UE Flashcards
Special test(s) to predict bursitis
Neer
Special test(s) to predict Partial Cuff Tear
Neer
Special test(s) to predict Full Thickness Cuff tear Pretest probability = \_\_\_% #/# tests positive = \_\_\_% posttest probability
Painful Arc sign
Infraspinatus strength test
Drop Arm Test (Codman’s)
Pretest probability = 65% #/# tests positive = 90% posttest probability
Special test(s) to predict Impingement overall Pretest probability = \_\_\_% #/# tests positive = \_\_\_% posttest probability; #/# tests positive = \_\_\_%
Painful Arc Sign
Infraspinatus Strength test
Hawkins-Kennedy Test
Pretest probability = 39%
3/3 tests positive = 90% posttest probability;
2/3 tests positive = 69%
Special test(s) to detect biceps brachii integrity/strength (of the tendon)
Speed’s Test
Yergason’s Test
Special test(s) to detect Bankart Lesion, which is a tear of the [ant/post] [sup/inf] labrum & glenoid rim
Special test(s) to detect Bankart Lesion, which is a tear of the ANTERIOR, INFERIOR labrum & glenoid rim
Crank Test
Special test(s) to detect SLAP lesion
- Compression-Rotation (Snyder)
- Anterior, Posterior Slide
- Speed’s Test
- O’Brien’s Test
- Yergason’s Test
- Crank Test (weak for slap, better for any labral tear)
Special test(s) to detect posterior instability (posterior capsule & ligaments)
Posterior Load & Shift
Special test(s) to detect anterior instability (anterior capsule & ligaments)
- Anterior Load & Shift
- Anterior Apprehension, Posterior (Jobe) Relocation, & Surprise Tests
Special test(s) to detect inferior & multidirectional instability (inferior capsule & ligaments)
Sulcus Sign @ 0* (or 20-50*)
**This is more specific for a superior labral tear
Special test(s) to detect impingement. What structures are affected?
STRUCTURES:
- Subacromial bursa
- Supraspinatus
- Long head biceps brachii
TESTS:
- Neer test
- Hawkins Kennedy
- Painful Arc
- Infraspinatus strength tests
- Coracoid impingement test (Long head biceps)
- Yergason’s test
Special test(s) to detect Rotator Cuff Tear. What structures are affected?
STRUCTURES:
- Supraspinatus
- Infraspinatus
- Long head biceps brachii
- *Subscapularis
TESTS:
- External Rotation Lag Sign I @ 20* (Infra- and supraspinatus)
- ER Lag sign II @ 90* ABD (infra- and teres minor)
- Drop Arm Test (HIGH specificity!)
- Empty Can, Full Can
- Infraspinatus Strength Tests (high specificity)
Tests that ALSO test subscap:
- IR Lag sign/Lift Off test (Subscap)
- Belly Press, Belly Off tests (subscap, biceps) HIGH specificity
- Horizontal/Cross-Body Adduction
Special test(s) to detect AC Joint injury?
Shear test
Palpation
Horizontal/Cross-Body Adduction
What is included in the shoulder clearing exam?
- Flexion with OP combined with Abduction
- HBB with OP
- Quadrant with OP
- Resisted cuff tests (elbow at 90* flexion, resist IR and ER)
Considerations in the following patients with shoulder complaints:
- Young mid/adult:
- Mid adult:
- Mid/senior adult:
- Shoulder dislocation:
- Female vs male pts
- Young mid/adult: Ca++ deposits
- Mid adult: Cuff degeneration
- Mid/senior adult: Frozen shoulder (adhesive capsulitis)
- Shoulder dislocation: Decreased recurrence with younger pts
- Female vs males: Females = higher incidence frozen shoulder
Visceral/ Organic/ Non-Musculoskeletal problems that show up as shoulder pain:
- Spleen:
- Gallbladder:
- Diaphragm:
- Cardiac:
- Pancoast Tumor:
- Spleen: pain L shoulder
- Gallbladder: pain R shoulder
- Diaphragm: pain FRONT of either or both shoulders
- Cardiac: (ANGINA) pain L shoulder, scapula, (and/or arm, jaw, neck)
- Pancoast Tumor: (APICAL LOBE OF LUNG) pain R shoulder, ulnar distribution UE
What are the 5 Ds of the subjective exam?
5Ds:
- Dizziness
- Diploplia
- Dysarthria
- Dysphasia
- Drop attacks (fainting)
What are the 3Ns of the subjective exam?
