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DPT 616 : MSK > Shoulder Pathophysiology > Flashcards

Shoulder Pathophysiology Flashcards

1
Q

why is the shoulder so prone to instability?

A

bc of the amount of mobility at the jt with mostly ligamentous/muscular restrictions and not a lot of bony stability

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2
Q

how much space should be in the subacromial (SA) space?

A

4-11 mm

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3
Q

what are the anatomic variants that can cause impingement at the shoulder?

A

type 1 (straight) acromion

type 2 (curved) acromion

type 3 (hooked) acromion

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4
Q

what is the most problematic acromion type?

A

type 3

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5
Q

what is the least problematic acromion type?

A

type 1

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6
Q

what things can contribute to shoulder impingement?

A

decreased SA space

anatomic variants

shoulder girdle kinematics

RC pathology

degenerative changes

overuse

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7
Q

the critical zone largely involves what two structures?

A

subacromial bursa

supraspinatus tendon

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8
Q

tendinitis in the shoulder primarily effects what 2 tendons?

A

supraspinatus tendon

long head of the biceps (LHB) tendon

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9
Q

how can RC weakness/fatigue contribute to tendinitis?

A

bc it causes the humeral head to rise higher and irritate the tendons

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10
Q

how can posterior capsule tightness contribute to tendinitis?

A

bc it causes the humeral head to rise superiorly and irritate the tendons

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11
Q

mobility impairments in what jts may cause tendinitis in the shoulder?

A

GH, SC, ST, AC

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12
Q

what things may contribute to tendinitis?

A

RC weakness/fatigue

capsular restrictions

anatomic variations

mobility impairments

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13
Q

those with tendinitis may develop what?

A

calcific tendinopathy or rupture

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14
Q

what % of those with tendinitis develop calcific tendinitis?

A

3-7%

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15
Q

are males or females more likely to develop calcific tendinitis?

A

females

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16
Q

what age group is more likely to develop calcific tendinitis?

A

those over 40 y/o

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17
Q

how can we differentiate tendinitis?

A

resistance testing and palpation

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18
Q

how is bursitis different from tendinitis, fx, arthritis, or dislocation?

A

there is pain with movt, no pain with resistance (or very minimal pain), and (+) impingement signs

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19
Q

bursitis causes pain with passive motion in what directions?

A

abduction

IR

horizontal adduction

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20
Q

where would someone with shoulder bursitis be tender?

A

subacromially at the greater tuberosity with the arm in extension

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21
Q

what are the special tests for impingement?

A

Hawkins Kennedy

Neer

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22
Q

how do we perform the HK test?

A

in sitting, flex, IR, add the arm and push up on their elbow

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23
Q

what is a positive HK test?

A

pain in the shoulder

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24
Q

how do we perform the Neer test?

A

in sitting, flex, IR the arm over the head and stabilize the scap

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25
Q

what is a positive Neer test?

A

pain in the shoulder with passive overpressure

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26
Q

what are the s/s of stage 1 bursitis?

A

localized edema

TTT anterior acromion

painful arc

pain related RC weakness

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27
Q

what age group is mostly affected by stage 1 bursitis?

A

those under 25 y/o

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28
Q

what can cause stage 1 bursitis?

A

acute or repeated trauma

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29
Q

what are the interventions for stage 1 bursitis?

A

RICE

non-provocative RC training

OMPT (ortho manual PT)

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30
Q

what are the interventions for impingement?

A

control inflammation

modalities for pain and edema

TFM

RC training

OMPT for jt mobility

NM re-ed (ST)

AD modifications

surgery

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31
Q

t/f: US is the first choice modality to treat impingement pain and edema

A

false

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32
Q

RC training starts with ______ motions—-> _______ motions—> ______ motions

A

pure, multiplanar, provocative

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33
Q

what surgeries may be done for impingement?

A

acromioplasty

RC repair

SA decompression

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34
Q

what makes up 50-75% of all shoulder injuries?

A

RC pathology

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35
Q

the RC helps with what?

A

centration of the humeral head in the glenoid

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36
Q

t/f: the RC has a role in both mobility and stability

A

true

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37
Q

what muscles are most involved in RC pathology?

A

supraspinatus>infraspinatus> subscapularis

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38
Q

t/f: decreased SA can cause RC pathology

A

true

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39
Q

RC pathology causes tension in what motions?

A

horizontal adduction

IR

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40
Q

t/f: RC pathology can cause anterior translation

A

true

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41
Q

t/f: tears in the RC decrease as we age

A

false, tears increase with age

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42
Q

what % of cadavers over 40 y/o had full thickness RCT?

