1
Q
What structures of the shoulder are affected in adhesive capsulitis?
A
Contractures of:
- Anterioinferior capsule
- Rotator Interval (space between supraspinatus and subscapularis tendons)
- Coracohumeral ligament
2
Q
What are the 2 types of adhesive capsulitis?
A
- Idiopathic/ primary
- Secondary/ Result of trauma
3
Q
In what gender is adhesive capsulitis more frequent?
A
- Female.
4
Q
At what age does adhesive capsulitis typically onset?
A
Between 40 - 60 yo.
5
Q
What health condition can lead to adhesive capsulitis?
A
- Diabetes
6
Q
What are the 4 stages of adhesive capsulitis?
A
1: Acute
2: Freezing
3: Frozen
4: Thawing
7
Q
How long does adhesive capsulitis typically take to run its course?
A
1 - 3 years.
8
Q
What pathology is associated with the acute stage of adhesive capsulitis?
A
Acute synovitis.
9
Q
What time frame does adhesive capsulitis typically occur over?
A
0 - 3 months.
10
Q
How are AROM and PROM affected in the acute stage of adhesive capsulitis?
A
- Pain on AROM (patient reluctant to move)
- PROM has empty endfeel
11
Q
If a patient is put under anesthesia in the acute stage of AC, how is the patient’s ROM affected?
A
It is normal.
12
Q
What pathology is associated with the freezing stage of AC?
A
Hypertrophic hypervascular synovitis; proliferation of scar tissue.
13
Q
Over what time frame does the freezing stage of AC typically occur?
A
Between 3 - 9 months.
14
Q
How are AROM and PROM affected during the freezing stage of AC?
A
Pain on AROM and empty endfeel PROM.
15
Q
How is ROM affected overall in the freezing stage?
A
- ROM severely limited
16
Q
What are the freezing and acute stages of AC referred to as together, and what do they determine?
A
They make up the inflammatory stage of AC, and determine the overall duration of the condition.
17
Q
What pathology is associated with the frozen stage of adhesive capsulitis?
A
- Dense mature scar tissue
- Decreased capsular volume (reduced redundant fold in capsule)
Contractures of: - Subscapularis
- Subacromial bursa
- Coracohumeral ligament
- Sarcomeres are lost
18
Q
How are AROM and PROM affected during the frozen stage of AC?
A
- No pain in either AROM or PROM, and a firm endfeel, but range is extremely limited.
19
Q
What is the time frame of the frozen stage of adhesive capsulitis typically?
A
- 5 - 9 months
20
Q
What pathology is associated with the thawing stage of AC?
A
- Restoration of capsular volume
21
Q
How are AROM and PROM affected by the thawing stage of AC?
A
- No pain on AROM or PROM, and range gradually improves.
22
Q
What is the time frame of the thawing stage of AC?
A
15 - 24 months.
23
Q
What is a capsular pattern?
A
- Specific type of limitation in joint movement
- ER most limited
- Abduction moderately limited
- IR least limited
24
Q
What joint’s kinematics will be altered by Adhesive Capsulitis?
A
- Glenohumeral.
25
What is the goal of treatment during the acute phase of AC?
- Interrupt pain and inflammation
| - Promote relaxation
26
How can the therapist educate the patient during the acute phase of AC?
- Pathogenesis
- Posture
- Activity modification
27
How are modalities used in the acute phase of AC?
- Controls pain, inflammation
| - Promotes relaxation
28
What type of exercising and manual therapy may be performed in the acute stage?
- Early closed chain (wall slides)
- AAROM (pain free)
- Aquatic exercise
- Conservative ROM
- Pendulum exercise
- Grade 1 and 2 mobs
29
What is the goal of treatment in the freezing stage of AC?
- Minimize pain, inflammation, adhesions, ROM restriction
30
How can the therapist educate the patient during stages 2 - 4?
- Posture
| - Necessity of HEP
31
How may modalities be used in the freezing stage of AC?
- Decrease pain
- Decrease inflammaiton
- Improve tissue extensibility
32
What exercises and manual therapy should be performed in the freezing stage of AC?
- Scapular training
- Specific rotator cuff strengthening
- AROM
- PROM
- Grade II and III mobilizations
33
What is the goal of treatment in the frozen and thawing stages of AC?
- Increase ROM
34
How may modalities be used in the frozen and thawing stages of AC?
- Promote relaxation
- Improve tissue extensibility
- Reduce treatment discomfort
35
What exercises and manual therapies should be used in the frozen and thawing stages of AC?
