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MSK III > Week 8 Introduction to Upper Limb Disorders > Flashcards

Week 8 Introduction to Upper Limb Disorders Flashcards

(52 cards)

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1
Q

What is the epidemiology of shoulder pain?

A
  1. 3rd most common MSK complaint (after Lx and Cx pain)
  2. Affect 7-36% of gen pop
  3. 8-13% of athletic pop
  4. 70% will have shoulder pain in their lifetime
  5. Prevalence increases with age - peaks and 60 - decreases
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2
Q

What is the prognosis of shoulder pain?

A

44% of shoulder pain resolves within 3 months; 50% within 6 months

40% have pain after 1 year

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3
Q

What factors determine poor outcome for shoulder pain?

A
  1. Long duration of symptoms
  2. High pain intensity
  3. High disability
  4. Middle aged
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4
Q

What is the epidemiology of elbow pain?

A
  1. 40% of people will have lateral epicondylitis at some point
  2. 3% prevalance in gen pop
  3. <1% prevalence for MEDIAL EPICONDYLITIS
  4. 80% recover in 1-3 yrs
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5
Q

At what ranges do the middle and inferior GH ligaments restrict GH movements and with which movements?

A

Middle GH ligament = anterior restraint at 45-60º ABD + limits extremes of ER

Inferior GH ligament = anterior band limits anterior translation in 90º ABD+ER

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6
Q

Which GH ligament does anterior shoulder instability most commonly involve?

A

Anterior portion of inferior ligament

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7
Q

Describe the contributions to GH stability as the arm moves from the side to the end range

A

In the early range, NIP (the suction effect) is largest
In the mid range - the RC works the hardest
In the late ranges - thats when the GH ligs come into play (although the RC still working)

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8
Q

Describe the deltoid and rotator cuff force couple

A
  1. During abduction the deltoid pulls SUPERIORLY
  2. This superior pull is balanced by the RC’s MEDIAL AND DOWNWARD pull on the humerus
  3. The supraspinatus ROLLS the humerus during abd + compression of humerus with medial force
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9
Q

Muscle forces at the shoulder are greatest at 60, 90, or 120º?

A

90º - highest compressive load and highest ABD mm force

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10
Q

Describe scapulohumeral rhythm

A

First 30º of abd occurs with little scapular motion

Then 2:1 humerus:scapular motion

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11
Q

What happens to the scapula during arm elevation?

A

The scapula ER+posteriorly tilts

ER = lateral border moving posteriorly

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12
Q

What is the clinical relevance of scaption

A
  1. Less impingement
  2. Less anterior capsule strain
  3. More functional position
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13
Q

What is the normal carrying angle?

A

10-15º on average and greater in females (5-10 in men and > 10-15 in women?)

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14
Q

To perform ADLS, what ROM do you need at the elbow?

A

30-130º

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15
Q

Describe the roll/glide direction for elbow flexion/extension and how it applies to manual therapy

A

Flexion - ulna rolls/glides anteriorly > PA glides

Extension - ulna rolls/glides posteriorly > AP glides

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16
Q

To perform ADLs, what ROM in supination/pronation do you need?

A

50º sup/pron

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17
Q

Describe RC tendinopathy/SAI

A

A clinical condition that includes tendinopathy of the RC +/- entrapment of subacromial structures during shoulder movement

SAI = encroachment of subacromial tissues d/t narrowing of the subacromial space

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18
Q

What is the etiology of RC pathology? 1º vs 2º

A 
1º = trauma, overuse
2º = encroachment (acromion type), scapular dyskinesis, post cuff weakness, post capsule tightness

3 factors that could play in SAI:

  1. Anatomy (acromion type)
  2. Scapular movement
  3. Anterior instability
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19
Q

What are physical exam findings in RC pathology?

A 
TTP over the area
Painful arc (70-120º)
IMT pxful
Poor scapulohumeral rhythm
\+ Hawkins, Allingham test
Atrophy possible if chronic
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20
Q

Imaging options for RC pathology?

A

MRI
US
XR - calcification of supapsin

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21
Q

Management of RC pathology?

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A

Surgery usually not recommended

  • address symptoms, NSAIDs, EPAs, rest
  • address the impairments (strengthen mm? stretch capsule? better scapular movement? technique? workload?)
22
Q

Prognosis of RC pathology?

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A

50% of people will recover from RC pathology in 6 months and 66% in 1.5-3 yrs WITHOUT surgery

POOR PROGNOSTiC FACTOS:

  • larger tears
  • poorer function
  • long duration of pain
23
Q

What is the evidence for exercise in RC pathology?

Study These Flashcards
A
  • should be first line of care for SAI pain

- literature supports exercise as Rx for RC pathology + SAI

24
Q

What is the evidence for manual therapy in shoulder pain?

