Exam 2: UE + Hip Flashcards
What are the 4 joints at the shoulder?
-Sternoclavicular
-Acromioclavicular
-Glenohumeral
-Scapulothoracic
How much of the humeral head is in contact with the glenoid?
-25% humeral head in contact with glenoid
-75% in contact with labrum
What is the most commonly dislocated joint in the body? Why?
-GHJ
-It lacks bony stability
What is the GHJ composed of?
-Fibrous capsule
-Ligaments
-Surrounding muscles
-Glenoid labrum
What muscles form part of the capsule?
-The rotator cuff
-Supraspinatus
-Infraspinatus
-Subscapularis
-Teres minor
What is joint approximation and what is it typically used for?
-Compression of a joint surface
-Used to promote reflexive stability, often used with weight bearing activities
-Thought to stimulate type 1 receptors and facilitate postural stabilizers
What is joint centration achieved by?
Achieved by the combined neuro-motor tasks of:
-Stabilization
-Dissociation
What is the self perpetuating pattern of movement dysfunction?
Any stressor to the nervous system, including acute and repetitive trauma, emotional stress, can up-regulate the sympathetic nervous system and pain which alter movement strategies that further increase dysfunction
What are local vs global muscles?
-Local: involved in joint stabilization; oxidative
-Global: movers; aerobic
Which of the rotator cuff muscles is the only one that pulls the humeral head posteriorly? Why?
Subscapularis, because internal rotation causes a posterior glide of the humerus
What is closed pack position of the GHJ?
90 degrees of abduction and full ER
What is open pack position of the GHJ?
55 degrees abduction, 30 degrees horizontal adduction
What is the capsular pattern of the GHJ?
-ER
-Abduction
-IR
What are special questions for the shoulder that a PT should ask the patient?
-Feeling of instability
-Popping, catching, painful popping
-Tingling
-Night time awakening
-Trouble lifting, reaching, etc.
What does night time awakening suggest for the shoulder?
Internal derangement
What are common causes of shoulder injuries?
-Traumatic
-Sports
-Overuse
-Insidious onset
What are the 3 types of Kibler classification for scapular dyskinesis?
-Type 1: inferior medial border
-Type 2: Medial border off ribs
-Type 3: elevated superior border
What is Kibler Type 1 scapular dyskinesis? What muscles are tight? Which are weak?
-Inferior medial border more prominent
-Anterior tilt of scapula
-Coracoid process often TTP
-Tight: pec minor, biceps SH
-Weak: lower trap, lats, serratus anterior
What is Kibler Type 2 scapular dyskinesis? What muscles are tight? Which are weak?
-Entire medial border off ribs
-Points glenoid fossa anteriorly
-Weak serratus anterior and lower traps
What is Kibler Type 3 scapular dyskinesis? What muscles are tight? Which are weak?
-Superior border of the scapula is elevated
-Usually with adhesive capsulitis
-Tight: upper trap
-Weak: lower trap
What level of the spine is the acromion at?
C7
What level of the spine is the medial portion of the spine of the scapula at?
T3
What level of the spine is the inferior border of the scapula at?
T7
What are common causes of shoulder pain that do not originate from the shoulder joint?
-C-spine nerve impingement
-Peripheral nerve entrapment
-Diaphragm irritation
-Intrathoracic tumors
-Gallbladder problems
-Myocardial ischemia
-Pancoast tumor
What are common shoulder orthopedic conditions?
-Acromioclavicular joint separation
-Adhesive capsulitis
-Biceps tendonitis
-Glenohumeral joint instability
-Glenohumeral joint OA
-Impingement syndrome
-Rotator cuff tear
-SLAP lesion
-Thoracic outlet syndrome
What is the mechanism of injury of acromioclavicular joint separation? What patient population is it more likely in?
-Commonly occurs in men and younger people
-Usually caused by a traumatic event such as FOOSH or direct blow to the anterior shoulder that results in AC joint ligament tears
-4-5x more prevalent than SC injuries
What are the 6 types of AC joint separation?
-Type I: AC joint ligaments are partially or completely disrupted
-Type II: AC joint ligaments are torn and coracoclavicular ligaments are partially disrupted
-Type III: coracoclavicular ligaments are completely disrupted
-Types IV-VI: uncommon; periosteum of the clavicle or deltoid/trap muscle are also torn
What are the subjective findings for AC joint separation?
-Relief reported with cradling the involved arm
-Localized pain over the AC joint
-Pain when lifting the arm
What are the objective findings for AC joint separation?
-Patient supports the arm in adducted position
-Swelling at the ACJ
-Pain is consistently aggravated by passively horizontally adducting arm
-+ cross body test
-+ AC resisted extension test
What are the interventions for ACJ injury?
-Acute: protection and rest
-Sub-acute: strengthening of surrounding muscles
What is frozen shoulder? What are the two types?
-Adhesive capsulitis of the shoulder
-Characterized by progressive and painful loss of active and passive ROM that follows capsular patterns
-Primary: idiopathic
-Secondary: traumatic or related to a disease process
What are the subjective findings of frozen shoulder?
-Diffuse aching at the shoulder
-Difficulty sleeping on the involved side
-Difficulty dressing and grooming
What are the objective findings of frozen shoulder?
-Insidious onset of severe shoulder pain
-Shoulder stiffness with markedly reduced external rotation
-Negative radiographic findings
-Varies according to stage
-Inability to elevate shoulder
-ER, abduction, IR limited
-Restriction of anterior and inferior glide of the GHJ
-Negative neuro tests
-Pain at end range of shoulder motions
What are the stages of adhesive capsulitis? How long does each stage last?
