Physical Therapy/Study Notes/Clinical Conditions

Clinical Conditions

Orthopedic, neurological, and cardiopulmonary conditions commonly encountered in physical therapy practice with evidence-based assessment and treatment approaches.

1. Shoulder Conditions 2. Knee Conditions 3. Spine Conditions 4. Hip Conditions

5. Neurological Conditions 6. Spinal Cord Injury 7. Cardiopulmonary Rehab 8. Special Tests Quick Reference

1. Shoulder Conditions

Adhesive Capsulitis (Frozen Shoulder)

Inflammation and fibrosis of glenohumeral joint capsule causing painful, progressive loss of ROM in a capsular pattern.

Capsular Pattern (GH Joint):

ER > ABD > IR (most limited to least)

Stages:

Freezing (painful) - 2-9 months
Frozen (stiff) - 4-12 months
Thawing (recovery) - 5-24 months

PT Interventions:

• Joint mobilization (grade I-II early, III-IV later)
• ROM exercises, stretching
• Modalities for pain

Rotator Cuff Pathology

SITS Muscles:

Supraspinatus - initiate ABD
Infraspinatus - ER
Teres minor - ER
Subscapularis - IR

Special Tests:

• Empty can test (supraspinatus)
• Drop arm test (large tear)
• Lift-off test (subscapularis)
• ER lag sign (infraspinatus)

Impingement Syndrome

Compression of supraspinatus tendon and subacromial bursa under acromion.

Special Tests:

• Neer test (flexion)
• Hawkins-Kennedy test (IR in flexion)
• Painful arc (60-120° ABD)

Treatment:

• Rotator cuff strengthening
• Scapular stabilization
• Postural correction
• Avoid overhead activities initially

2. Knee Conditions

ACL Injury

MOI:

• Non-contact pivoting
• Sudden deceleration
• Hyperextension
• Valgus stress with rotation

Special Tests:

• Anterior drawer test (90° flexion)
• Lachman test (20-30° flexion) - most sensitive
• Pivot shift test

Post-ACLR Protocol Phases:

Protection (0-2 weeks): ROM, quad sets
Early motion (2-6 weeks): Full extension, flexion to 90°
Strengthening (6-12 weeks): CKC exercises
Advanced (3-6 months): Sport-specific
Return to sport (6-12 months): Clearance testing

Meniscus Injury

Presentation:

• Joint line tenderness
• Locking/catching
• Effusion (delayed)
• Medial meniscus more common

Special Tests:

• McMurray test
• Apley compression test
• Thessaly test

Ligament Tests Summary

Ligament	Function	Tests
ACL	Prevents anterior tibial translation	Lachman, Anterior drawer, Pivot shift
PCL	Prevents posterior tibial translation	Posterior drawer, Posterior sag
MCL	Resists valgus stress	Valgus stress test (0° and 30°)
LCL	Resists varus stress	Varus stress test (0° and 30°)

Total Knee Arthroplasty (TKA)

• Goal: 0-90° ROM by discharge; 0-120° by 3 months
• Weight-bearing: Usually WBAT with walker
• CPM: Controversial; may use 0-6 hours/day
• Exercises: Quad sets, heel slides, SLR, ankle pumps
• Watch for: DVT, infection, stiffness

3. Spine Conditions

Disc Herniation

Nucleus pulposus protrudes through annulus fibrosus, potentially compressing nerve roots.

Presentation:

• Radicular symptoms (dermatomal)
• Positive SLR (lumbar) or Spurling (cervical)
• Neurological deficits may be present
• Worse with flexion, sitting

Common Levels:

• L4-L5 → L5 root
• L5-S1 → S1 root
• C5-C6 → C6 root
• C6-C7 → C7 root

McKenzie Approach:

• Extension-biased exercises for posterior disc
• Centralization = good prognosis
• Peripheralization = modify approach

Spinal Stenosis

Narrowing of spinal canal or foramen, often due to degenerative changes.

