Movement Links Certification Material
What is the ideal scapula alignment?
- positioned between T2 and T7
- medial border parallel to spine
- distance between spine and border: 3 inches
- "hugs" thorax and resting 30 degrees anterior of frontal plane
What is the normal clavicle position?
AC joint should be higher than the SC joint.
What should you suspect if you see horizontal clavicles?
Suspect depressed position of scapula
(Confirm scapular depression if superior angle of scapula is lower than T2)
How do you test for scapular muscle tone deficiency?
If you can get more than 1st IP under the inferior angle
What should you suspect if you see scapular muscle tone deficiency?
Lower trapezius and/or medial scapular stabilizer insufficiency
What does deltoid flatness tell you?
Early sign of shoulder dysfunction and/or C4 lesion
What is a positive test for head-neck position and does a positive test indicate?
lateral view of the head-neck should be 90 deg. If greater than 90 deg = positive. This indicates insufficiency of deep neck flexors
What is the ideal humeral alignment?
- Humeral head no more than 1/3 anterior to the acromion
- Olecranon faces posteriorly
- horizontal cubital crease
What are possible deficits of the abdomen and what does it mean?
Infrasternal angle: If >100 deg = IO dominance. <75 deg = EO dominance. Normal = 90.
- Lateral groove: abdominal incoordination
- abdominal crease: most likely dominance of upper portion of rectus abdominus
- Rib cage protrusion: reduced diaphragm and abdominal activation contributing to decreased IAP regulation necessary for spinal stability
- "pseudohernia": lateral bulge of abdominal wall = can indicate transverse abdominus insufficiency
If you see VMO hypertrophy, what can that indicate?
Possible from activities requiring knee hypertension
What does a "twitching" patella mean?
Inadequate proprioception from feet
How does ITB tightness present in males and females?
Females: flat
Males: groove
What should you test if you see medial rotation of the arms?
- Tightness of pecs/lats
- scapular protraction
What are possible faults of the single limb stance test and what does it mean?
- Excessive pre-shift > 1 inch (lateral pelvic shift): inhibited/weak glutes
- contralateral pelvis drop: weak glutes
- contralateral hip hike: QL substitution
- pelvic rotation/femoral internal rotation: stiff/dominant TFL/IT band
- Excessive trunk sway or inability to balance
Single limb stance test for proprioception 30 seconds norms?
20-49: 24-29 seconds
50-59: 21 seconds
60-69: 10 seconds
70-79: 4 seconds
What are the possible gait corrections?
hands on hips (compression) or hands overhead: if better = impairment is trunk stabilization. If doesn't get better = more hip or lower quarter issues
walk backwards: if better = work on glute inhibition
if no change = look at hip flexor length & IAP
What is a common movement fault with AROM lumbar extension?
Excessive segmental extension or hinging (crease)
What does normal sidebending look like?
Gradual C-curve
Movement errors with sidebending?
Curve is not smooth
Pivot at a particular segment
Lateral translation before sidebending
Where do you block in sidebending to try to help decrease the patient's pain?
Block as close to the pain as possible (put your hands where the crease is going to be and pull towards you)
What are corrections you can perform with the partial squat?
1. give supination cue at the foot
2. give ER to the femur to act as glutes
3. give tactile cue at greater trochanter to posteriorly shift femur
What are common movement errors in the partial squat?
- excessive lumbar flexion or extension
- excessive femoral internal rotation/adduction medial collapse
- excessive or inadequate pronation
- knee coming past the toes = quad dominant stretegy or decreased glute performance
Knee extension movement test in sitting: + signs?
if you see femur internal rotation = could mean stiff TFL and/or medial hamstrings
Sitting hip flexion test: + signs?
Trunk shift = assessing stability of T/L junction
What should you be looking for in supine A/PROM hip flexion test?
assess abdominal stability in sagittal plane
pelvic rotation when feeling ASIS with thumbs
Straight leg raise (glide test): assessment and + signs?
