OCS Introduction- Online Free study Guide

Welcome to the OCS study blog.  I will be sitting for the OCS exam in 2018.  This blog is created to spark conversation and discussion regarding the preparation for the exam.  I hope that this blog can help others aspiring to sit for the exam, and or increase conversation within our profession.  I will be trying to update this blog on a weekly basis.    Let it be known that this in no way is affiliated with the OCS or the American Board of Physical Therapy Specialties (ABPTS).  This is an unofficial study guide on topics that I feel are important as I prepare for the exam.  If others have a suggested topic of interest, I will attempt to provide up to date evidence based research regarding topics topics requested.   I hope this to be an open forum that will help myself and others deliver quality care to our patients. 
Let us first look at the knowledge areas that the OCS exam draws from.  The exam pulls from the approximate percentages below:

1. Human anatomy and physiology 10%
2. Movement Science 10%
3. Pathophysiology 10%
4. Orthopedic medical and surgical intervention 10%
5. Evidence based Orthopedic theory and Practice 10%
6. Critical inquiry and evidence based practice 10%
7. Examination 20%
8. Procedural Intervention 20%

Next look at how the different body regions approximately are covered:

1. Cranial and mandibular 5%
2. Cervical Spine 15%
3. Thoracic spine and ribs 5%
4. Lumbar Spine 20%
5. Shoulder 15%
6. Elbow 5%
7. Wrist Hand 5%
8. Pelvic girdle/SI 5%
9. Hip 5%
10. Thigh/knee 10%
11. Leg/Ankle/Foot 10%
Shoulder
“EVAL and TREAT”

For the typical shoulder referral with a prescription as “Eval and treat”, an exact shoulder diagnosis can be very difficult to find.  What we must understand is that most shoulder pathologies lie within a continuum of sxs, starting benign and progressing to more severe dysfunctions/pathologies.  In many cases patients sxs may begin with scapula dyskinesia, secondary to muscle imbalances, eventually causing repetitive stress injuries as tendonitis or impingement, that eventually can lead to rotator cuff pathology or structural damage.  Recognizing that a patient may fall anywhere within this progression is a difficult challenge.  There are very few definitive special tests that rule in or out a SLAP lesion versus an anterior impingement.   Let’s begin with an examination screening process that will begin to first rule in the shoulder, and second focus our direction.

History:
How did the symptoms begin?
 -Insidious onset, or trauma?
 -What brings on the sxs?
  -Repetitive overhead activity
  -Sitting Statically
  -Elbow hand Motion?

Where are the sxs located?
 -Anterior shoulder?
 -Posterior?
 -Scapular region?

What other complaints do they demonstrate?
 -Looseness or instability, may indicate GH instability or labral activity
 -Global pain with tightness, may indicate Adhesive capsulitis
 -Weakness, may be indicative or subacromial impingement, rotator cuff pathology

What is the patient’s profession?
 -Laborer
 -Desk work
Outcomes:
Outcomes can and should be performed to establish initial disability and to track progress
-Dash
-Shoulder pain and disability index
-Upper limb Lift and carry 
Screening Red Flags:
Left shoulder referred pain:
-Myocardial infarction
-Ruptured spleen

Right shoulder referred pain:
-Liver disease
-Pancreatic disease
-Gallbladder 

Both shoulder referred pain:
-Pancoast tumor
Yellow flags:
-Fear and avoidance
-Psychological illness
-Workman’s comp or attorney involvement
-Depression
Cervical Spine clearing:
-AROM in all directions
-PROM with over pressure
-Distraction/compression
Any reproduction of sxs may indicate further investigation of cervical spine
-Accessory motion assessment
-ULTT
-Repeated movement examination
-Traction

-Dermatome: 
 -C4 - Top of shoulder
 -C5 – Lateral shoulder
 -C6 – Tip of thumb
 -C7 – Tip of Middle 3rd digit
 -C8 – Tip fifth digit
 -T1 -  Medial Forearm

-Myotome:
-C4 – Shoulder shrug
 -C5 – Abduction
 -C6 – Elbow flexion, wrist extension
 -C7 – Elbow extension, Wrist flexion
 -C8 – Thumb abduction
 -T1 -  Finger abduction

-DTR:
 C5- Biceps
 C6- Brachioradialis
 C7- Triceps
Observation
Static:
 -Scapula position
  -Winging, rounded, tilted
 -Humeral Position
  -IR
 -Head position
  -Forward
 -AC joint
 -SC joint
Dynamic:
 -Scapulae rhythm
 -Shoulder Hiking
 -Shaking, juttering, quivering
PROM with overpressure
Flexion
Abduction
IR
ER
Horizontal Abduction
Horizontal adduction
MMT
Shoulder Flexion- Anterior Deltioid, Biceps, pec
Shoulder extension- Mid and lower trap
Shoulder Abduction- Deltoid, Supraspinatus
Internal Rotation- Subscapularis, Teres major
External Rotation- teres minor, infraspinatus
Other Resistive testing to consider:
-Serratus Anterior
-Lower and Middle Trap
-Rhomboid
Joint Accessory Motion
GH: Anterior, posterior, inferior, lateral distraction
AC: Posterior, anterior
SC: Posterior, Inferior and superior
Scapulothoracic
-Medial mobility
-Lateral mobility
-Superior and inferior
-Upward and downward rotation
Special tests
-See special test in additional sections
OK, so there are your typical screening options.  Let me know in the comments if you have any other questions or suggestions for the screening process.  We will discuss special tests in another section along with specific pathologies and treatment strategies.  Resources include Current concepts of orthopedic physical therapy, eMed, Physiopedia. 

 

 Shoulder Special Tests

Today we will be doing an overview of the special tests of the shoulder, that help the therapist develop a differential diagnosis. 

