UE Clinical Syndromes Flashcards
Impingement Syndrome
- Defn, Symptoms & MOI
mechanical impingement of subacromial structures
- pain ant/sup part of shoulder
- weakness
- stiffness
MOI - age, repetitive overhead, muscle or postural imbalances, structural asymmetery, impaired kinematics
Impingement Syndrome
-classifications
Classified as outlet vs. nonoutlet & intrinsic vs. extrinisic
- outlet = supraspinatus outlet encroached
- nonoutlet = secondary to thickening of bursa or RC tendons
- Intrinsic = RC weakness, overuse, or degenerative tendinopathy
- Extrinsic = shape of acromion, INSTABILITY, degeneration
»primary (involved structures in subacromial space) vs. secondary (DO NOT involve subacromial structures)
Stages of Impingement Syndrome
I - edema & hemorrhage of bursa cuff (<25 years old)
II - irreversible changes - fibrosis & tendonitis (25-40)
III - more chronic changes; partial or complete tears (40+)
Shoulder Instability
- defn & classifications
- treatment
instability/laxity of the shoulder joint
Classifications
- traumatic: usually due to bankart lesion (labral tear)
SYMP: recurrent dislocations
*positive Apprehension test
- atraumatic: overstretch
SYMP: tendonitis, sensation of instability & laxity
*negative Apprehension test
Treatment - scapular stabilization & RC strengthening
NO Manual therapy if hypermobile
Adhesive Capsulitis
- defn & classification
aka frozen shoulder
inflamed & fibrotic condition of capsuloligamentous tissue
Classification -
Primary (idiopathic)
Secondary (due to known disorders) - systemic, intrinsic or extrinsic factors
(see algorithm)
Adhesive Capsulitis
- Stages
Stage 1 = 0-3months
- pain w/ AROM & PROM
Stage 2 = 3-9months
- freezing stage
- chronic pain w/ AROM & PROM w/ limitations
Stage 3 = 9-15 months
- frozen stage
- minimal pain except at end of ROM
- significant limitations w/ hard end feels
Stage4 = 15-24 months
- thawing phase
- minimal pain & progressive ROM improvements
SLAP lesion
-defn, symptoms & MOI
“superior labral tear from anterior to posterior)
injury of labrum at attachment where tendon of the long head of the biceps attaches
Symptoms - pain & instability/lack of control w/ overhead activities; pos. O’brien’s test
MOI - repetitive overhead activities, sudden eccentric biceps contraction
SLAP lesion
-classification
There are 6 classifications
Type 2 is most common
- biceps anchor peels off from supraglenoid tubercle w/ detachment of labrum (ant to post)
Rupture of Biceps Brachii Long Head
-defn, symptoms & MOI
complete tear of tendon of biceps brachii (most commonly at supraglenoid tubercle - insertion point)
Symptoms - popping w/ pain that will ease –> tenderness over anterior shoulder
-popeye sign & positive speed’s test
MOI - lifting something heavy
Snapping Scapula
- defn, symptoms & MOI
abnormal articulation of scapulothracic joint that causes grinding sensation of scap
Symptoms - crepitis of scapula, pain w/ overhead activities, worse w/ abduction & eased w/ horz. adduction
MOI - repetitive overhead use, bony abnormalities, muscle imbalance (serratus ant & subscap)
Snapping Scapula
- differential diagnosis
scapular bursitis - pain & fullness over bursa (superior angle deep to levator scap)
