DISORDERS OF THE SHOULDER:

Diagnostic classifications are based on:

MobilitySpectrum of from Stiff to Unstable
Pain-Movt relationship selective tissue tensioning, painful arc,
observation of movt
Location of Sx
On AGE
Rotator Cuff Pathology
Impingement syndrome (Lateral/anterior shoulder pain)
o Compromise of subacromial space irritation of 1+ structures in
the space.
o Usually overhead athletes or people w/ repeated overhead
activity
o 1 & 2
o Objective tests: painful arc of motion, Neer, & Hawkins-Kennedy
Tendinopathy (Lateral/Anterior shoulder pain)
o Compression to supraspinatus (if impingement is cause)
o itis mostly in younger pts & -osis in older
o 24-50
Tendon tear (Lateral shoulder/arm pain)
o Critical Zone Theory less blood flow=> easier for tendon to
deteriorate
o Compression Forces + small PCSA + high demand-> increase
vulnerability
o Limited and painful elevation ROM & weakness + Visible atrophy
o Tests: AROM vs PROM, ER lag sign, Lift off, drop arm test, full can
& bear hug
o Classifications:
Partial-thickness and Full-thickness tear
Crescent, U-shape, L/Reverse L & Massive contracted
Single-row and 2 row repair
Biceps Tendinopathy (anterior shoulder/arm pain)
Tendinitis & -osis of the long head of the proximal biceps tendon
Young athletes and older individuals
MOI
o Repetitive overhead activities
o Subacromial impingement
o Tendon subluxation
Pain at endrange, tender bicipital groove, speeds test, Yergasons test
(elbow 90, resist pt supination)
Biceps tendon Rupture (Anterior Shoulder pain)
Disruption to integrity of the long head of the proximal biceps tendon
 Middle-age (usually acute) & Elderly (Usually degenerative)
o Acute eccentric contraction during resistance of heavy object
o Degenerative repetitive activities leading to gradual
degeneration
Ecchymosis and swelling
Popeye Sign, Biceps MMT, Speeds and Yergasons test
Surgical options
Tenodesis (anchoring tendon to the bone) vs repair
o w/ tenodesis the biceps is no longer a shoulder flexor

GHJ Osteoarthritis
Men > 45 and womens > 55
Diffuse, achy Sx, progressive stiffness, crepitus, loss of sleep and
limitation in function

Adhesive Capsulitis
Inflammation of GHJ capsule adhesions and fibrosis w/in the synovial
lining
40-60yrs & 70% female
MOI:
o 1: idiopathic & majority of cases
o 2: caused by something else such as
systemic: diabetes, thyroid dysfunction
Extrinsic: stroke, cardiovascular incidents
Intrinsic: immobilization, shoulder surgery, tendinopathy,
etc
Stages 1-4 (inflammatory, Freezing, Frozen, & Thawing)
o 0-3 months, 3-9months, 9-15 months, 15-24 months

The Unstable Shoulder

Dislocation/Subluxation:
11-30 & > 50yrs
MOI:
o most are anterior by force movement or FOOSH
TUBS:
o Traumatic, Unidirectional, Bankart injury, Surgery
Pain w/ movement, sleeping on affected side
Apprehension/relocation test & Sulcus sign
Bankart Lesion:
o Detachment of anterior/inferior labrum from glenoid
o Bony banker occurs 5% of cases
Hill-Sachs Lesion:
 o Compression Fx of posterolateral humeral head
o In > 80% of anterior dislocation
o Associated with Bankart lesions
Multidirectional instability (anterolateral pain)
Symptomatic laxity of GHJ in more than 1 direction
11-30yrs & throwing athletes & females
MOI:
o Chronic stress to shoulder
o Congenital ligamentous laxity
o Concurrent pathology
Signs and Sx
o AMBRI: atraumatic, multidirectional, bilateral, rehab, inferior
capsule shift
o Popping & clicking & shoulder looseness
o MDI Sulcus
o Apprehension/relocation test
Superior Labrum Anterior-to-Posterior (SLAP) Tear
4 types:
o Type 1 and 3, the biceps tendon is intact
o Type 2 & 4 have detachment of biceps tendon
o Type 3 & 4 are both bucket-handle tears of superior labrum
o Type 1 is degeneration of labrum & type 2 is the detachment of
the labrum
Usually young, overhead athletes or manual laborers
Resisted supination-ER test, Biceps load 1 & 2, Crank test
Fractures
Clavicle most common in pediatric
o Direct blow or indirect trauma (FOOSH)
Scapula 20-40 & high impact injury
Proximal Humerus Elderly; FOOSH;
o Greater tuberosity (1)
o Lesser Tuberosity (2)
o Anatomical neck (3)
o Surgical neck (4)
Little League Shoulder
Proximal humeral epiphysiolysis
Rotational stress
Insidious onset; non-focal shoulder pain; pain with resistance testing
ACJ injury
Contact sports; direct trauma or indirect trauma
Signs and Sx
o Focal tenderness
o Piano key deformity
 o Obriens test: 90 flex, 10 add, with thumb down, push down=
pain. (+) test if no pain with thumb up
o Cross-body adduction test: bring arm across body and look for
posterior pain
Types 1-6 (spain to complete separation of ACJ)
Pectoralis Major strain (anterior shoulder/chest pain)
Usually traumatic
Sudden or heavier than expected resistance into horizontal adduction
(bench press or pec flys are common MOI)

