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Patho 2 > UL MSK Pathologies > Flashcards

UL MSK Pathologies Flashcards

1
Q

Common Tendinopathy in UL

A 
Rotator Cuff Related Pain 
Lateral Epicondylitis (Tennis elbow) 
Medial Epicondylitis (Golfer's elbow)
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2
Q

Define Rotator Cuff Shoulder Related Pain (RCRSP)

A

Most common tendinopathy of upper limb
Includes:
• Sub-acromial pain syndrome (Impingement) - bursitis
• Rotator Cuff Tendinopathy
• Rotator Cuff Tears - including long head biceps brachii tear

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3
Q

Pathogenesis of rotator cuff tendinopathy

A

Extrinsic factors:

  1. Mechanical irritation of contents of subacromial space compression between greater tubercle and upper part of glenoid causes superior slide of humeral head in glenoid
  2. Postural dysfunction - FHP, protracted shoulder girdle, kyphosis, scapula position; Leads to alteration of force couples operating around shoulder & faulty movements
  3. Muscle imbalances:
    1. Weak / fatigued / injured rotator cuff
    2. Results in loss of deltoid: RC force couple
    3. Allows superior migration of humeral head
    4. Leading to repetitive impingement of subacromial soft tissue
    5. Results in inflammation & rotator cuff disease
  4. Impingement of rotator cuff tendons secondary to G/H instability = Failure of static or dynamic stabilisers of GH joint allows excessive translation of HH
  5. Occupational / environmental / training: Anything that involves repetitive overhead manoeuvres eg. Tennis; painting ceiling; stacking shelves

Intrinsic Factors:

Degeneration of RC tendons

Deconditioned tendon - An under loaded tendon has no stimulus to build healthy tissue, will fail if suddenly over loaded

Joint side wear & tear

  1. Acromial side RC tendon fibres thicker & stronger
  2. Joint side fibres more vulnerable to tensile loads
  3. Lesions often found on joint side of tendon not acromial side
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4
Q

Risk factors of rotator cuff shoulder related pain

A

Age 35-75

H/O repetitive movements at or above shoulder height, or of heavy lifting

Athletes, workers who perform overhead activities and the elderly

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5
Q

Clinical presentation of rotator cuff shoulder related pain

A

Altered scapular movement therefore have changes in scapulohumeral rhythm

Pain in the top and lateral side of the shoulder which is made worse by lifting the arm (for example when lifting a full kettle) or with overhead activities

There can be night pain

Active movements are painful and may be restricted, whereas passive movements tend to be full but painful

May be a painful arc of movement between 70-120 degrees of abduction (presence reinforces the diagnosis of a rotator cuff disorder)

Weakness &/or pain on isometric resisted testing - joint does very little mvt

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6
Q

Management of RCSRP

A

○ Surgery vs Physiotherapy - some evidence suggests that they have similar outcomes

○ Physiotherapy includes:

Load modification - at first progression back to normal activities as soon as pain allows

Education - on pathology and on reducing aggravating activities

Pain relief - NSAIDs / Ice / joint mobs / SSTMs

Exercise:

Improve Strength and tissue capacity

Exercise in one direction at a time eg. ER

Restore full AROM & PROM

Isometrics (if irritable)> Isotonic

Start slow (this biases muscle, fast exs biases tendon)

Don’t exercise at EOR

Work into ER – this increases SAS & decreases pressure on RC tendons

Add other movements (e.g. LR with abd)

Progressive dynamic strengthening of RC

Maintain & improve neuromuscular control

Maintain muscle strength of all shoulder muscles

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7
Q

Define Lateral epicondylitis/epicondylalgia (tennis elbow)

A

Most common overuse syndrome in the elbow
Tendinopathy involving the extensor muscles of the forearm
Epicondylalgia because no symptoms of tendinopathy
Affects radial nerve as it passes through heads of supinator - neural symptoms

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8
Q

Prevalence of Tennis Elbow

A
  • Affects 1-3% of the population
  • Male=Female
  • More common in 40s/50s
  • ECRB tendon is the most commonly affected; ECRL tendon 2nd most affected; Other common tendons affected = ED, EDM, ECU, supinator
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9
Q

Causes of Tennis Elbow

A

Repetitive activity involving the extensor tendons of the forearm - musicians, computer users, manual workers, racquet sports (improper training, poor technique, improper equipment)

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10
Q

Risk factors of Tennis Elbow

A

Smoking
Obesity

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11
Q

Prognosis of Tennis Elbow

A

○ Most cases are self limiting (90% recover within a year)
○ Re-occurance rate = 8%
○ If do not recover or reoccurance occurs - increased risk of surgery required

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12
Q

Clinical Presentation of Tennis Elbow

A

○ Pain located around the lateral epicondyle of the elbow, usually radiating in line with the extensors

