Nonsurgical Shoulder Complex Pathologies Flashcards
When does the fibroplastic stage of healing occur and what is it?
it follows the acute inflammatory stage, can last up to 6 weeks, and is the laying down of new tissue
Fibroplasia physiology
endothelial and fibroblast cells form capiallary buds and collagen
the formation of a functional scar occurs
increase in viscoelastic properties of new tissues
Maturation
can occur for a year post-injury
tissue regains mechanical strength
restoration of normal functioning occurs
Referred Pain
- can be myotomal or dermatomal from C5 or sclerotomal (fascial)
- can be caused from scapula, thoracic, or cervical
- visceral pain: cardiac, pulmonary, GI (gallbladder!!!!)
4 different pathologies associated with rotator cuff disease
Impingement
tendonitis
bursistis
tendinopathy
T/F there are intrinsic and extrinsic factors for impingment
true
define impingement
compression of the subacromial contents due to the encroachment of the humerus into the coracoacromial arch
the subacromial space is formed by what and contains what?
formed by coracoacromial arch and humeral head
contains rotator cuff tendons, long head of biceps tendon, and subacromial bursa
factors for impingemnt can be divided up into what?
- intrinsic
2. extrinsic: primary and secondary
Intrinsic factors for impingement (3)
- changes in vascularity of supraspinatus (critical zone)
- cuff degeneration (microtears)
- muscle dysfunction
What are force couples and what is their purpose
groups of muscles that work synergistically but often in opposite ways. purpose is to stabilize the scapula.
excessive upward rotation of the scapula can cause impingement
General extrinsic factors for impingement
muscles imbalances poor motor control postural functional stressors anatomical abnormalities
extrinsic primary impingement factors are ____ in nature
anatomical
extrinsic primary factors for impingement )3)
acromion types
osteophytes
tight posterior capsule
extrinsic secondary factors of impingement are caused by what
instability
secondary extrinsic factors of impingement
poor force couples
postural deviations
poor motor control
a tight posterior capsule will push the humerus in what direction?
anteriorly and superiorly
Neer Stages of Impingement
Stage 1: edema and hemorrhage
stage 2: fibrosis and tendonitis
stage 3: degeneration of tendon
(stage 1 and 2 are the same for Jobe classification)
stage 1 impingement
edema and hemorrhage
usually due to overuse, pain with prolonged activity
stage 2 impingement
fibrosis and tendonitis
pain at rest and with activitiy
mild strength loss
stage 3 impingement Neer
degeneration of tendon
partial tear
changes in RTC muscles
weakness, decresed ROM and fxn, pain
difference between stage 3 and 4 impingement for Jobe
stage 3= small tear
stage 4 = large tear
pain with tendonitis occurs with active or passive motion?
active!
Tendinitis occurs due to what?
repetitive stress, especially overuse and eccentric contractions
tendinitis primarily effects what 2 muscles?
supraspinatus and long head of biceps, but can effect any of RTC muscles
tendinitis presentation
pain with palpation and motion
loss of ROM and strength
end feel is boggy, firm, mushy
5/5 strength presentation with tendonitis tells us what?
acute exacerbation of a chronic condition (painter example)
with regards to the critical zone, what muscle are we worried about the vascularization of?
supraspinatus
most commonly involved bursa with bursitis of shoulder?
subacromial bursa (located within the subacromial space)
Chronic ____ presents with the same symptoms as ____ and what are they?
chronic bursitis presents with the same sx as tendonitis. sx = pain with movement, pain with palpation, loss of ROM and strength
bursitis pain is with active or passive motion?
both! pain with active and passive motion
causes of bursitis
due to compression and/or irritation of the bursa
can also occur due to trauma: falling onto hands jams the humeral head into the acromion
Bursitis
acute is very painful
chronic is associated with tendonitis
present w/ pain w/ AROM and PROM, decreased ROM and strength, tenderness with palpation
etiology of RTC tear
due to cumulative stress or trauma (FOOSH, espc. older adults)
most commonly invovled muscle for RTC tear
supraspinatus
giveaway symptom for acute RTC tear
night pain!
