Lecture Exam 1

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315 Terms

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Causes of Thoracic Outlet Syndrome

-Repetitive use of upper extremity in abducted and externally rotated position puts overhead athlete at risk for this

-Rotational torques around shoulder during throwing/pitching create repetitive stretching of axillary artery creating a tethering effect

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Differential Diagnoses for Thoracic Outlet Syndrome

-Humeral hypertrophy

-Pectoralis minor hypertrophy

-Subtle glenohumeral instability

-Herniated cervical disk

-Cervical nerve root impingement

-Brachial neuritis

-Carpal tunnel syndrome

-Cubital tunnel syndrome

-Vascular occlusive disease

-Malignant tumors about the head, neck and lungs

-Reflex sympathetic dystrophy

-Angina

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Thoracic Outlet

-The area where nerves comprising the brachial plexus, and vessels from the innominate artery leave the chest area

-Floor formed by upper border of first rib and roof by posterior inferior border of clavicle

-Subclavian artery and brachial plexus pass between the anterior scalene and middle scalene muscles

-Anterior scalene muscle originates from anterior tubercle of TPs of 3-6 cervical vertebra and insert on 1st rib at scalene tubercle

-Middle scalene originates from posterior tubercles of cervical vertebrae and insert on 1st rib behind the groove for the subclavian artery

-NV bundle progressess laterally under coracoid tip posterior to pec minor and anterior to the scapula and subscapularis muscle

-Subclavian artery and vein passes anterior to anterior scalene muscle as it exits thorax

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1st Thoracic Outlet Syndrome Anatomical Site

-The point at which the brachial plexus and subclavian artery are compressed as they pass over the first rib between the anterior and middle scalene muscles

-AKA Scalene/First rib syndromes

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2nd Thoracic Outlet Syndrome Anatomical Site

-Point at which axillary artery and brachial plexus are compressed between the clavicle and the first rib

-AKA Costoclavicular syndrome

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3rd Thoracic Outlet Syndrome Anatomical Site

-Point of compression between the pec minor muscle and the ribs

-AKA Pec Minor or Hyperabduction syndrome

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Thoracic Outlet Syndrome S/S

-Complaints of hands and fingers “falling asleep” (Most commonly the dominant arm)

-Heaviness and fatigability with activity

-Pain with activity that may be relieved during rest

-Symptoms may start distally and move proximal

-May have cyanosis or sensitivity to cold

-Night pain is common

-May see venous distension after activity (Want to rule out venous thrombosis)

Neurologic Symptoms

-Swelling in arm/hand

-Bluish discoloration

-Heaviness

-Pulsating lump over clavicle

-Deep, boring, toothache like pain in neck and shoulder

-Superficial vein distention in hand

Arterial or Venous Symptoms

-Paresthesia inside forearm/hand (C8-T1 dermatome)

-Difficulty with fine motor skills

-Cramps in forearm muscles

-Pain in arm/hand

-Numbness/Tingling in UE and/or neck

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Physical Examination for Thoracic Outlet Syndrom

-May have completely normal pulses with extremity at side

-Look at condition of skin

-Assess for discoloration

-Look for ulcerations

-Look for necrosis

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Adson’s Test: Scaleni Compression

-Patient seated with arms resting at side

-Patient asked to take a deep breath

-Elevate the chin and turn chin toward affected side

-Diminution or obliteration of radial pulse or change in blood pressure suggests TOS

-Compression of subclavian artery by anterior scalene

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Costoclavicular Syndrome Test

-Patient sitting/standing with arms at side

-Retract and depress scapula and take a deep breath

-Brings 1st rib under clavicle

-Diminution or obliteration of pulse considered positive

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Wright’s Test: Pec Minor Syndrome

-Patient seated with arm abducted and externally rotated above the plane of the shoulder

