Pathology of shoulder complex MSK Quiz 3

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RC tears: Nonoperative Management include

Immobilization may be needed to promote healing Management of pain and swelling NSAIDs, analgesics, ice packs, electrical stimulation, or other physical agents such as ultrasound Prefunctional phase Return to function phase Throughout each phase of recovery, various tissues can be stretched or torn

ER resistance test

Impingement

Adhesive Capsulitis / Freezing phase

In the early stages of this disabling condition, pain occurs both at rest and during activity

Postoperative Period

Initial postoperative care begins with a period of immobilization Medications for pain and swelling may be prescribed by the physician. Ice packs are applied to the shoulder for 20 minutes, three to five times daily. Patient can actively perform finger, hand, wrist, and elbow mobility exercises. Progressive motion and strengthening exercises Return to function phase

Shoulder pain in post-CVA patients is usually due to what?

Internal rotation contracture rather than the dislocation itself.

Internal Impingement

Involves structures within the glenohumeral joint, over head throwing activities. The humerus is abducted and internally rotated

Primary shoulder impingement

- compressive Intrinsic and extrinsic forces- now thought more due to intrinsic verses actual compression THINK BLOCKED

Overhand throwers such as baseball pitchers, water polo players, and javelin throwers are susceptible to

internal impingement, which occurs when he underside of the rotator cuff hits against the posterior superior glenoid labrum

IR resistance test

intra-articular Tear or impingement

Compression Rotation Test

labral tears

crank test

labral tears

Subacromial Rotator Cuff Impingement Classification Stage I

less than 25 y/o: localized inflammation, edema and minimal cuff trauma

What is the Hallmark sigh for adhesive capsulitis?

limited passive ER of 50% or Less than 30 degrees with arm at side Normal is 90

Primary frozen shoulder

not associated with a systemic condition or history of injury

Subacromial Rotator Cuff Impingement Classification Stage III

over 40 y/o: end-stage usually a tear associated

Bicipital tendonitis is inflammation of the LONG or SHORT head of the biceps due to ?

LONG repetitive overhead activities.

Speed's test

Long head of biceps Impingent SLAP lesions

The lack of external rotation causes

pain

Grade III AC sprains are severe and include the following

May include surgical intervention Equal long term results seen in surgical verse non-surgical intervention Open surgical repair, closed reduction immobilization, and progressive rehabilitation Initial course of treatment in physical therapy is to minimize pain and swelling Continuously reinforce compliance using the immobilizer Minimize downward displacement of UE(no carrying heavy purses) Use upper trap muscles!

Are clavicle fractures more common and primarily in men or women?

Men, under 25 years of age

Glenohumeral Joint ANTERIOR instability AND dislocation are more frequent or infrequent?

More frequent 90%: due to nature of osteology: 18-25y/o sporting activities

Is isolating shoulder function in the main planes of the body (flexion/extension, abduction/adduction, etc) appropriate?

NO

This ? test is examining the patient for ?

Neer, External Subacromial Impingement

Appropriate strategies for shoulder rehabilitation include

Obtain stable scapular platform as soon as possible Rehab the shoulder according to the stage of irritability Shorten the lever arm to decrease load

Proximal Humerus Fractures More complex fractures require what time of intervention?

Open reduction and internal fixation (ORIF) with screws and a plate, as well as prolonged periods of immobilization

Internal impingement becomes an injury when?

Over time, microtrauma from repetitive throwing results in damage to the rotator cuff (SLAP)

Which of the following interventions occur in the immediate postop (pre-functional phase of rehabilitation after a subacrominal decompression?

Pain control Ice packs Ultrasound Manual ROM exercises

Nonoperative Treatment of Impingement and Symptomatic Rotator Cuff Tears include 3 phases of rehabilitation

Phase I - prefunctional Phase II - return to function Phase III - return to activity

Hornblower's Sign

Positive if patient can not abduct due to pain - teres minor

AC joint therapy

Prefunction phase normally lasts 4 to 6 weeks Return to function closely follows the patient's level of motion and strength.

Total Shoulder Arthroplasty

Prosthetic replacement of the humeral head and glenoid cavity.

Internal Impingement, occurs to everyone during .

THROWING Therefore internal impingement in itself is NOT an injury.

Anterior Drawer Test

positive if there is instability/abnormal laxity

Yocum test

subacromial impingement Raise elbow without raising shoulder - test is positive if there is pain

Lift off test

subscapularis weakness/tear/pain

How are AC sprains I,II, III treated?

tconservatively with immobilization, meds, ROM and strengthening. Surgery needed for individuals who require repetitive lifting above shoulder level

Proximal Humerus Fractures Nondisplaced one-part fractures treatment

the affected arm is placed in an immobilizer

Adhesive Capsulitis (Frozen Shoulder)

inflammation of the capsule with fibrotic thickening of anterior capsule Primary: no known cause: DM Secondary: due underlying condition

Infraspinatus ER: lower-intensity strengthening exercise 40% max strength

to optimize activation from the rotator cuff and to de-emphasize input from deltoid In other words, low load to get infraspinatus to load

Most common scapular fractures occur

to the glenoid neck Treatment depends on whether or not there is associated glenohumeral instability

Which 4 muscles create the rotator cuff?

