Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
143 Cards in this Set
- Front
- Back
|
major stabilizers of the GH joint
|
in mid-ranges:
1. Active Rotator Cuff muscles 2. Active Long Head of Biceps 3. Active Deltoid (w/ arm abducted) |
|
|
anything contractile is considered to be an ________ stabilizer. Anything that does not contract, (i.e., Ligaments) is considered to be a __________ stabilizer.
|
active=contractile=muscle
passive=noncontractile=ligaments |
|
|
When ________is created, stability is created.
(tension or slack?) |
tension!
|
|
|
The _________ muscle(s) keep the head of the humerus centered in the glenoid fossa.
|
SITS
|
|
|
If the counteraction of the deltoid lifting the humerus does not happen, what can be pinched?
|
SITS - the humeral head is compressed to offset the pinch when deltoid elevates the arm
|
|
|
Muscle that elevates the arm
|
deltoid
|
|
|
Muscle that produces an upward translation of the humerus
|
deltoid
*and elevates the arm |
|
|
Which muscles are responsible for Horizontal compression of the humerus and Depression of the humeral head to counteract the deltoid?
|
SITS & Long head of Biceps tendon
|
|
|
SITS and LH biceps 2 jobs:
|
compress humeral head
depress humeral head (to counter deltoid) |
|
|
An imbalance between the deltoid and the rotators sets a patient up for _________________ problems.
|
rotator cuff
|
|
|
Depression of the humerus controlled by SITS and LH biceps. What is definition of depression of humerus (actions)?
|
flexion & abduction
|
|
|
Depression of humerus controlled by SITS and LH biceps.
Supraspinatus contribution? |
Pushes humeral head down and depresses it.
*in neutral, the supraspinatus is contoured around the head of h. |
|
|
Depression of humerus is controlled by SITS and LH biceps.
Infraspinatus, Teres Minor & Subscapularis contribution? |
produce a downward vector with contraction
*think of fiber direction of insertion going "home" to origin along vertebral scapular border |
|
|
Tendinopathy
|
generic term used to describe a pathology in and pain arising from a tendon
|
|
|
Tendinitis
|
a RARE inflammatory condition of a tendon. Catchall term since inflammatory infitrates within a tendon are not usually seen.
|
|
|
Tendinosis
|
NON-inflammatory DEGENERATIVE changes in a tendon due to aging, microtrauma, or vascular compromise. Can be asymptomatic.
|
|
|
most commonly affected muscle in rotator cuff tendinopathy (generic)
|
Supraspinatus
|
|
|
4 causes of rotator cuff tendinopathy
|
1. Trauma
2. Age-related degen (>35 yrs. old) 3. IMPINGEMENT 4. Tension overload (sports) |
|
|
Impingement syndrome description
|
compression of tissue at SUBACROMIAL space due to narrowing of this space
|
|
|
where is the subacromial space (SAS)
|
the space between the head of the humerus and the under-surface of the coraco-acromial arch
*impingement syndrome area |
|
|
describe the coraco-acromial arch
|
anterior 1/3 of acromion
AC joint itself Coraco-acromial ligament Coracoid process |
|
|
3 tissues affected in Impingement syndrome of SAS
|
*under coraco-acromial arch:
1. Subacromial bursa 2. Supraspinatus tendon 3. LH biceps tendon |
|
|
How to identify affected tissue of Impingement syndrome of SAS (subacromial bursa, supraspinatus tendon or LH of biceps tendon)?
|
MRI
|
|
|
How does functional narrowing of the SAS happen?
|
-Strength imbalance b/w deltoid & RC
-Tight posterior capsule -Decreased I. glide during Flex/aBduct |
|
|
Functional narrowing of SAS is commonly _______ muscles vs. ________muscle?
|
RC muscles vs. Deltoid muscle
|
|
|
Describe what happens when RC muscles are weak and deltoid overwhelms, creating functional narrowing of SAS...
|
Most common - strength imbalance/rotator cuff weakness allows deltoid to pull humerus S. during flex + aBduct. Results: compression of SAS tissues
|
|
|
Describe the effects of the common posterior capsule tightness, responsible for functional narrowing of SAS...
|
Normally during flex, humeral head stays centered in glenoid fossa. When tight post capsule, head translates A-P & I-S during flexion. This impinges the SAS tissues.
|
|
|
Describe the effects of common decreased inferior glide that causes a functional narrowing of the SAS...
