Shoulder Complex- RC Tear thru FSCS Flashcards
What are risk factors/etiologies for a rotator cuff tear?
- Gradual or degenerative tears including with repetitive overhead activities
- Acute tears, higher UE velocity, heavy lifting, impact (FOOSH)
What are the most common structures involved with a rotator cuff tear?
Supra or infraspinatus muscles
- possibly others
What are rotator cuff tears graded by?
size - S, M, L
partial or full thickness tear
What can cause a partial tear?
Excessive compression underneath tendon, wears away fibers
How often are the labrum and biceps involved with rotator cuff tears?
40-75% involved
What is a SLAP tear?
Superior Labral anterior/posterior tear
What causes a SLAP tear?
Long head of biceps excessively contracts and tears labrum
What may we have to have done to repair a SLAP tear?
surgically fixate biceps tendon (aka tenodesis)
What other trauma aside from a SLAP tear can cause a labrum and biceps tear?
Compression onto labrum with FOOSH
What are symptoms of a rotator cuff tear?
like impingement (INFLAMMATION) plus…
- acute or persistent
- hx of pop, click , or catch (high spec for labral tear)
- increased pain with repetitive overhead activities
What are signs of a rotator cuff tear?
Like impingement plus…
- painful arc around 90 degrees of elevation
- resisted/ MMT weak and painful
* flx & rotator cuff, particularly abd / ER/ possibly IR
- combined motions - possible inconsistent block
- stress tests possibly positive
What are some special test signs of a rotator cuff tear? How effective?
LR + = 9.84 if all positive, LR- = .54 if all negative
- over 65 yo
- weak ER
- night pain
What are indicators of a full thickness tear? How effective?
LR+ =28 if all positive, LR- = .09 if all negative
- over 60 yo
- positive painful arc, drop arm, and infraspinatus test
What is a test for the supra and infraspinatus? LR?
ER lag sign
LR+ = 5-28
What is a special test for. supraspinatus?
Drop arm - high spec (RULE OUT)
What are some tests for non-specific tears?
Empty can - high sens (RULE IN)
Jobe test - LR+=7.36; LR-=.1
What are some special tests for subscapularis?
Lift off - high spec (rule out)
Belly press (LR+ = 12.5-20)
Bear hug (LR+ = 7.23)
What special tests could possibly be positive (what structures)with a tear ?
For labrum and biceps
What is our patient rX for a rotator cuff tear?
Early ROM with degenerative tears
What is the ultimate purpose of MET for a rotator cuff tear?
Stabilization
Tissue proliferation for involved tissues
What is the biggest predictor of a tear going to sx?
A patients negative perception
What is the patients negative perception effecting surgery irrespective of?
size of tear
retraction
fatty inflitration
age
pain
What is retraction?
Tear of a tendon or muscle that is rather elastic, tear it and have it roll up, retracts away from attachment
- if there a while, loses ability to heal
What is the effectiveness of corticosteroid injections with rotator cuff tears?
No evidence of effectiveness within 4 weeks of shot
- only provides transient relief
What are the primary types of procedures done for RC tears?
Arthroscopoic (viewing) with arthroplasty (reconstruction)
What do the surgical procedures for RC tears include?
sewing fibers back together and reattaching to bone
- leave capsule and ligaments
- FULL ROM under anesthesia
What are the PT outcomes for degenerative tears?
Successful outcomes, like surgery, and especially for those with small or partial tears or those unfit for sx
What is the surgical outcome for degenerative tears?
Good clinical outcome with pain, ROM, strength, quality of life, and sleep
What type of outcomes are not as good as clinical outcomes?
Radiological
What are the PT outcomes for acute small to medium tears?
may help
if not progressing well, delays associated with poor surgical outcomes
What is the outcome of surgery with acute small to medium tears?
No difference from PT or slightly more beneficial
- more critical in younger patients due to higher activity levels
What is the PT outcome for those with multi-tendon and/or Massive full thickness tears?
May help, particularly in low demand patients or those unfit for sx
Increased likelihood of tear progression and arthropathy
What are the surgical outcomes for multi-tendon and/or massive full thickness tears?
Challenging with various options
~80% satisfaction rate
When are shoulder joint replacements mostly used?
With irrepairable tears
When are shoulder joint replacements less often used?