Supraspinatus Infraspinatus Teres minor Subscapularis

Proximal Humerus Fractures Nondisplaced one-part fractures are the most common type? Correct or incorrect treatment

Correct

The shoulder is made up of three main components

1. Osteology (bone) 2. Arthrology (joints) 3. Passive stabilizers: the labrum, superior glenohumeral ligament, middle glenohumeral ligament, inferior glenohumeral ligament and capsule

RSA: Reverse Total Shoulder requires strengthening at 12 or 6 weeks?

12 weeks ( 6 weeks for TSA)

How many muscles attach to the scapula

17

Subacromial Rotator Cuff Impingement Classification Stage II

25-40 y/o : progressive deterioration of the cuff

During normal shoulder abduction or flexion what is the natural ratio between the GH and scapulothoracic joint? Scapulohumeral Rhythm

2:1 ratio of GHJ to scapular movement

What are the movements and degrees in the 1st phase of GHJ? Scapulohumeral Rhythm

30 degrees abduction 60 degrees of flexion

RC tears: Nonoperative Management Period of protection lasting for up to

4 to 6 weeks

Positions: Resting (Joint space largest, soft tissues of ligaments and capsule on slack/OPEN PACK

55-70° abduction 30° horizontal adduction 60° elbow flexion 30° elevation of the forearm from horizontal plane

What is the ER/IR ratio typically in a normal healthy individual?

66%

Hill-Sachs lesion

A compression or "impaction fracture" of the POSTEROLATERAL aspect of the humeral head as a result of anterior shoulder instability

Empty Can (Jobe) Test - 30 degrees in scaption plane

External supraspinatus impingement

Patients over 60 usually will have a tear on MRI, usually asymptomatic or symptomatic?

Asymptomic

What is the most common rotator cuff tears?

Supraspinatus possible DROP ARM

Proximal Humerus Fractures - Complications

Avascular necrosis (AVN) An older population of patients with advancing osteoporosis who have four-part proximal humerus fracture

Horizontal adduction test

AC joint dysfunction Subacromial impingement Pinching

The pain associated with what type of sprain is typically reproduced with shoulder abduction to 90 degrees (the close packed position for the AC joint) and passive horizontal adduction of the glenohumeral joint?

AC joint sprain

GH joint instability and dislocation frequently occur after indirect trauma with the arm

Abducted Elevated Eternally rotated

AC sprain Grade I

Acromioclavicular ligaments STRETCHED but not torn. Coracoclavicular ligaments intact Minimal loss of function

AC sprain Grade II

Acromioclavicular ligaments ruptured/TORN and joint SEPARATED Coracoclavicular ligaments intact Moderate pain and some dysfunction

Instability- What is the predominant pattern of a shoulder with spasticity?

Adduction Internal rotation

A decrease in shoulder ROM, pain, inflammation, fibrous synovial adhesions, and reduction of the joint cavity characterizes

Adhesive capsulitis

What diagnosis is characterized by a decrease in shoulder ROM, pain, inflammation, fibrous synovial adhesions, and reduction of the joint cavity?

Adhesive capsulitis

Bankart lesion

An avulsion of the capsule and glenoid labrum off of the ANTERIOR rim of the glenoid resulting from traumatic ANTERIOR dislocation of the shoulder

Adhesive Capsulitis /Frozen phase

As the condition progresses, pain gradually subsides and then spontaneously disappears. Severely restricted motion and profound loss of function remain.

Secondary frozen shoulder

Systemic Extrinsic - MI or C/S DDD Intrinsic - Rotator Cuff or bicep tendinopathy

Your patient fell on his outstretched arm and dislocated his shoulder in the usual direction for this injury. In her initial evaluation the PT noted that the patient suffered a ? lesion, where the capsule and glenoid labrum avulsed off the anterior rim of the glenoid, as well as a ? lesion, where the posterior humeral head impacted the glenoid.

Bankart, Hill-Sachs

Yergason Test (Active Supination Against Resistance In This Position)

Biceps tendon & SLAP (Superior Labrum Anterior to Posterior)

Close Packed GH position

Close Packed GH: Full Abd & ER or full Add/Ext/IR (hammerlock)

RC tears: Nonoperative management include open or closed kinetic chain activities?