|
Decreased inferior glide during Flexion and ABduction raises the humeral head into the coraco-acromial arch instead of letting it drop/GLIDE downward into the fossa
|
|
|
Describe the decreased inferior glide during flexion & abduction as a result of functional narrowing of the SAS
|
Instead of sliding down into the hollow of the glenoid fossa when AB & flexing shoulder, the humeral head simply rolls upward on the superior border of the fossa
|
|
|
recap the top three reasons for impingements at the shoulder due to functional narrowing of the SAS
|
1. imbalance between RC & deltoid
2. tight posterior capsule of shoulder 3. decreased downward/inferior glide of humeral head during roll/glide that is supposed to happen upon flexion & abduction |
|
|
Scapular dysfunction and glenohumeral instability are 2 less common reasons for impingement due to?
|
functional narrowing of SAS
|
|
|
2 structural reasons impingement of the SAS occurs?
|
1. AC joint spurs
2. Abnormal acromion process shape |
|
|
2 inflammation/swelling causes that impinge the SAS:
|
1. Tension overload (microtears)
2. Acute trauma (FOOSH, dislocation) |
|
|
Chief complaint for impingement syndrome?
|
Anterolateral shoulder pain with possible LH biceps tendon pain
|
|
|
Referred pain pattern for the chief complaint of impingement syndrome (anterolateral shoulder pain w/ possible LH biceps involvement)
|
deltoid insertion + lateral arm = mimic C5
lateral forearm = mimic C6 |
|
|
Impingement syndrome typical patient
|
>35 unless athlete
Onset related to athletic activity, overhead work/job, and 30% (elderly) have no symptom onset cause |
|
|
Impingement can either have no cause of onset (30%-usually elderly) or it can have ?
|
-specific injury (rare) such as FOOSH
-No single event +cumulative +risk factors earlier (sports,etc.) |
|
|
How long does Impingement syndrome last?
|
Acute presentation is UNUSUAL!
Weeks or months afterward is normal presentation, when Sx fail to resolve |
|
|
3 ROTATOR CUFF strength tests for Impingement syndrome:
|
1. Supraspinatus/thumb up
2. Infraspinatus/Teres Minor 3. Subscapularis |
|
|
Which of the 3 ROTATOR CUFF strength tests for impingement present with pain?
|
Supraspinatus/thumb up test
-pain possible -no weakness or mild (4+/5) pain inhibited weakness |
|
|
2 ORTHOPEDIC tests for impingement syndrome
|
1. Impingement tests narrowing SAS using various combos of FLEXION & INTERNAL ROTATION
2. SUPRASPINATUS/THUMB DOWN press test to impinge SAS at greater tubercle under CA arch. |
|
|
Radiographic Imaging for impingement syndrome
|
***Plain radiographs***
-R/O STRUCTURAL causes -Calcific tendonitis -R/O bone pathology (tumor) |
|
|
Soft tissue imaging for impingement syndrome
|
***MRI***
D/Dx tendinopathy vs RC tear pain-inhibited weakness |
|
|
List some treatments for Impingement syndrome (general)
|
Joint manipulation/mobilization
Stretch & Strength Therapeutic (passive) modalities |
|
|
Joint manipulation/mobilization techniques for Impingement syndrome of SAS:
|
Glenohumeral techniques:
A-P glide, Distraction M-L, S-I glide, Long axis traction **all must be performed ABOVE 30 DEGREES ABDUCTION! |
|
|
What 2 manipulation/mobilizations of the glenohumeral joint must NOT be performed until a RC tear has been ruled out?
|
S-I glide
Long axis traction |
|
|
In general, what grade mobilization to use for acute impingement syndrome?
|
Grade 1 and 2 (O) mobilizations
|
|
|
In general, what grade mobilization to use for chronic impingement syndrome?
|
Grade 3 with MANIPULATION
|
|
|
When should you refer an Impingement syndrome patient out?
|
~fail of conservative care
~worsening pain/dysfun/weakness ~pain control needed for severe pain or difficulty sleeping (2nd opinion, co-mgmt, complete referral out of your office = options) |
|
|
Medical options for impingement syndrome:
|
medication = NSAIDS
Injection = cortisone, anesthetic physical therapy |
|
|
Surgical options for impingement syndrome
|
Debridement
Bursectomy Smoothing |
|
|
4 major causes of ROTATOR CUFF TENDINOPATHY
|
Impingement syndrome
Age-related degeneration Tension overload Trauma |
|
|
RC age-related degeneration can present after 40 due to unknown etiology. What is suspected and what is the presentation?