PICR of the femur: if hip/groin symptoms/pain are present during active hip flexion and/or knee flexion
if greater trochanter glides anteriorly or medially
Supine bent knee fall out: assessment and + signs?
abdominal stability in transverse plane
contralateral ASIS should not move more than 1/2 an inch before 50% of the available ROM
Curl-up movement test: assessment and + signs?
patient hooklying with PT hands underneath their heels
+:
- heel pressure decreases = hip flexor dominance
- anterior pelvic tilt
- trembling of muscles
Functional ankle dorsiflexion lunge test: assessment and + signs?
Normal: 4 inches from the wall with >35-38 degrees
= should be able to touch knee to wall
How do you test for piriformis end feel?
If it is above 60 degrees: longitudinal femoral compression with adduction and ER
If it is below 60 degrees: longitudinal femoral compression with adduction and IR
Prone knee flexion: normal test?
Knee flexes to 120 degrees without pelvic tilt, or lumbar rotation or extension
What are the common faults of the prone knee flexion test and what does it mean?
knee flexion <110 degrees: short quadriceps
Anterior pelvic tilt: stiff rectus femoris & deficient abdominal control
Pelvic rotation: stiff TFL + deficient abdominal control
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Prone hip rotation: normal test?
No pelvic movement in the first 50% of motion
What are the common faults of the prone knee rotation test and what does it mean?
limited rotation: imbalance between rotators + deficient abdominal control
Early pelvic motion: excessive lumbar movements
What is considered normal in the quadruped rock back test for LQ?
hips flex and lumbar spine remains flat
What are the common faults of the quadruped rock back test and what does it mean? (LQ)
Flexion of spine during first 50% of motion: long lumbar extensors, short/stiff rectus abdominus and hip extensors
Rotation of lumbar spine: paraspinal imbalance
Decreased hip flexion: short/stiff glute max & piriformis
Pelvic rotation: asymmetric short/stiff glute max & piriformis
What are the common faults of the quadruped rock forward test and what does it mean? (LQ)
marked extension at lower segments: excessive flexibility of spine + short hip flexors
What are the common faults of the sitting knee extension test and what does it mean? (LQ)
Lumbar spine flexes: hamstrings stiffer than lumbar spine + long lumbar paraspinals
Lumbar spine rotates: hamstrings stiffer than lumbar spine + unilaterally long lumbar paraspinals
Knee extends to <75 degrees: short hamstrings
Hip IR: short medial hamstrings + TFL dominance and inappropriately recruited
Ankle DF < 10 deg: short plantarflexors
What is considered normal for the siting knee extension test?
Lumbar spine remains flat and knee extends to within 10 degrees with hip flexed to 90 degrees and ankle DF at 10 degrees
What are the clinical definitions of anteversion and retroversion?
>15 degres IR = anteversion
< 5 degrees IR = retroversion
What is the normal sequence of prone hip extension movement pattern test?
Hamstrings --> glute max --> contralateral lumbar extensors --> ipsilateral lumbar extensors --> contra thoracolumbar extensors -> same side thoracolumbar extensors
Where are the 3 areas of proprioception?
- cervical spine
- pelvic girdle
- sole of foot
How do you perform post isometric relaxation?
take up slack to first barrier --> pt gently pushes 10-20% -> have pt breathe in and out --> take up further slack and repeat 3-5 times
How do you perform a post facilitation stretch?
Max hold at mid range for 7 seconds --> QUICKLY move to end-range and hold for 15 seconds -> rest for 20 seconds and repeat 5 times
What are the different ways to strengthen the foot intrinsics?
- x pattern around back of foot and toes with theraband
- manual correction into supination
- double heel raises with band
- forward lean practice
What are the 5 levels of abdominal strengthening?
Level 1 = marching
Level 2 = heel slide with return
Level 3 = marching with opposite foot hovering above the mat table
Level 4 = double heel slide
Level 5 = double knee extension without touching the mat table
What are the priciples of sensorimotor training?
- Posture: cervical, lumbar and foot positioning
- Proper breathing/IAP regulation
- Control: control center of gravity and eccentric movement
What are the criteria for normal scapular motion by the end of arm elevation?
