Upper Extremities Midterm

Front 1

Define:What is the most common musculoskeletal complaint? 2nd most common? 3rd most common?

Back 1

1. LBP
2. Neck pain
3. Shoulder pain

Front 2

Define: nociceptive pain

Back 2

Local pain, activation of PERIPHERAL nociceptor terminal endings

Front 3

Define: neuropathic pain

Back 3

Injury to a NERVE (nerve root, plexus, peripheral nerve)- radiculopathy, entrapment

Front 4

Define: GHJ Osteoarthritis

Back 4

Progressive, NON-inflammatory disease characterized by degenerative changes in the GH joint

Front 5

Define: Adhesive Capsulitis

Back 5

Chronic INFLAMMATORY disorder of GHJ followed by reactive joint fibrosis

Front 6

Define: Impingement Syndrome

Back 6

Compression of tissues in the SAS

- Subacromial bursa (bursitis)
- SSp tendon (tendinopathy)
- LH biceps (tendinopathy)

Front 7

What tissues are included in the SAS?

Back 7

- Subacromial bursa (bursitis)
- Supraspinatus tendon (tendinopathy)
- Long head of biceps (tendinopathy)

Front 8

What tendons are affected in a rotator cuff tendon?

Back 8

1st. Supraspinatus tendon (most common)
2nd. Infraspinatus tendon
3rd. Subscapularis tendon
4th. Teres minor tendon (rare)

Front 9

Define: ACJ Osteoarthritis

Back 9

Progressive NON-inflammatory disease characterized by degenerative changes in the ACJ

Front 10

Etiology/Pathophysiology of GHJ Osteoarthritis?

Back 10

None

Front 11

Etiology/Pathophysiology of Primary Adhesive Capsulitis

Back 11

Idiopathic

Front 12

Etiology/Pathophysiology of Secondary Adhesive Capsulitis

Back 12

Associated with:
- Systemic disorders (Diabetes Mellitus, Thyroid Disease, Autoimmune Disease)
- Shoulder disorders
- Non-shoulder disorders

Front 13

Etiology/Pathophysiology of Impingement Syndrome

Back 13

Supraspinatus TENDON pathology
1. Functional narrowing (common)- strength imbalance, tight posterior GHJ capsule, decreased S-I glide of GHJ, decreased upward rotation of scapula
2. Structural narrowing of SAS
3. Swelling in SAS

Front 14

Etiology/Pathophysiology of Rotator Cuff Tear

Back 14

Tear in TENDON
1. Age-related degeneration (most common in patients over 40 years old)
2. Impingement syndrome
3. Tension overload
4. Trauma- dislocation, FOOSH

2 & 3 are the most common in athletes

Front 15

Etiology/Pathophysiology of ACJ Separation

Back 15

Trauma
- Injury to ACJ capsule and ligament; injury to coracoclavicular ligament (types 2- 6)

Front 16

Typical history of a patient with GHJ Osteoarthritis

Back 16

1. Patient is OVER 60 years old
2. Patient complains of
- Gradual onset of pain
- Progressive worsening
- Aggravated by activity

Front 17

Typical age of a patient with adhesive capsulitis

Back 17

Between 40 and 60 years old

Front 18

Typical signs/symptoms of a patient with Stage 1: Adhesive Capsulitis

Back 18

INFLAMMATION STAGE

- Gradual onset of PAIN
- Progressively worsening
- Aggravated by activity

Front 19

Typical signs/symptoms of a patient with Stage 2: Adhesive Capsulitis

Back 19

FIBROSIS and CONTRACTURE STAGE

- Shoulder STIFFNESS
- Decreasing Pain

Front 20

Typical signs/symptoms of a patient with Stage 3: Adhesive Capsulitis

Back 20

REMODELS and STRETCHES

- Decreasing stiffness with minor pain

Front 21

Typical history of a patient with impingement syndrome

Back 21

- Patient is over 35 years old (unless they are an athlete)

Shoulder pain may include:
- Anterolateral shoulder pain
- Long head of biceps tendon and referred pain to deltoid insertion
- Lateral arm or forearm pain

Front 22

Impingement syndrome onset can be related to what?

Back 22

- Occupation: overhead work
- Overhead sports
- 30% unrelated to activity

Front 23

What will aggravate the symptoms of impingement syndrome?

