Quiz #7 Flashcards
what is subacromial impingment syndrome?
anatomic variations that lead to decreased subacromial space
what is the etiology of subacromial impingement syndrome?
space issue
anatomic variations
shoulder girdle kinematics
rotator cuff pathology
degenerative changes
overuse
what are the intrinsic factors of impingement?
vascular changes in RC tendons
tissue tension overload
collagen disorientation
collagen degeneration
what are the primary extrinsic factors of impingement?
structural posterior capsule tightness, anterior capsule tightness
RC pathology
increased superior migration of the humeral head
what are the secondary extrinsic factors of impingement?
instability, impaired coordination, weakness of the scapular stabilizers
what are the tertiary extrinsic factors of impingement?
contact of the greater tuberosity with the posterosuperior aspect of the glenoid when the arm is abducted and externally rotated
why would rotator cuff pathology cause impingement?
the RC isn’t depressing the humeral head to clear the acromion
what does the coracoacromial lig do?
spans the coronoid to acromion creating the coracoacromial arch where impingement can occur
what tendons run through the coracoacromial arch and can cause trouble in impingement?
supraspinatus, infraspinatus, and long biceps tendon as well as the subacromial bursa
what acromial variation is the most common?
curved
what acromial variation causes the most problems?
hooked
order these anatomical variation of the acromion from least to most problematic: hooked, flat, curved
flat<curved<hooked
what is the MOI for subacromial impingement syndrome?
overhead use
what is the history of subacromial impingement syndrome?
insidious onset
what is the CC of subacromial impingement syndrome?
OH pain
what are other complaints of subacromial impingement syndrome?
painful arc (80-120 deg abd)
what are the ROM limits of subacromial impingement syndrome?
passive abduction, IR, and horizontal adduction
what are the special tests for subacromial impingement?
(+) Hawkins Kennedy
(+) Neer
what are the contributing factors of subacromial impingement syndrome?
RC weakness
hooked acromion
shoulder kinesthesia
capsule tightness
decreased space
how much space does the subacromial space usually have?
4-11 mm
is a tight posterior or anterior capsule more common in subacromial impingement?
tight posterior capsule
t/f: RC weakness/fatigue, capsular restrictions, anatomical variations, mobility impairments all impact tendinitis
true
what tendons are affected by tendinitis most?
supraspinatus and long head of the biceps tendon
t/f: tendinitis/opathy can become calicific or rupture
true
what % of females over 40 y/o have tendinitis develop into calcific tendinopathy?
3-7%
how do we differentiate different tendons in tendinitis?
resistance testing
what is the history of tendinitis?
possible overuse
what is the CC of tendinitis?
OH pain
what is the MOI of tendinitis?
OH use and CTD
what are other complaints of tendinitis?
painful arc
what are comorbidities of tendinitis?
UE weakness
what are the ROM limitations in tendinitis?
OH loss of ROM an decreased IR/ER
what are the special tests for tendinitis?
HK, Neer, and resistive tests for pain
what are the contributing factors of tendinitis?
RC weakness, decreased space, shoulder kinesthesia, and instability
t/f: the treatment of bursitis and tendinitis are usually the same/similar
true
do we expect pain with muscles and tendon injuries?
yes
a tendon problem with no pain
tear
a tendon problem with pain
-opathy, -itis, -osis
t/f: it is easy to differentiate tendinopathy from arthritis, bursitis, fractures, and dislocations
false, these present very similarly
bursitis causes shoulder pain with what actions?
passive abduction, IR, and horizontal adduction
bursitis is TTP where?
in the subacromial with shoulder extension
is there pain with resistance testing of bursitis?
yes
what is the CC of bursitis?
OH pain
what is the MOI of bursitis?
OH use, CTD
what are other complaints with bursitis?
painful arc and resistance +/- pain
what are comorbidities of bursitis?
UE weakness
what are the ROM limitations of bursitis?
possible oH motion loss
what are the special tests for bursitis?
(+) HK
(+) Neer
what are the contributing factors of bursitis?
RC weakness, decreased space, hooked acromion, shoulder kinesthesia, and capsular tightness
what is stage 1 bursitis?
<25 y/o
localized edema
acute/repeated trauma
TTP anterior acromion
painful arc
pain related RC weakness
what is the intervention for stage 1 bursitis?
