Movement

System Impairment Syndromes

Cervical Spine
Extension-rotation:
Forward head; asymmetry in cervical spinal mm and/or scapula
alignment; pain with sidebend and extension; weak intrinsic cervical
flexors; dominant cervical rotators
Extension exercises (as below)
Diminish use of scalenes and SCM for rotation
Increase use of intrinsic cervical rotators
Sitting with back to wall cervical rotation (with supported UEs)
(keep chin down; do not lean head toward side rotating or
sidebend opposite direction)
Supine cervical rotation (easier)
Facing wall, arms supported-active cervical rotation (relax
upper traps)
Quadruped cervical rotation
Functional Instructions
Work station centered, avoid prolonged rotation TV,
video games; etc, avoid sidebend with phone; avoid 1
arm activities
Extension:
Forward head: pain with extension; translation greater than sagittal
rotation: weak intrinsic cervical flexors
Strengthen intrinsic flexors, improve flexibility of posterior
structures
Abdominals (and avoiding thoracic flexion)
Also look at axioscapular muscles, posterior thoracic spinal mm
Sitting with back to wall-capital flexion
Intrinsic cervical flexors in supine
Capital flexion
Capital flexion with heal lift (without and without A)
Intrinsic cervical extensors in prone/quadruped
Prone extension (roll)
Quadruped (roll) (harder than prone control scap)
Sitting with back to wall shoulder abduction and lateral
rotation (progression of capital flexion; recruits traps,
rhomboids, thoracic spinal mm)
Modifications: arms do not make full contact with wall;
fingertips on wall
Progression: Free weights, resistance bands
Sitting with back to wall shoulder flexion (progression of
capital flexion; stretches lats, levator scap, strengthens
intrinsic cervical flexors)
Modifications: scapular plane, palms facing each other

Progression: free weights, resistance bands

Wall slides: facing wall shoulder flexion
Modifications: scapular plane
Progrssion: resistance bands
Functional instructions
Using computer-good thoracic alignment, forearms
supported, check glasses
Flexion-rotation:
Decreased cervical lordosis, flat thoracic spine; pain with rotation-
associated flexion; excessive recruitment of extrinsic cervical rotators,
anterior and middle scalenes
Restore normal cervical inward curve
Avoid flexion of cervical spine
Increase thoracic flexion
Increase use of intrinsic cervical rotators
Correct sustained aymetrical positions
Avoid head/neck movements during body language
Sitting cervical rotation-Back to wall; UE supported (raise chin
up slightly, don not lean head toward side rotating)
Supine active cervical rotation (easier)
Quadruped active cervical rotation (even easier); allow tspine
to be slightly flexed
Facing wall, arms supported-active cervical rotation; relaxes
upper trap, raise head/chin slightly
Functional instructions:
Flex cervical spine
Avoid one arm activities
See flexion syndrome
Flexion:
Decreased cervical lordosis, flat thoracic spine; pain with flexion; lower
cervical flexion greater than upper thoracic flexion; excessive recruitment
of extrinsic neck flexors; poor recruitment of intrinsic neck extensors
during extension
Restore normal inward cervical curve
Improve intrinsic cervical extensors
Avoid prolonged cervical flexion
Prone active cervical extension (as above) avoid end range
Quadruped cervical extension
Functional instructions
Slump!
Avoid cervical flexion; lean forward with hip flex
Raise monitor
Pillow to increase lordosis
Eye glasses

 Thoracic Spine
Rotation-flexion:
Pain with thoracic flexion and rotation; long thoracic paraspinals and
scapulothoracic muscles (middle trap and rhomboids); short shoulder
girdle muscles ( pec minor and major, latissimus dorsi) and RA;
asymmetrical obliques; dominance of RA
Common in crew, squash, golf, diving, running, rotation at desk, shifted to
one side when sitting, leaning on 1 arm rest
Avoid leg crossing, sitting on one foot, unilateral arm rest
Prescribe unloading activities to relieve compression
Quadruped rocking
Back to wall with supported shoulder flexion
Inhalation to elevate ribs and elongate abs
Bilateral shoulder flexion at wall
Unilateral shoulder flexion in prone
Single leg stance with control of torso
Standing trunck flexion (supported) to improve hip flex
Shoulder flexion in quadruped
Prone trunk extension
Ab exercises with UE and LE motion
Flexion:
Pain with thoracic flexion (but not always painful!); must avoid flexion;
long thoracic paraspinals and scapulothoracic muscles; short anterior
axioscapular and axiohumeral (esp. lats with a kyphosis lordosis), short
RA
Prone trunk ext
Sit and stand back to wall and use UE motion
Light ab contraction to correct kyphosis
Rotation-extension:
Pain with thoracic region that radiates into lateral and anterior rib cage
or abdomen caused by thoracic rotation and extension; (sidelying or
sitting up in exaggerated position)
Racquest sports, gymnastics, ballet
Prevent extension and rotation, particularly with sitting and body
language
Use backrest; rotate chair not trunk; avoid unilateral arm rest;
avoid sitting on one foot
Unilateral arm or leg movements to recruit rotation control by
abs
Prone over pillows, unilateral arm movements (slide arm up)
Quadruped rocking
Quadruped unilateral shoulder flexion
Rotation:

Pain with thoracic rotation; rib cage asymmetries; asymmetries in

scapulothoracic and thoracic paraspinals; short stiff scapulohumeral
muscles; asymmetries of obliques
Common in tennis, squash, softball, sailing, running; rotation to one side
at desk, unilateral arm rest, sitting on one foot
Cue to reduce motion of rotation
Relax abs and then perform
Extension:
Pain with extension which occurs too easily; usually in interscapular
region
Common in dance or gymnastics
Teach gentle thoracic flexion, relax paraspinals,
See extension rotation
Increase abs
Engage abs to limit thoracic extension or excessive elevation of
rib cage during arm elevation (sitting, standing, quadruped)

 Lumbar Spine
Rotation-extension:
Causes of patients symptoms are extension and rotation motions
Caused by facet syndrome, spinal stenosis, spondylolisthesis, spinal
instability, DDD, OA of spine, herniated intervertebral disc
Spine is excessively flexible into extension and rotation
Hip flexors are stiffer than abdominal muscles
Hip abductor muscles are stiffer than lateral abdominal muscles
TFL is stiffer than abdominals
Latissimus dorsi is stiffer than abdominal muscles
During attempts to stand, increased back extensors than hip extensors
Treatment does not emphasize movement in opposite direction
except when excessive alignment impairments
Stop sitting on edge of chair
Stop leaning to one side
Must maintain hip rotational flexibility
Avoid standing with one hip adductred; avoid sway back
Should contract abdominal muscles isometrically for slight PPT
Sitting with back in straight back chair
Rolling: slide heel along bend to flex hip and knee then log roll
Moving in bed on side NOT back
Sit to stand push with hands to get to edge; use hands to push up
Stair climbing: contract abs and then lift leg to avoid lumbar
extension OR with lifting pahse may not have adequate hip
flexionneeds to lean forward
Walking needs to take small slow steps
Ther ex as used in confirming tests

