111),andthen
progressedtohavingthehandsstabilizedinthequadrupedposition,usingaball(Fig.16112).Theseexercisesarestartedatelevationsof60degreesorless
andaremovedupto90degreesofflexion,andthenabduction,astoleratedtoallowforhealingofthetissues.24,139,143,146
FIGURE16111
Closedchainexerciseusingupperextremitycompression.
FIGURE16112
Jointcompressioninthequadrupedposition.
Otherclosedchainexercisescanbeperformedbyplacingbothhandsonatableandflexingtheshouldertolessthan60degreesandabductingto45degrees.
Progressionismadetoweightbearingonatiltboardoracircularboard(Fig.16113)withintolerance.Otherexercisesthatprovidejointcompressioninclude
thefollowing:
FIGURE16113
Weightbearingonanunstablesurface.
Sidelyingtosittingtransfers(Fig.16114).
Elbowrest.Thepatientsupineinasemireclinedposition,leaningontheelbows,withthehumerusinaneutralorextendedposition(Fig.16115).This
exercisecanalsobeperformedwiththepatientinprone(Fig.16116).Manualresistancecanbeappliedbythecliniciantomaketheexercisemore
challenging.
Tablepressup.Thepatientstandsfacingawayfromthebedwiththehandsrestingonthebed.Whilesupportingthebodythoughthehandsandarms,the
patientmovestheirfeetfurtherawayfromthebed.Thepatientthenraisesandlowerstheirbodybystraighteningtheelbows(Fig.16117).Theexercise
canbemademorechallengingbymovingthefeetfurtherawayfromthebed.Thisexerciseworksthetricepsmuscles,thepectoralismajorandminor,
andthelatissimusdorsimuscles.13Thisexercisecanbeprogressedtoincludepushingandpullingexercisesandquadrupedandtripodbalancing(Fig.
16118).
FIGURE16114
Sidelyingtosittransfer.
FIGURE16115
Elbowrecline.
FIGURE16116
Proneonelbowswithshouldercompression.
FIGURE16117
Tablepushup.
FIGURE16118
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Quadricepsbalancing.
Flexibilityexercisestostretchboththejointcapsuleandtheshouldergirdlemusclesareavitalcomponentoftherehabilitationprocess.Theseincludethe
sleeperstretch(Fig.16119)performedinsidelyingonthethrowingsidetostabilizethescapulaagainstthebed,andboththeshoulderandelbowflexedto90
degreesVIDEOandthenwiththearmabductedto90degreesVIDEO.Therolloversleeperstretchexerciseissimilarexceptthattheshoulderisonlyflexed
5060degreesandthepatientisrolledforward3040degreesfromvertical.Bothexercisescanbemodifiedbyrollingthetrunkposteriorly2030degreesto
stabilizethescapulaandbyusingatowelplacedundertheelbowtoincreasethestretchattheposteriorshoulder.399GentlegradeIorIIoscillationsare
performedbytheclinicianastoleratedbythepatient.AnotherstretchthatcanbeperformedisthesupinehorizontaladductionwithIRstretch.Toperformthe
stretch,thepatientliesinthesupinepositionwiththeshoulderflexedto90degrees.Theclinicianappliesastabilizingforcetothelateralborderofthescapula
whilethearmishorizontallyadducted.Atthispoint,theclinicianappliesagentleforceintoIR.Cadavericstudiesdesignedtodeterminethebestpositionto
stretchtheposteriorshouldersofttissuestructureshavequantifiedthestrainontheposteriorcuffandcapsuleinanumberofpositions.400,401Thesestudies
reportedincreasedstrainontheposteriorcapsulewiththearmat60and90degreesofelevationcombinedwithIR.
FIGURE16119
Sleeperstretch.
Inthethrowingathlete,emphasisshouldbeplacedonhorizontaladductionoftheshoulderstretchingexercisestoimproveflexibilityoftheposteriorshoulder
region.Thetraditionalcrossbodystretchisperformedinstandingwithoutscapularstabilizationandusingtheoppositehandtohorizontallyadductthetargeted
shoulder(Fig.16120).Toenhancescapularstabilizationandtocontrolexcessiveexternalrotation,thetechniquecanbeperformedinsidelyingwiththetrunk
rolledposteriorly2030degrees.Ifthearmperformingthestretchisplacedsuperiorlytotheonebeingstretched,theamountofexternalrotationcanbe
controlledviacounterpressure.
FIGURE16120
Crossbodystretch.
CLINICALPEARL
Onestudy402thatexaminedtheimmediateeffectsofthesleeperstretch,performedthreetimesfor30seconds,foundanincreaseinbothhorizontaladduction
andinternalrotationROMfollowingthestretches.
Anotherstudy403reportedasignificantlygreaterincreaseinIRusingthecrossbodystretchascomparedtothesleeperstretch.
Tosupplementthestretchesappliedbytheclinician,anumberoftechniquescanbeusedbythepatienttomaintainandimprovetheROMgainsachievedinthe
clinic(seeTherapeuticTechniquessection).
Kineticchainpreparationcanbeginintheearlystageswhiletheshoulderisrecoveringfromtheinjuryorsurgery.Thelengthofthekineticchainrequired
dependsontheneedsofthepatientandthegoalsoftherehabilitativeprocess.Longerkineticchainsareassociatedwiththemoreactivepatients,andmay
includetheentirelowerkineticchainandthetrunkinadditiontotheupperextremity(seeBiomechanicssection).Kineticchainpreparationwillallowforthe
normalsequencingofvelocityandforcewhenthepatientreturnstotheirnormalactivitiesorathleticpursuits.139,143
AccordingtoKibler,139progressiontothefunctionalphaseoftherehabilitativeprocessrequiresthatthefollowingcriteriabemet:
Progressionoftissuehealing(healedorsufficientlystabilizedforactivemotionandtissueloading)
PainfreeROMofatleast120degreeelevation
Manualmusclestrengthinnonpathologicareas4+/5
Scapularcontrol,withdominantside/nondominantsidescapularasymmetrylessthan1.5cmwithlateralslidetest(LST)
FUNCTIONALPHASE
Thefunctionalphaseisdesignedtoaddressanytissueoverloadproblemsand/orfunctionalbiomechanicaldeficits.Thegoalsofthefunctionalphaseinclude
thefollowing:
Attainfullrangeofpainfreemotionwithnormaljointkinematics
Improvemusclestrengthtowithinnormallimits
Improveneuromuscularcontrol
Restorenormalmuscleforcecouples
CLINICALPEARL
Thenumberofrepetitionsthepatientisaskedtoperformshouldbebasedonthenumberthepatientcandocorrectlywithcontrolnotapredeterminednumber.
CLINICALPEARL
Generallyspeaking,exercisemachinesarenotfunctional,emphasizeanteriormusclegroupsratherthanposteriormusclegroups(oftenoppositeofthedesired
effect),anduselongleverarmsmakingcontrollingthemotiondifficultandincreasingtheriskofajointshear.
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Theexercisesduringthisphaseareperformedslowlyatfirstandarethenprogressedtohigherfunctionalspeeds.Isolatedmusclecontractionscanbeachieved
byplacingthepatientinthemuscletestpositionforthatmuscle.Threesetsofthestrengtheningexercisesshouldbeperformeddailyusingweightsof110lb.
Thenumberofrepetitionsisdeterminedbytissueresponse(pain,fatigue,andcompensatorypatterns).
Correctactivationandfunctioningofthescapulapivotersisessential.Properstrengtheningofthescapularpivotersassuresthatthescapulafollowsthe
humerus,providingdynamicstabilityandassuringsynchronyofthescapulohumeralrhythm.Asthescapulothoracicmusclesarenotrequiredtocontract
powerfullyovershortperiods,orproducelargeamountsofforce,itcouldbehypothesizedthatthescapulothoracicmusclesserveaprimarilyposturalfunction.
Thus,intherehabilitationofthescapulothoracicmuscles,theirposturalfunctionshouldbeaddressedandretrained.Thiscanbeaccomplishedintheformof
enduranceexercisesbytrainingthemuscleswithlowweightsandhighrepetitions.259
CLINICALPEARL
Whilethepatientisperformingexercisesforthescapulohumeralrhythm,theclinicianshouldnotethefollowing:404
Inthefirstphaseofarmabduction(030degrees),noorminimalscapulamovementshouldoccur.
Inthesecondphase(3090degrees),thescapulashouldrotatebutshowminimalprotractionorelevation.
Inthethirdphase(90108degrees),externalrotationtothehumerusisnecessary.
Inscaption,thescapulohumeralrhythmisslightlydifferent,withmoreindividualvariationinthemovement,andmorescapularrotationandprotractionare
common.404
Exercisesforthescapularpivotersincludethefollowing:
Shouldershrugs(periscapulartrapezius,levatorscapula).Resistancecanbeaddedtothisexercisebyhavingthepatientholddumbbellsinthehands.
Pronerowing.Thepatientliesproneonthetablewithaweightinthehand.Withtheelbowflexedtoapproximately90degrees,thepatientraisesthe
elbowtotheceiling(Fig.16121).Thisexercisestrengthenstheuppertrapezius,levatorscapulae,lowertrapezius,posteriordeltoid,andtoalesser
extent,themiddletrapezius,rhomboids,andmiddledeltoid.13,118,405
Modifiedpushups(seeFig.16108).
SidelyingabductionexercisesVIDEOareperformedwiththesubjectlyingonhisorhersideandmovinginto45degreeabductioninaneutralrotation
positionfromaneutraloradductedposition.UsingMRI,sidelyingabductionhasbeenshowntoproducethegreatestsignalintensityincreaseinthree
musclesoftherotatorcuff:supraspinatus,infraspinatus,andsubscapularis,aswellasthedeltoid.406Anumberofotherexerciseshavebeenreportedto
demonstratehighsubscapularisactivity.TheseincludeIRat90degreesofabduction,thepushupplus,thediagonalexercise(Fig.16122Aand122B),
andthedynamichugexercise(Fig.16123).
FIGURE16121
Pronerowing.
FIGURE16122
Diagonalexercisefortheupperextremity.A:Startposition.B:Endposition.
FIGURE16123
Dynamichugexercise.
Threeexercisesthatarespecificforthemiddleandlowertrapeziusincludethefollowing:
Scapularpinchesorsqueezes.
Thumbtubes.Theseareperformedwiththeelbowextendedandthethumbpointingposteriorlywhilegraspingresistivetubing.Thepatientthen
performsaseriesofshoulderextensionand/orhorizontalabductionmotionsatvariousdegreesofelevation.
Powersquarepatterns.Theseareperformedbyhavingthepatientelevatetheshoulders,pullback(retract)theshoulderswhilemaintainingtheelevation,
depressingtheshoulderswhilemaintainingtheretraction,andthenmovingtheshouldersforward(protracting)whilemaintainingthedepression.
Oncescapularcontrolhasbeenachieved,exercisesforthehumeralpositioners(therotatorcuffanddeltoid)canbeinitiatedtopreventhumeralheadmigration,
andtorestorevoluntaryarthrokinematiccontrolofthehumeralheadthroughrotatorcuffcoactivationandstabilization,aswellasactivationofthebicepsand
pectoralismajor.404Forexample,bystrengtheningtheinfraspinatus,teresminor,andsubscapularismuscles(relativetothesupraspinatusandthedeltoid),it
maybepossibletoreestablishthenormalbalanceandforcecoupleduringelevationoftheGHjoint.4,38,407
Openchainexercisesdesignedtofurtherstrengthentherotatorcuffmusclesareemphasized.Theseexercisesmayincludethefollowing:
Elevationintheplaneofthescapula(scaption)alsoknownasemptythecan,supraspinatusexercise,supraspinatusfly,andJobesexerciseis
definedtobeabductionintheplaneofthescapula(90degreescombinedwith30degreesofflexion)andIR(Fig.16124).336Althoughusefulasa
specialtest,thismotiondoesnothelptoreestablishscapulohumeralrhythmandcanbecounterproductiveasitisoftenpainfulearlyintherehabilitation
process.
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Elevationintheplaneofthescapula(scaption)inER(fullcanposition)(Fig.16125).Thisexercisestrengthensthescapulapivotersandmaybe
preferableinthepresenceofimpingement.13,118,405
FIGURE16124
Resistedemptycanexercise.
FIGURE16125
Resistedfullcanexercise.
CLINICALPEARL
Acontrolledlaboratorystudy408thatobservedscapularkinematicsduringarmelevationagainstanelasticloadfoundthatthechangesinscapularmotion
duringtheloadedconditionwereinadirectionthatcouldbeconsideredtohaveapotentialtoleadtoinjuries,suggestingcautionwhenusingtheseexercisesin
individualswithpoorscapularcontrol.
Militarypress.Thisexercise,whichisperformedbyraisingboththehandsfromshoulderheightstraightuptowardtheceiling,strengthensthe
supraspinatus,subscapularis,uppertrapezius,406anteriordeltoid,middleserratusanterior,lowerserratusanterior,andmiddledeltoid.13,118Asthe
militarypresscancauseimpingement,caremustbetakenwithitsuse.Thisexerciseisprobablybetterusedinapreventionprogram.
Scapularetractionwithhorizontalabductionoftheexternallyrotatedshoulder,doneinprone(Fig.1635).Blackburnetal.118demonstratedthat
externallyrotatingthehumerusduringproneexerciseincreasedEMGactivitytothehighestlevels.Horizontalabduction(90or100degrees)inER
strengthensthemiddletrapezius,infraspinatusandtoalesserextent,theteresminorandposteriordeltoid(Table1633).13,118,259,405Thepatientlies
proneonthetablewithbotharmsabductedto90or100degreesandthumbspointingtowardtheceiling.Withorwithoutaweightinthehand,thepatient
thenraiseshis/herthumbstowardtheceiling(Fig.1635).Ifthearmisabductedto100degreesinthefrontalplane,thelowertrapeziusisexercised.118
Scapularretractionwithhorizontalabductionoftheinternallyrotatedshoulder,performedinprone(Fig.16126)thisissimilartothepreviousexercise,
butthepatientnowhasthethumbspointingdowntowardtheground.Heorsheisagainproneandhisorherarmsareabductedtoapproximately90
degrees.Heorshethenraiseshisorherhypothenareminencetowardtheceiling.Thisexercisestrengthens,inorderofeffectiveness,theposterior
deltoid,middletrapezius,rhomboids,middledeltoid,levatorscapulae,infraspinatus,teresminor,uppertrapezius,andlowertrapezius.13,118,405This
exercisecanalsobedoneinstandingbyusingelasticresistance.
Scapulardump(asthoughtryingtoemptythingsoutofacan)exercisesthatincorporatearm,scapular,andtrunkmovements.
Shortarc(painfree)exercisesintoscaption,abduction,andforwardflexionto30degreesinitiallyandthento90degrees.Theseexercisesshouldbe
performedinERtofacilitateclearanceofthegreatertuberosityunderthecoracoacromialligament.
TABLE1633ScapularandHumeralControlExercises
ScapularControl HumeralControl
Bentoverrowing Pronehorizontalabduction
Pushupswithaplus(maximumshoulderprotraction) Scaptionininternalrotation(thumbsdown)
Pressups Scaptionwithexternalrotation(thumbsup)
Forwardpunchouts Proneextension
Sidelyinginternalandexternalrotation
Scapularsqueezes
Prone90degrees/90degrees(90degreeabduction,90degreeelbowflexion)externalrotation
FIGURE16126
ProneshoulderretractionwithglenohumeraljointinIR.
TheopenchainexercisesshouldalsoincluderesistedshoulderexternalVIDEO(Fig.16127)andinternalVIDEO(Fig.16128)rotationwiththearmin
increasingamountsofabductionVIDEOtostrengthentheinfraspinatus/teresminorandsubscapularismuscles,respectively.Toavoidconcurrentstrengthening
ofthedeltoidduringtheearlierphasesofstrengthening,thepatientisinstructedtoholdamagazineortowelrollbetweentheextremityandthetrunkwhile
strengtheningtherotatorcuffmuscles.Thisforcedadductionrelaxesthedeltoidandisolatestheobliquemusclesoftherotatorcuff.
FIGURE16127
Resistedexternalrotation.
FIGURE16128
ResistedIR.
Oncecontrolinmostoftherangehasbeenachieved,diagonalproprioceptiveneuromuscularfacilitation(PNF)exercisescanbeusedtoteachcontroland
stabilizationthroughoutthewholerange.TheshoulderD2pattern(flexion,abduction,andER)isespeciallyusefulforinstability.404
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Oncethemusclescancontractinthecorrectsequence,thehumeralpropellers(i.e.,thelatissimusdorsi,teresmajor,pectoralisminor,andpectoralismajor)are
trainedconcentrically,whilethehumeralpositionersandprotectors(i.e.,infraspinatus,teresminor,supraspinatus,posteriordeltoid,andbiceps)andscapula
pivotersaretrainedeccentrically.
Inadditiontoaddressingthemusculatureoftheshouldercomplex,theclinicianmustaddressthewholekineticchaininvolvedinanactivitytowhichthe
patientisplanningtoreturn.Thismayincluderehabilitationofthelegsandhipstofocusonthegenerationofappropriateactivityspecificforceandvelocity
fromthelowerextremity.139,143Examplesincludeexercisesthatdevelopnormalagonistantagonistforcecouplesinthelegssuchassquats,plyometricdepth
jumps,lunges,andhipextensions.Mostshoulderactivitiesinvolverotationanddiagonalpatterns.143,146Thustheexercisesmustincorporatetrunkrotation
exercises(usingmedicineballortubing),whichintegratelegandtrunkstabilizationandincorporatediagonalpatterns(Fig.16129).Theseexercisesare
progressedtoincorporatecombinedpatternsofhipandtrunkrotationinbothdirections,andhipandshoulderdiagonalpatternsfromthelefthiptotheright
shoulderandfromtherighthiptotheleftshoulder.143,146
FIGURE16129
Trunkrotationexerciseswithmedicineball.
Enduranceactivitiesinthelegsshouldalsobeemphasized.Bothaerobicenduranceforrecoveryfromexerciseboutsandanaerobicenduranceforagilityand
powerworkareadvocated.Thesecanbedoneusingminitrampolineexercises,agilitydrillswithrunningandjumping,jumpingjacks,andsliderorFitter
boards.139
Thearthrokinematicmovementsofthejointsintheentirekineticchainmustbeaddressedforhypomobilityandhypermobility,asappropriate.Thesejoints
includetheACjoint,theSCjoint,thescapulothoracicjoint,thecervicalandupperthoracicspine,andtheupperribs.Forexample,theclinicianshouldcheck
forGIRD,restrictionoftheinferiorGHligament,andanylossofrangeinthepectoralismajorandpectoralisminor.
CLINICALPEARL
Thecircleconceptofinstability35,144relatestothefactthatinjurytostructuresononesideofthejointsufficienttoresultininstabilitycan,simultaneously,
causeinjurytostructuresontheothersideorotherpartsofthejoint,particularlyinthepresenceoftrauma.Forexample,atraumaticanteriorinstabilityofthe
shouldercanleadtoinjuryoftheposteriorstructures.Thus,theclinicianmustalwaysbeawareofpotentialinjuriesontheoppositesideofthejointevenif
symptomsarepredominantlyononeside.Inaddition,ifajointishypermobileinonedirection,itmaybehypomobileintheoppositedirection.Forexample,
withanteriorinstability,theposteroinferiorcapsuletendstobetightandthereforerequiresmobilization,whereastheanteriorcapsuleishypermobileand
requiresprotection.404
Proprioceptionexercisescanbeintroducedassoonasthepatienthasgainedscapularcontrol.Theseexercisescanincludetheaforementionedclosedchain
activitiesfortheupperextremity.Openkineticchainactivitiesmayalsobeused,buttheyarenotaseffective,andtheydonotrequirethesamelevelof
stability.404
Activityspecificprogressionsmustbecompletedbeforefullreturntofunctionisallowed.Thisisdonetotestalloftheworkingcomponentsinvolvedinthe
activity.Veryfewdeviationsfromthenormalparametersofarmmotion,armposition,forcegeneration,smoothnessofallofthekineticchain,andfrom
preinjuryformshouldbeallowedasmostoftheseadaptationswillbebiomechanicallyinefficient.139,143,146,409,410Advancedstabilizationexercisesare
designedtotesttheabilityofthepatienttostabilizethescapulastaticallyinpositionsabove30degrees,mostcommonlyinanopenkineticchain.Thepatientis
askedtoperformisometricholdoreccentricbreakactivitiesoftheinternalandexternalrotatorsinvariouspositionsofGHabduction,scaption,andforward
flexion.Closedchainexercisesincludewallfalls,tablefalls,andbalancingondifferentbalancedevices.Closedchainexercisesinthisphasemayalsoinclude
thefollowing:
Regularpushups(Fig.16109)areprogressedastolerated.
Medicineballcatchandthrow(Fig.16130to16134)VIDEO.
FIGURE16130
Medicineballthrowandcatch.
FIGURE16131
FIGURE16132
FIGURE16133
FIGURE16134
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Dynamicweightshiftingexercisesareintroducedduringthisphase.Withthepatientweightbearingonallfoursinthequadrupedposition,andwhilekeeping
theirhandsstationaryinthesameposition,thepatientcanrockthebodyforwardandbackward,andsidetoside.Asimilarexercisecanbeperformedonan
unsteadysurfacebyusingequipmentsuchastheBOSUtrainerVIDEO.Alternatively,thepatientcanslidetheirhands,oronehand,forward,backward,and
sidetosidewhilemaintainingtheirtrunkstill.ResistancecanbeaddedusingaFitterboard(Fig.16135).
FIGURE16135
Fitterboardexerciseusingupperextremities.
Finally,dynamicstabilizationexercisesthatinvolvecontrolledeccentricmovementofthescapulawhilethearmmovesareintroduced.139Eccentricexercises
areparticularlyimportantforthosepatientswheretensileoverloadingissuspectedtobethecause,andfortheoverheadathletepopulation.388,411Exercises
suchasbentoverrows,andlungeswithdumbbellsaregoodexamples.
Thecriteriaforreturntoactivityincludethefollowing139:
Littleornopain
FunctionalROMwithinvolvementofthewholekineticchain
Normalmovementpatternsandfunctionalability
Appropriatelevelsoffitness
Nearnormalstrength
Abilitytoperformthenecessaryskills
Table1634maybereferredtoforatypicalprogramgivenforapitcherreturningtofullfunction.Thisprogramcanandshouldbemodifiedasneededbythe
clinician.Eachphasemaytakealongerorshortertimethanthatlisted,andtheprogramshouldbemonitoredclosely.
TABLE1634ThrowersTenProgram
Dumbbellexercisesforthedeltoidandsupraspinatusmuscles
Pronehorizontalshoulderabduction
Proneshoulderextension
Internalrotationat90degreeabductionoftheshoulderwithelastictubing
Externalrotationat90degreeabductionoftheshoulderwithelastictubing
Elbowflexion/extensionexerciseswithelastictubing
Serratusanteriorstrengthening:progressivepushups
DiagonalD2patternforshoulderflexionandextensionwithelastictubing
Pressups
Dumbbellwristextension/flexionandpronation/supination
DatafromWilkKE,ArrigoC,AndrewsJR.Rehabilitationoftheelbowinthethrowingathlete.JOrthopSportsPhysTher.199317:305317.
PRACTICEPATTERN4D:IMPAIREDJOINTMOBILITY,MOTORFUNCTION,MUSCLE
PERFORMANCE,RANGEOFMOTIONWITHCONNECTIVETISSUEDYSFUNCTION
Theprimaryimpairmentinpattern4D,whenappliedtotheshoulder,ishypomobilityduetocapsularrestriction.Inadditiontolimitedjointmovementand
decreasedROMassociatedwithpain,theimpairmentsinthispatternincludedecreasedmotorcontrolandmuscleperformance.
Theclinicalfindingsinthispatterninclude,butarenotlimitedto,pain,limitedROMinacapsularpatternofrestriction,analterationinthescapulohumeral
rhythm,crepitus,andapositiveimpingementsign.
Arthritis
TraumaticArthritisoftheGHJoint
TraumaticorprimaryGHarthritisisanentitythathasbeenwelldescribedanddocumentedbyNeeretal.,335,412whohighlightedthepresenceofsignificant
posteriorglenoiderosioncausingstaticposteriorsubluxationofthehumeralhead.TraumaticarthritisoftheGHjointrarelyoccursinindividualsundertheage
of45.Theconditionischaracterizedbypain,progressivefunctionalimpairment,andreportsofinstability.413Passivehorizontaladductionisusuallythemost
limitedandpainfulmotion.
Conservativeinterventionconsistsofrest,modificationofactivity,andNSAIDs.Electrotherapeuticmodalitiesandphysicalagentsmaybeusedtocontrolpain
andtheactiveinflammation.JointmobilizationsofgradeIorgradeIImayalsobeusedtodecreasepain.Oncepainandinflammationisundercontrol,the
rehabilitationprogressestostrengtheningoftheshoulderprotectorsandscapularpivoters,asdescribedintheInterventionStrategiessection.
Immobilization
Postsurgicalimmobilizationoccursatanyage,althoughitismorecommonintheelderly.Theclinicalprogressionissimilartothatoftraumaticarthritis.This
conditionshouldideallybetreatedbyprophylaxis.
RheumatoidArthritis
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RheumatoidarthritisisdescribedinChapter5.Conservativeinterventionforthispopulationincludespatienteducationonhowtheycaninfluencetheirdisease
processbyalleviatingtheimpairments,functionallimitations,anddisability.Electrotherapeuticmodalitiesandcryotherapycanbeusedtohelpcontrolpainand
inflammation.Thermalmodalitiesmayalsobeusedinthenonacutephases.Therapeuticexercisecanbebeneficialforthepatientswhoareweakandstiffprior
totheonsetofendstagearthritis,wheretheROMandstrengthcanberegained,oratleastmaintained.414However,cautionmustbeusedwiththosepatients
withendstagearthritiswhohavestiffnesssecondarytojointincongruity,astheymayactuallyhavetheirsymptomsexacerbatedwithaggressivestretching
exercises.414
Whenpainbecomestoosevereandconservativeinterventionisunabletorelievethispainandrestorefunction,surgicalmeasuresareconsidered.These
measuresmayincludesynovectomy,GHarthrodesis,ortotaljointarthroplasty.
SepticArthritis
SeeChapter5.
OsteonecrosisoftheHumeralHead
OsteonecrosisofthehumeralheadisdescribedinChapter5.
HemorrhagicShoulder(MilwaukeeShoulder)
Lpaulesnilehmorragique(thehemorrhagicshoulderoftheelderly)wasfirstdescribedin1968.Itconsistedofrecurrent,bloodstreakedeffusionsofthe
shoulderalongwithradiographicfindingsofseveredegenerativeGHarthritisandachronictearoftherotatorcuff.415ThetermMilwaukeeshoulderwasnot
introduceduntil1981.416418
TheconditiongenerallyaffectsasubsetoftheelderlypopulationwhohaveGHarthritisinconjunctionwithacompleterotatorcufftear.
OnetheorytoexplaintheMilwaukeeshoulderdescribesahydroxyapatitemineralphasethatdevelopsinthealteredcapsule,synovialtissue,ordegenerative
articularcartilage.Thisreleasesbasiccalciumphosphatecrystalsintothesynovialfluid.416418Thesecrystalsarephagocytizedbysynovialcellsandform
calciumphosphatecrystalmicrospheroids.Theseinducethereleaseofactivatedenzymesfromthesecells,causingdestructionoftheperiarticulartissuesand
articularsurfaces.419
Anothertheoryisthecuffteartheory.In1983,Neeretal.420postulatedthatuntreatedchronic,massivetearswouldleadtoadegeneratedGHjoint.The
mechanismofdestructionofthearticularcartilagewassaidtoincludemechanicalandnutritionalalterationsintheshoulder.420Themechanicalfactorsinclude
APinstabilityofthehumeralheadresultingfromamassivetearoftherotatorcuff,andruptureordislocationoftheLHBthatleadstoproximalmigrationof
thehumeralheadandacromialimpingement.419GHarticularwearwasthoughttooccurasaresultofrepetitivetraumafromthealteredbiomechanics
associatedwiththelossoftheprimaryandsecondarystabilizersoftheGHjoint.419Changesinthecompositionofthearticularcartilagefollowsbecauseof
inadequatediffusionofnutrientsandthediminishedquantityofsynovialfluid.419Degenerativearthritisandsubchondralcollapseeventuallydevelops.419
Iftheresultantrotatorcuffteararthropathycausesrelativelymildsymptoms,interventionshouldconsistofmildantiinflammatorymedicationandgentle
stretchingexercisestomaintainorregainafunctionalROM.419AstrengtheningprogramshouldfollowtoimprovetheactiveuseofthearmforADL.If
conservativemanagementfails,ahumeralhemiarthroplastyistheprocedureofchoicetoprovidereliablereliefofpainandfunctionalimprovement.419
FrozenShoulder/AdhesiveCapsulitis
Sincethisconditionalsoinvolvesaninflammationofthecapsule,apatientwiththisconditioncouldalsobeclassifiedunderpreferredpracticepattern4E.
ThefrozenshouldersyndromewasfirstdescribedbyDuplayin1872,421whousedthetermperiarthritisscapulohumeral.Itwasnotuntil1934thatCodman60
usedthetermfrozenshouldertodescribethiscondition.In1945,Neviaserintroducedthetermadhesivecapsulitistoreflecthisfindingsofachronic
inflammatoryprocessatsurgeryandautopsy.422
Althoughtheetiologyoffrozenshoulderremainselusive,theunderstandingofthepathophysiologyhasrecentlyimproved.Factorsassociatedwithadhesive
capsulitisincludefemalegender,423ageolderthan40years,424trauma,424diabetes,229,251,425428prolongedimmobilization,429thyroiddisease,430432
strokeormyocardialinfarction,426,433certainpsychiatricconditions,434,435andthepresenceofautoimmunediseases.436,437
Theprevalenceoffrozenshoulderinthegeneralpopulationisslightlygreaterthan2%,423,438and11%oftheadultdiabeticpopulation.425Approximately
70%ofpatientswithadhesivecapsulitisarewomen,and2030%ofthoseaffectedsubsequentlywillhaveadhesivecapsulitisdevelopintheopposite
shoulder.439Complicatingthediagnosisisthefactthattherearemanyconditionsthatcancauseshoulderstiffness(Tables1635and1636).
TABLE1635IntrinsicCausesofShoulderStiffness
Cause Example
Subacromial
Bursitis Calcifictendinitis
Snappingscapula
Tenosynovitis
Bicepstendon Partialorcompletetears
SLAPlesions
Impingementsyndrome
Rotatorcuff Partialrotatorcufftears
Completerotatorcufftears
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Cause Example
Fractures
Glenoid
Proximalhumerus
Surgery
Trauma Postoperativeshoulder,breast,head,neck,chest
Gastrointestinaldisorders
Esophagitis
Ulcer
Cholecystitis
Recurrentdislocationanteriorandposterior
Instabilityglenohumeral
Chronicdislocation
Glenohumeralandacromioclavicular
Osteoarthritis
Rheumatoid
Arthritides
Psoriatic
Infectious
Neuropathic
Osteonecrosis
Hemarthrosis
Miscellaneous
Osteochondromatosis
Suprascapularnervepalsy
DatafromCohenBS,RomeoAA,BachBR.Shoulderinjuries.In:BrotzmanSB,WilkKE,eds.ClinicalOrthopaedicRehabilitation.Philadelphia,PA:Mosby
2003:125250.
TABLE1636ExtrinsicCausesofShoulderStiffness
Cause Example
Parkinsonsdisease
Automaticdystrophy(CRPS)
Intradurallesions
Neuralcompression
Cervicaldiskdisease
Neurologic
Neurofibromata
Foraminalstenosis
Neurologicamyotrophy
Hemiplegia
Headtrauma
Muscular Poliomyositis
Myocardialinfarction
Cardiovascular Thoracicoutletsyndrome
Cerebralhemorrhage
Chronicbronchitis
Infections
Pulmonarytuberculosis
Diabetesmellitus
Progressivesystemicsclerosis(scleroderma)
Metabolic
Paget'sdisease
Thyroiddisease
Rheumatologicdisorders
Inflammatory
Polymyalgiarheumatica
Surgery
Axillarynodedissection,sternotomy,thoracotomy
Trauma
Fractures
Cervicalspine,ribs,elbow,hand,etc.
Medications Isoniazid,phenobarbitone
KlippelFeil
Sprengel'sdeformity
Glenoiddysplasia
Congenital Atresia
Contractures
Pectoralismajor
Axillaryfold
Depression
Behavioral
Hystericalparalysis
Referredpain Diaphragmaticirritation
Pancoasttumor
Neoplastic Lungcarcinoma
Metastaticdisease
DatafromCohenBS,RomeoAA,BachBR.Shoulderinjuries.In:BrotzmanSB,WilkKE,eds.ClinicalOrthopaedicRehabilitation.Philadelphia,PA:Mosby
2003:125250.
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NashandHazelman440havedescribedtheconceptofprimaryandsecondaryfrozenshoulders,withtheformeridiopathicinorigin,andthelattereither
traumaticinoriginorrelatedtoadiseaseprocess,neurologic,orcardiaccondition.
PrimaryAdhesiveCapsulitis
Primaryadhesivecapsulitisischaracterizedbyanidiopathic,progressive,andpainfullossofactiveandpassiveshouldermotion,particularlyER,whichcauses
theindividualtograduallylimittheuseofthearm.Difficultyisreportedwithputtingonajacketorcoat,puttingobjectsintobackpockets,orhooking
garmentsintheback.204,441443Inflammationandpaincancausemuscleguardingoftheshouldermuscles,withouttruefixedcontractureofthejointcapsule.
Disuseofthearmresultsinalossofshouldermobility,whereascontinueduseofthearmthroughpaincanresultindevelopmentofsubacromial
impingement.439Overaperiodofweeks,compensatorymovementsoftheshouldergirdledeveloptominimizepain.439Withtime,thereisresolutionofpain
andtheindividualisleftwithastiffshoulderandwithseverelimitationoffunction.
SecondaryorIdiopathicAdhesiveCapsulitis
ZuckermanandCuomo444definedidiopathicadhesivecapsulitisasaconditioncharacterizedbysubstantialrestrictionofbothactiveandpassiveshoulder
motionthatoccursintheabsenceofaknownintrinsicshoulderdisorder.Twoclinicalformsarerecognized:
1.Oneformisdefinedaswhenthepainismorenoticeablethanthemotionrestriction.Thisconditionisselflimiting,andthepatientspontaneously
recoverswithin6monthstoayear.Twostudies445,446ofpatientswithidiopathicadhesivecapsulitisfoundthatthevastmajorityofpatientswiththis
conditionweresuccessfullytreatedwithaspecificshoulderstretchingexerciseprogram.
2.Theotherformisdefinedaswhenthepain,whichcanradiatebelowtheelbow,isasnoticeableastherestriction.Thepatientcomplainsofpainatrest
andisunabletosleepontheinvolvedside.ERoftheGHjointisusuallyaffectedmorethanabductionorflexion.204Theinitialphaseofthiscondition
ischaracterizedbypainandprogressivelossofmotionlasting26months.Thisformrespondswelltoaseriesofcorticosteroidinjectionsorlocal
anesthetic(distensiontherapy).
Toformulatealogicalapproachtotheinterventionofpatientswithadhesivecapsulitis,theclinicianneedstodeterminethedegreeofinflammationand
irritability.Tohelpinthisdetermination,itisnecessarytohaveabetterunderstandingoftheunderlyingcellularandbiochemicalpathophysiologyofthis
disease.
Thereisdisagreementastowhethertheunderlyingpathologicprocessisaninflammatorycondition,447449orafibrosingcondition.450Significantevidence
exists436,437,449,451insupportofthehypothesisthattheunderlyingpathologicchangesinadhesivecapsulitisaresynovialinflammationwithsubsequent
reactivecapsularfibrosis,makingadhesivecapsulitisaninflammatoryandafibrosingcondition,dependingonthestageofthedisease.Theinitialbiologic
triggerinthiscascadeofinflammationandsubsequentfibrosisisunknown,althoughitislikelytoinvolvemultiplefactors.Insomeareas,thereseemstobea
seasonalvariationinpatientspresentingwithadhesivecapsulitis,suggestingthatavirusisresponsible.439
StagesofProgression
AdhesivecapsulitisissuggestedbyNeviaser422topassthroughfourstagesbasedonpathologicchangesinthesynoviumandthesubsynovium,witheach
stagehavinganindividualinterventionstrategy,althoughthereiscontroversyaboutthisidea.76
StageI
InstageI,patientspresentwithmildsignsandsymptomsoflessthan3monthsduration,whichareoftendescribedasachyatrestandsharpatextremesof
ROM.Thesymptomsoftenmimicthoseofanimpingementsyndrome,whererestrictionofmotionisminimalandpainthatappearstobeduetoarotatorcuff
tendinopathyhasbeenpresentforlessthan3months.However,thepatientreportsaprogressivelossofmotionandinterventionprotocolsforrotatorcuff
tendinopathyfail.Acapsularpatternofmotion(lossofERandabduction)ispresent,andamoresubtlelossofIRinadduction.Inadhesivecapsulitisdueto
type1diabetesmellitus,thecapsularpatternistypicallyequaltothelimitationofERandIR,whichisgreaterthanthelimitationofabduction.
Inthisearlystage,themajorityofmotionlossissecondarytothepainfulsynovitis,ratherthanatruecapsularcontraction.
StageII
Thisstage,oftenreferredtoastheFreezingStage,ischaracterizedbypersistent,andmoreintensepain,evenatrest.PatientspresentingwithstagesIandII
adhesivecapsulitishavepainonpalpationoftheanteriorandposteriorcapsulesanddescribepainradiatingtothedeltoidinsertion.Nightpainanddisturbed
sleepoccurduringacuteflares.Anintraarticularinjectionofsteroidandlocalanalgesicgivenbyaphysiciancanbeextremelyusefulinthediagnosisand
interventionofadhesivecapsulitis.439Aftertheinjection,passiveGHROMisreevaluated.Ifthepatienthassignificantimprovementinpainand
normalizationofmotion,thediagnosisofstageIadhesivecapsulitisisconfirmed.439Ifthepatienthasasignificantimprovementinpainbutnosignificant
improvementinROM,thenbydefinitionheorshehasstageIIadhesivecapsulitis,althoughitmustbeemphasizedthatthesestagesrepresentacontinuumof
theinflammatoryandscarringprocesses.447
InstageII,symptomshavebeenpresentfor39monthswithprogressivelossofROMandpersistenceofthepainpatterndescribedabove.Themotionlossin
stageIIadhesivecapsulitisreflectsalossofcapsularvolumeandaresponsetothepainfulsynovitis.Thepatientdemonstratesalossofmotioninallplanes,as
wellaspaininallpartsoftherange.Thepatientwilltypicallydemonstrateaninabilitytoreachoverhead,behindthehead,andbehindthebackresultingin
difficultydressing,selfgrooming,bringingeatingutensilstothemouth,andreachingthehandintothebackpocketofpants.EvaluationofAROMandPROM
shouldbeperformedbecausedocumentingtheinitialROM,especiallypassivemotion,iscriticalindeterminingtheefficacyoftheinterventionplan.Thereis
normallyadecreasedjointplayassociatedwithlimitedexternalrotationandabduction,withsomelimitationofIRandelevationinflexion.Thecausesofthe
restrictedPROMneedtobeassessedandadifferentiationmustbemadebetweenprotectivemuscleguarding,adaptivechangesinmusculotendinousstructures,
orcapsularadhesionsandcontracture.
CLINICALPEARL
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ItisimportanttonotethattherestrictedROMseeninpatientswithadhesivecapsulitisoccursbothactivelyandpassively,whichisincontrasttoanumberof
othershoulderconditioninwhichalossofAROMoftheGHjointoccurs,butreasonablygoodiffullPROMismaintained.72
StageIII
InstageIII,oftenreferredtoastheFrozenStage,patientspresentwithahistoryofpainfulstiffeningoftheshoulderandasignificantlossofROM.Symptoms
havebeenpresentfor914monthsandhavebeenobservedtochangewithtime.Patientsoftenreportahistoryofanextremelypainfulphasethathasresolved,
resultinginarelativelypainfreebutstiffshoulder.
Poorscapulohumeralrhythmisobservedduringelevationofthearm.Thereisadominanceoftheuppertrapeziusresultinginhikingoftheshouldergirdle.
ThisisattributedtoadecreasedinferiorglideoftheGHjoint,whichpreventsGHabduction.452Inaddition,thereisgeneralmuscleweaknesssecondaryto
decreaseduse.
StageIV
StageIV,alsoknownastheThawingStageforadhesivecapsulitis,ischaracterizedbytheslow,steadyrecoveryofsomeofthelostROMresultingfrom
capsularremodelinginresponsetouseofthearmandshoulder.Althoughmanypeoplefeellessrestrictedinthisphase,objectivemeasurementsshowonly
minorimprovement.453NoarthroscopicorhistologicdataareavailableforpatientswithstageIVadhesivecapsulitisbecausethesepatientsrarelyundergo
surgery.PatientswhopresentwithstagesIIIandIVadhesivecapsulitisoftenreportahistoryoflongstandingpainatrestandpainatnightthathaveresolved
spontaneously.454Theobjectivefindingstypicallyincludeastiffshoulder,withstrikingalterationofscapulohumeralmechanicsandlimiteduseofthearm
duringADL.Acapsularpatternofmotionisacharacteristicfinding.ResistanceintheformofacapsularendfeelisfeltbeforepainisreachedastheGHjoint
istakenthroughPROM.
OtherpathologicconditionsthatcancreateapainfulrestrictionofGHmotionshouldberuledout.Typically,thephysicianusesaroutineradiographic
evaluationtoruleoutothercausesforastiff,painfulshoulderincludingGHarthritis,calcifictendinopathy,orlongstandingrotatorcuffdisease.439
Radiographsusuallyarenegativeinpatientswithfrozenshoulder,althoughtheremaybeevidenceofdisuseosteopenia.439MRIhasbeenusedforinvestigative
purposesinpatientswithadhesivecapsulitisandhasshownanincreasedbloodflowtothesynoviuminfrozenshoulder.455
Intervention
Theconventionalmanagementforadhesivecapsulitisincorporatespatientadvice,analgesics,NSAIDs,steroidinjection,andawidearrayofPTmethods.456
TheprimarygoalofconservativeinterventionistherestorationoftheROMandfocusesontheapplicationofcontrolledtensilestressestoproduceelongation
oftherestrictingtissues.251,252,439,457459Oncethishasbeenestablished,strengtheningoftherotatorcuffandthethreepartsofthedeltoidmuscleis
important.SystematicreviewsconcerningPTinterventionswithadhesivecapsulitishavetraditionallycomparedtheefficacyofonecomponentofPT.For
example,comparingtheeffectofultrasoundaloneormobilizationalone.Theoutcomesfromthesestudieshavebeen,perhapsnotsurprisingly,poor.However,
whencombinedPTmethodsareanalyzed,theresultshavebeenmoreencouraging.Pajareyaetal.456performedarandomizedcontroltrialof122patientsto
studytheeffectivenessofibuprofenandacombinationofPTtechniquesversusibuprofenalone.ThePTintervention(threetimesaweekfor3weeks)included
shortwavediathermy,jointmobilizations,andpassiveGHstretchingexercisesuptothepatientstolerance.At3weeksitwasconcludedthatthePTgroup
demonstratedmorebeneficialeffectsthanthegroupusingibuprofenalone.456
Theseresultsmustbetakeninthecontextofearlierstudiesthathaveindicatedthatagradualreturnoffullmobilityoccurswithin18monthsto3yearsinmost
patients,evenwithoutspecificintervention.460462InaprospectivestudybyDiercksetal.,46377patientswithidiopathicfrozenshouldersyndromewere
includedtocomparetheeffectofintensivephysicalrehabilitationtreatment,includingpassivestretchingandmanualmobilization(stretchinggroup)versus
supportivetherapyandexerciseswithinpainlimits(supervisedneglectgroup).Allpatientswerefollowedupwithin24monthsafterthestartoftreatment.The
studyconcludedthatsupervisedneglectyieldedbetteroutcomesthanintensivePTandpassivestretchinginpatientswithfrozenshoulderwithregardtothe
functionalendresultandthespeedofrecovery.
Theseconflictingfindingsmaybetheresultofanincorrecttreatmentapproach.Asageneralguideline,thepatientwithcapsularrestrictionandlowirritability
mayrequireaggressivesofttissueandjointmobilization,whereaspatientswithhighirritabilitymayrequirepaineasingmanualtherapytechniques.464In
contrast,theemphasisoninterventionforlimitedROMduetononstructuralchangesisaimedataddressingthecauseofthepain.255,438,444,451,461,465467
Thetrustandconfidenceofthepatientisessential,anditisimportanttoensurethatnoharmiscaused,orthatthecliniciandoesnotindicateanyfrustration.
Duringtheacutephase,pendulumexercisesandlowgradejointmobilizationtechniquesarerecommendedtorelievepainandapplyagentlestretchtothe
capsule.Inaddition,passivestretchingoftheuppertrapeziusandlevatorscapulaemusclescanbeperformedbytheclinicianandthentaughttothepatientas
partofahomeexerciseprogram.Duringthesubacutephase,moreaggressiveROMexercisescanbeincorporatedusingPNFtechniques,wallclimbing,and
wall/cornerstretches.AsROMreturns,strengtheningbecomesthefocus,initiatingwithisometrics,andthenprogressivestrengtheningoftheshouldercomplex
duringthechronicphase.
CLINICALPEARL
ItisimportantforthecliniciantorememberthatCRPStypeIisapotentialcomplicationaftershoulderinjuryorimmobility(seeChapters5and18).
Anumberofquestionsareoftenraisedbythepatientwithregardtocorticosteroidinjections.Althoughthesequestionsarebestansweredbytheappropriate
physician,thereisextensiveinformationregardingtheefficacyofintraarticularcorticosteroidintheinterventionofpatientswithadhesivecapsulitis.468472
Hazelman473summarizednumerousstudiesontheuseofintraarticularcorticosteroidandreportedthatthesuccessofinterventionisdependentonthe
durationofsymptoms.
Patientstreatedwithin1monthoftheonsetofsymptomsrecoveredinanaverageof1.5months.
Patientstreatedwithin3monthsoftheonsetofsymptomsreportedasignificantimprovementinsymptoms.
Patientstreatedwithin25monthsoftheonsetofsymptomsrecoveredwithin8.1monthsofonsetofsymptoms.
Patientstreatedafter5ormoremonthsoftheonsetofsymptomshadamoredelayedrecovery,withthetimenecessaryforfullrecoveryreportedtobe
dependentonthedurationofsymptoms.
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Patientstreated612monthsaftertheonsetofsymptomsrequiredanaverageof14monthsforfullrecovery.
Thesedata,alongwithothers,supportthehypothesisthatadhesivecapsulitisisaninflammatoryandfibroticcondition.447,449,450,468,474Earlyintervention
withintraarticularcorticosteroidmayprovideachemicalablationofthesynovitis,thuslimitingthesubsequentdevelopmentoffibrosisandshorteningthe
naturalhistoryofthedisease.447Withresolutionofthesynovitisandlossofthecytokinestimulustothecapsularfibroblasts,capsularremodelingandrecovery
ofROMtakeplace.447
Surgicalinterventionisreservedforthosepatientswhodonotrespondtoconservativeintervention.Historically,arthroscopyhasbeenoflittlediagnosticand
therapeuticvalueinpatientswithadhesivecapsulitisoftheshoulder,424andclosedmanipulationappearstobetheoperationofchoiceifconservativemethods
fail.However,closedmanipulationiscontraindicatedinpatientswithsignificantosteopenia,recentsurgicalrepairofsofttissuesabouttheshoulder,orinthe
presenceoffractures,neurologicinjuryandinstability.439
SelectiveHypomobility
AgeneralizeddecreaseinshoulderROMmaybeduetoanumberofreasonssuchasarthritisoradhesivecapsulitis.Selectivehypomobilityisusuallytheresult
ofarestrictionofthejointcapsule.Anasymmetricalrestrictionofthecapsulecausesanobligatetranslationawayfromthesideofthejointwherethetightness
islocated.Forexample,aposteriorcapsulerestrictioncausesanincreaseinanteriortranslationofthehumeralheadduringcrossarmadductionandwith
flexionoftheGHjoint.45TheposteriorcapsulerestrictionalsoresultsinasuperiortranslationofthehumeralheadwithflexionoftheGHjoint.
Passivemovementtestingmaybeusedtodetectthedirectionofthehypomobilitybyexaminingtheendfeel,andtheamountoftranslationthatoccurs.Such
testsincludetheloadandshifttest,theanteriorreleasetest,andthesulcussigntest.ROMtestsareusedtodeterminetheamountofinternalandER.Thereisa
closeassociationbetweentheamountofIRattheGHjointandtheposteriorshouldercapsuletightness.475
Theinterventionforthisimpairmentincludesawarmupphaseusingamoistheatingpadorupperbodyergometer.Thepatientisthentaughtthepositionto
adopttostretchtherestrictedportionofthecapsule.Themaximumstretchpositionisthenmaintainedforapproximately20minutes,oraslongasthepatient
cantolerate,whicheveroccursfirst.Thepatientisinstructedtoperformthewarmupandstretchathome.Thedurationofthestretchisgraduallyincreased
untilthepatientisabletotoleratethestretchpositionfor60minutesperday.
Thepatientperformsmultipleangleisometricsorshortarcexercisesinthenewlyacquiredrangetoimproveneuromusculardynamiccontrol.WhenfullROM
hasbeenrestored,thepatientperformsfullrangeresistiveexercisesandcombinationsofarmandtrunkexercises,suchasPNF.
AccordingtoSahrmann,correctionofrestingscapularmalalignmentisalwaysindicatedinthispatientpopulation,particularlywhenthePROMisnot
restrictedbymorethan20degrees.215
DownwardlyRotatedScapula
TheGHjointbecomesthesiteofcompensationbecausethescapuladoesnotfullyrotateupwardly.215Thescapulashouldbeconstantlysupportedinits
correctpositionbyprovidingsupportforthearm.Exerciseinterventionshouldincludestrengtheningfortheserratusanteriorandthetrapezius.Stretching
exercisesareprescribedforthosemusclesfoundtobeadaptivelyshortenedintheexamination.Thosemusclesusuallyincludetherhomboidandlevator
scapulae.
ScapularDepression
Thissyndromeischaracterizedbyweaknessandlengtheningoftheuppertrapezius.215Itisoftenaccompaniedbyadaptiveshortnessofthelatissimusdorsi,
pectoralismajor,andpectoralisminor.WhenthescapulafailstoelevatesufficientlyduringGHflexionorabduction,thelowertrapeziusbecomesmore
dominantthanitsuppercounterpart.Theinterventionshouldfocusonprovidingsupportfortheshouldersothatitdoesnotbecomedepressed.Thepatientis
instructedtoperformshouldershrugswiththeGHjointinitsanatomicpositionandalsowiththeshoulderflexedabove120degrees.Amirrorcanbeusedto
teachthepatienttocorrectthedepressionoftheshouldergirdleduringarmelevation.Stretchingexercisesareprescribedforthosemusclesfoundtobe
shortenedintheexamination.
ScapularAbductionSyndrome
ThissyndromeischaracterizedbyexcessivescapularabductionduringGHflexionorabduction.215Itisalsoassociatedwithalengtheningofthetrapezius
andpossiblelengtheningoftherhomboidmusclesandadaptiveshorteningoftheserratusanterior,resultinginpoorcontrolofthescapula.Adaptiveshortness
ofthedeltoidorsupraspinatusmusclescanalsoindirectlyholdthescapulainanabductedposition.InterventionshouldfocusonstretchingtheshortGHand
thoracohumeralmusclesandimprovingtheperformanceoftheadductorcomponentsofthelowerandmiddletrapeziusmuscles.
ScapularWingingSyndrome
Thissyndromeischaracterizedbyaninabilitytoelevateand/orlowerthearmwithoutthescapulawingingoritsinferiorangletilting.Thissyndromeresults
fromaweaknessandadaptiveshortnessoftheserratusanterior,withaccompanyingshortnessofthepectoralisminorandscapulohumeralmuscles.
Interventionshouldfocusonstretchingthepectoralisminortocorrectthetiltingandserratusanteriorforstrengtheningandretraining.
HumeralAnteriorGlideSyndrome
Thissyndromeischaracterizedbyahumeralheadthatispositionedmorethanonethirdanteriorlytotheacromion,andwhichmovesanteriorlyduringGH
abduction.215Otherfindingstypicallyincluderelativetightnessoftheposteriorcapsulewhencomparedwiththeanterior,weakorlengthenedsubscapularis,
adaptiveshortnessofthescapulohumeralexternalrotators,andthepectoralismajor.
Interventionshouldshortenandstrengthenthesubscapularis,andstretchthehumeralexternalrotatorsandthepectoralismajor.
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HumeralSuperiorGlideSyndrome
ThissyndromeischaracterizedbyanexcessivemovementofthehumeralheadinasuperiordirectionduringGHflexion,abduction,orelevation.215Clinical
findingsusuallyincludeadaptiveshortnessofthedeltoid,weaknessoftherotatorcuffmuscles,andadaptiveshortnessofthehumeralinternaland/orexternal
rotators.Interventionfocusesonthedeltoidincreasingitslengthifshortened,anddiminishingitsactivityifdominant.Thepatientshouldbeinstructedto
avoidperformingactivitiesthatinvolveERinadductionaswellasabductionexercisesandresistedshoulderflexionwiththeelbowextended,asthesecan
exacerbatethecondition.
GlenohumeralInstability
Thestructuresinvolvedinthemaintenanceofthestaticanddynamicstabilityoftheshoulder,alsoprovideneurologicfeedbackthatmediatesreflex
stabilizationaroundthejoint.476,477LaxityisthephysiologicmotionandanecessaryattributeoftheGHjointthatallowsnormalROM,whichisnormally
asymptomatic.366Laxityisnotalwayssynonymouswithinstability.478Itisanecessaryattributeoftheshoulderthatpermitsmotion.Instabilityisthe
abnormalsymptomaticmotionoftheGHjointthataffectsnormaljointkinematicsandresultsinpain,subluxation,ordislocationofthe
shoulder.145,476,479,480
Intheearlyyearsoflife,theGHjointisfairlystableduetotheactivemechanismsstabilizingthejoint.However,ifanindividualbecomesdeconditioned,the
dynamicmechanismsbecomeunabletoprovidesupportandthejointbecomesinvolvedinaselfperpetuatingcycleofinstability,lessuse,moreshoulder
dysfunction,andfurtherinstability.Inadditiontoredundanceoftheshouldercapsule,underlyingcausesofGHinstabilitycanincludegenetic,collagen,and
biomechanicalfactors.366
Thereisconsiderablevariationintheamountoftranslationnormallyelicitedinanasymptomaticshoulder.364,365,369,481Shoulderlaxitytestsshowthat
translationsintheasymptomaticshoulderascomparedwiththecontralateralsymptomaticshouldercanbeaslargeas11mminonedirection.365,482Although
ithasbeenshownthathealthyshoulderscanhaveasymmetrictranslationinatleastonedirection,nohealthyshoulderisasymmetricinallthreedirections.365
CharacteristicofGHinstabilityisthecomplaintoftheshoulderslippingorpoppingoutduringoverheadactivities.Instabilityoftheshouldercanbe
classifiedbyfrequency(acuteorchronic),magnitude,direction,andorigin.76Acutetraumaticinstabilitywithdislocationoftheshoulderisthemostdramatic
variety,andoftenrequiresmanipulativereduction.Shoulderinstabilitymayalsobeclassifiedaccordingtothedirectionofthesubluxationaseither
unidirectional(anterior,posterior,orinferior),bidirectional,ormultidirectional.Posteriorinstability,whichresultseitherfromavulsionoftheposteriorglenoid
labrumfromtheposteriorglenoid,orstretchingoftheposteriorcapsuloligamentousstructures,isoftendifficulttodiagnosewithnosingletesthavinghigh
sensitivityandspecificity.Isolatedinferiordislocations,alsoknownasLuxatioerecta,areextremelyrare,accountingforonly0.5%ofall
dislocations.483,131,184,484
MostpatientspresentingwithhypermobilityorinstabilityoftheanteriorGHjointareathleticadolescentsoryoungadultswithjointlaxity.366,485Anterior
instabilityoccurswhentheabductedshoulderisrepetitivelyplacedintheanteriorapprehensionpositionofERandhorizontalabduction.Suchindividualsmay
havepainwithoverheadmovementsduetoaninabilitytocontrolthelaxitythroughmusclesupport.Theymaydevelopenoughinstabilitydirectedsuperiorly
thattheypresentwithimpingementlikesymptoms(instabilityimpingementoverlap),especiallyinpositionsofabductionandER.486Ingeneral,thepatients
havehadnormalasymptomaticshoulderfunctionuntilsomeeventprecipitatessymptoms.Theeventusuallyinvolvesonlyrelativelyminortraumawhen
comparedwiththetraumaticcausesofunidirectionalinstability,orrepetitivemicrotraumaasoccursinpatientswhoparticipateinswimmingand
gymnastics.286Themostcommonpresentingcomplaintispain.487,488
UnilateraldislocationsoccurringfromacutetraumaticeventsincludetheBankartlesionorHillSachslesion.TheBankartlesionisanavulsionoftheanterior
inferiorlabrumfromtheglenoidrimandrequiressurgicalstabilization(traumatic,unidirectionalinstabilitywithBankartlesionrequiringsurgeryorTUBS),
usingtheBankartprocedure,whichaddressesthelesionwithoutsignificantlossofER,489oracapsularreconstructionprocedure.
CLINICALPEARL
Multidirectionalinstability(seelater)isoftendescribedusingtheabbreviationAMBRII(atraumaticonsetofmultidirectionalinstabilitythatisaccompaniedby
bilaterallaxityorhypermobility.RehabilitationistheprimarycourseofinterventiontorestoreGHstability.However,ifanoperationisnecessary,aprocedure
suchasacapsulorrhaphyisperformedtotightentheinferiorcapsuleandtherotatorinterval).490
TheHillSachslesionisacompressionfractureoftheposteriorhumeralheadatthesitewherethehumeralheadimpactedtheinferiorglenoidrim.Dislocation
oftheGHjointisnotuncommoninolderpeople,althoughtheincidenceislessafter50yearsofage.204Chronicrecurrentdislocationsoftheshouldercan
leadtodegenerativearthritis.Anolderpersonwhodislocatesashoulderislikelytohaveconcurrentlytorntherotatorcuffandshouldbeexaminedwiththis
ideainmind.491493Lessertraumaticinjuriescancausesubluxationoftheshouldertosuchadegreethatrecurrentsubluxationratherthandislocationbecomes
thesourceofdysfunction.145
Thepredominantpatternofinstabilityisbestdeterminedfromthepatientsmedicalhistoryandprovocativemaneuversonphysicalexamination.366The
mechanismforasubluxationorrecurrentdislocationusuallyinvolvesaFOOSHinjury,wherebythearmisforcedintoabduction,extension,andER.Dueto
thepotentialfornerveinjurywiththesedislocations,athoroughneurovascularexaminationisessential.76
AnteriorInstability
AnteriorinstabilityoftheGHjointisthemostcommondirectionofinstability.Repetitiveoverheadactivitiessuchasthrowingcanleadtomicrotraumaatthe
shoulder,leadingtoeventualbreakdownofboththestaticanddynamicstabilizersofthejoint,orGHinstability.OncethestabilityoftheGHjointhasbeen
compromised,thestructuresoftherotatorcuffcanbecomeinjured,resultinginatearofoneormoreofthemuscles.Patientswhodescribesymptomsoccurring
intheabductedandexternallyrotatedpositionhavechronicanteroinferiorinstability.
Themechanismforananteriordislocationisabduction,ER,andextensionandiscommoninthrowingandracquetsports,gymnastics,andswimming.
Followinganacutetrauma,thepatienttypicallycomplainsofseverepainandasensethattheshoulderisout.Radiographsconfirmthedislocation,and
reductionisoftennecessary.FrankanteriorsubluxationanddislocationoftheGHjointisrareinchildrenbutcommoninadolescents.494Severepaincauses
thepatienttoimmobilizetheinvolvedarm,inaslightlyabductedandexternallyrotatedpositionwiththeotherhand.Spasmwilltypicallyoccurtostabilizethe
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joint.Thehumeralheadwillbepalpableanteriorlyandtheposteriorshoulderwillexhibitahollowbeneaththeacromion(seeSpecialTestssection).In
youngeragegroups(approximately25yearsandyounger),thechanceofrecurrentanteriordislocationaftertheinitialeventisgreaterthan95%.495
Recurrencesarerareinpatientsolderthan50yearsofage.480
Whenanteriorinstabilityissuspected,theclinicianshouldassessfortightnessoftheposteriorcapsule.Posteriorcapsuletightnesshasbeenshownto
accentuateanteriortranslationandsuperiormigration.370LossofIRinyoungpatientsmaybeanimportantfindingsuggestiveofposteriorcapsularcontracture
thatisoftenassociatedwithsubtleinstability.206Theposteriorjointglideisalsorestricted.Symptomsalsoincludevaryingdegreesofinstability,transient
neurologicsymptoms,andeasyfatigability.488Warneretal.496reportedalowerIRtoERratioforpeaktorqueandtotalworkinthedominantshoulderof
patientswithinstabilityascomparedwithhealthycontrols.ThissuggeststhatanassociationexistsbetweentherelativeIRweaknessandanteriorinstability.366
SLAPLesions
Athletesperformingoverheadmovements,particularlybaseballpitchers,maydevelopadeadarmsyndrome497inwhichtheyhaveapainfulshoulderwith
throwingandcannolongerthrowabaseballwiththeirpreinjuryvelocity.Themainproblemisusuallyatearofthesuperiorlabrum,thesocalledSLAP
lesion.1SLAPlesionsaredescribedassuperiorlabrallesionsthatarebothanteriorandposterior.353Thereareseveralinjurymechanismsthatarespeculatedto
beresponsibleforcreatingSLAPlesionsrangingfromsingletraumaticeventstorepetitivemicrotraumaticinjuries.10Duringadislocation,tearstotheglenoid
labrumoccurinisolationorincombination.ThesuperioraspectofthelabrumismoremobileandpronetoinjuryduetoitscloseattachmenttotheLHB
tendon.76ThelesiontypicallyresultsfromaFOOSHinjury,suddendecelerationortractionforcessuchascatchingafallingheavyobject,orchronicanterior
andposteriorinstability.353,498
TraumaticSLAPlesionscanalsodevelopinthenonathleticpopulation.498Thisoccursastheresultofafallormotorvehicleaccident(e.g.,driverswhohave
theirhandsonthewheelandsustainarearendimpact).
SLAPlesionshavetraditionallybeenclassifiedintofourmaintypes498bysignsandsymptoms:
TypeI.Thistypeinvolvesafrayinganddegenerationoftheedgeofthesuperiorlabrum.Thepatientlosestheabilitytohorizontallyabductorexternally
rotatewiththeforearmpronatedwithoutpain.499
TypeII.Thistypeinvolvesapathologicdetachmentofthelabrumandbicepstendonanchor,resultinginalossofthestabilizingeffectofthelabrumand
thebiceps.500
TypeIII.Thistypeinvolvesaverticaltearofthelabrum,similartothebuckethandletearofthekneemeniscus,althoughtheremainingportionsofthe
labrumandbicepsareintact.76
TypeIV.Thistypeinvolvesanextensionofthebuckethandletearintothebicepstendon,withportionsofthelabralflapandbicepstendondisplaceable
intotheGHjoint.76
Maffetetal.501havesuggestedexpandingtheclassificationscaletoatotalofsevencategories,addingdescriptionsfortypesVthroughVII.
TypeV.ThistypeischaracterizedbythepresenceofaBankartlesionoftheanteriorcapsulethatextendsintotheanteriorsuperiorlabrum.
TypeVI.Thistypeinvolvesadisruptionofthebicepstendonanchorwithananteriororposteriorsuperiorlabralflaptear.
TypeVII.ThisisdescribedastheextensionofaSLAPlesionanteriorlytoinvolvetheareainferiortothemiddleGHligament.
DiagnosisofaSLAPlesioncanoftenbedifficultasthesymptomsareverysimilartothoseofinstabilityandrotatorcuffdisease.Nofindingsonphysical
examinationhavebeenfoundtobespecificforidentifyingpatientswithaSLAPlesion.Thepatienttypicallycomplainsofpainwithoverheadactivitiesand
symptomsofcatchingorlocking.502
SeveralspecialtestscanbeusedtohelpidentifythepresenceofaSLAPlesion(seeSpecialTestssection),includingtheOBrien(activecompression)test,
theclunktest,338,339thecranktest,341theSpeedstest,498theJoberelocationtest,thebicepsloadtest,354andtheanteriorslidetest.349
ConservativeinterventionshouldaddresstheunderlyinghypermobilityorinstabilityoftheshoulderusingdynamicstabilizationexercisesoftheGHjointto
effectivelyreturnfunctionandsymptomaticrelieftothepatient(seeInterventionStrategiessection).
Arthroscopiclabraldebridementisnotaneffectivelongtermsolutionforlabralpathology.503
Studiesofsurgicallabralrepairsaregenerallygoodtoexcellentintermsofreturningpatientstotheirpriorlevelofactivity,whethersportsor
work.76,502,504,505
PosteriorInstability
Posteriorinstabilitiesarerareandonlycompriseapproximately2%ofallshoulderdislocations.187Posteriordislocationsareoftenassociatedwithseizure,
electricshock,divingintoashallowpool,ormotorvehicleaccidents.Patientswhohaveaposteriorinstabilitypatterntypicallyreportsymptomswiththearm
inaforwardflexed,adductedposition,suchaswhenpushingopenheavydoors.Posteriordislocationsareclassifiedassubacromial(posteriorandinferiorto
theacromionprocessthemostcommon),subglenoid(posteriorandinferiortotheglenoidrim),andsubspinous(medialtotheacromionandinferiortothe
scapularspine).76
Themostcharacteristicsignforaposteriordislocationisaloudclunkastheshoulderismovedfromaforwardflexedpositionintoabductionandexternal
rotation,apositivefindingthatisoftenmisdiagnosedasananteriordislocation.Thefindingsforaposteriordislocationareusuallyseverepain,limitedER,
oftentolessthan0degree,andlimitedelevationtolessthan90degrees.Thereisusuallyaposteriorprominenceandroundingoftheshoulderascomparedto
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theoppositeside,andaflatteningoftheanterioraspectsoftheshoulder.Lookingdownatthepatientsshouldersfrombehindcanbestassessthese
asymmetries.
InferiorInstability
Inferiordislocationsareveryuncommonandaretypicallyelicitedbycarryingheavyobjectsatonesside(i.e.,grocerybagsorasuitcase),orby
hyperabductionforcesthatcausealeveringofthehumeralneckagainsttheacromion.479,503
Thediagnosisforthistypeofdislocationisrelativelystraightforward,asthepatientsarmistypicallylockedinabduction.76Thesulcussigncanbeusedto
assessinferiorstability.
MultidirectionalInstability
MultidirectionalinstabilityisasymptomaticGHinstabilitythatispresentinmorethanonedirection.479Itiscommonlybelievedthatfemaleshavemorejoint
laxitythanmales,afactpropagatedbythemedicalliteratureandmedicaltraining.366Indescribingmultidirectionalinstabilityoftheshoulder,atypicalpatient
ispresented,asanadolescentfemalewhocanhabituallyandreproduciblysubluxoneorbothshoulders.484However,withtheexceptionofafewarticles,
thereisinadequateevidencetoconfirmthisview.OneoftheexceptionswasarecentstudybyBorsaetal.,506whichdemonstratedthathealthywomenhave
significantlymoreanteriorjointlaxityandlessanteriorjointstiffnessthandomen.AnotherstudybyHustonandWojtys507usedaninstrumentedarthrometer
toassesskneejointlaxityinathleticandnonathleticmenandwomen.Overall,theyfoundwomentohavesignificantlymorekneejointlaxitythanmen.
Interestingly,theyfoundthatathleticwomenhadsignificantlylesskneejointlaxitythannonathleticwomendid,andathleticmenhadsignificantlylessknee
jointlaxitythannonathleticmen.Thesefindingsimplythatphysicaltrainingandconditioningmaydecreasejointlaxity.506
Thepatientwithamultidirectionalinstabilityisdifficulttodiagnoseasthereisusuallynoassociatedtraumaticeventormechanismofinjury.Rotatorcuffpain
isoftenthefirstpresentingsymptom.Patientswithmultidirectionalinstabilitytypicallyhavescapulothoracicdyskinesiathatcontributestotheinstability.290
Lephartetal.508showedthatpatientswithmultidirectionalinstabilityalsohavedeficitsinshoulderproprioception.Thereforetheinterventionforpatientswith
instabilityshouldbeginwitharehabilitationprogramaimedatimprovingthedynamicstabilizers,neuromuscularcoordination,andproprioceptionoftheGH
andscapulothoracicjoints.24,366,509
Intervention
InterventiongoalsforGHinstabilityorhypermobilityaresimilarregardlessoftheinstabilityclassification.Thegoalistorestoredynamicstabilityandcontrol
totheshoulderusingthedynamicstabilizerstocontainthehumeralheadwithintheglenoid.19,115,187,486,509
Abriefperiodofslingimmobilizationisusuallynecessaryforcomfort.Prolongedimmobilizationshouldbeavoidedbecauseofthetendencyoftheshoulderto
stiffenquickly,especiallyintheelderlypopulation.204Forpatientswithananteriorinstability,ROMexercisesfortheGHjointshouldemphasizeposterior
capsulestretchingtodecreasetheaccentuationoftheanteriortranslationandsuperiormigration.Thepositionsandexercisestomodifyoravoidbasedonthe
directionofinstabilityareillustratedinTable1637.510
TABLE1637ExerciseModificationAccordingtotheDirectionofGlenohumeralInstability
Directionof
PositiontoAvoid ExercisestoModifyorAvoid
Instability
Chestpress,pulldown,pushup,benchpress,militarypress,
Anterior Combinedpositionofexternalrotation,extension,andabduction
flyes
Combinedpositionofhorizontaladduction,internalrotation,and Chestpress,pushup,benchpress,flyes,weightbearing
Posterior
flexion exercises
Inferior Fullelevation,dependentarm Shrugs,elbowcurls,inclinepress,militarypress
ThegeneralapproachforallformsofGHinstabilityincludesthefollowing:
Scapularstabilityexercises.Thesecanbestartedearlyandincludethescapularpinch(seeFig.1627)andshouldershrugexercises.24Inthisearlystage,
thecontrolofthescapulapositioncanbeaidedbytapingthescapularinaretractedorelevatedposition,orbytheuseofafigure8collar,bothofwhich
helptonormalizethescapularmusclefiringpattern.24
