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PHTH 517: Orthopedic Management I > Exam 2: UE + Hip > Flashcards

Exam 2: UE + Hip Flashcards

1
Q

What are the 4 joints at the shoulder?

A

-Sternoclavicular
-Acromioclavicular
-Glenohumeral
-Scapulothoracic

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2
Q

How much of the humeral head is in contact with the glenoid?

A

-25% humeral head in contact with glenoid
-75% in contact with labrum

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3
Q

What is the most commonly dislocated joint in the body? Why?

A

-GHJ
-It lacks bony stability

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4
Q

What is the GHJ composed of?

A

-Fibrous capsule
-Ligaments
-Surrounding muscles
-Glenoid labrum

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5
Q

What muscles form part of the capsule?

A

-The rotator cuff
-Supraspinatus
-Infraspinatus
-Subscapularis
-Teres minor

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6
Q

What is joint approximation and what is it typically used for?

A

-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

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7
Q

What is joint centration achieved by?

A

Achieved by the combined neuro-motor tasks of:
-Stabilization
-Dissociation

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8
Q

What is the self perpetuating pattern of movement dysfunction?

A

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

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9
Q

What are local vs global muscles?

A

-Local: involved in joint stabilization; oxidative
-Global: movers; aerobic

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10
Q

Which of the rotator cuff muscles is the only one that pulls the humeral head posteriorly? Why?

A

Subscapularis, because internal rotation causes a posterior glide of the humerus

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11
Q

What is closed pack position of the GHJ?

A

90 degrees of abduction and full ER

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12
Q

What is open pack position of the GHJ?

A

55 degrees abduction, 30 degrees horizontal adduction

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13
Q

What is the capsular pattern of the GHJ?

A

-ER
-Abduction
-IR

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14
Q

What are special questions for the shoulder that a PT should ask the patient?

A

-Feeling of instability
-Popping, catching, painful popping
-Tingling
-Night time awakening
-Trouble lifting, reaching, etc.

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15
Q

What does night time awakening suggest for the shoulder?

A

Internal derangement

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16
Q

What are common causes of shoulder injuries?

A

-Traumatic
-Sports
-Overuse
-Insidious onset

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17
Q

What are the 3 types of Kibler classification for scapular dyskinesis?

A

-Type 1: inferior medial border
-Type 2: Medial border off ribs
-Type 3: elevated superior border

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18
Q

What is Kibler Type 1 scapular dyskinesis? What muscles are tight? Which are weak?

A

-Inferior medial border more prominent
-Anterior tilt of scapula
-Coracoid process often TTP
-Tight: pec minor, biceps SH
-Weak: lower trap, lats, serratus anterior

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19
Q

What is Kibler Type 2 scapular dyskinesis? What muscles are tight? Which are weak?

A

-Entire medial border off ribs
-Points glenoid fossa anteriorly
-Weak serratus anterior and lower traps

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20
Q

What is Kibler Type 3 scapular dyskinesis? What muscles are tight? Which are weak?

A

-Superior border of the scapula is elevated
-Usually with adhesive capsulitis
-Tight: upper trap
-Weak: lower trap

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21
Q

What level of the spine is the acromion at?

A

C7

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22
Q

What level of the spine is the medial portion of the spine of the scapula at?

A

T3

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23
Q

What level of the spine is the inferior border of the scapula at?

A

T7

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24
Q

What are common causes of shoulder pain that do not originate from the shoulder joint?

A

-C-spine nerve impingement
-Peripheral nerve entrapment
-Diaphragm irritation
-Intrathoracic tumors
-Gallbladder problems
-Myocardial ischemia
-Pancoast tumor

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25
Q

What are common shoulder orthopedic conditions?

A

-Acromioclavicular joint separation
-Adhesive capsulitis
-Biceps tendonitis
-Glenohumeral joint instability
-Glenohumeral joint OA
-Impingement syndrome
-Rotator cuff tear
-SLAP lesion
-Thoracic outlet syndrome

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26
Q

What is the mechanism of injury of acromioclavicular joint separation? What patient population is it more likely in?

A

-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

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27
Q

What are the 6 types of AC joint separation?

A

-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

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28
Q

What are the subjective findings for AC joint separation?

A

-Relief reported with cradling the involved arm
-Localized pain over the AC joint
-Pain when lifting the arm

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29
Q

What are the objective findings for AC joint separation?

A

-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

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30
Q

What are the interventions for ACJ injury?

A

-Acute: protection and rest
-Sub-acute: strengthening of surrounding muscles

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31
Q

What is frozen shoulder? What are the two types?