Closed kinetic chain

AC sprain Grade III

Coracoclavicular and ligaments ruptured/TORN with wide SEPARATION of joint Ligament injury

Are fractures of the scapular body rare or most common?

COMMON 49% to 89% and demonstrate the highest incidence of associated injuries 35% to 98%

Which muscle is the PTA trying to strengthen with this exercise?

Subscapularis

Force Couple - Rotator cuff and deltoid

Supraspinatus Infraspinatus Subscapularis Teres minor

In the PREFUNCTIONAL STAGE following a shoulder dislocation, what signs does a PTA look for in a patient to determine whether or not exercises can be progressed?

Decrease pain Decrease swelling Improved strength

Capsular position

ER > Abd > IR

What will biasing the ratio during shoulder rehabilitation of patients with rotator cuff injury and anterior instability to 75% do?

Enhance the ability of the posterior rotator cuff (external rotators) to provide stabilization.

Adhesive Capsulitis /Thawing phase

Eventually the motion returns ~ 80-90% previous

After a stroke the patient has limitations in shoulder EXTERNAL or INTERNAL rotation?

External

Neer and Hawkins-Kennedy both test for

External Subacromial Impingement

A shoulder that stiffens in the CLASSIC PATTERN for the GH joint will be restricted in

External rotation Abduction Internal rotation

What is the most limited ROM/specific order

External rotation Abduction Internal rotation

Hawkins-Kennedy Test

External subacromial impingement

Proximal Humerus Fractures - Complications PTA role

Following and supervising a comprehensive program of early protected limited ROM submaximal isometrics for the scapular stabilizers rotator cuff, and upper arm muscles providing continued protection for the injured site

Rotator cuff tears are classified as

Full thickness Partial thickness Acute chronic Degenerative Small less 1 cm Medium 1-3 cm Large 3-5 cm Massive greater 5 cm

Surgery patients (Surgical Management and Rehabilitation)

Have less postoperative pain and reduced soft-tissue damage Require a prefunctional phase of rehabilitation that emphasizes protection ROM

Proximal Humerus Fractures Four-part classification

Humeral head Lesser tuberosity Greater tuberosity Humeral shaft

Glenohumeral joint POSTERIOR instability and dislocation are rare or common?

RARE usually only seizures

Anterior capsulolabral reconstruction procedure (Surgical Management and Rehabilitation)

Reattaches the capsule to the glenoid

Total Shoulder Arthroplasty general guidelines

Rehab: 0-3 weeks: allow healing of subscap, initiate PROM, pendulums, elbow AROM, ice precautions: use UE for waist level activities and bring hand to mouth with arm adducted. avoid lifting, carrying, pushing, leaning Cautious to remove ROM exercises when reach more 30 ER and more 130 flexion (those who had instability prior to sx) 3-8 weeks: PROM elevation 120, PROM ER 30, isometrics, strengthening at 6-8 weeks 8-16 weeks: AROM, increase function and strength of scap stabilizers more 16 weeks: work or sport

Clavicle Fractures

Result of direct or indirect trauma. Common and primarily affecting men under 25 years of age Care focused on achieving reduction of the fracture fragments, maintaining the reduction, and minimizing the immobilization of the glenohumeral joint of the affected arm Figure-of-eight bandage to maintain proper alignment of the area Duration of immobilization varies; authorities suggest healing takes 4 to 6 weeks or longer

RSA: Reverse Total Shoulder

Reverse shoulder TSA: indicated in management of massive or irreparable RC tears, prox humerus fx resulting in deficient RC, revision of prior TSA with RC deficiency rehab depends on preop deltoid fx, post op stiffness, quality of fixation sling for 4-6 weeks, avoid extension and adduction of shoulder, avoid ER in abduction those with good deltoid function can use arm for waist level activity for first 6 weeks first 3 weeks: 90 deg forward flexion and 20-30 deg ER Deltoid strength paramount

Force couple: downward rotation of scapula

Rhomboids,Levator scapulae, Pectoralis minor

The pain associated with the an AC joint sprain is typically reproduced with the shoulder abduction to 90 degrees (close packed position for the AC joint) and passive horizontal adduction of the GH joint. Right or Wrong

Right

Drop Arm Test

Rotator Cuff tear - supraspinatus

SLAP stands for what kind of tears?

S uperior L abrum A nterior P osterior

Bicipital tendonitis some involves the labrum aka

SLAP injury Bucket Handle tear to the top of the labrum

Rehabilitation of Primary and Secondary Rotator Cuff Impingement Exercises

Scapular stabilization exercises Modification of activities Local and systemic methods to control pain and swelling Corticosteroid injections Ice, ultrasound, iontophoresis, phonophoresis Stretching and strengthening exercises

Up to 80% of post-CVA patients have shoulder pain related to structural or functional instability which include

Shallow joint with poor natural bony fit combined with muscles that are either floppy or tight Reduced sensation Neglect/Lack of awareness of where arm is Poor positioning and handling

The normal ratio can become grossly imbalanced and fall well below the 66% normal ratio in what population?

