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Common Condition Revision > Chest/shoulder pain > Flashcards

Chest/shoulder pain Flashcards

1
Q

What are some red flags for acute chest pain?

A
  • Dizziness/syncope
  • Pain in arms L>R, jaw, in-between scapula
  • Thoracic pain
  • Sweating
  • Palpitations
  • Dyspnoea
  • Pain on inspiration
  • Pallor
  • Past history of: Ischemia, diabetes, hypertension
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2
Q

What are the probable diagnosis’ for chest pain?

A
  • Referred pain Tx facet joints or CV/CT
  • Muscle strains- intercostals
  • Costochondritis
  • Rib/vertebrae #
  • SC joint dysfunction
  • Thoracic outlet
  • Psychogenic
  • Angina
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3
Q

Serious disorders not to be missed with chest pain?

A
  • CVS: Unstable angina/AMI, Aortic dissection/ pulmonary embolism
  • Lung and breast cancer
  • Severe infections of the lungs/heart
  • Pneumothorax
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4
Q

What conditions are often missed with chest pain?

A
  • GORD/ reflux
  • Gastritis
  • Peptic ulcer
  • Herpes zoster - viral infections
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5
Q

What are some red flags with shoulder pain?

A
  • Heart or gallbladder referral
  • Lymphoma
  • OA and other degeneration
  • Rheumatoid arthritis
  • Trauma - Fracture/dislocations
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6
Q

What are the probable diagnosis’ with shoulder pain?

A
  • Subacromial impingement
  • Rotator cuff/bicep tendinopathy
  • Adhesive capsulitis
  • Glenoid labral tear
  • Cx referral (facet/disc/spinal nerve)
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7
Q

What is subacromial impingement and the risk factors associated with the condition?

A
  • Any structure that becomes compressed within the subacromial space (coracoacromial arch)
  • Risk factors include: Repeated overhead motion, lax surrounding structures, degeneration and calcified tendons
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8
Q

What signs are indicative of a shoulder impingement? What tests can be used?

A
  • Anterior and lateral pain over the shoulder
  • Pain with overhead movements
  • Patient won’t like to rest on affected side
  • Neers, hawkins-kennedy, empty can and painful arc
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9
Q

What are some clinical signs of rotator cuff tendinopathy? What tests can be used?

A
  • Pain over 90 degrees of abduction and altered painful arc movements
  • Anterior/lateral/posterior shoulder pain
  • Tenderness of muscle palpation
  • Reduced ROM

-Neers, hawkins-kennedy, empty can and painful arc

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10
Q

What is adhesive capsulitis?

A

Disabling disorder in the shoulder in which the connective tissue of the shoulder becomes inflamed and stiff, restricting ROM and causing chronic pain.

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11
Q

What are the three stages of adhesive capsulitis with its subsequent features?

A

Freezing stage: (Upto 9 months)
•Insidious onset of vague, dull pain at the deltoid insertion
•Pain with shoulder movement
•Nagging pain at night, with sleep deprivation and the inability to sleep on the affected side
•Marked limitation of active and passive shoulder rotation, particularly external rotation

Frozen stage: (4-20 months)
•Stiffness
•Severe loss of shoulder movement
•Pain lessened

Thawing stage: (5-26 months)
•Regain a functional ROM gradually

*6 month to 7 years after initial onset of symptoms frozen shoulder can go to the contralateral shoulder

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12
Q

What is the glenoid labrum?

A

A structure that deepens the glenoid fossa and aids to keep the humeral head within the glenoid cavity. Made from fibrocartilage which is poor vascularised implicating healing

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13
Q

What are some risk factors for a glenoid labral tear?

A
  • Repetitive throwing sports
  • Compression injuries (from an outstretched arm fall)
  • Traction injuries (as a result of an inferior traction applied to the humerus)
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14
Q

What are some clinical features of a glenoid labral tear?

A
  • Poorly defined pain that is posterior in location
  • Painful popping or clicking can be associated
  • History of throwing or falls/impact injuries
    • Obrien’s test and Apprehension/relocation test
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15
Q

What structures are you assessing when doing a cotton wool/ proprioception test?

A
  • Dermatomal distribution (mechano-receptors)
  • Peripheral cutaneous nerve
  • DCML
  • Thalamus (VPL- ventral postolateral nucleus)
  • Somatosensory cortex/ Post-central gyrus
  • Vocalising responce
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16
Q

What structures are you assessing when doing a pinprick wool test?

