Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
43 Cards in this Set
- Front
- Back
Progression of Supraspinatus RC Tear
|
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 |
|
Acute RC Full Thickness Tear - Cause
|
FOOSH or trying to break a fall
|
|
Acute RC Full Thickness Tear - Signs & Symptoms
|
• 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 |
|
RC Pathology Continuum
|
• 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 |
|
Clinical Presentation of RC Pathology
|
• 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 |
|
Function of RC in Baseball Pitching
|
• 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 |
|
Common Site of RC Degeneration
|
• deep surface of the anterior insertion of the supraspinatus near the LHB
(degenerative lesions only?) |
|
Explanation for Problematic Healing
|
• due to compromised vascularity, the large loads and the large deformations that the healing tissue must
endure |
|
Zipper Phenomenon
|
• 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 |
|
Clinical Presentation of Chronic Degenerative RC Tears
|
• > 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 |
|
Stiff Shoulder - Causes
|
• 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 |
|
Posterior Contracture (Thickening) - Causes
|
• secondary to degenerative change in the supraspinatus tendon
• eccentric overload of the posterior capsule in the throwing arm |
|
Posterior Contracture (Thickening) - Signs & Symptoms
|
• 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 |
|
Anterior Contracture (Adhesion) - Clinical Presentation
(i.e., anterior-superior) |
• 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 |
|
Anterior Contracture (Adhesion) - Signs & Symptoms
(i.e., anterior-superior) |
• 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 |
|
Anterior Contracture (Thickening) - Causes
|
• over tightened shoulder reconstructions or degenerative OA
|
|
Anterior Contracture (Thickening) - Signs & Symptoms
|
• excessive posterior glide of the humeral head
• limitation of abduction, ER, extension & horizontal extension |
|
RC Pathologies - Treatment
|
• 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 |
|
Plyometrics - Benefits
|
• 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 |
|
Plyometrics - Guidelines
|
• LE plyometrics can be done early in the rehab process
• UE plyometrics should be initiated in the later rehab stages |
|
Three Shoulder Clinical Syndromes
|
• painful
• unstable • hypomobile |
|
Two Most Common Tendons for RC Tears
|
• supraspinatus
• long head biceps |
|
Tendinosis
|
• progressive & degenerative without inflammation
|
|
Tendonitis
|
• acute inflammatory process
• common in young people • focal event |
|
Tendinopathy
|
• combo of pain and dysfunction in tendons
• no specific diagnosis • multifactorial problem |
|
5 Main Reasons for RC Pathology
|
• pectoralis muscle length
• scapular muscle performance • thoracic spine posture/mobility • GH capsule length/extensibility • RC muscle performance |
|
Two Most Common Locations (anatomical) for Impingement
|
• subacromial impingement
• in the RC itself = ‘internal impingement’ (RC tendons on articular surface/posterior glenoid rim) |
|
Internal Impingement - What is it
|
• impingement IN the cuff itself
• underneath side of tendons impinges on posterior glenoid rim • higher percentage of pathology starts here |
|
Age Related Tendon Changes
|
• 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’ |
|
Effect of Neo-Neuralization on Tendon
|
• reduces pain tolerance
|
|
Two Changes that Occur in Areas of Degeneration
|
• neo-neuralization
• fibrovascularization |
|
Pathophysiology of Tendinopathies
|
• 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) |
|
Most Common Point of Tendon for Degenerative Change
|
• site where tendon inserts into head of humerus
articular surface of the tendon |
|
Position Eliciting Most Impingement
|
abduction and external rotation
|
|
Tests to Rule In RC Tendinopathy
|
Hawkins Kennedy
Painful Arc Weak ER * 2/3 tests will rule in RC tendinopathy |
|
Tests with High Sensitivity to Rule Out RC Tendinopathy
|
Neer Test
Hawkins Kennedy Empty Can * Rule out RC if 3/3 tests are negative |
|
Tests with High Specificity to Rule In RC Tendinopathy
|
Drop Arm
Lift Off |
|
Drop Arm Test - What Makes it Positive?
|
• inability to abduct arm > 90° without trick movements
• painless weakness of resisted isometric abduction < 30° |
|
Effect of Capsular Pattern of Restriction on Alignment & Biomechanics
|
• 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 |
|
How Can You Tell the Difference Between Anterior and Posterior Contractures?
|
anterior contracture:
- night pain - escalates faster than posterior - loss of humeral extension & ER |
|
Effect of Ligamentous Structures on Anterior Contractures
|
superior glenohumeral ligament and coracohumeral ligament may contract and fibrose, drawing humeral head superiorly and anteriorly
|
|
Clinical Presentation of Adhesive Capsulitis
|
• females > males
• 40 - 50 years • sudden onset • relentless pain • hypothyroidism • diabetes |
|
Stiff Shoulder - Treatment
|
• relative rest
• cryotherapy • modalities • medications |