3 Ns:
- Numbness
- Nausea
- Nystagmus (and occasional neck pain)
Full thickness RC tears have been found to be associated with [high/low] cholesterol. Smoking is associated with [full/partial/both] thickness RC tears.
Full thickness RC tears have been found to be associated with HIGH cholesterol. Smoking is associated with FULL & PARTIAL thickness RC tears.
If a patient has limited shoulder ROM, what conditions may present with a capsular pattern?
CAPSULAR pattern
- Arthritis
- Trauma
- OA/DJD
- RA
- Adhesive capsulitis
If a patient has limited shoulder ROM, what conditions may present with a non-capsular pattern?
NON-CAPSULAR Pattern
- Acute bursitis
- Tendinitis, Strain
- Sprain
- AC or SC involvement
If pt has full PROM, what should you consider to be a possible contributor to pain?
Consider TENDONS and BURSAE
If pt does not have full PROM and has an empty end feel, consider…
Limited PROM, Empty end feel:
- Acute bursitis
- Acute frozen shoulder
If all extreme ROMs are painful and have a hard end feel, consider…
Painful and hard end feels:
- Capsular lesion
If all extreme ROMs are painful with a normal or spasm end feel, consider…
Painful extreme ROMs with normal or spasm end feels:
- AC or SC
- Chronic bursitis
- Tendinitis
With a painful arc, we may see tendinitis/impingement of the…
- Supraspinatus
- LHB
- Infraspinatus
- Subscapularis
AC and SC joint pain will be [general/ more localized] and increase over ___* of shoulder flexion.
AC and SC joint pain will be LOCAL and increase over 90* of shoulder flexion.
Common treatments in acute stage of shoulder injury
- Physical agents
- Gentle STM
- Passive movements (by PT or pt)
- Active movements with resistance as tolerated
- Pt education
- Cardio exercise if tolerated
Common treatments in chronic stage of shoulder injury
- STM
- Passive movements (by PT or pt)
- Resistance exercise: stability, mobility, neuromuscular re-ed
- Cardio exercise
- Functional activities
- Pt education
Impingement syndromes at the shoulder can be classified as anterior (___ & ___) or posterior (___).
Impingement syndromes at the shoulder can be classified as anterior (PRIMARY & SECONDARY) or posterior (INTERNAL).
GH joint instability can be traumatic (subluxation or dislocation) or acquired (secondary). Describe each using the known acronyms: AMBRI & TUBS. Which acronym goes with which?
Traumatic GH Jt Instability
- TUBS: Traumatic onset, Unidirectional anterior with Bankart lesion responding to Surgery
Acquired/secondary GH Jt instability
- AMBRI: A-tramautic cause, Multidirectional with Bilateral findings, Rehab is appropriate rx, and rarely may require Inferior capsular shift surgery.
Frozen shoulder, aka ___, describes shoulder pain that inhibits/limits [AROM/PROM] leading to loss of available motion. This follows a [capsular/ non-capsular] pattern. It has 3 phases: __, __, __. Treatment includes ___ and may involve an injection of __ in the [early/late] stage.
Frozen shoulder, aka ADHESIVE CAPSULITIS, describes shoulder pain that inhibits/limits AROM leading to loss of available motion. This follows a CAPSULAR pattern. It has 3 phases: INFLAMMATORY, JT CAPSULE RESTRICTION, GRADUAL RECOVERY OF MOTION. Treatment includes PT (Mobilization, exercise/PNF) and may involve an injection of CORTICOSTEROID in the EARLY stage.
What is the treatment for strains/tears and tendinosis/itis/opathy in the following stages?
Acute:
Chronic:
ACUTE
- Physical agents
- Guided healing
- Decrease pain and swelling
CHRONIC
- Friction massage
- STM
- Stretching
- Strengthening
A primary impingement is described as the impingement of the __, __, and ___ in the ___ space. This occurs in mostly [older/younger] ages and may be a degenerative process and potentially affected by the shape of the __.
A primary impingement is described as the impingement of the RC, BICEPS TENDONS, and BURSA in the SUBACROMIAL space. This occurs in mostly OLDER ages and may be a degenerative process and potentially affected by the shape of the ACROMION.
A secondary impingement generally happens due to overuse in [older/younger] age, typically in ___ [what type of person?] working ___ [what direction?]. It is characterized by laxity in the [ant/post] capsule and tightness in the [ant/post] capsule. We see dyskinesia of the __ and __ jt, and altered muscle dynamics. Associated with ____ lesion.
