1. Yellow signs: (symptoms) (6)
    • Abnormal signs and symptoms (unusual patterns of complaints)
    • Autonomic Nervous System symptoms
    • Bilateral symptoms
    • Nuerological symptoms
    • Symptoms peripheralizing
    • Upper motor nueron symptoms (spinal cord)signs
  2. Yellow signs:
    • Abnormal sensation patterns (does not follow dermatome or peripheral nerve patterns)
    • Circulatory or skin changes
    • Drop attacks
    • Fainting
    • Multiple inflamed joints
    • Multiple nerve root invovlement
    • Progressive weakness
    • Progressive gait disturbances
    • Pyschosocial stresses
    • Saddle Anesthesia
    • Vertigo
  3. Systematic Pain: (4)
    • Constant or waves of pain or spasm
    • Disturbs sleep
    • Deep aching or throbbing
    • Not aggravated by mechanical stresses
  4. Systematic Pain: Associated with the following: (10)
    • Cyclic and progressive symptoms
    • Fatigue
    • Jaudice
    • History of infection
    • Generalized weakness
    • Low grade fever
    • Migratory Arthralgias
    • Skin rash
    • Tumors
    • Weight loss
  5. Musculoskeletal Pain:
    • Aggravated by mechanical stress
    • Lessens at night
    • Sharp or superficial pain
    • Usually decreases with cessation of activity
    • Usually continues or intermittent
  6. Diagnosis of shoulder pathology: External Primary Impingement 1
    • Intermittent Mild Pain with overhead activities
    • Over the age of 35
  7. Diagnosis of shoulder pathology: External Primary Impingemet 2
    Mild to moderate Pain with overhead activities or strenous Activites
  8. Diagnosis of shoulder pathology: External Primary Impingment 3
    • Pain at rest or with activities
    • Night pain may occur
    • Scapular or R.C weakness is noted
  9. Diagnosis of shoulder pathology: RC tear Full thickness
    • Classic night pain
    • Weakness noted mostly in abduction and E.R
    • loss of motion
  10. Diagnosis of shoulder pathology: Adhesive capsulities (idiopathic frozen shoulder)
    • Inability to perform ADL's owing to loss of motion
    • Loss of motion may be percieved as weakness
  11. Diagnosis of shoulder pathology: Anterior Instability (with or without external secondary impingment)
    • Apprehension to mechanical shifting limits activities
    • Slipping,popping, or sliding may present as suitable instability
    • Apprehension usually assoc. with horizontal ABD and E.R
    • Anterior or Posterior Pain may be present
    • Weak scapula stabilizers
  12. Diagnosis of Shoulder pathology: Posterior Instability
    • Slipping or popping of the humerus out the back
    • May be assoc. with forward flx and I.R while the shoulder is under a compressive load
  13. Diagnosis of shoulder pathology: Multidirectional Instability
    • Looseness of shoulder in all directions
    • May be the most pronounced while carrying luggage or turning over while asleep
    • Pain may or may not be present
  14. Special Test: Instability, Anterior
    • Load and shift
    • Crank, Apprehension and Relocation test
  15. Special Test: Instability, Posterior
    • Load and shift
    • Posterior Apprehension
    • Norwood
  16. Special test: Instability, Inferior (Multidirectional)
    • Sulcus Sign
    • Feagan test
  17. Special Test: Impingement
    • Neer
    • Hawkins-kennedy
    • Posterior Internal Impingement test (PIIT)
  18. Special test: Labral Lesion
    • CLunk (Bankart)
    • Anterior slide (Bankart/ SLAP)
    • Active compression test O'Brien (SLAP)
    • Bicep tension test (SLAP)
  19. Special test: Scapular stability
    • Lateral scapular slide
    • Wall/floor pushup
    • Scapular retraction test
  20. Special test: Muscle tendon pathology
    • Speeds
    • Yergusons
    • Empty can
    • Lift off sign
    • Lag or "springy back" test (Supscapular: I.R, Infraspinatus, T.Minor: E.R)
    • Trapz weakness
    • Seratus Anterior Weakness
    • Pec Major and minor Weakness
  21. Special Test: Nuerological Involvement
    Upper Limb tension test