Trapezoid bursitis - pain at bursa @ junction of scapular spine & medial border
Scapulocostal syndrome
-defn, symptoms & MOI
formation of adhesions due to irritated bursa btwn scapula & thorax
Symptoms -
pain (medial border of scap & underlying rib cage), dyskinesia & tenderness w/ restriction & loss of motion
MOI - trauma, poor posture, prolonged immobilization
AC Separation
- defn, symptoms & MOI
disruption of ligaments involved in the AC joint that causes separation of AC
Symptoms -
- tenderness & pain, piano key sign, increased joint space, positive HAC or O’briens test
MOI - falling onto shoulder w/ arm adducted by side
AC Separation
-classifications
I - sprain of AC ligament
II - torn AC & sprained CC ligaments
III - torn AC & CC ligaments w/ dislocation
IV - AC & CC ligaments torn w/ clavicle displaced posteriorly
V - AC & CC ligaments torn w/ gross disparity btwn clavicle & scapula
VI - Ac & CC ligaments torn w/ clavicle displaced inferiorly to coracoid process
Humeral Head Fractures
- defn, symptoms, & MOI
one to four-part fractures (see article) - based on Neer’s classifications
Symptoms - patient guarding & avoidance of using arm, pain & swelling, possible hematoma
MOI - younger population usually high energy trauma (MVA & sports) & older population usually low trauma energy (FOOSH)
Lateral epicondylitis
-stages
Stage I - inflammation w/o alterations to the tendons
Stage II - tendinosis or angiofibrolastic degeneration
Stage III - pathological changes in the tendon
Stage IV - 2+3 & degenerative changes in the bone
Lateral epicondylitis
-defn, symptoms, MOI
DEFN - inflammation of the insertion of the extensor tendons
Symptoms - lateral elbow pain, weakened grip strength, “special tests” - chair, Cozen,s Mills
MOI - overuse (repetitive grasping w/ wrist in extension) or trauma
Treatment for lateral (and medial) epicondylitis
Injection + PT
- Education - avoid MOI, specific instructions to athletes
- Modalities - iontoforesis proven very beneficial
- Ther ex - stretching, strengthening, eccentric wrist extension
- Manual therapy - transverse tissue massage, Mill’s manipulation, radial head & cervical mobilizations
- Assistive device- brace to remove pressure
Medial Epicondylitis
-defn, symptoms, MOI
DEFN - inflammation of the insertion of FCR tendon & pronator teres
Symptoms - pain at medial elbow, pain w/ flexion & pronation
-“special tests” - resisted muscle test & passive stretch test
MOI - overuse; repetitive wrist flexion
Little Leaguer’s Elbow
-defn
a variety of injuries of the elbow; usually at medial epicondyle & seen in young baseball players
General Rule:
- Will have problem w/ the bone IF medial growth plate is open
- i.e. osteochondritis dissecans, growth plate fractures, apophysitis or fracture - Will have problem w/ ligament IF growth plate is closed
- i.e. MCL tear (tommy john), anterior capsule injury
Or can have olecranon trauma
Little Leaguer’s Elbow
-symptoms & MOI
Symptoms - pain in medial elbow, possible edema
MOI - excessive valgus stress, hyperextension & overuse
-high pitch volume, early use of breaking balls, inadequate biomechanics & lack of appropriate conditioning
Treatment for Little Leaguer’s Elbow
- Education is HUGE!
