Lecture Exam 1

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

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

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

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

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

3rd Thoracic Outlet Syndrome Anatomical Site

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

-AKA Pec Minor or Hyperabduction syndrome

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

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

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

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

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

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

Lindgren Test

To Test Left Side

-Rotate completely to right side

-Side bend to end range

-Assess for limited motion or bony end-feel

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

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

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

Criteria to Return to Sport for TOS

-Relief of symptoms

-Full shoulder ROM

-Full shoulder strength

-Full shoulder flexibility

-Begin interval sports program

Suprascapular Neuropathy

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

Differential Diagnoses for Suprascapular Neuropathy

-Rotator cuff pathology

-Cervical radiculopathy

-Brachial plexopathy

-Glenohumeral instability

-Adhesive capsulitis

-Acromioclavicular joint disease

-Thoracic outlet syndrome

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

Type 1 Suprascapular Notch

Entire superior border of scapula shows depression

Type 2 Suprascapular Notch

Wide, blunted, v-shaped notch

Type 3 Suprascapular Notch

Symmetrical and U-shaped

Type 4 Suprascapular Notch

Small v-shaped notch

Type 5 Suprascapular Notch

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

Type 6 Suprascapular Notch

-Transverse scapular ligament is completely ossified

-Has foramen of variable size

Injury at Suprascapular Notch

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

Injury at Spinoglenoid Region

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

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

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

Labrum

-Increases the superior inferior diameter by 75%

-Increases the anterior posterior diameter by 50%

-Increases depth from 2.5 mm to 5 mm

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

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

SLAP Lesion Symptoms

-Pain

-Pain worse with OH activity

-Painful “catching”

-Painful “popping”

Type 1 SLAP Lesion

-SLAP degenerated

-Marked fraying with degenerative appearance

-Periphery attached

-Biceps firmly attached

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

Type 3 SLAP Lesion

-Bucket handle type tear

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

Type 4 SLAP Lesion

-Bucket handle tear with extension into biceps

-Labral flap tends to displace into joint

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

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

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

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

Treatment of Type 3 SLAP Lesion

Excision of bucket handle tear

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

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

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

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

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

Treatment of Type 2 SLAP Lesion Weeks 8-10

-Weight bearing loaded exercises

-Done to avoid over compression of healing labrum

6 months

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

Treatment of Type 2 SLAP Lesion Month 7

-Allow full-velocity throwing from the mound

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

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

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

Upward/Downward Rotation

-Places glenoid fossa in optimal position to stabilize humeral head

-Elevates lateral clavicle

-SC and AC joint

Anterior/Posterior Tilt

-Occurs at the AC joint

-Accompanies anterior and posterior rotation of clavicle

-Anterior tipping results in prominent inferior angle

Decreased Upward Rotation

-Cause of “painful arc”

-Contributor SAIS

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

Superior/Inferior Translations

-AKA Elevation/Depression

-Shrugging shoulder

-Includes motions at the SC and AC joint

-Result of scapula following clavicle

-Upper Trap

-Levator Scapula

-Rhomboids

What are the scapulothoracic elevators?

-Lower Traps

-Lats

-Pec. Minor

-Subclavius

What are the scapulothoracic depressors?

Serratus Anterior

What is the scapulothoracic protractor?

-Serratus anterior

-Upper, middle, and lower Traps

What are the scapulothoracic upward rotators?

-Middle Traps

-Rhomboids

-Lower Traps

What are the scapulothoracic retractors?

-Serratus anterior

-Traps

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

SICK Scapula

-Scapula has Inferior medial border prominance

-Coracoid pain and malposition

-DysKinesis of movement

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

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

Shoulder dysfunction

What does the lateral scapular slide test asses for?

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

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

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

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

Rotator Cuff Tears

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

-Tendon

-Fibrocartilage

-Mineralized fibrocartilage

-Bone

What are the 4 different continuous zones of tissue composition?

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

Education (RTC)

Patients Must Understand:

-Sling use

-Immobilization

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

-Bursal side partial thickness

-Mid-substance

-Articular side

-Full thickness tear

What are the 4 types of RTC tears?

Bursal Side Partial Thickness Tear (RTC)

More often occur at the musculo-tendinous junction

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

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

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”

Tear Sizes (RTC)

-Small: Less than 1 cm

-Medium: 1-3 cm

-Large: 3-5 cm

-Massive: 5+ cm

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

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

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

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

Massive Tears (RTC)

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

-12 weeks before lifting against gravity

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

Post-Op Stiffness

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

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

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

RROM Guidelines (RTC)

-Protective to the surgical repair

-Shortened musculo-tendon unit length-tension

-Neuro-motor control

-Submaximal

-Pain-free

-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

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

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

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

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

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

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

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

Criteria to Progress to Phase 3 (RTC)

-Full ROM

-Minimal pain and tenderness

-Good MMT of IR, ER, and flexion