High Yield 2 Flashcards
Hx qs + sx of sciatica
Pain radiates from lower back into leg + foot
Can have weakness or sensory impairment
Radicular pain in L4-S3
Burning pain, numbness, tingling
Aggravated by flexion, Valsalva, prolonged standing
R/O RF: fever, weight loss, trauma, IVDU, bladder/ bowel dysfunction, saddle anesthesia
RF sciatica
Repetitive lifting, flexion or rotation (labourers, dancers, golfers)
Physical exam sciatica
Lumbar + Hip exam
Fasciculations can be present
ROM restricted in flexion + rotation
Sensation can be reduced
L4 - anteromedial leg, medial malleolus
L5 - lateral lower leg, 1st web space
S1 - back of lower leg, lateral aspect heel
Reduced strength
L4 - ankle dorsiflexion
L5 - big toe extension
S1 - ankle plantarflexion
Reduced reflexes
L4 - patella
S1 - achilles
Positive SLR
Positive slump test
DDx sciatica
Ankylosing spondylitis
Cauda equina
Facet arthropathy
Compression #
Disc herniation
OA of hip or spine
Sacroilitis
Spinal stenosis
Vascular claudication
Rx sciatica
6 wks conservative management - NSAIDs, PT, acupuncture
Can use epidural steroid injection for short term pain relief
Surgery if no improvement after 6 wks + severe pain, neuro deficits or severe dz (lumbar decompression)
Core stability + strengthening
Aerobic activity
Restoring motor function
Yoga
Weight loss
Most improve in 6 wks
Sinister causses of back pain + associated red flags
fracture (trauma, steroid use, menopause), infection (fever, IVDU, immunosuppression), cancer (wt loss, prev cancer), cauda equina (bladder/ bowel, saddle anesthesia, motor weakness)
RF for lumbar strain
Age
Activity
Occupation
Obesity
Smoking
Sedentary lifestyle
Psychosocial factors
Poor posture
DDx LBP
Herniated disc
OA
Posterior facet syndrome
Spondylolisthesis
Spinal stenosis
OP
AS
Referred pain
Tumor
Fracture
Rx lumbar strain
Paracetamol/ NSAIDs x2 wks
Tramadol if more severe
RMT, PT, acupuncture
Consider behavioral therapy
Stretching + strengthening
Yoga
Aqua therapy
Most resolve within 1-3mo
Prevention of LBP
Exercise
Posture training
Body mechanics training
Weight loss
Patterns of mechanical LBP
Back dominant pattern 1 = intermittent or constant, aggravated w/ flexion, extension can aggravate or relieve, normal neuro exam, discogenic, most common
Back dominant pattern 2 = intermittent, aggravated by extension, relieved by flexion, normal neuro exam, e.g. pars defect in gymnast
Leg dominant pattern 3 = constant, aggravated by flexion, positive SLR, sciatica
Leg dominant pattern 4 = intermittent, aggravated w/ walking + relieved w/ sitting, may have reduced root conduction, e.g. spinal stenosis
Cauda equina signs + sx
Severe LBP
Pain, numbness, weakness in legs
Saddle anesthesia
New onset bowel or bladder dysfunction
New onset sexual dysfunction
Absent reflexes
Gait disturbance
Causes of cauda equina
Ruptured lumbar disc
Spinal stenosis
Spine lesion/ tumor
Infection
Hemorrhage
#
Complication from MVA, fall
Birth defect
Common causes of cervical radiculopathy
Cervical disc dz (spondylosis), disc herniation, foraminal stenosis from facet joint hypertrophy, spinal stenosis, whiplash, RA, infection, tumor, cysts
Hx qs + sx cervical disc dz
Unilateral neck, shoulder or arm pain
Paresthesias, numbness, weakness, diminished reflexes
R/O red flags - gait disturbance, bladder/ bowel dysfunction, hand clumsiness, hyperreflexia, clonus, fever, wt loss, bilateral sx, night pain, IVDU
Physical exam findings cervical disc dz
C spine exam
Positive Spurling
Sx may improve w/ abduction of upper limb as this decreases stretch on nerve root
What is the classic pattern of myelopathy at C5-6?
