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Check the content of the courses: Herniation Vs Stenosis For stenosis: - pain relief with flexion. - pain increase with ext. - traction from supine. - sitting better than standing. For herniation: - Pain relief with extension. - Pain increase with flexion. - traction from prone. - standing better than sitting. Hip Special test: Patrick’s (Faber) Test To Identify hip dysfunction and muscle tightness. The patient lies supine. Passively flex, abduct, and externally rotate the hip test leg so that the foot of the test leg is on top of the knee of the opposite leg. Slowly lowers the knee of the test leg toward the examining table. A negative test is indicated by the test leg’s knee falling to the table or at least being parallel with the opposite leg. A positive test is indicated by the test leg’s knee remaining above the opposite straight leg. Positive the test indicates hip dysfunction, iliopsoas spasm, or sacroiliac joint dysfunction. Grind (Scouring) Test To Identify degenerative disorders of the hip joint. The patient lies supine. The examiner flexes and adducts the patient’s hip so that the hip faces the patient’s opposite shoulder and resistance to the movement is felt. The test is positive if the pain is reproduced in the hip joint and refers to the knee or elsewhere. Trendelenburg Sign To identify the weakness of the gluteus Medius or unstable hip joint. The patient is asked to stand on one lower limb. Normally, the pelvis on the opposite side should rise; this finding indicates a negative test. If the pelvis on the opposite side (non-stance side) drops when the patient stands on the affected leg, a positive test is indicated. Remember, the Gluteus Medius and Minimus are innervated by the superior gluteal nerve, But the Gluteus Maximus is innervated by the inferior gluteal nerve. Thomas Test To identify tightness of hip flexors. The patient lies supine while the examiner checks for excessive lordosis, which is usually present with tight hip flexors. The examiner flexes one of the patient’s hips, bringing the knee to the chest to flatten out the lumbar spine and to stabilize the pelvis. The patient holds the flexed hip against the chest. If there is no flexion contracture, the hip being tested (the straight leg) remains on the examining table. If a contracture is present, the patient’s straight leg rises off the table and a muscle stretch end feel will be felt. Remember, a positive Thomas test limits the hip extension, not flexion. So, the terminal stance phase of the gait cycle will be limited. Ober’s Test To identify tightness of tensor fascia Latae and iliotibial band. The patient is in the side-lying position with the lower leg flexed at the hip and knee for stability. The examiner then passively abducts and extends the patient’s upper leg with the knee straight or flexed to 90°. The examiner slowly lowers the upper limb. If a contracture is present, the leg remains abducted and does not fall to the table. Ely’s Test To identify tightness of rectus femoris. The patient lies prone, and the examiner passively flexes the patient’s knee. On flexion of the knee, the patient’s hip on the same side spontaneously flexes, indicating that the rectus femoris muscle is tight on that side and that the test is positive. Tripod Sign To identify tightness of hamstring muscle. The patient is seated with both knees flexed to 90° over the edge of the examining table. The examiner then passively extends one knee. If the hamstring muscles on that side are tight, the patient extends the trunk to relieve the tension in the hamstring muscles. The leg is returned to its starting position, and the other leg is tested and compared with the first side. Extension of the spine is indicative of a positive test. Piriformis Test To identify piriformis syndrome. The patient is in the side-lying position with the test leg uppermost. The patient flexes the tested hip to 60° with the knee flexed. The examiner stabilizes the hip with one hand and applies downward pressure to the knee. If the piriformis muscle is tight, pain is elicited in the muscle. If the piriformis muscle is pinching the sciatic nerve, pain results in the buttock, and sciatica may be experienced by the patient. Leg Length Test To identify true leg length discrepancy. True leg length is measured by placing the patient in a supine position with the ASICs level and the patient’s lower limbs perpendicular to the line joining the ASICs. Using a flexible tape measure, the examiner obtains the distance from the ASIS to the medial or lateral malleolus on