  22. Special test: Thoracic Outlet Syndromes
    ROOS test (EAST)
  23. R.C Lesion: History and Observation
    • History:
    • 30-50 yrs of age
    • Pain and weakness after eccentric load
    • Observation:
    • Normal bone and soft tissue outlines
    • Protective shoulder hike may be present
  24. R.C lesion: Active and Passive Movements
    • Active:
    • Weakness of ABD or Rotation, or both
    • Crepitus may be present
    • Passive:
    • Pain if impingement occurs
  25. R.C lesion: Resisted Isometric Movement
    Pain and weakness on ABD and E.R
  26. R.C lesion: Special Test and Palpation
    • Special test:
    • + Drop arm
    • + Empty Can test
    • Palpation:
    • Tender over R.C
  27. R.C lesion: Diagnostic Imaging
    • Radiography: Upw. displacement of H.H
    • Acromial Spurring
  28. Frozen Shoulder: History and Observation
    • History:
    • Age 45+ (isidious type)
    • Insidious onset or after trauma or surgery
    • Functional restriction of E.R, ABD, I.R
    • Observation:
    • Normal bone and soft tissue outlines
  29. Frozen Shoulder: Active and Passive Movements
    • Active:
    • Restricted ROM
    • Shoulder Hiking
    • Passive:
    • Limited ROM especially in:
    • E.R
    • ABD
    • I.R (capsular pattern)
  30. Frozen SHoulder: restricted Isometric movement and Special test
    • Restricted Iso movement:
    • Normal when arm at side
    • Special test:
    • None
  31. Frozen shoulder: Palpation and Diagnostic Imaging
    • Palpation:
    • Not painful unless capsule is stretched
    • Diagnostic:
    • Radiography: negative
    • Arthrography: decreased capsular size
  32. Atraumatic Instability: History and Observation
    • History:
    • 10-35 yrs. of age
    • Pain and instability with activity
    • No history of trauma
    • Observation:
    • Normal bone and soft tissue outlines
  33. Atraumatic Instability: Active and Passive Movements
    • Active:
    • Full or excessive ROM
    • Passive:
    • Normal or Excessive ROM
  34. Atraumatic Instability: Restricted Isometric Movement and Special test
    • Restricted isometric movement:
    • Normal
    • Special test:
    • + Load and Shift
    • + Apprehension
    • + Relocation
    • + Augmentation test
  35. Atraumatic Instability: Palpation and Diagnostic Imaging
    • Palpation:
    • Anterior or Posterior Pain
    • Diagnostic Imaging:
  36. Cervical Spondylosis: History and Palpation
    • History:
    • 50+ yrs.old
    • Acute or chronic
    • Observation:
    • Minimal or no cervical spine movement
    • Torticollis may be present
  37. Cervical Spondylosis: Active and Passive movements
    • Active:
    • Limited ROM with pain
    • Passive:
    • Limited ROM (symptoms may be exacerbated)
  38. Cervical Spondylosis: Resisted Isometric Movements and Special test
    • Restricted Isometric Movement:
    • Normal, except if nerve root is compressed
    • Myotome may be affected
    • Special test:
    • + Spurling
    • + Distraction
    • + ULTT
    • + Shoulder ABD
  39. Cervical Spondylosis: Sensory function and Reflexes and Palpation:
    • Sensory function/Reflexes:
    • Dermatomes and Reflexes Affected
    • Palpation:
    • Tender over appropriate vertebrae or facet
  40. Cervical Spondylosis: Diagnostic Imaging
    Radiography: Narrowing Osteophytes
  41. Diagnosis of Tendinosis compared to Tendinitis: Prevalence
    • Overuse Tendinosis:Common
    • Overuse Tendinitis: Rare
  42. Diagnosis of Tendinosis compared to Tendinitis: Time for recovery, early presentation and chronic presentation
    • Overuse Tendinosis:
    • Early: 6-10wks
    • Chronic: 3-6 months
    • Overuse Tendinitis:
    • Early: Several days to 2 wks
    • Chronic: 4-6 wks
  43. Diagnosis of Tendinosis compared to Tendinitis: Likely hood of full recovery to sport from chronic symptoms
    • Overuse Tendinosis: ~80%
    • Overuse Tendinitis: 99%
  44. Diagnosis of tendinosis compared to tendinitis: Conservative Therapy