-Prefreezing: 1-3 months
-Freezing: 3-9 months
-Thawing: 9-14 months
What are possible interventions for frozen shoulder?
-Patient education
-NSAIDs
-Steroid injection
-PT: ROM, joint mobilizations, pain management
What is the prognosis of frozen shoulder?
18 months to 3 years- some patients may never get back to their PLOF
What are three pathological disorders that can cause biceps tendonitis?
-Inflammatory/degenerative conditions
-Instability of the biceps tendon such as subluxation or dislocation of the tendon
-SLAP (superior labrum anterior or posterior) lesion
What is the mechanism of injury for biceps tendinopathy and SLAP lesions?
-FOOSH
-Traction mechanism: eccentric firing of the biceps muscle that causes injury to the superior labrum complex
-Peel-back: the arm is abducted and maximally externally rotated and the twisting of the biceps tendon may result in the “peel-back” of the anchor and its subsequent gradual or acute detachment from the superior glenoid
What are the subjective findings of biceps tendonitis?
-Diffuse and vague pain in the anterior shoulder or over the bicipital groove
-Painful AROM of shoulder flexion
What are the objective findings of biceps tendonitis?
-Tenderness over bicipital groove
-Possible loss of shoulder ROM
-May have painful arc
-Pain with resisted elbow flexion
-+ speeds test
-+ Yergason test
What are possible interventions for biceps tendonitis?
-Acute phase: pain and inflammation management
-Subacute phase: AROM exercises and early strengthening
-Phase 3: strengthening with emphasis on enhancing dynamic stability
-Phase 4: return to sport or high workloads
What are the different types of glenohumeral joint instability? Which is the most common?
-Anterior inferior
-Multidirectional
-Posterior
-Inferior
What is TUBS?
-Instability caused by a Traumatic event, is Unidirectional, associated with a Bankart lesion, often requires Surgery
-TUBS= traumatic, unidirectional, bankart, surgery
What is AMBRI?
-Atraumatic, Multidirectional, may be Bilateral, best treated by Rehabilitation, Inferior capsular shift is the surgery performed if rehab fails
-AMBRI= atraumatic, multidirectional, bilateral, rehabilitation, Inferior capsular shift surgery
What is the most common type of shoulder dislocation?
Anterior
What are the subjective findings of glenohumeral joint instability?
-Complaints of looseness of the shoulder or a “noisy” shoulder
-May or may not have a history of trauma
-Patients with anterior instability typically describe the sensation of the shoulder slipping out of joint when the arm is abducted and ER
-Tend to support arm in neutral position
-Patients with multidirectional instability may have vague symptoms, but tend to be activity related
What are the objective findings of glenohumeral joint instability?
-+ Sulcus sign
-Variable degrees of crepitation or popping
-Apprehension in extreme ROM such as IR and ER
-Generalized ligamentous laxity
-+ apprehension test
-+ surprise test
-+ posterior instability tests (Jerk)
What are possible interventions for glenohumeral joint instability?
-Rotator cuff strengthening
-Shoulder stability exercises
What is OA in the shoulder typically a result of?
Usually a long term consequence of trauma such as dislocation, fx, large RC tears
What are the subjective findings of shoulder OA?
-Gradual onset, deep-seated shoulder pain and stiffness
-Worst pain is typically in the posterior aspect
-Progressive loss of ROM
-Hx of trauma to the shoulder
What are the objective findings of shoulder OA?
-Forward humeral head, protracted scapula
-GH joint line tenderness
-Swelling around the joint
-Decreased active and passive ROM
-Crepitation with circumduction may or may not be present
-Radiographs will show joint space narrowing
-May have pseudolaxity
What are possible interventions for shoulder OA?
-Improve GHJ flexibility
-RC strengthening
What is subacromial pain syndrome (SAPS)?
-Mechanical impingement of the rotator cuff between the coracoacromial arch and the humeral head
-Anything that decreases the volume of this space can cause impingement
-Hypertrophy of the AC joint secondary to OA can also cause impingement
What are the 3 different types of acromions? Which is most likely to cause SAPS?
-Type 1: flat 17% of people
-Type 2: curved 43% of people
-Type 3: hooked 40% of people
What are the contents of the coracoacromial tunnel?
-Supraspinatus tendon
-Long head of biceps tendon
-Subacromial/subdeltoid bursa
-Coracohumeral ligament
What is subacromial decompression (SAD) and distal clavicular resection (DCR) surgery?
It is where the surgeons shave down part of the clavicle that can be causing impingement as well as some of the subacromial arch
What are the subjective findings of SAPS?
-Pain felt down the lateral aspect of the upper arm near the deltoid insertion, over the anterior proximal humerus, or in the periacromial area
-Functional loss of the shoulder attributable to pain, stiffness, weakness, and catching, especially when the arm is in flexion and IR
-Difficulty sleeping on the involved side
-Pain provoked by everyday activities such as putting on a coat, pouring coffee, etc.
What is stage I SAPS?
-Tenderness at supraspinatus insertion and anterior acromion
-Painful arc
-Weakness at 90 degrees abduction and flexion
What is stage II SAPS?
Physical exam reveals crepitus or catching at 100 degrees of elevation and restriction of PROM
What is stage III SAPS?
-Atrophy of the infraspinatus and supraspinatus
-More limitation in AROM than PROM compared to the other stages
What are the possible interventions for SAPS?
-Strengthen RC
-IR and ER isometrics initially
-Address strength deficits
What is a rotator cuff tear?
-Can be acute/traumatic or chronic/degenerative
-Described by size, location, direction, and depth
-Tears are usually longitudinal
-Occur in critical zone (avascular) situated at the anterior portion of the cuff within the subacromial space between the supraspinatus tendon and coracohumeral ligament
-Uncommon before age 40 unless associated with trauma
What are the subjective findings of a rotator cuff tear?