the same side. The measurement is repeated on the other side, and the results are compared. A difference of 1 to 1.3 cm (0.5 to 1 inch) is considered normal. Craig’s Test To identify abnormal femoral anteversion. The patient lies prone with the knee flexed to 90°. The examiner palpates the posterior aspect of the greater trochanter of the femur. The hip is then passively rotated medially and laterally until the greater trochanter is parallel with the examining table or reaches its most lateral position. The degree of anteversion can then be estimated, based on the angle of the lower leg with the vertical. Remember, - Normal anteversion angle: 8 – 15 degrees. - More than 15 is excessive anteversion. - Less than 8 is Retroversion. - children have 30 – 40 degrees of normal anteversion. - Patient with excessive anteversion, walks with toe-in gait, tibial and femoral medial rotation. Upper Cross Syndrome Individuals who present with upper crossed syndrome will show a forward head posture (FHP), hunching of the thoracic spine-as well as changed function in the shoulder girdle, elevated and protracted shoulders, scapular winging, and decreased mobility of the thoracic spine. Forward head posture, round shoulder, and kyphosis are postural deviations including excessive neck protraction and thoracic spine flexion, anterior tilt, and downward rotation of scapula with an inclining tendency and internal rotation of shoulder. Lower Cross Syndrome - LCS is a muscular imbalance that results in postural changes, which can lead to lower back pain over time. LCS is often caused by an overly sedentary lifestyle and/or poor posture. Prolonged sitting or injury can lead to development of shortened hip flexor muscles, and that leads to tightened lower back muscles. The tightened hip flexors eventually lead to weakened abdominal/core muscles, along with weakened gluteal/butt muscles. Postural effects of this condition are seen by an increased forward tilt of the pelvis that coincides with an excessive lower-back arch. However, this uneven pull of muscles has effects beyond the lumbo-pelvic-hip region. When this happens, your back muscles and hamstrings have to work harder, which can lead to low back and hamstring injuries. Will talk about grades of mobilization in the upcoming sections

Impingement Relevant Signs and Symptoms of Impingement - Anterior shoulder pain - Pain under the acromion - Lateral deltoid pain - Diffuse upper trapezius pain - Tenderness over greater tuberosity. Neer’s impingement test For impingement of supraspinatus, long head of biceps, sub-acromial bursa, and coracoacromial ligament. The patient’s arm is passively and forcibly fully elevated in the scapular plane with the arm medially rotated by the examiner. This passive stress causes the greater tuberosity to jam against the anteroinferior border of the acromion. The test is positive when reproduces symptoms of pain in the shoulder region. Note: - if the pain reproduced with the arm in the lateral rotation, check for acromioclavicular joint. - for coracoacromial ligament put the shoulder first in 10 to 20 degrees of adduction before internal rotation. Hawkins-Kennedy impingement test For impingement of supraspinatus, long head of biceps, subacromial bursa, and coracoacromial ligament. The arm of the patient is passively flexed up to 90 degrees in the plane of the scapula. The arm is stabilized, and the forearm is forced into internal rotation. Pain indicates a positive test for supraspinatus paratenonitis/tendinosis or secondary impingement. Yocum test The Yocum test is a modification of the Hawkins-Kennedy impingement test in which the patient’s hand is placed on the opposite shoulder and the examiner elevates the elbow. Pain indicates a positive test. Empty Can/ Jobe Test For tear/ impingement of supraspinatus tendon or suprascapular nerve neuropathy. The patient’s arm is abducted to 90° with neutral (no) rotation, and the examiner provides resistance to abduction. The shoulder is then medially rotated and angled forward 30° (“empty can” position) so that the patient’s thumbs point toward the floor in the plane of the scapula. Differentiate if the pain is present between two positions. The test is positive if reproduces pain in the supraspinatus tendon or weakness in the empty can position. Posterior Internal Impingement For a lesion of the posterior shoulder labrum and rotator cuff. Commonly caused by repetitive overhead activities. the posterior impingement occurs when the rotator cuff impinges against the posterosuperior edge of the glenoid when the arm is abducted, extended, and