Back 23

Overhead activities

Front 24

Typical history of a patient with a rotator cuff tear

Back 24

Patients are OVER 40 years old, unless they are an athlete

- Shoulder pain OR
- Shoulder pain and weakness

Front 25

Typical history of a patient with ACJ Osteoarthritis

Back 25

- Repetitive overhead work
- Complication of trauma
- Increased risk in patients doing heavy labor

Front 26

Typical history of a patient with ACJ separation

Back 26

- Direct trauma to point of shoulder (most common)
- FOOSH: less severe ACJ injury, but may injure tissues in SAS

Front 27

Physical exam findings of a patient with GHJ Osteoarthritis

Back 27

1. Decreased AROM and PROM of GHJ (no pattern)
2. Possible disuse atrophy
3. Crepitus in GHJ

Front 28

Physical exam findings of a patient in Stage 1: adhesive capsulitis

Back 28

INFLAMMATION STAGE
- MILD decreased AROM and PROM of GHJ (no pattern)

Front 29

Physical exam findings of a patient in stage 2: adhesive capsulitis

Back 29

FIBROSIS and CONTRACTURE STAGE
- Increasing loss of ROM
- GREATEST loss in EXTERNAL ROTATION
- CAPSULAR PATTERN possible

Front 30

Physical exam findings of a patient in stage 3: adhesive capsulitis

Back 30

REMODELS and STRETCHES Stage
- ROM improving

Front 31

Physical exam findings of a patient with impingement syndrome

Back 31

- Possible tenderness of: greater tubercle, anterolateral shoulder below acromion, long head of biceps tendon, ACJ
- Subacromial crepitis possible
- RC Strength tests: 5/5 (If pain is significant, may show 4+/5 weakness)
- Impingement test: positive
- Supraspinatus press test: may be positive

Front 32

Physical exam findings of a patient with a rotator cuff tear

Back 32

- Tenderness similar to impingement syndrome
- Subacromial crepitus possible
- RC Strength test: may range from 5/5 (small tear) to 4-/5 or weaker (large tear)
- Weakness of 2 muscles may indicate massive tear
- Impingement test: positive
- Supraspinatus press test: may be positive
- Drop arm: may be positive

Front 33

Physical exam findings of patient with ACJ osteoarthritis

Back 33

- ACJ tenderness
- Cross body adduction: positive

Front 34

Physical exam findings of patient with ACJ separation

Back 34

- Step defect (types 2-6)
- ACJ tenderness

Front 35

Imaging of GHJ Osteoarthritis

Back 35

Joint destruction

Front 36

Imaging of Adhesive capsulitis

Back 36

- Radiographs: normal
- CT/MRI: inflammation and/or thickened joint capsule

Front 37

Imaging of Impingement Syndrome

Back 37

Radiographs: may show structural causes of impingement
MRI: negative for a tear

Front 38

Imaging of Rotator Cuff tear

Back 38

- May show structural impingement
- MRI: POSITIVE for a tear

Front 39

Imaging of ACJ Osteoarthritis

Back 39

Joint destruction

Front 40

Imaging of ACJ Separation

Back 40

- Type 1: Negative
- Type 2 - 6: Step defect

Front 41

Define: Convergent Theory of Referred Pain

Back 41

If sensory nerves from two different sources synapse on the same second order neurons, then nociception that originates in the territory of one nerve (intestine) can be FELT as pain in the territory of the other nerves (skin)

Front 42

(3) Common Approaches to Diagnosis

Back 42

1. Search for red flags
2. Pattern recognition
3. Algorithmic method

Front 43

Define: Red Flags

Back 43

Signs and symptoms from the history, physical exam and response to care that are uncommon in the usual patient with mechanical shoulder pain, which can alert the doctor to the possibility of a more serious condition

Front 44

Define: Algorithmic method

Back 44

- A branching sequence of steps needed to solve a problem
- Also, a plan for connecting data

Front 45

(3) Most common causes of shoulder pain that present for treatment

Back 45

1. Glenohumeral joint disorders
2. Rotator cuff disorders
3. Acromioclavicular joint disorders

Front 46

Before applying manual force to a patient's shoulder, what must we rule out?