Neurogenic Claudication:

• Bilateral leg symptoms
• Relieved by flexion/sitting
• Worsened by extension/standing
• "Shopping cart" sign

Treatment:

• Flexion-biased exercises
• Williams flexion exercises
• Stationary bike
• Avoid extension

Red Flags - Require Immediate Referral

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction)
• Progressive neurological deficit
• Severe trauma
• Signs of infection or malignancy
• Sudden onset severe pain

4. Hip Conditions

Total Hip Arthroplasty (THA)

Posterior Approach Precautions (Most Common)

AVOID:

• Flexion >90°
• Adduction past midline
• Internal rotation

Anterior Approach Precautions

AVOID:

• Hyperextension
• External rotation
• Adduction

Note: Precautions may vary; follow surgeon protocol. Usually 6-12 weeks.

Hip Osteoarthritis

Capsular Pattern:

IR > Flexion > ABD (most limited to least)

Treatment:

• ROM exercises
• Strengthening (hip abductors key)
• Assistive device for unloading
• Aquatic therapy
• Weight management

5. Neurological Conditions

Stroke (CVA)

Upper motor neuron lesion resulting in contralateral hemiplegia/hemiparesis.

UMN Signs:

• Spasticity (velocity-dependent)
• Hyperreflexia
• Positive Babinski
• Clonus
• Synergy patterns

Synergy Patterns:

UE Flexor: Shoulder Add/IR, elbow flex, wrist/finger flex
LE Extensor: Hip Add/IR/Ext, knee ext, ankle PF/inv

Brunnstrom Stages of Recovery

Stage	Description
1	Flaccidity - no movement
2	Spasticity developing, synergies appearing
3	Spasticity marked, synergies present
4	Spasticity decreasing, some movement out of synergy
5	Spasticity waning, more isolated movement
6	Spasticity minimal, near-normal movement
7	Normal movement restored

Parkinson's Disease

Basal ganglia disorder due to dopamine deficiency.

Cardinal Signs (TRAP):

Tremor (resting, pill-rolling)
Rigidity (cogwheel, lead-pipe)
Akinesia/Bradykinesia
Postural instability

Gait Features:

• Festinating gait (accelerating)
• Reduced arm swing
• Shuffling steps
• Freezing episodes

PT Interventions:

• LSVT BIG (large amplitude movements)
• Visual/auditory cues for freezing
• Balance training
• Gait training with cues

6. Spinal Cord Injury

ASIA Impairment Scale

Grade	Description
A - Complete	No motor or sensory function below level (including S4-S5)
B - Sensory Incomplete	Sensory but no motor below level, including S4-S5
C - Motor Incomplete	Motor function below, >50% muscles below level <3 MMT
D - Motor Incomplete	Motor function below, >50% muscles below level ≥3 MMT
E - Normal	Normal motor and sensory function

Functional Expectations by Level

Level	Key Muscles	Functional Ability
C4	Diaphragm only	Ventilator dependent, power wheelchair
C5	Biceps, deltoid	Power wheelchair, feeding with setup
C6	Wrist extensors	Manual wheelchair (flat), tenodesis grasp
C7	Triceps	Manual wheelchair independent, transfers
T1	Hand intrinsics	Full UE function, wheelchair independent
T6-T12	Trunk muscles	Standing with KAFOs possible
L1-L2	Hip flexors	Ambulation with KAFOs and crutches
L3-L4	Knee extensors	Ambulation with AFOs

Autonomic Dysreflexia (T6 and above)

• Medical emergency! BP can reach 300/200 mmHg
• Triggered by noxious stimulus below level (full bladder most common)
• Symptoms: Severe headache, flushing above level, sweating, bradycardia
• Treatment: Sit up, loosen clothing, find and remove stimulus, seek emergency care

7. Cardiopulmonary Rehabilitation

Cardiac Rehabilitation Phases

Phase I (Inpatient)