laterally rotated. The patient is in a supine-lying position. the examiner places one hand under the patient’s elbow and the other hand grasping the wrist. the examiner passively abducts the shoulder 90 degrees, with 20 degrees flexion, and maximum lateral rotation. the test is positive if the pain is provoked on the posterior aspect of the shoulder. Tendon And Muscles Pathology Signs and symptoms Tendinitis and tendinosis - Point tenderness - Nocturnal pain - Pain initiated at the beginning of the activities - Pain radiates distally to the arm and forearm. Tendon rupture - Marked loss of strength. - Pain with active range of motion. - Possibly a bulge at the point of the muscle retraction. - Feeling of “pop” in the arm with the lifting activity. Muscle strain or tear - Localized swelling and bruising at the site of the injury. - Localized or diffused tenderness. - Pain with muscle contraction. - Shoulder inflammation may cause nerve irritation with peripheral numbness or tingling due to nerve impingement. Speed’s Test To Identify bicipital tendinosis/ tendinopathy. Upper limb in full extension and forearm supinated, resist shoulder flexion (dynamic test). Alternate – place the shoulder in 90-degree flexion or at the painful range and push the upper limb into an extension (static test). The test is positive when Pain in the long head of the biceps tendon or increased tenderness in the bicipital groove. Note: if profound weakness is noted during supination, biceps tear is suspected. Yorgason’s Test For Integrity of the transverse ligament. The transverse ligament is a small broad ligament that holds the tendon of the long head of the biceps brachii muscle in the groove between the greater and lesser tubercle on the humerus. Patient sitting with elbow flexed to 90° and stabilized against the thorax and with the forearm pronated. Resist the supination of forearm and external rotation of shoulder. The test is positive if the tendon of the long head of biceps pops out of the groove. BUT Tenderness in the bicipital groove alone without the dislocation may indicate bicipital tendinosis. Supraspinatus test (Empty can or jobe test). To assess supraspinatus tendon or suprascapular nerve. The test: See impingement section. Abdominal compression test/ belly press/napoleon test) For subscapularis muscle The patient is standing, the examiner places a hand on the abdomen below the xiphoid process so that the examiner can feel how much pressure the patient is applying to the abdomen. The patient places his hand on the examiner’s hand and pushes the hand as hard as he can into the stomach (medial shoulder rotation). While pushing the hand into the abdomen, the patient attempts to bring the elbow forward to the scapular plane, causing greater medial shoulder rotation. The test is positive when the patient is unable to maintain the pressure on the examiner’s hand while moving the elbow forward, or posteriorly flexes the wrist or extends the shoulder, the test is positive for a tear of the subscapularis muscle. Lift-Off Sign To assess subscapularis muscle. The patient is examined in standing and is asked to place his/her hand behind the back with the dorsum of the hand resting in the region of the mid- lumbar spine. The dorsum of the hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. The test is positive when the patient is unable to move the dorsum off the back constitutes an abnormal lift-off test and indicates subscapularis rupture or dysfunction. Clinically, it is better to place the dorsum of the hand and the level of the inferior angle of the scapula to isolate subscapularis muscle and to avoid the compensation using teres major, latissimus dorsi, posterior deltoid, and rhomboids. Lateral/External Rotation Lag test For infraspinatus and supraspinatus. The patient should be positioned in sitting with arm relaxed at their side. The examiner will passively flex the patient’s elbow to 90 degrees, abduct the shoulder 20 degrees, and maximally externally rotate the arm. While supporting the patient’s arm at the elbow, release the patient’s wrist, instructing them to hold this position of external rotation. The test is considered positive if the patient is unable to hold this position in external rotation. A positive external rotation lag sign occurs if the patient’s arm rotates internally as they are unable to maintain the externally rotated position. Anterior Glenohumeral Instability. Anterior glenohumeral instability means laxity of the anterior compartment of the shoulder with a difficulty to maintain the humeral head in a good position with the glenoid. 