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DPT 681 - MSK 1 > Rotator Cuff Pathologies > Flashcards

Rotator Cuff Pathologies Flashcards

1
Q

Rotator Cuff Pathologies

Shoulder Rotator Cuff Tears:

  • Classification = ?
  • Characteristics = ?
  • Manual Therapy = ?
  • Therapeutic Exercise = ?
A

Shoulder Rotator Cuff Tears:

Classification:

  • Rotator Cuff Tear
  • Rotator Cuff Tendonopathy
  • Rotator Cuff Syndrome
  • Supraspinatus Tear
  • Infraspinatus Tear
  • Full Thickness RTC tear

Characteristics:

Pain Pattern:

  • Anterior / Superior / Posterior shoulder Pain
  • Possible painful arc of motion 60-120d abduction
  • Pain with weakness
  • Pain worse at night and with activity

Risk Factors:

  • 35-64 Years Old
  • Falls
  • Overhead activities
  • Increase in UE activities
  • Prior shoulder pain/impingement

Observation:

  • Drop arm sign
  • Possible limited scapular upward mobility
  • Kyphotic Posture or limited thoracic mobility

Examination:

  • (+) Drop Arm Sign
  • Modified Jobe
  • Empty Can/Full Can
  • Lag signs
  • Lift off sign
  • Belly Press test

Manual Therapy:

Joint Mobilization:

  • Inferior / Posterior, Tractional GH Mobilizations
  • AC and SC mobs
  • Cervical & Thoracic mobilizations
  • Hyper or Painful = I/II
  • Hypo = III/IV/V

STM/MFR:

  • Cross Frictional Pin and Stretch to RTC
  • Pecs/Traps, Biceps

PNF:

  • PNF diagonal ROM/stretching
  • Multiple angle isometrics with humeral head control/centering
  • Contract relax stretching for improved mobility utilizing PNF
  • Increase speed with PNF for quick reversals from muscle groups and multiplanar activities

Therapeutic Exercise:

Motor:

  • RTC Strengthening endurance, reactivation.
  • Isometrics progressed to Theraband isotonics, weights, single plane progressing to multiple plane endurance
  • Scapular Muscular Strengthening
  • All Trapezius muscles, serratus, and rhomboids: Goals to improve scapular mobility and control.
  • Thoracic Postural Muscles
  • Improved mobility of T-spine in all planes especially extension and rotation.
  • Body blade
  • Rhythmical stabilization
  • Humeral head control to avoid anterior/superior migration
  • Undermining/challenging postural stability as progression.
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2
Q

Rotator Cuff Pathologies

Rotator Cuff Pathology Facts:

  • 3 facts about prevalence = ?
A

Rotator Cuff Pathology - Prevalence:

  • 11.1/1000 women
  • 8.4/1000 men
  • Peak age for high incidence 45-64 years old

Primary Impingement:

  • Cumulative mictrotrauma
  • Decreased subacromial space
  • Hooked acromion

MOI:

  • Insidious onset
  • Repetitive activities
  • FOOSH
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3
Q

Rotator Cuff Pathologies

Rotator Cuff Pathology Facts:

  • 3 symptoms = ?
A

Rotator Cuff Pathology Symptoms:

  • Nightpain
  • Pain with shoulder abduction, flextion, and rotation

Infraspinatus:

  • Ant.Lat. shoulder and scapula medial border

Subscapularis:

  • Post. shoulder and scapula, down medial arm to elbow.

Supraspinatus:

  • Sup. shoulder and over spine of scapula.

Secondary Impingement:

  • Excessive ROM into external rotation
  • Weakness of internal rotators
  • Decreased endurance ratios of the shoulder abductors and external rotators.
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4
Q

Rotator Cuff Pathologies

Rotator Cuff Pathology Facts:

  • 3 Signs = ?
A

Rotator Cuff Pathology DSM/Signs:

Scapular Mobility Impairments:

  • Decreased scapular posterior tilting
  • Decreased scapular upward rotatiom

Humeral Mobility Impairments:

  • Increased humeral anterior translation
  • Increased humeral superior translation

Primary Impingement:

  • Posterior capsule tightness
  • Weak shoulder abduction, rotation, and flexion
  • Painful arc
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5
Q

Rotator Cuff Pathologies

Rotator Cuff Pathology Facts:

  • 3 Special tests = ?
A

Rotator Cuff Pathology Special Tests:

  • Supine impingement test
  • Internal rotation lag sign
  • External rotation lag sign
  • Drop arm
  • Hornblower’s sign
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6
Q

Rotator Cuff Pathologies

What do RTC pathologies sound like during subjective patient interview = ?