-Reproduction and loss of distal pulse should raise suspicions

-Elevation of shoulder into abduction while checking pulse

-Have athlete turn head to opposite direction

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Roos Test

-Patient seated with bilateral arms elevated

-Active finger flexion and extension

-Held for up to 5 minutes

-Symptom reproduction is a positive test

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Lindgren Test

To Test Left Side

-Rotate completely to right side

-Side bend to end range

-Assess for limited motion or bony end-feel

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Prognostic Factors for Thoracic Outlet Syndrome

Positive

-Good compliance in program

-Modification of behaviors

-Having a sedentary job

Negative

-Obesity

-Double crush syndrome

-Prior trauma

-Psychosocial factors

-Compensation claims

-Litigation

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Posture (TOS)

-Critical due to relationship between NV structures and the shoulder girdle

-Abnormalities result in muscles being maintained in shortened position

-Results in adaptive shortening

-Secondary compression of brachial plexus

-Also places pec minor and scalene muscle groups in shortened state

-Forward head presents with loss of lower cervical lordosis and hyperextension of upper cervical spine causing decreased mobility and restricted ROM

-May cause elongation of middle and lower traps and shortening of serratus anterior placing them in a mechanical advantage

-Results in overuse of scapular elevators

-Strengthening may need to begin in supine position

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TOS Treatment

-Cervical support/roll may be beneficial

->Inserted in pillow at night and during rest

->Gives adequate support

-Scapular stabilization exercises very important

-Look for winging and tipping

-Clavicular mobs

-Stretches

-1st rib mobs

-Physical agents to help decrease inflammation

-Neural tension mobilization techniques

-Cervical spine strengthening

-Scapular exercises

-RTC exercises

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Criteria to Return to Sport for TOS

-Relief of symptoms

-Full shoulder ROM

-Full shoulder strength

-Full shoulder flexibility

-Begin interval sports program

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Suprascapular Neuropathy

A syndrome with a constellation of different etiologies leading to dysfunction of the suprascapular nerve

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Differential Diagnoses for Suprascapular Neuropathy

-Rotator cuff pathology

-Cervical radiculopathy

-Brachial plexopathy

-Glenohumeral instability

-Adhesive capsulitis

-Acromioclavicular joint disease

-Thoracic outlet syndrome

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Causes of Suprascapular Neuropathy

-Compression or traction at either the suprascapular notch or spinoglenoid region

-Overzealous mobilization of retracted rotator cuff tears

-Space occupying lesions

-Trauma

-Viral syndrome

-Repetitive use

-Perioperative injury

-Idiopathic

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Type 1 Suprascapular Notch

Entire superior border of scapula shows depression

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Type 2 Suprascapular Notch

Wide, blunted, v-shaped notch

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Type 3 Suprascapular Notch

Symmetrical and U-shaped

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Type 4 Suprascapular Notch

Small v-shaped notch

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Type 5 Suprascapular Notch

Similar to 2 but with partial ossification of medial portion of transverse scapular ligament

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Type 6 Suprascapular Notch

-Transverse scapular ligament is completely ossified

-Has foramen of variable size

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Injury at Suprascapular Notch

Injury to the nerve here causes weakness of both supraspinatus and infraspinatus muscles

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Injury at Spinoglenoid Region

Injury to the nerve here causes isolated weakness of the infraspinatus muscle

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Presentation of Suprascapular Neuropathy

-Poorly localized dull ache over lateral and posterior aspects of the shoulder

-Weakness of external rotation and abduction

-Pain and weakness more severe at suprascapular notch than at spinoglenoid notch

-Pain can be referred to lateral aspect of arm, ipsilateral side of neck or anterior chest wall

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Tenderness (SSN)

Suprascapular Notch Involvement

-Area bounded by clavicle and scapular spine

-May see wasting of supraspinatus and infraspinatus

-Deltoid remains normal

-Strength of external rotation and abduction are weak

Spinoglenoid Notch

-Less severe

-Painless isolated wasting of the infraspinatus

-Tenderness over spinoglenoid notch

-May not be as weak with ER due to compensation by posterior deltoid and teres minor

