Midterm Flashcards
What is the cause of primary impingement?
pathological narrowing of the subacromial space
What is the cause of secondary impingement?
anterior GH instability d/t repetitive overuse
What is the most common cause of shoulder pain?
impingement
What is the 3rd most frequently seen condition in general medical practice?
shoulder impingement
Structural risk factors for impingement? (4)
- acromial abnormalities 2. AC degeneration 3. altered tendon vascularity 4. calcification
Functional risk factors for impingement? (4)
- instability 2. muscular imbalance b/t int. rot./adductors and ext rot./abductors 3. tight posterior capsule 4. labral tears
Similarities in presentation of impingement for pts >35 and <35?
toothache-like pain, worse at night, worse after provoking activities
Differences in presentation of impingement for pts >35 and <35?
> 35 have shoulder weakness (d/t pain), often have crepitus, and can have complete tear of RCT w/ minor trauma
5 shoulder DDx’s?
- impingement 2. instability 3. bursitis 4. RCT 5. adhesive capsulitis
2 important DDXs to rule out w/ shoulder impingement?
- Cx sprain/strain d/t CAD 2. RA (look for bilateral Sx)
What is Neer’s pathogenesis?
3 stages of shoulder impingement
What is the first stage of Neer’s pathogenesis? Age range?
edema and tendinitis. More common in pts under 25
What is the second stage of Neers pathogenesis? Age range?
chronic inflammation, fibrosis of impinged tendon. More common in pts 25-40
What is the third stage of Neers pathogenesis? Age range?
tendon degeneration, rupture, arthritis. More common in pts over 40
Which stages of Neers pathogenesis are responsive to conservative care?
1 and 2
Physical exam: painful arc, painful active int. rot, tenderness, (+) modified Neers, Hawkins-Kennedy, possibly crepitus or instability. Dx?
shoulder impingement
T/F: superior translation and/or internal rotation of the humerus along with scapular protraction are considered “good” movements.
False
What is the difference between Tx for impingement vs. RTC?
for impingement, pt should be especially careful flexing and/or abducting the GH jt over 90 degrees
What other Tx has been shown to be effective for subacromial syndrome?
acupuncture
Are steroid injections effective for tx of impingement?
mixed results - may improve pain and function but no more effective than NSAIDs or PT
What is more effective for impingement syndrome: surgery or active, non-surgical tx?
active non-surgical tx
What is defined as “impingement d/t repetitive flexion, adduction, and internal rotation?”
swimmer’s shoulder
What Tx advice should you include for a pt with swimmers shoulder?
technique changes (avoid crossover and internal rotation, increase body roll toward pulling side of stroke)
What are the 3 types of instability?
- traumatic 2. atraumatic 3. acquired
what is the most common cause of dislocation?
traumatic P-A force with arm abducted and externally rotated
What is the Tx for a dislocation?
sling and refer (return for rehab)
What is the best method for relocating an anterior dislocation?
FARES method
What are the three anterior instability tests (performed in a cluster)?
anterior apprehension, relocation, release
What are the 2 posterior instability tests?
posterior apprehension, Norwoods
How do you interpret instability tests? (What is more predictive?)
apprehension is more predictive than pain
What are the conservative tx goals for shoulder instability? (4)
- improve scapular and clavicular ROM 2. strengthen rotator cuff 3. improve shoulder proprioception 4. activity/lifestyle modifications
5 common causes for poor response to conservative tx for instability?
- biceps tendinitis 2. rotator cuff tendinitis 3. shoulder impingement syndrome 4. subacromial bursitis 5. labral tears
When is surgery necessary (for shoulder instability)?
moderate to severe cases. Depends on labral damage
What is defined as “a syndrome characterized by shoulder pain and marked restriction of both active and passive GH ROM?”
adhesive capsulitis
How is the loss of AROM from adhesive capsulitis characterized?
“capsular pattern”
Which gender is more likely to have adhesive capsulitis?
females
Age group for adhesive capsulitis?
40-60 yrs
Common risk factors for adhesive capsulitis? (9)
- idiopathic 2. immobilization 3. chronic shoulder/AC Sx 4. shoulder/AC surgery 5. chronic neck Sx 6. diabetes 7. dupuytrens contracture 8. CRPS 9. Autoimmune
What are the 3 stages of adhesive capsulitis pathophysiology?
1 = freezing 2 = frozen 3 = thaw
time frame for stage 1 of adhesive capsulitis?
2 weeks to 9 mos
time frame for stage 2 of adhesive capsulitis?
4-12 mos
time frame for stage 3 of adhesive capsulitis?
6 mos - 2yrs
Primary symptom of stage 1 of adh. capsulitis?