A

What do RTC pathologies sound like during subjective patient interview:

  • Pain with Weakness
  • Sudden onset after a fall (younger patient and/or older)
  • Gradual onset with long history of shoulder pain (see progression on slide #2)
  • Worse at night, wakes them up at night, or with overhead activities
  • Persistent shoulder pain that doesn’t resolve with conservative treatment.
  • Pain at night that is progressive
  • Pain with resisted activities
  • Difficulty lifting, throwing, or pushing.
  • ROM limitations as the tear becomes worse
  • Protective behaviors to avoid pain with the shoulder
  • Irritated by direct pressure over the lateral shoulder such as sleeping on that shoulder
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7
Q

Rotator Cuff Pathologies

The primary function of the rotator cuff = ?

A

Rotator Cuff: The rotator cuff controls osteokinematic and arthrokinematic motion of the humeral head in the glenoid and along with the biceps depresses the humeral head during movements into elevation.

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8
Q

Rotator Cuff Pathologies

Full thickness tear presentations = ?

A

Full thickness tear presentations / Drop Arm Sign / Shrug Sign:

  • Weak and painful although at some point the pain may actually be less.
  • Typically, these are traumatic presentations. Degenerative tears as slow progressions towards this point and often seek out care before it gets to this point.
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9
Q

Rotator Cuff Pathologies

True or False?

  • Most minor rotator cuff patients don’t display a shrug sign or drop arm sign.
A

True - Most minor rotator cuff patients don’t display a shrug sign or drop arm sign.

  • So, they don’t look like full thickness patients.
  • They may have only slightly altered or reduced AROM.
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10
Q

Rotator Cuff Pathologies

Special tests for rotator cuff pathology include = ?

A

Special tests for rotator cuff pathology include:

  • Lateral Jobe Test
  • External Rotation Lag Sign (ERLS)
  • Supraspinatus “Empty Can” Test
  • Full can test
  • Drop-Arm Test
  • Hornblower’s Sign or Lateral Rotation Lag Test / Teres Minor & Infraspinatus Drop Sign
  • Belly Press/Belly Off/Napoleon Test/Abdominal Compression Test
  • Lift-off sign/Gerber test
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11
Q

Rotator Cuff Pathologies

Lateral Jobe Test = ?

A

Lateral Jobe Test:

  • Performing better in systematic review as a RTC tear test than empty can or full can.
  • Patient’s arms abducted to 90 degrees with full internal rotation.
  • Examiner applies an inferior force to the patients elbows as the patient resists.
  • Positive Test: indicated by pain reproduction or weakness or inability to perform the test.

  • SN = 81
  • SP = 89
  • Positive (+) LR = 7.36
  • Negative (-) = LR .10
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12
Q

Rotator Cuff Pathologies

External Rotation Lag Sign (ERLS) = ?

  • This test is good at doing what ?
A

External Rotation Lag Sign (ERLS):

  • The patient is seated with the examiner standing to the rear.
  • The examiner grasps the patient’s elbow with one hand and the wrist with the other.
  • The examiner places the elbow in 90 degrees of flexion and the shoulder in 20 degrees of elevation in the scapular plane.
  • The examiner passively externally rotates the shoulder to near end-range.

  • SN = 42
  • SP = 90
  • Postive (+) LR = 4.20
  • Negative (-) LR = .65
  • Test to assess the integrity and tears of the supraspinatus (SSP) and infraspinatus muscles?
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13
Q

Rotator Cuff Pathologies

“Empty Can” Test = ?

A

Supraspinatus “Empty Can” Test:

  • The patient elevates the arms to 90 degrees with thumbs up (full can position).
  • The examiner provides downward pressure on the arms and notes the patient’s strength.
  • The patient elevates the arms to 90 degrees and horizontally adducts 30 degrees (scapular plane) with thumbs pointed down as if “emptying a can.”
  • The examiner provides downward pressure on the arms and notes the patient’s strength.
  • Positive Test: For rotator cuff tear, examiner assessment of more weakness in the empty can position vs. the full can position, patient complaint of pain, or both.