Closedchainexercises.Thesearenormallyperformedwiththehandstabilizedonawallorobject,simulatenormalfunctionalpatterns,andreorganize
andreestablishnormalmotorfiringpatterns.24,141,146,289Allofthemovementsofthescapulaandshoulderarecoupledandarepredictablebasedon
armposition.153,511Similarlytothelowerextremity,closedchainexercisesshouldinvolveintegrationofallthejointsintheappropriatekineticchain
withthespecificscapularmaneuversofelevation,depression,retraction,andprotraction.24
Earlyexercisestorehabilitatescapulardyskinesis.Theseincludemodifiedpushups,andprogresstofacilitationpatternsthatincludehipextension,
trunkextension,andscapularretraction.410Clockexercises,inwhichthehandisplacedonawallandthescapulaisrotatedinelevation/depressionand
retraction/protraction,alsodevelopcoordinatedpatternsforscapularcontrol.410
Openchainexercisesfollowtheisometricandclosedchainactivitiesastheseexercisesaremorestrenuous.24OpenchainexercisesincludePNFpatterns,
diagonals,uprightrows,andERandscapularretractionactivities,aswellasmachineexercisesconsistingoflatpulldowns.24
Progressionofthescapularrehabilitationcanbeevaluatedusingthescapularslidemeasurements,andoncethelateralslideasymmetryislessthan1cm,
specificstrengtheningfortherotatorcuffcancommence.24
Besidesrehabilitation,activitymodificationstoavoidanyarmpositionsthatprovokesymptomscanbehelpful.366
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SprainedConoidandTrapezoidLigaments
Asprainoftheseligamentscanresultfromaclavicularfracture,butitcanalsooccurinsportsthatrequirethearmtobepulledintotheextremesofextension
orER.Painisfeltattheextremesofallpassivearmandscapulamovements.ForcedERwiththearminhorizontalabductionwillusuallybethemostpainful
test,anddifferentiationbetweenthetwostructuresismadebypalpationofthecoracoidprocess.Nolimitationofactiveshoulderrangeisusuallyfoundand
resistivemovementsarepainless.
Interventionsfortheseligamentsprainsincludeelectrotherapeuticmodalitiesandphysicalagents,transversefrictionmassage(TFM),andprogressionofROM
oftheshouldercomplexandstrengtheningoftheGHmusclesandscapularpivoters.
AcromioclavicularJointSprain
AninjurytotheACjoint,whichcanbecategorizedaseitheracutetraumaticorchronic,isreportedtobepresentin31%ofallpatientswithshoulder
pain.204,512Themajorityofacutetraumaticinjuriesoccurfromafallontotheshoulderwiththearmadductedattheside.Thegroundreactionforce(GRF)
producesdisplacementofthescapulainrelationtothedistalclavicle.Thechronicdisordermaybeatraumaticorposttraumatic,withtheformerbeingattributed
togeneralizedosteoarthritis,inflammatoryarthritis,ormechanicalproblemsofthemeniscusofthisjoint.70InjuriestotheACjointwereoriginallyclassified
byTossyetal.513andAllmanetal.87asincomplete(gradesIandII)andcomplete(gradeIII).Thisclassificationhasbeenexpandedtoincludesixtypesof
injuriesbasedonthedirectionandamountofdisplacement(Table1638).81,514516AswiththeSCjoint,ACjointinjuriesareclassifiedaccordingto
ligamentousinjuryratherthaninjurytothejointitself:
TABLE1638ClassificationofACInjuriesandClinicalFindings
Isolatedsprainofacromioclavicularligaments
Coracoclavicularligamentsintact
Deltoidandtrapezoidmusclesintact
TypeI TendernessandmildpainatACjoint
High(160180degrees)painfularc
Resistedadductionisoftenpainful
InterventioniswithTFM,ice,andpainfreeAROM
ACligamentisdisrupted
Sprainofcoracoclavicularligament
ACjointiswidermaybeaslightverticalseparationwhencomparedtothenormalshoulder
Coracoclavicularinterspacemaybeslightlyincreased
Deltoidandtrapezoidmusclesintact
TypeII
Moderatetoseverelocalpain
Tendernessincoracoclavicularspace
PROMallpainfulatendrangewithhorizontaladductionbeingthemostpainful
Resistedabductionandadductionareoftenpainful
InterventioninitiatedwithiceandpainfreeAROM/PROMTFMintroducedonday4
ACjointdislocatedandtheshouldercomplexdisplacedinferiorly
Coracoclavicularinterspace25100%greaterthannormalshoulder
Coracoclavicularligamentisdisrupted
Deltoidandtrapezoidmusclesareusuallydetachedfromthedistalendoftheclavicle
TypeIII
Afractureoftheclavicleisusuallypresentinpatientsunder13yrofage
Armheldbypatientinadductedposition
Obviousgapvisiblebetweenacromionandclavicle
AROMallpainfulPROMpainlessifdonecarefully
Pianokeyphenomenon(claviclespringsbackafterbeingpushedinferiorly)present
ACjointdislocatedandtheclavicleanatomicallydisplacedposteriorlyintoorthroughthetrapeziusmuscle
Coracoclavicularligamentscompletelydisrupted
TypeIV
Coracoclavicularinterspacemaybedisplacedbutmayappearnormal
Deltoidandtrapezoidmusclesaredetachedfromthedistalendoftheclavicle
ClavicledisplacedposteriorlySurgeryindicatedfortypesIVVI
ACligamentsdisrupted
TypeV ACjointdislocatedandgrossdisparitybetweentheclavicleandthescapula(300500%greaterthannormal)
Tendernessoverentirelateralhalfoftheclavicle
ACligamentsdisrupted
ACjointdislocatedandtheclavicleanatomicallydisplacedinferiorlytotheclavicleorthecoracoidprocess
TypeVI
Coracoclavicularinterspacereversedwiththeclaviclebeinginferiortotheacromionorthecoracoidprocess
CranialaspectofshoulderisflatterthanoppositesideOftenaccompaniedwithclavicleorupperribfractureand/orbrachialplexusinjury
AROM,activerangeofmotionPROM,passiverangeofmotionTFM,transversefrictionmassage.
DatafromAllmanFL.Fracturesandligamentousinjuriesoftheclavicleanditsarticulation.JBoneJointSurgAm.196749:774784RockwoodCAJr,Young
DC.Disordersoftheacromioclavicularjoint.In:RockwoodCAJr,MatsenFAIII,eds.TheShoulder.Philadelphia,PA:WBSaunders1990:413468.
TypeI.TendernessandmildpainattheACjoint.Sometimesthereisahigh,painfularc(160180degrees),andresistedadductionispainful.
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TypeII.Moderatetoseverelocalpainwithtendernessinthecoracoclavicularspace.Theclaviclemayappeartobeslightlyhigherthantheacromion,
althoughinrealitytheoppositeistrue.AllpassivemotionsarepainfulattheendofROM,andusuallybothresistedadductionandabductionarepainful.
PassiveposteroanteriortranslationattheACjointisgreaterthanthatoftheoppositejoint.
TypeIII.Thepatientusuallyholdsthearmagainstthebodyinaslightlyadductedpositionandexertsanupwardaxialpressurethroughthehumerus.An
obviousgapisvisiblebetweentheacromionandtheclavicle.Allactivemotionsarepainful,especiallyabduction.Thepianokeyphenomenonispresent
afterpushingtheclavicleinferiorly,itspringsbacktoitsoriginalposition.
TypeIV.SimilarfindingsasthoseoftypeIII,exceptthepainissevereandtheclavicleisdisplacedposteriorly.
TypeV.Thereisalargedistancebetweentheclavicleandcoracoidprocessandthereistendernesstopalpationovertheentirelateralhalfoftheclavicle.
TypeVI.Thesuperioraspectoftheaffectedshoulderisflatterthanthenoninvolvedside.Oftenthereareassociatedfracturesoftheclavicleandupper
ribs,aswellasinjurytothebrachialplexus.
TypesIIIIandVallinvolveinferiordisplacementoftheacromionwithrespecttotheclavicle.Theydifferaccordingtotheseverityofligamentousinjuryand
theamountofresultantdisplacement.517
TypesIandIItypicallyresultfromafallorablowtothepointonthelateralaspectoftheshoulder,oraFOOSHinjury.
TypesIIIandIVusuallyinvolveadislocation(commonlyreferredtoasanACseparation)andadistalclaviclefracture,bothofwhichcommonlydisruptthe
coracoclavicularligaments.70Inaddition,damagetothedeltoidandtrapeziusfascia,andrarelytheskin,canoccur.70
TypeIVinjuriesarecharacterizedbyposteriordisplacementoftheclavicle.
TypeVIinjurieshaveaclavicleinferiorlydisplacedintoeitherasubacromialorsubcoracoidposition.Thesetypes(IV,V,VI)alsohavecompleteruptureofall
theligamentcomplexesandaremuchrarerinjuriesthantypesIthroughIII.70
Inthepediatricpatient,ACsprainsareusuallygradeIorIIandmayoccurwithoutclavicularfracture.494GradeIIIsprainsinthispopulationcommonly
rupturetheposterior(dorsal)clavicularperiosteum.However,thecoracoclavicularligamentsandACligamentsremainintact.494
Theclinicalfindingsarebasedoninjuryseverity(Table1638).Patientswhohavesufferedaninjurytothejointtypicallypresentwithahistoryofeithera
distinctive,traumaticmechanismofinjuryoramoreinsidioustypeofonsetthatbeganwithpainanddysfunction.72Thejointisquitesuperficialanddirect
palpationisaccomplishedeasily.Thepatientmayreportthatthearmfeelsbetterwithasuperiorlydirectedsupportonthearm,suchasasling.Painistypically
reproducedattheendrangeofpassiveelevation,passiveERandIR,andespeciallywithpassivehorizontaladduction,acrossthechest.Thiscrossarmtest
compressestheACjointandishighlysensitiveforACjointpathology.70,75,81,518TheROMavailabledependsonthestageofhealingandseverity.Inthe
veryacutestage,rangemaybelimitedbypain,whereasthelessacutestagewillbepainfulattheendofrangeinfullelevationorhorizontaladduction.Pain,
crepitus,orhypermobilitymaybeencounteredwithmobilitytesting.Resistivemovementsareusuallypainless.Itisimportanttoassessforsecondaryinjuryto
thesurroundingsofttissuesandtotheotherthreearticulationsoftheshouldercomplexwhenthereisahistoryoftraumatotheACjoint.
Acompleteradiographicexaminationincludinga15degreesuperiorAPview,alateralYview,andanaxillaryfilmshouldconfirmthediagnosis.70
TheinterventionforACjointsprainsdependsontheseverityoftheinjuryandthephysicalrequirementsofthepatient.
TypesIandII.Thesepatientswillusuallyrecoverfullandpainlessfunctionwithconservativeintervention.75Althoughadhesivetapingdevicesand
orthoticshavebeenusedintheearlyphaseafterinjurytoattemptreductionoftheclavicleinthetypeIIinjury,theyhavenotdemonstratedefficacyin
anygoodexperimentaltrials.70Ice,nonsteroidalantiinflammatories,andanalgesicsshouldbeusedjudiciously.Mostphysiciansprescribeaslingfor1
2weeks.GentleROMexercisesandfunctionalrehabilitationarestartedimmediatelyfollowingimmobilization,andthenisometricexercisesare
prescribedforthosemuscleswithclavicularattachments.TheexercisesareprogressedtoPREsforthemusclesthatattachtotheclavicleandthescapular
pivoters.Agraduatedreturntofullactivityisveryimportant.Mostpatientswillbebacktofullsport/occupationparticipationwithin12weeks,although
theymayhaveaslightcosmeticdeformity.70
TypeIII.TheinterventionfortypeIIIinjuriesiscontroversial.70Asurveyoforthopaedicresidencyprogramsin1992revealedthat86.4%preferred
conservativeintervention.519Thenaturalhistoryofthisinjurywithconservativeinterventionsuggeststhatpatientshavenolongtermdifficultywith
painorlossoffunction.520524Amorerecentstudy525foundnostrengthdeficitsatfollowup,althoughdiscomfortathigherlevelsofactivitywasmore
pronounced.Thereisareportedhighcomplicationratewithattemptsatsurgicalstabilization.526,527Citingtheconcernregardinggreaterdisplacement,
someauthorshaveproposedsurgicalintervention,buttherehavebeenseveralcontrolledcomparativestudies518,526,527thatsuggestthatconservative
interventiongaveresultscomparabletothoseofsurgicallytreatedpatients,butwithoutsurgicalcomplications.70
Areasonableapproachwouldbetoinitiallytreatalltypesconservativelywithslingimmobilization,followedbysupervisedrehabilitation.70Oncetheslingis
removed,pendulumexercisescanbeinitiated.PROMintheextremesofmotionareavoidedforthefirst7days,butthegoalshouldbeforfullPROMafter23
weeks.AgraduatedresistanceexerciseprogramisinitiatedoncepainisimprovedandAROMisfull.Theseexercisesshouldemphasizestrengtheningofthe
deltoidanduppertrapeziusmusclesandpromotedynamicstabilizationoftheshouldercomplex.208Fullreturntosportisexpectedby612weeks.70If
patientsarestillfunctionallylimitedaftermorethan3months,asecondaryreconstructiveproceduremaybenecessary.70
TypesIV,V,andVI.Thesetypesofdisplacementallrequiresurgicalinterventionasfailuretoreducetheseandrepairthemmayleadtochronicpainand
dysfunction.70,75,70Thegreaterdisplacementandinjuryincludesdamagetothedeltoidandtrapeziusmuscleandfascia.Themostcommonoperative
approachisadistalclavicleexcision,orMumfordprocedure.ThepostsurgicalprogressioninvolvesgainingpainfreeROMpriortoadvancingto
exercisestoregainstrength,manualtechniquestonormalizearthrokinematics,andfunctionaltrainingtoimproveneuromuscularcontroloftheshoulder
complex.
Latecomplications,includingdegenerativechangesofthedistalclavicle,candevelopwithasubluxedclavicle.70Symptomsmaybetreatedwiththeselective
useofmodalitiesandsteroidinjections.Ifthisconservativeapproachfails,thenthepatientshouldbeconsideredasasurgicalcandidate.70
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AcromioclavicularJointArthrosis
ACjointarthrosismaybedegenerativeorposttraumatic.Itismostcommonlyseeninmiddleagedpatients,eitherasanisolatedentityorincombinationwith
rotatorcufftendinopathyandimpingementsyndrome.70,75
ACjointarthrosisisdiagnosedbythehistoryandphysicalexamination.Patientstypicallycomplainofpainlocallyordistributedtotheanterolateralneck,the
trapeziussupraspinatusregion,andtheanterolateraldeltoid.528Thispainisusuallyexacerbatedwithoverheadand/orflexedandadductedpositionsofthe
arm.70DirectpalpationtotheACjointwillsometimesreproducethepatientspain.Impingementoftherotatorcuffmustberuledout.Theselectiveuseof
cortisoneinjectionsintotheACjointorthesubacromialspacecanbeappliedtohelpdifferentiateACpainfromrotatorcufftendinopathyandtreatbothof
theseconditions.70,75
Conservativeinterventionconsistsofrest,modificationofactivity,andNSAIDs.Electrotherapeuticmodalitiesandcryotherapymaybeusedtocontrolpainand
theactiveinflammation.JointmobilizationsofgradeIorIImayalsobeusedtodecreasepain.Oncepainandinflammationareundercontrol,therehabilitation
progressestostrengtheningofthedynamicrestraintsoftheACjoint(primarilythedeltoid,trapezius,andpectorals).75,208Anyactivitiesinvolvingraisingthe
armabovetheleveloftheshoulderorreachingacrossthechestshouldbeavoidedasthesewilltendtoaggravatetheACjoint.204
SternoclavicularJointSprain
TheSCjointcansustainsprains,dislocations,orotherinjuries,butislessinvolvedthantheACjointwithosteoarthritisormechanicalconditions.204
PosteriorSCdislocations,althoughrare,arefrequentlydelayedintheirdiagnosis,andcanevenbelifethreateningduetothepressureplacedonmanyvital
structureslyingbetweenthesternumandthecervicalspinesuchasthetrachea,esophagus,andmajorbloodvessels.195However,mostofthesedislocations
occuranteriorlyandaremoreobvious.
AnytraumatotheshouldergirdlemaycauseanSCdislocation,althoughthejointismostcommonlyinjuredthroughmotorvehicleaccidents,followedby
sports.529Insports,themechanismofinjuryisusuallysecondarytoaFOOSHwiththearmineitheraflexedandadductedposition,orextendedandadducted
position.486Thewelldevelopedinterarticularmeniscuscanbetornandcanleadsecondarilytodegenerativechanges.Irritationofthisjointmayalsooccurin
inflammatoryconditions,suchasrheumatoidarthritisorrepetitivemicrotrauma.197Infectionofthisjointusuallyindicatesasystemicsource,suchasbacterial
endocarditis.204
AninjurytotheSCjointcanbesignificantbecausethejointplaysanintegralroleinscapularmotionthroughtheclaviclesarticulationwiththescapula.
Subjectively,thepatientreportsdiscomfortwithendrangemovementoftheshoulder.SCinjuriesaregradedaccordingtoseverityofinjurytotheligament
supportingthejointsratherthaninjurytothejointitself.65
TypeI.SprainofSCligament.
TypeII.Subluxation,partialtearofcapsularligaments,disk,orcostoclavicularligaments.
TypeIIA.Anteriorsubluxationthisisthemostcommongrade.
TypeIIB.Posteriorsubluxation.197
TypeIIIA.Anteriordislocation.
TypeIIIB.Posteriordislocation.
TypeIV.Habitualdislocation(rare).
TheclinicalpresentationforSCsprainsarecharacterizedbydeformity,localpainortenderness,andsubsequentecchymosis.Withaposteriordislocationor
subluxation,someshortnessofbreathorevenvenouscongestionintheneckmaybeseen,withdecreasedcirculationsometimesevidentinthearm.72
Chronicsubluxationordamagetotheintraarticulardiskcanproducelongtermdiscomfortwithrepetitivestrongmovementsoftheupperlimbandtherefore
mayrequiresurgicalstabilizationoftheSCjoint.72
Theconservativeinterventionforfirstorseconddegreesprains(providingthatthejointisdeemedstable)isaimedataddressingthefunctionoftheshoulder
complex,particularlytheendranges,andisdependentonthecause.Typicallytheshoulderisimmobilizedfor34days,aspaindictates.Inmoreseveresprains
(secondorthirddegreesprainwithinstabilityfollowingreduction),ashoulderslingorfigure8strapiswornfor23weekstominimizestressonthejoint,
andthenthearmmaybeprotectedforafurther2weeks.
Appropriatemodalitiesareusedtocontrolpainandtheinflammatoryprocess.
ROMexercisesareinitiatedearly,andcareistakentoavoidexcessivemovementattheSCjoint.Initially,untilthepainandinflammationisunder
control,activitiesshouldbelimitedtomidrange.ROMisincreasedbasedonpatienttolerance.
Anyhypomobilitiesoftheneighboringjointsareaddressedusingspecificmobilizationsofanappropriategrade.
Incaseswithresidualligamentouslaxity,stabilizationexercisesshouldfocusonstrengtheningthosemusclesthatattachtotheclavicle(pectoralisminor,
sternalfibersofthepectoralismajoranduppertrapezius),performedwithinrangesthatdonotstressthejoint.Exercisesincludeinclinebench,shoulder
shrugs,andtheseatedpushup.530Thescapularpivotersshouldalsobestrengthened.Forexample,exercisessuchasSuperman,bentoverrow,
rhomboids,andpushupswithaplusshouldbeincluded.530
Returntonormalactivityispermittedwhenthepatientnolongerhasassociatedpainwithmovementsoftheshouldercomplex,andtherehabilitation
programhasbeenprogressedtotheappropriatelevelofstressforthespecificdemandsofthepatientsactivity.
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ComplicationsofanteriorSCdislocationincludecosmeticdeformity,recurrentinstability,andlateosteoarthrosis.72Complicationsofposteriordislocation
includeallofthesepluspressureorruptureofthetrachea,pneumothorax,ruptureoftheesophagus,pressureonthesubclavianarteryofbrachialplexus,voice
changes,anddysphagia.72
TotalShoulderArthroplasty
Atotalshoulderarthroplasty(TSA),inwhichtheglenoidandhumeralsurfacesarereplaced,isasurgicaloptiontypicallyreservedforelderlypatientswith
cuffdeficientarthriticshoulders.531OtherpatientswhomayrequireaTSAincludethosewithbonetumors,rheumatoidarthritis,Pagetsdisease,osteonecrosis
ofthehumeralhead,fracturedislocations,andthosewhoincurrecurrentdislocations.532,533AreverseTSA(rTSA),isdesignedtoreversetheballandsocket
locationofthenativeshoulder,andistypicallyusedwhentherotatorcuffintegrityiscompromised.Ahemireplacementarthroplasty(hemiarthroplasty),isused
whenonesurface,thehumeralhead,isreplaced.
Theprimaryindicationforsurgicalinterventioniscomplaintsofunremittingpain,ratherthandecreasedmotion,andafailureofconservativemeasures.
Additionalconsiderationsincludepatientage,activitylevel,jobrequirements,andgeneralhealth.531
Acourseofpreoperativeinterventionisrecommended.ThisshouldincludeanassessmentofROM,scapularmobility,muscleimbalances,andpain.Thekey
musclestoexaminepreoperativelyforstrengthincludetherotatorcuff,deltoid,trapezius,rhomboids,serratusanterior,latissimusdorsi,teresmajor,and
pectoralismajorandminor.261Thepatientshouldbeprovidedwithexerciseinstructionandpatienteducationonpostsurgicalprecautions.Acourseofshoulder
stretchingbeforeaprostheticarthroplastymayimprovepostsurgicalfunction.534
TheTSAisaverydifficultprocedure,andtheoutcomedependsontheskillofthereconstruction,thesofttissuerepair,theorientationoftheimplants,andthe
successoftherehabilitation.420,532,535,536Thetotalshoulderreplacementprovidessignificantlygreaterpainreliefthanhemiarthroplasty,withapproximately
80%ofpatientsreportingpainreliefafterhemiarthroplastyversusmorethan90%aftershoulderreplacement.536
Fourtypesofreplacementcomponentshavetraditionallybeenused:
1.Unconstrained.Thisisthemostwidelyusedcomponentandconsistsofamodularinerthumeralcomponentthatexistswithahighdensitypolyethylene
glenoidcomponent.
2.Constrained.Thistype,inwhichtheglenoidandhumeralcomponentsarecoupledandfixedtobone,wasdesignedforpatientswhohadsevere
deteriorationoftherotatorcuffbutwithafunctioningdeltoid.However,duetothehighrateofassociatedcomplications,itisrarely,ifever,used
nowadays.
3.Reversedballandsocket.Thisdesignconsistsofasmallhumeralsocketthatslidesonalargerballshapedglenoidcomponent.
4.Semiconstrained.Thistypeinvolvestheuseofasmallerandsphericalhumeralheadwithaheadneckangleof60degrees,whichreportedlypermits
increasedROM.
Althoughsurgicaltechniquesvary,mostinvolvethedissectionofthesubscapularisorarotatorcuffrepair,oracombinationofboth.Thepatientisusually
placedinaslingoranelasticshoulderimmobilizerfollowingtheoperationthatpositionsthehumerusinadduction,IR,andslightforwardflexion.An
abductionsplintmaybeissuedifarotatorcuffrepairisperformedandiswornfor46weeks,accordingtothesurgeonsinstructions.Goalsforpostoperative
ROMarebasedonintraoperativeROMmeasurements.
Thelongtermoutcomefollowingshoulderarthroplastydependsonmanyfactorsincludingthequalityofthesofttissue(especiallytheintegrityoftherotator
cuff),thequalityofthebone,thetypeofimplantandfixationused,thepatientsexpectations,andthequalityoftherehabilitationprogram.261Mostsurgeons
havetheirownpostsurgicalrehabilitationprotocolsonlythesurgeonknowstheextentofsofttissuedamageandrepair,andanyguidelinescommunicatedto
theclinicianmustbestronglyadheredto.Typically,theonlymotionsnotallowedintheearlyweeksareactiveIRandactiveandpassiveERbeyond3540
degrees.
PATTERN4E:IMPAIREDJOINTMOBILITY,MOTORFUNCTION,MUSCLE
PERFORMANCE,RANGEOFMOTIONWITHLOCALIZEDINFLAMMATION
InadditiontothoseconditionsproducingimpairedROM,motorfunction,andmuscleperformanceattributedtoinflammation,thispatternincludesconditions
thatcausepainandmuscleguardingwithoutthepresenceofstructuralchanges.Suchconditionsincluderotatorcufftears,tendinopathy,bursitis,capsulitis,and
tenosynovitis.
RotatorCuffPathology
Fiftytoseventypercentofshoulderissuesseenbycliniciansarerelatedtoconditionsoftherotatorcuff(RC).537,538ThefrequencyofRCproblemsisnot
surprisingasthesestructuresplayanessentialroleinsupportingtheshouldercapsuleandholdingthehumeralheadinproperalignmentintheglenoidcavity.
Problemscanoccurfromanumberofsourcesincludingtrauma,attrition,andtheanatomicalstructureofthesubacromialspace.Thesupraspinatusisthe
tendonmostoftenaffectedbecauseofitslocationbeneaththeanterioracromion,anditsextensionsintotheinfraspinatustendonthatmayalsobecome
involved.539,540SignificanttearsoftheRCrarelyinvolvethesubscapularistendon.539,540
Anumberofmechanismsarerecognizedandincludecompression,tensileoverload,andmacrotrauma.
Compression.CompressionoftheRCcaneitherbeprimaryorsecondary.Primarycompressionisduetoareductioninthesizeofthesubacromialspace
(e.g.,atypeIIIhookedacromionprocessoracongenitallythickcoracoacromialligamentinyoungerpatients,oranosteophyteontheundersurfaceofthe
acromionprocessintheolderpatient).SecondarycompressionoccursasaresultofadecreaseinGHjointstabilitythatallowsthehumeralheadto
compresstheRC.
Tensileoverload.Tensileoverloadcanalsobeeitherprimaryorsecondary.PrimarytensileoverloadoccurswhentheRCattemptstoresisthorizontal
adduction,IR,anteriortranslation,anddistractionforcesduringsuchactivitiesasthrowing(thedecelerationphase)andhammering.Secondarytensile
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overloadoccursasaresultofGHinstabilitythatplacesgreaterdistractiveandtensileforcesontheRC,andeventualfailureofthetendon.
Macrotrauma.Macrotraumaandsubsequenttearingofthetendonresultswhentheforcesgeneratedbythetraumaexceedthetensilestrengthofthe
tendon.RCtearsarenotascommonintheskeletallyimmatureathleteasintheelderlyathlete.Indeed,theincidencesofRCtearincreaseswithage.
Approximately50%ofindividualsolderthan55yearsdemonstratedanarthrographicallydetectableRCtear.541Althoughcadaverstudiesofindividuals
olderthan40yearshavegenerallyshownaprevalenceoffullthicknessRCtearsbetween5%and20%,542theprevalenceofpartialthicknessRCtears
hasbeenshowntobeinthe3040%rangeinadultcadavers.542
AdetailedhistoryisimportanttodiagnoseanRCinjuryandthecause,anditcanhelptodeterminewhetherthepatientssymptomsarerelatedtorepetitive
motion,followingaspecificinjuryorevent,orareofamoreinsidiousonset(e.g.,referredsymptomsofcardiacorigin,orreferredsymptomsfromthecervical
spine).Activitiesandarmpositionsthatincreaseordecreasesymptomsarealsohelpfulindiagnosingandguidingtreatment.Priorepisodesofsimilar
symptomsmaygiveausefulcluetothepatientspresentcondition.Asocialhistoryshouldincludethepatientsoccupationandsport(includingposition),and
levelofathleticparticipation.Thepresenceofassociatedsymptoms(e.g.,lossofmotion,weakness,instability,numbness,swelling,catchingoftheshoulder)
alsoprovideshelpfulinformation.
Pain,weakness,andlossofshouldermotionarecommonsymptomsreportedwithRCpathology.Thepatientcomplainsinitiallyofadullacheradiatinginto
theupperandlowerarm.Thisacheisworseafteractivity,atnightwhenthepatientliesontheaffectedshoulder,andwithactionssuchasreachingabovethe
headorputtingonacoat.Thecharacteristicphysicalfindingisthepainfularc.Thepainmaybeginaround5060degreesofabductioninpatientswith
shoulderimmobility.
Inelderlypatients,symptomsareofteninsidiousandwithnospecificinjury.
ThecliniciancanoftendeterminetheinvolvedtendonbyresistingtheAROMofeachtendon.
Palpableanteriortendernessoverthecoracoacromialligamentiscommonwithimpingement.28,543Tendernessofthebicepstendonandatthesupraspinatus
insertionisalsocommonlyfound.
Patientswithapainfularcandtheabovehistory,butnopaintoresistedshouldermovements,arelikelytohavesubacromialsubdeltoidbursitis.204
AstudybyParketal.324evaluatedeightphysicalexaminationtestsforRCpathology(theNeerimpingementsign,HawkinsKennedyimpingementsign,
painfularcsign,supraspinatusmusclestrengthtest,Speedstest,crossbodyadductiontest,droparmsign,andinfraspinatusmusclestrengthtest)todetermine
theirdiagnosticvalues,includinglikelihoodratiosandposttestprobabilities,forthreedegreesofseverityinRCdisease:bursitis,partialthicknessRCtears,and
fullthicknessRCtears.Thesensitivity,specificity,positivepredictivevalue,negativepredictivevalue,andoverallaccuracyoftheeighttestsvaried
considerablythecombinationoftheHawkinsKennedyimpingementsign,thepainfularcsign,andtheinfraspinatusmuscletestyieldedthebestposttest
probability(95%)foranydegreeofimpingementsyndrome.Thecombinationofthepainfularcsign,droparmsign,andinfraspinatusmuscletestproducedthe
bestposttestprobability(91%)forfullthicknessRCtears.324Thestudyconcludedthattheseverityoftheimpingementsyndromeaffectsthediagnosticvalues
ofthecommonlyusedclinicaltestsandthatthevariableaccuracyofthesetestsshouldbetakenintoconsiderationwhenevaluatingpatientswithsymptomsof
RCdisease.324
RCtearsaredescribedbysize,location,direction,anddepth.
WeaknesstosomeextentalwaysaccompaniesRCtears.Theamountofweaknessisdirectlyrelatedtothesizeofthetear.1Forexample,withsmalltears,the
weaknessmaynotbedetectedandthepatientmayhavefullROM,althoughtheremaybeapainfularc.MassivetearsoftheRCpresentwithsuddenprofound
weaknesswithaninabilitytoraisethearmoverhead,andexhibitapositivedroparmsign(seeSpecialTestssection).544Inthissituation,infiltrationofthe
subacromialspacewithalocalanestheticmayeliminatethepainandallowmoreaccuratetestingofthemuscletendonunit.Theuseofcorticosteroid
injectionsforRCtearstopromotehealingiscontroversialbecauseoftheirassociationwithweakeningtheintegrityoftendonswithrepeateduse.Somestudies
havesupportedthisbelief,38,545547althoughonlyonecaseofRCrupturefollowingsteroidinjectionhasbeenreportedintheliterature.545Tworecentstudies
havedemonstratedthatcorticosteroidinjectionsaremoreeffectivethanantiinflammatorydrugsinthemanagementofRCproblems.548,549However,ifthe
patienthasnotrespondedto12wellplacedinjections,eitherotherinterventionmodalitiesshouldbeconsideredorthediagnosisquestioned.
Acutemassivetearsrequirepromptevaluationforsurgicalrepairbecauselittleisknownabouttheefficacyofconservativeintervention.1,304,550557However,
thepatientmaydecideagainstsurgeryforvariousreasons,includingconcernsaboutasuccessfulrepair,surgicalrisks,orlackoffunctionalimprovement.558
TheconservativeprogramforfullthicknessRCtearsisdirectedtowardstretchingandstrengtheningtheremainingRC,deltoid,pectoralismajor,andtrapezius
muscles.538,559Thepostsurgicalapproachisinitiatedwithsomeformofimmobilizationthatrestrictspositionsbasedonthesurgicalrepair,andpromotespain
control.Forexampleinopenrepairs,flexion,andabductionmightberestrictedforaslongas4weeks,orifthecapsulolabralcomplexhasbeenrepairedthe
patientmightspendupto2weeksinanairplaneorablationsplint.530Exercisesintheearlyphaseincludeshouldershrugs,isometrics,andthenAAROM
exercises.Oncethesubacutestageofhealinghasbeenachieved,thefocusoftherehabilitationprogramistoregainfullROMandtograduallyincreasethe
stresstohealingtissue.Atthisstage,AROMexercisesareinitiatedbeforeprogressingtogradualresistanceusingsurgicaltubingwithafocusonthe
restorationofnormalarthrokinematicsandanormalscapulothoracicrhythm.530Therehabilitationduringthefinalstageofhealingmirrorsthatofconservative
management.
Theconservativeinterventionforpatientswithapartialtearvaries.Ifthesymptomatictearispartial,thenaperiodofconservativeinterventionshouldbe
attempted.538,560562
StageI.Thefocusofearlyrehabilitationisthereductionofpainandinflammationthroughmodalities,activitymodifications,andNSAIDsprescribedby
thephysician.JobeandNuber165describeaprogramofkinesiologicrepairthatstrengthenstheRC(toincreasethedepressoreffectonthehumeralhead)
andthescapularpivoters,butavoidsanyincreaseintheelevatingeffectofthedeltoid.ThemainstaysofthisstrengtheningprogramaretheIRandER
exercises(Table1639).259Theseareinitiallyperformedasisometricexercisesatvariouspartsoftherange.Oncethesearetoleratedwell,concentric
exercisesofthescapularpivotersareintroducedbeginningwithmanualresistanceandprogressingtofreeweights(seeInterventionStrategiessection).
Careshouldbetakenwithexercisesthatinvolvetheuseofweightswiththearmflexedorabductedaway,oroverhead,asthesemayexacerbate
supraspinatusimpingementandtendinopathysymptomsifperformedintheearlystagesofrehabilitation.Theexercisesprescribedshouldbeasspecific
aspossible,andtailoredtothepatientsfunctionalandathleticgoals.Thelowerextremityandtrunkmusclesthatprovidecorestabilityshouldalsobe
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strengthened.Deficitsinstrength,strengthimbalances,andflexibilityinthelegs,hips,andtrunkshouldbeaddressed.Thisisparticularlysointhrowing
athletes,whererestrictionsofthehipandbackmotionarecommon.34,47,142,146
TABLE1639SpecificStrengtheningExercisesfortheShoulderGirdle
Muscle Exercise
Pronerow
Middletrapezius
Pronehorizontalabductionwiththearmand90degreeabductionwithER
Pronehorizontalat90degreeabductionwithER
Pronefullcan
Lowertrapezius
ProneERat90degreeabduction
BilateralER
Shouldershrugs
Uppertrapezius Pronerow
Pronehorizontalabductionat90degreeabductionwithER
Fullcan
Supraspinatus
Pronefullcan
Sitting,externalrotationofthearmwithatowelroll
Infraspinatusandteresminor Sidelyingexternalrotation
ProneERat90degreeabduction
Pronerow
Rhomboidsandlevatorscapulae Pronehorizontalabductionat90degreeabductionhipER
ProneextensionwithER
Dynamichug
Serratusanterior Pushupwithplus
Serratuspunch120degrees
Liftoff(Gerber)
IRat0degreeabduction
Subscapularis IRat90degreeabduction
IRdiagonalexercise
Shoulderdumps
Deltoid Sidelying,45degreeabduction
DatafromReinoldMM,EscamillaRF,WilkKE.Currentconceptsinthescientificandclinicalrationalebehindexercisesforglenohumeralandscapulothoracic
musculature.JOrthopSportsPhysTher.200939:105117.
Manualtechniquescanbeusedtoaddressanytightnessinthecapsule(usuallytheposteriorandinferioraspects)ormotionrestrictionsoftheSCorACjoints
(seeTherapeuticTechniquessection).Thepatientshouldbeinstructedonhowtoperformanisolatedposteriorcapsulestretch.
StageII.RestorationofROMusingexercises,stretchingtechniques,andselfmobilization.Duringthisstage,thepatientshouldbeexercisingwithfree
weights,withanemphasisoneccentricexercisesoftheRC.Concentricexercisesfortheuppertrapeziusanddeltoidareadded.Theseincludeshoulder
flexionandreverseflyes.Theserratusanteriorisstrengthenedusingpushupsandthepushupplus.Neuromuscularretrainingexercisesfortheshoulder
complexincluderockingonallfours,andtheFitterboard,asappropriate.Plyometricexercisesusingsmallmedicineballsandpushupswithahandclap
arealsoincludedduringthisstageasappropriate.NeuromusculartechniquescanalsobeappliedmanuallyandincludequickreversalsduringPNF
patterns.Othermanualtechniquesincludestretchingofthecapsuleandanyotherpericapsularstructuresthatappeartight.
StageIII.PNFdiagonalpatternsareinitiatedinthisstageinadditiontoeccentricexercisesoftheRC.Typicalexercisesperformedinthisstageinclude
themilitarypress,reverseflies,andpushups.
StageIV.Plyometricstrengtheningandsport/activityspecifictrainingwithagradualreturntonormalactivity.
SubacromialImpingementSyndrome
SISisarecurrentandtroublesomeconditioncloselyrelatedtoRCdisease.563InthepresenceofanormalRC,normalscapularpivoters,andnocapsular
contractures,thehumeralheadtranslateslessthan3mmsuperiorlyduringthemidrangesofactiveelevation,whereasattheendranges,APandsuperoinferior
translationsof410mmdooccur,allofwhicharecoupledwithspecificmotionsofIRorER.19,47,139,260,288,564567Anincreaseinsuperiortranslationwith
activeelevationmayresultinencroachmentofthecoracoacromialarch.39,564Thisencroachmentproducesacompressionofthesuprahumeralstructures
againsttheanteroinferioraspectoftheacromionandcoracoacromialligament.Repetitivecompressionofthesestructures,coupledwithotherpredisposing
factors,resultsinaconditioncalledSIS.SISwasfirstrecognizedbyJarjavay568in1867,andthetermimpingementsyndromewaspopularizedbyNeer39in
the1970s.
Bothintrinsicandextrinsicfactorshavebeenimplicatedasetiologiesoftheimpingementprocess,andanumberofimpingementtypeshaveevolved(Table16
40).Twoofthosetypesincludetheoutlet(intrinsic/internal)impingementandthenonoutlet(extrinsic/external)impingement(Fig.1663).
TABLE1640ClassificationofDifferentShoulderImpingementSyndromes
BasedontheStageof
BasedonDirectionofInstability BasedonProgressiveMicrotraumab
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GroupIA:Thisgroup,typicallyfoundintheolderpopulation,encompassesthose
patientswithpureandisolatedimpingementandnoinstability
StageI.Edema,hemorrhage GroupIB.Thisgroup,typicallyfoundintheolderpopulation,encompassesthose
(patientusually<25yr) patientswithinstabilitysecondarytomechanicaltrauma
Unidirectionalinstability(anterior,
StageII.Tendinitis/bursitisand GroupII.Patientsinthisgroup,whoareusuallyyoung(<35yr)overheadathletes,
posterior,orinferior)withorwithout
fibrosis(patientusually2540 demonstrateinstabilitywithimpingementsecondarytomicrotraumathatcomes
impingement
yr) fromoveruse
Multidirectionalinstabilitywithor
StageIII.Bonespursand GroupIII.Patientsinthisgroup,whoarealsotypicallyyoungoverheadathletes,
withoutimpingement
tendonrupture(patientusually demonstrateatraumatic,generalizedligamentouslaxity
>40yr) GroupIV.Patientsinthisgroupareyoung(<35yr)whohaveexperienceda
traumaticevent,resultingininstabilityintheabsenceofimpingement
aNeerC.Impingementlesions.ClinOrthopRelatRes.1983173:7177.
bKvitneRS,JobeFW,JobeCM.Shoulderinstabilityintheoverheadorthrowingathlete.ClinSportsMed.199514:917935.
OutletImpingement
ThistypeofimpingementoccursasaresultofabnormalcontactbetweentheRCundersurfaceandtheposterosuperiorglenoidrim(Fig.1663).Theetiologyof
posterosuperiorglenoidimpingementhasbeenasourceofmuchdebate.Neer39proposedthatatightorcrowdedsubacromialspace(e.g.,oneinwhichthe
spaceiscompromisedbyananterioracromialosteophyte)couldcauseamechanicalabrasionoftheRCagainsttheacromionwithabductionabove8090
degreeswithoutconcomitantER.Othershaveattributedinternalimpingementsecondarytoanteriormicroinstabilityandtightnessofthecapsuleposteriorly.
Whatevertheunderlyingcause,theabrasionofthesofttissuestructureslocatedbetweentheheadofthehumerusandtheroofoftheshoulderduringelevation
ofthearmproducesanirritation,inflammation,andtearingoftheRCmuscles,anirritationoftheLHB,andsubacromialbursitis.57,569,570
Thistypeofimpingementisknownasanoutletimpingementbecauseitoccursatthesupraspinatusoutletformedbythecoracoidprocess,theanterior
acromion,theACjoint,andthecoracoacromialligament.Itclinicallymanifestsasapainfularc.Apainfularcdescribesaregionofpaininaparticular
motion,whichhaspainfreeareasoneithersideofit.326Forexample,duringabductionthepatientmayfeelanonsetofpainat80degrees,whichthen
disappearsat100degrees.Thegeneralcauseofapainfularcisimpingementofatendersubacromialstructureduringmotion,althoughloosebodiesand
instabilitiesmayalsocauseapainfularc.
AlthoughNeerandPoppen571reportedthat9095%ofRCtearsweretheresultoftheoutletsubacromialimpingement,theroleofagerelatedorsenescent
degenerationandtensileoverloadhasbeenemphasizedmorerecently(seelater).569,570,572576
CLINICALPEARL
KennedyandHawkins201originallydescribedthetermswimmershoulderasanoutletimpingement,astheythoughtitwascausedbyimpingementofthe
rotatorcufftendonsunderthecoracoacromialarch.However,furtheranalysisindicatedthatthecourseofthisconditionismultifactorialincluding200
1.Strokebiomechanics,and/or
2.Overuseandfatigueofmusclesoftheshoulder,scapular,andupperback,and/or
3.Glenohumerallaxitywithsubsequentshoulderinstability
NonoutletImpingement
Nonoutletimpingement,sometimesreferredtoasposteriorinternalimpingement,inwhichthesubacromialspaceappearstobenormal,occursintheyounger
patientperformingrepetitiveoverheadmotions.ThemechanisminthisconditionappearstobeanimpingementoftheRCagainsttheposteriorsuperiorglenoid
labrumandthehumeralheadduringforcedhumeralelevationandIR.Thiscaneventuallyresultinposteriorsuperiortearsintheglenoidlabrum,andlesionsin
theposteriorhumeralhead(Bankartlesion).
PrimaryandSecondaryExtrinsicImpingements
Threeothertypesofimpingement,whichrelatetochronicdisordersoftheRC,havebeenproposed.
Primaryextrinsicimpingementreferstoanintrinsicdegenerativeprocessinthestructuresoccupyingthesubacromialspacethatoccurswhenthelesser
tuberosityofthehumerusencroachesonthecoracoidprocessduetohypertrophicdegenerativechangesattheACjoint,orothertrophicchangesinthe
coracoacromialarchorhumeralhead,allofwhichdecreasethesubacromialspace.Eventually,thesuperioraspectoftheRCiscompressedandabraded
bythesurroundingbonyandsofttissuesduetoanatomicalcrowding,posteriorcapsulartightness,and/orexcessivesuperiormigrationofthehumeral
head.577Patientswithprimaryimpingementaretypicallyovertheageof40andpresentwithlimitedhorizontalabduction(ascomparedwiththe
uninvolvedside),andlimitedIR(<50degrees).Thisconditioniscommonlytreatedoperatively.
Secondaryextrinsicimpingementoccurswhenthestaticanddynamicstabilizersoftheshoulderbecomecompromisedandfailtoprotectthejoint.This
resultsinmechanicalcompressionofthesuprahumeraltissuesduetohypermobilityorinstabilityofthejointandincreasedtranslationofthehumeral
head.Theinstabilitycanbeunidirectionalwithorwithoutimpingement,ormultidirectional.Althoughsomedegreeofhypermobilitycanbecontrolled
byahealthyrotatorcuff,weaknessorfatiguecaneventuallyleadtoinflammationofthesuprahumeraltissuesthroughrepetitivetrauma(see
GlenohumeralInstability).
CLINICALPEARL
Itisrecognizedthatprimaryimpingementsyndromeconditionscanleadtosecondaryimpingementifnotmanagedappropriately.578,579
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Internalextrinsicimpingement.TheprimarycauseofinternalextrinsicimpingementisGHinstabilityand/ortensileoverloadoftheRCresultinginpoor
controlofthehumeralheadduringthrowingactivitiesinvolvingforwardflexion,IR,andabduction.Patientsinthisgroupareusuallyyounger,havea
historyoftraumaticanteriorinstability,aposteriordefectofthehumeralhead,anddamagetotheposteriorglenoidlabrum.Theseindividualstypically
presentwithlimitedIR,excessiveER,andanterosuperiorhumeralheadmigration(seeScapularDyskinesis).193
Thus,thepathophysiologyofSISandRCdisordersmayhavebothintrinsicandextrinsicfactors.Inadditiontotheshapeandformoftheacromion,theamount
ofvascularizationtotheRC,thecorrectfunctioningofthedynamicstabilizers,andtheconditionoftheACjoint,anumberofotherintrinsicandextrinsic
factorshavebeenfoundtopredisposeanindividualtoSIS,includingthefollowing38,40,55,62,580:
1.Age.Theageofthepatientappearstobeanimportantetiologicfactorinthedevelopmentofsubacromialimpingementinassociationwithrepetitive
motion.541,581584Intheabsenceofrepetitivemotionasacausativefactor,SISismorecommonafterthethirddecadeoflifeandisuncommonin
individualsyoungerthan30years.38,39Inaddition,thereisanormalagerelatedincreaseinasymptomaticRCdefects.581583,584,585Constantand
Murley586havealsoshownthatthereisanagerelateddecreaseinshoulderfunctioninhealthyvolunteers.
2.Positionofthearmduringactivities.Thearmpositionadoptedduringactivitiesmaycontributetothedevelopmentofsubacromialimpingement
significantly.210Becauseofthetangentialvectorofdeltoidcontraction,thetendencyforsuperiortranslationofthehumeralheadisgreatestbetween60
and90degreesofelevation43,564,587ThusrepetitiveactivitiesinthisrangeofelevationplaceahighdemandontheRCtocounteractthistendency.In
addition,repetitiveactivitiesthatoccurduringhigherlevelsofelevationofthearmbringthegreatertuberosityandsupraspinatusinsertionintoclose
proximitytothecoracoacromialarch.43,564,587
3.Muscleimbalances.Sustainedorrepetitiveoverheadactivityrequiresthescapularpivoterstoconstantlymaintainappropriatescapular
rotation.38,108,121Fatigueofthescapularpivotersmayleadorcontributetorelativesubacromialimpingementbecauseofpoororasymmetricscapular
rotation.38,108,121Secondaryimpingementcanoccurbecauseofserratusanteriordysfunction,resultingintheanteriorandinferiormovementofthe
coracoacromialarch,whichreducesavailableclearancefortheRCandgreatertuberosityastheshoulderisflexedforward.4,108Scapularlagfrom
dysrhythmicscapulothoracicmotioncanalsocontributetosubacromialimpingementbecausetheacromionfailstorotatewiththehumerus,thereby
producingarelativedecreaseintheacromiohumeralinterval.4,108DefectsinproprioceptionandmotorcoordinationoftheRCandthedeltoidmuscle
wererecentlydiscussedasplayingamajorroleinthedevelopmentofSIS.588,589Inswimming,thegreatestpropulsiveforceisgeneratedbyadduction
andIRoftheupperextremitywiththepectoralismajorandlatissimusdorsiprovidingmostoftheforce.Thus,traininginducedadductionandIR
strengthcanleadtoanimbalanceandreducedglenohumeralstability.
4.Capsulartightness.590Capsulartightnessisacommonmechanicalproblemrelatedtoprimaryimpingementsyndromeandhasbeenreportedtooccurat
theposterior,108anterior,43andinferior452,551portionsofthecapsule.Individualswhoavoidpainfuloverheadactivity,orwhoarepredisposedto
motionimbalancesbecauseoftheirworkorsport,candevelopcapsulartightness.591Duringtheperiodofpainavoidanceorunbalancedmovement,the
capsularconnectivetissuemaylosetheabilitytolengthenduetodecreasedcriticalfiberdistanceandabnormalcollagenfibercrosslinking.Thisinturn
canleadtocapsulartightness,jointstiffness,painfulorlimitedfunction,andtoanearlieronsetorgreaterdegreeofsubacromialcompression,
particularlyinelevatedplanesofmovement.38,252,407,592Thisisparticularlytruewithaposteriorcapsularcontracture,whichcommonlycoexistswith
SISandRCdisease.Posteriorcapsularcontracturemayaddtotheabnormalsubacromialcontactbyproducingananterosuperiortranslationduringactive
elevation.37,38TightnessoftheposteriorcapsulecanalsocauseadecreaseinIRoftheGHjoint,whichleadstoanincreaseintheanteriorandsuperior
migrationofthehumeralhead.Incontrast,tightnessoftheanteroinferiorcapsuleresultsinlimitedER,preventingthegreatertuberosityfromsufficient
ERtoclearthecoracoacromialarch.117Thus,therestorationofcapsularmobilityisanimportantcomponentintherehabilitationprocess.
5.Posturalimbalance.Posturalimbalance,particularlyscapulothoracicdysfunctioninrelationtotheFHP,hasbeenimplicatedasanetiologicfactorin
secondaryimpingementsyndrome.38,291TheFHP,whichisassociatedwithanincreaseinthethoracickyphosisangle,aforwardshoulderposture,anda
scapulathatispositionedinrelativelymoreelevation,protraction,downwardrotation,andanteriortilthasbeencitedasapotentialetiologicfactorinthe
pathogenesisofSIS.593TheeffectofthesechangesleadstoalossofGHflexionandabductionrange,compressionandirritationoftheuppermost
(bursal)surfaceofthesupraspinatustendon,resultantchangesintheactivationpatternsofthelengthdependentforcecouples,andareductioninthe
rangeofGHelevation.593However,theevidenceforthisislimited,withresearchstudiesreportingequivocalfindings.225,231,243,258,594Postural
imbalancecanalsooccurasasecondarydevelopmentinprimarySIS.590
6.Repetitiveoverheadactivities.RepetitiveactivitiesthatinvolvehumeralflexionhavebeenreportedtopredisposeindividualstoRCdisorders.40,260In
fact,anyrepetitiveelevationbeyond90degreeshasthepotentialtoprovokeRCdisorders.43Astheshoulderisaninherentlyunstablejoint,muscle
forcesarecriticalformaintainingstability,correctmotion,andpainlessfunction.Forexample,inswimming,theserratusanterior(amajorscapular
stabilizer)andsubscapularis(aninternalrotatoroftheshoulder)areactivethroughouttheentireswimmingstrokeandarethereforepronetofatigue.595
7.Structuralasymmetry.Scapularasymmetryanditsroleinimpingementhavebeenwidelyreportedbyinvestigatorsofupperextremity
pathology.108,231,496,596Warneretal.496determinedthat57%oftheirsubjectswithimpingementsyndromedemonstratedstaticscapularpostural
asymmetry,andalldemonstratedweaknessofthescapularpivoters(rhomboids,serratusanterior,lowertrapezius,deltoid,andRC).
8.Thepositionofthehumerusatrest.Thiscanaffectthehealingprocessofpatientswithprimaryshoulderimpingementsyndrome.TheworkofRathburn
andMacnab56illustratedthedeleteriouswringingouteffectonRCtendonvascularitywithanadducteddependentpostureofthehumerus.
9.Impairedscapularkinematics.ManyresearchershavestudiedthescapularkinematicsinpatientswithSIS,butresultsofthesestudiestodatehavebeen
largelyvariable,becauseoftencontrolsubjectswereincludedwhowerenotmatchedtothesubjectswithSIS,orbecausethestudiescomparedshoulder
motionoftheaffectedshoulderwiththeasymptomaticsideonly.597
AstudybyMcClureetal.168includedamatchedcontrolgroupaswellasmeasurementsofseveralphysicalcharacteristicsofpatientswithSIS,including
kinematicsofthescapula,shoulderROM,shouldermuscleforce,andbothupperthoracicspineandshoulderrestingposture.Allsubjectswereexaminedwith
thefollowingtestsandmeasures:(1)goniometricmeasurementofshoulderROM,(2)assessmentofupperthoracicspineandscapularrestingposture,(3)
measurementofshoulderisometricmuscleforcewithahandhelddynamometer,and(4)assessmentofshoulderkinematicswithanelectromagneticmotion
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analysissystemduringthreeactiveshouldermotions(shoulderflexion,scapularplaneelevation,andERat90degreesofabduction).Thestudyhadthe
followingfindings:168,597
TherewerenodifferencesinrestingposturebetweenthesubjectswithandwithoutSIS.
TheSISgroupdemonstratedlessROMoftheshoulderinalldirectionsassessed,andlessisometricmuscleforceforshoulderERandscapularplane
elevation.
ThesubjectswithSISdemonstratedslightlygreaterupwardrotationofthescapulaandelevationoftheclaviclewithshoulderflexionandslightlymore
posteriortiltandretractionoftheclaviclewithscapularplaneelevationcomparedwiththosewhodidnothaveSIS.
GiventhelimitedmobilityanddecreasedshouldermuscleforceidentifiedintheSISgroupandthekinematicdifferencesidentifiedbetweenthetwogroups,it
istemptingtoconcludethattheweaknessoftheshouldermusculature,orlossofmobilityoftheshoulder,orboth,causecompensatoryscapulothoracic
movementstrategies.However,furtherresearchisneededtodeterminewhetheramanagementstrategythatspecificallyaddressestheidentifiedimpairmentsof
reducedmuscleforce,ROM,andalteredkinematicsresultsingreaterimprovementsinpain,activity,andparticipationthancompetingnoninvasive
managementstrategies.168,597
IfSISisallowedtoprogress,thepatientmovestheshoulderlessfrequentlyduetothepain.Thelackofmovementincreasesthepotentialofdeveloping
adhesivecapsulitis(frozenshoulder),particularlyintheolderpatient.Neer40dividedtheimpingementprocessintothreestages,althoughtheconditionisa
continuumofsymptomswithoverlapatthemarginsofeachstage.76Eachimpingementstageismanagedbasedonthespecificfindingsandtheintrinsicor
extrinsicfactorscontributingtotheproblem,whethertheyresultfromcompression,tensileoverload,ormacrotrauma.
StageI
Thisstageconsistsoflocalizedinflammation,slightbleeding,andedemaoftheRC.Thisstageistypicallyobservedinpatientsyoungerthan25yearsofage,
althoughitcanalsobeseeninolderpopulationsduetooveruse.Thepatientreportspainintheshoulderandahistoryofacutetraumaorrepetitive
microtrauma.
Thephysicalexaminationduringthisstagerevealstendernessatthesupraspinatusinsertionandanterioracromion,apainfularc,andweaknessoftheRC
secondarytopain,particularlywhentestedat90degreeabductionorflexion.Acromialelevationandscapularstabilizationareoftenjeopardizedearlyinthe
injuryprocessduetopainbasedinhibitionoftheserratusanteriorandlowertrapezius,andduetosubclinicaladaptationsalteringthepositionofthescapulato
accommodateinjurypatternsinsubluxationorimpingement.139,143StageIisareversiblecondition.
ThesubacromialspacecanbeidentifiedasasourceofimpingementbyusingtheNeerimpingementtestsupplementedwiththeHawkinsKennedy
impingementtest(seeSpecialTestssection).
Theemphasisduringtheinterventionofthisphaseistocontrolthepainandinflammation.Thepainfromsubacromialimpingementusuallyresolveswitha
periodofrestandactivitymodification.Restisadvocatedtopreventfurthertraumatotheareaandreduceexcessivescarformation.598Inadditiontotherest
andmodificationofactivities,painandinflammationmaybecontrolledwiththeuseofelectrotherapeuticmodalities,cryotherapy,andNSAIDsprescribedby
thephysician.
StageII
StageIIrepresentsaprogressiveprocessinthedeteriorationofthetissuesoftheRC.Thisstageisgenerallyseeninthe2640yearoldagegroup.Irritationof
thesubacromialstructurescontinuesasaresultoftheabnormalcontactwiththeacromion.Thesubacromialbursalosesitsabilitytolubricateandprotectthe
underlyingRC,andtendinopathyofthecuffdevelops.Thepatientoftenreportsthataspecificactivitybringsontheirsymptoms,especiallyanoverhead
activity.Painisgenerallylocatedonthetopoftheshoulderandwillradiatetothemidbrachiumintheregionofthedeltoidinsertion.Thephysicalexamination
revealscrepitusorcatchingatapproximately100degreesandrestrictionofPROM(duetofibrosis).Thisstageisnolongerreversiblewithjustrest.Although
thisstageoftenrespondstolongtermconservativecare,itcanprogresstoapartialthicknesstear.Ifthelevelofsymptomsissevereenough,surgeryisoften
required.ConservativeinterventionduringthisstageinvolvesaprogressivestrengtheningprogramasdescribedintheInterventionStrategiessection.599,600
CLINICALPEARL
AstudybyBangandDeyle601determinedthatacombinationofmanualtherapyappliedbyexperiencedcliniciansandsupervisedexercisewasbetterthan
exercisealonetoincreasestrength,decreasepain,andimprovefunctioninpatientswithSIS.
FifteentotwentyeightpercentofthosepatientsdiagnosedwithSISmayeventuallyrequiresurgery.407,554Surgicalinterventionisusuallyreservedforthose
whohavefailedtomakesatisfactoryimprovementoveraperiodof6months.However,atleasttworandomizedcontrolledclinicaltrialsthatexaminedthe
efficacyofconservativeinterventionwithSIShavefoundthatexercisesupervisedbyaphysicaltherapistwassuperiortoplaceboandwasaseffectiveas
surgicalsubacromialdecompressioncombinedwithpostoperativerehabilitationintheinterventionofpatientswithstageIIprimaryimpingement.601,602
Anotherrandomizedcontrolledstudy603reportedimprovedROM,decreasedpain,andincreasedfunctioninpatientswithshoulderpainwhounderwenta
programofindividualizedmusclestretching,strengthening,andretrainingversussurgery.603
StageIII
StageIIIistheendstage,commonintheover40agegroup,wheredestructionofthesofttissueandrupture,ormacrotraumaoftheRC,isseen(seeRotator
CuffPathologysection).Localizedatrophycanoccurwiththisstage.OsteophytesoftheacromionandACjointdevelop.Thewearoftheanterioraspectof
theacromiononthegreatertuberosityandthesupraspinatustendoneventuallyresultsinafullthicknesstearoftheRC.Thephysicalexaminationreveals
atrophyoftheinfraspinatusandsupraspinatus,andmorelimitationinAROMandPROMthantheotherstages.
PosteriorSuperiorGlenoidImpingement
PosteriorsuperiorglenoidimpingementisnewlyrecognizedasasourceofRCpathologyinathletes.Thistypeofimpingementisthoughttoresultfroman
impingementoftheRCbetweenthegreatertuberosityandtheposteriorsuperiorglenoidlabrum,althoughtheactualcausehasyettobedetermined.604,605
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Intervention
SeveralevidencebasedmedicalapproachestotreatRCpathologyexist,includingarthroscopicacromioplasty,606andcorticosteroidinjection.607Althoughan
arthroscopicrotatorcuffrepairappearstobearelativelyminorprocedure,postsurgicalrehabilitationislongandintensive.608Severalfactorscanaffectthe
extenttowhichapersonwillrecoverafterrotatorcuffrepairincludingdemographics(age,gender),clinicalvariables(bonemineraldensity,diabetesmellitus,
levelofsportsactivity,preoperativeshoulderROM,andobesity),cuffintegrity(sagittalsizeofthecufflesion,retractionofthecuff,fattyinfiltration,and
multipletendoninvolvement),andsurgicalprocedure(concomitantbiceps/ACjointprocedures).608
Inaddition,anumberofevidencebasedPTapproacheshavealsobeenrecognizedincludingposteriorshoulderstretch,273jointmobilization,609and
strengtheningandneuromuscularreeducation.610
CLINICALPEARL
AcontrolledlaboratorystudybyMuthetal.611thatassessedpain,rangeofmotion,function,scapularkinematics,andelectromyographicsignalamplitudeof
theshouldermusculaturebeforeandafterthoracicspinemanipulationinsubjectswithrotatorcufftendinopathyfoundimmediateimprovementinshoulder
painandfunctionpostmanipulation.However,itisunclearwhetherthemanipulationsalteredneurophysiologicalprocesses,neuromotorcontrol,orsegmental
spinekinematics.
Aprogressionfromisometricexercisestoclosechain,andfinallytoopenchainactivitiesbeginningwithscapulothoracicstrengtheningandscaptionretraining,
andthenproceedingtoRCstrengthening,isgenerallyrecommended(seeInterventionStrategiessection).
Scapulothoracicstrengtheningandscaptionretrainingexercisesincludeisometricscapularpinchesandshrugexercises,rowing,pressups,andthepush
upplus.ExercisestoimprovethescapulohumeralrhythmincludethePNFD2pattern,alternatingserratuspuncheswithtubing,andlatissimusdorsipull
downs.
Rotatorcuffstrengtheningexercisesincludetheemptycan,bicepscurl,IRandERoftheshoulderagainstresistivetubing,elbowextension,proneERof
theshoulder,andshoulderflexionandabduction(performedbelow90degrees).
PeriarticularSyndromes
Thehistoricalfeaturesofallthesesyndromesaresimilar.Painisincreasedafterexerciseandisusuallyworseatnight,oftenwakingthepatientfromsleep.
Certainmovements,suchasreachingabovetheheadorputtingonacoat,willproducepain.ERandIRmotionsareusuallywithinnormallimitswhen
comparedwiththeuninvolvedside,butabductionandflexionarepainfulbetween70and110degrees.Disordersoftheperiarticularinertstructures,suchas
thebursae,arecharacterizedbyanoncapsularpattern.Thesecanbedividedintotwosubgroups.Onegrouphasarestrictedrangeofpassivemovement,andthe
otherhasanunrestrictedrange.Twocommonperiarticularsyndromesthataffecttheshoulderinolderpatientsaresubacromialsubdeltoidbursitisandbicipital
tendinopathy.
AccordingtoNevasier,612primaryshoulderbursitisisseenonlyingout,rheumatoidarthritis,pyogenicinfections,andtuberculosis.613Secondarybursitis,due
totheproximityofthebursaetoaninflamedtendon,isfarmorecommon.
CalcifiedBursitis
Etiologyofthisconditionisaresultofdecreasedvascularization,cuffdegeneration,and/orincreasedlevelsoftheHLA1antigen.Therearethreerecognized
stages:
Precalcificcalciumdepositsinthematrixofvesicles
Calcificcontinuedcalciumdepositionandincreasedpressure
Postcalcificthebodydecreasesitsbloodsupplytotheareainanattempttogetridofthecalcium,producingseverepain(comparabletokidneystones)
TheconditionproducesalimitationofROMinalldirections,andtheareaisverytendertotouchorcompression.
Conservativeinterventionconsistsofanintramuscularsteroidinjectiontodecreasepainandinflammation,iceapplications,andCodmansexercisestorelieve
pressure.Typically,thepaindecreaseswithanincreaseinROMin4872hours.After72hours,thebursitisistreatedasatraumaticbursitis(seenext).
TraumaticBursitisandHemorrhagicBursitis
Traumaticbursitisistheresultofdirecttrauma.Butitcanalsobesecondarytoadegenerativerotatorcuff.Thepatientoftencomplainsofpainatnight.Painis
typicallyfeltoverthedeltoidanditsinsertion,withthearminextension.ThepatientdemonstrateslimitedAROMandPROMinanoncapsularpattern,andan
emptyendfeelatapproximately7080degreeswithGHabduction.
Theconditionrespondswelltoaconservativeregimenofpainandinflammationcontrol,capsularstretching(especiallyposteriorly),Codmansexercises,
manualtechniquestoincreasetheacromiohumeralinterval(scapuladownandback,inferiorglide),posturalreeducation,restorationofnormalsynergypatterns
fortheGHdepressors,andfunctionalrestoration.
CalcificTendinopathy
Calcifictendinitisor,moreaccuratelytermedcalcifictendinopathy,ischaracterizedbyareactivecalcificationthataffectstherotatorcufftendons.Itisa
commoncauseofshoulderpain.614Frequently,suchcalcificationsareincidentalradiographicfindingsinasymptomaticpatients.615Approximately50%of
patientswithcalcifictendinopathyhaveshoulderpain,616,617withassociatedacuteorchronicpainfulrestrictionsofshoulderROM,impactingADLs.
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Thecauseandpathogenesisofcalcificationsoftherotatorcuffareunclear.56,618Ischemiaasaresultofhypovascularizationinthesocalledcriticalzoneofthe
rotatorcuff,56degenerationofthetendons,618andmetabolicdisturbances619haveallbeensuggestedaspossiblecauses.AccordingtoUhthoffetal.,620,621
fibrocartilaginoustransformationofthetendontissueleadstocalciumdeposits.Thecourseofthediseasemaybecyclic,withspontaneousresorptionand
reconstitutionofthetendon.620,621Thefactorthattriggersmetaplasiahasnotyetbeendetermined,althoughtissuehypoxiaisthoughttobetheprimary
factor.619Clearly,degenerationoftherotatorcufftendonsisaprecursorforcalcification.204Bothshouldersareinvolvedat2030%ofpatientswithcalcific
tendinopathyoftheshoulder.616,617Calcifictendinopathyisobservedinfrequentlyinpeopleunderage40.204Theprevalenceofcalcifictendinopathyhasbeen
reportedtobebetween3%616and7%.622Calcifictendinopathycanbeacuteorchronic.621Ingeneral,theconditionisfoundmorefrequentlyinwomenthan
men.616Arelationshiptooccupationmustbeconsideredbecausethereisahighincidenceamongclericalworkers.621
Thecourseofcalcifictendinopathyisvariable.Inmostcases,thedepositsarelocated12cmfromtheinsertionofthesupraspinatustendononthegreater
tuberosity.615Insomepatients,thedepositsareabsorbedspontaneouslywithlimitedpain.Chroniccalcifictendinopathygenerallypresentswithimpingement
symptomsofpainwithoverheadmotion.Otherpatientshavepersistentandrecurringepisodesofseverepain.
Uhthoffetal.621suggestdividingcalcifictendinopathyintoaformativephaseandaresorptivephase.Intheformativephase,calciumdepositscrystallizewith
minimalinflammation.Painisusuallymildandselflimitingduringthisphase.Inthelater,resorptivephase,thecalcificmaterialchangesconsistencyfroma
solidtoapasteorliquid.Shoulderpainisseenmoreofteninthisphase.Thispaincanbesevereanddevelopabruptly.Duringtheseacuteepisodesofshoulder
pain,thephysicalexaminationisoftendifficultduetopainlimitingAROMandPROM.
Managementofcalcifictendinopathyisoftenconservative,consistingoficeapplicationsandpendulumexercises(prescribedintheacutephase)topreventthe
developmentofadhesivecapsulitis.76
Promisingresultshavebeenreportedforshockwavetherapy.623,624Ultrasoundtherapy,usingawideintensityrangeiscommonlyusedasaninterventionfor
painfulmusculoskeletaldisorders.625Thewayinwhichultrasoundstimulatesresorptionofcalciumdepositshasnotbeenestablished.615Itmaystimulatethe
accumulationofperipheralbloodmononuclearcellsbyactivatingendothelialcells.Itmayalsoactindirectlybyincreasingtheintracellularcalciumlevels.626
Athigherintensities,ultrasoundmaytriggeroracceleratethedisruptionofapatitelikemicrocrystals.Theappearanceofthesesmallercalciumcrystalsmay
thenstimulatemacrophagestoremovecalcificationsbyphagocytosis.627,628Finally,theincreasesinthetemperatureoftissueexposedtoultrasoundmay
increasebloodflow(i.e.,inducehyperemia)andmetabolism,thusfacilitatingthedisintegrationofcalciumdeposits.615
Invasiveinterventionsdirectedatthecalciumdeposits,suchasopensurgicalremovalofthedeposits,percutaneousneedleaspirationandclosedlavageofthe
depositswithlidocainereducepainandrestoreshoulderfunctioninsomepatients,butnotinall.204,617,629631
AcuteSubacromialSubdeltoidBursitis
Thisisanextremelyuncomfortablecondition.Activeelevationisverypainfulandgreatlyrestricted,andcanbeaccompaniedbyapainfularc.Whilemost
patientswithsubacromialsubdeltoidbursitisdescribeamechanicalmechanism,bilateralbursitisisoftenseeninpatientswithinflammatoryarthritis.204A
differentialdiagnosisshouldbemadebetweengoutyarthritis,septicarthritis,apathologicfracture,oradislocationoftheshoulder,andthesecanbe
differentiatedfromoneanotherbytheiraccompanyingsymptoms.Regardlessoftheseverityofthepain,otherconditionsneedtoberuledout.Theseinclude
subscapulartendinopathy,apectoralismajorlesion,asprainoftheconoidtrapezoidligament,orearlyGHarthritis.Thepainofbursitisisusuallyreproduced
withpassiveabductionat180degrees,passiveIR,andpassivehorizontaladduction.Resistivetestingmayalsoproducepain.Associatedandpredisposing
findingsmayalsobenoted.Theseincludewingingofthescapula,andforwardheadandroundedshoulderposture.
Withtheshoulderpositionedinextensiontoexposemoreofthebursa,palpationoftheshoulderregioncanelicittendernessoftherotatorcufftendonsand
tendernessofthesubacromialsubdeltoidbursaovertheanteriorhumeralhead.
Conservativeinterventionforthisconditioninvolvestheuseofmodalitiestohelpcontrolthepainandinflammation,andpatienteducationtoavoid
exacerbation.
PrimaryChronicSubacromialSubdeltoidBursitis
Twotypesofprimarychronicbursitisaredefined:
1.Thetypecausedbydegenerativechanges,especiallyofthesupraspinatusandACjoint.Thiscanproduceareducedspaceforthebursaandcausean
inflammatoryreactionofthebursa.
2.Thetypecausedbyasystemicdiseasesuchasrheumatoidarthritis.
Withprimarychronicbursitis,paindevelopsgradually.Thepainisusuallylocalizedtotheshoulderandlateraldeltoidarea,butitcanspreadintotheupper