Must teach correct biomechanis & know the guidelines/recommendations
-throwing not allowed for 4-6 weeks & then start gradual - Ther ex - core and upper limb strengthening
- Assistive Device - possible cast if excessive bone separation
Triceps tendinosis
-defn, symptoms, MOI
DEFN - inflammation & degeneration of the triceps tendon (usually at insertion point on olecranon)
Symptoms - pain & tenderness at post. elbow; pain w/ resisted elbow extension
MOI - overuse, repetitive sudden elbow extension
(pitching, shot put, javelin, bowling, heavy weight lifting)
Treatment for Triceps tendinosis
- Ther ex - French stretch & triceps towel stretch, triceps strengthening (eccentric, French press, etc)
- Assistive device: brace or strap
- Manual therapy - transverse massage
Radial Head Fracture
-types
Type I - small crack in radial head; bones still fit together
Type II - larger piece of bone is involved w/ slight displacement
Type III - comminuted & displaced
Type IV - dislocated & fractured
Radial Head Fracture
-defn, symptoms, MOI
DEFN - fracture of radial head (4 types)
-more frequent in women 30-40yrs old
Symptoms - pain & tenderness at lateral aspect of elbow w/ edema; limited forearm ROM esp. pronation/supination
MOI - FOOSH, elbow dislocation
Treatment for Radial Head Fracture
- Assistive device - cast or sling
- Education - immobilization during acute stages & while in cast (still move surrounding joints)
- Ther ex - PROM > AAROM > AROM > resistance training
- focus on pronation/supination & flexion
Pulled Elbow
-defn, symptoms, MOI
DEFN - subluxation of the radial head from capitellum
Symptoms - arm is held in extension & pronation by the childs side; pain w/ movement OR avoids movement completely
MOI - sudden jerk on the extended pronated arm
-i.e. pulling an uncooperative child or swinging them by the arms
Treatment for Pulled Elbow
- Education - explain MOI to parent & how to prevent
- Manual therapy - reduction maneuver (if it is not the first time) - effective immediately
- Assistive device - may require a sling if the child doesnt use the arm right away
- HEP - observe the child
Osteochondritis Dissecans
-defn, symptoms, MOI
DEFN - joint condition where the cartilage & a piece of bone come loose from the end of a bone
Symptoms - pain & swelling laterally & anteriorly, limited ROM, & clicking/locking
MOI - repetitive trauma or radialhumeral lateral compression forces
-compression causes the blood vessels to constrict which leads to bone necrosis
-common in baseball players - occurs during the cocking phase
Treatment for Osteochondritis Dissecans
Surgery is required if there is locking or clicking
- Education - biomechanics of pitchers
- Modalities - ice & E-stim (no ultrasound over childs growth plate)
- Ther ex - passive & active ROM & strengthening, function & sport related exercises
- Ass device - sling in acute stage
Olecranon Bursitis
-defn, symptoms & MOI
DEFN - inflammation of the bursa on posterior elbow
symptoms - edema, tenderness, pain, restricted ROM
MOI - traumatic, pressure (“students elbow”), infection, RA or gout
Treatment for Olecranon Bursitis
Usually not recommended for PT
- may requires oral anti-inflammatories or a steroid injection
- aspiration or if more severe a bursectomy
- PT’s role is education
Elbow Instability
-defn, symptoms
DEFN - general laxity w/n the elbow joint capsule
- can be conginetal or traumatic
- increases susceptibility to subluxation or dislocation
- humeroulnar joint is most commonly predisposed to recurrent instability
Symptoms of instability - pain, unusual noises, locking of the elbow towards extension, increased laxity in ligaments
MOI for dislocation of the Elbow
-terrible triad
dislocation is due to elbow instability.. can occur due to..
- Valgus force - FOOSH - lead to terrible triad (elbow dislocation, radial head & coronoid fx)
- Varus (rare)
- Anterior dislocation - blow to flexed elbow
- Posterior - due to excessive stretching
- Posterior lateral (most common) - 3 stages (subluxed, dislocated incompletely & full dislocation)
Treatment for Elbow Instability –> Dislocation
- Education - if they have instability it is chronic so must education about continued strengthening, ROM & avoidance of MOI
- NO manual therapy b/c already hypermobile
- Assistive device - if dislocated use a hinge splint
- Ther Ex - immobilization w/ periphery joint movement (acute), AROM & gentle stretching (subacute), strengthening & functional (chronic)
Colles’ Fracture
-defn, moi & symptoms
DEFN - fracture of the distal radius w/ dorsal displacement
MOI - FOOSH; extension + compression
SYMPTOMS - dinner fork deformity, swelling, decreased ROM, decreased grip strength
Treatment for Colles’ & Smith’s Fracture
Modalities - ice for edema
Manual therapy - massage scar tissue, joint glides
Ther. Ex - active exercises to promote circulation & movements of nerves
–> important to have high reps so they can return to function!