Hyperreflexia at triceps reflex (C7) and diminished bicep + supinator reflexes (C5 + 6)
DDx cervical disc dz
Peripheral nerve entrapment
Myelopathy
Brachial plexus lesion, inflammation or injury
Thoracic outlet syndrome
Spinal tumor
Infection
Complex regional pain
Pancoast tumor
Management cervical disc dz
PT, NSAIDs, avoidance of provocative activities, cervical traction, heat/ cold
Neck + shoulder muscle strengthening
ROM exercises
Resisted exercises as tolerated
Aerobic activity
Postural education
Ergonomic adjustments
When to refer to surgeon in cervical disc dz
Progressive or severe neuro deficit, myelopathy, muscle atrophy
Anterior cervical discectomy + fusion
Sx + hx questions disc herniation
Acute onset back pain, can present with multiple episodes
Can be triggered by heavy lifting or twisting motion w/ heavy object
Nerve compression worse when sitting or sleeping on stomach
Pain precipitated by sneezing or straining
R/O cauda equina
Physical exam disc herniation
Spinal exam
SLR positive
Decreased sensation, reflexes + weakness
Severe muscle spasm can cause abnormal posture (lateral bend to contralateral side)
Sx + physical exam findings of disc herniation at L3 + 4
Pain - Lower back, hip, posterolateral thigh, ant leg
Sensation - Anteromedial thigh, knee & calf
Motor weakness - Quads (knee extension), Thigh adductors, Tibialis Anterior (DF)
Atrophy - Quadriceps
Reflexes - Patellar tendon reflex ↓
Sx + physical exam findings of disc herniation at L4 + 5
Pain - Above SI joint, hip, lat thigh & leg
Sensation - Lat leg, 1st 3 toes
Motor weakness - DF of great toe (EHL) & ankle, difficulty walking on heels, foot drop may occur
Atrophy - Minor or nonspecific
Reflexes - Post tibial reflex or hamstring reflex ↓
Sx + physical exam findings of disc herniation at L5 + S1
Pain - Above SI joint, buttocks, hip, posterolateral thigh, leg, calf, bottom of foot
Sensation - Back of calf, lat heel, foot & baby toe, plantar surface of foot
Motor weakness - PF of foot (Gastrocs/soleus), PF of great toe (abductor hallicus), difficulty walking on toes
Atrophy - Gastrocs & Soleus
Reflexes - Achilles tendon reflex ↓
What are the myotomes of L1-S3?
L1 + L2 - hip flexion
L3 + L4 - knee extension
L5-S2 - knee flexion
S1 + S2 - plantar flexion
S2 + S3 - abduction toes
DDx of disc herniation
Cauda equina
Hip OA
Knee OA
Meralgia paresthetica
Piriformis syndrome
Sacroilitis
Spinal stenosis
Management + RTP of disc herniation
Regular FU 1-2 wks
RMT, acupuncture
Heat or ice after first 2-3 days
Bed rest x2 days max
NSAIDs, muscle relaxants
Lumbar support
Epidural steroid shot for short term relief
Surgery if no improvement in 12 wks or cord compression (discectomy)
RTP when pain free, normal ROM, without neurogenic pain, good core + extremity strength
What are the stages disc herniation?
Protrusion
Extrusion
Sequestration
Most common site of herniation + nerve root affected
L5-S1 affecting S1 nerve root w/ paracentral herniation + L5 root w/ foraminal herniation
Definition of scoliosis
Lateral curvature of spine >10 degrees by Cobb angle
Hx qs in scoliosis
Rate of worsening
Pain usually if curve >40
Difficulty breathing
Growth stage - puberty
Hx of lower limb #, joint infection, arthritis - could cause leg length discrepancy
FHx scoliosis
Physical exam in scoliosis
Tanner stage
Hypermobility + hyperelasticity
Shoulder asymmetry
Unequal scapular prominence
Elevated hip
Leg length discrepancy
Crankshaft phenomenon: progressive deformity resulting from continued growth of anterior aspect of spine after posterior arthrodesis
Plumb line testing - drop a line from C7 to demonstrate pelvic deviation
XRs for scoliosis
XR - standing full length PA + lateral films
Cobb angle
Management of scoliosis
Monitor q6mo until skeletal maturity
Bracing for skeletally immature w/ curves 30-50 degrees or if rapid progression
Rigo Cheneau de-rotational brace
Worn 23 hrs/ day until end of growth
PT
Surgery for curves >50
Posterior spinal fusion
If skeletally mature and Cobb angle <40, reassure + discharge
What does risk of curve progression in scoliosis depend on?
Pt’s maturity + size of curve
Complications of scoliosis
Reduced pulmonary function for pts with thoracic curves >60 degrees
MOI in cervical strain (whiplash)
Usually hyperextension of cervical spine causing stretch type injury
Sx of cervical strain
Pain - may have minimal pain immediately but develop over hours to days later
Muscle spasm/ tightness
Mechanism of injury anterior shoulder dislocation
Anterior - usually from provocative position of abduction + external rotation
Fall on outstretched arm
Tackling
Hx qs + sx for shoulder dislocation
Symptoms (r/o neck pain), shoulder pain, decrease ROM, numbness or tingling in fingers
Previous dislocations, fractures
“Dead arm” usually occurs w/ subluxation
Exam for ?shoulder dislocation
C spine exam
Shoulder exam
Neurovascular exam upper limb before + after reduction
Deltoid strength
Lateral shoulder sensation
Apprehension test
Relocation test - during apprehension test, posteriorly directed force applied to humerus w/ scapula stabilized - if sx resolve - positive test
Load + shift test - pt is seated, examiner stabilizes scapula and with other hand attempts to sublux humeral head anteriorly + posteriorly
If ?multidirectional instability, assess ligamentous laxity
RF for shoulder dislocation
Previous dislocation
Repetitive overhead sports or contact sports
Ligament laxity
XR views for shoulder dislocation
XR - AP, axillary lateral, scapular Y, orthogonal views (to r/o bony injuries)
West Point view (good for identifying bony Bankart/ anteroinferior glenoid rim #)
Stryker notch view (good for identifying Hill-Sachs lesion/ posterolateral humeral head compression #)
Post reduction views needed
head of humerus is medially displaced on AP (in anterior shoulder dislocation)
DDx shoulder dislocation
AC instability
SLAP lesion
