pathology Flashcards
What is calcific tendonitis in the shoulder?
- microscopic changes in hyaline cartilage and degeneration of collagen in tendon loosening and separating tendon fibers
- the separted fibers are pulverized into small particales that contain calcium salts
- the debris forms a liquid chalky area that is pressurized by the surrounding structures
C5-7 nerve root disorders will demonstrate weakness where?
- C5 deltiod, RTC, biceps
- C6 serratus
- C7 triceps, wrist flexors and adductors of the arm (lat)
how will limitations in active scapular rotation present?
- full passive and pain free shoulder ROM
- serratus weekness active limited to about 45 degrees
- trap weakness limited in the last 10 degrees
how would you differentiate pec major, teres group and lat weakness
- pec weak or pain with adduction, flexion and horz adduction
- teres minor- shoulder extesions with ER
- teres mjor- shoulder extension with IR
- lat- shoulder extension with IR
How can you isolate long head of biceps?
- resited shouder adduction in lengthened range with pain at the AC joint
- all other MMT and passive movement not producing pain
what is necessary for a normal functioning joint to work?
- stability
- mobility
- strength
How is the glenoid oriented?
tilts superiorly about 5 degree
2.slightly retroverted about 7 degrees
what structures contribute to the static stability of the GH joint?
- capsule
- labrum
- capusular ligament
- internal pressure
what ligament is most important for stability at 90 elevation and ER
inferior GH
What is the IAR of the GH joint
in the resting position it is usally medial and inferior to the tubercles about 6 mm from head of hymerus
- shights 1-2 mm with elevation superiorly
- what abduction it shifts the AC joit at about 60-90 degrees
How des the scapular positioning change with isometric testing of the shoulder in 90 flexion and why is this important?
- it tends to retract
2. t illustrates the critical importance of scapular stabilization with shoulder rotation
how does scapular position effect RTC function?
As the scapula retracts in to a millitary posture the IAR is moved up with the line of pull of the RTC creating compression of the joint with RTC activitation instead of downward glide
what is the relationship of the ROM of the scapular and GH joint
scapula has about 60 degrees of upward rotation while the GH elevates 120 degrees or 2:1
-15 degrees of shoulder flexion is 10 degree GH and 5 degree scapular
What is the muscle activation pattern with shoulder abduction
- deltiod and supraspinatus start things off
- infraspinatus and teres minor activity increases linearly
- subscap reach peak activation about 90 degrees
- infraspinatus increases until about 130 degrees
What are the activation patterns of pec major and deltoid with shoulder flexion and abduction
- deltiod helps with both
- pec does nothign with abduction, in flexion both head are working up to 55 degree flexion at which clavicular head shuts off
what is the activation pattern of the trap during flexion and abduction
- middle trap prime mover 150-180 and has a slight continuous activity
- middle most active in abduction and increases with activity through the flexion ROM
- lower trap and serratus are a rotatory force couple
- decreased lower trap activity with flexion
- lower and mid work together in the third phase of abduction
what is the rhomboid activity pattern with shoulder flexion and abduction
1.follows middle trap and is most active in abduction
what is the serratus activation pattern with shoulder abduction and flexion
- light continuous activity with trap and levator scapula to suppport the scapula
- works with lower trap to create rotatory force couple
- assis mid trap in the third phase of abduction (150-180)
how did Kapandji divide shoulder movements?
three phases
- 0-60
- 60-150
- 150-180
What are the arthokenematics 0-60 degrees of abduction
- scapular fixed against the rib cage
- scapula adducts decreasing tension on trapezoid
- deltoid pulls humeral head up as much as 3 mm in the first 30 degrees
- RTC counter acts the activity of the deltoid
- primarily motion at GH with a 3:1 ration GH to ST
What are the arthrokenematics of shoulder adduction in the second phase
60-150
- primarly the result of 60 degree of scapular rotation
- as scapula abduct conoid become taut
- axial rotation of AC and SC contirbute about 30 degrees
- greatest scapular motion relative to GH motion occurs from 80-140 at about 0.7:1
- peak deltoid activity at about 60 degrees
- peak shearing between 51-80 degrees wit no shearing by the end of the phase
what are the arthokenematics of the third phase of abduction/
150-180
- GH to ST motion changes ot 3.5:1
- upper trap decreases while middle trap become prime mover with lower and serratus helping
- t-spine decreases kyphosis and contralateral side bend occurs
- L-spine increased lordosis if both arms are raised at the same time
What is the the first phase of myo- and altho- kenematics with shoulder flexion?
0-60
- coracobracialis, anterior deltoid and clavicular fibers of pec activate the motion
- movement is limited by tension of the coracohumeral ligament
- movement is limited by tension from the teres group and infraspinatus
What is the the second phase of myo- and altho- kenematics with shoulder flexion?
60-120
- shoulder girdle become involved with about 60 degrees of scapular rotation
- SC and AC each rotate about 30 degrees
- trap and serratus get involved
What is the the third phase of myo- and altho- kenematics with shoulder flexion?
120-180
1.just like with abduction movement of the spinal column becomes necessary
what are the impingement sites of the shoulder?
suprahumeral-acromium and coracoacromial
coracohumeral
what is the suprahumeral space and what is in it?