Insidious onset but often related to H/O overuse without specific trauma

Symptom onset 24-72h after repeated wrist extensor activity

○ Variable pain reported – intermittent / continuous, varying in severity
○ Typically aggravated by resisted wrist / finger extension, forearm supination; Middle finger causes secondary stress to ECRB - ECRB acts as a fixator on 3rd MC
○ Stretching the tendon can also reproduce symptoms, as can gripping - increases compression on common extensor tendon

Eases with rest

Differential diagnosis:

  1. Radiohumeral bursitis
  2. Osteochondritis of capitulum
  3. Posterior Interosseous Nerve (PIN) entrapment - In some cases the radial nerve may become involved as the radial nerve splits into the superficial radial nerve and the posterior interosseous nerve (PIN) at the radiocapitellar joint. Neurological deficit: weakness of posterior interosseous nerve innervated muscles (finger and thumb extensors and abductor pollicis longus)
  4. Radial tunnel syndrome - PIN may become trapped by pericapsular structures
    1. Diffuse aching pain over wrist extensor muscles, possibly radiating to the dorsal aspect of the hand, or sharp, shooting pain along the dorsal forearm region. Pain often worse at night
    2. Rarely, sensory or motor changes
    3. Pain may be increased by resisted supination, neurodynamic tests, and/or nerve palpation
  5. Cervical radiculopathy
    1. Radiation of pain from cervical spine, reproduced by palpation and/or active or passive movements of the cervical spine
    2. Focal motor, reflex, or sensory changes associated with the affected nerve
  6. Elbow and forearm overuse injuries
  7. Medial epicondylitis
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13
Q

Medical Management of Tennis Elbow

A

NSAIDs - i.e. ibuprofen, naproxen
Corticosteroid Injections
Shockwave Therapy
Surgery - severe cases

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14
Q

Physiotherapy Management of Tennis Elbow

A

Load Management - stop under/overuse

Exercise:

Stretching:

  1. Prayer stretch
  2. Wrist extensor stretch
  3. Thumb stretch
  4. Wrist flexion/extension
  5. Forearm pronation/supination
  6. Elbow flexion/extension

Wrist extension re-training:

Sensorimotor palm-slide exercise for retraining of wrist extension. With the forearm resting in pronation on a table, the wrist should be slowly extended by sliding the fingertips along the table and lifting the knuckles. Emphasis is placed on avoiding metacarpophalangeal extension and finger flexion. Return to the starting position and repeat 10 times

Strengthening:

Wrist extension exercise can be performed over the edge of a table with elastic tubing or free

weights.

Isometric holds (30-60 seconds in duration)

are advocated for reactive or irritable tendinopathy,

while concentric and eccentric actions should be

performed slowly (4 seconds for each direction),

completing 2 to 3 sets of 10 repetitions for patients

with less irritable or degenerative tendinopathy, only moving in non-painful ROM.

Emphasis is placed on maintaining neutral radialulnar deviation of the wrist (by aligning the middle

metacarpal bone with the long axis of the forearm).

Progression may be achieved by increasing load

or performing the exercises with greater elbow

extension

Wrist radial deviation exercises

Forearm pronation supination exercises

Exercises should also address motor

control impairments, such as dissociation of wrist from finger extension and retraining of wrist alignment during gripping

Brace / Taping - reduce symptoms allowing them to calm down

Education - what the problem is, reduction of aggravating activities

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15
Q

Define Medial Epicondylitis/epicondylalgia (golfers elbow)

A

Overuse tendinopathy, similar to tennis elbow but affecting the common origin of the flexors and pronators
Affects ulnar nerve passing through heads of FCU - neural symptoms

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16
Q

Prevalence of Golfer’s Elbow

A
  • Prevalence 0.3-1.1%, Female > Male
  • Significantly less common than LE (approx. 10% incidence in comparison)
  • Age 40-60
  • Associated with golf, manual workers
  • Involves Pronator Teres and FCR
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17
Q

Prognosis of Golfer’s Elbow

A

60% recover w/ conservative treatment

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18
Q

Clinical Presentation of Golfer’s Elbow

A

○ Pain on the medial aspect of the elbow – tender on palpation
○ Aggravated by resisted / repetitive wrist flexion or pronation, valgus (ABD) stress, stretching tendons
○ Aggravated by throwing / gripping
○ Reduced grip strength
○ Can involve ulnar nerve (20%) - Dermatome of ulnar nerve = little finger, ring finger (excluding fingertip)

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19
Q

Medical management of Golfer’s Elbow

A

NSAIDs
Shockwave Therapy Corticosteroid injections
Surgery

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20
Q

Physiotherapy management of Golfer’s Elbow

A

Load management - gradual increase
Exercise - Strengthening exercises of wrist flexors and forearm pronators
Education
Taping / bracing - offload to reduce symptoms

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21
Q

Define De Quervain’s Tenosynovitis

A

Reactive thickening (inflammation) of the tendon sheath around EPB and APL

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22
Q

Prevalence of De Quervain’s Tenosynovitis

A

Tenosynovitis can be caused by unaccustomed movement, overuse or repetitive minor trauma of the thumb; May occur spontaneously (idiopathic)

The resulting synovial inflammation causes secondary thickening of the sheath and stenosis of the compartment, which further compromises the tendon.