A

-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

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32
Q

What are the subjective findings of frozen shoulder?

A

-Diffuse aching at the shoulder
-Difficulty sleeping on the involved side
-Difficulty dressing and grooming

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33
Q

What are the objective findings of frozen shoulder?

A

-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

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34
Q

What are the stages of adhesive capsulitis? How long does each stage last?

A

-Prefreezing: 1-3 months
-Freezing: 3-9 months
-Thawing: 9-14 months

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35
Q

What are possible interventions for frozen shoulder?

A

-Patient education
-NSAIDs
-Steroid injection
-PT: ROM, joint mobilizations, pain management

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36
Q

What is the prognosis of frozen shoulder?

A

18 months to 3 years- some patients may never get back to their PLOF

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37
Q

What are three pathological disorders that can cause biceps tendonitis?

A

-Inflammatory/degenerative conditions
-Instability of the biceps tendon such as subluxation or dislocation of the tendon
-SLAP (superior labrum anterior or posterior) lesion

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38
Q

What is the mechanism of injury for biceps tendinopathy and SLAP lesions?

A

-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

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39
Q

What are the subjective findings of biceps tendonitis?

A

-Diffuse and vague pain in the anterior shoulder or over the bicipital groove
-Painful AROM of shoulder flexion

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40
Q

What are the objective findings of biceps tendonitis?

A

-Tenderness over bicipital groove
-Possible loss of shoulder ROM
-May have painful arc
-Pain with resisted elbow flexion
-+ speeds test
-+ Yergason test

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41
Q

What are possible interventions for biceps tendonitis?

A

-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

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42
Q

What are the different types of glenohumeral joint instability? Which is the most common?

A

-Anterior inferior
-Multidirectional
-Posterior
-Inferior

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43
Q

What is TUBS?

A

-Instability caused by a Traumatic event, is Unidirectional, associated with a Bankart lesion, often requires Surgery
-TUBS= traumatic, unidirectional, bankart, surgery

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44
Q

What is AMBRI?

A

-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

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45
Q

What is the most common type of shoulder dislocation?

A

Anterior

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46
Q

What are the subjective findings of glenohumeral joint instability?

A

-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

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47
Q

What are the objective findings of glenohumeral joint instability?

A

-+ 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)

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48
Q

What are possible interventions for glenohumeral joint instability?

A

-Rotator cuff strengthening
-Shoulder stability exercises

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49
Q

What is OA in the shoulder typically a result of?

A

Usually a long term consequence of trauma such as dislocation, fx, large RC tears

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50
Q

What are the subjective findings of shoulder OA?

A

-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

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51
Q

What are the objective findings of shoulder OA?

A

-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

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52
Q

What are possible interventions for shoulder OA?

A

-Improve GHJ flexibility
-RC strengthening

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53
Q

What is subacromial pain syndrome (SAPS)?

A

-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

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54
Q

What are the 3 different types of acromions? Which is most likely to cause SAPS?

A

-Type 1: flat 17% of people
-Type 2: curved 43% of people
-Type 3: hooked 40% of people

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55
Q

What are the contents of the coracoacromial tunnel?

A

-Supraspinatus tendon
-Long head of biceps tendon
-Subacromial/subdeltoid bursa
-Coracohumeral ligament

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56
Q

What is subacromial decompression (SAD) and distal clavicular resection (DCR) surgery?

A

It is where the surgeons shave down part of the clavicle that can be causing impingement as well as some of the subacromial arch

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57
Q

What are the subjective findings of SAPS?

A

-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.

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58
Q

What is stage I SAPS?

A

-Tenderness at supraspinatus insertion and anterior acromion
-Painful arc
-Weakness at 90 degrees abduction and flexion

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59
Q

What is stage II SAPS?

A

Physical exam reveals crepitus or catching at 100 degrees of elevation and restriction of PROM

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60
Q

What is stage III SAPS?

A

-Atrophy of the infraspinatus and supraspinatus
-More limitation in AROM than PROM compared to the other stages

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61
Q

What are the possible interventions for SAPS?

A

-Strengthen RC
-IR and ER isometrics initially
-Address strength deficits

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62
Q

What is a rotator cuff tear?

A

-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

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63
Q

What are the subjective findings of a rotator cuff tear?

A

-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

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64
Q

What are the grades of rotator cuff tears?

A

-Small: < 1cm
-Medium: 1-3 cm
-Large: 3-5 cm
-Massive: > 5cm

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65
Q

What are the objective findings of rotator cuff tears?

A

-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

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66
Q

What are the diagnostic tools for rotator cuff tear?