# humeral head, coracoid, acromion
Biceps tendon subluxation
Subscapularis tear
Initial exam of acute shoulder dislocation - sideline
Locate greater tuberosity - likely anterior
Assess axillary nerve function (sensation around deltoid, fingers, wrist extension + flexion)
Assess peripheral pulses
Palpate SC joint, clavicle, AC joint, humerus, elbow
CI to closed reduction of shoulder dislocation
Humeral head + neck #
Significantly displaced
Severe scapula #
Methods to reduce dislocated shoulder
Analgesia, benzos to relax
Can use intra-articular lidocaine
Traction
Stimson - pt lying prone, weight applied to arm hanging down
Counter traction - pt lying supine, traction at 45 degrees of abduction w/ countertraction applied with sheet under axilla
Leverage
Kocher - pt supine, flex elbow to 90 degrees, adduction, externally rotate arm, forward flexion of shoulder
Other methods
Milch - stabilize humeral head, fully abduct arm, apply traction, push humeral head over glenoid rim
Self reduction - pt locks hands in front of ipsilateral knee, relax backwards, allowing gentle traction
Management Post shoulder reduction
neural assessment (axillary patch, deltoid function)
Re-examine AC, elbow, wrist
Immobilize w/ sling x1 wk
ROM exercises
Physiotherapy and AROM to begin at 3 weeks, no abduction/ER together for 6 wks
Rotator cuff strengthening - begin in plane of scapula
Scapular stabilization exercises include rowing, modified push ups w/ maximal protraction
When to refer for surgery in shoulder dislocations
If rotator cuff tear >50%, Hill-Sachs lesion >25%, glenoid defect >20%, failure of conservative therapy
Consider surgery if 1st time dislocation in young athletes or labourers, >2 dislocations in 1 season, participation in overhead sports, bony Bankart lesion
RTP shoulder dislocation
after full ROM and strength returned
Motion control braces can limit abduction + external rotation + decrease risk of future events
What is a Hills Sach lesion, how often does it occur, sx associated, athletes most at risk
cortical depression in posterolateral head of humerus
Results from forceful impaction of humeral head against anterior glenoid rim w/ anterior shoulder dislocation
Results in divot
40-90% of anterior shoulder dislocation
Can contribute to ongoing instability - associated w/ painful click, popping, catching
Young, throwing athletes
What is a Bankart + bony bankart lesion?
Injury to anterior glenoid labrum d/t anterior shoulder dislocation
Resulting pocket allows recurrent subluxation
Often accompanies Hill-Sachs lesion
“Bony bankart” includes #W
What other conditions are associated with shoulder dislocation?
Axillary nerve injury
Humeral head + neck #
Rotator cuff tears (often subscapularis)
Recurrence rate for shoulder dislocations in athletes <25
> 85%
MOI for posterior shoulder dislocation
trauma (axial load applied to upper extremity in forward flexion, adduction + internal rotation) or from sz or electrocution
RF + at risk sports for posterior shoulder dislocation
EDS, Charcot shoulder, at risk sports (football, swimming, golf, racquet sports)
Imaging for posterior shoulder dislocation
axillary view, Bedside US is v useful for diagnosis - CT or MRI if XRs neg but high suspicion
Management of posterior shoulder dislocation
early reduction
pt supine, apply longitudinal traction while elbow is flexed at 90 degrees, can use countertraction w/ sheet round chest
Apply gentle internal rotation + lateral traction
May need open reduction, especially if >3 wks or w/ associated #
Refer to ortho for long term management
Physical exam findings of posterior shoulder dislocation
arm held in internal rotation + adduction, external rotation is blocked, prominence of posterior aspect of shoulder, visible or palpable humeral head posteriorly
What is a burner/ stinger + what is the MOI
Brachial Plexus Injury
Traction to plexus when shoulder is depressed + head is forced away from injured side
Compression of cervical roots when head is forced towards side of injury
Direct blow to brachial plexus at supraclavicular fossa
RF for Brachial Plexus Injury
Previous burner
Limited ROM of neck or shoulder
Cervical canal + foraminal stenosis
Contact sports
Hx qs + sx Brachial Plexus Injury
Acute trauma to neck + shoulder causing burning or stinging in upper shoulder, radiating down
Relation to shoulder + neck mvmt
Usually lasts mins but can persist weeks
r/o concussion, neck injury, unstable shoulder
Physical exam Brachial Plexus Injury
Often holds arms close to body or shakes arm
Shoulder exam
Weakness most commonly occurs in deltoid, biceps, rotator cuff
Spurling may be positive
Tinel sign at supraclavicular fossa
When + what to order for ix in Brachial Plexus Injury
Not usually needed
C spine XRs if recurrent injury, weakness ongoing few days, neck pain, bilateral arm sx
EMG if sx lasting >3 wks
DDx Brachial Plexus Injury
C spine injury (bilateral sx, vertebral tenderness, lower extremity findings)
Shoulder dislocation
AC separation
Clavicle #
Thoracic outlet syndrome
Management + RTP for Brachial Plexus Injury
Can RTP once sx resolve
Neck exercises
Stretch tight muscles
Strengthen neck + shoulder
Prevention in future of Brachial Plexus Injury
Neck roll, shoulder pad lifter or rigid collar in football
Chest out posture
Ensure correct playing technique
RF for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis
Repetitive overhead activities (throwing, swimming, racquet sports, wt lifting)
Shoulder instability
Prev shoulder surgery
Smoking
Diabetes
<25y/o, impingement usually d/t laxity caused by instability
>25y/o, impingement usually d/t rotator cuff overuse
Sx + hx qs for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis
Insidious onset
Pain w/ overhead activities
Weakness, numbness
Worse in evening + night
No trauma
R/o C spine disease
Physical for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis
Shoulder exam
Painful arc 70-120 degrees
Reduced internal rotation d/t posterior capsular tightness
Neuro exam
suprascapular nerve (supraspinatus & infraspinatus), long thoracic nerve (serratus anterior), thoracodorsal nerve (latissimus dorsi), subscapular nerve (teres major & subscapular), axillary nerve/C5 (deltoid & sensation to lateral surface of the shoulder)
DDx for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis
Rotator cuff tear
Biceps tendinopathy
GH instability
Labral tear
Referred pain from neck
AC joint sprain/ OA
GH OA
Pancoast tumor
Suprascapular nerve palsy
Brachial plexus injury
Axillary nerve entrapment
Adhesive capsulitis
Thoracic outlet syndrome
Management of Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis
NSAIDs
Ice
Subacromial bursa steroid inj
Relative rest
PT
Shock wave therapy if calcific
Correction of training errors in racquet/throwing sports ( Poor kinetic chain movement, improper body positioning, improper hip movement)
Consider surgical referral for anterior acromioplasty if conservative rx fails
PRP, prolotherapy, acupuncture
Stretch posterior capsule
Address muscle imbalance & instability
Posture
ROM: Dangling arm circles, finger wall-walking, broom handle exercises
Sword from sheath, posterior dumbbell raises, scapular stabilization
RF for acute rotator cuff tear
Age, smoking, fam hx
Repetitive overhead use
Fall risk sports like skiing, surfing, horse riding
MOI for acute rotator cuff tear
Many involve acute-on-chronic injuries
For acute complete tears - fall, direct blow, forceful punch
Traumatic hyperextension, internal or external rotation of abducted arm o
Or, in those >40 years old, look for a complete rotator cuff tear with shoulder dislocation
Can develop insidiously
Sx of acute rotator cuff tear
Pain and weakness
Night pain
Pain sleeping on affected side
May radiate to elbow
Aggravated w/ reaching motion
Physical for acute rotator cuff tear
Reduced ROM
Pain w/ arm abduction from 80-120 degrees
Atrophy of muscles if chronic
Positive drop arm test
Positive lag sign (inability to maintain position of full external rotation)
Positive gerber’s (subscapularis)
Positive empty can test (supraspinatus)
Positive resisted external rotation (infraspinatus + teres minor)
Weakness and pain with rotator cuff strength testing
DDx for acute rotator cuff tear
Rotator cuff strain
Labrum tear
Unstable shoulder
Subacromial impingement
AC disorder
GH OA
Adhesive capsulitis
Ix for acute rotator cuff tear
XR - can show calcification, superior or anterior migration of humeral head (full thickness tear)
MRI or US
Diagnostic injection into subacromial bursa w/ 10ml 1% lidocaine - if no pain relief or improvement in strength
Management for acute rotator cuff tear
NSAIDs
Sling - limited to 2-3 wks
Subacromial steroid injection
ROM + strengthening
Prolotherapy, PRP
When to refer to surgeon for acute rotator cuff tear
An acute, complete tear of a rotator cuff tendon in a young, heathy individual
Partial tears after failed conservative therapy
RTP for acute rotator cuff tear
6mo if overhead athlete
RF for multidirectional GH instability
hyperlaxity, repetitive microtrauma (overhead motion): butterfly/ backstroke swimmers, pitchers, wt lifters, racquet sports
Hx + sx for multidirectional GH instability
Pain w/ overhead activities
Episodes of “dead arm”
Prev injuries + dislocations
Vague pain radiating to deltoid insertion, occurring after activity, better w/ rest
Inferior instability: pain, numbness while carrying suitcase (d/t traction on brachial plexus)
Posterior instability: pain while arm is forward flexed + internally rotated (pushing open heavy door, push ups, pull-through phase of rowing, blocking in football)
Physical for multidirectional GH instability
Shoulder exam
positive sulcus test indicates inferior instability
Load + shift test
Test for hypermobility
Management for multidirectional GH instability
typically these reduce spontaneously, can use short term sling (especially if recurrent)
Ice
PT
Emphasis on strengthening anterior deltoid + rotator cuff muscles (6 wks) then adding scapular stabilizers + improving proprioception (Watson program)
Correction of training errors in racquet/throwing/swimming sports (Poor kinetic chain movement, improper body positioning, improper hip movement)
Consider surgical referral for stabilization if fails conservative therapy
Consider referral to rheumatology if concern of collagen disorder & ophthalmologist
RTP for multidirectional GH instability
if pain free w/ normal strength at 6mo can RTP
Beighton score
(4/9 warrants further investigation)
Passively dorsiflex 5th MCP to >90 (Gorling’s sign) (1 point for L+R)
Passively touch forearm w/ thumb when flexing wrist (1 point for L+R)
Hyperextend elbow >10 degrees (1 point for L+R)
Hyperextend knee >10 degrees (1 point for L+R)
Place palms flat on floor without bending knees (1 point)
MOI AC separation
Direct impact over superolateral shoulder, forcing AC joint inferiorly
Injury occurs from depression of scapula
Physical for AC separation
Shoulder exam
Deformity (step off) of AC joint with type 3 + higher
Piano key sign (type 3 + 4 may have instability of lateral clavicle when depressed manually)
Pain w/ adduction
Cross body adduction test (pain = positive)
Ix for AC separation
XRs - true AP, scapular Y, lateral, axillary view (needed to assess posterior displacement of distal clavicle)
Zanca view good for assess AC joint
DDx for AC separation
Fractures of coracoid, acromion, clavicle
Rotator cuff injuries
SLAP lesion
Labral tear
GH dislocation
Brachial plexus injury
Management of AC separation
Type 1 + 2 = conservative (sling x1 wk, activity modification, ice, NSAIDs, PT w ROM exercises)
Type 3 = conservative first but may need surgery
Type 4, 5 + 6 = surgery
RTP for AC separation
When full, painless ROM + normal strength
Usually 6wks-6mo
What is a SLAP tear?
