exam II Flashcards
what is the leading cause of shoulder- related disability?
rotator cuff pathology
chronic shoulder pain affects what percentage of adults?
8%
what are the pathologies related to muscular in the shoulder?
rotator cuff and biceps
what are the pathologies relates to fracture in the shoulder?
glenoid rim
humeral head
proximal humerus
clavicle
scapula
what are the 5 main pathologies related to the shoulder?
muscular
sub acromial pain syndrome
adhesive capsulitis
dislocation and labral tear
fracture
this muscle initiates abduction to optimize deltoid function:
supraspinatus
this muscle is the largest and strongest muscle than all other muscles combined:
subscapularis
this muscle is more active in ER with the arm adducted:
infraspinatus
this muscle is more active with area ABD to 90 degrees:
teres minor
true or false:
the rotator cuff pathology is mostly affecting the dominant arm
true
what are the causes of the rotator cuff pathology?
- acute trauma
- degeneration
what are the risk factors for having a rotator cuff pathology?
> 40 yrs of age
repetitive lifting/overhead activities
athletes
tears in young adults secondary to trauma
what is tendinitis? what do we respond well with?
the inflammation of the tendon, is a sudden acute injury.
responds well to NSAIDS
usually resolves within 4-6 weeks
what is tendinopathy? and what is the recovery rate?
due to microtrauma
degeneration of the collagen fibers that form the tendon
= no true signs of inflammation
long term recovery!!!
what is the treatment goal for tendinitis?
REST
anti inflammatory medications
icing the tendon intermittently
what is the treatment goal for tendinosis?
we want to encourage formation of collagen and other proteins by physical therapy exercise and sometimes surgery (but hopefully not)
MOI of calcific tendinitis of RC:
excessive wear and tear
calcific tendinitis is mainly found in what people?
women over 40 years old
in the supraspinatus tendon
what are some symptoms of calcific tendinitis?
- sudden onset of pain
- intense pain w/ shoulder movement
- stiffness of shoulder
- loss of shoulder ROM
- pain disrupting sleep
- tender over RC
- loss of muscle mass
what is a grade 1 RC tear?
depth of a tear <3 mm
AKA <1/4 of tendon diameter
what is a grade 2 RC tear?
depth of the tear is 3-6mm
AKA <1/2 of tendon diameter
what is a grade 3 RC tear?
depth of the tear is > 6mm
AKA >1/2 of tendon diameter
what would a patient present to you with Bicep tendinitis?
- achy anterior shoulder pain by lifting/pushing/pulling
- pain with overhead activity
- location of pain is vague
- symptoms may improve with rest
what is the MOI with biceps tendinitis?
- repetitive motion
- partial traumatic biceps tendon ruptures may occur in combination with underlying tendinitis
what are the 4 risk factors for biceps tendinopathy?
- primary impingement
- secondary impingement
- associated activities
- secondary inflammation
what is the 2nd most common location of shoulder tendinopathy?
biceps tendinopathy!
list some of the secondary differential diagnoses that are associated with the biceps tendinopathy:
- scapular instability
- shoulder ligamentous instability
- lax anterior capsule
- tight posterior capsule
- labral tear
- RC tear
- bicipital groove spurring
what are some common complaints a patient would have regarding biceps tendinopathy?
- deep throbbing ache
- anterior shoulder pain
- localized to the bicipital groove
- pain worse at night
- sleeping on the affected side
- repetitive overhead motion causes aggravation
MOI of a biceps tear?
trauma
FOOSH
repetitive overhead motion
- anterior shoulder may bruise with visible bulge
what are some risk factors for a biceps tear?
- history of RC tear
- recurrent tendinitis
- contralateral biceps tendon rupture
- RA
- > 40 years
- poor conditioning
SAPS results in?
- bursitis
- calcific tendinitis
- supraspinatus tendinopathy
- partial RC tear
- RC degeneration
- biceps tendinopathy
what are the intrinsic factors of SAPS?
