Clinics Ii Midterm - Ghj

Front 1

Progression of Supraspinatus RC Tear

Back 1

Propogates posteriorly through the remainder of the supraspinatus, then into the infraspinatus & teres minor, crosses the bicipital groove to involve the
subscapularis, starting at the tope of the lesser tuberosity & extending inferiorly. Associated with rupture of the transverse humeral ligament & destabilization of the LHB tendon

Front 2

Acute RC Full Thickness Tear - Cause

Back 2

FOOSH or trying to break a fall

Front 3

Acute RC Full Thickness Tear - Signs & Symptoms

Back 3

• inability to abduct the arm actively beyond 90° without trick movements
• painless weakness of resisted isometric abduction < 30° of abduction
• large active passive ROM difference
• may be significant pain initially which is replaced by c/o weakness
• night pain is common
• significant loss of abduction strength

Front 4

RC Pathology Continuum

Back 4

• impingement  tendonitis/tendinopathy  partial RC tear  full thickness tear
• RC failure may progress as a major episode of tendon tearing or as creeping tears involving relatively few fibers at a time with thinning of the cuff tendon

Front 5

Clinical Presentation of RC Pathology

Back 5

• overhead athletes & workers
• > 35 years of age
• unusual in people < 40 years of age
• if in young people - partial thickness
or they may include the avulsion of bone from the tuberosity

Front 6

Function of RC in Baseball Pitching

Back 6

• stresses are the greatest in the follow-through phase after the ball has been released
• RC acts 1° to decelerate the humerus through eccentric muscle activity

Front 7

Common Site of RC Degeneration

Back 7

• deep surface of the anterior insertion of the supraspinatus near the LHB

(degenerative lesions only?)

Front 8

Explanation for Problematic Healing

Back 8

• due to compromised vascularity, the large loads and the large deformations that the healing tissue must
endure

Front 9

Zipper Phenomenon

Back 9

• failure of one fiber or of groups of fibers places greater loads on the adjacent fibers, favouring their failure
• when a tendon fiber fails, the muscle fiber to which it attaches retracts - increasing gap to be closed
• retraction places tension on the local vasculature = limitation of tendon blood flow in the area where healing is needed

Front 10

Clinical Presentation of Chronic Degenerative RC Tears

Back 10

• > 40 years of age
• hx of shoulder problems
• may be acute exacerbation superimposed on old problem
• associated with an increase in activity level or semi-traumatic event

Front 11

Stiff Shoulder - Causes

Back 11

• OA, fracture, post-surgical contracture, muscle imbalance & intra-articular capsular contracture
• with capsular restriction pattern - humeral head position relative to the glenoid is no longer centralized/optimal
• causes alteration in joint axis of motion, RC function, scapular position & muscle balances around the shoulder

Front 12

Posterior Contracture (Thickening) - Causes

Back 12

• secondary to degenerative change in the supraspinatus tendon
• eccentric overload of the posterior capsule in the throwing arm

Front 13

Posterior Contracture (Thickening) - Signs & Symptoms

Back 13

• limitation of horizontal flexion, IR & end-range flexion
• decreased posterior glide
• humeral head positioned anteriorly & superiorly
• impingement signs
• weakness of the ER’s & scapular stabilizers

Front 14

Anterior Contracture (Adhesion) - Clinical Presentation
(i.e., anterior-superior)

Back 14

• post-degenerative or overuse reaction in biceps
• post- RC surgery
• at risk b/c of anatomy:
- biceps tendon comes through the space between subscapularis and supraspinatus tendons gets impinged between 2 tendons
- coracohumeral lig and superior GH ligament also insert (will contract and fibrose - drawing humeral head upwards)
- congestion in area = impingement

Front 15

Anterior Contracture (Adhesion) - Signs & Symptoms
(i.e., anterior-superior)

Back 15

• anterosuperior placed humeral head at rest
• decreased posteroinferior glide
• limitation of end range extension, ER at 0° & HBB
• impingement signs limiting end range horizontal flexion & IR at 90° due to anterior
placement of the humeral head
• usually biceps and/or anteromedial site of pain
• significant night pain with sleep disturbance
• pain with ADL:
• putting arm into jacket
• washing under opposite arm
• doing up bra
• weakened RC particularly ER
• TP’s common in biceps & subscapularis
• +ve ULNT
• +ve impingement sign

Front 16

Anterior Contracture (Thickening) - Causes

Back 16

• over tightened shoulder reconstructions or degenerative OA

Front 17

Anterior Contracture (Thickening) - Signs & Symptoms

Back 17

• excessive posterior glide of the humeral head
• limitation of abduction, ER, extension & horizontal extension

Front 18

RC Pathologies - Treatment

Back 18

• strengthening: RC, scapular stabilizers (eccentric strengthening for intrinsic changes)
• stretching: pectorals & posterior capsule (spec
• manual therapy: shoulder & thoracic spine