-Significant weakness and pain with activities that involved abduction and ER
-Localized pain over the upper back, deltoid, shoulder, and arm
-A popping sensation may be present
What are the grades of rotator cuff tears?
-Small: < 1cm
-Medium: 1-3 cm
-Large: 3-5 cm
-Massive: > 5cm
What are the objective findings of rotator cuff tears?
-May reveal muscle asymmetry or atrophy
-Pain located at the greater tuberosity
-Loss of PROM and AROM
-+ special tests
-Weakness
-Massive tears present with sudden profound weakness
What are the diagnostic tools for rotator cuff tear?
-Special tests: drop arm, empty can, lift off test, ER lag sign
-Medical imaging
What are possible interventions for rotator cuff tears?
-Small or partial tears: intervention is directed toward strengthening the rotator cuff and scapular stabilizers
-Full thickness tears usually require surgery followed by PT
What is the criteria for operative interventions for rotator cuff tears?
-Patient younger than 60 years old
-Failure to improve after conservative regimen of at least 6 weeks
-Presence of a full thickness tear, either clinically or by imaging
-Patient’s need to use the involved shoulder in a vocation or an avocation
-Ability or willingness of the patients
What are the rotator cuff repair options? Which option leads to better tendon healing?
-Single row, double row, suture bridge, or transosseous repairs are all commonly performed
-Double row tends to repair more of the tissue back to the humeral insertion point which has led to better tendon healing
What are possible post-operative rotator cuff repair complications? How can these be avoided?
-Re-tear rates range anywhere between 25-70% of the time
-Those that do fail or re-tear do so within the first 3-6 months
-Avoiding early motion protects the surgical site
What percent muscle activation level must a post-operative RCR patient stay below?
Below 15% for 6 weeks post-op
What should be the protocol for the first 2 weeks following RCR?
Strict immobilization for 2 weeks, such as a sling
What is the strength of a RCR at 6 weeks post-op? What about at 12 weeks?
Only about 19-30% strength of normal and 29-50% at 12 weeks
When can AAROM be performed post RCR?
7 weeks
What is a SLAP lesion?
-Superior labral anterior posterior (SLAP) lesion
-Involve an injury to the superior glenoid labrum and the biceps
-Several injury mechanisms speculated- range from single traumatic to repeptitive microtraumatic injuries
What is the mechanism of injury of a SLAP lesion?
Typically results from FOOSH, sudden deceleration or traction forces such as catching a falling object, or chronic anterior or posterior instability
What are the subjective findings of SLAP lesions?
-History of trauma or overuse
-Complaints of pain and/or instability with overhead activities and symptoms of painful clicking, catching, or locking
What are the objective findings for a SLAP lesion?
-Symptoms very similar to those of instability and rotator cuff tears
-Positive findings of pain or clicking with maneuvers that place tensile or torsional load on the biceps, thereby stressing the loose anchor of the biceps-superior labrum complex
What are confirmatory special tests for SLAP lesions?
-O’Brien’s active compression
-Compression rotation test
-Crank test
-Biceps load II (or I)
-Kim test
-Jerk test
What are possible interventions for SLAP lesions?
-Conservative interventions should address the underlying hypermobility
-Dynamic stabilization exercises of GHJ
What is the prognosis for SLAP lesions?
-If conservative management fails, diagnostic arthroscopy is recommended
-Studies of surgical labral repairs are generally good to excellent in terms of returning patients to their prior level of activity
What is thoracic outlet syndrome (TOS)?
-Clinical syndrome characterized by symptoms attributable to compression of the neural or vascular anatomic structures (brachial plexus, subclavian artery or vein) that passes through the thoracic outlet
-Bony boundaries of the thoracic outlet include the clavicle, first rib, and scapula
What patient population is TOS more common in?
More common in women with onset of symptoms between 20-50 years old
What are the subjective findings of TOS?
-Symptoms are often vague and variable, chief complaint is diffsue arm and shoulder pain especially above 90 degrees of elevation
-Potential symptoms include pain localized in the neck, face, UE, chest, shoulder, and axilla
-Could have UE paresthesias, numbness, weakness, heaviness, fatigability, swelling
-Neural compression symptoms occur more frequently
What are the objective findings of TOS?
-Swelling or discoloration of the arm
-Auscultation may reveal the presence of bruits (abnormal sound/murmur) especially when doing provocative measures during special tests
-Difference in distal pulses compared to opposite side
-+ special tests
What trunk of the brachial plexus is most commonly effected by TOS? What specific symptoms would this cause?
-Lower trunk, which is made up of C8 and T1 nerve roots
-Supplies sensation to 4th and 5th digits, so there may be symptoms in those fingers
What are confirmatory special tests for TOS?
-Adson vascular test
-Allen pectolaris minor test
-Costoclavicular test
-Roos test
-Hyperabduction maneuver
-Passive shoulder shrug
What are possible interventions for TOS?
-Correction of postural abnormalities of the neck and shoulder girdle
-Pec minor release/stretches
-Strengthening of scapular muscles
-1st and 2nd rib mobilizations
What is the prognosis for TOS patients?
50-90% of patients with TOS respond rapidly to conservative interventions and regain normal, pain-free function of the UE
What is the criteria for surgical interventions for TOS?
-Failure to respond to conservative intervention within 4 months
-Signs of muscle atrophy
-Intermittent paresthesias being replaced by sensory loss
-Pain becoming incapacitating
What are the most common surgical interventions for TOS?
-Depression of the scalene muscles and resetting of the 1st rib
-Removal of the cervical rib (if present)
-Removal of the clavicle
-Severing of the pec minor
-Transection of the subclavius muscle above the coracoid ligament
What are the upward rotators of the scapula?
