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.
Management of Rotator Cuff Tendinopathy / Impingement: Physical Therapy
Physical therapy exercises for 6 weeks, then return to clinic for re-evaluation.
Conditions that will require sling immobilization include
shoulder dislocation and proximal humeral fractures.
indications of suspisions for x ray
fracture, dislocation
calcium deposits
degenerative or inflammatory changes
AC joint sprain presentation
swelling, bruising and point tenderness of the AC joint after a fall directly on the acromion with arm adducted.
MRI is used to evaluate
possible rotator cuff tears and other soft tissue etiology.
CT can be used in the setting of
complicated fracture, suspected tumor, or when MRI is contraindicated.
Ultrasound can be used to evaluate
soft tissue structures
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?
supraspinatus
impingement testing
neer test- passive hail hitler
hawkins kennedy- sea saw arm
apprehension test
This position reproduces the mechanism for anterior dislocation, and could create some anxiety in a patient with anterior instability.
apply anterior pressure
relocation test
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.
speed’s test
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.
Yergason’s test
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.
To test for labral injuries:
Clunk test
O’Brien Test
SLAP testing
clunk test
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.
obrien
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.
SLAP
Checks for a superior labral tear, also known as a ‘SLAP lesion’. It would elicit pain or possibly popping or clicking with labral pathology.
