25- shoulder pain

Question 1

conditions may present with shoulder pain?

Answer 1

A. Myocardial infarction
B. Cancer of the lung
C. Cholecystitis
D. Ruptured ectopic pregnancy

Question 2

which musculoskeletal causes of shoulder pain would merit urgent diagnosis and management?

Answer 2

Septic glenohumeral arthritis
Septic subacromial bursitis

–>loss of function, bacteremia

Question 3

if you suspect urgent musculoskeletal disorders, what should you do

Answer 3

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)

Question 4

treatment of septic shoulder pain

Answer 4

surgical drainage and tailored antibiotic therapy. Hospitalization is warranted if this diagnosis is confirmed.

Question 5

Patient carries the arm in an adducted and internally rotated position

Answer 5

Posterior dislocation

Question 6

Poor posture with scapulae protracted

Answer 6

Impingement syndrome

Question 7

Bony deformity in the area of the clavicle or AC joint

Answer 7

Fracture of the clavicle or sprain of the acromioclavicular (AC) joint

Question 8

Fullness of the anterior shoulder with a large dimple in the posterior shoulder

Answer 8

Anterior dislocation

Question 9

Atrophy of the larger muscles of the shoulder girdle, like the deltoid or pectoralis major

Answer 9

Immobilization or lack of use of the joint

Question 10

Atrophy of smaller muscles such as the supraspinatus or infraspinatus

Answer 10

Torn rotator cuff or nerve impingement

Question 11

If Mr. Chen had restricted passive as well as active ROM of the shoulder, what type of problems involving the shoulder might you consider?

Answer 11

joint disease (as opposed to muscle):
Adhesive capsulitis & Glenohumeral arthritis

Question 12

Adhesive capsulitis,

Answer 12

a condition common in patients with metabolic diseases such as diabetes and hypothyroidism in which there is contracture of the joint capsule

Question 13

Glenohumeral arthritis,

Answer 13

a much less common site of osteoarthritis than the primary weight-bearing joints of the lower extremity

Question 14

what would only compromise active ROM

Answer 14

Rotator cuff tear and impingement (conditions that may well occur together)

Question 15

Supraspinatous

Answer 15

Assists with raising of the arm (abduction)

Question 16

Infraspinatous

Answer 16

Assists with external rotation of the shoulde

Question 17

Teres minor

Answer 17

Assists the infraspinatous in external rotation of the shoulder

Question 18

Subscapularis

Answer 18

Assists with internal rotation of the shoulder

Question 19

What are the major anatomic stabilizers of the shoulder joint?

Answer 19

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.

Question 20

Tendinitis vs Tendinopathy

Answer 20

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.

Question 21

Rotator cuff tendinopathy

Answer 21

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.

Question 22

Torn rotator cuff

Answer 22

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

Question 23

Impingement syndrome with bursitis

Answer 23

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.

Question 24

Labral tear

Answer 24

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.

Question 25

Management of Rotator Cuff Tendinopathy / Impingement: Physical Therapy

Answer 25

Physical therapy exercises for 6 weeks, then return to clinic for re-evaluation.

Question 26

Conditions that will require sling immobilization include

Answer 26

shoulder dislocation and proximal humeral fractures.

Question 27

indications of suspisions for x ray

Answer 27

fracture, dislocation
calcium deposits
degenerative or inflammatory changes

Question 28

AC joint sprain presentation

Answer 28

swelling, bruising and point tenderness of the AC joint after a fall directly on the acromion with arm adducted.

Question 29

MRI is used to evaluate

Answer 29

possible rotator cuff tears and other soft tissue etiology.

Question 30

CT can be used in the setting of

Answer 30

complicated fracture, suspected tumor, or when MRI is contraindicated.

Question 31

Ultrasound can be used to evaluate

Answer 31

soft tissue structures

Question 32

Empty Can Test, the patient’s arms are placed in approximately 30-degrees of horizontal adduction with the shoulders abducted to 90-degrees. tests which muscle?

Answer 32

supraspinatus

Question 33

impingement testing

Answer 33

neer test- passive hail hitler

hawkins kennedy- sea saw arm

Question 34

apprehension test

Answer 34

This position reproduces the mechanism for anterior dislocation, and could create some anxiety in a patient with anterior instability.

apply anterior pressure

Question 35

relocation test

Answer 35

provide stabilizing posterior pressure to the humeral shaft while in the anterior apprehension position. A positive test would be a sense of relief, indicating the patient feels like the arm is less likely to dislocate anteriorly.

Question 36

speed’s test

Answer 36

Flex the patient’s elbow 20-30 degrees with the forearm in supination and the arm in about 60 degrees of flexion.

Resist forward flexion of the arm while palpating the patient’s biceps tendon over the anterior aspect of the shoulder.

Question 37

Yergason’s test

Answer 37

Flex the patient’s elbow to 90 degrees with the thumb up.

Grasp the wrist and resist attempts by the patient to actively supinate the arm and flex the elbow.

A positive finding for biceps tendinopathy would be pain in the anterior area of the shoulder.

Question 38

To test for labral injuries:

Answer 38

Clunk test
O’Brien Test
SLAP testing

Question 39

clunk test

Answer 39

With the patient supine, the examiner rotates the patient’s arm and loads (force applied) from extension through to forward flexion. The examiner is checking for a “clunk” sound or clicking sensation arising from the glenoid labrum that can indicate a labral tear even without instability.

Question 40

obrien

Answer 40

Have the patient stand with hands on his hips. Place one of your hands over the shoulder and the other hand behind the elbow. Apply anterior-superior force and ask the patient to push back against the force. Have the patient hold his shoulder in 90-degrees of forward flexion, 30 to 45-degrees of horizontal adduction, and maximal internal rotation. Grab his wrist and resist his attempt to horizontally adduct and forward flex the shoulder.

Question 41

SLAP

Answer 41

Checks for a superior labral tear, also known as a ‘SLAP lesion’. It would elicit pain or possibly popping or clicking with labral pathology.