A
  • Dermatomal distribution (nociceptors)
  • Peripheral cutaneous nerve
  • STT, spinoreticular, spinomesencephalic
  • Liseurs tract
  • Thalamus
  • Somatosensory cortex/ post-central gyrus
  • Vocalising responce
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17
Q

What nerve supplies the cutaneous ‘regimental band area’ or inferior deltoid area?

A

Axillary nerve

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18
Q

What nerve supplies the cutaneous posterior arm?

A

Radial nerve: a branch called inferior lateral brachial cutaneous nerve

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19
Q

What nerve supplies the cutaneous medial arm?

A

medial brachial cutaneous nerve

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20
Q

What nerve supplies the cutaneous lateral forearm?

A

Lateral anti brachial cutaneous nerve (terminal branch of musculocutaneous nerve)

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21
Q

What nerve supplies the cutaneous thenar eminence?

A

Median nerve

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22
Q

What nerve supplies the cutaneous lateral 3.5 digits

A

Median nerve

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23
Q

What nerve supplies the cutaneous medial 1.5 digits?

A

Ulnar nerve

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24
Q

What branches come off the Roots/Trunks of the brachial plexus?

A
  1. Dorsal Scap (Lev scap and rhomboids)
  2. Long Tx nerve (serratus ant)
  3. Suprascap (supra/infra spin)
  4. Nerve to Subclavius
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25
Q

What are the nerves that come off the cords of the brachial plexus?

A
  1. Upper subs cap
  2. Throacodorsal nerve
  3. Lower Subscap
  4. Medial pectoral nerve
  5. Medial brachial cutaneous nerve
  6. Medial ante brachial cutaneous nerve
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26
Q

What is the origin/insertion, NS and action of pec major?

A

Origin: Aterior surface of the medial clavicle and anterior surface of the sternum, the superior six costal cartilages and the aponeurosis of the external oblique muscle
Insertion: bicipital groove of the humerus
NS: lateral and medial pectoral nerve

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27
Q

What are the intermediate layer muscles of the back?

A

Iliocostalis- common tendinous origin –> inferior angles of the ribs
Longissimus- common tendinous origin –> lower ribs, TP’s of C2-T12 and mastoid process of the skull
Spinalis- common tendinous origin –> SP’s of C2- T1/8 and occipital bone

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28
Q

What are the deep muscles of the back?

A
  • Semispinalis
  • Multifidus
  • Rotatores
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29
Q

How is angina classified?

A

Stable: Gradual decrease in coronary blood flow, 50-70% of lumen compromised. It happens when you exert yourself physically or feel considerable stress
Unstable: Severe (>70%) or complete blockage. Chest pain that occurs at rest or with exertion or stress

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30
Q

What causes angina?

A

thrombosis + vasoconstriction when an atheroma has formed in the artery.

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31
Q

How can you differentiate psychogenic chest pain vs angina?

A 
Location of angina: Central chest pain (also referring down arm, neck, jaw, interscap)
Blood tests (troponin, creatinkinase) and ECG
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32
Q

Risk factors for DVT?

A
  • COCP
  • Long haul flights
  • Long term immobility
  • Obesity
  • Heart failure
  • Vessel wall damage: Recent surgery or intravenous drug use
  • Older age
  • Smoking
  • CVD
  • Pregnancy
  • Coagulation disorder
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33
Q

Classifications of pneumothorax?

A
  • Spontaneous: Primary (idiopathic- tall and skinny) and Secondary (catamenial pneumothorax, emphysema blebs)
  • Traumatic
  • Open, Close and Tension
34
Q

What forms the borders of the subacromial space?

A
  • Acromion
  • Coracoacromial lig
  • Coracoid process
  • Head of humerus
35
Q

What structures can be impinged in the subacromial space?

A
  • Subacromial bursae
  • Supraspinatus tendon
  • Biceps tendon (long head)
36
Q

What are some intrinsic/extrinsic factors/pathophysiology that cause subacromial impingement?

A

Intrinsic: alterations in biology, mechanical properties, morphology, and vascularity, calcification, micro-tearing

Extrinsic: Repeated overhead movements, scapula dyskensis, instability/ recurrent dislocation, structural abnormalities of the coracoacromial arch, postural abnormalities, rotator cuff and scapula muscle deficits

37
Q

What are some risk factors for adhesive capsulitis?

A
  • Women > Men
  • Comorbidities: diabetes, thyroid, autoimmune
  • 40-65yo
38
Q

What is a SLAP lesion?

