E3 - Shoulder Complex 3 -5 Flashcards
how do you treat tendinitis and tendinosis
pt education - load management
POLICED
how can NSAIDS affect healing of tendinitis and tendinosis
shout term pain relief if acute
delays healing if injury at insertion
poor response and no support in persistent presentation
why do NSAIDS not aid in healing during a persistent condition
tendon is structurally changing
the issue is not inflammation
how does bracing/taping/straps aid in treatment of tendinitis and tendinosis
decreases resistance arm
decreases stress on tendon
what is the soreness rule with ADLs and exercise
activities as long as the quality of movement is good and no symptoms during/after 24 hours
keep with the activity to give tendon load to maintain tendon response
what are the primary purposes of MET with tendinosis
tendon proliferation
what are the primary parameters of MET with tendinosis
implement after any acuity settles
heavy loads
slower eccentrics/3 sec muscle actions
what is the general rx of MET for tendinosis
2-3 sets of 10-15 reps to fatigue
2-3 exercises with involved tendon
8-12 weeks
what is the expected activity response of MET with tendinosis
mild-moderate increase in pain (5/10)
pain should ease to baseline levels before repeating exercises (24-48 hours)
my soreness rule
what are some complications that could delay healing in tendinosis
predisposition/prevalence of “failed healing response”
obesity
diabites
low grade inflammation
how does obesity affect tendinosis healing
excessive fat absorbes inflammaoryt cells away from tendon
how does diabetes affect tendinosis healing
excessive glucose impairs collagen production/remodeling
how does low grade inflammation affect healing with tendinosis
associated with systemic disease/poor diet
persistent inflammation limits proliferation/remodeling
what are MD rx’s for patients with tendinopathy
what is the rare intervention
cortisone injections for short-term benefits
glycerin trinitrate patches to increase circulation
surgical debridement
sclerosing injections - stiffens tendon for pain relief
t/f
MET is just/more beneficial than surgical debridement
true
what is surgical debridement and how is it intended to aid in tendon healing
surgeon scrapes tendon which increases blood flow leading to inflammatory response
how does scapular taping aid in impingement syndrome
improved short term pain
may provide an earlier “window” for MET and limit ADL provocation
no difference at 6 weeks
are modalities beneficial for patients with impingment syndrome
mostly not beneficial
are JM recommended for impingment syndrome
strong recommendation
GH joint
aids in regional interdependence
how does joint mobilities aid in the thoracic spine
accelerated recovery and reduced pain and disability immediately when compared to usual care
t/f
JMs added to exercise are more effective than exercise alone
true
is high-dose MET more beneficial than conventional low-dose exercise
what is low-dose exercise
yes
4-5 exercises for 3x10 reps
what time frame is MET beneficial for tendinosis
> 6 months of symptoms
what muscles in the shoulder are targeted with MET with tendinosis
cuff (SITS)
scapular exercises (MT/LT/Rhom/SA)
what is the PT rx regarding the HEP
HEP with supporting PT visits
not PT with supporting HEP
How many times per day should MET for tendinosis be performed
1-2x/day
what is the effect of MET after 3 months with tendinosis patients
70% improved pain/function
t/f
MET does not provide long-term benefits for impingement syndrome
fals
what are the results of subacromial decompression when compared to exercise alone
equally or no more effective and more expensive than exercise alone
what is the recommendation of subacromial decompression
should not be performed if atraumatic and present for more than 3 months (tendinosis)
what is regional interdependence
theory that impairment in one area of the body will contribute to an impairment in another
particularly persistent
what muscles act concentrically with overhead reaching
flexors
abductors
external rotators
what muscles act eccentrically with overhead reaching
extensors
adductors
internal rotators
what segment is most common cause of shoulder pain in regards to regional interdependence