- degenerative (age and bilateral)
- vascular
- anatomic
what are the extrinsic factors of SAPS?
- scapular muscle imbalance
- altered scapular mechanics
- RC muscle imbalance
- glenoid impingement
- precipitating factors
what is secondary impingement of SAPS? and what is it caused by?
- functional disturbance of centering of the HH
- this is caused by muscular imbalance!!
what is another secondary impingement part of SAPS? and what is it caused by?
- abnormal displacement of the ICR during elevation
- this is caused by soft tissue entrapment
describe the muscular imbalance of RC during the SAPS:
- repetitive eccentric overload or weakness
- this is associated with degenerative changes
describe the glenoid impingement factor for SAPS:
an example is an overhead throwing athlete
- HH is against the posterior- superior labrum
what is stage I of SAPS (Neer’s classification):
< 25 years old
- repetitive OH activity
- edema/hemorrhage
- pain along ant. aspect of shoulder
- deep/dull ache in sub-acromial space
- sharp pain with elevation of UE
- scapular downward rotation and anterior tilting
what is stage II of SAPS (Neer’s classification):
25-40 years old
symptoms > stage I
- pain with activity and night pain
- crepitus or catching
decreased PROM secondary to capsular fibrosis
what is stage III of SAPS (Neer’s classification):
> 40 years old
- history of chronic tendinitis and prolonged pain
- greater limitation in A/PROM
- capsular laxity with multidirectional instability
break tests are: weak and painful with ABD and ER
what are some risk factor for sub acromial bursitis?
- no gender prevalence
- people who participate in overhead activities
- primary and secondary external impingement
what is sub acromial bursitis caused by?
- repetitive motions
- muscle weakness
- incorrect posture
- direct trauma
- shoulder surgery/replacement
- calcium deposits in shoulder
- overgrowth or bone spurs
- infection
- autoimmune diseases
what are the risk factors for adhesive capsulitis?
40-65 years old
more females
- medical history of thyroid disease, DM, previous adhesive capsulitis
what are the systemic factors of adhesive capsulitis?
-DM
- thyroid disease
- other metabolic conditions
what are the extrinsic factors of adhesive capsulitis?
- CP disease
- cervical disc pathology
- stroke
- humerus fracture
- Parkinsons
what are the intrinsic factors of adhesive capsulitis?
- RC pathology
- biceps tendinopathy
- calcific tendinopathy
-AC joint arthritis
what would a patient present to you with adhesive capsulitis?
- gradual onset
- progressive worsening of pain and stiffness
- ROM loss active and passive
- functional C/O with sleeping/grooming/dressing/eating
what is the importance of ROM loss with adhesive capsulitis?
> 25% in at least 2 planes AND passive ER > 50% of uninvolved shoulder
OR
<30 degrees of ER
describe the stage I clinical course of adhesive capsulitis!
- up to 3 months
- sharp pain at end ROM
- achy pain at rest
- sleep disturbance
- hallmark sign stage 1 is here!!!!!!
- dx diagnosis of subacromial shoulder impingement
describe the stage 2 clinical course of adhesive capsulitis!
‘painful’ or ‘freezing’ stage
- gradual loss of motion in all directions
3 to 9 months
loss of motion under anesthesia
- arthroscopic examination happens
describe the stage 3 clinical course of adhesive capsulitis!
‘frozen’ stage
- pain and loss of motion
- 9 to 15 months
- synovitis lessens
- capsuloligamentous fibrosis results in loss of axillary fold and ROM
describe the stage 4 clinical course of adhesive capsulitis!
“thawing phase”
- pain begins to resolve
- significant stiffness from 15 to 24 months
- motions restrictions may persist
arthroscopy occurs here
do patients have muscle guarding with adhesive capsulitis?
yes yes yes duhh
describe the primary instability of the shoulder:
- trauma
- having subluxation or dislocation - more common in young males playing contact sports
what are the anatomical risk factors for instability?