A

5-20%

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43
Q

what % of cadavers over 40 y/o had partial thickness RCT?

A

30-40%

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44
Q

what are the s/s of RC pathology?

A

painful arc

pain during/after activity

TTT over GT, coracoacromial lig, and LHB tendon

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45
Q

what are the special tests for RC pathology?

A

drop arm test

ER lag (dropping) sign

Hornblower’s sign

lift off test (and belly press)

full/empty can test

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46
Q

what muscle is the drop arm test for?

A

supraspinatus/infraspinatus

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47
Q

what muscle is the ER Lag (dropping) sign for?

A

infraspinatus

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48
Q

what muscle is the Hornblower’s sign for?

A

teres minor

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49
Q

what muscle is the lift off test (and belly press test) for?

A

subscapularis

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50
Q

what muscle is the full/empty can test for?

A

supraspinatus

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51
Q

what are the RC precautions for 6 weeks?

A

keep the arm below shoulder level

no horizontal adduction past neutral

no extension past neutral

no IR/ER in 90 deg abduction

no WB

no AROM

no PREs

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52
Q

t/f: pts with RC pathology are usually in a sling the first time we see them

A

true

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53
Q

what are the goals of phase 1 RCT repair?

A

pt ed

controlling pain

ROM

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54
Q

what are the interventions of phase 1 RCT repair 1 day post op?

A

pendulums

sling

distal AROM

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55
Q

what are the interventions of phase 1 RCT repair 7-10 days post op?

A

PROM flex/ER

modalities

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56
Q

t/f: no PREs or AROM are done in phase 1 RCT repairs

A

true

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57
Q

when is phase 1 RCT repair?

A

0-6 weeks

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58
Q

what are the goals of phase 2 RCT repair?

A

ROM

NM control

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59
Q

what are the interventions of phase 2 RCT repair?

A

ext/IR/horizontal adduction stretch

submax MR for ER/IR (supported)

scapular PREs

ALL UNDER 90 DEG

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60
Q

t/f: all interventions during phase 2 RCT repairs should be under 90 deg of shoulder motion

A

true

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61
Q

when is phase 2 RCT repair?

A

6-12 weeks

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62
Q

what are the goals of phase 3 RCT repair?

A

full ROM

NM control

improve endurance

return to fxn

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63
Q

what are the interventions of phase 3 RCT repair?

A

PREs for adb, flex, ER at 45 deg in POS (supported)

MR ER/IR and delts

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64
Q

when is phase 3 RCT repair?

A

12-16 weeks

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65
Q

what are the goals of phase 4 RCT repair?

A

return for fxn

prevention

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66
Q

what are the interventions of phase 4 RCT repair?

A

bodyblade in elevated positions

sport-specific training

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67
Q

when is phase 4 RCT repair?

A

16 weeks to 6 months

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68
Q

does RCT or tendinopathy have more specific protocol that is more gradual with stresses on the RC?

A

RCT

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69
Q

how is GH instability classified?

A

by frequency, magnitude, direction, and origin

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70
Q

what is the difference bw dislocation and subluxation?

A

dislocation comes out completely, but subluxation comes out partially and goes back in

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71
Q

what % of GH instability is anterior GH instability?

A

80%

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72
Q

what kind of GH instability is the most common?

A

anterior

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73
Q

order the GH instabilities from most to least common: inferior, anterior, MDI (multidirectional instability), posterior

A

anterior>inferior>posterior>MDI

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74
Q

what % of those >30 y/o have GH instability?

A

> 79%

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75
Q

what % of those >40 y/o have GH instability?

A

15%

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76
Q

why do people have less GH instability as they age?

A

bc the structures of the shoulder tighten up

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77
Q

85% of anterior dislocations of the shoulder involve RCT in populations over the age of ____

A

40 y/o

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78
Q

what tests would be positive with GH instability?

A

(+) apprehension

(+) relocation

(+) sulcus

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79
Q

what are the conservative interventions for GH instability?

A

sling in protective phase

mobilization of posterior and inferior capsule bc they tend to be tight

stretch posterior cuff (sleeper stretch)

PREs for the RC

normalize ST, AC, SC mechanics

80
Q

how can we stretch the posterior cuff?

A

sleeper stretch

81
Q

what portions of the shoulder tend to be tight in GH instability?

A

posterior and inferior

82
Q

t/f: a tight posterior capsule puts the shoulder in ER and stresses the anterior capsule

A

true

83
Q

what does TUBS stand for?

A

Traumatic Unidirectional instability w/Bankart lesion requiring Surgery

84
Q

what is a Bankart lesion?

