Common Pathologies Of Upper Limb Flashcards
Rotator cuff is made of…
Supraspinatus, infraspinatus, teres minor and subscapularis
What do rotator cuff muscles do?
Hold head of humerus in the small glenoid fossa.
They have some physiological movements:
Supraspinatus is abduction
Infraspinatus is lateral rotation and ADDUCTION
Teres minor is lateral rotation, ADDUCTION and extension
Subscapularis is medial rotation
It is thought they do not all work together - posterior is more for flexion and anterior more for extension
Rotator cuff related shoulder pain is umbrella term for what?
SIRRLS
Subacromial pain syndrome
Impingement
Rotator cuff tear
Rotator cuff tendinopathy
Issues with long head of biceps tendon and subacromial bursitis
Describe theories related to rotator cuff tendinopathy
Tendon compression in subacromial space between the acromion and humoral head. Irritates tendon and causes changes, pain and dysfunction.
Intrinsic factors that cause tendon compression are overload, overuse and underuse of the tendon.
Another theory is that acromion process irritates superior part of rotator cuff tendons causing inflammation and damage.
Studies show damage is within the tendon or inferior to it
Newer accepted theory is tendon compressed between greater tuberosity and superior aspect of glenoid fossa. It causes excessive superior sliding of numeral head in the glenoid fossa
Genetics
Nutrition
Over 50s
Diabetics
People who work with shoulder above 90 degrees
CLINICAL PRESENTATION OF ROTATOR CUFF TENDINOPATHY
Pain and impairment of shoulder movement and function occurring in shoulder elevation (flexion or abduction) or on lateral rotation.
Slow working lower fibres of trapezius causing scapula to elevate and rotator superiorly earlier than it should do.
Increased superior glide of head of humerus in glenoid fossa.
Painful arc- flex or abduct with no pain and then pain occurs between 90-120 degrees and then less painful into full ROM
Rotator cuff tendinopathy if you have excessive or mal adaptive loads.
Rotator cuff normally stabilises head of humerus into the glenoid fossa.
Management of rotator cuff tendinopathy
Surgery to re attach the tendon or adjust it to attach to numeral head
Physio intervention can give exercises to improve scapulohumeral rhythm and increase strength of lower fibres of trapezius to improfe strength and mobility of the shoulder.
Educate patient about condition and the help we can give
Modify loads gradually to improve strength at shoulder
Evidence claims physio and surgery have similar outcomes
Steroid injections
Ice = reduce swelling and pain
Stretching to increase flexibility of shoulder
Heat= reduce shoulder stiffness
LATERAL EPICONDYLITIS / Tennis elbow
Can also be called lateral epicondylalgia as no inflammation.
Can affect radial nerve as it goes between two heads of supinator.
Most common overuse tendinopathy of the elbow caused by tendinopathy to the extensor muscles of the forearm.
Prevalence and incidence
Affects 1-3% of people
Male and females are equal
Around 90% improve within a year and recurrence rate is about 8% and may need surgery if it keeps happening.
Prognosis - most cases self limiting
2 risk factors are obesity and smoking
What is most commonly affected tendon?
ECRB followed by ECRL, supinator, ED, EDM and ECU
Often caused by repetitive use eg, musicians, c9puter users, manual users and racquet sports
Clinical presentation of tennis elbow
Pain at lateral epicondyle in line with the extensor tendon and pain can radiate into extensor muscles
Varying pain - intermittent, constant, high or low severity
Aggravated by wrist and finger extension, supination and grip
Stretching tendon can compress common extensor tendon and causes symptoms again
Middle finger extension may be painful as it adds extra stress to ECRB by fixating third metacarpal for middle finger extension.
Management of lateral epicondylitis
Load management- don’t over or underuse Exercises- to load tendon safely Taping and bracing- to reduce symptoms so we can increase loads safely Educate patient about condition and treatment NSAIDs- ibuprofen and naproxen Corticosteroid injections Shock wave therapy Surgery
Medial epicondylitis
Can be called golfers elbow
An overuse tendinopathy affecting the common flexor tendon at medial epicondyle for the flexors and pronators of the forearm.
It can involve the ulna nerve between two heads of Pronator teres
Incidence of medial epicondylitis
Less common than lateral (10% incidence)
Aged 40-60
Incidence is 0.3-1.1% and more in females and males
Associated with golfers and manual workers
Usually involves tendon of FCR and pronator teres
Clinical presentation of medial epicondylitis
Pain on medial aspect of elbow and tender to palpate
Aggravated by resisted wrist flexion or pronation, valgus stress and stretching the tendons FCR and pronator teres
Aggravated by throwing or gripping and reduce grip strength
Can involve the ulna nerve (20%) so there is pins and needles a new numbness in little finger and half of fourth finger.
