MSK Exam Flashcards
Supraspinatus Tendinopathy pain motion
Flexion abduction
Infraspinatus tendinopathy pain motion
ER
PT interventions with Tendinopathy
-correct altered movement
-scapular taping
-functional training
-sports specific training
Types of Full thickness RTC tear
Horizontal AP may involve more than 1 muscle
Longitudinal ML may involve just one muscle will do better with surgery and recovery
Rotator Cuff injury test item cluster
- Drop arm sign
- Painful arc + pain/catching between 60-120
- Infraspinatus with resisted ER at side + pain weakness lag
3 tests positive and age greater than 60 positive LR of 28
Ideal pt for successful RTC repair
-<65 age
-non smoker
-non DM
-repair done within 3 months of MOI
-minimal fatty infiltrates into RTC muscles
-less than 2 tendons torn
Why would you use an anatomical shoulder repair
-function RTC
-limited glenoid deformity
Why would you use a reverse shoulder repair
major rotator cuff pathology
Glenoid deformity
functioning deltoid
Do young athletes have good outcomes after TSA?
Yes near normal ranges for strength and function if rotator cuff was functioning prior to surgery
What is the most common age range for shoulder instability?
<20 yrs old 66-100%
Instability is defined as a clinical syndrome that occur when laxity produces____.
Symptoms
During end range of motion what is holding the glenoid/humerus complex
rotator cuff/biceps- dynamic
GH ligaments- static
At rest what is holding the glenoid/humerus complex in place
Negative pressure
TUBS
Traumatic
Unilateral
Bankart
Surgery
AMBRI
Atraumatic
Multidirectional
Bilateral
Rehab effective
Inferior shift
Explain the onset of anterior instability and if its common
90% of instability anteriorly
unidirectional and traumatic onset
Explain the onset of posterior instability and if it is common
2-10% most common with MVA or repetitive loading bench press
Explain Multidirectional instability
not associated with traumatic episodes
more acquired laxity- may have a connective tissue disorder
Most common in young women with hypermobility
Explain what the Rotator interval is and its relation to stability
interval between the subscapularis tendon and the supraspinatus tendon
related to stability
Best test cluster for MDI
sulcus sign
load and shift
arc of pain
history
What specific Pt education is necessary with MDI patients and generalized laxity?
there needs to be constant time investment, compliance and maintenance to show improvement
need to include dynamic stability
What is a bony bankart?
labrum damage and glenoid damage after traumatic dislocation
What is a soft bankart?
labrum damage only after traumatic dislocation
what is a hill sachs lesion?
when the posterior superior aspect of humeral head sustains a compression fracture after dislocation
What is the most common sequela after traumatic anterior shoulder dislocation?
reoccurance up to 90% for 11 to 20 yrs of age
Bankart lesion
length of immobilization, avoidance of overhead activities and supervised pt had no effect
What is the single best test for anterior shoulder instability?
apprehension/relocation
What are the 4ps for PT treatment of GH dislocation
- GH protectors- supra, infra, teres
- Scapular pivoters- trap, rhomboids, serratus
- Humeral positoners- deltoid
- Humeral propellers- pec and latt
A score of greater than 5 on the instability severity index puts a pt at a higher risk of dislocation what are these factors there are 6
- age
- loss of glenoid contour
- hill sachs lesion
- competitive sports individual
- contact sport/overhead
- shoulder hyperlaxity
What are the top 4 prognostic factors for surgery failure after dislocation.
- glenoid bone loss
- competitive sports participation
- hill sachs lesion
- age
What motion does the MGHL restrict
ER at 45 degrees of abduction
What motion does the IGHL complex restrict
ER at 90 degrees of abduction
What is the MOI for a superior glenoid labrum tear?
superior labrum can be torn from repetitive overhead activities, trauma, sudden avulsion, entrapment, hypermobility or instability
Best cluster to determine a tension SLAP
biceps load II
resisted supination ER test
Best cluster to determine a compression SLAP
crank/clunk
compression rotation
dynamic sheer
Are SLAP tears manageable with conservative treatment?
Yes up to 85% successful with non-op care
What 3 things need to be avoided after a SLAP repair
avoid aggressive early exercise and ROM
NO forceful stretching into ABD/ER
NO resistance with biceps in SLAP lesion
The following test cluster has a good ____ active compression test, throwers test, groove palpation to determine if a pt has biceps labrum pathology
sensitivity if negative good rule out
The following test clusters have a good ____ speeds test, yergasons test to determine if a pt has biceps labrum pathology
Specificity if positive rule in
Explain the difference between tenodesis and tenotomy for the biceps
tenodesis- reattachment of the biceps
no resisted elbow flexion for 6-8 weeks
Tenotomy- resection of the biceps
no precautions
With a grade 3 shoulder separation what ligaments are torn?
acromioclavicular
coracoclavicular- trapezoid and conoid
What are the common features of adhesive capsulitis?