Back 46

GHJ instability

Front 47

Which is the most common cause of all shoulder problems?

Back 47

Rotator cuff disorders

Front 48

Can you treat GHJ osteoarthritis with mobilization or manipulation?

Back 48

Yes

Front 49

What kind of medical management can be used for GHJ Osteoarthritis

Back 49

- NSAIDS
- Intra-articular corticosteroids (avoid repeated injuries)

Front 50

When would you use LOW grad mobilization?

Back 50

When PAIN is the dominant symptom

Front 51

Does LOW grade mobilization stretch tissues?

Back 51

NO

Front 52

What does LOW grade mobilization do?

Back 52

- Pain control
- Move synovial fluid
- Muscle relaxation
- Maintain joint play when ROM is not allowed

Front 53

Does HIGH grade mobilization stretch tissues?

Back 53

YES

Front 54

When would you use HIGH grade mobilization?

Back 54

For STIFFNESS and JOINT RESTRICTION

Front 55

What are some adjustments helpful for PAIN?

Back 55

LOW GRADE MOBILIZATION

- Lateral distraction
- Long axis traction
- Circumduction
- Anterior and Posterior Glide

Front 56

What are some adjustments helpful for STIFFNESS and JOINT RESTRICTION

Back 56

HIGH GRADE MOBILIZATION

- Lateral distraction
- Long axis traction
- Posterior glide
- Inferior glide
- Rotation: remove joint slack in rotation and to apply distraction or glide without compression

Front 57

Rotation to treat STIFFNESS and JOINT RESTRICTION can be combined with what?

Back 57

- Lateral distraction
- Anterior glide
- Posterior glide

Front 58

Treatment for Stage 1: Adhesive Capsulitis

Back 58

- Pain relief: prescription medication, corticosteroid injections, TENS
- LOW grade mobilization
- Codman's (pendulum) exercises

Front 59

Treatment for Stage 2 and Stage 3: Adhesive Capsulitis

Back 59

- Heat (pre-treatment)
- Passive stretching: low load, long duration
- Mobilization (low grade or high grade- high grade has an increased risk of inflammatory flair up)
- NO MANIPULATION
- Ice/cold (post-treatment)

Front 60

For adhesive capsulitis, which stage(s) is the chiropractor most effective?

Back 60

Stages 2 and 3

Front 61

Medical management of Adhesive Capsulitis

Back 61

- NSAIDS
- Corticosteroid injections

Front 62

Is surgery required for Adhesive Capsulitis?

Back 62

No, most respond with non-surgical treatment

Front 63

(4) Functions of the Rotator Cuff Muscles

Back 63

1. Rotate the humerus by working as individual muscles
2. Rotate the humerus by working with the deltoid to create a force couple
3. Stabilize the GHJ by compression of the humeral head of the humerus into the glenoid fossa
4. Stabilize the GHJ by depression of the humeral head during FLEXION and ABDUCTION

Front 64

What are the (4) individual muscles of the rotator cuff? What are their actions?

Back 64

1. Supraspinatus: ABduction
2. Subscapularis: Internal Rotation
3. Infraspinatus/4. Teres Minor: External Rotation

Front 65

Define: Force Couple

Back 65

Two forces of EQUAL magnitude acting in opposite directions to ROTATE a body around its axis of motion

Front 66

Infraspinatus/Teres Minor and Deltoid Force Couple aid in what actions?

Back 66

Flexion and ABduction

Front 67

What muscles are the most important stabilizers of the GHJ in the mid-ranges of motion?

Back 67

Rotator cuff muscles

- Supraspinatus, Infraspinatus/Teres Minor, Subscapularis

Front 68

How does the supraspinatus muscle counteract the SUPERIOR pull of the deltoid?

Back 68

- The supraspinatus in the relaxed neutral position must contour around the humeral head
- When supraspinatus contracts, it is pulled taught and pushes down on the humerus

Front 69

How does infraspinatus, teres minor and subscapularis counteract the SUPERIOR pull of the deltoid?

Back 69

Produce a downward vector with contraction (pull MEDIAL and INFERIOR)

Front 70

Define: tendinopathy

Back 70

A generic term used to describe pathology in and pain arising from a tendon

Front 71

Define: Tendonitis

Back 71

A rare INFLAMMATORY condition of a tendon

Front 72

Define: Tendinosis

Back 72

NON-INFLAMMATORY degenerative changes in a tendon commonly due to aging, microtrauma or vascular compromise

Tendinosis is not necessarily symptomatic

Front 73

Which muscle tendon is most commonly affected with rotator cuff tendinopathy?