Extension:
Similar to extension-rotation; motions that contribute to lumbar
extension increase symptoms
Thoracic kyphosis, swayed back, lumbar lordosis, anterior pelvic tilt
Stiff hip flexors, stiff latissimus dorsi
Hip flexors are more dominant than abdominals; back extensors
dominant hip extensors; external oblique long and weak
Primary objective is to correct lumbar lordosis; increase
abdominal activity
Heel slides
External oblique exercises in chapter 7
Bilateral knee to chest
Hip abduction and lateral rotation from flexion
Shoulder flexion to decreased kyphosis
Sidelying hip abduction
Prone knee flexion preventing anterior tilt
Prone hip lateral rotation to stretch TFL

 Quadruped rocking back

Sitting use back of chair, footstool, contract abs
Standing wall slides with lumbar flexion
Shoulder flexion with abs contracted
Contract abs when driving manual transmission, rotate hip

Rotation:
Rotation cause of pain; not common to find only rotation
syndromesidebending may also be classified as rotation
Transient symptoms
May have broad pelvis with narrow trunk, leg-length discrepancy (bony),
hip antetorsion or retrotorsion, scoliosis
Lumbar spine is flexible into rotation and lateral flexion in lower
segments; also during hip motions of adduction and rotation
Paraspinals are stiffer than lateral abdominal muscles; inadequate
recruitment of external oblique and contralateral internal oblique;
dominance of rectus; TFL, hip abductor may be short or stiff
Prevent rotation!
Rocking backward
Supine hip abduction/lateral rotation from flexion
Hip adduction/medial rotation
Abduction of shoulder on diagonal 135 degrees with weight
and then return movement of shoulder adduction to 90
degrees
Prone knee flexion and hip lateral rotation
Quadruped rocking backward to improve extensibility of hips
Quadruped unilateral shoulder flexion
Sitting knee extension
Standing lateral flexion with support at lateral side of waist

Rotation-flexion:
Most likely candidate it male 18 to 45 years old; they have less hips
flexion flexibility, are taller, and have longer tibias
Pain associated with sitting, bending, and twisting
Flat lumbar spine, leg-length discrepancy, hip retrotorsion or antetorsion,
PPT, hip extension, swayback, large abdomen
Lumbar spin eis more flexible into flexion and rotation than hamstring
and glute max muscles are extensible
Hamstring muscle are stiffer than back extensors
With swayback posture, rectus provides more trunk support than back
extensors
Rectus, TFL, and hamstring short and stiff
Primary objective is the improve control by abs to prevent
rotational movements; improve back extensor strength; improve
hip flexion

Supine hip and knee flexion, place folded towel under back
SKTC
Hip abduction-lateral rotation from flexion
Sidelying hip lateral rotation; hip abduction; hip adduction
Prone knee flexion and then hip rotation; also hip extension
with knee flexed also works on back extensor; prone shoulder
flexion
Quadruped rocking backward
Sitting knee extension with spine against straight-back chair
Standing forward bending at hips, lateral flexion with support
at side of thorax at L4/L5
Elevate seat to prevent lumbar flexion, move to edge before
standing

Flexion:
Most often acute herniated disk
Sitting with lumbar spine flexed with head and shoulders forward of the
spine
Structurally flat back
Tall with long trunk
Long tibias
High iliac crests
SKTC
Shoulder flexion with inhalation to stretch abs
Prone shoulder flexion, prone hip extension
Quadruped rocking back with hip flexion
Sitting knee extension
HS stretch 15-20 minutes at a time
Standing forward bend with hip flexion
Stretch abs with shoulder flexion

 Hip
Femoral anterior glide:
With and without medial rotation
Caused by inadequate posterior glide of femoral head during flexion;
excessive length of anterior capsule
Generalized hip pain, iliopsoas tendinopathy
NO ACTIVE HIP FLEXION. STRETCHING IS CONTRAINDICATED
Also iliopsoas bursitis, AVN, stress fracture of lesser trochanter or femur,
OA
Short lateral rotators (without medial rotation)
Anteverted hip, genu valgus, swayback, PPT, poor definition of glutes, hip
medial rotation, hip extension, hyperextended knees, pronated foot
TFL is more dominant than iliopsoas; also more dominant than PGM
Hamstrings dominant over glute max
Medial hamstring is more dominant than lateral
Improve posterior glide of femur
Reverse altered hip flexor dominanceshorten iliopsoas
Correct hip hyperextension and medial rotation if present
Quadruped rocking back most important, perform first
Supine passive hip flexion (may need slight lateral rotation and
abduction)
Prone knee flexion preventing pelvic anterior tilt or rotation or
hip joint abduction or rotation to stretch ITB
Prone hip IR to increase extensibility of ER
Prone hip extension ONLY with pillow under hips to avoid
stretching anterior capsule
Hip extension with knee flexed ONLY with pillow
Sidelying hip abduction with slight lateral rotation and
extension
Sitting knee extension with slight lateral rotation
Isometric hold of hip flexion at end range
Standing SLS contract glute max for ER
Sit to stand without allowing hip medial rotation
Do not sit with legs crossed

Femoral anterior glide with lateral rotation:
Adductor strain
Hockey and ice-skating
Anterior structures are stretched, posterior lateral rotators taut
Pain in groin worse in weight bearing; often occurs with hip extension
and lateral rotation; but may occur with flexion and lateral rotation
Femoral anteversion, tibial torsion, rigid foot, PPT, hip extension, knee
hyperextension, hip lateral rotation
Lateral rotators are recruited over medial rotators; hamstrings dominant
over glute max

Short hip extensors, glute max, lateral rotators, hamstrings, piriformis

Weak glute max, abductor medial rotator (TFL? Unsure by text), iliopsoas,
weak semimembranosus and semitendinosus
Improve posterior glide
Decrease dominance of hip extensor lateral rotator muscles
Improve medial rotators
Hook-lying adduct and rotate hip medially then reverse but
limit excursion in lateral direction (second part not always
added)
Prone knee flexed, rotate medially
Sidelying abduction with medial rotation and flexion
Quadruped rocking
Sitting isometric iliopsoas
Standing forward bend with hips while knees flexed
When sitting lean forward from hips
Avoid crossing legs

Hip adduction:
With or without medial rotation
Medial rotation: PGM, glute max, post capsule and lateral rotators are
weak or long, TFL shortcould be weak too; quads could be weak
All hip abductor muscles are weak or long
Short hip adductors
Causes wide pelvis, genu valgus, apparent leg length, pronated foot, sleep
on side
Sometimes causes piriformis syndrome; also IT band fasciitis
Pain in glute medius, deep hip pain, trochanteric bursitis, sciatica
Peroneal fascia may also be tight causing entrapment of peroneal nerve
Sartorius is often used for hip abduction in side-lying
Improve hip abductor and lateral rotators
Walk with cane if antalgic
Prone hip abduction, glute set, isometric lateral rotation (heel
squeeze)
Sidelying hip lateral rotation/abduction
When standing, even distribution of weight
No crossing legs
Stand at least every 30 minutes and tighten glutes
Do not allow knee to come together when standing
Pillow is sidelying between knees
IF TFL WEAK OR STRAINED:
Supine hip abduction with medial rotation
Active hip and knee flexion
Sidelying hip abduction
Prone knee flexion; hip lateral rotation to stretch ITB
Sitting knee extension without medial rotation