A

-Special tests: drop arm, empty can, lift off test, ER lag sign
-Medical imaging

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67
Q

What are possible interventions for rotator cuff tears?

A

-Small or partial tears: intervention is directed toward strengthening the rotator cuff and scapular stabilizers
-Full thickness tears usually require surgery followed by PT

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68
Q

What is the criteria for operative interventions for rotator cuff tears?

A

-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

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69
Q

What are the rotator cuff repair options? Which option leads to better tendon healing?

A

-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

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70
Q

What are possible post-operative rotator cuff repair complications? How can these be avoided?

A

-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

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71
Q

What percent muscle activation level must a post-operative RCR patient stay below?

A

Below 15% for 6 weeks post-op

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72
Q

What should be the protocol for the first 2 weeks following RCR?

A

Strict immobilization for 2 weeks, such as a sling

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73
Q

What is the strength of a RCR at 6 weeks post-op? What about at 12 weeks?

A

Only about 19-30% strength of normal and 29-50% at 12 weeks

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74
Q

When can AAROM be performed post RCR?

A

7 weeks

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75
Q

What is a SLAP lesion?

A

-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

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76
Q

What is the mechanism of injury of a SLAP lesion?

A

Typically results from FOOSH, sudden deceleration or traction forces such as catching a falling object, or chronic anterior or posterior instability

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77
Q

What are the subjective findings of SLAP lesions?

A

-History of trauma or overuse
-Complaints of pain and/or instability with overhead activities and symptoms of painful clicking, catching, or locking

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78
Q

What are the objective findings for a SLAP lesion?

A

-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

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79
Q

What are confirmatory special tests for SLAP lesions?

A

-O’Brien’s active compression
-Compression rotation test
-Crank test
-Biceps load II (or I)
-Kim test
-Jerk test

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80
Q

What are possible interventions for SLAP lesions?

A

-Conservative interventions should address the underlying hypermobility
-Dynamic stabilization exercises of GHJ

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81
Q

What is the prognosis for SLAP lesions?

A

-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

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82
Q

What is thoracic outlet syndrome (TOS)?

A

-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

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83
Q

What patient population is TOS more common in?

A

More common in women with onset of symptoms between 20-50 years old

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84
Q

What are the subjective findings of TOS?

A

-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

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85
Q

What are the objective findings of TOS?

A

-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

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86
Q

What trunk of the brachial plexus is most commonly effected by TOS? What specific symptoms would this cause?

A

-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

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87
Q

What are confirmatory special tests for TOS?

A

-Adson vascular test
-Allen pectolaris minor test
-Costoclavicular test
-Roos test
-Hyperabduction maneuver
-Passive shoulder shrug

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88
Q

What are possible interventions for TOS?

A

-Correction of postural abnormalities of the neck and shoulder girdle
-Pec minor release/stretches
-Strengthening of scapular muscles
-1st and 2nd rib mobilizations

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89
Q

What is the prognosis for TOS patients?

A

50-90% of patients with TOS respond rapidly to conservative interventions and regain normal, pain-free function of the UE

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90
Q

What is the criteria for surgical interventions for TOS?

A

-Failure to respond to conservative intervention within 4 months
-Signs of muscle atrophy
-Intermittent paresthesias being replaced by sensory loss
-Pain becoming incapacitating

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91
Q

What are the most common surgical interventions for TOS?

A

-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

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92
Q

What are the upward rotators of the scapula?

A

-Upper trap
-Serratus anterior
-Lower trap

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93
Q

What are the downward rotators of the scapula?

A

-Rhomboids
-Levator scapulae
-Pectoralis minor

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94
Q

What are the 3 articulations at the elbow?

A

-Humeroradial
-Humeroulnar
-Proximal radioulnar

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95
Q

What is the open and closed pack positions of the humeroulnar joint?

A

-Open: 70 degrees of flexion and 10 degrees of supination
-Closed: maximum extension and supination

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96
Q

What is the capsular pattern of the humeroulnar joint?

A

-Flexion > extension

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97
Q

What is the open and closed pack positions of the humeroradial joint?

A

-Open: extension and supination
-Closed: 90 degrees of elxion and 5 degrees of supination

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98
Q

What is the capsular pattern of the humeroradial joint?

A

There is none

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99
Q

What is the open and closed pack positions of the proximal radioulnar joint?

A

-Open: 70 degrees of flexion and 35 degrees of supination
-Closed: 5 degrees of supination

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100
Q

What is the carrying angle of the elbow? What is the normal carrying angle?

A

-The angle between the humerus and ulna
-10-15 degrees

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101
Q

What is the normal end feel of the humeroulnar joint?