- disproportionate articulating surfaces
- inadequate soft tissue support
what are the 5 D’s of instability??
direction
degree
duration
disorders
determinants other
describe the D of direction instability:
- anterior (most common)
- posterior
- inferior (rare)
- superior (rare)
describe the D of degree instability:
- subluxation and dislocation
describe the D of duration instability:
acute < 3 weeks
subacute 3-6 weeks
chronic < 6 weeks
recurrent
describe the D of determinants (other) instability
- traumas (micro, macro, atraumatic)
- age
- voluntary
descrie the D of disorders instability
- seizures
- NM disorders
- collagen disorders (ED, Marfans)
what is the patient history like with instability? (hint its TUBS)
- traumatic event leading to symptoms
- may/may not report history of instability
- direction is anterior or posterior
TUBS!!!!!!
what does TUBS stand for?
traumatic
unilateral
bankart
surgery
what is the patient history like with instability? ( hint its AMBRI)
- insidious or lacking MOI
- pain is nonspecific
- history of instability
C/O is achy/fatige/ decreased muscle performance
what does AMBRI stand for?
atraumatic
multidirectional
bilateral
rehabilitation
inferior capsular shift
what are the associated injuries with anterior dislocation?
bankart and hillsachs lesion
what is a bankart lesion?
a detachment of the anteroinferior labrum without IGHL involvement
what is the subglenoid posterior instability?
posterior and inferior to the glenoid
what is the subspinous posterior instability?
medial to acromion and inferior to the scapular spine
what is the subacromial posterior instability?
posterior to glenoid and inferior to the acromion
what are the associated injuries associated with posterior dislocation?
reverse bankart
Kim lesion
reverse hill Sachs
what is a reverse bankart?
posterior inferior capsulabral complex and posterior band of IGHL
what is a Kim lesion!
partial avulsion of posterior inferior labrum
what is a reverse hills Sachs???
fracture of anterior humeral head medial to the lesser tuberosity
why is an inferior instability rare?
the subglenoid: the HH is inferior to the glenoid!!
laxation erecta!!!!!!
- idk what that is but the HH is in contact with lateral chest wall
what are the 2 labral tears?
bankart and SLAP
describe the bankart and the MOI
MOI is trauma, repeated dislocations
< 30 years old
- nonspecific shoulder ache
- symptoms of instability
- catching sensation
- avoid FER secondary sensation of dislocation
what is the SLAP lesion MOI
traction injury, direct blow to the shoulder area, fall onto stretched arm, overhead throwing athletes
describe the SLAP lesion:
- nonspecific shoulder pain with overhead or cross body activities
- reports of popping/clicking/catching at shoulder joint
- deep vague pain within shoulder joint due to weakness and stiffness
what is the treatment for an AC sprain?
6 to 12 weeks
- surgical stabilization
what is the MOI for an AC sprain?
direct trauma to lateral shoulder with arm in adduction
FOOSH or fall on elbow
what is a 1st degree AC sprain?
no deformity
- pain with palpation and motion, ild stretch of AC ligament
what is a 2nd degree AC sprain?
displacement of the distal clavicle
- unable to abduct arm or bring across body due to pain
what is a 3rd degree AC sprain?
complete rupture of AC & CC ligaments with dislocation of distal clavicle
- severe pain/loss of motion and instability
an SC joint sprain is more common than what?
instability
what is a differential diagnosis for a SC joint sprain?
medial clavicle physical fracture; which doesnt fuse until 20-25 years
what is the MOI for an SC joint sprain?
trauma with high injury MVA or a contact collision sports
atraumatic
- younger patients with overhead elevation
what are some significant mediastinal injuries in relation to SC joint instability?
- dyspnea
- stridor
- dysphagia
- paresthesia
- tachypnea
- swelling and discoloration
- respiratory distress
what is a glenoid rim bony bankart lesion?
fracture of the anteroom inferior glenoid rim
what is a fracture of the humeral head?
an osseous defect or dent of the postero supero lateral humeral head
- occurs during anterior dislocation of the GH joint
what is the MOI for a clavicular fracture?