- scapula elevates but only slightly (6-10 deg)
- acromion should be aligned with C6-C7
- Scapula upwardly rotates to about 60 degrees
- Inferior angle reaches approximately to the midline of thorax
- scapula posteriorly tilts to 10 deg
Possible impairments for downwardly rotated scapula?
long upper traps or serratus anterior
short/stiff levator scapula & rhomboids
Short deltoids & supraspinatus
Possible impairments for depressed scapula?
long upper trapezius
Possible impairments for abducted scapula?
short serratus anterior
short/stiff scapulohumeral muscles
long rhomboids & traps
Possible impairments for adducted scapula?
short = rhomboids & traps
long serratus anterior
Possible impairments for winging/tilt scapula?
short/stiff scapulohumeral mm
short pectoralis minor
weak serratus anterior
rib hump
flat thorax
Possible impairments for elevated scapula?
short upper traps, levator scapula, rhomboids
Possible impairments for superior humerus?
short deltoids
insufficient rotator cuff
Possible impairments for anterior humerus?
stiff posterior capsule
long supscapularis
pectoralis dominance
Possible impairments for insufficient upward rotation/abduction of scapula in shoulder elevation?
short/stiff rhomboids
long serratus anterior
Possible impairments for excessive scapular elevation in shoulder elevation?
dominant upper trapezius
Possible impairments for scapular winging in shoulder elevation?
short/weak scapulohumeral muscles
long/weak serratus anterior
Possible impairments for winging in return from shoulder elevation?
short scapulohumeral mm
dominant pec minor
scap-hum mm not elongating as rapidly as thoraco scap mm
What is normal for shoulder ER test?
should not see scapular adduction in the first 35 degrees of shoulder ER
What are common faults of the shoulder ER test and what does it mean?
early scapular adduction: rhomboids are dominant/poor control of shoulder ER
Humeral head moves: posterior deltoid more dominant than infraspinatus and teres minor
What are common faults of the shoulder abduction test?
early girdle elevation with less than 60 degrees of humeral movement
Increased humeral internal rotation
What is normal for supine ER with shoulder 90/90?
90 degrees with good PICR
What are common faults of the supine IR with shoulder at 90/90?
<70 degrees: short/stiff infraspinatus & teres minor
Scapular anterior tilt: external rotators stiffer than lower traps
Anterior glide of humerus: laxity of anterior joint capsule
What are common faults of the supine ER with shoulder at 90/90?
<90 degrees: short teres major/subscap/pec major
Anterior or superior glide of humerus: stiff ER muscles, laxity of anterior joint capsule
What is normal for supine IR with shoulder 90/90?
70 degrees with good PICR
What are common faults of the prone IR with shoulder at 90/90?
<70 degrees: short/stiff infraspinatus & teres minor, posterior deltoid
Scapular anterior tilt: long/weak lower traps
Anterior glide of humerus: laxity of anterior joint capsule, stiff/short teres minor, infraspinatus, posterior delt
Scapular elevation: dominant upper traps
What are common faults of the prone ER with shoulder at 90/90?
<90 degrees: short teres major/subscapularis
Anterior or superior glide of humerus: laxity of anterior joint capsule, dominant posterior deltoid (note extension of arm)
Scapular abduction: long/weak traps and rhomboids
Scapular depression: dominant lower traps and lats + timing problem with GH external rotators
What is considered normal for the quadruped rock back test (UQ)?
Head and neck remain level
Scapula remain in constant position on thorax with upward rotation and abduction as the shoulder flexes
What are common faults of the quadruped rock back test and what does it mean (UQ)?
Prominent levator scapulae: levator scap is dominant as neck extensors
Cervical spine/head extends: short/dominant levator scap
Rotation of CS and head: same side levator scap is short, opposite side upper traps are dominant
Shoulder girdle elevates: short/stiff levators, upper traps, rhomboids + long/weak lower traps
Shoulder girdle depresses: short/stiff latissimus dorsi
Excessive scapular abduction: short/dominant serratus anterior + long/weak lower trapezius
Not enough scapular upward rotation: short/stiff rhomboids
What is considered normal for the quadruped rock forward test?
Scapula stays flat on the thorax
What are common faults of the quadruped rock forward test and what does it mean?
Winging: long/weak serratus anterior
Increased scapular adduction
Increased upper trap activation
What is considered normal for shoulder flexion in quadruped?