arm.Findingsfromtheobjectiveexaminationincludeapositivepainfularcintoabductionorforwardflexion,butfullmovementinotherdirections.Oneor
moreresistedtestsareoftenpainful,butmaybenegativeifrepeatedwithaninferiorpullonthearm.
Theinterventionofchoiceisacourseoflocalanestheticinjections.
SecondaryChronicSubacromialSubdeltoidBursitis
Secondarychronicbursitisismorecommonthantheprimarytypeandresultsfromothershoulderpathologies,includingaruptureofthemedialcoracohumeral
ligament.Similartoprimarychronicbursitis,thepaindevelopsgraduallyintheshoulderandlateraldeltoidregion,butcanradiateintotheupperarm.
Theobjectivefindingsarethesameasthosefortheprimarychronicbursitis.However,theexceptionisthatotherpathologiesarepresentandmakeaspecific
diagnosismoredifficult.
Theinterventionofchoiceissimilartoprimarychronicbursitis,althoughtheprimarylesionshouldbesoughtandtreated.
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BicipitalTendinopathy
TendinopathyoftheLHBoccursmoreoftenasasecondaryconditionrelatedtoanimpingementsyndrome.442,612SlatisandAalto632describedathreepart
classificationforbicepslesions:
TypeA:Impingementtendinopathy,whichoccurssecondarytoimpingementsyndromeandrotatorcuffdisease.Sincethetendonpassesbeneaththe
anterioredgeoftheacromion,impingementcancausebicepstendinopathyaswellasrotatorcuffproblems.
TypeB:Asubluxationofthebicepstendon.
TypeC:Attritiontendinopathy,commonlyassociatedwithspurringandfraying.
Inaddition,thebicepstendonsheathisadirectextensionoftheGHjoint,andinflammatoryconditionssuchasrheumatoidarthritiscaninvolvethebiceps
tendon.
Otherresearchers633haveproposedtwomaincategoriesrelatedtoagewithyoungerpatientsdevelopingproblemsduetorepetitivetraumaandanomaliesof
thebicipitalgroove,andtheolderagegroupdevelopingproblemsassociatedwithdegenerativechangesinthetendon.
ThepainassociatedwithinflammationoftheLHBistypicallyfeltalongtheanteriorlateralaspectoftheshoulderwithradiationintothebicepsmuscle,and
tendernessisnoteddirectlyoverthebicipitalgroove.
Objectivefindingsforthisconditionincludethefollowing:
FullAROMandPROM,althoughpainisoftenreportedattheendrangeofflexionandabduction.
NormalaccessoryglidesattheGHjoint(negatingtheneedtousejointmobilizations).442,612
Painonpalpationofthebicipitalgroovewhilethearmispositionedat10degreesofIR.
Painwithresistedelbowflexionorresistedforwardflexionoftheshoulder.
Painonpassivestretchofthebicepstendon.
PositiveSpeedstest.
Everyattemptmustbemadetoidentifyassociatedlesions(e.g.,thoseaffectingtheglenoidlabrumandrotatorcuff)ortonoteanycontributingfactors(e.g.,a
poorlystabilizedscapular,thehypomobilecervicaland/orthoracicspine,oralteredmusclerecruitmentpatterns).72
Theconservativeinterventionforbicepstendinopathysecondarytochronicimpingementissimilartothatdescribedforrotatorcufftendinopathy.These
includeelectrotherapeuticmodalities,physicalagents,NSAIDs,TFM,andgentlestretchingofthecontractiletissues.CaremustbetakenwiththeTFMsoasto
notexacerbatetheacutelyorchronicallyinflamedtissue.Oncethepainandinflammationareundercontrol,thepatientisprogressedthroughROMexercises
withinthepainfreeranges.IntensivestrengtheningisinitiatedwhenfullpainfreeAROMhasbeenrestored.
SubluxingBicepsTendon
TheLHBtendon,withitsproximalpointofexitata3040degreeanglefromthestraightlineofthetendonandthetunnel,swingsfromonesideofthegroove
totheotherduringthemotionsofIRandERofthehumerus.29Ifthegrooveisshallow,thetendonmayforceitswayoverthelesserorgreatertuberosity,
tearingthetransversehumeralligamentintheprocess.Repeatedsubluxationwearsdownthetuberosityandincreasesthefrequencyofthesubluxation.
Ifthegrooveisnarrowandtight,theconstantpressureofthetendonhasthepotentialtocausetendinopathyorevenruptureofthetendon.29
Thepain,notoftensevere,hasthesamereferralpatternasthatofbicipitaltendinopathy.AclickistypicallyfeltduringabductionandERmotions,with
reductionofthetendonoccurringwithadductionandIR.Thereistendernessoverthebicipitalgroove,whichfollowsthegrooveasthearmisrotated.OnIR,
thegrooveisunderthecoracoid,andduringERitisattheanteromedialline.29
Theinterventiondependslargelyonhowimportantathleticsistotheparticipant.Conservativeinterventioninvolvesthetemporaryavoidanceofthepainand
clickprovokingmovementsandtheapplicationofTFM.Inseverecases,surgicalinterventionmaybeindicated,whichoffersexcellentresults.29
RuptureoftheLongHeadofBiceps
AtotalruptureoftheLHBisusuallyseeninmiddleagedpatients,resultingfromrepeatedinjectionsofsteroidintothebicipitalgrooveorincasesofchronic
impingement.204Thetendonisavascular,andasitweakens,ittearswithaminimalamountofforce.
Patientsusuallyreporthearingorfeelingasnapatthetimeoftheinjury.Typically,ruptureisfollowedbyafewweeksofmildtomoderatepain,followedby
resolutionofthepainandrestorationofnormalfunction.204Whenattemptsaremadetocontractthebiceps,themusclebellyrollsdownoverthedistal
humerus,producingaswellingclosetotheelbowinsteadofinthemiddleofthearm:thesocalledPopeyesign.Functionallimitationsareunusualafterthis
rupture,especiallyintheolderpopulation,becausetheshortheadofthebicepsremainsintact.634Typically,thereisanegligiblelossofelbowflexionand
supinationstrength.
Surgicalrepairisrarelyindicatedexceptintheyounger,activepopulation(<50years).Withorwithoutsurgery,aruptureoftheLHBincreasestheriskof
developinganSIS.Thisresultsfromtheshortheadofthebicepspullingthehumeralheadupward,withoutthepresenceofthelongheadtoholdthehumeral
headdownward.
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PATTERN4G:IMPAIREDJOINTMOBILITY,MOTORFUNCTION,MUSCLE
PERFORMANCE,RANGEOFMOTIONWITHFRACTURES
AtraumaticOsteolysisoftheDistalClavicle
Atraumaticosteolysisofthedistalclavicle(AODC)wasfirstdescribedin1959byEhricht.635
Theetiologyisthoughttobeastressfailureofthedistalclavicleduetoaninitialstressfracture,followedbycysticanderosivechangessecondarytobone
resorption.70Subsequentboneformationandremodelingcannotoccurbecauseofcontinuedstressonthejoint.70
Itismostcommoninathletesinvolvedinprolongedweighttrainingandappearstobeontheincrease.Therecentincreaseinincidencemaybeduetothe
emphasisonstrengthtrainingregimensinsport.InagroupofDanishweightlifters,theprevalencewasfoundtobe27%comparedwithanormal(nonweight
lifting)controlgroup.636
Thesymptomsusuallybegininsidiously.Theyareusuallydescribedasapainful,dullachelocalizedtotheACjoint.Theache,whichtendstobeworseatthe
beginningofexercise,mayradiateintothedeltoidandtrapezius.Benchpresses,dips,andpushupsareusuallythemostpainfulexercises.Abductionofthe
armbeyond90degreescausespain.Throwingisalsopainful.Onexamination,thereispointtendernessattheACjointandforcedarmadductionacrossthe
chestincreasesthesymptoms.Symptomsarebilateralin20%ofcases.
Themostcommondifferentialdiagnosestobeconsideredarecervicalspondylosisandrotatorcuffdisease.AODCcanbedistinguishedfromrotatorcuff
tendinopathybyselectiveinjectionofanestheticintotheACjoint.Anabolishmentofthepainwiththeprovocativemaneuverssubsequenttotheinjection
helpsconfirmthediagnosis.
Themajorityofpatientswiththisconditionrespondtoconservativemanagementandactivitymodification,withmostimprovingbyreducingoreliminating
theirstrengthtrainingactivities.636However,evenafterseveralyearslayoff,ifstrengthtrainingisreinstitutedatthesamelevel,thesymptomswillcommonly
recur.637,638Otheraspectsofconservativeinterventioninvolveheat,NSAIDs,ROM,andstretchingandstrengtheningexercises.Theexercisesshouldbe
performedbelow90degreesofabduction.Ultrasoundhasalsobeenadvocated.636Althoughaconsideration,intraarticularinjectionofsteroiddoesnot
providelonglastingsuccess.Itismorehelpfultoaidinthediagnosisandpredictingsurgicalsuccess.
Conservativeinterventionfailureisanindicationforsurgicalmanagement.Thisconsistsofresectionofthedistalclavicle,eitheropenorarthroscopic.
ClavicleFractures
Fracturesoftheclavicleaccountfor510%ofallfracturesand3540%ofshouldergirdleinjuriesinadults.Theclavicleisthemostcommonlyfracturedbone
inchildhood.87FracturesoftheclavicleusuallyresultfromaFOOSH,afallorblowtothepointoftheshoulder,orlesscommonlyfromadirectblow.
Theclassicpresentationfollowingaclavicularfractureisguardedshouldermotionsanddifficultyelevatingthearmbeyond60degrees.Aclaviculardeformity
mayalsobeobservable.Thereisalsoexquisitetendernesstopalpationorpercussion(bonytap)overthefracturesite.Horizontaladductionispainful.The
diagnosisisconfirmedbyradiograph.
Theconservativeinterventionforclaviclefracturesincludesapproximationofthefractureendsfollowedbyimmobilizationwithaslingandfigure8strapfor
36weeks.AAROMandthenAROMexercisesfortheshouldercanbeinitiatedonceclinicalunionhasbeenestablished(in23weeks).Duetothe
importanceoftheclavicleinshoulderfunction,jointmobilizationsarestartedimmediatelyaftertheperiodofimmobilizationandstrengtheningexercisesfor
thedeltoid,pectoralismajor,anduppertrapeziusmusclesareprescribedwhenappropriate.Aswithallshoulderinjuries,theclinicianshouldensurethatthe
scapulohumeralrhythmisnormalandsymmetricalandthattheessentialstabilizingmusculatureoftheGHjointisintact.Normalhealingtimesforclavicular
fractureare6weeksinyoungchildrenin8weeksinadults.639Surgicalinterventionisreservedforthosecasesinvolvingneurovascularcompression,anopen
fracture,associatedfractures,andmarkeddisplacement.
ProximalHumeralFractures
Aproximalhumeralfracture,involvingtheproximalthirdofthehumerus,isthemostcommonfractureofthehumerusintheyoungandtheelderly.Inthe
skeletallyimmaturepatient,thefracturefrequentlypresentsasanepiphysealfractureoftheproximalhumeralgrowthplateastheresultfromadirectblowto
theanterior,lateral,orposterolateralaspectofthehumerus,oraFOOSHinjury.640Intheelderly,thefracturesusuallyoccurthroughosteopenicbone
followingminimaltrauma.
Themajorityofproximalhumeralfracturesarestablewithnosignificantdisplacementofthefracture.Thistypeistypicallytreatedconservatively,withan
emphasisoncontrollingdistaledemaandstiffness,andearlymotionattheshouldertopreventthedevelopmentofarthrofibrosissecondarytoprolonged
immobilization.641
Thearmisusuallyimmobilizedinaslinguntilpainanddiscomfortsubsides,oftenafter2weeksifthefractureisclassifiedasnondisplacedandstable.Ifthe
fractureisclassifiedasnondisplaced,itisconsideredunstableandtheimmobilizationperiodistypicallyapproximately4weeks.AROMexercisesforthewrist
andhandareinitiatedimmediatelyfollowingimmobilization.Typically,passiveandactiveassistedexercisesfortheshouldercanbeinitiatedapproximately1
weekafterinjury.Clinicalunityofthefractureusuallyoccursafter14weeks.Thiscanbetestedbyhavingthepatientstandwiththeinvolvedarmattheirside
withtheelbowflexed.Theclinicianplacesonehandonthehumeralhead,andthengentlyrotatesthehumeruswiththeother.Clinicalunityisestablishedwhen
thefracturefragmentsmoveinunison,andthemovementisfreeofcrepitation.Atthispoint,gentleAROMexercisesareinitiatedfortheshoulderandelbow.
Onceclinicalunionisconfirmedbyradiograph(usuallyataround6weeks),fullPROMexercisestotheshoulderandelbowareperformed,withPREs
typicallyinitiatedat68weeks.
ScapularFractures
Scapularfracturesarenotcommon,accountingforonly1%ofallfractures,3%ofallshoulderinjuriesand5%offracturesinvolvingtheentireshoulder.642
Theanatomicfeaturesofthescapulaprovideinsightintothemechanismsofinjuryandofferaconvenientclassificationsystem(Table1641)643
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TABLE1641ClassificationofGlenoidCavityFractures
Type Description
IA Anteriorrimfracture
IB Posteriorrimfracture
II Fracturelinethroughtheglenoidfossaexitingatthelateralborderofthescapula
III Fracturelinethroughtheglenoidfossaexitingatthesuperiorborderofthescapula
IV Fracturelinethroughtheglenoidfossaexitingatthemedialborderofthescapula
VA CombinationoftypesIIandIV
VB CombinationoftypesIIIandIV
VC CombinationoftypesII,III,andIV
VI Comminutedfracture
Injuriestothebodyorthespineofthescapulatypicallyresultfromadirectblowwithsignificantforce,suchasfromamotorvehicleaccidentorafall.
Acromioninjuriesusuallyresultfromadirectdownwardforcetotheshoulder.
Scapularneckfracturesmostfrequentlyresultfromananteriororposteriorforceappliedtotheshoulder.
Glenoidrimfracturesmostoftenresultfromforcetransmittedalongthehumerusafterafallontoaflexedelbow.
Stellateglenoidfracturesusuallyfollowadirectblowtothelateralshoulder.
Coracoidprocessfracturesmayresultfromeitheradirectblowtothesuperioraspectoftheshoulderoraforcefulmuscularcontractionthatcausesan
avulsionfracture.
Inadditiontoahistoryoftrauma,themostcommonfindingsaretenderness,edema,andecchymosisovertheaffectedarea.Inaddition,theupperextremityis
heldinadduction,andanyattempttoabducttheextremityincreasespain.
Mostscapularfractures,dependingonlocationandclassification,canbetreatedsuccessfullywithoutsurgicalintervention.Conservativeinterventionconsists
ofapproximately710daysofslingimmobilization,followedbyaprogressingregimenofpendularandgentlePROMexercisesascomfortandcontrol
allow.72Oncesufficienthealinghasbeendemonstratedradiographically,thepatientisencouragedtodiscontinueimmobilizationandproceedwithAAROM
andAROMexercises.Exercisesthatstrengthenthemusclesthatattachtothescapulaandthosethatarisefromthescapulamustbeintroducedattheearliest
opportunity.
INTEGRATIONOFPATTERNS4BAND4D:IMPAIREDJOINTMOBILITY,MOTOR
FUNCTION,MUSCLEPERFORMANCE,RANGEOFMOTIONSECONDARYTOIMPAIRED
POSTURE,ANDCONNECTIVETISSUEDYSFUNCTION
ScapularDyskinesis
Strengtheningandstretchingexercisesforscapularmusclesareacommonpartofrehabilitationprogramsdesignedforpeoplewithshoulderdysfunctions.
Scapulardyskinesisisanalterationinthenormalpositionormotionofthescapulathatoccursduringcoupledscapulohumeralmovementsasaresponseto
shoulderdysfunction.644Thecausesaremany(Table1642).Itshouldbesuspectedinpatientswithshoulderinjuryandcanbeidentifiedandclassifiedby
specificphysicalexamination.Therearethreetypesofscapulardyskinesis:
TABLE1642PotentialCausesofScapularDyskinesis
PotentialCauses Examples
Excessivescapularprotractionandacromialdepressioninallstagesofmotionwhichincreasestheriskforimpingement
Abnormalityinbony
xcessiverestingkyphosis
postureorinjury
Forwardheadposturecreatestightnesstotheanteriorneckmusculature,whichagaininturnfacilitatestheabnormalscapulaposition
ACjointinjuriesor
Canalterthecenterofrotationofthescapula,leadingtofaultymechanics
instabilities
Alterationsinvolvingtheserratusanteriorandlowertrapeziusareacommonsourceofdysfunction,especiallyincasesofsecondary
Musclefunction
impingement
alterations
Microtraumaduetoexcessivestraininthemuscles,fatigue,andinhibitionduetopain
Nervedamage Ararecause
Especiallyoftheanteriormusculaturethatattachestothecoracoidprocess(pectoralisminorandshortbicepshead)cancreatean
Contractures
anteriortiltandforwardleantothescapula,ascantightnesstotheposteriorcapsuleandlatissimus
DatafromKiblerWB,McMullenJ.Scapulardyskinesisanditsrelationtoshoulderpain.JAmAcadOrthopSurg.200311:142151.
TypeIischaracterizedbyprominenceoftheinferiormedialscapularborder.Inthrowers,thistypemaybereferredtoasaSICKscapula(malpositionof
theScapula,prominenceoftheInferiormedialborderofthescapula,Coracoidpain,andmalposition,andscapulardyskinesia).269Athrowerwiththis
syndromepresentswithanapparentdroppedscapulainthesymptomaticshouldercomparedwiththecontralateralshouldersscapularposition.
Viewedfrombehind,theinferiormedialscapularborderappearsveryprominent,withthesuperiormedialborderandacromionlessprominent.When
viewedfromthefront,thistilting(protraction)ofthescapulamakestheshoulderappeartobelowerthantheoppositeside.269Thepectoralisminor
tightensasthecoracoidtiltsinferiorly,andshiftslaterallyawayfromthemidline,anditsinsertionatthecoracoidbecomesverytender.269
TypeIIischaracterizedbyprotrusionoftheentiremedialborder.
TypeIIIinvolvessuperiortranslationoftheentirescapulaandprominenceofthesuperiormedialborder.
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Evaluationofthepatientshouldincludethetrunksegments,hipandlowerextremityfunction,andscapularpositionandmovementanalysis.Theremaybepain
atthecoracoidprocess,andtheentiremedialbordermaybetenderwithtriggerpointsfoundintheuppertrapezius.Theremayevenbepainfulscartissue
foundinthemusculatureduetolongstandingdyskinesis.Motionaboutthescapulothoracicjointshouldbesmoothwithnocatchingorrapidmovements,
whicharemoreoftenseenduringtheloweringphaseofthearm.Strengthtestingcanincludetheisometricscapularpinch,theSAT,thescapularretractiontest,
andtheLST.Onceallthefactorsinvolvedinthedysfunctionoftheshoulderareidentified,treatmentcanbeginonrestoringnormalscapularpositionand
movement.Moreextensivetherapy,includingstrengthening,shouldnotoccuruntilthisstepisaccomplishedotherwisetheshoulderisbeingworkedinafaulty
position.
Theinterventionofscapulardyskinesisisdirectedatmanagingunderlyingcausesandrestoringnormalscapularmuscleactivationpatternsbykineticchain
basedrehabilitationprotocols.Leg,back,andtrunkflexibilityandstrengthshouldbenormalized,andexercisesthatemphasizekineticchainactivationofthe
leg,trunk,andscapulashouldbeinstituted.Usefulcombinationsofmovementstoallowactivationincludetrunkextensionandscapularretraction,trunk
rotationandscapularretraction,andoneleggedstanceanddiagonaltrunkrotationandscapularretraction.Alloftheseexercisesfacilitatelowertrapezius
muscleactivation.
SnappingScapular
Thetermsnappingscapulahasbeenusedtodescribetheclinicalscenariooftendernessatthesuperomedialangleofthescapula,painfulscapulothoracic
motion,andscapulothoraciccrepitus.92,645648Infrequently,anunderlyingcauseforthescapulothoracicdyskinesiaisidentified.Theuncommonetiologiesof
snappingscapulaincludescapularexostoses,malunitedscapularorribfractures,andSprengelsdeformity.646,649651Painisusuallyreportedatthe
superomedialangleofthescapula,withorwithoutscapulothoraciccrepitus.
Theinterventionforthisconditionisbasedonthecause.Commoncausesforthisconditionareaninflammationofthebursabetweenthescapulaandthorax
(scapulothoracicbursitis),prominenceofthesuperomedialangleofthescapula,andmuscularimbalanceofthescapularpivoters.92,646648,652655
INTEGRATIONOFPATTERNS4B,4C,4F,AND5F:IMPAIREDJOINTMOBILITY,MOTOR
FUNCTION,MUSCLEPERFORMANCE,RANGEOFMOTIONSECONDARYTOIMPAIRED
POSTURE,SPINALDISORDERS,MYOFASCIALPAINDYSFUNCTION,THORACIC
OUTLETSYNDROME,COMPLEXREGIONALPAINSYNDROME,PERIPHERALNERVE
ENTRAPMENT
ImpairedPosture
Patientswithimpairedposturehavefunctionallimitationsassociatedwithmuscleimbalances,repetitivealteredjointmobility,andpain.Impairedpostureis
commonlyassociatedwithreferredpaintotheshoulder.ThemostcommonposturereferringpaintotheshoulderisaFHPwithroundedshoulders.This
postureischaracterizedbyhypertrophyoftheanteriorchestandcervicalmusculature(includingthepectoralisminormuscleandtheanteriorandmedial
scalenemuscles).ThepositionadoptedintheFHPcancompromisethespaceinthescalenetriangleandcausecompressionoftheneurovascularstructures,
resultinginaconditioncalledTOS(seeChapter23).464
Thisposturecanalsoleadtosofttissuerestrictionsoftheanteriorshouldermuscles,suboccipitalmuscles,andshoulderrotators.464
TheinterventionincludesaconservativeregimeofposturalreeducationandexercisestorestorethenormalsynergypatternsforGHdepressors,toincrease
shoulderstability,andfacilitatefunctionalrestoration(seeChapter25).Cervicalandthoracicstabilizationexercisesmaybeintroducedinadditiontothe
correctionofanymuscleimbalances.
ReferredPain
SeeChapter5.
ScapulocostalSyndrome
Althoughthissyndromehasbeendocumented,656658itispoorlyunderstood.Scapulocostalsyndrome(SCS)isanenthesopathy(adisorderoftheattachment
ofaligament,tendon,jointcapsule,ormuscletobone)oftheoriginoftheserratusposteriorsuperiormuscle.Clinically,itappearsthatSCSisadistinctvariety
offibromyalgia.658
SCShasbeenpostulatedtohavemanycausesincluding658
ischemia659
triggerpoint656
posturaldegeneration660,661
physicalsloth662
Clinicalfindingsforthissyndromeincludethefollowing658:
Painofacervicobrachialnature,describedasburningandaching,isthemostcommonpresentingsymptom.
Activeandpassivemotionsoftheshouldergirdleareusuallyfullandpainfree.
Pooroverallphysicalconditioning.
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Conservativeintervention,whichincludesintralesionalinjectionsandphysicalrehabilitationinvolvingROM,strengthening,andconditioningexercises,was
showninonestudy658tobesuccessfulin95.9%of201patients.
SubclavianStealSyndrome
SeeChapter5.
MyofascialPainSyndrome
Shoulderpaincanoftenbecausedbymyofascialdysfunction.Thefollowingmusclesaremostcommonlyinvolved.Theinterventionstrategiesformyofascial
triggerpointsaredescribedinChapter10.
Infraspinatus
Theinfraspinatusisafrequentcauseofmyofascialshoulderpain,withthetriggerpointsinthismusclecommonlyreferringpaindeepintotheshoulderjoint.
Duetotheseverityofthereferredpainfromthismusclestriggerpoints,itisoftenmisdiagnosedassubdeltoidbursitisorsupraspinatustendinopathy.
Paincanalsobefeltintheanteriorshoulderandanteriorupperarm.Inextremecases,thepainmayrefertotheextensorareaoftheforearmandintothehand.
Clinicalfindingscanincludethefollowing:663
Ahistoryofsleepingdifficultyontheinvolvedsidebecauseofpressureontriggerpoints.Sleepingontheuninvolvedsidecanalsoproducepainbecause
ofstretchingofthemuscle.Supportingtheinvolvedarmonapillowwhilesleepingontheuninvolvedsideisasignificanthelp.
LimitedIRandadductionoftheshoulder,includinghorizontaladductioninseverecases.
Shouldergirdlemusclefatigueratherthanweakness.Painiselicitedonresistedtestingoftheinfraspinatusandmiddleandposteriordeltoidmuscles.
Decreasedgripstrength.
Positivesignsofsubacromialimpingementduetodysfunctionoftheinfraspinatus.
AnteriorDeltoid
Anteriordeltoidtriggerpointstypicallyreferpainandtendernessintheareaofthemuscleitself.ClinicalfindingsincludedecreasedERandextensionofthe
shoulder.
PosteriorDeltoid
Triggerpointsinthismuscle(locatedposteriortothehumeralhead)andinthelevatorscapulaearethemostfrequentcauseofmyogenicposteriorshoulder
pain.663Painiselicitedonresistedtesting,reachingacrosstotheoppositeshoulderanteriorlyandtowardtheendofERwhilethearmisabductedat90
degreesbecauseoftheshorteningactioninthemuscle.663
LevatorScapulae
Thismuscleisoneofthemostfrequentmyofascialsourcesofshoulderandneckpain.Painreferenceistothebaseoftheneck,theposteriorshoulderjointover
theareaofthehumeralhead,andalongthemedialscapularborder.
Clinicalfindingsincludethefollowing:
painfulipsilateralrotationoftheneck,
alimitationoffullshoulderabductionaccompaniedbyreproductionofposteriorshoulderpain.663
Thesetriggerpointsareactivatedbyholdingatelephonereceiverbetweentheshoulderandearsleepingonasofawiththeheadonthearmrest,whichcauses
prolongedstretchingdeformationofthemuscleposturalstressduetoshouldergirdleasymmetryandpsychologicdistress.663
Scalenes
Thepainpatternissimilarforallthreescalenesandcanincludetheanteriorchest,theupperarmbothanterolaterallyandposteriorly,thethumbandindex
finger,andthemedialscapulararea.663Tendernessisreferredtotheinfraclavicularfossaanddisappearsimmediatelyafterinactivationofthetriggerpoints.
Supraspinatus
Rarelyoccurringinisolation,supraspinatustriggerpointsreferpainaroundtheshoulderarea,particularlytothemiddeltoidregion,andthelateralepicondyle
ofthehumerus.Whenthemuscleislessseverelyinvolved,thepatientwillhavedifficultyfullyabductingtheshoulder.
Asdescribedpreviously,supraspinatusdysfunctioncanhavewiderangingconsequencesinshoulderbiomechanics.
Subscapularis
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Painfromsubscapularistriggerpointsisfeltatrestoronmotionovertheposteriorshoulder.Thepainmayalsoextendoverthescapulaandposteromedialarm
asfarasthewrist.
Clinicalfindingsincludethefollowing:
painfulandlimitedshoulderabduction,especiallyifERofthearmisaddedtothemovement,
painfulresistedshoulderadductionandIR,
decreasedposteriorglideoftheGHjoint,
positivesubacromialimpingementsigns.
Trapezius
Thetriggerpointsofthetrapeziusareusuallyfoundintheuppertrapeziusnearthedistalclavicleandinthelowerborderofthelowertrapeziusnearthemedial
scapularborder.Bothareasreferpainandtendernesstothetopoftheshoulderovertheacromion.663ThesetriggerpointsmaycausetendernessoftheAC
jointligaments.Triggerpointsinthelowertrapeziuscanreferpainintotheipsilateralposteriorneckandsuboccipitalregion.663
ThoracicOutletSyndrome
ThechiefcomplaintofTOSisoneofdiffusearmandshoulderpain,especiallywhenthearmiselevatedbeyond90degrees.Potentialsymptomsincludepain
localizedintheneck,face,head,upperextremity,chest,shoulder,oraxillaandupperextremityparesthesias,numbness,weakness,heaviness,fatigability,
swelling,discoloration,ulceration,orRaynaudsphenomenon.TOSisdescribedinChapter25.
BrachialPlexusNeuropathy
Brachialplexusneuropathy,alsoknownasidiopathicbrachialneuritis,acuteshoulderneuritis,neuralgicamyotrophy,orParsonageTurnersyndromeisa
conditionthatisoftenmisdiagnosedasithasasimilarclinicalpresentationtootherpathologiessuchascardiacdisease,cervicalradiculopathy,shoulder
impingement,arotatorcufftear,adhesivecapsulitis,andcalcifictendinopathy.664667
Thetypicalclinicalpresentationofthisconditionisanacuteonsetofsharp,severepainintheupperextremity,whichoftenawakesthepatientatnightandlast
forafewdaystoweeks.Soonafter,whenthepainlessens,thepatientnoticesweaknessintheinvolvedextremityand,withstrengthtesting,moderate
weaknesstototalparalysisoftheshouldergirdlemaybepresent.668DiagnostictestingmayincludeEM,andnerveconductionstudies.
Intheacutestages,NSAIDscanbeusedtocontrolthepain.Oncethepainlevelistolerable,PTisadvocatedtorestore/maintainfullROMandtoregain
strength.669Inaddition,aslingcanbeusedtosupporttheweightofthearmwhensitting,standing,andwalkingtosupportthescapularstabilizingmuscles
againsttheweightofthearm.670
CrutchPalsy
Crutchpalsy,atypeofbrachialplexusneuropathy,whichcommonlyfollowstheuseofaxillarycrutchesisrarebutwellrecognized.Thereareanumberof
documentedreportsofcompressiveneuropathiesstemmingfromtheincorrectuseofaxillarycrutches,thesocalledcrutchpalsy.671673Theincorrectuseof
axillarycrutches,withexcessiveweightbearingontheaxillarybar,leadstoasevenfoldincreaseinforceontheaxilla.Thistypeofpalsycanalsobecausedby
anindividualleaningoverthebackofachairsothattheaxillaiscompressedforaprolongedperiodoftime.Thediagnosisofcrutchpalsyisusuallymade
clinicallybytakingacarefulhistoryandperformingaphysicalexamination.Thisincludesobservationofthepatientduringambulationusingcrutchesand
lookingattheaxillaforsuchsignsofchronicirritationashyperpigmentationandskinhypertrophy.Adetailedneurologicexaminationisusuallysufficientto
determinethecordorterminalbranch(es)involvedandtheleveloftheinvolvement.671
ComplexRegionalPain(Shoulder/Hand)Syndrome
ThisconditionisdescribedindetailinChapter18.
CervicalRadiculitis
Theonsetofcervicalradiculitis(seeChapter25)canbeinsidiousortraumatic,orsecondarytoshoulderdiseasesuchasadhesivecapsulitis.216,675
Thepatientreportsawiderangeofsymptoms.Theserangefrommilddiscomforttoseverepainthatisassociatedwithneckmotionrestrictions,particularly
hyperextensionandrotation.71,676
Objectively,theremaybealossofcervicallordosiswithassociatedparavertebralmusclespasm.Palpationmayrevealtendernessovertheposterioraspectof
theneck,whichcanexacerbatetheradicularsymptomsinthearm.677Thetestingofmusclestrength,sensation,andmusclestretchreflexesshouldhelp
confirmthediagnosis.
Conservativeinterventionconsistsofthecontrolofpainandinflammationthroughrestandactivitymodification.Thepatientiseducatedonpositionstoavoid,
includingrotationtowardtheinvolvedsideandneckextension.Oncethepainiscontrolled,theprogramisprogressedtocervicalROMandstrengthening
exercises,posturaleducation,andgeneralstrengtheningandconditioningoftheupperextremities.
Thereareanumberofcommonperipheralnerveneuropathiesintheshoulderregion(seeChapter3),whicharebeingrecognizedwithincreasingfrequency.
Thenervesthatcanbeinjuredintheregionincludethesuprascapular,accessory,longthoracic,axillary,posterior(dorsal)scapular,andmusculocutaneous.
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QuadrilateralSpaceSyndrome
Idiopathicquadrilateralspacesyndrome,acompressionoftheaxillarynerveasitpasseswiththeposteriorcircumflexarterythroughthequadrilateralspace,is
rare.
Thetypicalclinicalpresentationincludes:658
Vague,poorlylocalizedshoulderdiscomfort,
Painwithfatiguewhenthepatientattemptstomaintainthearmaboveshoulderlevel,
Paresthesiasinanondermatomalpattern,
Tendernesstopalpationinthequadrilateralspacecanoccur.678
Theinitialinterventionisconservativeandincludesrest,musclerelaxants,andNSAIDs.Surgerymayberequiredifthereisnoimprovementin36months.678
AdverseNeuralTension
Anabnormalresponsetomechanicalstimuliofneuraltissueistermedadverseneuraltension(seeChapter12).679,680TheGHjointcanbethesourceof
neurologictensionduetomultidirectionalinstability,directtrauma,orpoorpostureandresultanttensiononthebrachialplexus.216,681Themovementsof
shoulderERanddepressionstretchthebrachialplexus.Sideflexionofthecervicalspineawayfromthetestedsidealsostretchesthebrachialplexus.Oftenthe
patientadoptsposturestocompensatefortightneurologicstructuresandrelievethetensiononthebrachialplexus.Oneofthemostcommonoftheseadaptive
posturesiselevationoftheshouldergirdle.
Adhesionsofthebrachialplexuscanbedetectedusingtheupperlimbtensiontests1and2(refertoChapter12).680
AxillaryWebSyndrome
Axillarywebsyndrome(AWS),orlymphaticcording,isacomplicationofbreastcancerthatimpactsthemusculoskeletalandlymphaticsystems.AWS
typicallyfollowssurgeryforbreastneoplasia.AlthoughtheetiologyandpathogenesisofAWShasnotbeencompletelydetermined,thereisagrowing
consensusthatthecauseisduetoahypercoagulationandfibrosisinandaroundthelymphaticvesselsintheaxilla.682Morespecifically,AWSconsistsofone
ormore(frequentlytwoorthree)cordsofsubcutaneoustissuethatoriginatefromtheaxilla,spreadtotheanteromedialsurfaceofthearmdowntotheelbow
andthenmoveintotheanteromedialaspectoftheforearmandsometimesintotherootofthethumb.683
TheclassicclinicalfindingswithAWSisasignificantlimitationinshoulderabductionrangeofmotion,andthisisoftentheprimaryreasonthepatientseeks
treatment.684Thepatientmayalsoreportsymptomsofpain,numbness,orpulling,thatarefeltthroughoutthearmandforearm,sometimesextendingintothe
hand.SincethesymptomsofAWScandevelopyearsafteranaxillarynodedissection,itisimportantforthecliniciantoincludethedifferentialdiagnosisof
AWSinanypatientwhohasahistoryoflymphnodedissectionwiththeaforementionedfindings.684
AlthoughtherehaveonlybeenafewstudiesregardingthePTinterventionforAWS,itwouldappearthattherecommendedtreatmentplanwouldinclude
manuallymphdrainage,neuralmobilizationsoftheupperextremity,manualtherapy(softtissuetechniques),685patienteducation,andROMexercises.685
THERAPEUTICTECHNIQUES
TechniquestoIncreaseJointMobility
Withsomeslightvariations,thesametechniquesthatareusedtoexaminethejointglidesoftheshouldercomplex(seePassiveAccessoryMotionTests
section)canbeusedtomobilizethejoints,withtheclinicianvaryingtheintensityofthemobilizationsbasedontheintentofthetreatment,patientresponse,
andthestageoftissuehealing.Unlikethetestingpositions,wherethejointisplacedintherestingposition,thejointpositionformobilizationtechniques
varies:
Therestingpositionisusedifgentletechniquesaretobeused.
TherestrictedROMisapproximatedifmoreaggressivetechniquesaretobeused.
Thepurposesofjointmobilizationincludethefollowing:
toincreaseaccessorymotion
toincreaseROM
todecreasepain
toimproveperiarticularmuscleperformance.
Jointmobilizationmaybepreferabletostretchingattheshoulderbecauseitprovidesaprecisestretchtoaspecificpartofthecapsule.Italsocanbeperformed
withlesspain,reducedloadonotherperiarticularstructures,andlesscompressiveforceonarticularstructures438,687ascomparedwithphysiologic
stretching.1Anumberofstudies291,688,689haveexaminedtheefficacyofpassivejointmobilizationand/orPROM.Theyfoundthismodeofinterventiontobe
effectiveforenhancingROMinthepatientwithSIS.Investigatorshavesuggestedthatjointmobilization,especiallyposteriorgliding,mayhaveanimportant
roleinrestoringcapsularextensibilityinprimarySIS452,496bypreventingorstretchingabnormalcollagencrosslinkage,253rupturingadhesions,690reducing
edema,691orreducingpain.692InadditiontotheGHjoint,theclinicianshouldalsoensurethatthemobilityattheAC,SC,andscapulothoracicjointsare
normal.
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Kaltenborn294stressedtheimportanceofpromotingjointglidesforincreasingcapsularmobilityandpreventionofjointcompressionandperiarticularsoft
tissueinjurythatmayoccurwithlongleverangularmobilizations.447Sustainedmanualcapsulestretchesareparticularlyeffectiveinregaining
motion.1,693,694Lowload,prolongedstretchingproducesplasticelongationoftissuesasopposedtothehightensileresistanceseeninhighload,brief
stretching.459,695(i.e.,thearmisbroughttoendrange,pushedslightlybeyondthatrange,andheldinthatpositionfor1020seconds).
GlenohumeralJoint
DistractionoftheGHJoint
ThisisageneraltechniquetostretchGHcapsule.
InferiorGlideoftheGHJoint
ThistechniquecanbeusedtoincreaseGHabduction
PosteriorGlideoftheGHJoint
ThistechniquecanbeusedtoincreaseGHIR,flexion,andhorizontaladduction.
AnteriorGlideoftheGHJoint
ThistechniquecanbeusedtoincreaseGHER,extension,andhorizontalabduction.Cautionmustbeusedwhenusingthistechniqueinpatientswithahistory
ofGHsubluxation/dislocation.
ScapulothoracicJoint
Distraction
Thistechniqueisageneraltechniquetoapplyastretchtotheserratusanteriorandtobreakupadhesionsatthescapulothoracicjoint.
SuperiorGlide
ThistechniqueisappliedtoincreaseROMintoscapulothoracicjointelevationandER.
InferiorGlide
ThistechniqueisappliedtoincreaseROMintoscapulothoracicjointdepressionandIR.
MedialGlide
ThistechniquecanbeusedforincreasingROMintoscapulothoracicjointretraction,depression,andIR.
LateralGlide
AlthoughthistechniquecanbeusedforincreasingROMintoscapulothoracicjointprotraction,elevation,andER,itshouldbeusedwithcautioninpatients
withpostureimpairmentsinvolvingshoulderasthismotionmightalreadybehypermobile.
SternoclavicularJoint
TheSCjointrarelyneedsmobilizingasitisoftenhypermobile.
AcromioclavicularJoint
AnteriorandPosteriorRotationoftheClavicle
Thistechniquecanbeusedtohelpwiththeoverallmotionoftheclavicle,althoughthesemotionsmayalreadybehypermobile.
SuperiorGlideoftheAcromionontheClavicle
ThistechniquecanbeusedasageneralmobilizationtechniqueandisparticularlyusefulifthepatientsACjointistendertopalpation.
SPECIFICPASSIVEPHYSIOLOGICMOBILIZATION:HUMERUSANDSCAPULA
QuadrantTechnique
ThequadranttechniquepreviouslydescribedastheLocktest(specialtestsoftheshoulder)canalsobeusedasamobilizationtechnique.Thisisdoneby
adjustingtheintensityaccordingtotheirritabilityofthecondition.Ifthepainissevere,gradeIV(smalloscillatorytechniquesjustintothetissueresistance)are
used.Ifthistechniquedecreasesthepain,thetechniqueisreappliedandreassessed.Iftheinterventionproducesnochangeinthesymptoms,theclinician
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increasesthegradeslightlyorincreasesthevigorandreassesses.Iftheinterventionproducesanincreaseinpain,thecliniciancontinueswiththesame
interventionbutatalessergrade.
ScapularAssist
Theclinicianstandsbehindthepatient.Thescapulaisstabilizedwithonehandand,asthepatientraisesthearm,thescapulamotionisassistedbyapplyinga
compressiveforceoverthescapulawithonehandwhilestabilizingtheACjointwiththeotherhand(Fig.1619).Asimilartechniquemaybeusedfor
increasingmotionattheendrangeofarmelevation.ThisisagoodtechniquetogainROMduringtheperiodwhenthescapularcontrollersarebeing
strengthenedbuthavenotreachedthepointwhentheyareabletoworkindependently.
PosteriorCapsule(Sleeper)Stretch
Thepatientisinsidelyingwiththeaffectedshouldertowardthetableandthearmat90degreesofforwardflexion.166Thepatientisaskedtorollforwardto
approximately45degreeangle.Atthispointscapularwingingshouldbenoticeable.Theclinicianstandsbehindthepatientandappliespressurewiththepalm
ofthehandontothemedialborderofthescapular.193Thescapulaisthendepresseddowntowardtheposteriorthoraxreversingthescapularwinging,withthe
amountofscapulapressuregaugedbytheclinicianspositioninrelationtothepatient.Theamountofforwardrollandthedegreeofforwardflexionofthe
involvedextremityareimportantvariablesinadjustingthetechnique.
SPECIFICPASSIVE/ACTIVEPHYSIOLOGICMOBILIZATIONOFTHESHOULDER
ElevationthroughAbduction
Thepatientliesinthesupinepositionwithhisorherheadsupported.Thepatientsupperextremityisadductedacrosshisorherabdomen.Theclinician
palpatestheposterioraspectofthepatientswristwithonehandandtheproximalforearmwiththeother.Themotionbarrierislocalizedbyinstructingthe
patienttoelevatethearminthescaptionplanetothelimitofthephysiologicROM.696Fromthisposition,thepatientisinstructedtoholdstillwhilethe
clinicianappliesagentleresistanceintofurtherelevation.Thecontractionisheldfor35seconds,afterwhichthepatientisinstructedtorelaxcompletely.The
newbarrierofelevation/abductionislocatedandthemobilizationisrepeated.
ElevationthroughAdduction
Thetechniqueisidenticaltotheonealreadydescribedwiththeexceptionthattheabductioncomponentisreplacedbyoneofadductionsothatthepatient
performsacombinationofelevationandadduction.696
MOBILIZATIONSWITHMOVEMENT
DecreasedElevation
Thepatientisseatedandtheclinicianstandsonhisorheruninvolvedside.Theclinicianplacesonehandoverthescapulaoftheinvolvedside.Usingtheother
hand,theclinicianreachesaroundthefrontofthepatienttoplacethethenareminenceorabelt(Fig.16136)ontheanterioraspectoftheheadofthehumerus
oftheinvolvedshoulder.Thepatientisaskedtoelevatehisorherarmwhiletheclinicianappliesaposteriorglidetothehumeralhead(avoidingpressureover
thesensitivecoracoidprocess).697Ifthistechniqueissuccessful,thepatientisaskedtoholdaweightwhileelevatingthearm(Fig.16136).
FIGURE16136
Mobilizationwithmovementtoincreaseelevation.
DecreasedInternalRotation
Thepatientisseatedwithhisorherhandsasfarbehindthebackaspossible.Theclinicianstandsfacingthepatientontheinvolvedside.Theclinicianplaces
onehandonthepatientsforearmandthewebspaceofotherhandinthepatientsaxillatostabilizethescapulabyusingalumbricalgrip(Fig.16137).697
Whilemaintainingthestabilizationofthescapula,theclinicianglidesthehumerusinferiorlyintheglenoidfossausingthehandattheelbowandappliesan
adductionforcebypressingtheirabdomenagainstthepatient(seeFig.16137)asthepatientinternallyrotatestheshoulder(usingtheirotherhandtohelpif
necessary).Thetechniquecanalsobeperformedusingabelt(Fig.16138).
FIGURE16137
MobilizationwithmovementtoincreaseIR.
FIGURE16138
MobilizationwithmovementtoincreaseIRusingbelt.
TransverseFrictionMassage
DeepTFMisagoodtreatmentadjunctfortendonandligamentinjuriesoftheshoulder.Sincetheprocedureneedstobeperformedataspecificarea,the
examinationmustaccuratelydeterminewhichstructureisinvolved.
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Biceps
Thepatientispositionedwiththeshoulderabductedto30degreesandtheelbowflexed.Theclinicianstandsatthepatientssideandsupportsthearm(Fig.16
139).Theclinicianplaceshisorherfingersonthebicepstendonandalternatelyappliesamedialandlateralglidemotiontothetendontocreategentlefriction.
FIGURE16139
Transversefrictionmassageofbicepstendon.
Supraspinatus
Thesupraspinatustendonislocatedjustdistaltotheanterolateralcorneroftheacromion.Itcanbecomemorediscerniblebypositioningthepatientsarmin
slightextensionbehindtheback(Fig.16140).Themassageisappliedperpendiculartothetendonatthepointofrelativehypovascularity,whichislocated
approximately1cmproximaltoitsinsertionintothegreatertuberosityofthehumerus.60
FIGURE16140
Transversefrictionmassageofthesupraspinatustendon.
RhythmicStabilization
Thepatientispositionedonallfourlimbs.Thepatientraisestheinvolvedarmtoapproximately90degreesofflexionandisaskedtoholdthisposition(Fig.
16141)whiletheclinicianappliesaseriesofcontrolledalternatingisometriccontractionsoftheagonistandantagonistmusclestostimulatemovementofthe
agonist,anddevelopstability,whilemonitoringscapularmuscleactivity.
FIGURE16141
Rhythmicstabilizationinquadruped.
Thesameexercisecanbeperformedinavarietyofpositions.
SelfStretches
TheSaw
Thisexercisecanbeusedtostretchtheanteriorcapsulewhenmotionabove90degreesisrestricted.Thepatientcanbeinthestandingorsittingposition.
Maintaininghisorherarminapproximately90degreesofelbowflexion,thepatientisaskedtoperformasawingmotionasthoughcuttingthroughwood(Fig.
16142).
FIGURE16142
Thesaw.
WallWalking
Wallwalkingcanbeusedwhenattemptingtoregainfullrangeelevation.Clockexercisesareavariationofwallwalking.Thehandismovedtothevarious
positionsonanimaginaryclockfaceonthewall,rangingfrom8oclock,through12oclock,to4oclock.Thisallowsforrotationofthehumerusthroughout
varyingdegreesofflexionorabductiontoreplicaterotatorcuffactivity.Thisexerciseisfirstperformedagainstafixedresistancesuchasawallora
countertop,andthencanbemovedtomoveableresistancesuchasaballorsomeothermoveableimplement.
Pulleys
Pulleyexercisesarecommonlyusedasanactiveassistedexercisetohelpregainfulloverheadmotion.However,itisrecommendedthatpulleyexercisesnotbe
useduntilthepatienthasatleast120degreesofelevation,andthenonlyusedinapainfreearctodecreasethepotentialforimpingement.
WallCornerStretch
Thisstretchisusedtoincreasetheflexibilityoftheanteriorjointcapsule,pectoralismajorandminor,anteriordeltoid,andcoracobrachialis.Thepatientstands
inacornerandplacesbothhandsandforearmsonthewall,sothattheupperarmsarelevelwiththeshoulders.Thestretchisappliedbymovingthetrunk
towardthewall,whilekeepingitperpendiculartothefloor.Theexercisecanbemodifiedtostretchoneshoulderbyperformingtheexerciseinadoorway.
HorizontalAbductorsandPosteriorCapsule
Thehorizontalabductors(posteriordeltoid,infraspinatus,teresminor,rhomboids,andmiddletrapezius)andtheposteriorjointcapsulearestretchedbyhaving
thepatientpullthearmacrossthefrontoftheirbody(Fig.16143).Thisexerciseshouldbeusedwithcautionforthosepatientswithanimpingementsyndrome
orACdysfunction.
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FIGURE16143
Horizontaladductionstretch.
InferiorCapsule
Theinferiorcapsulestretchisperformedbyplacingthearminthefullyelevatedoverheadposition(Fig.16144).
FIGURE16144
Inferiorcapsulestretch.
PectoralisMinor
Thepectoralisminorcanbestretchedbyaskingthepatienttoclasphisorherhandsbehindthehead(Fig.16145).Fromthisposition,thepatientattemptsto
movetheelbowsinaposteriordirection.Initially,thecliniciancanmonitortheexercisetoensurethatthestretchisoccurringinthecorrectregion.
FIGURE16145
Pectoralisminorstretch.
ShoulderFlexors
ATbarorLbarisusedforthisexercise.Twopositionsareuseddependingontheintentofthestretch.
Tostretchthelatissimusdorsi,teresmajorandminor,theposteriordeltoid,triceps,andinferiorjointcapsule,thepatientliesinsupinepositionwiththearm
overhead(Fig.16146).Overpressurecanbeappliedwiththebar.
FIGURE16146
Tbarexerciseforflexion.
Tostretchtheanteriordeltoid,coracobrachialis,pectoralismajor,biceps,andanteriorjointcapsule,thepatientsarmispositionedouttothesidein
approximately90degreesofabduction.Thepatientextendsthearmasfarasiscomfortable(Fig.16147).Thebarcanbeusedtoapplyoverpressureinto
furthershoulderextension.
FIGURE16147
Tbarexerciseforextension.
ShoulderInternalRotators
ATbarorLbarisusedforthisexercise.Thepatientliesinsupineposition.Thearmisflexedattheelbowandinoneofthethreepositionsofabductionatthe
shoulder:0degrees,90degrees(seeFig.16148),and130degrees.Foreachofthethreepositions,theshoulderisexternallyrotatedasfarasiscomfortable.
Overpressureisthenappliedbythebartostretchthesubscapularis,pectoralismajor,anteriordeltoid,latissimusdorsi,andtheanteriorjointcapsule.
FIGURE16148
Tbarexerciseforexternalrotation.
ShoulderExternalRotators
ATbarorLbarisusedforthisexercise.Thepatientliesinsupineposition.Theelbowisflexedandthearmisabductedintooneofthethreepositionsatthe
shoulder:0degrees,90degrees,and130degrees.Foreachofthethreepositions,theshoulderisinternallyrotatedasfarasiscomfortable.Overpressurecan
thenbeappliedusingthebartostretchtheinfraspinatus,teresminor,posteriordeltoid,andposteriorjointcapsule.
Alternatively,thepatientcansitsidewaystoatable.Theentireupperarmisplacedonthetabletop,bendingthetrunkasnecessary.Theelbowisflexedto
approximately90degrees.Usingtheotherarm,thepatientgraspstheforearmoftheinvolvedarmandmovesitintoIRasfarasiscomfortable.Rhythmic
oscillations,orholdrelaxtechniques,canbeappliedattheendofrange.
TowelStretch
Thetowelstretchexercise(Fig.16149)combinesthemotionsofERandIRandstretchesthecapsuleaccordingly.
FIGURE16149
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Towelstretch.
AUTOMOBILIZATIONTECHNIQUES
InferiorDistraction
Thisisagoodtechniqueifthepatientsshoulderabductionrangeislimitedtobelow90degrees.Thepatientsitssidewaysnexttoatable.Theinvolvedarmis
comfortablypositionedusingatowelrollorpillowinasmuchabductionascanbetoleratedpainlessly.Theelbowisinfullextension(Fig.16150).Usingthe
uninvolvedhand,oratowelwrappedaroundthehumerus,thepatientgraspsthesuperoanterioraspectoftheproximalhumerusoftheinvolvedarm(seeFig.
16150).Fromthisposition,aninferiorglideisproducedbypushingthehumerusdirectlydownward,orpullingthetoweltowardthefloor.Rhythmic
oscillationscanbeused.
FIGURE16150
Selfinferiordistraction.
Ifthepatienthasmorethan90degreesofabduction,anothertechniqueispreferable.Thepatientstandsagainstawallwiththeinvolvedshoulderpositioned
comfortablyintoabduction.Theelbowisflexedtoapproximately90degreesandthefleshypartoftheforearmrestsagainstawall.Theotherhandgraspsthe
superoanterioraspectoftheproximalhumerusoftheinvolvedarmandappliesaninferiorglidebypushingthehumerusdownwardtowardthefloor.
InferiorDistractionwithAdduction
Thepatientstandsorsitsonastool.Atowelrollisplacedundertheaxilla,andthearmtobemobilizedispositionedacrossthechest.Usingtheuninvolved
hand,thepatientgraspstheinvolvedforearmjustabovethestyloidprocessesandpullsthearmrhythmicallyacrossthechestintoGHadduction,and
downwardtowardthefloor(Fig.16151).
FIGURE16151
Inferiordistractionwithadduction.
CASESTUDYSHOULDERPAINWITHCERTAINMOTIONSHISTORYANDSYSTEMSREVIEWGeneralDemographics
Thepatientisa22yearoldmalewholivesathomewithhisparents.
Insidiousonsetofintermittentleftshoulderpainbegan2weeksago,withareportofoccasionalreferralofpainintotheupperleftarm.Thepatientdenies
numbnessortinglingintotheleftupperextremity.Painincreasedsufficientlythepastweektopromptthepatienttoseeaphysician,whodiagnosedthe
conditionasrotatorcuffimpingementandprescribedPTandNSAIDs.Thepatientwasalsoplacedonworkrestrictionsmaximumliftlimitedto10lb.
Nohistoryofleftshoulderpain.
MedicalandSurgicalHistory
Unremarkable.
Medications
Ibuprofen,800mgdaily.
FunctionalStatusandActivityLevel
Thepatientreportedstiffnessandsorenessoftheleftshoulderonarisinginthemorningandagainattheendofthedayafterworking.Difficultywasalso
reportedwithputtingonajacket,drivingtoworkwhichtakes45minutes,andtheuseofahedgetrimmer.Thepatientreportedthattheshoulderpaininterrupts
hissleeptwotothreetimeseverynightandthathewashavingdifficultycombinghishair,brushinghisteeth,orliftinghisarmwithoutpain.Healsoreported
thatheenjoyedswimmingbutcannotswimthecrawlorbackstrokebecauseofthepain.Thepatientdescribedcrackingandpoppingoftheshoulderwith
activity.
HealthStatus(SelfReport)
Generallyingoodhealthbutpaininterfereswithtasksathomeandatwork.
Questions
1.Whatstructure(s)doyoususpecttobeinvolvedinthispatient?
2.Whatcouldthehistoryofpainwithcertainoverheadmovementsindicate?
3.Whydoyouthinkthepatientssymptomsareworsenedwithcertainfunctionalandrecreationalactivities?
4.Whatadditionalquestionswouldyouasktohelpruleoutcervicalinvolvementorpainreferredfromavisceralstructure?
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5.Whatisyourworkinghypothesisatthisstage?Listthevariousdiagnosesthatcouldpresentwiththesesignsandsymptoms,andthetestsyouwoulduse
toruleouteachone.
6.Doesthispresentation/historywarrantaCyriaxupperquarter/quadrantscanningexamination?Whyorwhynot?
CASESTUDYSTIFFANDPAINFULSHOULDERHISTORYANDSYSTEMSREVIEWGeneralDemographics
Thepatientisa55yearoldfemalewholivesalone.
Thepatientreportsa7monthhistoryofunilateralshouldergirdlestiffness,pain,andweaknesswithadiagnosisfromthephysicianofrightfrozenshoulder.
Therewasnohistoryoftrauma,butthepatientreportedanabruptonsetofveryseverepain7monthsprior.Withinseveraldays,shealsohadrightforearmand
thumbpainoflesserseverity,andweaknessoftherightshoulder.
Theforearmandthumbpainhadsinceresolved,andalthoughtherewassomerestrictedmotionoftheshoulder,themoremarkedpainfulstiffnessofthe
shoulderdidnotoccuruntil2or3monthsaftertheonsetofsymptoms.After3months,shewashavingdifficultiesperformingherjobfunctionsandsought
medicalattention.Thusfar,shehadbeentreatedwithaseriesoftwocorticosteroidinjections,bothofwhichhadgivenhershorttermrelief.
Nonworkrelatedrightshoulderinjury5yearsago,whichresolvedin2monthswithacourseofPT,includingROMandstrengtheningexercises,whichshe
followedfor1monthafterdischargefromPT.
MedicalandSurgicalHistory
Unremarkable.Gallbladdersurgery2yearsago.
Medications
Daily800mgibuprofenandhighbloodpressuremedication.
OtherTestsandMeasures
None.
Occupational,Employment,andSchool
Patientwasamailreceptionclerkforthepostalservice,andherjobinvolvedmonitoringincomingmail,whichrequiredrepeatedopeningandliftingofmail
packages.
Stiffness/sorenessoccursatthefirsthourinthemorning,andagainattheendofthedayafterworking.Paininterfereswithsleeptwotimespernight,
especiallywithrollinginbedordrivingtowork,whichtakes30minutes.Thepatientdiscontinuedhernormalthreetimesaweekaerobicworkoutandupper
andlowerbodyresistanceexercisesapproximately3monthsago.
Ingeneral,thepatientisingoodhealth,exceptforaminorheartproblem(congestiveheartfailure)andhighbloodpressure.
Questions
1.Atthispointintheexamination,isitpossibletodeterminethepatientsdiagnosis?Whyorwhynot?
2.Whatdoesthehistoryofpainwithsleepingontheshoulderandpain/stiffnessinthemorningtelltheclinician?
3.Whydoyouthinkthepatientssymptomsarerelatedtotimeofday?
4.Whatadditionalquestionswouldyouasktohelpruleoutpainreferredfromavisceralstructuregiventhepatientsmedicalhistory?
5.Doyouhaveaworkinghypothesisatthisstage?Listthevariousdiagnosesthatcouldpresentwiththesesignsandsymptoms,andthetestsyouwould
usetoruleouteachone.
6.Doesthispresentation/historywarrantascan?Whyorwhynot?
7.Doyouthinkthepatientsageisafactor?
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EnnekingWF,HorowitzM.Theintraarticulareffectsofimmobilizationonthehumanknee.JBoneandJointSurg.197254A:973985.
691.
RandallT,PortneyL,HarrisB.Effectsofjointmobilizationonjointstiffnessandactivemotionofthemetacarpophalangealjoint.JOrthopSportsPhysTher.
199216:3036.[PubMed:18796775]
692.
WykeBD.Theneurologyofjoints.AnnRCollSurgEngl.196741:2550.[PubMed:4951631]
693.
AremA,MaddenJ.Effectsofstressonhealingwounds:Intermittentnoncyclicaltension.JSurgRes.197142:528543.
694.
WarrenCG,LehmannJF,KoblanskiJN.Elongationofrattail:Effectofloadandtemperature.ArchPhysMedRehabil.197152:465474.[PubMed:
5116032]
695.
LightKE,NuzikS.Lowloadprolongedstretchvshighloadbriefstretchintreatingkneecontractures.PhysTher.198464:330333.[PubMed:6366834]
696.
LeeDG.AWorkbookofManualTherapyTechniquesfortheUpperExtremity.2nded.Delta,B.C.:DOPC1991.
697.
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CHAPTER17:Elbow
CHAPTEROBJECTIVES
1.Describetheanatomyofthejoints,ligaments,muscles,andbloodandnervesupplycomprisingtheelbow
complex.
2.Describethebiomechanicsoftheelbowcomplex,includingopenandclosepackedpositions,normaland
abnormaljointbarriers,forcecouples,andstabilizers.
3.Describethepurposeandcomponentsofthetestsandmeasuresfortheelbowcomplex.
4.Performacomprehensiveexaminationoftheelbowcomplex,includingpalpationofthearticularandsoft
tissuestructures,specificpassivemobility,andpassivearticularmobilitytests,andstabilitytests.
5.Evaluatethetotalexaminationdatatoestablishaprognosis.
6.Describetherelationshipbetweenmuscleimbalanceandfunctionalperformanceoftheelbow.
7.Outlinethesignificanceofthekeyfindingsfromthetestsandmeasuresandestablishadiagnosisor
workinghypothesis.
8.Summarizethevariouscausesofelbowdysfunction.
9.Developselfreliantinterventionstrategiesbasedonclinicalfindingsandestablishedgoals.
10.Describeanddemonstrateinterventionstrategiesandtechniquesbasedonclinicalfindingsandestablished
goals.
11.Evaluatetheinterventioneffectivenessinordertoprogressormodifyanintervention.
12.Plananeffectivehomeprogramandinstructthepatientinsame.
OVERVIEW
Theelbowservesanimportantlinkagefunctionthatenablesproperpositioningofthehandandthetransmission
ofpowerfromtheshouldertothehand,thusaugmentingtheversatilityandagilityoftheupperextremity.
Unliketheshoulder,theelbowcomplexisaninherentlystrongandstablejoint,becauseoftheinterrelationship
ofitsarticularsurfacesandligamentousconstraints.However,thestabilityoftheelbowcomplexallowslittlein
thewayofcompensatoryadjustments,makingitparticularlyvulnerabletooveruseinjuryfromrepetitious
muscleactivityandsuddenmovementsofaccelerationanddeceleration.Appropriatediagnosisandtreatment
requireadetailedunderstandingofthenormalanatomyoftheelbow.
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ANATOMY
Theelbowcomplex,enclosedwithinthecapsuleofthecubitalarticulation,iscomposedofthreedistinct
articulations:thehumeroulnarjoint,thehumeroradialjoint,andtheproximalradioulnarjoint.Theanteriorjoint
capsuleoftheelboworiginatesfromthedistalhumerusproximaltotheradialandcoronoidfossa,fromwhereit
theninsertsdistallyintotherimofthecoronoidandtheannularligament(AL).1Posteriorly,thecapsule
incorporatestheareaproximaltotheolecranonprocessitattachesdistallyalongthearticularmarginofthe
sigmoidnotchandtheproximalaspectoftheolecranonfossa.2
CLINICALPEARL
Thejointcapsuleoftheelbowcomplexisthinbutstrongandisreinforcedmediallyandlaterallybyligaments.
Anteriorly,thecapsulecontributes38%oftheresistancetovalgusforceand32%oftheresistancetovarusforce
infullextension.3Thecapsuleofthejointdoesnotrespondwelltoinjuryorprolongedimmobilizationand
oftenformsthickscartissue,whichmayresultinflexioncontracturesoftheelbow.46
HUMEROULNARJOINT
Thehumeroulnar(trochlear)jointisauniaxialhingejointformedbetweentheincongruentsaddleshapedjoint
surfacesofthespoolshapedtrochleaofthehumerusandthetrochlearnotchoftheproximalulna(Fig.171).
Anteriorly,thehumeraltrochleargrooveisverticalandparalleltothelongitudinalgroove,while,posteriorly,the
grooverunsobliquelylateralanddistal,forminganacuteangleofabout15degreeswiththelongitudinalaxisof
thehumerus.7Thisvalgusangulationisreferredtoasthecarryingangleoftheelbow.Threehundreddegrees
ofthearticularsurfaceofthetrochleaiscoveredwithhyalinecartilage,comparedwithonly180degreesonthe
trochlearnotch.8
FIGURE171
Thebonystructuresoftheelbowcomplex.(Reproduced,withpermission,fromChapter31.Arm.In:Morton
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Thecarryingangleservestodirecttheulnalaterallyduringextensionandincreasethepotentialforelbow
flexionmotion,astheoffsetallowsroomanteriorlyforapproximationofthemusclesofthearmandforearm.
Thecarryingangleisapproximately1114degreesinmalesand1316degreesinfemales.911
Therestingoropenpackedpositionforthehumeroulnarjointis70degreesofflexionwith10degreesof
forearmsupination.Theclosepackedpositionisfullextensionandmaximumforearmsupination.Forthepart
ofthejointbetweenthecoronoidprocessandthehumerus,theclosepackedpositionismaximumflexion.The
capsularpatternismuchmorelimitationofflexionthanextension.12
HUMERORADIALJOINT
Thehumeroradial(radiocapitellar)jointisauniaxialhingejointformedbetweenthesphericalcapitellumofthe
humerusandtheconcavefoveaoftheradialhead(seeFig.171).Thedesignofthisjointallowstheelbowto
flexandextendandfortheradiustorotate.Thesuperiorsurfaceoftheproximalendoftheradiusisbiconcave
whiletheheadoftheradiusisslightlyoval.Theradialtuberosity(seeFig.172)servesasasiteofattachment
forthebicepsbrachii(seeFig.172).Thehumeruswidensattheelbowandformsthemedialandlateral
epicondyles.
FIGURE172
Thebiceps.(Reproduced,withpermission,fromChapter31.Arm.In:MortonDA,ForemanK,AlbertineKH.
eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
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CLINICALPEARL
Theresting,oropenpacked,positionofthehumeroradialjointisextensionandforearmsupination.Theclose
packedpositionisapproximately90degreesofelbowflexionand5degreesofsupination.Thereisnotrue
capsularpatternatthisjoint,althoughclinicallyanequallimitationofpronationandsupinationisobserved.
PROXIMALRADIOULNARJOINT
Theradiusandtheulnaliesidebyside,withtheradiusbeingtheshorterandmorelateralofthetwoforearm
bones.Theproximalorsuperiorradioulnarjointisauniaxialpivotjoint.Itisformedbetweentheperipheryof
theconvexradialhead,andthefibrousosseousringformedbytheconcaveradialnotchoftheulna(seeFig.17
3),whichliesdistaltothetrochlearnotch,andtheAL.TheAL(Fig.174)forms80%ofthearticularsurfaceof
theproximalradioulnarjoint(seeALlater).
FIGURE173
Theproximalradioulnarjoint,andthetwomajormovements:(A)supination,and(B)pronation.(Reproduced,
withpermission,fromChapter31.Arm.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:Gross
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FIGURE174
Elbowjointwithligamentsdetailed.(Reproduced,withpermission,fromChapter31.Arm.In:MortonDA,
CLINICALPEARL
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Theresting,oropenpacked,positionfortheproximalradioulnarjointis70degreesofflexionand35degreesof
forearmsupination.Theclosedpackedpositionis5degreesofforearmsupination.Thecapsularpatternis
minimaltolossofmotion,withpainattheendrangesofpronationandsupination.12
Theproximalanddistalradioulnarjointstogetherformabicondylarjoint.Aninterosseousmembrane
sometimesreferredtoasthemiddleradioulnararticulationandlocatedbetweentheradiusandtheulna,serves
tohelpdistributeforcesthroughouttheforearm,andprovidemuscleattachment.Mostofthefibersofthe
interosseousmembraneoftheforearmaredirectedawayfromtheradiusinanobliquemedialanddistal
direction.8Approximately8%ofthecompressionforceduetobearingweighttotheforearmcrossesthewrist
betweenthelateralsideofthecarpusandtheradius.8Theremaining20%ofthecompressionforcepasses
acrossthemedialsideofthecarpalbonesandtheulna.8Becauseofthefiberorientationoftheinterosseous
membrane,someoftheproximallydirectedforcethroughtheradiusistransferredacrossthemembranetothe
ulna.13
LIGAMENTS
Supportfortheelbowcomplexisprovidedthroughstrongligaments(Fig.174).
MedialLigamentComplex
Theulnacollateralligament(UCL)ormedialcollateralligament(MCL)extendsfromthecentraltwothirdsof
theanteroinferiorsurfaceofthemedialepicondyletotheproximalmedialulna,fromjustposteriortotheaxisof
theelbowmedialepicondyle,1416tojustdistaltothetipofthecoronoid(seeFig.174).17,18
ThefanshapedMCListhemostimportantligamentintheelbowforprovidingstabilityagainstvalgusstress,
particularlyintherangeof20130degreesofflexionandextension,19withthehumeroradialjointfunctioning
asasecondarystabilizertovalgusloads.20,21TheMCLachievesthisstabilitythroughalmostthetotalrangeof
flexionandextensionduetoitseccentriclocationwithrespecttotheaxisofelbowmotion.2225Infullelbow
extension,valgusstabilityoftheelbowisprovidedequallybytheMCL,thejointcapsule,andthejoint
interactions.5
TherearethreedistinctcomponentsoftheMCL14,17,26,27:theanteriorbundle,thetransversebundle,andthe
posteriorbundle(Fig.174).
AnteriorBundle
TheanteriorbundleoftheMCListhestrongestandstiffestoftheelbowcollateralligaments,withanaverage
loadtofailureof260newtons(N).19TheanteriorbundleoftheMCLinsertsanaverageof18mmdistaltothe
coronoidtip,andiscomposedoftwoothercomponents,theanteriorbandandtheposteriorband,whichperform
reciprocalfunctions:17,22,26
Theanteriorbandoftheanteriorbundleisthemostimportantcomponentoftheligamentouscomplex,
becauseitprimarilystabilizestheelbowagainstvalgusstressintherangesof060degreesofflexion,and
becomesasecondaryrestraintwithfurtherflexion.3,14,17,2022,24,26,28Theanteriorbandisprimarily
responsibleforstabilityagainstvalgusstressesat30,60,and90degreesofflexion,makingitthemost
importantcomponentinresistingthevalgusforcesassociatedwithoverheadsportsactivities.1Recently,
Ochietal.15determinedthatthedeepmiddleportionoftheanteriorband,previouslydescribedasthe
guidingbundle,27isaprimelimitingfactorinhumeroulnarmotion.22,29
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Theposteriorbandistautfrom60to120degreesofelbowflexionandisasecondaryrestrainttovalgus
stressat30degreesand90degreesofflexion,butaprimaryrestrainttovalgusat120degreesofelbow
flexion.26Theposteriorbandfunctionsasanequalcorestraintwiththeanteriorbandatterminalelbow
flexion,3,19,22,26,28andalsoactsasaprimaryrestrainttopassiveelbowextension.Inthehigherdegrees
offlexion,theposteriorbandisnearlyisometricandisthusfunctionallyimportantintheoverheadathlete
incounteractingvalgusstresses.30
Oblique(Transverse)Bundle
Theobliquebundle,alsoknownasCoopersligament,isvariablypresent.14,17,31Itdoesnotcrosstheelbow
jointandcomprisesfibersrunningalongthemedialjointcapsulefromthetipoftheolecranontothemedial
ulna,justdistaltothecoronoid.14,32Thetransversefibershavelittleroleinelbowstabilityduetothefactthat
theybothoriginateandinsertontheulna.
PosteriorObliqueBundle
TheposteriorbundleoftheMCLoriginatesfromthemedialepicondyleandinsertsontothemedialmarginof
thesemilunarnotch,formingthefloorofthecubitaltunnelandathickeningoftheposteriorelbow
capsule.32,33Beingthinnerandweakerthantheanteriorbundle,theposteriorbundlebecomestautat60degrees
ofelbowflexionbutprovidesonlysecondaryrestrainttovalgusstressatflexionbeyond90degrees.22,23
LateralLigamentComplex
Unlikethemedialligamentcomplex,thelateralligamentouscomplex(seeFig.174)islessdiscrete,and
individualvariationiscommon.ThelateralcomplexconsistsoftheAL,thelateralradialcollateralligament
(LCL),andthelateralulnarcollateralligament(LUCL).19TheLCLcoursesdistallyandformsabroadconjoint
insertionontotheproximalulna.34,35Theproximalmarginofthisconjoinedinsertionbeginsattheproximal
aspectoftheradialhead,justinferiortotheradialnotch.Fromhere,itprogressesalongaroughridgeinline
withthesupinatorcrestoftheulna.19TheLCLiscloselyassociatedwiththeinsertionsoftheextensorcarpi
radialisbrevis(ECRB)andthesupinator,withthelattermusclecrossingthisligamentcomplexobliquelyfrom