The first dorsal compartment (APL & EPB) and the second dorsal compartment (ECRB) are most commonly affected.

The flexor tendons are affected far less frequently.

Overuse may involve eccentric lowering of the wrist into ulnar deviation with load, e.g.

  1. Lifting heavy dishes
  2. Painting
  3. Golf
  4. Hedge trimming
  5. Pruning
  6. Wringing activity

More common in women - 1.3% vs 0.5% (male)

More commonly reported in new mothers - the way they lift their babies involves eccentric ulnar deviation

Age most commonly 40s-50s

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23
Q

Pathology of De Quervain’s Tenosynovitis

A

The extensor retinaculum contains 6 compartments which transmit tendons lined with synovium

Inflammation of synovial sheaths of EPB & APL

Swelling of the sheaths and eventual thickening as swelling becomes organised

Adhesions may develop between tendon and sheath restricting normal tendon movement

Constriction of enclosed tendons = ‘stenosing tenosynovitis’

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24
Q

Clinical presentation of De Quervain’s Tenosynovitis

A

Pain on the radial side of the wrist that can be referred to the thumb

History of unaccustomed activity

Visible swelling over distal end of radius

Tendon sheath feels thick and hard

Tenderness most acute at tip of radial styloid

Weakness of grip

Aggravated by resisted thumb extension / abduction, or by stretching the affected tendons (Finkelstein Test)

Finkelstein’s Test

  1. Patient makes a closed fist with thumb tucked inside
  2. Passive ulnar deviation is performed maintaining the wrist in a neutral position
  3. Positive: reproduction of pain
  4. Negative: uncomfortable but not painful
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25
Q

Medical management of De Quervain’s Tenosynovitis

A

NSAIDs
Corticosteroid Injection Surgery

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26
Q

Physiotherapy management of De Quervain’s tenosynovitis

A

Splinting - calm symptoms however symptoms may reappear after splint removal; To rest the fingers and thumb for a period of 3 to 4 weeks.

Load Management - increase ability of tendon to w/stand load; gentle return to activity enouraged

Education - what the issue is, reduce activities aggravating symptoms

Exercises - strengthening of APB and EPL

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27
Q

Define Strains

A

Muscle or tendon injury – involves over contracting or lengthening a muscle causing tearing of collagen

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28
Q

Grade 1 of a strain/sprain

A

Mild, overstretched, micro-tears
Localised pain and tenderness
Minimal bruising/swelling/loss of function
No loss of strength and ROM

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29
Q

Grade 2 of a strain/sprain

A

Moderate, partial-tears
Immediate onset of all inflammatory signs
Poorly localised pain
Moderate swelling/bruising/loss of function
Painful and reduced ROM
Reduced strength and painful resisted movement

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30
Q

Grade 3 of a strain/sprain

A

Severe, complete tear
Inability to contract, separation may be evident
May hear audible ‘pop’ or ‘crack’
Immediate swelling, pain and bruising
Over time symptoms may be lower than grade II

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31
Q

Prevalence of strains

A
  • More common in 2+ joint muscles as greater risk of overstretching
  • Eccentric contractions (deceleration phase)
  • Muscles with higher percentage of type II fibres
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32
Q

Medical management of strains

A

○ Surgery - for grade III; physiotherapy required afterwards

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33
Q

Physiotherapy management of strains

A

Depends on severity of strain – healing times
POLICE - protection, optimal loading, ice, compression, elevation; PRICE - swap optimal loading for rest.
Mobilisation – as soon as possible because increases chance of recovery
Strength / loading - once full ROM is recovered
Proprioception - after strengthening
Endurance training - depending on patients goals/lifestyles

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34
Q

Define Sprains

A

Stretch and/or tear of a ligament
Usually caused by the joint being forced suddenly outside of its usual ROM, and the inelastic fibres are stretched to far

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35
Q

Prognosis of sprains

A

most recover with conservative management
Although most severe require surgery to reconstruct ligament

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36
Q

Prevalence of sprains

A

Commonly occurs in ankles

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37
Q

Physiotherapy management of sprains

A

similar to strains
○ Dependent on severity – healing times
○ POLICE - protection, optimal loading, ice, compression, elevation; PRICE - swap optimal loading for rest.
○ Early mobilisation - increase chance of recovery
○ Early weightbearing - if appropriate
○ Exercises - encourage mobility in a safe way
○ Education - about injury and healing
○ Return to sport (if applicable)
○ Surgery - severe cases; physio required post-surgery

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38
Q

Define Carpal Tunnel Syndrome

A

Median nerve is compressed where it passes through the carpal tunnel

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39
Q

Prevalence of Carpal Tunnel Syndrome

A

Most common peripheral nerve entrapment syndrome
1 in 10 people develop carpal tunnel at some point
Female>Male - more significant difference with increasing age

Younger presentations usually have coexisting pathologies

Risk factors:

  1. Diabetes (Type I and II)
  2. Menopause
  3. Hypothyroidism
  4. Obesity
  5. RA
  6. Pregnancy
  7. Family history
  8. Female>Male 8:1,
  9. Age 40-50, chances increase after this age
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40
Q

Causes of Carpal Tunnel Syndrome

A

Oedema, tendon inflammation, hormonal changes, cysts in the carpal tunnel, repetitive manual activity can contribute to nerve compression in this area

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41
Q

Prognosis of Carpal Tunnel Syndrome

A

Depends on severity of symptoms:
Mild to moderate – respond well to conservative (mild = 6 weeks ->referred to another physio for opinion)
Severe – more likely to require surgery

42
Q

Clinical presentation of Carpal Tunnel Syndrome

A

Begins with intermittent nocturnal Pain, paraesthesia, anaesthesia in thumb & lateral 2½ fingers, that increases in frequency, then develops into waking hours

More severe cases – weakness of median nerve innervated muscles atrophy (thenar eminence wasting)

Whole hand may become affected and pain/aching may extend up into the forearm

Can progress to difficulty with fine motor tasks - as thenar eminence muscles weakened -> loss of thumb flexion, ABD, ADD, opposition

Difficulty fine motor tasks, gripping things, often drop objects.

Prolonged and intense symptoms.

Uni or bilateral - Dominant hand tends to be worse affected.

May be unable to differentiate between hot and cold.

Aggs - physical activity

Eases - hanging arm over side of bed & shaking hand

Assessment:

Observe and palpate for tenderness, swelling, warmth, discolouration.

Sensation testing of fingers, thumb, palm using gentle touch or pin-prick is suggestive of the condition if numbness, i.e. Positive.

Hot and cold sensation testing may reveal deficiencies if positive too.

Thenar eminence muscle strength tests may reveal weakness and atrophy here may be observed. Resist thumb actions of flexion, abduction and opposition.

Tinel’s sign – tap sharply over the median nerve on the anterior aspect of the wrist (sharp tingling in fingers is positive for the condition).

Phalen’s test active flexion of the wrist(s) for up to 1 minute (sharp tingling in thumb and fingers is positive for the condition).

Differentiate with cervical spine pathology

43
Q

Management of Carpal Tunnel Syndrome

A

Education – lifestyle modification
Load management
Splinting – night time; calm symptoms during sleep
Exercise
Corticosteroid Injection - if conservative measures are not working
Surgery - if conservative measures are not working

44
Q

Define Adhesive Capsulitis (frozen shoulder)

A

Formation of excessive scar tissue or adhesions across the glenohumeral joint leading to stiffness, pain and dysfunction
Affects glenohumeral ligaments and joint capsule

45
Q

Prevalence of frozen shoulder

A

Common, debilitating condition

Reported prevalence of 2-5%

Most common in 40-60 year age group

Affects women > men

Characterised by pain & stiffness in the shoulder which passes through 3 stages

20% incidence in patients with diabetes

Bilateral involvement in up to 40-50% of cases

Self-limiting condition - 3 consecutive phases; spontaneous resolution

Prognosis - Mean duration from onset to recovery: 30 months

Usually leads to full functional recovery within 1-4 years but studies show 20-50% of patients had permanent restriction to movement compared to the uninvolved side, however, only 11% reported residual functional limitations

46
Q

Types of Frozen Shoulder

A

Primary (idiopathic) - occurs spontaneously
Secondary – often after trauma, e.g. #, shoulder surgery, fall that does not cause a specific shoulder injury but leads to adhesive capsulitis

47
Q

Risk factors of Frozen Shoulder

A

Female (70%) > Male (Males respond less well to treatment)

Previous AC in other arm

Age >40

Trauma - e.g. #, shoulder surgery, fall that does not cause a specific shoulder injury but leads to adhesive capsulitis

HLA-B27 +ve - blood test indicating if high risk of developing autoimmune diseases

Ankylosing spondylitis

Reactive arthritis

Cerebrovascular Disease

Coronary Artery Disease

Diabetes - 20% incidence; these patients have worst outcomes - more likely to have longer lasting symptoms, bilateral symptoms, recurrence

Hyperthyroidism

Previous/current Dupuytren’s disease

48
Q

Stage 1/3 of Frozen Shoulder Pathology

A

Painful (Freezing) Phase (2-9 months)

Primary complaint of shoulder pain, especially at night

Arthroscopically – evidence of synovitis (inflammation of synovium) without adhesions

Histologically inflammatory cell infiltration of the synovium

49
Q

Stage 2/3 of Frozen Shoulder Pathology

A

Stiff (Frozen) Phase (4-12 months)

The pain becomes less severe but is present at the EOR. Stiffness remains and there

is reduction in the range of shoulder movements. Function can be substantially limited.