 Sit to stand avoiding adduction and medial rotation

SLS with glute contraction
Walking using a cane, contract glue at heel-strike

Hip extension with knee extension syndrome:
Insufficient participation of glute max during hip extension or quads
during knee extension
Hamstrings contract when the foot is fixed to extend the knee
Hamstring strain (caused by being hip extensor or knee extensor) also by
intrinsic lateral rotators of hip insufficient
Pain at ischial tuberosity; pain along HS muscle belly, pain with hip ext or
knee flex
Swayback, hip extension, medial hip rotation, knee hyperextension, ankle
PF
Hip flexion is stiff due to HS hypertrophy
Improve strength of synergistic muscles; do not use HS
Quadruped rocking backward
Supine unilateral hip and knee flexion
SLR DO NOT allow opposite HS to contract
Prone hip extension with hip flexed with pillowslight lateral
rotation is good to add
Heel squeeze
Sidelying hip abduction with slight ER
Sitting knee extension without extending or medially rotating
hip
Sit to stand with body leaning forward
Strengthen iliopsoas if swayback!
Standing SLS with glute contraction
Step up bringing thigh to knee
Posture: avoid hip or knee (hyper)extension; glute contract at heel
strike; return from forward bending glute max contraction not
forward swaying hips

Femoral accessory hypermobility:
Early degenerative changes in the hip joint, but without great loss of
motion; some could have labral tears
Subtle impairments of superior glide with rotation
Compression into joint; may occur with stretching of rectus or HS
Distraction should alleviate during stretches
Deep pain in anterior groin, anteromedial thigh
Slight antalgic gait
Assess prone passive knee flexion; greater trochanter will laterally rotate
or glide superiorly (flexion of hip); knee extension; rotate medially
Dominance of HS over glute max; quads and TFL over iliopsoas

 Reduce hyper mobility; improve extensibility of hamstrings and

quads
Quadruped hip abd and ER rocking backward until femur
rotates laterally; but DO NOT stretch intrinsic hip rotators
Prone knee flexion, stopping with rotation of femur; distraction
is helpful
Side-lying hip abduction in neutral
Sitting knee extension until medial rotation of femur
Isometric iliopsoas in sitting
Eliminate all weight training of quads and HS
Exercise iliopsoas, glute medius, glut minimus, hip ERs
No cycling!

Femoral hypomobility:
DJD with capsular signs
Marked limitation in flexion, extension, rotation, abduction, adduction
Pain deep in joint and referred to inner or anterior thigh
Joint stiffens after rest
Limited hip extension so exaggerated pelvis rotation or anterior tilt
during stance phase; also lumbar extension and rotation
Hip flexion contracture
Leg length discrepancy
Dominant hip flexor muscles; work on hip extensors strength
Primary objective is to maintain as much ROM as possible
Standing long-axis distraction with 4-7# weight can try medial
and lateral rotation
Supine SKTC to stretch hip flexors (DO NOT PLACE WEIGHT
CAUSES ANT. DISPLACEMENT OF FEMORAL HEAD)
Quadruped rocking back pushing with hands
Prone knee flexion
Hip lateral rotation with knee flexion
Hip abduction
Standing wall slides
Walking glute contraction with heel strike
If compensating with lumbar extenson, flex knees
Sitting on wedge if does not have 90 degrees of flexion
Sitting to standing front edge of chair

Hip lateral rotation:
Characterized by insufficient participation of intrinsic hip lateral rotator
muscles (piriformis, obturators, gemelli, quadratus femoris)
Shortened piriformis with sciatica
Pain just above gluteal fold down posterior aspect of thigh to knee
Misdiagnosed as HS strain
Hip retrotorsion

Hip lateral rotators are stiff than medial rotators

Stretch into medial rotation
Quadruped with hip abducted and ER; rock backward
Avoid sitting for prolonged periods
Also avoid hip extension and lateral rotation

Femoral lateral glide with short-axis distraction:
Similar to adduction syndrome except laxity of abductor muscles severe
enough to cause femoral head to glide laterally to point of subluxation
Prominent greater trochanter, anterior to midline and distal of the center
of the acertabulum
Must flex, abduct, and rotate femur laterally with one hand and guide
proximal femur at trochanter into appropriate alignment
Femur medially rotates and adducts; weak glute medius
During abduction, flexes and medially rotates
Prone extension also medial rotation
Wide pelvis, prominent trochanters
Eliminate laxity of hip abductors; avoid subluxation of femur
NO QUADRUPED
Supine heel slide keeping neutral rotation
Prone hip abduction and lateral rotation
Isometric hip lateral rotation (heel squeeze)
Hip extension with knee flexed
Sidelying abduction with ER
Sitting knee extension with neutral femur
Standing SLS ER
Avoid crossing legs or standing with hip in adduction

 Knee (tibiofemoral)
Tibiofemoral rotation (TFR) with valgus or varus:
Characterized by knee pain associated with impaired rotation of the
tibiofemoral joint; excessive rotation between the the tibia and femur can
be seen during tests of alignment, movement, and functional activities
Pain along joint line, peripatellar regions, or at the insertion of ITB
Pain with walking stair climbing
Ballet dancers, runner, equestrians, sedentary workers
Valgas TFLVal
Excessive medial rotation or adduction of femur relative to tibia; or
excessive lateral rotation or abduction of the tibia relative to the
femur resulting in knee valgus
More common in men
PFPS, ITB friction syndrome
Reduced extensibility of TFL-ITB
Poor hip lateral rotators and hip abductors; poor tibial lateral rotators
Correct TFRVal during functional activities
Improve hip lateral rotators, abductors, and tibial medial rotators
Increase extensibility TFL-ITB
Address foot PRN
Correct hyperextension
Align knees over feet with neutral rotation of femur and tibia
Correct femoral IR; contract glutes and hip lateral rotators
DO NOT CORRECT FOR TIBIAL OR FEMORAL TORSION
Gait contract glutes
Weight shift with unilateral contraction (glute med and lateral
rotators)
Walk with feet apart to shift adduction moment to medial knee
Sit to stand quadriceps and glutes, lean forward (squeeze your
rear and keep knee over 2nd toe do not let knees come together.
Can use TBand around distal femurs
Lift foot while driving, do not cross legs
Hip lateral rotator isometrics in prone, hip abduction in prone,
hip abd with lateral rotation in sidelying, hip lateral rotation
against resistance bands in sitting, lunges; hip extension in
prone with knee flexed progress to standing hip ext with
bands; SLS glute contraction and then with opposite LE motion
TFL-ITB extensibility prone knee flexion (bilateral), prone hip
lateral rotation, 2joint hip flexor test stretch, ober test, abs
Posterior X taping
Orthotics to correct pronation
Proprioception and balance
Varus TFRVar
Excessive rotation of tibiofemoral joint, but with knee varus

Varus thrust during gait; common with posterolateral corner injury

(hip IR and knee hyperextension)
Associated with OA of medial knee
Toe out to reduce symptoms
Mild to moderate laxity of LCL
Reduced extensibility of TFL-ITB; poor performance of hip lateral
rotators and abductors
Often ankle DF and pronation are limited
Correct TFRvar during functional activities
Improve performance of hip lateral rotators
Improve shock absorption during gait
Improve alignment by unlocking knees, align knees over feet
with neutral rotation of hips by decreasing hip IR (contract
glutes)
Heel-to-toe gait pattern for shock absorption
Toe out gait, walk with feet slightly closer together
SPC in ipsilateral side! De-weight medial knee
Hip ER strength
X taping

