IDENTIFICATION OF ORTHOPEDIC PROBLEMS
FOLLOWING NEUROLOGICAL IMPAIRMENT (...or vice versa...???)
"It just goes to show... you never know exactly what you are going to find
when you enter a dragon's lair." - Bilbo Baggins
Exactly what will YOU find when you go into a patient's room?...home...the
A common complication YOU may find in addition to orthopedic problems...
Strokes may be caused from embolisms, thrombotic plaques, arteriosclerotic
changes to arteries supplying the brain, or hemorrhage in the brain.
Presentation is diverse, depending on the location of the lesion.
Immediately following stroke clients with motor involvement generally have
low tone. Extremities are heavy, flaccid, and demonstrate decreased deep
tendon reflexes and lack of voluntary motor control. Ryerson (1995) states
that this state of low tone may persist for weeks or months. Problems
associated with low tone include the following:
The trunk is the critical site for development of abnormal movement (Fisher
1987) patterns because trunk movements form the basis for postural control
of movement. (Ryerson 1995)
- Most patients assume a slumped posture in sitting with weight
bearing just behind the ischial tuberosities. Lateral flexion of
the trunk generally occurs to the involved side.
Thoracic kyphosis and lumbar lordosis occur with accompanying
stretch weakness to the back extensors and shortening to the
rectus abdominals. Generally patients forward flex at the level
of the trunk where the ribcage ends.
- Because muscles stabilizing the ribs are also flaccid there is
a lack of ribcage stability.
The scapula of clients with low tone drifts into elevation and downward
rotation with winging and or tipping (scapula gets tipped outward away from
the thorax due to lack of scapular stability usually provided by the
serratus anterior). This occurs primarily as a result of gravitational
forces. Because of the trunk position described above, this position of
downward rotation and elevation is encouraged.
C. Glenohumeral joint
- Gravity pulls the scapula into downward rotation.
- The client's posture of forward trunk flexion reinforces
scapular downward rotation and promotes elevation of the scapula
on the thorax.
- Sternocleidomastoid becomes tightened leading to altered line
of pull of the AC and SC joints.
- Orientation of the Glenoid Fossa changes so that instead of
facing upward, forward and outward it orients downward. This
compromises the structural stability of the gleno-humeral joint.
- Tipping and winging of the scapula results.
- The rotator cuff usually has low tone and lacks the functional
movement needed to stabilize the humeral head in the glenoid
- Gravity exerts a downward pull on the head of the humerus.
- The biomechanics of dynamical glenohumeral joint movement are
- Because the arm is positioned frequently in internal rotation,
adduction and a few degrees of extension, the latissimus dorsi
and the pectoralis major become shortened. The results in stretch
weakness to the external rotators of the rotator cuff (teres
minor and subscapularis).
- Subluxations can then occur (see following).
- Mechanical factors causing inferior subluxation
- Superior part of the GH joint capsule is initially normally
taut. Because the muscles that cause the head of the humerus to
glide inferiorly in the glenoid are weak, mobility of the
gleno-humeral joint into flexion and abduction is impaired. The
superior portion of the joint eventually becomes stretched
secondary to gravitational forces. As the capsule is stretched,
stability is then provided by the coracohumeral ligament (Jenson
- Over stretching of the superior capsule of the GH joint
(above) leads to decreased stability of the glenohumeral joint.
- Mal-alignment of the glenoid fossa occurs secondary to
scapular downward rotation.
- The scapula fails to lie flat on the chest wall (tipping).
- Dynamic factors causing inferior subluxation
- The rotator cuff becomes overstretched and
cannot seat the head of the humerus, glide it
inferiorly during abduction, or provide
external rotation during abduction movements.
- Overstretching of the serratus anterior,
upper and lower trapezius with shortening of
the levator scapulae compromises the clients
ability to upwardly rotate the scapula and to
maintain proper glenoid position.
- Results of inferior subluxation
- The humerus falls into internal rotation
- Pectorals, latissimus, teres major and
anterior capsule of the GH joint become
- There is a resultant loss of external
rotation at the GH joint and accompanying
stretch weakness of the rotator cuff.
- Brachial Plexus Injuries: As head of
humerus moves inferiorly it encounters teres
major......as this muscle stretches and loses
elasticity pressure is placed on the brachial
plexus/brachial artery. The most frequently
injured cord is the lateral cord which
innervates the rotator cuff.
- Attempted arm movement with the joint in this
- Poor mechanics
- Impingement of:
- Supraspinatus tendon -
leading to pain and inability
- Long head of the biceps -
leading to tendinitis, pain,
and a position of elbow
flexion and supination,
secondary to pain.
- Sub acromial bursa -
leading to bursitis and pain.
