pathologie 1

Question 1

The student is able to name the causes of primary impingement.

Answer 1

Impingement means entrapment of soft tissues in the subacromial space. A distinction is made between primary and secondary impingement:

→ Primary (physio can usually not do a lot)
Structural narrowing of subacromial space

• Osteoarthritis: Acosteophyte ‘extra bone growth’
• Angular acromion (X-ray)
• Swollen soft tissues (tendon/bursa)

Question 2

The student is able to name the causes of secondary impingement.

Answer 2

Secondary (physiotherapy can help)
Constriction during specific postures and/or movements

• Rotator cuff dysfunction (e.g. the supraspintus muscle pulls the humeral head at abduction not sufficiently caudal)
• GH instability
• Scapular dyskinesia
• Biceps/SLAP injury (superior labrum anterior posterior lesion. The tendon of the biceps brachii caput longum pushes the humeral head downward in flexion.
  If the tendon does not do this properly, there is not enough space under the acromion during flexion)
• GIRD glenohumeral internal rotation deficit
• Overload (surmenage)
• Trauma

Question 3

The student is able to name the symptomatology of a shoulder impingement.

Answer 3

• Pain (anterolateral)→deltoid region
• Painful arc: pain on abduction of the arm
• Pain on elevation
• Pain/weakness on resistance: external rotation and abduction

Question 4

The student is able to name different pathologies that could cause impingement complaints.

Answer 4

• Tendinopathy
• Calcification of the tendon
• Bursitis
• Central and peripheral sensitization
• Tendon ruptures of the RC or biceps caput longum (complete rupture or wholly or partially perforated)

Question 5

The student is able to explain what an impingement is.

Answer 5

SAPS: subacromial pain syndrome: space under the acromion. In the past this was called impingement, but now there is doubt whether impingement is a correct term.

Below the acromion is the subacromial space. In the subacromial space there are several structures: ligaments, tendons, capsule, bursa.

Impingement is an entrapment of the soft tissues in the subacromial space

Question 6

The student knows the aetiology of impingement complaints of the shoulder.

Answer 6

There is no apparent cause for impingement/SAPS (idiopathic). The abnormalities that can be considered a possible cause of shoulder complaints are described below:

• Abnormalities of structures in the subacromial space: ligaments, tendons, capsule, bursa
• Abnormalities of the glenohumeral joint (osteoarthritis and frozen shoulder)
• Glenohumeral Instability
• Abnormalities of the AC or SC joint (eg osteoarthritis)
• Functional disorders of the cervical spine or the cervicothoracic spine

Question 7

The student is able to explain what a frozen shoulder is.

Answer 7

Frozen shoulder is an idiopathic condition in the shoulder, in which there is an increasing limitation of movement.

MMP2 and MMP9 are matrix protein proteolytic enzymes. These substances break down elastin. Somehow, these substances are produced more in someone with a frozen shoulder. These substances therefore ensure that holes are made in the haircut, because the elastin in the haircut is broken down.

• Fibroblasts: want to fill in the gap (repair)
• Myofibroblasts: want to bring the wound edges (holes) back together

This causes the capsel to contract and become stiff, reducing in size and thereby decreasing the range of motion.

Question 8

The student is able to describe the different stages of a frozen shoulder.

Answer 8

Average duration is 30 months

• Freezing (2-9 months): pain + start ROM decrease (suddenly the shoulder starts to hurt more, movement restriction increases)
• Frozen (4-12 months): ROM limited, pain decreases. Mainly movement restriction
• Thawing (5-26 months): ROM increases pain and decreases range of motion

Question 9

The student is able to describe different stages of an AC dislocation.

Answer 9

• Tossy 1: all 3 ligaments are stretched (lig. accromioclavicular and lig. coracoclavicular (consists of 2))
• Tossy 2: lig accromioclavicular is torn, lig. coracoclavicular is stretched
• Tossy 3: all 3 ligaments are torn

Rockwood is described at the time of surgery:

• Rockwood 1, 2 and 3: are the tossy’s
• Rockwood 4: clavicle shoots posterior
• Rockwood 5: clavicle shoots cranial
• Rockwood 6: clavicle shoots forward and below coracoid process

Type 4, 5, and 6 are the types that require surgery.
Rockwood 4, 5 and 6 are all Tossy type 3, but here the clavicle did not stay in the same place, but shot in a certain direction.