    • Overuse Tendinosis: Encouragement of Collagen synthesis maturation and strength
    • Overuse Tendinitis: Anti-inflammatory modalities and drugs
  45. Diagnosis of Tendinosis compared to Tendinitis: Role of surgery, Prognosis, time of recovery from surgery
    • Overuse Tendinosis:
    • Surgery: Exercise abnormal tissue
    • Prognosis: 70-85%
    • Recovery: 4-6 mo
    • Overuse Tendinitis:
    • Surgery: Not known
    • Prognosis: 95%
    • Recovery: 3-4 wks
  46. Signs and Symptoms of Peripheral Nerve Involvement: Spinal Accessory nerve
    • Inability to abduct arm beyond 90 degrees
    • Pain in shoulder on ABD
  47. Signs and Symptoms of Peripheral nerve Involvement: Long Thoracic Nerve
    • Pain on flexing fully extended arm
    • Inability to flex fully extended arm
    • Winging starts at 90 degrees of forward flexion
  48. Signs and symptoms of Peripheral Nerve involvement: Suprascapular Nerve
    • Increased pain on forward shoulder flexion
    • Shoulder weakness (partial loss of humeral control)
    • Pain increases with scapular ABD
    • Pain increases with Cervical rotation to opposite side
  49. Signs and symptoms of peripheral nerve involvement: Axillary (circumflex)nerve
    Inability to abduct arm with nuetral rotation
  50. Signs and symptoms of peripheral nerve involvement: Musculocutaneous Nerve
    Weak elbow flexion with forearm supinated
  51. Classification of GH painful arcs: Night Pain
    • Anterior: Yes
    • Posterior: Yes
    • Superior: Maybe
  52. Classification of GH painful arcs: Age
    • Anterior: 50+
    • Posterior: 50+
    • Superior: 40+
  53. Classification of GH painful arcs: Sex Ratio
    • Anterior: F>M
    • Posterior: F>M
    • Superior: M>F
  54. Classification of GH painful arcs: Aggravated by:
    • Anterior: E.R and ABD
    • Posterior: I.R and ABD
    • Superior: ABD
  55. Classification of GH painful arcs: Tenderness
    • Anterior: Lesser tuberosity
    • Posterior: Posterior Aspect of G. tuberosity
    • Superior: G. Tuberosity
  56. Classification of GH painful arcs: AC joint involvement
    • Anterior: No
    • Posterior: No
    • Superior: Often
  57. Classification of GH painful arcs: Calcification (if present)
    • Anterior:
    • Supraspinatus
    • Infraspinatus
    • and/or Subscapularis
    • Posterior:
    • Supraspinatus
    • and/or Infraspinatus
    • Superior:
    • Supraspinatus
    • and/or Subscapularis
  58. Classification of GH painful arcs: Third-degree strain biceps brachii (long head)
    • Anterior: No
    • Posterior: No
    • Superior: Occasional
  59. Classification of GH painful arcs: Prognosis
    • Anterior: Good
    • Posterior: Good
    • Superior: Poor (without surgery)
  60. Levator Scapulae: Referral Pattern
    Over muscle to posterior shoulder and along medial border of scapula
  61. Latissimus Dorsi: Referral Pattern
    • Inferior angle of Scapula up to posterior and anterior shoulder into posterior arm
    • May refer to area above iliac crest
  62. Rhomboids: Referral pattern
    Medial border of scapula
  63. Supraspinatus: Referral Pattern
    • Over shoulder cap and above spine of scapula
    • Sometimes down lateral aspect of arm to proximal forearm
  64. Infraspinatus: Referral Pattern
    • Anterolateral shoulder and medial border of scapula
    • May refer down lateral aspect of arm
  65. Teres Minor: Referral Pattern
    Near deltiod insertion, up to shoulder cap, and down lateral arm to elbow
  66. Subscapularis: Referral Pattern
    Posterior shoulder to scapulaand down posteromedial and anteromedial aspect of arm to elbow
  67. Teres Major: Referral Pattern
    Shoulder cap down lateral aspect of arm to elbow
  68. Deltoid: Referral Pattern
    Over muscle and posterior gleniod area of shoulder
  69. Coracobrachialis: Referral Pattern
    Anterior shoulder and down posterior arm
  70. Peripheral Nerve injury: Suprascapular C5-6: Affected Muscle,sensory,reflex
    • Muscle Weakness:
    • Supraspinatus, Infraspinatus