-Isolated wasting of infraspinatus

-Cross arm adduction may increase symptoms

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Labrum

-Increases the superior inferior diameter by 75%

-Increases the anterior posterior diameter by 50%

-Increases depth from 2.5 mm to 5 mm

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SLAP Lesions

-Biceps contracting eccentrically to decelerate the extending elbow during follow-through phase of pitching

-The disruption of the superior labrum-biceps complex involving tearing or separation or both of the superior labrum beginning posterior to the biceps tendon insertion and extending anteriorly

-The classic description of a patient with this is one whose shoulder has pain with throwing activities and palpable clicking

-Rarely seen without the presence of instability

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Mechanism of Injury for SLAP Lesions

Traumatic

-FOOSH

-Bracing during MVA

-Compression of joint surfaces

-Subluxation or dislocation

-Posterior damage with fall

Repetitive OH Activities

-Superior labrum with biceps tendon/traction

Peel Back Mechanism

-Shoulder is forcefully abducted, extended and externally rotated

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SLAP Lesion Symptoms

-Pain

-Pain worse with OH activity

-Painful “catching”

-Painful “popping”

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Type 1 SLAP Lesion

-SLAP degenerated

-Marked fraying with degenerative appearance

-Periphery attached

-Biceps firmly attached

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Type 2 SLAP Lesion

-Degenerated and fraying

-Superior labrum and biceps tendon stripped off the underlying glenoid

-Results in labral-biceps anchor unstable and pulled away from glenoid

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Type 3 SLAP Lesion

-Bucket handle type tear

-Central portion displaced into the joint while periphery firmly attached to glenoid

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Type 4 SLAP Lesion

-Bucket handle tear with extension into biceps

-Labral flap tends to displace into joint

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Peel-Back Mechanism

-When arm is brought into abduction and external rotation, the biceps tendon assumes a more vertical and posterior angle

-This angle produces a twist at the base of the biceps, which transmits a torsional force to the posterior superior labrum, causing it to rotate medially over the corner of the glenoid

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No ER beyond 0 degrees for at least 3 weeks post-op

What is the clinical implications of the peel-back mechanism?

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Treatment of Type 1 SLAP Lesion

-Torn and frayed labrum is debrided back to intact labrum

-Careful preservation of attachment of labrum and biceps tendon to the glenoid

-ROM as tolerated

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Treatment of Type 3 SLAP Lesion

Excision of bucket handle tear

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Treatment of Type 4 SLAP Lesion

-Treated with excision of the bucket-handle portion of the tear, with resection continuing into the split portion of the biceps tendon

-In some instances the split in the biceps tendon and the labrum can be repaired with sutures placed arthroscopically

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Treatment of Type 2 SLAP Lesion Week 1

-Sling immobilization at all times for 4 weeks

-Gentle PROM only (Full ROM by 6 weeks with combined external rotation and abduction achieved last)

Protection

-Flexion to 90 degrees for first 2 weeks

-Avoid biceps resistance exercises for 10-12 weeks

-No ER beyond neutral for 4 weeks

-Scapular plane ER to 15 degrees and IR to 45 degrees for 2 weeks

-ER to 40 degrees by 6 weeks

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Treatment for Type 2 SLAP Lesion Weeks 2-3

-Codman, pendulum

-Elbow wrist and hand exercises started the day after surgery

-PROM: 0-90 degrees of flexion

-Abduction and ER in adduction

-Scapular exercises in side lying

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Treatment of Type 2 SLAP Lesion Weeks 4-8

-Discontinue sling

-Progressive PROM to full as tolerated in all planes

-ER/IR at 90 degrees abduction at 4 weeks

-90-100 degrees of ER at 90 degrees abduction at 8 weeks

-Begin passive posterior capsule/IR stretches and mobilization

-Isometric exercises immediately

-IR/ER and flexion/extension initially

-Rhythmic stabilization drills

-Tubing and light weight isotonic exercises at 4 weeks

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Treatment of Type 2 SLAP Lesion Weeks 12-16

-Continue all stretching and flexibility programs as above

-Begin progressive strengthening of the RTC, scapular stabilizers and biceps

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Treatment of Type 2 SLAP Lesion Weeks 8-10

-Weight bearing loaded exercises

-Done to avoid over compression of healing labrum

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6 months

At what point can you start throwing from the mound during a type 2 SLAP lesion rehab program?