- fall onto lateral shoulder
- FOOSH
- direct impact on the shaft
what is a group 1 clavicle fracture:
middle 3rd of the clavicle is fractured
what is a group 2 clavicle fracture:
- distal third of clavicle
- 5 subtypes
what is a group 3 clavicle fracture:
proximal clavicle
what is a scapular fracture: and tell me the location
- high impact trauma
- associated with serious bony or soft tissue injury
intrarticular glenoid
what is avascular necrosis?
- secondary to acute vascular insult to proximal humerus
- collapse and irregularity of HH with loss of bony support for articular cartilage
what does ASEPTIC stand for that relates to systemic avascular necrosis?
alcohol, aids
steroids
erlenmeyer flask
pancreatitis
trauma
idiopathic infection
caisson’s
what is the SLAP repair?
- arthroscopic
- debridement of torn portion of superior labrum
- abrasion of superior glenoid
- reattach superior labrum and LHB tendon
- anterior stabilization pre
what is a Bankart repair?
- open or arthroscopic
- abrade glenoid rim to increase healing rate
- reattachment of the anterioinferior labrum to glenoid lip
what is the capsulorrhaphy?
- open or arthroscopic
- tighten the capsule to reduce overall capsule volume
- tailored to direction of greatest instability
what are SAD indications for surgery?
- pain with OH motion and loss of function more than 6 months
- lack of improvement with conservative management
- stage II of Neer’s classification
- intact or minor RC tear
what are the SAD procedures for surgery?
- arthroscopic (or open)
- deltoid remains intact during arthroscopic
- mini open =
- remove subacromial bursa
- release coracoacromial ligament
- reset anterior acromial protuberance
- removal of AC joint osteophytes
what is the phase I goal of TSA
- allow early healing of capsule
- increase PROM
- decrease shoulder pain
what is the phase 2 goal of TSA
- improve ROM
- improve dynamic stabilization and strength
- decrease pain and inflammation
- increase functional activities
what is the phase 3 goal of TSA
- improve strength shoulder musculature
- neuromuscular control of shoulder complex
- improve functional activities
what are some precautions for reverse TSA?
- wear a sling during day and sleeping for 4 weeks
- avoid arm and hand motions behind back and cross body
demographics for patient with lateral epicondylitis?
males = females
age 45-54 yrs old
oral corticosteroid use
- PMH of CTS, RC pathology, and dequervians tenosynovitis
what muscle is mainly effected in lateral epicondylitis?
ECRB
because of tendinitis/tendinopathy and radial nerve entrapment
describe a clinical picture of a patient with lateral epicondylitis:
- pain with grasping
- pain over lateral aspect of elbow
- decreased grip strength
- point of tenderness distal to lateral epicondyle
– negative Xray
medial epicondylitis is also known as
golfers elbow
what are the patient demographics for medial epicondylitis?
male = female
40-60 yrs old- in peak working years
- common flexor tendon troup
what is the common flexor tendon group (hint there is 5)
- pronator teres
- flexor carpi radialis
- palmaris longus
- flexor carpi ulnaris
- flexor digitorum superficialis
what is a clinical picture for medial epicondylitis?
- medial elbow pain localized on the medial epicondyle
- exacerbated by activity
- insidious onset
- associated with overhead throwing, golf, tennis
what are some examination findings with someone who has medial epicondylitis?
- tenderness 5-10mm distal to medial epicondyle
- pain/weakness with resistance testing
- elbow motion is normal
MOI for distal biceps strain?
history of elbow or repetitive motions
- flexion or supination
clinical picture of distal biceps rupture?
