The shoulder flexion jam test

The shoulder flexion jam test is also known as the Neer's test¹¹. It is a special test for shoulder impingement syndrome, which is a condition that results from compression of the rotator cuff tendons or the subacromial bursa under the acromion process of the scapula¹.

The procedure of the shoulder flexion jam test is as follows²⁴:

- The examiner stands behind the patient and stabilizes the scapula with one hand.

- The examiner passively flexes the patient's shoulder and elbow to 90 degrees, then pronates the forearm and internally rotates the shoulder with some force.

- The test is positive if the patient reports pain, especially near the end range of motion.

The shoulder flexion jam test can help rule out cervical neck pathology as a source of shoulder pain, as well as other shoulder conditions such as rotator cuff tear, biceps tendinitis, or glenoid labrum injury⁷⁹. However, the test is not very specific and may produce false-positive results in patients with osteoarthritis, adhesive capsulitis, or acromioclavicular joint pathology¹⁸. Therefore, it is recommended to use the test in combination with other clinical tests or imaging studies to confirm the diagnosis of shoulder impingement syndrome¹⁶.

The salute test

The salute test is also known as the Yergason's test¹ or the transverse humeral ligament test². It is a special test for the shoulder joint that evaluates the stability of the long head of the biceps tendon and the integrity of the transverse humeral ligament³.

The procedure of the salute test is as follows⁴:

- The patient stands or sits with the elbow flexed to 90 degrees and the forearm pronated.

- The examiner stands behind the patient and places one hand on the patient's elbow and the other hand on the patient's wrist.

- The examiner resists the patient's active supination and external rotation of the forearm, while palpating the bicipital groove with the thumb of the hand on the elbow.

- The test is positive if the patient reports pain or a snapping sensation in the bicipital groove, indicating a subluxation or dislocation of the biceps tendon or a tear of the transverse humeral ligament.

The salute test can help rule out biceps tendon pathology, such as tendinitis, tenosynovitis, or rupture, as well as rotator cuff pathology, such as impingement, partial tear, or full-thickness tear³⁵. However, the test is not very specific and may produce false-positive results in patients with other shoulder conditions, such as glenohumeral instability, labral tear, or acromioclavicular joint arthritis³⁶. Therefore, it is recommended to use the test in combination with other clinical tests or imaging studies to confirm the diagnosis of biceps tendon or rotator cuff pathology³⁷.

The appreciation test

The appreciation test.

The appreciation test is also known as the Thematic Apperception Test (TAT) or the picture interpretation technique⁴. It is a projective psychological test that involves describing ambiguous scenes to learn more about a person's emotions, motivations, and personality⁴.

The procedure of the appreciation test is as follows⁴:

- The person is shown a series of picture cards depicting a variety of ambiguous characters, scenes, and situations.

- The person is asked to tell as dramatic a story as they can for each picture presented, including what has led up to the event, what is happening, the thoughts and feelings of the characters, and the outcome of the story.

- The examiner interprets the person's responses based on the themes, conflicts, and needs that are expressed.

The appreciation test can help rule out or identify psychological conditions, such as depression, anxiety, personality disorders, or thought disorders⁶. It can also be used to assess someone's coping skills, self-esteem, interpersonal relationships, and social adjustment⁴. However, the test is not very reliable or valid, and the results may vary depending on the examiner's skill, bias, and theoretical orientation⁴⁶. Therefore, it is recommended to use the test in combination with other clinical methods or standardized measures to confirm the diagnosis of psychological pathology⁴⁶.

Chin tucks exercise

It a simple and effective exercise that can help improve neck ,jaw strength and posture. They primarily target the muscles in the neck ,jaw and upper back.

How to Perform Chin Tucks:

Sit or stand with a straight spine.

Relax your shoulders and keep your eyes focused straight ahead.

Gently tuck your chin toward your chest without tilting your head down.

Hold the position for a few seconds, feeling a stretch at the back of your neck.

And relax. 

Intensity: Chin tucks are a low-intensity exercise. Perform them with control and focus on proper form rather than speed or force.

Duration: Hold the tucked position for 5-10 seconds initially, gradually increasing as you build strength.

Repetition: Start with 5-10 repetitions and progress as your neck muscles become stronger.

Frequency: Perform chin tucks 2-3 times a day, especially if you have a desk job or spend long hours looking at screens.:

 Benefits:

1. Posture Improvement: Chin tucks contribute to better posture by helping to align the head jaw and neck. Improved posture can have a positive cascading effect on the entire spine, reducing strain on the lower back and promoting overall spinal health.