A

-Flexion: soft tissue
-Extension: bony

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102
Q

What is the normal end feel of the radioulnar joint?

A

-Supination: capsular
-Pronation: bony

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103
Q

What are the major ligament of the elbow? What motions do they restrict?

A

-Ulnar collateral ligament (UCL): resists valgus stress
-Radial collateral ligament: resists varus stress
-Annular ligament: supports radial head

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104
Q

What are the 2 bands of the UCL? Which band is more important? When is each band taut?

A

-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

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105
Q

How much stability does the radial collateral ligaments provide to the lateral elbow?

A

-RCL provides 30-50% stability
-Boney structures provide the other 50-70% of stability

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106
Q

What is the “4th” joint of the elbow?

A

The interosseous membrane between the ulna and radisu

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107
Q

What is the most common diagnosis for lateral elbow pain?

A

Lateral epicondylalgia

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108
Q

What is the most common diagnosis for medial elbow pain?

A

-Medial epicondylalgia
-UCL sprain
-Ulnar nerve compression

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109
Q

What is the most common diagnosis for posterior elbow pain?

A

-Olecranon bursitis
-Triceps tendinosis
-Valgus extension overload (VEO)

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110
Q

What is the most common diagnosis for cubital fossa elbow pain?

A

-Tear of the brachialis
-Biceps brachii tear

111
Q

What are common orthopedic conditions of the elbow?

A

-OA
-Fracture of the radial head
-Olecranon bursitis
-Biceps tendon rupture
-Triceps tendon rupture
-Lateral epicondylalgia
-Medial epicondylaglia
-UCL tear
-“Little league elbow”

112
Q

What patient population is elbow OA most common in?

A

Most common in men ages 40-60 with a history of strenuous work, throwing sports, or trauma

113
Q

What are the subjective findings of elbow OA?

A

-Pain, stiffness
-Mechanical locking
-Deformity

114
Q

What are the subjective findings of elbow RA?

A

Pain and swelling

115
Q

What are the subjective findings for septic arthritis of the elbow?

A

-Acute and severe pain, stiffness, and warmth
-Swelling
-Effusion
-Fever, chills, malaise

116
Q

What is septic arthritis?

A

A painful joint infection that occurs when bacteria, viruses, or fungi invade a joint’s tissues and fluid

117
Q

What are the objective findings for elbow RA?

A

-Joint swelling
-Rheumatoid nodules over the olecranon and extensor surface of the forearm
-Tenderness
-Joint instability

118
Q

What are the objective findings of elbow OA?

A

-Joint line tenderness
-Reduced ROM

119
Q

What are the objective findings of septic arthritis of the elbow?

A

Severely painful and restricted ROM in the presence of significant effusion and warmth

120
Q

What are possible interventions for OA of the elbow?

A

-Rest
-NSAIDs
-Gentle stretching
-Activity modification

121
Q

What are possible interventions for RA of the elbow?

A

-Intra-articular corticosteroid injection
-PT
-Splints

122
Q

What is the primary indication for total elbow arthroplasty?

A

-Patients with RA with advanced joint destruction and severe limitations
-Patients with OA with severe limitations and/or pain

123
Q

What is the mechanism of injury for a fracture of the radial head?

A

-Usually from a FOOSH
-Force of impact transmitted up the hand through the wrist and forearm to the radial head

124
Q

What are the 4 types of radial head fractures?

A

-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

125
Q

What are the subjective findings of a radial head fracture?

A

-Complaints of pain and swelling over the lateral aspect of the elbow
-Loss of elbow motion related to pain inhibition and joint diffusion

126
Q

What are the objective findings of a fracture of the radial head?

A

-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

127
Q

What are confirmatory tests for radial head fracture?

A

-Patient history and physical exam findings
-Radiographs

128
Q

What are possible interventions for type I radial head fx?

A

-Sling or splint initially
-Early AROM as soon as pain allows
-Strengthening begins at 3 weeks

129
Q

What is the rule of 3’s for type II radial head fx?

A

-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

130
Q

What are the possible interventions for type III radial head fx?

A

-Surgical excision of bone fragments or internal fixation
-Rehab after fixation usually lasts 12 weeks
-Do NOT begin AAROM pronation/supination until week 6

131
Q

What is olecranon bursitis?

A

-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

132
Q

What patient population is olecranon bursitis most common in?

A

-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

133
Q

What are the subjective findings of olecranon bursitis?

A

-Complaints of pain and swelling that can be gradual as in chronic cases or sudden acute injury
-Patients often note decreased ROM or an ability to don a long-sleeved shirt

134
Q

What are the objective findings of olecranon bursitis?