A

avulsion of the anterior-inferior labrum from the glenoid rim and requires surgical stabilization

85
Q

t/f: Bankart lesions require surgical stabilization

A

true

86
Q

what is a Hill-Sachs lesion?

A

compression fx of the posterior humeral head where the head impacts the inferior glenoid rim

87
Q

what is a Bankart repair?

A

reattachment of the labrum and GH ligs to the anterior glenoid

detachment/reattachment of the subscapularis

88
Q

what motion tends to be limited post Bankart repair bc the subscap is detached and reattached?

A

ER

89
Q

how long is ER usually limited post Bankart repair?

A

6-8 weeks

90
Q

does a Bankart repair tighten the anterior or posterior capsule?

A

anterior capsule

91
Q

t/f: we often want a little tightness following repairs to prevent dislocation in the future

A

true

92
Q

when is phase 1 Bankart repair?

A

0-4 weeks

93
Q

what are the goals of phase 1 Bankart lesion repair?

A

pt ed

controlling pain

ROM

94
Q

what are the interventions day 1 post-op Bankart lesion repair?

A

precautions

pendulums

distal AROM

ice

95
Q

what are the interventions day 7-10 post op Bankart lesion repair?

A

stretch for flex/ER at 45 deg in POS (no >30 deg)

96
Q

when is phase 2 Bankart lesion repair?

A

4-6 weeks

97
Q

what are the goals of phase 2 Bankart lesion repair?

A

normalize GH and ST arthrokinematics

increased strength

98
Q

what are the interventions of phase 2 Bankart lesion repair?

A

stretch for ext/IR/hor add

MR for stabilization

PREs for IR/ER/ext

shrugs

retractions

99
Q

when is phase 3 Bankart lesion repair?

A

6-12 weeks

100
Q

what are the goals of phase 3 Bankart lesion repair?

A

increased RC, delts, and ST muscle strength

PREs in provocative positions

101
Q

what are the interventions for phase 3 Bankart lesion repair?

A

PREs for abd/flex/ER at 45 deg POS

PREs into provocative positions

bodyblade progression

plyoball (chest press)

102
Q

when is phase 4 Bankart lesion repair?

A

12-16 weeks

103
Q

what are the goals of phase 4 Bankart lesion repair?

A

return to fxn

104
Q

what are the interventions for phase 4 Bankart lesion repair?

A

OH bodyblade

plyoball throwing

sport-specific training

105
Q

what does AMBRI stand for?

A

Atraumatic, Multidirectional instability, Bilateral, Rehab, Inferior (anterior) capsular shift

106
Q

what causes AMBRI?

A

systemic laxity (born loose)

107
Q

t/f: AMBRI tends to be more amenable to rehab and conservative treatment

A

true

108
Q

what may progressive laxity due to gradual reduction in muscle fxn lead to?

A

AMBRI

109
Q

what symptoms does AMRBI produce?

A

impingement-like s/s w/abduction and ER

110
Q

AMBRI may result in what conditions?

A

degenerative arthritis or RCT

111
Q

t/f: AMBRI is an anterior/inferior capsular shift

A

true

112
Q

what is the “pants over vest” treatment for AMBRI?

A

closure of the rotator interval bw the subscap and the supraspinatus

113
Q

is conservative or surgical management of AMBRI more effective?

A

conservative management

114
Q

what can we work on in AMBRI?

A

limiting ROM

proprioception

shoulder mechanics

ST/GH rhythm

115
Q

what are systemic contributors to adhesive capsulitis?

A

DM

hypo/hyperthyroidism

hypoadrenalism

116
Q

what are the extrinsic contributors to adhesive capsulitis?

A

cardiopulmonary disease

cervical disc dysfxn

CVA

humeral fx

Parkinsonism

117
Q

what are the intrinsic contributors to adhesive capsulitis?

A

RC tendinitis

RCT

biceps tendinitis

calcific tendinitis

AC arthritis

118
Q

t/f: adhesive capsulitis is an insidious onset inflammatory disorder

A

true

119
Q

is there usually a known major event that causes adhesive capsulitis?

A

no, the pt usually didn’t do anything or had a really minor injury

120
Q

what is adhesive capsulitis?

A

a cascade of inflammation w/subsequent fibrosis

121
Q

what are the s/s of primary adhesive capsulitis?

A

idiopathic and progressive

gradual loss of ER

progressive loss of fxn

inflammation and pain w/muscles guarding

compensatory scapular motion (scap engages too early)

resolution of pain with stiff shoulder

122
Q

primary adhesive capsulitis results in a gradual loss of what motion?

