Foundation content of musculoskeletal system

Anatomical position

Anatomical position refers to a standardized posture of the human body used as a reference point for describing anatomical structures and movements.

Specifications:

• The body is upright and facing forward.
• Feet are flat and parallel, with toes pointing straight ahead.
• Arms are extended at the sides, with palms facing forward.
• Head is held erect, with eyes looking straight ahead.

Definitions

Anterior

Front of the body, or the direction toward the front

Posterior

Back of the body, or the direction toward the back

Median

Towards the middle of the body

Lateral

Towards the side of the body

Superior

Above or higher than another body part

Inferior

Below or lower than another body part

Distal

Further away from the center of the body

Proximal

Closer to the trunk of the body

Ventral

Close to the anterior of a structure

Dorsal

Close to the back of a structure

Sagittal plane

Runs vertically through the body, dividing it into left and right halves

Frontal (coronal) plane

Runs vertically through the body, dividing it into front (anterior) and back (posterior) halves

Axial (transverse) plane

Runs horizontally through the body, dividing it into top (superior) and bottom (inferior) halves

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Basics of strength training

Strength training refers to a type of exercise program designed to increase muscle strength and mass. It involves performing exercises that challenge the muscles to work against resistance, such as lifting weights, using resistance bands, or performing bodyweight exercises. There are multiple factors contributing to the overall success of an appropriate strength training program.

Muscle fiber types

Muscles types are defined by how they produce energy and how quickly they fatigue

Slow Twitch (Type I)

• Slow contraction speed
• Low force production
• Highly resistant to fatigue
• Example: Postural muscles

Fast Twitch (Type IIA)

• Fast contraction speed
• Fatigue resistant
• Can be influenced by training
• Examples: Muscles used for strength and movement

Fast Twitch (Type IIB)

• Fast contraction speed
• High force production
• Susceptible to quick fatigue
• Examples: Muscles for quick movements and eye muscles

Guidelines for strength training

The foundational concepts of strength training are:

• Overload principle
  • Increasing the amount of resistance added to the muscle over period of time
• Specificity of training
  • Train the muscle or muscle groups necessary to perform activity
  • Resistance needs to be added differently to each muscle and/or muscle group to exhibit hypertrophy
• Training effects are reversible
  • If training ceases, the amount of resistance that can be applied to a muscle will be lost

Changes to the muscle fibers and the amount of motor units recruited with initiation of strength training takes 6-8 weeks to occur with a consistent training program

Contraindications to strength training

• Active inflammation or acute condition
• Severe pain during or greater than 24 hours after initiation of exercise

Types of exercise for strength training

Isometric

• Muscle contraction without change in muscle length
• Typically used during acute phase of healing or when learning muscle control
• Example: Quad sets

Isotonic

• Muscle length shortens and lengthens with muscle contraction; weight changes during ROM
• Used during sub-acute and chronic phases of healing when pain and inflammation is reduced and adequate motor planning and control have been established
• Example: Bicep curls with 20 pound weight

Isokinetic

• Muscle length shortens and lengthens with muscle contraction; weight stays the same throughout ROM
• Used during the sub-acute phase of healing when concern of re-injuring muscle is a concern due to control of movement and resistance throughout the movement
• Example: Isokinetic machines

Endurance training

Endurance training refers to a type of physical exercise that aims to improve the body’s ability to sustain physical activity for prolonged periods. It involves engaging in activities that require moderate-to-high intensity effort over extended timeframes, such as running, swimming, cycling, or hiking. Endurance training helps enhance cardiovascular health, pulmonary ventilation, muscle strength, and overall fitness by increasing the body’s oxygen consumption and utilization capacity.

Effects of endurance training:

• Capillary growth: More capillaries in muscles improve blood flow and oxygen delivery.
• Cardiac adaptations: Stronger heart muscle, increased stroke volume, and improved cardiac output.
• Metabolic benefits: Enhanced ability to utilize fat as fuel during exercise.
• Improved VO2 max: The maximum amount of oxygen your body can use during exercise increases significantly with endurance training

Guidelines for endurance training

• At least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous aerobic activity per week (per American Heart Association
  • Spread exercise out throughout the week
• Being with low duration and intensity while progressing to longer duration and intensity over a period of time

Contraindications for endurance training

• Unstable angina
• Acute coronary syndrome
• Uncontrolled arrhythmias
• Acute heart failure
• High degree atrioventricular block
• Severe aortic stenosis
• Coronary artery stenosis
• Recent stroke or transient ischemic attack
• Uncontrolled diabetes mellitus
• Uncontrolled hypertension
• Hyperthyroidism
• Severe COPD
• Cerebrovascular or musculoskeletal disease
• Significant anemia
• Important electrolyte imbalance

Coordination and balance training

Coordination and balance training are ways to improve your ability to control your body’s movement and maintain stability.