RICE, non-rpovocative RC training, OMPT to improve jt mobility
what is arthrogenic inhibition?
pain around a jt inhibits the muscles around it
what is the Hawkins Kennedy test?
shoulder flexion to 90 deg
elbow flexion to 90 deg
IR
what things can be tested with the HK test?
subacromial impingement syndrome
bursitis
tendinitis
possibly AMBRI
what is the Neer test?
depress the scap
IR
max flexion of the GH
what things can be tested using the Neer test?
subacromial impingement
bursitis
tendinitis
possibly AMBRI
what is the intervention for bursitis/tendinitis?
control inflammation
modalities for pain and edema
TFM
RC training (pure motion, multiplanar motions, provocative motions)
OMPT (orthopedic manual PT) for jt stability
NM re-education (ST)
ADL modification
surgery (acromioplasty, RC repair, SA decompression)
RC pathology accounts for what % of all shoulder injuries?
50-70%
order these tendons from most to least affected in RC pathology: infraspinatus, subscapularis, supraspinatus
supraspinatus>infraspinatus>subscapularis
what is the CC in RC pathology?
pain and weakness
what is the MOI of RC pathology?
OH and CTD
what are other complaints with RC pathology?
painful arc
what are the comorbidities of RC pathology?
being older than 50 y/o
what are the ROM limitations in RC pathology?
decreased flexion and rotation
what are the special tests for RC pathology?
(+) drop arm
ER Lag
Hornblower
full/empty can
lift off
what are the contributing factors of RC pathology?
decreased space
RC weakness
hooked acromion
tight capsule
instability
progression of SAI and tendinopathy
in RC pathology there is compression of what?
the SA space
in RC pathology there is tension in what motions?
horizontal adduction
IR
anterior translation
distraction (throwing)
t/f: RC tears increase with age
true
in people over 40 y/o, what % RC tears are full thickness and what % are partial thickness?
5-20% are full thickness
30-40% are partial thickness
t/f: RC tears could be on either the bursa side or jt side of the tendons
true
what are the s/s of RC pathology?
painful arc
pain during/after activity
TTP at the GH, coracoacromial lig, and LHB tendon
what is the drop arm test?
resist pure abduction
supraspinatus test
what is the ER Lag test?
put the pt in ER and see if they can hold the position
infraspinatus test
what is the Hornblower’s sign?
ask pt to hold max ER with 90 flexion
teres minor test
what is the lift off test?
have pt go into IR w/hand behind back
subscapularis test
what is the empty can test?
resist the pt in scaption to see if it elicits pain
thumb down
supraspinatus test
what is the full can test?
resist the pt in scaption to see if it elicits pain
thumb up
supraspinatus test
less provocative than empty can
what is the disadvantage of open repair of the RC?
you have to cut through the deltoids
what is the advantage of using an arthroscope for RC repair?
you can just split some of the fibers of the deltoids to get to the RC w/o cutting the deltoids
less trauma, easier repair, easier recovery
why are holes drilled in the bone with RC repairs?
the tendon is pulled into the raw bone to heal the bone with the tendon and form a new entheses
what is the point of an acromioplasty?
to create more SA space
what is patch augmentation for RC repair?
using patches of porous type 1 collagen to improve vascularity and collagen formation and encourage natural healing with native tissue
for large tears (3-5cm)
for PT who had prior repairs/chronic tears
what is the difference b/w allografts and autografts?
autografts come from yourself, while allografts come from someone else/some other source
what is phase 1 of RC repair healing?
0-6 wks
goals: pt education, control pain, ROM
post op day 1: sling or abduction splint (3-6 wks), pendulums, distal AROM
post op day 7-10: PROM flexion and ER, modalities
no AROM or PREs
what is phase 2 of RC repair healing?
6-12 wks
goals: ROM, NM control
intervention: ER, IR, horizontal adduction stretch, submax manual resistance ER/IR, subscap PREs (all <90 deg)
what is phase 3 of RC repair healing?
12-16 weeks
goals: full ROM, NM control, endurance, return to fxn
intervention: PREs for abduction, flexion, and ER at 45 deg in POS, PREs in ER/IR, deltoid
what is phase 4 of RC repair healing?
16 weeks to 6 months
goals: return to fxn, prevention
intervention: proprioception and plyometrics, sport-specific training
is there greater mobility or stability in the GH jt?
mobility
what does it mean when a jt is reduced?
it is put back in place
what is the etiology of GH instability?
laxity
mobility>stability
dislocation/subluxation
how is GH instability classified?
by frequency, magnitude, direction, and origin
what is the indicidence of GH instability?
anterior (80%) >inferior>posterior
what is the reoccurrence rate of GH instability in people older than 40?
15%
what is the reoccurrence rate of GH instability in people older than 30?
> 79%
why is the incidence of GH instability less as you age?
bc you do less provocative motions as you age and the jts stiffen
85% of anterior dislocations involve RCT in people older than…
40 y/o
t/f: a tight posterior capsule may cause the shoulder to go forward?
true
what are the special tests for GH instability?