Arthroscopically synovitis is resolved (inflammation settled), significant adhesions – axillary fold obliterated

Histologically - Dense collagenous tissue within capsule

50
Q

Stage 3 of Frozen Shoulder Pathology

A

Recovery (Thawing) Phase (12-42 months)

Gradual improvement in range of movement with less stiffness

51
Q

Clinical presentation of Frozen Shoulder

A

Usually present first with gradual onset of shoulder pain & is felt at deltoid region

Followed by painful and gradual loss of AROM & PROM in capsular pattern (LR > Abd > MR)

AROM/PROM affected as inert tissue affected by adhesions formed

Decreased ER on AROM & PROM is usually sufficiently diagnostic; seen as difficulty putting on jacket

Passive ROM with firm, painful end feel

Inability to sleep on affected side

X-rays = normal - Imaging not necessary for diagnosis but can rule out other conditions, i.e. OA, pancoast tumour - lung cancer at apex of the lungs; <1% patients of stiff shoulder have this; 25% patients w/ this tumour have delayed diagnosis because of misdiagnosed shoulder problems

52
Q

Medical management of Frozen Shoulder

A
  • NSAIDs
  • Corticosteroid Injections - reduce pain and inflammation
  • Hydrodilatation - injection of large amount of fluid into shoulder joint capsule to stretch it out and tear adhesions apart (Less invasive than surgery)
  • Surgery - 2 types: Capsular Release (safer than MUA), MUA (Manipulation under anaesthesia)
53
Q

Physiotherapy management of Frozen Shoulder

A

Early mobilisation

Early pain management is key to allow this
Manual therapy and exercises included

Education

the patient must understand the process of frozen shoulder and that it may take 1-4 years to recover

Determine:-

  1. main problems
  2. phase 1,2 or 3
  3. SIN factors - pain will be guiding factor to alter rehab: stretches to discomfort but not to pain

Painful phase:

Key aim: reduce pain

<3/12 consider CSI

>3/12 avoid CSI - seems to increase length of time of resolution

NSAIDs?

ADVICE - the patient must understand the process of frozen shoulder and that it may take 1-4 years to recover

Maximise ROM

Freezing phase

Key aim: maximise ROM and function

Mobs

Self-management programme - RC interval (supero-anterior capsule) stretched in neutral ER

Advice

Resolution phase

Key aim: maximise ROM restore function

Active exercise programme /self-management programme

Mobilisation/stretching

54
Q

Prevalence of Clavicle #

A

Mostly result from a fall, normally on to shoulder - fall on side of shoulder or FOOSH
Neuro / vascular structures nearby can be affected, i.e. brachial plexus, subclavian vessels
Mid-shaft (most common) > Lateral (2nd most common) > Medial (4.5% of clavicle #)

55
Q

Medical management of clavicle #

A

Surgical - more severe injuries - displaced #
Similar physio treatment post-op

56
Q

Physiotherapy management of clavicle #

A

Conservative - less severe injuries - non-displaced #
Sling use - usually 3 weeks
Physiotherapy - involves early mobilisation of shoulder and shoulder girdle, progression into loading, as appropriate

57
Q

Prevalence of proximal humerus #

A

Normally occurs as a result of a fall
Third most common fractures in the elderly, more common in women (2:1)
Classified depending on how many fragments are displaced:
1-part # = no displacements
2-part # = 1 displacement
3-part # = 2 displacements
4-part # = 3 displacements

58
Q

Management of proximal humerus #

A

Collar and cuff (2-3/52) - type of sling with a pink foam material
Followed by progressive active management
The more elderly the patient the slower they progress and are more likely to be left with reduced ROM and function post-treatment; could result in frozen shoulder
Surgery - most severe cases require surgical fixation

59
Q

Prevalence of distal radius #

A

Commonly occurs due to FOOSH

60
Q

Types of distal radius #

A

Colles’ Fracture – most common – extra-articular (# occurs out of joint capsule), dorsally displaced distal radius fracture; associated with dinner fork defomity

Smith’s Fracture – extra-articular, anterior displacement of distal radius

Barton’s Fracture – intra-articular fracture with associated dislocation of the RCJ

61
Q

Medical management of distal radius #

A

Splint
Casts
K-Wires - for fixation (lasts 4-6 weeks) - inserted into bone and hook remains outside of body, allowing for wires to be removed later
Surgery - MUA

62
Q

Physiotherapy management of distal radius #

A

Physiotherapy following period of immobilisation - involves manipulation to re-align #

Mainly to increase mobility, strength and function at wrist

63
Q

Prevalence of Scaphoid #

A

Most commonly fractured carpal bone (70% of carpal bone #)
Often from a FOOSH
Waist (80% scaphoid #) > Prox Pole > Distal pole (least at risk)
Proximal pole has poor blood supply -risk of AVN
Risk of non-union (5%)
Pain over anatomical snuffbox
Approx 25% initial scaphoid # not seen in X-ray - if in doubt patient wrist will be immobilised and X-ray repeated in 10-14 days later when its more visible

64
Q

Management of scaphoid #

A

Cast - period of immobilisation
Surgery - more severe cases require surgical fixation
Physiotherapy after immobilisation period - mainly to improve mobility, strength and function

65
Q

Prevalence of OA

A

○ Most common form of arthritis, can develop in any synovial joint.
○ Most common in knees, hips and small joints of hand.

