Exam II Study Guide Flashcards
Subacromial Rotator Cuff Secondary Impingement
Loss of normal biomechanics, loss of normal inferior humeral glide w/ upward humeral rotation (flexion, abduction)
Neer’s 3 stages of impingement (Stage I)
Young (<25 y/o)
Edema and hemorrhage
Pain with > 90 degrees ABD
Neer’s 3 stages of impingement (Stage II)
Age 25-40 y/o, Fibrosis, Irreversible changes in supraspinatus, bicep tendon, Pain at night, difficulty positioning shoulder for comfort
Neer’s 3 stages of impingement (Stage III)
Age > 40 y/o, Tendon degeneration/supraspinatus tears, Hx of shoulder pain, Muscle weakness/atrophy (disuse atrophy pattern). Will most likely need surgery.
Anterior Subluxation/Dislocation
Shoulder horizontal abduction w/ ER
Posterior Subluxation/Dislocation
Shoulder adducted, IR’d, and loaded
Multi-directional instability of GH
Congenital laxity (not much can be done rehab wise, usually surgical)
Subluxation may be anterior, posterior, or inferior
Dislocation
Complete separation of humeral head from glenoid cavity, Humerus does not spontaneously reduce
Subluxation
Partial separation; results in soft tissue strain at shoulder, Humerus spontaneously reduces
Bankart lesion
Avulsion of capsule and glenoid labrum off anterior glenoid rim, result of traumatic anterior shoulder dislocation
Hill-Sachs lesion
A compression or “impaction fracture” of the posteromedial aspect of the humeral head after anterior shoulder dislocation
Type I Labral tear
degeneration of superior labrum; loss of horizontal abduction w/ ER
Type II labral tear
detachment of labrum and biceps tendon anchor with loss of stability
Type III labral tear
vertical tear of labrum, biceps intact
Type IV labral tear
tear of labrum into biceps tendon
SLAP (superior labral tear from anterior to posterior) lesion repair
Debridement of torn labrum, Reattachment of labrum and bicep tendon
Bankart lesion surgical rehabilitation
Reattachment of torn capsule and labrum to glenoid, immobilization 1-8 weeks, maintain hand, wrist, and elbow ROM
Anterior Bankart repair precautions
Avoid anterior dislocation position (i.e. ER with horizontal abduction)
Reverse Bankart repair precautions
Avoid flexion > 90, horizontal adduction, and IR
Adhesive Capsulitis
Frozen shoulder, Insidious onset between 40-60 y/o, associated w/ trigger points, guarding of subscapularis
Stages of development: Adhesive Capsulitis
Freezing (2-3 weeks)
Continuous pain (including at rest), severe limitation of movement soon after onset
Frozen (4-12 months)
Atrophy, pain (although less, and occurring primarily with movement), loss of ROM
Thawing (12-24+ months)
↓ pain, restricted ROM
Rheumatoid Arthritis Symptoms
Morning stiffness greater than one hour, joints may feel tender, warm, and stiff when not used for an hour, joint pain is symmetrical, loss of ROM, Deformity
Synovitis
synovial hyperplasia, destruction of articular cartilage, pannus formation, increased intracapsular pressure, and joint surface irregularities.
Pannus
Destructive vascular granulation tissue, Disrupts synovial function, Destroys collagen, cartilage and subchondral bone
Erythrocyte Sedimentation Rate
Relative activity of disease process, Non-specific measure of inflammation
Synovial Fluid Exam
increased WBC, signs of breakdown are increased collagenase and increased debris (proteins)
Commonly involved joints with RA
MCP, Wrist, Knee, Ankle/foot, Upper cervical spine
Cervical Spine deformities with RA
occiput (C2), transverse ligament laxity, subluxation/sub-axial subluxation (2mm=suspicious, 4mm=severe), possible neurological involvement
Knee deformities with RA
genu valgus, bakers cyst
Ankle/ Foot deformities with RA
Pronation, Hallux valgus, Claw toes
RA stage I
Synovitis:
Synovial membranedemonstrates infiltrating small lymphocytes
Joint effusions
X-rays: no destructive changes
RA stage 2
Inflamed synovial tissue now proliferates & begins to grow into joint cavity across articular cartilage (which it gradually destroys)
Narrowing of joint due to loss of articular cartilage
RA stage 3
Pannus of synovium
Eroded articular cartilage & exposed sub-chondral bone
X-rays show extensive cartilage loss, erosions @ margins of joint
RA stage 4
End-stage disease
Inflammatory process is subsiding
Fibrous or bony ankylosing of joint will end its functional life
Nodules
Osteoarthritis pathology
Destruction of cartilage
Surface irregularities
Osteophyte Formation
Subchondral bone thickening
Secondary inflammation of periarticular structures
Osteoarthritis symptoms
Decreased ROM, Stiffness (Relieved by movement), Pain (Deep; aggravated by activity), Deformity, Crepitus
Lateral Epicondylalgia