Less with age related changes
Why is a reverse total shoulder arthroplasty superior to hemiarthroplasty?
Pain relief, function, active elevation
What happens to the biomechanics during a reverse total shoulder arthroplasty?
Convex/Concave joint relationship reversed
Is the RC left intact with a reverse total shoulder?
Yes typically, with the possible exception of supraspinatus due to retraction/damage
What can a total shoulder arthroplasty do overall?
Make movement more efficient as with all shoulder conditions
What should be avoided post total shoulder?
hyperextended position/motion
What is the patient rx for 0-6 weeks post total shoulder?
POLICED including immobilization with sling out of the house
- waist level and mid-line AROM restrictions
- no pushing, pulling, lifting
What is the ROM restriction with total shoulders 0-6 weeks post op?
Progressive ROM 2x a day, may be delayed up to 4 weeks for better healing without negative consequences
What exercises are included in progressive ROM for 0-6 week post TSA?
AAROM
- pendulums
-standing pulley or supine flexion
- supine IR/ER
Stretching into ER
Scapular PREs
Why could progressive ROM be delayed post total shoulder?
Have to make sure no delay in healing
- a lot of times in older individuals with bone density issues
Can you move the shoulder girdle after total shoulder surgery?
YES, use muscles of shoulder girdle to work not the shoulder joint
- ie : retracton depression etc
What is the patient rx for 6-8 weeks post total shoulder?
DC sling
Add:
- sitting pulley
- isometric shoulder PREs in neutral
- standing AROM into flexion
- Across then up the back PROM
What is the patient rx for 8-12 weeks post total shoulder?
isotonic shoulder PREs
What is the patient rx for 12-16 weeks post total shoulder?
Add in gym type exercises
** most able to play golf at 4 months
What are the outcomes of a total shoulder arthroplasty?
Good to excellent results
90% able to participate in sports without significant restriction if activity was performed preoperatively
What are some rehab protocol highlights for rotator cuff tears?
- request surgial report - not all same
- best if criterion and time based
- Bracing in 15 degrees of ER
- TENS for pain management
- get them moving
- supervised PT beneficial
- early isometric loading improved outcomes
What are the outcomes of early vs delayed mobilization with rotator cuff tears for post of?
similar outcomes - GET THE PATIENT MOVING
What can make prognosis after surgery more favorable
*Younger age
*biological male
* higher bone density
* No diabetes/ obesity
* higher fitness levels
* greater pre-operative ROM
* Smaller and single tear
* less retraction / fatter infiltration
* no biceps/ AC involvement
What are some functional questionnaries for Frozen Shoulder Contraction Syndrome?
- DASH - Disabilities of the arm, shoulder and hand
- ASES - American shoulder and elbow surgeons shoulder scale
- SPADI - Shoulder Pain and Disability Index
What are other names for Frozen Shoulder Contraction Syndrome (FSCS)?
Adhesive capsulitis
Frozen Shoulder
What is the incidence of frozen shoulder?
1-5.3%
What causes frozen shoulder to be frequently misdiagnosed?
any multi - directional limitation in ROM
What are risk factors for frozen shoulder?
40-65 years of age
Biological female
Previous adhesive capsulitis
family history
What is associated with frozen shoulder?
Systemic low grade inflammation
- hypothyroidism
- diabetes
What is frozen shoulder most often due to?
Pathology, particularly autoimmune conditions (i.e. - diabetes, hypothyroidism, etc.)
What is the secondary etiology of frozen shoulder?
Concomitant (naturally accompanying or associated) injury and period of immobilization
What is the pathogenesis of frozen shoulder?
- More often inflammation of GH capsule and ligaments
- persistent inflammation
- fibrosis such as contracture
- reduced joint volume
What type of impingement is most likely to occur?
Hypomobility
What structures are involved with frozen shoulder contracture syndrome?
GH capsule and ligaments
Joint space
What are the symptoms of frozen shoulder contracture syndrome?
like impingement plus…
- gradual and progressive pain and loss of motion
- functional limitations with reaching, sleeping and other basic ADLs
What are some signs we would find of frozen shoulder contracture syndrome?