A

Swelling over the olecranon process that can vary in size from a slight distention to a mass as large as 6cm

135
Q

What is a sign of infection with olecranon bursitis?

A

Redness and heat

136
Q

What are confirmatory special tests for olecranon bursitis?

A

-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

137
Q

What are possible interventions for olecranon bursitis?

A

-RICE
-Early motion
-Infected bursa needs prompt medical attention

138
Q

What is the mechanism of injury of a biceps tendon rupture?

A

Involve a sudden contraction of the biceps against a significant load with the elbow in 90 degrees of flexion

139
Q

What population is biceps tendon ruptures most common in?

A

Most commonly occurs in muscular males in their 50’s

140
Q

What is the subjective findings of biceps tendon ruptures?

A

-Sharp, tearing pain concurrent with an acute injury
-Patient often describes loss of strength in activities involving elbow flexion and supination

141
Q

What are the objective findings of biceps tendon rupture?

A

-Ecchymosis in antecubital fossa
-Visible deformity (full rupture)
-Loss of strength in elbow flexion
-Loss of forearm supination strength

142
Q

What are the possible treatment options for biceps tendon rupture?

A

-Most active individuals have a repair
-If older, they usually do not repair it

143
Q

What is the mechanism of injury of a triceps tendon rupture?

A

Occurs when a deceleration force occurs during elbow extension or with an uncoordinated contraction of the triceps muscle against the flexing elbow

144
Q

What are the objective findings of a triceps tendon rupture?

A

Commonly has loss of elbow extension strength and an inability to extend overhead against gravity

145
Q

What are possible treatment options for triceps tendon rupture?

A

-Surgical repair indicated with complete rupture
-Partial tear can be treated conservatively with immobilization for 3 weeks then gradual progression of ROM and strength

146
Q

What is lateral epicondylalgia?

A

-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

147
Q

What population is lateral epicondylalgia most common in?

A

-Occurs most commonly between the ages of 35-50
-Seldom seen in those less than 20 y.o.
-Usually effects the dominant arm

148
Q

What is the mechanism of injury of lateral epicondylalgia?

A

-Repetitive grasping with wrist extension
-Participants of tennis, baseball, racquetball, etc.

149
Q

Which tendon is the most commonly effected in lateral epicondylalgia?

A

Extensor carpi radialis brevis

150
Q

How can you differentiate between extensor carpi radialis brevis and longus when someone has lateral epicondylalgia?

A

-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

151
Q

What is a grade 1 lateral epicondylalgia?

A

-Injury probably inflammatory
-Not associated with pathologic alterations
-Likely to resolve

152
Q

What is a grade 2 lateral epicondylalgia?

A

-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

153
Q

What is a grade 3 lateral epicondylalgia?

A

Injury is associated with pathologic changes and complete structural failure (partial tears)

154
Q

What is a grade 4 lateral epicondylalgia?

A

-Macroscopic tears
-Associated with other changes such as fibrosis, matrix calcification, and hard osseous calcification
-May be related to use of cortisone

155
Q

What are the subjective findings of lateral epicondylalgia?

A

-Complaints of diffuse achiness and morning stiffness of the elbow
-Reports of localized tenderness over the lateral aspect of the elbow

156
Q

What are the objective findings of lateral epicondylalgia?

A

-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

157
Q

What are the 5 types of tendon lesions for lateral epicondylalgia?

A

-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

158
Q

What are the confirmatory special tests for lateral epicondylalgia?

A

-Cozen’s
-Mill’s
-Maudley’s

159
Q

What are possible interventions for lateral epicondylalgia?

A

-Wrist strengthening
-Radial head mobs
-Brace?
-Corticosteroid injections
-Manual therapy

160
Q

What percent of patients with lateral epicondylalgia improve within a year?

A

80%

161
Q

What is medial epicondylalgia?

A

Tendinopathy at the attachment of the flexor or pronator muscles at the medial humeral epicondyle
-Mechanism related to overuse

162
Q

How common is medial epicondylalgia compared to lateral epicondylalgia?

A

Only 1/3 as common as lateral epicondylalgia

163
Q

Which tendon is most commonly affected with medial epicondylalgia?

A

Pronator teres

164
Q

What are the subjective findings of medial epicondylalgia?

A

-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

165
Q

What are the objective findings of medial epicondylalgia?

A

-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

166
Q

What are possible interventions for medial epicondylalgia?

A

-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

167
Q

How do you know when to progress exercises with medial epicondylalgia?