Disorders of the Cervical Spine

Local pain pain of tissue damage
Remote:
o Neuropathic: damage to neural structures
Radicular pain/Sx mechanical compression of a spinal
nerve root
Space occupying lesions Disc pathology or
Degenerative changes (DJD/DDD)
Happens when impingement of dorsal ganglion.
Valsalva Maneuver intraabdominal pressure &
reproduce Sx
Wainers Cluster: Spurlings, Upper limb Tension Test,
C-rot <60, Neck distraction
o Referred at distance from site of pathology
Cervical Disc Pathology:
<40ys
MOI:
o Repetitive or sustained cervical spine loading & stress
o Trauma (whiplash, sudden Flexion of c-spine)
o Worst w/ flexion & contralateral sidebending
o Worst with prolongued sitting
Cervical Degenerative Disc Disease
Intervertebral Disc Complex
o Weakening of annulus fibrosis and vertebral endplates
o Loss of disc height, Osteophyte formation, fusing segments,
Stenosis
Cervical Degenerative Joint Disease
IVF and Facet joints
Articular damage osteophyte formation, fusing of segments, decreased
spaces
Cervical Spondylosis (DDD or DJD)
> 40yrs
Sx:
o Centralized or unilateral neck pain & neck stiffness
o Cracking or crunching in neck
o Reffered pain associated w facet and/or disc
Cervical Spinal stenosis
Central
o Vertebral foramen
o Disc, hypertrophic bone and/or ligament flavum
o Congenitally smaller cervical myelopathy bilateral Sx
Lateral
o Intervetebral foramen
o Disc, hypertrophic bone unilateral or bilateral Sx
Extension movt is worst
Cervical Myelopathy:
>40yrs
MOI:
o Disc pathology, Spondylosis, trauma, MS, RA
Signs & Sx
o May have scapular, cervical or shoulder pain
o General UE & LE weakness or stiffness
o Gait ataxia
o Bowel/bladder dysfunction
Surgeries:
Anterior Cervical Discectomy and Fusion (ACDF)
o Relieves spinal cord or nerve root compression
o Complete disc removal and osteophytes
o Bone graft from iliac crest to replace disc & fusion of 2 vertebra

Coupled motion of Cervical Spine: sidebend & contralateral rotation

Cervical Facet Dysfunction:

Joint
o Limited and painful ROM w/ increased overpressure
o Pain reproduced with joint play
Extension, Ipsilateral rrot & SB, C/S Quadrant Test
o Segmental motion test hypomobile or hypermobile
Capsule
o Limited and painful ROM w/ overpressure
o Pain reproduced with joint play
Flexion, Contralateral Rot & SB,
o Segmental motion test hypo/hypermobile
Torticollis:
Contracted state of SCM
Development of fibrosis abnormal uterus position or difficult
childbirth
L CMT left sidebend and R rotation
Lead to plagiocephaly oblique head; flat head syndrome
Cervicogenic headaches
Unilateral pain referred from a source in the neck and felt in 1+ regions
of head/face
o OA joint; AA joint; C2-C3 facet joint & IVD, upper cervical muscles
o 53% in pts after whiplash
Whiplash disorders
process of head/neck forcefully displaced in one or X directions
group of pathologies
Upper Cervical Instability
Anatomical Structure Disruption
o C1-C2 or dens fracture
Whiplash or history of osteoporosis
o Ligamentous insufficiency
Trauma (whiplash), RA, Down Syndrome
Alar and Transverse ligament
o Sx
5 Ds, motor or sensory deficits, hesitant to move head or
neck, lump in throat
o Odontoid Fracture
Type 1 may impact alar lig, loss of rotational stability
Type 2 located at base, A-P instability, Transverse lig
compromised
Type 3 located at body; AP instability, Transverse lig
compromised

SCOLIOSIS
Lateral curvature of the spine with a rotary component (>10)
Classifications
Nonstructural- Reversible
o Habitual poor posture
o Leg length discrepancy (Most common Cause)- when discrepancy
fixed- curvature self corrects
o Pain
o Hysteria
Structural- Irreversible
o Congenital
 Failure for vertebrae to form normally, absence of vertebra,
partially formed vertebra
o neuropathic
caused by the presence of a neurological or muscular
disease
defects in CNS altered proprioception or diminished
control of the paraspinals
abnormal forces transmitted to vertebral units either b/c
the muscles show spasticity or flaccidity
Bracing?
o Idiopathic
80-85% of cases
genetic transmission is a factor
<9 is equally distributed but >10, 90% are female
> curve, more rapid the progression
Rissers Sign 1-5 depending on how much of pelvis is covered
how skeletally mature the individual is. The higher the score, the more
skeletally mature they are.
Location of curve based on apex of the curve
Primary or Major curve
Compensatory curve
o Develop above or below the 1 curve and in the opposite
direction to 1 curve
o Able to straighten nonstructural
Double major curve
o 2 primary curves that are structural
Cobbs method measurement of curve apex of curvature and line at the
most tilted vertebra below and above curvature and then perpendicular lines
from each original line.
Spinous process and vertebral body are deviated towards convex side.
o Lamina thinner on concave side and thicker on convex
<15-20 observed for progression
b/w 20 & 40 bracing to prevent further progression of curvature
Milwaukee Brace for high thoracic curve
Boston Brace Thoraco-lumbar curvature

Scheurmann Disease
b/w 13 & 17 yrs; 2nd most common idiopathic spinal deformity
Ossification of the ring apophysis of the T- & L-spine
Hyperkyphosis apex around T7-T9

THORACIC SPINE
 Degenerative:
o DJD, DDD, Stenosis
Not Degenerative
o Disc pathology, facet joint/joint capsule dysfunction
Stenosis
o Central @ Cervical and Thoracic myelopathy upper motor
neuron
o Lateral @ all levels radiculopathy
Radiculopathy
o Nerve irritation signs
+ tension signs & paresthesia
o Neurological signs of nerve compression
Vertebral body Fractures
o Traumatic or osteoporotic fracture
>60; Hx of osteoporosis; fractures from trivial events such
as bending over or getting out of bed
o Pain w all ROM and worse w/ weight bearing; better in supine;
tenderness at SP
Ribs
o Pain w/ coughing, sneezing, Deep breaths
o Fractures traumatic or non traumatic (sneezing or coughing)
o Rib Dysfunction
Direct trauma or subluxation
Twisting/rotational movt or postural dysfunction jt
dysfunction
Costochondral injuries
o Traumatic blow
o Problems beathing, stretching pec, using pecs
o Women >40
Thoracic outlet syndrome
o Nerves and/or blood vessels in Thoracic Outlet become
compressed
o Classifications:
Neurogenic (brachial plexus)
Vasogenic (subclavian a)
Non-specific (sub-clinical neurogenic)
o Causes: cervical rib, muscle tightness
Tight scalenes or pec minor
Elevated 1st rib
o Special tests:
Adsons: compress scalenes
Costoclavicular: stretch clavicle
 Roos: thoracic outlet syndrome test pt abd. To 90 and ER
GHJ then open/closes hand for 3 minutes and see if they
can do it without reproduction of Sx
RULE OUT CERVICAL SPINE WITH SPECIAL TESTS