2. Reduced Forward Head Posture: Forward head posture is a common issue, especially in individuals who spend extended periods looking at screens. Chin tucks can help counteract this forward head position, reducing the load on the cervical spine.

3. Muscle Strengthening: Chin tucks engage the muscles in the neck jaw and upper back, promoting strength in these areas. This can contribute to overall muscle balance and stability throughout the upper body.

4. Tension Relief: Individuals experiencing neck ,jaw and shoulder  tension may find relief through regular chin tuck exercises. These exercises can help relax tight muscles and reduce discomfort associated with poor posture

Precautions:

1. Consultation with a Professional: If you have any underlying health conditions, such as neck injuries, herniated discs, or neurological problems, it's advisable to consult with a healthcare professional or a physical therapist before starting chin tucks.

2. Pain or Discomfort: While mild discomfort or a stretch is normal, if you experience pain during or after performing chin tucks, stop the exercise and seek advice from a healthcare professional.

3. Gradual Progression: Start with a low number of repetitions and short durations, gradually increasing as your neck muscles become stronger. Avoid overexertion.

4. Posture Awareness: Be mindful of your overall posture throughout the day, not just during exercises. Make adjustments to avoid prolonged periods of forward head posture.

Indications: 

1. Postural Issues: Chin tucks are beneficial for individuals with poor posture, especially forward head posture often associated with desk work and screen time.

2. Neck Pain or Tension: People experiencing mild to moderate neck pain or tension, particularly due to poor posture, may find relief through regular chin tuck exercises.

3. Rehabilitation: Chin tucks can be included in neck rehabilitation programs prescribed by healthcare professionals for certain conditions.

Contraindications:

1. Acute Neck Injuries: Individuals with acute neck injuries, such as recent strains, sprains, or fractures, should avoid chin tuck exercises until they have healed.

2. Severe Pain or Discomfort: If you experience severe pain or discomfort during or after performing chin tucks, it's advisable to avoid the exercise and consult with a healthcare professional.

3. Neurological Conditions: People with certain neurological conditions affecting the neck or spine may need to avoid or modify chin tuck exercises. Consultation with a healthcare provider is crucial in such cases. 

Popliteus tendinitis

 Popliteus tendinitis is characterized by inflammation andpain at the knee joint on the back part of the outer side of theknee and the outer side just above the knee at the popliteus

tendon.

Common Signs and Symptoms:

• Pain and tenderness over the popliteus tendon at the outerknee or back of the knee on the outer side

• Pain that is worse when standing on the leg with the kneebent slightly or when walking or running, just as the foot ofthe affected leg lifts off the ground

• Pain that is worse when rotating the leg

• Pain that starts or recurs after running a particular distance

• Crepitation (a crackling sound) when the tendon is movedor touched (uncommon, except when tested just after exercising)

  Causes :

Overuse of the popliteus muscle-tendon unit, usually in anathlete who runs or trains on hills or banked surfaces

Risk Increases With

 • Sports or activities that require a lot of downhill walkingor running, such as with backpacking, cross-country running, and distance running; also, running on a banked

track or next to the curb on the street (a banked surface)

• Poor physical conditioning (strength and flexibility)

• Inadequate warm-up before practice or play

• Flat feet

Diagnostic Test:

1. Garrick Test

Patient seated, hip and knee are both flexed to 90°. The patient actively externally rotates the lower leg and this is resisted by the examiner. A positive test is pain during the maneuver in the location of the popliteus muscle or tendon.

PHYSICAL THERAPY

1. Reverse heel tap

Attach a resistance band on to the forefoot of the non–weight-bearing leg (NWBL).The foot on the NWBL moves behind the stance leg via external rotation of the hip and knee flexion.

The foot of the NWBL continues to move behind the stance leg with increasing internal tibial rotation.Completion of the concentric exercise. The return to start position provides an eccentric muscle effort.

2. Step up and down

Place one foot on top of a small raised platform. Keeping the raised leg slightly bent at the knee, step forward with the opposite leg. Next, step backwards, then to the right and left of the foot planted on the step. Repeat this motion for 20 to 25 repetitions.

3. Leg curls

Attach one end of a resistance band to the base of a closed door or stable surface, such as a heavy table leg, at floor level. Place the other end of the band loop securely around one ankle. Lie on the floor, face down, with both feet toward the area where the band is initially attached. Lift the banded heel up and toward the glutes in a slow and steady motion. For more resistance, move farther away from the door or table. Slowly lower the foot to the starting position and repeat for 20 to 25 repetitions.

