2.1 Upper Extremity Conditions & PTA Interventions
Key Takeaways
- Rotator cuff repair (RCR) post-op typically follows four phases: maximum protection (weeks 0-6 sling, passive range of motion (PROM) only), active motion (weeks 6-12), strengthening (weeks 12-16), and return-to-activity (weeks 16-24+).
- Adhesive capsulitis (frozen shoulder) progresses through three stages — freezing (painful, 2-9 months), frozen (stiff, 4-12 months), and thawing (recovery, 5-26 months); PTA modality and stretch intensity must match the stage.
- Lateral epicondylalgia (tennis elbow) responds to eccentric wrist extensor loading; medial epicondylalgia (golfer's elbow) responds to eccentric wrist flexor/pronator loading.
- After distal radius open reduction internal fixation (ORIF), edema control and digit/elbow/shoulder ROM begin immediately while the wrist is immobilized; wrist active range of motion (AROM) typically starts at week 2-6 per surgeon protocol.
- PTAs may collect ROM, manual muscle testing (MMT), girth, and pain data and modify dosage within the plan of care (POC), but cannot change the POC, perform initial evaluations, or progress patients beyond physical therapist (PT)-set phase criteria.
Why Upper Extremity Conditions Dominate the Musculoskeletal Domain
The Federation of State Boards of Physical Therapy (FSBPT) content outline allots 31-40 items to musculoskeletal content, and upper-extremity (UE) post-op cases recur because the rehab is phase-driven and protocol-specific. The exam tests whether you can recognize a phase, identify the matching intervention, and recognize when something is outside the plan of care (POC) — the PT-authored document the PTA executes.
Shoulder Conditions
Rotator Cuff Repair (RCR) Post-Op
Most surgeons use an immobilization sling for 4-6 weeks. Early progression depends on tear size, tissue quality, and fixation. A typical timeline:
| Phase | Weeks | PTA-Implemented Intervention | Key Precaution |
|---|---|---|---|
| I: Maximum protection | 0-6 | Sling, pendulums, passive range of motion (PROM) in safe arcs, scapular setting | No active shoulder motion; no resisted internal/external rotation (IR/ER) |
| II: Active motion | 6-12 | Active-assisted range of motion (AAROM) to active range of motion (AROM), scapular stabilizers, light isometrics | No lifting >1-2 lb; avoid combined extension + IR (anterior capsule stress) |
| III: Strengthening | 12-16 | Resisted IR/ER in scapular plane, prone Y/T/W, closed-chain at wall | Watch for pain >3/10 with resistance |
| IV: Return-to-activity | 16-24+ | Plyometrics, sport- or job-specific drills | Surgeon clearance required for overhead loading |
Adhesive Capsulitis (Frozen Shoulder)
A progressive glenohumeral capsular contracture. The three stages drive intervention intensity:
- Freezing (painful): Pain dominates, ROM loss begins. PTA emphasizes pain-free PROM, modalities, gentle pendulums. Aggressive stretching worsens symptoms.
- Frozen (stiff): Pain reduces, capsular end-feel limits ROM. PTA implements low-load long-duration (LLLD) stretches and joint mobilization grades I-II within POC.
- Thawing (recovery): Motion returns. PTA progresses end-range stretching, strengthening, and functional reach.
Capsular pattern of restriction at the shoulder: lateral rotation > abduction > medial rotation.
Acromioclavicular (AC) Joint Injuries
Graded I-VI using the Rockwood classification. Grades I-II (sprain to subluxation) are managed conservatively with sling 1-3 weeks, isometrics, then progressive scapular and rotator cuff strengthening. Grades III-VI vary by surgeon preference; surgical fixation requires similar phase-based caution to RCR.
Elbow Conditions
Lateral Epicondylalgia (Tennis Elbow)
Tendinopathy of the common extensor origin, most often extensor carpi radialis brevis (ECRB). Provocation: resisted wrist extension or middle-finger extension with the elbow extended (Cozen / Mill tests). Best-evidence interventions a PTA can implement: eccentric wrist extensor loading, isometric holds for analgesia, soft-tissue mobilization, counterforce brace, activity modification.
Medial Epicondylalgia (Golfer's Elbow)
Tendinopathy of the common flexor-pronator origin. Provocation: resisted wrist flexion and pronation. PTA program mirrors lateral epicondylalgia but loads the flexor-pronator group eccentrically.
Post-Fracture Rehab (Radial Head, Olecranon, Supracondylar)
Most elbow fractures are immobilized 1-3 weeks, then AROM begins early to prevent the elbow's characteristic stiffness. The PTA collects goniometry weekly; flexion and supination return slowest. Heat before stretch, ice after, and no passive end-range force without PT clearance.
Wrist & Hand Conditions
Carpal Tunnel Syndrome (CTS)
Compression of the median nerve under the transverse carpal ligament. Symptoms: night paresthesias in the thumb, index, middle, and lateral half of the ring finger; positive Phalen, Tinel, and carpal compression tests. Conservative PTA implementation includes neutral-wrist night splints, nerve gliding, ergonomic education, and tendon glides.
Distal Radius Fracture (Colles)
After cast immobilization or ORIF, the PTA prioritizes edema control, digit AROM, and shoulder/elbow ROM during the immobilization window to prevent secondary stiffness. Wrist AROM typically begins at week 2 (ORIF) to week 6 (closed reduction). Grip strengthening waits until the surgeon clears loading, usually weeks 6-8.
PTA Decision-Making Inside the Plan of Care
A PTA may collect ROM, MMT, girth, edema, and pain data and modify dosage (reps, sets, resistance, hold time) within the PT's POC. A PTA may not change the POC, add new diagnoses, perform initial evaluations, or progress a patient past a written phase criterion. When data suggests the patient is outside expected response — for example, a 90-degree shoulder flexion plateau at week 8 post-RCR — the PTA communicates with the supervising PT before changing the program.
Quick Reference: Capsular Patterns (Cyriax)
| Joint | Capsular Pattern (Most to Least Restricted) |
|---|---|
| Shoulder (GH) | Lateral rotation > abduction > medial rotation |
| Elbow | Flexion > extension |
| Wrist | Flexion = extension |
| Hand MCP/IP | Flexion > extension |
A PTA is treating a patient 5 weeks after right rotator cuff repair. The PT's plan of care lists passive range of motion only with a sling between sessions until week 6. The patient asks the PTA to begin active shoulder elevation today because it 'feels ready.' What is the MOST appropriate PTA action?
During data collection for a patient with adhesive capsulitis in the 'freezing' stage, which finding would BEST justify the PTA reducing stretch intensity at today's visit?