distaltoproximalatitsulnarattachmentandbecomingconfluentwiththeunderlyingALandLCLmore
proximallyatitshumeralorigin.19TheLUCLoriginatesfromthelateralepicondylefromwhereitpassesover
theALandthenbeginstoblendwithitdistallywhereitinsertsontothesupinatorcrestoftheulna.14Itis
unclearastohowmuchstabilityisprovidedbytheLUCL,butitmayhelppreventposterolateralrotary
instability.36
Asaunit,thelateralligamentcomplexfunctionstomaintaintheulnohumeralandradiohumeraljointsina
reducedpositionwhentheelbowisloadedinsupination.Morespecifically,theanteriorportionoftheLCL
stabilizestheproximalradioulnarjointduringfullsupinationtheposteriorportionstabilizesthejointduring
pronation.AstheaxisofrotationpassesthroughtheoriginoftheLCL,thevariousfibersofthisligament
maintainconsistentpatternsoftensionwhethervarus,valgus,ornoforceisappliedtotheelbowthroughoutthe
arcofflexion.14,28TheLCLcontributesonly9%oftherestrainttovarusstressat90degreesofflexion.In
extension,theLCLcontributes14%ofthisrestraint.28
Insufficientlateralsupportoftheelbowcomplexresultsinlateralgappingattheulnohumeraljointandposterior
translationoftheradialheadinrelationtothecapitellum.19However,theproximalradioulnarrelationship
remainsundisturbed.
CLINICALPEARL
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Asmuchas50%ofelbowstabilityistheresultofthejointcapsule,MCL,andtheLCL.Theremaining50%is
associatedwiththebonystructureofthejoint.Otherstructuresalsoprovidepassivesupporttotheelbow
complex.Secondaryrestraintsofthelateralelbowconsistofthebonyarticulations,andtheextensormuscles
withtheirfascialbandsandintermuscularsepta(seeForceCouplesoftheElbow).Secondaryrestraintsofthe
lateralelbowconsistofthebonyarticulations,thejointcapsule(seeFig.174),andtheextensormuscleswith
theirfascialbandsandintermuscularsepta.Theseindependentlysupporttheforearmunitfromlaterallyrotating
awayfromthehumerusbyvirtueoftheiranatomicarrangement,andprovideasecondarystaticanddynamic
vectorsupportingthelateraljoint.35
AnnularLigament
TheAL(Fig.174),whichiswiderproximallyanddistally,runsaroundtheradialheadfromtheanteriorandthe
posteriormarginoftheradialnotch,toapproximatetheradialheadtotheradialnotchandenclosetheradial
circumference.TheALformsabandthatencircles80%oftheradialheadandfunctionstomaintainthe
relationshipbetweentheheadoftheradiusandthehumerusandulna.TheinternalcircumferenceoftheALis
linedwithcartilagetoreducethefrictionagainsttheradialheadduringpronationandsupination.8Theexternal
surfaceoftheligamentreceivesattachmentsfromtheelbowcapsule,theLCL,andthesupinatormuscle.
QuadrateLigament
Thequadrateligamentisashort,stoutligamentthatarisesjustbelowtheradialnotchoftheulnaandattachesto
themedialsurfaceoftheneckoftheradius.8Thisligamentlendsstructuralsupporttothecapsuleofthe
proximalradioulnarjoint.8
BURSAE
Therearenumerousbursaeintheelbowregion.23Theolecranonbursaisthemainbursaoftheelbowcomplex
andliesposteriorlybetweentheskinandtheolecranonprocess.Undernormalconditions,thebursadoesnot
communicatewiththeelbowjoint,althoughitssuperficiallocationputsitathighriskofinjuryfromdirect
traumatotheelbow.
Otherbursaeintheposteriorelbowregionincludethedeepintratendinousbursaandadeepsubtendinousbursa,
whicharepresentbetweenthetricepstendonandolecranon.Anteriorly,thebicipitoradialbursaseparatesthe
bicepstendonfromtheradialtuberosity.Alongthemedialandlateralaspectsoftheelbowarethesubcutaneous
medialepicondylarbursaandthesubcutaneouslateralepicondylarbursa.37
Muscles
AsummaryofthemusclesoftheelbowisoutlinedinTable171.Themusclesoftheforearmarecontained
withinthreemajorfascialcompartments,theanteriorforearm,theposteriorforearm,andthecompartment
referredtoasthemobilewad(Table172).
TABLE171MusclesoftheElbow,Forearm,Wrist,andHand:TheirActions,NerveSupply,andNerveRoot
Derivation
NerveRoot
Muscles NerveSupply Action
Derivation
Triceps Radial C78 Elbowextension
Anconeus Radial C78,(T1)
Brachialis Musculocutaneous C56,(C7) ElbowFlexion
Bicepsbrachii Musculocutaneous C56
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NerveRoot
Derivation
Brachioradialis Radial C56,(C7)
Bicepsbrachii Musculocutaneous C56 Supinationoftheforearm
Posterior
Supinator interosseous C56
(radial)
Anterior
Pronator
interosseous C8,T1 Pronationoftheforearm
quadratus
(median)
Pronatorteres Median C67
Flexorcarpi
Median C67
radialis
Extensorcarpi
Radial C67 Extensionofthewrist
radialislongus
Posterior
Extensorcarpi
interosseous C78
radialisbrevis
(radial)
Posterior
Extensorcarpi
interosseous C78
ulnaris
(radial)
Flexorcarpi
Median C67 Flexionofthewrist
radialis
Flexorcarpi
Ulnar C78
ulnaris
Flexorcarpi
Ulnar C78 Ulnardeviationofthewrist
ulnaris
Posterior
Extensorcarpi
interosseous C78
ulnaris
(radial)
Flexorcarpi
Median C67 Radialdeviationofthewrist
radialis
Extensorcarpi
Radial C67
radialislongus
Posterior
Abductor
interosseous C78
pollicislongus
(radial)
Posterior
Extensor
interosseous C78
pollicisbrevis
(radial)
Extensor Posterior
digitorum interosseous C78 Extensionofthefingers
communis (radial)
Posterior
Extensor
interosseous C78
indicis
(radial)
Posterior
Extensordigiti
interosseous C78
minimi
(radial)
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NerveRoot
Derivation
Lateral:anterior
Flexor interosseous
digitorum C8,T1 Flexionofthefingers(lateralaspectflexesthesecondand
(median)
profundus C8,T1 thirddigitsmedialaspectflexesthefourthandfifthdigits
Medial:Ulnar
Flexor
digitorum Median C78,T1 Flexionofthefingers
superficialis
TABLE172MuscleCompartmentsoftheForearm
Compartment PrincipalMuscles
Pronatorteres
Flexorcarpiradialis
Palmarislongus
Flexordigitorumsuperficialis
Anterior
Flexordigitorumprofundus
Flexorpollicislongus
Flexorcarpiulnaris
Pronatorquadratus
Abductorpollicislongus
Extensorpollicisbrevis
Extensorpollicislongus
Posterior Extensordigitorumcommunis
Extensordigitorumproprius
Extensordigitiquinti
Extensorcarpiulnaris
Brachioradialis
Mobilewad Extensorcarpiradialislongus
Extensorcarpiradialisbrevis
ElbowFlexors
Anatomic,biomechanic,andelectromyographic(EMG)analyseshavedemonstratedthattheprimemoversof
elbowflexionarethebiceps,brachialis,andbrachioradialis(seeTable171).38Thepronatorteres,flexorcarpi
radialis(FCR),flexorcarpiulnaris(FCU)(Fig.175),andtheextensorcarpiradialislongus(ECRL)musclesare
consideredtobeweakflexorsoftheelbow.37Mostelbowflexors,andessentiallyallthemajorsupinatorand
pronatormuscles,havetheirdistalattachmentsontheradius.8Contractionofthesemuscles,therefore,pullsthe
radiusproximallyagainstthehumeroradialjoint.39,40Thecombinedeffortsofalltheelbowflexorscancreate
largeamountsofelbowflexiontorque.Theinterosseousmembranetransfersanddissipatesaportionofthis
muscleforcetotheradiusandtotheulna.8Thereverseactionoftheelbowflexorscanbeusedinaclosedchain
activitybybringingtheupperarmclosertotheforearmsuchaswhenperformingapullup.41
FIGURE175
Musclesoftheanteriorforearm.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,
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BicepsBrachii
Thebicepsisatwoheadedmusclethatspanstwojoints.Theshortheadofthebicepsarisesfromthetipofthe
coracoidprocessofthescapulawhereitmesheswiththecoracobrachialisandpectoralisminortendon,whereas
thelongheadarisesfromthesupraglenoidtuberosityofthescapula(Fig.172).Thebicepshastwoinsertions:a
commontendinousinsertionattheradialtuberosityandbythelacertusfibrosus(bicipitalaponeurosis)that
emanatesfromthebicepsmusclebellyatthelevelofthemusculotendinousjunctionandcrossesdistallyand
mediallytoinsertalongthesubcutaneousborderoftheulnar(seeFig.172).42
Attheelbow,thebicepsisadominantflexor,butitssecondaryfunctionissupinationoftheforearm.43The
supinationactionofthebicepsincreasesthemoretheelbowisflexedandismaximalat90degrees.It
diminishesagainwhentheelbowisfullyflexed.No,44orlimited,45bicepsmuscleactivityhasbeen
demonstratedduringelbowflexion,withtheforearmpronated.37Thebiceps,viaitslonghead,alsofunctionsas
ashoulderflexor(seeChapter16).
Brachialis
Thebrachialis(Fig.176)originatesfromthelowertwothirdsoftheanteriorsurfaceofthehumerusandinserts
ontheulnartuberosityandthecoronoidprocess.Thebrachialisistheworkhorseoftheelbowandfunctionsto
flextheelbowregardlessofthedegreeofpronationandsupinationoftheforearm,45Itisthemostpowerful
flexoroftheelbowwhentheforearmispronated.46
FIGURE176
Thebrachialismuscle.(Reproduced,withpermission,fromChapter31.Arm.In:MortonDA,ForemanK,
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Brachioradialis
Thebrachioradialis(Fig.175)arisesfromtheproximaltwothirdsofthelateralsupracondylarridgeofthe
humerusandthelateralintermuscularseptum.Ittravelsdowntheforearmandinsertsonthelateralborderofthe
styloidprocessonthedistalaspectoftheradius.
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Thebrachioradialisappearstohaveanumberoffunctions,twoofwhichoccurwithrapidmovementsofelbow
flexion.Initiallyitfunctionsasashuntmuscle,overcomingcentrifugalforcesactingontheelbow,andthenby
addingpowertoincreasethespeedofflexion.43
Thebrachioradialisalsofunctionstobringapronatedorsupinatedforearmbackintotheneutralpositionof
pronationandsupination.Intheneutralorpronatedposition,themuscleactsasaflexoroftheelbow,anaction
thatdiminisheswhentheforearmisheldinsupination.45,47
PronatorTeres
Thepronatorteres(seeFig.175)hastwoheadsoforigin:ahumeralheadandanulnarhead.Thehumeralhead
arisesfromthemedialepicondylarridgeofthehumerusandcommonflexortendon,whereastheulnarhead
arisesfromthemedialaspectofthecoronoidprocessoftheulna.Thepronatorteresinsertsontheanterolateral
surfaceofthemidpointoftheradius.Themusclefunctionspredominantlytopronatetheforearm,butcanalso
assistwithelbowflexion.5,46,47
TheECRLarisesfromapointsuperiortothelateralepicondyleofthehumerusonthelowerthirdofthe
supracondylarridge,justdistaltothebrachioradialis.Ittravelsdowntheforearmtoinsertontheposterior
surfaceofthebaseofthesecondmetacarpal.Themusclefunctionsasaweakflexoroftheelbow,aswellas
assistingwithwristextensionandradialdeviation.
FlexorCarpiRadialis
TheFCR(seeFig.175)arisesfromthecommonflexortendononthemedialepicondyleofthehumerusand
insertsonthebaseofthesecondandthirdmetacarpalbones.TheFCRfunctionstoflextheelbowandwristbut
alsoassistsinpronationandradialdeviationofthewrist.
FlexorCarpiUlnaris
TheFCU(seeFig.175)hastwoheadsoforigin.Thehumeralheadarisesfromthecommonflexortendonon
themedialepicondyleofthehumerus.Itinsertsonthepisiform,hamate,andfifthmetacarpalbones.TheFCU
functionstoassistwithelbowflexioninadditiontoflexionandulnardeviationofthewrist.
ForearmPronators
PronatorTeres
Seeabove.
PronatorQuadratus
Thefibersofthepronatorquadratusrunperpendiculartothedirectionofthearm,runningfromthemostdistal
quarteroftheanteriorulnatothedistalquarteroftheanteriorradius(seeFig.175).Itistheonlymusclethat
attachesonlytotheulnaatoneendandtheradiusattheotherend.
Thepronatorquadratusisthemainpronatorofthehand.
FlexorCarpiRadialis
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Seeabove.
ForearmSupinators
Biceps
Theeffectivenessofthebicepsasasupinatorisgreatestwhentheelbowisflexedto90degrees,placingthe
bicepstendonata90degreeangletotheradius.Incontrast,withtheelbowflexedonly30degrees,muchofthe
rotationalefficiencyofthebicepsislost.41
Supinator
Thesupinatororiginatesfromthelateralepicondyleofthehumerus,LCL,theAL,thesupinatorcrest,andthe
ulnarfossa.Itinsertsonthesuperiorthirdoftheanteriorandlateralsurfaceoftheradius.Thesupinatormuscle
isarelentlessforearmsupinator,similartothebrachialisduringelbowflexion.Thesupinatorfunctionsto
supinatetheforearminanyelbowposition,whilethepreviouslymentionedECRLandbrevisworkassupinators
duringfastmovements,andagainstresistance.
Thenervoussystemusuallyrecruitsthesupinatormuscleforlowpowertasksthatrequireasupinationmotion
only,whilethebicepsremainsrelativelyinactiveafineexampleofthelawofparsimony(seeChapter3).8
CLINICALPEARL
Themusclesabouttheelbowhelpprovidestabilitybycompressingthejointsurfacesthroughmuscular
contraction.48Theflexorandpronatormuscles,whichoriginateatthemedialepicondyle,provideadditional
staticanddynamicsupporttothemedialelbow,5withtheFCUandflexordigitorumsuperficialisbeingthemost
effectiveinthisregard.49
ElbowExtensors
Therearetwomusclesthatextendtheelbow:thetricepsandtheanconeus(seeTable171).
TricepsBrachii
Thetricepsbrachii(Fig.177)hasthreeheadsoforigin.Thelongheadarisesfromtheinfraglenoidtuberosityof
thescapula,thelateralheadfromtheposteriorandlateralsurfaceofthehumerus,andthemedialheadfromthe
lowerposteriorsurfaceofthehumerus.Themuscleinsertsonthesuperoposteriorsurfaceoftheolecranonand
deepfasciaoftheforearm.Thetricepshasitsmaximalforceinmovementsthatcombinebothelbowextension
andshoulderextension.Likethebiceps,itisatwojointmuscle.Themedialheadofthetricepsistheworkhorse
ofelbowextension,withthelateralandlongheadsrecruitedduringheavierloads.50Duringstrongcontractions
ofthetriceps,forexample,apushup,whichinvolvesacombinationofelbowextensionandshoulderflexion,as
thetricepsstronglycontractstoextendtheelbow,theshouldersimultaneouslyflexesbytheactionofthe
anteriordeltoid,whichoverpowerstheshoulderextensiontorqueofthelongheadofthetriceps.41
FIGURE177
Thetriceps.(Reproduced,withpermission,fromChapter31.Arm.In:MortonDA,ForemanK,AlbertineKH.
eds.TheBigPicture:GrossAnatomy.NewYork,NY:McGrawHill2011.)
Anconeus
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Theanconeusarisesfromthelateralepicondyleofthehumerusandinsertsonthelateralaspectoftheolecranon
andposteriorsurfaceoftheulna.Theexactfunctionoftheanconeusinhumanshasyettobedetermined,
althoughitappearstobeafourthheadoftheelbowextensionmechanism,similartothequadricepsofthe
knee.8Ithasbeensuggestedthatinadditiontoassistingwithelbowextension,forearmpronation,and
supination,theanconeusfunctionstostabilizetheulnarheadinallpositions(exceptradialdeviation)andtopull
thesubanconeusbursaandthejointcapsuleoutofthewayduringextension,thusavoidingimpingement.5,51
Theanconeushasalsobeenfoundtostabilizetheelbowduringforearmpronationandsupination.45
CLINICALPEARL
Tendonitisoftheanconeuscanmimictenniselbowwhilehypertrophyoftheanconeusmusclecancompressthe
ulnarnerve.52
CUBITALTUNNEL
Thecubitaltunnel,afibroosseouscanal,wasoriginallydescribedbyFeindelandStratford.53Theulnarnerve
passesthroughthistunnel.ThefloorofthetunnelisformedbytheMCL,whereastheroofisformedbyan
aponeurosis,thearcuateligament,orOsbornesband,whichextendsfromthemedialepicondyletothe
olecranonandarisesfromtheoriginofthetwoheadsoftheFCU.5457Themedialheadofthetriceps
constitutestheposteriorborderofthetunnel,anditsanteriorandlateralbordersareformedbythemedial
epicondyleandolecranon,respectively.30
Thevolumeofthecubitaltunnelisgreatestwiththeelbowheldinextension.58Astheelbowisbroughtintofull
flexion,thereisa55%decreaseincanalvolume.54Vanderpooletal.59reportedthatwitheach45degreesof
flexionoftheelbow,therewasaconcomitant5mmincreaseindistancebetweentheulnarandhumeral
attachmentsofthearcuateligament.Atfullelbowflexion,therewasa40%elongationoftheligamentanda
decreaseincanalheightofapproximately2.5mm.
Afewotherfactorshavebeenassociatedwithadecreaseinthesizeofthecubitaltunnel.Theseincludespace
occupyinglesions,osteoarthritis,rheumatoidarthritis,heterotopicboneformation,ortraumatothenerve.58
Patientswithsystemicconditionssuchasdiabetesmellitus,hypothyroidism,alcoholism,andrenalfailurealso
mayhaveapredisposition.60
BulgingoftheMCLhasalsobeendescribedasafactor.59Morethan40%ofathleteswithvalgusinstability
developulnarneuritissecondarytoirritationfrominflammationoftheMCL.61,62
ODriscolletal.57reportedthatthegrooveontheinferioraspectofthemedialepicondylewasnotasdeepasthe
grooveposteriorly,andthefloorofthecanalseemstorisewithelbowflexion.57Thesechangesleadtoan
alterationofthecrosssectionalareaofthecubitaltunnelfromaroundedsurfacetoatriangularorelliptic
surfacewithelbowflexion.54,58
CLINICALPEARL
Thevolumeofthecubitaltunnelisgreatestwiththeelbowheldinextension.
CUBITALFOSSA
Thecubitalfossa(Fig.178)representsatriangularspace,ordepressionthatislocatedontheanteriorsurfaceof
theelbowjoint,andwhichservesasanentrywaytotheforearm,orantebrachium.Theboundariesofthe
fossaareasfollows:
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FIGURE178
Thecubitalfossa.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,ForemanK,
Lateral.BrachioradialisandECRLmuscles
Medial.Pronatorteresmuscle
Proximal.Animaginarylinethatpassesthroughthehumeralcondyles
Floor.Brachialismuscle.
Thecontentsofthefossainclude(seeFig.178):
thetendonofthebicepsbrachii,whichliesasthecentralstructureinthefossa
themediannerve,whichrunsalongthelateraledgeofthepronatorteresmuscle
thebrachialartery,whichentersthefossajustlateraltothemediannerveandjustmedialtothebiceps
brachiitendon
theradialnerve(notshown),whichrunsalongthemedialedgeofthebrachioradialisandECRLmuscles
andisvulnerabletoinjuryhereand
themediancubitalorintermediatecubitalcutaneousvein,whichcrossesthesurfaceofthefossa.
NERVES
Theneurologicsupplyofthebones,joints,muscles,andskinoftheelbowandforearmisderivedfromtheC5
throughC8nerveroots,whichexitfromtheintervertebralforaminaofC45throughC7T1(Figs.176and17
9).63
FIGURE179
Nervesupplyoftheelbowandforearm.(Reproduced,withpermission,fromChapter31.Arm.In:MortonDA,
UlnarNerve(C8T1)
Fromitsoriginasthelargestbranchofthemedialcordofthebrachialplexus,theulnarnervecontinuesalong
theanteriorcompartmentofthearm,beforepassingthroughthemedialintermuscularseptumatthelevelofthe
coracobrachialisinsertion.
Attheleveloftheelbow,theulnarnervepassesposteriortothemedialepicondyle,whereitentersthecubital
tunnel.Ulnarnervecompressioninthecubitaltunnelisacommonentrapmentneuropathyoftheupper
extremity,secondonlytocarpaltunnelsyndrome(CTS).64Afterleavingthecubitaltunnel,theulnarnerve
passesbetweenthetwoheadsoftheFCUoriginandtraversesthedeepflexorpronatoraponeurosis.65,66
MedianNerve(C5T1)
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Themediannerveextendsmediallydowntheupperarmacrosstheanterioraspectofelbowjoint.Theligament
ofStruthersarisesfromanabnormalspurontheshaftofthehumerusandrunstothemedialsupracondylar
process.56Thesupracondylarprocesswithitsligamentousextensionenclosesaforamen,boundedmediallyby
themedialintermuscularseptum,andthedistalanteriorsurfaceofthemedialepicondyle,throughwhichthe
brachialarteryandmediannervepass.67
Asthemediannervepassesthroughthecubitalfossa,theanteriorinterosseousnerve(AIN)branchesoffit,asit
passesthroughthetwoheadsofthepronatorteresmuscle.TheAINsuppliesthemotorinnervationtotheindex
andmiddleflexordigitorumprofundus(FDP),theflexorpollicislongus(FPL),andthepronatorquadratus.
RadialNerve(C5T1)
Theradialnervesitssuperiorlyandmediallyintheupperarmandwindsaroundthehumeralshaft.Atapoint
approximately1012cmproximaltotheelbowjoint,theradialnervepassesfromtheposteriorcompartmentof
thearmbypiercingthelateralintermuscularseptum.68Thenervetravelsintheanteriorforearmbetweenthe
brachialismuscleandthebicepstendonmedially,andthebrachioradialis,ECRL,andECRBmuscleslaterally.68
Withinanareaapproximately3cmproximalordistaltotheelbowjoint,theradialnervebranchesintoadeep
mixednerve,theposteriorinterosseousnerve(PIN),andasuperficialsensorybranch.69,70Afterdividing,the
twoterminaldivisionsusuallyfollowthesamecourse,sharingasingleepineuriumforseveralcentimeters,
beforethesuperficialradialnervemovesanteriorlytolieontheundersurfaceofthebrachioradialis,andthe
deepbranchtravelsposteriorlytoentertheradialtunnel/supinatorcanal,distaltotheoriginoftheECRB,atthe
leveloftheradiohumeraljoint.68Enteringthecanal,thedeepbranchsuppliestheECRBthenpassesdeeptothe
superficialheadofthesupinator,wherethearcadeofFrhse1canimpingeonthenerve.71,72
Thenervecontinuesbetweenthetwoheadsofthesupinatorandinnervatesthismuscleduringitspassagetothe
posterolateralaspectoftheradius.Onemergingfromthesupinator,amotordivision(supplyingtheabductor
pollicislongus,extensorpollicisbrevis,extensorindicisproprius,andextensorpollicislongusmuscles)anda
mixedlateralbranch(supplyingtheextensorcarpiulnaris[ECU],extensordigitorumcommunis,andextensor
digitiminimimuscles)arerecognized.Thelateralbranchcontinuesalongtheposteriorradialborderofthe
radiustothewristasthesensorybranchofthePIN,whichinnervatestheposterior(dorsal)capsuleofthewrist
andintercarpaljoints(seeChapter18).68,72
TheRadialTunnel/SupinatorCanal
Theradialtunnelliesontheanterioraspectoftheradiusandisapproximatelythreetofourfingerbreadthslong,
beginningjustproximaltotheradiohumeraljointandendingatthesitewherethePINpassesdeeptothe
superficialpartofthesupinatormuscle.73Thelateralwallofthetunnelisformedbythebrachioradialis,ECRL,
andECRB.Thesemusclescrossoverthenervetoformtheanteriorwalloftheradialtunnelaswell,whilethe
floorofthetunnelisformedbythecapsuleofthehumeroradialjoint,andthemedialwalliscomposedofthe
brachialisandbicepstendon.68
1ThearcadeofFrhseisaninvertedarchedstructurethatlieswithin1cmdistalofthefibrousedgeofthe
ECRBandapproximately24cmdistaltotheradiohumeraljoint.Itrepresentstheproximalborderofthe
superficialheadofthesupinator,throughwhichtheradialnervepasses.
VASCULARSUPPLY
Thevascularsupplytotheelbow(Fig.1710)includesthebrachialartery,theradialandulnararteries,the
middleandradialcollateralarterylaterally,andthesuperiorandinferiorulnarcollateralarteries.37
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FIGURE1710
Vascularsupplyoftheelbowandforearm.(Reproduced,withpermission,fromChapter31.Arm.In:Morton
BIOMECHANICS
Thereisstillcontroversyintheliteratureastotheprecisebiomechanicsoftheelbow,74andhowtheaxesof
motionrelatetotheanatomyofthejoint.Biomechanically,theelbowpredominantlyfunctionsasanimportant
centrallinkintheupperextremitykineticchain,allowingforthegenerationandtransferofforcesthatoccurin
theupperextremity.Thecommonstressesthatoccurattheelbowincludevalgusstress,whichresultsinmedial
tensionandlateralcompressionloadingvarusstress,whichresultsinlateraltensionloadingextensionstress
andmultiplecombinationsofthesestresses.Theseforcesproducerepetitivetensileloadsontheligamentous
andmuscularsupportsystemsaroundtheelbow,andcompressiveandshearloadsonthebonyconstraints.75
Trulyimpressiveloadscanbeplacedontheelbowduringactivitiessuchasthrowingorpitching(seeChapter
30).
Itisimportantthattheelbowisabletomovefreelyandpainlesslythroughoutitsavailablemotion.These
motionsincludeelbowflexionandextension,andforearmpronationandsupination.
FlexionExtension
Flexionextensionoftheelbowcomplexoccursaboutarelativelyfixedaxisofrotationpassingthroughthe
centerofarcsformedbythetrochleaandthecapitellum(Fig.171).Themaximalrangeofpassivemotion
generallyavailabletotheelbowisfrom5degreesofhyperextensionto145degreesofflexion.Fullactive
extensioninthenormalelbowissome510degreesshortofthatobtainablebyforcedextension,duetopassive
muscularrestraints(biceps,brachialis,andsupinator).76,77Passiveextensionislimitedbytheimpactofthe
olecranonprocessontheolecranonfossa,tensioninthedermis,thefibersoftheMCL,andtheanterior
capsule.78Excessiveectopicboneformationaroundtheolecranonfossacanalsolimitfullpassiveextension.
Passiveflexionislimitedbybonystructures(theheadoftheradiusagainsttheradialfossaandthecoronoid
processagainstthecoronoidfossa),tensionoftheposteriorcapsularligament,softtissueapproximation,and
passivetensioninthetriceps.78
SupinationPronation
Pronationandsupinationrequiresimultaneousjointmovementattheproximalanddistalradioulnarjoints(Fig.
173).8Thelongitudinalaxisofrotationaboutwhichsupinationandpronationoccurisconsideredtopass
throughthecenteroftheheadoftheradiustotheconvexarticularsurfaceoftheulnaratthedistalradioulnar
joint.Supinationattheproximalradioulnarjointoccursasaspinningoftheradialheadwithinthefibroosseous
ringformedbytheALandradialnotchoftheulna.8Thearthrokinematicsofpronationattheproximal
radioulnarjointoccursbysimilarmechanisms.
Restrictionsinthepassiverangeofpronationandsupinationmotionscanoccurfromtightnessinmuscleand/or
connectivetissues(Table173).79,80
TABLE173StructuresthatcanRestrictSupinationandPronation
LimitSupination LimitPronation
Pronatorteres,pronatorquadratus Bicepsorsupinatormuscles
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LimitSupination LimitPronation
Posterior(dorsal)capsularligamentatthedistal
Palmarcapsularligamentatthedistalradioulnarjoint radioulnarjoint
Obliquecord,interosseousmembrane,andquadrate
ligament
Ulnocarpalcomplex Ulnocarpalcomplex
DatafromNeumannDA.Elbowandforearmcomplex.In:NeumannDA,ed.Kinesiologyofthe
MusculoskeletalSystem:FoundationsforPhysicalRehabilitation.St.Louis,MO:Mosby,2002:133171.
DatafromKleinmanWB,GrahamTJ.Thedistalradioulnarjointcapsule:Clinicalanatomyandrolein
posttraumaticlimitationofforearmrotation.JHandSurgAm.199823:588599.
DatafromBertJM,LinscheidRL,McElfreshEC.Rotatorycontractureoftheforearm.JBoneJointSurgAm.
198062:11631168.
HUMEROULNARJOINT
Themotionsthatoccuratthehumeroulnarjointinvolveimpureflexionandextension,whichareprimarilythe
resultofrotationoftheconcavetrochlearnotchoftheulnaabouttheconvextrochleaofthehumerus.Atthe
humeroulnararticulation,flexioninvolvesananteriorrollandadistal/anteriorslideattheulnarjointsurface.
Duringextension,thereisaposteriorrollandaproximal/posteriorslideattheulnarjointsurface.Fromasagittal
section,thefirmmechanicallinkbetweenthetrochlearandthetrochlearnotch,however,limitsthemotionto
essentiallyasagittalplane.8
HUMERORADIALJOINT
Anymotionattheelbowandforearmcomplexinvolvesmotionatthehumeroradialjoint.Thus,anylimitation
ofmotionatthehumeroradialjointcandisruptbothflexionandextension,andpronationandsupination.8
Duringflexionandextensionoftheelbow,thehumeroradialjointfollowsthepathwaydictatedbytheanatomy
oftheulnohumeraljointtowhichitisfirmlyattachedbytheannularandinterosseousligaments.63Atthe
humeroradialarticulation,flexioninvolvesananteriorrollandananteriorslideattheradialjointsurface.
Duringextension,thereisaposteriorrollandaposteriorslideattheradialjointsurface.Atrestinfullextension,
littleifanyphysicalcontactexistsatthehumeroradialjoint.8,81
Duringactiveflexion,however,musclecontractionpullstheradialfoveaagainstthecapitulum.82,83
Somesupinationandpronationalsooccuratthisjointduetoaspinningoftheradialhead.
Althoughthehumeroradialjointprovidesminimalstructuralstabilitytotheelbowcomplex,itdoesprovidean
importantbonyresistanceagainstavalgusforce.8,21
PROXIMALRADIOULNARJOINT
Attheproximalradioulnarjoint,onedegreeoffreedomexists,permittingpronationandsupination(Fig.173).
Boththefasciaandthemusculatureoftheforearmdependontheintegrityoftheinterosseousradioulnar
relationshipfortheirmechanicalefficiency.63
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Theproximalradioulnarjointisstructurallyanovoid,withverylittleswingavailabletoitduetoitsligamentous
constraints.Asaconsequence,itsmovementisconfinedtoaccommodatingtheosteokinematicspinofthe
radius.Astheradialheadformstheconvexpartner,thereisatendencyfortheradialheadtomove
posterolaterallyduringpronationandanteromediallyduringsupination,butthesemovementsarestrongly
curtailedbytheannularandinterosseousligaments.Atthejointsurfaces,pronationinvolvesananteriorrollof
thecomplexrimoftheradialheadandaposteriorslide.Duringsupination,thereisaposteriorrolloftherimof
theradialheadandananteriorslide.
COUPLEDMOTIONS
Conjunctrotationsoccurattheelbowcomplexwithallmotions.Inaddition,theelbowmotionsofflexionand
extensionareassociatedwithadductionandabductionmotions.Theabilitytoabductandadductcaneasilybe
observedduringpronationandsupination.Inthefullysupinatedposition,theulnaismuchnearerthemidlineof
thebodythanitisinfullpronation.Therefore,abductionoccurswithpronation,andadductionoccurswith
supination.
Theabductionthatoccurswithextensionoccursatthehumeroulnarjointandismoreapparentthanreal.An
increaseinthecarryingangleoftheforearmduringextensionmustnotbeconfusedwiththeabductionofthe
ulna,whichoccursbecauseoftheunequalrangesofextensionbetweentheulnaandthehumerus,andtheradius
andthehumerus(thecapitellumbeingorientedmoreanteriorlythanthetrochlear).Thisinequityproducesa
conjuncthumeraladductionwithflexionandaconjuncthumeroulnarabductionwithextension,bothofwhich
arecontrolledbythelateralandMCL.63
Thus,itisapparentthatpronationsupinationandflexionextensionareinterdependent,andeachisaconjunct
motionoftheother,atleastattheextremesoftherange.Sincepronationandsupinationinvolvetheproximal
anddistalradioulnarjointsandthehumeroulnar,humeroradial,andradiocarpaljoints,mechanicaldysfunction
ofanyofthesejointsmaybecomeapparent,especiallyintheextremesofelbowflexionorextension.63
FORCECOUPLESOFTHEELBOW
Theroleoftheelbowmusculatureasdynamicjointstabilizersisstillsomewhatunclear.Bothvarusandvalgus
forcesareproducedbymusclesduringelbowmotions.ThevalgusforcesareproducedbytheECU,EDC,
ECRL,andbrachioradialis,whilevarusforcesareproducedbytheFCR,FDS,pronatorteres,andFCU.Forces
transmittedacrossthearticulatingsurfacesincludetheforcescreatedbymusclesworkingtogethertoproduce
thedesiredactivity.Theimportantforcecouplesoftheelbowinclude:84
thetriceps/bicepsduringelbowextensionandflexion
pronatorteresandpronatorquadratus/supinatorduringforearmpronationandsupination
FCR,FCU,flexordigitorumcommunis/ECRL,ECRB,andextensorcommunisduringwristflexionand
extensionand
triceps/bicepsandbrachioradialispronatorteres/supinatorandFCR,FCU/ECRB,andECRLduring
activitiesrequiringelbowstabilization.
EXAMINATION
Sincetheelbowisoneofthemultiplelinksoftheupperextremitykineticchain,athoroughstaticanddynamic
examinationoftheentireupperextremityandcervicalspineaswellasthetrunkshouldbeperformedinaddition
toexaminationoftheelbowproper.Thephysicalexaminationmustincludeatleastinspection,rangeofmotion
(ROM)testing,palpation,provocativetesting,andneuromusculartesting.Theinterventionsforthecommon
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pathologiesoftheelbowcomplexandtheirinterventionsaredetailedaftertheexaminationisdescribed.An
understandingofbothisobviouslynecessary.Asmentionofthevariouspathologiesoccurswithreferencetothe
testsandmeasuresandviceversa,thereaderisencouragedtoswitchbetweenthetwo.
HISTORY
Duringthehistory,theclinicianmustdeterminethechiefcomplaintandlocationofsymptoms.Inadditiontothe
questionslistedunderhistoryinChapter4,answerstothefollowingquestionsmustbeobtained:
Whatisthepatientschiefcomplaint?Thepatientschiefcomplaintcanoftenaffordcluesastothe
underlyingpathology.Forexample,achiefcomplaintofpainuponleaningonthepointoftheelbowis
usuallyassociatedwitholecranonbursitis.
Howoldisthepatient?Thereareanumberofagerelatedelbowconditions.Forexample,paininayoung
childwouldbesuggestiveofnursemaidselbow(dislocationoftheheadoftheradius),elbowpain
betweentheagesof15and20couldbeosteochondritisdissecans,andtenniselbow(lateralepicondylosis)
typicallyoccursinindividuals35yearsofageorolder.
Wasthereamechanismofinjuryoranyantecedenttrauma?Traumaticelbowinjuriesoftenoccur
followingafallonanoutstretchedhand(FOOSH)injury.Thistypeoffallcanresultinanumberofupper
extremityandneckinjuries.Attheelbow,theFOOSHinjurycanresultinahyperextensioninjuryofthe
joint.Ifthefallwasonthetipoftheelbow,ortherewasblunttraumatotheolecranonprocess,thismay
indicateanolecranonbursitis,ulnarnervelesion,orolecranonfracture.85Ifthepatientreportsan
insidiousonsetofsymptoms,especiallyifthepatienthascomplainedofweaknessandpain,theclinician
shouldconsiderperforminganexaminationofthecervicalspine,andanupperquarterscreening
examinationaspartoftheoverallexamination.
Isthepatientrightorlefthanddominant?Thismayhaveanimpactontheabilityoftheelbowtorestor
onthefunctionalstatusofthepatient.
Isthereahistoryofpainfollowingoveruseorrepetitiveactivities?Elbowinjuriesarecommoninsports
aswellasfromcumulativeoveruseintheathleteandnonathlete.Forexample,repetitivehyperextension,
accompaniedbypronationoftheelbow,canstressthedistalbicepsandlacertusfibrosusinthecubital
fossa.86
Arethesymptomsrelatedtothepatientsoccupation?Theimproperuseorunaccustomeduseoftools
suchashammers,saws,andscrewdriverscancauselateralormedialelbowpain.
Isthereanyhistoryoflockingorcatchingoftheelbowwithmovement?Twingesofpain,orlockingof
theelbow,couldindicatealoosebodywithinthejoint.Aninabilitytofullyextendtheelbowmayindicate
anumberofconditionsincludingsynovitisoftheelbow,85especiallyifitisaccompaniedbypainand
fullnessoftheparaolecranongrooves.87
Isthepatientanathlete?Ahistoryofapopfollowedbypainandswellingonthemedialaspectofthe
elbowinathrowingathletemayindicateanMCLsprain.88Individualsinvolvedinracquetsports
commonlydeveloplateralelbowpainsuggestinglateralepicondylosis(tenniselbow).Inthesesituations,
itiswellworthinvestigatingrecentchangesinequipment(e.g.,tennisracquetheadsize,stringtension,
gripsize).
Howlonghasthepatienthadthesymptomsandwerethesymptomsimprovingorworsening?Such
informationcangivecluesastothestageofhealingorseriousnessofthecondition.
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Wherearethesymptomslocated?Determiningthedetailscanhelpthecliniciandeterminewhetherthe
symptomsarefromalocalsource,orwhethertheyarereferred,ortheresultofcompromisetoa
peripheralnerve,orcervicalspinenerveroot(radiculopathy).Withfewexceptions,paininaparticular
areaoftheelbowiscausedbythesurroundingorunderlyingphysicalstructures(Table174).
Lateralelbowpain.Epicondylosisshouldbesuspectedifthereistendernessoverabonyprominence
(Fig.1711).
Medialelbowpain.Thisisusuallyduetoatendinopathyatthesiteoftheattachmentofthesuperficial
forearmflexorsandthepronatorteresmuscletothemedialepicondyle(Fig.1712).88However,itmay
alsoindicateanMCLsprainoranulnarnervecompression.
Posteriorelbowpain.Thissuggestsolecranonbursitis,tricepstendinosis,oravalgusextension
overload.89
Cubitalfossapain.Thisismostlikelytoresultfromatearofthebrachialismuscleatthe
musculotendinousjunctionandisacommoninjuryinrockclimbers,90orabicepsbrachiilesion.Cubital
fossapainmayalsobeassociatedwithacompressionofthePINoracapsularinjury.91
Leftarmandelbowpain.This,whenprecipitatedbyphysicalexertionandrelievedbyrest,should
suggestangina.88
Arethereanyassociatedjointnoisesorcrepitus?Asnappingelbowissynonymouswiththerelatively
commonrecurrentdislocationoftheulnarnerve.However,themedialheadofthetricepsmuscleor
tendonmayalsodislocateoverthemedialepicondyleandresultinsnappingeitherastheelbowisflexed
orasitisextendedfromaflexedposition.85Dislocationofthemedialheadofthetricepscanoccurin
combinationwithdislocationoftheulnarnerve,producingtheclinicalfindingofatleasttwosnapsatthe
elbow,withorwithoutdiscomfortonthemedialsideoftheelbowandwithorwithoutulnarneuropathy.
Jointcrepitusmayalsoindicatethepresenceofaloosebodyorsynovitis.Catchingorlockingsensations
aresuggestiveofjointinstabilityoraloosejointbody.
Whichactivitiesorarmpositionsappeartoaggravatethecondition?Graspingandtwistingactivitiestend
tostresstheelbowstructures.
Isthepainconstantorintermittent?Avisualanalogscalecanbeusedtorecordthepatientspainlevel.
Isthereanyassociatedpainintheneckorshoulder?Theintrinsicpainoftheelbowstructuresis
exacerbatedbythemovementoftheelbowjoint,whereasreferredpainisusuallyindependentofelbow
activity(seeSystemsReview,later).85,92
Arethereanyotherjointsthatappeartobepainful?Thisfindingmaysuggestasystemicorinfectious
component.
Arethesymptomsbetterorworseatparticulartimesofdayornight?
Arethereanysensorychanges,paresthesia,andmuscleweaknessintheipsilaterallimb?Such
neurologicalfindingsaresuggestiveofaspinalnerverootorperipheralnervelesion.
Isthereanyunderlyingjointdisease?Severaltypesofarthritidesorosteochondrosisdissecansdevelopin
theelbowregionwithoutaknowncause.89
Howistheconditionaffectingthepatientsfunctioninactivitiesofdailylivingandrecreationalpursuits?
Hasthepatienthadthisconditionbeforeand,ifso,howwasittreatedandwhatwastheoutcome?
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Isthepatienttakinganymedications?Whatconditionsinadditiontothepresentconditionarethe
medicationsfor?
Howisthepatientsgeneralhealth?
TABLE174DifferentialDiagnosisofElbowPainAccordingtoSymptomLocation
Location PossibleDisorders
Anterior Anteriorcapsularstrain
Distalbicepstendonrupture/tendinopathy
Dislocationoftheelbow
Pronatorsyndrome(throwers)
Medial Medialepicondylitis
Ulnarcollateralligamentinjury(MCL)
Ulnaneuritisorulnarnervesubluxation
Flexorpronatormusclestrain
Fracture
Littleleagueelbowinskeletallyimmaturethrowers
Valgusextensionoverloadoverusesymptoms
Posteromedial Olecranontipstressfracture
Posteriorimpingementinthrowers
Trochlearchondromalacia
Posterior Olecranonbursitis
Olecranonprocessstressfracture
Tricepstendinopathy
Lateral Capitellumfracture
Cervicalradiculopathyreferredpain
Lateralepicondylitis
Lateralcollateralinjury
Osteochondraldegenerativechanges
Osteochondritisdissecans(Panner'sdisease)
Posteriorinterosseousnervesyndrome
Radialheadfracture
Radialtunnelsyndrome
Synovitis
MCL,medialcollateralligament.
DatafromConwayJE.Clinicalevaluationofelbowinjuriesintheathlete.JMusculoskeletalMed.198810:20
28WilkKE,AndrewsJR.Elbowinjuries.In:BrotzmanSB,WilkKE,eds.ClinicalOrthopaedic
Rehabilitation.Philadelphia,PA:Mosby2003:85123.
FIGURE1711
Lateralviewoftheelbow.
FIGURE1712
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Medialviewoftheelbow.
SYSTEMSREVIEW
Signsorsymptomsofavisceral,vascular,neurogenic,psychogenic,spondylogenic,orsystemicdisorderthat
maybelocalorreferredaredescribedinChapter5.Conditionsthatareoutofthescopeofphysicaltherapy
requirethatthepatientbereferredtoanappropriatehealthcareprovider.Scenariosrelatedtotheelbowthat
warrantfurtherinvestigationincludeaninsidiousonsetofsymptomsandcomplaintsofnumbnessorparesthesia
intheupperextremity.TheCyriaxscanningexamination(seeChapters4and5)canhelphighlightthepresence
orabsenceofneurologicalcomplicationsincludingspinalnerverootandperipheralnervepalsies.Thescanning
examinationincludesstrengthtestingofthekeymuscles(seeResistiveTesting),sensationtesting,andreflex
testing(seeNeurologicExamination).
Reproductionofthepatientselboworothersymptomswithcervicalmotion,ratherthanelbowmovement,isa
strongindicatorofacervicalandupperthoracicsource(ligaments,muscles,zygapophysialjoints,anddisks)for
thesymptoms,witheitherthesegmentalrootsorthebrachialplexusbeinginvolved.19
Inadditiontothecervicalandupperthoracicspine,therelatedjointsreferringsymptomstotheelbowrequire
clearing,especiallytheshoulder.
Systemiccausesofinsidiouselbowpainincludegout,infectivearthritis,polyarthritis,andvasculardisorders,
suchasVolkmannsischemia(seeChapter5).Morningstiffnesslastingformorethan1hour,constitutional
signs,andphysicalsignsofjointinflammationareallindicativeofaninflammatorydisease.Systemic
conditionsaretypicallyassociatedwithothersignsandsymptomsthatarenotrelatedtomovementandthatare
systemicinnature(fever,chills,etc.).Respiratoryandcardiovascularconditionsmustalsocomeinto
considerationwhenexaminingtheelbow.85Theupperarmisveryclosetothechestanditsviscera,sothe
referenceofsymptomstotheelbowfromthesestructurescanoccur.
CLINICALPEARL
Severeprogressivepainnotaffectedbymovement,persistentthroughoutthedayandnight,andassociatedwith
systemicsignsmayindicatereferredpainfrommalignancy.
TestsandMeasures
Followingthehistoryandsystemsreview,theclinicianshouldbeabletodeterminethesuitabilityofthepatient
forphysicaltherapy.
TESTSANDMEASURES
Observation
Foranaccurateandthoroughexaminationoftheelbow,theclinicianmustbeabletovisualizebotharms.The
involvedelbowshouldbeinspectedforscars,deformities,andswelling.Anyasymmetryinsizeorpositioning
betweentheextremitiesshouldbenoted.Theearliestsignofelboweffusionisalossoftheelbowdimples.Most
swellingappearsbeneaththelateralepicondyle.Evenminorswellingoreffusionpreventsfullextensionofthe
elbow.Anteriorjointeffusionisevidenceofsignificantswelling.Gradualswellingovertheposteriortipofthe
elbow,whichcanbegolfballsizedandisoftennottendertopalpation,isusuallyolecranonbursitis.The
clinicianshouldobservefornormalsofttissueandbonycontours.Hypertrophyofthedominantforearmis
commonintennisplayersandpitchers.
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CLINICALPEARL
Suddenswellingintheabsenceoftraumasuggestsinfection,inflammation,orgout.
Theclinicianshouldobservethecarryingangleoftheinvolvedelbow(theangleformedbetweenthearmand
theforearm)andcompareittotheotherside.Thecarryinganglevariesfrom13to16degreesforfemales,and
11to14degreesformales.5,11Anydifferenceinthecarryingangleoftheelbowisobviouswhentheelbowisin
extension.Anincreasedcarryingangle(>15degrees)iscalledcubitusvalgus.Cubitusvarus,orgunstock
deformity,isthetermusedtodescribeadecreasedcarryingangle(<10degrees).Themostcommoncausesof
analteredcarryinganglearepasttraumaorepiphysealgrowthdisturbances.Forexample,acubitusvalguscan
becausedbyalateralepicondylarfracture,whereasacubitusvarusisfrequentlytheresultofasupracondylar
fracture.
Thetriangularrelationshipoftheepicondylesandtheolecranonat90degreesofelbowflexionandatfull
extensionisoftendisruptedinthepresenceofafracture,dislocation,ordegeneration.At90degreesofflexion,
thethreebonylandmarksformanisoscelestriangle,andwhenthearmisextended,theyformastraight
line.89,93
Excessivetensionattheelbowcanbeproducedinoccupationsthatplacetheelbowsinsustainedpositionsof
flexionandadduction(e.g.,keyboardoperators).Thetensionincreasesresistancetomovementandjointplayat
theelbow.94,95ElbowflexionalsoincreasestensionatthefibrousarchthatconnectsthetwoheadsoftheFCU,
whichcanleadtocompressionoftheulnarnerve.96
Acombinationofsustainedflexionandarestrictioninjointplaydecreasestheoverallvolumeofthecubital
tunnel,whichcanfurtherincreasethepotentialofulnarnervecompression.96,97
CLINICALPEARL
Thepronatedforearmposition,combinedwithelbowflexion,wristextension,andcyclicfingerflexionand
extension,createsshearingandcompressiveforcesatseveralsofttissueinterfacesintheforearm.98,99The
pronatorsandextensordigitorumcommunisadaptivelyshortenovertimebecauseofprolongedcontractionsin
theirmostshortenedpositions.94,98
Palpation
Sincetheyaresuperficial,mostoftheelbowstructuresareeasilypalpable(Figs.1711and1712),makingit
easierforthecliniciantopinpointthespecificareaofpain.However,incasesinwhichthepainismorediffuse,
thediagnosisbecomessomewhatmoredifficult.
Palpationoftheelbowcomplexisbestperformedwiththepatientseatedorsupine,sotheyareabletorelax.A
logicalsequencebasedonsurfaceanatomyisoutlinedbelow.
BonyStructures
Bonystructuresfeelhard,whereasligamentousstructuresfeelfirm.Bonypalpationoftheelbowshouldstart
withassessmentforcrepitusduringflexionandextensionoftheelbow.Thepresenceofpain,swelling,or
temperatureelevationshouldalsobeappreciated.
Medialepicondyle(Fig.1712).Themedialepicondylecanbepalpatedonthemedialaspectofthedistal
humerus.Justanterioranddistaltothemedialepicondyleonecanpalpatefromproximaltodistalthe
muscleoriginsofthepronatorteres,FCR,palmarislongus,FDS,andFCU.100Justposteriortothemedial
epicondyle,theulnargroovecanbepalpated,ascantheulnarnervetravelingwithin.
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Olecranonprocess.Theolecranon(seeFig.1711)shouldbeeasytolocateontheposterioraspectofthe
elbow.Theolecranonbursawillnotbepalpableunlessinflamedorthickened.Theolecranonendsdistally
inapoint.Justdistaltothispoint,theposteriorborderoftheulnacanbepalpatedalongitsentirelength
(seeFig.1711).Theclinicianshouldassessforcrepitusintheolecranonfossaaswellasforanysubtle
extensionblockagesuggestiveofsynovitis,orthepresenceofintraarticularloosebodies.
Lateralepicondyle(Fig.1711).Midwaybetweentheolecranonandthelateralepicondyleistheanconeus
muscle.Thelateralepicondyleismoredifficulttopalpatethanthemedialepicondyleastheformeris
coveredbyalargemassofextensormuscle,calledtheextensorbundleorwad.
Supracondylarridge(seeFig.1711).Thesupracondylarridgeisjustsuperiortothelateralepicondyle.A
numberoftendons/musclesarelocatedintheregionbetweenthelateralsupracondylarridgeandthe
lateralepicondyle.Themusclesfromproximaltodistalarethebrachioradialis,ECRL,ECRB,andthe
EDC.Byaskingthepatienttomakeafistwiththewristinslightextension,theECRLcanbefeltonthe
supracondylarridge.89
Thejointline.Thejointlineislocatedatapointapproximately2cmdownfromanimaginaryline
joiningthetwoepicondyles,whichpassesmediallyandinferiorly.Thejointlinesarefirmonpalpation
andliebetweentwostructuresthatareharder.89
Headoftheradius.Theradialheadislocatedintheskindepressionimmediatelydistaltothelateral
epicondyle.Topalpatetheradialhead(seeFig.1711)atthehumeroradialjoint,theclinicianplacesthe
indexfingeronthelateralhumeralepicondyle.Fromhere,theindexfingerslidesposteriorlyanddistally
betweenthehumerusandtheradialhead(seeFig.1711).Rotationoftheradialheadwillbenotedwith
pronationandsupination.89Atraumaticallydislocatedradiuswillappearoutofpositionandtenderto
palpation.
Afterexaminingtheelbowsbonycomponents,attentionshouldbeturnedtotheelbowssofttissuestructures,
whichmaybedividedintofourclinicalzones:medial,posterior,lateral,andanterior.89Theelbowssofttissue
structuresarebestappreciatedin90degreesofflexion.Swellingoftheelbowcanbelocalizedasinaswollen
olecranonbursaordiffuseasinasupracondylarfracture.
Themedialaspectoftheelbowcontainstheulnarnerve,thewristflexorpronatormusclegroup(Fig.1713),
andtheMCL.Theulnarnervecanbefeltasasofttubulecoursingthroughthegroovebetweenthemedial
epicondyleandtheolecranonprocess.Secondarydamagetotheulnarnervecanoccurinsupracondylaror
epicondylarinjuries.89Thefourmusclesofthewristflexorpronatormusclegroup,pronatorteres,FCR,
palmarislongus,andFCU(seeFig.1713),originatefromthemedialepicondylebeforedivergingintoseparate
pathsdowntheforearm(seeMuscles,later).Overuseoftheflexormassresultsinpainandpalpable
tendernessatthemedialepicondyle,extendingapproximately13cmdistaltotheepicondyle.Paindueto
medialelbowtendinosiswillbeintensifiedwithprovocativetesting,suchasresistivewristflexionandforearm
pronationwiththeelbowextendedand,inadvancedcases,withtheelbowflexedaswell.ThefanshapedMCL
connectsthemedialepicondyletothemedialmarginoftheulnastrochlearnotch.Theanteriorbundleofthe
MCLligamentisusuallypalpablewiththeelbowflexedfrom30to60degrees.Tendernessinthisareacanbe
duetoMCLsprain.ThevalgusstresstestisperformedtoassessMCLstability(seelater).
FIGURE1713
Thewristflexorpronatormusclegroup.
Withinthelateralaspectoftheelbowarethewristextensors,theLCL,andtheAL.Thethreemusclesofthe
wristextensorgroup,brachioradialis,ECRL,andECRB,arepalpatedasaunit,withtheforearminaneutral
positionandthewristatrest(seeMuscles,later).Thesethreemusclesarecommonlyinvolvedinlateral
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epicondylosisortenniselbow.PalpabletendernessovertheECRBiscommoninthiscondition.Paindueto
lateralelbowtendinosisisintensifiedwithresistedwristandfingerextensionwiththeelbowextendedand,in
advancedcases,withtheelbowflexedaswell.89TheLCLextendsfromthelateralepicondyletothesideofthe
AL,aringshapedbandlocateddeeptotheextensoraponeurosis,cuppingtheradialheadandneck.Although
theLCLisdifficulttodirectlypalpatebecauseoftheoverlyingmusculature,disruptionofeithertheLCLorthe
ALcanbeassessedbypalpationoftheareaandbythevarusstresstest(seelater).
Muscles
Biceps.Theshortheadofthebicepsislocatedatthecoracoidprocess(togetherwiththecoracobrachialis
muscle).89Thelongheadofthebicepscannotbepalpatedatitsorigin,butitispalpableinthe
intertuberculargrooveoftheproximalhumerus.Themusclebellyofthebicepsiseasilyidentifiable,
especiallywithresistedelbowflexionandforearmsupination.
Brachialis.Theoriginofthebrachialiscanbepalpatedposteriortothedeltoidtuberosity.Itsinsertioncan
bepalpatedatapointmedialtothemusculotendinousjunctionofthebiceps,attheproximalborderofthe
bicipitalaponeurosis.89
Brachioradialis.Thebrachioradialiscanbepalpatedontheradialborderofthecubitalfossadistallyto
theradialstyloidprocess.
Commonflexororiginatthemedialepicondyle.
Commonextensororiginatthelateralepicondyle.
Supinator.Thebordersofthesupinatorwithinthecubitalfossaareformedbythebrachioradialis
(radially),pronatorteres(ulnarly),andtendonofthebiceps(proximally).89
Triceps.Palpationofthetricepscanbesimplifiedbyhavingthepatientabductthearmto90degrees.The
lateralheadofthetricepsbordersdirectlyonthebrachialmuscle,whereasthemedialheadruns
underneathboththelongandlateralheadsofthetriceps.Thesetwoheadsofthetricepscanbepalpated
untiltheircommoninsertionattheolecranon(Fig.1714).89
Anconeus.Thissmallmusculartrianglecanbepalpatedbetweentheolecranon,theposteriorborderofthe
ulna,andthelateralepicondyle.Ifcrepitusisfeltatfullelbowextension,thecliniciancanmanuallypush
thesubanconeusbursasuperiorlyduringelbowextension.Ifthecrepitusdecreases,adysfunctionofthe
anconeusshouldbesuspected,whichcanbetreatedwithelectricalstimulationandmobilizationofthe
olecranoninamedialorlateraldirection.
FIGURE1714
Palpationofthetricepsattheelbow.
ActiveRangeofMotionwithPassiveOverpressure
Thepatientwithelbowpainshouldhaveadetailedassessmentofhisorhermotion(Figs.1715and1716).The
ROMcanbeassessedwiththepatientseated,althoughelbowextensionisbetterevaluatedwiththepatient
standing.Thepatientisaskedtoperformactiveflexionandextensionoftheelbow,pronation,andsupinationof
theforearm,andwristflexionandextension,withtherangesbeingrecordedusingagoniometer(seeChapter
13)VIDEO:
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FIGURE1715
Examinationsequenceinthepresenceofsymptomswithnormalorexcessiveactiverangeofmotioninthe
elbow.
FIGURE1716
Examinationsequenceinthepresenceofpainfulflexionand/orextensionattheelbow.
Flexion:activeelbowflexion(Fig.1717)is140150degrees.
Extension:activeelbowextensionis0degrees,althoughuptoa10degreehyperextensionisnot
uncommon,especiallyinwomen.Thishyperextensionisconsiderednormalifitisequalonbothsides,
andthereisnohistoryoftrauma.
Supination:activesupination(Fig.1718)shouldbe85degreeswithnosubstitutemotions(adduction)
occurringattheshoulder.
Pronation:activepronationisapproximately75degreeswithnosubstitutemotions(abduction)occurring
attheshoulder.
FIGURE1717
Elbowflexion.
FIGURE1718
Forearmsupination.
Wristflexionandextensionandforearmsupinationandpronationshouldbetestedwiththeelbowflexedto90
degreesandthenfullyextended.
InastudybyArmstrongetal.,101theintratester,intertester,andinterdevice(universalstandardgoniometers,a
computerizedgoniometer,andamechanicalrotationmeasuringdevice)reliabilityofROMmeasurementsofthe
elbowandforearmwasassessed.Intratesterreliabilitywashighforallthreemeasuringdevices.101Intertester
reliabilitywashighforflexionandextensionmeasurementswiththecomputerizedgoniometerandmoderatefor
flexionandextensionmeasurementswiththeuniversalgoniometer.101Intertesterreliabilitywashighfor
pronationandsupinationwithallthreedevices.101Theauthorsconcludedthatreliablemeasurementsofelbow
andforearmmovementareobtainable,regardlessofthelevelofexperience,whenstandardizedmethodsare
used.101
Capsularornoncapsularpatternsshouldbedetermined.Thecapsularpatternattheelbowischaracterizedbythe
limitationofmoreflexionthanextension.Ifmotionrestrictionsarepresent,thenatureandlocationofthe
motionbarrier,andtherelationshipofpaintothemotionbarriershouldbenoted.102
Theendfeelsofelbowmotionshouldbeclassifiedaseithercompliant,suggestingsofttissuerestriction,or
rigid,suggestingamechanicalbonylimit.Passivelimitationwarrantsfurtherinvestigationforthesourceofthe
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mechanicalblockage.Painthatoccursatthelimit(s)ofmotionsuggestsbonyimpingement.Theclinicianshould
alsonotethedegreeofulnaradductionorabductionthatoccurswiththeelbowmotions.
Passivepronationandsupinationareappliedbygraspingtheproximalaspectoftheforearm.Passive
overpressureissuperimposedattheendoftheavailablerangesofflexionandextension,usingtheappropriate
conjunctrotations.Internalrotationoftheforearm(pronation)istheconjunctrotationassociatedwithelbow
extensionexternalrotationoftheforearm(supination)istheconjunctrotationassociatedwithelbow
flexion.78,86Normalvaluesforelbowpronationandsupinationareapproximately75degreepronationand85
degreesupination.5
CLINICALPEARL
DecreasedsupinationandpronationarefrequentsequelaeofaCollesfracture,advanceddegenerativechanges,
dislocations,andfracturesoftheforearmandelbow.
Ifthereisagrosslossofpronationandsupinationposttrauma,afracturedradialheadisapossibility.Of
particularinterestistheacutelimitationofsupinationandextensioninchildren,whichlikelyresultsfroma
pulledelbow(alsoreferredtoasnursemaidselbow,seeInterventionStrategiessection).
Passiveelbowflexion(Fig.1719)shouldhaveanendfeelofsofttissueapproximation.Elbowflexion
combinedwithsupinationshouldhaveacapsularendfeelwhereaselbowflexioncombinedwithpronation
shouldhaveabonyendfeel.Passiveflexionmayaggravateanulnarnerveneuropathy.78Lossofnormalelbow
flexion(140degrees)maybecausedbyosteophyticarthritis,intraarticularloosebodies,posteriorcapsule
tightness,orpossiblytricepstendinosis.
FIGURE1719
Passiveelbowflexion.
Passiveelbowextension(Fig.1720)shouldhaveabonyendfeel.Aspringyendfeelmayindicatealoose
body.Elbowextensionisusuallythefirstmotiontobelimitedandthelasttoberestoredwithintrinsicjoint
problems.78,86Theclinicianshouldbeparticularlycarefulofanelbowthathaslostagrossamountofextension
posttrauma,especiallyifaccompaniedbyapainfulweaknessofelbowextension,asthismayindicatean
olecranonfracture.Asignificantlossofmotion,withnoaccompanyingweakness,couldindicatemyositis
ossificans.
FIGURE1720
Passiveelbowextension.
CLINICALPEARL
Painthroughoutthecentralarcofflexionandextension,orpronationandsupination,impliesdegenerationof
thehumeroulnarorproximalradioulnarjoints,respectively.
CombinedMotions
CombinedmovementtestingisusedtoassessthepatientwhohasafullROMbutstillhascomplaintsofpain.
Thefollowingcombinationsareassessed:
Elbowflexion,adduction,andforearmpronation(Fig.1721)
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Elbowflexion,abduction,andforearmsupination(seeFig.1722)
Elbowextension,abduction,andforearmpronation(Fig.1723)
Elbowextension,adduction,andforearmsupination(seeFig.1724)
FIGURE1721
Combinedmotionofelbowflexionandpronation.
FIGURE1722
Combinedmotionofelbowflexionandpronation.
FIGURE1723
Combinedmotionofelbowextensionandpronation.
FIGURE1724
Combinedmotionofelbowextensionandsupination.
ResistiveTesting
Inadditiontoalloftheshouldermusclesthatinsertatorneartheelbow(biceps,brachialis,andtriceps),the
clinicianmustalsotesttheothermusclesresponsibleforelbowflexion(Fig.1725)andextensionandthe
musclesinvolvedwithforearmsupination,pronation,andwristflexionandextension.Elbowflexionstrengthis
normally70%greaterthanextensionstrength.103Muscleflexionpowerisgreatestintherangeof90110
degreesofflexionwiththeforearmsupinated.Incontrast,theflexionpowerisonly75%ofmaximumwhenthe
elbowispositionedin45135degreesofflexion.104Supinationstrengthisnormally15%greaterthanpronation
strength.103Theuseofadynamometerfortestingupperextremitymusclegroupshasbeenfoundtobe
reliable.105Usingmakeorbreaktestsalsoproducereliableresults.106Themostpainfulmovementor
movementsshouldbetestedlast.
FIGURE1725
Symptomsreproducedwithresistedtestingattheelbow.
ElbowFlexion(C56)
Resistedelbowflexionistestedwiththeelbowflexedto90degrees,withtheforearminpronationVIDEO,then
insupination(Fig.1726)VIDEO,andtheninneutralrotationVIDEO.Painwithresistedelbowflexionmost
frequentlyimplicatesthebiceps,especiallyifresistedsupinationisalsopainful.Thebrachialisisimplicatedif
resistedelbowflexionwiththeforearminfullpronationispainful.Thebrachioradialisisrarelyinvolved.Both
sidesaretestedforcomparison.
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FIGURE1726
Resistedelbowflexion.
ElbowExtension(C7)
Resistedelbowextensionistestedwithforearmpronation,supination,andneutral.Bothsidesaretestedfor
comparison.Painwithresistedelbowextensionimplicatesthetricepsmuscle,althoughtheanconeusmuscle
couldalsobeinvolved.
ForearmPronation/Supination(C57)
Theclinicianshouldtestthestrengthoftheforearmmusclesbygraspingthepatientshandinahandshake.The
patientshouldbeaskedtoexertmaximumpressuretoturnthepalmfirstup(usingsupinators)andthendown
(usingpronators).Supinationisprimarilythefunctionofthesupinatormuscle,withaugmentationfromthe
bicepsbrachiiforquicknessortoovercomeresistance.Supinatorfunctioncanbeeffectivelyisolatedduringthe
clinicalassessment,byplacingtheelbowinextensionVIDEOornearterminalelbowflexionVIDEO.Both
thesepositionsdecreasethemechanicaladvantageofthebicepsbrachii.Aweaknesswithsupinationmay
indicatearupture,orasubluxationofthebicepstendonattheshoulder.ItmayalsoindicateaC56nerveroot
lesion,radialnervelesion(supinator),ormusculocutaneousnervelesion(biceps).Thesupinatormuscleisrarely
injured.
Pronatorweaknessisassociatedwithruptureofthepronatorteresfromthemedialepicondyle,fractureofthe
medialelbow,andlesionsoftheC67ormediannerveroots.Pronatorquadratusweakness,whichistestedwith
theelbowheldinaflexedpositionVIDEOtoneutralizethehumeralheadofthepronatorteresmusclecould
indicatealesionoftheAIN.Thepronatorteresorquadratusmuscles,whichcanbetestedtogetherVIDEOare
rarelyinjured.Individualswithmedialorlateralepicondylosiswillalsofindtheaforementionedmaneuvers
painful,andresistedwristflexionandextensioncanbeusedtohelpdifferentiatetheformerandthelatter,
respectively.
WristFlexion
TheFCUisthestrongestwristflexor.Totesttheflexors,theclinicianstabilizesthepatientsmidforearmwith
onehandwhileplacingthefingersoftheotherhandinthepatientspalm,withthepalmfacingthepatient(Fig.
1727).Thepatientattemptstoflexthewrist,withtheelbowflexedandthenextended.Weaknessisevidentin
ruptureofthemuscleorigin,lesionsinvolvingtheulnar(C8,T1)ormediannerve(C6,C7),ortendinopathyat
themedialelbowifpainisreported.
FIGURE1727
Resistedwristflexion.
WristExtension
ThemostpowerfulwristextensoristheECU.Totestthewristextensors,theclinicianshandsareplacedinthe
samepositionasintheprecedingtest,withthepatientspalmfacingawayfromthepatient.Thepatientisasked
toextendthewrist,withtheelbowflexed(Fig.1728)andthenextended.Ruptureoftheextensororigin,lesions
oftheC68nerveroot,orlateralepicondylosiscancauseweakness.
FIGURE1728
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Resistedwristextension.
RadialDeviation
Resistedradialdeviationistestedwiththeelbowat90degreesofelbowflexion,andatfullelbowextension(see
Chapter18).Painwithresistedradialdeviationisusuallytheresultoflateralepicondylosis.
UlnarDeviation
Resistedulnardeviation,althoughrarelyaffected,istestedwiththefingersinfullflexion,andtheninfull
extension(seeChapter18).
ExtensionofFingers25
Forresistedextensionoffingers25,theelbowispositionedinfullextension,thewristinneutral,andthe
metacarpophalangeal(MCP)jointsat90degreesofflexion.Painhereisusuallytheresultofextensordigitorum
tendinopathyorlateralepicondylosis.
ExtensionofFingers23
Forresistedextensionoffingers23,thepatientispositionedasabove.Painwithresistanceimplicateslateral
epicondylosis.
Iftheabovetestingproceduresarenegative,orifthepatienthascomplainedthatthecombinedmovements
causethesymptoms,resistedtestingcanbeperformedusingcombinedmovements.Forexample,testingelbow
flexioninsupination/pronationinvaryingdegreesofelbowflexion.
NeurologicExamination
Sensationabouttheelbowissuppliedbyfourdifferentnervesandisevaluatedasfollows:lateralarm(axillary
nerve,C5),lateralforearm(musculocutaneousnerve,C6),medialforearm(antebrachialcutaneousnerve,C8),
andthemedialarm(brachialcutaneousnerve,T1).SensorytestingmayincludeSemmesWeinsteinsensibility
andtwopointdiscrimination(seeChapters3and18).AnEMGevaluationcansupplementtheneuromuscular
physicalexaminationasneeded.Thethreemajormusclestretchreflexesoftheelbowarethebiceps
(musculocutaneousnerve,C5),brachioradialis(radialnerve,C6),andthetriceps(radialnerve,C7).Thebiceps
reflexiselicitedbyplacingathumboverthebicepstendoninthecubitalfossaandstrikingitwithareflex
hammerwhilethepatientsarmisrelaxedandpartiallyflexed(Fig.1729).Thebicepsmuscleshouldbefeltor
seentojerkslightly.Thebrachioradialisreflexisaradialjerkelicitedbytappingthebrachioradialistendonat
thedistalendoftheradius(Fig.1730).Thetricepsreflexcanbeelicitedwiththearminthesamepositionof
partial,relaxedflexion(Fig.1731).Thetricepsmuscleshouldjerkwhenthetricepstendonistappedwhereit
crossestheolecranonfossa.Depressed,exaggerated,orabsentupperextremityreflexesarenotedandcompared
withreflextestingattheotherelbow.
FIGURE1729
BicepsDTR.
FIGURE1730
BrachioradialisDTR.
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FIGURE1731
TricepsDTR.
FunctionalAssessment
ThefunctionalstrengthoftheelbowcomplexcanbeassessedusingthetestsoutlinedinTable175.Likethe
shoulder,theelbowservestopositionthehandforfunctionalactivities.Anumberofstudieshavereportedthe
ROMrequirementsforeverydayactivities.AtotalROMof60100degreesofelbowflexionand100degreesof
supinationpronationarerequiredfortaskssuchaseating,dressing,anddailyhygiene.TheROMrequiredfor
athleticactivities,suchasthrowingabaseball,requiresatleast1020%greaterROM.
TABLE175FunctionalTestingoftheElbow
StartingPosition Action FunctionalTest
Sitting,cuffweightattachedto
Elbowflexion 5lbweight:functional
wrist
34lbweight:functionallyfair
Activeflexion(0lb):functionally
poor
Cannotflexelbow:nonfunctional
Elbowextensionwithwallpush
Standing 5reps:functional
up
34reps:functionallyfair
12reps:functionallypoor
0reps:nonfunctional
Standingfacingdoor Turningdoorknobintosupination 5reps:functional
0reps:nonfunctional
Standingfacingdoor Turningdoorknobintopronation 5reps:functional
0reps:nonfunctional
DatafromPalmerML,EplerM.ClinicalAssessmentProceduresinPhysicalTherapy.Philadelphia,PA:JB
Lippincott1990.
PassiveArticularMotionTesting
Thepassivearticularmobilitytestsareusedtoexaminethearthrokinematicmotionsofajointortheaccessory
jointglides(seeChapter4).
UlnohumeralJoint
Thepatientispositionedinsupine,withtheirheadsupported.Thecliniciansitsorstandstofacethepatient.
Distraction/Compression
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Theclinicianwrapsthefingersaroundtheproximalthirdoftheforearm(Fig.1732).Theclinicianappliesa