  • SN = 44
  • SP = 90
  • Positive (+) LR = 4.37
  • Negative (-) LR = 0.62
  • QUADAS = 10
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14
Q

Rotator Cuff Pathologies

Full can test = ?

A

Full Can Test:

  • The patient elevates the arms to 90 degrees with thumbs up (full can position).
  • The examiner provides downward pressure on the arms and notes the patient’s strength.
  • A positive test for rotator cuff tear is examiner assessment of more weakness in the involved shoulder, patient complaint of pain, or both.

  • Utility score is 3 because of conflicting data
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15
Q

Rotator Cuff Pathologies

Drop Arm Test = ?

A

Drop Arm Test:

  • The patient is standing with the examiner, standing to the front.
  • The examiner grasps the patient’s wrist and passively abducts the patient’s shoulder to 90 degrees.
  • The examiner releases the patient’s arm with instructions to slowly lower the arm.
  • A positive test for supraspinatus tear is the inability by the patient to lower the arm.
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16
Q

Rotator Cuff Pathologies

Hornblower’s Sign or Lateral Rotation Lag Test = ?

A

Hornblower’s:

  • The patient is seated, and the examiner supports the patient’s shoulder in 90 degrees of abduction in the scapular plane.
  • The elbow is flexed to 90 degrees and the patient is asked to forcefully externally rotate the shoulder against the examiner’s resistance.
  • A positive test is indicated by the inability of the patient to externally rotate in this position.
  • The sign is actually where the hand falls down towards the mouth or as the video shows it the patient is only able to raise the arm up to the mouth instead of ER at 90d abduction

Alternatively, this test can be performed as an Infraspinatus drop test, don’t confuse this with the supraspinatus drop arm test, in which no resistance is applied, and the patient is simply trying to hold.

If the arm drops then the test is positive:

  • The patient is seated with the examiner standing to the rear.
  • The examiner grasps the patient’s elbow with one hand and the wrist with the other.
  • The examiner places the elbow in 90 degrees of flexion and the shoulder in 90 degrees of elevation in the scapular plane.
  • The examiner passively externally rotates the shoulder to near end-range.
  • The examiner asks the patient to maintain this position as the patient’s wrist is released.
  • A positive test for infraspinatus tear is indicated by a lag that occurs with the inability of the patient to maintain the arm near full external rotation.
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17
Q

Rotator Cuff Pathologies

Belly Press / Belly Off / Napoleon Test / Abdominal Compression Test = ?

A

Belly Press / Belly Off / Napoleon Test / Abdominal Compression Test:

  • The patient can sit or stand with elbow flexed to 90 degrees.
  • The patient internally rotates the shoulder, causing the palm of the hand to be pressed into the stomach.
  • Positive Test: Weakness in subscapularis. This is lack of pressure on the belly in upper left picture. By the elbow dropping behind the body into extension or inability of the patient to keep the hand on their abdomen.
  • Excessive compensation of wrist flexion is another sign of failure.

  • SN = 40 (NR)
  • SP = 98 (NR)
  • Psitive (+) LR = 20
  • Negative (−) LR = 0.61
  • QUADAS = 11
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18
Q

Rotator Cuff Pathologies

Lift-off sign / Gerber test = ?

A

Lift-off sign / Gerber test:

  • The patient is seated with affected arm behind his or her back.
  • The patient is asked to lift the arm off the back.
  • Positive Test: For subscapularis tear is indicated by inability of the patient to lift the arm off the back.
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19
Q

Rotator Cuff Pathologies

A
20
Q

Rotator Cuff Pathologies

Early RTC Rehab Phase I:

  • (1-6 weeks) post-surgery = ?
A

Early RTC Rehab Phase I:
(1-6 weeks) post-surgery

21
Q

Rotator Cuff Pathologies

PNF Techniques:

  • ROM techniques include = ?
A

PNF ROM Techniques:

  • Hold Relax: Slower less aggressive transitions to address pain and ROM limitations.
  • Hold Relax Active Contraction: Same as above only the patient moves actively not passively after isometric.
  • Contract Relax: More aggressive quicker transitions from contract to relax in order to address ROM limitations.
22
Q

Rotator Cuff Pathologies

PNF Techniques:

  • Strengthening techniques include = ?
A

PNF Strength Techniques:

  • Rhythmic Initiation: Teaching/initiation of movement for tone. PROM, AAROM, finally AROM outside of traditional D1/D2 patterns.
  • Repeated Contractions: Quick stretch followed by isometrics.
  • Alternating isometrics: No movement isometric can be at multiple angles.
  • Rhythmic Stabilization: Twisting isometrics.
  • Slow (stabilizing) Reversals: Concentric IR followed by ER.
  • Slow (stabilizing) Reversal hold: Same as above with holds at the end of concentric.
  • Agonist Reversals: Concentric agonist followed by eccentric lengthening of that same agonist
23
Q

Rotator Cuff Pathologies

PNF Techniques For ROM:

  • Hold Relax = ?
A

PNF Techniques For ROM - Hold Relax:

  • (For PAIN and ROM restrictions)
  • Strong isometric contraction of the restricting muscles (antagonists) is resisted, followed by voluntary relaxation, and passive movement into the newly gained range of the agonist pattern.
  • Hold relax more for pain. Slower less aggressive.
24
Q

Rotator Cuff Pathologies

PNF Techniques For ROM:

  • Hold Relax Active Contraction = ?
A

PNF Techniques For ROM - Hold Relax Active Contraction (HRAC):

  • Similar to HR except movement into the newly gained range of the agonist pattern is active, not passive.
25
Q

Rotator Cuff Pathologies

PNF Techniques For ROM:

  • Contract Relax = ?
A

PNF Techniques For ROM - Contract Relax:

  • (More for ROM restrictions than pain)
  • Strong, small range isotonic contraction of the restricting muscles (antagonists) with emphasis on the rotators is followed by an isometric hold.
  • The contraction is held for 5-8 seconds and is then followed by voluntary relaxation and movement into the new range of the agonist pattern.
  • Movement can be passive but active contraction is preferred.
  • Trying to move into IR then relax into ER.
  • More for stretching than pain
26
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Rhythmic initiation (RI) = ?
A

Rhythmic initiation (RI):

  • Improving mobility, who have difficulty initiating functional movements.
  • Sequential application of first passive, then active assisted, then active and then active or slightly resisted motion.
27
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Repeated contractions = ?
A

Repeated contractions:

  • First a quick stretch is applied to facilitated the muscle then a one directionality isometrics agonist.
  • Facilitation so easier for patient neuro but in ortho post surgical patients the quick stretch might be too aggressive early on.
28
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Alternating isometrics (AI) / isometric reversals = ?
A

Alternating isometrics (AI) / isometric reversals:

  • Stability and strength
  • Isometric contraction of both agonist and antagonist muscle groups in an alternating manner with no movement.
  • We used this a lot with capsular, dislocation, and labral patients.
29
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Rhythmic stabilization (RS) = ?
A

Rhythmic stabilization (RS):

  • No motion is allowed (don’t let me move you).
  • Co-contraction changing trying to twist/rotate.
  • In Neuro utilized in the trunk but in shoulder we would see asymetrical Isometric contraction of the agonist followed by an isometric contraction of the antagonist.
  • One hand is pushing into ER at elbow and other into IR at wrist/hand.
30
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Slow reversal (SR) = ?
A

Slow reversal (SR):

  • (Controlled mobility, strength, skill)
  • Muscle weakness, joint stiffness, impaired coordination.
  • Concentric action of agonist muscle- concentric action of antagonist muscle.
31
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Slow Reversal Holds = ?
A

Slow Reversal Holds:

  • More advance version of slow reversal after the back and forth you have a isometric hold at the end of each movement
32
Q

Rotator Cuff Pathologies

PNF Strength Techniques:

  • Agonist reversal (AgR) / combined isotonics = ?
A

Agonist reversal (AgR) / combined isotonics:

  • Controlled mobility
  • Resistance to a concentric contraction, stabilizing hold, then resistance to eccentric contraction (concentric-isometric-eccentric contraction of agonist muscle)
33
Q

Rotator Cuff Pathologies

PNF = ?

A

PNF (Proprioceptive Neural Facilitation):

  • Term that represents a large umbrella of treatment applications designed to incorporate multiplanar directional movements as apposed to other single plane exercises.
34
Q

Rotator Cuff Pathologies

RTC exercises include = ?