Smith’s Fracture
-defn, MOI, symptoms
DEFN - fracture of the distal radius w/ volar displacement
MOI - FOOSH; flexion + compression
SYMPTOMS - edema, decreased & painful ROM, decreased grip strength
Scaphoid Fracture
-defn, MOI, symptoms
DEFN - fracture of scaphoid carpal
MOI - FOOSH; extension + compression + radial deviation
SYMPTOMS - painful palpation in anatomical snuff box, painful/limited ROM, painful compression/axial loading
Treatment for Scaphoid Fracture
Can be conservative or surgical
- usually conservative FIRST; surgical if not healed after 6 months (or in special cases)
Immobilization for 2-6 months in spica brace
Modalities - heat to increase circulation
Boxer’s Fracture
-defn, MOI, symptoms
DEFN - fracture of the distal portion-neck- of metacarpal (typically 4th or 5th)
MOI - boxing or punching
SYMPTOMS - swelling at MC, pain w/ MMT
Mallet Finger
-defn, MOI, symptoms
DEFN - avulsion of the extensor tendon from the DIP
MOI - forced flexion from direct force on DIP
–> common in basketball players
SYMPTOMS - cannot extend DIP, deformity of DIP
Treatment of Mallet Finger
Volar splint (if partial tear)
If complete tear it is usually left alone or can be surgically repaired
Few exercises to strengthen extensor tendon once healed
Scaphoid-Lunate Disassociation
-defn, MOI, symptoms, treatments
DEFN - injury to the ligament connecting the scaphoid and lunate
MOI - FOOSH & other trauma
SYMPTOMS - localized pain, swelling, clicking, pain w/ extension, increased mobility (glides), pain w/ weight bearing
–> special test = Positive Watson’s Test: locate and stabilize scaphoid; passively move patient from UD to RD; positive if scaphoid moves dorsally
TREATMENTS - immobilization, modalities & surgery
Lunate Dislocation
-defn, MOI, symptoms, & treatment
DEFN - volar dislocation of the lunate
MOI - FOOSH
SYMPTOMS - pain w/ palpation, limited/painful ROM, N/T in median nerve distribution (due to compression)
TREATMENTS:
- surgical reduction or immobilization (3-4 weeks)
- limit wrist extension ~ 2 months
Keinbock’s Disease
-defn, history, symptoms
DEFN - osteonecrosis/AVN of a bone following a fracture
HISTORY/MOI - FOOSH or compression fracture
SYMPTOMS - local tenderness, swelling, limited motion, pain w/ gripping & increased healing time
Treatment for Keinbock’s Disease
GOAL = restore blood supply
How do we prevent it?
- Initial immobilization following fracture
- Thermal modalities (paraffin, heat, etc)
- ROM/Glides, Ther.ex to increase circulation
If all those fail, surgery for bone graft or prosthetic carpal
Bennett’s Fracture
-defn, MOI, symptoms
DEFN - oblique, intra-articular fracture of first metacarpal
- volar segment held in place (bigger piece) & remaining segment is pulled radially & dorsally by APL
MOI - FOOSH (forced abd) OR axial blow directed against partially flexed metacarpal (fist fight)
SYMPTOMS - pain, swelling, defect in thumb (radial notch), unable to grab or pinch, N/T in thumb & wrist
Treatment for Bennett’s Fracture
Modalities: ice initially, heat later
Ther Ex: gentle ROM at 6 weeks, functional activities at 8 weeks, & normal activity at 12 weeks
Manual therapy: chronic stage only
HEP: AROM & PROM every hour!