RTC tear pain
pain with acute tear, may be diffuse but specific upon palpation
chronic or complete tear may not have pain
night pain very common overall
RTC tear
complete tear is palpable: firm and bony
ROM: look at quality of mvmt. often will substitute with abduction because supraspinatus does first 30 degrees
causes of adhesive capsulitis
idiopathic (insidious onset), can be due to trauma, post surgery, or neuropathic
who does adhesive capsulitis affect
females more than males, age 40-60
physical presentation of adhesive capsulitis
decreased scapulohumeral rhythm, less than 90-135 degrees elevation, 50-60% of normal ER
name the stages of adhesive capsulitis (4)
- pre-adhesive
- freezing
- frozen
- thawing
Pre-adhesive stage of adhesive capsulitis
gradually lose motion, may not be aware it is happening, pain with use, capsular end feel, minorly decreased ROM, commonly misdiagnosed
stage 1
freezing stage of adhesive capsulitis
stage 2
very painful!!!!
synovial thickening, trigger points, can last for several weeks (10-36), open end feel
frozen stage of adhesive capsulitis
stage 3
pain decreases, stiffness, weakness, lasts 4-12 months
thawing stage of adhesive capsulitis
lasts 5-42 months
decreased pain, increased ROM, end feel softens, increased functional use of UE
purpose of PT for adhesive capsulitis if it will resolve without PT?
reduce the overall amount of ROM patient will lose
keep patient functional
education on reoccurance - must do exercises for life
AC joint separation
occurs from falling on shoulder or FOOSH
we can treat type 1 and 2 conservatively via taping or bracing
can physically see separation in types 4,5,6
most common fracture type for UE
humeral
presentation of fractures
pain, limited ROM, altered scapulohumeral rhythm
non-displaced fracture will be immoblized in sling. no cast. can move it. work on ROM within first 2 weeks of injury to prevent adhesive capsulitis
presentation of labral tears
catching, popping, sx like impingement, instability, pain, scapular dyskinesia
SLAP stands for
superior labral anterior to posterior
most common type of SLAP leasion
type 2
can progress over time from 1-4
long head of biceps attaches to labrum
clicking, popping usually indicates what?
labral tear (Stage 3 or 4)
etiology of anterior shoulder instability
force into abduction and ER, FOOSH, posterior blow to shoulder
present with subluxation or dislocation
pathologies associated with anterior shoulder instability
anterior capsule lesions, bankart lesion, hill sach lesion, brachial plexus injury
Hill-SACH lesion
small compression fracture on posterior aspect of humeral head. occurs during an anterior dislocation. Technically the fracture is on the anterior aspect but it is considered posterior when in an abducted, ER position
posterior shoulder instability
force into IR and adduction
labral tear or reverse hill sach can occur or compression fracture of humral head
multidirectional instability is due to
occupational, recreational or congenital
throwers, swimmers, gymnasts
present similar to impingement with pain, potential subluxing
pathologies associated with multidriectional instability
loose labrum and multi-laxity of capsule
Snapping scapula
causes: bursistis, muscle imbalances, bony alignment, luschka’s tubercles (bump on superior medial border of scapula)
pain, crepitus, potential scapular winging
presentation of arthritis (OA or RA)
pain, joint deformity, decreased ROM and strength, functional impairments
chief complaint will be pain
what is thoracic outlet syndrome?
compression of the neurovascular bundle producing neurovascualr compromise. 90% is neurogenic ( rather than vascular)
etiology of thoracic outlet syndrome?
postural deviations, compression injuries, muscle hypertonicity of scalenes, cervical rib, soft tissue abnormalities
epidemiology of thoracic outlet syndrome?
female more than males ,age 20-50, history of trauma, type a personality
presentation of thoracic outlet syndrome?
diffuse pain radiating to arm that is non-dermatomal
fatigue and ache, weakness, paresthesias
hand feels cold = vascualr
costal breather, postural deficits
dull achy sensation that progresses down arm, arm feels heavy
common compression sites of thoracic outlet syndrome?
scalene triangle
costoclavicular space (1st rib and clavicle)
pec minor and chest wall
Scapular dyskinesis
abnormal motion of the scapula
due to weak traps, SA, muscle imalances, nerve palsy, muscle tightness
difference btwn bursitis and adhesive capsulitis with ROM
AROM and PROM equally as painful = adhesive capsulitis
bursitis will get more PROM than active before being limited by pain
