3 -UE Advanced Ortho Issues (copy)

Glenohumeral instability

• Cause: congenital jt laxity, microtrauma (repetitive activities, especially overhead), single traumatic injury (ex. MVA); can be unidirectional (ex. ant or post, or multidirectional)

• Characteristics: rotator cuffe tear, bankar and Hill Sachs lesions

How can glenohumeral instability be treated?

• Shoulder isometrics (abd, flex, ext, etc.) with increasing intensity

• Postural education and stretching to avoid rounded shoulders, etc.

• Shoulder strengthening (ext, flexion, abd, progress to overhead

• Closed chain exercise (wall circle, push-up progression, UE walkouts)

What are precautions and educational tips for glenohumeral instability?

• Avoid end range motions such as ER, ext, and hor abd

• Posture directly effects stability of GH joint and can lead to compromise

Biceps Tendon Pathology

• Rupture of tendon (can be chronic or acute)

• Can become inflamed from subacromial impingement

• Exacerbated by postural dysfunction

• Rx: activity mod, posture education and strengthening, modalities for pain and inflammation

• Special tests: Speeds, and Yergason’s

If a person has a rotator cuff tear, which is the most likely tendon to be torn?

Supraspinatus

What are some characteristics of rotator cuff tear?

• Types: Small < 1cm, Medium < 3cm, Large < 5 cm) - can also be full thickness or partial thickness

• It is very common for people to have asymptomatic tears of the rotator cuff

What special tests are used to test for rotator cuff tear?

Drop arm test, Supraspinatus test, Lift-off test

Phase 1 conservative treatment for rotator cuff pathology

Modalities to control pain and inflammation. Gentle PROM and AAROM. Pain-free isometrics for scapular and GH strengthening

Phase 2 conservative treatment for rotator cuff pathology

AROM in pain-free range with emphasis on ensuring correct arthrokinematics. Prone "I" "Y" and "T" AROM exercises. Low level strengthening with resistance bands and light weights. Closed kinetic chain kinetic activities

Phase 3 conservative treatment for rotator cuff pathology

Prone "I" "Y" and "T" exercises with light weights. Progressively challenging dynamic strengthening exercises. Progressive CKC exercise

Many people over age 60 have asymptomatic rotator cuff tears.

True

Primary Impingment

Impingement from mechanical compression of the rotator cuff tendons (primarily supraspinatus)as they pass under the coracoacromial ligament between the acromion and coracoid process

• Can also involve impingement of the subacromial bursa and long head of the biceps tendon

• Special tests - Hawkins-Kennedy and Neer Impingement

Secondary Impingement

Impingement that is related to glenohumeral instability which creates a reduced subacromial space.

Thoracic outlet syndrome

A term used to describe a group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels (arteries and veins) in the lower neck and upper chest area

• Named for the space between your lower neck and upper chest where this grouping of nerves and blood vessels is found

What special tests are used to test for thoracic outlet syndrome?

Adson, Allen and Roos Tests

What interventions are used in physical therapy to treat thoracic outlet syndrome?

• Mobilization of the first rib

• Stretching and soft tissue mobilization to tight musculature (scalenes, upper trapezius, pectoralis minor

• Postural education and strengthening of related muscles

What causes ligamentous instability int he elbow?

• Traumatic injury (elbow dislocation or FOOSH)

• Repetitive microtrauma from overhead throwing

What surgery is commonly used where a tendon from elsewhere in the body is used to replace the UCL (of the elbow)?

Tommy John

Cubital tunnel syndrome

Irritation of the ulnar nerve in the groove between the medial epicondyle of the humerus and the olecranon process

• Patients present with tenderness at the medial elbow, paresthesia in the fourth and fifth digits, pain with elbow flexion in the acute stage

• Patients often complain of waking at night with pain as the elbow is often flexed when sleeping(nerve compressed).

What type of interventions are used to treat cubital tunnel syndrome?

• Ulnar nerve gliding

• Activity modification to avoid compression of the medial elbow

• AROM of the elbow and forearm

• Progression to resisted motions

• Gripping exercises

• Cervical and shoulder/scapular ROM and strengthening as needed

Lateral epicondylagia/tendinopathy

Patients present with pain with gripping exercises and resisted wrist extension. Especially common in people who perform high rate of repetitive hand activities and athletic activities with excessive gripping and wrist extension (tennis)

Medial epicondylagia/tendinopathy

Patient present with point tenderness on the medial epicondyle, pain and weakness with wrist and finger flexion and weakened grip. Especially common in people who perform excessive overhead throwing, heavy weight lifting and occupations with constant vibratory force, repetitive forceful gripping/lifting.

What is used to treat lateral/medial epicondylagia?

• Modalities to control pain and inflammation

• Nerve gliding exercises

• Stretching and soft tissue mobilization of related muscles

• AROM progressing to pain-free strengthening

• Emphasis on eccentric strengthening exercises

• Assessment of shoulder girdle arthokinematics

• Postural education and assessment to ensure proper body mechanics with equipment

What special tests are used to diagnose medial/lateral epicondylagia?

Cozen's test (lateral epicondylitis), medial epicondylitis test, lateral epicondylitis test

Carpal Tunnel Syndrome

Compression of the median nerve as it passes between the carpal bones and the transverse carpal ligament

• Risk factors: females, high reps of hand/wrist, vibratory tools, obesity, RA, diabetes

• Presentation: pain, numbness and tingling along middle and index fingers and thumb, and atrophy of thenar mms

• Complain of waking up at night and dropping objects

What interventions are used to treat carpal tunnel syndrome?

• Activity modification to reduce aggravating activities

• Median nerve glides

• Pain-free AROM of the wrist and hand progressing to strengthening exercises

• Postural education and scapular strengthening

• Often occurs with cervical radiculopathy

De Quervain Tenosynovitis

Thickening of the abductor pollicis longus and extensor pollicis brevis tendon

• Presentation: increased pain with thumb movements and ulnar/radial deviation: often complains of pain with grasping object, wringing a washcloth and using a hammer

What interventions are used to test for De Quervains Tenosynovitis?

• Thumb spica splint

• Patient education for activity modification

• Pain-free wrist and thumb PROM with progression to AROM and then resistance exercises

• Possible use of ultrasound and KT tape

• Physician will often prescribe NSAIDs

• Often treated by OTs.

What test(s) are used to diagnose De Quervains Tenosynovitis?

Finkelstein

Bankart lesion

Avulsion of the capsule and glenoid labrum off the anterior rim

Hill Sachs Lesion

Impaction fracture of the posterolateral humeral head