-Upper trap
-Serratus anterior
-Lower trap
What are the downward rotators of the scapula?
-Rhomboids
-Levator scapulae
-Pectoralis minor
What are the 3 articulations at the elbow?
-Humeroradial
-Humeroulnar
-Proximal radioulnar
What is the open and closed pack positions of the humeroulnar joint?
-Open: 70 degrees of flexion and 10 degrees of supination
-Closed: maximum extension and supination
What is the capsular pattern of the humeroulnar joint?
-Flexion > extension
What is the open and closed pack positions of the humeroradial joint?
-Open: extension and supination
-Closed: 90 degrees of flexion and 5 degrees of supination
What is the capsular pattern of the humeroradial joint?
There is none
What is the open and closed pack positions of the proximal radioulnar joint?
-Open: 70 degrees of flexion and 35 degrees of supination
-Closed: 5 degrees of supination
What is the carrying angle of the elbow? What is the normal carrying angle?
-The angle between the humerus and ulna
-10-15 degrees
What is the normal end feel of the humeroulnar joint?
-Flexion: soft tissue
-Extension: bony
What is the normal end feel of the radioulnar joint?
-Supination: capsular
-Pronation: bony
What are the major ligament of the elbow? What motions do they restrict?
-Ulnar collateral ligament (UCL): resists valgus stress
-Radial collateral ligament: resists varus stress
-Annular ligament: supports radial head
What are the 2 bands of the UCL? Which band is more important? When is each band taut?
-Anterior and posterior bands
-Anterior band is more important as it resists valgus stress
-Anterior band: taut from 0-70 degrees of flexion
-Posterior band: taut between 60-120 degrees of flexion
How much stability does the radial collateral ligaments provide to the lateral elbow?
-RCL provides 30-50% stability
-Boney structures provide the other 50-70% of stability
What is the “4th” joint of the elbow?
The interosseous membrane between the ulna and radisu
What is the most common diagnosis for lateral elbow pain?
Lateral epicondylalgia
What is the most common diagnosis for medial elbow pain?
-Medial epicondylalgia
-UCL sprain
-Ulnar nerve compression
What is the most common diagnosis for posterior elbow pain?
-Olecranon bursitis
-Triceps tendinosis
-Valgus extension overload (VEO)
What is the most common diagnosis for cubital fossa elbow pain?
-Tear of the brachialis
-Biceps brachii tear
What are common orthopedic conditions of the elbow?
-OA
-Fracture of the radial head
-Olecranon bursitis
-Biceps tendon rupture
-Triceps tendon rupture
-Lateral epicondylalgia
-Medial epicondylaglia
-UCL tear
-“Little league elbow”
What patient population is elbow OA most common in?
Most common in men ages 40-60 with a history of strenuous work, throwing sports, or trauma
What are the subjective findings of elbow OA?
-Pain, stiffness
-Mechanical locking
-Deformity
What are the subjective findings of elbow RA?
Pain and swelling
What are the subjective findings for septic arthritis of the elbow?
-Acute and severe pain, stiffness, and warmth
-Swelling
-Effusion
-Fever, chills, malaise
What is septic arthritis?
A painful joint infection that occurs when bacteria, viruses, or fungi invade a joint’s tissues and fluid
What are the objective findings for elbow RA?
-Joint swelling
-Rheumatoid nodules over the olecranon and extensor surface of the forearm
-Tenderness
-Joint instability
What are the objective findings of elbow OA?
-Joint line tenderness
-Reduced ROM
What are the objective findings of septic arthritis of the elbow?
Severely painful and restricted ROM in the presence of significant effusion and warmth
What are possible interventions for OA of the elbow?
-Rest
-NSAIDs
-Gentle stretching
-Activity modification
What are possible interventions for RA of the elbow?
-Intra-articular corticosteroid injection
-PT
-Splints
What is the primary indication for total elbow arthroplasty?
-Patients with RA with advanced joint destruction and severe limitations
-Patients with OA with severe limitations and/or pain
What is the mechanism of injury for a fracture of the radial head?
-Usually from a FOOSH
-Force of impact transmitted up the hand through the wrist and forearm to the radial head
What are the 4 types of radial head fractures?
-Type I: non-displaced or minimally displaced fx
-Type II: displaced more than 2 mm at the articular surface
-Type III: severely comminuted (bunch of pieces) fx of the radial head and neck
-Type IV: associated with ulnohumeral dislocation
What are the subjective findings of a radial head fracture?
-Complaints of pain and swelling over the lateral aspect of the elbow
-Loss of elbow motion related to pain inhibition and joint diffusion
What are the objective findings of a fracture of the radial head?
-Palpate carefully and feel for deformity at radial head
-Assess neurovascular function for all nerves of the forearm and hand
-Tender over the lateral aspect of the elbow joint
-Passive forearm pronation/supination is typically limited and may have palpable crepitus
-AROM and PROM with flexion and extension may be limited
What are confirmatory tests for radial head fracture?
-Patient history and physical exam findings
-Radiographs
What are possible interventions for type I radial head fx?
-Sling or splint initially
-Early AROM as soon as pain allows
-Strengthening begins at 3 weeks
What is the rule of 3’s for type II radial head fx?
-Non-surgical is considered if the fx involves less than 1/3 of the articular surface
-Less than 30 degrees of angulation
-Displacement is less than 3mm
What are the possible interventions for type III radial head fx?
-Surgical excision of bone fragments or internal fixation
-Rehab after fixation usually lasts 12 weeks
-Do NOT begin AAROM pronation/supination until week 6
What is olecranon bursitis?