- More specific scapular training
- Reestablish force couples
- Continued rotator cuff strengthening
- AROM that reestablishes scapular and GH mechanics
- Aggresive stretching (PNF, STM, Low load prolonged stretch)
- Grades III and IV.
36
What are intrinsic or primary causes of rotator cuff tears?
- Subacromial space issues such as:
Hooked acromion or rough undersurface
Degenerative changes in AC/ subscapularis
Decreased vascularity
37
What are extrinsic/ secondary causes of rotator cuff tears?
```
- Strength/ Environmental
G-H force couple dyskinesia
S-T force couple dyskinesia
Posture
Excessive overhead use of arm
Posterior capsule shortening
```
38
In what decades does the incidence of partial RC tears peak?
5th and 6th decades.
39
How many over the age of 60 have evidence of a full thickness RC tear?
5 - 40 %.
40
What type of RC tear is prevalent in 25 - 40 year olds?
- Partial thickness
41
What are 3 examples of diagnostic imaging results that confirm a tear of the RC?
- Calcific deposits in subacromial space on plain film'
- Absent axillary fold with contrast medium in plain film or seen in MRI
- Ultrasound showing an absence of tendon
42
What forces make up the deltoid force couple of the rotator cuff?
- Deltoid elevates the arm, and superiorly translates the humeral head
- RC off sets deltoid with inferior and medial forces (esp. infraspinatus, teres minor and subscap), and limit anterior and posterior translation of the humeral head .
43
What forces make up the scapular force couple?
- Upper, middle, and lower trapezius, and the serratus anterior work in concert to rotate the scapula.
44
What scapular forces are required to maximize the subacromial space?
- Upward rotation
- Posterior tilt
- External rotation
45
How does scapular position affect the force production capabilities of the RC muscles?
By changing the length-tension relationships.
46
How can RC impingement be caused by a lack of scapular rotation?
Humerus translates superiorly into acromion.
47
How can RC impingement be caused by a failure of scapular adduction?
- The head of the humerus translates anteriorly.
48
Describe neer stage 1 rotator cuff tears.
- Edema and hemmorage
- Minimal weakness
- Excessive overhead use
- Traumatic change, etc....
49
What age group is usually affected by stage 1 RC tears?
- < 25 y/o
50
Describe neer stage 2 RC tears.
- Fibrosis and tendonitis of cuff and bursa following repeated mechanical inflammation.
- chronic changes due to repeated trauma
51
What age ranges are usually affected by neer stage 2 RC tears?
25 - 40 y/o
52
Describe neer stage 3 RC tears.
- Bone spurs
- Incomplete and complete tears of cuff and biceps tendon
- Degeneration of remaining tendons
- Degeneration of skeletal structure
- OA of joint
53
What age ranges are typically affected by neer stage 3 RC tears?
40 < y/o
54
What is PT treatment protocol for an acute RC tear?
- Ice
- Meds
- Rest
- Correct joint mechanics
- Stabilize scap
- Strengthen RC
- Correct posture/ instability
55
How long should conservative treatment of RC tears be provided before surgery is considered?
- At least 6 months
56
What type of RC problems may require surgery?
- Complete RC tears
- Impingement (acromioplasty/ subacromial decompression)
- Capsular repair for instability
57
What is the procedure for post-op RC PT management?
- Gentle PROM/ AROM
- Modalities
- Light UE closed chain ex
- Stabilizaiton ex
58
What nerves are affected first in thoracic outlet syndrome?
- Sensory before motor
59
What is the characteristic symptom of thoracic outlet syndrome?
- Poorly localized aching pain.
60
What 3 pathologies must be ruled out when testing for thoracic outlet?
- CTS
- Radiculopathy
- Distal nerve compression
61
What 2 postures provoke symptoms of thoracic outlet?
- Forward head
| - Protracted shoulders
62
What bony structures contribute to the incidence of thoracic outlet?
- Cervical rib
| - C7 transverse process
63
What nerve distribution is disproportionately affected by thoracic outlet?
- Ulnar nerve
64
What muscles are involved in thoracic outlet?
Anterior and middle scalenes.
65
What can cause impingement by the scalenes?
- Forward head posture
- Scalene hypertrophy/ tightness
- Surgical positions
66
What type of thoracic outlet is aggravated by overhead tasks and some cervical positions?
Scalene groove.
67
What methods are used to treat thoracic outlet due to the scalene groove?
- Soft tissue release
| - Postural correction
68
How are an elevation in the ribs related to thoracic outlet syndrome?