Superior labral tear from anterior to posterior (shoulder)
MOI for SLAP tear
Can be acute or chronic
Acute: compression d/t fall on outstretched arm or onto adducted shoulder, traction from swift pull, humeral head shearing (seatbelt)
Chronic: throwing/ overhead activity
What are the 4 most common types of SLAP lesion?
Type 1 = degenerative fraying of labrum
2 = detached labral/ biceps complex
3 = bucket handle tear
4 = bucket handle tear w/ extension into biceps tendon
RF for SLAP tear
Repetitive overhead motion
Shoulder instability or trauma
Underlying laxity
Hx + sx for SLAP tear
Non specific shoulder pain
Commonly anterior/ superior
Catching, clicking, popping
Decreased performance (reduced strength, accuracy)
Sense of instability
Physical for SLAP tear
Shoulder exam
O’Brien (compression rotation) test positive
Speed test positive
Yergasons positive
Ix for SLAP tear
MRA best, then MRI
GH arthroscopy is gold standard
DDx for SLAP tear
GH OA
Rotator cuff impingement, tendinopathy, tear
Biceps tendinopathy, tear
Shoulder instability
AC joint OA
Cervical radiculopathy
Management of SLAP tear
Conservative but may need surgery if no improvement in 3-6mo
Relative rest, PT, NSAIDs
Surgery - debridement, SLAP repair, subacromial decompression
Post op care: sling x4 wks, ROM exercises, PT
Rotator cuff strengthening
Scapular stabilizer strengthening
Posterior capsule strengthening
RTP SLAP tear
2-6mo
Prevention of SLAP tear
Monitoring pitch counts in youth
Ensure proper overhead mechanics
Pathology of adhesive capsulitis
Thickening, fibrosis + contraction of GH joint capsule
RF for adhesive capsulitis
Shoulder immobilization
Diabetes
Thyroid dz
Stroke
Females
Age 40-70
Types of adhesive capsulitis
Primary
Secondary (following trauma, immobilisation, systemic illness)
Hx + sx adhesive capsulitis
Progressive shoulder pain
Worse w/ any movement (passive + active)
Pain worse at night
Functional impairment
Physical of adhesive capsulitis
Decreased ROM + pain
Phases of adhesive capsulitis
1 = painful, insidious onset nocturnal pain, no ROM impairment - lasts 2-9mo
2 = progressive limitation of ROM in all directions - lasts 4-12mo
3 = thawing, sx gradually improve over 5-24mo
DDx of adhesive capsulitis
Rotator cuff pathology
Impingement syndrome
Biceps tendinopathy
OA
Cervical radiculopathy
PMR
Management of adhesive capsulitis
Spontaneously recover
Treatment focused on sx control - NSAIDs, steroid inj, PT, suprascapular nerve blocks
CH ligament hydrodilatation
Surgery: manipulation under anesthesia or capsular release
Time frame for recovery
18-30mo
RF activities for Suprascapular nerve palsy
Volleyball - particularly “floating serve”
Overhead throwing
MOI for Suprascapular nerve palsy
Traction injury (repetitive overhead activity)
Compression from cyst, tumor, ligament
Direct trauma (scapular #)
Iatrogenic (eg during repair of rotator cuff tear or SLAP tear)
What is the suprascapular nerve and what does it supply?