66
Q

Medical management of OA

A

Corticosteroid Injection
Surgery - most severe cases; joint replacements (common), debridement

67
Q

Physiotherapy management of OA

A

§ Exercises for mobility and strength
Hydrotherapy - different form of exercises in hydrotherapy pool; warmer (34oC) than standard pool, providing therapeutic affect; buoyancy of pool also provides a therapeutic affect
Manual therapy
Education

68
Q

Define Rheumatoid Arthritis (RA)

A

Systemic autoimmune disease (body’s immune system attacks the joint) characterised by inflammatory arthritis with extra-articular involvement

69
Q

Pathology of RA

A

Synovium is infiltrated by immune cells.
Fibroblasts and inflammatory cells lead to osteoclast generation resulting in bone erosion and loss of joint integrity.
Systemic inflammation and autoimmunity in RA begin long before the onset of joint inflammation

70
Q

Prevalence of RA

A

○ Most prevalent in North America and Northern Europe
○ Female > Male - 2-3:1
○ Prevalence increases with age
○ Paediatric population – RA = Juvenile Idiopathic Arthritis; Idiopathic = occurs spontaneously or w/out a known cause
○ Polyarthritis of small joints of hands – PIP, MCP, RCJ
○ Other commonly affected joints – elbows, shoulders, hips, knees, ankles, MTP

71
Q

Risk factors of RA

A

Genetic Factors (non-modifiable)

Modifiable: Smoking, Air pollution (difficult to modify), Obesity, Low Vitamin D

72
Q

Clinical Presentation of RA

A

○ Insidious (gradual) onset over a period of months
○ Joint stiffness in the morning
○ Fatigue
○ Deformity (formed overtime due to bone erosion and loss of joint integrity)
○ Pain
○ Weakness and restricted mobility in affected joints
○ If Cx is involved it can lead to cervical instability between C1 and C2 - affecting dens and surrounding ligts = reducing stability

73
Q

Medical management of RA

A 
GOAL = symptom management 
Pharmacological management (key treatment) – Disease Modifying Anti-Rheumatic Drugs (DMARDs) 
Nutrition - help with symptom management
74
Q

Physiotherapy management of RA

A

Appropriate exercise programme to maintain mobility, strength and function for as long as possible; also to manage flare-ups
Advice and education

75
Q

Define shoulder dislocation

A

Dislocation can occur anteriorly or posteriorly (<5%) - humeral head dis-articulates either anteriorly/posteriorly

76
Q

What are the static and dynamic shoulder stabilisers

A

ANATOMIC:

Labrum: triangular fibrocartilaginous rim attached around margins of fossa & improves joint congruency as well as providing a surface of attachment for glenohumeral ligaments

Continuous with biceps long head tendon – important for SLAP lesions

Negative intra-articular pressure

STATIC: Capsuligamentous structures

Ligaments:

  1. Glenohumeral ligaments:(thickenings of anterior capsule; superior, middle & inferior)
  2. Inferior g/h ligament most important in preventing anterior & inferior translation
  3. Middle g/h ligament resists ER & abd

Rotator cuff tendons blend with & re-inforce capsule superiorly by supraspinatus, anteriorly by subscapularis, posteriorly by teres minor & infraspinatus

Coracohumeral lig + superior capsule + inactive supraspinatus provide static stabilisation in dependent arm

Capsule:

  1. Capsule is thin & is strengthened by the ligaments (glenohumeral & coracohumeral) & the muscles. Inferior part of capsule is thinnest, dislocation most common in this direction.
  2. Lax capsule allows large ROM
  3. Tight inferiorly on abd.
  4. Tight ant on ER
  5. Tight post on IR

DYNAMIC:

Rotator cuff:

Reinforce capsule – static stability

Provide dynamic stability

Produce compressive force

Maintain optimal relationship of HH with glenoid through ROM - resist & control HH translation

Maintain sub-acromial space & Prevent impingement

Any imbalance in RC can lead to disturbed S-H rhythm & dysfunction eg. impingement

Supraspinatus & deltoid important compressors at 90° abd.

Subscap. important in decreasing displacement aided by infraspinatus

Rotator crescent = area of relative avascularity approx 1cm from insertion of supraspinatus & infraspinatus tendons

Stability heavily dependent on muscles to maintain integrity

Structures limiting inferior translation:

  1. Negative intra-articular pressure
  2. Superior GH ligament

Structures limiting anterior translation:

  1. Anterior capsule and ligs - GHL
  2. Subscapularis & long head of biceps tendon
  3. Inferior GH ligament (in abduction)

Structures limiting posterior translation:

  1. Posterior capsule
  2. Inferior GH ligament
  3. Teres minor & infraspinatus tendons
77
Q

Pathology of Anterior Shoulder Dislocation

A

Movement on its own = anterior glide of humeral head on glenoid fossa
Inferior GH ligt = primary ligamentous restraint to ant displacement