Neurovascular bundle can become compressed between the clavicle and 1st rib.
69
What posture causes TO between the clavicle and 1st rib?
- Depressed, retracted shoulders
| - Carrying backpacks, and other heavy loads
70
What test can be performed to determine TO at the clavicle and 1st rib?
Military posture will lead to increased pulse.
71
What muscle is related to compressing the neurovascular bundle against the ribs causing TO?
Pec minor.
72
What provokes TO symptoms when the bundle is compressed between the ribs and pec minor?
- Overhead activity.
73
What is the treatment for TO due to the clavicle and first rib?
Strengthen scap elevators.
74
What is the treatment for TO due to pec minor and the rib cage?
- Strengthen scap stabilizers
| - Stretch pecs.
75
What 4 elements contribute to glenohumeral joint stability?
- Articular geometry
- Static capsuloligamentous complex
- Dynamic muscular stabilizers
- NM control
76
What are the 2 more common abnormal GH motions, and what muscle causes these?
- Excessive anterior translation durin glateral rotation and abduction
- Excessive anterior translation during medial rotation
- Due to deltoid muscle
77
What is the 4 step continuum of shoulder instability?
- Normal
- Lax/ hypermobile (joint congruent, but unloaded)
- Subluxed (partially congruent)
- Dislocated (no congruence)
78
How does the RC contribute to GH stability?
- Passive muscle tension
- Compression from contraction
- Motion blockage from contracted muscles
79
How does the motion in the shoulder contribute to GH stability?
Tightening of the joint capsule due to motion.
80
What 2 joints contribute to centering the humerus on the glenoid?
- GH
| - ST
81
What causes most acute GH dislocations?
Trauma.
- Bankart lesion
- Hill-sachs deformity
82
What amount of Bankart injuries are successfully rehabilitated without surgery?
>=20%
83
What is a bankart lesion?
Avulsion of anterior, inferior GH ligament, and anterior labrum.
(soft tissue injury)
84
What is a hill-sachs deformity?
- Humeral head crushes into glenoid.
85
What causes chronic GH dislocation?
- Due to instability
| - Instability --> Subluxation --> Dislocaiton
86
What is the success rate of GH dislocation rehabilitation without surgery?
>80 %
87
What does AMBRI mean?
- Atraumatic
- Multidirectional
- Bilateral
- Requiring Rehabilitation
- Inferior Capsular Shift (rare)
88
How are acute and chronic GH dislocation related?
- Traumatic generally linked to future chronic dislocation
89
What are 4 typically methods of presentation of GH dislocation?
- Positive apprehension sign with anterior tenderness
- RC weakness (due to tear)
- Deltoid weakness/ lateral shoulder sensory loss if axillary nerve is damaged
- UE in ER with anterior prominence of humeral head (acute)
90
What is conservative treatment for a GH dislocation?
- Improve dynamic stability/ proprioception of GH joint
- Immobilize for up to 3 weeks (IR or ER)
- Avoid forceful ER
- No PROM/ stretching
- Focus on neuromuscular coordination/ re-education
91
What are surgical interventions for GH dislocation?
- Anterior capsular shift
| - Anterior capsulolabral reconstruction if bankart present
92
How do patients <20 y/o typically respond to treatment for GH dislocation?
- High rate of recurrence
93
How should patients >40y/o be monitored during treatment?
- Minimize immobilization
| - If no change after 2 weeks, check for RC tear.
94
What are 2 common mechanisms of AC injury?
- FOOSH driving humerus into acromion
| - Direct blow to lateral shoulder
95
What 3 tests may be used to rule in AC joint injury?
- Cross-over sign
- Active compression
- Resisted extension test
96
How can an AC joint injury be ruled out?
- Negative cross-over sign
| - No tenderness
97
Describe 1st, 2nd, and 3rd degree AC ligament disruptions.
1: No instability
2: A-P instability
3: Gross instability with distal clavicle riding high
98
What muscles can be trained to stabilize the AC joint?
None. No muscles cross the AC joint.
99
What surgical maneuver is performed with extreme degradation of the AC joint?
- Portion of clavicle removed, and muscles hold arm on body.
100
How is a 1st degree AC joint sprain treated?
- Treat pain
- Joint protection
- Progressive return to activity
101
How is a 2nd degree AC joint sprain treated?
- Sling
- Pain control
- Progress from passive to active exercise as tolerated (2 - 3 weeks)
102
How is a 3rd degree AC joint sprain treated?
- Longer immobilization
- Pain control
- Progress from passive to active exercise
103
What is the progression of exercise for an AC joint injury?