Assistive device: thumb spica
Education: protection and focus on non-affected joints during immobilization
TFCC
-defn, MOI, symptoms
Triangular Fibrocartilage Complex Disc Injury
DEFN - disruption of TFCC disc;
- grade I = traumatic & grade II = degenerative conditions
MOI - FOOSH; repetitive UD
SYMPTOMS - pain on ulnar aspect of wrist, increased w/ UD & extension & forearm rotation; swelling, crepitus, weakness, instability
–> special tests: hypersupination; Fovea Sign (apply pressure in groove that separates ulnar styloid process & ulna head), loading wrist into UD and extension
Treatment for TFCC Injury
Can be conservative (splint, steroid shot, PT) or surgical
Conservative:
Education: use of splint, description of injury
Modalities: ultrasound, E-stim, ice
Assistive Device: splint for 4-6 weeks
Manual Therapy: radial glide (for UD), prox/distal radioulnar medial & lateral glides for supination/pronation
Ther Ex: stretching & strengthening; esp pron/sup, flex/ext & UD/RD
Carpal Tunnel Syndrome
-defn, MOI, symptoms
DEFN - inflammation of the flexor tendons that compresses the median nerve in the carpal tunnel
MOI - repetitive use of flexors w/ wrist extension, prolonged rest on palm, or traumatic
SYMPTOMS - N/T in median nerve distribution, painful ROM, nocturnal pain, thenar atrophy
–> special tests: Phalens/Reverse Phalens test, Tinel’s Test
Treatment for Carpal Tunnel
Education: Must treat the source of the problem (ergonomics, activity modification)
Assistive Device: splint to limit excessive flexor use when wrist is extended; also noctural splint
Exercises: nerve & tendon glides
Manual therapy: carpal bone mobilization
Medical manageent: NSAIDS, carpal tunnel release
- evidence supports surgical treatment as more effective
De Quervain’s Syndrome
-defn, MOI, symptoms
DEFN - tendonitis of the abductor pollicis longus & extensor pollicis brevis; tenosynovitis of the first dorsal compartment of the hand
— aka trigger thumb, texting thumb, gaming thumb
MOI - overuse; repetitive activity or forceful gripping w/ UD
SYMPTOMS - radial wrist pain w/ thumb movements, tenderness over first dorsal compartment, crepitus in tendon region
Treatment of De Quervain’s Syndrome
Conservative or surgical release
Assistive device: thumb spica brace (3 weeks)
Modalities: ultrasound, iontophoresis
Manual therapy: transverse friction massage, radial glide, soft tissue & myofascial release therapy
Education: ergonomics, avoid exacerbation & activities
Ther Ex (HEP): stretching, ROM & strengthening
Raynaud’s Phenomenon
- defn, MOI, symptoms
- primary vs. secondary
DEFN - disorder marked by brief episodes of vasospasm (narrowing in BV’s) specifically in hands and toes
- primary = idiopathic
- secondary = due to comorbid/underlying condition
MOI - direct cause unknown, idiopathic
–> triggered by cold temps & emotional stress
SYMPTOMS - decreased circulation, diffuse pain, pale fingers
- digital pallor –> cyanosis –> rubor
- Throbbing & tingling w/ return of blood
- special test: Allen’s test
Treatment for Raynaud’s Phenomenon
-pharmacological & non-pharm
Mainly will be pharmacological & lifestyle changes (if secondary)
- Ca channel blockers, angiotensin converting enzyme inhibitors & ang. II receptor antagonists
- exercise diet, clothing & smoking cessation
Non-pharmacological treatments:
Modalities: biofeedback, thermal
Manual therapy: massage to increase blood flow
Ther Ex: stress ball squeezes, AROM
Education: reduce stress, increase activity, stop smoking, wear enough layers of clothes
Dupuytren’s Contracture
-defn, MOI, symptoms
DEFN - palmar fascia constriction; forces fingers to stay in flexed position (most commonly 4/5th digits & in men)
MOI - idiopathic; could be due to genetics, autoimmune rsn, or overproduction of collagen
SYMPTOMS - progressively thickening of palm of hand
- Nodule
- Cord
- Inability to straighten finger
Treatment for Dupuytren’s Contracture (4 approaches)
- Surgical release w/ 2-3 months of therapy