A

-When no pain at rest, start more intense stretching
-When no pain with stretching, start resistance training

168
Q

What is the mechanism of injury of an ulnar collateral (medial) ligament tear?

A

-Chronic attenuation of valgus and ER forces
-FOOSH
-Baseball throwing, football throwing, tennis serve, etc.

169
Q

What structure is also commonly injured with a UCL tear?

A

-Irritation of the ulnar nerve
-Symptoms of ulnar neuritis may be present

170
Q

What are the subjective findings of UCL tear?

A

Complaints of medial elbow pain at the ligaments origin or insertion

171
Q

What are the objective findings of UCL tear?

A

-Tenderness with palpation along UCL
-Tenderness over the ulnar nerve and a + Tinel sign
-Possible loss of terminal elbow extension
-+ valgus stress test
-MRI

172
Q

What are possible interventions of UCL tear?

A

-Early symptoms of UCL injury include rest and activity modification for 2-4 weeks
-Strengthening and stretching
-Initial emphasis on isometrics

173
Q

When is surgery indicated for UCL tears?

A

-Competitive throwing athletes
-Pt’s involved in heavy manual labor

174
Q

What is little league elbow? What patient population does it occur in?

A

-Apophysitis of the medial epicondyle or injury to the UCL
-Osteochondritis dissecans of the capitulum
-8-15 year olds

175
Q

What are the subjective findings of little league elbow?

A

-Medial elbow pain
-Decreased throwing effectiveness and distance
-Swelling
-Occasional flexion contractures

176
Q

What is used to diagnose little league elbow?

A

-MRI
-Radiographs
-Physical exam

177
Q

What is the mechanism of injury of little league elbow?

A

-During cocking and acceleration phase of pitching
-Valgus stress
-Shearing forces in the posterior elbow
-Compression along the lateral elbow

178
Q

What is median nerve entrapment?

A

-Entrapment of the median nerve from the pronator teres muscle
-Also know as pronator teres syndrome

179
Q

What is the subjective findings of pronator teres syndrome?

A

-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

180
Q

What are the objective findings of pronator teres syndrome?

A

-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

181
Q

What are the possible interventions for pronator teres syndrome?

A

-Responds well to activity modification
-Rest, NSAIDs, ice
-Restore flexibility and strength of wrist flexors and forearm pronators
-Manual techniques to break up adhesions

182
Q

What is the pattern of the trabeculae in the proximal femur?

A

-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

183
Q

What is the capsular pattern of the hip?

A

-Flexion
-Abduction
-Medial rotation

184
Q

How many bones make up the hip joint?

A

-4 bones
-Pubis
-Ilium
-Ischium
-Femur

185
Q

How many Newton pounds does it take to dislocate the hip?

A

400

186
Q

What is the vascularity of the femoral head?

A

-Ligamentum teres (1/3 supply)
-Circumflex artery
-Superior & inferior gluteal arteries

187
Q

What is the labrum?

A

Fibrocatilaginous tissue that increases the joint congruency and stability

188
Q

What are the 4 major ligaments of the hip?

A

-Anterior iliofemoral “Y” ligament
-Pubofemoral
-Posterior ischiofemoral
-Ligamentum teres

189
Q

What motions does the ligamentum teres restrict?

A

At 90 degrees of hip flexion it limits IR & ER

190
Q

What are the flexors of the hip?

A

-Iliacus
-Psoas
-TFL
-Rectus femoris
-Sartorius
-Adductor longus
-Pectineus

191
Q

What are the extensors of the hip?

A

-Glute max
-Hamstrings
-Adductor magnus

192
Q

What are the abductors of the hip?

A

-Glute med
-TFL
-Superior glute max
-Glute min

193
Q

What are the adductors of the hip?

A

-Adductor group
-Pectineus
-Gracilis
-Pectineus

194
Q

What are the medial rotators of the hip?

A

-No pure rotator
-TFL
-Glute minimus
-Glute medius anterior fibers
-Adductor group
-Semimembranosus/tendinosis

195
Q

What are the lateral rotators of the hip?

A

-Obturator internus/externus
-Gemelli
-Quadratus femoris
-Piriformis
-Glute max
-Posterior fibers of glute med
-Biceps femoris

196
Q

What is normal hip extension ROM?

A

10-15 degrees

197
Q

What is normal hip abduction ROM?

A

30-50 degrees

198
Q

What is normal hip adduction ROM?

A

25-30 degrees

199
Q

What is normal hip external rotation ROM?

A

40-60 degrees

200
Q

What is normal hip internal rotation ROM?

A

30-40 degrees

201
Q

What is the normal angle between the femoral neck and shaft?