gradual onset
pain near the insertion of the deltoid
inability to sleep on affected side
painful and restrictive active and passive ROM
normal radiologic appearance
What are the Risk Factors for Adhesive Capsulitis
women>men
Diabetes
Thyroid dysfunction
age 40-65
previous episode of adhesive capsulitis
What are the 4 stages and time frame for adhesive capsulitis
stage 1: 0-3 months
stage 2: 3-9 months freezing stage
stage 3: 9-15 months frozen stage
stage 4: 15-24 months thawing phase more stiff doesn’t hurt
Is passive stretching and mobilization good for individuals with frozen shoulder?
study showed that supervised neglect pt showed greater improvements
How should we rule in adhesive capsulitis
- age 40-65
- pt reports gradual onset
- pain and stiffness sleeping, ADLS
- GH PROM limited in multiple planes
- PROM to end range reproduce pt symptoms
- GH mobility glides limited in all direction
no radiological evidence of arthritis
associated diagnosis shoulder pain with mobility deficits
subacromial pain syndrome
adhesive capsulitis
associated diagnosis shoulder pain with radiating pain
TOS
Cervical radic
Associated diagnosis shoulder pain with movement coordination
Subacromial pain syndrome
MDI: bankart
SLAP
Tendonosis
Associated diagnosis shoulder pain with muscle force production deficits
rotator cuff tear
subacromial pain
What is the primary muscle involved in lateral epicondyalgia?
extensor carpi radialis brevis
Lateral epicondyalgia also known as ___
Tennis elbow
inflammation of the common extensor tendon
If a younger patient is presenting with common sx of lateral epicondylalgia what do you think?
elbow Apophysitis is an inflammation or stress injury to the areas on or around growth plates in children and adolescents.
avoid heavy slow resistance
What should be ruled out with lateral elbow pain?
Cervical radiculopthy
TOS
Radial tunnel syndrome
Radial head injury
What muscles are involved in medial epicondylagia
flexor carpi ulnaris
flexor carpi radialis
pronator teres
Medial epicondylagia is also known as ___.
Golfers elbow/pitchers elbow
What needs to be ruled out in medial elbow pain
laxity in the ulnar collateral ligament
Cervical spine
what is the risk factors for osteochondritis dessicans
-associated with gymnast and throwing
-trauma
-age 15-20
- Males>Females
what are the signs and symptoms of Osteochondritis dessicans
joint effusion
pain with activity locking
constant pain, ADL impairment
what is snapping elbow?
lateral elbow pain with palpable/audiable snapping during flexion/extension
What should be ruled out in snapping elbow?
posteriorlateral instability
lateral epicondylagia
OCD with loose body
what is the MOI and most common elbow dislocation direction
posterior due to a hyperextension force
What should you do before you reduce an pts elbow dislocation?
get imaging to make sure that there are no additional fractures most common addition fracture is the coronoid fracture
What are the ROM progressions based on age/tissue after elbow surgery?
younger-immobilize longer
older- earlier AAROM to prevent stiffness and contractures
What are some common complications with elbow dislocations?
fracture
laceration of brachialis and biceps
ulnar/median nerve injuries
brachial artery injury
flexion contracture
myositis ossificans- calcium deposite in brachialis
What is the MOI and risk factor group for biceps tendon rupture?
males
age 50
sudden contraction against a significant load
During late cocking of acceleration for throwing what force is seen at the elbow joint and what ligament does this impact
valgus force
ulnar collateral ligament- provides stability at 20-130 degrees of motion
If there is disruption of the UCL and medial instability what two other things occur at the elbow joint?
- posteriomedial compression injury
-impingement of medial olecranon on trochlea and olecranon fossa - lateral compression injury
-impingement of the radial head on capitulum
what can posterior medial compression and lateral compression lead too?
chondromalacia- breakdown of tissue cartilage
osteophyte formation
OCD
Loose bodies
An xray is needed if a pt has elbow trauma and one of the following to rule out a fracture
- unable to fully extend elbow
- bony tenderness
-raidal head
-medial epicondyle
-lateral epicondyle
-olecranon process - bruising ecchymosis around the elbow
When is the volume of the cubital tunnel the largest?
when the elbow is in full extension
What nerve runs through the cubital tunnel
Ulnar nerve
In severe cases of cubital tunnel what observations may you see in the hand?
- atrophy of the ulnar intrinsic muscles on hypothenar eminence
- clawing of ring and small fingers
Special test to test for Cubital Tunnel
- elbow flexion test
- shoulder IR test
- tinels sign
- froments sign
- wartenburgs
What is the MOI and signs/symptoms of high radial nerve palsy
most common during midshaft humeral fracture
SS: loss of wrist extension (wrist drop)
loss of finger/thumb extension
loss of sensation in first dorsal web space
What is the MOI and signs/symptoms of radial tunnel syndrome?
compression of deep radial nerve branch at the supinator
may mimic tennis elbow but 5cm distally
weakness, aching cramping
difficulty extending wrist, thumb fingers
difficulty grasping objects
Special tests for radial tunnel
third finger sign at radial tunnel
reproduction of symptoms with direct pressure over nerve
What is the MOI and signs and symptoms of pronator teres syndrome?