Arises from trunk of brachial plexus at Erb point
Carries fibers from C5 + 6
Innervates supraspinatus + AC + GH joints
Sx of distal vs proximal Suprascapular nerve palsy
Distal vs proximal
Distal - painless, infraspinatus atrophy, weakness of external rotation
Proximal - pain in posterior/ lateral shoulder, weakness + atrophy of supraspinatus + infraspinatus
Physical for Suprascapular nerve palsy
Shoulder exam
Infra + supraspinatus atrophy
Resisted external rotation weakness
Positive Jobe (empty can) test for supraspinatus
Tenderness on palpation of scapular notch
Ix for Suprascapular nerve palsy
XR neck + shoulder
Magnetic resonance neurography is gold standard
EMG nerve studies - wait min 3-4 wks after onset of sx
DDx for Suprascapular nerve palsy
Cervical radiculopathy
Brachial plexus injury
Rotator cuff pathology
Labral pathology
Parsonage-Turner syndrome (Brachial neuritis - sudden severe pain then weakness)
Management of Suprascapular nerve palsy
Conservative management unless there is a lesion causing nerve ocmpression
Rest from overhead activity
PT for strengthening external rotation and stabilize scapula
NSAIDs
Origin of Axillary Nerve
C5-6 rami, branch of posterior cord of brachial plexus
MOI of Axillary Nerve Injury
Traction injury during anterior dislocation or fracture
Compression injury d/t direct blow to anterolateral deltoid
Quadrilateral space syndrome
Iatrogenic during shoulder surgery
RF for Axillary Nerve Injury
Anterior shoulder dislocation
Humeral head #
Hockey, football, rugby
Repetitive overhead sports
Hx + sx of Axillary Nerve Injury
Easy fatigability w/ overhead activities
Decreased strength w/ shoulder abduction
Paresthesia or numbness in lateral upper arm
Physical for Axillary Nerve Injury
Shoulder exam
Deltoid or teres minor atrophy
Weakness in shoulder abduction (deltoid)
Weakness in external rotation (teres minor)
Tenderness to palpate posterior shoulder in quadrilateral space
Ix for Axillary Nerve Injury
XRs - shoulder + C spine
MRI
EMG studies - min 3 wk after onset
DDx for Axillary Nerve Injury
Brachial plexus syndrome
Cervical radiculopathy
Management of Axillary Nerve Injury
Non operative initially
ROM
Relative rest
Strengthening
Avoidance of triggering activity
Electrical stimulation of deltoid to prevent atropy
Surgery if no improvement in 3-6mo
RF for Biceps Tendinopathy
Males
50-60 y/o
Repetitive use of upper limb
Hx / sx for Biceps Tendinopathy
Anterior shoulder pain localized over bicipital groove, may radiate distally
Pain aggravated by overhead activities
Physical for Biceps Tendinopathy
Point tenderness over bicipital groove w/ arm in 10 degrees internal rotation
Speed test positive
Yergason test positive
Upper cut test positive
Ix for Biceps Tendinopathy
MRI (best) or US
DDx of Biceps Tendinopathy
Rotator cuff tendinopathy
Impingement
Labral tear
Subacromial bursitis
AC separation
GH OA
Thoracic outlet syndrome
Pancoast tumor
Tumor at apex of lung causing arm weakness + shoulder pain
Management of Biceps Tendinopathy
Rest, ice, NSAIDs
ROM exercises
PT - scapular stabilization, rotator cuff + biceps strengthening, US waves
Surgery for refractory cases
MOI of clavicle # + common sports
Direct trauma, fall onto shoulder
Football, lacrosse, hockey
Physical for clavicle #
Ecchymosis or tenting over skin over #
Tenderness to palpate
Fracture motion or crepitus w/ palpation
Pulmonary + neurovascular exam
Ix for clavicle #
XR - AP, Zanca, axillary views
CT may be required
DDx for clavicle #
AC joint injury
GH dislocation
Rotator cuff tear
Humeral head #
Management of clavicle #
Non operative
Sling
ROM + active shoulder flexion to 40 degrees once pain improves
Avoid ROM >45 degrees of forward flexion until healed
Operative
Indications: displaced or shortened, comminuted middle-third #, distal clavicle #, neurovascular compromise, open #, tenting over skin
May be considered in young healthy athletes with goal of expediting RTP
1 wk after injury then every 2-4 wks until union occurs
XRs q4wks
Timeframe for recovery of clavicle #
Clinically within 6-8 wks
Radiographically 8-12 wks
RTP when radiographically healed for contact sports
Prevention of future clavicle #
Can use donut pads to protect clavicle from re-injury
MOI of humerus #
Humeral head: fall onto outstretched hand, high energy trauma in young or low energy trauma in old, excessive rotation of arm in abducted position, electric shock or seizure, pathologic # from mets
RF for humerus #
Elderly
Females
OP
Falls
Smoking
Steroids
RA
Sx of humerus #
Pain around greater tuberosity
Difficulty initiating active motion
Physical for humerus #
Shoulder exam inc neurovascular exam before and after immobilization
Arm adducted + held closely to chest
Shoulder effusion
Ix for humerus #
AP, scapular Y, axillary
May need CT
DDx for humerus #
Shoulder dislocation
Acute hemorrhagic bursitis
AC separation
Traumatic rotator cuff tear
Management of humerus #
Non operative vs surgical - refer to ortho
Surgery
Non operative
Sling x2 wks
PT
Closed reduction w/ ortho
RF for non union of humerus #
displacement, inadequate immobilization, aggressive rehab, pt non compliance, OP, alcohol use, smoking, steroids
Sx of Little League Shoulder
Months of progressive pain w/ throwing
Physical for Little League Shoulder
Tenderness over anterolateral proximal humerus
Weakness w/ resisted shoulder abduction, internal + external rotation
Ix for Little League Shoulder
XR - widening of proximal humerus growth plate
Management of Little League Shoulder
Rest from throwing x3-12mo
PT focused on rotator cuff strengthening
What is Thoracic Outlet Syndrome?