Tibiofemoral hypomobility syndrome:
Limitation in physiologic motion of the knee, OA
Pain with WB, walking, standing, stairs, relieved with rest
Knee flexion in standing
Decreased extensibility of hip flexors, HS, ankle plantarflexors
Poor performance of glutes, lateral rotators, gastrocs, quads
Improve knee flexion and extension ROM
Improve performance of glutes, hip ERs, quads, gastrocs
Improve aerobic conditioning
Educate on functional activities
Caution against repetitive rotation of knee with foot fixed
Consider compression forces
Assistive device PRN
Gait with heel-to-toe pattern
Sit-to-standegde of chair, contract quads and glutes, NO ADD
20-30 minutes change position
fitness
strengthening exercises as in TFRVal
also gastroc strengthening, abs and quads
IF MALALIGNMENT OR LAXITY NO QUAD STRENGTHENING.
It will accelerate degenerationuse functional sit<->stand,
step up,down, partial wall squats
Hip and knee extension in supine with opposite hip held to
chest
Knee flexion in prone

Hip ER in prone
Ankle DF with knee extended
Knee extension in sitting to improve HS extensibility
Accessory and physiologic mobilizations
Distraction mobilization
Bracing
Neuromuscular training

Knee extension without and with patellar superior glide:
Knee pain associated with quad dominance that results in excessive pull
on the patella, patellar tendon, or tibial tuberclepoor hip extensors
KextSGpatellar tendon and retinacula are relatively more flexible than
quads, patella moves superiorly in trochlear grove
Runners, football linemen, dancers, jumping
Insall-Salvati ratio 1.67
Often shift body weight posteriorly like in squat
Short rectus femoris
Poor performance of glutes and hamstrings
Decrease stiffness of quads
Improve glute and HS contribution to hip ext
Increase inferior glide and decrease superior glide of patella
KextSG
Sitting-reduce amount of knee flexion to reduce pain
Sitting manual inferior glide
Gaitincrease push off
Sit to standedge of chair, flex at hips and contract glutes
Reduce quad strengthening exercises
Resistive glutes and HS
Prone hip extension with knee flexed
Weight shifting
SLS
Hip extension in standing with resistance
Lunges
Squats
Prone knee flexion stretch ( may need towel under distal thigh
to allow patella to move) or 2 joint hip flexor test position
avoid anterior tilt or pelvic rotation KextSG need to stabilize
patella during stretching, may need tape
Patellar taping KextSG
Patella inferior glides and mobilizations with movement

Knee hyperextension:
Knee pain associated with an impaired knee extensor mechanism
Dominance of HS and poor performance of glutes and quads
Must rule out TFR syndrome first

Pain in peripatellar region or tibiofemoral joint aggravated by prolonged

standing or activities requiring rapid knee extension (swimming martial
arts race walkers)
Soft tissues of posterior knee are primarily responsible for resistance
needed to prevent extension
Compresses fat pat, stretches ACL
Short stiff gastroc (not always), short HS
Poor glute max and quads
Decreased hyperextension of knee
Improve glute max and quads
Decrease recruitment of HS
Relax knees, correct PPT
Use heel-to-toe pattern, walk with knees slightly flexed
Step up lifting body up and forward, not knee backward
Prone hip ext with knee flexed pillow under belly to prevent
hyperextension
Weight shifting
SLS
Resisted hip ext
Sit to stand
Wall sits
Step ups
Lunges
Squats
Sitting knee ext with ankle DF for HS and gastroc flexibility
Taping posterior X or McConnell taping under knee
Proprioception, balance, and perturbations

Patellar lateral glide:
Knee pain as a result of impaired patellar relationship within the
trochlear groove
Imbalance between vastus lateralis and vastus medialis obliquus
May also have tight ITB
Pain with stairs, running, squatting
Often secondary diagnosis with TFR or knee hyperextension
Short stiff lateral patella retinaculum, may also have short glute max as it
pulls on ITB
Decrease stiffnss of TFL-ITB
Improve quads
Sittingreduce knee flexioninitially sitting with thighs
abducted due to stiff ITB and then gradually adducte
Sit to stand use quads at edge of chair
Stairs-glutes and quads
Sit-to-stand->step-ups->lateral step ups->squats->lunges-
>step-downs

Avoid open chain 60-90 degrees

Prone knee flexion for ITB stretch, 2joint hip flexor length
stretch
Manual stabilization of patella or with tape
Strengthen PGM and glute max
Patellar mobilization

 Foot and Ankle

Pronation:
Pronation at the foot and ankle during weight bearing activities that is
excessive and/or when there is insufficient movement of the foot in the
direction of supination
Pronation can occur in hindfoot, midfoot, and/or forefoot
Plantarfascia, PTT, anterior tibialis muscle, tibial nerve, Achilles tendon,
metatarsal heads, interdigital nerves, medial column joints
Calcaneal eversion, medial bulge (prominence of talonavicular joint), low
medial longitudinal arch, forefoot abduction, splayed forefoot often have
hip IR, knee IR, femoral anteversion, medial tibial torsion, genu valgus
Subtalar neutral with forefoot varusthen get compensatory calcaneal
eversion or forefoot/midfoot pronationcould also be valgus hindfoot
Excessive calcaneal eversion in early and midstance phases; excessive
arch flattening in midstance, and/or insufficient supination in later stance
Poor contraction of gastroc
Increased pressure through medial aspect of foot and 2-3 met heads with
calluses in these areas
When running, often have midfoot or forefoot contactincreasing stress
on gastroc and post. Tib.
Cue to contract gastroc and post tib to lift heel and raise medial
longitudinal arch
Contract glutes on heel strike
Gastroc-SLHR calcaneus should invert and elevate
Weak post glute medius, glute max, intrinsic hip lateral rotators
Walking/running contract gastroc by lifting the heel
Raise medial longitudinal arch
Contract glute muscles
Hit with heel first
PRE PF, PF-inv, HR, single-leg hopping
Towel crunches
Posterior hip strengthening
Runners stretch, dropping heel off step, long sitting towel DF
(gastroc and soleus)
Talocrural joint posterior glide or distraction
DF splint
Limited EDL flexibilityneeds stretching
1st MTP dorsiflexion stretch
Anterior glide of 1st MTP joint
Shoe prescription
Orthoses
Taping

Supination:
Supination of the foot during heel strike to midstance

Can occur in hindfoot, midfoot, or forefoot

Plantar aponeurosis, peroneal tendon, Achilles tendonitis, met heads,
lateral column joints
Calcaneal inversion, lateral bulge, high medial longitudinal arch, forefoot
adduction, narrow forefoot; hip lateral rotation, knee lateral rotation;
subtalar neutral is hindfoot or forefoot varus with limited joint mobility;
can also have valgus hindfoot; plantarflexed first ray (dropped first ray)
Walking and running usually impairment includes calcaneal inversion at
heel strike and it remains that way through push off; absence of
pronation; lateral WB; late whip to medial side during push off; can cause
varus motions at knee; increased pressure at met heads, particularly the
1st MTP; cues to soften landing with knee flexion or roll medially sooner;
can post the heel laterally to encourage eversion; arch support to increase
contact area
Single leg hopping high hopper
Decreased talocrural DF during late stance results in early heel rise or
transfer of weight laterally
Limited 1st MTP DF results in transfer of force medial at late stance or
keeps forece lateral
Limited subtalar joint eversion
Calluses on 1st and 5th met heads
Walking and running soften landing, hit more centrally on the heel
ROM as in pronation syndrome
Footwear prescription
Orthosesnot for everyoneonly if significant structural
variations, recurrent problem
Taping for arch support, Achilles taping

