25- shoulder pain Flashcards
conditions may present with shoulder pain?
A. Myocardial infarction
B. Cancer of the lung
C. Cholecystitis
D. Ruptured ectopic pregnancy
which musculoskeletal causes of shoulder pain would merit urgent diagnosis and management?
Septic glenohumeral arthritis
Septic subacromial bursitis
–>loss of function, bacteremia
if you suspect urgent musculoskeletal disorders, what should you do
Urgent evaluation (with ultrasound or MRI) and immediate, same day consultation with an orthopedic surgeon.
Definitive evaluation will include aspiration and culture of related fluid. (staph or strep usually)
treatment of septic shoulder pain
surgical drainage and tailored antibiotic therapy. Hospitalization is warranted if this diagnosis is confirmed.
Patient carries the arm in an adducted and internally rotated position
Posterior dislocation
Poor posture with scapulae protracted
Impingement syndrome
Bony deformity in the area of the clavicle or AC joint
Fracture of the clavicle or sprain of the acromioclavicular (AC) joint
Fullness of the anterior shoulder with a large dimple in the posterior shoulder
Anterior dislocation
Atrophy of the larger muscles of the shoulder girdle, like the deltoid or pectoralis major
Immobilization or lack of use of the joint
Atrophy of smaller muscles such as the supraspinatus or infraspinatus
Torn rotator cuff or nerve impingement
If Mr. Chen had restricted passive as well as active ROM of the shoulder, what type of problems involving the shoulder might you consider?
joint disease (as opposed to muscle): Adhesive capsulitis & Glenohumeral arthritis
Adhesive capsulitis,
a condition common in patients with metabolic diseases such as diabetes and hypothyroidism in which there is contracture of the joint capsule
Glenohumeral arthritis,
a much less common site of osteoarthritis than the primary weight-bearing joints of the lower extremity
what would only compromise active ROM
Rotator cuff tear and impingement (conditions that may well occur together)
Supraspinatous
Assists with raising of the arm (abduction)
Infraspinatous
Assists with external rotation of the shoulde
Teres minor
Assists the infraspinatous in external rotation of the shoulder
Subscapularis
Assists with internal rotation of the shoulder
What are the major anatomic stabilizers of the shoulder joint?
Labrum-Adds stability by increasing the articulating surface area and depth of the glenoid fossa.
Rotator muscle group: Essential dynamic stabilizer of shoulder joint.
Glenohumeral or “capsular” ligaments: Provide added support and static stability to the shoulder joint.
Tendinitis vs Tendinopathy
Tendinitis implies an inflammatory etiology that occurs only in the first days after an acute tendon injury; not appropriate unless injury is very acute.
Tendinopathy is a more general term that may imply a degenerative pathology. It is a chronic condition that is characterized by a fibroblastic response, lack of acute phase reactants, and collagenous degeneration.
Rotator cuff tendinopathy
Positive Apley’s Scratch test leads one towards this diagnosis, but is not definitive.
Weakness and pain with empty can testing strongly suggests supraspinatus (i.e., rotator cuff) pathology.
Limited active ROM due to pain supports this diagnosis.
Torn rotator cuff
Limited ROM with significant pain is a hallmark of the physical exam in the patient with a partial or complete rotator cuff tear. In a complete tear, the patient will likely not be able to raise his arm above his head.
Significant weakness with strength testing.
Young athletes tend to present with traumatic torn rotator cuff, whereas older people present with insidious onset because of the degenerative process that occurs
Impingement syndrome with bursitis
Apley’s Scratch test causes pain and/or limited range of motion with these conditions.
Neer and Hawkins-Kennedy tests used to rule out these conditions.
Labral tear
Labral tears may occur through repetitive damage from glenohumeral joint instability or secondary to frank dislocations or other sudden trauma.
Clunk and O’Brien’s tests are the best clinical special tests for labral pathology.
diagnosis of exclusion.
