5. Shoulder Flashcards
What are the common red flags for shoulder pain?
Previous history of cancer Age >50 Unexplained weight loss Pain at rest Constant pain Night pain Pain at multiple sites Constitutional signs Failure to improve with conservative care (4-6 weeks duration). L shoulder – should consider MI
What sort of things should we ask in history to give us a better clue?
Patient age- can give us indication to type of pathology present (think tendinopathy)
- social Hx- sport or occupation (impression of repetative loading)
- frequency (or recent change in)
- duration
- nature
Anterior pain?- LHB tendinopathy
- localised over ACJ- ACJ involvment
- anterolateral pain- referral to deltoid tuberosity- subacromial structures involved, RC, GHJ pathology
Mechanical clicks, feeling of apprehansion or instability- mechanical or functional instability
Presences of numbness- nerve injury following dislocation or other trauma?
Onset- Insideous- frozen shoulder, arthropathy (ACJ or GHJ), subacromial impingement (SAPS), atraumatic instability
- traumatic- RC tear, labral, dislocation, sprain, fracture
- secondary to immobilisation
Pain behaviour:
with shoulder movement (repetition) or position (overhead)
-pain at rest- inflammatory, mechanical??
What things should we be looking for in the physical exam of shoulders?
Observation:
-scapula (resting position, winging), HH (anterior, sulcus sign, step deformity), muscel bulk.
Functional tests- use the patients description of events to guide this.
ROM- guided by subjective information
- painful arc? EROM pain?
- PROM> AROM, with AROM pain limited
Palpation:
- tenderness over SA margins
- TPT’s or hypertonicity
- crepitus or mechanical clicks
Impingement tests
What are the probable Dx of the Shoulder?
What are serious disorders we should rule out?
Things to consider if patient is responding to tx?
Masquerades?
- C spine refferal
- SAPS (rotator cuff tendinopathy, SA bursitis, RC tear
- Adhesive capsulitis
- labral tear- SLAP, non-SLAP
- biceps tendinopathy
Serious disorders to rule out?
- Cardiovascular referral (myocardial infarction, angina)
- neoplasia (pancoast tumor, primary or secondary in humerus)
- severe infections (septic arthritis
- thrombosis
Pitfalls:- things to consider if pt not responding and serious already ruled out
- Gout/ pseudogout
- OA of ACJ
- Polymyalgia rheumatica
Masquerades?
Depression
Diabetes- increased risk of adhesive capsulitis
-Drugs- corticosteroids could lead to AVN of humeral head, anabolic steroids can result in osteolysis of the ACJ
What are some special concerns with shoulder pain?
Asymmetry in shoulder contour between sides
changes on affected side
associated with a loss of rotation
Abnormal sensorimotor status
Warm and redness of the shoulder area Constitutional symptoms
History of trauma
Unremitting pain not associated with direct movement
of the shoulder
Severe, sharp stabbing pain of several minutes duration
Diagnosis tips:
Systemic Origin
Left shoulder Location
Fek it look at slide 15
What is Kehr’s sign?
Its teh occurence of acute pain in the tip of the shoulder due to the prescnce of other irritants in the peritoneal cavity when a wpersons is lying down and teh legs are elevated.
Slide 17
What is the Right shoulder locations for the following>
Peptic ulcer (spleen or postoperative laparoscopy)
Myocardial ischemia
Hepatic/ billary
-acute cholecystitis
-gall bladder
-liver disease (hepatitis, cirrhosid, metastatic tumors, abscess)
Pulmonary: Pleurisy Pneumothorac -pancoast tumor -Pneumonia
Kideny
Gynaecologic: Endometriosis
Slide 17
What are the clinical signs of a shoulder impingement? a
Contemporary thoughts are the impingement is considered a clinical sign, rather than a diagnosis.
Can occur without signs of RC pathology.
RC pathology rarely will exist without impingement signs.