Insufficient dorsiflexion:
Insufficient talocrural DF; occurs during midstance to pushoff or during
swing phaseno supination or pronation impairment
Plantar aponeurosis, Achilles tendinitis, posterior calcaneal bursa,
anterior tibialis muscle, deep fibular nerve, talocrural joint pain, met
heads
Walking and running:early heel rise, knee hyperextension, increased
progression angle3 ways to compensate
Poor eccentric use of gastrocs
Footwearlift heel above toe
Walking and runningactive contraction of gastroc and soleus
Joint mobilization to increase talocrural DF
Tape anterior progressing inferiorly and posteriorly on sides of
talus to calcaneus
Also use towel for self mobilization during closed chain activities
Footwear prescription
Heel lift

Hypomobility:
Limitation in physiological and accessory motions of foot and ankle;
degenerative changes or long immobilization
Calf is atrophied
Foot and ankle are large due to edema
Decreased step length on uninvolved side, decreased stance time on
involved, increased progression angle, little heel strike, little push off,
knee may hyperextend, often requires assistive device unable to run or
hop
Limited motion throughout; limited strength throughout; unable to
complete SLHR
Lack of balance
Aggressive ROM treatment planprolonged stretching with
braces, casts, joint mobilization and manipulation
Tband PRE->heel raise on machine->B/L HR->SLHR->dynamic
bilateral and single-leg hopping, cutting, sport specific
EO/EC solid, uneven progress to marching, kicking balls, walking
backward
Large shoe; steel shank in sole of shoe, rocker at the toes
Total contact orthosis, heel lift

Proximal tibiofibular glide:
Posterior and/or superior motion of fibula on tibua during HS contraction
Pain in posterolateral or lateral aspect of tibtib joint and associated
history of lateral ankle sprains
Pain with resisted HS contraction
Limited HS length and limited talocrural DF
Stabilization of fibula decreases symtpoms
Positional fault after ankle sprain or movement impairment as result of
HS contraction
Glide fibular
Increase HS flexibility
Increase talocrural DF
Tape!

 Shoulder
Scapular downward rotation:
Impaired scapular movement, which often causes or is associated with
impaired humeral motion, insufficient scapular upward rotation; inferior
angle does not reach midaxillary line
Could be tendinopathy, impingement, tear, thoracic outlet,
humeralsubluxation, instability, neck pain with or without radiating
pain, AC joint pain, SC joint pain
Structure: thoracic kyphosis, scoliosis, large breasts, obesity, heavy arms,
long trunk and short arms
Impairments: short deltoids, short supraspinatus (leads to humeral abd),
excessive length of trap, stiff levator and rhomboids
Often combined with shoulder abduction syndrome
Downward rotation of rhomboids and levator dominant over traps and
serratus ; short pec minor can interfere with upward rotation because of
ant tilt; lat downward pull on humerus and inf. Angle of scapula
depressing shoulder girdle
Sit with arms supported
Eliminate resistive exercises requiring scapular add with
shoulder less than 120 degrees
Avoid shoulder shrugs, except with shoulders flexed
Supine shoulder flexion, assist with opposite UE for scapular
upward rotation
Quadruped rocking
Scapular depression:
Similar to downward rotation except rhomboids and levator are not
short; upper trap long and weak, lats and pec major and pec minor short
Impingement, tear, subluxation, AC pain, neck pain with or without
radiating pain, pain in trap or levator, thoracic outlet
Scapula depressed and fails to elevate sufficiently during GH flexion/abd
(depression can occur at last phase 90 degrees or initial phase 0 degrees)
Long neck, narrow shoulders, long trunk, short arms, heavy arms, large
breasts
Clavicle horizontal, superior angle lower than 2nd
Upper trap does not elevate, lower trap is more dominant than upper trap
Passive support
Shoulder shrugs with shoulder flexed at 120 degrees
Shoulder flexion with emphasis on correcting depression
Scapular abduction:
Excessive scapular abduction during GH flex/abd, axillary border of
scapula protrudes more than inch beyond thorax or inf angle reaches
beyond midaxillary line
Impingement, anterior subluxation, tendinopathy (biceps, infraspinatus,
supraspinatus), infradeltoid bursitis, interscapular pain in rhomboids and
middle traps, SC joint pain
First half shoulder flexion mostly GH joint, 2nd half 1 to 1

Excessive length of trapezius, maybe rhomboids, short serratus anterior

When prone, scapula will abduct with GH lateral rortation
Kyphosis, long arms, large thorax, large breasts, abducted scapula, medial
rotation of humerus can pull scapula into abduction (pec major), lateral
rotation of humerus (short lateral rotators), quadruped scapular
abduction from shortening of serratus or stiffness of scapulohumeral
muscles because limits horizontal add of GH adductions
Shortness of deltoid or supraspinatus causes humeral abduction which
then pulls scapula into abducted position; hypertrophied pec major
Stretch glenohumeral and thoracohumeral muscles
Increase strength of lower and middle trap
Scapular adduction
Slide arms up wall, then adduct scapulae, progress to facing
away from wall, progress to prone
Stretch pec major and minor
Stretch medial and lateral rotation with weights in supine
Stretch scapulohumeral muscles with back to wall with passive
shoulder adduction
Scapular winging and tilting:
Inability to flex shoulder actively above 120 degrees with serve winging
indicates denervation
GH impingement, tendinopathy, bursitis, tear, thoracic outlet
Tilt of inferior angle or wing of vertebral border; can occur during return
from elevation
Short or weak serratus anterior, short pec minor, short scapulohumeral
muscles
Stretch pec minor
Retrain serratus
Quadruped rocking from heels forward
Elbow flexed to 120 back against wall shoulder flex to 60
degrees to control winging
Humeral anterior glide:
Pain is present in the anterior or anteromedial aspect of shoulder joint.
Pain is increased with shoulder IR, hyperextension, horizontal abduction,
also shoulder flexion 80 to 180 degrees, pain along biceps. Could have
ant. Dislocation
More than 1/3 humeral head anterior to acromion, humeral head
anterior to distal humerus, slight indentation posteriorly
Anterior joint capsule more flexibile than posterior capsule or lateral
rotators
Pec major more active than subscapularis
Dominance of teres minor and infraspinatus over subscapularis as
shoulder depressor
Passive IR in supine with 90 degree abduction
Horizontal adduction supine (passive)

