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MSK 1 > 9/27 - Rotator Cuff NonOp > Flashcards

9/27 - Rotator Cuff NonOp Flashcards

1
Q

what are 3 different terms that all describe subacromial shoulder pain

A

subacromial impingement syndrome
rotator cuff tendinopathy
rotator cuff related shoulder pain

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2
Q

scapulohumeral rhythm ratio for 180deg of shoulder elevation

A

2deg of GH motion for every 1deg of ST motion

180deg shoulder elevation
- 120deg humeral elevation
- 60deg scap rotation

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3
Q

the coordinated effort in scapulohumeral rhythm is important for what function

A

overhead function
- shoulder elevation

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4
Q

what is the primary function of the rotator cuff

A

offset force of deltoid
- the ER and IR that it also does is less important

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5
Q

what does the RC provide at the GH joint

A

dynamic stabilization by compressing humeral head into glenoid

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6
Q

what is the relationship of the RC muscles to the GH joint capsule

A

RC muscles blend w capsule & create dynamic ligament tension
- since fibers blend, when cuff contracts provides tension in the capsule

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7
Q

what are the force couples at work in the shoulder joint

A

deltoid - RC
anterior-posterior RC
upper trap - serratus anterior

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8
Q

what happens when there is an unopposed deltoid

A

superior migration

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9
Q

what ms are included in the anterior and posterior force couple

A

anterior - subscap
posterior - infra and teres minor

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10
Q

why would an isolated supraspinatus injury have a good prognosis

A

not part of a force couple

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11
Q

what osteokinematics is the upper trap - serratus anterior force couple responsible for

A

shoulder elevation
upward rotation of the scap

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12
Q

what are 4 functions of the upper trap - serratus anterior force couple

A
  1. optimal position of glenoid
  2. deltoid length - tension
  3. prevents impingement
  4. stable base to recruit scap musculature
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13
Q

how does the upper trap - serratus anterior force couple prevent impingement

A

creates posterior tipping which inc the subacromial space

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14
Q

what are extrinsic mechanisms behind subacromial impingement

A

subacromial compression
- acromial arch shape
- posture (more forward, less space)
- ms performance (dec, less upward rotation)

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15
Q

what are intrinsic mechanisms for subacromial impingement

A

age
- dec vascularity >40yo (healing potential declines)
- tendon degeneration

hypercholesterolemia
DM
smoking

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16
Q

what do all intrinsic mechanisms play a role in? where else does this apply other than non-op cases?

A

tissue’s ability to heal

relates to post op
- quality of tissue relates to how well do after surgery

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17
Q

what is in the subacromial space? what role do these play in subacromial impingement?

A

tendons of RC
LHB tendon
subacromial bursa
superior capsule

all can create sx if compressed

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18
Q

how does sub acromial space change w shoulder motion

A

in a normal shoulder - space gets smaller as you get up and above head

space is 1/2 the size it was w shoulder down when shoulder raised at 90deg

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19
Q

what is a hypothesis for subacromial impingement

A

dec ST upward rotation inc risk for RC compression d/t dec clearance in subacromial space

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20
Q

what combined motion w shoulder elevation can inc sub acromial clearance if reduced scap upward rotation

A

max IR
- RC insertions may have passed under lateral acromion at 90deg

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21
Q

what motions inc the acromiohumeral distance at 45deg of elevation

A

inc ST upward rotation
posterior tilt

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22
Q

what can change the impact of dec ST upward elevation on subacromial space

A

depends on angle of elevation

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23
Q

how does dec ST upward rotation change the risk of compression

A

shifts risks to lower angles

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24
Q

the subacromial space is the smallest between what angles

A

50-70deg

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25
Q

how does the position of the RC change during shoulder elevation? what is the relevance of this when it comes to sx of compression

A

RC already medial to acromion in most at 90deg elevation
- RC compression at lower angles may become sx in midrange due to inc force production

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26
Q

what would sx >90deg of elevation be related to

A

internal impingement (RC vs glenoid) or biceps

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27
Q

what was the old school of thought behind the mechanism of impingement? why is this not thought anymore?