- complete partial rupture
- antecubital pain
- presence of hematoma
- unable to palpate tendon at insertion
- paint with active contraction into flexion
MOI for pronator teres syndrome:
quick and repetitive grasping activities
- may occur after trauma
greater incidence in men than women
RAREEE
clinical picture of pronator teres syndrome?
- palmar surface pain
+ tinels sign - weak flexor pollicis longus and abductor pollicis brevis
- variable sensory loss
MOI for cubital tunnel syndrome:
- leaning on elbow on hard surfece
- bending elbow for sustained periods of time
- may result of abnormal bone growth
cubital tunnel syndrome define it:
- 2nd most common nerve entrapment
- ulnar nerve involvement
treatment for cubital tunnel syndrome is?
- activity avoidance
- protective pad over the ulnar groove
- splint for night wearing
symptoms of cubital tunnel syndrome:
- weakness in ring and pinky finger
- decreased grip
- muscle wasting in hand
- claw deformity
what is posterior interosseous nerve syndrome?
- intermittent compression to radial nerve
- worse with forearm rotation and lifting activities
30-50 year olds
more common in women
what is the clinical picture of a patient with posterior interosseous nerve syndrome?
no sensory changes
- motor changes due to pain disuse
- deep ache in dorsoradial proximal forearm
UCL sprain/tear describe it:
- UCL is the primary stabilizer for valgus force at elbow
- happens in contact and overthrowing athletes
- 15-24 year olds
what is the management of care for a UCL sprain/tear?
Initial rest
NSAIDS
ice
PT
Tommy John surgery (if needed)
describe the patient presentation of someone with a UCL sprain/tear:
sudden “pop” or pain along inside of elbow
- pain when accelerating the arm
- pain, tingling, numbness in pinky and ring fingers
- pain on inside of elbow after a period of throwing
MOI for a LCL injury
FOOSH leading to dislocation of radial head and lateral stabilizing structures
what is the clinical diagnosis of a LCL injury?
- history of instability
- clicking
- lateral elbow pain
- POSITIVE pivot shift test
MRI is needed
use an allograft tendon during surgery
patient demographics for olecranon bursitis:
males
30 - 60 years
location is superficial to insertion of triceps tendon
MOI for olecranon bursitis:
single direct blow/ trauma
repetitive microtrauma
- infection
RA, DM, alcoholism, HIV, Gout
clinical picture of olecranon bursitis:
- swelling, redness, heat, pain
swelling can limit elbow movement
infection- fever malaise
repetitive episodes can lead to degenerative changes in bursa
medical management of olecranon bursitis:
- NSAIDS
- needle aspiration
- surgery in extreme cases
how can you tell the difference between bursitis vs infection?
- history of injury
- signs of systemic infection
- evaluate fluid
- could lead to cellulitis
what is myositis ossificans
- post traumatic ossification
- occur at many different locations in body
- referred to as heterotypic ossification
what is the clinical picture of myositis ossificans?
- painful
rapidly enlarging tender mass with muscle fibers - radiolucent initially radiopaque
- overtime bone is resorbed
- firm mass palpable in muscle
pathology of osteochondritis dissecans?
fragment of articular cartilage with or without subchondral bone which can become partially or fully separated from the parent bone
- common in knee and elbow
categories for osteochondritis dissecans
- intact: rest from aggravating activities
- partial: articular cartilage is fractured but remains constant
- complete: free loose body within joint capsule
What is the most common pediatric injury’?