A

125 degrees

202
Q

What is coxa vara?

A

-Decreased angle between the femoral neck and shaft
-105 degrees
-More horizontal

203
Q

What is coxa valga?

A

-Increased angle between the femoral neck and shaft
-140 degrees
-More vertical

204
Q

Does coxa vara or valga put someone at higher risk of fx?

A

Coxa vara because now there is an increased load on the neck of the femur

205
Q

What complications can occur from having coxa valga?

A

-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

206
Q

What complications can occur from having coxa valga?

A

-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

207
Q

What is femoral anteversion?

A

-Increased anterior angle between neck and shaft of femur in the transverse plane
-Anterior orientation of the femoral neck
-Results in more hip IR

208
Q

What is femoral retroversion?

A

-Increased posterior angle between neck and shaft of femur in the transverse plane
-Results in more hip ER
-Out toeing gait

209
Q

What are common orthopedic conditions of the hip?

A

-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

210
Q

What occurs during avascular necrosis of the femoral head?

A

Variable areas of dead trabecular bone and bone marrow extending to and including the subchondral plate

211
Q

What are the subjective findings of avascular necrosis of the femoral head?

A

-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

212
Q

What are common risk factors for avascular necrosis of the femoral head?

A

-Cumulative corticosteroid total dose
-Alcohol use
-Systemic lupus
-Sickle cell disease
-Trauma
-Cancer

213
Q

What are objective findings for avascular necrosis of the femoral head?

A

-Usually painful ROM, especially IR
-Patients have pain with attempted SLR
-Antalgic gait

214
Q

What is used to diagnose avascular necrosis?

A

Imaging

215
Q

What interventions are available for avascular necrosis?

A

Surgery

216
Q

What is the prognosis for avascular necrosis of the femoral head?

A

-Success is related to the stage at which care is initiated
-Complication of AVN include incomplete fx and superimposed degenerative arthritis

217
Q

What is Legg-Calve-Perthes Disease?

A

-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

218
Q

Who is at higher risk of Legg-Calve-Perthes disease?

A

4x more common in boys

219
Q

What are subjective findings in Legg-Calve-Perthes?

A

-Vague ache in the groin that radiates to the medial thigh and inner aspect of the knee
-Muscle spasm

220
Q

What are objective findings of Legg-Calve-Perthes?

A

-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

221
Q

What is used to diagnose Legg-Calve-Perthes?

A

-Imaging
-AP and frog-lateral radiographs of the pelvis

222
Q

What are interventions for Legg-Calve-Perthes?

A

-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

223
Q

What is slipped capital femoral epiphysis (SCFE)?

A

-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

224
Q

What are the subjective findings for slipped capital femoral epiphysis (SCFE)?

A

-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

225
Q

What are the objective findings for slipped capital femoral epiphysis (SCFE)?

A

-Limp
-Decreased ROM
-The involved extremity may be 1-3 cm shorter

226
Q

What is the only pediatric disorder that causes greater loss of IR when hip is moved into a flexed position?

A

Slipped capital femoral epiphysis (SCFE)

227
Q

What are risk factors for slipped capital femoral epiphysis (SCFE)?

A

-Obesity
-Male
-Greater involvement with sports activities

228
Q

What is used to diagnose slipped capital femoral epiphysis (SCFE)?

A

-Radiographs
-IR with hip flexed to 90 degrees

229
Q

What are interventions for slipped capital femoral epiphysis (SCFE)?

A

-Relief of symptoms
-Containment of the femoral head
-Restoration of ROM
-Surgical fixation

230
Q

What is the mechanism of injury for a stress fracture of the femoral neck?

A

-Results from accelerated bone remodeling in response to repeated stress
-Occurs commonly in military recruits and athletes, especially runners

231
Q

Where does a stress fracture of the femoral neck typically occur in older people? What about in younger people?

A

-Older: superior side of the femoral neck
-Younger: inferior side of the femoral neck

232
Q

What are subjective findings of stress fractures of the femoral neck?

A

-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

233
Q

What are the objective findings of stress fractures of the femoral neck?

A

-Physical exam usually negative
-May be empty end feel or pain at end ranges of IR & ER

234
Q

What special tests can help diagnose stress fractures of the femoral neck?

A

-Resisted straight leg raise + for pain
-Auscultory patellar-pubic test +
-Fulcrum test + for pain
-Radiographs

235
Q

What are interventions for stress fractures of the femoral neck?

A

-Surgically for all tension-side fx
-Bed rest or complete NWB

236
Q

What is a hamstring strain?