A

a mechanical problem
- run out of space and pinch stuff in between
- true mechanical = compression of tissues

hasn’t been shown in all pts
pts can have nonmechanical impingement
- from tension in musculature

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28
Q

how does mechanical vs nonmechanical impingements differ in treatment plans

A

they don’t - overall treatment is the same
- interventions for hypomobility and dec strength

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29
Q

what are 5 etiology behind shoulder impingement

A
  1. humeral head depressor weakness / fatigue
  2. GH instability
  3. posterior capsule tightness
  4. scap dyskinesia / ms weakness
  5. subacromial crowding (ie bone spurs, other anatomical changes)
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30
Q

is acute or chronic etiology more commonly seen w shoulder impingement

A

acute is rare
chronic more common - usually overuse

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31
Q

what are 3 chronic etiologies of shoulder impingement

A

repetitive microtrauma
throwing sports
vocational demands

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32
Q

how do the presenting sx differ in the late cocking phase on location of path

A

anterior instability = anterior pain
posterior impingement = posterior pain

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33
Q

what does it mean to have painful arc? when is this typically seen?

A

hurts starting at 50-70deg and then as get more flexion, starts to feel better
- seen in subacromial pain syndrome

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34
Q

what are sx of subacromial pain syndrome

A

ant lat shoulder pain
pain >/= 90deg
painful arc
pain worse at night

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35
Q

what sx are seen w a RC tear

A

ant lat shoulder pain
dec strength**
night pain
pain wakes from sleep***

36
Q

what sx are seen w posterior internal impingement

A

post shoulder pain in ABD-ER
overhead athletes have dec performance

37
Q

what sx are seen w long head of biceps tendinopathy

A

ant shoulder pain w shoulder flex and arm sup

38
Q

what role does the biceps play in the function of an overhead athletes

A

deceleration phase of throwing

39
Q

what frequently leads to LHB tendinopathy bc of one of its functions

A

can provide stability, esp if ligamentous structures slacking
- has to work harder, esp if RC path

40
Q

r/i findings for subacromial pain syndrome

A

(+) impingement signs
painful arc
pain w resisted ER
(+) LHB tests

41
Q

r/i findings for substantial RC tear

A

age >60yo
(+) lag signs
weakness
atrophy

42
Q

what type of problem should you think if lacking AROM and PROM

A

joint problem (ie adhesive capsulitis)

43
Q

what type of problem should you think if poor AROM but good PROM

A

muscular problem

44
Q

what is the biggest differential between subacromial pain syndrome and RC path

A

whether dec strength or not

45
Q

what are 6 general areas of predisposing factors that can lead to impingement if impairments occur at those areas

A
  1. AC joint
  2. bursa
  3. capsule/ligaments
  4. scapula
  5. acromion
  6. RC
46
Q

what impairment at AC joint could lead to impingement

A

degenerative bone spurs
- where acromion and clavicle meet is a common place for bone changes

47
Q

what impairment of the bursa can lead to impingement

A

chronic thickening
- the more irritation, will get thicker
- won’t have same properties

48
Q

what impairment of the capsule/ligaments can lead to impingement

A

hypermobility
hypomobility

49
Q

what impairment at the scapula can lead to impingement

A

abnormal position/rhythm
- winging
- anterior tipping

anterior tipping may be d/t pec minor tight
- brings acromion forward and dec space

50
Q

what impairment at the acromion can lead to impingement

A

shape
- if curved or hooked

51
Q

what impairment at the rotator cuff can lead to impingement

A

impaired force couples
unopposed delt

52
Q

what does a shrug sign indicate

A

delt overpowers the RC
- RC should hold joint in place while delt does that

53
Q

etiology of a primary impingement

A

disruption of normal mechanics

54
Q

what is a characteristic of primary impingement

A

hypomobile

55
Q

what are important things to look at in subacromial pain syndrome bc can often have similar sx as impingements

A

strength and ROM

56
Q

what are ways to normalize motion when treating primary impingement

A

capsular tightness
- inferior and posterior mobs

soft tissue adaptive changes
- pec minor
- if ms length issues

57
Q

whaat muscles should be rehabed to improve dynamic stability when treating a primary impingement