- The rest of rotator cuff -
As elevation or abduction at
the gleno-humeral joint occurs
the head of the humerus is
"jammed" into the acromion
process and impingement
Ryerson and Levit (1987) describe anterior subluxation as occurring
primarily in patients who get return of back extension without
abdominals. Causes include the following:
- In clients who tend to sublux anteriorly the
scapula usually lies elevated due to
tightness/recruitment of the upper trapezius and
levator without stabilization by the lower trap
and the serratus anterior.
- Gleno-humeral extension occurs from tightness
of the latissimus dorsi so that the distal end of
the humerus falls behind the GH joint with
pressure anteriorly on the head of the humerus.
- The head of the humerus then moves anteriorly
causing impingement on the long head of the
-This biceps impingement can cause elbow
flexion and forearm supination common in
patients following CVA.
This is again described by Ryerson and Levit (1987) as a condition in
which the humerus is lodged under the acromion process. This occurs as
a result of humeral abduction activity without appropriate scapular
TREATMENT STRATEGIES FOR THE HEMIPLEGIC SHOULDER
- The scapula is in a position of downward
- The scapula is elevated on the chest wall.
- The humerus is usually positioned in internal
rotation (from positioning and tightness of the
pectoralis and latissimus dorsi) without rotator
cuff strength. It is pulled up under the acromial
- Clients attempt to move their arm with whatever
muscles are available. The first to return include
the levator scapulae which promotes downward
rotation of the scapula.
- As clients attempt to move their arms over
their heads, the deltoid acts usually without
rotator cuff innervation. This pulls the head of
the humerus up into the superohumeral space
causing impingement and pain.
- Improper weight bearing can also lead to
impingement of structures in the superohumeral
space and pain.
- Clients with this condition may need joint
mobilization to get an inferior glide of the head
of the humerus.
- If superior subluxation is allowed to continue,
the coracohumeral ligament may be torn leading to
structural instability of the gleno-humeral joint.
C. LOWER EXTREMITY
- Positioning in Bed or in Wheelchair
Use of a table
- Upper Extremity Weight Bearing
Improve trunk Control
Increase motor Control of Arm
Increase Sensory input
Increase ROM - facilitate inactive muscles
Wear for transfers/gait if there is a greater than 2 finger
subluxation inferiorly at the gleno-humeral joint.
- Joint Mobilization
When low tone exists in the lower extremity, clients are largely under
the influences of gravity. As the client attempts to stand, the pelvis
tilts either anteriorly or posteriorly and is depressed on the
affected side secondary to the affects of gravity. This leads to knee
and hip flexion. This frequently leads to plantar flexion of the
involved foot with weight borne on the forefoot. (Ryerson 1995)
III. Head Injury
Head injuries are most frequently caused by automobile accidents. The
damage from head injury may by physical, cognitive, or behavioral.
Patients tend to move into these patterns and ability to isolate
movement out of these patterns is a sign of good potential as the
number of available movement combinations greatly increases. (Winkler,
- Cognitive problems following head injury. *See appendix A for
Poor Emotional Control
Impulsivity and lack of inhibition
Lack of Insight/ Denial of Disability
Lack of Empathy - Self Centeredness
- Physical Manifestations of a head injury can vary from very mild to
severe. As tone increases in the client following head injury or later
stages post stroke the following changes may be seen:
The first muscles to return after stroke or head injury tend
to be levator scapulae, quadratus lumborum and the
latissimus dorsi. This can lead to a compromised position of
the scapula (discussed above) as well as a hip that (instead
of listing downward into gravity) becomes elevated with a
- UPPER EXTREMITY
Upper extremity: Typical patterns of return are seen in the
upper extremity of persons who have head injury. These
- Scapula: Downwardly rotated, winging,
and/or tipping from the thoracic wall.
Scapula is also frequently elevated on
the thorax. Gleno-humeral stability is
at risk due to poor orientation of the
- Gleno-humeral Joint: Adduction,
extension, and internal rotation occurs
from shortening of the pectoralis major
and the latissimus dorsi. This can lead
to stretch weakness of the rotator cuff.
KEEP THE ARM OUT OF INTERNAL ROTATION AS
MUCH AS POSSIBLE!!
- Elbow: Flexion with pronated forearm
largely due to pressure frequently
placed on the long head of the biceps.
- Wrist: Usually flexed with ulnar
deviation from gravitational forces.
- Fingers: Flexed...with severe tone
thumb adducts into the palm of the hand
and the fingers flex around it.
- LOWER EXTREMITY:
Two patterns are commonly seen in clients following stroke or head
- Flexor pattern:
Pelvis: rotated posteriorly and elevated.
Hip: Flexion, External Rotation, Abduction
- Extensor Pattern:
Pelvis: Posteriorly rotated and may be elevated or
Hip: Extension/Internal Rotation/Adduction
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