Thoracic and lumbar spine remain still
What are common faults for shoulder flexion in quadruped and what does it mean?
Rotation of the thoracic spine is greater than 1/2 an inch with shoulder flexion = POOR ABDOMINAL CONTROL
What are the common faults of the scapular test at 0 deg and at 90 deg (pushing against the wall)?
Increased scapular anterior tilt
Increased scapular internal rotation
Increased scapular downward rotation
If your patient has pain with shoulder flexion AROM, what are some corrections you can perform?
Assisted upward rotation
Assisted posterior tilt
What is considered normal for the posterior shoulder mm length test?
elbow should cross to at least midline without scapular movement
What is considered normal for the pectoralis major mm length test?
shoulder elevation to 135 deg for sternal and 90 deg for clavicular
Should be able to touch arm to table
Clare says =
Sternal = 10-15 degrees below table at 135 abduction
Middle = 30 degrees below table at 90
Clavicular = "arm should hang freely below table" in extension
What is considered normal for the biceps short head mm length test?
Elbow should fully extend with forearm pronation without any movement of the shoulder joint
What are common faults for the active arm elevation test?
Before 120 degrees of shoulder elevation:
- T/L extension
- rib flare
What is considered normal for the head flexion movement pattern test?
O-A nodding + cervical flexion
What are common faults for the head flexion movement pattern test?
- early chin jutting during the first 10 degrees
- SCM prominence
- trembling of mm
- rib flaring/elevation
What are the norms for the deep neck flexor endurance test?
Males: 38.9 +/- 20/1 seconds
Females: 29.4 +/- 13.7 seconds
How do you find the end-feel for the upper trapezius?
Flexion --> sidebend away -> rotate towards the side being stretched
How do you find the end-feel for the levator scapulae?
Flexion --> sidebend away -> rotate away from the side being stretched
If you see a crease in the shoulder with lower trap performance testing, what does it mean and how do you fix it?
Rhomboids trying to compensate by going into shoulder IR = thumb up testing for more ER
What is considered normal for the push-up test?
minimal to no movement of the scapulae until the end of the push-up into scapular abduction
What are positive findings for the push-up test?
- scapular adduction "kissing scapula"
- scapular elevation
- scapular internal rotation (winging)
What are the criteria for sway back? Possible impairments?
shoulders >2" posterior to greater trochanter
Infrasternal angle: Normal, IO dominant, EO dominant
Normal 90 degrees
>100 degrees: short IO (dominant), long (insufficient) EO
<75 degrees: short (dominant) EO
What are the possible impairments for sway back posture?
Possible impairments: long EO, short RA and IO
What is the criteria for paraspinal assymetry? Possible impairments?
>1/2" difference when measured from 2" lateral from spinous process
What are the possible impairments for paraspinal assymetry?
- hypertrophied paraspinals
- spine rotated to prominent side
- scoliosis
Pelvis normal alignment
Normal: line between ASIS and PSIS within 15 degrees of horizontal line
Pelvis Anterior Pelvic tilt criteria and possible impairments?
ASIS 20 degrees lower than PSIS
Possible impairments: long EO, short hip flexors
Pelvis Posterior Pelvic tilt criteria and possible impairments?
ASIS 20 degrees higher than PSIS
Possible Impairments: short abdominals, long iliopsoas
Pelvic rotation criteria and possible impairments?
ASIS on 1 side anterior to the other side
Possible Impairments: TFL short on side toward which pelvis is rotated (MR)
Pelvic lateral tilt: hand position to check, criteria, impairments associated with high and low side
web-space on hand of iliac crest
1 iliac crest is >1/2" higher than the other
Possible Impairments: high side = long abductor mm; low side= short hip abductor mm
Hip joint: assessment from lateral view, criteria for flexed/extended hip
Angle made between line bisecting pelvis and line bisecting femur (locate greater trochanter)
Flexed >10 degree hip flexion
possible impairments: shoft hip flexors
Extended >10 degrees hip extension
possible hip flexors long illiopsoas; short hams
What are possible impairments for knee hyperextension?
possible impairments:
- weak quads
- inadequate ankle dorsiflexion
- insufficient glute strength
- joint hypermobility
- habitual standing habit
What does a thickened achilles tendon indicate?