Back 73

Supraspinatus tendon

Front 74

Rotator cuff tendinopathy typically occurs in what age group?

Back 74

Patients over 35 years old

Front 75

Major causes of rotator cuff tendinopathy?

Back 75

- Trauma
- Age related degeneration
- Tension overload
- Impingement syndrome

Front 76

What is the most common cause of symptomatic rotator cuff tendinopathy?

Back 76

Impingement syndrome

Front 77

Define: Impingement syndrome

Back 77

Compression of tissue in subacromial space (between the humeral head and the undersurface of the coracoacromial arch)

Front 78

What is the most common cause of rotator cuff tears?

Back 78

Age-related degeneration

Front 79

Where is the subacromial space?

Back 79

Space between the coracoacromial arch and the head of the humerus

Front 80

What (4) things compose the coracoacromial arch?

Back 80

- Anterior 1/3 of the acromion
- AC joint
- Coracoacromial (CA) ligament
- Coracoid process

Front 81

What takes up the most space in the subacromial space?

Back 81

Supraspinatus tendon

Front 82

What (3) tissues are impinged in the SAS?

Back 82

1. Subacromial bursa (DDX: subacromial bursitis)
2. Supraspinatus tendon (DDX: supraspinatus tendinopathy)
3. Long head biceps tendon (DDX: LHBT tendinopathy)

Front 83

Major causes of impingement

Back 83

1. Functional narrowing of SAS
2. Structural narrowing of SAS
3. Swelling in the SAS

Front 84

Which is the most common cause of impingement?

Back 84

Functional narrowing of SAS

Front 85

What happens with a tight posterior GHJ capsule with impingement?

Back 85

During flexion and abduction, the humeral head translates anterior and superior causing impingement

Front 86

What is the treatment of a tight posterior GHJ capsule?

Back 86

Mobilization targeting the posterior capsule: favor A-P glide and try to stretch the capsule

Front 87

What are (2) examples of functional narrowing of SAS

Back 87

1. Decreased S-I Glide with ABduction causes impingement
2. Decreased upward rotation of the scapula during flexion and ABduction- this action does not move the acromion out of the way of the humerus and will cause impingement

Front 88

What are (2) examples of structural narrowing of the SAS?

Back 88

1. ACJ spur (always on the inferior border of the acromion)
2. Abnormal shape of acromion: congenital; acromion is more narrow or flat and will start to limit the space available

Front 89

What (2) factors cause swelling in the SAS?

Back 89

1. Tension overload
2. Acute trauma

Front 90

What is the cause of the majority of impingement syndromes?

Back 90

- Most have no single precipitating event
- Due to functional and structural impingement combined with cumulative effects of repetitive impingement from overhead sports, overhead occupation

Front 91

How long do symptoms of impingement syndrome last?

Back 91

- Most patients present weeks or months after onset
- Unusual for patients to have acute symptoms

Front 92

(4) probable areas of tenderness on a patient with impingement syndrome?

Back 92

1. AC joint (part of the coracoacromial arch)
2. Anterior and lateral edge of acromion
3. Insertion of supraspinatus on greater tuberosity
4. LHBT

Front 93

Purpose of impingement tests

Back 93

All will narrow the SAS with various combinations of limiting scapular upward rotation, humeral flexion, and internal rotation.

Front 94

Define: Neer Test

Back 94

Purposely trying to cause impingement

Front 95

Define: Hawkin's Test

Back 95

Puts greater tubercle into SAS to pinch it

Front 96

Define: Supraspinatus press test

Back 96

- More likely to cause pain and pain-inhibited weakness than "full can" test if impingement presents
- Internal rotation narrows the SAS by bringing the greater tuberosity under the coracoacromial arch

Front 97

Treatments/Adjustments that would be good for a patient with Impingement syndrome

Back 97

- Long axis traction
- S-I glide
- Lateral distraction (M-L)
- A-P glide

Front 98

All adjustments for impingement syndrome must be performed how?