C5-6
dysfunctional overhead reaching is due to what muscle group
excessively recruited internal rotators that share innervation from C6
inhibition and protective hypertonicity of external rotators
how does excessively recruited IRs by C5-6 affect GH movement
humeral head pulled anterior of coracoid process
creates excess tension and compression underneath LHB tendon that can lead to tendinopathy
how does inhibition and protective hypertonicity of external rotation affect GH motion
greater tubercle won’t efficiently move fully out from acromion
impingement of supraspinatus and LHB tendons that can lead to tendinopathy
how does C2-3 dysfunction affect overhead reaching
scapula elevated or elevation compensation
creates excess tension and compression on supraspinatus
what will occur if scapular depressors are inhibited
scapula won’t depress
impingement especially >150 degrees
supraspinatus and lHB tendons will impinge and can lead to tendinopathy
t/f
GH and AC joint will not compensate with hypermobility/instability to reach higher with overhead reaching
False
the GH and AC joints will compensate with hypermobility/instability with overhead reaching
in regard to the muscle, what can limit optimal motion
imbalances of position
muscle activity
can treating one area of the body (the spine) influence outcomes at another area that may seem unrelated
yes
what are the risk factors of rotator cuff tear
gradual/degernative (tendinosis)
repetitive overhead activities
what are the risk factors of acute rotator cuff tears
high UE velocity
heavy lifting
impact with fall on outstretched hand (FOOSH)
what structure is most commonly torn in rotator cuff tear
supraspinatus or infraspinatus
how are rotator cuff tears graded
size (S,M,L)
partial/full thickness tear
what is a SLAP tear
superior labral anterior/posterior tear
long head of biceps excessively contracts and tears labrum
what are common traumas that can cause rotator cuff tears
SLAP tear
compression onto labrum with FOOSH
what are the S&S of rotator cuff tears
worse impingement
increased pain with repetitive overhead activities
painful arc around 90 degrees elevation
resisted test - weak and painful
stress test - possibly positive
positive special test
what motions will most likely be weak and painful with rotator cuff
flexion
ABD/ER (supraspinatus)
IR (subscapularis)
if patient experiences pain with compression, what structures in the shoulder are most likely involved after a rotator cuff tear
labrum
What S&S indicate a rotator cuff tear
> 65 y.o.
weak ER
night pain
what S&S indicates a full-thickness tear
> /=60 y.o.
painful arc
drop arm
ER MMT
high/low specificity: drop arm
high specificity
indicates supraspinatus tear
what kind of tests are lift off, belly press, and bear hug
high specificity
tests subscapularis tears
what is the general PT Rx for rotator cuff tears
treat as worse case of hypermobility with tissue damage that has occurred
how does early ROM with degenerative tears affect RC recovery
accelerated recovery
limited tendon healing with large tears
what are the MET ultimate purposes for RC tear
stabilization
tissue proliferation of muscle, tendon, labrum
what is the biggest predictor of if a tear will go to surgery
patient’s negative perception
what is the prognosis of corticosteroid injections for RC tears
no evidence of effectiveness
only provides transient relief
what are primary arthroscopic procedures with arthroplasty
sewing fibers back together and reattaching to bone
full ROM under anesthesia
what is the prognosis of PT with degenerative tears
successful outcomes especially for those unfit for surgery or with small/partial tears
what is the prognosis of surgery for those with degenerative tears
good clinical outcome with pain, ROM, strength, quality of life, sleep
are radiological outcomes as good as clinical outcomes? why or why not?
no
clinical outcomes are better than imaging
structure does have to change to get better function
imaging can find things that have no symptoms
what is the impact of PT for acute small-medium tears
possibly can help
if not progressing well, delays associated with poor surgical outcomes
is surgery or PT more beneficial with small-medium tears?