A

ER

123
Q

what are the risk factors for adhesive capsulitis?

A

female

over 40 y/o

trauma

DM

prolonged immobilization

thyroid disease

stroke

MI

psychosocial overlay

autoimmune disease

post-menopausal

124
Q

what are the s/s of stage 1 adhesive capsulitis?

A

mild impingement-like symptoms

<3 months

empty>capsular end feel

development of capsular pattern (ER>abd>IR)

125
Q

what is the capsular pattern in stage 1 adhesive capsulitis?

A

ER>abd>IR

126
Q

is there more of an empty or capsular end feel with stage 1 adhesive capsulitis?

A

empty end feel

127
Q

how long ago do symptoms start with stage 1 adhesive capsulitis?

A

<3 months ago

128
Q

what are the s/s of stage 2 adhesive capsulitis?

A

TTT over anterior shoulder w/radiation into delts insertion

improved pain but no change in ROM post injection

decreased ROM in all planes

loss of capsular volume

129
Q

in stage 2 adhesive capsulitis, where is it tender?

A

over the anterior shoulder w/radiation into the delts insertion

130
Q

when is stage 3 adhesive capsulitis?

A

9-14 months after onset

131
Q

what stage of adhesive capsulitis is marked by severe pain w/resolution into extreme stiffness?

A

stage 3 adhesive capsulitis

132
Q

what are the s/s of stage 3 adhesive capsulitis?

A

severe pain w/resolution into extreme stiffness

poor SH rhythm w/UT dominance

decreased inferior GH glide

133
Q

what stage of adhesive capulitis is the “thawing stage”?

A

stage 4

134
Q

why is stage 4 adhesive capsulitis called the “thawing stage”?

A

bc things are calming down and ROM is increasing

135
Q

what GH glide is decreased in stage 3 adhesive capsulitis?

A

inferior GH glide

136
Q

what are the s/s of stage 4 adhesive capsulitis?

A

some return of motion

capsular end feel and pattern

radiograph=disuse osteopenia

MRI=increased perfusion to synovium

arthrogram=reduced axillary fold

137
Q

what would a radiograph reveal in stage 4 adhesive capsulitis?

A

disuse osteopenia

138
Q

what would an MRI reveal in stage 4 adhesive capsulitis?

A

increased perfusion to synovium

139
Q

what would an arthrogram reveal in stage 4 adhesive capsulitis?

A

reduced axillary fold

140
Q

what are the goals of interventions for adhesive capsulitis?

A

controlled stress to restricted tissues through mobilization and stretching

141
Q

t/f: adhesive capsulitis is self-limiting with gradual return to full mobility in 18 months to 3 years

A

true

142
Q

at 7 years after adhesive capsulitis, 30% of pts have decreased ____ and 50% have ____ and ____

A

mobility, pain, stiffness

143
Q

success of corticosteroid injections for adhesive capsulitis depends on what?

A

duration of symptoms

144
Q

what is the goal of corticosteroid injections for adhesive capsulitis?

A

to limit synovitis and subsequent fibrosis

145
Q

when is MUA (manipulation under anesthesia) or MUGA (manipulation under general anesthesia) used for adhesive capsulitis?

A

if conservative measures fail

146
Q

what conditions would indicate that we should avoid MUA/MUGA?

A

osteopenia

recent RCT repair

fx

neurologic injury

instability

147
Q

what is a SLAP lesion?

A

superior labral tears anterior to posterior

148
Q

where are SLAP lesions?

A

10-2 o’clock

149
Q

what part of the labrum is most susceptible to injury due to its mobility and close association with the LHB tendon?

A

superior labrum

150
Q

t/f: SLAP lesions may occur in combo with other impairments during dislocation

A

true

151
Q

SLAP lesions are usually due to what?

A

FOOSH

sudden traction forces

instability

152
Q

what is the most common MOI of SLAP lesions?

A

falls (31%)

153
Q

what is the second most common MOI of SLAP lesions?

A

dislocation (19%)

154
Q

what is the third most common MOI of SLAP lesions?

A

lifting (16%)

155
Q

what is a type 1 SLAP lesion?

A

fraying w/reduction in hor abd, ER w/forearm pronated

156
Q

what is a type 2 SLAP lesion?

A

detachment of the labrum and biceps tendon anchor w/loss of stabilization

157
Q

what is a type 3 SLAP lesion?

A

vertical tear of the labrum (like a bucket handle)

158
Q

what is a type 4 SLAP lesion?

A

extension of tear to the biceps tendon which displaces into GH jt

159
Q

what are the special tests for SLAP lesions/glenoid labrum?