 Shoulder flexion with lateral rotation, lean into wall (facing it)
to allow for inferior/posterior glide
Stretch pec major
After all of these, then strengthen subscapularis prone
shoulder abducted to 90, elbow flexed to 90, isometric end
range IR, as progress allow 50 degrees of motion
Quadruped rock backward by pushing with arms to increase
posterior glide of humerus
Humeral superior glide:
Pain anterior and lateral aspects of acromion during shoulder abduction,
IR, ER
Impingement, Tendinopathy, bursitis, biceps tendinopathy, calcific
tendinitis, rotator cuff tear, early adhesive capsulitis
During elevation, excessive proximal motion of head of humerus against
acromion results in impingement of humeral head against AC ligament or
acromion, often accompanied by scapular downward rotation
Shoulders can be elevated (humerus) or depressed (scapula)
Humeral motion, particularly superior glide is more flexible than scapular
motion BUT scapular motion is more because in superior position
humerus cannot abduct as much
Dominance of deltoid over supraspinatus and other rotator
cuffdecreased with elbow flexed
Restriction of posterior, inferior and lateral capsule
Both lateral and medial rotators can be short
Correct scapular depression
Supine medial and lateral rotation ROM
Prone lateral rotation using infraspinatus and teres minornot
deltoid!
NO ER with shoulder in adduction
Shoulder flexion with elbow bent! Can use downward pressure
to depress head of humerus
No leaning on hand or elbow
Shoulder medial rotation:
Pain at lateral and anterior aspects of humeral head in region of acromion
Pain between 80 and 180 degrees of flexion
Insufficient lateral rotation stresses subacromial structures and causes
impingement of soft tissues
Impingement, tendinopathy, bursitis, bicipial tendinopathy, calcific
tendinitis, rotator cuff tear, early adhesive capsulitis
Humerus is medially rotated even at middle and end range of elevation
Can be caused by broad hips/narrow shoulders, cubital fossa is medial
Lateral rotators are more extensible than medial rotatorsbut lateral
rotators may be stiff if scapular in abduction
Overuse of pec major and teres major (sawing, water siing, windsurfing)
Dominant latissimus dorsi

Shortness of pec major will limit flexion without IR; short lat can do it
also
Stretch medial rotators
Restrain scapula while shoulder flexed
Prone shoulder ER without scapular motion (use adductors
and serratus to stabilize) (may need 1/10 normal effort)
Glenohumeral hypomobility:
Adhesive capsulitis and frozen shoulder
Range is limited 40-50% in all directions
Movement occurs more readily in scapulothoracic joint
Flexion and abduction, excessive scapular elevation and trunk motion
Medial rotation, anterior tilt of scapula
Dominant muscle is deltoid
All scapulohumeral muscles are short
Excessive length of serratus anterior and lower trap
All GH muscles weak
Self range
Passive shoulder flexion with elbow bent
Passive flexion by leaning into wall
Supine 50-85 degrees abduction and horizontal flexion, hold
weight, pull into medial rotation, must prevent anterior glide of
humerus and tilt of scapula
Abduction avoided until 75% ER
ER should be performed in adducted position and abducted
position
Rocking backward in quadruped for posterior/inferior glide

 Elbow
Wrist extension with forearm pronation:
Lateral elbow pain provoked by gripping and lifting activities resulting in
overuse of wrist extensors
ECRL (elbow extended), ECRB (flexed)test with wrist extension
Underuse of biecps and supinator
Excessive wrist extension
Excessive GH abduction
Wrist extensors short.may cause medial rotation of humerus instead of
pronation of wrist
Improve alignment and movement patterns of wrist, forearm,
elbow, and shoulder
Increase elbow flexion and forearm supinated
Increase flexibility wrist and finger extensors and finger flexors
As pain decreases, strengthen wrist extensors, forearm pronators,
and supinators very gradually
Forearm strap, splint to immobilize wrist

Elbow hypomobility:
Significant limitation of accessory and physiological motion of the elbow;
flexion loss is usually greater than extension; usually also have loss of
supination and pronation
Often due to prolonged immobilization of trauma
Movement impairments of excessive elbow flexion, forearm pronation
and associated GH extension; elbow is often swollen
Compensatory scapular anterior tilt or shoulder extension during elbow
extension; scapular adduction and posterior tilt shoulder flexion and
trunk extension during elbow flexion; shoulder adduction and lateral
rotation during supination; shoulder abduction and medial rotation
during prontation
Capsular end-feel AROM and PROM about equal
Primary focus is to increased AROM and PROM, at least -30
degrees extension, 130 degrees flexion, 50 degrees pronation and
supination
Edema and scar management
AROM, PROM
Hold-relax, contract-relax
Joint mobilization
Splinting
Heat modalitis
Push through increased symptoms

Elbow flexion (Cubital Tunnel syndrome):
Prolonged or repeated elbow flexion places excessive stresses on ulnar
nerve at medial elbow

May be associated with forearm pronation, wrist flexion or extension, and

shoulder abduction
Shoulder abduction, forearm pronation and wrist extension elongate the
nerve; FCU contraction compresses the nerves
Numbness and tingling n the small and ring fingers; pain in medial elbow;
deep ache in proximal forearm, weak grip (late stage)
Increased with elbow flexion during sleep, pressure on medial elbow;
resisted elbow flexion and wrist flexion
Habitual elbow flexion, wrist flexion with ulnar deviation, could have
claw hand or Wartenberg sign (abd of 5th digit); avoiding elbow flexion
past 70 degrees decreases symptoms
FCU could be stiff or short
Could also have shoulder girdle impairments such as scapular depression
Should test grip, lateral, three-point pinch, and Froment
Test palmar and dorsal interossei, 4th & 5th lumbricals, adductor pollicis,
FDP of 4th & 5th fingers and FCU
If no weakness or sensory loss, conservative treatment; if
weakness develops consult physician
4 weeks to 6 months
pt education on avoiding repetitive activities or prolonged
postures of elbow flexion greater than 70 degrees, direct pressure
to medial elbow, forearm pronation, and wrist flexion. Minimize
valgus force
increase flexibility of FCU
nerve glide
correct scapular impairments
PROM of MCP and IP is loss of AROM
Elbow pad
Anti-claw splint

Elbow valgus syndrome with and without extension:
Excessive valgus of elbow resulting in laxity or sprain of UCL
Common in baseball pitches and racquet sports
Often associated with ulnar nerve injury
May progress to pain with extension
Increase strength of wrist flexors and forearm pronator
(with extension) also emphasis eccentric control of biceps brachii
to decrease forces on the posterior elbow
avoid resisted horizontal adduction and medial rotation of
shoulder
(with extension) also avoid end ROM extension
restore normal elbow, forearm, and wrist ROM
minimize elbow contracture
stretch wrist and finger extensors
strengthen wrist flexors and progress to pronation

as tenderness decreases strengthen elbow flex/ext, wrist

flex/ext, forearm pronation and supination progression:
isometric, concentric, eccentric
after 6 weeks can do valgus loading exercises
correct shoulder girdle impairments of GH ER, scapular
adduction, posterior tilt, and ER
(with extension) eccentric control
(without extension) hinged brace to prevent valgus; (with
extension) taping or splinting to avoid extension

Elbow extension:
Posterior elbow pain at end-range of elbow extension
Normal or excessive elbow joint ext ROM (source is joint structures)
Limited (source of pain is muscle, tendon, joint)
Avoid end ROM
Improve biceps eccentric control
Taping or splinting to avoid end-range ext
Nerve entrapment
Posterior Forearm Nerve Entrapment:
Includes radial tunnel (RT) and posterior interosseous nerve
syndrome (PINS) associated with compression of deep branch of
radial nerve
RT minimal loss of strength, but painful
Increase biceps, decrease wrist extensors
Avoid wrist extension, forearm pronation & supination, elbow
extension
Increase flexibility of wrist extensors, finger extensors, and
supinator
Can also stretch wrist and finger flexors
Address shoulder impairments
Splint 90 degrees elbow flex, wrist ext, forearm supinated
Modalitis US 1mHz 1.0 W/cm2 15 minutes, TENS,ionto, cryo
PINS may have pain, but significant muscle weakness no sensory loss
PROM to fingers and thumb flexion and extension; AROM and
strength as innervation returns
Splint dynamic thumb and finger extension
Decompression of nerve after 3 months
Anterior Forearm Nerve Entrapment:
Pronator syndrome (PS) and anterior interosseous nerve syndrome
(AINS)
AINS compression of motor branch of median nerve in proximal
forearm, loss of strength, no sensory changes; weakness of FPL, FDP
to index finger, pronator quadratus
PS minimal loss of strength, but painful, may have sensation changes