(+) apprehension
(+) relocation
(+) sulcus
what is the apprehension sign?
put the pt in supine and take them into abduction and ER
(+)=pt acts scared and freaks out about the shoulder popping out
what is the relocation sign?
put pressure on the apprehension sign and the pt feels better
used to keep the glenoid in the fossa
what is the sulcus sign?
purpose: inferior GH instability testing
pt position: sitting w/arm at their side
PT position: next to the pt
procedure: palpate the superior aspect of the GH jt w/ inferior distraction for the humerus
interpretation: (+) if >1 finger gap is noted
when would conservative intervention be used?
in the protective phase
what are conservative interventions used with GH instability?
mobilization of the post and info capsules
scratch the post cuff (sleeper stretch)
PREs for RC
normalize ST, AC, SC mechanics
what does TUBS stand for?
Traumatic Unidirectional instability w/Bankart lesion requiring Surgery
what is a Bankart lesion?
avulsion of the anterior labrum from the glenoid rim that requires surgery
3-6 o’clock tear
what is a Hill-Sachs lesion?
compression fx of the posterior humeral head where the head is impacted in the inferior glenoid rim
what does a Bankart repair involve?
reattachment of labrum and GH to anterior glenoid
detachment and reattachment of the subscap
tightens the anterior capsule
arthroscopic
what are the phase 1 Bankart rehab guidelines?
0-4 weeks
goals: pt education, control pain, ROM
post op day 1: precautions, pendulums, distal AROM, grip strengthening, and ice
post op day 7-10: stretch for flexion, ER at 45 deg in POS (no >30 deg)
what are the phase 2 Bankart rehab guidelines?
4-6 weeks
goals: normalize GH, ST arthrokinematics, increase strength
interventions: stretch ER/IR, horizontal adduction, flexion to 90 deg, manual resistance for stabilization, PREs for IR/ER/extension, shrugs, retractions
what are the phase 3 Bankart rehab guidelines?
6-12 wks
goals: increase strength RC, delta, ST muscles, PREs in provocative positions, body blade progression, plyoball (chest pass)
what are the phase 4 Bankart rehab guidelines?
12-16 wks
goals: return to fxn
intervention: OH bodyblades, plyoball throwing, sport-specific training
what is the MOI of TUBS?
ER w/abd
what motions are limited in TUBS?
ER w/abd
what are the special tests for TUBS?
(+) sulcus
(+) apprehension
(+) apprehension w/rot
what does AMBRI stand for?
Atraumatic, Multidirectional instability, Bilateral, Rehab, Inferior (ant) capsular shift
what is the hx of AMBRI?
“born loose”
general instability
systemic laxity
what is the CC of AMBRI?
pain
feels loose
what is the CC of TUBS?
pain
what is the hx of TUBS?
trauma
what are the comorbidities of AMBRI?
posterior systemic laxity
what are the ROM limitations in AMBRI?
too much motion
pain and instability with ER and abd
what are the special tests for AMBRI?
(+) sulcus
(+) apprehension
(+) apprehension with relocation
possibly (+) HK and Neer
what is the MOI of Bankart tears?
dislocation: ant and inf
tackle injury
what are the ROM limitations in Bankart lesion?
ER
abduction
(especially when combined)
t/f: AMBRI has impingement-like symptoms with abd and ER
true
t/f: AMBRI may results in degenerative arthritis or RCT
true
what does the “pants over vest” mean with AMBRI?
the loose tissue will be folded over itself and tightened
what can be done for AMBRI?
“pants over vest”
closure of the rotator interval b/w the subscap and supraspinatus
is surgery or conservative management more effective in AMBRI?
conservative management
what is phase 1 of rehab for capsular shift?
0-4 wks
goals: independent w/precautions and HEP, control pain, ROM
post op day 1: precautions, pendulums, distal AROM, ice
t/f: you may be happy with losing some ROM in AMBRI management to prevent future injury
true
what is phase 2 of rehab for capsular shift?
4-6 wks
goals: normalize GH, ST arthrokinematics, increase strength, decrease pain
intervention: stretch flexion, ER in POS, manual resistance for GH, ST stabilization, shrugs, retractions, bodyblade
what is phase 3 of rehab for capsular shift?
6-12 wks
goals: increase strength RC, delta, increase strength ST, biceps, triceps, forearm muscles, PREs in provocative positions
intervention: stretch for extension, IR, horizontal adduction, PREs for abduction, flexion at 45 deg in POS, non-provocative bodyblades and progress to functional positions, plyoball progression (chest press)
what is phase 4 of rehab for capsular shift?
12-16 wks
goals: return to fxn
intervention: OH bodyblades, plyoball throwing, sport-specific training
what is a SLAP lesion?