ELBOW, WRIST & HAND

Olecranon bursitis
Direct trauma, repetitive friction or compression
Localized swelling, warmth and palpable tenderness to olecranon
Sx worsen with tricep activation or direct pressure
Nursemaid Elbow (posterior/lateral elbow tenderness)
Children 3mo-3yrs (girls>boys)
Axial traction to extended elbow
Posterior Impingement syndrome (Elbow) (posterior/medial elbow pain)
Overhead throwing athletes in contact sports that involve
hyperextension
MOI:
o Valgus extension overload or single traumatic hyperextension
Sx worsen with end-range extension
Medial Elbow
Medial Epicondylopathy (common flexor tendon)
o Insidious onset and often due to repetitive motions and overuse
Cubital Tunnel Syndrome (Ulnar Nerve)
o Ulnar n. entrapment/compression/friction
Cubital tunnel retinaculum
Deep flexor/pronator fascia
o 2 most common compression syndrome (Carpal tunnel 1st)
nd

o thanar muscles are fine

o if weakness in both thanar and hypothenar eminence not a
nerve root radiculopathy
Ulnar Collateral ligament injury (UCL)
o Valgus stress from repetitive throwing microtears
o Tests: palpation, valgus stress test, milky maneuver
Little Leaguers Elbow (medial epicondyle, apophysis, radial head,
humeral trochlea)
o Apophysitis or avulsion of medial epicondylar epiphysis
o Compressive and shearing forces involvement of radial head
and capitellum (2nd ossification site) Osteochondritis Dissecans
o CRITOE 6 ossification centers
Capitellum, Radius, Internal (medial) epicondyle, Trochlea,
Olecranon, External (lateral) epicondyle
Osteochondritis dissecans vs Osteochondral defect
 o Dissecans starts from bone to cartilage; usually in younger
individuals (10-15), usually due to lack of vascularization
If predisposed trauma can kick start the disease
20-25% cases are bilateral
o Defect missing piece of bone in cartilage, usually due to
trauma.
Biceps Tendon Distal Rupture
40-60yrs active male on dominant arm
elbow flexion under heavy load
Pop audible; abnormal shape of biceps; most common tear from
bicipital aponeurosis
Lateral Elbow
Lateral epicondylopathy (common extensor tendon)
o ECRB origin is most common
Radial Tunnel Syndrome (Deep Radial N)
o Compression of N.
o Pain @ lateral elbow and forearm (tenderness more distal the lat.
Epicondyle)
o Repetitive elbow extension with forearm rotation
o Weakness and Numbness= NOT PRESENT
Wartenburg syndrome (Superficial Radial N)
o Pain & sensory deficits
o Entrapment b/w brachioradialis & ECRL
o Sensory @ dorsal aspect of hand and some wrist)
Posterior I.O. Nerve entrapment (Posterior I.O. nerve)
o Entrapment @ Arcade of Frohse (thru supinator)
o Pain: Posterior/lateral forearm wrist
o MOTOR DEFICITS: Finger extensors, ECU
Radial Collateral ligament injury (Radial Collateral Lig)
o Pain @ lateral elbow (especially w/ elbow extension & supination)
o Chronic varus stress (from CRUTCHES)
High Radial N Injury
o Usually from compression to Axilla (CRUTCHES!)
o mid-shaft humerus Fx
o compression of lateral head of triceps (mostly weight lifters)
o Affect everything below triceps that is innervated by Radial n
Wrist & Hand
DeQuervains Syndrome (Intersection Syndrome)
o Repetitive wrist & thumb extension w/ radial deviation
o APL and EPB muscle bellies
Triangular Fibrocartilage Complex Tear
o Falling onto pronated hyperextended wrist (Compression)
 o Force applied to anterior forearm or wrist with twisting
(Distraction)
Ulnar Collateral Lig Injury (Thumb)
o Skiiers thumb
o overuse injury MCP injury
Thumb CMC Arthritis
o Most common OA in hand (Base of 1st metacarpal & Trapezium)