If no change 8-12 weeks refer back to physician

Avoid repeated grasping and forearm pronation and
supination
Increase flexibility of pronator teres, finger flexors, biceps
brachii, median nerve
Improve strength of supinator and shoulder girdle
Static splint elbow 90, forearm neutral, wrist 25 ext
Modalitis US, estim, ionto

Wrist flexion with forearm pronation:
Golfers elbow
Overuse of wrist flexors and forearm pronators
Stretch and strengthen muscles isometric to isotonic concentric to
eccentric
Initially elbow flexed when working on wrist ROM
Forearm strap
Modalities

Ulnoumeral and radiohumeral multidirectional accessory hypermobility:
Elbow pain with impaired rotation of the elbow joint (increased rotation
of ulna and radius related to humerus)
Includes posterolateral rotatory instability

 Wrist (Proposed Syndromes)

Flexion
Extension
Wrist flexion or extension with radial or ulnar deviation
Wrist hypomobility
Accessory hypermobility

 Hand
Insufficient finger and/or thumb flexion:
Most commonly secondary to trauma, injury, or prolonged
immobilization
Causes:
Flexor tendon adhesion
Extensor tendon adhesion
Shortness of extrinsic extensors
MP collateral ligament shortness and/or adhesion
IP joint dorsal capsule shortness and/or adhesion
Shortness of oblique retinacular ligament
Shortness of interossei and lumbricals
Swan neck deformity
Ligament sprain
Weakness of finger or thumb flexors
Rupture of finger or thumb flexors
Inability to make fist, difficulty gripping objects, difficulty using hand for
functional activities
Resting alignment of decreased flexion; MP extension with increased IP
flexion and adducted thumb (stiff hand posture)
Joint adjacent to limited joint will flex more readily
During finger flexion, wrist or fingers move into extension if finger
extensors are short, during finger flexion, wrist flexes if finger joint
structures are the source of limited finger flexion
Assess for ligament integrity, joint accessory motion
Test length of extrinsic finger or thumb flexors, extrinsic finger or thumb
extensors, and interossei muscles
Test strength
Hypomobility
Flexor tendon adhesion: AROM<PROM, extrinsic finger/thumb
flexor length tests +, palpable adherence, strong MMT in limited
range
Retrograde massage over flexors; passive stretch composite
finger extension; static splint; tendon gliding; isolated DIP
active flexion; isolated PIP flexion (other fingers extended
passively); resisted flexion; dynamic splint in extension;
Russian for active flexion, ultrasound over adhesion, UE
strengthening
Extensor tendon adhesion: AROM<PROM, extrinsic finger/thumb
extensor length tests +, palpable adherence, strong MMT in limited
range
Retrograde massage over adhesion; passive or active stretches
(composite finger flexion, flexion glove, active wrist flexion
with dumbbell); active extension; resisted extension;

static/progressive splinting into flexion; moist heat; Russian

stim; ultrasound, UE resistance
Extensor muscle shortness: normal AROM, PROM extension,
extrinsic extensor muscle length test +
Same as extensor tendon adhesion
MCP collateral ligament shortness or adhesion: equal limitation
PROM, AROM regardless of position of adjacent joints, firm end
feel, decreased PA glide of proximal phalanx on metacarpal
AROM and PROM to specific structure; blocking exercises; joint
mobilization (volar glide and distraction to increase flexion);
passive PIP extension (usu. Also limited with flexion
syndrome) and dorsal joint mobilization; static splints;
dynamic splints (glove, progressive flexion splint and
progressive extension splint); CPM; hot pack/cold
pack/paraffin; estim, US
IP joint dorsal capsule shortness or adhesion: AROM, PROM equal
regardless of position of adjacent joints, firm end feel, decreased
PA of more distal phalanx on more proximal one
Same as MCP collateral ligament shortness
Shortness of oblique retinacular ligament: short ORL test (DIP
joint flexion limited with PIP extended but not with PIP flexed);
Boutonniere deformity possible
Simultaneous DIP flexion with PIP extension (active, passive,
resistive)
Shortness of Interossei and Lumbricals: composite passive finger
flexion can be normal with short interossei because not stretched
when MP are flexed; composite extension can be normal, not
stretched over IP joints, TTP muscle bellies
Passive stretch MP in full extension and passively flex IP joints;
active MP ext IP flex; active/passive MP abd and add with IP
joints flexed; resistive hook grip, static/dynamic splint in same
ext/flex pattern; patient education to avoid intrinsic-plus
position
Swan neck deformity: PIP hyperextension, MP & DIP flexed
Caused by hypermobility of PIP (lax volar plate), intrinsic
shortness, mallet finger, fx of middle phalanx with
shortening, extensor tendon adhesion over dorsum of hand,
extensor tendon shortness, nonfunctional FDS, volar
subluxation of MP
Active and passive stretch; active and passive composite finger
and wrist flexion to maintain EDC length; pt education to avoid
faulty movement patterns; night splint with MPs in ext and IP
flexion; button hole splint during day
Ligament sprain
Force Production Deficit

 Weakness of finger and/or thumb flexors: active less than passive,

strength 2/5, passive ROM normal
Progressive overload; every other day 3 sets of 15 reps; more
often at grades <3+/5
Rupture of finger and/or thumb flexors: absent active function,
passive is normal, absent tenodesis, sudden onset with audible
pop
See MD

Insufficient finger and/or thumb extension:
Insufficient finger and thumb extension AROM
It may be caused by
Flexor tendon adhesion
Retrograde massage, passive stretching to flexors, static splint
in extension, active flexion (composite and blocked),
differential tendon gliding, resisted flexion, static
progressive/dynamic splinting into extension, moist heat,
Russian stim, US, PRE for UE
Extensor tendon adhesion
Retrograde massage, passive and active stretches to extensors,
flexion glove, active extension (composite and blocked),
differential tendon gliding, resisted extension, static
progressive/dynamic splinting into flexion, moist heat, Russian
stim, US, PRE of UE (order: circular massage, active exercise,
retrograde massage with active exercise, composite stretching
passively, dynamic or static progressive splinting, resistive)
Flexor shortness
Passive or active PIP extension to stretch volar plate, joint
mobilization (dorsal glide), static progressive splints, dynamic
splints to PIP (20-30 minutes 6-8 times/day), anti-claw splint
(encourage PIP extension with MP extension blocked by
splint), CPM (stage I or after tenolysis), hot/cold packs,
paraffin, estim for active assistive contraction, US
MP, PIP, DIP volar plate or accessory collateral ligament shortness
or adhesion
Same as flexor shortness
Shortness of ORL
Active, passive, resistive exercises into simultaneous PIP ext
and DIP flex
Shortness of interossei and lumbricals
Passive stretch (MP in extension while passively flexing the IP),
active hook fist, active and passive MP joint abduction or
adduction (IPs flexed, MP extended), resistive hook grip, static
progressive/dynamic splinting , pt education to avoid
prolonged grip, frequent stretching