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Treatment of Type 2 SLAP Lesion Month 7

-Allow full-velocity throwing from the mound

-Continue strengthening and posterior capsule stretching long-term (Indefinitely)

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Type 4: Bucket-Handle with Extension into Biceps Treatment (SLAP Lesion)

ROM

-Dependent on technique

-Excision sling for 3 weeks

-Full ROM by 6 weeks

Protection

-Avoid biceps resistance for 6 weeks if tenodesis or 10 weeks if repaired

Return to Sport

-8-10 weeks with excision and tenodesis

-Return to throwing 3-4 months

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Scapula

-Not true joint

-Point of contract between posterior lateral wall of thorax and anterior surface of scapula

-In anatomical position usually between 2nd and 7th rib

-Medial border located about 6 cm from spine

-Position varies

-Internally rotation 30-45 degrees from coronal plane (Scapular plane)

-Tipped anteriorly 10-20 degrees from vertical

-Upwardly rotated 10-20 degrees from vertical

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Upward/Downward Rotation

-Places glenoid fossa in optimal position to stabilize humeral head

-Elevates lateral clavicle

-SC and AC joint

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Anterior/Posterior Tilt

-Occurs at the AC joint

-Accompanies anterior and posterior rotation of clavicle

-Anterior tipping results in prominent inferior angle

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Decreased Upward Rotation

-Cause of “painful arc”

-Contributor SAIS

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Decreased Posterior Tilt

-Range is much less than that of upward rotation

-Elevates the anterior acromion which is predominate site of impingement

-May be more important

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Superior/Inferior Translations

-AKA Elevation/Depression

-Shrugging shoulder

-Includes motions at the SC and AC joint

-Result of scapula following clavicle

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-Upper Trap

-Levator Scapula

-Rhomboids

What are the scapulothoracic elevators?

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-Lower Traps

-Lats

-Pec. Minor

-Subclavius

What are the scapulothoracic depressors?

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Serratus Anterior

What is the scapulothoracic protractor?

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-Serratus anterior

-Upper, middle, and lower Traps

What are the scapulothoracic upward rotators?

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-Middle Traps

-Rhomboids

-Lower Traps

What are the scapulothoracic retractors?

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-Serratus anterior

-Traps

Weakness of what muscles may accompany impingement syndrome or GH instability?

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SICK Scapula

-Scapula has Inferior medial border prominance

-Coracoid pain and malposition

-DysKinesis of movement

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Causes of Scapular Dysfunction

Bony

-Thoracic kyphosis

-Clavicle fractures non union or mal union

Joint

-AC instability

-AC arthrosis

-Instability

-GH internal derangement

Neurologic

-Cervical radiculopathy

-Long thoracic nerve

-Spinal accessory nerve

Alterations in Muscle Activation

-Serratus anterior

-Upper/Lower trap force couple

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Scapular Examination

-Visual observation to determine presence or absence of scapular dyskinesis

-Effect of manual correction of the scapular dysfunction on symptoms

-Evaluation of surrounding anatomic structures that may be responsible for observable dyskinesis

-PROM/AROM loss

-Pec minor and short head of biceps

-Lats

-GH joint capsule

-MMT

-Scapular asymmetry in motion of position

-Abnormal motion and symmetry noted in those with and without pathology

-Scapular motion alterations and pain not always related

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Shoulder dysfunction

What does the lateral scapular slide test asses for?