85%-95% of shoulder dislocation is anterior dislocation. Maybe this instability comes from a shoulder dislocation while accompanied by a Hills-Sachs lesion or Bankart lesion. - A Bankart lesion is the name for a tear that happens in the lower rim of the labrum. Once the labrum is torn, it's much easier for the humerus to slip out of its socket. Bankart lesion occurs in the anteroinferior direction from the 3 o’clock to 7 o’clock position. - A Hill-Sachs lesion is an injury that occurs secondary to an anterior shoulder dislocation. The humeral head 'collides' with the anterior part of the glenoid, causing a lesion, bone loss, defect, and deformity of the humeral head. With anterior shoulder dislocation, damage of labrum, glenoid, anterior capsule, or brachial plexus could occur. A common nerve injury: the Axillary nerve. A common vascular injury: the brachial artery. The mechanisms of injury: Traction of the arm anteriorly or fall onto an outstretched hand (FOOSH). Load And Shift Test - Anterior For instability of the glenohumeral joint. Normally, the humeral head feels a bit more anterior when it is properly “seated” in the glenoid. For best results, the muscles about the shoulder should be as relaxed as possible. The examiner stands or sits slightly behind the patient and stabilizes the shoulder with one hand over the clavicle and scapula. Using the other hand, the examiner grasps the head of the humerus with the thumb over the the posterior humeral head and the fingers over the anterior humeral head. The examiner moves the fingers along the anterior humerus and the thumb along the posterior humerus to feel if the humerus is seated relative to the glenoid. If the fingers “dip in” anteriorly as they move medially but the thumb does not, it indicates the humeral head is sitting anteriorly (Normal) and this is the “load” portion of the test. Then the examiner shift/move the head of the humerus anteriorly and posteriorly to check the amount of the head translation and comparing with the sound side (the shift portion of the test). The load and shift test may also be done in a supine lying position. To test anterior translation, the patient’s arm is taken to 45° to 60° scaption (abduction in the plane of the scapula). Three-Grade for Anterior Translation Normally: Translates 0% to 25% of the diameter of the humeral head. Grade I: Up to 50% of humeral head translation. Grade II: The humeral head has more than 50% translation. Grade III: The humeral head rides over the glenoid rim and does not spontaneously reduce. Apprehension (Crank) Test For anterior dislocation of the shoulder Patient supine, the examiner abducts the arm to 90° and laterally rotates the patient’s shoulder slowly. By placing a hand under the glenohumeral joint to act as a fulcrum, the apprehension test becomes the Fulcrum Test. If the examiner then applies posterior translation stress to the head of the humerus or the arm (anterior to posterior), the patient commonly loses the apprehension, any pain that is present commonly decreases, that confirms the anterior instability, and the apprehension test becomes the Relocation Test. After the relocation of the examiner suddenly releases his hand, the patient going to feel sudden apprehension. The test is called now the “Surprise” Test. Remember that the test is positive when the pain decreased with the Relocation Test. The test is positive if the patient feels pain and does not allow or does not like to move the shoulder (Apprehension) in that direction to simulate anterior dislocation. If the apprehension is dominant: The diagnosis is glenohumeral instability, subluxation, or dislocation. If the pain is dominant: The diagnosis is pseudo-laxity or anterior instability either at the glenohumeral joint or scapulothoracic joint with secondary impingement or a posterior SLAP lesion. Do not forget, when you finish the test release the external rotation first then release the relocation to avoid more pain or apprehension for the patient. Posterior glenohumeral instability Load And Shift Test – Posterior Same as the load and shift – anterior BUT the humeral head translation will be posterior. And remember that normally the posterior translation is more than the anterior one. For posterior translation, translation of 50% of the diameter of the humeral head is considered normal. Normally, the posterior translation is never less than the anterior translation. Posterior Apprehension Test /Stress Test For posterior stability of the shoulder The patient should be supine or sitting while the examiner elevates the patient’s shoulder in the