A

A Superior labral tear that goes from anterior –> posterior

39
Q

Define Costochondritis

A

Inflammatory condition affecting the sternocostal joints or costochondral junctions

40
Q

How does costrochondritis differ from Tietze’s syndrome?

A

Costochondritis: Not usually accompanied by swelling
Tietze: associated with visible and painful enlargement of the costochondral junction

41
Q

What are some aetiological factors associated with costochondritis?

A

•Often associated with infection, trauma, rheumatological disease and neoplasia

42
Q

What are some aetiological factors associated with rib #?

A

• Trauma: Direct blow to ribcage- undisplaced or displaced rib #, or CC displacement
• Coughing/sneezing fits – respiratory complaint
• Pathological- cancer, osteoporosis
• Stress fractures- due to excessive muscle traction at rib attachments
o Rowers, fast bowlers, baseball pitchers, golfers

43
Q

What are some management options for rib fractures?

A
  • Surgical: reduction and internal fixation
  • Oral and local analgesia
  • Deep breathing exercises
  • Extremely painful and remain tender to palpation for at least 3-4 weeks
44
Q

What type of joint is the sternoclavicular joint?

A

diarthrodial joint, which forms the only synovial articulation between the upper limb and the axial skeleton.

45
Q

How long will a rib fracture take to heal?

A

t

46
Q

How long will a costochdonral/ sternoclavicular joint sprain take to heal?

A 
Grade 1
1 - 4 weeks 
Grade 2
3 weeks - 6 months 
Grade 3 (surgery required)
6 weeks - 1 year
47
Q

What is the most common mechanism for a sternoclavicular joint sprain?

A

They generally occur in active, young males as a consequence of the high-energy mechanism of injury.
Others: MVA and falls

48
Q

What ligaments (and one mm) hold together the sternoclavicular joint?

A

The joint is shallow and its stability is therefore mainly dependent upon the integrity of four distinct ligaments, and the subclavius muscle.

  • Interclavicular ligament
  • Anterior SC ligament
  • Posterior capsular ligament
  • Costoclavicular liagament
  • Subclavius muscle
49
Q

What is a side-strain?

A

a condition described as internal oblique muscle tear at the rib or costal cartilage insertion

50
Q

What are the gradings of side strains?

A

Grade 1: Athlete may attempt to carry on but feel a tightness and slight pain on the affected side

Grade 2: More severe pain occurring on movement including minor trunk movements, confirmed by pain on stretching away and also rotating towards the affected side (Stretching + contraction of the muscle)

Grade 3: All trunk movements and sometimes breathing can be painful and pain is extremely severe

51
Q

What are some intrinsic/extrinsic factors that could lead to SAPS?

A

Extrinsic: repeated overhead motion, muscle deficit, ligament laxity (ie in pregnancy relaxin)

Intrinsic: Degeneration (OA), calcification of tendons

52
Q

What is rotator cuff tedinopathy?

A

Irritation/ Inflammation of the rotator cuff muscle tendons.

53
Q

What are common aeitological factors for rotator cuff tendinopathy patients?

A

Multifactorial but can include:

  • Throwing athletes
  • Advanced age
  • Repetitive overhead shoulder movements
  • Hx of shoulder instability
54
Q

Origin/ Insertion NS and Action of Supraspinatus

A

Origin: Supraspinous Fosaa
Insertion: Superior facet of the greater tubercle of the humerus
NS: Suprascapular nerve
Action: First 45 degrees of abduction

55
Q

Origin/ Insertion NS and Action of Infraspinatus

A

Origin: Infraspinous Fossa
Insertion: Middle facet of the greater tubercle of the humerus
NS: Suprascapular nerve
Action: External rotation

56
Q

Origin/ Insertion NS and Action of Subscapularis

A

Origin: Subscapularis Fossa
Insertion: Inferior tubercle of the humerus
NS: Subscapular nerve
Action: Internal Rotation and adduction of the arm

57
Q

Origin/ Insertion NS and Action of Teres Minor

A

Origin: inferior angle of the scapular
Insertion: Inferior facet of the greater tubercle of the humerus
NS: Axillary nerve
Action: External rotation

58
Q

Estimated recovery period for a primary tendinopathy/ tendinitis?

A

3 - 7 Weeks

59
Q

Estimated recovery period for a secondary tendinopathy?

A

6 Weeks - 3 Months

60
Q

Estimated recovery period for a tertiary tendinopathy/ complete rupture?

A

3 - 6 Months

61
Q

What are the clinical signs/ symptoms of a rotator cuff tendinopathy?