- Stregthening
- Dynamic strengthening
- Sport/occupation specific ex
104
What position should be avoided when performing exercises for AC rehabilitation?
- Supine due to scapula being trapped, and limited causing greater clavicle movement
105
What are 2 common mechanisms of SC joint injury?
- Blunt force to sternum or clavicle
| - Lateral compression from clavicle
106
In what direction does the SC joint usually dislocate?
- Anterior/ inferior
107
What problems can arise from a posterior SC joint dislocation?
- NV compromise
| - Breathing/ swallowing problems
108
What percentage of shoulder injuries occur at the SC joint?
3 %.
109
What are 3 common mechanisms of labral tears?
- FOOSH
- Dislocation
- Strong bicep contraction
110
What is a stable labral tear?
- Pain without locking or clicking
111
What is an unstable labral tear?
- Pain with locking or clicking
112
Which joint injury does a labral tear produce similar symptoms to?
- Similar to AC joint.
113
What are the 4 types of SLAP lesions, and which is most common?
- Rough edge (cracks and splits along central edge)
- Labrum torn off glenoid (most common)
- Bucket handle
- Tear including bicep tendon
114
What can PTs do to treat SLAP lesions?
- Rebalance muscles
- Correct dyskinesis
- Improve mobility
- But, cannot heal labrum
115
What is the 3 step process to stable labral tear retraining?
- NSAIDs/ cortisone injection
- Scapular stabilization/ RTC retraining
- Strengthen up to 90 %
116
What type of treatment do unstable labral tears usually require?
- Arthroscopic debridement and stabilization of unstable tears
- Conservative treatment is rarely sucessful
117
What are the 3 categories of LH biceps pathology?
- Inflammatory/ degenerative
- Instability
- SLAP lesions/ biceps tendon anchor abnormalities
118
What causes inflammatory/ degenerative pathology in the LH of the biceps?
- Repetitive overhead motion causes impingement at coracoacromial arch
- Tight posterior capsule
119
What type of injury does biceps tendon instability typically occur in concert with?
- RC injury
120
What are 3 common causes of SLAP lesions/ biceps tendon anchor abnormalities?
- Shearing from compression at superior glenoid rum
- traction from eccentric contraction of LHB
- Peel back from twisting of LHB with abduction and max ER.
121
What is typical conservative treatment for LHB injury?
- Pain management, PROM
- Progress to AROM/ strengthening
- RC training/ dynamic stability
122
Why is conservative treatment for LHB injury often unsuccessful?
Involvement of RC.
123
What are 4 surgical treatments for LHB treatment?
- Decompression
- Tenotomy
- Tenodesis
- SLAP repair
124
What are 4 common causes of subacromial bursitis?
- Trauma
- Poor GH mechanics
- Deconditioning
- Inflammation due to RC impingement
125
In what populations is subacromial bursitis more common?
Middle-aged to older patients.
126
What are the characteristic symptoms of subacromial bursitis?
- Acute onset of sever pain; painful arc
| - Rotation not usually limited
127
What is the normal treatment for subacromial bursitis?
- Rest
- Ice
- Gentle, pain-free AROM
- Improve GH and ST control/ conditioning
128
What is subacromial bursitis a precursor to?
Rotator cuff problems
129
When is joint arthroplasty indicated?
- Conservative management fails
| - No other options are available to restore relatively pain free joint function
130
What are 3 types of pathologies that indicate joint arthroplasty?
- Destructive arthidities (OA, RA, Ankylosing Spondylosis, Marfan's, Lyme
- Trauma/ fracture
- Avascular necrosis
131
What is a shoulder surface replacement?
- surface of humerus replaced.
132
What is a unipolar hemiarthroplasty?
- Half of humeral head replaced
133
What is a bipolar hemiarthroplasty?
- Head moves inside of a shell which articulates with the glenoid
134
What is a total shoulder replacement?
Glenoid and humerus replaced.
135
What does it mean for a total shoulder replacement to be constrained?
Small humeral head in deep glenoid.
More stability, less mobility.
136
What is a semiconstrained total shoulder replacement?
- Concave humerus on convex glenoid "ball"
137
What has better outcomes: TSR due to OA, RA, or TC?
OA > RA and RC
138
How is a completely displaced humeral fracture treated?
- Pins
- Wires
- Screws
- Plates
139
What damage is there is a completely displaced humeral fracture?
- Soft tissue damage
| - AVN
140
How is an incomplete, non-displaced humeral fracture treated?
- With a sling
Musculoskeletal I
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