Biceps Involvement:
Speeds test
-Biceps tendinitis
 + test pain in bicipital groove or tenderness
Yergasons Test
-Laxity in transvers humeral ligament and or biceps tendonitis
 +Popping or snapping in bicipital groove, pain and tenderness
Ludingtons Sign
-Rule out long head of bicep rupture
 +Diminished or no tension under long head of the bicep tendon
RailRoad Wistle test
-Speeds test with pressure on biceps
-Biceps tendonitis or impingement
 + pain decreasing versus speeds test
Impingement tests:
Hawkins-Kennedy
-Supraspinatus and bicep tendon impingement
 + pain with resistance
Neers Test
-Shoulder impingement of supraspinatus and or biceps
 + Shoulder pain and apprehension with motion
Empty Can
-Impingement of supraspinatus, or pathology
 + Pain or weakness
Cluster Findings for Impingement
3 or greater + tests indicate +subacromial Impingement with a + LR of 2.93
 -Hawkins-Kennedy
 -Neers
 -Painful arc
 -Empty Can
 -ER resistance
AC joint
Acromioclavicular joint compression
-Tests Acromioclavicaulr and Coracoclavicular ligaments
 +pain with compression
Acromioclavicualr Joint stress
-Stresses sternoclavicular ligament and AC joint
 + pain
Spring sign
-Instability of AC joint
 + inferior shift of clavicle with pressure, superior shift with pressure relief
Cross Impingment Test
-AC join sprain
 + Pain on superior shoulder

SLAP Lesion
O’Briens Test
-Identifies a SLAP lesion
 +Pain present with IR, and diminished ER position
Glenoid Labrum and instability testing
Clunk Test
-Identifies a glenoid labrum Tear
 +clunking or grinding sensation with pain provocation
Anterior Apprehension Test
-Anterior capsule, compromised glenoid labrum
 +Resistance of movement or apprehension or pain
Jobe Relocation Test
-Anterior instability
 +decrease pain or decrease apprehension with anterior apprehension test
Anterior Drawer
-Tests for anterior instability
 +Increase anterior translation of the humeral head
Sulcus Sign
-Inferior Instability
 +Pain provocation with distraction, or palpable humeral head
Grind Test
-Grinding or clunking
 + Glenoid labrum Tear
Jerk Test
-Possible posterior subluxation or dislocation
 +Posterior apprehension or pain

Anterior INstabulity cluster findingsn:
If 2/3 tests are + the minimum + LR ratio is 18
 -Jobe relocation test
 -Anterior Drawer
 -Apprehension test
Thoracic outlet
Adsons Maneuver
-Thoracic outlet
 +Absent radial pulse
Allens test
-Thoracic outlet
 +Absent radial pulse
Roos test
-Thoracic outlet, or Neurovascular compromise
 +Unable to hold position

Rotator cuff Pathology
Drop arm Test
-Rotator cuff pathology
+Patient unable to slowly lower arm without pain
Lift off test
-Subscapular pathology
 + Unable to left hand off of buttocks or increase pain
Resources include Current concepts of Orthopedic physical therapy, Emed, Phyiopedia.
Let me know if you have additional comments or tests you would like to be added. 
Shoulder Impingement
Today we will be looking at the diagnosis of impingement.  Remember most shoulder impairments lie on a continuum of care, that is the shoulder pathology starts small with muscle imbalances, progresses repetitive stress secondary to biomechanical deficits, and results in some type of structural damage.   
Subacromial impingement begins is typically result of poor biomechanics or as a result of decreases subacromial space.  Therefore, in the continuum of care it is a product of repetitive stress to the underlying tissue of the acromion process.   The official definition of the subacromial impingement is the compression coraco-acromial arch and the humerous.
Let’s review the most commonly injured soft tissue. 
-Supraspinatus muscle
-Long head of the bicep
-Infraspinatus
-Teres minor
-Subscapularis
-Subacromial bursa
With that being said there are two types of impingements:  Structural and functional. 
Structural impingement-A reduction in the subacomial spaces secondary to boney growth, instability, calcification, boney structure etc.
The shape of the acromion process can play a large role in structural impingement. 
The acromion comes in 3 shapes or types:
Type I, flat
Type II, Curved
Type III, Hooked and most likely causing repetitive compression and irritation of the sub acromial structures
Functional Impingement: is caused by improper mechanic’s secondary to muscle imbalances, or GH instability
Functional impingement occurs because of bad mechanics, instability and poor posture that cause a decrease in space at a lower degree of shoulder movement.

Common causes include

Posture
 -Forward head
 -IR humeral head
 -Protracted scap

Muscle Imbalances
 -Tight UT, Levator scap, Pec minor
 -Weak Middle and lower trap

Instability
 -Anterior Instability allows anterior translation of humeral head

Scapula Dyskinesia
 -More in depth look at Scapula mechanics can be found on Scapulae dyskinesia page here.
Diagnostics
Cluster Findings for Impingement
3 or greater + tests indicate +subacromial Impingement with a + LR of 2.93
 -Hawkins-Kennedy
 -Neers
 -Painful arc
 -Empty Can
 -ER resistance

To RULE OUT  High Sensitivity
- A negative Hawkins Kennedy, Neer or horizontal adduction
Other differential diagnosis
 -Drop arm sign for infraspinatus
 -Lift of test for subscapularis

Stages of impingement
Stage I:
 Edema and hemorrhage- less 25 years old
Stage II:
 Fibrotic tendon changes- 25-40 year olds
Stage III:
 Involves tendon rupture from increasing fibrotic tissues- greater then 50 y/o
Treatment
Acute; rest, ice NSAIDS
Subacute chronic: Correct muscle imbalances, posture education