Supracondylar humeral fracture which is due to falling off moderate height onto extended elbow
MOI for an intracondylar fracture:
Severe fall onto olecranon of elbow
• Olecranon drives wedge between condyles causing a split
• May completely displace from the parent bone
MOI to the radial head / neck
MOI:
• FOOSH
• 85% occur between 30-60 y/o
• Females > males
• Females on average 7-16 years older than males with this fracture
Describe the clinical presentation of a patient with a fracture to the radial head/ neck of the elbow
• Pain on the outside of the elbow
• Swelling in the elbow joint
• Difficulty in bending or straightening the elbow accompanied by pain
• Inability or difficulty in turning the forearm (palm up to palm down or vice versa)
MOI of subluxation or dislocation to the radial head of elbow
Picking up child from floor by hand
• Pulled wrist to prevent fall
Patient demographics for a subluxation or dislocation to the radial head/ neck of elbow
Common pediatric condition
• Between 1-4 y/o (average 2.5 years)
• Left arm more affected
• Females > males
MOI of a posterior elbow dislocation
▪ FOOSH – with elbow slightly flexed
▪ Severe hyperextension
▪ Distal humerus driven forward, radius and ulna dislocate posterior.
Metabolic Disorders typically relate to bone reabsorption rate and include what?
- Osteoporosis
- Osteomalcia
- Paget Disease
Osteoblast is responsible for what ?
Responsible for new bone formation
Osteoclast is responsible for?
Responsible for old bone reabsorption
What are the types of bone ?
Trabecular or Cancellous – which are a Spongy Inner Bone
What is the outer hard bone called ?
Cortical
What is softening of the bone called?
Osteomalacia
When you have low bone mass what is this called ?
Osteopenia
When you have decreased bone density what is this called?
Osteoporosis
What is the Most common Metabolic Bone Disease affecting at least 10 million Americans
Osteoporosis
Who is affected by osteoporosis ?
women who are post-menopausal
and estrogen deficient
24% of women over the age of 50 years die from
complications within 1 year after an osteoporotic
related hip fracture
Affects 2 million men
What are some nonmodifiable risk factors for osteoporosis ?
Age >50
Caucasian/Asian
Northern European
Family History of Osteoporosis
Long periods inactivity, immobilization, long term care
Depression
What are some modifiable risk factors for osteoporosis?
Physical activity
Alcohol use
Tobacco use
Diet and nutrition
Corticosteroids use
Do actions when you are young affect bone older in life?
Uh yes ?
Signs and symptoms for osteoporosis are .
Height loss
Posture
Back pain
Possible fracture
3 tests for osteoporosis are ?
Bone mineral density test
Z score
T score
What are some treatments for osteoporosis :
Smoking cessation
Reducing alcohol intake
Nutritional components
Physical activity and exercise
Calcium, Vitamin D and diet important factors
Estrogen (post-menopausal women) and Biophosphates useful medications
Orthopedic intervention as needed
What is osteomalacia ?
Progressive disease lacks mineralization of bone which results in softening of bones
Stems from insufficient Vitamin D, Calcium or phosphate
Patients with osteomalcia are at increased risk for Osteoporosis, is this true or false.
True
What are some treatment considerations for osteomalacia:
We must address nutrition and/or absorption
Patient education similar to osteoporosis
weight bearing exercises should be beneficial
What is paget disease?
Also know as osteitis deformans
This is the 2nd most common metabolic disease!!!
Considered a Progressive disorder of the skeletal system
Increased bone resorption by osteoclasts and excessive, unorganized new bone formation by osteoblasts.
What happens during Paget’s disease?
Initially abnormal osteoclasts proliferate at increased rate
Rapid resorption doesn’t allow the osteoblastic activity to keep up so the fibrous tissue replaces bone
Within the later phases, instead of normal cancellous bone there is coarse, thickened struts of trabecular bone, and the cortical bone is irregularly thickened, rough, and pitted.
After the later phases the bone is now heavily calcified and enlarged but weakened with a chaotic woven pattern!!
What is the diagnosis for Paget’s disease?
It is usually based on the characteristic bone deformities and radiologic bony changes
A screen test measures alkaline phosphate levels which are normally high in this disease
What are some treatment considerations for Paget’s disease?
Bisphosphates
NSAIDs to control pain
Surgery to repair fractures
exercise!!
How come we have to be aware of metabolic bone conditions in our patients ?
Manual therapy
Patient education
Fall prevention
AND screening patients who are undiagnosed
Important for prescribing types of exercises