Typically indicative of previous ankle/foot injuries
What are the three shapes of the heel and what does it mean?
Rounded: normal
Quadratic: posterior center of gravity
Pointed: anterior center of gravity
What is the relevance of anterior and posterior center of mass in standing (not the foot)?
Anterior: stresses lumbar spine into extension and increases paraspinal activity which further increases compresses forces onto lumbar segments
Posterior: overuses anterior musculature
How do you confirm hypertrophied vs rotated segments?
With sidebending
Hypertrophied: contralateral side bending is limited
Rotated group dysfuntion: ipsilateral side bending is limited
What structure is implicated in a pronated foot? What is a possible impairment?
longitudinal arch flattened
possible impairments: long posterior tib
What does a rigid foot do during a partial squat? What are possible impairments?
Supinated
does not flatten during partial squat
possible impairments: decreased DF range
*should see flattening for shock absorption
Hammer toes occur at what joint in the toes? possible impairments?
PIP joint flexion
Possible impairments: toe flexor and extensor short; tend to keep COM posterior during sit-stand
What are the criteria for a normal partial squat? (knee position)
NORM = knee flexes 45 degrees with heel on ground; knee over 2nd toe
Single leg stance NORM
no change in pelvic tilt or rotation
What is occuring if there is lateral trunk flexion with SLS? What are the possible impairments?
SB towards stance leg
possible impairments: weakness of stance hip abductors, weak and long stance hip abductors
What is occurring if there is hip adduction with SLS? What are the possible impairments?
trendelenburg
possible impairments: weak glutes
What is occurring if there is posterior rotation in the transverse plane (femoral internal rotation) in SLS? What are the possible impairments?
long and weak hip LR, stiff/ dominant TFL-ITB (short MR)
What should a normal forward bend look like?
70 degrees hip flexion
Hip flexion should preced lumbar flexion
Final position: 20 degrees of flexion in lumbar spine; reversal of curve
What does it mean if there is a decreased reversal of curve during lumbar flexion? What tests would you do to confirm?
possible impairment:
short lumbar extensors
hypomobile spinal segments
TESTS: mobs, HF length, hip extension mvt test, IAP test
What are the norms for lumbar flexion - hip flexion angle for men and women? What does it mean if the angle is too large?
men: <75 degrees; possible impairments = short/stiff lumbar extensors, hypomobile hips
Women: <85 degrees; possible impairments = long trunk, higher COM
>100 degrees; possible impairments = long hams/ hip extensors, possible hypermobility
What does it mean if the ischial tuberosities shifts posteriorly >5 inches from the heel in forward bending?
Hypomobile ankle joint/tight calves
short hamstrings
neural tension/gliding dysfunction
Return from FWB NORM
movement initiated with hip extension
What does it mean if a patient returns from FWB primarily initiated by the spine and not the hips?
short lumbar extensors, short hip flexors
What does it mean/what impairments might be present if a patient returns from FWB with hip sway?
Marked DF, forward sway of hips with lumbar extension
*will usually see upper trunk lined up behind hips when returned to normal stance
Possible impairments: weak hip extensor muscles
Rotation NORM
Symmetrical rotation of about 30 degrees between T8-T11
Supine knee to chest NORM
hip flexes 120 degrees before spine moves
What could it mean if supine knee to chest is <120 degrees?
short/stiff Gmax
What could it mean if supine knee to chest is >120 degrees or sacrum lifts off of the table?
long lumbar paraspinals + stiff hips
What is an impairment possible during AROM lumbar extension? What would you test for if this occurred?
occurs from hinged point (pivots at the horizontal crease)
Possible impairments:
- Hypomobile spinal segments above or below hinged point
- short hip flexors
- stiff/short paraspinals
- impaired trunk muscle coordination
What does normal sidebending look like?
Symmetrical curve thorughout LS with most SB occuring in lower thoracic spine
SB Decreased ipsilateral SB***??
Spine rotated to prominent side (increased paraspinal bulk) = short/stiff paraspinals
SB increased ipsilateral SB***???
spine rotated to same side
What does normal straight leg raise look like?
