PDII MSK UE

what are articular structures?

joint capsule, articular cartilage, synovium, snyovial fluid, intra-articular ligaments, juxta-articular bone

typical sx for articular structures

• poorly localized pain

• swelling/tenderness of joint

• instability

• crepitus

what is crepitus?

cracking/popping/grinding sound or sensation occurring when joints move

what are the causes of typical sx of articular structures?

normal physiology, arthritis, fractures, ligament/tendon issues, SC emphysema (history is super helpful!)

examples of extra-articular structures

periarticular ligaments, tendons, bursa, muscle, fascia, bone, nerve, overlying skin

ligaments

connect bone to bone

tendons

connect muscle to bone

cartilage

collagen matrix overlying bony surfaces

bursa

pouches of synovial fluid under tendons, muscles, bones, joints

what are typical sx of extra-articular structures?

• point tenderness

• worse with contraction of muscle/resisted motion

• strength may be affected

• limits active ROM (pt can NOT move the limb)

• passive ROM is intact (YOU can move the limb)

joint

• pain w/ active AND passive ROM

• swelling

• no radiation

muscle

• pain with active ROM (and sometimes passive)

• no swelling

• no radiation

tendon

• pain w active ROM (resistance) w/ no passive ROM

• no swelling

• no radiation

ligament

• pain with active ROM only w stress, not really pain w passive ROM

• acute swelling

• no radiation

nerve

• pain w active/passive ROM variable

• no swelling

• RADIATION

fibrous joint

no movement

bones separated by fibrous tissue or cartilage

example of fibrous joint

sutures of skull

cartilaginous joint

• joint is slightly movable

• bones separated by fibrocartilaginous discs

what is in the fibro cartilaginous discs?

nucleus pulpous cushioning bony movement

example of cartilaginous joints

vertebral bodies of spine

synovial joint

• joint is freely movable

• bones covered by articular cartilage

• bones separated by synovial cavity

• synovial membrane secretes synovial fluid lubricating joint movement

(ie shoulder/knee)

types of synovial joint

• spheroidal (ball and socket)

• hinge

• condylar

acute trauma

• inciting sudden incident

• possible deformity/swelling

examples of acute trauma

fracture, ligament/tendon tear, dislocation

chronic/overuse issues

• history with repetitive activity

• gradual onset

• worse with continued use

• minimal swelling

examples of chronic/overuse issues

tendinopathy, stress fracture, bursitis

order of MSK exam

1. inspection

2. palpation

3. ROM (active then passive)

4. strength testing (tendons/muscles to see how they work)

5. neuro/vascular exam

6. special tests

inflammatory changes

inspection: swelling or erythema

palpation: warmth or tenderness

why is ROM important?

• joint function/stability

• integrity of extra-articular structures

what is different with neuro and MSK passive ROM?

MSK passive to see the extent of joint mobility

manual muscle testing (MMT)

graded technique for objective measurement of perceived muscle strength based on pt’s ability to resistance to opposing force

grading of muscle strength

0 = no contraction

1 = visible muscle twitch

2 = weak contraction, no gravity

3 = weak contraction, gravity, no resistance

4 = weak contraction, some resistance

5 = full resistance

neuro-vascular testing

• assess spinothalamic and dorsal column pathways (light touch/vibration and pain: sharp/dull)

• circulation (distal pulses, capillary refill)

anterior shoulder landmarks

1. sternoclavicular joint

2. clavicle

3. acromioclavicular joint

4. acromion

5. coracoid process

6. greater tubercle

7. lesser tubercle

8. subdeltoid bursa

9. subacromial bursa

greater tubercle is important because?

that is where the biceps brachii long head inserts into

rotator cuff role

abduction, internal/external rotation

what rotator cuff muscles insert on greater tubercle?

• supraspinatus muscle

• infraspinatus muscle

• teres minor

what rotator cuff inserts on lesser tubercle?

subscapularis muscle (non-palpable)

supraspinatous movement

shoulder/arm abduction

infraspinatous (bigger) and teres minor movement

external rotation and stabilizer

subscapularis movement

internal rotation and stabilizer

to evaluate adduction has to what?

cross the midline

what strength testing of shoulder do you usually not check?

internal/external rotation strength

examples of things causing shoulder pain?

• rotator cuff issues (tears, tendonitis, impingement = tendonapathy)

• bursitis

• adhesive capsulitis

• shoulder dislocation

• cervical radiculopathy

RF of rotator cuff disorders

1. age (more common middle age-elderly)

2. repetitive motion (overhead activity)

3. smoking

4. obesity

5. trauma

6. DM

in rotator cuff issues, which muscle affected the most?

supraspinatus most (abduction), then infraspinatus

s/sx of rotator cuff issues

• shoulder pain

• weakness/limited ROM

to cause rotator cuff issues, tends to be one thing. T/F?

false, it’s usually multifactorial - degenerative, impingement, overload

d/dx for rotator cuff issues

• bursitis

• impingement

• cervical radiculopathy

• ACS

rotator cuff issue: inspection

atrophy

→ inc prominence of scapular spine, can occur within 2 weeks related to disuse (esp if torn completely)

rotator cuff issue findings

• Atrophy

• Tenderness @ muscle/insertion

• Limited ROM

• Weak strength with resisted testing

drop arm test

fully abduct past 90 degrees, then slowly lower arms until held at 90 degrees

deltoid muscle plays a role when?

when you raise your arm at 90 degrees and plus

before then = supraspinatus

if pt has issues with drop arm test, what are you thinking?