longitudinalforcethroughtheproximalforearm,atananglethatis45degreeslessflexionthanthepositionof
theulnarshaft,toeitherdistractorcompresstheulnohumeraljoint.Thequalityandquantityofmotionare
noted.Thetestisrepeatedontheoppositeextremityandthefindingscompared.Analternativemethodinvolves
positioningthepatientinprone,withthehumerusbeingsupportedonthetableandthearmhangingoverthe
edgeofthetable(Fig.1733).Usingonehandtostabilizethehumerus,theclinicianusestheotherhandtoapply
adistractionforceattheulnohumeraljoint.Thispositioncanalsobeusedtoassessthemedialandlateralglides
ofthisjoint(Fig.1734).
FIGURE1732
Ulnohumeraldistraction/compression.
FIGURE1733
Ulnohumeraldistraction.
FIGURE1734
Medialandlateralglidesoftheulnohumeraljoint.
MedialGlide
Theclinicianglidestheulnamediallyonthefixedhumerusalongthemediolateralplaneofthejointline.The
qualityandquantityofmotionarenoted.Thetestisrepeatedontheoppositeextremityandthefindings
compared.
LateralGlide
Theclinicianglidestheulnalaterallyonthefixedhumerusalongthemediolateralplaneofthejointline.The
qualityandquantityofmotionarenoted.Thetestisrepeatedontheoppositeextremityandthefindings
compared.
RadiohumeralJoint
Thepatientispositionedinsittingorsupine,withtheirarmrestingonthetable.Thefollowingtestsare
performed107,108:
AnteriorGlide
Theclinicianstabilizesthehumerusandappliesananteriorglideoftheradius(Fig.1735),toassessthe
accessoryglidethataccompaniesflexion.
FIGURE1735
Radiohumeraljointglides.
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PosteriorGlide
Theclinicianstabilizesthehumerusandappliesaposteriorglideoftheradius(seeFig.1735)toassessthe
accessoryglidethataccompaniesextension.
Distraction
Theclinicianstabilizestheradialheadandthelateralepicondylewithonehand.Withtheotherhand,the
cliniciangraspstheradiusandappliesalongitudinaldistractionforcealongthelengthoftheradius(Fig.1736).
Alongitudinalcompressionforcecanbeappliedusingthesamepatientclinicianposition.
FIGURE1736
Distractionoftheradius.
MotionTestingoftheRadialHead
Thepatientispositionedinsittingorsupine,withtheclinicianfacingthepatient.Theradialheadislocatedby
flexingandextendingtheelbow.Oncelocated,theradialheadisgraspedbytheclinicianbetweenthethumb
andtheindexfinger(seeFig.1736).Theradialheadismovedinananteriorandposteriordirection,andany
restrictionofmotionisnoted.Theposteriorglideoftheradiusiscoupledwithpronation/extension,andanterior
glideiscoupledwithsupination/flexion.Themostcommondysfunctionoftheradialheadisaposteriorradial
head,whichisaccompaniedbyalossoftheanteriorglide.
StressTests
Medial(Ulnar)CollateralLigament(ValgusTest)
Thepatientispositionedinsupine,withtheirheadsupported.Theclinicianstabilizesthedistalhumeruswith
onehandandpalpatesthedistalforearmwiththeother.TheanteriorbandoftheMCLtightensintherangeof
20120degreesofflexion,becominglaxinfullextension,beforetighteningagaininhyperextension.The
posteriorbundleistautinflexionbeyond55degrees.3,14,23,86
Theanteriorbandistestedbyflexingtheelbowtobetween20and30degreestounlocktheolecranonfromits
fossa,asavalgusstressisappliedcontinuously(Fig.1737).25,61
FIGURE1737
Ulnarcollateralligamentstresstest.
Theposteriorbandisbesttestedusingamilkingmaneuver.Thepatientisseated,andthearmispositionedin
shoulderflexion,elbowflexionbeyond55degrees,andforearmsupination.Theclinicianpullsdownwardon
thepatientsthumb(Fig.1738).25Thismaneuvergeneratesavalgusstressontheflexedelbow.Apositivesign
isindicatedbythereproductionofpain.
FIGURE1738
Milkingmaneuver.
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Thetestsarerepeatedontheoppositeextremityandthefindingscompared.Nodiagnosticaccuracystudieshave
beenperformedtodeterminethesensitivityorspecificityofthistest.
LateralPivotShiftApprehensionTest
Thelateralpivotshifttestisusedinthediagnosisofposterolateralrotatoryinstability.36Thepatientis
positionedinsupine,withtheinvolvedextremityoverhead.Thecliniciangraspsthepatientswristandelbow.
Theelbowissupinatedwithamildforceatthewrist,andavalgusmomentandcompressiveforceisappliedto
theelbowduringflexion(Fig.1739).36Thisresultsinatypicalapprehensionresponsewithreproductionofthe
patientssymptomsandasensethattheelbowisabouttodislocate.Reproducingtheactualsubluxation,andthe
clunkthatoccurswithreductionusuallycanonlybeaccomplishedwiththepatientundergeneralanesthesiaor
occasionallyafterinjectingalocalanestheticintotheelbow.
FIGURE1739
Lateralpivotshiftapprehensiontest.
Lateral(Radial)CollateralLigament(VarusTest)
TheLCListestedwiththeelbowpositionedin530degreesshortoffullextension.Theclinicianstabilizesthe
humerusandadductstheulna,producingavarusforceattheelbow(Fig.1740).Theendfeelisnoted.No
diagnosticaccuracystudieshavebeenperformedtodeterminethesensitivityorspecificityofthistest.
FIGURE1740
Radialcollateralligamentstresstest.
SpecialTests
Anumberofspecialtestsfortheelbowexist.Thediagnosticusefulnessforsomeofthesetestsisoutlinedin
Table176.
TABLE176DiagnosticUsefulnessofSomeSpecialTestsfortheElbow
Testand
QUADAS
Related StudyDescription Reliability Sensitivity Specificity LR+ LR DOR
Score
Diagnosis
Evaluatedtheclinicalusefulness
ofprovocativetestingin32
subjectswith
Elbow electrodiagnosticallyproven
flexion cubitaltunnelsyndromeusing
(cubital Tinel'ssign,elbowflexion NT 75 99 75 0.25 297 7
tunnel (withoutwristextensionandwith
syndrome) forearmsupinationheldfor60
seconds),pressureprovocation,
andcombinedelbowflexionand
pressureprovocation.a
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Testand
QUADAS
Related StudyDescription Reliability Sensitivity Specificity LR+ LR DOR
Score
Diagnosis
Pressure
provocation
(cubital NT 89 98 45 0.11 396 7
tunnel
syndrome)
Percussion
test/Tinel's
sign(cubital NT 70 98 35 0.31 114 7
tunnel
syndrome
110of114patientswithacute
Elbow elbowinjuryunderwent
extension radiographicevaluation.Inability
(elbow toextendtheelbowwasfoundin NT 97 69 3.1 0.04 72 10
fracture) 37of38patientswithbone
injury.b
Moving 21patients,whounderwent
valgusstress surgicalinterventionformedial
(chronic elbowpainduetomedial
medial collateralligamentinsufficiency NT 100 75 4 0 NA 10
collateral orotherabnormalityofchronic
ligamenttear valgusoverload,wereassessed
ofthe
elbow) preoperativelywiththistest.c
25consecutivepatientswith
presumptivedistalbicepstendon
Biceps ruptureswereevaluatedusing
squeezetest thistest.Thetestwaspositivein
(distalbiceps 24patients.21of22patientshad NT 96 100 N/A 0.04 N/A 9
tendon operativeconfirmationofa
rupture) completedistalbicepstendon
rupture.d
aNovakCB,LeeGW,MackinnonSE,etal.Provocativetestingforcubitaltunnelsyndrome.JHandsurg.
199419:817820.
bDochertyMA,SchwabRA,MaOJ.Canelbowextensionbeusedasatestofclinicallysignificantinjury?
SouthMedJ.200295:539541.
cODriscollSW,LawtonRL,SmithAM.Themovingvalgusstresstestformedialcollateralligamenttearsof
theelbow.AmJSportsMed.200533:231239.
dRulandRT,DunbarRP,BowenJD.Thebicepssqueezetestfordiagnosisofdistalbicepstendonruptures.Clin
OrthopRelatRes.2005128131.
TennisElbow
Anumberoftestsexistfortenniselbow(lateralepicondylosis).Threearedescribedhere.
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ChairTest
Thepatientispositionedinfrontofachairandisaskedtoliftthechairwhilemaintainingtheshouldersin
adduction,theelbowsextended,andtheforearmspronated.109Apositivetestisthereproductionoflateral
elbowpain.
CozensTest
Theclinicianstabilizesthepatientselbowwithonehand,andthepatientisaskedtopronatetheforearmand
extendandradiallydeviatethewristagainstthemanualresistanceoftheclinician(Fig.1741).Areproduction
ofpainintheareaofthelateralepicondyleindicatesapositivetest.Nodiagnosticaccuracystudieshavebeen
performedtodeterminethesensitivityorspecificityofthistest.
FIGURE1741
Cozenstest.
MillsTest
Theclinicianpalpatesthepatientslateralepicondylewithonehandwhilepronatingthepatientsforearm,fully
flexingthewrist,andextendingtheelbow(Fig.1742).Areproductionofpainintheareaofthelateral
epicondyleindicatesapositivetest.Nodiagnosticaccuracystudieshavebeenperformedtodeterminethe
sensitivityorspecificityofthistest.
FIGURE1742
Millstest.
MaudsleyTest
Thepatientisseatedfacingtheclinician.Usingonehand,thecliniciangraspsthepatientswrist,andusingthe
otherhand,resiststhirddigit(middlefinger)extension,stressingtheextensordigitorummuscle(Fig.1743).A
positivetestisareproductionofpainalongthelateralepicondyle.Nodiagnosticaccuracystudieshavebeen
performedtodeterminethesensitivityorspecificityofthistest.
FIGURE1743
Maudsleytest.
GolfersElbow(MedialEpicondylosis)
Theclinicianpalpatesthemedialepicondylewithonehandwhilesupinatingtheforearmandextendingthewrist
andelbowwiththeotherhand.Areproductionofpainintheareaofthemedialepicondyleindicatesapositive
test.
ElbowFlexionTestforCubitalTunnelSyndrome
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Thepatientispositionedinsittingorstandingwithbotharmsandshouldersintheanatomicposition.The
patientisaskedtodepressbothshoulders,flexbothelbowsmaximally,andsupinatetheforearms(Fig.1744).
Thepatientisthenaskedtoextendthewrists.110Thispositionismaintainedfor35minutesandthenthe
patientisaskedtodescribeanysymptoms.Tinglingorparesthesiaintheulnardistributionoftheforearmand
handindicatesapositivetest.
FIGURE1744
Elbowflexiontest.
PressureProvocativeTestforCubitalTunnelSyndrome
Pressureisappliedbytheclinician,proximaltothecubitaltunnel,withtheelbowheldin20degreesofflexion
andtheforearminsupination(Fig.1745).111
FIGURE1745
Pressureprovocativetestforcubitaltunnelsyndrome.
PercussionTest/TinelsSign(attheElbow)forCubitalTunnelSyndrome
Theclinicianlocatesthegroovebetweentheolecranonprocessandthemedialepicondylethroughwhichthe
ulnarnervepasses.Thisgrooveistappedfourtosixtimesbytheindexfingeroftheclinician(Fig.1746).A
positivesignisindicatedbyatinglingsensationintheulnardistributionoftheforearmandhanddistallytothe
tappingpoint.
FIGURE1746
Percussiontest/Tinelssign(attheelbow).
ElbowExtensionTest
Thepatientispositionedinsupineandisaskedtofullyextendtheelbow.Apositivetestforelbowfractureis
indicatedbythepatientsinabilitytofullyextendtheelbow.
MovingValgusStressTest
Thepatientispositionedinsitting,andtheclinicianstandsbehindthepatient.Theclinicianpositionsthe
patientsshoulderin8090degreesofabductionand100120degreesofelbowflexion(Fig.1747).The
clinicianappliesamodestvalgustorquetotheelbowuntiltheshoulderreachesfullexternalrotation.While
applyingaconstantvalgustorque,theelbowisquicklyextendedto30degrees.Apositivetestforachronic
MCLtearoftheelbowisthereproductionofmedialelbowpainwhenforciblyextendingtheelbowfroma
flexedpositionbetween120and70degrees.
FIGURE1747
Movingvalgusstresstest.
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BicepsSqueezeTest
Thepatientisseatedwiththeforearmrestingcomfortablyinthepatientslapwiththeelbowflexedto
approximately6080degreesandtheforearminslightpronation.Standingontheinvolvedside,theclinician
squeezesthebicepsfirmlywithonehandstablizingtheupperextremityandtheotherhandaroundthebellyof
thebicepsbrachii(Fig.1748).Apositivetestforadistalbicepstendonruptureisalossofforearmsupination
asthebicepsbrachiiissqueezed.
FIGURE1748
Bicepssqueezetest.
RadiographicEvaluation
Thestandardxrayseriesoftheelbowincludesanteroposterior(AP)andlateralviews(seeChapter7).
THEEVALUATION
Followingtheexamination,andoncetheclinicalfindingshavebeenrecorded,theclinicianmustdeterminea
specificdiagnosisoraworkinghypothesis,basedonasummaryofallofthefindings.Thisdiagnosiscanbe
structurerelated(medicaldiagnosis)(Tables177and178),oradiagnosisbasedonthepreferredpractice
patternsasdescribedintheGuidetoPhysicalTherapistPractice.
TABLE177DifferentialDiagnosisforCommonCausesofElbowPain
PatientAge Mechanismof Areaof Symptoms
Condition Observation
(years) Injury Symptoms Aggravatedby
Repetitive
hyperextensionof
Anterior
theelbowwith Elbowextension
Bicipital aspectofthe
2050 pronationor andshoulder Unremarkable
tendinopathy distalpartof
repetitivestressful extension
thearm
pronation
supination
Overuseofthe
upperarmand Activities
Posterior
Triceps elbow,especially involvingelbow Possibleswellingnearthe
2050 aspectof
tendinopathy inactivitieslike extensionorfull pointoftheelbow
elbow
throwingand elbowflexion
hammering
Activities
Lateral Lateralaspect Possibleswelling(over
3555 Gradualoveruse involvingwrist
epicondylosis ofelbow lateralelbow)
extension/grasping
Anteromedial Activities
Medial Possibleswelling(over
3555 Gradualoveruse aspectof involvingwrist
epicondylosis medialelbow)
elbow flexion
Posterior
Olecranon Contactwith Swellingoverposterior
2050 Trauma aspectof
bursitis posteriorelbow elbow
elbow
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Medial Excessivevalgus Valgusstressof
collateral forcetomedial Ulnaraspect theelbow, Mayhaveecchymosisover
ligament 2045 compartmentof oftheelbow throwing,and ulnaraspect
injury theelbow pitching
Medialelbow, Activities
Ulnarnerve Gradualoveruse forearm,and involvingelbow Atrophyofhandmusclesif
2040
entrapment Trauma handMedial andwrist chronic
11/2fingers extension
Radialnerve Canbeoveruse,
Varies Lateralelbow Varies Usuallyunremarkable
entrapment directtrauma
Activities
Anterior
Median involvingfull Atrophyofanterior
forearm
nerve 2040 Gradualoveruse elbowextension forearmandhandmuscles
Lateral31/2
entrapment orpronationofthe ifchronic
fingers
forearm
AROM PROM EndFeel Resisted SpecialTests TendernesswithPalpation
Painwith Distalbicepsbelly
Possiblepain passive Painonelbow Themusculotendinous
withelbow shoulderand flexionand portionofthebiceps
flexion elbow supination Bicipitalinsertionofthe
extension radialtuberosity
Elbow
extension Painwith
Possiblepain passive Painonelbow
Posterioraspectofelbow
withextreme shoulderand extension
elbow elbowflexion
flexion
Painon
resistedwrist
Painonwrist
Possiblepain extensionand
flexionwith
onwrist radial
theforearm Lateralelbow(overthe
flexionwith deviation,with CozenMills
pronatedand ECRBandECRL)
elbow theelbow
theelbow
extension extended
extended
Painonfinger
extension
Painon
combined Passivesupination
Painon
Painonwrist wrist oftheforearmand
pronationwith Anteromedialelbow
extension extensionand extensionofthe
wristflexion
forearm wristandelbow
supination
Valgusstresswith
Possiblepain elbowflexedat
withextreme Painonfull Strongand 25degreesand Posteriorelbow
elbow elbowflexion painfree
flexion humerusin
externalrotation
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Passive
Painwithfull
extensionof Dependson Usually
extension Ulnaraspectofelbow
theelbow, severity unremarkable
possible
valgusstress
Elbowflexionand
Inabilityto pressure
fullyclose Fullandpain Weaknessof provocativetest
hand free grip Tinelsatelbow Anteromedialelbow
Wartenbergssign
Fromentssign
Painwith
resisted
Maximaltendernessis
forearm
Usually Usually usuallyelicitedoverthe
supination,
unremarkable unremarkable radialtunnelifradial
resisted
tunnelsyndrome
extensionof
middlefinger
Benedictionsign
Inabilityto
performOK Overthepronatorteres4
Weaknesson sign(anterior cmdistaltothecubital
Painon pronation, interosseous crease,withconcurrent
Fullandpain
forearm wristflexion, syndrome) resistanceagainst
free
pronation andthumb Resisted pronation,elbowflexion,
opposition supination andwristflexion
(compressionof pronatorsyndrome
thelacertus
fibrosus)
AROM,activerangeofmotionPROM,passiverangeofmotionECRB,extensorcarpiradialisbrevisECRL,
extensorcarpiradialislongus.
TABLE178FindingsinCommonConditionsoftheElbowandForearm
Condition Findings
Valgusextension Tendernessaroundthetipoftheolecranon
overload Painwithforcedpassiveelbowextension
syndrome Increasedvalguslaxity(variable)
Tendernessoverthecourseoftheulnarnerve
AbnormalTinelssignovertheulnarnerve,asitpassesthroughthecubitaltunnel(medial
elbow)
Ulnarnervecompressiontestabnormal
Cubitaltunnel Elbowflexiontestabnormal(variable)
syndrome Abnormalsensation(twopointdiscriminationorlighttouch),intheulnardistribution:little
fingerulnaraspectofringfingerulnaraspectofhand
Possibleweaknessandatrophyoftheulnarinnervatedintrinsicmusclesofthehand
Possibleweaknessofflexordigitorumprofundustothelittlefinger
Possiblesignsofconcomitantulnarnerveinstability,elbowinstability,orelbowdeformity
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Condition Findings
Tendernessintheextensormusclemassoftheforearm(distaltolateralepicondyle)atthe
arcadeofFrhse
Radialtunnel Longfingerextensiontestreproducespain
syndrome Weaknessoffingerandthumbextensorsandextensorcarpiulnaris
Tendernessoverthepronatorteresintheproximalforearm
Possibleabnormalsensation(twopointdiscriminationorlighttouch)inthemediannerve
distribution:thumb,indexfinger,longfinger,andradialsideofringfinger
Onoccasion,prolongedresistedpronationreproducessymptomsofweaknessofmedian
innervatedmuscle
Pronatorteres
Rare,butoftenincorrectlydiagnosedascarpaltunnel
syndrome
Resistedelbowflexionandforearmsupinationreproducesymptomsduetocompressionat
thelacertusfibrosus
Resistedlongfingerproximalinterphalangealjointflexionreproducessymptomsdueto
compressionbytheflexordigitorumsuperficialis
Possibleweaknessofmedianinnervatedmuscles
Anterior
Weaknessofflexorpollicislongusandflexordigitorumprofundustoindexfinger
interosseousnerve
Weaknessofpronatorquadratus
syndrome
Swelling
Distalbiceps Ecchymosis
tendonrupture Palpablegapinthebicepstendon
Weakorabsentelbowflexionandsupination
Medialelbowjointpaininathrower
Completetearsopenonvalgusstresstestingwiththeelbowflexedat25degreescompared
MCLstrainortear
totheuninvolvedside,whereasincompletetearsaretenderonpalpationoftheMCLbutdo
notopenonvalgusstressing
Meanageis23years
Historyiscriticaltomakingdiagnosis:reportsoflongitudinaltractiononanextended
Nursemaids
elbow,resultinginapartialslippageoftheannularligamentovertheheadoftheradiusand
elbow(pulled
intotheradiocapitellarjoint
elbowsyndrome)
Childtypicallyholdsthearmattheside,withthehandpronated(palmdown)
Closedreductionwithmanipulationishighlysuccessful
Coversaspectrumofpathologiesabouttheelbowjointinyoungdeveloping(pediatric)
throwers
Fourdistinctvulnerableareastothrowingstress:(1)medialelbowtensionoverload(2)
Littleleague lateralarticularsurfacecompressionoverload(3)posteriormedialshearforcesand(4)
elbow extensionoverloadofthelateralrestraints
MaypresentasPannersdisease(necrosisofthecapitellum),OCD,medialepicondylar
fracture,medialapophysitis,medialligamentrupture,andposteriorosteophyteformationat
thetipoftheolecranon
MCL,medialcollateralligament.
DatafromBirnieR,ReiderB.Elbowandforearm.In:ReiderB,ed.OrthopaedicPhysicalExamination.
Philadelphia,PA:WBSaunders1999:6798.WithpermissionfromWBSaunders.
INTERVENTIONSTRATEGIES
Theinterventionfollowingelbowinjuryorelbowsurgeryfollowsasequentialandprogressivemultiphase
approach.However,duetotheuniqueorientationoftheelbowcomplex,theclinicianisfacedwithmultiple
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clinicalchallengestosuccessfullyrehabilitatetheinjuredelbowandshouldalwaysconsiderthefunctional
expectationsoftheindividualpatientwhendeterminingthemostappropriateintervention.7
Thetechniquestoincreasejointmobilityandthetechniquestoincreasesofttissueextensibilityaredescribedin
theTherapeuticTechniquessection.
ACUTEPHASE
Thegoalsoftheacutephaseofelbowrehabilitationinclude:
protectionoftheinjurysite
restorationofpainfreeROMintheentirekineticchain
improvementofpatientcomfortbydecreasingpainandinflammation
retardationofmuscleatrophy
minimizationofthedetrimentaleffectsofimmobilizationandactivityrestriction112117
maintenanceofgeneralcardiovascularfitnessand
ensuringthatthepatientisindependentwithahomeexerciseprogram.
Duringtheearlystagesoftheacutephase,theprinciplesofPRICEMEM(protection,rest,ice,compression,
elevation,manualtherapy,earlymotion,andmedication)areappliedasappropriate.Icingfor2030minutes,
threetofourtimesaday,concurrentwithnonsteroidalantiinflammatorydrugs(NSAIDs)oraspirin,canaidin
reducingpainandswelling.
CLINICALPEARL
Corticosteroidinjectionshavebeenadvocatedforelbowinjuriestopromoteandprogresshealing.Althoughthe
useoflocalinjectionsincreasestherisksofdisruptingtissueplanes,fenestrationoftheareaoftendonosismay
bebeneficialbecauseofthebleedingthatoccursinthenewchannels,whichhasthepotentialfortransforminga
failedintrinsichealingprocessintoanextrinsicresponse.118,119
Earlyactiveassistedandpassiveexercisesareperformedinallplanesoftheshoulder,elbow(Fig.1749)
VIDEO,andwristmotionsVIDEO,tonourishthearticularcartilageandassistincollagentissuesynthesisand
organization.7,120123Astheavailablerangeattheelbowoccursatthehumeroulnar,humeroradial,and
proximalanddistalradioulnarjoints,restrictionsorlaxitiesatanyofthesejointscanaffecttheeventual
outcomeoftherehabilitativeprocess.
FIGURE1749
PROM/AAROMofelbowflexion.
Theformationofanelbowflexioncontracturemustbeavoided,asthiscontracturecanplaceabnormalstresses
ontheelbowcomplex,especiallyduringathleticactivities.124Oneofthemostcommoncausesofjoint
contractureattheelbowisscarringoftheanteriorcapsule,andattheinsertionsiteofthebrachialis.7This
scarringcanbeminimizedbyperformingjointmobilizationstothehumeroulnarandhumeroradialjoints.A
posteriorglideoftheulnaonthehumerusisusedtohelprestoreelbowextension.Theanteriorcapsulecanbe
stretchedusinglongduration,lowintensitystretchingtoproduceaplasticresponsefromthecollagen
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tissue.7,125,126Suchastretchcanbeaccomplishedbypositioningthepatientinsupine,withatowelrollplaced
undertheelbowjoint,andtheforearmhangingovertheedgeofthebed(Fig.1750).Alightweight(24lb)is
placedinthehand,andtheelbowisextendedasfarasiscomfortable.Thepassivestretchismaintainedfor57
minutes,avoidingexcessivepainmanifestedbyaprotectivemuscleresponse.Thisexercisebecomesan
importantcomponentofthepatientshomeexerciseprogram.Theelbowflexors(Fig.1751)andwristflexors
(Fig.1752)canalsobestretchedmanuallybythepatientaspartofthehomeexerciseprogram.
FIGURE1750
Passiveelbowextensionusingweightinthehand.
FIGURE1751
Elbowandwristflexorstretch.
FIGURE1752
Wristflexorandelbowflexorstretch.
Initially,thepatientisadvisedtodecreasethelevelofactivitywiththelevelofpainasthelimitingfactor,but
withoutimmobilizingtheinjuredpartcompletely.
Patientsareinitiallyinstructedtoperformsubmaximalisometricexercisesatmultipleanglesfortheelbow
flexorsandextensors,theforearmsupinatorsandpronators,andthewristflexorsandextensors.Oncethefull
painfreeROMhasbeenachieved,thepatientsstrengtheningprogramisprogressedfromthemultipleangle
isometricstoconcentricprogressiveresistanceexercises(PREs)usingdumbbellsorsurgicaltubing.Low
resistanceisusedinitiallywithonetotwosetsof10repetitions,progressingastoleratedtofivesetsof10
repetitions.Oncefivesetsof10repetitionscanbeperformedwithoutpainandinaslowandcontrolledmanner,
additionalresistanceisaddedin13lbincrements.7Theresistancebasedexerciseprogramisthemainstayof
nonoperativeinterventionfortheelbowandservestoretardmuscleatrophyoftheelbowandwristmusculature.
Patientsareadvancedinconcordancewiththeirabilitytoparticipateintheprogram.Patientsshouldbetaught
howtoperformtheseexercisesindependentlyattheearliestopportunity.
Specificexercisestoincreasestrengthshouldincludethefollowing:
ConcentricexercisestothewristflexorsVIDEOandextensorsVIDEO,elbowflexorsVIDEOand
extensorsVIDEO,andradialVIDEOandulnardeviatorsVIDEO,performedatvaryingspeedsand
resistance.Theseincludewristcurls(Fig.1753),reversewristcurls(Fig.1754)VIDEO,neutralwrist
curlsVIDEO,bicepscurl(Fig.1755),andtricepsstrengthening(Fig.1756)resistedpronation(Fig.17
57),resistedsupination(Fig.1758)VIDEO.Theexercisesareinitiallyperformedusinglowspeedsand
resistancethespeedandtheintensityofresistancearethengraduallyincreased.
Thebroomhandleexercise,whichisarecommendedexerciseforthewristflexorsandextensors.A
weightistiedtoaropeorpieceofstringapproximately3ftinlength,whichisthentiedtoabroomhandle
ordowel.Thebroomhandleisheldoutinfrontofthepatientwiththepalmsdown(forwristextensors,
seeFig.1759)orpalmsup(forwristflexors).Thepatientthenrollsthestringontothehandle/dowelto
raiseandthenlowertheweight.
Tennisballsqueezes(Fig.1760)toimprovegripstrength(oncesymptomshavesubsided).
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Exercisestoincreasethestrengthofopposingmuscles,suchastheflexorsofthewristanddigits,inorder
tobalancetheforcecouple.
FIGURE1753
WristflexorPREs.
FIGURE1754
WristextensorPREs.
FIGURE1755
ElbowflexionPREs.
FIGURE1756
Tricepsstrengthening.
FIGURE1757
Strengtheningexerciseforpronators.
FIGURE1758
Strengtheningexerciseforsupinators.
FIGURE1759
Broomhandleexercise.
FIGURE1760
Tennisballsqueezes.
Shoulderexercisesshouldalsobeintroducedasearlyaspossible,althoughcautionshouldbeusedwithshoulder
externalrotationexercisesbecauseofthepotentialforvalgusstresstotheelbow.7,119,127,128Intheearlier
phasesofpain,modificationofactivitymayinvolvealternatingbetweenlowandhighintensity
workouts.129,130Enduranceisdevelopedovertime,asthepatientbecomesabletotoleratemorerepetitionsand
sustainedactivities.Ifenduranceisnotdevelopedandthemuscletendonunitbecomesfatigued,themuscular
portioncannolongerabsorbthestresses,andgreaterstressesareabsorbedbythetendon.131Throughoutall
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phasesofrehabilitationandexercise,training,shouldbewithinphysiologiclimitsforcellularresponseand
homeostasis.132Therefore,relativerestissometimesadvisedduringpainfulperiods.
Stabilityattheshoulderandtheelbowisextremelyimportantforthosepatientsreturningtooverheadsportsand
canbeaddressedusingproprioceptiveneuromuscularfacilitation(PNF)patternswithincreasingresistance.
Inthepresenceofjointlaxitythatisnotcontrollablewithadequateexerciseorergonomicmodifications,bracing
canbeeffective.
Progressiontothenextphaseoccurswhenthepatienthasfull,painfreeROM,andstrengthatleast70%ofthe
contralaterallimb.
FUNCTIONALPHASE
Thefunctionalphaseaddressesanytissueoverloadproblemsandfunctionalbiomechanicaldeficits.Thegoalsof
thefunctionalphaseinclude:
restoringnormaljointkinematics
improvingmusclestrengthtowithinnormallimits
improvingneuromuscularcontrol
restoringthenormalstrengthandrelationshipsofthemuscleforcecouples.
Ifthefeetandtrunkarestabilizedduringanactivity,theupperquarterkineticchaininvolvesthecervicalspine,
thoracicoutlet,thoracicspine,shoulder,elbow,wrist,andhand.Theupperquarteroperatesasamechanicalunit
whoselinksarefunctionallyinterdependentononeanother.
Theclinicianmustbeawareofanysubstitutionsasindividualswillinstinctivelymodifytheirexercisestoavoid
motionsinvolvingpainful,injuredtissues,andtopreventfurtherabuseoftheoverusedtissues.130,132Insuch
cases,theexercisesmustbecorrectedordiscontinued.
Cocontractionofthemusclesaroundtheelbowcanbeproducedwithclosedchainexercisessuchasthepush
up,quadrupedexercises,anddips,incorporatingawiderangeofequipmentsuchasgymnasticballs,BAPS
boards,minitramp,andslideboard(seeChapter16).
Trainingcanalsoinvolvedynamicmusclecocontractionsinanopenkineticchainbyusingballisticmovement
patterns,withelastictubingincorporatingPNFdiagonals.Theseballisticmovements,whichcanbeincreasedin
termsofspeedbasedontolerance,resultinsynchronousactivationofagonistsandantagonists.133135
Thefunctionofthebicepsisintegraltothestabilityoftheelbowcomplexandmustbeexercised,emphasizing
slowandfastmuscularcontractionsinbothconcentricandeccentricmodes.7
Wilketal.7advocatethefollowingdrilltoenhancethedynamicstabilityoftheelbow:
Thepatientflexestheelbowagainstresistanceprovidedbyelastictubing.
Thepatientholdsapositionisometricallywhiletheclinicianemploysrhythmicstabilizationresistance
anteriorlyandposteriorly.
Theprocedureisrepeatedforthewristflexorsextensorsandtheforearmpronatorssupinators.
Plyometricexercisesareintroducedastoleratedandasappropriate:136
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Thepatientgraspsalengthofelastictubingandfullyflexestheelbow,withtheshoulderflexedtoabout
60degrees(Fig.1761).Thispositionismaintainedbriefly.Thepatientthenreleasestheisometrichold,
allowingtheelbowtoextendrapidly.Asthefullextensionisreached,themovementisquicklyreversed
backintofullelbowflexion.136Theforearmpronatorssupinatorscanallbeexercisedinasimilar
fashion.
Foroverheadathletes,ERexercisescanbeperformedwithelastictubingat0degreesofshoulder
abductionand90degreesofelbowflexion(Fig.1762),beforeprogressingtomoreabduction.
PlyometricweightedballthrowsintoIRat0degreesofshoulderabduction(Fig.1763),andat90
degreesofshoulderabduction(Fig.1764).
Proneplyometricweightedballthrowswiththepatientsarmpositionedat90degreesofshoulder
abductionand90degreesofelbowflexion(Fig.1765).
Plyometricwristflipsandsnaps(Figs.1766and1767)
FIGURE1761
Plyometricexercisewithelastictubing.
FIGURE1762
ERexercisesperformedat0degreesofshoulderabductionand90degreesofelbowflexion.
FIGURE1763
PlyometricmedicineballthrowsintoIRat0degreesofshoulderabduction.
FIGURE1764
PlyometricmedicineballthrowsintoIRat90degreesofshoulderabduction.
FIGURE1765
Proneweightedballthrows.
FIGURE1766
Plyometricwristflips.
FIGURE1767
Plyometricwristsnaps.
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Theshoulderstabilizers,triceps,andthewristflexorsextensorscanbetrainedasaunitusingSwissballpush
ups(Fig.1768),PNFpatternsusingTband(Figs.1769and1770),andmedicineballthrows(Fig.1771).
FIGURE1768
Swissballpushups.
FIGURE1769
UEPNFusingTband.
FIGURE1770
UEPNFusingTband.
FIGURE1771
Medicineballthrows.
Sportsspecifictrainingisessentialbeforeanathletereturnstoplay.Thereshouldbeagradualtransitionbackto
sportsactivitiesandotherstrenuousactivitiesofdailyliving,dependingontherecoveryoftheinvolvedtissues
andtherestorationoftheathleticskillsrequiredtoperformtheactivity.Toooften,patientsreturntofullactivity
prematurely,withresultingreinjury.Thisisbothfrustratinganddiscouragingforthepatient.
Inorderfortheathletetobeginthereturntosportingactivities,theelbowmusthavefull,painfreeROMno
painortendernessonphysicalexaminationandadequatemusclestrength,power,andendurancethatis90%of
theuninvolvedside.7
Thoseathleteswhoarereturningtothrowingcanundergoastrengthcomparisonthroughisokinetictesting.This
canbeachievedwiththepatientintheseatedposition.Speedsof180degreespersecondand300degreesper
secondareused.Abilateralcomparisonshouldindicatethattheoverheadathleteselbowflexorsare1020%
stronger,theelbowextensorsare515%strongerwhencomparedtotheuninvolvedside,andthattheflexor
extensorratioshouldbe7080%at180degreespersecond,and6369%at300degreespersecond.7
Advancedstrengtheningexercisesspecificforthepatientsactivity/positionareemphasizedduringthelatterpart
ofthisphase.Theseincludehighspeed/highenergystrengtheningandeccentricmuscularcontractions
performedinfunctionalpositions.7
PRACTICEPATTERN4D:IMPAIREDJOINTMOBILITY,
MOTORFUNCTION,MUSCLEPERFORMANCE,ANDRANGE
OFMOTIONASSOCIATEDWITHCONNECTIVETISSUE
DYSFUNCTION
Impairmentsinvolvingcapsularrestrictionincludeeveryformofarthritis.Itisimportantthattheclinician
establishthecauseofarthritisusingthehistory,thetestsandmeasures,resultsfromanyimagingstudies,and
findingsfromanylaboratorytestsbeforeinitiatingtreatment.
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TraumaticArthritis
Traumaattheelbowhasthepotentialtoproducetraumaticarthritis.Themostcommonmechanismisthe
hyperextensioninjury,resultinginasprainoftheanteriorcapsuleandtheanteriorbandofthemedial(ulnar)
collateralligament.Thepatienttypicallycomplainsofdiffuseelbowpain,especiallyonthemedialaspect.Upon
examination,acapsularpatternofpassiveflexionmorelimitedthanextensionispresent,whereasthemotionsof
pronationandsupinationareunaffected.Traumaticarthritisoftheelbowisusuallytreatedwithacorticosteroid
injectioninadults,whereasinchildrenabriefperiodofimmobilizationinasling,followedbygentlepassive
andactiverangeofmotion(PROMandAROM),isrecommended.
Arthrosis
SeeChapter5.
OsteochondritisDissecansCapitellum
Osteochondritisdissecansoccursinmanyareasoftheadolescentskeleton,andpatientsusuallypresentwithan
insidiousonsetofdiffuselateralelbowpainaccompaniedbyadecreaseintheROM,includinglocking.137The
etiologyofthisconditionisnotcompletelyunderstood,butitsoccurrenceintheelbowsofadolescentsprobably
relatestoafocalarterialinjuryandsubsequentbonenecrosisresultingfromincreasedradiohumerallateral
compressionforces.138
Painisusuallyfeltatthehumeroradialjointandisincreasedwithactivitiesthatinvolvepronationand
supination.Physicalexaminationusuallydemonstratesalossoffullactiveandpassiveelbowextension.
Resistivetestingcanproducecrepitus,inadditiontopainatthehumeroradialjoint.138Xraysmayreveala
flatteningorfocaldistortionofthecapitellumandperhapsevenloosebodies.
Interventionforthisconditiondependsonthefindingsfromtheradiographic,clinical,and,onoccasion,
arthroscopicexaminationbutusuallyfocusesonthecontrolofpain.138Usually34monthsofnonabusive
activitywithexercisesdirectedtowardminimizingthestrengthlossduringtherestperiodoftenproveseffective.
Theexercisesprescribedaresimilartothoseforlateralepicondylosiswithanemphasisonbicepsandtriceps
strengthandmuscularbalancetocontrolelbowextensionforces.Amotionlimitingbracecanbeusedtoreduce
stress.
Surgicalinterventionisreservedforpatientswhodonotrespondtoconservativemeasures,orthosewithloose
bodiesorseparationofthecartilagecap.138
RadiocapitellarChondromalacia
Radiocapitellarchondromalaciaoftheelbowoccursbecauseofrepetitivevalgusforces,suchasthose
encounteredinthrowingsports.Suchactivitiescanresultinlateralelbowjointcompressionofthehumeroradial
articulation,andsometimessubsequentdamagetotheradialhead,thecapitellum,orboth.Frankosteochondral
fractureandloosebodiesmayalsooccur(osteochondritisdissecans).
Thetypicalpresentingsymptomsarecrepitus,catching,locking,andlateralelbowpainwithactiveflexionand
extensionandpronationsupinationoftheelbow.Swellingandlocalizedtendernessarenotedattheinvolved
site.
Anaxialloadappliedwithpassivesupination,andpronationoftenprovokespainandcanbehelpfulin
differentiatingthisconditionfromlateralepicondylosis.Radiographsmayshowalossofjointspace,marginal
osteophytes,and,possibly,loosebodies.
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MildcasesofthisconditionrespondtoNSAIDsandthoseexercisesprescribedforlateralepicondylosis.
However,caremustbetakentoperformexerciseswithinpainfreerangesonlytoensurejointsafety.
PosteriorElbowImpingement
Posteriorelbowimpingementresultsfrommechanicalabutmentofboneandsofttissuesintheposterior
compartmentoftheelbow.Pathologicprocessessuchasfibroustissuedepositsintheolecranonfossa,chondral
injury,osteophytes,andloosebodiesaresometimesresponsible.139MCLinsufficiencymayalsobepresent.
Radiographymayshowposteriororposteromedialosteophytesandloosebodies.
Surgicalremovaloftheosteophytesandloosebodiesisindicatedifsymptomsdonotresolvewitha
conservativetreatmentconsistingofROMandstrengtheningexercises.
MalpositioningoftheElbow
AbductedUlnaLesion
ThislesionusuallyresultsfromaFOOSHinjury,forcingtheulnamediallyintofullextensionandabduction.
Clinicalfindingsincludethefollowing140:
Anincreasedcarryingangleandapparentlongerradiusthatisforcedtoglidedistally.Initially,thehandis
heldinslightulnardeviationduetoarelativedistalshiftoftheradius.However,thisusuallyadapts,
producinganulnarcarpalshiftduetothepulloftheradialdeviatorsandwristextensors.
Theelbowflexionmaybedecreased,butusuallyonlyanabnormalhardendfeelisdetected.
Theforearmsupinationmaybedecreased,butusuallyonlyanabnormalhardendfeelisdetected.
Thelateralglideattheelbowisdecreasedwithanabnormallyhardendfeel(theulnaisunabletoadduct).
decreasedwristextension.
Therearepotentiallymanyandvariedconsequencesofthislesion,including:140
thedevelopmentoftenniselbowsymptomsastheradialdeviatorsoverworktocorrecttheulnardeviation
anulnarnervetractioninjury,MCLsprain,andmedialepicondylosisduetotheincreasedcarryingangle
carpaldysfunctionduetotheabnormalwristbiomechanicsbecauseofthedistallydisplacedradius
MCLlaxityduetotheadaptationoccurringtocorrecttheulnardeviationand
hypertonicityandoveruseoftheradialdeviatorsandextensorsasthehandattemptstoadoptaneutral
positionbyattemptingtoradiallydeviateorextend.
Theinterventionfortheseconditionsincludesacorrectionofthemalpositionwitheitherjointmobilizationsora
highvelocitythrust.
AdductedUlnaLesions
Intheadductedulnalesion,thereisnoinvolvementofthewrist.Infact,theheadoftheradiusimpactsthe
capitellum,resultingindecreasedelbowextensionandforearmpronation,andclinicalfindingsthatareexactly
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theoppositeofthosedescribedabove.Theconsequencesofthislesionarelessseverethanwiththeabducted
ulna,astheshiftofthewristislessduetotheaccommodationbytheulnarmeniscus,buttheyinclude:140
thedevelopmentoftenniselbowsymptomsduetotheprolongedstretchonthecommonextensortendon
LCLlaxity
minorcarpaldysfunctionand
ulnarmeniscustearingduetocontinuouscompression.
PosteriorRadialHead(ExternalRotationoftheUlna)Lesion
Withthislesion,theradialheadshiftsposteriorlyintoextensiononthehumerusandtheulna.Thereistypically
ahistoryinvolvingforcedorexcessivesupination.ROMtestingdemonstratesdecreasedelbowextensionand
forearmpronation.Passiveaccessorymotiontestingrevealsadecreasedmedialradialglideandadecreased
gappingspacebetweentheulnaandtheradius.
AnteriorRadialHead(InternalRotationoftheUlna)Lesion
Withthislesion,theradialheadshiftsanteriorlyintoflexiononthehumerusandtheulna.Thereistypicallya
historyinvolvingforcedorexcessivepronation.ROMtestingdemonstratesdecreasedelbowflexionand
forearmsupination.Passiveaccessorymotiontestingrevealsadecreasedlateralradialglide.
Medial(Ulnar)CollateralLigamentSprain
ThemostcommonmechanismsassociatedwithMCLsprainsareachronicattenuationofvalgusandexternal
rotationforces,22,31,61,141,142asseenwithatennisserveorduringabaseballthrowingpitch,143,144and
posttraumatic,usuallyfollowingaFOOSHinjury.19Relatedinjuriesaftertraumamayincludefracturesofthe
radialhead,olecranon,ormedialhumeralepicondyle.22,31AnMCLinjurycanalsobeiatrogenic,secondaryto
anexcessivemedialepicondylectomyforcubitaltunnelsyndrome,145,146orirritationoftheulnarnerve,
secondarytoinflammationoftheligamentouscomplex.61,147,148
Themostcommonpatientcomplaintismedialelbowpainatthesiteoftheligamentsorigin,138oratthe
insertionsiteincasesofanacuteavulsion.19Astheprimaryrestrainttovalgusstressistheanteriorbundleof
theMCL,14,2024,28thephysicalexaminationofanindividualwithpresumedmedialjointinsufficiencyshould
focusonpalpationofthecourseoftheMCL.19Valgusstresstestingoftheelbowmustalsobeperformed.
Animportantsecondarystabilizeroftheelbowisthearticulargeometryofthejointcomplex.3,21Repetitive
stresstothejointcanleadtoosteophyteformationanddegenerativechanges,whichcanproducemedialelbow
pain.
TheinterventionforanMCLinjuryincludesrestandactivitymodificationorrestrictionforabout24weeks,
ROMexercises,modalities,andNSAIDs.30Duringtheacutephase,thegoalsareasfollows:
ToincreaseROM
TopromotehealingofMCL
Toretardmuscularatrophy
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Todecreasepainandinflammation(iceandcompression)
MethodstoincreaseROMduringthisperiodinclude:
brace(optional)nonpainfulROM(2090degrees)and
activeassistedROM,passiveROMelbowandwrist(nonpainfulrange).
StrengtheningandstretchingoftheFCU,pronatorteres,andFDSareinitiatedoncetheacuteinflammatory
stagehassubsided.TheseexercisesareperformedinthepainfreemidROM.49,143,149,150Emphasisisplaced
onisometricexercisesoftheforearmflexors,ulnardeviators,andpronators,inordertoenhancetheirroleas
secondarystabilizersofthemedialjoint.Inaddition,strengtheningoftheshoulderandelbowmusclesare
incorporatedtopreventorminimizeinjuryandtofacilitaterehabilitationoftheupperextremity.49,138Duringthe
subacutephase,thegoalistograduallyincreasemotion0135degrees(increase10degrees/week).Concentric
exercisesareinitiated,whichshouldinclude:
wristcurls
wristextensionPREs
pronationsupinationPREsand
bicepstricepsPREs.
Criteriatoadvancetothechronicphaseinclude:
fullROM
nopainortenderness
noincreaseinlaxity
thestrengthat4/5ofelbowflexorsextensors.
Thegoalsduringthechronicphaseinclude:
improvestrength,power,andenduranceand
improveneuromuscularcontrol.
Thesegoalscanbeachievedusingthefollowingexercises:
initiatingexercisetubingandshoulderprogram
bicepstricepsprogram
supinationpronationPREsand
wristextensionflexionPREs.
Asappropriate,awellsupervisedthrowingandconditioningprogramisinitiatedatapproximately3months.30
Criteriaforprogressiontoreturntothrowinginclude:
full,nonpainfulROM
noincreaseinlaxityand
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isokinetictestingfulfillscriteria.
OperativerepairoftheMCLtypicallyisrequiredonlyincompetitivethrowingathletesorthoseinvolvedin
heavymanuallabor,19asvalguslaxityhasbeenshowntocauseminimalfunctionalimpairmentwithnormal
activitiesofdailyliving.31Thesurgicalrepairorreconstructioncanbeperformedwithorwithoutulnarnerve
transposition.151TheTommyJohntechniqueisasurgicalprocedureinwhichtheUCLisreplacedbyatendon
fromelsewhereinthebody.Thepalmarislongustendon,whichhasbeenfoundtohaveatensilestrengthof357
N,isthemostfrequentlyusedgraft,152althoughtheplantarisandtoeextensortendonscanalsobeused.141
Lateral(Radial)CollateralLigamentSprain
Posterolateralrotatoryinstabilityresultsfrominsufficiencyofthelateralsofttissuesupportoftheelbow,
especiallytheLCLcomplex.34,36,153Themechanismofinjurytypicallyinvolvesacombinationofaxial
compression,externalrotation,andvalgusforceappliedtotheelbow.154,155Itmayalsohaveaniatrogenic
originandhasbeenreportedafteroverlyaggressivedebridementofthelateralsofttissuesofpatientswith
recalcitranttenniselbow.153,156
ElbowInstability
Boththehumeroulnarandthehumeroradialarticulationprovideapproximately50%oftheoverallstabilityof
theelbow.21,24,25Additionalsupportissuppliedbyligamentsandmuscles.
Althoughelbowinstabilityhasbeendocumentedfordecades,theclinicaltestsformakingthediagnosisof
elbowinstabilityarerelativelyrecent.36,154
Thefollowingfiveitemclassificationsystemforelbowinstabilityisusefulforcorrectdiagnosingandtreatment
decisionmaking:157159
1.Thetiming(acute,chronic,orrecurrent).
2.Thearticulation(s)involved.Sincetheelbowisacomplexjoint,therearetwocategoriesofelbow
instability,accordingtothearticulation(s)involved,althoughtheinstabilitycaninvolvebothjointsina
combinedfashion:157
a.Theulnohumeraljoint.Theinstabilityofthishingejoint,whichismostcommonlypredisposedto
recurrentinstability,canbecongenitaloracquiredalthoughtheformerisrare.
b.Theproximalradioulnarjoint.Thisinvolvesasubluxationordislocationoftheradialheadfrom
theulna,whichcanbecongenitaloracquired.Dislocationoftheradialheadfromtheulnaisusually
traumaticandoftenpartofaMonteggiafracturesubluxation.
3.Thedirectionofdisplacement(valgus,varus,anterior,orposterolateralrotatory).
a.Valgusdisplacement.Themedialstabilizersoftheelbowarethestrongest.Themechanismof
injuryforavalgusdisplacementisusuallyaFOOSHinjuryandoccursinindividualswhoperform
overheadmovementssuchassledgehammerusersandbaseballpitchersandjavelinthrowers.142
Theinstabilityischaracterizedbypainintheanteromedialaspectofthearm,amoderatetosevere
flexionlimitation(acute),andapositivevalgustestat20degreesofflexion.Valgusinstabilityis
seeninoneoftwovarieties:posttraumaticorchronicoverload.157
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PosttraumaticValgusInstability.Thistypeisoftenassociatedwithdisruptionofthesofttissues
onthemedialsideoftheelbow,includingtheMCL,andthecommonflexorandpronatororigin.160
Valgusinstabilityisusuallyfoundinpatientswithradialheadfracturesassociatedwithtearsofthe
MCL,orinpatientswithsevereelbowinstabilityfollowingadislocationthathasdisruptedthe
lateralligamentcomplex.
Chronic.Thistypetypicallyoccursfromrepetitivemicrotraumaoroverload,resultingin
attenuationorruptureoftheanteriorbandoftheMCL.
b.Varusdisplacement.Becauseoftheanatomicdesignoftheelbow,anyforceacrosstheelbow
principallydistortstheelbowinavalgusdirection,usuallyincombinationwithexternalrotation
rotatoryforceasoccursfromaFOOSHinjury.Thus,apurevarusmechanismofinjuryis
uncommon.139Lateralinstabilitycanoccuracutelyinpatientswithelbowdislocationsandinmany
patientswithrecurrentorchronicinstabilitywhentheLCLfailstoheal.157Patientswithavarus
instabilityareunlikelytocomplainofsymptomsexceptwhenusingtheirarmsasweightbearing
extremities(usingcrutches).157
4.Anteriordisplacements.Theseinjuries,whicharerare,usuallyoccurfromablowtotheflexedelbow,
whichdrivestheolecranonanteriorly.161Associatedinjuriesincludefracturesoftheolecranon,with
varyingdegreesofthespraintothecollateralligamentsanddamagetothevesselsandnervesaroundthe
joint.Onexamination,thearmappearsshorter,whileparadoxicallytheforearmappearselongatedand
heldinsupination.Theelbowisusuallyheldinextension.
5.Posteriordisplacements.Posteriorelbowdisplacements,whicharemuchmorecommonthananterioror
lateraldisplacements,involveaposteriorlydisplacedulnainrelationtothedistalhumerus.Thepatients
armisheldin45degreesofflexion.Posteriordisplacementscanbefurthersubdividedintothreetypes:
posterior,posteriormedial,andposteriorlateral.153,159Themostcommonisusuallyposteriorlateral
ratherthandirectposterior,sothatthecoronoidpassesinferiortothetrochlea,andtheulnardisplacement
onthehumerusisthreedimensional(theradiusmoveswiththeulna),suchthattheulnasupinates
(externallyrotates)awayfromthetrochlea.157Themostcommonmechanismforaposterolateral
instabilityinvolvesproximalattenuationoravulsionoftheligamentousandmuscularoriginsfromthe
lateralepicondyleduringatraumaticevent.TheLCListheprimarystaticrestraintagainstposterolateral
rotatoryinstability.33,34,160,162164Thelateralpivotshifttest,alsocalledtheposterolateralrotatory
instabilitytest,iscommonlyusedtoassistinthediagnosis.139Thesurgicalinterventionforposterolateral
rotatoryinstabilityinvolvesarepairofthecommontendonandligamentoriginstothelateral
epicondyle.19
6.Thedegreeofdisplacement(subluxationordislocation).Posterolateralrotatoryinstabilitiestypically
consistofthreestages,eachofwhichhasspecificclinical,radiographic,andpathologicfeaturesthatare
predictableandhaveimplicationsfortreatment:157
a.Stage1.Theelbowsubluxatesinaposterolateralrotatorydirection,andthepatienthasan
associatedpositivelateralpivotshifttest.
b.Stage2.Theelbowdislocatesincompletelysothatthecoronoidisperchedunderthetrochlea.
c.Stage3.Theelbowdislocatesfullysothatthecoronoidrestsbehindthehumerus.
7.Thepresenceorabsenceofassociatedfractures.Elbowsubluxationsanddislocationscanbeassociated
withelbowfractures.Fracturedislocationsmostcommonlyinvolvethecoronoidand/orradialhead,an
injurysodifficulttotreatandpronetounsatisfactoryresultsthatithasbeentermedtheterribletriadof
theelbow.165
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Thediagnosisofelbowinstabilityismadebythehistoryandacarefulphysicalexamination.Patientstypically
presentwithahistoryofrecurrentpainfulclicking,snapping,clunking,orlockingoftheelbow,thatoccursin
theextensionportionofthearcofmotionwiththeforearminsupination.157Anexaminationoftheperipheral
nervesanddistalpulsesisnecessarytohelpdeterminetheseverityoftheinstability.Swellingmaymakethe
diagnosisofelbowinstabilitydifficult.However,iftheclinicianpalpatesthetwoepicondylesandthetipofthe
olecranon,thefollowingfindingshelpdeterminethediagnosis:
Ifthethreepointsareonthesameplane,asupracondylarfractureissuspected.
Iftheolecranonisdisplacedfromtheplaneoftheepicondyles,aposteriordislocationissuspected.
Thediagnosisofadislocationcanbeconfirmedbyaradiograph.
Withpatientspresentingwithahistoryofdislocation,thediagnosisofrecurrentelbowinstabilityistobe
suspected.Thisdiagnosisshouldalsobeconsideredwhentherehasbeentraumawithoutdislocation.Recurrent
instabilitymayalsobecausedbysurgeriessuchastenniselbowsurgeryorsurgeryontheradial
head.36,153,156,157
Conservativeinterventionforelbowinstabilityshouldfocusontheentirekineticchain,includingthelower
extremitiesandtrunk.Posteriorcapsulartightnessintheshouldermustbeaddressed.166168
Duringtheinflammatoryphase,theinterventionincludes:
immobilizationoftheelbowpositionedat90degreesofflexioninawellpaddedposteriorsplintfor34
days
initiationoflightgrippingexercises(puttyortennisball)
avoidanceofanypassiveROM(patienttoperformactiveROMwhentheposteriorsplintisremovedand
replacedwithahingedelbowbraceorsling),andanyvalgusstressestotheelbowand
useofcryotherapyandhighvoltagegalvanicstimulation(HVGS).
Atdays414theposteriorsplintisreplacedwithahingedelbowbraceinitiallysetat1590degrees.
Exercisesduringthisphaseshouldinclude:
wristandfingeractiveROMinallplanes
activeelbowROM(whileavoidingvalgusstress)flexionextensionsupinationpronation
multiangleflexionisometrics
multiangleextensionisometrics(whileavoidingvalgusstress)
wristcurls/reversewristcurls
lightbicepscurlsand
shoulderexercises(avoidanceofexternalrotationoftheshoulder,becausethisplacesvalgusstressatthe
elbow).Theelbowshouldbestabilizedduringshoulderexercises.
Ataround26weeks,thehingedbraceissetfrom0degreestofullflexion.Exercisesinclude:
PREprogressionofelbowandwristexercises
gentlelowload,longdurationstretchingisinitiatedaround56weekstoenhanceextension
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gradualprogressionofweightwithcurls,elbowextension,andsoon
initiationofsportsspecificexercisesanddrillsand
Externalrotationandinternalrotationexercisesoftheshouldermaybeincorporatedat68weeks.
Anintervalthrowingprogramcanbeinitiatedataround8weeks.However,thereshouldbenoreturntoplay
untilstrengthis8590%oftheuninvolvedlimb.PNF,rhythmicstabilization,andplyometricexercisesareused
toimprovefunctionalstabilizationofthejoint,beginningwithtwohandedexercisesinthenonprovocative
rangeswiththeelbowclosetothebody,andprogressingtoonehandedactivitieswiththeinvolvedarmin
functionalorsportsrelatedpositions.37
Surgicalinterventionisreservedforthosepatientsinwhomconservativemeasuresfail.
PRACTICEPATTERN4E:IMPAIREDJOINTMOBILITY,
MOTORFUNCTION,MUSCLEPERFORMANCE,ANDRANGE
OFMOTIONASSOCIATEDWITHLOCALIZED
INFLAMMATION
Overuseinjuriesattheelbow,whicharerelativelycommon,resultfromrepetitivetraumathatleadstolocal
tissuedamageintheformofcellularandextracellulardegeneration,whichcanbecumulativeandresultin
tendinopathyortendinosis,stressfractures,ligamentsprains,ormusclemyositis.Bothintrinsicandextrinsic
factorscontributetooveruseinjuries.Intrinsicfactorsincludebiomechanicalabnormalitiesextrinsicfactorsare
primarilytrainingerrors(incorrecttechnique,improperequipment,andchangesinthedurationorfrequencyof
activity).
OlecranonBursitis
Becauseofitssuperficiallocation,theolecranonbursaiseasilyinjuredthroughdirecttraumaorcanbeirritated
throughrepetitivegrazingandweightbearing,resultinginbursitis.Olecranonbursitisiscommoninindividuals
whospendlongperiodsweightbearingthroughtheelbows,suchasstudents,orwherethepotentialforfalling
andstrikinganelbowonhardplayingsurfacesishigh.169
Acutebursitispresentsasaswellingovertheolecranonprocessthatcanvaryinsizefromaslightdistensiontoa
largemassseveralcentimetersindiameter.170Inchroniccases,thepainandswellingcanbegradual,orsudden
asinacuteinjuryoraninfection.Aninflamedbursacanoccasionallybecomeinfected,requiringdifferentiation
betweensepticandnonsepticbursitis.171
Rednessandheatsuggestinfection,whereasexquisitetendernessindicatestraumaorinfectionastheunderlying
cause.PatientsoftennoteadecreasedROMoraninabilitytodonalongsleevedshirt.172Whilstasimple
posttraumaticbursitiscanbetreatedwiththeprinciplesofPRICEMEM,theinfectedbursaneedsprompt
medicalattention.172
Includedinthedifferentialdiagnosesofolecranonbursitisareacutefractures,rheumatoidarthritis,gout,and
synovialcysts.170Ifthepatientisexperiencingsignificantpainordiscomfortwiththemovementoftheelbow,a
slinghelpstoreducethesesymptomsandcalmthejoint.170Inthosecasesofmarkedswelling,ortodistinguish
betweenasepticandnonsepticbursitis,aspirationistheappropriatemanagement.Aspirationalsohelpsto
reducethelevelofdiscomfortandrestrictionofmovement.Theaspiratedfluidisculturedandevaluatedfor
crystalstoruleoutinfectionorgout.Afteraspiration,theelbowshouldbemaintainedinasplintandslingand
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reevaluatedafter1week.Bursitisthatrecursdespitethreeormorerepeatedaspirations,oraninfectionthatdoes
notrespondtoantibiotics,requiresevaluationforsurgicalexcision.170,172
Injectionofcorticosteroidsisusedtomanagechronicbursitisoncethediagnosisofinfectionhasbeen
excluded.170
OlecranonImpingementSyndrome
Repetitiveimpingementoftheolecranonintheolecranonfossamayoccurwithvalgusstressesinthrowing
sports.Stresstobotharticularsurfacesofthejointmayresultintheformationofloosebodies,osteophytes,
chondromalacia,andsynovitis.173
Thepatientmayreportcatching,clicking,andcrepitus,whichareworsenedbyelbowextension.Fullelbow
extensionmaybelimitedbyamechanicalblock.Xraysconfirmloosebodies,olecranonosteophytes,and
commonlyassociatedanteriorelbowchanges.
Mildcasesrespondtoarehabilitationprogramfocusingonrestorationofnormalmotion,strength,and
endurance.Continuedpain,loosebodies,ormechanicalblockageareindicationsforsurgery.
TendonInjuriesoftheElbow
Tendoninjuriesofthisregioncanbedividedintoseveralcategoriesonthebasisofthenatureoftheironsetand
thetissuesinvolved.Whileacutetendoninjuriesaretraumaticinnature,chronicoveruseinjuriesaretheresult
ofmultiplemicrotraumaticeventsthatcausedisruptionoftheinternalstructureofthetendonandproduce
tendinopathyortendinosis.
BicipitalTendinosis
Bicipitaltendinosistypicallyresultsfromrepetitivehyperextensionoftheelbowwithpronation,orrepetitive
flexioncombinedwithstressfulpronationsupination.86Typicallythepatientcomplainsofpainlocatedatthe
anterioraspectofthedistalpartofthearm,withtendernesstopalpationofthedistalbicepsbelly,the
musculotendinousportionofthebiceps,orthebicipitalinsertionoftheradialtuberosity.78,86Otherfindings
includeareproductionofpainwithresistedelbowflexionandsupination,andwithpassiveshoulderandelbow
extension.
Theconservativeinterventionfocusesonregainingthestrength,endurance,andflexibilityofthe
flexor/supinatormechanism,andonstrengtheningtheshoulderstabilizers.Otherapproachesinvolve
electrotherapeuticandthermalmodalities,transversefrictionmassage,triggerpointassessment,andspecific
elbowjointmobilizations.
BicepsTendonRupture
Thedistalbicepstendoncanbeavulsedpartiallyorcompletelyeitheratthemusculotendinousjunctionoratthe
radialtuberosity,thelatterofwhichismorecommon.42Avulsionsofthebicepstendonattheelbowoccur
almostexclusivelyinmales,andthemostcommonscenarioisaruptureofthedominantelbowofamuscular
maleinhisfifthdecadeoflife.174Bicepsrupturestypicallyinvolveasuddencontractureofthebicepsagainsta
significantloadwiththeelbowin90degreesofflexion.42
Clinicalfindingsvarydependingontheextentoftherupturewhetheritispartialorcomplete.Thetypical
historyincludesareportofasharp,tearingpainconcurrentwithanacuteinjuryintheantecubitalfossa.139The
sharppaintypicallydissipateswithinhourstodaysandisfollowedbyadullache.42Thepatientmayalso
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describenoticingalossofstrengthinactivitiesinvolvingelbowflexionandsupination(e.g.,turningadoor
knob,orliftingobjects).42Theobjectivefindingsmayincludeecchymosisintheantecubitalfossa,visible
deformity(completerupture),apalpabledefectofthedistalbiceps(partialrupture),lossofstrengthofelbow
flexionandgrip,butespeciallyalossofforearmsupinationstrength.175
Although,inlowfunctioningormedicallycomplicatedpatients,nonoperativemeasuresmaybepursued,in
activeindividuals,thenormalrecommendationisprimaryrepairoftheacutetendonavulsion.42Ifnotrepaired,
an88%lossofelbowflexionanda74%lossofsupinationstrengthcanbeexpected.176Postoperatively,the
elbowisprotectedfor68weeks,afterwhichunrestrictedROMandgentlestrengtheningexercisesareinitiated.
Returntounrestrictedactivityisusuallynotalloweduntilnearly6monthsofhealinghaspassed.139
TricepsTendinosis
Tricepstendinosisisachronicconditionstemmingfromoveruse,repetitiveextension,andrepetitive,heavy
liftingwhichcanoccurinsuchactivitiesascompetitiveweightlifting,boxing,gymnastics,throwing,and
racquetsports.
Subjectively,thepatientreportslocalizedtendernessofthetricepsinsertionattheolecranonwithpalpationthat
isaggravatedwithresistedelbowextension.Strengthtestingtypicallyshowsaweaknessofelbowextension.
Xraysareindicatedtoruleoutolecranonapophysitisinadolescenceandanavulsionfractureinadults.
TheinitialstagesoftheinterventionemphasizetheprinciplesofPRICEMEM.Therapeuticexercisesemphasize
strengthoftheelbowextensormechanism,withafocusonclosedchainexercisesfortheinvolvedupper
extremity.173Inaddition,shoulderstrengtheningandscapularstabilizationexercisesareintroduced.
TricepsTendonRupture
Adistaltricepstendonrupture,whichisrelativelyuncommon,usuallyoccurswhenadecelerationforceoccurs
duringelbowextensionorwithanuncoordinatedcontractionofthetricepsmuscleagainsttheflexingelbow.177
Aswiththebicepstendonrupture,thephysicalfindingsdependonwhethertheavulsionispartialorcomplete,
butthemostcommonfindingsincludealossofelbowextensionstrength,andaninabilitytoextendoverhead
againstgravity.Atendondefectmaybepresentiftheteariscomplete.139
Primaryrepairisthetreatmentofchoiceinacutecompleteruptures.Thepartialinjurymaybetreated
conservativelywithimmobilizationforabout3weeks,followedbyagradualprogressionofROMand
strengtheningexercises.
BrachialisStrain
Abrachialisstrainisrelativelyrare,butthebrachialisispronetomyositisossificans,apathologicbone
formation,duetothefactthatitislikelytohemorrhagewheninjured(seelater).
Typically,thepatientreportspainthatisfeltontheanterioraspectofthedistalpartofthearm,andthereis
palpabletendernessinthemusclebellyofthebrachialis.Resistedsupinationisnotpainful,althoughresisted
elbowflexioncombinedwithforearmpronationis.
Theconservativeinterventioninvolveselectrotherapeuticandthermalmodalities,transversefrictionmassage,
triggerpointassessment,correctionofmuscleimbalances,andspecificelbowjointmobilizations.
Epicondylosis
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Whilethetermsepicondylitisandtendinitishavebeencommonlyusedtodescribetenniselbowandgolfers
elbow,histopathologicstudieshavedemonstratedthattheseconditionsareoftennotinflammatoryconditions
rather,theyaredegenerativeconditions.Therefore,epicondylosis,orangioblastictendinosis,betterdescribethe
condition.Epicondylosisiscommoninpersonswhofrequentlyoverusetheupperarm,particularlywith
activitiesthatinvolverotationofthearmwithflexionandextension.Tendonchangesduetoepicondylosis
includedensepopulationsoffibroblasts,vascularhyperplasia,anddisorganizecollagen.178Twotypesof
epicondylosisarecommonlydescribed:lateralepicondylosis(tenniselbow)andmedialepicondylosis(golfers
elbow).Lateralepicondylosisisfarmorecommonthanmedialepicondylosiswithanannualprevalenceof1
2%inthegeneralpublic,179and4050%inrecreationaltennisplayersduringtheirlifetime.180
LateralEpicondylosis(TennisElbow)
Lateralepicondylosisisacostlymusculoskeletaldisorder,characterizedbydegenerationofthetendonand
frequentlyreportedpainatthelateralaspectoftheelbow.181MRIfindingsdemonstratethatthecommon
extensortendonoriginisinvolvedandshowsincreasedsignalintensity,withtheregionofgreatestsignal
abnormalitybeingattheoriginoftheECRBtendonfromthelateralepicondyleofthehumerus.Thetendonsof
thecommonextensorbundleconnecttothemusclesthatcontrolwristextensionandradialdeviation.138
Asmentioned,tennisplayersarecommonlyaffected,butitalsoaffectsthosewithprofessionsthatrequire
repetitiveand/orforceful/heavymanualtasks,nonneutralwristpostures,andrepetitivegripping.182,183
Lateralepicondylosisusuallyresultsfromoverusealthoughitcanbetraumaticinorigin.Theoveruseinjuries
tendtoinvolveabusivetissuetraumasecondarytorepetitiveactivity,whichpromotesmicrotraumatictissue
failure.Thosetendonsthatwraparoundaconvexsurfaceortheapexofaconcavity,andthosethatcrosstwo
joints,areparticularlyvulnerabletooveruseinjuries,asarethosewithareasofscantvascularsupply,orthose
subjectedtorepetitivetension.184Onepossibleetiologyforoveruseattheelbowisthefactthatthehanddoes
nothaveasupportivefunctionbutfunctionspredominantlytograspsomeobject.Repetitivegrasping,withthe
wristpositionedinextension,placestheelbowatrisk.Participantsoftennis,baseball,javelin,golf,squash,
racquetball,swimming,andweightliftingareallpredisposedtothisrisk.139
ClinicalPresentation
Athoroughbutfocusedhistoryandphysicalexaminationarecriticaltoatimelyandaccuratediagnosis.Painis
theprimarysymptomoflateralepicondylosis.181Historicalfactorsshouldbesolicited,suchastobaccouse,
occupation,handdominance,recreationalactivities,durationofsymptoms,andpriorepisodesandattempted
treatments.42Thepainisoftenrelatedtoactivitiesthatinvolvewristextension/grasp,asitisthewristextensors
thatmustcontractduringgraspingactivitiestostabilizethewrist.Forexample,pouringagallonofmilkmay
reproducethesymptoms.Diffuseachinessandmorningstiffnessarealsocommoncomplaints.138Occasionally
thepainisexperiencedatnight,andthepatientmayreportdroppingobjectsfrequently,especiallyiftheyare
carriedwiththepalmfacingdown.Thepaincanbeassessedusingaselfreportedmeasuresuchasthepatient
ratedtenniselbowevaluation(PRTEE),185avalid,reliable,andsensitiveclinicalinstrumentforindividuals
withchroniclateralepicondylosis(Table179).186
TABLE179TennisElbowQuestionnaire
PatientName:__________________________________________ Date:__________________
Thequestionsbelowwillhelpusunderstandtheamountofdifficultyyouhavehadwithyourarminthepast
week.Youwillbedescribingyouraveragearmsymptomsoverthepastweekonascale010.Pleaseprovide
ananswerforallquestions.Ifyoudidnotperformanactivitybecauseofpainorbecauseyouwereunable,then
youshouldcirclea10.Ifyouareunsurepleaseestimatetothebestofyourability.Onlyleaveitemsblankif
youneverperformthatactivity.Pleaseindicatethisbydrawingalinecompletelythroughthequestion.
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1.PAINinyouraffectedarm