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Fatigue

-Resulted in upward rotation in mid to end ROM of elevation

-Excessive scapular movement may place additional stress GH capsular structures leading to instability

-Instantaneous center of rotation for GH joint altered

-Reduced force generating capacities

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Impingement

-Compression of the RTC, subacromial bursa, and biceps tendon against the anterior undersurface of the acromion and coracoacromial ligament during elevation

-Multiple factors

-Poor scapular muscle function

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Scapular Exercises

-Straight plane side lying scapular patterns

-Side lying scapular PNF patterns

-Straight plane seated scapular patterns

-Shoulder flexion

-Scaption

-Abduction

-Push up +

-Horizontal abduction

-Horizontal abduction with shoulder ER

-Prone extension

-Rowing

-Press up

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Incidence of Rotator Cuff Tears

-25% of individuals in 5th decade of life (40-49 years old) have this

-Majority of those occur in individuals 45+ years old due to attritional and mechanical factors

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Rotator Cuff Tears

May be associated with smoking, repeated steroid injections, and systemic diseases such as RA, gout, and neurogenic disorders

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-Tendon

-Fibrocartilage

-Mineralized fibrocartilage

-Bone

What are the 4 different continuous zones of tissue composition?

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Primary Goals of Surgery/Rehab (RTC)

Restore Functional Abilities of the Upper Limb

-Maintain integrity of repair

-Reduce pain (Muscle inhibition)

-Re-establish passive mobility

-Re-establish muscular balance/motor control

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Education (RTC)

Patients Must Understand:

-Sling use

-Immobilization

-Maximum improvement in pain and function may not occur until 1 year after surgery

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-Bursal side partial thickness

-Mid-substance

-Articular side

-Full thickness tear

What are the 4 types of RTC tears?

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Bursal Side Partial Thickness Tear (RTC)

More often occur at the musculo-tendinous junction

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Partial Thickness Tear (RTC)

-Superficial fibers from CH ligament

-Superficial fibers of supraspinatus and infraspinatus

-Deeper fibers of supraspinatus and infraspinatus

-Deep extension of CH ligament

-True joint capsule

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Articular Side Tear (RTC)

-Often seen at the insertion site where vascularity and sensation may be less than that of bursal side tears

-May explain pain after debridement and SAD

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Acute Extension of a Tear (RTC)

-Patient may relate their pain to a recent event

-With continued questioning you may find a previous history of shoulder pain

-This recent event may be the “straw that broke the camels back”

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Tear Sizes (RTC)

-Small: Less than 1 cm

-Medium: 1-3 cm

-Large: 3-5 cm

-Massive: 5+ cm

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History (RTC)

-Any event significant or not, followed by persistent shoulder pain

-Pain worse with overhead activities involving ER

-Pain into lateral upper arm

-Night time pain hallmark sign

-Shoulder weakness and fatigue with ADLs

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Physical Presentation (RTC)

-May have atrophy, depending on chronicity of tear

-Tenderness along tuberosities and AC joint

-Full-thickness tear may be palpable

-Crepitus with elevation of arm

ROM

-PROM generally greater than active

-Loss of AROM

MMT

-Weakness of external rotation without pain sign of non-reactive full-thickness tear

-Weakness with pain may indicate reactive full-thickness tear of partial-thickness tear

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Small Tears (RTC)

-Occur in middle aged patients

-Usually tear along the lines of the muscle fibers

-May require deltoid splitting approach for surgery

-Can be sutured so that the pull of the RTC muscles contraction will not separate fixation

-Time for rehab accelerated since deltoid is split rather than taken down

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Medium and Large Tears (RTC)

-May require deltoid to be taken down during surgery

-Tear can be more perpendicular to line of pull of contraction of the RTC

-Will need more protection during healing phase

-3 weeks for soft tissue to take

-6 weeks for maturation of deltoids and RTC to withstand arm against gravity

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Massive Tears (RTC)

-Approximately 6 weeks should be allowed before moderate stress is applied to the repaired structures

-12 weeks before lifting against gravity

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Diagnosis of RTC Tears

-Age greater than 60 years

-Weakness in shoulder abduction

-Positive impingement sign (Neer’s HK)

-98% chance of full-thickness RTC tear

-Positive painful arc sign

-A drop arm sign

-Weakness in external rotation

-90+% chance of having full-thickness RTC tear

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Post-Op Stiffness

What is one of the most common issues following RTC repair surgery?