78
Q

Prevalence of Anterior Shoulder Dislocation

A

Often caused by the arm being positioned in abduction and external rotation (apprehension position); apprehension position used for shoulder instability tests
In this position there is often a AP force resulting in humeral head displacing antero-inferiorly
Can result in many types of lesions
Concurrent rotator cuff injuries can also occur
Vascular / neural structures at risk - particularly structures w/in axilla and brachial plexus

79
Q

What lesions can an Anterior Shoulder Dislocation result in

A

Hills-Sachs lesion - small # or cortical depression (depression in bone) on posterolateral aspect of humeral head; caused by impaction of humeral head against rim of the glenoid as dislocation occurs
Bankart lesion - damage to attachment point of the labrum to the glenoid margin; normally occurs anteriorly to anterior dislocation; Bony Bankart lesion = if associated w/ # of glenoid sometimes
Superior Labrum Anterior and Posterior (SLAP) lesion - Tears of the superior labrum near to the origin of the long head of biceps; common in throwing athletes
Humeral Avulsion Glenohumeral Ligament (HAGL) lesion - Inferior Glenohumeral Ligament is ripped off the humerus with dislocation of the shoulder
Anterior Labral Periosteal Sleeve Avulsion (ALPSA) lesion - the anterior labro-ligamentous complex rolls up in a sleeve -like fashion and becomes displaced medially and inferiorly, “the medialised Bankart lesion”

80
Q

Prevalence of Posterior Shoulder Dislocation

A

Usually caused by a blow to the front of the shoulder often with the arm flexed at the shoulder in adduction and internal rotation

Can also occur during seizures or electrocutions

Can be easily overlooked on an AP x-ray

Concurrent injuries to rotator cuff (mainly subscap) and posterior labrum, HOH # (can progress to AVN or OA)

On examination person may hold the shoulder in adduction and internal rotation. There may be an abnormal shoulder contour

81
Q

Prognosis of shoulder dislocations

A

19.6% recurrence rate, mostly in first two years
Higher recurrence rate in males
Higher recurrence in younger patients (49.2% if aged 10-19)
Those with recurrence are more likely to have a shoulder stabilisation surgery

82
Q

Define Shoulder Instability

A

Unable to control or stabilise the joint during motion or in a static position either because static restraints have been injured or because muscle controlling the joint are weak or the force couples are unbalanced

Characterised by disruption of the dynamic and static stabilisers of the GHJ leading to subluxation (partial loss of contact between joint surfaces) or dislocation (the complete loss of contact between joint surfaces) or apprehension

83
Q

Causes of Shoulder Instability

A

Traumatic (96%):

Shoulder is dislocated by an external force

As the shoulder does not heal in the correct anatomical position, or structures do not heal properly, the person is more susceptible to recurrent dislocations and further damage

Atraumatic:

From chronic recurrent use, causing change in mobility of the shoulder

Congenital - secondary to hypermobility syndrome or ehlers-danlos syndrome - affects connective tissue structure causing laxity of static stabilisers in shoulder

Common in adolescent females with hypermobile joint

84
Q

Risk factors of Shoulder Instability

A

Previous dislocation = damage to static stabilisers - more likely to get recurrent dislocations because they have shoulder instability

85
Q

Types of Shoulder Instability

A

Anterior
Posterior
Inferior
Multidirectional - often caused by congenital conditions because they cause a general laxity in static stabilisers

86
Q

Classifications of shoulder instability

A

PRIMARY : Dislocation

T : traumatic

U : unidirectional instability - MOI: anterior most common (98%):ER+ABD; Posterior (2%)

B : Bankhart lesion - Capsular tear +/- detachment of labrum (labral tears common in throwing athletes); anteroinferior tear to labrum

S : Surgery

Apprehension in certain positions, decreased ROM into Abd + LR

SECONDARY : Poor neuromuscular control

A: atraumatic

M: multi-directional instabilty

B: bilateral

R: rehabilitation

I: inferior capsular shift

No history of injury

Excessive capsular / ligament laxity OR decreased neuromuscular control / muscle imbalance – may be related to posture / type of use

May predispose to impingement in young age group

Inferior instabilities are usually part of multidirectional instability

CONGENITAL

osseous/labral defect

Soft tissue abnormality

87
Q

Clinical Presentation of Shoulder Instability

A

General

Clicking / Pain

Positive apprehension test / relocation test (anterior) / load & shift test

Increased accessory motion at GHJ in the direction of instability; increased ROM compared to other limb

Positive sulcus sign

Age < 35

H/O shoulder feeling that it moves partly or completely ‘out of joint’ and may be concerned their shoulder may dislocate during certain activities or sports

If the instability is longstanding, there may be hand or arm weakness, tingling or numbness from proximal nerve traction

Primary (traumatic)

Pain around ant.lat. shoulder

Limited AROM

RHS rhythm

Positive apprehension test

Neural / vascular changes

Wasting of deltoid/rotator cuff

Secondary (atraumatic)