surgery has no difference from PT
more critical in younger patients bc of high activity levels
what patients with multi-tendon/massive full-thickness tears would benefit from PT
low demand patients or those unfit for surgery
increased likelihood of tear progresssion and arthropathy
why is there an increased likelihood of tear progression and arthropathy with supra/infraspinatus tear
multitendon involvement
increased stress on surrounding tissues
__% satisfaction rate is consistent with surgery for multi-tendon/massive full-thickness tears
80%
joint replacement is mostly used for ____ tears
irreparable
what would classify an irreparable tear
2 ends of the tendon with full thickness tear
has no blood supply = dries and pulls apart
what is the new joint arthroplasty for a reverse total shoulder arthroplasty
concave on convex
describe the results of a reverse total shoulder arthroplasty
90% able to participate in sports without significant restriction
good-excellent results
what individuals have the best prognosis after surgery
younger male
high bone density
no diabetes/obesity
small/single tear
what type of impingement is frozen shoulder contraction syndrome
primary (hypomobile)
what are 3 examples of functional questionnaires for frozen shoulder contraction syndrome
DASH
ASES
SPADI
what are 2 other names for frozen shoulder contraction syndrome
adhesive capsulitis
frozen shoulder
t/f
frozen shoulder contraction syndrome is frequently misdiagnosed with any multi-directional limitation in ROM
true
what are the risk factors for frozen shoulder contraction syndrome
female
hypothyroidism
40-65
previous adhesive capsulitis
diabetes
family history
what are the primary causes of frozen shoulder contraction syndrome
pathology, autoimmune disease
what are the secondary causes of frozen shoulder contraction syndrome
concomitant injury
period of immobilization
what are the common structural changes of frozen shoulder contraction syndrome
inflammation of GH capsule and ligaments
reduced joint volume
what causes reduced joint volume
fluid loss cause structures to bunch up and capsule shrinks around it
what structures are involved with frozen shoulder contraction syndrome
GH capsule and ligaments
joint space
what symptoms are to be expected with frozen shoulder contraction syndrome
gradual and progressive pain
loss of motion
functional limitations with reaching, sleeping, basic ADLs
what is the capsular pattern of restriction with frozen shoulder contraction syndrome
ER > ABD > FLX > IR
what are the signs of frozen shoulder contraction syndrome
CM - consistent block
RST/MMT - possibly weak or painful depending on stage
Stress test - dstx possibly + depending on stage
Accessory motion - hypomobil e
Special tests - + for impingement
can you skip/avoid a stage with frozen shoulder contraction syndrome
no, each stage lasts an undetermined amount of time
describe stage 1/inital of frozen shoulder contraction syndrome
gradual onset
achy/sharp with use
unable to lie on side
high irritability
PROM > AROM
empty/painful end feel
describe stage 2/freezing frozen shoulder contraction syndrome
constant pain - worse at night
high irritability
moderate-severe limitations
PROM > AROM
empty and painful endfeel
describe stage 3/frozen of frozen shoulder contraction syndrome
stiffness is worse than pain
intermittent pain
moderate irritability
moderate-severe limitations with pain at end rage
PROM = AROM
firm end feel
describe stage 4/thawing of frozen shoulder contraction syndrome
minimal-no pain
low irritability
ROM gradually improves
firm end feel
t/f
early dx of frozen shoulder contraction syndrome is very difficult due to irritability
true
what are the PT rx for frozen shoulder contraction syndrome
POLICED
pt education of 4 courses
promote pain-free functional activity
match intensity of stretching/JM with S&S
what modalities are beneficial for frozen shoulder contraction syndrome
cryotherapy - additional benefit to JM, improved pain, ROM, function
LASER
what grade JM shows mixed benefits for pain/ROM in frozen shoulder contraction syndrome
grade 3-5
what is the focus of MET for frozen shoulder contraction syndrome
elasticity and mobility increases
offset disuse of inhibited muscles
____ approach is effective for most patients
multimodal
t/f
cortisone injections show short term benefits when added to therex and JMs with FSCS
true
t/f
capsular release is supported by RCTs
false
capsular release is not supported by RCTs
how long does stage 1 of FSCS last
~1-2 months
course of pain and mobility deficits may last 12-18 months
if left untreated, how long does FSCS take to resolve
12-42 months
what joint is the most commonly dislocated joint
GH
what direction is the GH joint most commonly dislocated
anterior
what is the mechanism of anterior GH dislocation
ER (anterior glide), ABD (inferior glide) with FOOSH
what type of shoulder impingement is dislocation considered
primary
what is the mechanism of posterior GH dislocation
90 degree flexion with FOOSH
why is shoulder dislocation recurrent
once tissue is stretched/torn it is most likely left laxed (mechanical instability)
typically younger people that use arm frequently
most likely results in surgery
what structures are involved with dislocation
stretch/tear capsule/ligament
anterior labrum tear
SLAP