Back 98

With arm 30° abduction in the scapular plane

Front 99

Medical treatment of impingement syndrome

Back 99

- NSAIDS
- Subacromial corticosteroid injections

Front 100

Is surgical treatment effective for structural causes or swelling in the SAS?

Back 100

Yes

Front 101

Is surgical treatment effective for functional causes of impingement?

Back 101

NO

Front 102

Define: massive tear

Back 102

Effects at least 2 tendons

Front 103

Reasons rotator cuff tears do not heal:

Back 103

- Constant traction on the supraspinatus by the weight of the arm keeps the torn edges separated
- Degenerative nature of most tears does not provide an environment for healing
- Poor vascular supply of the tendon at the most common site of tears
- Most tears are on the articular side (torn fibers are bathed in synovial fluid which disrupts healing factors)

Front 104

Causes of weakness in rotator cuff tears:

Back 104

1. Pain inhibited weakness (only if pain is significant)
2. Tendon fiber failure
3. Atrophy (seen in chronic conditions)

Front 105

Drop Arm Test for Rotator Cuff Tear

Back 105

- Eccentric loading of the supraspinatus
- Only 7% sensitivity for RC tear
- 98% specificity

Therefore: a positive drop arm test almost assures the diagnosis of a rotator cuff tear (high specificity), but a negative test does not rule out a rotator cuff tear (low sensitivity)

Front 106

Impingement tests for Rotator Cuff tear

Back 106

- Often positive in supraspinatus tears
- 75% sensitivity
- Only 45% specificity

Therefore: a positive impingement test does not assure the diagnosis of a rotator tear (low specificity), but a negative test helps to rule out a rotator cuff tear

Front 107

How to differentiate between supraspinatus tendinopathy and a small tear

Back 107

- Both will present as either 1) Pain and no weakness, or 2) Pain and mild weakness
- MD may perform lidocaine test (rules out tendionpathy)
- Failure of conservative care will usually prompt an MRI

Front 108

What techniques are good for a supraspinatus tear/tendinopathy? How do these techniques need to be performed?

Back 108

- A-P glides (stretching the posterior capsule)
- Lateral distraction (M-L)

These need to be performed with the arm 30° abduction in the scapular plane

Front 109

Would you recommend long axis traction for a patient with a supraspinatus tendinopathy or tear?

Back 109

NO

Front 110

Would you recommend SI glides for a patient with supraspinatus tendinopathy or tear?

Back 110

NO

Front 111

Which ligaments are the major stabilizing ligaments of the ACJ?

Back 111

Coracoclavicular ligaments
- Conoid Ligament
- Trapezoid ligament

Front 112

Can osteoarthritis of the ACJ be treated with mobilization? With manipulation?

Back 112

Yes to both

Front 113

Medical management of ACJ osteoarthritis

Back 113

- NSAIDS
- INTRA-ARTICULAR corticosteroids

Front 114

ACJ Type I

Treatment?

Back 114

SPRAIN

- Partial disruption of AC ligaments and joint capsule

Treatment: ice, rest; later- strengthening exercises (trapezius and deltoid)

Front 115

ACJ Type II

Treatment?

Back 115

SEPARATION

- Ruptured AC ligament and joint capsule with INCOMPLETE injury to coracoclavicular ligament

Treatment: same as Type I (ice, rest; later strengthening exercises- trapezius and deltoid)
- Brace to depress the clavicle and reduce separation (dislocation)
- Gentled ROM can begin 48 hours post-injury

Front 116

ACJ Type III

Treatment?

Back 116

SEPARATION

- Ruptured AC ligament, joint capsule, and coracoclavicular ligament

Treatment: same as Type II
- (Type I: ice, rest, later strengthening exercises)
- (Type II: brace to depress the clavicle and reduce separation, gentle ROM 48 hours after post injury)

Front 117

Which types of ACJ sprains/separations can be treated with mobilization/manipulation?

Back 117

Type I and Type II

Front 118

What injury will cause NO damage to coracoclavicular ligaments?

Back 118

FOOSH

Front 119

FOOSH injury vs. Fall on Point

Back 119

FOOSH is
- Less severe o ACJ
- Damage to AC ligaments
- No damage to coracoclavicular ligaments
- This mechanism cause traum to tissues in the subacromial space