A secondary impingement generally happens due to overuse in YOUNGER age, typically in OVERHEAD ATHLETES. It is characterized by laxity in the ANTERIOR capsule and tightness in the POSTERIOR capsule. We see dyskinesia of the SCAPULA & GH jt and altered muscle dynamics. Associated with SLAP lesion.
An internal impingement generally occurs in ___ (what population?). In this injury, the undersurface of the RC contacts the [ant/post]-[sup/inf] labrum. You can test for this using the ___ test.
An internal impingement generally occurs in OVERHEAD ATHLETES. In this injury, the undersurface of the RC contacts the POSTERIOR-SUPERIOR labrum. You can test for this using the ANTERIOR APPREHENSION test.
Treatment for impingement may include…
- Postural correction
- Exercise to balance muscle strength & endurance
- Mobilization of posterior capsule
- Scapular taping
- Thrust manipulation
Impingements and cumulative trauma can lead to ___ which can lead to ___ because of decreased use, which can lead to __ & ___.
Impingements and cumulative trauma can lead to CUFF DISORDERS which can lead to FROZEN SHOULDER because of decreased use, which can lead to THORACIC OUTLET SYNDROME & CRPS.
With secondary (AMBRI) GH joint instability, there [is/ is not] a hx of trauma, and c/o ___. The objective exam is mostly normal except for positive special tests for ___ (e.g. ___).
With secondary (AMBRI) GH joint instability, there IS NOT a hx of trauma, and c/o INSTABILITY. The objective exam is mostly normal except for positive special tests for INSTABILITY (e.g. LOAD & SHIFT).
With TUBS type GH instability, there is a hx of traumatic [ant/post] dislocation and recurrent ____. The UE will appear [elevated/depressed] and [IR/ER]. Pt will have muscle guarding and pain in [flex/ext/abd/add/ER/IR] (pick 2!). We’ll see a positive __ and ___ test with tenderness [ant/post].
With TUBS type GH instability, there is a hx of traumatic ANTERIOR dislocation and recurrent APPREHENSION/ DISLOCATION. The UE will appear ELEVATED and ER. Pt will have muscle guarding and pain in ABD & ER. We’ll see a positive ANTERIOR APPREHENSION and JOBE RELOCATION test with tenderness ANTERIORLY.
Patients with DJD/OA of the shoulder likely have a history of previously mentioned disorders which lead to ___ and ___. These patients have painful __, difficulty ___, and [normal/incr/decr] ROM. Treatment includes __ an d__.
Patients with DJD/OA of the shoulder likely have a history of previously mentioned disorders which lead to ABNORMAL MECHANICS and DECREASED USE. These patients have painful CREPITUS, difficulty SLEEPING, and DECREASED ROM. Treatment includes JOINT MOBS and STM, ETC.
AC and SC joint sprains occur following a fall on the __. They’re graded as ___. Treatment includes __ and __.
AC and SC joint sprains occur following a fall on the SHOULDER. They’re graded as Grades 1-3 (3=worst separation). Treatment includes TAPING and GUIDED HEALING.
A carrying angle >___* is called cubitus valgus. A carrying angle >__* is called cubitus varus.
A carrying angle >15* is called cubitus valgus. A carrying angle >5* is called cubitus varus.
What 4 things do you look for when assessing passive accessory movements?
Quantity
Quality
Sx
End Feel
What are the contributors to dynamic stability at the medial elbow?
Flexor Carpi Ulnaris (primary)
Flexor Digitorum Superficialis (secondary)
Pronator teres (least)
[Males/females] have larger forearm circumference and greater grip strength. Grip strength is greatest in ages __-__. A normal difference between dominant and non dominant forearm circumference is __ cm, or about ___% difference in grip strength. Grip strength [increases/ decreases] with age.
MALES have larger forearm circumference and greater grip strength than females. Grip strength is greatest in ages 35-44. A normal difference between dominant and non dominant forearm circumference is 1-2 cm, or about 10% difference in grip strength. Grip strength DECREASES with age.
In patients with lateral epicondylitis, [flexion/ extension] grip strength is greater on the involved side, while there is no difference on the uninvolved side.
In patients with lateral epicondylitis, FLEXION grip strength is greater than extension grip strength on the involved side, while there is no difference on the uninvolved side.