describe fibrocartilage
thicker and concave than articular cartilage
outer portion is thick/inner portion is thin
widens and deepens joint surface
where is fibrocartilage located
shoulder and hip labrum
SC/AC
tibiofemoral, ulnotriquetral, intervertebral, pubic symphysis
describe the outer portion of collagen
primarily type 1 collagen
resists tension for stabilization
majority type in all fibrocartilage
describe the inner portion of collagen
secondarily and less type 2, 3, and 4 collagen
resistes compression for shock absorption
t/f
stabilized structures are highly neural
true
allows for proprioception/kinesthesia like ligament/annulus for stabilization
describe the outer portion of fibrocartilage
vascular and neural tissue
describe the inner portion of fibrocartilage
hypo or avascular
aneural
alymphatic
describe fibrocartilage healing
better at periphery d/t greater vascularity
when does tensile strength initially impove
3-5 weeks
greater strength when dense fibrous tissue fills in @ 8-12 weeks
what are the MET focus for fibrocartilage
tissue integrity/proliferation with vascularity issues
stabilization
what other structures could possibly be injured during GH dislocation
RC tear
neurovasular structures
what symptoms are common with GH dislocation
trauma in characteristic position
acute presentation
what signs are common with GH dislocation
ROM - limited/painful most directions
RST/MMT - weak/painful in most directions
ST - likely + depending on structures involved
what is hill sachs lesion
compression fracture of humeral head
what is the PT rx for immobilization after dislocation
up to 6 weeks
improve rotator cuff activation with contralateral UE use (uninjured side) and ipsilateral hand squeezing activities (injured side)
immobilization for shorter periods after dislocation favors
muscle integrity
proprioception
peripheral and central neural activity
dynamic stability
what are the MET focuses for dislocation
stabilization
tissue integrity and proliferation
with anterior dislocation, what motions are initially contraindicated for MET
what motions are beneficial to exercise
ER, FLX, ABD ROM are initially contra-indicated
IR, EXT, ADD initially beneficial
what MET exercises are initially beneficial with dislocation
isometrics and isotonics
recurrent dislocations highly likely if < ___ years of age
30
what is a coracoid transfer
reposition coracoid process and coracobrachialis and short biceps head to GH neck
what is capsular shift/capsuloraphy
most common
overlap of torn portions of capsular folds
what age group most commonly experience proximal humeral fractures
elderly
what is the cause of most proximal humeral fractures
FOOSH
what structures are involved with proximal humeral fractures
surgical humeral neck
what are complications of proximal humeral fracture
axillary artery damage
adhesive capsulitis from prolonged immobilization
what are the symptoms of axillary artery damage
coldness and blanching
emergency referral
possible avascular necrosis
what is the cause of clavicular fracture
compression mechanism through long axis of clavicle
fall on lateral side of shoulder
where is the clavicular fracture located
weak spot at S curve
most likely snaps in middle
what complications can occur with clavicular fracture
large displacement may require surgery
epiphyseal plate injury - last bone to ossify @ 18-25 years
what test can be used to determine if there is a fracture in the shoulder
olecranon-manubrium percussion test
when does PT begin after a fracture
clinical union occurs between 4-8 weeks
pain is not typically from bone
What is the focus of PT following a fracture
consequences of prolonged immobilization where every tissue is negatively influenced
what is proximal humeral apophysitis
little league shoulder
most common in male adolescents
mostly overhead throwers/racquet sports
what is the cause of proximal humeral apophysitis or little league shoulder
growth with high activity
high activity on changing structure (growth plate)
what are the structural changes that are common with PHA
bone growth exceeds rotator cuff lengthening
increased tendon tension
growth plate is weak spot
most often inflammation
what are complications associated with PHA
avulsion (pulling/tearing away)
premature closure - very rare
what are the symptoms associated with proximal humeral apophysitis
gradual onset of shoulder pain with oversue
“pop” can indicate trauma/avulsion
what signs indicate PHA
impingment like
asymmetry ER weakness compared to IR
special tests - + impingement test
what is the most common sign of PHA
Palpation - TTP over antero-/posterolateral aspect of proximal humerus
what is included with pt education with PHA
soreness rule
load management
movement cues
what is the treatment of PHA
pt education
POLICED
throwing mechanics
what should be avoided with treatment of PHA
prolonged stretching d/t vulnerability of growth plate
what is the treatment of PHA
normalize motion
MET
return to play
what is the focus of MET for PHA
cuff, trunk, LE impairments
caution with muscle/tendons attached to growth plate
what is the prognosis of PHA
most return to preinjury levels at 2 months, possibly 2-8 months
~4-5 months to return to competition with an avulsion
can become recurrent/persistent problem
at what age does the growth plate typically close
16-20 years