SubLabral tears Anterior to Posterior (10-2 o clock) at the origin of the biceps tendon
is the superior or posterior labrum most susceptible due to its mobility and close association w/the LHB tendon?
superior
what lesion is due to FOOSH, sudden traction forces, and instability?
SLAP lesion
what does FOOSH stand for?
fall on an outstretched hand
what is the MOI of SLAP lesions?
FOOSH (31%)
traction-dislocation (19%)
instability
tackle
throwing
lifting (16%)
what are the special tests for SLAP lesions?
(+) O’Brien’s
(+) Crank
(+) Biceps load
what is an O’Brien test?
resist shoulder flexion and IR, then flex and ER
(+)=pain and weakness more with IR than ER
what is the pain associated with SLAP lesions?
non-specific pain
clicking and grinding sometimes
is a SLAP lesion a dx of exclusion?
not necessarily
what is the crank test?
pt is seated and shoulder is at 160 deg flexion
add compression with IR and ER
pain with clicking/crunching
what is the biceps load test?
lay pt in supine w/shoulder in ER and abduction
resist elbow flexion and forearm supination at the same time
(+)=pain with resistance
can also pronate them and extend the elbow to stretch the biceps instead of contracting
what does it mean to cluster test?
to do several tests together to have a higher deg of confidence that a condition may be present
what is the dx and intervention for SLAP lesion?
similar to RC and instability
special tests for the labrum
address the underlying instability
labral repair has more favorable outcomes than debridement
address secondary impairments
what is the systemic etiology of adhesive capsulitis?
diabetes
hypothyroidism
hyperthyroidism
hypoadrenalism
what is the extrinsic etiology of adhesive capsulitis?
cardiopulmonary disease
cervical disc disease
CVA (from not as much shoulder movement)
humeral fx
Parkinsonism
what is the etiology of adhesive capsulitis?
RC tendinitis
RC tears
biceps tendinitis
calcific tendinitis
AC arthritis
what is the hx adhesive capsulitis?
insidious
minor injury
what is the CC of adhesive capsulitis?
pain
stiffness
loss of ROM
what is the MOI of adhesive capsulitis?
insidious
minor injury
what are the comorbidities of adhesive capsulitis?
women over 40
post menopause
DM
hypo/hyperthyroidism
hypoadrenalism
hx of CVA
what is the general etiology of adhesive capsulitis?
capsule goes through inflammatory process for some reason and can’t lift the arm anymore
cascade of inflammation w/subsequent fibrosis
what is primary adhesive capsulitis?
idiopathic and progressive
gradual loss of ER
progressive loss of fxn
inflammation and pain w/muscle guarding
compensatory scap movement (kicks in a lot earlier)
resolution of pain w/stiff shoulder
what is secondary adhesive capsulitis?
substantial restriction of both AROM/PROM that occur in the absence of pathology
pain>ROM loss (self-limiting w/recovery in 6-12 months)
pain=ROM loss (capsular pattern and may require injection)
what are the 3 phases adhesive capsulitis?
freezing, frozen, thawing
in the capsular pattern with adhesive capsulitis, what is the order or loss of ER, abd, IR
ER>abd>IR
what are the risk factors for adhesive capsulitis?
female
> 40 y/o
trauma
DM
prolonged immobilization
thyroid disease
stroke
MI
psychosocial overlay
autoimmune disease
post-menopausal
what is stage 1 adhesive capsulitis?
mild impingement-like symptoms
<3 months
empty>capsular end feel
development of capsular pattern (ER>abd>IR)
what is stage 2 adhesive capsulitis?
TTP over anterior shoulder w/radiation into deltoid insertion
improved pain but no change in ROM post injection
decreased ROM in all planes
loss of capsular volume
what is stage 3 adhesive capsulitis?
9-14 mo
severe pain stage w/resolution into extreme stiffness
poor SH rhythm w/UT dominance
decreased inferior GH glide
what is stage 4 adhesive capsulitis?
“thawing stage”
some return of motion
capsular end feel and pattern
radiographs reveale disuse osteopenia, MRI shows increased perfusion to synovium
what is the goal of intervention with adhesive capsulitis?
controlled stress to restricted tissues through mobilization and stretching
when will self-limiting adhesive capsulitis return to full mobility with intervention?
18 months-3 years (at 7 years, 30% decreased mobility, 50% pain and stiffness)
t/f: success of corticosteroid injections for adhesive capsulitis depends on duration of symptoms
true
what is the point of corticosteroid injections for adhesive capsulitis?
to limit synovitis and subsequent fibrosis
when is MUA used in adhesive capsulitis?
when conservative measures fail except for osteopenia, recent RCT repair, fx, neurologic injury, and instability
what is MUA and MUGA?
manipulation under anesthesia
manipulation under general anesthesia
used to break up adhesions