|
vascular insufficiency
asymptomatic OR weakness without pain |
|
|
Where RC tendinopathy is not caused by impingement, age or trauma, it is caused by?
|
Tension overload: repetitive eccentric contraction as seen in overhead throwing or occupation
|
|
|
What are some RC tendinopathy Trauma causes:
|
traumatic dislocation, FOOSH
*result in contusion or tear |
|
|
_________ subacromial bursitis is rare.
|
Primary
*gout, rheumatoid arthritis, pyogenic infections, TB |
|
|
_________ subacromial bursitis is commmon.
|
SECONDARY
*impingement syndrome (3 causes), spread of inflammation, axon reflex |
|
|
Describe secondary subacromial bursitis:
|
Subac. bursitis causes impingement of SAS, spreads inflammation to shoulder general, and the axon reflex is distorted ~ (supraspinatus, GHJ, subacromial bursa all innervated by SUPRASCAPULAR nv.)
|
|
|
Orthopedic tests for tissues in the subacromial space have a _____ sensitivity and a _____ specificity
|
high sensitive
low specific |
|
|
Beyond rotator cuff tendinopathy, we screen for a rotator cuff TEAR. What two manipulations/mobilizations are not done if there is an RC tear?
|
Long axis traction and S-I glide
|
|
|
Most common rotator muscle torn?
|
Supraspinatus
|
|
|
Least common rotator muscle tear?
|
Teres minor
|
|
|
Levels of RC injuries (3)
|
Tendinopathy
Partial thickness tear Full thickness tear |
|
|
most common cause of RC tears in non-athletic population (this means you)
|
tendinopathy due to AGE-related degeneration
*40 year olds and up |
|
|
Common causes of RC tears in athletic population (includes working population at risk due to repetitive overhead activity)
|
Tendinopathy due to IMPINGEMENT & TENSION OVERLOAD
*under 35 year olds |
|
|
Uncommon cause of RC cuff tears that cause either partial thickness or full thickness tears?
|
TRAUMA! and drama, no doubt. Mostly seen after traumatic dislocation and in older population
*over 40 |
|
|
How do RC tears usually begin?
|
as partial-thickness (PT) tears at the anterior edge of the supraspinatus near the biceps tendon
|
|
|
Why do partial thickness RC tears have a limited ability to heal?
|
Avascularity of tendon due to constant tension~ c.t. keeps ends separated, retracted, not healing~ degenerative state of fibers~ most tears are on articular underside & awash in synovial fluid that disrupts healing factors
|
|
|
RC tears progress from partial to full because?
|
Failure of partially torn cuff causes increased load on remaining fibers. Full tear then occurs, progressing posteriorly.
|
|
|
Describe typical RC tear chief complaint, both the patient and the presentation...
|
-weakness with or w/o pain
-if due to age-related degeneration only, weakness only symptom -Local & referred pain similar to RC tendinopathy |
|
|
most painful RC injury?
(tendinopathy, partial tear, full tear) |
partial tear
|
|
|
Physical exam for a RC tear
|
1. DROP-Arm test (supraspinatus)
2. Supraspinatus strength and/or PRESS tests 3. Infraspinatus & Subscapularis STRENGTH tests 4. IMPINGEMENT tests |
|
|
The Drop-Arm test for supraspinatus tests this muscle in an __________ contraction/load.
|
eccentric = drop arm = supraspinatus
|
|
|
Hallmark of supraspinatus strength and/or press test
|
WEAKNESS (with or without pain)
|
|
|
best evidence of a Massive RC tear
|
weakness of the supraspinatus AND infraspinatus or subscapularis, in the ABSENCE of radiculopathy or neuropathy
|
|
|
Regarding an RC tear, this test may be positive if PAIN is present
|
Impingement test
|
|
|
Full thickness RC tear causes SIGNIFICANT weakness, with or w/o pain. How to describe tendinopathy vs. RC tear?
|
A tendinopathy may have pain and NO weakness, or pain and PAIN INHIBITED mild weakness. Partial tears may also have pain with mild to moderate weakness, but partial tears are often MORE PAINFUL than either tendinopathy or full tears.
|
|
|
How to differentiate between tendinopathy and Partial thickness tear?
|
use an MRI to rule out a RC tear. Use lidocaine. If lidocaine helps, then...
|
|
|
If lidocaine kills pain, then the injury is a (tendinopathy or RC partial tear)?