Ratetheaverageamountofpaininyourarmoverthepastweekbycirclingthenumberthatbestdescribesyour
painonascalefrom010.Azero(0)meansthatyoudidnothaveanypainandaten(10)meansthatyouhad
theworstpainimaginable.
RATEYOURPAIN: Nopain WorstImaginable
Whenyouareatrest 0 1 2 3 4 5 6 7 8 9 10
Whendoingataskwithrepeatedmovement 0 1 2 3 4 5 6 7 8 9 10
Whencarryingaplasticbagofgroceries 0 1 2 3 4 5 6 7 8 9 10
Whenyourpainwasatitsleast 0 1 2 3 4 5 6 7 8 9 10
Whenyourpainwasatitsworst 0 1 2 3 4 5 6 7 8 9 10
2.FUNCTIONALDISABILITY
SPECIFICACTIVITIES
Ratetheaverageamountofdifficultyyouexperiencedperformingeachofthetaskslistedbelow,overthepast
week,bycirclingthenumberthatbestdescribesyourdifficultyonascaleof010.Azero(0)meansyoudid
notexperienceanydifficultyandaten(10)meansitwassodifficultyouwereunabletodoitatall.
Nodifficulty Unabletodo
Turnadoorknoborkey 0 1 2 3 4 5 6 7 8 9 10
Carryagrocerybagorbriefcasebythehandle 0 1 2 3 4 5 6 7 8 9 10
Liftafullcoffeecuporglassofmilktoyourmouth 0 1 2 3 4 5 6 7 8 9 10
Openajar 0 1 2 3 4 5 6 7 8 9 10
Pulluppants 0 1 2 3 4 5 6 7 8 9 10
Wringoutawashclothorwettowel 0 1 2 3 4 5 6 7 8 9 10
3.USUALACTIVITIES
Ratetheamountofdifficultyyouexperiencedperformingyourusualactivitiesineachoftheareaslistedbelow,
overthepastweek,bycirclingthenumberthatbestdescribesyourdifficultyonascaleof010.Byusual
activities,wemeantheactivitiesthatyouperformedbeforeyoustartedhavingaproblemwithyourarm.A
zero(0)meansyoudidnotexperienceanydifficultyandaten(10)meansitwassodifficultthatyouwere
unabletodoanyofyourusualactivities.
Nodifficulty Unabletodo
1.Personalactivities(dressing,washing) 0 1 2 3 4 5 6 7 8 9 10
2.Householdwork(cleaning,maintenance) 0 1 2 3 4 5 6 7 8 9 10
3.Work(yourjoboreverydaywork) 0 1 2 3 4 5 6 7 8 9 10
4.Recreationalorsportingactivities 0 1 2 3 4 5 6 7 8 9 10
Comments:
PRTEEScoringInstructions
Minimizenonresponsebycheckingformswhenthepatientcompletesthem.Makesurethatthepatientleftan
itemblankbecausetheycouldnotdoit,thattheyunderstandthatshouldhaverecordedthisitemasa10.If
thepatientisunsurebecausetheyhaverarelyperformedanactivityinthepastweek,thentheyshouldbe
encouragedtoestimatetheiraveragedifficulty.Thiswillbemoreaccuratethanleavingitblank.Iftheynever
performanactivitytheywillnotbeabletoestimateandshouldleaveitblank.Ifitemsfromasubscaleareleft
blank,thenyoucansubstitutetheaveragescorefromthatsubscale.
PainSubscaleAddup5items.Bestscore=0Worstscore=50
SpecificActivitiesAddup6items.BestScore=0WorstScore=60
UsualActivitiesAddup4items.BestScore=0WorstScore=40
FunctionSubscale(SpecificActivities+UsualActivities)/2Bestscore=0Worstscore=50
TotalScore=PainSubscale+FunctionSubscale(painanddisabilitycontributeequallytoscore).BestScore=
0WorstScore=100
Reliabilityofsubscalesandtotalscorearesufficientlyhighthatbothsubscalesandtotalarereportable.
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DatafromOverendTJ,WuoriFearnJL,KramerJF,MacDermidJC.Reliabilityofapatientratedforearm
evaluationquestionnaireforpatientswithlateralepicondylitis.JHandTher.199912:3137.
PalpabletendernessisusuallyfoundovertheECRBandECRL,especiallyatthelateralepicondyle,withthesite
ofmaximumtendernessmostcommonlybeingovertheanterioraspectofthelateralepicondyle.138
TheROMteststypicallyrevealthefollowing:
activemotionsareusuallypainless,althoughtheremaybeapainwithwristflexionwhencombinedwith
elbowextension.
passivemotioncanproducepain,especiallywithpassivewristflexionwiththeforearmpronatedandthe
elbowextended.
Theresistedteststypicallyreproducesymptomswithresistedwristextensionandradialdeviationwiththe
elbowextended.Painfreegripstrengthisthemostcommonlyaffectedmotorimpairment.187Rateofforce
developmentisconsideredtobeameasureoftheabilitytorapidlygeneratestrengthandisassociatedwith
higherfunctionalperformance.188A2007cohortstudybyDorfetal.189foundthatwiththeelbowinextension,
theaffectedsidehad50%gripstrengthwhencomparedtotheunaffectedside.Painonresistedmiddlefinger
extensionhasalsobeenreported(MaudsleytestseeSpecialTests).Thechairtest(seeSpecialTests),and
CozensorMillsspecialtestsaretypicallypositive.
Thecervicalspine,shoulder,andwristmustalsobeexamined.Asalargenumberoftenniselbowsappeartobe
secondarytoadysfunctionofeitherthecervicalspineortheshoulder,182testingisometricwristextensionin
varyingpositionsofthecervicalspineorshoulderwillhelpdifferentiatethecause.Iftheprimarycauseis
remote,theamountofdiscomfortontestingwillvarywithchangesintheheadorshouldergirdleposition.Ifthe
paindisappearsentirelyduringthesemaneuvers,therecanbenosymptomaticpathologicchangesattheelbow,
andnolocaltreatmentisrequired.However,usuallythepainisreducedratherthanbeingeliminated,indicating
thatthecausemayberemoteandlocalpathologicchangeshavesincesupervened.Ifthediagnosisoflateral
epicondylosisisclearfollowingthehistoryandphysicalexamination,diagnosticimagingisnotindicated.42
However,ifuncertaintyexists,imaginganddiagnostictestcanbeusefulforexploringthedifferentialdiagnosis,
includingradiocapitellarchondromalacia,posterolateralelbowinstability,plica,loosebodies,malignancy,
cervicalradiculopathy(C6orC7),orcompressionofthePINatthearcadeofFrosche(supinatorsyndrome).42
Intervention
Todate,thereisnoconsensusontheoptimaltreatmentapproachforlateralepicondylosis,whichisinlargepart
duetoitsunclearunderlyingetiology.182Thus,therearenumerousinterventionscitedforthiscondition,both
medicalandsurgical.190Infact,morethan40treatmentshavebeensuggested,indicatingthattheidealremedy
hasyettobefound,althoughthereisagreementthattheinitialmanagementshouldbeconservative.Many
studiesoftheuseofphysicaltherapyinthemanagementoftenniselbowarepoorlydesignedandstatistically
weak.191,192
Thegoalsduringtheacutephasearetodecreaseinflammation/pain,promotetissuehealing,increaseflexibility,
andretardmuscleatrophy.Methodstoaccomplishthisinclude:193
cryotherapy
whirlpool
HVGS
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phonophoresis
iontophoresis
stretchesfor
wristextensionflexion
elbowextensionflexion
forearmsupinationpronationand
avoidanceofpainfulmovements(suchasgripping).
Duringthesubacutephase,thegoalsshouldbeto193
improveflexibility
increasemuscularstrengthandendurance
increasefunctionalactivitiesandreturntofunction
emphasizeconcentriceccentricstrengtheningwithafocuson
wristextensionflexion
forearmpronationsupination
elbowflexionextension
initiateshoulderstrengthening(ifdeficienciesarenoted)
continueflexibilityexercises
usecounterforcebrace
continueuseofcryotherapyafterexerciseorfunction
initiategradualreturntostressfulactivitiesand
graduallyreinitiatepreviouslypainfulmovements.
Duringthechronicphase,thegoalshouldbeto193
improvemuscularstrengthandendurance
maintain/enhanceflexibility
graduallyreturntohighlevelsportsactivities
continuestrengtheningexercises(emphasizeeccentricconcentric)
continuetoemphasizedeficienciesinshoulderandelbowstrength
continueflexibilityexercises
graduallydiminishtheuseofthecounterforcebrace
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continuetousecryotherapyasneededpostexercise
initiategradualreturntosportsactivity
equipmentmodifications(gripsize,stringtension,andplayingsurface)and
emphasizemaintenance.
Theeffectivenessofultrasoundfortenniselbowisundetermined.Onestudy194foundultrasoundtobeeffective
inaplacebocontrolled,doubleblindtrial,195butanotherstudy,196foundnodifference.Arecentrandomized
pilotstudybyStruijsetal.197of31patientsdiagnosedwithtenniselbowfoundthatmanipulationofthewrist
wasmoreeffectiveatafollowupof36weeksthanultrasound,frictionmassage,andmusclestretchingand
strengtheningexercises.Thewristmanipulationusedwasananterior(ventral)manipulationofthescaphoid
(refertoChapter18),whichwasrepeated15times,twotimesaweek,withamaximumofnineintervention
sessions.Inarandomizedstudyof18subjects,198jointmobilizationtotheradialheadcombinedwith
neurodynamictechniquestotheradialnervewascomparedwithaprogramconsistingofultrasound,transverse
frictionmassage,andstrengtheningandstretchingexercises.At3monthfollowup,onlythegroupreceiving
jointmobilizationsandneurodynamicinterventionshadimproved.
Morerecently,therehasbeenatrendtowardtreatmentofthecervicalandthoracicspineswiththisdisorder.
Vincenzinoetal.199demonstratedthatcervicallateralglidesresultedinanimmediateimprovementinpainat
thelateralelbow,inpainfreegripstrength,andinincreasedROMduringupperlimbneurodynamictestingin
patientswithlateralepicondylosis.AretrospectivestudybyClelandetal.200demonstratedthatpatients
receivingmanualtherapytechniquesdirectedatthecervicalspineachievedsimilarsuccessratesasagroupwho
receivedtreatmentsolelydirectedattheelbow,butthattheyachievedthissuccessinsignificantlyfewervisits(p
=0.01).AnotherclinicaltrialbyClelandetal.201whichcomparedtheoutcomesof10patientswithlateral
epicondylosiswhowererandomlyassignedtoreceivelocalizedtreatmentorlocalizedtreatmentplusmanual
therapytothecervicothoracicspine,foundthatthelattergroupdemonstratedgreaterimprovementinall
outcomemeasuresascomparedtothetreatmentgroupreceivingthelocalizedmanagement.Replicationofthese
resultsisneededinalargescalerandomizedclinicaltrialwithacontrolgroupandalongertermfollowup
beforeanymeaningfulconclusionscanbedrawn.
InarandomizedtrialbyBissetetal.202thatinvestigatedtheefficacyofphysicaltherapyfortenniselbow
(combiningmobilizationswithmovement[MWM]techniquesandexercise)comparedwithawaitandsee
approachorcorticosteroidinjectionsovera52weekperiodconcludedthatthephysicaltherapyinterventionhad
asuperiorbenefittoawaitandseeapproachinthefirst6weeksandtocortisoneinjectionsafter6weeks.
Otherformsofphysicaltherapyincludingelectrotherapyandthermotherapyhavenotbeenproventobe
effective.194
Thepatientmaybeprescribedanorthoticdeviceasatreatmentstrategy,andmanydifferenttypesofbracesand
otherorthoticdevicesareavailable.Themaintypeisabandorstraparoundthemusclebellyofthewrist
extensors.Theoretically,bindingthemusclewithaclasp,band,orbraceshouldlimitexpansionandthereby
decreasethecontributiontoforceproductionbymusclefibersproximaltotheband.203However,thebenefitsof
tenniselbowbracesremainunproven.SnyderMacklerandEplerreportedonacomparisonofastandard
tenniselbowbraceandonewithanairfilledbladder,204butitisnotpossibletoextrapolatefromtheirfindings
totheefficacyoftenniselbowbracesinthemanagementoftenniselbow.Counterforcebracing205(suchasthe
CountRForcebracefromMedicalSports,Arlington,VA)hasbeenshownto
beneficiallyimpactforcecoupleimbalancesandalteredmovements,127,206,207
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decreaseangularaccelerationattheelbow208and
decreaseEMGactivity.208
However,tenniselbowbraceshavebeenshowntohavelittleeffectinvibrationaldampening.209Asan
alternativetobracing,Gellman210recommendsaprotective20degreewristextensionsplintfortenniselbowto
helpoffloadtheECRB.138InastudybyStruijsetal.,203atotalof180patientswererandomizedintothree
groups:braceonlytreatment,physicaltherapy,andacombinationofthese.Mainoutcomemeasureswere
successrate,theseverityofcomplaints,pain,disability,andsatisfaction.Physicaltherapywassuperiortobrace
onlyat6weeksforpain,disability,andsatisfaction.Contrarily,braceonlytreatmentwassuperiorintheability
ofdailyactivities.Combinationtreatmentwassuperiortobraceontheseverityofcomplaints,disability,and
satisfaction.At26and52weeks,nosignificantdifferenceswereidentified.203Theresultsfromthestudywould
tendtoindicatethatthebracetreatmentmightbeusefulasaninitialtherapy.
TheMillsmanipulation(seeInterventionsection),athrusttechniquethatisintendedtomaximallystretchthe
ECRBtendoninordertotrytopullapartthetwosurfacesofthepainfulscar,hasbeenrecommendedtotreat
truetenniselbow.211Manipulationofthiskindhasalsobeenadvocatedinotherstudies.212214
NirschlandSobel119haveattemptedtodeterminewhetherthepresentingsymptomsarehelpfulinboth
diagnosinganddirectingtheintervention.Thisinformationwaspreviouslypublishedintheformofatable.119
Types1and2.Benign(nonharmful)pain:Type1painischaracterizedbystiffnessormildsorenessafter
activityandresolveswithin24hours.Type2painismarkedbystiffnessormildsorenessafterexercise,
lastsmorethan48hours,isrelievedwithwarmupexercises,isnotpresentduringactivity,andresolves
within72hoursafterthecessationofactivity.Thepainassociatedwithtypes1and2maybedueto
peritendinousinflammation.
Type3.Semibenign(likelynonharmful)pain:Type3painischaracterizedbystiffnessormildsoreness
beforeactivityandispartiallyrelievedbywarmupexercises.Thepaindoesnotpreventparticipationin
theactivityandisonlymildduringactivity.However,minoradjustmentsinthetechnique,intensity,and
durationofactivityareneededtocontrolthepain.Type3painmaynecessitatetheuseofnonsteroidal
antiinflammatorymedications.
Type4.Semiharmfulpain:Type4painismoreintensethantype3painandproduceschangesinthe
performanceofaspecificsportsorworkrelatedactivity.Mildpainaccompaniestheactivitiesofdaily
living.Type4painmayreflecttendondamage.
Types57.Harmfulpain:Type5pain,whichischaracterizedasmoderateorseverebefore,during,and
afterexercise,greatlyaltersorpreventstheperformanceoftheactivity.Painaccompaniesbutdoesnot
preventtheperformanceofactivitiesofdailyliving.Completerestcontrolsthepain.Type5painreflects
permanenttendondamage.Type6pain,whichissimilartotype5pain,preventstheperformanceof
activitiesofdailylivingandpersistsdespitecompleterest.Type7painisaconsistent,achingpainthat
intensifieswithactivity,andthatregularlyinterruptssleep.
Thepainoftypes1and2isusuallyselflimitingwhenproperprecautionsaretaken.Types3and4usually
respondtononoperativemedicaltherapy.Thepaintypesof57aremorelikelytonecessitateoperative
treatment.119
Johnson215recommendsanexerciseregimenconsistingofPREstothewristextensors,withtheelbowflexedto
90degreesandalsowiththeelbowstraight.Theexercisesareperformedona10repetitionmaximum,morning
andnight.Gradually,theweightisincreasedsothatthe10repetitionmaximumisalwaysmaintained.Thepain
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mayincreaseforthefirstweekortwoorthree,butbythefifthorsixthweeks,theelbowpainwillbebetter.An
icepackorheatingpadcanbeusedduringthepainfulperiod.215
Sinceeccentricexercisesaretypicallyadvocatedfortendoninjuries,onestudy216randomlyassigned38
patientstoacontractrelaxstretchingoreccentricexercisetreatmentgroup.Seventyonepercentreportedfull
recoveryintheeccentricexercisegroup,with39%inthecontractrelaxstretchinggroup.216TheelasticFlexBar
(Theraband,HygienicCorp,Akron,Ohio)producesaneccentricoverloadtowristandforearmmusculatureby
preloadingthewristandfingermusculaturefollowedbyaslowereccentriccontraction.Atwistingexercise
usingtheFlexBarcanbedesignedtoeccentricallyloadthewristextensors.Toeccentricallystrengthenthewrist
extensorsoftherightupperextremity,thepatientgraspsoneendoftheFlexBarwiththerighthand(Fig.1772).
TheFlexBaristhengraspedbythelefthand(Fig.1773)andbothelbowsareextendedwiththeforearms
supinated(Fig.1774).Onceinthisposition,thepatienttwiststheFlexBarintowristflexionusingtheright
hand(Fig.1775).
FIGURE1772
Startpositionfortwistingexercise.
FIGURE1773
PatientgraspsFlexBarusinglefthand.
FIGURE1774
BothhandsholdingFlexBarwithelbowsextended,forearmspronated.
FIGURE1775
PatienttwiststheFlexBarintowristflexionusingrighthand.
Incorrecttechnique,particularlywithracquetsports,isthecauseofmanyelbowproblems.Emphasisshouldbe
placedonrecruitingthewholeoftheshoulderandtrunkwhenhittingtheball,soastodissipatetheforcesas
widelyaspossible.Itisimportanttohitstrokeswithafirmwristandnotbymeansofwristmovementstoreturn
theball.Alatebackhandintennisshouldbecorrectedasthisstrokeisthemostcommoncauseofstresstothe
elbowifperformedincorrectly.130,217,218Whereastheforehanddemonstratesgoodweighttransferthefaulty
backhandhasnoforwardweighttransfer,andthefrontshoulderisusuallyelevated.172Thetrunkleansaway
fromthenetatthetimeofimpact,andtheracquetheadisdown.172Theelbowandwristextendbeforeimpact,
andthepowersourceisforearmextensioninthepronatedposition,resultinginastrokethatisnonrhythmicand
jerkyandwithsharppronationatfollowthrough.172Sometimestheuseofatwohandedbackhandmaybe
helpful.Onetheorytosupportthisisthattheonehandedbackhandlinksfivebodypartspriortoimpact(hipsto
trunktoshouldertoelbowtowrist),whilethetwohandedbackhandonlylinkstwobodyparts(hipstotrunk)
priortoimpactwiththeball.138
Theballshouldbehitwiththecenterpointofthestrings,orsweetspot.Whentheballishitincorrectly,the
forcesaretransmittedasanacutestrainupandalongthemusclemasstotheextensororiginattheelbow.217
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Inadditiontocorrectingpoortechnique,patienteducationshouldaddressracquetsize,gripsize,andstring
tension.Afiberglass,graphite,orwoodracquetismoreforgivingthanametalone.Tennisracquetswithlarger
headsizesreducearmvibration.219Tennisracquetsshouldbestrungwithgut,asitismoreresilientthannylon
strings,to5255lbtoallowtheimpacttobespreadoverslightlymoretimeanddecreasetheforcestransmitted
totheforearmmuscles.220,221Currently,theuseofamidsizedmediumflex,graphitetennisracquetwith
looselystrungnylonmonofilamentisrecommended.Thegripsizeshouldnotbetoolargeortoosmall,222and
anincreasedracquethandlediameterishelpfulforplayerswithrelativelyweakwristextensors.
Ifthesymptomsarenotcontrolledwiththeabovemeasures,localinjectionofacorticosteroidmaybehelpful.It
wasnotuntilthe1950sthattheinjectionofcorticosteroidswasfirstreported.223225FreelandandGribble
foundthathydrocortisonewasneithermorenorlesseffectivethanprocaineandconcludedthattheshortterm
reliefofpainwasanonspecificresponsethatmaybeduetothevolumeoffluidinjectedortothetraumaof
introducingtheneedle.224Subsequentlyanumberofstudieshaveshownsteroidstobebeneficial,andthishas
remainedoneofthemainstaysofconservativetreatment.226228
OperativeIntervention
Surgeryisindicatedifthesymptomsdonotresolvedespiteaproperlyperformedconservativeintervention
lasting6months.139Asimplehandshaketestcanhelptodeterminewhethersurgicalinterventionisrequired.229
Thepatientisaskedtoperformafirmhandshakewiththeelbowextended,andthensupinatetheforearmagainst
resistance.Thecliniciannoteswhetherthepatientreportshavingpainattheoriginoftheextensorsofthewrist.
Theelbowisthenflexedto90degrees,andthesamemaneuverisperformed.Ifthepainisdecreasedinthe
flexedposition,operativetreatmentislesslikelytobeneeded.Ifthepainisequallyseverewiththeelbowflexed
andextended,thenoperativeinterventionismorelikelytobeneeded.229
Thegoalsofoperativetreatmentoftendinosisoftheelbowaretoresectthepathologicmaterialtostimulate
neovascularizationbyproducingfocusedlocalbleeding,andtocreateahealthyscarwhiledoingtheleast
possiblestructuraldamagetothesurroundingtissues.Postoperatively,acarefullyguidedresistancebased
rehabilitationprogramisrecommended.
MedialEpicondylosis(GolfersElbow)
Medialepicondylosisisonlyonethirdascommonaslateralepicondylosis.100Itprimarilyinvolvesa
tendinopathyofthecommonflexororigin,specificallytheFCRandthehumeralheadofthepronator
teres.49,100,230Toalesserextent,thepalmarislongus,FCU,andFDSmayalsobeinvolved.217
Aswithtenniselbow,golferselbowisnotonlyfoundinathletesthatplaygolfbutcanalsobefoundin
throwingathletes,andworkersinoccupationsthatdemandrepetitivewristflexionactivities.Althoughthe
mechanismformedialepicondylosiscaninvolvedirecttrauma,itismorelikelytobecausedbyoveruseor
repetitivestress.Thiscommonlyoccursforthreereasons:
Fatigueoftheflexorpronatortissuesinresponsetorepeatedstress.
Apredispositionformedialligamentousinjuryduetoasuddenchangeinthelevelsofstress.231
TheMCLfailstosufficientlystabilizeagainstthevalgusforces.232
MedialepicondylosisusuallybeginsasamicrotearattheinterfacebetweenthepronatorteresandFCRorigins
withsubsequentdevelopmentoffibroticandinflammatorygranulationtissue.30Aninflammationdevelopsinan
attempttospeeduptissueproductiontocompensatefortheincreasedrateofmicrodamagecausedbyincreased
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useanddecreasedrecoverytime.233Chronicsymptomsresultfromalossofextensibilityofthetissues,leaving
thetendonunabletocopeeffectivelywithtensileloads.
ClinicalPresentation
Thetypicalclinicalpresentationformedialepicondylosisispainandtendernessovertheflexorpronatororigin,
slightlydistalandanteriortothemedialepicondyle.Thesymptomsaretypicallyreportedtobeexacerbatedwith
eitherresistedwristflexionandpronationorpassivewristextensionandsupination.30,100
Differentialdiagnosisformedialelbowsymptomsincludes:234
MCLinjuryorinsufficiency22,235,236
ulnarnerveentrapment(ulnarneuritis,whichalsocommonlyoccursalongwithmedialepicondylosis)
and
medialelbowintraarticularpathology.237
Intervention
Conservativeinterventionformedialepicondylosishasbeenshowntohavesuccessratesashighas90%.100
Theconservativeinterventionforthisconditioninitiallyinvolvesrest,activitymodification,andlocal
modalities.Completeimmobilizationisusuallynotrecommendedasiteliminatesthestressesnecessaryfor
maturationofnewcollagentissue.Oncetheacutephasehaspassed,thefocusswitchestorestoringROMand
correctinganyimbalancesofflexibilityandstrength.Thestrengtheningprograminitiallyincludesmultiangle
isometrics,andthenconcentricandeccentricexercisesoftheflexorpronatormuscles.Similartothetreatment
oflateralepicondylosis,atwistingexerciseusingtheFlexBarcanbedesignedtoeccentricallyloadthewrist
flexors.Toeccentricallystrengthenthewristflexorsoftherightupperextremity,thepatientgraspsoneendof
theFlexBarwiththerighthand(Fig.1776).TheFlexBaristhengraspedbythelefthand(Fig.1777),andboth
elbowsareextendedwiththerightforearmsupinatedandtheleftforearmpronated(Fig.1778).Onceinthis
position,thepatienttwiststheFlexBarintowristextensionusingtherighthand(Fig.1779)
FIGURE1776
Startpositionfortwistingexercise.
FIGURE1777
PatientgraspsFlexBarusingrighthand.
FIGURE1778
BothhandsholdingFlexBarwithelbowsextended,rightforearmsupinated,leftforearmpronated.
FIGURE1779
PatienttwiststheFlexBarintowristextensionusingrighthand.
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Splintingortheuseofacounterforcebracemaybeausefuladjunct.30
INTEGRATIONOFPRACTICEPATTERNS4FAND5F:
IMPAIREDJOINTMOBILITY,MOTORFUNCTION,MUSCLE
PERFORMANCE,ANDRANGEOFMOTION,ORREFLEX
INTEGRITYSECONDARYTOSPINALDISORDERS,
PERIPHERALNERVEENTRAPMENTS,COMPARTMENT
SYNDROME,ANDMYOFASCIALPAINDYSFUNCTION
CompressiveNeuropathies
Intheregionoftheelbow,thereareamultitudeofsiteswheretheperipheralnervescanbeentrappedor
compressed(Table1710),withinvolvementoftheulnarandmedianandradialnervesandtheirbranchesbeing
byfarthemostcommon.68Table1711outlinesasummaryofconservativemanagementstrategiesforthe
variousnerveentrapments.
TABLE1710NerveInjuriesabouttheElbow
Nerve MotorLoss SensoryLoss FunctionalLoss
Pronatorteres
Flexorcarpi
radialis
Palmarislongus
Palmarislongus
Flexor
digitorum
Pronationweakness
superficialis Palmaraspectofhandwith
Wristflexionandabductionweakness
Flexorpollicis thumb,index,middle,andlateral
Lossofradialdeviationatwrist
Mediannerve(C6 longus halfofringfinger
Inabilitytoopposeorflexthumb
8,T1) Lateralhalfof Posterior(dorsal)aspectofdistal
Thumbabductionweakness
flexor thirdofindex,middle,and
Weakgrip
digitorum lateralhalfofringfinger
Weakornopinch(apehanddeformity)
profundus
Pronator
quadratus
Thenar
eminence
Lateraltwo
lumbricals
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Flexorpollicis
longus
Lateralhalfof
flexor
digitorum Pronationweakness,especiallyat90
Anterior profundus degreeelbowflexion
interosseousnerve Pronator Weaknessofoppositionandthumb
None
(branchofmedian quadratus flexion
nerve) Thenar Weakfingerflexion
eminence Weakpinch(notiptotip)
muscles
Lateraltwo
lumbricals
Flexorcarpi
ulnaris
Medialhalfof
Weakwristflexion
flexor
Lossofulnardeviationatwrist
digitorum
Lossofdistalflexionoflittlefinger
profundus
Posterior(dorsal)andpalmar Lossofabductionandadductionof
Ulnarnerve(C78, Palmarisbrevis
aspectoflittleandmedialhalfof fingers
T1) Hypothenar
ringfinger Inabilitytoextendsecondandthird
eminence
phalangesoflittleandringfingers
Adductor
(benedictionhanddeformity)
pollicis
Lossofthumbadduction
Medialtwo
lumbricals
Allinterossei
Anconeus
Brachioradialis
Extensorcarpi
radialislongus
andbrevis
Extensor Posterioraspectofhand(lateral
Lossofsupination
digitorum twothirds)
Lossofwristextension(wristdrop)
Extensor Posterioraspectandlateral
Radialnerve(C58, Inabilitytograsp
pollicislongus aspectofthumb
T1) Inabilitytostabilizewrist
andbrevis Proximaltwothirdsofposterior
Lossoffingerextension
Abductor aspectofindex,middle,andhalf
Inabilitytoabductthumbs
pollicislongus ofringfinger
Extensorcarpi
ulnaris
Extensorindicis
Extensordigiti
minimi
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Extensorcarpi
radialisand
brevis
Extensor
digitorum
Extensor Weakwristextension
Posterior
pollicislongus Weakfingerextension
interosseousnerve
andbrevis None Difficultystabilizingwrist
(branchofradial
Abductor Difficultywithgrasping
nerve)
pollicislongus Inabilitytoabductthumb
Extensorcarpi
ulnaris
Extensorindicis
Extensordigiti
minimi
DatafromMageeDJ.OrthopaedicPhysicalAssessment.2ndeds.Philadelphia,PA:WBSaunders2008.
TABLE1711SummaryofConservativeManagementforNerveEntrapments
Entrapment
Nerve Intervention
Site
Carpaltunnel Splintwristinneutralpositionatnight
Median Proximal Stretchingexercisesforpronatorteres
forearm Restperiodsinsupination
Splintwristinneutralpositionatnight
Elbowpad
Guyonscanal
Ulnar Education:positioninginelbowextensionanddecreasingdirect
Cubitaltunnel
pressureonnerve
Stretchtheflexorcarpiulnaris
Radial(posterior Arcadeof Positioninginsupinationandavoidrepetitivepronationand
interosseous) Frhse supinationactivities
Positioninginsupinationandavoidrepetitivepronationand
Radial(sensory) Forearm
supinationactivities
Avoidprovocativepositions
Brachialplexus Supraclavicular Stretchshortenedmusclesandstrengthenweakenedscapular
muscles
UlnarNerveEntrapment(CubitalTunnelSyndrome)
Althoughtheulnarnerveiswellprotectedabovetheelbow,thenervecanbecompressedorentrappedata
numberoflocations.Nirschlhasdividedthemedialepicondylargrooveintothreezones:238,239
zoneI:proximaltothemedialepicondyle
zoneII:thelevelofthemedialepicondyle(retrocondylargroove)and
zoneIII:distaltothemedialepicondyle(cubitaltunnel).
RepetitiveoverusecanresultincompressionoftheulnarnerveinzoneIIIbyatightFCUmuscle.173
EntrapmentcanalsobeprecipitatedinzonesIIandIIIbyasubluxatingulnarnerve,inzoneIIbyelbow
synovitis,inzoneIorIIbyacubitusvalgusdeformity,orinzoneIbythemedialintermuscularseptum,which
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slopesfromathickwidebaseatthemedialepicondyle,toaweakandthinedgemoreproximalonthehumeral
shaft.60,66,173
Ithasbeensuggestedthatbecauseofthesuperficiallocationoftheulnarnerve,anyrepetitivemotionmay
initiateacycleofinflammationandedemathatinhibitsthenormalglidingofthenerve.55,240Additionalinjury
occurswhentractionforcescausedbyelbowflexionproduceanadditionalcompressiveforceontheinternal
architectureofthenerve.58,241Theseverityofnerveinjurywillbedependentonthemagnitude,duration,and
characteroftheappliedforces.55,240
Theanconeushasalsobeenreportedasacauseofcubitaltunnelsyndromeandhasbeenfoundtooccurin3
28%ofhumananatomicspecimenelbows,57,242andinasmanyas9%ofpatientsundergoingsurgicaltreatment
forcubitaltunnelsyndrome.243
Theclinicalfindingsforanulnarnerveentrapmentdependonthelocationofthelesionandmayinclude:244
activityrelatedpainorparesthesiasinvolvingthefourthandfifthdigits,accompaniedbypainthatmay
extendproximallyordistallyonthemedialaspectoftheelbow
painorparesthesiasworseatnight
decreasedsensationintheulnardistributionofthehand
progressiveinabilitytoseparatethefingers
lossofgrippoweranddexterity
atrophyorweaknessoftheulnarintrinsicmusclesofthehand(latesign)
clawingcontractureoftheringandlittlefingers(latesign)245
positiveelbowflexionandpressureprovocativetest
positiveWartenbergssignandFromentssign(seeChapter18)and
positiveTinelssignattheelbow.
Conservativeinterventionisrecommendedforpatientswithintermittentsymptomsandwithoutchangesintwo
pointdiscriminationormuscleatrophy.Activitymodificationwithprotectionoverthecubitaltunnelwithan
elbowpadplacedonthemedialposterioraspect,244limitingrepetitiveextremeelbowflexion,andnight
splintingat4060degreesmaybehelpful.58Inseverecases,thesplintiswornduringtheday,ortheelbowis
castatabout45degrees.Exercisesmustnotreproducethedistalnervesymptomsandmay,therefore,initially
needtobeperformedinlimitedarcsofmotion.173Forthosepatientswhofailtorespondtoconservative
managementafter34months,andwhohavemuscleatrophy,persistentsensorychanges,orpersistent
symptoms,surgicaldecompression,orananteriortranspositionoftheulnarnerveisavailable.66
MedianNerveEntrapment(HumeralSupracondylarProcessSyndrome)
Mediannerveentrapmentattheelbowisrelativelyrare,althoughitisoftenmisdiagnosedasCTS.97Themost
proximalsiteatwhichthemediannervecanbecompressedisinthedistalarmbytheligamentofStruthers,an
anatomicvariantpresentin0.72.7%ofthepopulation.246VeryfewcasesofaligamentofStruthersneuropathy
aredescribedintheliterature.67,247,248Thepatientmaycomplainofpaininthewristormedialforearm,which
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isexacerbatedwithfullelbowextensionorpronationoftheforearm.67,248Thepatientmayalsoreport
paresthesiasintheindexorlongfinger.67
Intheantecubitalarea,therearethreesitesofpotentialmediannerveentrapment.97Onesiteisasthenerve
passesunderthelacertusfibrosus,orbicipitalaponeurosis,afascialbandextendingfromthebicepstendonto
theforearmfascia.249Thesecondsiteisatthelevelofthepronatorteresmuscleafterthenervecrossesthe
elbow.ThethirdpotentialsiteisasthemediannervetravelsundertheFDS.Compressionofthemediannerveat
anyoneofthesethreesitesconstituteswhatisdescribedintheliteratureasthepronatorsyndrome(PS).
PronatorSyndrome
Thepatienttypicallycomplainsofaninsidiousonsetofpainthatisusuallyfeltontheanterioraspectofthe
elbow,radialsideofthepalm,andthepalmarsideofthefirst,second,third,andhalfofthefourthdigits.There
isoftenassociatedheavinessoftheforearm.97UnlikeCTS,thereisnoTinelssignatthewrist,andthereare
nonocturnalsymptoms.250,251Paincanbereproducedwith64
pressureappliedoverthepronatorteres4cmdistaltothecubitalcreasewithconcurrentresistanceagainst
pronation,elbowflexion,andwristflexion252
resistedsupination(duetocompressionofthelacertusfibrosus)and
resistanceofthelongfingerflexors(duetocompressionbytheFDSarch).
Diagnosisisconfirmedelectromyographically.PStypicallyrespondswelltoactivitymodification(removingthe
causativeactivity),rest,NSAIDs,ice,andtherestorationofproperflexibilityandstrengthofthewristflexors
andforearmpronators.Rehabilitationwillmostbenefitthosecasesinwhichcompressionisrelatedtomedial
elbowtendinosis.Inthesecases,gentlemassagealongthefibersmayaidinthebreakingofadhesions.Surgical
reliefmaybeneededinrecalcitrantcases.250
AnteriorInterosseousSyndrome
AnteriorinterosseoussyndromewasfirstdescribedbyTinelin1918andwasfurtherdelineatedbyKilohand
Nevinin1952.250
PotentialsourcesofentrapmentoftheAINincludetheGantzersmuscle(anaccessoryheadoftheFPL),andthe
FCRmuscle.97,249,253
CompressionoftheAINresultsinforearmpain,andmotorlossoftheFPL,pronatorquadratus,andthelateral
halfoftheFDP,suchthatthepatientisunabletoperformtheOKsignwiththeindexfingerandthumb.This
mustbedifferentiatedfromaruptureofthemuscleoritstendon.Nosensorychangesoccur,eventhoughthe
AINcarriessensoryinformationfromthedistalradioulnarjoint,radiocarpaljoint,andintercarpaljoints.254
Painandweaknessaretypicallyprovokedwithresistedflexionoftheinterphalangeal(IP)jointofthethumband
withthedistalinterphalangeal(DIP)jointoftheindexfinger.
Thedifferentialdiagnosisincludesneuralgicamyotrophy,FPLtendonrupture,andindexfingerFDPrupture.
MostcasesofAINsyndrometypicallyresolvespontaneously.255
AlthoughthePSandtheAINsyndromesarerelativelyrare,itisimportanttobeabletodifferentiallydiagnose
thesyndromesincasesofsuspectedCTS.ParesthesiaisabsentinAINandpresentinbothPSandCTS.256CTS
involvesparesthesiainthelateral3digits,whereasPSinvolvesparesthesiainthelateral3digitsandoftenin
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thedistributionofthepalmarcutaneousbranchofthemediannerve.256TheparesthesiainCTSmaybe
reproducedbycompressionoverthewristorPhalenstest,whereasPSrequirescompressionatthepronator
terestoreproduceparesthesia.Tinelssignispresentatthewristin80%ofcasesofCTSandispresentatthe
pronatorteresinPSinlessthan50%ofcases.256AINsyndromeiseasilydifferentiatedfromCTSbythelackof
paresthesiacomplaints.256
RadialNerveEntrapment
Theradialnerveisthemostcommonlyinjuredperipheralnerve(seeChapter3)and,becauseofitsspiralcourse
acrossthebackofthemidshaftofthehumerus,anditsrelativelyfixedpositioninthedistalarmasitpenetrates
thelateralintermuscularseptum,itisthemostfrequentlyinjurednerveassociatedwithfracturesofthehumerus.
Anumberofradialnerveentrapmentsarerecognizedandarenamedaccordingtothelocationatwhichthey
occur.Fourradialnerveentrapmentsarecommonlycited:highradialnervepalsy,posteriorinterosseousnerve
syndrome(PINS),radialtunnelsyndrome(RTS),andsuperficialradialnervepalsy.Thevarioussymptomsof
theseentrapmentscanaidthecliniciantodeterminethelevelofentrapment.
CLINICALPEARL
Therearemotorandsensoryinvolvementswiththehighradialnervepalsy,motorinvolvementwiththePINS,
painwiththeRTS,andsensorydisturbanceswiththesuperficialradialnervepalsy.257Symptomsofpain,
cramping,andtendernessintheproximalposterior(dorsal)forearm,withoutmuscleweakness,areassociated
withRTS,whereasPINSinvolvesthelossofmotorfunctionofsomeorallofthemusclesinnervatedbythePIN
andisthuscharacterizedbyweakness.257
HighRadialNerveCompression
Aspontaneousnervecompressionmayoccurinthemidarmatthelevelofthelateralheadofthetricepsdueto
strenuousmuscularexercise.258Amidshafthumerusfracturecanresultinaradialneuropathyatthespiral
grooveofthehumerusin14%ofhumeralfractures.259Regardlessofthecause,ahighradialnervepalsywill
resultinalossofwristextension,aninabilitytoextendthefingersandthumb,andadecreaseinsensibilityof
thefirstposterior(dorsal)webspace.257Involvementofthetricepsmuscleisdependentonthelevelof
compression.Acervicalradiculopathyandthoracicoutletsyndromemustbeconsideredinthedifferential
diagnosis.
PosteriorInterosseousNerveSyndrome
TherearefourpotentialsitesofcompressionofthePINasittraversesthroughtheradialtunnel:68,71,257,260
thefibrousbandsthatconnectthebrachialistothebrachioradialis.73,261
thevascularleashofHenry,afanofbloodvesselsthatcrossthenerveattheleveloftheradial
neck.71,73,262
amedialproximalportion(leadingedge)oftheECRB.71,73
Betweenfibrousbandsattheproximalanddistaledgeofthesupinator.263Theproximalborderofthe
supinator,throughwhichtheradialnervepasses,isreferredtoasthearcadeofFrhse.
SymptomsofPINentrapmentincludelateralelbowpainthatradiatesintothedistalforearmandisaggravated
byrepetitivepronationandsupinationmostspecificallyresistedsupination.Tendernessisnoted34cmdistal
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tothelateralepicondyleswheretheradialnervecrossestheradialheadandpenetratesthesupinatormuscle.PIN
palsyproducesaninabilitytoextendtheMCPjointsofthethumb,index,long,ring,orsmallfingerseither
individuallyorincombination.264,265Inaddition,thereisalossofthumbIPextensionandradialabductionof
thethumb.257SincethePINcaninnervatetheECRBpriortothenervesentranceintotheradialtunnel,this
musclemaynotbeinvolvedinthePINpalsy.Thus,whencompressionwithintheradialtunnelissufficientto
causeparalysis,butthereisnopalsy,theconditionistermedPINS.250
Initialconservativeinterventionincludesrest,activitymodification,andtheuseofacockupsplint.Regular
gentlestretchingofthewristextensormuscles,withtheelbowheldinfullextension,isbegunaftera
spontaneousrecovery.250
RadialTunnelSyndrome
RTSinvolvescompressionofthedeepbranchoftheradialnerve.MicheleandKrueger266havebeencredited
withrecognizingRTSasadistinctentityandgaveitthenameradialPS.ThetermRTSwasintroducedbyRoles
andMaudsley,73whosuggestedthatRTSwasthecauseofresistanttenniselbowpain.
ThesamestructuresimplicatedinPINcompressionsyndromecancauseRTSalthoughRTSisoftenthoughtof
asadynamiccompressionsyndrome.267Thisisbecausecompressionofthenerveoccursduringelbow
extension,forearmpronation,andwristflexion,whichcausestheECRBandthefibrousedgeofthesuperficial
partofthesupinatortotightenaroundthenerve.Thesymptomsfromthiscompressioncanmimicthoseof
tenniselbow,namelytendernessoverthelateralaspectoftheelbow,painonpassivestretchingoftheextensor
muscles,andpainonresistedextensionofthewristandfingers.73,267Menandwomenareequallyaffected,and
thecompressionappearstobecommoninthefourthtosixthdecadesoflife.71
Pain,whichispoorlylocalizedovertheradialaspectoftheproximalforearm,isthemostcommonprimary
presentingsymptominRTS.Infact,itistheonlynervecompressionsyndromeinwhichthesignsand
symptomsarenotbasedonthenervedistribution.268
Uponpalpation,maximaltendernessisusuallyelicitedovertheradialtunnel,some5cmdistaltothelateral
epicondyle,anteriortotheradialneck.Resistedmiddlefingerextension,73whichtightensthefascialoriginof
theECRB,andresistedsupinationoftheforearmwiththeelbowfullyextended71shouldreproducethepainat
thepointofmaximaltenderness.Positioningthearminelbowextension,forearmpronation,andwristflexion
producessignificantcompressionoftheradialnerve.250
Conservativeinterventionshouldfocusoneducationtoavoidtheprovocativepositioningofthearminto
forcefulextensionandsupinationofthewristandforearmandshouldincluderest,stretching,and
splinting.73,269
Ifawristimmobilizationsplintisused,itisfittedin45degreesofextensionforcontinualwear.
Surgicalinterventionisreservedforpatientswhosesymptomsarenotrelievedbyconservativeintervention.
RadialSensoryNerveEntrapment
ThetermWartenbergssyndrome270orcheiralgiaparestheticaisusedtodescribeamononeuritisofthe
superficialradialnerve,whichcanbecomeentrappedwhereitpiercesthefasciabetweenthebrachioradialisand
ECRLtendons.249,257Symptomsincludeshootingorburningpainalongtheposteriorradialforearm,wrist,and
thumb,associatedwithwristflexionandulnardeviation.257Thesesymptomscanleadthecliniciantobelieve
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thatthefirstcarpometacarpaljointand/ortendonsoftheanatomicsnuffboxareinvolved,andthatdeQuervains
diseaseispresent.
MusculocutaneousNerveEntrapment
Thebrachialisisapureelbowflexor,whereasthebicepsbrachiiisanelbowflexorandsupinatorofthe
forearm.46,271Withcompletelossofmotorfunctionofthesetwomusclesduetoalesionofthe
musculocutaneousnerve,functionalelbowflexionstrengthcanstillbeobtainedwithcontractionofthe
brachioradialisandpronatorteres.272TheECRL,FCU,FCR,andpalmarislongusmayalsoassistinflexingthe
elbow.273Thebrachioradialishasabettermechanicaladvantagewhentheelbowisflexedto90degreesandis
moreactivewhentheforearmisinthepronatedorneutralposition.273Thepronatorterescanproducefull
elbowflexion,butthisisaccompaniedbyforearmpronation.272,274Thus,withacompletemusculocutaneous
nervepalsy,fullantigravityelbowflexioncanstillbeobtainedbutisstrongestwiththeelbowflexedat90
degreesandtheforearmpronated.
AcuteCompartmentSyndrome
SeeChapter5.
MyofascialPainDysfunction
Elbowpain,whennotrelatedtothejointortomicrotearingofthecommonflexororextensortendons,is
commonlyreferredintotheelbowfromanumberofsources,includingmyofascial.Evenifmicrotearingis
present,triggerpointscanalsobepresentintherelevantmuscles,placingachronicstrainonthattendon.
Supinator
Thismusclereferspainandtendernessprimarilytothelateralepicondyleoftheelbow,butalsototheposterior
(dorsal)webspacebetweenthethumbandindexfinger.AccordingtoTravellandSimons,275eachofthe
commonsitesfortenniselbowcanbeaccountedforbytriggerpointsinthesupinator,ECRL,andtriceps
muscles.
Supinatorpainreferralisactivatedbyplayingtenniswithanextendedelbow,whichdoesnotallowthebiceps
brachiitotakepartinthesupinationrequiredtocontroltheheadofthetennisracquet.276
TricepsBrachii
Atriggerpointinthemedialheadofthetricepsisacommoncauseoflateralelbowpainfromthelateralsideof
thismuscleorofmedialelbowpainfromthemedialsideofthismuscle.276
INTEGRATIONOFPRACTICEPATTERNS4GAND4I:
IMPAIREDJOINTMOBILITY,MOTORFUNCTION,MUSCLE
PERFORMANCE,ANDRANGEOFMOTION,ASSOCIATED
WITHFRACTURESANDBONYORSOFTTISSUESURGICAL
PROCEDURES
RadialHeadFractures
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Radialheadfracturesanddislocationsaretraumaticinjuries(exceptfortheoccurrenceofcongenitalradialhead
dislocations),usuallyfromaFOOSHwiththeforceofimpacttransmittedupthehandthroughthewristand
forearmtotheradialhead,whichisforcedintothecapitellum.Bothoftheseconditionsrequireadequate
treatmenttopreventdisabilityfromstiffness,deformity,posttraumaticarthritis,nervedamage,orotherserious
complications.277Thesefracturesanddislocationsmaybeisolatedjusttotheradialhead(andneck)andthe
lateralelbow(andproximalforearm),ortheymaybepartofacombinedcomplexfracturepattern,involving
otherstructuresoftheelbow,andeventhedistalhumerus,orforearmandwrist.Bluntorpenetratingtrauma
rarelycausesradialheadinjury.Thewrist,especiallythedistalradioulnarjoint,maybedamaged
simultaneously,andthepresenceofwristpain,grinding,orswellingshouldbedetermined.Thepresenceof
bleeding,evenwithsmallpuncturewounds,shouldalertthecliniciantothepossibilityofopeninjury.
Neurovascularsymptomsofnumbness,tingling,orlossofsensationshouldbeidentifiedtoruleoutnerveor
vascularinjury.Thepresenceofseverepainshouldalertthecliniciantothepossibilityofcompartment
syndrome.
Patientswithradialheadfracturesanddislocationspresentwithlocalizedswelling,tenderness,anddecreased
motion.Theclinicianshouldpalpatetheelbow,especiallytheradialhead,feelingfordeformity,andthewrist
shouldbeexamined,especiallyfeelingforthestabilityofthedistalradioulnarjoint.Allthreemajornervesof
theforearmareatriskofelbowfracturesanddislocations,sotheclinicianshouldalsocarefullyassess
neurovascularfunctionforallofthenervesoftheforearmandhand.
Radialheadfracturespresentseveralchallenges,astheradialheadisasecondarystabilizerforvalgusforcesat
theelbowaswellasarestraintagainstlongitudinalforcesalongtheforearm.278CompromiseoftheMCL
makestheradialheadamoreimportantstabilizeroftheelbow.5,278,279Asuccessfuloutcomecorrelatesdirectly
withtheaccuracyofanatomicreduction,restorationofmechanicalstabilitythatallowsearlymotion,and
considerationofthesofttissues.Surgicaloptionsforradialheadfracturesordislocationsincludeclosed
reductionwithcastingorearlymotionoropenreductionwithinternalfixation(ORIF),replacement,or
resection.Openmanagement(includinginternalfixation,replacement,orexcisiondependingonthefracture)is
associatedwithabetterlongtermfunction.
IntheMasonclassification,thefractureisatypeIifitisundisplacedandisgenerallytreatednonoperatively
withasplintoraslingfor3days,andactiveelbowflexionexercisesbeinginitiatedimmediately.Thefractureis
typeIIifasinglefragmentisdisplaced,butmaystillbetreatednonoperativelyifthedisplacementisminimal.A
typeIIIfractureiscomminutedandusuallyrequiresoperativeinterventionbutmayoccasionallybetreated
closedwithearlymotioniftheradialheadisnotreconstructible.
Followingimmobilization,asmuchearlymobilizationasthepatientcantolerateisthekeytoafavorable
outcome.Strengthening,initiallyinvolvingisometricexercises,beginsat3weeksandprogressestoconcentric
exercisesat56weeks.Heavyresistanceisnotperformeduntilafter8weeks,orwhenadequatehealingis
demonstratedonradiographs.WhatfollowsisapostfractureorpostsurgicalprotocolfortypeIfracture,ora
typeIIorIIIfracturethathasbeenstabilizedwithORIF.193
AcutePhase
Duringtheacutephase,thegoalsaretodecreasepainandinflammation,regainfullwristandelbowROM,and
toretardmuscularatrophy.ActiveassistedandactiveROMexercisesareinitiatedattheelbowwiththegoalto
regainaminimumof15105degreesafter2weeks.Grippingexercisesusingputtycanbeinitiatedinaddition
toisometricstrengtheningexercisesoftheelbowandwrist.Finally,concentricstrengtheningexercisesforthe
wristcanbeinitiated.
SubacutePhase
ThegoalsduringthisphasearetomaintainfullelbowROM,progresstoelbowstrengthening,andtogradually
increasefunctionaldemands.Shoulderstrengtheningexercisesareinitiatedandprogressedthatfocusonthe
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rotatorcuffwhiletheROMexercisesfortheelbowarecontinued.TheactiveassistedROMandpassiveROM
exercisesareinitiatedintosupinationpronationtotolerance.
ChronicPhase
ThegoalsduringthisphasearetomaintainfullelbowROM,increasestrength,power,andendurance,andto
graduallyinitiatesportingactivitiesasappropriate.Eccentricelbowflexionextensionandplyometricexercises
areinitiatedandcontinueduntilabout12weeks.
Fractureswithradialheadsurfaceinvolvementofmorethan30%,fracturefragmentdisplacement,andtypeIII
characteristicsrequiremanagementbyanorthopaedicsurgeon.170
MonteggiaFracture
Monteggiafracturedislocationsareaparticulartypeofradialheadinjury,involvingacombinationofa
dislocationoftheproximalendoftheradiusandafractureoftheulna.Insteadoftheradialheaddislocation,the
radialheadorneckmaybefractured.Theselesionstypicallyresultfromadirectblowtotheforearmora
FOOSHinjurywiththearmpositionedineitherhyperextensionorhyperpronation.Theclassificationof
MonteggiafracturedislocationsisoutlinedinTable1712.
TABLE1712ClassificationofMonteggiaFractureDislocations
Type Description Equivalent(s) %
Type Anteriordislocationoftheradialheadandanterior Radialheadorneckfractureinsteadof
60
I angulationoftheulnafracture dislocation
Type Posteriordislocationoftheradialheadandposterior Posteriorelbowdislocation.Radialheador
105
II angulationoftheulnafracture neckfractureinsteadofdislocation
Type Lateraldislocationoftheradialheadwithproximal Radialheadorneckfractureinsteadof
20
III ulnafracture dislocation
Type Anteriordislocationoftheradialheadandproximal Radialheadorneckfractureinsteadof
5
IV shaftsofbothbonesfracturedatsamelevel dislocation
DatafromRabinSI.RadialHeadFractures.Availableat:http://www.emedicine.com/orthoped/topic276.htm,
2005.
Althoughrelativelyrare,thesefracturescanpresentwithseriousproblemsandpoorfunctionaloutcomes
withoutpropercare.280,281Suchcomplicationsincludedamagetotheposteriorbranchoftheradialnerve,AIN,
andtheulnarnerve,aswellasnonunionandpoorAROM.280
ForMonteggiafracturedislocations,besttreatmentincludesopenreductioninternalfixationoftheulna
diaphysealfracture.Followingthesurgery,theelbowisimmobilizedforabout4weeksin90120degreesof
elbowflexion,afterwhichAROMexercisesforelbowflexionandforearmsupinationareinitiated.AROMinto
extensionbeyond90degreesbegins46weekspostoperatively.
CoronoidFracture
Thecoronoidformsasignificantportionofthearticularsurfaceoftheproximalulna.Itservesasanimportant
attachmentsiteformusclesandligamentsabouttheelbowandisessentialforelbowstability.1Coronoid
fractures,whicharemostcommonlyseenwithhighenergyinjuries,areclassifiedaccordingtothesizeofthe
fragmenttype:1,282
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TypeI:Tipavulsion.Thesefracturesaregenerallystableandcanbetreatedassimpledislocationswith
earlymotion.
TypeII:involveslessthan50%oftheheightofthecoronoid.
ManyoftheseareunstableandrequireORIF.
TypeIII:involvemorethan50%oftheheightofthecoronoidandfrequentlyareaccompaniedbyan
instabilityoftheelbow.ORIForahingedexternalfixatormayberequiredtomaintainthereduction.
EssexLoprestiFractures
Thistypeoffractureisdefinedasafractureoftheradialheadwithproximalradiusmigrationanddisruptionof
thedistalradioulnarjointandinterosseousmembrane,283whichtypicallyresultsfromaFOOSHinjury.284
GentleAROMforforearmrotationisinitiatedabout6weeksaftersurgeryandimmobilizationinaMuenster
cast.
PannersDisease
Pannersdisease(osteochondrosisdeformansorosteochondritis)isanasepticorosteonecrosisofthe
epiphysis.285Althoughrelatedtodirecttraumaortochangesinthecirculation,theactualetiologyisunknown.
Pannersdiseaseisrarelyseenbeforetheageof5yearsandaftertheageof16years,anditalmostexclusively
(90%)affectsboys.Themainpresentingsymptomsareapainatthelateralaspectoftheelbow,swelling,anda
limitationofelbowmovementinanoncapsularpattern.Ifadisplacedfragmentispresent,thereisoftena
painlesslimitationofelbowextension,withasoftendfeel,butahardendfeelwhenflexionislimited.12
Conservativeinterventioninvolvesrestfromthrowingorimpactloadingstress,withashortperiodofsplint
immobilizationsometimesbeingnecessary.Theexerciseprogressionisbasedonclinicalfindingsandpatient
tolerance.
OlecranonFracture
Anolecranonprocessfractureisfairlycommonduetoitssubcutaneouslocationandisusuallycausedbyeither
ahighoralowenergyinjury,suchasafallbackwardontotheelboworaFOOSHinjury,whichproduces
passiveelbowflexioncombinedwithasuddenpowerfulcontractionofthetricepsmuscle,resultinginan
avulsionfractureoftheolecranon.286,287
Theclassicsignsofanavulsionfractureinvolvingthetricepsisalossofactiveelbowextensionapalpablegap,
pain,andswellingatthefracturesiteandalargehematomadevelopingintodiffuseecchymosis.288
Thefocusoftheinterventionforthenondisplacedorminimallydisplacedfracturesistoallowrestorationofthe
articularsurfacesandmaintainingtricepsfunctionwhileallowinganearlyROM.Theelbowisimmobilizedina
posteriorsplintorelbowimmobilizer,withtheelbowflexedat90degrees.Pronationandsupinationarestarted
at23days,andpainfreeflexionandextensionmotionsbeginat2weeks.TheROMexercisesavoidfull
flexionforupto2months,andresistanceexercisesareavoidedforupto3months.Protectedimmobilization
shouldcontinueuntilthereisevidenceofunion(6weeks).
AllotherfracturesrequireanORIForexcisionofthebonefragmentswithrepairoftheextensor
mechanism.280,286,287,289Rehabilitationfollowingthesurgicalprocedureisdependentontheextentofthe
surgeryandthelengthoftheimmobilization,althoughtheemphasisonregainingearlymotionremainsthe
same.
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PathologicBoneFormation
Pathologicboneformationabouttheelbowoccursinseveraldistinctforms,whichincludeheterotopic
ossification,myositisossificans,periarticularcalcification,andectopicossification.290
Heterotopicossificationisdefinedastheformationofmaturelamellarboneinnonosseoustissues.
Myositisossificansreferstoheterotopicossificationthatformsininflammatorymuscle.Althoughheterotopic
ossificationandmyositisossificansareradiographicallyandhistologicallysimilar,theseprocessesare
distinguishedbytheiranatomiclocations.291
Periarticularcalcificationreferstocollectionsofcalciumpyrophosphateswithinsofttissuessuchasthe
collateralligamentsorjointcapsule.
Thetermectopicossificationincludesheterotopicossificationandmyositisossificans.Sincemostcasesof
pathologicboneformationabouttheelbowconsistofheterotopicossificationandmyositisossificans,ectopic
ossificationisthemostappropriatedescriptivetermforthisprocess.
Ectopicossificationabouttheelbowcanresultfromdirectinjury,neuralaxistrauma,burns,andgenetic
disorders,292althoughdirectelbowtraumaisthemostcommoncause.293Althoughelbowectopicossification
maybeasymptomatic,itfrequentlycausessevereelbowstiffnessorevenankylosis,andaresultantlossof
function.86,102
ReganandReilly294outlinedfollowingthreefactorsthatpredisposetheelbowtoposttraumaticstiffness:
Thehighdegreeofarticularcongruity
Theconformityoftheelbowjoint
Thecoveringoftheanteriorjointcapsulebythebrachialis,predisposingittoposttraumaticectopic
ossification.Posttraumaticelbowectopicossificationtypicallybeginstoform2weeksaftertrauma,
surgery,burn,orneurologicinsult,294296resultinginlocalizedtissueswellingandtenderness,
hyperemia,andpain.
Mobilizationafterelbowinjuryoftenisdelayed,becauseitisdifficulttoachieverigidinternalfixationof
comminutedelbowfractures.Furthermore,posttraumaticelbowstiffnessmayoccurdespiteearlyaggressive
motionandprophylacticmeasures.
Elbowstiffnessmaydevelop14monthsafteraninitialphaseofmotionrecoveryafterinjury.297Thepatients
chiefcomplaintmaybepain,stiffness,instability,sensoryloss,weakness,orlocking.Ifthepainispresent,itis
locatedanteriorly,inthemiddlethirdofthearm.
Limitedactiveandpassiveelbowflexionandextensionarecharacteristicsofectopicossificationformation
abouttheelbow.However,insomepatients,activeandpassiveelbowmotionmayremainnormal,especiallyin
theearlyphase.However,evenwithaggressiveintervention,includingstaticanddynamicsplintingandfrequent
activeandpassiveROMexercises,elbowmotionmaydiminish.Strengthtestingrevealsweakandpainfulelbow
flexionandextension,andtheendfeelsofelbowROMbecomerigidorabrupt.Oncetheectopicossification
matures,usuallyat39monthsaftertheinjury,elbowROMremainsstableaslongastheactiveandpassive
ROMprogramiscontinued.
Ectopicossificationabouttheelbowmayleadtodelayednervepalsy.Theulnarnerveismostcommonly
affectedhowever,tardymedianandradialpalsieshavealsobeenreported.298300Thiscomplicationmayoccur
severalmonthsormanyyearsaftertheformationofectopicbone.
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Plainradiographsestablishthediagnosisofectopicossification,defineitslocation,andshowitsmaturity.
Radiographsshowectopicossificationasearlyas2weeksafterinjury,andjointincongruity,osteophytes,and/or
malunionwillalsobeapparent.
Nearlyallpatientswhopresentwithelbowstiffnessandectopicossificationshouldbestartedonanaggressive,
activemotionprogramtocombattheprogressivelossofmotionthatoccursduringectopicossification
maturation.Insomepatients,elbowmotionmayimprovehowever,inothers,lossofmotionoccurs,and
ankylosismayresult.Activeexercises,passiveexercises,continuouspassivemotion,dynamicsplinting,and
staticsplintinghaveallbeenadvocated,althoughsomeauthorssuggestthatpassiveelbowexercisesenhance
elbowectopicossificationformationandexacerbateelbowstiffness,301eventhoughthereislittleevidenceto
supportthisbelief.Untilthereisaprospectivestudycomparingpatientswithelbowinjuriestreatedwithpassive
stretchingwithpatientstreatedwithoutpassivestretching,therelationshipbetweenpassiveelbowmotionand
ectopicossificationformationwillremainunclear.However,thepassiveforceshouldbeappliedslowlyand
progressivelysoasnottocauseanyfurtherdamagetothesofttissuesandtherebyprovokeanexacerbation.
Unlessthereisacontraindication,allpatientsarestartedonanactiveandactiveassistedROMprogram.
SplintingisalsocommonlyusedtorestoreelbowROM.Springloadedhingeddynamicsplintsmaybeusedto
counteractflexionandextensioncontractures.Patientsareinstructedtowearthesesplintsforsix1hoursessions
dailyandwhiletheysleep.Ifflexionandextensionarelimited,thepatientisissuedadynamicflexionsplintand
adynamicextensionsplintandinstructedtoalternateuseofthem.Turnbucklesplintsalsoareavailableandare
typicallyusedforrigidcontractures.Thissplintallowsthepatienttoimpartastaticconstantstretchtothesoft
tissuesbytighteningtheturnbuckle.293
Elbowectopicossificationcanbepreventedinmanycaseswithprophylacticmeasures.Patientswhosustainan
elbowinjuryandhaveariskfactorforectopicossificationshouldbetreatedtopreventthiscomplication.Two
formsofprophylaxisareavailable:
Chemotherapeuticagents.TheseincludeNSAIDs.NSAIDshavebeenshowntodecreasetheincidence
andseverityofectopicossificationaboutthehip.Nostudiesexistregardingitseffectonelbowectopic
ossification.
Lowdoseexternalbeamradiation.Clinicalstudiesshowedthatthismodalityinhibitsectopicossification
formationaftertotalhiparthroplasty.302,303
PEDIATRICPATHOLOGY
AcquiredandcongenitalpediatricconditionsoftheelbowaredescribedinChapter30.
SupracondylarFractureofHumerus
Thistypeoffracture,whichoccursmostcommonlyinchildren,involvestheflatandflareddistalmetaphysisof
thehumerus,asaresultofhyperextensionorafallonaflexedelbow.Theforcesaretransmittedthroughthe
elbowjointtothedistalhumerus.Thedistalhumeralfragmentisusuallyposteriorlydisplaced(extensiontype).
Sometimes,afollowthroughoffragmentsresultsinaproximalfragmentpiercingtheanteriorperiosteum,
brachialismuscle,andpossiblythebrachialarteryandmediannerve(flexiontype).Ifthebrachialarteryis
pierced,theinjuryispotentiallylimbthreatening.
Thechildtypicallypresentswithmarkedswellingoftheelbowwithanobviousdeformityandecchymosis.
Becauseofthenatureofthiscondition,peripheralcirculationandnervefunctionmustbeassessed.
Theinterventionisdependentonseverity.Nondisplacedfracturesareimmobilizedinasimpleslingorshoulder
immobilizer,withtheelbowflexedfor3weeks,whereasdisplacedfracturesrequireclosedreductionand
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immobilizationinacastthatdoesnotconstrictcirculation,for3weeks.Duringtheperiodofimmobilization,the
patientiscloselymonitoredforchangesinperipheralcirculation.Followingtheperiodofimmobilization,ifthe
postreductionevaluationisacceptable,AROMexercisesareinitiatedinanefforttoregainfullextension.
Strengtheningofthebicepsandtricepsisalsoaddressed.
THERAPEUTICTECHNIQUES
TECHNIQUESTOINCREASEJOINTMOBILITY
AnumberoftechniquesexisttoincreasejointmobilityandROMfromgeneraltechniquestoveryspecific
techniques.
PassiveAccessoryMobilizations
Withsomeslightvariations,thesametechniquesthatareusedtoexaminethepassiveaccessorymotionsofthe
elbowcomplexcanbeusedtomobilizethejoints,withtheclinicianvaryingtheamplitudeandthevelocityof
thetechnique(i.e.,grade)ofthemobilizationsbasedontheintentofthetreatment,patientresponse,thestageof
tissuehealing,andtheirritabilityofthejoint.
Ulnohumeral
Distraction/Compression
Thesearegeneraltechniquesthatcanbeusedtoimproveoverallelbowmotionintoflexionandextension.
MedialGlide
Thistechniqueiscommonlyusedaspartoftheinterventionformedialepicondylosis.
LateralGlide
Thistechniqueiscommonlyusedaspartoftheinterventionforlateralepicondylosis.
Radiohumeral
AnteriorGlide
Thistechniquecanbeusedtoimproveelbowflexion(Fig.1736).
PosteriorGlide
Thistechniquecanbeusedtoimproveelbowextension(seeFig.1736).
Distraction
Thistechniqueiscommonlyusedaspartoftheinterventionforahumeroradialjointcompressionpositional
fault(Fig.1737).
Compression
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Thistechniqueiscommonlyusedaspartoftheinterventionforahumeroradialjointdistractionpositionalfault
(Fig.1737).
ProximalRadioulnarJoint
Anteromedial/PosterolateralGlide
Theclinicianglidestheradialheadanteromedially(toincreasesupination)/posterolaterally(toincrease
pronation)attheproximalradioulnarjoint(seeFig.1738).
MobilizationswithMovements
ToIncreaseMotionattheElbowandforTennisElbow
Thepatientispositionedinsupinewiththeinvolvedarmonthebed,andtheforearmsupinated.Abeltis
wrappedaroundtheposterioraspectoftheclinicianandaroundthepatientsforearmsothatthebeltedgeis
levelwiththeelbowjoint(Fig.1780).304,305Usingonehand,theclinicianstabilizesthepatientshumerus,
whiletheotherhandsupportsthepatientsforearmandwrist(seeFig.1780).Fromthisposition,theulnais
glidedlaterallyasthecliniciangentlymovestheirhipsbackward.Adjustmentsinthedirectionofthe
mobilizationglidearemadewithrespecttothecarryingangleoftheelbow.Ifthereisnopain,thepatient
activelyflexesorextendstheirelbowwhilethemobilizationforceismaintained.Theactivemotioncanbe
progressedtoresistedwristextensionorresistedgrippingperformedduringthemobilization.
FIGURE1780
Mobilizationswithmovementtoincreaseelbowmotion.
TransverseFrictionalMassage
TFMisusedtotreatanumberofsofttissuestructuresaroundtheelbow.
StrainorOveruseoftheBrachialisMuscleBelly
Althoughuncommon,lesionsofthebrachialismusclebellyaremostoftenseeninlongdistancecrosscountry
skierswithinadequatetraining.Inthefollowingexample,therightbrachialisistreated.
Thepatientispositionednexttotheshortsideofthetreatmenttable,sitting,withtheelbowin90degreesof
flexionandtheforearmrestingonthetableinmaximalsupination.Thecliniciansitsnexttothelongsideofthe
treatmenttablediagonallyfacingthepatient.Theclinicianlocatesthesiteofthelesionbypalpation.Inmost
cases,theinvolvedsiteisdirectlyinthemiddle(betweenmedialandlateral)ofthemusclebelly,atthelevelof
thebicepsmusculotendinousjunction.Theclinicianplacesthemiddlefingerjustlateraltothemusculotendinous
junctionofthebrachialis(Fig.1781).Theotherhandholdsthepatientsforearm.Thebrachialis
musculotendinousjunctionispassivelymovedmedially,asfaraspossible,withthefinger.Afterexerting
pressureposteriorly,theclinicianperformsTFMinalateraldirection.
FIGURE1781
TFMtobrachialismusclebelly.
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StrainorOveruseoftheMuscleBellyMusculotendinousJunctionoftheBiceps
Lesionsofthebicepsmusclebellyormusculotendinousjunctioncanoccurasaresultofcarryingaheavyobject
orfromforcefulthrowingactivities.Inthefollowingexample,therightbicepstendonistreated.
Thepatientispositionednexttotheshortsideofthetreatmenttable,sitting,withtheelbowin90degreesof
flexionandtheforearmrestingonthetableinsupination.Thecliniciansitsnexttothelongsideofthetreatment
tablediagonallyfacingthepatient.Theclinicianlocatesthesiteofthelesionbypalpation.
Thisisdonebymeansofapinchgripbetweenthecliniciansthumbandindexfingeroftherighthand,which
graspstheposterioraspectofthemusclebelly,whiletheotherhandfixesthepatientsforearm.Thetransverse
frictionoccursthroughaflatpinchingtogetherofthethumbandindexfinger.Simultaneousextensionofthe
wristcanbeaddedtopullthemusclebellyfiberstransverselythroughthefingers.
Thebicepsmusculotendinousjunctionistreatedinmuchthesameway.
InsertionTendinopathyoftheTriceps
Transversefrictionisindicatedforlesionsatthemusculotendinousjunction(rare),thetendon,ortheteno
osseousinsertionofthetriceps.Insertiontendinopathyofthetricepscanoccurasaresultofchronicabuseor
macrotrauma.
Thepatientispositionedproneonthetreatmenttable,withtheupperarmrestingonthetableandtheforearm
hangingovertheedgeofthetable.Thecliniciansitsnexttothepatientatthepatientsinvolvedside.Theexact
siteofthelesionisconfirmedbypalpation.Withonehand,theclinicianholdsthepatientselbowinslightly
morethan90degreesofflexion.Thefingersoftheotherhandareplacedatthesiteofthelesion(Fig.1782).
FIGURE1782
TFMtotriceps.
Staticstretchingofthetricepsiscombinedwiththetransversefriction.
InsertionTendinopathyattheMedialHumeralEpicondyle(GolfersElbow)
Thepatientsitswiththeinvolvedarmelevatedsidewaystojustbelowthehorizontal.Theelbowisextendedand
theforearm,supinated.Thecliniciansitsonachairorstoolnexttothepatient.Iftherightelbowistobetreated,
theclinicianstabilizesthepatientsforearmandholdstheelbowinslightflexion.Todeterminethemostpainful
siteofthelesion,thetipoftheindexfingercarefullypalpatestheanteriorplateauofthemedialhumeral
epicondyle(Fig.1783).Duringthefriction,thejointpositionofthefingerdoesnotchange.Thefrictionmotion
consistsofminimalwristextensionandanevensmalleramountofadductionofthearm.
FIGURE1783
TFMofthemedialepicondyle.
TendinopathyoftheExtensorCarpiRadialisBrevis
Thepatientispositioned,sitting,nexttotheshortendofthetreatmenttable.Theupperarmispositionedin45
degreesofabduction,withtheelbowinapproximately80degreesofflexionandtheforearminpronation.The
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cliniciansitsdiagonallyfacingthepatient.ThetendonoftheECRBbrevisislocated.Inthepronatedforearm,
theECRBtendonrunsovertheradialhead(Fig.1784).Inmostcases,thetendonfeltis,infact,thecommon
tendonoftheECRBandtheextensordigitorum.Sometimes,twotendonsarepalpatedthemedialoneisthe
ECRB.TFMisperformedbymovingthefingerinamedialtolateraldirectionoverthetendon.
FIGURE1784
TFMattheradialheadforECRB.
TechniquestoIncreaseSoftTissueExtensibility
Anincreaseinflexibilityisachievedthrougharoutinestretchingprogramthatmaybeinstitutedearlyinthe
courseoftreatment,withemphasisonstretchingtheentirehand,forearm,andshouldercomplex.Stretching
shouldfollowtheapplicationoflocalheatsuchasthataffordedbyahotpack,ultrasoundortransversefriction
massage.Patientsshouldbetaughthowtoperformthesetechniquesonthemselvesattheearliestopportunity.
Ineachofthefollowingtechniques,thestretchismaintainedforapproximately30seconds.
Biceps
Thepatientstandsbyatableandplacesthebackofthehandonthetabletopwiththeforearmsupinated.The
elbowisgraduallyextended,andtheforearmismovedintofurthersupination(Fig.1785).
FIGURE1785
Bicepsstretch.
ElbowandWristFlexors
Thepatientispositionedinstanding.Astretchingstrapissecuredtothepatientsfootandgraspedbythehand
oftheinvolvedside.Maintainingtheforearminasupinatedpositionandtheelbowextendedasfaraspossible,
thepatientraisestheirarmouttotheside(Fig.1751)untilastretchitfelt.
WristandFingerExtensors
StretchingoftheECRBisalwayscombinedwithstretchingoftheECRLandextensordigitorumandis
indicatedinalltypesoftennisandgolferselbow.
Thepatientispositionedinsitting.Theupperarmisheldhorizontally,withtheelbowflexed90degrees,the
forearmpronated,andthewristflexed.Thepatientusesthelefthandtograsptheirrighthandandpositionsthe
wristinmaximalflexionandulnardeviation,withtheforearminmaximalpronation(Fig.1786).Theelbowis
broughtveryslowlyintoextension.
FIGURE1786
Wristandfingerextensorstretch.
StretchforGolfersElbow
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Thefunctionofthelongwristflexorsisflexionoftheelbow,pronationoftheforearm,andflexionofthewrist.
Thepatientsitsonachair,withtheinvolvedarmelevatedapproximately60degrees.Theelbowisslightly
flexed,theforearmsupinated,andthewristextended(Fig.1752).Thepatientbringsthewristandfingersinto
asmuchextensionaspossibleusingtheuninvolvedhand(seeFig.1752).Whileholdingthewristinmaximal
extension,theclinicianveryslowlyextendsthepatientselbow.Assoonaspainormuscleguardingoccurs,the
motionisstopped,andtheelbowisbroughtslightlybackintomoreflexion.Ifthepaindisappearsafterafew
seconds,theelbowcanbebroughtfurtherintoextension.
WeightBearingWristFlexorStretch
Thisstretchisperformedbyaskingthepatienttopositionthehandpalmsidedownonatableandtopositionthe
elbowinslightflexion,thewristintomaximalulnardeviationandextension,andtheforearminmaximal
pronation(Fig.1787).Beingcarefultoavoidpainandmusclesplinting,thepatientslowlystraightensthe
elbow.Thestretchshouldbeheldforapproximately40seconds.Atthispoint,thepatientcangentlypullthe
fingersupfromthetabletostretchtheflexormusclesofthepalm.Againstveryslightresistance(performedby
theotherhand),thearmisthenbroughtbacktotheoriginalposition.Thisstretchingprocedureisrepeatedsix
timesbeforerepeatingtheentireprocedure.
FIGURE1787
Weightbearingwristflexorstretch.
HighVelocity,LowAmplitudeThrusting
MillsManipulation
Thistechniqueisdesignedtobreakadhesionsofthecommonextensortendonandlettheorbicularligamentslip
backtoitsnormalposition.12TheMills,manipulationisusedinsteadofslowlystretchingthetissuesduringthe
lastfewdegreesofmaximalelbowextension.
Thismanipulationisindicatedonlyforcertainpatients,namely,those
whodemonstratefullactiveandpassiveelbowextensionwithanormalendfeeland
whoseelbowdemonstratesonlyaslightlimitationofmotionwithamyofascialendfeel.
Priortothemanipulation,transversefrictionsshouldbeappliedtothesiteinordertosoftenthescar.
Thepatientispositionedinsitting,withtheclinicianstandingbehindthepatientsshoulder(seeFig.1742).The
patientswristisflexed.Maintainingthepositionofthepatientswrist,theclinicianextendstheelbow.The
Mills,maneuverinvolvesaforcibleextensionoftheelbowwhilesimultaneousdigitalpressureisexertedover
thepointofmaximumtenderness.Ifthewristflexionisnotmaintained,theforcewillbethroughtheelbow
joint.Millsstressedtheneedtoelicitanaudibleclickduringtheprocedure,althoughinpracticemanynormal
elbowscanbemadetoclickbythesamemaneuver,306indicatingthattheclickisprobablycoincidental.
Amodificationtothepatientpositioncanbeusedforthismanipulation.Thepatientispositionedinsupine,with
theirarmofftheedgeofthetable.Theclinicianadjuststhetableheightsothatthepatientselbowjointcanbe
restedontheirthigh,whilethecliniciansfootisincontactwiththefloor.Thepatientsarmisthenplacedin
slightshoulderextensionandfullinternalrotation(palmdown).Inthisposition,thevarioustendonscanbe
testedastotheirlevelofinvolvementbyhavingeachonecontract.Theinvolvedtendonisthensoftenedup
usingtransversefrictionbeforethemanipulationisappliedusingtheaforementionedpositions.Thepatients
elbowisthenslightlyraisedoffthecliniciansthighandthendroppedquicklybackontothethigh.
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Followingthemanipulation,exercisestostretchthescarshouldbecarriedout.
CASESTUDYLATERALELBOWPAINHISTORYHistoryofCurrentCondition
A43yearoldfemalepatientpresentswithcomplaintsofleftlateralelbowpain,whichshereportshavingfor
aboutayear.Thepatientdescribestheonsetofelbowpainasgradualandattributesittoherworkasan
electronicsassembler,whereshespendsthedaypullingoutplugs.Overtime,thepainhasworsenedtothepoint
whereithurtsallofthetime.Althoughthepatienthastriedacourseofantiinflammatories,theywere
discontinuedduetoanadversereaction.Thepatienthasbeenplacedonlightdutyatwork,withalifting
restrictionof10lb.
Nopasthistoryofleftelbowpain.
PastMedicalandSurgicalHistory
Unremarkable.
Medications
None.
LivingEnvironment
Livesinatwostoryhouse.
Occupational,Employment,andSchool
Assemblylineworker.Highschooleducation.
Thepatientsgoalsweretodecreasepainwithactivitiesofdailylivingandtobeabletoreturntoworkwithout
pain.
Ingeneralgoodhealth,butpaininterfereswithtasksathomeandatwork.
Questions
1.Whatisthemostcommondiagnosischaracterizedbylateralelbowpain?
2.Whatcanahistoryofgradualonsettelltheclinician?
3.Whatcanahistoryofrepetitiveactivitytelltheclinician?
4.Whatfindingsdoyouexpecttonoteinthephysicalexaminationintermsofpalpation,resistivetests,and
specialtests?