A
  • Pain at over 90 degrees of abduction
    (May see deviations of movement such as moving body to allow arm swing to achieve – recruitment of other muscles)
  • Pain over the anterior/&lateral/& posterior shoulder
  • Tenderness upon palpation, particularly over supraspinatus
  • Internal rotation reduced (putting supraspinatus on stretch)
62
Q

What are the ortho tests for a rotator cuff tendinopathy?

A
  • Nears Impingement
  • Hawkins Kennedy
  • Painful arc
  • Passive full flexion
  • Empty Can
63
Q

What two aspects of the patient should be focused on when treating rotator cuff tendinopathy?

A

Treating the tendon:

  • Avoid aggravating factors
  • Rest/ de-load
  • Ice/ NSAIDs

Treat underlying factors:

  • Muscle deficits
  • Hypertonicity
  • ROM
64
Q

What is the pathophysiology of a tendinopathy?

A
  • Tendon becomes becoming swollen and hypercellular due influx of inflammatory response
  • Collagen matrix becomes disorganised resulting in a weaker and inflamed tendon.
65
Q

Origin/insertion, NS and action of biceps brachii?

A

Origin
Short Head: Apex of the coracoid process of the scapula.
Long Head: Supraglenoid tubercle of the scapula.
Insertion: Bicipital tubercle of the radius
NS: musculocutaneous nerve (C5/6)
Action: flexion of the elbow and GH joint. The short head assists with shoulder adduction. The long head may assist with abduction if the humerus is laterally rotated.

66
Q

What are the three theories of the pathophys of biceps tendinopathy?

A
  1. Mechanical Theory
  2. Vascular Theory
  3. Neural Modulation
67
Q

What is the Mechanical Theory of biceps tendinopathy?

A

Mechanical theory - This theory states that repetitive loading of the tendon results in microscopic degeneration. Fibroplasia occurs within the tendon, resulting in scar tissue.

68
Q

What is the Vascular Theory of biceps tendinopathy?

A

Vascular theory - According to this theory, tendon degeneration occurs as a result of focal areas of vascular compromise.

69
Q

What is the Neural Modulation Theory of biceps tendinopathy?

A

Neural modulation - The newest of the 3 theories, this focuses on the assumption that tendinopathy results from neurally mediated mast cell degranulation and the release of substance P.

70
Q

What are the ortho tests for biceps tendinoapthy?

A
  • Speeds test

- Yergansons

71
Q

What ligaments make up the acromioclavicular joint?

A
  • Coracoclavicular ligament (conoid and a trapazoid part)
  • Coracoacromial ligament
  • Acromioclavicular ligament
  • AC joint capsule
72
Q

What type of joint is the AC joint?

A

Plan synovial/ gliding joint

73
Q

Common mechanism of an AC joint sprain/ dislocation?

A
  • Contact sports (hip-and-shoulder)
  • MVA
  • Falls
  • FOOSH
74
Q

What a common sign if an AC dislocation?

A

Step defect

75
Q

What are the 5 grades of AC joint sprain?

A

I- sprain of the capsule causing local tenderness, especially in horizontal flexion
II- Tearing of the AC and CC ligaments, possible small step deformity
III & IV- complete tearing of AC and CC lig, obvious step deformity
V- High levels of displacement, surgery required

76
Q

Ortho test for AC joint sprain?

A

Horizontal flexion

Shearing if the joint

77
Q

What is the difference between a SLAP and Bunkhart labral lesion?

A

SLAP (superior labral tear ant to post): They attributed this lesion to the biceps tendon being pulled off the labrum as a result of force generated during the throwing motion

Bankhart: Tear on the inferior aspect due to dislocation of GH

78
Q

Clinical signs/symptoms and ortho tests for Labral tears?

A
  • Positive apprehension/ Obriens
  • Superior shoulder pain
  • Clicking and pain with abduction and or overhead movements
  • Weakness, pain or difficulty performing eccentric bicep movements e.g. biceps curls
  • Tenderness to palpate over the rotator cuff muscles
  • May report that it feels like their shoulder is “catching” on something (Type 3 and 4)
79
Q

Sports with higher side-strain prevalence?

A
  • Cricketers
  • Javelin
  • Shotput
  • Tennis
  • Rowing
  • Baseball
80
Q

Internal Oblique origin/insertion/attachment/NS

A

Origin: TL fascia, iliac crest and inguinal ligament
Insertion: linea alba, ribs 10 - 12
NS: Ilioinguinal nerve and subcostal nerves
Action: Trunk rotation and support/compress viscera

Common Condition Revision (6 decks)

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