- Needle aponeurotomy (needle divides the cords)
- Collagenase injection (enzyme that breakes up collagen)
- Corticosteroid injection (pain relief)
Education: importance to catch early so it doesn’t progress to surgery; avoid tight grips
Modalities: massage, heat
Ther Ex: intensive stretching program & strengthening
Manual Therapy: deep tissue or cross-frictional massage
Assistive device: post surgery custom splint/brace
Risk Factors for Dupuytren’s Contracture
> 50, men, northern european descent, family history, tobacco & alcohol use, diabetes
Risk Factors for Raynaud’s Phenomenon
Cold, gender, family history, tobacco, CT, occupation, previous injury
Differential Diagnosis for the elbow
-anterior vs. medial vs posterior vs. lateral
Anterior = pronator syndrome, ant. capsular strain, biceps rupture OR elbow dislocation
Medial = MCL injury, medial epicondylitis, ulnar neuritis, OR fracture
Posterior = olecranon fracture or bursitis, stress fracture, OR triceps tendonitis
Lateral = LCL injury, lateral epicondylitis, osteocondral degeneration, osteocondritis dissecans, radial head fracture OR capitelum fracture
Typical Treatment Progression (specifically for shoulder, but can be applied to all joints)
- Postural correction & proprioception
- ROM & flexibility
- Strengthening
- Functional exercises & endurance
Treatment for Impingement Syndrome
First must address the underlying problem!
—> education about biomechanics
Ther Ex - postural corrections, ROM, stretching (pecs) & strengthening (scapular & RC muscles)
Manual therapy - inferior & posterior glides to open subacromial space
Assistive device - sling (acute), kinesio tape
HEP - pendulum & other ther. ex
Treatment for Adhesive Capsulitis
- Education - explain nature of disease & prepare for extended recovery
- Modalities - hot packs & TENS
- Ther Ex - stretching; hold-relax stretch & low load prolonged stress
- Manual therapy - ER w/ inferior glide (RCI) & glides for general mobility
- Grade III distraction, Grade III-IV mobilizations, NO MANIPULATIONS - Assistive device - low load prolonged stress equipment
- HEP - pendulum & AAROM 3x/day
Treatment for SLAP Lesions
- Ther Ex - scapular stabilization & posterior capsule stretching (sleeper, cross body)
- Manual therapy - depending on exam findings
- Assistive device - sling when acute
Treatment for Rupture of Biceps Brachii Long Head
- Education - avoid heavy lifting 3-4 weeks
- Ther Ex - post op immobilization –> PROM/AROM –> RC and periscapular resistance training –> throwing program –> return to activity
- Manual therapy - as needed for ROM
- Ass. device - sling 2-4 weeks after surgery, hinged brace or cast
- HEP - AROM in all planes of movement to end range; 3x20, 3x per day
Treatment for Snapping Scapula
If its due to overuse you can treat it conservatively, if its a lesion or body abnormality then requires surgery
- Ther Ex - improve muscular endurance of upper thoracic musculature & posture training, stretch upper pecs & trap
- HEP - posture training
- Manual Therapy - PAM’s of scapula, distraction grade III & medial glide
Treatment for Scapulocostal Syndrome
- Ther Ex - serratus anterior punches, subscapular adduction & prone retraction (I,T,Y)
- HEP - floor/wall angels
- Manual therapy - scapular mobilization & trigger point release
- Education - postural re-education
Treatment for AC Separation
Depends on type and if surgically fixed or conservatively
- Ther Ex - shoulder ROM > isometrics > isotonic & stretching
- Education - sling/brace
- Manual therapy - to regain shoulder motion
Treatment for Humeral Head Fractures
usually treated conservatively; can be treated surgically if younger and requires higher level of function
- Modalities - ultrasound in subacute stage to increase blood flow
- Ther Ex - start ASAP - PROM > AAROM > AROM, pendulums, grip strengthening, postural corrections, isometrics & isotonics
- Manual Therapy - only in subacute/chronic phase