Effects of coordination and balance training

• Reduced fall risk
  • Improving ability to react quickly and maintain stability, overall reducing fall risk
• Improved coordination
  • Allows for smoother movements, better agility, and quicker reaction times
• Improved proprioception:
  • Balance exercises stimulate the nervous system to better sense your body’s position in space, enhancing proprioception.
• Better posture:
  • Regular balance training can help maintain proper alignment and posture by strengthening the muscles that support axial skeleton
• Muscle strength and endurance:
  • Improved muscle activation, leading to increased muscle strength and endurance throughout the body

Guidelines for coordination and balance training

The typical sequence of coordination and balance training interventions begin with axial/postural stability activities progressing to the peripheral system. The activities will also begin as static and progress to more dynamic activities in nature.

Interventions that can be used are as follows:

• Therapeutic exercises
• Postural training
• Weight shifting activities
• Sit-to-stands
• Gait training
• Dual tasking
• Changing surfaces
• Sensory training

Contraindications for coordination and balance training

• Acute injuries
• Severe pain
• Unstable joints
• Recent surgery
• Significant neurological impairments
• Severe dizziness or vertigo
• Poor vision
• Cardiovascular instability
• Uncontrolled medical conditions,

Aquatic Therapy

Aquatic therapy, also known as hydrotherapy, is a form of physical therapy that involves performing exercises and movements in water. It utilizes the buoyancy, resistance, and warmth of the water to improve physical function, reduce pain, and enhance rehabilitation.

Related Physics

• Buoyancy: Force of water on immersed body segment, decreasing body weight and joint off-loading
• Cohesion: Water molecules adhering to each other, creating resistance
• Density: Proportional to water depth, providing additional resistance
  • The deeper the individual is submerged the harder the activity will be for an individual

Water Temperatures

• Cooler water: Used for high-intensity exercises- seen more in athletes
• Warmer water: Used to improve mobility and flexibility while decreasing pain -common rehab population
  • 90-94°F (32-34°C is common range

Precautions for aquatic therapy

• Fear of water
• Patients with heat intolerance

Contraindications for aquatic therapy

• Bowel/bladder incontinence
• Severe kidney disease
• Seizures
• Uncontrolled cardiac or respiratory disorders
• Peripheral vascular disease (PVD)
• Open wounds
• Active bleeding
• Active infections

Ways to progress an therapeutic approach

Exercise progression is the process of making an exercise more challenging over time. It’s a key part of any training routine that helps you maintain and improve your fitness level. Below are ways in which a therapist can progress exercise over a period of time.

Progressions examples

1. Small Motion → Large Motion
2. Low Center of Gravity → High Center of Gravity
3. Low Resistance → High Resistance
4. Slow Movements → Fast Movements
5. Stable Surface → Unstable Surface
6. Large Base of Support → Small Base of Support
7. Closed Environment → Open Environment
8. All Sensory Input → Limited Sensory Input
9. Extrinsic Feedback → Intrinsic Feedback
10. Eccentric Exercises → Concentric Exercises

Osteokinematics and Arthrokinematics

Osteokinematics is the study of bone movement, while arthrokinematics is the study of joint surface movement.Both are branches of biomechanics that describe how the body moves.