5.Whatadditionalquestionswouldyouasktohelpruleoutreferralofpainfromthecervicalspineor
shoulder?
6.Listthevariousdiagnosesthatcouldpresentwiththesesignsandsymptoms,andthetestsyouwoulduse
toruleouteachone.
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7.Doesthispresentationandhistorywarrantanupperquarterscanningexamination?Whyorwhynot?
CASESTUDYMEDIALELBOWPAINHISTORYHistoryofCurrentCondition
A23yearoldapprenticecarpenterwasseenintheclinicwithcomplaintsofrightelbowpain,whichhereported
havingforthelastfewmonths.Thepatientdescribedtheonsetofmedialelbowpainasgradualandattributedit
tohiswork,wherehespendsmostofthedayusingcarpentrytools.Overtime,thepainhadworsenedtothe
pointwhereithurtallofthetime.Thepatientwenttoseehisphysicianwhoprescribedacourseofanti
inflammatorymedicationsandphysicaltherapyandplacedthepatientonlightdutyatwork.
Nopasthistoryofelbowpain.
PastMedicalandSurgicalHistory
Unremarkable.
Medications
Ibuprofen,800mgaday.
Thepatientsgoalsweretodecreasepainwithactivitiesofdailylivingandrecreationalsportsandtobeableto
returntoworkwithoutpain.
Ingeneralgoodhealth,butpaininterfereswithtasksathomeandatwork.
Questions
1.Whatstructure(s)doyoususpecttobeatfaultwithcomplaintsofmedialelbowpain?
2.Whatistheprobablemechanismofinjuryforthispatient?
3.Whattypeofactivitieswouldyouexpecttoexacerbatethiscondition?
4.Whatadditionalquestionswouldyouask?
5.Listthevariousdiagnosesthatcouldpresentwiththesesignsandsymptomsandthetestsyouwoulduse
toruleouteachone.
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undefined
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CHAPTER18:TheForearm,Wrist,andHand
CHAPTEROBJECTIVES
1.Describetheanatomyofthejoints,ligaments,muscles,blood,andnervesupplythatcomprisetheforearm,wrist,andhand.
2.Describethebiomechanicsoftheforearm,wrist,andhand,includingopenandclosepackedpositions,normalandabnormaljointbarriers,andstabilizers.
3.Describethepurposeandcomponentsofthetestsandmeasuresfortheforearm,wrist,andhand.
4.Describetherelationshipbetweenmuscleimbalanceandfunctionalperformanceoftheforearm,wrist,andhand.
5.Performacomprehensiveexaminationoftheforearm,wrist,andhand,includingpalpationofthearticularandsofttissuestructures,specificpassivemobility,and
passivearticularmobilitytests,andstabilitytests.
6.Outlinethesignificanceofthekeyfindingsfromthetestsandmeasuresandestablishadiagnosis.
7.Summarizethevariouscausesoftheforearm,wrist,andhanddysfunction.
8.Developselfreliantinterventionstrategiesbasedonclinicalfindingsandestablishedgoals.
9.Evaluatetheinterventioneffectivenessinordertoprogressormodifyanintervention.
10.Plananeffectivehomeprogramandinstructthepatientinsame.
OVERVIEW
Ahandisaverypersonalthing.Itistheinterfacebetweenthepatientandhisorherworld.Itisanemblemofstrength,beauty,skill,sexuality,andsensibility.Whenitis
damaged,itbecomesasymbolofvulnerabilityofthewholepatient.
PaulW.Brand(19142003)
Inasense,theshoulder,elbow,andwristjoints(Fig.181)aremerelymechanicaldevicesthatcontributetotheusefulnessofthehand.1Thecorrectsynchronizationof
thesebiologicaldevices,coupledwithpatientmotivation,producesaremarkablelevelofdexterityandprecision.
FIGURE181
Arm,wrist,andhandjointstructures.(Reproduced,withpermission,fromChapter29.OverviewoftheUpperLimb.In:MortonDA,ForemanK,AlbertineKH.eds.The
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Thecarpus,orwrist,representsahighlycomplexanatomicstructure,comprisingacorestructureof8bonesmorethan20radiocarpal,intercarpal,andcarpometacarpal
(CMC)joints26namedintercarpalligamentsand6ormorepartsofthetriangularfibrocartilagecomplex(TFCC).2Whilethesestructurescanbedifferentiated
anatomically,theyarefunctionallyinterrelatedwithmovementinonejointhavinganeffectonthemotionofneighboringjoints.Thisrelationshipextendsasfarasthe
elbow.
Thehandaccountsforabout90%ofupperlimbfunction.3Thethumb,whichisinvolvedin4050%ofhandfunction,isthemorefunctionallyimportantofthedigits.3
Theindexandmiddlefingersareeachinvolvedinabout20%ofhandfunction,andarethesecondmostimportant,withtheringfingerbeingtheleastimportant.The
middlefingeristhestrongestfingerandisimportantforbothprecisionandpowerfunctions.3
Thefollowingsectionsdescribetherespectivebones,joints,softtissues,andnerves,detailingboththeirindividualandcollectivefunctions.Forsimplicityssake,the
forearm,wrist,andhandareseparatedintotheirvariouscompartments.
ANATOMY
DistalRadioulnarJoint
Thedistalradioulnarjoint(DRUJ)playsasignificantroleinwristandforearmfunction.TheDRUJisauniaxialpivotjointthatjoinsthedistalradiusandulnaandan
articulardisk(Fig.181).Thearticulardisk,knownastheTFCC,assistsinbindingthedistalradiusandisthemainstabilizeroftheDRUJ(seethenextsection).4
Atitsdistalend,theradiuswidenstoformabroad,concavearticularsurface.Thearticularsurfacehasanulnarinclinationinthefrontalplane,whichaverages23
degrees,andananterior(palmar)inclinationinthesagittalplane,whichaverages11degrees.5Thedistalendoftheulnaexpandsslightlylaterallyintoaroundedhead
andmediallyintoanulnarstyloidprocess(Fig.181).TheroundedheadoftheulnarheadcontactsboththeulnarnotchoftheradiuslaterallyandtheTFCCdistally.6The
ulnarstyloidprocessisapproximatelyonehalfinchshorterthantheradialstyloidprocess,resultinginmoreulnardeviationthanradialdeviationbeingavailable.6The
articularcapsule,whichattachestothearticularmarginsoftheradiusandulnaandtothediskenclosingtheinferiorradioulnarjoint,islax.Anterior(palmar)and
posterior(dorsal)radioulnarligamentsstrengthenthecapsuleanteriorlyandposteriorly.Forearmsupinationtightenstheanteriorcapsuleandpronationtightensthe
posteriorpart,addingtotheoverallstabilityofthewrist.7
TheDRUJfunctionstotransmittheloadsfromthehandtotheforearm.
CLINICALPEARL
TherestingoropenpackedpositionfortheDRUJis10degreesofsupination.
TheclosepackedpositionfortheDRUJis5degreesofsupination.
ThecapsularpatternfortheDRUJispainatextremesofpronation/supination.
TriangularFibrocartilageComplex
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TheTFCCessentiallycomprisesafibrocartilagediskinterposedbetweenthemedialproximalrowandthedistalulnawithinthemedialaspectofthewrist.8Theprimary
functionoftheTFCCistoenhancejointcongruityandtocushionagainstcompressiveforces.Indeed,theTFCCtransmitsabout20%oftheaxialloadfromthehandto
theforearm.7Thebroadbaseofthediskisattachedtothemedialedgeoftheulnarnotchoftheradius,anditsapexisattachedtothelateralaspectofthebaseoftheulnar
styloidprocess.Thedisksanteriorandposteriorbordersarethickened.
AnumberofligamentsoriginatefromtheTFCCandprovidesupporttoit.Theseincludetheulnolunateandulnotriquetralligaments,theulnarcollateral,andthe
radioulnarligaments.OtherstructuresthatlendsupporttotheTFCCincludethefollowing:
Theulnocarpalligaments.
Thesheathoftheextensorcarpiulnaris(ECU)tendon,whichistheonlywristtendonthatbroadlyconnectstotheTFCC.
BoththesuperiorandtheinferiorarticularsurfacesoftheTFCCaresmoothandconcave.8Thediskseparatesthedistalulnafromdirectcontactwiththecarpalsbut
allowsglidingbetweenthecarpals,disk,andulnaduringforearmpronationandsupination.8,9
TheTFCCisinnervatedbybranchesoftheposteriorinterosseous,ulnar,andposterior(dorsal)sensoryulnarnerves.9
TheWrist
Thewristcomprisesthedistalradiusandulna,eightcarpalbones,andthebasesoffivemetacarpals(Fig.181).Thecarpalboneslieintwotransverserows.Theproximal
rowcontains(lateraltomedial)thescaphoid(navicular),lunate,triquetrum,andpisiform.Thedistalrowholdsthetrapezium,trapezoid,capitate,andhamate.
RadiocarpalJoint
Theradiocarpaljoint,abiaxialellipsoidjoint,isformed,bythelarge,articularconcavesurfaceofthedistalendoftheradius,theproximalcarpalrow,andtheTFCC.The
lunateandtriquetrumarticulatewiththeTFCC.Aradialstyloidprocessprojectsdistallyfromthelateralsideoftheradius.Acartilagecoveredulnarnotchoccupiesthe
distalmedialsideoftheradius.10Posteriorly,aposterior(dorsal)(Lister)tuberclearisesnearthecenteroftheradius,formingapulleyaroundwhichtheextensorpollicis
longus(EPL)tendonpasses.9Listertubercleisacommonsiteofattritionalchangesandpotentialtendonrupture.11
CLINICALPEARL
Therestingoropenpackedpositionfortheradiocarpaljointisneutralwithslightulnardeviation.
Theclosepackedpositionfortheradiocarpaljointisfullextensionwithradialdeviation.
Thecapsularpatternfortheradiocarpaljointisflexionandextensionequallylimited.
TheCarpals
Scaphoid
Thescaphoid(Fig.181)isthelargestoftheproximalcarpalrowbones,anditsshaperesemblesthatofaboatorcanoe(thustheoldtermnavicular).9Thescaphoidbone
linkstheproximalanddistalcarpalrowsandhelpsprovidestabilitytothewristjoint.
Thescaphoidistetheredtotheproximalcarpalrowbyanumberofstrongligamentousattachments,andtwothirdsofitssurfaceareaisarticular.Theproximalsurfaceof
thescaphoidisconvexandarticulateswiththeradius.Themedialsurfaceisconcaveandarticulateswiththecapitate.10Thearticulatingsurfaceforthelunateisflat.The
distalsurfaceconsistsoftwoconvexfacetsforarticulationwiththetrapeziumandtrapezoid(thescaphotrapeziotrapezoidjoint).9Theroundtubercleontheinferolateral
partofitsanterior(palmar)surfaceservesastheattachmentoftheflexorretinaculumandtheabductorpollicisbrevis(APB).10Thebloodvesselstothisboneenterthe
scaphoidatordistaltothewrist.Thisconfigurationpredisposesafractureontheproximalaspecttoasepticnecrosis.12Inaddition,asthescaphoidplaysacriticalrolein
coordinatingandstabilizingmovementsbetweentheproximalandthedistalrowsofthecarpals,damagetotheintrinsicandextrinsicligamentsthatsupportthescaphoid
canresultinpersistentpainanddysfunctionwithloadingactivities.1315
Lunate
Thelunate(Fig.181)articulatesbetweenthescaphoidandthetriquetrumintheproximalcarpalrow.Itssmoothconvexproximalsurfacearticulateswiththeradiusand
theTFCCatthelunatefossa.10Itslateralsurfacecontainsaflatsemilunarfacetforthescaphoid.Themedialsurfacearticulateswiththetriquetrum.Thedistalsurfaceis
deeplyconcaveandarticulateswiththeedgeofthehamateinadductionandthemedialaspectofthecapitate.10
Triquetrum
Thetriquetrum(Fig.181)isapyramidshapedbone.Itarticulateswiththepisiformonitsdistalanterior(palmar)surfaceatthepisiformtriquetraljoint.10Thealmost
squaredistalmedialsurfaceofthetriquetrumarticulateswiththeconcavoconvexsurfaceofthehamate.Theulnarcollateralligament(UCL)attachestothemedialand
posterior(dorsal)surfacesofthetriquetrum.10TheproximalsurfaceofthetriquetrumarticulateswiththeTFCCinfulladduction.9Thelateralsurfaceofthetriquetrum
articulateswiththelunate.
Pisiform
Thepisiform(Fig.181),asitsnameimplies,isshapedlikeaPwithaposterior(dorsal)flatarticularfacetforthetriquetrum.10Thepisiform,formedwithinthetendon
oftheflexorcarpiulnaris(FCU),isasesamoidboneandservesasanattachmentfortheflexorretinaculum,abductordigitiminimi(ADM),UCL,pisohamateligament,
andpisometacarpalligament.ThepisiformalsofunctionstoincreasetheflexionmomentoftheFCU.9
Asmentioned,thepisiformarticulateswiththeanterior(palmar)surfaceofthetriquetralandisthusseparatedfromtheothercarpalbones,allofwhicharticulatewith
theirneighbors.Thepisiformiscloselyrelatedtotheulnararteryandnerveonitsradialborder,thenervebeingthecloser.16
Trapezium
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Thetrapezium(Fig.181)hasagrooveonitsmedialanterior(palmar)surfacewhichcontainsthetendonoftheFCR.10Toitsmarginsareattachedtwolayersofthe
flexorretinaculum.Theopponenspollicis(OP)isbetweentheflexorpollicisbrevis(FPB)distallyandtheAPBproximally.10Thelateralsurfaceservesasanattachment
sitefortheradialcollateralligamentandcapsularligamentofthefirstCMCjoint.Thedistalarticulatingsurfaceofthetrapeziumissaddleshaped.Medially,itsconcave
surfacearticulateswiththetrapezoid,whereasmoredistallyitsconvexsurfacearticulateswiththesecondmetacarpalbase.10Proximally,itsconcavesurfacearticulates
withthescaphoid.
Trapezoid
Thetrapezoid(Fig.181)issmallandirregular.Thedistalsurfacearticulateswiththegroovedsecondmetacarpalbase.Themedialsurfacearticulatesviaaconcavefacet
withthedistalpartofthecapitate.Thelateralsurfaceofthetrapezoidarticulateswiththetrapezium,anditsproximalsurfacearticulateswiththescaphoidbone.10
Capitate
Thecapitate(Fig.181)isthemostcentralandthelargestofthecarpalbones.Itsdistalaspectarticulateswiththethirdmetacarpalbase.Itslateralborderarticulateswith
themedialsideofthesecondmetacarpalbase.10Theconvexproximalheadofthecapitatearticulateswiththelunateandscaphoid.Themedialsurfaceofthehead
articulateswiththelunate,andthelateralaspectoftheheadarticulateswiththescaphoid.10Medially,thecapitatearticulateswiththehamate.
Withitscentrallocation,thecapitateservesasthekeystoneoftheproximaltransversearch.Thisarchisimportanttotheprehensileactivityofthehand.9,17,18
Hamate
Thehamate(Fig.181)isacuneiformboneandcontributestothemedialwallofthecarpaltunnel.Tothehook(hamulus)ofthehamateisattachedtheflexor
retinaculum.Thehamatearticulateswiththreecarpalbonesandtwometacarpals.9Themedialsurfacearticulateswiththetriquetrumandbyassociationwiththe
pisohamateligament,thepisiform.Thelateralsurfacearticulateswiththecapitate.10Onitsdistalaspect,thehamatearticulateswiththefourthandfifthmetacarpal
heads.
CLINICALPEARL
Therestingoropenpackedpositionfortheintercarpaljointisneutralorslightflexion.
Theclosepackedpositionfortheintercarpaljointisfullextension.
Thereisnorecognizedcapsularpatternoftheintercarpaljoints.
MidcarpalJoints
Themidcarpaljointliesbetweenthetworowsofcarpals.Itisreferredtoasacompoundarticulationbecauseeachrowhasbothaconcaveandaconvexsegment.Wrist
flexion,extension,andradialdeviationaremainlymidcarpaljointmotions.Approximately50%ofthetotalarcofwristflexionandextensionoccuratthemidcarpallevel
withmoreflexion(66%)occurringthanextension(34%).19
Theproximalrowofthecarpalsisconvexlaterallyandconcavemedially.Thescaphoid,lunate,trapeziumtrapezoid,andtriquetrumpresentwithaconcavesurfacetothe
distalrowofcarpals.Thescaphoid,capitate,andhamatepresentaconvexsurfacetoareciprocallyarrangeddistalrow.
CLINICALPEARL
Therestingoropenpackedpositionforthemidcarpaljointisneutralorslightflexionwithulnardeviation.
Theclosepackedpositionforthemidcarpaljointisfullextensionwithulnardeviation.
Thecapsularpatternforthemidcarpaljointisanequallimitationofflexionandextension.
FirstCMCJoint
Thethumbisthemostimportantdigitofthehandandgreatlymagnifiesthecomplexityofhumanprehension.20,21Functionally,thesellar(saddleshaped)CMCjointis
themostimportantjointofthethumbandconsistsofthearticulationbetweenthebaseofthefirstmetacarpalandthedistalaspectofthetrapezium.
Thearticularsurfacesofthetrapeziumandtheproximalendofthefirstmetacarpalarereciprocallyshaped.Threeotheradjacentarticulationsarefunctionallyrelatedto
thisjoint,whichincludethejointsbetweenthetrapeziumandthescaphoid,thetrapeziumandthetrapezoid,andthebaseofthefirstmetacarpalandtheradialsideofthe
baseofthesecondmetacarpal.20,21
Motionsthatcanoccuratthisjointincludeflexion/extension,adduction/abduction,andopposition,thelatterofwhichincludesvaryingamountsofflexion,internal
rotation,andanterior(palmar)adduction(seeBiomechanics).AlthoughthejointcapsuleofthefirstCMCjointislargeandrelativelyloose,motionsatthejointare
controlledandsupportedbymuscleactionsandbyatleastfiveligaments:anterioroblique,ulnarcollateral,intermetacarpal,posterioroblique,andradialcollateral.In
general,mostofthethumbligamentsareplacedontensionwithabduction,extension,andopposition.20,21
CLINICALPEARL
TherestingoropenpackedpositionofthefirstCMCjointismidwaybetweenabductionandadduction,andmidwaybetweenflexionandextension.
TheclosepackedpositionofthefirstCMCjointisfullopposition.
Thecapsularpatternofthefirstmetacarpaljointisthumbabduction,thenextension.
OtherCMCJoints
Thedistalbordersofthedistalcarpalrowbonesarticulatewiththebasesofthemetacarpals,therebyformingtheCMCjoints.TheCMCarticulationsofthefingers
permitonlyglidingmovements.TheCMCjointsprogressinmobilityfromthesecondtothefifth,withthesecondandthirdmetacarpaljointsbeingrelativelyimmobile,
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andthustheprimarystabilizingjointsofthehand.ThefourthandfifthCMCjointsaremoremobiletopermitthehandtoadapttoobjectsofdifferentshapesduring
grasping.
StabilityfortheCMCjointsisprovidedbytheanterior(palmar)andposterior(dorsal)CMCandintermetacarpalligaments.Whilethetrapezoidarticulateswithonlyone
metacarpal,alloftheothermembersofthedistalcarpalrowcombineonecarpalbonewithtwoormoremetacarpals.
CLINICALPEARL
TherestingoropenpackedpositionoftheCMCjointsofthefingersismidwaybetweenflexionandextension.
TheclosepackedpositionoftheCMCjointsofthefingersisfullflexion.
ThecapsularpatternoftheCMCjointsofthefingersisequallimitationinalldirections
MetacarpophalangealJoints
Thefivemetacarpalsresembleminiatureversionsofthelongbonesofthebody,withelongatedshaftsandexpandedends.Themetacarpophalangeal(MCP)jointofthe
thumbisahingejoint.Itsbonyconfiguration,whichresemblestheinterphalangeal(IP)joints,providesitwithsomeinherentstability.Inaddition,supportforthejointis
providedbyanterior(palmar)andcollateralligaments.TheMCPjointofthethumbconsistsofaconvexsurfaceontheheadofthemetacarpalandaconcavesurfaceon
thebaseofthephalanx.Theareaofthearticulatingsurfaceisincreasedbythepresenceofavolarplate,whichallowsagreaterrangeofmotionthanwouldbeavailable
otherwise.Approximately7580degreesofflexionisavailableatthisjoint.Theextensionmovements,aswellastheabductionandadductionmotions,arenegligible.
Traction,gliding,androtatoryaccessorymovementsarealsopresent.
Thesecondthroughfifthmetacarpalsarticulatewiththerespectiveproximalphalangeswithinbiaxialjoints.Theirwidened,proximalbasesarticulatewiththecarpalsand
withoneanotherinplanejoints.10Theirbiconvexdistalheadsarebroaderanteriorlythanposteriorly,thesignificanceofwhichisdiscussedlater.
TheMCPjointsallowflexionextensionandmediallateraldeviationassociatedwithaslightdegreeofaxialrotation.ThedesignoftheMCPjointallowsforgreat
amplitudeofmovement,attheexpenseofstability.
Approximately90degreesofflexionisavailableatthesecondMCP,withtheamountofavailableflexionprogressivelyincreasingtowardthefifthMCP.Active
extensionatthesejointsis2530degreeswhile90degreescanbeobtainedpassively.AlossofflexionandextensionattheCMCjointofthelittlefingerreducesthe
amountofoppositionavailable,resultingindysfunctionoftheprehensilepatternanddifficultyinmakingafist.6Approximately20degreesofabduction/adductioncan
occurineitherdirectionattheMCP,withmorebeingavailableinextensionthaninflexion.AbductionadductionmovementsoftheMCPjointsarerestrictedinflexion
andfreeinextension.
CLINICALPEARL
TherestingoropenpackedpositionoftheMCPjointsisslightflexion.
TheclosepackedpositionoftheMCPjointsisfullopposition(thumb)/fullflexion(fingers).
ThecapsularpatternoftheMCPjointsisflexion,thenextension
ThejointcapsulesareattachedtothearticularmarginsofthemetacarpalsandphalangesandsurroundtheMCPjoints.Thejointcapsuleofthesejointsisrelativelylax
andredundantbutisendowedwithcollateralligamentsthatpassposteriortothejointaxisforflexion/extensionoftheMCPjoints(Fig.1811).Although,thesecollateral
ligamentsarelaxinextension,theybecometautinapproximately7090degreesofflexionoftheMCPjoint.22
CLINICALPEARL
ContractureofthecollateralligamentsisamajorcauseoflossofMCPflexion.TheMCPjointsshouldnever,underanycircumstances,beimmobilizedinextensionor
hyperextensionbyaretractionofthecollateralligaments,whichwouldresultintheirlocking.23Instead,thefingersshouldbesplintedwiththeMCPjointsflexedto70
90degrees.
Theposterior(dorsal)hoodapparatusreinforces(orreplaces)theposterior(dorsal)jointcapsules.Thefibrocartilaginousvolarplatesreinforcetheanterior(palmar)
aspectsofthejoints(Fig.1812).Thevolarplatesattachfirmlytothephalangealbasesbutconnectonlylooselytothemetacarpalheadsbymembranousfibers.Their
posterior(dorsal)surfacecontributestothejointarea,whereastheiranterior(palmar)surfacechannelsthefingerflexortendons.23
Theasymmetryofthemetacarpalheadsaswellasthedifferenceinlengthanddirectionofthecollateralligamentsalsoexplainstherotationalmovementoftheproximal
phalanxduringflexionextensionandwhytheulnardeviationofthedigitsnormallyisgreaterthantheradialdeviation.23Therotarymovementsthatoccurarecalled
conjunctrotations.Theindexfingerhasaconjunctrotationofinternalrotationwithabductionandflexion,whereastheringandlittlefingereachhaveaconjunctrotation
ofexternalrotationwithabductionandflexion.Themiddlefingerisnotthoughttohaveaconjunctrotation.
CLINICALPEARL
IncontrasttotheIParticulations,whicharestablethroughoutmostoftheirrangeofmovements,theMCPjointsarestableonlyinflexion.23
IPJoints
Adjacentphalangesarticulateinhingejointsthatallowmotioninonlyoneplane:sagittal.ThecongruencyoftheIPjointsurfacescontributesgreatlytoIPjointstability.
Inaddition,theIPjointsaresurroundedbyjointcapsulesthatareattachedtothearticularmarginsofthephalanges.
ProximalInterphalangealJoint
Theproximalinterphalangeal(PIP)jointisahingedjointcapableofflexionandextension.Thesupportingligamentsandtendonsprovidethebulkofthestaticand
dynamicstabilityofthisjointasittravelsthroughanormalrangeof110degrees.22,2427Thecapsulesurroundingthearticularsurfaceofthejointiscomposedofthe
volarplate,lateralandaccessorycollateralligaments,andextensorexpansion.
TheproximalIPjointisstableinallpositions.Theconfigurationofthevolarplateallowsittofunctionasastaticrestrainttohyperextensionandtoinfluencethe
mechanicaladvantageoftheflexortendonsattheinitiationofPIPjointflexion.22Thevolarplatealsoincreasesthesurfacearea.Thisallowsforagreaterrangeof
motionthanwouldbeavailableotherwise.
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Thethickcollateralligaments(trueandaccessory)ofthePIPjointcombinewiththevolarplatetoprovidelateralstability:thecollateralligamentsofthePIPjointsare
maximallytautat25degreesoffingerflexion.22Forthisreason,theIPjointsareusuallysplintedin25degreesofflexionfollowingsurgerytopreventjointcontractures.
Thesplintingpositionischangedasthepatientresumesfunction.
TheflexortendonsystematthelevelofthePIPjointislesscomplexthantheextensormechanismandcontributesverylittletoinjuriesaboutthePIPjoint.22
Thephalangealbaseseffectivelyformasellarsurface,withboneprojectionsallowingforawiderangeofaccessorymovementstoaccommodatethegrippingofalarge
arrayofirregularsurfaces.
Themotionsavailableatthesejointsconsistofapproximately110degreesofflexionatthePIPjointsand90degreesatthethumbIPjoint.Extensionreaches0degreesat
thePIPjointsand25degreesatthethumbIPjoint.Traction,gliding,andaccessorymovementsalsooccurattheIPjoints.
DistalInterphalangealJoints
Thedistalinterphalangeal(DIP)jointhassimilarstructuresasthePIPjointbutlessstabilityandallowssomehyperextension.Themotionsavailableatthesejoints
consistofapproximately90degreesofflexionand25degreesofextension.Traction,gliding,andaccessorymovementsalsooccurattheDIPjoints.
CLINICALPEARL
TherestingoropenpackedpositionfortheIPjointsisslightflexion.
TheclosepackedpositionfortheIPjointsisfullextension.
ThecapsularpatternoftheIPjointsisflexion,extension.
CarpalLigaments
Excessivemigrationofthecarpalbonesispreventedbystrongligaments(Table181)andbytheulnarsupportprovidedbytheTFCC.Themajorligamentsofthewrist
aredepictedinFigure182.
FIGURE182
Themajorligamentsofthewrist.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:Gross
TABLE181LigamentsoftheWrist
Interosseous IntrinsicMidcarpal ExtrinsicRadiocarpal/Ulnocarpal
Distalrow Posterior(dorsal) Posterior(dorsal)
Trapeziumtrapezoid Scaphotriquetral Posterior(dorsal)radiocarpal
Trapezoidcapitate Posterior(dorsal)intercarpal
Capitohamate
Proximalrow Anterior(palmar) Anterior(palmar)
Scapholunate Scaphotrapeziotrapezoid Radioscaphocapitate
Lunotriquetral Scaphocapitate Longradiolunate
Triquetrocapitate Shortradiolunate
Triquetrohamate Radioscapholunate
Ulnolunate
Ulnotriquetral
Ulnocapitate
Theligamentsofthewristprovidesupportfortheregion.Theseligamentscanbedividedintotwotypes:extrinsicandintrinsic(Table181).Theextrinsicanterior
(palmar)ligamentsprovidethemajorityofwriststability.Theintrinsicligamentsserveasrotationalrestraints,bindingtheproximalrowintoaunitofrotational
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stability.28Theproximalrowofcarpalshasnomuscleinsertions.Itsstabilitydependsentirelyonthecapsularandinterosseousligamentsbetweenthescaphoid,lunate,
andtriquetrum.29Theligamentsbetweentheproximalandthedistalcarpalrowsprovidesupport,centeringespeciallyonthecapitate.10Themidcarpalligaments,which
arelongerthantheinterosseousligaments,crossthemidcarpaljointandconnectbonesofthedistalandproximalrowsonboththeposterior(dorsal)andtheanterior
(palmar)surfaces.9Nomidcarpalligamentsdirectlyattachtothelunate.
AntebrachialFascia
Theantebrachialfasciaisadenseconnectivetissuethatencasestheforearmandmaintainstherelationshipsofthetendonsthatcrossthewrist.Thefasciaisfirmly
attachedtothesubcutaneousborderoftheulna,fromwhichitsendsaseptumtotheradius.Thisseptumdividestheforearmintoananteriorcompartmentandaposterior
compartment(seeMusclesoftheWristandForearm).
TheExtensorRetinaculum
Atthepointwherethetendonscrossthewrist,thereisaligamentousstructurecalledaretinaculumthatappearstolayoverthetendonsandtheirsheaths(Fig.183).This
retinaculumservestopreventthetendonsfrombowstringingwhenthetendonsturnacorneratthewrist.30Theextensorretinaculumextendsfromthelateralborderof
thedistalradiusacrosstheposterior(dorsal)surfaceofthedistalforearmontotheposteriorsurfaceofthedistalulnaandulnarstyloidprocess.Itthenwrapspartway
aroundtheulnatoattachtothetriquetrumandpisiformbones.Theretinaculumandtheunderlyingbonesformsixtunnellikestructurescalledfibroosseous
compartmentsonthedorsumofthewrist(Fig.183).Thecompartments,fromlateraltomedial,containthetendonsof
abductorpollicislongus(APL)andextensorpollicisbrevis(EPB)
extensorcarpiradialislongus(ECRL)andbrevis(ECRB)
EPL
extensordigitorum(ED)(fourtendons)andextensorindicis(EI)(notshowninFig.183)
extensordigitiminimi(EDM)
ECU
FIGURE183
Extensorretinaculumandextensortendons.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:
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Asthesetendonspassthroughthecompartments,theyareinvestedwithsynovialsheaths.
Theposterior(dorsal)compartmentsservetoenhancetheefficiencyandeffectivenessofthewristandfingerextensors(seeExtensorHood)(Fig.184).Proximaltothe
metacarpalheads,juncturetendineaeconnectthefourtendonsoftheEDmuscles,limitingtheirindependentmotion.6Forexample,flexionofthemiddleandlittlefingers
restrictsextensionoftheringfingerMCPjointbecausethejuncturetendineaepullstheringfingerextensortendondistally.Conversely,extensionoftheringfingerexerts
anextensorforceuponitsneighbors,suchthattheycanbeactivelyextendedevenifthemiddleandlittlefingerextensortendonsareseveredproximaltothejuncture.6
FIGURE184
Extensorhoodandsmallerligamentsofthehand.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.TheBig
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TheFlexorRetinaculum
Theflexorretinaculum(transversecarpalligament)spanstheregionbetweenthepisiform,hamate,scaphoid,andtrapezium,transformingthecarpalarchintoatunnel,
throughwhichthemediannerveandsomeofthetendonsofthehandpass(Fig.185).Theproximalattachmentoftheretinaculumisatthetubercleofthescaphoidand
thepisiform.Thehookofthehamateandthetubercleofthetrapeziumserveasitsdistalattachment.Theretinaculumalso6:
FIGURE185
Flexorretinaculumandflexortendons.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:Gross
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servesasanattachmentsiteforthethenarandhypothenarmuscles
helpsmaintainthetransversecarpalarch
actsasarestraintagainstbowstringingoftheextrinsicflexortendons,and
protectsthemediannerve.
Intheconditionknownascarpaltunnelsyndrome(CTS),themediannerveiscompressedinthisrelativelyunyieldingspace(seeInterventionStrategies).The
structuresthatpassdeeptotheflexorretinaculum(Fig.185)include
flexordigitorumsuperficialis(FDS),
flexordigitorumprofundus(FDP),
flexorpollicislongus(FPL),and
flexorcarpiradialis(FCR).
Thestructuresthatpasssuperficialtotheflexorretinaculuminclude
theulnarnerveandartery,
thetendonofthepalmarislongus,and
thesensorybranch(anterior(palmar)branch)ofthemediannerve.
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Fibroussheathsbetweenthedistalanterior(palmar)creaseandthePIPjointsbindtheflexortendonstothefingers.Somesurgeonsrefertotheareawherethesheaths
containtwotendonsasnomansland.6
CarpalTunnel
Thecarpaltunnelservesasachannelforthemediannerveandnineflexortendons(Fig.185).Thefloorofthetunnelisformedbytheanterior(palmar)radiocarpal
ligamentandtheanterior(palmar)ligamentcomplex.Asmentionedpreviously,theroofofthetunnelisformedbytheflexorretinaculum.Theradialandulnarareformed
bycarpalbones(hookofhamateandtrapezium,respectively).Themediannervedividesintoamotorbranchanddistalsensorybrancheswithinthetunnel.
TunnelofGuyon
ThetunnelofGuyonislocatedsuperficialtotheflexorretinaculum,betweenthehookofthehamateandthepisiformbones.Theanterior(palmar)carpalligament,
palmarisbrevismuscle,andtheanterior(palmar)aponeurosisformitsroof.Itsfloorisformedbytheflexorretinaculum(transversecarpalligament),pisohamate
ligament,andpisometacarpalligament.6Thetunnelfunctionsasapassagewayfortheulnarnerveandarteryintothehand.
Phalanges
The14phalangeseachconsistofabase,shaft,andhead(Fig.181).Twoshallowdepressions,whichcorrespondtothepulleyshapedheadsoftheadjacentphalanges,
marktheconcaveproximalbases.Twodistinctconvexcondylesproducethepulleyshapedconfigurationofthephalangealheads.6
Anterior(Palmar)Aponeurosis
Theanterior(palmar)aponeurosis,whichconsistsofadensefibrousstructurecontinuouswiththepalmarislongustendonandfasciacoveringthethenarandhypothenar
muscles,islocatedjustdeeptothesubcutaneoustissue(Fig.185).Theaponeurosistravelsdistallytoattachtothetransversemetacarpalligamentsandflexortendon
sheaths.Theaponeurosisofferssomeprotectionfortheulnararteryandnerve,anddigitalvesselsandnerves.Fromthecentralregionofthepalm,theaponeurosis
continuestowardthefingersandsplitsintofourslips.AstheseslipsapproachtheMCPjoints,theysplitandwraparoundthetendonsoftheirrespectivedigit.Dupuytren
contractureisafibroticconditionoftheanterior(palmar)aponeurosisthatresultsinnoduleformationorscarringoftheaponeurosisandwhichmayultimatelycause
fingerflexioncontractures(seeInterventionStrategies).
ExtensorHood
AttheleveloftheMCPjoint,thetendonoftheEDfansouttocovertheposterior(dorsal)aspectofthejointinahoodlikestructure(Fig.184).Acomplextendonthat
coverstheposterior(dorsal)aspectofthedigitsisformedfromacombinationofthetendonsofinsertionfromtheED,EI,andEDM.Thedistalportionofthehood
receivesthetendonsofthelumbricalsandinterosseiovertheproximalphalanx.Thetendonsoftheintrinsicmusclespassanterior(palmar)totheMCPjointaxesbut
posterior(dorsal)tothePIPandDIPjointaxes(Fig.186).BetweentheMCPandthePIPjoints,thecomplete,complexEDtendon(afterallcontributionshavebeen
received)splitsintothreeparts:acentralslipandtwolateralbands6:
FIGURE186
Thetendonsoftheintrinsicmusclesinrelationtothejoints.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.The
Acentralband.Thisbandinsertsintotheproximalposterior(dorsal)edgeofthemiddlephalanx.
Thelateralbands.Thesebandsrejoinoverthemiddlephalanxintoaterminaltendon,whichinsertsintotheproximalposterior(dorsal)edgeofthedistalphalanx.
Ruptureofthetendoninsertionintothedistalphalanxproducesamalletfinger(seeInterventionStrategies).Thelateralbands,comprisedofthefibersfrom
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bothextrinsicandintrinsictendons,arepreventedfromdislocatingposteriorly(dorsally)bythetransverseretinacularligaments,whichlinkthemtothevolarplates
ofthePIPjoints.6
ThearrangementofthemusclesandtendonsinthisexpansionhoodcreatesacablelikesystemthatprovidesamechanismforextendingtheMCPandIPjointsand
allowsthelumbricalandpossiblyinterosseousmusclestoassistintheflexionoftheMCPjoints.
Stretchingorlaxityofthesesupportingstructuresallowsbowstringingofthelateralbands,whichtransmitexcessiveextensionforcetothePIPjoint.6
Theobliqueretinacularligament(Landsmeerligament)assistsintheextensorhoodmechanism.TheligamentattachesbetweenthePIPvolarplate,whereitisanterior
(palmar)tothePIPjointaxis,andtheterminaltendon,whereitisposterior(dorsal)totheDIPjointaxis.ThisrelationshiptothePIPandDIPjointsisessentiallythe
sameasthatoftheintrinsicmuscles(lumbricalsandinterosseous)totheMCPandPIPjointswhenthePIPjointextends,theobliqueretinacularligamentexertsa
passiveextensorforceontheDIPjoint,andwhenthePIPjointflexes,itallowstheDIPjointtoflex.31
PIPjointpositionalsomayinfluenceDIPjointpositionthroughlateralbandaction.ThelateralbandsnormallyslippalmarlyuponPIPjointflexion,decreasingthe
excursionrequiredforfullDIPjointflexion.Ifscartissuetethersthelateralbandssothattheydonotmovepalmarly,thensimultaneousfullflexionatboththePIPand
theDIPjointsatthesametimeisnotpossible.6
SynovialSheaths
Synovialsheathscanbethoughtofaslongnarrowballoonsfilledwithsynovialfluid,whichwraparoundatendonsothatonepartoftheballoonwall(viscerallayer)is
directlyonthetendon,whiletheotherpartoftheballoonwall(parietallayer)isseparate.30Duringwristmotions,thesheathsmovelongitudinally,reducingfriction.
Atthewrist,thetendonsofboththeFDSandtheFDPareessentiallycoveredbyasynovialsheathandpassposterior(dorsal)(deep)totheflexorretinaculum.TheFDP
tendonsareposterior(dorsal)tothoseoftheFDS.
Inthepalm,theFDSandFDPtendonsarecoveredforavariabledistancebyasynovialsheath.
Atthebaseofthedigits,bothsetsoftendonsenterafibroosseoustunnelformedbythebonesofthedigit(headofthemetatarsalsandphalanges)andafibrousdigital
tendonsheathontheanterior(palmar)surfaceofthedigits.
FlexorPulleys
Annular(A)andcruciate(C)pulleysrestraintheflexortendonstothemetacarpalsandphalangesandcontributetofibroosseoustunnelsthroughwhichthetendons
travel.11TheA1pulleyarisesfromtheMCPjointandvolarplateA2fromtheproximalphalanxA3fromthePIPjointvolarplateA4fromthemiddlephalanxandA5
fromtheDIPjointvolarplate.11TheC1pulleyoriginatesneartheheadoftheproximalphalanxC2nearthebaseofthemiddlephalanxandC3neartheheadofthe
middlephalanx.11
ThepulleysystemofthethumbincludestheA1arisingfromtheMCPjointanterior(palmar)plate,A2fromtheIPjointanterior(palmar)plate,andtheobliquepulley
fromtheproximalphalanx.11
AnatomicSnuffbox
Theanatomicsnuffbox(Fig.187)isadepressionontheposterior(dorsal)surfaceofthehandatthebaseofthethumb,justdistaltotheradius.Thisstructurecanbe
observedduringactiveradialabductionofthethumb.TheradialborderofthesnuffboxisformedbythetendonsoftheAPLandEPBwhiletheulnarborderisformedby
thetendonoftheEPL.ThedeepbranchoftheradialarteryandthetendinousinsertionoftheECRLarealongthefloorofthesnuffbox.Underneaththesestructures,the
scaphoidandtrapeziumbonesarefound.
FIGURE187
Anatomicsnuffbox.
CLINICALPEARL
Tendernesswithpalpationintheanatomicsnuffboxsuggestsascaphoidfracture,butalsocanpresentinminorwristinjuriesorotherconditions.4
MOBILEARCHSYSTEMS
Thebonesandsofttissuesofthehandformanumberoffunctionalarchesofthehandthatprovideaperfectbalanceofforcedistributioninanequiangularspiral.The
archesofthehand,whichareallconcavepalmarly,servetoenhanceprehensilefunction.Thisprehensilefunctionisbestillustratedbytheabilityofthehumanhandto
graspanegg.Anumberofarchesarecommonlyrecognized:
Thetransversearch.Theproximal,relativelyimmobiletransversearchisformedbytheanterior(palmar)concavityofthecarpalbones.6Thiscarpalarch,
deepenedbytheanterior(palmar)projectionsofthescaphoidandtrapeziumlaterallyandthepisiformandhamatemedially,shouldcorrespondtotheconcavityof
thewrist.Thedistaltransversearchismoremobileandisdefinedbythealignmentofthemetacarpals.Thisarchallowsthehandtoadapttoobjectsheldinthe
palm.11
Themetacarpalarch.Thisarch,formedbythemetacarpalheads,isarelativelymobiletransversearch.
Thelongitudinalarch.Thisisspecificallythearchofthemiddlefingerandthearchoftheindexfinger.Thelongitudinalarch,whichcontributestopowerful
gripping,spansthehandlengthwise,withitskeystoneattheMCPjoints.6
Theobliquearches.Thesearchesareformedbythethumbinoppositiontotheotherfingers.
MusclesoftheWristandForearm
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Themusclesoftheforearm,wrist,andhand(Table182)(Figs.188to1810)canbesubdividedinto19intrinsicmusclesand24extrinsicmuscles.Theintrinsicmuscles
arelocatedentirelywithinthehandtheyariseandinsertwithinthehand.Theextrinsicmuscles,whosemusclebellieslieproximaltothewrist,originateintheforearm
andinsertwithinthehand.4Theflexors,whicharelocatedintheanteriorcompartment,flexthewristanddigitswhiletheextensors,locatedintheposteriorcompartment,
extendthewristandthedigits.
TABLE182MusclesoftheWristandHand:TheirActionsandNerveSupply
Action Muscles NerveSupply
Extensorcarpiradialislongus Radial
Wristextension Extensorcarpiradialisbrevis Posteriorinterosseous
Extensorcarpiulnaris Posteriorinterosseous
Flexorcarpiradialis Median
Wristflexion
Flexorcarpiulnaris Ulnar
Flexorcarpiulnaris Ulnar
Ulnardeviationofwrist
Extensorcarpiulnaris Posteriorinterosseous
Flexorcarpiradialis Median
Extensorcarpiradialislongus Radial
Radialdeviationofwrist
Abductorpollicislongus Posteriorinterosseous
Extensorpollicisbrevis Posteriorinterosseous
Extensordigitorumcommunis Posteriorinterosseous
Fingerextension Extensorindicis Posteriorinterosseous
Extensordigitiminimi Posteriorinterosseous
Flexordigitorumprofundus Anteriorinterosseous,lateraltwodigits
Ulnar,medialtwodigitsMedian
Flexordigitorumsuperficialis Median
Fingerflexion Lumbricals Firstandsecond:median
Thirdandfourth:ulnar
Interossei Ulnar
Flexordigitiminimi Ulnar
Posterior(dorsal)interossei Ulnar
Abductionoffingers
Abductordigitiminimi Ulnar
Adductionoffingers Anterior(palmar)interossei Ulnar
Extensorpollicislongus Posteriorinterosseous
Thumbextension Extensorpollicisbrevis Posteriorinterosseous
Flexorpollicisbrevis Superficialhead:median
Deephead:ulnar
Thumbflexion
Flexorpollicislongus Anteriorinterosseous
Opponenspollicis Median
Abductionofthumb
Abductorpollicisbrevis Median
Adductionofthumb Adductorpollicis Ulnar
Opponenspollicis Median
Flexorpollicisbrevis Superficialhead:median
Oppositionofthumbandlittlefinger
Abductorpollicisbrevis Median
Opponensdigitiminimi Ulnar
ECU,ExtensorcarpiulnarisEPL,extensorpollicislongusAPB,abductorpollicisbrevisFCU,flexorcarpiulnarisADM,abductordigitiminimiOP,opponens
pollicisFPB,flexorpollicisbrevisEPB,extensorpollicisbrevisECRL,extensorcarpiradialislongusECRB,extensorcarpiradialisbrevisEDC,extensordigitorum
communisEDM,extensordigitiminimiAP,AdductorPollicisFDM,flexordigitiminimiODM,OpponensDigitiMinimi.
FIGURE188
Musclesoftheforearm,wrist,andhand.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:
FIGURE189
Musclesoftheforearm,wrist,andhand.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:
FIGURE1810
Musclesandnervesupplyoftheforearm,wrist,andhand.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,ForemanK,AlbertineKH.eds.The
Thedesignoftheextrinsicandintrinsicmusclegroupsprovidesforalargenumberofmusclestoactonthehandwithoutexcessivebulkiness.Theextrinsictendons
enhancewriststabilitybybalancingflexorandextensorforcesandcompressingthecarpals.
Theamountoftendonexcursiondeterminestheavailablerangeofmotionatajoint.Tocalculatetheamountoftendonexcursionneededtoproduceacertainnumberof
degreesofjointmotioninvolvesanappreciationofgeometry.Acirclesradiusequalsapproximately1radian(57.29degrees).Themathematicalradius,whichis
equivalenttothemomentarm,representstheamountoftendonexcursionrequiredtomovethejointthrough1radian.32Forexample,ifajointsmomentarmis10mm,
thetendonmustglide10mmtomovethejoint60degrees(approximately1radian)or5mmtomovethejoint30degrees(1/2radian).11
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AnteriorCompartmentoftheForearm
SuperficialMuscles
PronatorTeres
ThepronatorteresisdescribedinChapter17.
FlexorCarpiRadialis
TheFCRoriginatesfromthemedialhumeralepicondyleaspartofthecommonflexortendon.Itinsertsontheanteriorsurfaceandbaseofthesecondmetacarpal,
possiblyprovidingasliptothethirdmetacarpal.TheFCRisinnervatedbythemediannerveandfunctionstoflexandradiallydeviatethewrist.
PalmarisLongus
Theinconsistentpalmarislongusarisesfromthemedialhumeralepicondyleaspartofthecommonflexortendonandinsertsonthetransversecarpalligamentand
anterior(palmar)aponeurosis.Itreceivesitsinnervationfromthemediannerve.Thefunctionofthepalmarislongusistoflexthewrist,anditmayplayaroleinthumb
abductioninsomepeople.18
FlexorCarpiUlnaris
TheFCUarisesfromtwoheads.Thehumeralheadarisesfromthemedialhumeralepicondyleaspartofthecommonflexortendon,whiletheulnarheadarisesfromthe
proximalportionofthesubcutaneousborderoftheulna.TheFCUinsertsdirectlyontothepisiform,thehamateviathepisohamateligament,andontotheanteriorsurface
ofthebaseofthefifthmetacarpal,viathepisometacarpalligament.TheFCUisinnervatedbytheulnarnerveandfunctionstoflexandulnarlydeviatethewrist.
IntermediateMuscle
FlexorDigitorumSuperficialis
TheFDShasathreeheadedorigin.Thehumeralheadarisesfromthemedialhumeralepicondyleaspartofthecommonflexortendon.Theulnarheadarisesfromthe
coronoidprocessoftheulna.Theradialheadarisesfromtheobliquelineoftheradius.TheFDSinsertsonthemiddlephalanxofthemedialfourdigitsviaasplit,sling
tendon.ThismuscleisinnervatedbythemediannerveandservestoflextheproximalandmiddleIPjointsofthemedialfourdigitsandassistwithelbowflexionand
wristflexion.TheFDSpossessestendonsthatarecapableofrelativelyindependentactionateachfinger.
DeepMuscles
FlexorPollicisLongus
TheFPLhasitsoriginontheventralsurfaceoftheradius,medialborderofthecoronoidprocessoftheulna,andtheadjacentinterosseousmembrane.Itinsertsonthe
distalphalanxofthethumb.TheFPLisinnervatedbytheanteriorinterosseousbranchofthemediannerve,anditfunctionstoflexthethumb.
FlexorDigitorumProfundus
TheFDParisesfromthemedialandanterior(ventral)surfacesoftheproximalulna,theadjacentinterosseousmembrane,andthedeepfasciaoftheforearm.TheFDP
insertsonthebaseofthedistalphalangesofthemedialfourdigits.TheFDPhasadualnervesupply:themedialtwoheadsaresuppliedbytheulnarnervewhilethe
lateraltwoheadsaresuppliedbytheanteriorinterosseousbranchofthemediannerve.TheFDPfunctionstoflextheDIPjointsaftertheFDSflexesthesecondphalanges
andassistswithflexionofthewrist.ThetendonsoftheFDSandFDPareheldagainstthephalangesbyafibroussheath.Atstrategiclocationsalongthesheath,the
previouslymentionedfivedenseannularpulleys(designatedA1,A2,A3,A4,andA5)andthreethinnercruciformpulleys(designatedC1,C2,andC3)preventtendon
bowstringing.33
UnliketheFDStendons,theFDPtendonscannotactindependently.ToisolatethePIPjointflexorfunctionofthesetwomuscles,aclinicianholdstheadjoiningfinger(s)
inextensionwhilethepatientattemptstoflexthefingerbeingtested.Thisanchorstheprofundusmuscleofthefingerbeingtesteddistallyandallowsthesuperficialis
muscletoactaloneatthePIPjoint.
TendinousconnectionsbetweentheFDPandtheFPLareacommonanatomicanomaly,whichhavebeenlinkedtoaconditioncausingchronicforearmpain,called
Linburgsyndrome,34althoughtheassociationisbynomeansconclusive.35
PronatorQuadratus
Thepronatorquadratusarisesfromtheanterior(ventral)surfaceanddistalquarteroftheulnaandinsertsontheanterior(ventral)surfaceanddistalquarteroftheradius.
Themusclefunctionstopronatetheforearm,anditisinnervatedbytheanteriorinterosseousbranchofthemediannerve.Thepronatorquadratusiswelldesigned
biomechanicallyasaneffectivetorqueproducerandastabilizeroftheDRUJitslineofforceisorientedalmostperpendiculartotheforearmsaxisofrotation.36
PosteriorCompartmentoftheForearm
SuperficialMuscles
TheECRLtakesitsoriginatthesupracondylarridgeofthehumerusabout45cmproximaltotheepicondyle,andthethickestpartofthemuscleisproximaltothe
elbowjoint.TheECRLinsertsonthebaseofthesecondmetacarpalandfunctionstoextendandradiallydeviatethewrist.Italsoplaysaroleinelbowflexion,losinga
partofitswristactionwhentheelbowisflexed.23
ExtensorCarpiRadialisBrevis
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TheECRBarisesfromthecommonextensortendononthelateralepicondyleofthehumerus(seeChapter17)andfromtheradialcollateralligament.Itinsertsonthe
posteriorsurfaceofthebaseofthethirdmetacarpalboneandreceivesitsnervesupplyfromtheposteriorinterosseousbranchoftheradialnerve.Themusclestretches
acrosstheradialheadduringforearmpronation,resultinginincreasedtensilestresswhentheforearmispronated,thewristisflexed,andtheelbowisextended.Themore
mediallocationoftheECRBcomparedtotheECRLmakesittheprimarywristextensor,butithasalsoaslightactionofradialdeviation.
EDandEDM
TheEDarisesfromthelateralhumeralepicondyle,partofthecommonextensortendonwhiletheEDMarisesfromamuscularslipfromtheulnaraspectoftheED
muscle.TheEDinsertsonthelateralandposterior(dorsal)aspectofthemedialfourdigits,whiletheEDMinsertsontheproximalphalanxofthefifthdigit.Both
musclesareinnervatedbytheposteriorinterosseousbranchoftheradialnerve.WhiletheEDfunctionstoextendthemedialfourdigits,theEDMextendsthefifthdigit.
ExtensorCarpiUlnaris
TheECUarisesfromthecommonextensortendononthelateralepicondyleofthehumerusandtheposteriorborderoftheulna.Itinsertsonthemedialsideofthebase
ofthefifthmetacarpalbone.Itisinnervatedbytheposteriorinterosseousbranchoftheradialnerve.TheECUisanextensorofthewristinsupinationandprimarily
causesulnardeviationofthewristinpronation,workinginsynergywiththeFCUtopreventradialdeviationduringpronation.23
Extensionofthewristisdependentonthreemuscles:
ECRL
ECRB
ECU
TheECRBandECRLarecommonlyconsideredtobesimilarmuscles,butinfacttheydifferinmanyrespectsandhaveverydifferentmomentarmsofextension.37The
ECRB,becauseofitsoriginontheepicondyle,isnotaffectedbythepositionoftheelbow,sothatallofitsactionisonthewrist,makingitthemosteffectiveextensorof
thewrist(becauseithasthegreatesttensionandthemostfavorablemomentarm).23Takentogether,bothECRtendonscompriseabout10%ofthemusclemassofthe
forearmand76%ofthemusclemassoftheextensorsofthewrist.38TheECRLhaslongermuscularfibers,mostlyattheleveloftheelbow.TheECRLonlybecomesa
wristextensorafterradialdeviationisbalancedagainsttheulnarforcesoftheECU.
TheECU,theantagonistoftheEPL,hastheweakestmomentofextension,whichbecomeszerowhenthewristisincompletepronation.
DeepMuscles
AbductorPollicisLongus
TheAPLarisesfromtheposterior(dorsal)surfaceoftheproximalportionoftheradius,ulna,andinterosseousmembraneandinsertsontheanterior(ventral)surfaceof
thebaseofthefirstmetacarpal.TheAPLisinnervatedbytheposteriorinterosseousbranchoftheradialnerveandfunctionsintheabduction,extension,andexternal
rotationofthefirstmetacarpal.
ExtensorPollicisBrevis
TheEPBarisesfromtheposterior(dorsal)surfaceoftheradiusandinterosseousmembrane,justdistaltotheoriginoftheAPL.Itinsertsontheposterior(dorsal)surface
oftheproximalphalanxofthethumbviatheextensorexpansion.TheEPBisinnervatedbytheposteriorinterosseousbranchoftheradialnerveandfunctionstoextend
theproximalphalanxofthethumb.
ExtensorPollicisLongus
TheEPLarisesfromtheposterior(dorsal)surfaceofthemidportionoftheulnaandinterosseousmembrane.Itinsertsontheposterior(dorsal)surfaceofthedistal
phalanxofthethumbviatheextensorexpansion.TheEPLisinnervatedbytheposteriorinterosseousbranchoftheradialnerve.Itfunctionsintheextensionofthedistal
phalanxofthethumbandisthusinvolvedintheextensionofthemiddlephalanxandtheMCPjointofthethumb.
ExtensorIndicis
TheEIarisesfromtheposterior(dorsal)surfaceoftheulna,distaltotheotherdeepmuscles,andinsertsontheextensorexpansionoftheindexfinger.Itisinnervatedby
theposteriorinterosseousbranchoftheradialnerveandisinvolvedintheextensionoftheproximalphalanxoftheindexfinger.
MusclesoftheHand
Themusclesofthehand(Fig.1811)arethosethatoriginateandinsertwithinthehandandareresponsibleforfinefingermovements.
ShortMusclesoftheThumb
AbductorPollicisBrevis
TheAPBarisesfromtheflexorretinaculumandthetrapeziumboneandinsertsontheradialaspectoftheproximalphalanxofthethumb.Itisinnervatedbythemedian
nerveandfunctionstoabductthefirstmetacarpalandproximalphalanxofthethumb.
FlexorPollicisBrevis
TheFPBarisesfromtwoheads.Thesuperficialheadarisesfromtheflexorretinaculumandthetrapeziumbonewhilethedeepheadarisesfromthefloorofthecarpal
canal.TheFPBinsertsonthebaseoftheproximalphalanxofthethumb.Thesuperficialheadreceivesitsinnervationfromthemediannervewhilethedeepheadis
innervatedbytheulnarnerve.TheFPBfunctionstoflextheproximalphalanxofthethumb.
OpponensPollicis
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TheOParisesfromtheflexorretinaculumandthetrapeziumboneandinsertsalongtheradialsurfaceofthefirstmetacarpal.TheOPisinnervatedbythemediannerve
andfunctionstoflex,rotate,andslightlyabductthefirstmetacarpalacrossthepalmtoallowfortheoppositionwitheachoftheotherdigits.
AdductorPollicis
Theadductorpollicis(AP)arisesfromtwoheads.Thetransverseheadoriginatesfromtheventralsurfaceoftheshaftofthethirdmetacarpal,whiletheobliquehead
originatesfromthetrapezium,trapezoid,andcapitatebones,andthebaseofthesecondandthirdmetacarpalbone.TheAPinsertsontheulnarsideofthebaseofthe
proximalphalanxofthethumbandisinnervatedbythedeepbranchoftheulnarnerve.TheAPfunctionstoadductthethumbandaidsinthumbopposition.
ShortMusclesoftheFifthDigit
AbductorDigitiMinimi
TheADMarisesfromthepisiformboneandthetendonoftheFCU.Itinsertsontheulnaraspectofthebaseoftheproximalphalanxofthefifthdigit,togetherwiththe
flexordigitiminimi(FDM)brevis.Itisinnervatedbythedeepbranchoftheulnarnerveandfunctionstoabductthefifthdigit.
FlexorDigitiMinimi
TheFDMoriginatesfromtheflexorretinaculumandthehookofthehamatebone.Itinsertsontheulnaraspectofthebaseoftheproximalphalanxofthefifthdigit,
togetherwiththeADM.Itisinnervatedbythedeepbranchoftheulnarnerveandfunctionstoflextheproximalphalanxofthefifthdigit.
DeepbranchesoftheulnararteryandnerveenterthethenarmassandcourseintothedeepregionofthehandbypassingbetweentheADMandtheFDM.
OpponensDigitiMinimi
Theopponensdigitiminimi(ODM)arisesfromtheflexorretinaculumandthehookofthehamateboneandinsertsontheulnarborderoftheshaftofthefifthmetacarpal
bone.Itisinnervatedbythedeepbranchoftheulnarnerveandfunctionstoprovideasmallamountofflexionandexternalrotationofthefifthdigit.
InterosseousMusclesoftheHand
Theinterosseimusclesofthehandaredividedbyanatomyandfunctionintoanterior(palmar)andposterior(dorsal)interossei.
Anterior(Palmar)Interossei
Thethreeanterior(palmar)interosseihaveavarietyoforiginsandinsertions.Thefirstinterosseousoriginatesfromtheulnarsurfaceofthesecondmetacarpalboneand
insertsontheulnarsideoftheproximalphalanxoftheseconddigit.Thesecondanterior(palmar)interosseousarisesfromtheradialsideofthefourthmetacarpalbone
andinsertsontheradialsideoftheproximalphalanxofthefourthdigit.Thethirdanterior(palmar)interosseousoriginatesfromtheradialsideofthefifthmetacarpal
boneandinsertsontheradialsideoftheproximalphalanxofthefifthdigit.Theanterior(palmar)interosseiareinnervatedbythedeepbranchoftheulnarnerve,and
eachmusclefunctionstoadductthedigittowhichitisattachedtowardthemiddledigit.Theanterior(palmar)interosseialsofunctiontoextendthedistalandthenthe
middlephalanges.
Posterior(Dorsal)Interossei
Thefourposterior(dorsal)interosseihaveasimilarlyvariedoriginandinsertionastheiranterior(palmar)counterparts.Theposterior(dorsal)interosseioriginateviatwo
headsfromadjacentsidesofthemetacarpalbones.Thefirstposterior(dorsal)interosseousmuscleinsertsintotheradialsideoftheproximalphalanxoftheseconddigit.
Thesecondinsertsintotheradialsideoftheproximalphalanxofthethirddigit.Thethirdinsertsintotheulnarsideoftheproximalphalanxofthethirddigitandthe
fourthinsertsintotheulnarsideoftheproximalphalanxofthefourthdigit.Theposterior(dorsal)interosseireceivetheirinnervationfromthedeepbranchoftheulnar
nerve.Theposterior(dorsal)interosseiabducttheindex,middleandringfingersfromthemidlineofthehand.
Lumbricals
ThelumbricalmusclesareusuallyfoursmallintrinsicmusclesofthehandthatoriginatefromtheFDPtendonsandinsertintotheposterior(dorsal)hoodapparatus.
Occasionally,morethanfourlumbricalsarefoundinonehand.39
Duringcontraction,theypulltheFDPtendonsdistally,thuspossessingtheuniqueabilitytorelaxtheirownantagonist.6TheyfunctiontoperformthemotionofIPjoint
extensionwiththeMCPjointheldinextensionandcanassistinMCPflexion.23
Thelumbricalmusclesalsoserveanimportantroleintheproprioceptionofthehand,providingfeedbackaboutthepositionandmovementofthehandandfingerjoints.6
Ininstancesoflumbricalspasmorcontracture,attemptstoflexthefingersviatheprofundusresultintransmissionofforcethroughthelumbricalsintotheextensor
apparatus,producingextensionratherthanflexion.6Alumbricalplusdeformityoccursifthereisexcessivelumbricalforce,orifthereisimbalanceofopposingforces,
whichproducesexaggeratedlumbricalaction(i.e.,MCPjointflexionandIPjointextension).6
Thelumbricalshavedualinnervation.LumbricalsIandIIareinnervatedtypicallybythemediannervewhilethethirdandfourthlumbricalsareinnervatedbytheulnar
nerve.
Neurology
Thethreeperipheralnervesthatsupplytheskinandmusclesofthewristandhandincludethemedian,ulnar,andradialnerves(Fig.1812).
MedianNerve
Themediannerveenterstheforearmbycoursinganteriorlythroughthemedialaspectofthecubitalfossaandpassingdeeptothelacertusfibrosis,betweentheheadsof
thepronatorteresmuscle.Belowtheelbow,muscularbranchesleavethenerveandinnervatetheFCR,palmarislongus,andpronatorteresmuscles.Theanterior
interosseousbranchinnervatesthepronatorquadratus,FPL,andtheFDPtotheindexfingerandmiddlefingersandsometimestheringfinger.
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Approximately8cmproximaltothewrist,themediannervegivesoffasensorybranch,theanterior(palmar)cutaneousnervethatpassessuperficialtotheflexor
retinaculumandremainsoutsidethecarpaltunnel.Thisnerveinnervatestheskinofthecentralaspectofthepalm,overthethenareminence.Therestofthemediannerve
passesdistallytothewrist,whereitentersthecarpaltunnel,whichpassesdeeptotheflexorretinaculum.
Thenerveentersthehandthroughthecarpaltunnel,deeptothetendonofthepalmarislongusandinbetweenthetendonsoftheFPLandFDS(themoreradialofthe
two).Fromthispoint,thenervedividesintotwobranches:amotorbranchwhichpassesposterior(dorsal)totheflexorretinaculumandasensorybranch.
MotorBranch
Thisshortbranchentersthethenareminence,whereitusuallysuppliestheAPBandOPmuscles,theFPB(occasionally),andthefirstandsecondlumbricalmuscles.
SensoryBranch
Thesensoryanterior(palmar)digitalbranchinnervatestheanterior(palmar)surfaceandposterior(dorsal)aspectofthedistalphalangesofthethumb,secondandthird
fingers,andtheradialhalfoftheforefinger.
Anumberofmediannerveentrapmentsyndromesexist(refertoPeripheralNerveEntrapment),eachwiththeirownclinicalfeaturesandfunctionalimplications.For
example,entrapmentofthemediannerveinthecarpaltunnelmayresultinnumbness,pain,orparesthesiaofthefingersandthumbandmayseverelyhinderapatients
abilitytoperformprecisionmaneuversduetolossofcriticalsensoryandmotorfunctioninthethumb,index,andmiddlefingers.
UlnarNerve
Theulnarnervehasbeenreferredtoasthenerveoffinemovementsofthehand.Theulnarnerveoriginatesfromtheinferiorrootsofthebrachialplexus(C8T1).Two
branchesoftheulnarnerveariseinthemidforearm:
Theanterior(palmar)cutaneousbranch.Theanterior(palmar)cutaneousbranchsuppliesaportionoftheskinoverthehypothenareminence.
Theposterior(dorsal)cutaneousbranch.About810cmproximaltotheulnarstyloidprocess,theposterior(dorsal)cutaneousbranchoftheulnarnervesplits
fromthemaintrunk.Theposterior(dorsal)cutaneousbranchterminatesintotwoposterior(dorsal)digitalbranchesthatsupplysensationtotheposterior(dorsal)
andulnaraspectofthemiddlephalanxoftheringandlittlefingers.40
Beforereachingthewrist,theulnarnervebranchestoinnervatetheFDPandtheFCU.
Atthewrist,theulnarnerveemergesjustlateraltothetendonoftheFCUasitpassessuperficialtotheflexorretinaculum.Theulnarnervepassesintothehandviathe
tunnelofGuyon,whereitdividesintoitssuperficialanddeep,terminalbranches.Thedeep(motor)branchsuppliestheFDM,ADM,ODM,AP,palmarisbrevis,third
andfourthlumbricals,deepheadoftheFPB,andtheinterossei.Thesuperficialbranch,whichisprimarilysensorywiththeexceptionofitsinnervationtothepalmaris
brevis,dividesintothreebranches.40Thefirstofthesethreebranchesisasensorybranchtotheulnaraspectofthelittlefinger,andthesecondisasensorybranchtothe
centralulnaranterior(palmar)area.Thethirdbranchoftenreferredtoasthecommondigitalnerve,innervatesthefourthintermetacarpalspace.Thecommondigital
nervefurtherdividesintotwoproperdigitalnervessupplyingtheulnarportionoftheringfingerandtheradialportionofthelittlefinger.40
Anumberofulnarnerveentrapmentsyndromesexist(refertoPeripheralNerveEntrapment),eachwiththeirownclinicalfeaturesandfunctionalimplications.
RadialNerve
Astheradialnerveentersthecubitalfossa,ittypicallysplitsintoasuperficialanddeepbranch.Thesuperficialbranchtypicallycoursesdistallyalongthelateralborderof
theforearmundercoverofthebrachioradialismuscleandtendon.Atthewrist,thisbranchdividesintofourtofivedigitalbranches,whichprovidecutaneousand
articularinnervation.Thecutaneousinnervationincludesthelateraltwothirdsofthedorsumofthehandandtheposterior(dorsal)lateral2fingerstotheproximal
phalanx.
Allofthemotorbranchesoftheradialnervearelocatedintheforearm.Thedeepbranch(posteriorinterosseousnerve)typicallypenetratestheanterior(ventral)surface
of,andpassesthroughthesupinatormuscle.ItreachesthedeepregionoftheposteriorforearmbypassingthroughthearcadeofFrhse.Thenervecourses
subcutaneouslyfromthemidportionoftheforearmtoanareaadjacenttothestyloidprocessoftheradiusandterminatesontheposterioraspectofthewrist.
CLINICALPEARL
Radialnerveentrapment(refertoPeripheralNerveEntrapment)mayresultinalossofextensionatthewristandMCPjointsofthefingers,andthumbextensionand
abduction.Sincethewristextensormusclesaresynergistsandstabilizersforthefingerflexormusclesduringgripping,thislosscansignificantlyhamperhandfunction.
VasculatureoftheWristandHand
Thebrachialarterybifurcatesattheelbowintoradialandulnarbranches,whicharethemainarterialbranchestothehand(Fig.1813).
FIGURE1811
Musclesofthehand.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.New
York,NY:McGrawHill2011.)
FIGURE1812
Nervesofthehand.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.NewYork,
NY:McGrawHill2011.)
FIGURE1813
Vascularsupplytothehand.(Reproduced,withpermission,fromChapter33.Hand.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.
NewYork,NY:McGrawHill2011.)
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RadialArtery
Theradialarteryisformedfromthelateralbranchofthebifurcationofthebrachialartery.Thearterygivesoffbranchesintheproximalportionoftheforearmthatform
ananastomosisaroundtheelbowjoint.Itrunsdistallyunderthecoverofthebrachioradialismuscle.Justproximaltothewrist,itislocatedbetweenthebrachioradialis
andtheFCRtendons.Asmallbranchcalledthesuperficialanterior(palmar)arteryleavestheradialartery58mmproximaltothetipoftheradialstyloid,passes
betweentheFCRandthebrachioradialis,andcontinuesdistallytocontributetothesuperficialanterior(palmar)arch,whichsuppliesthethenarmass.Theradialartery
hassevenmajorcarpalbranches:threeposterior(dorsal),threeanterior(palmar),andafinalbranchthatcontinuesdistally(seebelow).
UlnarArtery
Theulnararteryoriginatesasthemedialbranchofthebifurcationofthebrachialartery.Ittoogivesoffbranchesintheproximalportionoftheforearmthatforman
anastomosisaroundtheelbowjoint.Thearterypassesposterior(dorsal)totheulnarheadofthepronatorteresandcoursesdistallydeeptotheFDS,atwhichpointit
passesinthegroovebetweentheFCUandFDP,inthecompanyoftheulnarnerve.Intheproximalportionoftheforearm,thearterygivesoffacommoninterosseous
branch.Thearterybifurcates,givingrisetotheanteriorandposteriorinterosseousarteries,whichprovidebloodtostructuresinthedeepanteriorandposterior
compartmentsoftheforearm.Thearteryemergesatthewrist,justlateraltothetendonoftheFCU.ItthenpassesthroughthetunnelofGuyonandentersthesuperficial
compartmentofthehand.Atthelevelofthecarpus,theulnararterygivesoffalatticeworkoffinevesselsthatspantheposterior(dorsal)andanterior(palmar)aspectsof
themedialcarpals.Proximaltotheendoftheulna,therearethreebranches:abranchtotheposterior(dorsal)radiocarpalarch,onetotheanterior(palmar)radiocarpal
arch,andonetotheproximalpoleofthepisiformandtotheanterior(palmar)aspectofthetriquetrum.41
VascularArchesoftheHand
Posterior(Dorsal)Arches
Theposterior(dorsal)archesareconnectedlongitudinallyattheirmedialandlateralaspectsbytheulnarandradialarteries.Theyareconnectedcentrallybytheposterior
(dorsal)branchoftheanteriorinterosseousartery.Therearethreeposterior(dorsal)transversearches:theradiocarpal,theintercarpal,andthebasalmetacarpal41:
Posterior(dorsal)radiocarpal.Theradiocarpalarchissuppliedbybranchesoftheradialandulnararteriesandtheposterior(dorsal)branchoftheanterior
interosseousartery.
Posterior(dorsal)intercarpal.Theposterior(dorsal)intercarpalarchhasavariablesupply,whichcanincludetheradial,ulnar,andanteriorinterosseousarteries.
Basalmetacarpal.Thebasalmetacarpalarchissuppliedbyperforatingarteriesfromthesecond,third,andfourthinterosseousspaces.Itcontributestothe
vascularityofthedistalcarpalrowthroughanastomoseswiththeintercarpalarch.
Anterior(palmar)arches.Similartotheposterior(dorsal)vascularity,theanterior(palmar)vascularityiscomposedofthreetransversearches:theanterior
(palmar)radiocarpal,theanterior(palmar)intercarpal,andthedeepanterior(palmar)arch41:
Anterior(palmar)radiocarpal.Thisarchsuppliestheanterior(palmar)surfaceofthelunateandtriquetrum.
Anterior(palmar)intercarpal.Thisarchissmallandisnotamajorcontributorofnutrientvesselstothecarpals.
Deepanterior(palmar).Thisarchcontributestotheradialandulnarrecurrentarteriesandsendsperforatingbranchestotheposterior(dorsal)basalmetacarpal
archandtotheanterior(palmar)metacarpalarteries.
BIOMECHANICS
Thewrististhekeyjointofthehandandcontainsseveralsegmentswhosecombinedmovementscreateatotalrangeofmotionthatisgreaterthanthesumofits
individualparts.23Theosteokinematicsofthewristarelimitedtotwodegreesoffreedom:flexionextensionandulnarradialdeviation(Fig.1814).Wristcircumduction
afullcircularmotionmadebythewristisacombinationofthesemovements.42Theapparentaxialrotationofthepalmcalledpronationandsupinationoccursat
theproximalandDRUJs,withthehandmovingwiththeradius,notseparatelyfromit.42Thearthrokinematicsthatoccuratthejointsofthewristandhandare
summarizedinTable106.
FIGURE1814
Movementsofthewrist.(Reproduced,withpermission,fromChapter32.Forearm.In:MortonDA,ForemanK,AlbertineKH.eds.TheBigPicture:GrossAnatomy.
NewYork,NY:McGrawHill2011.)
PronationandSupination
Thetrueaxisforpronationsupinationatthewristmaybesituatedanywherebetweentheradialandulnarstyloid,resultinginnotone,butmanypronationsupination
axes.43,44
Approximately7590degreesofforearmpronationisavailable.Duringpronation,theconcaveulnarnotchoftheradiusglidesaroundtheperipheralsurfaceofthe
relativelyfixedconvexulnarhead.Pronationislimitedbythebonyimpactionbetweentheradiusandtheulna.
Approximately8590degreesofforearmsupinationisavailable.Supinationislimitedbytheinterosseousmembraneandthebonyimpactionbetweentheulnar
notchoftheradiusandtheulnarstyloidprocess.
CongruencyoftheDRUJsurfacesismaximalatthemidrangeofmotion,althoughthejointisnotconsideredtobetrulylockedinthisposition.6Atthisposition,the
TFCCismaximallystretched,andtheinterosseousmembraneisrelativelylax.
Atthejointsurfaces,theconcaveradiusslidesinthesamedirectionasthephysiologicalmotionsothatitslidesanteriorlywithpronationandposteriorlywithsupination.
TheproximalandDRUJsareintimatelyrelatedbiomechanically,withthefunctionandstabilityofbothjointsdependentontheconfigurationof,andthedistance
between,thetwobones.Thisconfigurationanddistancemaintainligamentandmuscletension.45Achangeinthelengthoftheulnaofaslittleas2mmresultsina
changeinthetransmissionofforcesof540%.46
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MovementoftheHandontheForearm
Duetothemorphologyofthewrist,movementatthisjointcomplexinvolvesacoordinatedinteractionbetweenanumberofarticulations.Theseincludetheradiocarpal
joint,theproximalrowofcarpals,andthedistalrowofcarpals.Allofthesejointspermitthemotiontooccuraroundtwoaxes:anteriorposteriorinflexionextension,
andtransverseinradialandulnardeviation.Wristextensionisaccompaniedbyaslightradialdeviationandpronationoftheforearm.Wristflexionisaccompaniedbya
slightulnardeviationandsupinationoftheforearm.
Anumberofconceptshavebeenproposedovertheyearstoexplainthebiomechanicsofwristmotion.4760Theessentialkinematicsofthesagittalplaneinvolvethe
mechanismofthecarpalbonemotionsrelatedtothecentralcolumnofthewristformedbytheseriesofarticulationsamongtheradius,lunate,capitate,andthird
metacarpalbone.42Withinthisconcept:
theradiocarpaljointisrepresentedbythearticulationbetweentheradiusandlunatecomposedoftheradius,scaphoid,trapezoid,trapezium,andthecolumnofthe
thumb
theCMCjointisassumedtobearigidarticulationbetweenthecapitateandthebaseofthethirdmetacarpal
Theulnarormedialcompartmentofthemidcarpaljointisrepresentedbythearticulationbetweenthelunateandcapitate.Thiscolumnstronglysupportsthe
movementsinthecentralcolumn,whilesimultaneouslyanchoringthewristtotheradius.48
Underthecolumnconcept,theradialandulnarcolumnsareproposedtomovewiththecentralcolumnduetomutualdisplacementsbetweentheproximalfacetsofthe
scaphoidandlunate.Inaddition,theproximalcarpalsareconsideredtomoveattheradiocarpalandmidcarpallevels.23,49
FlexionandExtensionMovementsoftheWrist
Themovementsofflexionandextensionofthewristaresharedbetweentheradiocarpalarticulationandtheintercarpalarticulationinvaryingproportions.19The
arthrokinematicsarebasedonsynchronousconvexonconcaverotationsattheradiocarpalandmidcarpaljoints.42
Duringwristextension,mostofthemotionoccursattheradiocarpaljoint(66.5%or40degreesvs.33.5%or20degreesatthemidcarpaljoint)andisaccompanied
withslightradialdeviationandpronationoftheforearm.19
Duringwristflexion,mostofthemotionoccursinthemidcarpaljoint(60%or40degrees,vs.40%or30degreesattheradiocarpaljoint)andisaccompaniedby
slightulnardeviationandsupinationoftheforearm.19
Extension
Attheradiocarpaljoint,extensionoccursastheconvexsurfacesofthescaphoidandlunaterollposteriorly(dorsally)ontheradiusandsimultaneouslyslideanteriorly
(palmarly).42Rotationdirectsthelunatesdistalsurfaceinanextended,posterior(dorsal)direction.Atthemidcarpaljoint,theconvexheadofthecapitaterolls
posteriorly(dorsally)ontheconcavelunateandsimultaneouslyslidesinananterior(palmar)direction.42Whenthewristisextended,theradiolunotriquetraland
radiocapitateligamentsarestretched,andtensiondevelopswithinthewristandfingerflexormuscles.Tensionwithinthestructuresstabilizesthewristinitsclosepacked
positionofextension.42,61,62
Lossofactiveextensioninthewristconstitutesaconsiderablefunctionalimpairment,includingthefollowing23:
Areductioningripstrength.
Changesinmusclelengthtensionrelationships,whichhasseriousimplicationswhenconsideringtheactionoftheextrinsicmusclesofthehand.Forexample,the
strengthofthethumbandfingerflexorsrequiresnormalmotionandfunctionofwristextension.
Flexion
Thearthrokinematicsofwristflexionaresimilartothosedescribedinextensionbutoccurinareversefashion.
FrontalLateralMovementsoftheWrist
Likeflexionandextension,themovementsofulnaandradialdeviationofthewristaresharedbetweentheradiocarpalarticulationandtheintercarpalarticulationin
varyingproportions(Fig.1815).19Theamountofdeviationisapproximately40degreesofulnardeviationand15degreesofradialdeviation.Thereisaphysiological
ulnardeviationatrest,whichiseasilydemonstratedclinicallyandradiographically.
FIGURE1815
Amodelofthecentralcolumnoftherightwristshowingulnarandradialdeviation.
UlnarDeviation
Ulnardeviationoccursprimarilyattheradiocarpaljoint.62Duringulnardeviation,theradiocarpalandmidcarpaljointscontributefairlyequallytotheoverallmotion
(Fig.1815).42Attheradiocarpaljoint,thescaphoid,lunate,andtriquetrumrollulnarlyandslideasignificantdistanceradially.42Ulnardeviationofthemidcarpaljoint
occursprimarilyfromthecapitaterollingulnarlyandslidingslightlyradially.42Ulnardeviationislimitedbytheradialcollateralligament.62Althoughulnardeviation
bringsthetriquetrumintocontactwiththeTFCC,thelackofdirectulnartriquetralarticulationpermitsagreaterrangeofulnardeviation.Themusclewiththebest
biomechanicaladvantagetoproduceulnardeviationofthewristinpronationistheECU.23
RadialDeviation
Radialdeviationatthewristoccursthroughsimilararthrokinematicsasdescribedforulnardeviation(Fig.1815).42Radialdeviationoccursprimarilybetweenthe
proximalandthedistalrowsofthecarpalbones.ThemotionofradialdeviationislimitedbytheimpactofthescaphoidontotheradialstyloidandtheUCL.TheAPL
19/86
11/20/2016
andEPBarebestsuitedtoproduceradialdeviationofthewrist.23
CLINICALPEARL
Extensionofthewristisaccompaniedbyradialdeviation,andflexionofthewristisaccompaniedbyulnardeviation.Thewristalsoallowsrelativelyextensivetraction
andglidingaccessorymovement.
Anumberofstudieshaveexaminedthenecessaryrangeofmotionatthewristtoperformfunctionalactivities.Thesestudiesreportthatatleast5degreesofwristflexion,
35degreesofwristextension,10degreesofradialdeviation,and15degreesofulnardeviationareneededtoperformcommonpersonalcareactivitiescomfortably.63,64
Lessmotionisrequiredfor90%ofpersonalcareactivities:

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Intrinsic(Local) Systemic Extrinsic

Type ConductionVelocity(m/s) Function

CordandNerve LevelofInjury MotorLoss CutaneousLoss

Examination Percent Scorea

Segmental MuscleorMuscleGroup Reliability LR QUADAS

Reflex ElicitingStimulus PositiveResponse Pathology

NerveorDermatome Reliability LR QUADAS

Conditions Findings Protocol

Joint Action DegreesofMotion

Bony Producedbybonetoboneapproximation Normal:elbowextension

Type Cause CharacteristicsandExamples

Type Causes CharacteristicsandExamples

Objective Intervention Example

VascularClaudication NeurogenicClaudication SpinalStenosis

Method Strengths Limitations

Fat Tissue High T1W High(slightlylowerthanonT1W)

Ion Polarity Solution Purpose/Condition

Healthbelief Ajzendand TRAismostsuccessfulwhenappliedtobehaviorunderanindividuals

Theory Proponents Description

Group Action MechanismofAction SideEffects

TraditionalScale VerbalRating Revised10GradeScale VerbalRating

Elevationflexion 170180 Tissuestretch StretchingofGH,AC,SCjointcapsule

DiagnosticTestor PositiveLikelihood NegativeLikelihood

Droparmtest 125painfulshouldersaged1870yr,meanage51.6yrf 0.08 0.972.80 0.95

Speed'stestforbicepsorSLAP 45patientswithshoulderpainagerange1680yrj 0.90 0.14 1.05 0.11

PatientAge Mechanismof Areaof Symptoms

PatientAge Mechanismof Areaof Symptoms

Nerve MotorLoss SensoryLoss FunctionalLoss

Nerve MotorLoss SensoryLoss FunctionalLoss

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Dutton's Orthopaedic Examination Evaluation and Treatment 4ed

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