PAIN (synovitis). AROM is diminished (PROM ok)
Sx of stage 2 of adh. capsulitis?
pain, diminished AROM and PROM
Sx of stage 3 of adh capsulitis?
pain gradually decreases, AROM slowly returns. marked capsular pattern of movement
What is the time threshold for sling use for adh capsulitis?
1 week
What are the 2 PROM exercises recommended for early adh. capsulitis Tx?
codmans arm swings, table/wall walking.
what PROM exercises should you add for adhesive capsulitis in late tx?
broomstick and towel stretching (NO buddy stretching)
What will contrast MRI show in a pt with adh. capsulitis?
diminished jt cavity size
What % of adh. capsulitis cases self-resolve w/in 2 years?
60%
How long is some degree of pain and stiffness common in adh. capsulitis (after Dx)?
5-10 years
Adhesive capsulitis may be assoc. with an increased risk of what condition?
stroke
What is the most commonly affected tendon for calcific tendonitis?
supraspinatus
Why is the distal rotator cuff tendon more prone to calcific tendonitis?
poorly vascularized
What is calcific tendinitis aka?
hydroxyapatite deposition disease (HADD)
Which gender is more likely to have calcific tendinitis?
women
What age group is more likely to have calcific tendinitis?
40-60 yrs
What are the 2 types of calcific tendinitis?
type 1 = idiopathic type 2 = metabolic
Which type of calcific tendinitis is most common?
type 1 - idiopathic
Which arm is more likely affected with calcific tendinitis?
Non-dominant arm
What is the usual mech of injury with calcific tendinitis?
unclear - rarely related to a specific event
onset of calcific tendinitis - rapid or gradual?
acute, rapid onset
What condition does the onset of calcific tendinitis resemble?
gout
Is calcific tendinitis worse in the AM or PM?
worse at night - positional night pain
How is calcific tendinitis definitively dx’ed?
via plain film radiographs comparing int. and ext. rotation
when should you perform cross-fiber massage and myofascial release for calcific tendinitis?
only in latent phases of condition
which PT modalities have been shown to improve pain and function in calcific tendinitis?
US and extracorporeal shock wave therapy (ESWT)
What are the most likely causes of bicipital tendonitis?
impingement and subluxating tendon syndrome
What is primary bicipital tendonitis?
isolated inflamm. of tendon w/o any assoc. shoulder pathology
What is secondary bicipital tendonitis?
inflamm. assoc. w/ shoulder pathology such as impingement syndrome or RCT
What population most commonly gets bicipital tendinopathy?
athletes aged 18-35
bicipital tendon rupture is most common in what age group?
over 50
Bicipital tendonitis etiology? (3)
- repetitive overuse 2. assoc. shoulder pathology 3. inflamm. conditions affecting the GH jt
risk factors for complete rupture of biceps tendon? (6)
- history of RCT 2. recurrent tendonitis 3. contralateral biceps tendon rupture 4. RA 5. age >40 6. poor conditioning
Usual presentation of biciptal tendinopathy?
deep throbbing ache in anterior shoulder (usually in bicipital groove), with radiation to deltoid tubercle and/or anterior elbow
Is bicipital tendinopathy worse in AM or PM?
night pain
What is “popeye sign”?
bulge above elbow d/t distal msl retraction
Which tests have been established to clearly diagnose or r/o specific shoulder pathologies?
no individual physical exam test. (trick question!)
Which ortho tests are used to test for bicipital tendinopathy?
speeds test, hyperextension test, modified yergason
What are plain film radiographs used for regarding bicipital tendinopathy?
to rule out DJD and bony causes of impingement
What is imaging US used for regarding bicipital tendinopathy?
assess for biceps rupture, subluxation, or dislocation
what are MRI/CT used for regarding bicipital tendinopathy?
help ID rotator cuff or labral tears
What is injection of local anesthetic used for regarding bicipital tendinopathy?
to isolate bicipital tendinitis from rotator cuff tendinitis
What is the best first line approach to Tx for bicipital tendinitis?
conservative tx approach (POLICE, US, indirect light massage, activity modification)
When is surgery indicated for bicipital tendinopathy? (3)
- Sx persist after 3 mos of Tx 2. other shoulder conditions (instability, labral tears) develop 3. rupture is intolerable d/t interference w/ ADLs
Where is pain from the subscap tendon usually?
typically anterolateral w/ potential referral to wrist
what is the typical MOI for acute supscap tendonitis?
same as GH dislocation - P-A force
which ortho tests will be positive for subscap tendonitis?
(+) Napoleon and Hug tests
Maybe (+) Lift Off and Int. Rot. lag tests
What is the key to improving Sx of subscap tendinopathy?
trigger pt therapy (myofascial release also effective)
Which joints should you adjust for subscap tendinopathy?
scapulocostal, GH, AC (in addition to spine)
Which msls should be rehabbed for subscap tendinopathy?
all rotator cuff msls, in addition to biceps
What indicates a good prognosis for subscap tendinopathy?