Definitions

Osteokinematics

Movement between two bones (flexion/extension, IR/ER)

Arthrokinematics

Movement of joint surfaces such as roll, glide, spin- such movements are used to improve range of motion

Rule of convex surface moving on fixed concave surface

Roll and glide occur in opposite directions to allow for motion to occur- movement of distal and proximal segments are in opposite directions

Rule of concave surface moving on fixed convex surface

Roll and glide occur in the same direction to allow for motion to occur- movement of distal and proximal segments are in the same direction

Arthokinematics rules

Shoulder (Convex on Concave Rule)

• Flexion: Roll anterior, slide posterior
• Horizontal Adduction: Roll anterior, slide posterior
• Internal Rotation: Roll anterior, slide posterior
• Extension: Roll posterior, slide anterior
• Horizontal Abduction: Roll posterior, slide anterior
• External Rotation: Roll posterior, slide anterior
• Abduction: Roll superior, slide inferior

Elbow (Concave on Convex Rule)

• Flexion: Roll anterior, slide anterior
• Extension: Roll posterior, slide posterior

Wrist (Convex on Concave Rule)

• Flexion: Roll anterior, slide posterior
• Extension: Roll posterior, slide anterior
• Radial Deviation: Roll radial, slide ulnar
• Ulnar Deviation: Roll ulnar, slide radial

Hip (Convex on Concave Rule)

• Flexion: Roll anterior, slide posterior
• Extension: Roll posterior, slide anterior
• Adduction: Roll medial, slide superior
• Abduction: Roll lateral, slide** inferior**
• Internal Rotation: Roll medial, slide posterior
• External Rotation: Roll lateral, slide anterior

Knee (Concave on Convex Rule)

• Flexion: Roll posterior, slide anterior
• Extension: Roll anterior, slide posterior

Ankle (Convex on Concave Rule)

• Dorsiflexion: Roll anterior, slide posterior
• Plantarflexion: Roll posterior, slide anterior
• Supination/Inversion: Roll medial, slide lateral
• Pronation/Eversion: Roll lateral, slide medial

Joint Mobilization

Joint mobilization is a manual therapy technique that involves moving a joint passively to improve its range of motion and reduce pain. The above arthrokinematics chart are the ways in which the therapist will perform joint mobilizations at each joint.

Indications for joint mobilization

• Pain
• Muscle spasm
• Joint hypomobility
• Functional limitation at joint ROM

Precautions for joint mobilization

• Joint hypermobility
• Joint effusion
• Inflammation

Contraindications for mobilization

• Malignancy
• Fracture
• Bone disease
• Rheumatoid arthritis (RA)
• Individuals on anticoagulants

The grades of joint mobilization (Maitland approach)

• Grade I - small amplitude movement at the beginning of the joint’s range of motion
  • Typically used in acute phases for pain management
• Grade II- large amplitude movement within the joint’s range
  • Typically used in sub-acute phases for return of range of motion
• Grade III- large amplitude movement reaching the limit of the joint’s range
  • Typically used in sub-acute phases for return of range of motion
• Grade IV - small amplitude movement at the end of the joint’s range
  • Typically used in acute phases for pain management

Joint Positions

Joint position or mechanics are ways to define the joint’s level of stability, An open position (also called loose packed position or resting position) refers to a joint position where the articulating surfaces have minimal contact, ligaments are relaxed, and the joint has the least stability. A closed position (also called a close-packed position) is when the joint surfaces are fully congruent, ligaments are maximally taut, and the joint is at its most stable position. The open position are those in which joint mobilizations will occur.

Resting and closed positions

• Sternoclavicular
  • Resting position: arm resting at side
  • Closed position: arm maximally elevated
• Arcomoclavicular
  • Resting position: arm resting at side
  • Closed position: arm abducted to 90 degrees
• Glenohumeral
  • Resting position: 40-55 degrees abduction; 30 degrees of horizontal adduction
  • Closed position: maximum abduction and external rotation
• Humeroulnar (elbow)
  • Resting position: 70 degrees flexion, 10 degrees supination
  • Closed position: full extension and supination
• Humeroradial (elbow)
  • Resting position: full extension and supination
  • Closed position: 90 degrees flexion and 5 degrees supination
• Proximal radioulnar (forearm)
  • Resting position: 70 degrees flexion and 35 degrees supination
  • Closed position: 5 degrees supination
• Proximal radioulnar (forearm)
  • Resting position: 10 degrees supination
  • Closed position: 5 degrees supnation
• Radio/ulnarcarpal
  • Resting position: neutral with slight ulnar deviation
  • Closed position: full extension with radial deviation
• Hip
  • Resting position: 30 degrees flexion, 30 degrees abduction, and slight lateral rotation
  • Closed position: full extension, abduction, and internal rotation
• Knee
  • Resting position: 25 degree flexion
  • Closed position: full extension and external rotation
• Talocural (ankle/foot)
  • Resting position: mid inversion/eversion and 10 degrees plantar flexion
  • Closed position: full dorsiflexion
• Subtalar (ankle/foot)
  • Resting position: midway between inversion and eversion
  • Closed position: full inversion
• Midtarsal (ankle/foot)
  • Resting position: midway between inversion and eversion
  • Closed position: full supination
• Tarsometatarsal (ankle/foot)
  • Resting position: midway between supination/pronation
  • Closed position: full supination