80 degrees hip flexion, Greater trochanter maintains a constant position (PICR)
SLR with greater trochanter moves ant/posterior impairments
stiff posterior capsule, short hams
What are the possible impairments if a patient demonstrates femoral internal rotation with SLR?
Long and insufficient iliopsoas
Long and stiff external rotators
What does normal hip abduction/ bent knee fallout asses?
assesses abdominal stability in the transverse plane
What does a failed bent knee fallout pelvic rotation look like? What are the potential impairments?
pelvis (contralateral ASIS) rotates >1/2" during the first 50% of LE motion
Impairments: abdominal control deficiency (IO and contralteral EO)
Assessment of pelvic tilt, should consist of what 2/3 findings?
1. increase or decrease in the depth of the lumbar curve
2. marked deviation from the horizontal line between ASIS and PSIS
3. increase or decrease in hip joint angle with neutral knee joint alignment.
What are the 3 criteria for femoral internal rotation when assessing the alignment of the femur?
1. bulk of medial HS more posterior than lateral HS
2. palpate femoral condyles (should be in the same plane) - medial condyle more posterior
3. Popliteal crease (should be horizontal), oblique angle
popliteal crease: what's normal and if there is an oblquity what are the deviations observed during specific phases of the gait cycle?
normal is horizontal or slight downward slope
Excessive obliquity = femoral internal rotation during loading response in gait OR excessive tibial external rotation during knee flexion in swing phase
3 Main phases of degenerative disorders of the spine
Temporary dysfunction, segmental instability/hypermobility, hypomobility
What is the path of instantaneous center of rotation (PICR)?
a point about which a rigid body rotates about a given instant of time. A major determinant is the forced couple action on the joint. Equal and opposite forces.
What is a MSI (Movement System Impairment)
An alteration in the precision of motion is an impairment. Syndrome because multiples impairments contribute to the altered motion.
What is an MSI diagnosis?
Named for movement direction or alignment that most consistently elicits symptoms and when corrected, reduces symptoms.
What muscles of the tonic system?
FLEXORS: prone to tightness
What muscles of the phasic system?
EXTENSORS: prone to weakness and inhibition
What movements are consistent with tonic chain/muscles of the upper quarter?
flexion, IR, adduction, pronation
What movements are consistent with phasic chain/muscles of the upper quarter?
extension, ER, abduction, supination
What movements are consistent with tonic chain/muscles of the lower quarter?
PF, IV, hip flexion, IR, adduction
What movements are consistent with phasic chain/muscles of the lower quarter?
DF, EV, hip extension, ER, abduction
Upper crossed syndrome
TONIC: tight pecs, suboccipitals, UT, levator; PHASIC: weak/inhibited DNF, MT and LT, serratus.
What are the most common sites of joint dysfunction with upper crossed syndrome?
Most common sites of jt dysfunction = C0-C1, C4-5, Shld, T4
Lower crossed syndrome
TONIC: tight hip flexors and Thoraco-lumbar extensors; PHASIC: weak/inhibited abdominals and gluts.
What are the most common sites of joint dysfunction with lower crossed syndrome?
Most common sites of jt dysfunction = L4-5, L5-S1, SI, Hip
Lower crossed syndrome A
Imbalance of hip musculature, associated with hip pathology, deeper short lordosis
Lower crossed syndrome B
Imbalances of abdominal and lumbar muscles, associated with thoraco-lumbar pathology, shallow long lordosis
What is functional joint centration and what is it's purpose?
Dynamic neuromuscular strategy that leads to the optimal joint position that allows for the most effective mechanical advantage. Allows for optimal load transference across the joint and along the kinetic chain.
Posture
The "speech" of the brain. Adopted in any position, is a reflection of the neuromuscular status of the person. Directs the clinician to appropriate joint mobility, muscle length, or strength tests to confirm what is observed in a static position.
What do you look for when using the baseline static approach in assessing posture?
base of support (WB areas), alignment, symmetry, soft tissue "folds and creases", muscle tone.
What is a stiff muscle?
muscle can be taken passively into FULL length (ROM) but has increased resistance, may also have trigger points
What is a short muscle?
Muscle does not reach full length when taken passively, may also have increased resistance and trigger points.
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