A

RTC Exercises:

(a) Shoulder slides on countertop

  • Best passive exercise (first 4-6 weeks for post op)

(b) Pain control techniques - (after 4-6 weeks if surgical or immediately upon evaluation if non-surgical)

  • Codmens
  • Wall walking AAROM
  • Isometrics

(c) Wand Exercises

(d) Subscapularis Strengthening

(e) PNF/Hold Relax Techniques - (I.E. Manual Resisted isometrics with resultant stretching into new ROM)

  • Goal #1 is to promote better mobility
  • Goal #2 Progress to strengthening as allowed/tolerated
  • Goal #3 Gain joint stability if needed

(f) Mid/Low Trapezius resisted exercise

(g) Advanced Manual Resisted Eccentric strengthening with Perturbations

(h) External Rotators Strengthening

(i) Progressions:

  • Shoulder extension and combined external rotation isotonic
  • Body blade
  • Alternating ER/IR at multiple angles

(j) Advancing RTC

  • (supra/infra/teres minor) strengthening

(k) Low Trap Strengthening

(l) Serratus Anterior Strengthening

(m) Alternate Impingement/RTC Treatment

  • Laser
  • Dry Needling
  • Kinesio tape
  • Cross Friction
  • Pin & Stretch treatments
35
Q

Rotator Cuff Pathologies

RTC exercises:

  • Shoulder slides on countertop = ?
A

Shoulder slides on countertop:

  • Best passive exercise (first 4-6 weeks for post op).
36
Q

Rotator Cuff Pathologies

RTC exercises for pain control techniques include = ?

A

RTC exercises for pain control:

  • Codsmens
  • Wall walking AAROM
  • Isometrics
37
Q

Rotator Cuff Pathologies

RTC exercises:

  • Wand exercises = ?
A

Wand exercises:

*

38
Q

Rotator Cuff Pathologies

RTC exercises:

  • Subscapularis Strengthening = ?
A

Subscapularis Strengthening:

*

39
Q

Rotator Cuff Pathologies

RTC exercises:

  • Goals of PNF / hold relax techniques = ?
A

PNF/Hold Relax Techniques:

  • Manual Resisted isometrics with resultant stretching into new ROM

Goals:

  • Goal #1 is to promote better mobility
  • Goal #2 Progress to strengthening as allowed/tolerated
  • Goal #3 Gain joint stability if needed
40
Q

Rotator Cuff Pathologies

RTC exercises:

  • Mid/Low Trapezius resisted exercise = ?
A

Mid / low trapezius resisted exercise:

*

41
Q

Rotator Cuff Pathologies

RTC exercises:

  • Advanced Manual Resisted Eccentric strengthening with Perturbations = ?
A

Advanced Manual Resisted Eccentric strengthening with Perturbations:

*

42
Q

Rotator Cuff Pathologies

RTC exercises:

  • External Rotators Strengthening = ?
A

External Rotators Strengthening:

Notes from PowerPoint:
* Scapular retraction exercise and rows have poor upper trap to lower trap ratios.

  • If they are to be used, they are best at 0 degrees of abduction.
  • High activation of the infra and supraspinatus, as well as the lower trap with both L and W positioning. Both demonstrated good low trap to upper trap ratios.
  • External rotation, being in the frontal plane, had preferential activation of the Teres minor compared to the infraspinatus. Best with oscillation and two bands.
  • Patients with shoulder pain co-contract the thoracic and abdominal muscles more than controls.
43
Q

Rotator Cuff Pathologies

RTC exercises:

  • Alternative Cuff strengthening frequently seen in clinic = ?
A

Alternative Cuff strengthening frequently seen in clinic:

*

44
Q

Rotator Cuff Pathologies

RTC exercises:

Alternative Cuff strengthening frequently seen in clinic = ?

A
45
Q

Rotator Cuff Pathologies

RTC exercises:

Low Trap Strengthening = ?

A

Low Trap Strengthening:

*

46
Q

Rotator Cuff Pathologies

RTC exercises:

Serratus Anterior Strengthening = ?

A

Serratus Anterior Strengthening:

*

47
Q

Rotator Cuff Pathologies

RTC exercises:

  • Manual Therapy for RTC = ?
A

Manual Therapy for RTC is the same as noted for Impingement.

DPT 681 - MSK 1 (17 decks)

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