Full or excessive ROM

Pain at EOR on movement

Clunking, sensation of ‘coming out’ of joint

Dead arm on overhead activities – particularly with anterior instabilities

Loose / empty end feel on passive testing

Positive stress tests - sulcus test, anterior aprehension test, load & shift tests

88
Q

Medical management of Shoulder Instability

A

Surgery – depending on structural impairments, i.e. labral tears
Physio takes a post-op role after a period of immobilisation (4 weeks)

89
Q

Physiotherapy management of shoulder instability

A

primarily focused on training dynamic stabilisers

Neuromuscular retraining +++

Stretching / mobilisation tight capsule / rotator cuff

Other structures may require stretching, i.e. pectoralis majors shortened = pulling shoulder anteriorly

Postural re-ed

Strength Training - of deltoid - plays stabilising role in GHJ

Proprioception Training

90
Q

Define Dupuytren Disease

A

Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis)

91
Q

Pathology of Dupuytren’s Disease

A
  • Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis) resulting in;
  • Flexion contracture of the MCP and PIP joints leading to loss of function
  • Occurs slowly, typically progresses over the course of several years; normally affects 4th and 5th fingers but can affect others
  • Commonly begins with thickening of the skin, then bands (palpable at first; only visible over time) of fibrotic tissue form in the palmar area caused by fibroblast proliferation causing collagen deposits, leading to contracture of palmar fascia (aponeurosis)
  • Eventually leading to the affected fingers being pulled into flexion.
  • Typically occurs bilaterally
92
Q

Prevalence of Dupuytren Disease

A

An inherited autosomal dominant trait

Most common in people of Northern European descent

Males > Females - difference becomes less with increasing age

Average age of onset 60, incidence increases with increasing age

Onset at an early age usually means aggressive disease

Environmental Factors – alcohol intake, smoking, manual labour, low body weight / BMI, use of anticonvulsant drugs

Associated with diabetes, epilepsy, HIV, adhesive capsulitis, cancer

93
Q

Clinical features of Dupuytren’s Disease

A

Nodular thickening, palm

Gradually extends distally

Involves ring &/or little finger

Pain, seldom marked

Bilateral, 1 more than other

Palm is puckered, nodular & thick

Flexion deformities at MCP & PIP joints

Dorsal knuckle pads may be thickened (Garrod’s pads)

94
Q

Medical management of Dupuytren Disease

A

Surgical Intervention is the mainstay of treatment; different levels of surgery depending on severity:

  1. Simple fasciotomy – early stage DD, contracted cord is cut through small incisions but not surgically removed – least invasive
  2. Fasciectomy – partial or total removal of the diseased palmar fascia including the contracted cord / nodule
  3. Dermofasciectomy – removes all diseased tissue, also removes overlying skin and fat, then required a full thickness skin graft to cover the surgical site – severe, recurrent Dupuytrens
  4. Amputation of the digits may be considered as a last resort
95
Q

Physiotherapy management of Dupuytren Disease

A

Aimed at restoring mobility at finger joints

Pre-operative:

  1. Splinting
  2. Massage
  3. Passive stretching
  4. Active exercises

Main role is post-operative:

  1. Splinting - can be custom-made by hand therapists
  2. Passive stretching
  3. Active exercises
  4. Strengthening
  5. Functional activities
  6. Education and advice
  7. Oedema and scar management - really important because if scar begins to contract leads to recurrence
96
Q

Prognosis of Dupuytren disease

A

Following surgery, prognosis is good initially

Recurrence is frequent

Early onset carries poorer prognosis

Proximal IP joint contractures soon become irreversible

97
Q

Define Acromioclavicular joint injuries

A

Acromioclavicular joint injuries can involve stretching or tearing of the acromioclavicular or coracoclavicular ligaments and subluxation or dislocation of the acromioclavicular joint

98
Q

Aetiology of Acromioclavicular injuries

A

Most commonly occur in men aged 20-50 years

MOI: a fall onto the point of the shoulder during sporting activity or FOOSH

Grade I: Intact joint with minor tear of the acromioclavicular ligaments.

Grade II: Up to 50% vertical subluxation of the clavicle with rupture of the acromioclavicular ligament and stretching of the coracoclavicular ligaments.

Grade III: more than 50% vertical subluxation of the clavicle with complete rupture of both acromioclavicular and coracoclavicular ligaments

99
Q

Clinical features of an acromioclavicular subluxation/dislocation

A

tenderness localised to the AC joint, limited range of movement due to pain, high arc pain or a positive cross arm test

Step deformity, TOP - increased clavicle angle to acromion

Decreased HF / elevation. above 90º

100
Q

Management of acromioclavicular subluxations/dislocations

A

Conservative:

POLICE +

Mobilisation - if stiffer

Active exs

Surgical:

A/C joint stabilisation using coracohumeral ligament

Surgical management of A/C joint only in cases where there is continuing pain or disability or failure of conservative treatment 3 months post injury

101
Q
A

Patho 2 (30 decks)

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