Why? |
TENDINOPATHY: because there is pain-inhibited weakness with tendinopathy. Get rid of pain with lidocaine, get rid of weakness. Partial tear weakness is from tendon fiber failure. Lidocaine can't fix that!
|
|
|
Use an MRI to rule out (2)
|
1. RC tear
2. Other pathology |
|
|
Do not adjust a RC tear, but do...
|
*Mobilization of GH joint, exercises and therapeutic modalities (passive). *Mobilize and adjust the AC joint, SC joint, ST articulation, Thoracic spine)
|
|
|
Name the therapeutic modalities
|
ice/heat
electric stim ultrasound laser |
|
|
Are there studies on mobilization/manipulation in treating rotator cuff tears?
|
No, anecdotal reports only. No published descriptions or protocols.
|
|
|
What manipulation/mobilization does Gann warn to avoid?
|
S-I glide of the glenohumeral joint, for fear of further tearing the supraspinatus
|
|
|
Based on Muraki's cadaver Grade 3 sustained mobilization study on a repaired supraspinatus tendon, what should you NOT do?
|
Use zero aBduction.
* All mobilizations significantly strained the repaired supraspinatus tendon (RC tear) when no abduction used. |
|
|
Muraki's cadaver Grade 3 supraspinatus repair showed we should use?
|
30 degree aBduction in scapular plane
Inferior glide significantly strained the tendon, even in 30* plane, but... anterior, posterior and M-L distractions were OK! |
|
|
cardinal rules of rotator cuff tear mobilization/manipulation...
|
-don't manipulate
-do use 30* aBduction in scapular plane -inferior glide is terrible |
|
|
On a patient with supraspinatus tear (MRI verified) or supraspinatus weakness (tear unverified), do NOT perform:
|
techniques at 0 degree abduction
any S-I glide techniques, including long axis traction |
|
|
Techniques which may help a supraspinatus injury...
|
All performed with arm ABOVE 30* abduction to slacken supraspinatus tendon...A-P glides and M-L distract.
|
|
|
4 reasons to refer a patient with a rotator cuff tear out of your office:
|
1. Acute RC tear
2. Fail of conservative care 3. Worse pain, weakness, dysfunction 4. Pain control ~ severe pain, sleep |
|
|
medical treatment for RC tear
|
NSAIDs
Injection (cortisone) Physical therapy |
|
|
Surgical treatment for RC tear
|
Debridement
Acromioplasty with debridement Rotator cuff repair with debridement |
|
|
Active stabilizers of the GH joint are only good during regular ranges of motion, not during _______
|
extremes.
|
|
|
3 Active stabilizers of GHJ
|
Deltoid (abduction)
LH biceps Rotator Cuff muscles |
|
|
EXTREMEs of motion in GHJ are supported by?
|
LIGAMENTS (only stability in extremes, not mid-range)
GLENOID LABRUM NEGATIVE PRESSURE |
|
|
What ligaments support GHJ in extremes:
|
Inferior, Anterior, Superior Glenohumeral ligaments & Joint capsule
|
|
|
3 causes of Instability
|
1. ACUTE
2. Repetitive motion 3. Ligament laxity |
|
|
Is instability symptomatic or asymptomatic?
|
SYMPTOMatic!!
|
|
|
Kinds of Instability (3)
|
~Dislocation (all the way)
~Subluxation (almost) ~Microinstability (athletes - repetitive extremes) |
|
|
2 causes of instability:
|
95% is Trauma
5% Congenital Laxity of ligaments |
|
|
Trauma is instability in _____ direction(s).
|
one
|
|
|
Congenital ligament laxity allows instability in _____ direction(s).
|
all
|
|
|
95% of all dislocations are
|
anterior & inferior (and due to trauma 95%) of the time
|
|
|
placement of arm when dislocates anterior & inferior
|
abducted, extended, externally rotated
|
|
|
Which tissues are injured during anterior & inferior dislocation of GHJ?
|
1. inferior glenohumeral ligament (hammock)
2. anterior/inferior glenoid labrum 3. RC tear - SUBSCAPULARIS most common |
|
|
Patient presentation of anterior & inferior dislocation will show them holding their arm slightly
|
abducted
|
|
|
What vital should you take when ant/inf. dislocation?
|
Peripheral pulse!
