Otho-test#1

•	Thoracic outlet syndrome (TOS) – neurovascular symptoms in the upper extremity due to pressure on the nerves and vessels in the area.
•	Bounded by the 1st rib, T1, and corpus sterni (body of sternum).
•	Venous compression occurs 1st – you’ll see edema, pain, and enlarged veins.

3 TOS categories
1.	Anterior scalene syndrome – compression b/with anterior and medial scalene.  >> Adson’s test and Modified Adson’s.  NEUROLOGIC SYMPTOMS.
1.	Costoclavicular syndrome (1st rib syndrome) – compressed b/w clavicle and 1st rib.  >> Costoclavicular maneuver. VASCULAR SYMPTOMS.
1.	Hyperabduction syndrome – compression b/w pec minor/coronoid process/costoclavicular lig (thickened fascia).  >> Wright’s test.

•	Other reasons for symptoms in the area that’s not TOS.  – Neoplasm in the apex of the lung can compress vein/artery/nerves.  MI, strokes, and others.

•	Adson’s - patient seated, and arm in question is parallel to floor at shoulder level.  Then patient rotates and extends head ipsilaterally. 
•	Checking for reproduction of symptom or diminished radial pulse.
•	Then have patient hold deep breath in above position and check for same signs.
•	Modified Adson’s – same as above but the head is rotated contralaterally.

•	Allen’s maneuver

•	Costoclavicular test – patient seated arms to side and Dr. obtains bilateral radial pulses.
•	Checking for contour, amplitude, etc.
•	Then extend patients arms with slight abduction and placing chin to chest.
•	(+) if there’s a difference in pulses.

•	 Canalis cervicoaxillaris is a triangle shape b/w 1st rib and clavicle.

•	Halsteads maneuver – patient seated, obtain radial pulse, then traction arm downward and have patient extend head backward.

•	Roos test – patient seated arms parallel with floor at shoulder level, elbows flexed, and wave fingers for 3 min.  (This closes the space b/w the 1st rib and clavicle).

•	Wright’s test (hyperabduction test) – do Allen’s test 1st.
•	Patient seated get radial pulse and abducts arm 180 degrees, noting where the pulse diminishes.

•	Allen’s test – occlude both radial and ulnar arteries at the wrist and release to see if hand flushes back to color. Then re-block and release the other side and see if flushes.
•	Dermatome – an area of skin innervated by a single nerve root.
•	Dermatomal pain – sharp, tingly, and localized.
•	Myotomal pain – referral patterns, not localized, aching, and dull.

•	Fibromyalgia – no known cause, patient has to have 18 of 25 tender pts.  >> These are different than trigger pts.  
•	A trigger pt travels (refers).
•	Sclerotogenous (somatic referral) pain – comes from bones, capsules, joints, ligaments, etc.

10/8/1999

Whiplash
1.	Does it exist?
1.	Severity.
1.	Long term problems?

•	There is no ortho test for diagnosing whiplash.
•	There may be increased muscle tension, decreased cervical lordosis, and decreased active/passive/resisted ROM.
•	Couple your findings for a Dx.
•	Take Hx, how accident occurred, what happened, did they lose consciousness, have amnesia, were they in their seat belt, do they remember the accident, physical findings, exams, and x-rays.

•	Watched a video on whiplash.

•	Onset of pain is delayed because inflammation hasn’t set in yet.

•	Strain – over-stretching or overexertion of some part of muscle or tendon.
•	Sprain – joint injury in which some fibers of a supporting ligament are ruptured.
•	Spasm – violent involuntary contraction of muscle.  This limits or reduces joint ROM.
•	The above 3 are usu. part of a whiplash injury.

•	Sprain and strain – have 1o, 2o, and 3o grades.
•	Sprain - 1o = tearing of < 1/3 of fibers.
•	2o = tearing of up to 2/3 of fibers.
•	3o = tearing > 2/3 or complete tearing of fibers.
•	Strain – 1o = tearing some of the muscle fibers.
•	2o = more tearing of fibers and subdermal ecchymosis.
•	3o = complete transsection of fibers.

•	George’s test – includes Hx, palpation, auscultation, comparison of systolic/diastolic, and everything else.
•	George’s maneuver – patient rotates and extends head.

Whiplash
•	Causes anterior component damage.
•	SCM pain, increased tenderness, dysphagia due to muscle damage, and/or esophageal lacerations, ALL, sympathetic chain, artery damage, and/or TMJ damage.
•	Also causes posterior component damage.
•	Ligament damage – ligamentum nuchae, intertransverse and interspinous ligaments, yellow ligament and then capsular ligament (instability of c-spine here).
•	Muscle damage – traps, and other posterior muscles.
•	Vertebral arteries damage.  

•	Cervical whiplash syndromes – table 6-7.
•	Grade I – cervical stiffness, x-ray normal.
•	Grade II – palpation tenderness and muscle guarding, headache, dizziness, and x-ray > hypo-lordosis.  >> Mild instability.
•	Grade III – swelling and spasm, decrease ROM, and moderate instability.
•	Grade IV – pain, spasm, disability, bilateral radicular symptoms, severe restriction, and X-ray needed to rule out fracture, or ligament tear.
•	Grade V – need surgery to rule out fracture or facet dislocation.

•	Lateral femoral cutaneous nerve can be compressed by lap belt.
•	Seat belts and air bags can cause injuries.

•	inflammation – mediated by 
1.	Amines (histamine/epinephrine/NE) -  vascular permeability.
a.	Histamine – vasodialates.
a.	Epi/NE – vasoconstrict.
1.	Kinins (bradykinin) – causes  in pain, vasodialates,  vascular permeability, and  leukocyte migration.
1.	Proteins and tissue extracts -  vascular permeability.

3 types of muscle.
1.	Labile – undergoes mitosis constantly.
1.	Stable – only undergoes mitosis when something tells it to.
1.	Permanent – doesn’t undergo mitosis.
•	When you damage muscle it damages stable cells, and so then they’ll undergo mitosis.
•	Fibroblast – builds scar tissue.
•	If there’s no stress applied to bone, the bone will reabsorb.
•	Mvt. and stress is necessary for bone growth and strength.

DJD
•	Facet arthrosis – facet joint degeneration.
•	Spondylosis – vertebral body degeneration.
•	To destroy a synovial joint – you can infect it, smash it, or be hypermobile.

Evaluating TOS
•	Establish Hx.
•	Perform ROM.
1.	Extension - 45-50.
2.	Flexion – (pure) 110; (w/ circumduction) 180.          These mvts are limited by the 
3.	Abduction – (w/external rotation) 180.                      greater tubercle of the humerus.
4.	Adduction (hyper) - 50.
5.	External rotation - 90.       1. These mvts may be done w/ the arm at the side (make sure
6.	Internal rotation - 90.        they don’t just supinate forearm), or 2. w/ elbows flexed and parallel w/ the floor, then perform rotations.

•	it is hard to isolate pure motion in the shoulder.
•	The muscles used in external rotation are – posterior deltoid, teres minor, infraspinatus, and in addition supraspinatus in the #2 test position in 5 and 6 above.
•	Muscles used in internal rotation are – subscapularis, pec minor, lats, and teres major.