A

posterior cuff
scap ms

58
Q

what are 5 treatment interventions for primary impingement

A
  1. dec pain/inflammation
  2. normalize motion
  3. improve dynamic stability/endurance
  4. postural correction
  5. pt ed / activity modifications
59
Q

what should you be educating your patients on when treating primary impingement

A

avoid repetitive microtrauma

60
Q

sx of secondary impingement

A

hypermobility of static stabilizers

61
Q

MOI of secondary impingement

A

overuse leads to loss of dynamic stability provided by rotator cuff

62
Q

common pt population of secondary impingement

A

younger - 15-40yo

63
Q

etiology of secondary impingement (8)

A
  1. static stabilizers stretched
  2. inc GH translation
  3. RC fatigues (RC working harder to keep joint stable)
  4. overuse tendinitis
  5. tendon fibers fail
  6. RC unable to control HOH during elevation (and offset force of delt)
  7. superior migration occurs
  8. RC dysfunction & pain
64
Q

what is the goal of treatment for secondary impingement

A

help provide dynamic stability by inc strength of RC and scap stabilizers

65
Q

secondary impingement treatment interventions

A

cuff strengthening
- focus posterior
scap stabilization
- retraction
- protraction
- depression
NM influences
avoid repetitive microtrauma

66
Q

how does a normal shoulder translate

A

posterior

67
Q

MOI for posterior internal impingement (4)

A
  1. ABD & ER (late cocking phase)
  2. overhead athletes have excessive anterior translation & GH ER
  3. compressive force b/w greater tub and posterior/superior labrum
  4. undersurface of supraspinatus and infraspinatus implicated
68
Q

pathophys of primary and secondary impingements

A

outlet impingement
- abutting superior surface of HOH on acromion

69
Q

presentation of posterior internal impingement

A

pain w excessive ER at 90deg ABD
sx w overhead activities
hx of recurrent sx
loss of control and velocity

70
Q

test to r/i posterior internal impingement

A

(+) jobe subluxation/relocation

71
Q

interventions for posterior internal impingement are similar to interventions of what?

A

secondary impingement
- difference is where sx are which is d/t where and how the tissues are being impacted

72
Q

physical exam for posterior internal impingement

A

posterior pain on palpation
- infraspinatus tendon
anterior capsule laxity
posterior shoulder tightness
normal ROM
- inc ER and dec IR
- GIRD
weak external rotators
weak scap ms

73
Q

why do you see anterior capsule laxity in overhead athletes

A

so much ER allowed

74
Q

describe how IR/ER arc of motion changes in overhead athletes

A

shoulder IR/ER arc = 180deg
- arc shifts w inc ER so less IR

75
Q

where do you want to especially promote dynamic stability via perturbations for posterior internal impingement

A

challenging positions
- aka late cocking phase

76
Q

PT interventions for posterior internal impingement

A

dec pain/inflammation
- avoid irritating motions/activities
dynamic stability of RC
- rhythmic stabilization
- closed chain drills
scap ms training
- emphasize retraction & depression
NM training
- perturbaiton
proper throwing mechanics

77
Q

what structures are involved w posterior internal impingement that sx may be coming from (6)

A

subacromial bursa
RC ms/tendons
acromion
coracoacromial ligament
capsule
intra-articular structures

78
Q

what are factors that should be addressed when treating posterior internal impingement (4)

A
  1. altered shoulder kinematics (2deg capsular tightness
  2. RC/scap ms dysfunction
  3. overuse
  4. poor posture
79
Q

what are interventions for posterior internal impingement dependent on

A

pts and reactivity
weak = stronger
stiff = move

80
Q

what types of treatments have strong recs for posterior internal impingement

A

exercise
- home and/or clinic
- pain <5/10
- (+) resistance
- 12wks
exercise & manual therapy
- joint mobs, MWM, STM, manips

81
Q

who is appropriate for a corticosteroid injection as an intervention for posterior internal impingement

A

if reactivity is high
- pain w ADLs not performance of sport

can’t work on deficits until reactivity calms down

82
Q

what modality should you not use on posterior internal impingement

A

laser

83
Q

what modalities have no evidence of effectiveness in treating posterior internal impingement

A

US
extracorporeal shockwave therapy

84
Q

why is extracorporeal shockwave therapy making a comeback to treat posterior internal impingement

A

option if can’t do corticosteroid bc of DM

85
Q

what are the best interventions for posterior internal impingement

A

therex
mobs

86
Q

op vs nonop w a RC tear

A

do well w/o surgery if go to PT
try PT before surgery

MSK 1 (31 decks)

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