o Women> Men
Dupuytrens Contracture
o Thickening of connective tissue in palmar fascia that can
progress to tendon like cords that adhere to tendon sheaths and
result in finger flexion contractures.
o Idiopathic; start out as nodule but progresses to tendon sheath
o Surgery can cause as much scar tissue so surgeons try to avoid
surgery
Boutonniere Deformity
o Flexion of PIP and Extension of PIP due to central slip of extensor
digitorum ruptures
Trauma or due to RA
Mallet Finger
o Rupture of Extensor tendon at distal phalanx (CANNOT EXTEND
DIP)
Swan Neck Deformity
o Hyperextension of the PIP accompanied by flexion of DIP
o Not due to rupture of tendon but instead due to laxity
Jersey Finger
o Common in sports
o Rupture of FDP insertion on distal phalanx
o Cannot flex DIP
Smiths Fracture
o FOOSH with wrist flexed
o Distal portion of the wrist & hand are displaced anteriorly in
relationship to proximal forearm
Colles Fracture
o FOOSH with wrist Extended
o Distal portion of the wrist & hand are displaced posteriorly &
laterally=> dinner-fork deformity
Boxers Fracture
o 10-29yrs & M>W
o fingers flexed in a fist position w/ force stronger than the bone
directed @ MC head of 5th digit.
 Musculo-skeletal Neoplasms
Metastatic Cancers
o Tumors from solid tissue and not from blood origin
Name: based on appearance & presumed histognetic origin
Musculo-skeletal tumors
o Soft tissue mass/bony mass/ pain/ pathologic fracture/ incidental
findings
Cachexia
o Syndrome characterized by weight loss, anemia, weakness, early
satiety
TMN Staging system
o Tumor size
o Nodes involved
o Metastasis
Osteoid Sarcoma
o Early 20s; M>F; Benign bone lesion
o 40% found on proximal femur
o Constant Dull pain, worse at night
o CT best visualization of type of lesion
Osteoid Osteoma
o Creates inflamed cavity around bone
Well vascularized
Osteoclasts are present
o Will resolve without treatment in average of 33 months
o Can have optional surgery if pt doesnt want to deal with the pain
Multiple Myeloma
o Overgrowth of plasma cells in the bone marrow can crowd out
the normal blood-forming cells.
o Can cause anemia
o Tell osteoclasts to eat bone
o Spreads to involve entire bone marrow DEATH
o Most common 1 cancer of bone in adults
o High level of protein in the blood & urine and high levels of Ca in
blood
o Can really tell in the head
o Treatable but not curable
o Chemotherapy, Radiation therapy Surgical (to prevent bone
fractures)
o Stem cell transplant w/ high dose chemotherapy more effective
o Biphosphonates anti-bone resorptive activity & anti-tumor
mechanism
o 5-year survival rate
Stage 1 50%
 Stage 2 40%
Stage 3 10-25%
o OsteoSarcoma
Developmental dysplasia of the peripheral growth plate
(adolescents probs)
Usually in long bones
Firm, non-tender, immobile mass near end of a long bone
Symptomatic lesion caused by irritation of overlying soft
tissue
RAPID bone growth during growth spur/half of tumors in
femur
Chemotherapy shrink tumor which aids resection
prevent spread
Radiological not responsive
Surgical Resection of involved bone
Involves grafting, muscle transfers, bone graft and
maybe amputation of bone affected
Erwins Sarcoma
o Rare tumor/ metaphysis and diaphysis of bone, mostly in femur
o 64% in ages b/w 11-20 and 3% in <3yo
o no genetic factors
o Surgical resection or chemotherapy
o Sensitive to Chemo and radiotherapy
o High-dose chemo may need a stem cell transplantation
o Most lethal of all bone cancers
Limb Salvage Surgery
Remove bone & soft tissue cancers while preserving function and
appearance of involved limb, avoiding amputation