- ROM - typically a loss of ER then Abduction then Flexion then internal rotation
- Combined motions - consistent block
- Resisted/MMT possibly weak and/or painful depending on stage
- Accessory motion testing - hypomobile
- Special tests positive for impingement
What is the order that ROM is lost with frozen shoulder contraction syndrome
typically a loss of ER then Abduction then Flexion then internal rotation
What are the symptoms of stage 1 frozen shoulder contraction syndrome?
Gradual onset, achy at rest, sharp with use, night pain common, unable to lie on involved side
What is the irritability of stage 1 frozen shoulder contraction syndrome?
High
What would we find with ROM with stage 1 frozen shoulder contraction syndrome?
AROM significantly less than PROM
What is the end feel with stage 1 frozen shoulder contraction syndrome?
Empty and painful
What are the symptoms of stage II frozen shoulder contraction syndrome?
Constant pain, particularly at night
What is the irritability of stage II frozen shoulder?
HIGH
What would we find with ROM of stage II frozen shoulder?
Moderate - severe limitations in AROM less than PROM
What is the end feel of stage II frozen shoulder?
Empty and painful
What are the symptoms of stage III frozen shoulder contraction syndrome?
Stiffness more than pain & intermittent pain
What is the irritability of stage III frozen shoulder contraction syndrome?
Moderate
What would we find with ROM with stage III frozen shoulder contraction syndrome?
Moderate to severe limitations with pain at end range
- AROM like PROM
What would be the end feel with stage III frozen shoulder contraction syndrome?
Firm
What are the symptoms of stage IV frozen shoulder contraction syndrome?
Minimal to no pain
What do we call stage III of frozen shoulder contraction syndrome?
Thawing
What is the irritability of stage IV frozen shoulder contraction syndrome?
LOW
What would we find with ROM with stage IV frozen shoulder contraction syndrome?
Gradually improves
What is the end feel of stage IV frozen shoulder contraction syndrome?
Firm
What are tests and measures for frozen shoulder done by?
Exclusion
What can we use as tests and measures for frozen shoulder?
Normal radiographs
clinical presentation
What is the most common way we are able to test frozen shoulder?
Through clinical presentation
- early dx very difficult due to irritability
What is the patient rx for frozen shoulder contraction syndrome?
POLICED
Pt education
What would patient education with frozen shoulder contraction syndrome include?
Describe natural course of 4 stages
promote pain free functional activity
Match intensity of stretching/JMs with S&S
What are some modalities for frozen shoulder contraction syndrome?
Cryotherapy
LASER
JMs
STM
What is cryotherapy good for with frozen shoulder contraction syndrome?
Additional benefit to JM and modalities for pain/ROM/function
What is LASER good for with frozen shoulder?
Evidence for short term and long term functional changes
What is the benefit of JMs for frozen shoulder contraction syndrome?
Benefits pain and ROM
What is the evidence for benefits for JMs on grades III and IV frozen shoulder contraction syndrome?
Moderate evidence for short and long term benefits
When do JMs have inconsistent benefit with frozen shoulder contraction syndrome?
When added to exercise in shoulders with gradual onset
What kind of evidence for JMS with frozen shoulder contraction syndrome is there ?
WEAK
What type of evidence is there for STM with frozen shoulder contraction syndrome?
moderate
What do we use STM for with frozen shoulder contraction syndrome?
ROM/Flexibility
What does MET primarily focus on with frozen shoulder contraction syndrome?
Elasticity and mobility increases
- also offset disuse, particularly with inhibited muscles as you need to control improving mobility
What is the strategy that is effective for MOST patients with frozen shoulder contraction syndrome?
Multimodal approach
What is the evidence for use of oral steroids with frozen shoulder contraction syndrome?
Moderate evidence for SHORT term
What is the benefit of a cortisone injection with frozen shoulder contraction syndrome?
Short and mid-term benefit
- short term benefit when added to therex and JMs
What is the effectiveness of manipulation under anesthesia?
Quesitonable
- no difference to exercise alone
- recalcitrant ( having an obstinately uncooperative attitude toward authority or discipline??) conditions respond well
What MD rx is not supported for RCTs?
Capsular release
How long does stage I last of frozen shoulder?
~1-2 months
How long can the course of pain and mobility deficits last with frozen shoulder?
12-18 months
How many achieve minimal symptoms and defecits?
Most
If untreated, frozen shoulder can resolve after how long?
12-42 months
How many are without pain in the future with untreated frozen shoulder?
~50% with pain out to 4.5-7 years