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Rehab PROM (RTC)

-Use of early joint mobs and ROM prevent: Adhesions, contractures, and periarticular structures

-PROM exercises need to be started early in the rehabilitation program to prevent selective hypomobilities from developing

->These lead to obligate GH translations

Accessory Movements

-Caudal glides

-Posterior glides

-Anterior glides in 30 degrees of scaption

Physiological Movements

-Flexion

-Scaption

-ER (Based on type of repair)

-IR

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Obligate GH Translations

-Occur when capsule has asymmetrical tightness

-May be selective posterior or inferior

-Surgery probably did not change this tightness which could have been there for years

-Asymmetrical tightness of the capsule causes obligate translations in a direction opposite to the tight tissue constraint

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RROM Guidelines (RTC)

-Protective to the surgical repair

-Shortened musculo-tendon unit length-tension

-Neuro-motor control

-Submaximal

-Pain-free

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-AROM Based on Tear Size (RTC)

-Conservative Sling Use (RTC)

-Small tears: 4 weeks

-Medium tears: 6 weeks

-Large tears: 8 weeks

-Massive tears: 12 weeks

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Phase 1 Goals (RTC)

-Reestablish non-painful ROM

-Maintain integrity of repair

-Retard muscular atrophy

-Prevent muscular inhibition

-Decrease pain/inflammation

-Independence in modified ADLs

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Phase 1 Precautions (RTC)

-No AROM

-No lifting objects, reaching behind back, excessive stretching or sudden movements

-Maintain arm in brace, sling

-Sling use for 4-5 weeks

-No support of body weight by hands

-Keep incisions dry and clean

-No passive pully exercise yet

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Criteria to Progress to Phase 2 (RTC)

-Passive forward elevation to 125+ degrees

-Passive ER/IR in scapular plane to 75+ degrees

-Passive abduction in scapular plane to 90 degrees

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Days 1-6 Post-Op (RTC)

ROM

-Pendulum exercises

-Abduction brace/sling (Sleep also)

-No rope and pulley

-Finger, wrist and elbow AROM

-Gripping exercises

-Passive PROM of shoulder (Supine)

->Flexion to 110 degrees

->ER/IR in scapular plane <30 degrees

-Cervical spine AROM

Education

-Posture

-Joint protection

-Importance of brace/sling

-Pain medication use

Pain and Inflammation

-Cryotherapy

-E-stim

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Days 7-35 Post-Op (RTC)

-Continue sling use

-Pendulum exercises

-PROM (Supine)

->Flexion to tolerance

->ER in scapular plane to 30+ degrees

->IR in scapular plane to body/chest

-Elbow, hand, forearm, wrist and finger AROM

-Resisted isometrics/isotonics for elbow, hand, forearm, wrist and fingers

-Begin gentle GH submaximal isometrics in “Balance position”

-Continue cryotherapy

-Conditioning program (Walking, stationary bike)

-Aquatherapy at 3 weeks if wounds healed

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Goals for Phase 2 (RTC)

-Allow healing of soft tissue

-Do not overstress healing tissue

-Normalize arthrokinematics

-Gradually restore full PROM (Weeks 5-6)

-Improve neuromuscular control of shoulder complex

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Precautions for Phase 2 (RTC)

-No lifting

-No support of full body weight on hands

-No sudden jerking motions

-No excessive behind the back motions

-No bike or ergometer until week 6

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Criteria to Progress to Phase 3 (RTC)

-Full ROM

-Minimal pain and tenderness

-Good MMT of IR, ER, and flexion