4. Gastrocnemius stretching , Standing

 Place hands on wall. Extend right / left leg, keeping the front knee somewhat bent.Slightly point your toes inward on your back foot.Keeping your right / left heel on the floor and your knee straight, shift your weight 

toward the wall, not allowing your back to arch.

You should feel a gentle stretch in the right / left calf. Hold this position for 7_ seconds.

Repeat 3-5 times. Complete this stretch 3 times per day. #behindthekneepain 

5. Stretching of Soleus, Standing

 Place hands on wall.Extend right / left leg, keeping the other knee somewhat bent.Slightly point your toes inward on your back foot. Keep your right / left heel on the floor, bend your back knee, and slightly shift your 

weight over the back leg so that you feel a gentle stretch deep in your back calf.

 Hold this position for 7 seconds.

Repeat 3-5 times. Complete this stretch 3times per day.

6. Stretching of Hamstrings, Standing

 Stand or sit and extend your right / left leg, placing your foot on a chair or foot stool. Keeping a slight arch in your low back and your hips straight forward.Lead with your chest and lean forward at the waist until you feel a gentle stretch in the back of your right / left knee or thigh. (When done correctly, this exercise requires leaning only a small distance.) Hold this position for 7 seconds.

Repeat 5times. 

7. Hip Flexor Stretch

This stretch focuses on the muscles running along the back and outside of your knee, according to the Sports Injury Clinic. Place one leg in front of your with your knee bent. Your foot should be planted on the ground and facing forward. The other leg should be bent with your knee on the floor. Slowly push 

your hips forward while keeping your back straight. You will feel a stretch in your upper leg. Hold this position for a count of 30 seconds. Repeat three sets of three repetitions daily.  

8. Half squat

Stand with your feet about hip distance apart. If you feel unstable, hold onto a wall or back of a chair for balance.Maintain a long spine and lifted chest as you bend gently through your hips and knees. Let the hips bend just about 10 inches as if you're sitting toward a chair. Keep your feet planted, weight in your heels.

Pause for three to five counts and straighten back up to a stand.Repeat 10 to 12 times.

9. Heel Cord Stretch

Stand facing a wall.Place your healthy leg forward and bend the knee slightly.Place the injured leg straight behind you with the heel flat and the toes pointed in a little bit.Keep your heels flat on the floor and press your hip complex forward, toward the wall.

Hold for 30 seconds.

10. Calf Raises

Stand and face the back of a chair; hold on for balance.Distribute your weight evenly over both feet.Bend your left knee behind you and place all your weight on your right foot.Raise your right heel as high as you can and then lower it slowly.Repeat 10 times

11. Isometrics exercise of quadriceps will help to maintain muscle power of quadriceps muscle, Isometrics: Initial isometrics with quadriceps contractions done with the knee fully extended and in different positions at 20-degree increments as knee flexion improves May discontinue isometrics when the patient can sit comfortably.

12. Straight leg raises: 

Sit flat on the floor with the legs straight out in front of you. Raise one leg off the floor keeping the knee straight. Hold for 3 to 5 seconds before lowering back to the ground. Repeat 10 to 20 times. This exercise can be done daily. Progress the exercise by increasing the length of hold and the number of reps.

 

13. Compression: 

This may help decrease blood flow and accompanied by elevation will serve to decrease both blood flow and excess interstitial fluid accumulation. The goal is to prevent hematoma formation and interstitial edema, thus decreasing tissue ischemia. However, if the immobilization phase is prolonged, it will be detrimental to muscle regeneration. Cryotherapy, accompanied by compression, should be applied for 15–20 min at a time with 30–60 min between applications. During this time period, the quadriceps should be kept relatively immobile to allow for appropriate healing and prevent further injury.

Electrotherapy

◾ULTRASOUND THERAPY: UltraSound is a therapeutic modality that generates ultrasound causes deep heat, provides micro-massage to soft tissue, increases flexibility, promotes healing of tissue as well improves localized blood supply to the area, and ultimately pain relief.

◾SHORT WAVE DIATHERMY: short wave diathermy is a deep heating modality that uses heat to provide pain relief, it improves the blood supply to targeted muscle, removal of waste products

◾TENS: transcutaneous electrical nerve stimulation is an electrical modality that provides pain relief by providing pain modulation.TENS closes the gate mechanism at the anterior grey horn in the spinal cord. also stimulates the endogenous opioid system which prevents the release of substance p at the anterior grey horn.