Neurogenic or vascular sx in upper extremity d/t compression of brachial plexus + subclavian vessels by skeletal or muscular structures above 1st rib and behind clavicle
Can be neurogenic (most commonly), arterial or venous
RF for Thoracic Outlet Syndrome
Repetitive overhead activity
Poor posture
Middle aged females
Cervical rib
Trauma
Obesity
Hx + sx of Thoracic Outlet Syndrome
Neurogenic or vascular sx associated w/ certain positions
Arm, shoulder, neck pain
Numbness or tingling (commonly in ulnar distribution)
Cramping
Motor weakness (late finding)
Gilliatt-Sumner hand (severe wasting of abductor pollicis brevis + hypothenar muscles)
Venous: edema, cyanosis, heaviness in hand, venous distension
Arterial: often asymptomatic until embolization occurs. Pallor, pain, paresthesias, coolness, decreased pulses
Worse w/ lifting heavy objects, overhead activities, shoulder abduction, external rotation
Physical for Thoracic Outlet Syndrome
Neurovascular exam of upper limb
Bruit in supraclavicular space
Provocative tests:
Adson’s Test
Purpose: Assesses compression of the subclavian artery by the scalene muscles.
Procedure:
The patient sits or stands with their arms relaxed.
The examiner palpates the radial pulse on the affected side.
The patient is instructed to extend their neck and rotate their head toward the affected side while taking a deep breath and holding it.
Positive Test: A decrease or disappearance of the radial pulse and/or reproduction of symptoms (e.g., pain, tingling, weakness).
Roos Test (Elevated Arm Stress Test)
Purpose: Assesses both vascular and neurogenic components.
Procedure:
The patient abducts their arms to 90°, externally rotates the shoulders, and flexes the elbows to 90°.
The patient then opens and closes their hands repeatedly for 3 minutes.
Positive Test: Inability to complete the test due to pain, heaviness, numbness, or tingling in the arms or hands.
Wright’s Test (Hyperabduction Test)
Purpose: Evaluates compression of the neurovascular bundle under the pectoralis minor muscle or the coracoid process.
Procedure:
The patient’s arm is passively abducted and externally rotated while the examiner monitors the radial pulse.
The patient may also be asked to turn their head away from the tested arm.
Positive Test: A decrease in radial pulse or reproduction of symptoms.
Ix for Thoracic Outlet Syndrome
Clinical diagnosis
If vascular, consider hypercoagulable workup
XRs of C spine + shoulder
MRI
EMG studies
DDx for Thoracic Outlet Syndrome
Cervical disc disorders
Rotator cuff pathology
Brachial plexus neuritis
Carpal tunnel
Ulnar nerve entrapment
MS
Management of Thoracic Outlet Syndrome
Conservative therapy except if acute vascular compromise or progressive neuro deficits or refractory sx despite treatment
NSAIDs
Muscle relaxants
Wt loss
PT - exercises + trigger point injection
Botox into scalene muscles
Postural retraining
Strengthening of muscles that elevate shoulder girdle
Pectoral + scalene strengthening + stretching
What is Lateral epicondylitis?
Tennis elbow
Overuse injury involving the extensor/supinator muscles that originate on the lateral epicondylar region of the distal humerus
More common than medial epicondylitis
Extensor carpi radialis brevis usually involved
MOI of Lateral epicondylitis
Repetitive strain or direct blow to epicondyle or sudden forceful pull or forceful extension or incorrect tennis play
Hx + sx of Lateral epicondylitis
Pain at lateral elbow, insidious onset
Acute pain w/ shaking hands, gripping objects, turning doorknob, pouring tear, sweeping
Triggers - new racquet, new backswing, new string tension, increased playing
Physical for Lateral epicondylitis
Point tenderness over lateral epicondyle
Pain w/ Cozen’s test (pain w/ passive wrist flexion and resisted extension)
Tenderness w/ resisted middle finger extension
Tender w/ resisted supination
DDx for Lateral epicondylitis
PIN entrapment
Radial tunnel syndrome
C7 radiculopathy
Humeral #
Radial head #
Posterior pinch syndrome/ plica of elbow
OA elbow
Loose body
OCD of capitellum
Management of Lateral epicondylitis
NSAIDs, ice, relative rest
Steroid inj
Counterforce elbow brace
Wrist splints (use at night)
Taping during activity
PRP, prolotherapy, topical nitrates
Refer for surgery if no improvement in 6mo
PT - laser therapy, dry needling
Ortho for decompression/ release surgery
Prevention of Lateral epicondylitis
Reduce playing time
Learn proper technique
Strengthen muscles
Proper equipment (racquet size, string tension, dry tennis balls)
RF for Lateral epicondylitis
More common in women
>40 y/o
Smoking
Obesity
Poor technique
Playing tennis >2hrs daily
Backhanded hitting style
Common in carpenters, labourers that swing a hammer/ tool
Hx + sx of medial epicondylitis
Gradual onset
Pain + tenderness along medial elbow
Difficulty gripping
Decreased wrist strength
Physical for medial epicondylitis
Tender over medial epicondyle
Resisted wrist flexion + pronation causes pain
DDx for medial epicondylitis
Ulnar neuritis
Cubital tunnel syndrome
Inflammatory arthritis
Cervical radiculopathy
Thoracic outlet syndrome
Management of medial epicondylitis
NSAIDs, ice
Elbow strap or counter-force brace
Wrist splint if pain on wakening
Nitro patch
OT, PT
Can consider steroid injection
Stretching + strengthening
Wrist extension + flexion curls, forearm pronation + supination, gripping, finger extension (using rubber band around fingers)
RF for medial epicondylitis
More common in non-overlapping grip (baseball), rock climbers
Racquet sports, tennis, golf, throwing
RF for biceps tendon rupture
Males
Age >30
Anabolic steroid use
Smoking
Pre-existing biceps or rotator cuff tendinopathy
Commonly associated conditions w/ biceps tendon rupture
Supraspinatus + subscapularis tears
SLAP lesions
Types of biceps tendon rupture
Distal bicep tendon ruptures are only about 10% of all bicep tendon ruptures
The vast majority are proximal ruptures of the long head of the biceps tendon, which do very well without surgical intervention and result in minimal strength loss.