Study These Flashcards
A
  • may assist when ADDED to exercise

- may help with pain in SAI but effects on function unclear

25
Describe adhesive capsulitis
An inflammatory condition of the shoulder joint - results in thickening+fibrosis of the joint capsule - esp the anterior capusoligament complex and the inferior GH ligament
26
What is the etiology of adhesive capsulitis?
- unclear cause/idiopathic - 40-65 yrs, F>M - diabetes+thyroid predispose - common post immobilisation, trauma
27
Prognosis of adhesive capsulitis?
``` 4 stages: 1st stage - 3 months - painful 2nd stage - 3-9 months 3rd stage - 9-15 months 4th stage - upto 2 yrs ``` FREEZING - gradual onset GH px, sharp pain in terminal ROM, px at night FROZEN - subsiding pain, loss of ROM in capsular pattern, px in terminal ROM THAWING - spontaneous improvement in ROM
28
Physical exam findings in AC?
- sharp pain with AROM/PROM - capsular pattern of ROM loss - reduced PAM
29
How to make the diagnosis of AC?
- pt 40-65 yrs - gradual onset - progressive worsening - pain + stiffness limit ADLs - PROM restricted globally - especially ER - GH ER/IR more limited with ADB from 45º to 90º - restricted PAMs
30
Management of AC?
``` Stage 1+2 - address symptoms Stage 3+4 - treat stiffness* - mobs - stretches - strengthening ``` NON CONSERVATIVE: - hydrodialation - MUA+cortisone+analgesic+PT? - cortisone injection *evidence generally is weak for manual therapy but may help improve ROM/function
31
Prognosis of AC
- can last upto 2 yrs - slower recovery if diabetic - mobility losses recorded at 4 yr + 7yrs but no effects on function
32
Define GH instability
Excessive translation of the humeral head in the glenoid fossa during shoulder motion; pathology ranges from subluxation to complete dislocation
33
What are the passive and active stabilisers of the GHJ?
Passive: - NIP - ligaments - capsule/labrum complex Active: - scapular stabilisers - RC mm's - biceps tendon
34
What are the different causes of GH instability?
1. Traumatic - indirect - provocative position - direct - blow to humerus 2. Repetitive microtrauma - eg. baseball - repetitive extremes of overhead movement in ER; strains the capsule; attenuates the antero-inferior passive restraints 3. Multidirectional GH instability - developmental dysplasia - generalized laxity - labral insufficiency - excessive capsular compliance - ABSENCE OF TRAUMA
35
Descirbe TUBS and AMBRI
TUBS = torn loose - traumatic - unidirectional - bankart lesion - surgery AMBRI - born loose - atraumatic - multidirectional - bilateral - rehab - inferior capsule procedure
36
Physical exam findings for GH instability? | Imaging findings?
Dislocation: - deformity - ++ pain - mm spasm Instability - + apprehension sign Imaging: XR to check for bony injury after dislocation MRI to check for labrum/ligamentous integrity
37
Management
Dislocation: - relocation (A+E procedure) - immob in ER - reduces chance of recurrence - gentle ROM - strengthening - motor control retraining - passive stretching (alt - functional exercise
38
Discuss the exercise approach for strengthenign after dislocation
RC strengthening - esp those mm's which oppose the direction of instability Scap stabilisers Progress to x's in less stable range Proprioceptive x's
39
What is the prognosis for shoulder dislocaiton?
- 5-95% risk of recurrence - higher risk in younger patients and increased risk with continuing sport participation - less likely to recur if good management after first episode - less likely with increasing age
40
Describe the Hill Sachs lesion
With anterior dislocation - the posterior humerus can ram into the glenoid rim, thereby damaging the humeral head - this is known as the Hill Sach's lesion makes dislocations more likely involved in 7-34% of dislocation; higher rate in recurrent dislocators
41
Describe the Bankart lesion
With anterior dilocation, this can damage the anteroinferior glenoid labrum (bony Bankart lesion is when it chips away the bone along with the labrum) - therefore makes the GH joint less stable since labrum is attenuated Occurs 60-80% of the time - so it's lucky if you DONT have a Bankart lesion!
42
Management for recurrent instability
- trial of rehab - modify activity - brace - surgical stabilisation often needed
43
Describe the AC joint ligaments
- acromioclavicular ligaments - coracoclavicular ligaments (trapezoind + conoid portions) - coracoacromial ligaments
44
Describe the 6 types of AC joint injury
Type 1: AC joint capsule strain - px with adduction+localized tenderness Type 2: Complete tear of AC ligaments+strain of CC ligaments; step deformity Type 3 and 5 - Complete tear of CC ligaments (conoid+trapezoid); marked step deformity; type 5 has more displacement and greater ST injury than 3 Types 4-6 - complete rupture of all ligaments - rarer than types 1-3
45
Management of AC joint injuries
Ice - 2-3 days for Type 1; upto 6 wks for Type 2,3 Immobs with sling Isometric strengthening once pain permits RTS ok when pain free and full ROM Taping SURGERY for Type 4-6 and for Type 3 if no response to conservative rx
46
Other causes of AC joint injury
1. Repetitive microtrauma to AC joint or after Type 2,3 injury which damages menicus within the AC joint 2. Osteolysis of clavicle 3. AC joint OA (d/t recurrent injuries)
47
What are SLAP lesions?
Lesions of the labrum that extend from anterior to the biceps tendon to posterior to the tendon 4 types of SLAP lesions: 1. Intact labrum but has fraying/degeneration * 2. Detachment of superior labrum+tendon from the glenoid rim (MOST COMMON) 3. Superior labrum is displaced into the GHJ but the tendon and labral rim are intact 4. Tendon and superior labrum displaced into the joint *remember this is different to a Bankart lesion which occur anterioinferiorly in the labrum
48
Aetiology/MOI of SLAP lesions?
- most common way to injure labrum is excessive traction on labrum via the tendon (dropping and catching heavy object) - cocking phase and eccentric phase in throwing; excess overhead activity - 'peel-back' traction on labrum via the tendon during cocking phase
49
Clinical features of SLAP lesions
- pain in the shoulder with overhead or behind the back motions - popping/catching/grinding
50
Physical exam findings in SLAP lesions
TTP over anterior aspect of shoulder + O Briens test MRA with contrast
51
Management of SLAP lesions
- conservative unless structural damage with instable labrum and associated damage to RC or GH dislocation -
52
Prognosis of SLAP lesions
- with conservative rx - 50% RTS - strengthening to RC, scapula, stretching - avoid early tension on biceps tendon and slowly progress - if post op SLAP repair - no resisted biceps work for 8 weeks; no aggressive strengthening for 12 weeks

MSK III (4 decks)

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