TOS Flashcards
WHAT IS TOS
Neuromuscular compression/compromise of brachial plexus/or subclavian-axillary vessels as they exit thoracic cavity and enter UE
Neurologic TOS
MC lower truck (c8/T1)
- due to abnormal nerve stretch or compression
- MC in women with drooping shoulders
- starts medially and moves lateral
Type of TOS most common in women with drooping shoulders
Neurologic
Vascular tOS
Involved subclavian artery and vein
- may see unilateral arm swelling
- MC in men
- position may help
MC type of TOS in men
Vascular
S/s of vascular TOS
Decreased capillary refill
Diminished pulse
Cold extremity
Cyanosis/white
DDX: raynauds
Reasons for creating of pressure in TOS
- 1st rib creates floor for compression
- traps brachial plexus and subclavian vessels between ribs and other structures
- clavicle
- pec minor
- scalene
- cervical ribs
- elongated c7 TVP
- subclavius hypertrophy
- bony callous/exostosis
What are the four outlets possible for TOS
- Sternocostovertebral space
- Scalene triangle
- Costoclavicular space
- Coracopectoral space
What makes up the sternocostovertebral space
Sternum
Spine
First rib
What makes up the scalene triangle
Anterior, middle scalene and first rib
Costoclavicular triangle-what is it made of?
Clavicle
First rib
Subclavian muscle
What makes up for coraco pectoral space
Coracoid process
And pec minor
Classic presentation of TOS
- diffuse arm symptoms
- pain/numbness/tingling
- often path down to 4/5th digits
- weak grip strength
- worse with overhead activity
- MC lower plexus c8-T1
Causes of TOS
Trauma Posture-rounded shoulders Tight scalene Tight pectoralis Cervical ribs (RARE -1:1000)
To manage TOS what would you strentch and what strengthen
Stretch: pecs and scalene
Strengthen: rhomboid/ middle/lower traps, deep neck flexors
Can tape or brace for proprioceptive training/postural correction
What artery runs between scalene muscles and then it becomes _____ and then _____
Subclavian becomes axillary and then brachial
The brachial artery (originally subclavian A…axillary…) branches at the cubical fossa into ____ and ____ arteries
Ulnar and radial
Radial artery runs between what muscles
Brachioradialis and flexor carpi radialis
The radial artery runs between what muscles
Brachioradialis and flexor carpi radialis
What artery lies under flexor carpi ulnaris
Ulnar
Where does the ulnar artery lie
Under flexor carpi ulnaris
Why is blood supply to hand even if one is occluded
They form an anastomoses—deep and superficial palmar arches
What are the 4 articulations within the shoulder
GH
AC
SC
ST (scapulothoracic)
Most common cause of shoulder pain in adults
Subluxation
Subacromial impingement syndrome
Rotator cuff issues
How will shoulder ROMs be affected by rotator cuff tear? Adhesive capsulitis?
-AROM diminished
Both AROM/PROM diminished
Normal ROM of shoulder
Flexion Extension Abduction Adduction External rotation Internal rotation
Flexion: 180 Extension: 50 Abduction: 180 Adduction: 50 External rotation: 90 Internal rotation : 90+
Muscles that comprise rotator cuff
SITS
Supraspinatous
Infraspinatous
Teres minor
Subscapularis
Function of supraspinatous
Abduct arm
Function of infraspinatous
External rotation
Function of teres minor
External rotation/ lateral rotation
Function of subscapularis
Internal rotation/aka medial rotation
Pneumonic to remember actions of SITS muscles
SITS ALL morning
A: abduct
L
L: lateral rotation/external rotation
M: medial rotation/internal rotation
MC place for rotator cuff injuries and MC complaint
Supraspinatous (abduct arm)
Issues with overhead activities
Increased risk of tear after 40
Supraspinatus passes beneath _____ and inserts on ____ ____ of ____ passing beneath ____ ____ that forms a fibrous arch over the tendon
Acromion
Greater tubercle of humerus
Coracoacromial ligament
Causes of impingement/tendinitis/bursitis
Bursa inflammation
- inflammation of R.C. tendon
- ca+ deposits within R.C. tendons due to wear/tear
S/s of impingement/tendinitis/bursitis
Achy pain worse with activity
-often radiation of biceps area in front of upper arm
Where might an impingement be found
Supraspinatous
Biceps tendon
Subacromial bursa
History in patients with R.C. impingement
Sports with overhead repetitive motions
Baseball, volleyball, tennis, CrossFit, swimming, electricians, painters etc
MC space for impingement in older adults
Subacromial space
Pain and tenderness at ANTERIOR JOINT
Usually associate with degenerative changes
Tx for impingement
Ice Rest from aggravating activity Myofascial release Crossfriction massage Stretch posterior capsule S-I adjustment of GH
Supraspinatus tendiopathy cause
Repeated abduction of shoulder leading to impingement of supraspinatus tendon within narrow space
MC tendinopathy in the UE
Supraspinatus tear MC in? And s/s?
Elderly (men 60+)
S/s similar to chronic subacromial impingement
S/s of incomplete vs complete supraspinatous tear
Imcomplete: cause of painful arc syndrome
Complete: impairs ability to abduct shoulder
- pain at tip of shoulder and down into UE
- tenderness below margin of acromion
Painful arc syndrome seen when
Incomplete supraspinatous tear
Painful arc syndrome
Pain midrange of shoulder abduction
-70-11 degrees
If painful arc syndrome is felt during AROM but not PROM indicates….?