    • Sensory Alteration:
    • Top of shoulder from clavicle to scapula spine
    • Pain in posterior shoulder radiating into arm
    • Reflexes Affected:
    • None
  71. Peripheral Nerve Injury: Suprascapular: Mechanism of Injury
    • Compression in suprascapular notch
    • Compression in spinogleniod notch
    • Stretch into scapular protraction plus horizontal ADD
    • Direct blow
    • Space occupying lesion (ex.ganglion)
  72. Peripheral nerve Injury: Axillary (circumflex) nerve (posterior cord C5-6): Affected muscles,sensory,reflex
    • Muscle weaknes:
    • Deltiod, T. Minor (arm ABD)
    • Sensory Alteration:
    • Deltoid area
    • Anterior shoulder pain
    • Reflexes: None
  73. Peripheral nerve injury: Axillary nerve: Mechanism of Injury
    • Anterior GH dislocation or fx of surgical neck of humerus
    • Forced ABD
    • Surgery for Instability
  74. Peripheral Nerve Injury: Radial Nerve C5-8, T1: Affected muscle,sensory, reflex
    • Muscle weakness:
    • Shoulder, wrist, and hand extensors
    • Sensory alteration:
    • Dorsum of hand
    • Reflexes:
    • Triceps
  75. Peripheral nerve injury: Radial nerve: Mechanism of injury
    • Fracture Humeral shaft
    • Pressure (ex. crutch palsy)
  76. Peripheral nerve injury: Long thoracic nerve C5-7: Affected muscles,sensory, reflex
    • Muscle weakness:
    • Serratus Anterior (scapular control)
    • -No sensory and reflex alteration
  77. Peripheral nerve injury: Long thoracic nerve: Mechanism of injury
    • Direct blow
    • Traction
    • Compression against internal chest wall (backpack injury)
    • Heavy effort above shoulder height
    • Repititive strain
  78. Peripheral Nerve injury: Musculocutaneous Nerve C5-7: affected muscles, sensory, reflex
    • Muscle weakness:
    • Bicep brachii, Coracobrachialis, brachialis (elbow flexion)
    • Sensory Alteration:
    • Lateral aspect of the forearm
    • Reflex:
    • Bicep
  79. Peripheral Nerve injury: Musculocutaneous nerve: Mechanism of injury
    • Compression
    • Muscle Hypertrophy
    • Direct blow
    • Fx (clavicle and humerus)
    • Dislocation (anterior)
    • Surgery (Putti-Platt, Bankart)
  80. Peripheral Nerve Injury: Spinal Accessory Nerve XI C3-4: affected muscles,sensory,reflex
    • Muscle weakness:
    • Trapz (shoulder elevation)
    • Sensory alteration:
    • Brachial Plexus symptoms b/c of drooping of shoulder
    • shoulder aching
    • Reflex: none
  81. Peripheral Nerve Injury: Spinal Accessory: Mechanism of injury:
    • Direct Blow
    • Traction (shoulder depression and neck rotation to opposite side
    • Biopsy
  82. Peripheral nerve Injury: Subscapular Nerve Posterior Cord C5-6: affected muscles,sensory,reflex
    • Muscle weakness:
    • Subscapular, T. Major (I.R)
    • - No sensory or reflex alteration
  83. Peripheral Nerve Injury: Subscapular Nerve: Mechanism of injury
    • Direct blow
    • Traction
  84. Peripheral nerve injury: Dorsal Scapular C5: affected muscle,sensory,reflex
    • Muscle weakness:
    • Rhomboids, Levator Scapulae (Scapular retraction and elevation)
    • -No Sensory Alteration or reflex
  85. Peripheral nerve injury: Dorsal Scapular: Mechanism of Injury
    • Direct blow
    • Compression
  86. Peripheral Nerve injury: Lateral Pectoral nerve C5-6: affected muscles,sensory,reflex
    • Muscle weakness:
    • Pec major and minor
    • -No Sensory or reflex alteration
  87. Peripheral nerve injury: Lateral Pectoral Nerve: Mechanism of Injury
    Direct blow
  88. Peripheral Nerve injury: Thoracodorsal C6-8: affected muscles,sensory,reflex
    • Muscle weakness:
    • Lats
    • No sensory or reflex alteration
  89. Peripheral nerve injury: Thoracodorsal
    • Direct Blow
    • Compression
  90. Peripheral nerve injury: Supraclavicular nerve: Sensory and Mechanism of Injury Only!
    • Sensory:
    • Mild clavicular pain
    • Sensory loss over anterior shoulder
    • Mechanism:
    • Compression
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