plane of the scapula to 90° while using the other hand to stabilize the scapula. The examiner then applies a force posteriorly on the patient’s elbow while horizontally adducting and internally rotating the arm. Apprehension is a positive sign. Inferior glenohumeral instability. Symptoms and signs - insidious and progressive increase in popping, clicking, or clunking of the shoulder. - weakness and paresthesia may be present. once the patient gets inferior instability, he has a high tendency for anterior and posterior instability. Sulcus Sign For the inferior laxity of the glenohumeral joint The patient is examined in sitting or standing and the shoulder is in a neutral position with 20 – 50 degrees of abduction. It is important that the shoulder muscles are relaxed, and that stress is applied above the elbow to eliminate the effect of the biceps and triceps brachii. With the arm grasped inferior traction is applied. The examiner watches for a dimpling of the skin below the acromion. Palpation reveals widening of the subacromial space between the acromion and the humeral head. Grades of Sulcus Sign +1: <1cm +2: 1-2 cm +3: >2cm Labral Tears of Glenoid. The glenoid labrum is a fibrocartilaginous structure rim attached around the margin of the glenoid cavity in the shoulder blade. The shoulder joint is considered a ball and socket joint. Signs and symptoms - Aching pain in the shoulder. - A feeling of instability. - clicking or popping with motion. - weakness and pain with overhead activities. - Trapezius and thoracic pain. - Pain with biceps contraction. - tenderness over the anterior joint line. - A Bankart lesion is the name for a tear that happens in the lower rim of the labrum. Once the labrum is torn, it's much easier for the humerus to slip out of its socket. Bankart lesion occurs in the anteroinferior direction from the 3 o’clock to 7 o’clock position. - A Hill-Sachs lesion is an injury that occurs secondary to an anterior shoulder dislocation. The humeral head 'collides' with the anterior part of the glenoid, causing a lesion, bone loss, defect, and deformity of the humeral head. - A SLAP lesion, the labrum is detached from the glenoid from 10 o’clock to 2 o’clock position. Active Compression test/ O’BRIEN test Part 1 The patient is placed in the standing position with the arm forward flexed to 90° and the elbow fully extended. The arm is then horizontally adducted 10° to 15° (starting position) and medially rotated so the thumb faces downward. The examiner applies a downward eccentric force to the arm. Part 2 The arm is returned to the starting position and the palm is supinated so the shoulder is laterally rotated, and the downward eccentric load is repeated. Result If pain on the joint line or painful clicking is produced inside the shoulder (not over the acromioclavicular joint) in part 1 of the test and eliminated or decreased in part 2, the test is considered positive for labral abnormalities. Biceps Tension Test Remember that the long head of the biceps is attached to the labrum. And you have to differentiate between the biceps tendon and labrum. Remember also that speed test for Biceps tendon pathology and Biceps tension test for the labrum pathology. So, first, you have to do the speed test to rule out the biceps pathology then start with the Biceps tension test. The patient arm is abducted 90° and laterally rotated. the examiner then applies an eccentric adduction force. The test is positive if the adduction force reproduces the pain. Biceps Load Test For superior labrum The patient is in a supine position, the shoulder is 90° abduction, the elbow is 90° flexion, and the forearm is supinated. The examiner: - One hand supports the elbow, and the other hand grasps the wrist. - Lateral rotate the patient shoulder (apprehension). - Once the apprehension appears, stop the lateral rotation and hold the position. The Patient: - asked to flex the elbow against the examiner’s resistance. The test is positive for SLAP lesions if the apprehension and the pain increase or remain the same. The test is negative for SLAP if the pain decreases, or the patient feels comfortable. Acromioclavicular Acromioclavicular Shear Test For the dysfunction of AC joint such as arthritis, separation. The patient is in a sitting position, the examiner cups his or her hands over the deltoid muscle with one hand on the clavicle and the other hand on the spine of the scapula. The examiner then squeezes the heels of the hands together. The test is positive if the pain in the AC joint is reproduced. Acromioclavicular Crossover/Adduction Test For the dysfunction