Special test(s) for lateral epicondylitis
- Passively pronate, flex wrist, extend elbow
- Resist radial deviation/extension (pt in forearm pronation and holding a fist)
- Resist distal 3rd PIP during finger extension
Special test(s) for medial epicondylitis
- Passively supinate, extend elbow and wrist
What local structures could evoke lateral symptoms at the elbow? What could be referred here?
- Superior radioulnar jt
- Radiohumeral jt
- Annular lig. of radial head
- Radial collateral lig
- Common extensor tendon at lat epicondyle
- Radial n (posterior interosseous n) entrapment at supinator muscle (mimics tennis elbow)
PLUS referred pain from C5, C6 n roots, as well as lateral & dorsal (posterior) antebrachial cutaneous nn
What local structures could evoke medial symptoms at the elbow? What could be referred here?
- Humeroulnar jt
- Medial collateral lig
- Common flexor tendon at medial epicondyle
- Ulnar n entrapment at cubital tunnel
Referred:
- T1 nerve root: Medial brachial & medial antebrachial cutaneous nn
What local structures could evoke anterior/central symptoms at the elbow? What could be referred here?
- Humeroulnar jt (deep pain)
- Superior radioulnar jt (deep pain)
- Brachialis muscle (deep pain)
- Distal biceps brachii common tendon (superficial pain)
Referred:
- C6 nerve root: medial antebrachial cutaneous n
What local structures could evoke posterior symptoms at the elbow? What could be referred here?
- Humeroulnar jt
- Triceps common tendon
- Brachialis m (deep pain)
- Olecranon bursa
Refererd:
- C7 n root: dorsal (posterior) antebrachial cutaneous n
What other musculoskeletal areas might refer to the elbow?
- C spine joints & soft tissue (mimic tennis elbow)
- GH Jt and subacromial structures
- Wrist & hand jts and soft tissue
- Local peripheral n irritation or adverse mechanical tension
Predictors of poor outcome in lateral epicondylitis include [minimal/ severe], [short/long] duration elbow pain and ___ pain.
Predictors of poor outcome in lateral epicondylitis include SEVERE, LONG duration elbow pain and NECK pain.
With lateral and medial epicondylitis, we see [normal/ incr/ decr] grip strength and [pain/ no pain].
With lateral and medial epicondylitis, we see DECREASED grip strength and PAIN
What is the preferred treatment for lateral epicondylitis?
Taping!
Splint vs band: no difference in grip strength or pain after 6 wks
Splinting is expensive, uses more medical services, and has limited duty
Muscle function and pain measures are more impaired in [lateral/ medial] epicondylitis.
Muscle function and pain measures are MORE IMPAIRED in LATERAL vs medial epicondylitis.
Posterolateral rotary instability involves the following:
- Cubitus [varus/ valgus] (with increased effects in __-__* flexion)
- [Varus/valgus] stress/instability
- ___ strain (ligament)
- ___ and ___ insufficiency (muscles)
- Cubitus VARUS (with increased effects in 20-30* flexion)
- VALGUS stress/instability
- LATERAL UCL strain (ligament)
- FCU and FDS insufficiency (muscles)
Special tests for posterolateral rotary instability include…
- Pivot shift test
- Table top relocation
- Push up sign, Chair sign
- Medial forearm MMT
Common bursitis at the elbow: ___ bursitis
Olecranon bursitis (large bump posterior to olecranon)
With elbow DJD, we see ____ impingement. This generally involves the following:
- [varus/ valgus] extension overload (e.g. from ___)
- ___ (lig) insufficiency at __* flexion
- Increased [varus/valgus] angle
- [Incr/decr] medial jt contact area
- [incr/decr] medial jt contact pressure
With elbow DJD, we see POSTEROMEDIAL (COMPARTMENT) impingement. This generally involves the following:
- VALGUS extension overload (e.g. from OVERHEAD THROWING/DECELERATION)
- UCL insufficiency at 30* FLEXION
- Increased VALGUS angle
- DECREASED medial jt contact area
- INCREASED medial jt contact pressure
Common treatments for ACUTE elbow DJD include…
- Modalities
- Gentle STM
- Passive movements (by PT or pt)
- AROM, resistance as tolerated
- Pt education
- Cardio exercise if tolerated
Common treatments for CHRONIC elbow DJD include…
- STM
- Passive movements (by PT or pt)
- Resistance exercise: stability, mobility, neuromuscular re-ed
- Pt education
- Cardio exercise
- Functional activities