-Inflammation of the bursa located between the olecranon process of the ulna and the overlying skin
-Easily bruised through direct trauma or irritated through repetitive weight bearing
What patient population is olecranon bursitis most common in?
-Students and wrestlers
-Athletes who play basketball, football, indoor soccer, and hockey in which the potential for falling and striking an elbow on hard playing surfaces is high
What are the subjective findings of olecranon bursitis?
-Complaints of pain and swelling that can be gradual as in chronic cases or sudden acute injury
-Patients often note decreased ROM or an inability to don a long-sleeved shirt
What are the objective findings of olecranon bursitis?
Swelling over the olecranon process that can vary in size from a slight distention to a mass as large as 6cm
What is a sign of infection with olecranon bursitis?
Redness and heat
What are confirmatory special tests for olecranon bursitis?
-Lab eval of the bursal aspirate
-Aspiration also helps reduce the level of discomfort and restriction of movement
-Cell count, gram stain, and crystal analysis to differentiate between traumatic, infection, or gout
What are possible interventions for olecranon bursitis?
-RICE
-Early motion
-Infected bursa needs prompt medical attention
What is the mechanism of injury of a biceps tendon rupture?
Involve a sudden contraction of the biceps against a significant load with the elbow in 90 degrees of flexion
What population is biceps tendon ruptures most common in?
Most commonly occurs in muscular males in their 50’s
What is the subjective findings of biceps tendon ruptures?
-Sharp, tearing pain concurrent with an acute injury
-Patient often describes loss of strength in activities involving elbow flexion and supination
What are the objective findings of biceps tendon rupture?
-Ecchymosis in antecubital fossa
-Visible deformity (full rupture)
-Loss of strength in elbow flexion
-Loss of forearm supination strength
What are the possible treatment options for biceps tendon rupture?
-Most active individuals have a repair
-If older, they usually do not repair it
What is the mechanism of injury of a triceps tendon rupture?
Occurs when a deceleration force occurs during elbow extension or with an uncoordinated contraction of the triceps muscle against the flexing elbow
What are the objective findings of a triceps tendon rupture?
Commonly has loss of elbow extension strength and an inability to extend overhead against gravity
What are possible treatment options for triceps tendon rupture?
-Surgical repair indicated with complete rupture
-Partial tear can be treated conservatively with immobilization for 3 weeks then gradual progression of ROM and strength
What is lateral epicondylalgia?
-Pathological condition of the common extensor muscles at their origin on the lateral humeral epicondyle
-Specifically involves the tendons that control wrist extension and radial deviation resulting in pain on the lateral side of the elbow
-Affects between 1-3% of the population
What population is lateral epicondylalgia most common in?
-Occurs most commonly between the ages of 35-50
-Seldom seen in those less than 20 y.o.
-Usually effects the dominant arm
What is the mechanism of injury of lateral epicondylalgia?
-Repetitive grasping with wrist extension
-Participants of tennis, baseball, racquetball, etc.
Which tendon is the most commonly effected in lateral epicondylalgia?
Extensor carpi radialis brevis
How can you differentiate between extensor carpi radialis brevis and longus when someone has lateral epicondylalgia?
-Resisted wrist extension with elbow flexed and then with the elbow straight
-ECRB will hurt the same with both
-ECRL will hurt more with elbow straight
What is a grade 1 lateral epicondylalgia?
-Injury probably inflammatory
-Not associated with pathologic alterations
-Likely to resolve
What is a grade 2 lateral epicondylalgia?
-Injury associated with pathologic alterations such as tendinosis or angiofibroblastic degeneration
-This stage most commonly associated with sports related overuse injuries
-Within the tendon, there is fibroblastic and vascular response (tendinosis) rather than an inflammatory response
What is a grade 3 lateral epicondylalgia?
Injury is associated with pathologic changes and complete structural failure (partial tears)
What is a grade 4 lateral epicondylalgia?
-Macroscopic tears
-Associated with other changes such as fibrosis, matrix calcification, and hard osseous calcification
-May be related to use of cortisone
What are the subjective findings of lateral epicondylalgia?
-Complaints of diffuse achiness and morning stiffness of the elbow
-Reports of localized tenderness over the lateral aspect of the elbow
What are the objective findings of lateral epicondylalgia?
-Tenderness usually over the ECRB and ECRL
-AROM usually painless
-PROM into wrist flexion with forearm pronated and elbow extended can be painful
-Resisted tests typically reproduce symptoms especially wrist extension and radial deviation
What are the 5 types of tendon lesions for lateral epicondylalgia?
-Type 1: lesion at origin of ECRL
-Type 2: insertion of ECRB
-Type 3: pain at the radial head
-Type 4: ECRB muscle belly strain
-Type 5: inflammation at the origin of the extensor digitorum
What are the confirmatory special tests for lateral epicondylalgia?
-Cozen’s
-Mill’s
-Maudley’s
What are possible interventions for lateral epicondylalgia?
-Wrist strengthening
-Radial head mobs
-Brace?
-Corticosteroid injections
-Manual therapy
What percent of patients with lateral epicondylalgia improve within a year?
80%
What is medial epicondylalgia?
-Tendinopathy at the attachment of the flexor or pronator muscles at the medial humeral epicondyle
-Mechanism related to overuse
How common is medial epicondylalgia compared to lateral epicondylalgia?
Only 1/3 as common as lateral epicondylalgia
Which tendon is most commonly affected with medial epicondylalgia?
Pronator teres
What are the subjective findings of medial epicondylalgia?
-Complaints of pain along the medial elbow
-History of unaccustomed repetitive lifting, tooling, hammering, or sports activities involving tight gripping
-Reports of increased pain with active wrist flexion and pronation
What are the objective findings of medial epicondylalgia?