Capsular patterns

A capsular pattern is a specific limitation in range of motion that indicates joint tightness or inflammation. It’s a combination of pain and limited movement that can occur in any joint that’s controlled by muscles. Certain pathologies as denoted in later chapters will be defined specifically from the capsular pattern that exists within the joint.

Below are capsular patterns of joints

• Glenohumeral
  • External rotation, abduction, internal rotation
• Sternoclavicular
  • Shoulder levation
• Acromioclavicular
  • Shoulder elevation
• Humeroulnar
  • Flexion, extension
• Humeroradial
  • Flexion, extension
• Proximal radioulnar
  • Pronation, supination
• Distal radioulnar
  • Pronation, supination
• Wrist
  • Flexion, extension
• Hip
  • Flexion, internal rotation, abduction
• Knee
  • Flexion
• Tibiofibular (proximal and distal)
  • Equal limitations of flexion and extension

End feels of joints

End feel of a joint refers to the sensation a clinician feels when they reach the limit of a joint’s passive range of motion during an assessment, essentially describing the quality of tissue resistance at the end of movement. The end feels can be characterized as soft, firm, or hard depending on the tissues that are limiting the motion. By evaluating the end feel, a clinician can determine if a joint is moving within its normal range and identify potential abnormalities like inflammation, ligamentous damage, or joint stiffness.

Below are the characteristics of normal end feels:

• Soft end feel:
  • Occurs when soft tissues like muscles meet, often felt as a cushioned sensation (example: knee flexion)
• Firm end feel:
  • A more defined resistance, usually due to the tension of ligaments or joint capsule at the end of range (example: wrist flexion)
• Hard end feel:
  • A sudden, abrupt stop to movement, typically caused by bone-on-bone contact (example: elbow extension)

Pathological end feels are those indicating there has been injury to joint, tendon, or muscle.

Pathological end feels that may be present

• Springy block
  • A rebounding sensation often associated with internal joint derangements like a torn meniscus
• Empty end feel:
  • Significant pain experienced before reaching the end of the range of motion, usually indicating acute inflammation
• Boggy or soft end feel
  • A “mushy” sensation due to joint effusion or edema, typically seen in acute injuries
• Hard end feel
  • Excessive bony resistance beyond the normal end point, potentially from osteoarthritis or bone spurs
• Muscle spasm end feel
  • Sudden, sharp resistance due to muscle guarding, causing pain and limiting movement

Phases of healing and types of musculoskeletal interventions

The musculoskeletal system has three stages in which disease processes can be classified- 1. Acute or inflammatory phase, 2. Subacute or proliferative phase, and 3. Chronic phase.

The acute phase refers to the initial inflammatory stage following an injury, characterized by pain, swelling, and redness. The acute phase typically lasts for 3-7 days.

The subacute phase is the subsequent repair stage where new tissue begins to grow and the body starts to rebuild damaged structures, usually occurring a few days after the initial injury and lasting several weeks.

The chronic phase is not a natural part of healing but occurs when healing has stopped in either the acute or subacute phase. Injuries are classified as chronic if no progression past the acute or subacute phases for greater than 3 months.

Interventions in each phase

Acute phase

• Pain management
• Maitland mobilizations- grade** I or IV**
• Joint protection to prevent further injury
• Edema management
• Therapeutic Exercise: 40%-60% of 1 rep max in pain-free ROM
• Stretching is contraindicated

Subacute phase

• Avoid overuse pain as resting pain should be at minimum
• Stretching initiated to aid in restoring full range of motion
• Endurance training will begin
• **Resistance training **training will begin
• Postural and biomechanical education

Chronic phase

• Identify healing phase (acute vs subacute) and make intervention selections based on phase of healing
• Emphasize postural and biomechanical strengthening
• Improve flexibility and joint alignment