A

-Strain or rupture of 1 or more HS muscles
-Usually takes place during eccentric loading

237
Q

What are the key subjective findings for a HS strain?

A

-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

238
Q

What are objective findings for a HS strain?

A

-TTP
-Tenderness reported with passive stretching
-Pain with resisted knee flexion

239
Q

What are rehab timelines for the 3 grades of HS strain?

A

-Grade I: continue activities
-Grade II: 5-21 days
-Grade III: 3-12 weeks

240
Q

What is the most common adductor pathology?

A

Hip adductor tendinopathy

241
Q

What is the most common cause of groin pain?

A

Adductor strain or tendinopathy

242
Q

What is the mechanism of injury for hip adductor tendinopathy?

A

-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

243
Q

What are the subjective findings for adductor tendinopathy?

A

-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

244
Q

What are the objective findings for adductor tendinopathy? What degree of hip flexion targets which muscles?

A

-Pain with passive abduction
-Pain with resistance
-TTP
-0 degrees: gracilis
-45 degrees: add. longus
-90 degrees: pectineus

245
Q

What are interventions for adductor tendinopathy?

A

-RICE in acute stage
-Hip adductor isometrics
-Graded resistive program

246
Q

What is the prognosis for adductor tendinopathy?

A

Most patients fully recover fully or only have minimal pain with high intensity activities

247
Q

What are subjective findings with hip OA?

A

-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

248
Q

What are objective findings for hip OA?

A

-Early signs include restriction of IR, abduction, or flexion and pain at end range
-Scour +
-FABER may be +

249
Q

What are interventions for hip OA?

A

-Relieving symptoms, reduce risk of progression
-Education
-Modalities
-Swimming or cycling
-Reduction in BW
-Walking stick
-Joint mobs
-Stretches
-Hip strengthening

250
Q

What is snapping hip?

A

-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

251
Q

What are subjective findings of snapping hip?

A

-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

252
Q

What are objective findings for snapping hip?

A

-IT band can be felt subluxing
-Snapping of the iliopsoas tendon may be palpated
-Obers may be +
-Thomas may be +

253
Q

What are interventions for snapping hip?

A

-Improve muscle length
-Correct strength imbalances

254
Q

What is the prognosis for snapping hip?

A

Responds well to conservative management

255
Q

What are the subjective findings with trochanteric bursitis?

A

-Lateral thigh, groin, or gluteal pain
-Pain when lying on involved side
-Pain usually worse when rising from a seated or recumbent position

256
Q

What are objective findings of trochanteric bursitis?

A

-TTP
-Pain will get much worse with STM
-Resisted abd, ER, or ext painful
-Tightness of hip adductors
-Obers test +

257
Q

What are interventions for trochanteric bursitis?

A

-Stretching lateral thigh soft tissues
-Flexibility of ER
-Hip abd strengthening
-Establishing muscular balance
-Orthotics

258
Q

What is the prognosis for trochanteric bursitis?

A

-Responds well to conservative measures
-Corticosteroid injection may help

259
Q

What is the etiology of hip labral tears?

A

-Trauma
-FAI
-Capsular laxity or hip hypermobility
-Dysplasia
-Degeneration
-Often goes undiagnosed for extended periods of time

260
Q

What are the subjective findings of labral tears?

A

-Anterior hip or groin pain
-Often mechanical symptoms of clicking, locking, or giving way

261
Q

What are the objective findings of hip labral tears?

A

-FADIR +
-Anterior or posterior labral tear tests +

262
Q

What are interventions for hip labral tears?

A

-PT/conservative management: limit pivoting motions, strengthen inhibited muscles, assess foot motion
-Arthroscopic debridement of tear

263
Q

What is femoral acetabular impingement (FAI)?

A

-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

264
Q

What is FAI a precursor to?

A

OA and labral tears

265
Q

What can PTs do to manage FAI?

A

-Restore mobility and function
-Decrease pain
-Correct muscular imbalances
-Avoid surgery

266
Q

What is the prevalence of FAI?

A

-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

267
Q

What are the two types of FAI?

A

-CAM
-Pincer

268
Q

What is CAM FAI?

A

-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 +

269
Q

What is pincer FAI?

A

-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

270
Q

What percent of patients with FAI have both CAM and pincer impingement?

A

86%

271
Q

What are common symptoms with FAI and/or labral tears?

A

-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

272
Q

What activities should patients with FAI avoid?

A

-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

273
Q

What surgical options are there for FAI and/or labral tears?

A

-Arthroscopic repair
-Trimming of bony rim
-Severe cases may require open operation with larger incision

PHTH 517: Orthopedic Management I (3 decks)

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