A

O’Brien test

Crank test (and Kim test)

biceps load test

160
Q

how do we perform the O’Brien test?

A

in sitting, flex 90 deg and IR the arm then flex 90 deg and ER the arm with 10 deg hor add and resist shoulder flexion

161
Q

what is a positive O’Brien test?

A

IR>ER pain and weakness

pain inside=SLAP

pain on top=AC jt

162
Q

how do we perform the Crank test?

A

in sitting, put the arm into 160 deg elevation w/elbow flexion, some deg of shoulder stabilization with the other hand, and compression with ER/IR

163
Q

what is a positive Crank test?

A

pain

164
Q

how do we perform the Kim test?

A

in sitting, put them arm in 130 deg in POS (plane of scap) with elbow flexion and apply compression

165
Q

what is a positive Kim test?

A

pain

166
Q

how do we perform the biceps load test?

A

in supine, abduct the shoulder to 90 deg, ER, and supinate with the palm facing the head in supine, and resist elbow flexion

167
Q

what is a positive biceps load test?

A

pain

168
Q

t/f: the diagnosis of glenoid labrum dysfxn is similar to RC pathology

A

true

169
Q

how are glenoid labrum lesions diagnosed?

A

(+) special tests for the labrum

170
Q

t/f: interventions for glenoid labrum lesions should address underlying instability

A

true

171
Q

does a labral repair or debridement have more favorable outcomes?

A

labral repair

172
Q

why are SLAP lesions hard to dx?

A

bc there is not a lot of weakness, nondescript shoulder pain, (+) labral tests, and instability at the shoulder

173
Q

what nerves are most at risk in the shoulder for peripheral nerve entrapment?

A

long thoracic nerve

axillary nerve

spinal accessory nerve

suprascapular nerves

174
Q

what muscle is innervated by the long thoracic nerve?

A

serratus anterior (SA)

175
Q

what muscles are innervated by the axillary nerve?

A

delts

teres minor

176
Q

what muscles are innervated by the spinal accessory nerve?

A

traps

SCM

177
Q

what muscles are innervated by the suprascapular nerve?

A

suprapsinatus

infraspinatus

178
Q

SA weakess is prominent in the ____ plane, while UT weakness is prominent in the ___ plane

A

sagittal, frontal

179
Q

is the vascular or neurogenic aspects of thoracic outlet syndrome (TOS) easier to dx?

A

vascular bc there are no specific tests for the neurogenic aspects

180
Q

t/f: TOS is a dx of exclusion

A

true

181
Q

where are paresthesia in TOS?

A

non-dermatomal distribution

182
Q

where can there be pain in TOS?

A

traps

shoulder/arm

supraclavicular region

chest

occipital HA

all 5 digits

digits 4/5

digits 1/3

183
Q

what muscles can cause pinching points in TOS?

A

scalenes

pec minor

184
Q

what are the special tests for TOS?

A

Adson test

Allen test

ROOS test

Wright test

Military press test

185
Q

how do we perform the Adson test?

A

in sitting stabilize the scap, palpate the radial pulse, move the arm into abd, ER, ext and have the pt look at the arm and hold their breath to feel if the pulse changes

186
Q

what is a positive Adson test?

A

change in pulse, discoloration, pain

187
Q

how do we perform the Allen test?

A

in sitting, palpate the radial pulse, bring the arm into 90 deg abd and elbow flexion and tell the pt to look away from the arm and hold their breath to feel for changes in pulse

188
Q

what is a positive Allen test?

A

change in pulse, discoloration, pain

189
Q

how do we perform the ROOS test?

A

in sitting or standing, raise the BL shoulder to 90 deg abduction, ER, and flex the elbows and open and close the hands for 3 minutes

190
Q

what is a positive ROOS test?

A

discoloration, pain, paresthesia

191
Q

how do we perform the Wright test?

A

in sitting, palpate the radial pulse and bring the arm into 180 deg ER and take a deep breath

192
Q

what is a positive Wright test?

A

discoloration, pain, change in pulse

193
Q

how do we perform the Military press test?

A

in standing, palpate the radial pulse and retract the shoulders in exaggerated military posture with palms facing out

194
Q

what is a positive Military press test?

A

discoloration, pain, paresthesia

195
Q

what is an intervention for TOS?

A

1st rib depression mobilization

196
Q

how do we perform 1st rib depression mobilization?

A

have the pt in sitting and the therapist in 1/2 kneeling on the table with one hand controlling the head and the other MCP on sup aspect of the 1st rib

move the head into SB as force is applied to an inf direction to the 1st rib

DPT 616 : MSK (23 decks)

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