supraspinatus disorder or bicipital tendonitis

what is empty can test?

elevate arms to 90 degrees and internally rotate arms, have pt resist downward pressure on arms

empty can is associated with what?

most specific for supraspinatus disorder

infraspinatus test

elbows at sides and arms flexed to 90 degrees when supinated, apply pressure to wrist while pt pushes against (attempted external rotation)

infraspinatus test is associated with what?

infraspinatus or teres minor disorder

lift off

patient places arm behind back in internal rotation of shoulder and presses out against providers hand

lift of test is associated with?

subscapularis disorder

belly press

provider hand against patient abd, patient places palm against providers hand and presses in toward abod against resistance

belly press is associated with what?

subscapularis disorder

TOC of rotator cuff issues

pt

rotator cuff work-up

• xrays (not required) - can show rotator cuff injury based off of location of humeral head in relation to glenoid and acromion

• U/S: shows superficial tendon/muscle lesion, bursitis

• MRI: accurate for full-thickness tears, less reliable for partial thickness tears (most specific)

tendon tear MRI grading

full tear > grade 3 > grade 2 > grade 1

impingement syndrome

compression of structures around glenohumeral joint (rotator cuff tendons (supraspinatus) and subacromial bursa)

presentation of impingement syndrome looks similar to what?

rotator cuff tendinopathy

RF of impingement syndrome

• poor muscular dev

• repetitive overhead sports activity

• occupation with repetitive work at/above shoulder

impingement syndrome findings

• muscular atrophy

• ROM/strength affected

impingement syndrome special tests

• neer’s sign

• hawkins-kennedy

what is affected in impingement syndrome?

Abduction, flexion, external rotation (any movements that have to do with head of humerus bumping into acromion)

neer’s sign

arm pronated and internally rotated, provider lifts arm passively (forward flexion)

looking for pain/limited ROM

what is neer’s sign assoc with?=

• supraspinatus impingement

• sub-acromial bursitis

• rotator cuff tendonitis

=

hawkins-kennedy test

shoulder in forward flexion, elbow flexed and pronated, passively rotate arm internally

looking for discomfort

what is hawkins-kennedy test assoc with?

• supraspinatus impingement

• rotator cuff tendonitis

• (sub-acromial bursitis)

sub-acromial bursa

located between acromion and head of humerus (over supraspinatus tendon)

what movement of shoulder will compress shoulder bursa?

abductino and forward flexion

sub acromion bursa sits on top of what?

supraspinatus tendon

findings shoulder bursitis

• palpable

• painful/tender (pinpoint tenderness)

• limited flexion, abduction, rotation

RF for shoulder bursitis

• trauma

• prolonged pressure to area

• crystal-induced arthropathy (gout)

• overuse

• inflammatory arthritis

• infections

s/sx shoulder bursitis

pain worse with movements compressing bursa

possible swelling

d/dx of shoulder bursitis

• fracture

• AC pathology

• rotator cuff pathology

shoulder bursitis special test

• neer’s impingement

• hawkin’s kennedy test

work-up for bursitis

imaging is rarely used, can be used if conservative treatment (NSAID, ICE, PT) isn’t helping

can use ketorolac, meloxicam, toradol, naproxen, ibuprofen

AC cross over test

evaluates AC joint (arthritis and separation)

positive AC cross over test

pain with passive adduction

AC joint separation RF

• Male

• Sports

• Trauma (superior or lateral direct blow to shoulder with arm adducted)

  • Less common: fall on outstretched arm (driving humeral head into acromion)

s/sx of ac joint separation

shoulder pain

AC joint separation d/dx

• rotator curr pathology

• brachial plexus injury

• subluxation of glenohumeral joint

• fracture (rib/clavicle)

AC joint separation exam findings

• Prominent AC joint (sticking out)

• Tenderness over AC joint

• ROM affected d/t pain

• AC Cross over test: pain when compressing AC joint

• neur/vascular exam intact

evaluation of AC joint

• x-ray: evaluating bilateral AC joints for comparison

• if arm is internally rotated → higher sensitivity for detecting type III injuries

type III injury: acromioclavicular (AC) and coracoclavicular (CC) ligaments are completely torn → clavicle separating from the scapula and shifting upwards

Adhesive Capsulitis

inflammation of articular capsule (anterior fibrous capsule formed by tendon insertion of rotator cuff and glenohumeral joint capsule)

adhesive capsulitis ROM

limited ROM - passive and active

RF adhesive capsulitis

• immobilization (after surgery/injury)*

• female

• DM (w/o evidence of osteoarthritic changes)

• thyroid disease

s/sx of adhesive capsulitis

• generalized shoulder pain

• limited ROM

3 phases of adhesive capsulitis

1. initial painful phase: diffuse, severe/disabling pain, worse at night, ROM intact

2. intermediate phase: stiffness/dec ROM with dec amount of pain

3. recovery phase: return of ROM (5-24 m)

adhesive capsulitis exam

• nothing on inspection

• palpation: painful glenohumeral joint

• dec active/passive ROM on impacted side (only in intermediate phase)

(apley scratch test)

apley scratch test

• evaluate shoulder rotation, pain and limitations in ROM

• difficulty = rotator cuff disorder or adhesive capsulitis

work-up for adhesive capsulitis

x-rays not usually needed

MRI shows changes in soft tissue, rules out rotator cuff injuries

bicipital tendinitis

inflammation of long head of biceps tendon and tendon sheath