Tennis elbow, Common extensor tendinopathy/overuse syndrome (ECRB, ECRL, ED, EDM), often associated with cervical spine pathology of C5
Lateral Epicondylalgia symptoms
Pain on palpation of the common extensor tendon especially over ECRB, Pain with resisted wrist extension, Pain on stretch of the wrist extensors, Grip strength with dynamometer painful and limited
Medial Epicondylalgia
Golfers elbow, overuse injury of the pronator teres, FCR, FD, FCU
Medial Epicondylalgia symptoms
Pain with screwdriver/hammer use, golfing, baseball
Palpation tenderness along medial epicondyle and common flexor tendon/muscles
Discomfort with combined wrist/elbow extension
Pain with resisted wrist flexion and forearm pronation
Medial Valgus Stress Overload
Valgus Extension Overload (VEO)/Pitchers Elbow
Repetitive stress @ ulnar collateral ligament leads to microtrauma of collagen
Common in overhead athletes and pitchers
Medial Valgus Stress Overload symptoms
Pain over medial elbow and posterior aspect of olecranon, Increased valgus of elbow, Pronator mass hypertrophy, Loss of extension ROM
Supracondylar Fracture
Transverse Fracture of the Distal Humerus, Usually children, Treatment usually CR in elbow flexion, possibly PP
Distal humerus displaced posteriorly
Fall on extended outstretched arm
Distal humerus displaced anteriorly
Direct trauma to the posterior elbow
Volkmann Ischemic Contracture
Severe pain in forearm muscles
Limited and painful finger movement
Paresthesia
Median nerve with loss of sensation
Loss of radial pulse
Pallor and paralysis
Radial Head Fracture
Fall on outstretched arm
1/3 of all elbow fractures
May result in change in elbow carrying angle
Radial Head Fracture type I
Type I: Non-displaced
Immobilization 1-4 weeks
Gentle pain free ROM
Radial Head Fracture type II
Type 2: Marginal fracture with displacement
ORIF
Immobilization in hinged splint
ROM as allowed by surgeon
Joint Mobilizations (pronation/supination)
Radial Head Fracture Type III
Type 3: Comminuted & Displaced
Excision of fracture
Change in carrying angle
ROM as allowed by surgeon
Radial Head Fracture Type IV
Type IV: Radial Head Fracture + Elbow Dislocation
Excision of fracture
Change in carrying angle
ROM as allowed by surgeon
Type 3 and 4 typically demonstrate extension lag
Olecranon Fracture Non Displaced
Immobilization
Gentle Active ROM after 3 weeks of immobilization
No flexion greater than 90 degrees for 6-8 weeks
Olecrannon Fracture Displaced
ORIF
No flexion greater than 90 degrees for 8 weeks
Progressive weight-bearing and exercise
Continued ROM, AROM, AAROM may be necessary
Acute Carpal Tunnel Syndrome signs and symptoms
Paresthesia with repetitive finger flexion
Numbness at night
Symptoms decrease with shaking of hands
Subacute carpal tunnel syndrome signs and symptoms
Paresthesia
More consistent weakness, difficulty with fine motor activities
Chronic carpal tunnel syndrome signs and symptoms
Paresthesia constant
Muscle wasting thenar eminence (FPB, APB, OP)
Loss of opposition of the thumb
Fine motor function impairments (writing, prehension, dexterity)
loss of grip strength
Carpal tunnel syndrome CPR
Age > 45
Shaking hands relieves symptoms
Wrist ratio > .67
divide AP by ML wrist width
Reduced sensation median nerve (@ thumb)
Symptom Severity Scale Score > 1.9
DeQuervain’s Tenosynovitis
Thickening of the synovial sheaths of the APL & EPB, idiopathic, may be due to repetitive thumb movements
DeQuervain’s Tenosynovitis symptoms
Pain, tenderness and swelling over radial wrist
Dupuytren Disease
Formation of pits and firm nodules that lie just below the skin of the palm, Flexion contractures of the MCP and PIP joints (usually fingers 4 and 5), often bilateral
Mallet Finger
Interruption of the extensor tendon mechanism over the DIP joint (Zone 1), usually trauma induced
Mallet finger rehabilitation
Begin gentle ROM at 6 - 8 weeks, increasing flexion (20° increments/week) as long as active full extension is not compromised
Jammed Finger/Volar Plate Injury symptoms
pain, stiffness, catching, hyperextension deformity > 15 degrees
flexor tendon/repair injuries Immobilization
following repair, the wrist and hand casted or splinted for 3 - 4 weeks before beginning active and passive exercise
flexor tendon/repair injuries early passive Immobilization
passive flexion and active extension allowed within splint limits
flexor tendon/repair injuries Early active mobilization
with these programs, the tendon is moved actively within 48 hours of repair and within carefully outlined limits set by the surgeon
Colles Fracture
Radial fracture with dorsal displacement of the distal fragment and radial shift of the carpal bones
Smith’s Fracture (Reverse Colles Fracture)
Distal portion of radial fracture dislocates palmarly
