Common Upper limb pathologies Flashcards
Common disorders
RC disorders= tendinopathy (most affected= supraspinatus) and tear
GHJ disorder= AC and OA
AC joint= can be subluxation/dislocation or stretching/ tearing of AC lig or coracoclavicular lig
biomechanics of GH elevation- how to gain full elevation
normal functioning force couples= deltoid+RC/ lower cuff/LR/ SA and traps
normal movement at AC &SC& ST joints, normal humeroscapular rhythm, good thoracic spine mobility
what does the amount of thoracic spine kyphosis affect
influences the ability of us to flex and abd shoulder
frozen shoulder- what affects movement
most common in women age 40-60, characterised by pain and stiffness in shoulder- 3 stages, gradual insidious onset
pathology= initial inflammatory process leading to fibrosis of capsule, RC interval (SGH and CH lig and subscap tendon) and anterior capsule most affected- loss of capsular flexibility and decreased ROM
what is the rotator interval
section between supraspinatus and subscapularis tendon, involve CH lig coming off coracoid process underneath biceps LH. when you get frozen shoulder this section of the capsule becomes fibrosed and thickened (loss of ROM)
what movement is worse for frozen shoulder
LR worse as anterior capsule stretches when arm above head- can lead to differentiation
stages of adhesive capsulitis
stage 1- painful phase (10-36 weeks), stage 2- stuff phase (4-12 months), stage 3- recovery phase (12-42 months) mean duration from onset to recovery= 30 months
diagnosis criteria- adhesive capsulitis
shoulder pain that comes on slowly and is felt at deltoid region, painful restriction of AROM/ PROM, capsular pattern (LR (most affected)>ABD>MR), inability to sleep on affected side, X ray= only way to differential diagnosis from OA
management stage 1
reduce pain, <3/12= consider SCI, >3/12= avoid CSI (extend recovery period), NSAIDs, advice, maximise ROM
management stage 2 and 3
stage 2- maximise ROM and function, mobs, self management programme, advice,
stage 3- maximise ROM and function, mobs, self management programme, advice, active exercise programme, stertching
what part of capsule needs to be stretched
superior part of capsule to get rotator interval zone
surgical management of adhesive capsulitis
MUA, joint distension (H20)- stretches capsule with water=break adhesions, open surgical release
RC tendinopathy
shoulder weakness and catching- should not have limited end feel to movement, should have pain and weakness on isometric resisted testing
what happens if you get tendinopathy of supraspinatus tendon
if supraspinatus is dysfunctional then deltoid pull humeral head upwards- meaning rest of RC aren’t maintaining position= compression of tendon (severe= bone formed in tendon_
types of RC tendinopathy
tendinitis- acute tendon overuse (young adult), tendinosis- under stressed- overload tendon condition with a degenerative, non-inflammatory pathology
tears- over 40’s= full/partial thickness
calcification- calcific deposits within tendon
rotator crescent and cable
cable= thickened area of capsule creates cord like structure, cre
factors causing tendinopathy- intrinsic- decreased vascularity of RC tendon
degenerative vascularity of RC tendon, critical zone of hypovascularity- 1cm medial to insertion of RC tendon, most degenerative RC tears occur in this zone
factors causing tendinopathy- intrinsic- deconditioned tendon
an under loaded tendon has no stimulus to build healthy tissue, will fail if suddenly over loaded, tendon becomes oedematous due to increased water content but not inflamed, absence of inflammatory cells
factors causing tendinopathy- intrinsic- joint side wear and tear
acromail side RC tendon fibres thicker and stronger, joint side fibres more vulnerable to tensile loads, lesions often found on joint side of tendon not acromial
factors causing tendinopathy- extrinsic-
mechanical irritation of contents of subacromial space due to compression by external factors
factors causing tendinopathy- extrinsic- sub acromial space
floor= humeral head, roof- inferior surface of acromion + a-c joint + coracoacromial ligament, contents= RC tendon + LHB + subacromial and sub deltoid bursa
factors causing tendinopathy- extrinsic- postural dysfunction
FHP, protracted shoulder girdle, kyphosis, scapula position
leads to alterations of force couples operating around shoulder and faulty movement
factors causing tendinopathy- extrinsic- muscle imbalance
weak/fatigued/ injured RC, results in loss of deltoid= RC force couple, allows superior migration of humeral head, leading to repetitive impingement of subacromial soft tissue, results in inflammation and RC disease
factors causing tendinopathy- extrinsic- impingement of RC tendons secondary to G/H instability
failure of static or dynamic stabilizers of GHJ allows excessive translation of HH
factors causing tendinopathy- extrinsic- bony abnormalities
shape of acromion= hook shape more likely to cause tendon compression, bony abnormalities, occupational/ environmental- anything that involves repetitive overhead manoeuvres
RC tendinopathy presentation- general
anterior shoulder/subacromial pain, painful arc, painful loss of shoulder function particularly on overhead activities
RC tendinopathy presentation- tendinitis
younger patient (<35 years), often have h/o overuse, strong and painful isometric ER and Abd, no loss of AROM/PROM, positive impingement test
RC tendinopathy presentation-tendinosis and tears
tendinosis- middle aged patient + h/o more activity than usual and loss of A/PROM and weak and painful isometric ER and abd
tears- >40 years, weak and painless isometric tests of ER and abd, atrophy of RC and deltoid muscle
RC tendinopathy- principles of treatment
acute management- pain releif (NSAIDs/ ice), improve strength and tissue capacity- exercise in 1 direction at a time, isometric>isotonic (less irritability), start slow, don’t exercise at EOR, add other movements
maintain muscle strength of all shoulders
Observations of A/PROM
PROM should be full, AROM will be painful/ isometric and special test= problems
RC treatment- tendon tear
dependent on size and location of tear, tears <3cm managed conservatively, surgery indicated for massive tears >3cms and those were conservative treatment is ineffective
what is GH instability
the patient is unable to control or stabilize the joint during motion or in a static position either because static restraints have been injured or because muscle controlling the joint are weak or the force couples are unbalanced
instability presentation- primary
pain around ant and lat shoulder, limited AROM, RHS rhythm, positive apprehension test, neural/vascular changes, wasting of deltoid/ RC
instability presentation- secondary (atraumatic)
full or excessive ROM, pain at EOR, clunking, sensation of coming out, altered sensation on overhead movements, loose/empty end feel, positive stress test
instability management- surgical
bankhart reconstruction- reattachment of antero-inferior labrum to glenoid margin, anterior inferior capsular shift- tighten anterior capsule and decrease available capsular volume
instability management- conservative
neuromuscular retraining, stretching/ mobs tight capsule/ rotator cuff, postural re-ed