MOI for biceps tendon rupture
Happens when elbow is eccentrically loaded suddenly. Ex: unloading an item from the back of a truck that falls into your arms, causing your bent elbow to suddenly straighten.
Sx of biceps tendon rupture
Patients may feel a painful “pop” at the time of injury
Pain - usually more proximal
Weakness is most noted with supination (can’t turn doorknob)
Patients often notice the change in appearance of their bicep contour
Physical for biceps tendon rupture
Distal
Bruising, often medial elbow
Loss of strength in resisted elbow flexion + supination
Reverse Popeye sign
Hook test: With an intact distal biceps, you can hook your finger under the bicep tendon from the lateral side when their elbow is flexed 90 degrees and they are actively supinating. There is nothing to “hook” in a distal bicep rupture.
Biceps squeeze test positive
Proximal
Popeye sign (visible lump deformity in midupper arm)
Motor function usually preserved
Positive Speed + Yergason tests
Management of biceps tendon rupture
Proximal
Immobilization in posterior elbow splint w/ elbow at 90 degrees + forearm in full supination
Passive ROM exercises
Strengthening at 4 wks
RTP 2-3mo
May warrant surgery in young athletes
Distal
Immobilization in posterior elbow splint w/ elbow at 90 degrees + forearm in full supination
Refer to ortho for surgery
Complications of biceps tendon rupture
Loss of elbow flexion + forearm supination strength
Causes of olecranon bursitis
Direct injury
Prolonged pressure (elbow leaning on table)
Overuse - repetitive flexion of elbow
RA
Sx of olecranon bursitis + hx qs
Pain
R/O systemic infection
Physical for olecranon bursitis
Elbow exam
Normal ROM
Bursal swelling
Ix for olecranon bursitis
US
If systemic sx, do joint aspirate for gram stain, C+S
Management of olecranon bursitis
Non septic - stiff elbow pad, NSAIDs
If ?septic - aspiration, abx
RF for ganglion cyst
Females
Repetitive strain of hand + wrist
Sx of ganglion cyst
Painless cyst over joint or tendon sheath
Can be painful if causing compression
Physical for ganglion cyst
Firm smooth mass
Usually fixed to deeper structures
Readily transilluminates
DDx for ganglion cyst
Epidermal inclusion cyst
Lipoma
Rheumatoid nodule
Tophus
Management of ganglion cyst
Often spontaneously resolve
Aspiration but high risk of recurrence
Surgery but higher risk of complications
What is De Quervain Tenosynovitis?
Stenosing tenosynovitis of 1st dorsal compartment of wrist
RF + common sports for De Quervain Tenosynovitis
30-50 y/o
Females
Pregnancy
Golfing, wrestling, racquet sports, javelin
Excessive cell phone use
MOI for De Quervain Tenosynovitis
Overuse
Direct trauma
Sx of De Quervain Tenosynovitis
Pain along radial styloid
Aggravated by moving wrist or thumb
Physical for De Quervain Tenosynovitis
Tenderness on palpation of APL + EPB tendons
Positive Finkelstein test (ulnar deviation of hand + thumb)
DDx of De Quervain Tenosynovitis
Thumb carpometacarpal OA
Radial styloid #
Scaphoid #
Radial neuritis
Management of De Quervain Tenosynovitis
Rest, ice, splinting, NSAIDs
Steroid shot into 1st dorsal compartment - works well
Refer for surgery if conservative therapy fails >3mo
Red flags on exam indicating C spine myelopathy (cord compression)
hyperreflexia, Babinski sign, ankle clonus, Lhermitte sign, lower extremity weakness, muscle atrophy in bilateral hands, gait disturbance
What are the Waddell signs + what is it for?
To assess for nonorganic causes of back pain (psychological, socioeconomic)
Superficial tenderness w/ palpation but nonanatomic over large area
Axial loading causing LBP
Rotation of hips + shoulders together causing LBP
Formal SLR positive but distracted SLR not positive
Glove + stocking sensation loss