Shoulder patients and in overhead athletes

Significant or insignificant use of ER-based training for the patient with shoulder dysfunction?

Significant

For every 2 degrees of glenohumeral abduction the scapula must do what? Scapulohumeral Rhythm

Simultaneously upwardly rotate roughly 1 degree

Bicipital tendonitis can be tested as positive if there is pain with palpation in these 2 tests

Speed's Yeargson's

4 stages of adhesive capsulitis

Stage 1: pre-adhesive, synovitis, mild end range pain, often misdiagnosed as impingement Stage 2: freezing, thickened red synovitis, acute discomfort, painful end ranges, connective tissue changes resulting in loss of ROM Stage 3: frozen, fibrotic, less synovitis, mature adhesions, less pain Stage 4: severe restriction, no synovitis, thawing, painless stiffness

Pure plane abduction puts acromion right over the humeral head which can create

Subacromial Impingement

Painful Arc

Subacromial Impingement supraspinatus or bicep

Surgical Management of Shoulder Impingement and Rotator Cuff Tears

Subacromial decompression (SAD) Acromioplasty Open arthrotomy or an arthroscopic procedure Postoperative rehabilitation Similar to nonoperative Phase I Phase II Phase III

What is the common cause of shoulder pain?

The tendons of the rotator cuff are crowded, buttressed, or compressed under the coracoacromial arch, resulting in mechanical wear, stress, and friction.

What is the primary indication for total shoulder arthroplasty?

UNREMITTING PAIN not functionality

Force couple: upward rotation of scapula

Upper trapezius, Serratus anterior, Lower trapezius

When do AC sprains and dislocations occur?

Usually result from a fall on the acromion/direct force or when a force is transmitted from a fall on an outstretched arm proximally to the AC joint

What are the 4 phases in throwing?

Wind up Cocking Acceleration Deceleration or Follow-through

Shoulder pain in post-CVA patients is usually due to INTERNAL ROTATION CONTRACTURE rather than dislocation itself. Yay or Nah

Yay

Limitations in shoulder external rotation play an important role in shoulder pain after

a stroke: With spasticity, the affected arm rests in a predominant pattern of shoulder adduction and internal rotation Without active or passive ranging of the shoulder, internal rotation contracture of the shoulder ensues, and pain follows The lack external rotation explains the etiology of shoulder

The combination of abduction and external rotation in the cocking phase of throwing causes

an impingement of the underside of the rotator cuff against the posterior (back) superior (top) labrum.

The most common direction for laxity and instability of the shoulder joint is

anterior

The treatment for scapular fractures is conservative if

associated injuries have not occurred, using ice and immobilization with shoulder immobilization for 2 to 3 weeks.

Impingement symptoms are usually made worse with overhead activities; the patient must modify activities of daily living (ADLs) and all other motions

below 80 to 90 degrees elevation

Out of the 4 phases, what phase does internal impingement occur?

cocking

The supraspinatus provides a direct

compression

Scapular Fractures result form

direct and severe trauma

Secondary impingement - scapula thoracic articulation

due to underlying instability

Secondary shoulder impingement

due to underlying laxity of the shoulder THINK INSTABILITY

Towel roll application has been shown to

elevate muscular activity by 10% in infraspinatus compared to no towel.

Surgery patients receive slow and protective

external rotation up to 12 weeks postoperatively to ensure healing of all soft tissue.

Apprehensive test

if patient is apprehensive this indicates dislocation/instability

Relocation test

immediately performed after positive result of apprehension test (anterior dislocation)if symptoms are relieved test is positive, indicating anterior instability

Adhesive Capsulitis

increased incidence with DM and thyroid disease 40-65 years, more females, increased risk for involvement of opposite shoulder 12-18 month self-limited process Primary FS: not associated with a systemic condition or history of injury Secondary FS: systemic, extrinsic (MI or c/s ddd), intrinsic (Rc or biceps tendinopathy)

3rd phase, Scapulohumeral Rhythm

more GHJ again

2nd phase, Scapulohumeral Rhythm

more scapula with 1:1 ratio

Bicipital tendonitis treatment:

reduce symptoms activity management improve mechanics return to activities

Rotator cuff tears can be from

trauma or degenerative

Adhesive Capsulitis Acute phase

treatment is focused on controlling inflammation and symptoms of pain. Main goal is to reduce PAIN Physician-prescribed analgesics, NSAIDs, and intraarticular steroid injections can provide some pain relief. ...Injection f/b 6 weeks of PT...then decide on treatment progression

The shoulder is the MOST mobile of all joints with MULTIPLE planes of motion. True or false

true


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