No comorbidities
What indicates a poor prognosis for subscap tendinopathy?
impingement, instability, and/or labral tears present and not managed
What are the static AC stabilizers?
AC ligaments, coracoclavicular ligs
What are the dynamic AC stabilizers?
deltoid, trapezius, serratus anterior
What % of shoulder girdle injuries are AC sprains?
10%
Etiology of AC sprains? (4)
- direct trauma to posterolateral shoulder 2. FOOSH 3. distraction loading 4. insidious
Which grade of AC sprain will you see a step defect?
Grade 2 and above
What grade of AC sprain should be referred?
Grades 4-6
What condition may occur with repetitive heavy GH use (without trauma)?
AC osteolysis
Why should you refer a pt with AC osteolysis?
to rule out and monitor for other osteolytic processes
What three test bundle should you perform for AC sprain? (higher PPV)
Obriens, horizontal passive adduction, resisted horizontal abduction
Which condition are Paxino’s pinch and Dugas test used for?
AC sprain
conservative Tx for AC sprain?
POLICE, taping, mobilize if possible, GH exercises to tolerance
When should you sling an AC sprain?
both waking and non-waking hours, with “rest” periods - allow for as much AROM as possible
What are the 2 types of labral tears?
SLAP lesion, Bankart lesion
What is a SLAP lesion?
superior (A-P) detachment
What is a Bankart lesion?
anterior-inferior detachment
Which type of labral tear is more common?
SLAP lesion
What is the main cause of SLAP lesion?
repetitive use
What is the main cause of Bankart lesion?
dislocation
Which gender is more likely to have a labral tear?
male
Which arm is more likely to have a labral tear?
dominant arm
S/Sx of labral tear?
shoulder pain, popping/catching, positive labral tests, instability, Rot cuff weakness/tenderness
DDX for labral tear? (4)
RCT, impingement, biceps tendinopathy, instability
3 general labral tear ortho tests?
obriens, crank, clunk
3 ortho tests for SLAP lesions?
anterior shift, provocation, biceps load
What grade of labral tear should be referred for surgical consult?
grade 2 and above
When should you suspect a labral tear? (3)
- conservative Tx fails 2. recurring PAINFUL snapping/crepitus 3. overt instability
MFTPs in which msls can refer to the lateral shoulder/arm? (7)
SITS, scalenes, coracobrachialis, deltoid
MFTPs in which msls can refer to the anterior shoulder/arm? (8)
Supraspinatus, infraspinatus, biceps, scalenes, pecs, subclavius, coracobrachialis, deltoid
MFTPs in which msls can refer to the posterior shoulder/arm? (12)
SITS, levator, scalenes, serratus posterior, latissimus, teres major, coracobrachialis, triceps, deltoid
MFTPs in which msls can refer to the medial arm/elbow? (5)
subscap, lats, pecs, serratus anterior and posterior
MFTPs in which msls can refer to the lateral elbow? (8)
SITS, scalenes, subclavius, triceps, deltoid
MFTPs in which msls can refer to the wrist/hand? (11)
Supraspinatus, infraspinatus, subscap, scalenes, serratus anterior and posterior, Pecs, lats, coracobrachialis, brachialis, triceps
What is the age group at higher risk for RCTs?
over 50 yrs
Risk factors for RCTs? (4)
- previous steroid inj. 2. overweight/obesity 3. CVD 4. smokers
Where is pain usually localized to in RCTs?
anterolateral aspect of shoulder
Are all RCTs painful?
No - can be painless
What is the more common onset of RCT?
progressive Sx from repetitive overuse
What ortho tests are used to test for RCTs?
Apleys 1&2 (screening), Codmans arm drop, Lift Off, Trumpeters, Napoleon, Hug Test, Empty can
Which ortho test has a high PPV for RCT in pts over 60?
Codmans arm drop
Should pts with an RCT be given a sling?
systematic review showed complications from immobilization
What mobilization positions should be avoided with RCTs?
any that stretch the posterior cuff
On x-ray of an RCT, what is a diminished acromial-humeral interval (AHI) indicative of?
large tear
What is considered the gold standard for Dx of RCTs?
MRI
How quickly do mild RCTs heal?
1-4 weeks
How quickly do moderate RCTs heal?
2wks-1 year
How quickly do severe RCTs heal (without referral)?
2months - over 1 year
Are steroid injections beneficial for RCTs?
some benefit in ACUTE RCT, ineffective for CHRONIC
Is platelet rich plasma (PRP) effective for RCTs?
may be
Is surgery or PT more effective for improving pain and function at 1 year in small and medium RCTs?
Surgery