Axillary n. is injured 42% of time. Make sure pulse is not cut off. |
|
|
benefits and risks of immediate reduction
|
w/o x-ray for first timer is risky (repeat offender is less risky) of FRACTURE. Immediate reduction stops pain and spasm.
|
|
|
benefits and risks of waiting for hospital reduction
|
fracture risk minimized with XRAYs but pain meds necessary due to waiting because spasm and intense pain will have set in by then
|
|
|
Closed reductions
|
manual reset
Milch (slow) Hippocratic Traction-Counter Traction |
|
|
TIme in sling after closed reduction
|
4-6 wkx
|
|
|
Does laxity necessarily mean instability?
|
no
|
|
|
3 reasons for dislocation
|
Trauma (acute or repetitive)
Congenital ligament laxity |
|
|
major causes of subluxation
|
ACUTE trauma
Repetitive trauma (laxity may not necessarily be unstable) |
|
|
Young get surgery for ant/inf. dislocation. Why?
|
60-90% chance of recurrence if not surgically repaired but closed reduction instead.
|
|
|
Old get coservative treatment for dislocation. Why?
|
only 15% likelihood of recurrence
|
|
|
Subluxation exam
|
Apprehension test!
General ligament laxity (test other joint so you'll know if it's congenital!) |
|
|
Results from chronic overuse/repetitve trauma OR from congenital ligament laxity
|
Microinstability
|
|
|
when does microinstability hurt?
|
when performing task but not when resting
|
|
|
What kind of sports/jobs incur microinstability?
|
OVERHEAD
|
|
|
Regarding instability (dislocation, subluxation, micro), do not mobilize in the
|
direction of the instability!
*No P-A, no external rotation w/ shoulder aBduction (don't recreate the injury in your office) |
|
|
Early phase of instability treatment (dislocation, subluxation, micro)
|
distraction
If arm in sling, do with arm at side. If arm free, do near open-packed position. |
|
|
Early treatment goals for instability (dislocation, subluxation, micro)
|
reduce pain
move synovial fluid maintain joint play |
|
|
pain
synovial fluid joint play |
goals of reducing pain, moving synovial fluid, and maintaining joint play for grades I and II oscillation distraction for acute instability phase (dislocation, subluxation, microinstability)
|
|
|
Regarding posterior capsule treatment for Anterior Instability (dislocation/subux/micro):
|
Use ONLY Anterior - Posterior direction.
NO rotation with abduction or P-A glides. Ever. |
|
|
How does Posterior capsule tightness affect GHJ?
|
Pushes head of humerus anteriorly, Destabilizes anterior glenohumeral ligament and joint capsule
|
|
|
Movement of Posterior capsule tightness that causes impingement?
|
NW!
(meaning A-P and I-S, so slams head of humerus into acromion and pinches rotators) |
|
|
Cause of primary adhesive capsulitis (frozen shoulder)?
|
unknown (idiopathic)
|
|
|
Causes of secondary ad cap?
|
Diabetes - Hypothyroid - Autoimmune - RC disuse - Chest/breast surgery - Prolonged immobilization - THYROID - heart attack - Shoulder trauma
|
|
|
Describe character of ad cap?
|
Gradual onset of pain
Increase inflammation Increase fibrosis **Loss of active & passive ROM (both!) |
|
|
3 stages of ad cap:
|
1. Pain - synovium inflamed
2. Frozen - fibrosis, scar 3. Thawing - remodeling |
|
|
age of avg ad cap patients
|
50's
|
|
|
If a patient comes in younger than 50's with signs of ad cap or sudden onset of shoulder pain, is it ad cap?
|
probably not
|
|
|
Describe ad cap of patient
|
50's
gradual worse unresponsive aggravated awakens from sleep |
|
|
order of loss of motion with ad cap
|
External (most)
ABduction Internal |
|
|
Will ad cap show on an x-ray?
|
no
|
|
|
If you see much joint capsule on MRI, suspect adhesive capsulitis. Why?
|
Normally not very visible. Enlarged, swollen, fibrotic, scarred, inflammed visible is ad cap. TIGHT
|
|
|
pain management during acute stage 1 ad cap
|
Codman's exercises, pain relief, no aggressive treatment
|
|
|
Stage 2 (frozen) and Stage 3 (thaw) ad cap treatment
|
Ultrasound, moist heat
Mild mobilization Ice |
|
|
High grade III mobilizations were shown to be more effective for ad cap than grades I and II, but?
|
not much more.
Grade III better in FROZEN |
|
|
when to refer out for ad cap
|
no improvement in 6-12 weeks
x-rays suspicious finding |
|
|
when are steroids and NSAIDS used for ad cap
|
stage 1
|
|
|
Most ad caps respond with non-surgical treatment.
|
capsular distention
open capsule release arthroscopic manip under anesthesia |