◾Cold therapy: used to relieve inflammation and reduce pain, Ice Massage- Ice on the area of inflammation for anti-inflammatory effects. Use ice in a paper or Styrofoam cup (peeled away) for 5-7 minutes, make sure to avoid frostbite.

◾Use Circulatory Boost TShellz Wraps®:

∆After swelling and inflammation have been reduced with cold compression.

∆Before exercise or workouts to warm up your injury to prevent re-injury.

∆Before and after surgery during rehabilitation to warm up your tissues before exercising or stretching.

∆Anytime you feel the tissue in your leg has stiffened up, is tight and your mobility is reduced causing you more pain.

∆Anytime you have sore or aching tissue around your injury.

∆Any other situation where you need to increase blood flow to your tendon to relax your soft tissue, relieve pain, prevent re-injury and enhance flexibility of your tissue.

Medication

NSAID

Corticosteroid

Muscle relaxer

Tarsal tunnel syndrome

 Tarsal tunnel syndrome:

 is the compression of an important nerve that runs through your ankle and into your foot. It’s possible to develop tarsal tunnel syndrome after spraining your ankle, overusing your feet, or developing arthritis or diabetes

Causes:-

Tarsal tunnel syndrome (TTS) is caused by compression of the posterior tibial nerve as it travels through the tarsal tunnel. Compression of the posterior tibial nerve can cause pain, tingling or numbness in the foot

Symptoms:

Burning sensations.

Numbness.

Tingling or “pins and needles” sensations.

Weakness in your foot muscles

Diagnosis:

🔹Tinel’s test:

 Physical therapist gently taps your tibial nerve. If you experience pain or tingling that reproduce your symptoms, it may point to TTS.

🔹Dorsiflexion – Eversion Test:  

Place the patient’s foot into full dorsiflexion and eversion and hold for 5-10 seconds

The results are that it elicits the patient’s symptoms

🔹Electromyogram (EMG): 

This two-part test uses an electrical impulse to measure your nerve and muscle function.

🔹MRI: 

MRIs use magnets and radio waves to take detailed images of soft tissue and bones inside of your body. Your healthcare provider may order an MRI to evaluate an injury or nerve damage or a mass putting pressure on your tibial nerve

  

◾Gait Analysis:

Assess for abnormalities (excessive pronation/supination, out-toeing, excessive inversion/eversion, antalgic gait, etc.)

◾Sensory Testing

Test light touch, 2-point discrimination, and pinprick in the lower extremity

Deficits will be in the distribution of the posterior tibial nerve

◾Palpation:

Tender to palpation in between the medial malleolus and Achilles tendon

Painful in 60-100% of those affected

◾Range of Motion (ROM):

Focus on ankle and toe ROM

 Physical therapy

⚫Heel-toe raises

Using the back of a chair or counter for support, lift the heels off the floor to stand on the toes.Hold for 5 seconds before slowly lowering back down to the floor.Repeat the exercise 15 times.Do two sets, with a 30-second rest between each set.

As the injured foot becomes stronger, try standing on the injured foot only.

⚫Balance exercise

Stand beside a chair, using it for support if needed, with the injured foot furthest from the chair.Stand on the injured foot and slightly bend the knee.Bend forward from the waist and reach forward with the hand furthest from the chair.Repeat 15 times for two sets.

Reach the hand furthest from the chair across the body, toward the chair.

Repeat 15 times for two sets.

⚫Calf stretch

Stand and face a wall with the hands placed on the wall at eye level.Take a lunge position by placing the injured foot slightly behind with the heel flat on the ground and the other leg slightly forwards with a bent knee.Turn the back foot inwards slightly.Gently lean towards the wall until there is a stretch in the back calf.

Hold in this position for 15–30 seconds.

Return to the start and repeat 3 times.

Repeat the entire exercise several times a day.

⚫Soleus muscle stretch

Lean forwards pressing the back heel into the ground until a stretch is felt

If it is not possible to feel a stretch, then place something underneath the toes to raise the front of the foot.Or put the ball of the foot up against the wall and push the knee forwards

Bending the knee takes the Gastrocnemius muscle, which attaches above the knee, out of the stretch

⚫ Ball Rolling 

Stretching the plantar fascia is by rolling it over a round or cylindrical shaped object such as a ball, rolling pin or can of soup. The can of soup can be placed in the freezer to include a cold therapy effect as well.

Roll the foot repeatedly over the ball applying downward pressure onto the plantar fascia. It acts like a deep tissue massage to help stretch the fascia.

