Common Upper limb pathologies

Question 1

Common disorders

Answer 1

RC disorders= tendinopathy (most affected= supraspinatus) and tear
GHJ disorder= AC and OA
AC joint= can be subluxation/dislocation or stretching/ tearing of AC lig or coracoclavicular lig

Question 2

biomechanics of GH elevation- how to gain full elevation

Answer 2

normal functioning force couples= deltoid+RC/ lower cuff/LR/ SA and traps
normal movement at AC &SC& ST joints, normal humeroscapular rhythm, good thoracic spine mobility

Question 3

what does the amount of thoracic spine kyphosis affect

Answer 3

influences the ability of us to flex and abd shoulder

Question 4

frozen shoulder- what affects movement

Answer 4

most common in women age 40-60, characterised by pain and stiffness in shoulder- 3 stages, gradual insidious onset
pathology= initial inflammatory process leading to fibrosis of capsule, RC interval (SGH and CH lig and subscap tendon) and anterior capsule most affected- loss of capsular flexibility and decreased ROM

Question 5

what is the rotator interval

Answer 5

section between supraspinatus and subscapularis tendon, involve CH lig coming off coracoid process underneath biceps LH. when you get frozen shoulder this section of the capsule becomes fibrosed and thickened (loss of ROM)

Question 6

what movement is worse for frozen shoulder

Answer 6

LR worse as anterior capsule stretches when arm above head- can lead to differentiation

Question 7

stages of adhesive capsulitis

Answer 7

stage 1- painful phase (10-36 weeks), stage 2- stuff phase (4-12 months), stage 3- recovery phase (12-42 months) mean duration from onset to recovery= 30 months

Question 8

diagnosis criteria- adhesive capsulitis

Answer 8

shoulder pain that comes on slowly and is felt at deltoid region, painful restriction of AROM/ PROM, capsular pattern (LR (most affected)>ABD>MR), inability to sleep on affected side, X ray= only way to differential diagnosis from OA

Question 9

management stage 1

Answer 9

reduce pain, <3/12= consider SCI, >3/12= avoid CSI (extend recovery period), NSAIDs, advice, maximise ROM

Question 10

management stage 2 and 3

Answer 10

stage 2- maximise ROM and function, mobs, self management programme, advice,
stage 3- maximise ROM and function, mobs, self management programme, advice, active exercise programme, stertching

Question 11

what part of capsule needs to be stretched

Answer 11

superior part of capsule to get rotator interval zone

Question 12

surgical management of adhesive capsulitis

Answer 12

MUA, joint distension (H20)- stretches capsule with water=break adhesions, open surgical release

Question 13

RC tendinopathy

Answer 13

shoulder weakness and catching- should not have limited end feel to movement, should have pain and weakness on isometric resisted testing

Question 14

what happens if you get tendinopathy of supraspinatus tendon

Answer 14

if supraspinatus is dysfunctional then deltoid pull humeral head upwards- meaning rest of RC aren’t maintaining position= compression of tendon (severe= bone formed in tendon_

Question 15

types of RC tendinopathy

Answer 15

tendinitis- acute tendon overuse (young adult), tendinosis- under stressed- overload tendon condition with a degenerative, non-inflammatory pathology
tears- over 40’s= full/partial thickness
calcification- calcific deposits within tendon

Question 16

rotator crescent and cable

Answer 16

cable= thickened area of capsule creates cord like structure, cre

Question 17

factors causing tendinopathy- intrinsic- decreased vascularity of RC tendon

Answer 17

degenerative vascularity of RC tendon, critical zone of hypovascularity- 1cm medial to insertion of RC tendon, most degenerative RC tears occur in this zone

Question 18

factors causing tendinopathy- intrinsic- deconditioned tendon

Answer 18

an under loaded tendon has no stimulus to build healthy tissue, will fail if suddenly over loaded, tendon becomes oedematous due to increased water content but not inflamed, absence of inflammatory cells

Question 19

factors causing tendinopathy- intrinsic- joint side wear and tear

Answer 19

acromail side RC tendon fibres thicker and stronger, joint side fibres more vulnerable to tensile loads, lesions often found on joint side of tendon not acromial

Question 20

factors causing tendinopathy- extrinsic-

Answer 20

mechanical irritation of contents of subacromial space due to compression by external factors

Question 21

factors causing tendinopathy- extrinsic- sub acromial space

Answer 21

floor= humeral head, roof- inferior surface of acromion + a-c joint + coracoacromial ligament, contents= RC tendon + LHB + subacromial and sub deltoid bursa

Question 22

factors causing tendinopathy- extrinsic- postural dysfunction

Answer 22

FHP, protracted shoulder girdle, kyphosis, scapula position

leads to alterations of force couples operating around shoulder and faulty movement

Question 23

factors causing tendinopathy- extrinsic- muscle imbalance

Answer 23

weak/fatigued/ injured RC, results in loss of deltoid= RC force couple, allows superior migration of humeral head, leading to repetitive impingement of subacromial soft tissue, results in inflammation and RC disease

Question 24

factors causing tendinopathy- extrinsic- impingement of RC tendons secondary to G/H instability

Answer 24

failure of static or dynamic stabilizers of GHJ allows excessive translation of HH

Question 25

factors causing tendinopathy- extrinsic- bony abnormalities

Answer 25

shape of acromion= hook shape more likely to cause tendon compression, bony abnormalities, occupational/ environmental- anything that involves repetitive overhead manoeuvres

Question 26

RC tendinopathy presentation- general

Answer 26

anterior shoulder/subacromial pain, painful arc, painful loss of shoulder function particularly on overhead activities

Question 27

RC tendinopathy presentation- tendinitis

Answer 27

younger patient (<35 years), often have h/o overuse, strong and painful isometric ER and Abd, no loss of AROM/PROM, positive impingement test

Question 28

RC tendinopathy presentation-tendinosis and tears

Answer 28

tendinosis- middle aged patient + h/o more activity than usual and loss of A/PROM and weak and painful isometric ER and abd
tears- >40 years, weak and painless isometric tests of ER and abd, atrophy of RC and deltoid muscle

Question 29

RC tendinopathy- principles of treatment

Answer 29

acute management- pain releif (NSAIDs/ ice), improve strength and tissue capacity- exercise in 1 direction at a time, isometric>isotonic (less irritability), start slow, don’t exercise at EOR, add other movements
maintain muscle strength of all shoulders

Question 30

Observations of A/PROM

Answer 30

PROM should be full, AROM will be painful/ isometric and special test= problems

Question 31

RC treatment- tendon tear

Answer 31

dependent on size and location of tear, tears <3cm managed conservatively, surgery indicated for massive tears >3cms and those were conservative treatment is ineffective

Question 32

what is GH instability

Answer 32

the patient is unable to control or stabilize 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

Question 33

instability presentation- primary

Answer 33

pain around ant and lat shoulder, limited AROM, RHS rhythm, positive apprehension test, neural/vascular changes, wasting of deltoid/ RC

Question 34

instability presentation- secondary (atraumatic)

Answer 34

full or excessive ROM, pain at EOR, clunking, sensation of coming out, altered sensation on overhead movements, loose/empty end feel, positive stress test

Question 35

instability management- surgical

Answer 35

bankhart reconstruction- reattachment of antero-inferior labrum to glenoid margin, anterior inferior capsular shift- tighten anterior capsule and decrease available capsular volume

Question 36

instability management- conservative

Answer 36

neuromuscular retraining, stretching/ mobs tight capsule/ rotator cuff, postural re-ed