 Ligament sprain
Weakness of EDC or thumb extensors
Progressive overload 3x10-15 every other day
Weak interossei and lumbricals
Clawing due to ulnar nerve injury, anti-claw splints, PROM (MP
flex and IP extension if loss of AROM)
Radial Nerve injury with paralysis of finger and thumb extensors
AROM, PROM to all joints, splint: dynamic finger MP and
thumb extension splint at all times except for PROM exercises,
wrist cock up at night
Rupture of finger or thumb extensors

Insufficient thumb palmar abduction and/or opposition:
Insufficient thumb palmar abduction and/or opposition
Force production deficit (decreased strength)
Passive thumb abduction and/or opposition > AROM
2/5 strength APB, OP
Hypomobility (physiological and accessory motion)
Possible median nerve injury with contracture of thumb muscles
PROM normal and greater than AROM
Strength 1/5
Opposition splint to prevent contracture, thumb web active
and passive stretching to prevent contracture, APB & OP
strengthening
If contracted: Opposition splint for functional use, DC to motor
point 3x/day 10 reps, web stretching
Contracture
Active abduction and/or opposition = PROM and limited
Palpable scar
Accessory motions CMC decreased
End range pain with PROM
Progressive stretching of webspace using Otoform K or
elastomer with splinting, active and passive web space
stretching, practice grasping with stretched web space
Subluxation secondary to OA of CMC joint (joint pain and stiffness,
limited motion) (repeated needlework, use of scissors)
AROM = PROM
Swelling CMC joint
Adduction deformity of CMC joint
Likely decreased accessory motions
Pain in multiple direction
Joint protection strategies, build up pencil, avoid strong grip
and pinch, use jar opener, splint thumb spica (forearm or hand
based), if MP hyperextends splint, paraffin

Decreased 1st web space, muscle atrophy, scar

Inability to maintain longitudinal arch of thumb
Muscle length test of adductor pollicis, FPB
Swansos crank and grind
Shoulder sign test

Thumb carpometacarpal accessory hypermobility:
Pain at CMC joint, but alignment and movement impairments occur at all
joints
CMC may be extended/abducted or adducted/flexed
Can have MP flexion with IP extension OR MP hyperextension and IP
flexion
Adductor pollicis and FPB are overused in relation to APL, APB, opponens
pollicis, EPB, FPL
MUST HAVE MODIFIABLE MOVEMENT PATTERN(no neuro or late
stage arthritis)
Pain in CMC with pinch; c/o weak thumb
Writers, hairdressers, surgeons
Inability to maintain the arc of pinch
Movement pattern for thumb extension:
CMC extends more than MP (boutonniere MP flexion IP extension)
Avoid CMC extension (decrease use of APL)
Increase MP extension (increase use of EPB)
Avoid IP extension (increase use of FPL, decrease thumb
intrinsics)
OR MP extends more than CMC (swan neck MP hyperextension IP
flexion)
Increase CMC extension and abduction (increase APL)
Increase IP extension (increase EPL)
Avoid excessive MP extension (increase FPB)
OR CMC adducts; EPL dominates APL
Abduct CMC slightly then extend
Movement pattern for thumb flexion:
CMC flexes more readily than MP
Maintain CMC in extension and abduction (increase us of APL)
Flex MP (increase use of FPB at longer length)
OR CMC remains abducted and extended while MP flexes excessively
and IP maintain ext
Increase flexion at IP and CMC
Avoid excessive MP flexion and IP ext (decrease use of thumb
intrinsics)
OR CMC adducts and supinates
CMC abducted and in neutral by strengthening OP and APB
Movement pattern for thumb abduction: MP abducts more than CMC

 Block MP abduction with splint and work on CMC palmar

abduction (increase extensibility of adductor pollicis with use of
APB)
AROM = PROM, may be painful abduction and extension
+ Swansons crank and grind
May have swollen CMC, TTP, crepitus, decreased pinch strength
Primary treatment is to educate patient to maintain arc of thumb
during active, functional, and resisted isometric thumb
movements
Abduction for CMC joint not MP or IP
Once all movement patterns normal, strengthen muscle
Splinting: stabilize CMC, correct MP alignment to help CMC alignment
Modify tools , avoid grip and pinch, dycem to open jar, key holder, build
up circumference of grip on handles, build up pencil

Finger (or thumb) flexion with rotation:
Normal alignment of finger is not maintained during finger flexion (1 or
more of: longitudinal arch, neutral rotation, or neutral
abduction/adduction of finger)
Finger AROM and strength are usually normal
Must have modifiable movement impairment to be considered in this
class
Dont forget upper part of kinetic chain
Pain in MCP or PIP
Lots of typing, carrying bag by handle with finger in UD, grasping golf
club, cutting hair, music
MP flexion with IP extension (loss of longitudinal arc of finger) and UD
of MP during flexion
Interossei on one side is overused relative to opposite interossei
and to the ED (MP joint), the FDP and FDS (IP joints)
Rotation of finger at MP during resisted isometric finger flexion
Index figer MP adducts and supinates rather than staying in neutral
rotation during index finger flexion with abd (overuse of 1st PI over 1st
DI)
Shortness of interossei on one side
Increase use of finger flexors over interossei
Neutral rotation, normal longitudinal arc
Stretch interossei

Finger (or thumb) flexion without rotation:
Poorly localized symptoms in the hand, wrist, forearm
Repetitive activity
Dont forget upper part of kinetic chain
MP flexion with IP extension
Overuse of both interossei over FDS, FDP, ED

 Correct arc of finger by increasing MP extension (use ED) and

increase IP flexion (use FDP and FDS)
Flexion of MP with PIP hypertext, DIP flexion (swan-neck)
Laxity of volar plate at PIP)
Overuse of interossei over FDS, FDP, ED
Increase MP extension (use ED) and increase PIP flexion (use
FDS)
Flexion of PIP with DIP hyperextension (boutonniere)
Overuse of FDS relative to FDP and laxity of volar plate at DIP
Increase DIP flexion (use FDP)
Shot ORL
Educate to maintain arc and neutral rotation of fingers
Stretch antagonistic muscles
Resistive after able to perform movement pattern correctly
Modify tools used at work, musical instruments
Splint to stretch

Source or regional impairment of hand:

Sacpular alignment: vertebral borders vertical & 2.5-3 inches from vertebrae; 10
degrees ant. Tilt, 30-40 degrees IR, between T2-T7

Thoracic alignment: kyphosis, posterior trunk sway, flat back, rotation, scoliosis

Rib cage alignment: subcostal angle 90 degrees
widening of subcostal angle: obese, poor ab strength; short Int. oblique, long ex.
Oblique (too many sit ups!)
elevation: overdeveloped pectoral muscles
narrowing of subcostal angle: overdeveloped abs

Sternum: pectus excavatum, pectus carinatum

Footwear:

Heel counterposterior component around the heelshould be firm and fit
snuglyimportant in pronation

Densityincreased for pronation, cushioned for supination


(if neutral calcaneus, pronation at midfootdensity should be only at
medial midfoot, vice versa

Flexibilityshould only bend at toe breakshould match with MTP joint
line

Heel-to-toe heightlifted heel to compensate for limited DF (common in
pronation and supination)

Arch supportoften not substantial, can add scaphoid or navicular pads

Last shapestraight, semi-curved, curvedbisection of heel to toe
(longitudinal) into equal partsfit to patientdo not try to change foot by changing
last, straight for pronation, curved for supination