Surgery usually required
Scaphoid-Lunate Advanced Collapse (SLAC)
Disruption of the scapholunate ligament
SLAC Proximal Row Carpectomy
60% of normal ROM as compared to opposite wrist and over 90% of normal grip strength
SLAC Four corner fusion
less than 50% ROM and about 75% grip strength
Tibial Plateau Fracture
High energy trauma (e.g. falls, MVA)
Ensure no SX of compartment syndrome
Beware: 50% of closed tibial plateau fractures have menisci and collateral ligament tears
Metatarsal Stress Fractures
Rhythmic overload
Females > Males
Contributing factors
Skeletal malalignment (cavus feet)
Improper footwear
Stress Fractures symptoms
-Stiffness/soreness after activity
-Mild soreness/pain during activity that persists afterward
-Pain during activity that alters performance
-Pain during and after, does not subside with complete rest
SAD Rehabilitation overview (weeks 0-6)
Sling 2-7 days, but early mobilization encouraged, PROM and AAROM done daily to achieve full ROM, scapular stabilization
SAD Rehabilitation Overview (weeks 6-10)
Once ROM achieved, ensure physiologic movement in available range, scapular balance, Once scapular stability achieved, progress to overhead movement, Pain free ROM with adequate strength
Glenohumeral instability rehab weeks 1-3
-Immobilizer when not exercising
-ER and extension limited to neutral
-Flexion/elevation to 90° via AAROM
-Scapular stabilization (isometric)
Glenohumeral instability rehab weeks 3-6
-ER to 45°
-Immobilizer discontinued (per surgeon)
-AAROM/wand exercises
-Scapular stabilization progressed – No humeral movement
Glenohumeral instability rehab weeks 6-12
-Full AROM
-Progress scapular stabilization with -UE movement and weight-bearing
-PNF patterns
-Functional movements avoiding previously unstable position
Glenohumeral instability rehab weeks 12-18
More sport or activity-specific
Plyometrics added
Bankart Surgical Rehabilitation
Immobilization 1-8 weeks, Maintain hand, wrist, elbow ROM, CV fitness maintained
SLAP Repair Rehabilitation 0-2 weeks
flexion limited to 60°
ER limited to 15° in neutral position
IR limited to 45° in neutral position
Pendulum exercises
SLAP Repair Rehabilitation 3-4 weeks
flexion limited to 90°
ER limited to 30° and IR to 60°
Wand Exercises
SLAP Repair Rehabilitation 6-8 weeks
Progress to full ROM
SLAP Repair Rehabilitation Subacute Phase (8-12 weeks post op)
Horizontal ABD/ADD
PNF patterns
IR and ER strengthening with arm in protected position (towel roll)
Progressive UE weight bearing (hands and knees)
Stage 1 Disc degeneration
dysfunction, tears in the annulus, hypermobility of the facet joints
Stage 2 disc degeneration
instability, Disc reabsorption, Degeneration of facet joints with capsular laxity, Subluxation
Stage 3 disc degeneration
stabilization, Osteophyte formation, Stenosis (narrowing)
Herniated nucleus pulposus causes
Weight
Repetition
Sedentary (sitting)
Smoking
Degenerative disc disease symptoms
Gradual onset of pain
Intermittent and recurring pain over several years
Pain increases with activity or static positioning
Stiffness
Pain into buttock/ sclerotome
Vertebral Osteophytes
Loss of disc height
Compressive forces increase
Osteophyte formation
Central spinal stenosis
Narrowing of the spinal canal
Lateral spinal stenosis
Narrowing of the intervertebral foramina
Lumbar Spinal Stenosis CPR
Bilat Symptoms
Leg Pain > Back Pain
Pain during walking or standing
Pain relief upon sitting
Age > 48 years
Spondylolysis
defect of pars interarticularis (crack)
Spondylolithesis
bilateral defect with displacement of the superior vertebra
Spondylolithesis type I
Congenital- malformation of sacrum/ L5
Spondylolithesis type II
Isthmic Spondylolithesis- mechanical stress leads to stress fracture at par interarticularis
Spondylolithesis type III
Degenerative (older)
Spondylolithesis type IV
Traumatic (football) Casting
Spondylolithesis type V
Pathologic (tumor)
Spondylolithesis grade I treatment
usually not symptomatic
Spondylolithesis grade II treatment
education to avoid extension and begin spinal stabilization. May use casting to reduce anterior shear forces and allow healing
Spondylolithesis grade III treatment
conservative treatment may be attempted. Surgery?
Spondylolithesis grade IV treatment
surgery due to neurological involvement
Osteoid Osteoma
Benign (noncancerous) bone tumor that usually develops in the long bones of the body, such as the femur (thighbone) and tibia (shinbone), does not spread, Most likely in children and young adults age 4-25
Males 3x > females, great responses to aspirin
Spondylolithesis grade I
<25% slippage
Spondylolithesis grade II
25-50% slippage
Spondylolithesis grade III
50-75% slippage
Spondylolithesis grade IV
> 75% slippage