• early pain reduction is critical - may include:
- relative rest - cryotherapy
- modalities
- medications
• scapular stabilization exercises
• CKC exercises
• combined stabilizing exercises
- scapular clock
- fitter exercises
• resisted scapular exercises (therapist assisted)
• push-up exercises
• push-ups with a “plus” exercises
• PNF patterns
• stretching truly short muscles only
• integration of lower kinetic chain core stabilization
• lower kinetic chain exercises
• aerobic conditioning

Front 19

Plyometrics - Benefits

Back 19

• increased joint position sense
• decreased time to peak torque generation
• increased IR power in comparison with conventional isotonic training
• increased throwing distance in comparison with conventional isotonic training o the patient should catch the ball, decelerate it & then immediately accelerate it in the opposite direction

Front 20

Plyometrics - Guidelines

Back 20

• LE plyometrics can be done early in the rehab process
• UE plyometrics should be initiated in the later rehab stages

Front 21

Three Shoulder Clinical Syndromes

Back 21

• painful
• unstable
• hypomobile

Front 22

Two Most Common Tendons for RC Tears

Back 22

• supraspinatus
• long head biceps

Front 23

Tendinosis

Back 23

• progressive & degenerative without inflammation

Front 24

Tendonitis

Back 24

• acute inflammatory process
• common in young people
• focal event

Front 25

Tendinopathy

Back 25

• combo of pain and dysfunction in tendons
• no specific diagnosis
• multifactorial problem

Front 26

5 Main Reasons for RC Pathology

Back 26

• pectoralis muscle length
• scapular muscle performance
• thoracic spine posture/mobility
• GH capsule length/extensibility
• RC muscle performance

Front 27

Two Most Common Locations (anatomical) for Impingement

Back 27

• subacromial impingement
• in the RC itself = ‘internal impingement’ (RC tendons on articular surface/posterior glenoid rim)

Front 28

Internal Impingement - What is it

Back 28

• impingement IN the cuff itself
• underneath side of tendons impinges on posterior glenoid rim
• higher percentage of pathology starts here

Front 29

Age Related Tendon Changes

Back 29

• decreased elasticity
• decreased tensile strength
• increased fibrovascular proliferation
• reduced GAG/PG content (proteoglycans) - decreased viscolelastic properties
• reduced collagen content
• increased proportion of type III (weaker) collagen
• increased ‘avascularity’

Front 30

Effect of Neo-Neuralization on Tendon

Back 30

• reduces pain tolerance

Front 31

Two Changes that Occur in Areas of Degeneration

Back 31

• neo-neuralization
• fibrovascularization

Front 32

Pathophysiology of Tendinopathies

Back 32

• vascular changes: increasing zone of avascularity, neovascularization / neo-neuralization in areas of degenerative change
• tendon matrix changes: increased type 3 (weaker/disorganized) fibers
• increased tenocyte apoptosis (cell death)
• load changes - supraspinatus tendon (bursal versus articular)

Front 33

Most Common Point of Tendon for Degenerative Change

Back 33

• site where tendon inserts into head of humerus
articular surface of the tendon

Front 34

Position Eliciting Most Impingement

Back 34

abduction and external rotation

Front 35

Tests to Rule In RC Tendinopathy

Back 35

Hawkins Kennedy
Painful Arc
Weak ER

* 2/3 tests will rule in RC tendinopathy

Front 36

Tests with High Sensitivity to Rule Out RC Tendinopathy

Back 36

Neer Test
Hawkins Kennedy
Empty Can

* Rule out RC if 3/3 tests are negative

Front 37

Tests with High Specificity to Rule In RC Tendinopathy

Back 37

Drop Arm
Lift Off

Front 38

Drop Arm Test - What Makes it Positive?

Back 38

• inability to abduct arm > 90° without trick movements
• painless weakness of resisted isometric abduction < 30°

Front 39

Effect of Capsular Pattern of Restriction on Alignment & Biomechanics

Back 39

• head of humerus will no longer be central or optimal
• stiffness will push head of the humerus anteriorly
• alters joint axis of motion, RC functioning & scapular positioning
• muscle imbalances

Front 40

How Can You Tell the Difference Between Anterior and Posterior Contractures?

Back 40

anterior contracture:
- night pain
- escalates faster than posterior
- loss of humeral extension & ER

Front 41

Effect of Ligamentous Structures on Anterior Contractures

Back 41

superior glenohumeral ligament and coracohumeral ligament may contract and fibrose, drawing humeral head superiorly and anteriorly

Front 42

Clinical Presentation of Adhesive Capsulitis

Back 42

• females > males
• 40 - 50 years
• sudden onset
• relentless pain
• hypothyroidism
• diabetes

Front 43

Stiff Shoulder - Treatment

Back 43

• relative rest
• cryotherapy
• modalities
• medications