Muscle/tendon issue
Where is subacromial bursa located
Between acromion process and greater tubercle of humerus
S/s of subacromial bursitis
- anterior/lateral shoulder pain
- overhead lifting aggravates
- pain worse at night
Cause of subacromial bursitis
Trauma Repetitive movements Inflamed joint: arthritis, gout, high inflammatory diet Overload Increased risk with age
What is biciptial tendinitis
Inflammation of the long head of biceps tendon
Long head of biceps tendon runs through where and what restrains it
Bicipital groove
Transverse numeral ligament restrains
Who’s at risk for bicipital tendonitis
Swimming, gymnastics, sports involving throwing (follow through) and occupations with overhead shoulder work or heavy lifting
S/s of bicipital tendonitis
- pain in anterior shoulder (over bicipital groove) occasionally radiating down to elbow
- overhead activities reproduce pain (especially abduction/ext. rotation ) aka cocking arm to throw
Pain where in impingement syndrome of infraspinatous and teres minor
Recall they’re the lateral/external rotators
Pain in posterolateral aspect
All actions of subscapularis
Medially rotate and depress humerus at GH joint
When does shoulder instability occur
When head of humerus dislocates from glenoid fossa
Shoulder laxity
In swimmer and throwing athlete. Loose enough to allow excessive external rotation
Shoulder instability
Unwanted translation of numeral head on glenoid
Mc moves anterior and inferior
Anterior inferior shoulder dislocation
MC in younger after indirect trauma with arm abducted, extended and externally rotated
Posterior shoulder dislocation
Rare
Direct driving force against lower end of humerus with arm flexed forward
Clinical findings with posterior shoulder dislocation
Decreased fullness of numeral head in anterior and increased in posterior. Swelling masks
Flatter appearance of shoulder and elbow faces out
Complications of shoulder instability/dislocation in younger people
Ligament or muscle gives away
Often transverse tear across capsule
Complications from shoulder instability/dislocation in older people
Ligaments become more firm…may cause avulsion fracture because bone less strong
Complications to humerus head in shoulder dislocation
Compression/impaction fracture of posterolateral aspect of humeral head
Hill-Sachs lesion/hatchet deformity
What does glenoid labrum do
Increase surface area
Increase depth/concavity
Decrease translation
Key role in GH stability
In younger people the tensile strength of the labrum is ____ than the capsule, so ____ prone to injury when _____ stress applied to GH joint
Less
More
Anterior
Bankart lesion
Anteroinferior labrum torn
“Bottom”
MC with anterior traumatic dislocation
Detached from 3-7 o’clock
Results in bother anterior and posterior structural injury
Stability of inferior GH ligament lost
SLAP lesion
Superior labrum anterior and posterior
Labrum detaches from 10-2 position
Often due to FOOSH injury, deceleration when throwing or sudden traction to biceps
What leads to SLAP lesion
Deceleration when throwing
FOOSH injury
Sudden traction to biceps
Type 1 SLAP lesion
Superior labrum markedly frayed but attachments intact
Type 2 SLAP lesion
Superior labrum has a small tear
Instability of labrum-biceps complex ***
What type of SLAP lesion is MC
Type 2
Small tear in superior labrum and instability of labradoodles-biceps complex
What type of SLAP lesion causes instability of labrum-biceps complex
Type 2
Type 3 SLAP lesion
Bucket-handle tear of labrum that may displace into joint
Labrum biceps attachment intact
What type of SLAP lesion causes bucket-handle tear
Type 3
Type 4 SLAP lesion
Bucket-handle tear of labrum that extends into biceps tendon allowing tendon to sublux into joint
Superior labrum markedly frayed by attachments intact
Type 1 sLAP lesion
Superior labrum has a small tear and instability of labral-biceps complex
Type 2 slap lesion
Bucket-handle tear of labrum that may displace into joint
Labral biceps attachment intact
Type 3 slap lesion
causes of shoulder instability/dislocation
Repetitive strain—looser ligaments due to repetitive overhead motion
- naturally looser ligaments in all directions
- trauma
Humeral head injury
Compression/impaction fraction of posterolateral aspect of humeral head
Complications of humeral head injury
Hill-Sachs lesion/hatchet deformity
Hill-Sachs lesion/hatchet deformity seen when
Humeral head injury
Bankart lesion seen with which dislocation
Anterior GH
cause of AC injury
Fall or blow to lateral acromion
S/s of AC injury
Pain in superior/lateral shoulder during cross-arm test (abduct arm across chest)
What test can you do you differentiate impingement from AC?
Cross arm test.
Adhesive capsulitis MC in?
Older adults
What causes adhesive capsulitis
Idiopathic
Minimal trauma
MC in diabetic patients
S/s of adhesive capsulitis
Achy pain similar to impingement
Decrease in PROM and AROM
Cannot see on X-ray
S/s of OA
Pain/stiffness similar to adhesive capsulitis
Achy pain awakens at night
AROM/PROM decreased
Can see on X-ray!!!***