- bound by the coracoacromial ligament
- contians subacromial bursa, head of biceps tendon, supraspinatus, articular cartilage, and joint capsule
- 9-10 mm across and 6mm when pathological
what is the coracohumeral space and what is in it?
- lies between the coracoid process and lessor tubercle
- contains the subcoracoid bursa, subscapularis bursa, and subscap tendon
- about 8.7 mm when healthy and 6.8 when pathological
how does neutral passive ER effect loading pattern when you suspect impingement?
the supraspinatus tendon is moved out from under the coracoacromial ligament and the tip of the acromium is moved into an area with greater space
how can a vascular comprimise occur in the long head of the biceps?
- with sustained forward flexion the long head of the biceps is compressed under the coracoacromial ligament
what motion would expect pain with if there is a long head biceps impingement and what movement would reduce the pain?
- they will have pain with supinated mid range shoulder flexion to 90 degrees with full elbow extension
- IR would reduced the pain
what are the four models of shoulder impingement?
- inflamatory
- mechanical
- vascular
- postural
what is a jumping shoulder?
supraspinatus develops a nodule that catches as it passess under the acromial arch
How would you expect a chronically irritated tendon to look?
- decreased number of inflamitory cells
- tendon can become dull, gray and edematous
- fibroblast invade and vascularization increases
how is blood flow to the shoulder effected by arm position?
in a zone about 1 cm proximal to the insertion of the supraspinatus on the greater tuberosity complete blockage occurs at 0 degree add and restarts at about 15 degree abduction
what are some typcial causes of protracted scapula?
- RTC pathology
- thoracic kyphosis
- cerical injury
- nerve root injry
- MTL
- dysfunction leading to high costal breathing
how can a protracted scapula impact shoulder pathology?
- puts the acromium into a protracted and depressed posture and decreasign the space available for movement
- reducted muscle firing effiecency
- abnormal length tension relationships
- tight posterior GH capsule
- decreased capacity for stored muscular energy
What is Neer’s classification of impingments?
- stage I- edema and hemmorage, tenderness with palpation, painful arc 60-120, symptoms wth resistance at 90 degrees
- stage II- decreased subacromial space, volutary reduction in activty, crepitation secondary to fibrosis, radiographic changes, no longer reversalbe
- stage iii- RTC tears, bicep rupture, boney changes, AC involvment, superior migration of humeral head
what movements emphasized supraspinatus
- prone horzontal adbuction
2. scaption with IR
what movement emphasizes subscap
scaption with ER
what movement emphasizes infraspinatus
prone horizontal abduction in ER
what movement emphasizes teres minor?
prone horizontal abduction in ER
what movements emphasize the different parts of the trap?
- upper-prone horz abduc with IR
- middle- neutral hand
- lower-ER
what is the concept of segmental circulation?
the indirect effect of increased blood flow to the target muscle by exercising the muscle around it
how does chonic tendonitis effect exercise prescription?
the muscle is already over taxed and has no energy to give so you have to decrease the tone and provide segmental circulation
what are the 8 primary bursa of the shoulder?
- subscap and capsuel
- infraspinatus and capsule
- summit of acromium
- coracoid and capsuel
- beneath coracobrachialis muscle
- b/w teres major and long head of try
- anterior and posterior to lat tendon
- subdeltoid or acromial
what is the subdeltoid bursa
- provides smooth gliding for RTC and inner deltoid
- adheres to the coracoacromial ligament and acormium
- extends over the greater tuberosity, inferior deltoid, under the coracoid and postiorly to the acromium
what bursa of the shoulder are continuous with the capsule
1.subscap
2,infraspinatus
what would you expect to find with subdeltoid bursitis>
- palpatable thickening, tenderness and increased skin temp over bursa
- non capsular pattern of ROM loss
- decreased pain with distraction of the GH
what is the function of the RTC
arthokenematic motion to keep the humerus in the center of the glenoid
what muscle can you rule out when there is a painful arc of motion?
deltoid because it can’t get impinged
What is the cyriax differerential for supraspinatus lesion?
location of pain dictates location of lesion
- painful arc- lesion medial to greater tuberotisty
- pain arc with ER- lesion is more anterior with IR it is more posterior
- end of ROM- deeper lesion requiring pinching of greater tuberosity on glenoid rim
- no pain- muscular
DD of shoulder abduction weakness
- supraspinatus
- suprascapular or axillary nerve
- C5
- space occupying leasion in the acromial space
DD supraspinatus impingement
- painful arc
- sharp catching
- full ROM
- ER rotation relieve catching
- pain referred to deltoid tubercle
- IR from neutral increases pain
DD biceps impingment
- pain with palm up resistance with outstretched
- reduced pain with IR
- tenderness over biceps
What test would differentiate biceps versus supraspinatus
empty can because biceps in not active in the position
how does the biceps change with degeneration
- splaying and narrowing of the tendon
- synovial proliferation
- fibrouis adhesions to the tendon
- altered gliding mechanism within the sheath
DD biceps tendon subluxation
- Yergason’s=- palpate tendon in neutral position and have patient resist ER and supination
- abduct and ER the shoulder and palpate the tending
- passive rotation of shoulder should feel it pop out or snap