-TTP about 5 mm distal to medial epicondyle
-Pain elicited on resisted wrist flexion and pronation
-Pain at extremes of passive wrist extension, supination, and ulnar deviation
What are possible interventions for medial epicondylalgia?
-Conservative intervention has 90% success rate
-Initially rest and activity modification
-Restore ROM, strength, and flexibility after acute phase
-Strengthening program progresses to include concentric and eccentric
How do you know when to progress exercises with medial epicondylalgia?
-When no pain at rest, start more intense stretching
-When no pain with stretching, start resistance training
What is the mechanism of injury of an ulnar collateral (medial) ligament tear?
-Chronic attenuation of valgus and ER forces
-FOOSH
-Baseball throwing, football throwing, tennis serve, etc.
What structure is also commonly injured with a UCL tear?
-Irritation of the ulnar nerve
-Symptoms of ulnar neuritis may be present
What are the subjective findings of UCL tear?
Complaints of medial elbow pain at the ligaments origin or insertion
What are the objective findings of UCL tear?
-Tenderness with palpation along UCL
-Tenderness over the ulnar nerve and a + Tinel sign
-Possible loss of terminal elbow extension
-+ valgus stress test
-MRI
What are possible interventions of UCL tear?
-Early symptoms of UCL injury include rest and activity modification for 2-4 weeks
-Strengthening and stretching
-Initial emphasis on isometrics
When is surgery indicated for UCL tears?
-Competitive throwing athletes
-Pt’s involved in heavy manual labor
What is little league elbow? What patient population does it occur in?
-Apophysitis of the medial epicondyle or injury to the UCL
-Osteochondritis dissecans of the capitulum
-8-15 year olds
What are the subjective findings of little league elbow?
-Medial elbow pain
-Decreased throwing effectiveness and distance
-Swelling
-Occasional flexion contractures
What is used to diagnose little league elbow?
-MRI
-Radiographs
-Physical exam
What is the mechanism of injury of little league elbow?
-During cocking and acceleration phase of pitching
-Valgus stress
-Shearing forces in the posterior elbow
-Compression along the lateral elbow
What is median nerve entrapment?
-Entrapment of the median nerve from the pronator teres muscle
-Also know as pronator teres syndrome
What is the subjective findings of pronator teres syndrome?
-Insidious pain felt on the anterior aspect of the elbow, radial side of the palm, and the palmar side of the 1st, 2nd, and 3rd digits
What are the objective findings of pronator teres syndrome?
-Pressure over the pronator teres 4cm distal to cubital crease with concurrent resistance against pronation, elbow flexion, and wrist flexion
-Pain with resisted pronation
-Pain with resistance of the long finger flexors
-+ pronator teres syndrome test
What are the possible interventions for pronator teres syndrome?
-Responds well to activity modification
-Rest, NSAIDs, ice
-Restore flexibility and strength of wrist flexors and forearm pronators
-Manual techniques to break up adhesions
What is the pattern of the trabeculae in the proximal femur?
-Horizontal and vertical patterns that cross over each other
-There is a zone of weakness where there is no trabeculae in the inferior portion of the neck of the femur
What is the capsular pattern of the hip?
-Flexion
-Abduction
-Medial rotation
How many bones make up the hip joint?
-4 bones
-Pubis
-Ilium
-Ischium
-Femur
How many Newton pounds does it take to dislocate the hip?
400
What is the vascularity of the femoral head?
-Ligamentum teres (1/3 supply)
-Circumflex artery
-Superior & inferior gluteal arteries
What is the labrum?
Fibrocatilaginous tissue that increases the joint congruency and stability
What are the 4 major ligaments of the hip?
-Anterior iliofemoral “Y” ligament
-Pubofemoral
-Posterior ischiofemoral
-Ligamentum teres
What motions does the ligamentum teres restrict?
At 90 degrees of hip flexion it limits IR & ER
What are the flexors of the hip?
-Iliacus
-Psoas
-TFL
-Rectus femoris
-Sartorius
-Adductor longus
-Pectineus
What are the extensors of the hip?
-Glute max
-Hamstrings
-Adductor magnus
What are the abductors of the hip?
-Glute med
-TFL
-Superior glute max
-Glute min
What are the adductors of the hip?
-Adductor group
-Gracilis
-Pectineus
What are the medial rotators of the hip?
-No pure rotator
-TFL
-Glute minimus
-Glute medius anterior fibers
-Adductor group
-Semimembranosus/tendinosis
What are the lateral rotators of the hip?
-Obturator internus/externus
-Gemelli
-Quadratus femoris
-Piriformis
-Glute max
-Posterior fibers of glute med
-Biceps femoris
What is normal hip extension ROM?
10-15 degrees
What is normal hip abduction ROM?
30-50 degrees
What is normal hip adduction ROM?
25-30 degrees
What is normal hip external rotation ROM?
40-60 degrees
What is normal hip internal rotation ROM?
30-40 degrees
What is the normal angle between the femoral neck and shaft?
125 degrees
What is coxa vara?
-Decreased angle between the femoral neck and shaft
-105 degrees
-More horizontal
What is coxa valga?
-Increased angle between the femoral neck and shaft
-140 degrees
-More vertical
Does coxa vara or valga put someone at higher risk of fx?
Coxa vara because now there is an increased load on the neck of the femur
What complications can occur from having coxa valga?
-Increased stress across joint surfaces due to more vertical femoral neck
-Increases overall length of LE
-Decrease physiologic angle at knee
-More likely to get FAI
What complications can occur from having coxa vara?