compression of median nerve between pronator teres insertions
paresthesis following a median nerve distribution
no nocturnal symptoms (unlike CTS)
associates with repetitive activities like car mechanic
What is the MOI and signs and symptoms associated with anterior interosseous syndrome
compression of median nerve in the muscle bellies of the pronator teres
SS: pt will be unable to make the OKAY sign
sensory testing is normal
weakness is major complaint
Explain positive and negative ulnar variance
positive ulnar variance creates more weight bearing in the ulnar portion of the wrist may be more likely to have compression injury
negative ulnar variance leads to increase load through the radius and creates lack of stability on the ulnar side of the wrist
Explain the different functional arches in the hand
2 transverse arches
1 longitudinal arch
this allows for fingers and thumb to hold objects in hand
Explain the extensor mechanism in the hand
complex tendon that creates a pulley system to extend the MCP and IPs allows intrinsics to assist in extension
What happens if a pully tendon ruptures in the hand?
leads to a tendon bowstringing
Explain the function of the flexor retinaculum
-roof of carpal tunnel
-protects the median nerve
-prevents bowstringing of flexor tendon
-helps preserve the transverse arch
Explain the function of the extensor retinaculum
-prevents bowstringing of the extensor tendons
-creates the 6 extensor compartments
What bones are attachments for the flexor retiaculum?
scaphoid
hamate
pisiform
trapezium
What is in extensor compartment 1 and 3
compartment 1: abductor pollicis longus extensor pollicis brevis
compartment 3: extensor pollicis longus
Describe the MOI of colles fracture
dorsal displacement of the distal radius
FOOSH
Describe the MOI of a smith fracture
volar displacement of the distal radius
fall on the back of the hand
What is the most common carpal fracture and how should it be managed?
scaphoid fracture
xray doesn’t show line for a few weeks
treat as if it is fractured and return to imaging in 2 weeks
What are the clinical signs of a scaphoid fracture and what are we worried about? is it high sen or spec?
- tenderness in anatomic snuff box
- tenderness over scaphoid tubercle
- pain with a longitudinal compression of the thumb
high sensitivity if all three are negative rule out
If a metacarpal is immobilized how is it casted and why?
casted at 60-70 degrees of flexion for the prevention of collateral ligament contractures
What are some complications following a fracture in the hand?
-malunion
-non union
-avascular necrosis
-tendon injuries
-tendon ruptures
-nerve damage
-secondary OA
-stiffness
-loss of grip strength
What is the prevalence of OA in the hand and is it more common in men or women?
women and over 80% in elderly population
which joints are most affected with OA in the hand?
DIP—– 1st CMC & PIP—- MCP
Where are heberden and bouchard nodes found
OA
heberden: DIP
bouchard: PIP
what is the leading cause of pain in the hand? and what is the special test?
1 CMC OA
1st CMC grind test
What is the difference between RA and OA?
RA is an inflammatory disease that destroys soft tissue, articular surface and bone most often affects the MCP and the PIP can result in Ulnar drift
often has fatigue and morning siffness longer than 1 hour
name the location of a swan neck and a boutonnière deformity?
swan neck: extension of volar plate
boutonnière: flexion volar plate
Describe the MOI and SS of De Quervains tenosynovitis?
MOI: progressive compression entrapment of Abductor pollicis longus and extensor pollicis brevis
special tests: ecchoffs and WHAT
If a patient cannot actively flex or extend in the hand and you suspect a tendon laceration or rupture what should you do?
refer
Explain MOI and SS for skiers thum
tear of ulnar collateral ligament of the thumb
pain in webspace pinch weak
grade 1-3 depending on laxity
Explain the MOI and SS of TFCC
FOOSH or repetitive rotational loading
pain in ulnar region with grip and rotation
If you get a positve scaphoid shift what should you do
refer to orthopedic because have potential to progress to OA and scapholunate advanced collapse
Explain carpal tunnel MOI and SS
most common compression in UE
median nerve compression
Who is at greater risk for carpal tunnel?
female>male
45-59
size of tunnel
obesity
smoking/alcohol use
What are the special test for carpal tunnel and high spin or snout?
tinels
phalens
carpal compression
high spin specificity rule in
What is the CPG for carpal tunnel
shaking hands for sx relief
wrist ratio >.67
hand severity scale >1.9
diminished sensation median nerve
age >45
Acording to the new Carpal tunnel CPG what should you not do?
do not asses lateral pinch strength
do not asses grip strength <3 months post carpal tunnel release
do not use low level laser, iontophoresis
What is the 6 item CTS symptom scale for Carpal tunnel
- numbness in median nerve distribution
- nocturnal numbness
- thenar muscular atrophy
- positive tinels sign
- positve phalans
- loss of 2 pt dicrimination
What is Guyon canal syndrome?
ulnar nerve entrapment or compression
cause is pressure or trauma
decreased sensation in ulnar nerve distribution
froment sign
wartenberg sing
tinnels sing
grip strength