• Low-level activity
• 1-3 METs
• ADLs, self-care
• Education

Phase II (Outpatient)

• Supervised exercise
• 3-5 METs
• ECG monitored
• 2-3x/week, 8-12 weeks

Phase III-IV (Maintenance)

• Independent exercise
• 5-8+ METs
• Community-based
• Lifelong

Exercise Guidelines

Target HR: 60-80% HRmax or HR at which symptoms occur minus 10-15 bpm
RPE: 11-14 on Borg scale ("fairly light" to "somewhat hard")
Duration: 20-60 minutes
Frequency: 3-5 days/week

Signs to Stop Exercise

• Chest pain, angina
• Severe dyspnea
• SBP drop >10-20 mmHg with increased workload
• SBP >250 mmHg or DBP >115 mmHg
• New arrhythmia
• Dizziness, pallor, cyanosis
• Excessive fatigue
• Failure of HR to increase with exercise

Pulmonary Rehabilitation

Breathing Exercises:

• Diaphragmatic breathing
• Pursed-lip breathing
• Segmental breathing

Airway Clearance:

• Postural drainage
• Percussion, vibration
• Huffing, coughing
• ACBT (Active Cycle)

8. Special Tests Quick Reference

Region	Test	Tests For
Shoulder	Neer test	Impingement
	Empty can test	Supraspinatus
	Apprehension test	Anterior instability
	Speed's test	Biceps tendinopathy
Elbow	Cozen's test	Lateral epicondylitis
Elbow	Reverse Cozen's	Medial epicondylitis
Wrist/Hand	Phalen's test	Carpal tunnel syndrome
Wrist/Hand	Finkelstein's test	De Quervain's tenosynovitis
Hip	FABER test	SI joint / hip pathology
Hip	Trendelenburg test	Hip abductor weakness
Spine	SLR (Straight Leg Raise)	Lumbar nerve root (L4-S2)
	Slump test	Neural tension
	Spurling test	Cervical nerve root

Key Takeaways for the Board Exam

Capsular Patterns

• Shoulder: ER > ABD > IR
• Hip: IR > Flex > ABD
• Knee: Flex > Ext

THA Precautions (Posterior)

• No flexion >90°
• No adduction past midline
• No internal rotation

ACL Tests

• Lachman (most sensitive)
• Anterior drawer
• Pivot shift

Stroke/SCI

• UMN: Spasticity, hyperreflexia
• Brunnstrom stages 1-7
• Autonomic dysreflexia: T6 and above

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Clinical Conditions

Table of Contents

1. Shoulder Conditions

Adhesive Capsulitis (Frozen Shoulder)

Rotator Cuff Pathology

Impingement Syndrome

2. Knee Conditions

ACL Injury

Meniscus Injury

Ligament Tests Summary

Total Knee Arthroplasty (TKA)

3. Spine Conditions

Disc Herniation

Spinal Stenosis

Red Flags - Require Immediate Referral

4. Hip Conditions

Total Hip Arthroplasty (THA)

Posterior Approach Precautions (Most Common)

Anterior Approach Precautions

Hip Osteoarthritis

5. Neurological Conditions

Stroke (CVA)

Brunnstrom Stages of Recovery

Parkinson's Disease

6. Spinal Cord Injury

ASIA Impairment Scale

Functional Expectations by Level

Autonomic Dysreflexia (T6 and above)

7. Cardiopulmonary Rehabilitation

Cardiac Rehabilitation Phases

Phase I (Inpatient)

Phase II (Outpatient)

Phase III-IV (Maintenance)

Exercise Guidelines

Signs to Stop Exercise

Pulmonary Rehabilitation

8. Special Tests Quick Reference

Key Takeaways for the Board Exam

Capsular Patterns

THA Precautions (Posterior)

ACL Tests

Stroke/SCI

PT Study Notes

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