Rheumatoid Arthritis & Related Disorders

Autoimmune Disorders
o Body attack its own tissues by creating destruction of normal
cells
RA
o Ulnar deviation of fingers b/c pulley system gets messed up
o Chronic, inflammatiory, systemic, autoimmune disorder with
widespread involvement of connective tissue
Exarcebations (period of pain and feeling bad) &
Remissions (period of feeling better)
Never will be at same level as when first diagnosed
o Signs and Sx
Vague musculoskeletal weakness
Neck pain and stiffness
Systemic involvement & fatigue
 o 4 Stages:
Synovial Swelling
Whole lining becomes hypertrophied, presenting as
soft tissue swelling of the joint
Darker yellow, cloudy and decreased viscocity
Pannus Formation
Asymmetric wear and erosion of joints
Subchondral bone is directly weight bearing
Villous projections grow into the joint space
Inflammatory response followed by exacerbations &
remissions
Vascular proliferation
Chronic Active Phase
Erosion & inflammation continues; pain; disability
Erosion of transverse ligament major concern
Chronic Inactive Phase
Pannus formation increases joint deformity
Autofusion can occur
o Make patients feel better even though
traumatic function limitations
o Usually MCP and PIP involvement as well as carpal joints
IF DIPSEVERY DIRECTIONOA NOT RA
o Rheumatoid Nodules
Found in tendon sheaths, bursa, joint capsule and painless
unless over bony prominences
o No cure but instead Drug therapy
Prednisone anti-inflammatory that can accelerate
osteoporosid and cause cushingoid appearance (moonface,
hump back, red cheeks)
NSAIDS
DMARDS neutralize effects of proinflammatory cytokines
& slow down proteins that promote destruction of joint
tissue
Sjogrens syndrome
o Dry eyes and mouth; swollen salivary glands and fatigue
o 9/10 are women; all races and groups
o cannot produce saliva tooth decay & dry mouth; dental
infections
o Drugs
Increase saliva Salagen (saliva) & Evoxac (tears)
Systemic Lupus Erythematosus (SLE)
o Autoimmune disease that can affect any part of body, especially
organ function
 o Occurs at any age; usually women; most cases during childbirth
years
o Great Immitator
o Exarcebartions & Remissions
o NO JOINT INVOLVEMENT
o Cannot be out in sun Malar Rash butterfly rash in face!
Discoid lesions @ areas exposed to sunlight
o Raynauds phenomenon constriction of small blood vessel in
the fingers & toes resulting in pain & sometimes numbness
Triggered by cold weather or stress
o Treatment:
Reduce inflammation
Prevent flares and treat them
Control Sx like joint pain & fatigue
Minimize damage to organs
o PTs Role
Balance exercise with exacerbation/remission bouts
Cushing Syndrome
When body is exposed to high levels of hormone cortisol for prolonged
periods of time
Fatty hum b/w shoulders, round face, purple stretch marks
Cause bone loss, HTN & Diabetes
Gout-Etiology
Increase urate production
Decreased renal elimination of urate or combo of both
GOUT
o Excessive uric acid in blood Hyperuricemia
o They have exacerbations and remissions
o Comes on overnight patients will wake up with this condition
o Deposition of tophi
o ALL ASIAN MEN HAVE GOUT Dr. Baldwins words
o Blood tests and synovial fluid lab results are the way to diagnose
this
o Liquor and red meats can cause this
o Tophi:
Irregular hard masses of urate crystals
Needled shaped
Will absorb some of the radio light beams?
o Treatment:
NSAIDS
No alcohol; hard shoe to prevent ROM of great toe
Allopurinol decrease uric acid formation
Regulate diets
 High in complex carbs, low in protein and <30% fat!
Scleroderma
Hardening and tightening of skin & connective tissue
Under Rheumatic diseases/autoimmune
Overproduction of collagen in bodys tissue
b/w 30-50
exposure to gold and coal mining; paint thinners and some chemo
drugs
2 types:
o Localized: only skin is affected
Morphea Oval shaped thickened patches that are white
in middle w/ purple borders
Linear more in children and bands of hardened skin on
arms, legs and forehead (one side of body)
o Systemic: skin & organs
Calcinosis
Raynauds phenomenon
Esophageal dysfunction
Sclerodactyly
Telangiectasias

REVIEW FOR FINAL:

35pts/70questions
shoulder12q
cervical + thoracic 12-14
elbow/forearm/wrist & hand 8-10
tissue healing 10-12
RA & related disorders- 8-10
Neoplasms 8-10

Integration 15-17