Chicken and egg scenario
Types of impingement:
Primary
SA – most common SC
Secondary SA
SC
Glenoid (internal)
Primary SA impingement Proposed to be due to encroachment from above Acromial spur, Thickened CAL ACJ arthropathy Mal-union of acromion Secondary SA impingement: Functional narrowing d/t: Sub-clinical instability GHJ motor control disorder Sub-optimal RC function Scapular stabiliser weakness RC fatigue or overuse
Body diagram: Anterior lateral pain, with potential referral to deltoid insertion Suggests SA structures involved. Pain behaviour Overhead activities IR in positions of elevation Physical Exam: TOP: acromial margins or SA space Painful arc during active shoulder elevation (abd>flex) +/- EOR pain Worse with humerus IR What about orthopaedic tests?
Sub-acromial Pain syndrome
Some tests have amazing sensitivity ( good at reproducing symptoms), others excellent specificity.
One cluster:
Hawkins-Kennedy test, the painful arc, and infraspinatus
muscle test.
Diercks et al 2014. Guideline for diagnosis and treatment of subacromial pain syndrome
Another:
Hawkins-Kennedy test, Neers, painful arc, empty can and
infraspinatus muscle test.
>3/5 provides: Sensitivity (0.75), Specificity (0.74).
Investigations and management:
SAPS
Investigations:
Ultrasound is likely an accurate method for the
detection or exclusion of rotator cuff tendinopathy,
subacromial bursitis, biceps tendon rupture, and calcific
tendinosis. Ottenheijm et al 2010
Advised as the most cost-effective and valuable diagnostic imaging if non-operative treatment fails.
May be combined with conventional radiography to determine extent of osteoarthritis, osseous abnormality or presence of calcium deposits.
Management:
This diagnosis guides the Chiropractor as to whether their
intervention is warranted.
On it’s own does not provide enough information to direct management.
Management should be based on:
Dominant classification:
Movement impairment? Motor control? Postural loading?
Intrinsic and Extrinsic factors contributing
Stage
Patients activities and participation restrictions
Goals and preferences of the patient
Take into account presence of underlying pathology (ie Tendinopathy if confirmed via US).
Mobilisations (MWM)
STT (MRT, TPT, CFM)
NMFTs (
Motor control retraining (particular scapula)
Specific strengthening, endurance and proprioceptive training
“A specific, progressive exercise program focusing on training the rotator cuff and scapular stabilisers was effective in improving function, reducing pain and reducing the need of surgery for patients with chronic subacromial impingement syndrome.” Holmgren A et al (2012)
Related home exercise and management
EPA (pain and inflammation management)
Past history of shoulder dislocations
Mc anterior dislocation (recurrence rate is 60-90% in young active individuals)
Complains of pain and weakness when the arm is placed in either an overhead position or apprehension position (90 degrees flx/abd and ER)
Feelings of instability are direction specific
Physical examination: Weakness of local muscles (ie
RC)
Instability tests:
Increased ROM + accessory movements
Altered end feel Apprehension
Axillary nerve damage? Investigations:
MR arthrography or arthroscope are ideal to diagnose a bankart lesion.
Post-traumatic GH instability
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Clinical presentation Young M) Bilateral, multidirectional Gradual onset of pain related to sport Good ROM – excessive (hypermobile) +ive impingement signs +ve instability tets Sulcus sign, AP, PA drawer tests Apprehension and relocation tests Management Assess the rotator cuff muscles and Ensure correct biomechanics Adequate strength May require progressive training of scapula and RC muscles. Activity modification Assess the kinematic chain
Atraumatic GH instability
Clinical presentation:
Anterior shoulder pain
in bicipital groove
Can be difficult to distinguish from associated pathology especially RC
Pain on speeds test – questionable specificity
Long Head of Biceps Pathology
Management:
Address impairments that are contributing to the disorder.
As SAPS rehabilitation.
History
Vague, diffuse
shoulder pain
Insidious onset, slowly progressive
Present at rest AND exacerbated by movement or activity
History of manual labour.
Physical examination: Painful, restricted
global loss of motion Crepitus
GHJ OA
Investigations
Investigations:
Joint space narrowing Marginal osteophytes Glenoid erosions.