-Results in increased downward shear forces of the femoral head
-Reduces compressive forces but increase shear and torsional forces at the femoral head/neck junction
-More likely to fx
What is femoral anteversion?
-Increased anterior angle between neck and shaft of femur in the transverse plane
-Anterior orientation of the femoral neck
-Results in more hip IR
What is femoral retroversion?
-Increased posterior angle between neck and shaft of femur in the transverse plane
-Results in more hip ER
-Out toeing gait
What are common orthopedic conditions of the hip?
-Avascular necrosis of the femoral head
-Legg-Calve Perthes Disease
-Slipped capital femoral epiphysis (SCFE)
-Stress fracture of the femoral neck
-Hamstring strain
-Hip adductor tendinopathy
-OA of the hip
-Snapping hip
-Trochanteric bursitis
-Hip labral tears
What occurs during avascular necrosis of the femoral head?
Variable areas of dead trabecular bone and bone marrow extending to and including the subchondral plate
What are the subjective findings of avascular necrosis of the femoral head?
-Pain in the groin, can radiate to the lateral hip, knee, or buttocks
-“Throbbing and deep”
-Most often pain is intermittent and gradual onset
-Antalgic shift
What are common risk factors for avascular necrosis of the femoral head?
-Cumulative corticosteroid total dose
-Alcohol use
-Systemic lupus
-Sickle cell disease
-Trauma
-Cancer
What are objective findings for avascular necrosis of the femoral head?
-Usually painful ROM, especially IR
-Patients have pain with attempted SLR
-Antalgic gait
What is used to diagnose avascular necrosis?
Imaging
What interventions are available for avascular necrosis?
Surgery
What is the prognosis for avascular necrosis of the femoral head?
-Success is related to the stage at which care is initiated
-Complication of AVN include incomplete fx and superimposed degenerative arthritis
What is Legg-Calve-Perthes Disease?
-Idiopathic osteonecrosis of the femoral head in kids aged 4-10 years
-Children are usually malformed with less blood
-The speculated cause is localized manifestation of generalized disorder of the epiphyseal cartilage in the proximal femur
-Unilateral in 90% of patients
Who is at higher risk of Legg-Calve-Perthes disease?
4x more common in boys
What are subjective findings in Legg-Calve-Perthes?
-Vague ache in the groin that radiates to the medial thigh and inner aspect of the knee
-Muscle spasm
What are objective findings of Legg-Calve-Perthes?
-Limp
-Dragging of the leg
-Atrophy of thigh muscles
-Child may be small for their age
-Positive trendelenburg
-Out-toeing of the involved LE
-Decreased abduction and IR
-May be a hip flexion contracture
What is used to diagnose Legg-Calve-Perthes?
-Imaging
-AP and frog-lateral radiographs of the pelvis
What are interventions for Legg-Calve-Perthes?
-For children less than 6 years old and minimal capital femoral epiphysis and normal ROM, physical exams and radiographs every 2 months
-More severe cases would likely be treated with surgery
What is slipped capital femoral epiphysis (SCFE)?
-Displacement of the femoral head through the epiphysis that typically occurs during the adolescent growth spurt
-Femoral head remains in acetabulum and neck is displaced anteriorly
-Most common disorder of the hip in adolescents
What are the subjective findings for slipped capital femoral epiphysis (SCFE)?
-Pain exacerbated by activity
-Hx of groin pain or medial thigh pain
-May be mild weakness in the leg
-May be no hx of trauma, can be as minimal as turning over in bed
What are the objective findings for slipped capital femoral epiphysis (SCFE)?
-Limp
-Decreased ROM
-The involved extremity may be 1-3 cm shorter
What is the only pediatric disorder that causes greater loss of IR when hip is moved into a flexed position?
Slipped capital femoral epiphysis (SCFE)
What are risk factors for slipped capital femoral epiphysis (SCFE)?
-Obesity
-Male
-Greater involvement with sports activities
What is used to diagnose slipped capital femoral epiphysis (SCFE)?
-Radiographs
-IR with hip flexed to 90 degrees
What are interventions for slipped capital femoral epiphysis (SCFE)?
-Relief of symptoms
-Containment of the femoral head
-Restoration of ROM
-Surgical fixation
What is the mechanism of injury for a stress fracture of the femoral neck?
-Results from accelerated bone remodeling in response to repeated stress
-Occurs commonly in military recruits and athletes, especially runners
Where does a stress fracture of the femoral neck typically occur in older people? What about in younger people?
-Older: superior side of the femoral neck
-Younger: inferior side of the femoral neck
What are subjective findings of stress fractures of the femoral neck?
-Onset of hip pain, often associated with recent change in training or change in training surface
-Pain in the deep thigh
-Pain usually occurs with weight bearing or at the extremes of hip motion
What are the objective findings of stress fractures of the femoral neck?
-Physical exam usually negative
-May be empty end feel or pain at end ranges of IR & ER
What special tests can help diagnose stress fractures of the femoral neck?
-Resisted straight leg raise + for pain
-Auscultory patellar-pubic test +
-Fulcrum test + for pain
-Radiographs
What are interventions for stress fractures of the femoral neck?
-Surgically for all tension-side fx
-Bed rest or complete NWB
What is a hamstring strain?
-Strain or rupture of 1 or more HS muscles
-Usually takes place during eccentric loading
What are the key subjective findings for a HS strain?
-Distinct mechanism of injury w/ immediate pain during full stride running or while decelerating quickly
-May hear a “pop”
-Posterior thigh pain, worsened with knee flexion
What are objective findings for a HS strain?
-TTP
-Tenderness reported with passive stretching
-Pain with resisted knee flexion
What are rehab timelines for the 3 grades of HS strain?