of the acromioclavicular or sternoclavicular joint. The patient is sitting or standing. The examiner: - Place on hand on the opposite shoulder for support. - Passively flexes the shoulder to 90 and then adducts the arm as far as possible. The test is positive if the pain is reproduced over the acromioclavicular or the sternoclavicular joint. Thoracic Outlet Syndrome- TOC Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between the collarbone (the clavicle) and the first rib (thoracic outlet) are compressed. This can cause shoulder and neck pain and numbness till the fingers. There are three main types: neurogenic, venous, and arterial. The neurogenic type is the most common 95% and presents with pain, weakness, and occasionally loss of muscle. The venous type 4% results in swelling, pain, and possibly a bluish coloration of the arm. The arterial type 1% results in pain, coldness, and pallor of the arm. TOS may result from trauma, repetitive arm movements, tumors, pregnancy, or anatomical variations such as a cervical rib. TOS can be attributed to: - Congenital abnormalities like a cervical rib, prolonged transverse process, and muscular abnormalities (e.g., in the scalenus anterior muscle). - Trauma (e.g., whiplash injuries) or repetitive strain is frequently implicated. - Rarer acquired causes include tumors (especially Pancoast tumors), hyperostosis, and osteomyelitis. Remember, Pancoast tumor may cause thoracic outlet syndrome so patients with Pancoast tumor may feel numbness in the fingers and weakness of intrinsic muscle of the hand. Mechanism Of Injury - Poor posture (forward head and droopy shoulder). - Prolonged overhead activities. - Excessive carrying of heavy objects. - Wearing a heavy coat or backpack causes shoulder depression. Halstead Maneuver/Test For the pathology of structures that pass through the thoracic outlet. The examiner finds the radial pulse and applies downward traction on the tested extremity while the patient’s neck is hyperextended, and the head is rotated to the opposite side. The Absence or disappearance of a pulse indicates a positive test for thoracic outlet syndrome. Adson’s Test For the pathology of structures that pass through the thoracic outlet. The examiner locates the radial pulse. The patient’s head is rotated to face the tested shoulder. The patient then extends the head while the examiner laterally rotates and extends the patient’s shoulder. The patient is instructed to take a deep breath and hold it. disappearances of the pulse indicate a positive test. Costoclavicular Syndrome (Military Brace) Test For the pathology of structures that pass through the thoracic outlet. The examiner palpates the radial pulse and then draws the patient’s shoulder down and back. A positive test is indicated by an absence of the pulse and implies possible thoracic outlet syndrome (costoclavicular syndrome). This test is particularly effective in patients who complain of symptoms while wearing a backpack or heavy coat. Wright (Hyperabduction) Test For the pathology of structures that pass through the thoracic outlet. The patient sitting, locate the radial pulse of the extremity being tested. Move shoulder into maximum abduction and external rotation. Taking a deep breath and rotating head opposite to the test site. The test is positive if Neurological or vascular symptoms (disappearance of pulse) are reproduced. Roos Test For the pathology of structures that pass through the thoracic outlet. The patient stands and abducts the arms to 90°, laterally rotates the shoulder, and flexes the elbows to 90° so that the elbows are slightly behind the frontal plane. The patient then opens and closes the hands slowly for 3 minutes The test is positive If the patient is unable to keep the arms in the starting position for 3 minutes or suffers ischemic pain, heaviness or profound weakness of the arm, or numbness and tingling of the hand during the minutes.

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You can find all sections of physical therapy throughout the self-learning & the live course - Musculoskeletal. - Neurology. - Cardiopulmonary. - Lymphatics. - Integumentary. - Pediatric. - Other Systems: Endocrine, GIT - Research. - Pharmacology. - Modalities. - Assistive devices. - Professional responsibility. ALL INCLUDED WITH THE COURSES Check the content of the courses:

Master your skills in musculoskeletal assessment, evaluation, diagnosis, and intervention Dr. Mohamed H. Desoki PT, DPT, t.DPT, OCS, M-AAOMPT, FiT-AAMT, APTA Clinical Instructor, NPTE Instructor.

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