Management of medial epicondylitis
Education Exercises Gradually increase the load to stress the tendons Offload tendon using taping or bracing to cope with increased loads NSAIDs Corticosteroid injections Shock wave therapy Surgery
About 60-90% recover with conservative management and don’t need surgery
De Quervain’s syndrome
A reactive thickening of the tendon sheaths of EPB and APL
It can occur as idiopathic or overuse of the thumb
Overuse may include eccentric lowering of the wrist into ulna deviation with load
More common in women than men
Common in new mothers as they lift baby into radial deviation and then lower baby down into ulna deviation with the weight of baby in the hands
Age is 40-50
Incidence in women is 1.3% and men it is 0.5%
Describe the pathophysiology of De Quervain’s
There’s inflammation of synovial sheaths around EPB and APL.
This leads to swelling, fibrosis and thickening of the sheath.
Adhesions develop between the tendon and its sheath so the tendon normally slides easily within it but adhesions limit tendon movement.
Enclosed tendons are constricted and compressed so there is some more inflammation.
Clinical presentation of De Quervain’s
Pain on radial side of the wrist and pain radiates into the thumb
Aggravated by radial deviation of wrist and resisted thumb extension or abduction as the tendons bring on pain.
Stretching tendons will hurt
Finkelstein’s test: tuck thumb into the fist and ulna deviate which produces pain in the tendons and confirms this problem.
Painful when you palpate the tendons
Management of this condition
Splinting- can immobilise the thumb for rest but when they take it off it may hurt again, so we need to rest and use load management.
Exercises
Load management
Education
Corticosteroid injections
NSAIDs
Surgery
Define a strain
Strain is an injury to a muscle or tendon caused by over contracting or over lengthening leading to tears of the collagen.
Describe grade 1 strain
A grade 1 is mild.
The muscle or tendon is overstretched with micro tears in the collagen
Localised pain and tenderness
No visible bruising
Minimal swelling
Minimal loss of function
Strength and ROM are intact
Grade 2 strain
Grade 2 is moderate.
Partial tear of muscle or tendon.
Immediate cardinal signs of inflammation.
Pain is poorly localised
Moderate bruising
Moderate swelling
Decreased strength and pain on resisted testing
Painful ROM or slight reduction in ROM
Grade 3 strain
Grade 3 is severe
Complete rupture of a tendon or a muscle
Inability to contract muscle
Separation may be evident
Pop or crack noise
Immediate pain, swelling and bruising
As you progress the pain may be less than grade 2
Where would you see a strain?
Most commonly in 2-joint muscles because a movement of one joint can increase tension of the muscle and overstretch it or eccentric contractions of the muscle.
Mainly in muscles with more type 2 twitch muscle fibres - fast twitch with high contraction speeds.
Management of strains
Depending on severity and healing times
POLICE or PRICE
Mobilise injury as early as possible for maximal healing
Once ROM is back, work on strength and loading of the muscle
Proprioception
Endurance training- the type we do depends on patient goals
Grade 3 needs surgery but the physio management after is the same
Define sprain
A stretch or tear of a ligament
Usually caused by the joint being forced outside of normal ROM and in elastic collagen fibres will stretch too far and tear.
Most common are ankle sprains and has grades 1,2 and 3
Prognosis = most recover with conservative management but in very severe cases surgery needs to reconstruct the ligament
How are sprains managed?
Depending on severity and healing times, POLICE or PRICE
Early mobilisation Early WB Exercises to maintain loads Education Return to sport if appplicable
Severe cases use surgery
Carpal tunnel formation
Flexor retinaculum is the roof and the contents are tendons of FDS, FDP and FPL plus median nerve.
Flexor retinaculum attaches at high points of carpal bones so this is pisiform, hook of hamate, scaphoid tubercle and ridge of trapezium,
Carpal tunnel syndrome
The most common peripheral nerve entrapment.
The median nerve is compressed in the tunnel.
Compression may be caused by oedema, inflammation of tendon, hormonal changes or repetitive manual activity. Anything that reduces the space compresses median nerve.
1 in 10 people get it
More common in females than males and the difference increases with age
Name 6 risk factors for carpal tunnel syndrome
Obesity Pregnancy Hypothyroidism Arthritis Menopause Diabetes
Prognosis
Mild to moderate is resolved with conservative management
Severe needs surgery
Clinical presentation of carpal tunnel
Intermittent nocturnal paraesthesia- pins and needles and numbness during the night and increases in frequency over time and into daylight hours too
Loss of sensation
In severe cases, the median nerve provides minimal motor supply to muscles it supplies eg, thenar eminence wasting of muscles (atrophy) and these muscles are weaker.
Pain
Symptoms likely to follow path of median nerve then more distributed
Progresses to difficulty with fine motor tasks
What would we do to test if someone has carpal tunnel syndrome?
Test the thumb strength in resisted abduction , ADDUCTION and flexion, which would be reduced if motor fibres are affected.
Test sensory changes in the hand using light and deep touch and sharp and blunt sensations
Tinel’s sign= tap the part of tunnel where median nerve passes to see if symptoms are reproduced
Phalen’s test= put hand into position where median nerve is compressed and hold to see if symptoms reproduced
How do we manage carpal tunnel syndrome?
Education- maybe life style modifications?
Load management
Splints- at night especially to reduce compression
Exercises
Corticosteroid injections
Surgery
If the carpal tunnel syndrome is mild it should improve in 6 weeks of conservative management, then they are referred for a second opinion.