-Grade I: continue activities
-Grade II: 5-21 days
-Grade III: 3-12 weeks
What is the most common adductor pathology?
Hip adductor tendinopathy
What is the most common cause of groin pain?
Adductor strain or tendinopathy
What is the mechanism of injury for hip adductor tendinopathy?
-Constant exposure to repetitive loading with activities that involve twisting and turning
-Other theory is muscular imbalance of the combined action of the muscles stabilizing the hip joint
What are the subjective findings for adductor tendinopathy?
-Twinging or stabbing pain in the groin area with quick starts and stops
-Edema or ecchymosis
-Symptoms are aggravated with running, especially directional changes, kicking, SL exercises, cutting, and lunges
What are the objective findings for adductor tendinopathy? What degree of hip flexion targets which muscles?
-Pain with passive abduction
-Pain with resistance
-TTP
-0 degrees: gracilis
-45 degrees: add. longus
-90 degrees: pectineus
What are interventions for adductor tendinopathy?
-RICE in acute stage
-Hip adductor isometrics
-Graded resistive program
What is the prognosis for adductor tendinopathy?
Most patients fully recover fully or only have minimal pain with high intensity activities
What are subjective findings with hip OA?
-Insidious onset of pain
-Progressively worsens with activity
-Painful, limping gait
-Physical activity may induce bouts of pain that last several hours
-May have difficulty climbing stairs & putting on socks
What are objective findings for hip OA?
-Early signs include restriction of IR, abduction, or flexion and pain at end range
-Scour +
-FABER may be +
What are interventions for hip OA?
-Relieving symptoms, reduce risk of progression
-Education
-Modalities
-Swimming or cycling
-Reduction in BW
-Walking stick
-Joint mobs
-Stretches
-Hip strengthening
What is snapping hip?
-Characterized by a snapping or popping sensation that occurs as tendons around the hip move over bony prominences
-Internal: iliopsoas snapping over structures deep to it
-External: snapping of ITB pr glute max over greater trochanter
-Intra-articular: synovial chondromatosis, loose bodies, fracture fragments, and labral tears
What are subjective findings of snapping hip?
-Complaints of snapping or popping localized to greater trochanter
-Snapping cause by subluxation of the iliopsoas tendon
-May be complaints of pain associated with the snapping if the trochanteric bursitis is inflammed
What are objective findings for snapping hip?
-IT band can be felt subluxing
-Snapping of the iliopsoas tendon may be palpated
-Obers may be +
-Thomas may be +
What are interventions for snapping hip?
-Improve muscle length
-Correct strength imbalances
What is the prognosis for snapping hip?
Responds well to conservative management
What are the subjective findings with trochanteric bursitis?
-Lateral thigh, groin, or gluteal pain
-Pain when lying on involved side
-Pain usually worse when rising from a seated or recumbent position
What are objective findings of trochanteric bursitis?
-TTP
-Pain will get much worse with STM
-Resisted abd, ER, or ext painful
-Tightness of hip adductors
-Obers test +
What are interventions for trochanteric bursitis?
-Stretching lateral thigh soft tissues
-Flexibility of ER
-Hip abd strengthening
-Establishing muscular balance
-Orthotics
What is the prognosis for trochanteric bursitis?
-Responds well to conservative measures
-Corticosteroid injection may help
What is the etiology of hip labral tears?
-Trauma
-FAI
-Capsular laxity or hip hypermobility
-Dysplasia
-Degeneration
-Often goes undiagnosed for extended periods of time
What are the subjective findings of labral tears?
-Anterior hip or groin pain
-Often mechanical symptoms of clicking, locking, or giving way
What are the objective findings of hip labral tears?
-FADIR +
-Anterior or posterior labral tear tests +
What are interventions for hip labral tears?
-PT/conservative management: limit pivoting motions, strengthen inhibited muscles, assess foot motion
-Arthroscopic debridement of tear
What is femoral acetabular impingement (FAI)?
-Abnormal bony prominences on the neck of the femur or acetabular rim due to contact between the femoral head-neck junction and the acetabular rim
-Impingement occurs with combined movements, usually flexion and IR or ER
-Prolonged impingement can lead to damage to the labrum and subchondral bone
What is FAI a precursor to?
OA and labral tears
What can PTs do to manage FAI?
-Restore mobility and function
-Decrease pain
-Correct muscular imbalances
-Avoid surgery
What is the prevalence of FAI?
-More common in 20-40 y.o.
-Athletes make up 15% of reported FAI cases
-Sport with repetitive end range hyperextension or hyperflexion combined with abduction at an increased risk for labral tears
What are the two types of FAI?
-CAM
-Pincer
What is CAM FAI?
-Aspherical femoral head
-Bony prominence at anterolateral head-neck junction
-Impinges on the rim of the labrum
-Leads to superior OA
-More common in young athletic males
-FADIR +
What is pincer FAI?
-Over-coverage of femoral head by the acetabulum which impinges on the neck of the femur
-Leads to posterior inferior or central OA
-Middle aged females more common
-Hip extension + ER will be painful
What percent of patients with FAI have both CAM and pincer impingement?
86%
What are common symptoms with FAI and/or labral tears?
-Anterior groin pain
-The C sign
-Described as dull and aching
-Pain is worse with prolonged sitting
-Occasional sharp catching pain with activity
-Increase symptoms with flexion, adduction, and internal rotation
-May limp
What activities should patients with FAI avoid?
-End range flexion, adduction, and internal rotation
-Treadmill running as it encourages internal rotation
-Upright cycling
-Sitting with hips flexed and neutral spine for long periods of time
What surgical options are there for FAI and/or labral tears?
-Arthroscopic repair
-Trimming of bony rim
-Severe cases may require open operation with larger incision