⚫Resistance band ankle inversion

A resistance band is tied around the foot with the other end attached to a fixed point

The foot is turned inwards against the resistance of the band.Slowly return to the start position, rest and repeat 10-20 times

Begin with only 10 reps and gradually increase

This can be performed every day provided it is pain-free. To make it harder, start with the band under increased tension by shortening the section being used

⚫Ankle rotation – 

Just like all other parts of the body, exercising the ankles helps to keep them strong. For this exercise, sit on a chair and shake your ankles for a few seconds. After this, rotate the ankles gently clockwise about four to five times then repeat the same with counterclockwise motion.

⚫The pencil lift – 

The pencil lift is done by placing a pencil on the floor then picking it up with the toes and holding it for about ten seconds. You should repeat this exercise, relaxing after every round.

⚫TOE FLEXORS/PLANTAR FASCIA STRETCH

Sit on a chair or on the floor for this exercise.

Bring the foot you would like to stretch in towards you by bending your knee.Place the heel of one hand along the tips of all of your toes.Run your fingers around the ball of your feet and under your sole.Using your fingers and your hand, pull all of your toes back towards you.Be sure to not forget about your little toe.

Hold this position

Electrotherapy

TENS

Ultrasound therapy 

Acupuncture 

Shock wave diathermy 

K tapping 

Orthotic management:-

Braces, casts or splints:

 A cast or splint keeps your foot in place to encourage nerve healing. If you have flat feet or severe symptoms, your healthcare provider may recommend a brace to reduce pressure on your feet. Orthotics: You may use custom-made shoe inserts (orthotics).

Injection therapy: 

For very painful or disabling symptoms, a doctor may inject anti-inflammatory medication, such as corticosteroids and local anesthetics, directly into the nerve. 

Williams flexion exercises for low back pain

 Williams flexion exercises are a series of physical therapy exercises primarily aimed at improving lower back flexibility and strength. These exercises were developed by Dr. Paul Williams to help manage and alleviate lower back pain, particularly in cases of lumbar disc herniation and stenosis. 

Benefits:

1. Lower Back Pain Relief Williams flexion exercises are primarily used to alleviate lower back pain, especially in cases of lumbar disc herniation and stenosis 

2. Improved Flexibility: They can help increase flexibility in the lower back and hamstrings.

3. Core Strengthening: These exercises engage the abdominal and lower back muscles, helping to strengthen the core.

4. Posture Improvement: Practicing these exercises can lead to better posture by promoting awareness of spinal alignment.

5. Non-Invasive: Williams flexion exercises are non-invasive and do not require equipment, making them accessible for many people

Sets, Intensity, and Duration:

The number of sets and intensity can vary based on an individual’s fitness level, flexibility, and specific needs. However, a typical starting point might be to perform 1 to 2 sets of each exercise with 10 to 15 repetitions. The intensity should be moderate, focusing on controlled movements and stretches. Over time, as you become more comfortable with the exercises, you can gradually increase the repetitions or duration.

Frequency:

It is generally recommended to perform Williams flexion exercises regularly, ideally on a daily basis or as prescribed by a physical therapist. Consistency is key to achieving and maintaining the benefits.

Indications:

1. Lumbar Disc Herniation: Williams flexion exercises are often recommended for individuals with lumbar disc herniation as they can help alleviate pain and improve the condition.

2. Spinal stenosis:

These exercise can be there helpful in stenosis during flexion exercise t This position opens up the constricted bony canals, decompressing the nerve root(s) and enabling patients to perform the exercise more efficiently with lesser pain.

3. Lower Back Pain: These exercises can be beneficial for those experiencing lower back pain due to various causes, not limited to disc issues.

4. Flexibility Improvement: Anyone looking to improve their lower back and hamstring flexibility can benefit from these exercises.

Contraindications:

1.Severe Spinal Conditions: People with severe spinal conditions such as severe spinal stenosis, spondylolisthesis, or ankylosing spondylitis should avoid Williams flexion exercises, as they may exacerbate these conditions.

2. Acute Injuries: If you have an acute lower back injury or inflammation, it’s essential to consult with a healthcare professional before attempting these exercises.

3. Individual Variances: Not all exercises may be suitable for every individual, and it’s essential to consult with a physical therapist or healthcare provider for a personalized exercise plan that takes into consideration your specific condition and needs.

Always consult  physical therapist before starting any exercise program, especially if you have a pre-existing medical condition or are recovering from an injury. They can provide personalized guidance and modifications to ensure the exercises are safe and effective for your unique situation.